Every finding on record at Carlisle Skilled Nursing and Rehabilitation Center

Based on facility policy review, nurse aide competency review, clinical record review, review of select facility documentation, hospital discharge summary, and staff interviews, it was determined that the facility failed to provide adequate supervision and assistance to prevent accidents for one of 29 residents reviewed (Resident 111), which resulted in actual harm for Resident 111 as evidenced by a femur fracture.Review of facility policy, titled Falls Management last reviewed January 15, 2026, read, in part, Patients will be assessed for risk of falling as part of the nursing assessment process. Interventions to reduce risk and minimize injury will be implemented as appropriate. Implement and document patient-centered interventions according to individual risk factors in the patient's plan of care. Educate staff, patient, and/or patient representative(s) as appropriate to increase awareness of 'at risk' patients and to provide possible strategies to minimize risk for falls. Review of checklist, titled Turning and Repositioning not dated, read, in part, Critical elements: Stands on the side of the bed opposite to where caregiver will turn the patient. Moves patient to the side nearest caregiver (moves patient in segments or with a drawsheet). Review of Resident 111's clinical record revealed she had a BIMS (Brief Interview for Mental Status- a quick test that looks at how well you think, learn and remember) score of 9 out of a possible 15, indicating a degree of cognitive impairment, and diagnoses that included history of falling, repeated falls, and displaced fracture of lateral condyle of unspecified femur, initial encounter for closed fracture (fracture of one of the two articular projections at the distal end of the femur). Review of Resident 111's clinical record revealed her transfer ambulation status was full mechanical lift, and her bed mobility status was one assist. Review of Resident 111's comprehensive care plan revealed a focus area of [Resident 111] is at risk for falls last revised June 4, 2026, with an intervention for implement safety precautions, with a created date of May 22, 2026. Review of facility incident report dated July 1, 2026, read, in part, [Employee 4] came out to the nursing station and said that the patient had fallen off the bed. Patient was getting changed so she could go to lunch. Resident stated she was reaching for the side of the bed to roll over and she rolled onto the floor. Nurse Practitioner ordered x-rays of the right femur and hip. The decision was later made to transfer [Resident 111] to the emergency department for further work up. Review of signed statement written by Employee 4 (Nurse Aide) dated July 1, 2026, revealed At 11:30 AM, [Resident 111] had asked me to be changed. I grabbed [Employee 5 (Nurse Aide)] to help me transfer her because she is a Hoyer lift (a medical device designed to safely lift and transfer individuals with limited mobility from one surface to another using a sling and mechanical lifting system). We safely got her into bed. She is a 1 assist in bed so [Employee 5] had left the room. I had rolled her to get the clean brief under her. I grabbed the new brief that was on the bed. When I let go of her hip she had rolled out of bed. I went to put a pillow under her head immediately. I knew the nurse practitioner was next door so I ran and got her then stayed with [Resident 111]. Review of follow-up statement from Employee 4 on July 22, 2026, revealed The resident was up in her wheelchair and asked to get changed. I grabbed another nurse aide, [Employee 5] to help me as [Resident 111] is a Hoyer lift. We positioned her in the bed. She helps with rolling and turning. She is very good about directions and following them. I was standing on the door side of the bed and helped [Resident 111] roll towards the window. As she rolled she was going to the bathroom. I took my hand off her hip to adjust the brief and [Resident 111] scooted herself towards the edge of the bed to hold onto the grab bar and she rolled onto the floor. She was facing away from me. I tried to catch her but couldn't. I immediately yelled for help. Review of facility document, titled On the Spot Education! dated July 1, 2026, revealed Education: Care with residents- roll towards you not away from you. Ask for assistance from another staff member or nurse if needed. The document was signed by Employee 4 on July 1, 2026. Review of Resident 111's Hospital Discharge summary dated [DATE], read, in, part, Discharge Plan: Principal Problem: Closed bicondylar fracture of distal end of right femur. Assessment: Postop day 4 ORIF (Open Reduction and Internal Fixation, a surgical procedure used to repair broken bones by realigning them and securing them with internal hardware) right distal femur with plate and screws and placement of external fixator. Plan: Patient is to be no weightbearing right lower extremity bed to chair transfers only. The external fixator should be in place for 6 weeks. During an interview with the Director of Nursing on July 22, 2026, at 2:18 PM, she revealed she would expect nurse aides to roll residents towards them and not away from them to prevent falls and accidents. The facility failed to provide adequate assistance to prevent accidents, which resulted in actual harm for Resident 111 as evidenced by a femur fracture requiring surgical intervention. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, clinical record, observations, and resident and staff interviews, it was determined the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status, which resulted in actual harm as evidence by weight loss for one of five Residents reviewed (Resident 1). Also, the facility failed to adequately monitor and document fluid restrictions for one of five residents reviewed (Resident 8), and failed to reweigh and notify the physician and dietician of significant weight loss for one of five residents reviewed (Resident 21).Findings include: Review of facility policy, titled Weights and Heights, last reviewed January 15, 2026, revealed the following Based on the patient's comprehensive assessment, the Center will ensure that all patients maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the patient's clinical condition demonstrates that it is not possible for the patient's preferences to indicate otherwise. Patients are weighed upon admission and/or re-admission, then weekly for four weeks and monthly thereafter. Additional weights may be obtained at the discretion of the interdisciplinary care team. If the body weight of a patient is not as expected, re-weigh the patient. Notify the physician/APP (advanced practice provider) and Dietician of significant weight changes. Notify the patient/patient representative of the weight change. Review of facility policy, titled Enteral Management, revision date July 17, 2026, revealed, . enteral feedings will be provided through a nasogastric (a small, soft tube that goes through the nose, down the throat and into the stomach), gastrostomy (tube placed through the abdomen into the stomach), or jejunostomy tube (tube placed through the skin of the abdomen into the midsection of the small intestine) according to written physician/APP order. Review of Resident 1's clinical record revealed diagnoses that included severe protein-calorie malnutrition (inadequate intake of protein and calories) and malignant neoplasm of the tongue (cancerous growth on the tongue). Review of Resident 1's progress notes revealed a note by the facility dietitian dated June 18, 2026, at 11:23 AM, that read, in part, New order: Administer Jevity 1.5 continuous via Pump 80ml [milliliters] per hour for 20 hours per day or until 1600ml has infused. Flush w/ H2O 58ml per hour while TF infuses. Start time 8pm. This will provide 1600ml total volume, 2400 kcal, 102g protein and 2376ml total fluids (1216ml free water and 1160ml flush). Review of Resident 1's assessment titled dietary screening for malnutrition, at risk for malnutrition, morbid-obesity-ALTRA, dated June 22, 2026, revealed section C. 2. Is the resident at risk for malnutrition was marked yes. Review of Resident 1's comprehensive care plan revealed Resident 1 was at nutritional risk for malnutrition related to tongue cancer, dysphagia, severe protein-calorie malnutrition, the need to tube feed to meet needs, and wound healing. An intervention initiated on June 22, 2026, indicated to assess for signs and symptoms of malnutrition including weights per facility protocol. Resident 1's care plan also revealed that Resident 1 had an enteral feeding tube to meet nutritional needs due to Dysphagia (difficulty swallowing) with an intervention for Jevity 1.5 continuous via pump 80 ml per hour for 20 hours per day or until 1600ml has infused, initiated June 18, 2026. Review of Resident 1's physician orders revealed the following orders: NPO (nothing by mouth) for Dysphagia, enteral feed Jevity 1.5 calories administer via pump 80 ml (milliliters) per hour. Hours per day 20 or until total nutrient delivered, and weight today, dated July 3, 2026. Observation on July 20, 2026, at approximately 1:00 PM, revealed Resident 1's feeding pump was off and the tubing was disconnected from Resident 1's G tube (gastrostomy tube). A one liter bottle of Jevity 1.5 calorie with 200 ml remaining in the bottle was hanging on the dispensing apparatus at Resident 1's bedside. The bottle was dated July 19, 2026, 8:00 PM. Additional observation on July 20, 2026, at 2:30 PM, revealed Resident 1's feeding pump was off and the tubing was disconnected from Resident 1's G tube, with 200 mL (milliliters) of Jevity 1.5 calories remaining in the bottle. Interview with Resident 1 during observation noted above revealed that staff had disconnected the feeding tube earlier that morning. Observation on July 21, 2026, at approximately 9:30 AM, revealed Resident 1's feeding pump was turned off and the tubing was disconnected from Resident 1's G tube (gastrostomy). One liter (1000 milliters) bottle of Jevity 1.5 cal with 300 ml was remaining in the bottle. The bottle was dated July 20, 2026, 8:00 PM. Interview with Resident 1 at the time of the above observation revealed that staff disconnected his enteral feeding and told him that the enteral feeding was finished. Observation on July 22, 2026, at approximately 9:40 AM, revealed Resident 1's feeding pump was turned off. One liter bottle of Jevity 1.5 cal with 0 ml remaining in the bottle. The bottle was dated July 21, 2026, 8:00 PM. Review of Resident 1's progress notes revealed a note written by the facility dietitian dated July 8, 2026, indicating Enteral Feed: Jevity 1.5 at 80 ml/hr x 20 hours (Provides: 1600 mL, 2400 kcal, 102 g [grams] PRO [protein], 1216 ml free water). Review of Resident 1's current and discontinued physician orders failed to reveal an order for weight monitoring weekly for four weeks and monthly thereafter. Review of Resident 1's vital signs documentation revealed an admission weight of 172.8 pounds, obtained on June 18, 2026. Further review of Resident 1's clinical record failed to reveal documentation of any additional weights or documentation indicating the amount and duration of enteral feedings that Resident 1 received. During an interview on July 22, 2026, at 1:55 PM, with the Nursing Home Administrator (NHA), Director of Nursing (DON), and Employee 1 (Regional Clinical Support Nurse), it was revealed that the facility could not provide additional information relating to why Resident 1's was not being administered the full amount of feeding recommended by the dietician and why Resident 1's weight had not been obtained. Additional review of Resident 1's clinical record revealed a weight of 160.4 pounds documented on July 23, 2026 (a 12-pound weight loss), indicating that Resident 1 had a 7.18% weight loss in 35 days. During a final interview on July 23, 2026, at 2:01 PM, with the NHA, DON, and Employee 1 it was revealed the facility's expectation is for enteral feedings be fully administered, orders for weight monitoring be in place, and resident weights would be obtained. The facility failed to monitor Resident 1's weight, administer the full amount of enteral feedings, and document the amount and duration of enteral feedings Resident 1 received. Weight obtained during the onsite visit revealed Resident 1 lost 12.4 pounds in 35 days since admission to the facility. Review of Resident 8's clinical record revealed diagnoses that included Chronic Diastolic Congestive Heart Failure (CHF - excessive body/lung fluid caused by a weakened heart muscle) and Ischemic Cardiomyopathy (heart muscled is weakened and struggles to pump blood efficiently because of long-term damage caused by a lack of blood supply). Review of Resident 8's orders revealed she was ordered fluid restrictions of 1800 milliliters per day. Nursing was to provide 720 milliliters per day-360 ml dayshift, 240 ml evening shift and 120 ml night shift. Dietary was to provide 1080 milliliters per day, which was to be 360 milliliters per meal. Review of Resident 8's meal intake documentation revealed that there was no documentation for fluid intake during meals or snacks. Review of Resident 8's medication administration record (MAR) failed to reveal documentation for milliliters of fluid provided by nursing staff from May 21, 2026, evening shift through June 3, 2026, day shift. Review of Resident 8's MAR for June 2026 revealed an order for Fluid restrictions for each shift -360 ml day shift, 240 ml evening shift, and 120 ml night shift. Seven times on day shift, the Resident was provided more than 360 ml of fluid. Two times on evening, Resident 8 was provided more than 240 ml, and four times on night shift she was provided more than 120 ml. There was also eight times where no fluid amount was documented. Review of Resident 8's MAR for July 2026 revealed three times on dayshift that the Resident was provided more than 360 ml. There were two times on evening shift that the Resident was provided more than 240 ml, and four times on night shift that more than 120 ml was provided. There was also six times that no fluid amount was documented. During a staff interview with Employee 1 on July 23, 2026, at 11:16 AM, she revealed her expectation would be that nursing staff would be documenting an amount in milliliters if a resident is ordered fluid restrictions and that there would be a task placed in for documentation of milliliters of fluids taken with meals. During an interview with the NHA, DON, and Employee 1 on July 23, 2026, at 1:38 PM, the DON revealed her expectation is for nursing staff to be documenting fluids accurately during the shift and following orders for the correct amount of fluids ordered. Review of Resident 21's clinical record revealed diagnoses that included Dementia (a loss of memory, language, and thinking skills that is severe enough to get in the way of daily life) and Hypothyroidism (a clinical condition where the thyroid gland-a small butterfly-shaped gland in your neck-underproduces essential thyroid hormones). Review of Resident 21's orders revealed a monthly weight was ordered through July 10, 2026, and was ordered weekly starting July 14. 2026. There was a 20-pound weight loss per documentation from July 1 to 3, 2026. A re-weigh was to be completed if there was a significant change, per policy, and there was no re-weigh obtained until July 8, 2026. Review of Resident 21's clinical record revealed a July 4, 2026, at 5:26 PM, notation from the physician indicating that the Resident was overweight. Review of a notation from the nurse practitioner on July 6, 2026, at 1:38 PM, noted the Resident's weight log was reviewed and was stable, and the Resident was overweight. Review of Resident 21's clinical record revealed a Nutritional assessment dated [DATE], in part, noting a significant, unplanned, undesirable 10.2 % weight loss in one month and a 9.3% weight loss in 3 months. Evaluation/nutrition plan recommends liberalizing diet due to significant weight loss and weekly weights for 4 weeks. During a staff interview with Employee 1 on July 22, 2026, at 1:40 PM, she confirmed that the expectation is that residents who have a significant weight change would be reweighed to confirm that the weight is accurate and that the physician and dietician would be made aware if there are significant changes. Further review of Resident 21's vital sign documentation revealed a weight of 172.3 pounds taken on July 21, 2026, via mechanical lift and a weight of 182.4 pounds taken on July 23, 2026, via mechanical lift. During a staff interview with the NHA, DON, and Employee 1 on July 23, 2026, at 1:45 PM, Employee 1 revealed that they would be having maintenance check the scales on the mechanical lifts for accuracy and proper functioning due to significant weight changes noted. 28 Pa Code 201.18(b)(1) Management28 Pa Code 211.2(d)(3) Medical director28 Pa Code 211.12(c)(d)(1)(3)(5) Nursing Services

Based on facility policy review, personnel file review, and staff interview, it was determined that the facility failed to ensure that residents were protected from the potential for abuse by failing to perform licensure or registry verifications prior to hire for three of four personnel files reviewed (Employees 7, 8, and 9).Findings include: Review of facility policy, titled OPS300 Abuse Prohibition, with a last review date of November 14, 2025, revealed, in part, The Center will implement an abuse prohibition program through the following: Screening of potential hires. The Center will screen potential employees for a history of abuse, neglect, or mistreating patients, including attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries. Review of personnel file for Employee 7 (Licensed Practical Nurse) revealed that her date of hire was April 28, 2026. Further review of the personnel file revealed that the facility completed her license verification on July 13, 2026. Review of personnel file for Employee 8 (Nurse Aide) revealed that her date of hire was May 12, 2026. Further review of the personnel file revealed that the facility completed her registry verification on May 13, 2026. Review of personnel file for Employee 9 (Dietician) revealed that his date of hire was July 6, 2026. Further review of the personnel file revealed that the facility completed his license verification on July 9, 2026. During a staff interview with the Nursing Home Administrator (NHA), Director of Nursing, and Employee 1 (Regional Clinical Support Nurse) on July 22, 2026, at 1:44 PM, Employee 1 confirmed that license and registry verification should be completed prior to or upon hire. The NHA indicated that the facility had identified issues in their hiring process and have implemented a Performance Improvement Plan. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 201.19(3) Personnel policies and procedures.

Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure residents with limited mobility receive appropriate services, equipment, and assistance to maintain or improve mobility for four of four residents reviewed for limited range of motion (Residents 6, 7, 11, and 34).Findings include: Review of facility policy, titled NSG232 Restorative Nursing with a last revision date of July 17, 2026, revealed, in part, Restorative Nursing Program refers to nursing intervention that promotes the patient's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. Restorative programs are coordinated by nursing or in collaboration with rehabilitation and are patient specific based on individual patient needs. A licensed nurse must supervise the activities in a restorative nursing program. 2. Develop restorative nursing programs appropriate to the patient's identified needs. 3. Develop specific measurable goals and document goals and interventions on the patient's restorative care plan. 4. Implement the restorative nursing program according to the specifics on the care plan. 5. Evaluate program quarterly. 6. Document: 6.1 Daily on Restorative Nursing Record in PointClickCare (PCC) ADL Point of Care (POC); 6.2 Quarterly evaluation by licensed nurse in Care Plan Evaluation progress note. Review of Resident 6's clinical record revealed diagnoses that included displaced intertrochanteric fracture of the right femur, initial encounter for a closed fracture, muscle weakness, and low back pain. During an interview with Resident 6 on July 20, 2026, at 10:39 AM, she revealed she had finished working with therapy, but she was unsure if she had a restorative nursing program (RNP- an individualized, nurse supervised plan that helps long term care residents maintain or regain functional abilities such as walking, dressing, eating, mobility, and communication). Review of Resident 6's occupational therapy Discharge summary dated [DATE], revealed Discharge reason: Maximum potential achieved. Referral for RNP. Review of Resident 6's comprehensive care plan revealed a focus area Restorative Ambulation: [Resident 6] demonstrates a deficit in ambulation, recent hospitalization for hip fracture with surgical repair, with interventions including Goal: Patient will walk 150 feet with rolling walker, and Supervision: Provide verbal cueing and walk along with patient, created on April 30, 2026. Review of Resident 6's RNP documentation from May 2026 to present, revealed her program was marked as Not applicable on May 1, 2, 4, 6-8, 10, 13, 14, 16-18, 19, 23, 24, 27, and 31, 2026; June 2, 3, 9, 11, 15-17, 20, 21, and 30, 2026; and July 4, 10, 14, 15, 17, 19, 20 and 21, 2026. During an interview with Employee 1 (Regional Clinical Support Nurse) on July 22, 2026, at 2:11 PM, she revealed she has no information to provide as to why the staff are marking not applicable for Resident 6's RNP program on the aforementioned days, but sometimes she refuses the program, and she plans to do education with staff regarding marking refused instead of marking not applicable for refusals. During an interview with the Director of Nursing (DON) on July 23, 2026, at 1:14 PM, she revealed she would expect RNP programs to be implemented or documented that they were refused if refused. Review of Resident 7's clinical record revealed diagnoses that included osteoarthritis (protective cartilage that cushions the ends of the bones wears down over time) and fibromyalgia (chronic condition that causes widespread pain, fatigue and sleep problems). Review of Resident 7's comprehensive plan of care revealed a focus area for restorative range of motion stating Resident 7 demonstrated loss of range of motion in lower extremities, date initiated February 2, 2026, with an intervention for active and active assisted range of motion. Review of Resident 7's occupational therapy discharge summary signed June 25, 2026, revealed discharge reason maximum potential achieved, referred for RNP/FMP. Further review of Resident 7's clinical record failed to reveal documentation of a restorative range of motion being completed. During an interview on July 23, 2026, at 1:57 PM, with the Nursing Home Administrator, DON, and Employee 1, it was revealed that Resident 7's RNP was missed and never added to the task when the care plan was developed. The DON stated it was the expectation of the facility that restorative programs be completed. Review of Resident 11's clinical record revealed diagnoses that included progressive multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves which disrupts communication between the brain and the body), osteoarthritis, and weakness. Review of Resident 11's care plan revealed a care plan focus for self-care deficit related to generalized weakness and multiple sclerosis revised December 6, 2022. Interventions included, but were not limited to, active assisted range of motion to bilateral upper extremities twice a day with activities of daily living with an initiated date of September 15, 2025. Review of Resident 11's range of motion task documentation between June 22, 2026, and July 21, 2026, revealed that on nine occasions (June 22 and 26 [two entries], 2026; July 3, 7, 10 [two entries], 12, and 17, 2026) were documented as Not Applicable. Email communication received from Employee 1 on July 22, 2026, at 11:48 AM, indicated that she cannot justify staff documenting Resident 11's restorative range of motion program as not applicable. During a staff interview with the NHA, DON, and Employee 1 on July 22, 2026, at 1:33 PM, Employee 1 and the DON confirmed that they would expect nursing staff to provide programs as ordered or document accurately as to why the programs were not provided. Review of Resident 34's clinical record revealed diagnoses that included Parkinson's Disease (long term degenerative disorder of the central nervous system that mainly affects the motor system) and cognitive communication deficit (a group of disorders that affect a person's ability to communicate, which can cause difficulty with understanding or producing language and nonverbal communication skills, such as gestures and facial expressions). Review of Resident 34's care plan revealed a care plan focus for self-care deficit related to physical limitations, muscle wasting and atrophy with a revision date of February 18, 2024. Interventions included, but were not limited to, active range of motion to bilateral lower extremities twice a day during activities of daily living dated August 4, 2025. Review of Resident 34's range of motion task documentation between June 23, 2026, and July 22, 2026, revealed that 26 occasions (June 24 [two entries], 25 [two entries], 27, 29 [two entries], and 30, 2026; July 1 [four entries], 2 [two entries], 3, 7, 8, 12 [three entries], 13, 14, 15, and 16 [four entries], 2026) were documented as Not Applicable. During a staff interview with the NHA, DON, and Employee 1 on July 23, 2026, at 1:27 PM, the DON confirmed that she would expect nursing staff to provide programs as ordered or document accurately as to why the programs were not provided. 28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 211.10(c) Resident care policies.28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on clinical record review, facility policy review, as well as resident, resident representative, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for four of 29 residents reviewed (Residents 1, 34, 85, and 130), and failed to ensure that care plan meetings were held, residents were invited, and that the required interdisciplinary team members attended care plan meetings for three of 29 residents reviewed (Residents 6, 34, 106).Findings include: Facility policy, titled Person-Centered Care Plan, revised [DATE], read, in part, The interdisciplinary team, in conjunction with the patient and/or patient representative, as appropriate, will establish the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. 6. Care plans will be: 6.2 Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals.7. Care Plan Meetings: 7.1 The physician/advanced practice provider (APP) must participate as part of the interdisciplinary team, and may arrange with the Center alternative methods, other than attendance at care planning conferences, of providing his/her input such as one-on-one discussions, conference calls and/or physician/APP orders. 8. The Center has the responsibility to assist patients to participate by: 8.1 Extending invitations to patient and representative sent in advance; 8.2 Holding care planning meetings at the time of day when the patient is functioning best; 8.3 Facilitating the inclusion of the patient/representative(s) to attend; and 8.4 Incorporating the patient's personal and cultural preferences in developing goals of care. 9. Care plan meetings will be documented by use of the Care Plan Meeting note. Review of Resident 1's clinical record revealed diagnoses that included severe protein-calorie malnutrition (inadequate intake of protein and calories) and malignant neoplasm of the tongue (cancerous growth on the tongue). Review of Resident 1's physician orders revealed an order for DNR (do not resuscitate). Review of Resident 1's POLST revealed a code status of DNR with comfort measures, signed by Resident 1 and the physician on [DATE]. Review of Resident 1's comprehensive plan of care revealed that Resident 1 has an established code status of full code, initiated [DATE]. Review of Resident 1's progress notes revealed a social services care plan meeting note dated [DATE], at 11:38 AM, that indicated advance directives were reviewed and that Resident 1 did not want CPR (cardiopulmonary resuscitation). Interviews with Employee 18 and Employee 19 on [DATE], at approximately 12:30 PM, revealed that they would check the physician's order or the POLST for a resident's code status. An interview on [DATE], at 1:52 PM, with the Nursing Home Administrator (NHA), the Director of Nursing (DON), and Employee 1 (Regional Clinical Support Nurse) revealed that Resident 1 had recently decided to change his code status from full code to DNR. Employee 1 stated that it was the facility's expectation that care plans be revised timely. Review of Resident 6's clinical record revealed diagnoses that included displaced intertrochanteric fracture of the right femur, initial encounter for a closed fracture, muscle weakness, and low back pain. During an interview with Resident 6 on [DATE], at 10:49 AM, she stated she does not have quarterly care plan meetings. Review of Resident 6's clinical record revealed her last care plan meeting was held on [DATE], and was a phone call between the social worker and Resident 6's granddaughter and husband, and her daughter attended in person; it did not reflect that Resident 6 attended or was invited to attend the meeting. During an interview with the DON on [DATE], at 1:03 PM, she revealed she would expect residents to have care plan meetings on a quarterly basis, that residents are invited to their meetings as appropriate, and the meeting would be held with the interdisciplinary team. Review of Resident 34's clinical record revealed diagnoses that included Parkinson's Disease (long term degenerative disorder of the central nervous system that mainly affects the motor system) and cognitive communication deficit (a group of disorders that affect a person's ability to communicate, which can cause difficulty with understanding or producing language and nonverbal communication skills such as gestures and facial expressions). During an interview with Resident 34 on [DATE], at 11:25 AM, Resident 34 indicated that he has not participated in any of his care plan meetings. Review of Resident 34's clinical record revealed that he had attended his care plan meeting on [DATE], along with Social Services and the Nursing Unit Manager. Review of Resident 34's clinical record failed to reveal that a care plan meeting was held after his [DATE], annual assessment was completed. Review of Resident 34's clinical record revealed that he had attended his care plan meeting on [DATE], and [DATE], with Social Services and no other interdisciplinary team members were present. During a staff interview with the NHA, DON, and Employee 1 on [DATE], at 1:35 PM, all confirmed that they would expect residents to be invited to their care plans and that all appropriate interdisciplinary team members would attend the care plan meeting. Employee 1 indicated that the former Social Worker had been placed on a Performance Improvement Plan because of this concern. Employee 1 further indicated that Social Worker was no longer employed at the facility. The NHA indicated that they have implemented a performance improvement plan in place to address this concern. Further review of Resident 34's clinical record revealed that he was seen by an audiologist on [DATE], after he had reported to nursing staff that he was experiencing hearing loss. The audiologist made recommendations for treatment to address Resident 34's hearing loss. Review of Resident 34's clinical record revealed that he has been receiving pain medications specifically for his left shoulder since [DATE]. Review of Resident 34's annual assessment dated [DATE], revealed that he had limited range of motion of an upper extremity on one side. Review of Resident 34's care plan failed to reveal that he had hearing loss, ongoing pain in his left shoulder or contractures to his left hand. During a staff interview with the NHA, DON, and Employee 1 on [DATE], between 1:23 PM and 1:27 PM, the DON confirmed that Resident 34's care plan should have been revised to reflect his left shoulder pain, hearing loss, and hand contracture. Review of Resident 85's clinical record revealed diagnoses that included dementia (a decline in mental ability severe enough to interfere with daily life, commonly involving memory loss, poor judgment, and changes in mood) and demyelinating disease of the central nervous system (multiple sclerosis-a condition that damages the protective sheath covering nerve fibers in the brain and spinal cord). During an interview on [DATE], at 12:22 PM, with Resident 85's Representative, it was revealed that his wife's care plan does not reflect what is being done for her. Review of Resident 85's comprehensive plan of care on [DATE], at 10:41 AM, revealed her comprehensive care plan was not updated from the care plan meeting [DATE]. During an interview on [DATE], at 1:42 PM, with the NHA and the DON revealed their expectation is for the care plan to be updated immediately after a care plan meeting. Review of Resident 106's clinical record revealed diagnoses that included Parkinson's disease (brain disorder causing tremors, muscle stiffness, and slow movement) and chronic kidney disease stage 3A (mild-moderate loss of kidney function). During an interview on [DATE] at 9:48 AM, with Resident 106's Representative, it was revealed that they have not received an invitation to Resident 106's care plan meetings for several months. Review of Resident 106's progress notes revealed a care conference sign in sheet dated [DATE], indicating that nursing, social services, and the Resident Representative attended the meeting. Further review of Resident 106's clinical record failed to reveal documentation that any additional care plan meeting had been held. Review of Resident 106's minimum data set assessment (MDS - assessment tool utilized to identify a residents' physical, mental, and psychosocial needs) revealed that Resident 1 had a significant change MDS on [DATE], and quarterly MDSs on February 17, 2026, and [DATE]. During an interview on [DATE], at 1:36 PM, with the NHA, DON, and Employee 1, it was revealed that the facility was unable to provide additional information relating to Resident 106's care plan meetings. The NHA stated that there had been an issue with the previous social worker and care plan meetings were not being held. The social worker had been placed on a performance improvement plan and eventually terminated. The NHA stated that was the facility's expectation that care plan meetings be held, residents and representatives be invited, and that the required members of the interdisciplinary team be present at the meetings. Review of Resident 130's clinical record revealed diagnoses that included paraplegia (partial or complete paralysis of the lower half of the body) and person injured in unspecified motor-vehicle accident, traffic and subsequent encounter. Review of Resident 130's care plan indicated trapeze to use for repositioning in bed. Review of bed safety evaluation dated [DATE], indicated the Resident was dependent for turning and repositioning in bed. During an interview on [DATE], at 12:20 PM, with Employee 1, she confirmed that the care plan should not have trapeze in and that she would be removing it from the care plan. Her expectation is that care plans are kept up to date with resident status and care. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication and failed to appropriately monitor a resident receiving dialysis services for one of one residents reviewed (Resident 4). Findings include: Review of facility policy, titled NSG253 Dialysis: Hemodialysis (HD) - Communication and Documentation, with a last revision date of June 15, 2022, revealed, in part, Center staff will communicate with the certified dialysis facility regarding the ongoing assessment of the patient's condition by monitoring for complications before and after hemodialysis (HD) treatments received at a certified dialysis facility.1. Prior to a patient leaving the Center for HD, a licensed nurse will complete the top portion of the Hemodialysis Communication Record or the state required form and send with the patient to his/her HD facility visit.2. Following completion of the HD, the dialysis facility nurse should complete and return the form and return it or other communication to the Center with the patient.3. Upon return of the patient to the Center, a licensed nurse will:3.1 Review the certified dialysis facility communication;3.2 Evaluate/observe the patient; and3.3 Complete the post-hemodialysis treatment section on the Hemodialysis Communication Record or state required form. Review of Resident 4's clinical record revealed diagnoses that included end-stage renal disease (ESRD-condition in which a person's kidneys cease functioning on a permanent basis) and dependence on renal dialysis (an artificial process for removing waste products and excess fluids from the body that is needed when the kidneys are not functioning properly). Review of Resident 4's physician orders revealed the following orders: Dialysis Monday, Wednesday, and Friday dated January 14, 2026; Monitor Hemodialysis site for signs/symptoms of complications (e.g. bleeding, swelling, pain, drainage, odor, hardness or redness at site). Notify the physician and dialysis center immediately with any urgent problems dated October 19, 2023, and June 10, 2026; Predialysis- Please obtain VSS, check bruit and thrill and document a nurses note. Fill out dialysis sheet with vital signs and weight and send entire book with Resident to dialysis every Monday, Wednesday, and Friday dated June 10, 2026; and Upon return from dialysis ensure dialysis sheet is filled out in binder. Ensure there is Pre-During-Post Dialysis vital signs and weight in the afternoon every Monday, Wednesday, and Friday dated June 12, 2026. Review of Resident 4's dialysis communication sheets for May 2026 through July 2026 revealed:1) May 1 and 25, 2026, facility dialysis communication sheet was missing;2) May 4, 6, 8, 11, 13, 15, 22, and 27, 2026, facility dialysis communication sheet was not completed upon return to the facility; 3) May 19, 2026, facility dialysis communication sheet was not completed upon return and was attached to the dialysis center report dated May 18, 2026;4) Facility dialysis communication sheet undated was attached to the dialysis center report dated May 20, 2026, and was not completed upon return to the facility;5) Facility dialysis communication sheet dated May 28, 2026, and was attached to the dialysis center report dated May 29, 2026, and was not completed upon return to the facility;6) June 1 and 10, 2026, facility dialysis communication sheet not completed upon return and there was facility dialysis communication sheet that was not dated but was in binder with the dialysis center's report dated June 3, 2026; and7) July 13, 2026, the facility dialysis communication sheet was missing. Review of Resident 4's Medication and Treatment Administration Records for May 2026 revealed the following:1) Monitoring of hemodialysis site was noted to be blank on May 22 and 24, 2026, evening shifts; and 2) Post dialysis weights were not documented on May 15 and 29, 2026, (15 was marked with an X and the 29 said NA). Review of Resident 4's Medication and Treatment Administration Records for June 2026 revealed the following:1) Pre-dialysis weights were recorded as NA on June 15, 17, and 26, 2026;2) Monitoring of hemodialysis shunt thrill and bruit was noted to be recorded as NA June 13 and 14, 2026 evening shift; was blank on June 20, 2026, evening shift and June 26, 2026, day shift; and was recorded as N on June 26, 2026, evening shift; and3) Monitoring of hemodialysis site was blank on June 2, 5, and 20, 2026, evening shift and June 26, 2026, day shift. Review of Resident 4's Medication and Treatment Administration Records for July 2026 revealed the following:1) Pre-dialysis weights were marked NA on July 8, 13, 15, 17, and 20, 2026;2) Monitoring of hemodialysis shunt thrill and bruit was noted to be blank on July 11 and 12, 2026, evening shift and July 13, 2026, day shift; was documented as NA on July 10, 11, 12, 13, 14, and 15, 2026, night shift; July 13, 2026, evening shift; and July 16, 2026, day shift; and was recorded as N on July 14, 2026, day and evening shift, and July 15, 2026, day shift; and3) Monitoring of hemodialysis site was blank on July 11 and 12, 2026, evening shift. During a staff interview with the Nursing Home Administrator (NHA), Director of Nursing, and Employee 1 (Regional Clinical Support Nurse) on July 23, 2026, at 1:22 PM, the NHA confirmed that she would expect Resident 4's dialysis communication sheets be completed thoroughly and would expect her to be monitored appropriately according to physician orders with accurate documentation to reflect monitoring and care provided. Email communication received from Employee 1 on July 23, 2026, at 2:21 PM, indicated that she had no additional information regarding Resident 4's dialysis shunt monitoring and that education will be completed on how to properly document. 28 Pa. Code 201.18(b)(1) Management.28 Pa Code 211.5(f) Medical records.28 Pa. Code 211.10(c) Resident care policies.28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on policy review, grievance review, resident council meeting minute review, facility audit review, and resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for three out of three nursing units (East, West, and Arcadia).Findings include: Review of the facility policy, titled NSG101 Call Lights with a last review and revised date of July 15, 2026, revealed, Staff will respond to call lights and communication devices promptly. During an interview with Resident 6 on July 20, 2026, at 10:49 AM, revealed the Resident had a concern for long call bell wait times. During an interview with Resident 18 on July 20, 2026, at 11:41 AM, revealed the Resident had a concern for long call bell wait times. During an interview with Resident 138 on July 20, 2026, at 12:36 PM, revealed the Resident had a concern for long call bell wait times and sometimes waits up to 60 minutes for assistance. During an interview with Resident 2 on July 21, 2026, at 9:22 AM, revealed the Resident had a concern for long call bell wait times. Interviews conducted during a group meeting with Resident Council on July 21, 2026, at 1:30 PM, revealed that six out of six residents had concerns with long call bell wait times and staff coming in to turn their call bell off without provided care to them. Review of the facility's grievance log for the past four months revealed there have been grievances filed on April 16, 2026; May 6 and 29, 2026; and June 10, 2026, with concerns for long call bell wait times. Review of call bell audits provided by the facility revealed the following:June 13, 2026, a resident's call light was on for 29 minutes before being answered by staff.June 18, 2026, a resident's call light was on for 39 minutes before being answered by staff, with the resident waiting for someone to assist them to the bathroom.June 24, 2026, a resident's call light was on for 49 minutes until being answered by staff.June 24, 2026, a resident's call light was on for 60 minutes before being answered by staff. The resident turned their call light on at 1:14 PM wanting to get changed before bingo at 2:00 PM, and it was not answered until 2:14 PM. Review of Resident Council Meeting minutes from May 6, 2026, revealed that residents had concerns for long call bell wait times up to 1 1/2 hours. Departmental Response Action included that education will be provided to East and [NAME] Wing clinical staff, dated May 8, 2026. Review of Resident Council Meeting minutes from June 3, 2026, revealed that residents reported continued concerns regarding extended wait times to have call bells answered - from 20 minutes to 1 1/2 hours. Departmental Response Action included nursing leadership will continue to review staffing coverage, perform call bell response time audits, and continue staff education on the importance of prompt responses, dated June 4, 2026. Review of Resident Council Meeting minutes from July 9, 2026, revealed that call light response times continued to be a concern, including being out of reach on the floor and extended wait times. Departmental Response Action included staff education on call bell response times and expectations of answering them, call bell audits to determine pattern continue. Interview conducted with the Nursing Home Administrator on July 23, 2026, at 1:14 PM, revealed that she would expect call bells to be answered timely. 28 Pa. Code 211.12 (a)(c)(d)(4)(5) Nursing Services.28 Pa. Code 201.18 (e)(1)(2)(3)(6) Management

Based on clinical record reviews, observation, and resident and staff interviews, it was determined that the facility failed to ensure that residents received proper treatment and assistive devices to maintain hearing abilities for two out of four residents reviewed for hearing (Residents 34 and 115).Findings include: Review of Resident 34's clinical record revealed diagnoses that included Parkinson's Disease (long term degenerative disorder of the central nervous system that mainly affects the motor system) and cognitive communication deficit (a group of disorders that affect a person's ability to communicate, which can cause difficulty with understanding or producing language and nonverbal communication skills such as gestures and facial expressions). During an interview with Resident 34 on July 20, 2026, at 11:25 AM, Resident 34 indicated that he was experiencing hearing loss and was awaiting hearing aids. Review of Resident 34's clinical record revealed an audiology consultation completed on May 28, 2026, after he had reported to nursing staff that he was experiencing hearing loss. The consultation report indicated that Resident 34 had cerumen (wax) in both ears that was occluding his ears and that he had a moderate to severe sensorineural hearing loss in both ears. The consultation report further indicated that the wax was too hard and densely compacted for safe removal. The audiologist indicated that Resident 34 needed a softening agent, such as Debrox, and gave recommendations for the following treatment plan:1. Have patient rolled over with right ear pointed towards the ceiling.2. Place 1-3 drops of softening agent in the right ear.3. Have patient remain in this position for 15 minutes. Softening agent must remain on top of cerumen.4. Flush ear at end of the day.5. Repeat in left ear.Complete this process 1x per day for 7 days.This will either completely clear out the patient's ear completely or soften the wax enough to allow for removal by me at the next facility visit. The consultation report failed to reveal that Resident 34's primary physician had reviewed the report or recommendations. Review of Resident 34's clinical record failed to reveal that Resident 34 had received the recommended treatment by the audiologist for his hearing loss. During a staff interview with the Nursing Home Administrator (NHA), Director of Nursing (DON), and Employee 1 (Regional Clinical Support Nurse) on July 23, 2026, at 10:33 AM, Employee 1 confirmed that the recommendation for Debrox for Resident 34 was never implemented. She said that Resident 34's physician had been contacted and that the order had now been implemented. During a final staff interview with the NHA, DON, and Employee 1 on July 23, 2026, at 1:25 PM, the DON confirmed that she would expect the audiologist recommendation for Debrox to have been reviewed by Resident 34's physician and treatment implemented in May when originally recommended for Resident 34's hearing loss. Review of Resident 115's clinical record revealed diagnosis that included hypertension (high blood pressure) and chronic kidney disease (a condition where the kidneys are damaged over time, affecting their ability to perform essential functions). During an interview with Resident 115 on July 20, 2026, at 9:47 AM, she revealed that she was very hard of hearing and had difficulty communicating because of it. Resident 115 revealed that she had hearing aids but left them in the dining room. During an observation of Resident 115 on July 20, 2026, at 9:48 AM, revealed she did not have any hearing aids or amplifiers in her ears during the conversation. Review of Resident 115's Quarterly MDS (Minimum Data Set is part of the federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated May 11, 2026, revealed Section B0200. Hearing, ability to hear was marked 3. Highly impaired, and section B0300. Hearing Aid, Hearing aid or other hearing appliance used was marked 1. Yes, indicating the Resident had a hearing device in use. Review of Resident 115's care plan revealed she has impaired communication as evidenced by impaired hearing, with an initiation date of October 21, 2024. Further review of the care plan failed to include any intervention or documentation indicating the use of a hearing device. Review of Resident 115's physician orders failed to include any order for a hearing device. Review of Resident 115's clinical record revealed that she had an audiology consult on May 28, 2026, where the Resident reported she had hearing loss. Further review of the consult revealed the Resident had moderate to severe sensorineural hearing loss (permanent type of hearing loss caused by damage to the inner ear or auditory nerve, affecting the ability to convert sound waves into signals the brain can interpret) and would benefit from hearing aids. During a staff interview with the NHA and Employee 1 on July 23, 2026, at 1:17 PM, revealed that Resident 115 had hearing amplifiers that the nurse puts in and takes out, and that they would expect the Resident to have an order for them as well as them to be care planned. 28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy reviews, clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that it was free from a medication error rate of five percent or greater based on four medication errors out of 25 opportunities.Findings include: Review of facility policy, titled Medication Administration Enteral Tubes, dated January 2025, revealed, in part, Crushed medications are not mixed together. The powder from each medication is mixed with water before administration. The standard of practice is that crushed medications should not be combined and given all at once via feeding tube. Each medication is given separately to avoid interaction and clumping. The enteral tubing is flushed with water between each medication to avoid physical interaction of the medications. Review of facility policy, titled Medication Administration General Guidelines, dated January 2025, revealed, in part, Medications are administered in accordance with written orders of the prescriber. Observation of Employee 2 (Licensed Practical Nurse) on July 21, 2026, between 8:50 AM and 9:02 AM, revealed that Employee 2 placed both of Resident 1's ordered morning medications into a single plastic pouch, crushed them, and then administered them to Resident 1 utilizing his enteral gastrostomy tube(G-tube: a flexible feeding tube placed through the abdominal wall and into the stomach which allows nutrition to be placed directly into the stomach). Observation of Employee 2 on July 21, 2026, between 9:03 AM and 9:15 AM, revealed that Employee 2 failed to administer Resident 38 the ordered dose of one medication. Resident 38's physician order was to administer MiraLAX 17 grams/one capful every day in 4-8 ounces of water, juice, soda, coffee, or tea for constipation. Directions indicated to stir until dissolved and then administer immediately. Employee 2 was observed pouring the powder into the cap and measuring a full dose. She then took a plastic spoon and removed one spoonful. She proceeded to pour the rest of the dose back into the bottle. Employee 2 indicated that she only gives Resident 38 a spoonful of the medication because if she gave her the full dose she would be pooping on herself. In addition, the solution was observed to be clear when she administered it to Resident 38 instead of cloudy, which would indicate that the powder was not dissolved completely. Observation of Employee 3 (Licensed Practical Nurse) on July 22, 2026, between 8:40 AM and 8:58 AM, revealed that when she administered Resident 67 her morning medications, Resident 67 reported pain in her left arm and hand. Employee 3 returned to the medication cart, reviewed Resident 67's physician orders, and took Resident 38's temperature which was 97.7 Fahrenheit (F). Employee 3 then retrieved Tylenol 325 milligrams two tablets from the medication cart and administered them to Resident 67. Review of Resident 67's physician orders revealed orders for Tylenol Tablet 325 milligrams give two tablets by mouth every four hours as needed for elevated temperature greater than 101 degrees F, not to exceed three grams (3000 milligrams) in 24 hours, dated November 12, 2022; and Tylenol Extra Strength 500 milligrams give two tablets three times a day for arthritis pain (an ordered total of 3 grams per 24-hour period). During a staff interview with Employee 3 on July 23, 2026, at 9:08 AM, she confirmed that she administered the Tylenol to Resident 67 for pain even though the order indicated that it was ordered for a fever. Employee 3 said she must have overlooked that in Resident 67's order since most all residents generally have Tylenol ordered as needed for pain. During medication administration observations there were 4 errors and 25 opportunities, resulting in a medication error rate of 16%. During a staff interview with the Nursing Home Administrator (NHA), Director of Nursing (DON), and Employee 1 (Regional Clinical Support Nurse) on July 23, 2026, at 1:34 PM, the NHA and DON confirmed that they would expect nursing staff to administer medications as ordered and to follow appropriate administration guidelines. 28 Pa. Code 211.9(a)(1) Pharmacy services.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to properly label medication vials, failed to dispose of medications upon a resident's discharge, and failed to monitor medication refrigerator temperatures to ensure refrigerated medications are stored at an acceptable temperature in two of two medication rooms observed (West Hall and Arcadia Unit); and failed to discard medications with illegible manufacturer expiration dates in one of three medication carts observed (East Wing D Hall).Findings include: Review of facility policy, titled Medication Administration Enteral Tubes, dated January 2025, revealed, in part, 17. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. No medications are kept on top of the cart. Review of facility policy, titled Storage of Medications, dated February 2026, revealed, in part, Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. 11. Medications requiring 'refrigeration' or 'temperatures between 2 C (36 F) and 8 C (46 F)' are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage 'in a cool place' may be refrigerated unless otherwise directed on the label as 'cool' temperatures are those between 8 C (46 F) and 15 C (59 F). A temperature log or tracking mechanism is maintained to verify that temperature has remained within accepted limits. The temperature of any refrigerator that stores vaccines should be monitored and recorded twice daily. 14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal. During a medication pass observation with Employee 2 on July 21, 2026, between 9:03 AM and 9:15 AM, for Resident 38 revealed that Employee 2 had prepared a dose of miraLAX in a plastic cup and placed other ordered pills into a plastic pill cup when she realized she did not have one of Resident 38's medications. Employee 2 indicated that she needed to go to the medication room to retrieve a new bottle. She placed the cup of pills inside the medication cart and locked the cart. She then took a tissue from the tissue box on her medication cart and placed over the top of the plastic cup containing the miraLAX. She tucked the tissue along the inside of the cup and left it sitting on her cart while she went to the medication room. After retrieving the additional medication for the medication room, she returned to her cart, retrieved the cup of pills from inside the cart, placed the additional medication in the cart, removed the tissue from the top of the miraLAX and proceeded into Resident 38's room and administered the medications. Employee 2 failed to secure medications properly while she was away from her medication cart. Observation of the [NAME] Wing Medication Room on July 21, 2026, at 1:00 PM, with Employee 14 (Licensed Practical Nurse) revealed two boxes of opened vials of octreotide acetate (a man-made protein that is similar to a hormone in the body called somatostatin. Octreotide lowers many substances in the body such as insulin and glucagon [involved in regulating blood sugar], growth hormone, and chemicals that affect digestion) with no opened date indicated. The labeling indicated that the medication was to be discarded 14 days after opening. Employee 14 indicated that the resident the medication was ordered for had been discharged for a while. Review of the clinical record revealed the Resident had been discharged from the facility on April 2, 2026. Employee 14 indicated that she would discard the vials. Observation of the Arcadia Unit Medication Room on July 21, 2026, at 1:23 PM, with Employee 16 (Licensed Practical Nurse) revealed an opened bottle of tuberculin skin test solution with no opened date indicated on the vial or box. Employee 16 confirmed that there was no open date indicated on the vial and she was observed discarding the vial into a sharps container. During a medication pass observation with Employee 17 (Licensed Practical Nurse) on July 22, 2026, between 9:15 AM and 9:30 AM, for Resident 99, it was noted that a house stock bottle of aspirin 81 milligrams was dated with an open date of July 17, 2026, but the manufacturer expiration date was illegible. Employee 17 confirmed that the date was illegible but administered one tablet from the bottle to Resident 99 and then placed the bottle in his pocket and said he would discard it and get a new bottle for the medication cart. Review of the Temperature Log for the [NAME] Wing medication refrigerator dated July 2026 in the medication room revealed that temperatures were to be checked and recorded twice a day. The review also revealed that the medication refrigerator temperatures were not recorded at all on July 1, 2, 5, 18, and 19; and on all other dates were only recorded once in the AM slot. Review of the Temperature Log for the [NAME] Wing Medication Room for June 2026, revealed that the medication refrigerator temperatures were not recorded at all on June 2, 6, 7, 12, and 16; and on all other dates temperatures were only recorded once in the AM slot. Review of the Temperature Log for the [NAME] Wing Medication Room for May 2026, revealed that the medication refrigerator temperatures were not recorded at all on May 1, 5, 9, 10, 19, and 29; and on all other dates temperatures were only recorded once in the AM slot. Review of the Temperature Log for the Arcadia Unit Medication Room for July 2026, revealed that the medication refrigerator temperatures were only recorded once on June 5 and 17 in the AM slot and once on June 18 in the PM slot. Review of the Temperature Log for the Arcadia Unit Medication Room for June 2026, revealed that the medication refrigerator temperatures were only recorded once on June 20 in the AM slot and once on June 21 in the PM slot. Review of the Temperature Log for the Arcadia Unit Medication Room for May 2026, revealed that the medication refrigerator temperatures were not recorded at all on May 9 and 24; were recorded once on May 1, 8, 15, 18, and 23 in the AM slot; and recorded once on May 2, 10, and 19 in the PM slot. During a staff interview with the Nursing Home Administrator, Director of Nursing, and Employee 1 (Regional Clinical Support Nurse) on July 22, 2026, at 1:38 PM, Employee 1 and the NHA acknowledged that they would expect medications to be stored and discarded properly. The NHA confirmed that medication refrigerator temperatures should be taken and recorded twice a day. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.9(a)(1)(j)(1) Pharmacy services.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policy reviews, clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure staff implemented appropriate infection control guidelines during medication administration for two of six residents observed (Residents 1 and 79), during wound care for one of one resident observed (Resident 1), and failed to implement appropriate infection control precautions per facility policy and physician orders for one of 29 residents reviewed (Resident 65).Findings include: Review of the facility policy, titled Medication Administration General Guidelines, dated January 2025, revealed, in part, Hands are washed with soap and water and gloves applied before administration of .ophthalmic [eye] .enteral [feeding tube] medications. Hands are washed with soap and water again after administration and with any resident contact. Antimicrobial hand sanitizer may be used in place of soap and water as allowed per state nursing regulations and facility policy. Review of facility policy, titled Medication Administration Enteral Tubes, dated January 2025, revealed, in part, 1. Perform hand hygiene. 2. Prepare medications for administration. 4. Put on gloves. 18. Clean feeding syringe and return to bedside stand. Remove gloves perform hand hygiene. Review of the facility policy, titled IC203 Hand Hygiene, with a last review date of March 20, 2026, revealed, in part, The use of gloves does not replace hand hygiene. If a task requires gloves, perform hand hygiene before donning gloves and immediately after removing gloves. 2. Hand hygiene techniques: 2.1 To wash hands with soap and water, 2.2 To decontaminate hands with alcohol-based rub. Review of facility policy, titled Enhanced Barrier Precautions, with a last review date of May 15, 2026, revealed, in part, 1. Post the appropriate Enhanced Barrier Precautions (EBP) sign on the patient's room door. 3. Follow the Centers for Disease Control and Prevention (CDC) Guidance: Enhanced Barrier applies to all patients with any of the following: Infection or colonization with a targeted MDRO when contact precautions do not apply, chronic wounds and/or indwelling medical devices (e.g. central line, urinary catheter, enteral feeding tube. PPE should be used during these high contact patient care activities: dressing; bathing/showering; transferring; providing hygiene; changing linens; changing briefs or assisting with toileting; device care or use central line, urinary catheter, enteral feeding; and wound care-any skin opening requiring a dressing. Required PPE: gown and gloves prior to high contact care activity. 4. Personal Protective Equipment (PPE) should be readily accessible and located outside of the patient's room. Review of Resident 1's clinical record revealed diagnoses that included severe protein-calorie malnutrition (a severe nutritional deficiency caused by inadequate or absorption of protein and energy-calories), cancer of the tongue, and presence of a gastrostomy tube (G-tube: a flexible feeding tube placed through the abdominal wall and into the stomach, which allows nutrition to be placed directly into the stomach). Review of Resident 1's physician orders revealed an order for Enhanced Barrier Precautions related to feeding tube and indwelling urinary catheter dated June 18, 2026. Observation of Resident 1's room on July 21, 2026, at 8:48 AM, revealed that signage was posted beside his door indicating that he was on Enhanced Barrier Precautions. The signage indicated that gown and gloves should be worn when providing high contact care with the specific examples given as were indicated in the facility policy. A cart containing all necessary PPE was also present just to the left of his doorway in the hall directly under the EBP sign. During a medication pass observation of Employee 2 (Licensed Practical Nurse) for Resident 1 on July 21, 2026, between 8:50 AM and 9:02 AM, revealed that Employee 2 failed to perform hand hygiene prior to preparing his medications. Employee 2 was observed to touch the inside of the medication cup with her finger. Employee 2 then placed Resident 1's ordered dose of Tylenol into that cup. Employee 2 realized she did not have Resident 1's other ordered medication available in the cart. She placed the cup with the Tylenol in the top drawer of the medication cart and went to the nursing station to get assistance with retrieving Resident 1's other medication from the emergency stock. Employee 2 was observed standing at the desk while Employee 14 (Licensed Practical Nurse) was retrieving the medication. Employee 14 then summoned Employee 2 into the medication room to witness the withdrawal. After obtaining Resident 1's medication, she returned to the medication cart. Employee 2 failed to perform any hand hygiene when she returned to the cart. She popped open the medication package and placed the pill into her hand and then dropped it into the cup with the Tylenol. Employee 2 then proceeded to get a plastic pill pouch to crush the medications. Employee 2 was observed to touch the inside of the packet with her fingers to open it and she then placed the medications into the packet and crushed them. Employee 2 then entered Resident 1's room to administer his medications. Employee 2 failed to perform hand hygiene and don gown and gloves prior to entering Resident 1's room. After entering the room, she donned gloves and proceeded to administer Resident 1's medications through his gastrostomy tube. After administering Resident 1's medications, she removed her gloves and went into bathroom and rinsed the syringe. She returned to the bedside and placed the syringe in a graduate dated July 19, 2026. Employee 2 failed to perform any hand hygiene prior to leaving Resident 1's room. Employee 2 proceeded to her medication cart, logged into the computer, and began documenting Resident 1's medication administration. During a medication pass observation with Employee 2 on July 21, 2026, between 9:03 AM and 9:15 AM, for Resident 38 revealed that Employee 2 had prepared a dose of miraLAX in a plastic cup and placed other ordered pills into a plastic pill cup when she realized she did not have one of Resident 38's medications. Employee 2 indicated that she needed to go to the medication room to retrieve a new bottle. Employee 2 placed the cup of pills inside the medication cart and locked the cart. Employee 2 then took a tissue from the tissue box on her medication cart and placed over the top of the plastic cup containing the miraLAX. She tucked the tissue along the inside of the cup and left it sitting on her cart while she went to the medication room. After retrieving the additional medication from the medication room, she returned to her cart, retrieved the cup of pills from inside the cart, placed the additional medication in the cup, and placed the bottle in the drawer. Employee 2 then removed the tissue from the top of the miraLAX and proceeded into Resident 38's room and administered the medications. Employee 2 failed to perform hand hygiene upon returning to her medication cart. Employee 2 unlocked the cart, retrieved the cup of pills, added the additional medication, removed the tissue from the top of the miraLAX and entered Resident 38's room where she was observed to administer Resident 38 her medications. During a hallway observation on July 21, 2026, at 9:38 AM, Employee 2 was observed to administer medications and eye drops to Resident 79 without performing hand hygiene before or after. Employee 2 was also not observed to wear gloves while administering the eye drops. During a staff interview with the Nursing Home Administrator (NHA), Director of Nursing (DON), and Employee 1 (Regional Clinical Support Nurse) on July 21, 2026, at 9:30 AM, observations of Employee 2 were shared. Employee 1 indicated that Employee 2 would be sent home immediately. During a final staff interview with the NHA, DON, and Employee 1 on July 23, 2026, at 1:34 PM, the NHA and DON confirmed that they would expect nurses to follow appropriate infection control practices during medication administration. Further review of Resident 1's clinical record revealed that he had an unstageable pressure ulcer on his left hip (a wound where the true depth cannot be determined because it is covered by slough). Review of Resident 1's physician orders revealed an order to cleanse his left hip pressure ulcer with wound cleanser solution, apply Medihoney, cover with calcium alginate and foam dressing daily and PRN (as needed) dated July 23, 2026. Observation of wound care on Resident 1 on July 23, 2026, at 10:37 AM, revealed Employee 14 (Licensed Practical Nurse) donned and doffed gloves during the treatment and did not perform hand hygiene after every glove changes on four occurrences. During an interview with Employee 14 on July 23, 2026, at 11:24 AM, she confirmed that she had changed her gloves multiple times during the dressing change without performing hand hygiene with every glove change. During a staff interview with the NHA, DON, and Employee 1 on July 23, 2026, at 1:50 PM, Employee 1 revealed their expectation is hand hygiene protocol would be followed. Review of Resident 65's clinical record revealed diagnoses that included diabetes (a chronic condition that occurs when the body cannot effectively use insulin, a hormone that regulates blood sugar levels) and anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). Observation of Resident 65's room on July 21, 2026, at 10:22 AM, revealed there was no EBP signage posted on or beside her door and there was no PPE equipment outside of her room. Electronic communication received from Employee 1 on July 21, 2026, at 3:21 PM, revealed that Resident 65 was on EBP for a wound infection. Review of Resident 65's care plan revealed that she is at risk for skin breakdown: right lateral foot: diabetic foot ulcer left plantar foot: diabetic foot ulcer; with an intervention for enhanced barrier precaution in place until wound is healed, date initiated on July 7, 2026. Observation of Resident 65's room on July 22, 2026, at 9:54 AM, revealed she has an EBP sign posted beside her door with no PPE observed outside of her room. Review of Resident 65's physician's orders revealed an order for infection precautions - enhances barrier - wound, with an active date of July 21, 2026. During an interview with the NHA and Employee 1 on July 23, 2026, at 1:15 PM, revealed that the PPE for Resident 65's room was located inside her bathroom due to a resident being injured from roaming the hallway with PPE outside of a resident's room previously. The NHA revealed that she would have expected there to be EBP signage outside of Resident 65's room. 28 Pa, Code 201.14(a)Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.10(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on facility policy review, review of personnel files, and staff interviews, it was determined the facility failed to ensure abuse training upon hire was completed for two of five employees reviewed (Employees 7 and 13).Findings include: Review of facility policy, titled OPS300 Abuse Prohibition, with a last review date of November 14, 2025, revealed, in part, The Center will implement an abuse prohibition program through the following: Training of employees (both new employees and ongoing training for all employees); Training and reporting obligations will be provided to all employees - through orientation, Code of Conduct training, and a minimum of annually - and will include: 4.1 the Abuse Prohibition policy and 4.8 dementia management and patient abuse prevention. Review of personnel file for Employee 7 (Licensed Practical Nurse) revealed that her date of hire was April 28, 2026. Further review of the personnel file failed to reveal any documentation Employee 7 had completed any new employee orientation to include training on the facility abuse prohibition policy. Review of personnel file for Employee 13 (Nurse Aide) revealed that his date of hire was June 16, 2026. Further review of the personnel file failed to reveal any documentation that Employee 13 had completed any new employee orientation to include training on the facility abuse prohibition policy. During a staff interview with the Nursing Home Administrator (NHA), Director of Nursing, and Employee 1 (Regional Clinical Support Nurse) on July 22, 2026, at 1:44 PM, Employee 1 confirmed that abuse prohibition training should be completed upon hire as part of the facility orientation program and that they had no additional information to provide. The NHA indicated that the facility had identified issues in their hiring process and have implemented a Performance Improvement Plan. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 201.19(6)(7) Personnel policies and procedures.28 Pa. Code 201.20(a)(b)(d) Staff development.

Based on facility policy review, clinical record reviews, observations, and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards during medication administration for four of six residents observed (Residents 1, 38, and 99) and failed to ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for one of two resident's reviewed for respiratory care (Resident 2).Findings include: Review of facility policy, titled Medication Administration Enteral Tubes, dated [DATE], revealed, in part, Crushed medications are not mixed together. The powder from each medication is mixed with water before administration. The standard of practice is that crushed medications should not be combined and given all at once via feeding tube. Each medication is given separately to avoid interaction and clumping. The enteral tubing is flushed with water between each medication to avoid physical interaction of the medications. Verify tube placement per facility protocol. Check gastric content for residual feeding. Return residual volumes to the stomach. Report any residual above 100 milliliters. Review of facility policy, titled Medication Administration General Guidelines, dated [DATE], revealed, in part, 1. Medications are administered in accordance with written orders of the prescriber. If a dose seems excessive considering the resident's age and condition, or a medication order seems unrelated to the resident's current diagnosis or condition, the nurse calls the provider pharmacy for clarification prior to the administration of the medication. If necessary, the nurse contacts the prescriber for clarification. 8. Check expiration date on package/container. No expired medication shall be administered to a resident. a. Drugs dispensed in the manufacturer's original container will be labeled with the manufacturer's expiration date. Review of facility policy, titled Bi-level Positive Airway Pressure (BiPAP)/Continuous Positive Airway Pressure (CPAP) last revised [DATE], read, in part, Bi-level Positive Airway Pressure (BiPAP) and/or Continuous Positive Airway Pressure (CPAP) is set up and monitored by a licensed nurse or Respiratory Therapist (RT) with a physician's/advanced practice provider's (APP) order. Approved ventilators must be set up and settings maintained by a RT, but may be monitored by a licensed nurse. Review of Resident 1's clinical record revealed diagnoses that included severe protein-calorie malnutrition (a severe nutritional deficiency caused by inadequate or absorption of protein and energy-calories), cancer of the tongue, and presence of a gastrostomy tube (G-tube: a flexible feeding tube placed through the abdominal wall and into the stomach which allows nutrition to be placed directly into the stomach). Review of Resident 1's physician orders revealed orders for Enteral Feed: Check for gastric residual volume (GRV) every shift prior to medication administration via tube. If GRV is greater than 250 milliliters (ml) or over, hold medication, notify physician, and document amount in mL; and Enteral Feed: Flush tube with 30 ml of water before and after each medication pass every shift for enteral feed or 30 ml as ordered. Flush tube with at least 15 ml of water between each medication. Auscultate for presence of Bowel Sounds prior to medication administration via tube, dated [DATE]. During a medication pass observation of Employee 2 (Licensed Practical Nurse) for Resident 1 on [DATE], between 8:50 AM and 9:02 AM, revealed that Employee 2 placed both of Resident 1's ordered morning medications into a single plastic pouch and crushed them and entered his room. She added tap water to the crushed medications in Resident 1's bathroom. Employee 2 then applied gloves without performing hand hygiene. She disconnected the tube feeding bag in preparation to administer medications. She opened and attached a new syringe to Resident 1's g-tube after removing the plunger from the syringe. Employee 2 then poured approximately 20 ml of water into the syringe and then added the plunger back to syringe and pushed the water through. She then disconnected the syringe and removed the plunger. She reconnected the syringe and poured the water containing Resident 1's medications into the tube and allowed the medications to flow through by gravity. She then poured in approximately 20 ml of water and allowed it to flow through by gravity. She then disconnected the syringe and replaced the plunger into the syringe. She removed her gloves and then went into bathroom and rinsed the syringe. She returned to the bedside and placed the syringe in a graduate dated [DATE]. Employee 2 failed to perform hand hygiene prior to donning gloves for medication administration or after medication administration. Employee 2 failed to clean the g-tube port before attaching the syringe to the port. Employee 2 failed to verify placement or check for residual as per Resident 1's physician orders. Employee 2 failed to date the new syringe she was observed to open and, although, she rinsed the syringe after using it, she placed in a graduate sitting on Resident 1's bedside stand dated [DATE]. Review of Resident 1's [DATE] Medication Administration Record revealed that Employee 2 documented that Resident 1's GRV was 45 ml, that she flushed the g-tube with a total amount of 60 ml and that she auscultated Resident 1's bowel sounds prior to medication administration. Review of Resident 38's clinical record revealed diagnoses that included constipation and hypertension (high blood pressure). Review of Resident 38's physician order's revealed an order for MiraLAX 17 grams/one capful every day in 4-8 ounces of water, juice, soda, coffee, or tea for constipation. Directions indicated to stir until dissolved and then administer immediately, dated [DATE]. During a medication pass observation of Employee 2 on [DATE], between 9:03 AM and 9:15 AM, revealed that Employee 2 failed to administer Resident 38 the ordered dose of miraLAX. Employee 2 was observed pouring the powder into the cap and measuring a full dose. She then took a plastic spoon and removed one spoonful. She proceeded to pour the rest of the dose back into the bottle. Employee 2 indicated that she only gives Resident 38 a spoonful of the medication because if she gave her the full dose she would be pooping on herself. Review of Employee 2's documentation of the miraLAX revealed that Resident 38 was documented as receiving her ordered dose. Employee 2 failed to indicate that only a partial dose was administered. During a staff interview with the Nursing Home Administrator (NHA), Director of Nursing (DON), and Employee 1 (Regional Clinical Support Nurse) on [DATE], at 9:30 AM, observations of Employee 2 with Residents 1 and 38 were shared. Employee 1 indicated that Employee 2 would be sent home immediately and that additional education would be provided. Review of Resident 99's clinical record revealed diagnoses that included hypertension and hyperlipidemia (abnormally high levels of fats). Review of Resident 99's physician orders revealed an order for Aspirin tablet chewable 81 milligrams give one tablet one time a day for blood clot prevention, dated [DATE]. During a medication pass observation with Employee 17 (Licensed Practical Nurse) on [DATE], between 9:15 AM and 9:30 AM, for Resident 99, it was noted that a house stock bottle of aspirin 81 milligrams was dated with an open date of [DATE], but the manufacturer expiration date was illegible. Employee 17 confirmed that the date was illegible but administered one tablet from the bottle to Resident 99 and then placed the bottle in his pocket and said he would discard it and get a new bottle for the medication cart later. During a final staff interview with Employee 1 in the presence of the NHA and DON on [DATE], at 1:34 PM, regarding Employees' 1, 13, and 17 actions during medication pass observations, the NHA and DON confirmed that they would expect all nurses to follow physician orders and practice appropriate professional standards. Review of Resident 2's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD an ongoing lung condition caused by damage to the lungs), sleep apnea (a potentially serious condition that causes breathing to stop and start multiple times during sleep), and hypertension. Review of Resident 2's physician orders revealed an order for CPAP (a medical therapy that helps people with sleep apnea breathe more easily during sleep by delivering continuous air pressure through a mask) AUTO: Pressure Settings: Min/Max 8/25, apply at HS (bedtime), remove in AM, with a start date of [DATE]. Review of Resident 2's comprehensive care plan revealed a focus area [Resident 2] has impaired respiratory function related to COPD, sleep apnea, with an intervention for Give oxygen therapy as ordered by the physician, created on February 4, 2024. During an interview with Resident 2 on [DATE], at 9:25 AM, he revealed he wears a CPAP in the evening. Review of Resident 2's [DATE] TAR (Medication Administration Record- documentation for medication/treatment administered or monitored) revealed under the section to document removal of his CPAP in the morning, it was marked NN for Nurses Note on [DATE]-11, 13-15, 17-19, 22, 25, and 27-29, 2026. Review of Resident 2's [DATE] TAR revealed under the section to document removal of his CPAP in the morning, it was marked NN on [DATE], 6-9, 11-13, 15-17, and 20-22, 2026. Review of Nurses' Notes linked to the TAR for the aforementioned CPAP treatments in [DATE] and [DATE] stated either Did not wear overnight or did not use overnight. Review of Resident 2's clinical record revealed no education was noted to be provided to the Resident regarding CPAP use. Review of Resident 2's comprehensive care plan failed to note that he refuses his CPAP or takes it off himself throughout the night. During an interview with the NHA, DON, and Employee 1 on [DATE], at 2:18 PM, Employee 1 revealed the staff are documenting he did not wear it, but it is actually that he wore it and self-removed it at some point throughout the night. She further revealed that the respiratory therapist has provided education on proper CPAP use but she did not document it, and that there should be documented education regarding proper CPAP use and staff should document that he removed it, not that he didn't wear it. 28 Pa, Code 201.14(a)Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.10(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 29 residents reviewed (Residents 7, 47, and 56).Findings include: Review of Resident 7's clinical record revealed diagnoses that included schizoaffective disorder (mental health condition that includes symptoms of both schizophrenia and mood disorders) and bipolar disorder (unusual shifts in mood, ranging from extreme highs to lows). Review of Resident 7's physician orders revealed the following orders: risperidone (antipsychotic medication) 0.5 mg (milligrams) in the morning for bipolar disorder and bupropion HCL XR (antidepressant medication) 300 mg one time a day for depression, and mirtazapine (antidepressant medication) 7.5 mg at bedtime for antidepressant. Review of Resident 7's significant change minimum data sets (MDS - assessment tool utilized to identify a residents' physical, mental, and psychosocial needs) dated May 15, 2026, indicated a GDR (gradual dose reduction) had not been documented as contraindicated by Resident 7's physician. Review of Resident 7's psychiatry note dated April 16, 2026, revealed a GDR note indicating that on January 21, 2026, a GDR was not clinically advisable due to high risk for relapse of target symptoms related to diagnoses of depression, bipolar disorder, and schizoaffective disorder. During an interview on July 23, 2026, at 2:14 PM, with the Nursing Home Administrator (NHA), the Director of Nursing (DON), and Employee 1, it was revealed that Resident 7's aforementioned MDS was incorrect and it was the expectation of the facility that MDS be coded correctly. Review of Resident 47's clinical record revealed diagnoses that included parkinsonism (a set of movement symptoms - slowness, rigidity, and tremor - that can occur in Parkinson's disease and other conditions), low back pain, and difficulty in walking. Review of Resident 47's admission and 5 Day MDS assessments (Minimum Data Set - an assessment tool to review all care areas specific to the resident's physical, mental or psychosocial needs) with ARD (Assessment Reference Date- last day of the assessment period) revealed it was marked no for Received non-medication intervention for pain? Review of Resident 47's July 2026 MAR (Medication Administration Record- documentation for medication/treatment administered or monitored) revealed she was documented as receiving repositioning as a non-pharmalogical intervention for pain on July 18, 2026. During an interview with Employee 12 (MDS Coordinator) on July 23, 2026, at 11:01 AM, she revealed Resident 47's aforementioned MDS assessments are incorrect, as she should have been marked yes for having non-pharmalogical interventions for pain during the ARD lookback period. During an interview with the DON on July 23, 2026, at 1:02 PM, she revealed she would expect MDS assessments to be coded accurately. Review of Resident 56's clinical record revealed diagnoses that included hypertension (high blood pressure) and dementia (the loss of cognitive functioning that interferes with a person's daily life and activities). Review of Resident 56's physician orders revealed an order for wander guard/wander elopement device due to poor safety awareness, with an original start date of April 18, 2025. Review of Resident 56's care plan revealed the Resident was an elopement risk, with an intervention for a wander guard, which was initiated on April 16, 2025. Review of Resident 56's Quarterly MDS dated [DATE], revealed that Section P0200. Alarms, E. Wander/elopement alarm was marked 0. Not used, signifying that Resident 56 did not have a wander guard in use. During an interview with the NHA on July 23, 2026, at 1:19 PM, she revealed that Resident 56's MDS was incorrect and should have been documented as him having a wander guard used daily. 28 Pa. Code 211.5(f) Medical records.28 Pa Code 211.12 (d)(3)(5) Nursing Services.

Based on clinical record review and staff interviews, it was determined the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months for one of 29 residents reviewed (Resident 6). Findings include: Review of Resident 6's clinical record revealed diagnoses that included displaced intertrochanteric fracture of the right femur, initial encounter for a closed fracture, muscle weakness, and low back pain. Review of Resident 6's clinical record revealed she had a Quarterly MDS (Minimum Data Set- assessment tool utilized to identify residents' physical, mental and psychosocial needs) Assessment on March 10, 2026, and her next assessment was an Annual MDS Assessment completed on July 16, 2026. During an interview with Employee 12 (MDS Coordinator) on July 22, 2026, at 2:41 PM, she revealed Resident 6 should have had an assessment completed every 3 months. During an interview with the Director of Nursing on July 23, 2026, at 1:03 PM, she revealed she would expect MDS assessments to be completed at least quarterly. 28 Pa. Code 211.5(d)(3)(5) Nursing services

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to ensure the residents' right to a clean, comfortable, and homelike environment, including housekeeping and maintenance services, to maintain a sanitary, orderly and comfortable interior for three of 29 residents reviewed (Residents 6, 34, and 67).Findings include: Review of facility policy, titled OPS200 Safe and Homelike Environment, with a last revised date of November 14, 2025, revealed, in part, The resident/patient has the right to a safe, clean, comfortable, and homelike environment that de-emphasizes the institutional character of the setting. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Observation in Resident 6's room on July 20, 2026, at 10:40 AM; July 21, 2026, at 2:01 PM; and July 22, 2026, at 9:52 AM, revealed her wallpaper was torn and there were two large black scratch marks along the wall. During a staff interview with the Nursing Home Administrator (NHA), the Director of Nursing (DON), and the Employee 1 (Regional Clinical Support Nurse) on July 22, 2026, at 2:09 PM, the NHA revealed the concerns in Resident 6's room would be addressed and she would expect residents to have a clean, comfortable and homelike environment. Observation of Resident 34's room on July 20, 2026, at 11:29 AM, revealed that his trash can had an incontinent brief smeared with a brown substance, and that the trash can was overflowing onto the floor. In addition, there was a potato chip bag visible under his nightstand, an empty juice container on floor, a light brown colored spill stain down the wall at the foot of his bed brown spill stain on wall, a brown colored substance on his bed linens, and his privacy curtain was noted to have brown smears in approximately three different areas. Observation of Resident 34's room on July 20, 2026, at 12:11 PM, revealed a housekeeper exiting his room. Immediate observation of his room revealed food debris particles on the floor, the chip bag was still visible under the nightstand on the floor, and the stains were still present on the wall and the privacy curtain. All his bed linens and been stripped from the bed and the trash can had been emptied. Observation of Resident 34's room on July 21, 2026, at 1:18 PM, revealed the stains were still present on the wall and privacy curtain and that the chip bag was still visible under the nightstand on the floor. In addition, there was a brown smear and a yellow discoloration on his bedspread. Observation of Resident 34's room on July 22, 2026, at 12:51 PM, revealed the stains were still present on the wall and privacy curtain, and that the chip bag was still visible under the nightstand on the floor. During a staff interview with the NHA, the DON, and the Employee 1 on July 22, 2026, at 1:31 PM, Employee 1 confirmed that she would expect resident rooms to be cleaned thoroughly to include walls. Employee 1 also indicated that she would expect staff to change privacy curtains when they are noted to be soiled. Observation of Resident 67's room on July 22, 2026, at 8:40 AM, revealed that Resident 67's mattress was not on the bed correctly. The mattress was noted to have the foot end positioned at the head of the bed. There were four more observations throughout the day on July 22, 2026, at 8:50 AM, 12:45 AM, 12:40 PM and 2:30 PM, that revealed the mattress remained on Resident 67's bed with the foot end at the head of the bed. Observation of Resident 67's room on July 23, 2026, at 8:46 AM, while accompanied by the NHA, revealed the foot end of the mattress was at the head of the bed. During an interview with the NHA on July 23, 2026, at 8:46 AM, she confirmed the foot end of the mattress should be at the foot end of the bed. The NHA revealed there was no reason Resident 67's mattress should be placed on her bed positioned this way. The NHA revealed her expectation is that the staff should note the mattress positioning during bed linen changes and correct the situation at once. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1)(3)(e)(2.1) Management.

Based on facility policy review, clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to determine a resident's right to self-administer medications was clinically appropriate for one of one resident reviewed (Resident 1).Findings include: Facility policy, titled Medication Administration General Guideline, dated January 2025, read, in part, 15. Residents are allowed to self-administer medications when specifically authorized by the prescriber, the nursing care center's Interdisciplinary Team (IDT), and in accordance with procedures for self-administration of medications and state regulations. Facility policy, titled Medications: Self-administration, last revised October 15, 2024, read, in part, Patients who request to self-administer medications will be evaluated for safe and clinically appropriate capability based on the patient's functionality and health condition. If it is determined that the patient is able to self-administer: A physician/advanced practice provider (APP) order is required. Self-administration and medication self-storage must be care planned. When applicable, patient must be provided with a secure, locked area to maintain medications. Patient must be instructed in self-administration. Evaluation of capability must be performed initially, quarterly, and with any significant change in condition. Review of Resident 1's clinical record revealed diagnoses that included severe protein-calorie malnutrition (inadequate intake of protein and calories) and malignant neoplasm of the tongue (cancerous growth on the tongue). Observation on July 22, 2026, at 2:40 PM, revealed a bottle of saline nasal spray on Resident 1's bedside table. An interview with Resident 1 revealed that staff gave him the bottle of saline nasal spray so that he could use it when he needed it. Review of Resident 1's physician orders revealed an order for ocean nasal spray nasal solution (saline) two times a day for dry nasal passages, order date July 6, 2026. Review of Resident 1's clinical record failed to reveal any assessment of Resident 1's cognitive and physical ability to self-administer the medication. During a staff interview with the Nursing Home Administrator, the Director of Nursing, and Employee 1 on July 23, 2026, at 1:52 PM, it was confirmed that there was no assessment completed to determine Resident 1's cognitive and physical ability to self-administer the medication. Employee 1 stated that it was the facility's expectation that medication not be left at resident's bedsides unless the resident has been evaluated for self-administration of medications. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.10(d) Resident Care Policies.28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services.

Based on facility policy review, clinical record reviews, observations, and staff interview, it was determined that the facility failed to promote an environment that enhances each resident's dignity by storing incontinent briefs in open view for two of 29 residents reviewed (Residents 30 and 34).Findings include: Review of facility policy, titled OPS206 Resident Rights Under Federal Law with a last revised date of February 1, 2023, and a last review date of June 12, 2025, indicated under the section titled Purpose that the facility was to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her self-esteem and self-worth. Also, in Section 1 Resident Rights revealed 1.1 The facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality. Review of Resident 30's clinical record revealed diagnoses that included anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and adjustment disorder (reaction to a life change or another type of stressor which leads to a subjective, personal experience of mixed anxiety and depression). Observation of Resident 30's room on July 22, 2026, at 9:15 AM, revealed seven incontinent briefs stacked on a stand in the room, visible from the hallway. Review of Resident 34's clinical record revealed diagnoses that included Parkinson's Disease (long term degenerative disorder of the central nervous system that mainly affects the motor system) and cognitive communication deficit (a group of disorders that affect a person's ability to communicate which can cause difficulty with understanding or producing language and nonverbal communication skills such as gestures and facial expressions). Observation of Resident 34's room on July 20, 2026, at 11:25 AM, revealed six incontinent briefs stacked on his heating and air conditioning unit. Observation of Resident 34's room on July 21, 2026, at 1:20 PM, revealed five incontinent briefs stacked on his heating and air conditioning unit. Observation of Resident 34's room on July 22, 2026, at 12:50 PM, revealed four incontinent briefs stacked on his heating and air conditioning unit. During a staff interview with the Nursing Home Administrator (NHA), the Director of Nursing, and the Regional Clinical Support Nurse (RCSN) on July 22, 2026, at 1:33 PM, the RCSN confirmed that she would expect a resident's incontinent briefs to be stored out of sight to maintain resident dignity. The NHA agreed. 28 Pa. Code 201.29(a) Resident rights.28 Pa. Code 211.12(d)(1)(2) Nursing services.

Based on policy review and resident and staff interviews, it was determined that the facility failed to ensure the resident has the right to privacy when receiving mail and packages for two of 29 residents reviewed (Residents 4 and 110).Findings include: Review of the facility policy, titled REC214 Patient/Resident Mail Delivery with a last revised and reviewed date of July 17, 2026, revealed Patients/Residents have the right to privacy in written communications, to send and promptly receive unopened mail and other letters, packages, and other materials delivered to the Center/Community, including those delivered through a means other than a postal service, and to have access to stationery, postage, and writing implements at their own expense. Procedure: 1. The Recreation Director or designee will: 1.2 Ensure that mail is delivered to the person unopened or postmarked within 24 hours, including Saturday. During an interview with Resident 4 at the resident council meeting on July 21, 2026, at 1:30 PM, she revealed that staff at the facility have opened her mail thinking it was insurance papers prior to giving it to her, and would deliver it to her opened with a note on it saying that they thought it was for her insurance but it was not so they are returning it to the Resident. Resident 4 revealed she did not give them consent to open her mail. During a resident group meeting on July 21, 2026, at 1:30 PM, it was revealed that staff open Resident 110's packages before giving them to her. During an interview with Resident 110 on July 22, 2026, at 10:01 AM, she revealed that staff would open her Amazon packages without her present and then bring whatever was in the package to her after they went through everything. Resident 110 revealed that her friend orders her snacks, hygiene things, and some clothing from Amazon and can track when it is delivered to the facility, and she will not receive the package until two or three days after it's delivered and sometimes has to go ask for them from the staff. Resident 110 revealed that staff told her they have to make sure she is not ordering knives as they had an issue with a resident ordering them in the past. Resident 110 revealed that she did not give consent for staff to open her packages. Review of Resident 110's clinical record revealed she had a Brief Interview for Mental Status (BIMS) Evaluation completed on April 17, 2026, and scored a 15, which indicates she was cognitively intact. During an interview with an Activities Assistant (Employee 6) on July 22, 2026, at 10:15 AM, she revealed that she did previously open Resident 110's packages without her present before giving them to her because the facility used to have an issue with residents ordering knives in the mail. During an interview with the Nursing Home Administrator (NHA) on July 22, 2026, at 2:00 PM, she revealed that she would expect resident's right to privacy to be honored and that resident packages should not be opened by staff prior to giving them to the resident. 28 Pa. Code 201.29(a) Resident rights.

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a baseline care plan that included the minimum healthcare information necessary to properly care for a resident was developed and implemented within 48 hours of admission for one of 29 residents reviewed (Resident 1).Findings Include: Facility policy, titled OPS416 Person-Centered Care Plan, revision date September 15, 2025, read, in part, 1. Baseline Care Plan . 1.1.7. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the patient and patient representative, if applicable.1.1. 7.2. Interventions shall be initiated that address the patient's current needs including: 1.1.7.2.1 Any health and safety concerns to prevent decline or injury, such as elopement, fall, or pressure injury risk. 1.1.7.2.3 Any special needs such as for IV therapy, dialysis, or wound care. Review of Resident 1's clinical record revealed diagnoses that included severe protein-calorie malnutrition (inadequate intake of protein and calories) and malignant neoplasm of the tongue (cancerous growth on the tongue). Additional Review of Resident 1's clinical record revealed that he was admitted to the facility from the hospital on June 16, 2026. Review of Resident 1's admission skin assessment dated [DATE], revealed the following skin conditions were noted as present on admission: unstageable left hip pressure ulcer/injury, stage 1 buttocks pressure ulcer/injury, right antecubital skin tear, and a left forearm skin tear. Review of Resident 1's baseline plan of care failed to reveal a focus area or any interventions for skin concerns or treatments. During an interview on July 23, 2026, at 2:29 PM, with the Nursing Home Administrator, the Director of Nursing (DON), and Employee 1, it was confirmed that Resident 1's skin concerns were not included in the baseline care plan and that Resident 1's skin concerns were not added until July 17, 2026. The DON stated it was the expectation of the facility that baseline care plans be completed accurately. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on clinical record review select document review and staff interviews, it was determined that the facility failed to complete routine and weekly skin checks for one of five residents reviewed (Resident 1). In addition, the facility failed to provide timely and comprehensive care and services after a change in condition including a respiratory assessment on a resident in respiratory distress, which resulted in harm as evidenced by hospital admission for respiratory failure that required intubation and abnormal labs for one of five residents reviewed (Resident 2).Findings Include: Review of Resident 1's clinical record revealed diagnoses that included multiple sclerosis (a chronic autoimmune disease where the immune system attacks the protective myelin sheath covering nerve fibers in the central nervous system, disrupting brain-body communication), diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels, dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking), and zoster encephalitis (severe inflammation of the brain caused by reactivation of the virus that causes chickenpox and shingles). Clinical record documented hospital transfer on January 29, 2026, for seizure activity. Review of Resident 1's hospital record documented shingles positive, shingles rash on anterior abdomen and treated with Acyclovir (antiviral medication). Review of Resident 1's care plan documented intervention that included to observe skin for abnormalities and report to the Nurse Practitioner, initiated September 10, 2019; and report changes in skin integrity found during daily care, initiated October 14, 2019. Report changes in skin integrity found during daily care, initiated October 14, 2019. Review of Resident 1's January 2026, Medication Administration Record (documentation of administration of medication, treatments or nursing interventions) documented N (indicating that the skin check was not done) on January 7th, 14th, 21st, and 28th. Further clinical record review failed to reveal progress notes regarding the aforementioned skin checks. Interview with Employee 7, (Regional clinical support) on March 20, 2026, at 2:18 PM revealed that the weekly skin check should've been completed on Resident 1. Review of Resident 2's clinical record revealed diagnoses that included Alzheimer's disease (progressive brain disorder that slowly damages nerve cells, causing a gradual loss of memory, thinking and language abilities), thyroid cancer, and metastatic cancer of the liver, colon, and lymph nodes. Review of Resident 2's laboratory report dated March 11, 2026, revealed the following abnormal lab results: Sodium level 152 (normal 136-145), Chloride 108 (Normal 98-107), calculated osmolality 316.81 (Normal 275-295 [elevated levels often caused by dehydration]) and Potassium 3.4 (normal 3.5-5.1). Review of Nurse Practitioner note dated March 11th at 9:41 PM read, in part, follow up visit for medical management/lab review, resident was noted to be lethargic (decreased mental alertness and physical energy), unresponsive to verbal stimuli (does not respond to verbal commands or questions), continues on D5W (intravenous fluids) at 50ml/hr for hypernatremia (high sodium)/dehydration and potassium chloride 40 meq for 1 dose to be administered. Review of the physician orders revealed an order dated March 11, 2026, for Potassium Chloride Oral Packet 40 MEQ. Give 40 mEq by mouth one time for Hypokalemia. Review of the March Medication Administration Record (MAR) revealed it was not documented as administered. Review of the nursing note on March 12, 2026, stated that the resident is lethargic but opens eyes when spoken to, she refused breakfast but did drink ensure and milk. Laboratory report dated March 13, 2026, revealed worsening of the following abnormal lab results: Sodium 156, Chloride 117, calculated osmolality 324.4; and below normal levels of potassium 3.3, and calcium 7.7 (8.5-10.5). Nurse Practitioner note dated March 13th 2026, read, in part, follow-up visit for medical management/lab review, lethargic, nonresponsive to verbal stimuli, continue D5W at 50ml/hr. for hyponatremia/dehydration, potassium chloride 40meq one dose to be administered. Review of the nursing note dated March 14, 2026, noted that she refused meals but did drink 20 ml for breakfast, 60 ml for lunch and 120 ml for dinner. Review of the nursing note dated March 15, 2026, at 5:01 PM, revealed that the physician was at Resident 2's bedside and ordered for resident to be sent to the emergency room for evaluation and treatment. Review of the physician note entered as a Late Entry on March 15, 2026, at 5:52 PM, stated that the resident was seen for an acute visit and was noted to be unresponsive. Further review of progress notes revealed a SBAR (a structured communication tool used in healthcare to convey critical patient information clearly and efficiently) dated March 15, 2026, at 5:58 PM by Employee 1, Registered Nurse Supervisor, read, in part, the change in condition was fever and unresponsiveness. The following vital signs were documented on the SBAR: 3:48 PM pulse 128 beats per minute (normal 60-100); 3:48 PM respiration 12 breaths per minute; 3:48 PM oxygen saturation 95% on room air, 3:48 PM temperature 98.6 degrees Fahrenheit and at 5:59 PM her blood pressure was recorded at 118/75. The SBAR tool failed to document abnormal laboratory results, new medications, and IV fluids she was receiving. It noted that a respiratory assessment was not clinically applicable to the change in condition being reported. It also noted that a neurological assessment was not clinically applicable to the change in condition being reported. The primary diagnosis documented was muscle wasting with additional diagnoses of cancer and dementia, and noted resident was a full code. The documented time the family was notified of the Resident being transferred to the hospital was noted as 5:00 PM. There were no vital signs obtained after the change in condition except for her blood pressure. There was also no assessment from a nurse about the resident's condition. Emergency Medical Services (EMS) care record dated March 15, 2026, documented that the emergency call placed to 911 was on March 15, 2026, at 5:54 PM, and they were on scene at 5:59 PM.Review of the EMS narrative stated the following: Emergency medical services are required due to the Resident being lethargic and unconscious. Care was delayed due to waiting for access to a locked unit; staff members were observed on their phone not answering the door. Upon entering the resident's room there were no staff members present. Resident was lying supine on the bed, breathing was shallow. Resident was immediately placed on a non- rebreather and monitor, vital were obtained. Several attempts were made to nursing staff for reports and information. Resident was moved to the stretcher by EMS staff. Paperwork was gathered from staff. Resident's respiratory rate decreased and was placed on an EtCO2 (a medical device used to deliver oxygen and monitor exhaled carbon dioxide levels). While in route, several ice packs applied to help with cooling, normal saline was administered via IV and report called to the hospital requesting respiratory standby. Resident respiratory rate became insufficient, and a bag valve mask was used to ventilate the resident. Interview with Employee 2, Licensed Practical Nurse on March 18, 2026, at 1:11 PM revealed she obtained vitals at 3:48 PM and called Employee 1 (RN supervisor), who came over before the physician. After the physician was in with the resident he came out and stated she needed to go out now. She called the RN supervisor who started the paperwork, while she called the responsible party to let her know Resident 2 was being sent to the ER. She stated that the nurse aid was supposed to stay with the resident. She went to the Supervisor office and helped the RN with paperwork that was needed sent to the hospital which took a few minutes. She then went to another resident's room to check a blood sugar and assist that resident. She stated that she didn't realize that EMS came in to Resident 2's room. A few minutes later the RN came out of Resident 2's room asking for help and she went into Resident 2's room where EMS was with Resident 2. During an interview with Employee 1 (RN) on March 18, 2026, AT 3:30 PM, she stated that when the doctor ordered the resident to be sent out, she called 911 and started paperwork. When she went back to Resident 2's room, EMS were the only ones in the room so she called for the LPN since she knew the resident. She confirmed that she did not assess the resident because she was being sent out for low sodium levels. She could not provide a timeline as for when 911 was called. Interview with Emergency Response Personnel 1 on March 19, 2026, at 1:19 PM revealed they entered the building without difficulty and were aware of the location of Resident 2. Once at the door they rang the bell to gain access to the unit four times before they gained access. When they entered the room there was no staff in the room with the resident. Emergency Response Personnel 2 called three times for help, as they needed to know the resident's code status and a brief medical history. Approximately 15 minutes passed, a staff member entered the room and asked what they needed to which EMS responded, a Nurse. A Nurse entered the room and stated she was the resident's nurse and stated the resident had a temperature of 99.4 degrees Fahrenheit thirty minutes ago. When asked for the resident past medical history the Nurse responded all she knew was that the resident had dementia. They asked about what medications she takes and were told she hasn't been taking medications. As they were heading out of the unit both Nurses met them at the door to let them off the unit and handed them paperwork regarding medical information. Interview with Eployee7 (Regional Clinical Coordinator) and the Director of Nursing on March 20, 2026, at 2:18 PM it was revealed that a staff member should've been at the main entrance to escort EMS onto the unit, and that the nurse should've stayed with the resident. The RN supervisor or the nurse on the unit should've given report to EMS. It was also revealed that the SBAR tool should've included the altered lab values and the IV hydration, it should've been accurate. The RN should've also completed vitals when the LPN informed her of the change in condition of the Resident. The Director of Nursing stated that the potassium was placed on hold by the Nurse Practitioner and would provide documentation; however, no documentation was provided. The nurse failed to assess the resident after a change in condition. After the physician ordered the resident to be sent to the hospital, documentation revealed a delay of approximately 54 minutes to call 911. Facility staff did not stay with the resident to ensure any additional interventions were needed if the resident had a further decline. The facility failed to assess Resident 2's respiratory status, despite her being in respiratory distress, which required EMS to administer oxygen via non re-breather mask at a rate of 15L/min when they arrived. EMS did not receive an oral report or a thorough written report of the resident's condition. Review of Emergency Department (ED) physician progress note revealed that they tried calling the facility multiple times without success to get report. Upon arrival to the ED the resident was intubated (a medical procedure where a tube is inserted through the mouth to maintain and open airway and deliver oxygen). Labs were completed while in the ED and the resident was given IV fluids and IV electrolyte replacement (magnesium, calcium and potassium). A second set of labs revealed the improvement in labs. Sodium decreased from 153 to 149 and Potassium increased from 2.4 to 3.6. Review of hospital records revealed that on March 16, 2026, the resident was admitted to the Intensive Care Unit with diagnoses that included acute respiratory failure, failure to thrive, cardiac arrest, hypocalcemia (low calcium) and hypokalemia (low potassium). The facility failed to provide timely and comprehensive care and services after a change in condition resulting in harm, as evidenced by further clinical decline. 28 Pa. code 201.14(a) Responsibility of licensee28 Pa code 201.18(b)(1) Management28 Pa code 211.12(c)(d)(1)(3)(5) Nursing services

Based on facility policy reviews, observations, clinical record reviews, review of facility master menu diet guide sheets, and staff interviews, it was determined that the facility failed to provide an altered texture diet, as prescribed by the physician, for six residents (Residents 2, 9, 12, 14, 60, and 101) observed. This failure placed 14 additional residents that had similar diet needs at a high risk for death and resulted in an Immediate Jeopardy situation (Residents 12, 13, 39, 50, 51, 62, 68, 73, 74, 78, 98, 108, 110, and 289). Findings include: Review of facility policy, titled Consistency Alterations and Therapeutic Menus dated May 1, 2023, read, in part, Purpose: To provide diets as ordered by the physician/advanced practice provider. Review of facility policy, titled Dysphagia Management dated May 1, 2023, read, in part, Residents who have swallowing difficulties/dysphagia will receive treatment interventions to promote adequate nutrition and hydration. Review of physician's orders revealed that Residents 2, 9, 12, 14, 60, and 101, were ordered the dysphagia advanced texture diet (special diets for people who have difficulty chewing and/or swallowing- dysphagia). Review of facility master menu diet guide sheets revealed the dysphagia advanced diets should be served chopped carrots as their vegetable at lunch on Wednesday of the Week 1 Menu. Review of facility recipe for sliced carrots, read, in part, the dysphagia advanced diet texture (Soft and Bite Size Level 6) should be served carrots that are cooked, tender, no bigger than ½-inch by ½-inch pieces (1.5 cm x 1.5 cm). Observations during tray line meal service on June 25, 2025, between 11:33 AM and 12:05 PM, revealed Residents 2, 9, 12, 14, 60, and 101 had notation on their meal tickets that they should be served chopped carrots, but they were served round slices of carrots that were larger than bite size pieces. Observations on June 25, 2025, between 12:08 PM and 12:19 PM, revealed Residents 2, 9, 12, 14, 60, and 101, had been served the round slices of carrots. Interview with Employee 1 (Certified Dietary Manager) on June 25, 2025, at 12:20 PM, revealed that the kitchen had in fact served sliced carrots instead of chopped carrots that day at lunch for the dysphagia advanced diet textures, and that the carrot slices served were larger than the guidelines of no bigger than ½-inch by ½-inch pieces (1.5 cm x 1.5 cm). Interview with Employee 2 (Speech Language Pathologist) on June 25, 2025, at 2:09 PM, revealed she has not recommended any adjustments to the facility master menu diet guide sheets to change the guidance on what should be served. She further revealed her expectation that food should be served from the kitchen staff at the appropriate textures, including dysphagia advanced diets, which have guidelines for the carrots to be no bigger than ½-inch by ½-inch pieces (1.5 cm x 1.5 cm), consistent with the International Dysphagia Diet Standardization Initiative's recommendations. Review of physician's orders revealed Residents 12, 13, 39, 50, 51, 62, 68, 73, 74, 78, 98, 108, 110, and 289, were also ordered the dysphagia advanced texture diet. Interview with the Nursing Home Administrator (NHA) on June 26, 2025, at 8:47 AM, revealed his expectation that the facility master menu diet guide sheets for mechanically altered diets should be followed. The NHA was notified of the IJ situation on June 25, 2024, at 1:19 PM, and was provided the IJ template. An Immediate Action Plan was requested. The Immediate Action Plan was provided by the NHA on June 25, 2024, at 5:23 PM, and approved at 5:40 PM. The approved plan included: 1. A full audit of facility residents will occur to ensure that facility residents with altered texture diets are identified to ensure all diet orders, meal tracker/tray tickets are accurate. 2. Diet texture education will occur for nursing staff, dietary staff and anyone that assists with meal service. 3. Education will be initiated for facility nursing staff, and any staff who assist in meal service to check resident identifier/diet order/ticket prior to serving meal tray to any resident and if there are any discrepancies, notify his/her direct supervisor and dietary staff to ensure correction is made immediately. 4. Education for dietary staff will be initiated to ensure the meals served match the residents' meal tickets and consistencies are accurate prior to leaving the food line. 5. The Director of Nursing/designee will re-educate current staff regarding proper diet texture identification and proper checks of diet texture per provider order, which includes the process noted above. The Director of Nursing/designee will begin education June 25, 2025. As of June 25, 2025, 100% of available staff have been educated on this policy. 6. Any staff member that has not been educated, will be prior to the start of his/her next shift. Any staff member that has not been scheduled, on leave of absence (FMLA), vacation, or PRN [as needed] staff will be educated prior to returning to his/her next shift. New hires/agency staff are educated on food and fluid textures during orientation. 7. The facility will conduct audits for tray accuracy daily of each meal for one week to ensure the altered texture diets are present. The facility will conduct ongoing audits weekly for four weeks to ensure accuracy of altered texture diets. On June 26, 2025, between 7:39 AM and 8:25 AM, breakfast tray line meal service was observed to ensure all residents received the appropriate texture diet per their physician order. The audit of dinner service on June 25, 2025, as well as they audit of breakfast service on June 26, 2025, were reviewed without concern. Staff interviews revealed the facility had re-educated staff on mechanically altered diets and the master menu diet guide sheet. Interviews were conducted with three registered nurses, three licensed practical nurses, five nursing assistants, four dietary employees, and the dietary manager; all were able to verbalize their role in providing appropriate diet textures. On June 25, 2025, at 9:01 AM, the Immediate Jeopardy was lifted when the action plan implementation was verified. Observations on June 25, 2025, between 11:33 AM and 12:05 PM, revealed that the facility failed to provide food in a form ordered by the physician to meet the individual needs of six residents Resident's 2, 9, 12, 14, 60, and 101. This failure placed 14 additional residents that had similar diet needs at a high risk for death and resulted in an Immediate Jeopardy situation for Residents 12, 13, 39, 50, 51, 62, 68, 73, 74, 78, 98, 108, 110, and 289. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing services

Based on clinical record review, facility document review, policy review and staff interviews, it was determined that the facility failed to conduct thorough fall investigations for one of six residents reviewed for falls (Resident 81) and failed to ensure that residents who expressed suicidal ideations were provided supervision and safety interventions were put into place to prevent serious bodily injury and/or death. This failure resulted in Resident 59 cutting himself and an immediate jeapordy situation. Findings include: Review of facility policy, titled Procedure: Suicide Precautions, last reviewed May 7, 2025, revealed the facility procedure included the following: 1. Evaluate patients with suicidal behavior or ideation. 2. Notify Physician/advanced practice provider (APP) of patients with suicidal behavior or ideation . 3. For Patients who exhibit suicidal behavior: 3.1 Obtain order for suicide precautions from the physician/APP. Implementation of suicide precautions should not be delayed while awaiting physician order. 3.2 Evaluate immediate safety needs. Remove any potentially dangerous equipment or objects that may be used for self-harm from the patient's room. 3.2.1 Sharp items such as knives, razors, pens, nail clippers, scissors, etc.; .3.2.3. Other items such as electrical cords, straps, belts, plastic bags, and clothing that could be used for self-harm (e.g., shoe laces). 3.3 Provide one-on-one (1:1) supervision of the patient at all times, including when the patient is sleeping or in the bathroom .3.3.2 Designated staff members providing 1:1 supervision: 3.3.2.1. Must have sight of the patient at all times. At no time should the observer leave the patient they are observing unless relieved by an alternate staff member to supervise the patient; .3.3.2.3. Will document patient activities (e.g., sleeping, eating, etc.), behavior (e.g., yelling), and locations (e.g., patient room, bathroom), and applicable interventions/actions taken every 30 minutes on the Continuous 1:1 supervision Flowsheet. 3.4 Verify windows cannot be opened. Notify Maintenance to seal or secure windows, if needed .3.9 Continue suicide precautions every shift until: 3.9.1 Patient is transferred to psychiatric/behavioral health facility; 3.9.2 Consulting psychiatrist/physician discontinues precautions. 3.9.2.1. Do not discontinue 1:1 supervision without a physician's order. 3.10 Document: .3.10.5 Time of initiation of suicide precautions; .3.10.7 Continuous 1:1 Supervision Flowsheet; .3.10.8 Continuation of suicide precautions every shift; 3.10.9 Discontinuation of suicide precautions or transfer out to another facility. Review of Resident 59's clinical record revealed diagnoses that included anxiety disorder - unspecified (mental health disorder characterized by excessive worry and/or fear) and adjustment disorder with depressed mood (mental health disorder that is characterized by emotional and/or behavioral changes that are in response to stressful life events and/or changes). Review of an incident report dated April 27, 2025, completed by Employee 10 (Registered Nurse), revealed the incident description read, Approximately [7:30 PM], this writer was called to the unit to speak with [Resident 59]. Upon arrival to the residents room, [Resident 59] was seen sitting quietly in his bedside chair. A [Nurse Aide] reported that the resident had previously asked her if there is an attorney in the building because he needs to speak to one before he kills himself. Staff reported to the charge nurse [Employee 7] who attempted to speak to the resident, however res[ident] refused to speak. Frequent checks initiated, another [Nurse Aide] went to the room to check on the resident and found the res[ident] holding a sharp edged yellow plastic [object] in his left hand with some other pieces of the plastic on the bedside table. [Nurse Aide] stated that she turned res[ident] right-hand and saw blood, at this time, resident asked him how much does he need to go down. Staff immediately notified charge nurse [of injury] . Review of witness statement by Employee 8 (Nurse Aide) revealed, At about 7:15 PM [Resident 59] came to me at the nurses station and asked me if there is a lawyer in this building to talk to. I told him not at this time. I continued to ask him why he wanted a lawyer. He said I want on[e] before [he] kill myself. I told him lets go and talk to the nurse [Employee 7]. We went but he didn't say anything and went back to his room. At about 5 minutes after [another Nurse Aide] went to his room and I saw him trying to cut his arm. We notified the nurse. Review of witness statement by Employee 7 (Licensed Practical Nurse, identified as change nurse), revealed, [Resident 59] had approached [Nurse Aide] in regards of a lawyer. She had brought [Resident 59] to me but he waved his hands in a 'whatever' gesture and walked off. I call his name and he did not reply at that time. Currently I was pulling medication for someone else. One [Nurse Aide] came to get me and one [Nurse Aide] was in the room talking to him. Called the supervisor to the unit at [7:35] PM . Review of witness statement by Employee 9 (Nurse Aide) revealed, Resident [59] came to the desk saying he wanted a lawyer because he was going to slit his throat. I was really worried so I went into his room started to talk to him. As he was talking, I saw blood on his wrist. He has started to cut his wrist. We talked a little while. Then the nurse came in and got the supervisor. They sent him out. At 7:35 PM [Employee 8] notified Employee 10 (Registered Nurse). Employee 10 then performed an assessment on Resident 59 while Resident 59 was in the dining room for supervision. The physician was then notified and emergency medical services were called. During a staff interview on June 25, 2025, at 1:20 PM, Employee 8 stated that on April 27, 2025, Resident 59 approached her with suicidal ideations. At which time she and Resident 59 walked to Employee 7 (LPN) who was performing medication pass. Employee 8 stated that at that time she did not see any cuts, or blood on Resident 59's arms, wrists or hands. During the staff interview, Employee 8 stated that one-to-one observation of Resident 59 was not initiated by Employee 7, though, Employee 8 did keep an eye on Resident 59 from the hallway while Resident 59 was in his room. However, based on review of the statements as identified above, it was determined that Resident 59 was not supervised at the time of the initial self-injury, as it was stated that blood not observed at approximately 7:15 PM, but observed when Employee 9 went into Resident 59's room to speak with him which was at an undetermined time. Review of the available information revealed that the time Employee 7 was notified of Resident 59's suicidal ideation was approximately 7:15 PM on April 27, 2025. At that time, Employee 7 did not initiate the facility's suicide precautions protocol. Specifically, Employee 7 failed to assess the Resident and initiate one-to-one supervision; failed to immediately notify the registered nurse supervisor (Employee 10); and failed to notified the attending physician. Employee 7 also failed to evaluate the immediate safety needs of Resident 59, including checking his room and removing sharp objects. This failure led to the ability of Resident 59 to self-harm with a sharp piece of plastic. Review of Resident 59's clinical record revealed no order for suicidal precautions or one-to-one supervision were obtained or entered into the electronic health record in response to Resident 59's expressed suicidal ideation on April 27, 2025. On June 25, 2025, at 1:39 PM, the Nursing Home Administrator (NHA) was notified of an Immediate Jeopardy situation in regard to the facility staff failing to implement the facility's suicide precautions protocol. At that time, the NHA was provided with the Immediate Jeopardy template and an Immediate Jeopardy Removal Plan was requested. On June 25, 2025, at 5:17 PM, NHA submitted an Immediate Jeopardy Removal plan. After review, the Immediate Jeopardy Removal plan was accepted on June 25, 2025, at 5:40 PM. The approved removal plan included: 1. A full audit of facility residents to identify any resident(s) actively experiencing suicidal ideation. 2. For any resident identified as having suicidal ideation, the environmental will be evaluation for safety and any items that are unsafe will be removed from the room. Windows will be checked to ensure they are secure and not a risk to resident safety. Staff member will stay with the resident until orders have been given by the provider and interventions are place. 3. A change in condition assessment will be completed as well as provider and resident representative notification. 4. Orders for one-to-one and any other necessary measures will be obtained and entered in the electronic health record until the resident is discharged to an appropriate healthcare center, or the medical provider has assessed and deemed the resident is no longer at risk. 5. If a one-to-one is ordered for a resident, documentation will be completed per policy/procedure until the resident is discharged or the order for one-to-one is discontinued by the medical provider. 6. The facility will educate current staff regarding the facility's suicide precautions protocol. 7. The facility will audit five residents with psychiatric history or depression diagnosis to identify any suicidal ideation for four weeks. On June 26, 2025, between 8:25 AM and 9:25 AM, review of residents revealed no further residents were experiencing suicidal ideations. Interviews with staff, which included Registered Nurses, Licensed Practical Nurses, and Nurse Aides, revealed staff were educated upon start of shift and were knowledgeable of the facility's suicide precautions protocol and the facility's one-to-one procedure. On June 25, 2025, at 9:30 AM, the Immediate Jeopardy was lifted after implementation of the Removal Plan was verified. During an interview on June 26, 2025, at 10:05 PM, the NHA confirmed that one-to-one observation is considered constant supervision with staff within arms-length of the resident being supervised. During the staff interview, the NHA revealed it was the facility's expectation that the facility's suicide precautions policy would be followed when a resident expresses suicidal ideations. The facility failed to implement the facility's suicide precautions protocol, as identified above, immediately upon being made aware of Resident 59's suicidal ideations on April 27, 2025. This failure placed Resident 59 at high risk for serious injury and/or death and resulted in an Immediate Jeopardy situation for Resident 59. Review of facility policy, titled Falls Management last revised March 15, 2024, read, in part, Patients will be assessed for risk of falling as part of the nursing assessment process. Interventions to reduce risk and minimize injury will be implemented as appropriate. Patients experiencing a fall will receive appropriate care and post-fall interventions will be implemented. In the event a fall occurs, an assessment will be completed to determine possible injury. Review of Resident 81's clinical record revealed diagnoses that included unspecified fracture of lower end of right radius (a fracture that occurs in the lower end of the radius bone near the wrist), repeated falls, and unsteadiness on feet. Review of select facility fall report dated December 25, 2024, detailed a fall sustained by Resident 81. Under the section for Statements it read, No statements found. Review of select facility fall report dated February 11, 2025, detailed a fall sustained by Resident 81. Under the section for Statements it read, No statements found. Interview with the Director of Nursing on June 26, 2025, at 12:16 PM, she revealed she was unable to locate witness statements collected from staff in response to Resident 81's falls on the aforementioned dates, and she would expect thorough fall investigations to be conducted. 28 Pa. code 201.14(a) Responsibility of licensee 28 Pa code 201.18(b)(1) Management 28 Pa code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review, hospital records, staff interviews, and review of the facility incident report, it was determined that the facility failed to ensure that care and services were provided timely following a fall with fracture for one of three residents reviewed (Resident 1), which resulted in harm as evidenced by uncontrolled fracture-related pain and delayed corrective treatment. Findings include: Review of Resident 1's clinical record revealed diagnoses that included atrial fibrillation (irregular heart beat), congestive heart failure (CHF - weakness of the heart that leads to buildup of fluid in the lungs and surrounding body tissues), and chronic obstructive pulmonary disease (COPD - chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of the facility incident report, revealed that Resident 1 experienced an unwitnessed fall between 4:45 and 5:00 AM on April 3, 2024. Further review of the report revealed, resident was found lying on the bathroom floor after staff had noted knocking noise coming from resident's bathroom. Resident states that she thought she had her call light on (light was not on) and wanted to go to the bathroom. Resident had ambulated without staff assistance and had fallen onto back Noted resident stating discomfort in left wrist. On assessment, swelling/bruising noted. Resident transferred to bed. Left arm elevated and cool compress applied .MD [doctor] updated, xray of left wrist to be obtained. The pain level evaluation documented on the incident report indicated a pain level of 3 out of 10 with facial grimacing noted. Review of Resident 1's clinical record failed to reveal any evidence that neurovascular assessments (evaluation for impaired blood flow to the extremities) were completed following Resident 1's wrist injury. Review of nursing progress note dated April 3, 2024, revealed that at 6:04 AM the X-ray was ordered. Review of Resident 1's April 2024 MAR (Medication Administration Record - form used to document physician orders as well as when and how medications are administered to a resident) revealed an order for Norco (opioid pain medication used to treat moderate to severe pain) every 12 hours as needed for pain, effective April 2, 2024. Further review revealed it was administered to Resident 1 at 8:27 AM on April 3, 2024. Review of the MAR revealed that Employee 2 (Licensed Practical Nurse) documented that the Norco was ineffective in treating Resident 1's pain. The x-ray was completed at 9:29 AM; three hours and 25 minutes after it was ordered. Review of Resident 1's X-ray report revealed that Resident 1 had a fracture involving the distal radius with mild displacement (wrist fracture). At 10:15 AM, MD 1 was notified via text message of the X-ray results and that Resident 1 was requesting to go to the emergency room . Review of Resident 1's April 2024 MAR, revealed that at 10:20 AM on April 3, 2024, the Resident's pain level had increased, and was noted to be a 5 out of 10, and Tylenol 650 mg was administered to her at that time. Further review revealed that it was notated by Employee 2 that the Tylenol was ineffective in treating Resident 1's pain. On April 3, 2024, at 12:12 PM, Resident 1 refused wound care stating, I have so much pain in my arm. I can't do it right now. Approximately two hours after being notified of Resident 1's x-ray results, MD 1 responded to the notification and gave orders to transfer Resident 1 to the hospital. Review of physician order details revealed that the order to send Resident 1 to the emergency room was created and confirmed by Employee 5 at 12:19 PM on April 3, 2024. Review of Resident 1's hospital records dated April 3, 2024, revealed that upon arrival to the hospital: Resident 1 reported a pain rating of 6 out of 10 and received Fentanyl (opioid medication used to treat severe pain) in the emergency department; Resident 1 was noted to have obvious deformity and immediate pain following her fall; Resident 1 was diagnosed with acute impacted comminuted displaced angulated intra-articular fracture of the distal radius [type of fracture involving the distal radius (the forearm bone near the wrist) being broken in multiple places, with the bone fragments shifted and potentially affecting the joint], with substantial surrounding posttraumatic soft tissue swelling. Further review of the hospital records revealed Resident 1 required local anesthesia and a closed reduction (a non-invasive procedure where the broken bone is put back into place, allowing for it to grow back together in better alignment; best prognosis when performed as soon as possible after the bone breaks). During an interview with Employee 2 on April 8, 2024, at 9:44 AM, he confirmed that Resident 1 was alert and oriented. He revealed that on the day of Resident 1's fall, Resident 1 informed him that her wrist was very painful. Employee 2 confirmed that he administered pain medication to Resident 1, after which Resident 1 stated the pain subsided a little bit but was still present. Employee 2 revealed that Resident 1's wrist appeared abnormal. Employee 2 also revealed that Resident 1 refused wound treatment due to wrist pain, and asked to be sent to the hospital. During an interview with Employee 4 (Registered Nurse) on April 8, 2024, at 10:06 AM, she revealed that she assessed Resident 1 following her fall. She revealed that Resident 1 had bruising and swelling to her left wrist, and that Resident 1 stated there was some discomfort. During an interview with Employee 6 on April 8, 2024, at 10:41 AM, Employee 6 revealed that on the date of Resident 1's fall, when she delivered Resident 1's breakfast tray, Resident 1 was hysterically crying and was in pain. Employee 6 stated that Resident 1's wrist appeared abnormal. Employee 6 stated that she tried to reassure Resident 1, who ate a little bit of her breakfast and dozed off. When Resident 1 awoke, she put her call light on again. Per Employee 6, Resident 1 stated she couldn't take the pain anymore and asked if she could have anything for pain. Employee 6 stated that she spoke to Employee 2 about this request, who informed her that he had already given Resident 1 pain medication and could not readminister it for another 12 hours, but that he would give Resident 1 Tylenol. Employee 6 stated that Resident 1 requested to be taken to the hospital, which Employee 6 stated she passed along to Employee 3 (Licensed Practical Nurse). Employee 6 also stated she informed Employee 5 (Registered Nurse) that Resident 1 was in a lot of pain. During an interview with Employee 5 April 8, 2024, at 10:52 AM, she revealed that when she received Resident 1's x-ray results, she went back to talk to Resident 1. She revealed that Resident 1's wrist was swollen, probably more than I thought it was going to be based on report. She revealed that she spoke to Resident 1's son and informed him that she had notified MD 1 about the x-ray and was awaiting a response. Employee 5 confirmed that there was a time lapse of a couple of hours between the time she notified MD 1 of the x-ray results, and when the facility received the physician response/order to transfer Resident 1 to the emergency room . Per email correspondence received from the Nursing Home Administrator on April 11, 2024, at 12:50 PM, she confirmed that as soon as Employee 5 received Resident 1's x-ray results, she notified MD 1 of the results via text message at 10:15 AM on April 3, 2024. During an interview with the Director of Nursing on April 8, 2024, at 12:31 PM, she revealed the expectation that if Resident 1 was experiencing uncontrolled pain, an assessment should have been completed and the physician should have been notified. She confirmed that she was not able to locate evidence that neurovascular assessments were completed following Resident 1's injury, but that she would expect that a Registered Nurse would complete these assessments and document them in the clinical record. Lastly, she revealed the expectation that the physician would have responded to the facility request to transfer Resident 1 in a timely manner, and that when a timely response was not received, nursing staff should have reached out to the physician again, and if still no response, staff should have contacted another facility physician, possibly the Medical Director. Review of Resident 1's clinical record failed to reveal any evidence that the physician was notified of Resident 1's unmanaged pain, or that the facility took any additional steps to manage her uncontrolled pain at any point during the timeframe between her fall and her transfer to the hospital (approximately 7 hours and 45 minutes). Additionally, the facility failed to complete neurovascular assessments to ensure proper circulation following injury, and failed to act timely to ensure Resident 1's transfer to the hospital following her fall. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents, which resulted in actual harm, evidenced by fractures involving the base of the right first proximal phalanx (toe bone) and base of second and fourth metatarsals (long bones found in the foot) with mild displacement, for one of 26 residents reviewed (Resident 106). Findings Include: Review of the facility provided policy titled Fall management, long-term care revised February 18, 2022, revealed Falls can also result from extrinsic factors, such as poor lighting, unsafe footwear, slippery throw rugs, highly waxed floors, unfamiliar surroundings, and misuse of assistive devices. Review of Resident 106's clinical record revealed diagnoses that included [CONDITION(S)] (longstanding disease of the kidneys leading to [CONDITION(S)]), [CONDITION(S)] (high levels of fat particles in the blood), muscle weakness, and repeated falls. Review of Resident 106's Activities of Daily Living care plan included interventions dated March 21, 2022, to transfer with two assist, stand pivot (resident is assisted to standing position and then pivots feet), onto left side. The care plan also noted that the assistive/adaptive equipment used by Resident 106 was a wheelchair. Review of the Resident's quarterly Minimum Data Set (MDS) (a periodic assessment tool) dated May 27, 2022, coded walking in room and walking in corridor as activity did not occur. Under the balance during transitions and walking section, walking is coded as activity did not occur. Under mobility devices, wheelchair is the only assistive device noted for Resident 106. Review of Resident 106's clinical record revealed a progress note, created June 3, 2022, at 2:56 PM, stating that on June 3, 2022, at approximately 9:30 AM, Employee 1 (Licensed Practical Nurse [LPN]) assisted Resident 106 to the bathroom using a gait belt and walker. Further review of the progress note revealed that, as Employee 1 and Resident 106 approached the toilet, the Resident became anxious and gave up, leaning back placing all her weight on to nurse. Nurse lowered Resident to the floor onto buttock and leaned her upper body against the wall. The LPN's progress note also stated that Resident 106 had no injuries, was able to move all extremities within baseline, and had no complaints of pain. Review of a late entry Registered Nurse (RN) progress note, created on June 4, 2022, at 3:41 PM, revealed that at approximately 9:30 AM [on June 3, 2022], Resident 106 was found sitting up against the wall/corner of the bathroom in front of the toilet. The note states that Resident 106 was wearing sneakers and had no complaints of pain at the time of the fall. Resident 106 was able to move all extremities without any pain, difficulty or discomfort. Further review of the progress note revealed that Resident 106 is a two assist for transfers per her care plan. Review of facility reported incident, dated June 16, 2022, revealed that later in the evening on June 3, 2022, Resident 106 was observed with redness to the top of the right foot. The physician was contacted and X-rays of right foot were ordered. Review of Resident 106's progress notes revealed a late entry progress note on June 10, 2022, with an effective date of June 3, 2022. The progress note stated that an order was placed for an X-ray of Resident's foot related to pain. Review of Resident 106's physician orders revealed an order for a STAT (immediate) X-ray of the right foot post fall to rule out fracture. The order was dated June 3, 2022, at 11:52 PM. Review of Resident 106's X-ray report revealed that the STAT X-ray was not completed until June 4, 2022, at 11:30 AM. The X-ray results revealed an avulsion fracture (when a small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone) involving the base of right first proximal phalanx (toe bone) and base of second and fourth metatarsals (long bones found in the foot) with mild displacement. On June 8, 2022, Resident 106 was seen by orthopedics with recommendations for weight bearing as tolerated with walker and stiff soled shoe, ice as needed and to follow-up in one month. Review of Resident 106's nursing progress note dated June 7, 2022, revealed that the interdisciplinary team met to discuss Resident 106's fall that occurred on June 3, 2022. The note stated Resident was to be a two person assist with transfers and the nurse in question did not check the Kardex before transferring resident. Review of Resident 106's clinical record revealed no documentation of any other incidents after the fall in the bathroom until the positive X-ray results. Further review of the clinical record revealed no evidence that the Resident's sneakers were removed and that there was any physical inspection of her feet at the time of the incident. During an interview on September 14, 2022, at 2:21 PM, the Nursing Home Administrator stated that, as a result of the aforementioned incident, all staff were educated on following the care plans and Kardex of Residents. During and interview with the Director of Nursing on September 19, 2022 at 11:55 AM, she confirmed that Resident 106 was not supposed to be ambulating at the time of the fall. The Resident was stand to pivot with transfers, meaning that a pivot was the maximum that she could do. She also confirmed that she was on therapy caseload and the only assistive device the Resident had was a wheelchair. The facility failed to implement the appropriate transfer status interventions to assure Resident 106's safety during a transfer to the bathroom, resulting in a fall with actual harm as evidenced by an acute avulsion fracture involving base of right first proximal phalanx and base of second and fourth metatarsals with mild displacement. The post fall RN assessment of Resident 106 was not documented in Resident 106's clinical record until after the results of the x-ray were received showing the fracture. The LPN did not follow the care plan for transfer and ambulation of the Resident. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on facility policy review, clinical record review, review of facility incident reports, and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect, which resulted in actual harm, evidenced by fractures involving the base of the right first proximal phalanx (toe bone) and base of second and fourth metatarsals (long bones found in the foot) with mild displacement, for one of 26 residents reviewed (Resident 106); and failed to ensure that residents were free from verbal abuse for one of 26 residents reviewed (Resident 263). Findings Include: Review of facility policy titled Patient Protection Abuse, Neglect, Mistreatment and Misappropriation Prevention dated October 2021, revealed The most critical step toward detecting and preventing abuse is acknowledging that no one should be subjected to violent, abusive, humiliating, exploitive or neglectful behavior. Knowledge of the patient's co-morbid conditions and contributing factors allows staff to provide care specific to each patient. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. Review of Resident 106's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 106's Activities of Daily Living care plan included interventions dated March 21, 2022, to transfer with two assist, stand pivot (resident is assisted to standing position and then pivots feet), onto left side. The care plan also noted that the assistive/adaptive equipment used by Resident 106 was a wheelchair. Review of the Resident's quarterly Minimum Data Set (MDS) (a periodic assessment tool) dated May 27, 2022, coded walking in room and walking in corridor as activity did not occur. Under the balance during transitions and walking section, walking is coded as activity did not occur. Under mobility devices, wheelchair is the only assistive device noted for Resident 106. Review of Resident 106's clinical record revealed a progress note, created June 3, 2022, at 2:56 PM, stating that on June 3, 2022, at approximately 9:30 AM, Employee 1 (Licensed Practical Nurse [LPN]) assisted Resident 106 to the bathroom using a gait belt and walker. Further review of the progress note revealed that, as Employee 1 and Resident 106 approached the toilet, the Resident became anxious and gave up, leaning back placing all her weight on to nurse. Nurse lowered resident to the floor onto buttock and leaned her upper body against the wall. The LPN's progress note also stated that Resident 106 had no injuries, was able to move all extremities within baseline, and had no complaints of pain. Review of a late entry Registered Nurse (RN) progress note, created on June 4, 2022, at 3:41 PM, revealed that at approximately 9:30 AM [on June 3, 2022], Resident 106 was found sitting up against the wall/corner of the bathroom in front of the toilet. The note states that Resident 106 was wearing sneakers and had no complaints of pain at the time of the fall. Resident 106 was able to move all extremities without any pain, difficulty, or discomfort. Further review of the progress note revealed that Resident 106 is a two assist for transfers per her care plan. Review of facility reported incident, dated June 16, 2022, revealed that later in the evening on June 3, 2022, Resident 106 was observed with redness to the top of the right foot. The physician was contacted and X-rays of right foot were ordered. Review of Resident 106's progress notes revealed a late entry progress note on June 10, 2022, with an effective date of June 3, 2022. The progress note stated that an order was placed for an X-ray of Resident's foot related to pain. Review of Resident 106's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was dated June 3, 2022, at 11:52 PM. Review of Resident 106's X-ray report revealed that the STAT X-ray was not completed until June 4, 2022, at 11:30 AM. The X-ray results revealed an avulsion fracture (when a small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone) involving the base of right first proximal phalanx (toe bone) and base of second and fourth metatarsals (long bones found in the foot) with mild displacement. On June 8, 2022, Resident 106 was seen by orthopedics with recommendations for weight bearing as tolerated with walker and stiff soled shoe, ice as needed and to follow-up in one month. Review of Employee 1's statement, dated June 7, 2022, revealed that Resident 106 needed to use the restroom. Employee 1 started pulling the wheelchair towards Resident 106, but Resident 106 requested to walk. Employee 1 observed a walker and gait belt in Resident 106's room, so Employee 1 placed the gait belt on Resident 106, placed the walker in front of her, and they began walking to the bathroom. Employee 1 stated when they got to the bathroom door, Resident 106 began giving up, leaning back, placing her weight on Employee 1. Employee 1 attempted to pivot Resident 106 towards the toilet, putting her knee behind her against her buttocks, and using the gait belt, but Employee 1 was unable to pivot Resident 106 to the toilet. Employee 1 then lowered Resident 106 to the floor. Further review of Employee 1's statement revealed I was not aware of any restrictions of [Resident 106's] transfer status. I was just trying to help out and take the resident to the bathroom instead of making her wait while I looked for a CNA [certified nurse aide]. Seeing a walker and a gait belt gave me the indication that the resident was capable of walking along with the fact that she requested to walk versus using the wheelchair. I'm all about maximizing independence therefore I would never deny a resident the opportunity to walk when they're requesting to unless I know they can't or it's unsafe for them to do so. In this case apparently what I'm being told is she was not cleared to walk with staff only PT [physical therapy] but the fact that she had assistive devices such as the [NAME] and gait belt in her room made that misleading. Review of Resident 106's nursing progress note dated June 7, 2022, revealed that the interdisciplinary team met to discuss Resident 106's fall that occurred on June 3, 2022. The note stated Resident was to be a two person assist with transfers and the nurse in question did not check the Kardex before transferring resident. Review of facility reported incident, with a final submission date of June 16, 2022, revealed It was determined that the LPN [Employee 1] was neglectful due to transferring the resident with the wrong transfer status that resulted in injury. Review of Resident 106's clinical record revealed no documentation of any other incidents after the fall in the bathroom until the positive X-ray results. Further review of the clinical record revealed no evidence that the Resident's sneakers were removed and that there was any physical inspection of her feet at the time of the incident. During an interview on September 14, 2022, at 2:21 PM, the Nursing Home Administrator (NHA) stated that, as a result of the aforementioned incident, all staff were educated on following the care plans and Kardex of Residents. During an interview with the Director of Nursing on September 19, 2022 at 11:55 AM, she confirmed that Resident 106 was not supposed to be ambulating at the time of the fall. The resident was stand to pivot with transfers, meaning that a pivot was the maximum that she could do. She also confirmed that she was on therapy caseload and the only assistive device the Resident had was a wheelchair. The facility failed to ensure that Resident 106 was free from neglect when Employee 1 did not follow Resident 106's care planned interventions and transferred Resident 106 independently and independently assisted the resident as she ambulated using a walker, resulting in a fall with actual harm as evidenced by an acute avulsion fracture involving base of right first proximal phalanx and base of second and fourth metatarsals with mild displacement. The post fall RN assessment of Resident 106 was not documented in Resident 106's clinical record until after the results of the x-ray were received showing the fracture. The LPN did not follow the care plan for transfer and ambulation of the Resident. Review of Resident 263's closed clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility abuse investigation revealed that on June 2, 2022, Employee 10 was made aware of an abuse allegation towards Resident 263. Review of Employee 10's witness statement revealed that Employee 10 was made aware that Employee 15 was overheard being short and aggressive with Resident 263. Review of Employee 11's witness statement, undated, revealed that on June 2, 2022, Employee 11 approached Resident 263's room and noted that Resident 263 was in the bathroom with Employee 15. Employee 11 overheard Employee 15 saying to Resident 263 This is every two hours and you know that and Employee 15 sharply told Resident 263 Open your legs, stand up, sit down and I'm not dealing with your whining today. Employee 11 stated she immediately reported this to Employee 10. Review of Resident 263's witness statement revealed that when Resident 263 was asked about being sad, Resident 263 stated that Employee 15 said Resident 263 should only have to be checked on every two hours for a brief change, and stated she hoped Resident 263 be sent out of here. Resident 263 was asked what sent out here meant. Resident 263 stated that Employee 15 wanted him out due to the way he was acting. Resident 263 stated he no longer wanted Employee 15 to care for him. Review of Employee 13's witness statement, dated June 2, 2022, revealed that on June 2, 2022, Resident 263 was crying and stated that Employee 15 was very rude and mean to him and Employee 15 stated The psych ward is going to take you away and also I hope they do take you away from here. Review of Employee 14's witness statement, dated June 2, 2022, revealed that on June 2, 2022, Resident 263 was crying, stating that Employee 15 was very mean to him. Resident 263 stated Employee 15 told me the psych ward was coming to get me and I hope they take you out of here. Review of Employee 15's witness statement, dated June 2, 2022, at 2:26 PM, revealed that, while Employee 15 had Resident 263 in the bathroom, Resident 263 was asked to stand but he would not stand or move his legs to be changed. Resident 263 began to cry uncontrollably and Employee 15 stated I do not need the whining. Employee 15 stated she finished changing Resident 263 and he was passed to the Activities Director for a one-to-one. Employee 15 was disciplined for verbal abuse and then terminated effective June 3, 2022. On September 15, 2022, at 12:35 PM, the above verbal abuse against Resident 263 was discussed with the NHA, who stated she was not employed at the facility when the verbal abuse occurred. She stated that Employee 10 and Employee 15 are no longer employed at the facility. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of facility documentation, clinical records, and interviews with staff it was determined that the facility failed to provide proper supervision and implement interventions to prevent an accident for one of seven residents reviewed (Resident 3), resulting in harm when the resident fell , receiving a fractured left hip. Findings include: Review of Resident 3's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 3's significant change Minimum Data Set assessment (MDS-periodic assessment of resident needs) dated (MONTH) 24, (YEAR), revealed, under functional status for activities of daily living for toileting, that Resident 3 required the extensive physical assistance of 2 + persons. Review of Resident 3's Kardex (a form used by staff to communicate important information on residents and provides a quick summary of individual resident needs) revealed that for safety staff supervision when in bathroom was listed. Review of the facility's incident report dated (MONTH) 21, (YEAR), and nursing progress notes dated the same day, revealed Resident 3 was being toileted by Nurse Aide (NA) 1 who had assisted her to the bathroom and then left. Resident 3 was subsequently found on the floor and complained of pain to left hip and leg. Physician and family were notified, and X-rays were ordered and revealed a left [MEDICAL CONDITION]. Resident was transferred to the hospital for further evaluation and treatment. Review of facility investigation documentation included a telephone statement provided to the facility by NA 1 dated (MONTH) 22, (YEAR), which stated, I put her in the bathroom and took the wheelchair out of the room, put down 2 other residents and then I came back into the room, she was on the floor. Her wheelchair was back in the bathroom. I'm guessing she got up and put it back herself. I did know she shouldn't be left alone. I didn't check the Kardex. During an interview on (MONTH) 14, 2019, at 2:30 PM with the Nursing Home Administrator she stated her expectation is that the resident's care plan be followed and that the Kardex should be referred to and followed when providing care to residents. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 11/8/18, 12/8/17. 28 Pa. Code 201.18(b)(1) Management. Previously cited 11/8/18. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 201.18(e)(1) Management. Previously cited 12/8/17. 28 Pa. Code 201.29(a)(d) Resident rights. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 11/8/18. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 12/8/17. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited 11/8/18, 12/8/17.

Based on review of clinical records, select facility policy review, and staff interviews, it was determined that the facility failed to ensure that one of 3 sampled residents was free of a significant medication error (Resident R1). Findings include: The "Leave of Absence, Resident Discharge with Medication or Other Change of Status" policy reviewed by the facility on July 19, 2011, states that "upon resident leave of absence, the facility nurse and prescriber should review the list of current medications ordered; the total number of doses required for each medication, and the length of time the resident will need each medication." Review of November 2011, physician orders [REDACTED]. His prescribed medications included [MEDICATION NAME] 20 milligrams (mg) 3 tablets twice daily (used to treat excessive fluid accumulation in the body), and potassium chloride (K-Dur, a potassium supplement) 10 mEq (milliequivalents) given once daily. Resident R1's interdisciplinary progress notes (IDPN) dated November 20, 2011, indicated that he left the facility for a leave of absence (LOA) for the week with his son. The approximate return was for Friday or Saturday, November 25 or 26, 2011. The progress note indicated that the facility sent Resident R1's medications with his son. Review of the facility's Request for Leave of Absence Medications form (used to request medications from the pharmacy) completed November 17, 2011, revealed that an eight day supply of medications was to be sent and included, among other medications, [MEDICATION NAME] 60 mg twice daily and K-Dur 10 mEq daily. The delivery receipt from the pharmacy, dated November 18, 2011, indicated that both medications were delivered to the facility. The [MEDICATION NAME] was listed as 48 pills sent and the potassium was listed on the receipt twice indicating that 16 tablets were sent rather than the 8 that would have been needed. Interview with Registered Nurse, RN1 on November 29, 2011, at 3:00 p.m., revealed that she assisted the resident's family when they picked the resident up for the LOA on November 20, 2011. RN1 gave the medications to the daughter-in-law but did not explain the medications to her. RN1 could not recall giving the daughter-in-law a copy of the November 2011, Medical Administration Record (MAR), which would list all the medications and times they were given by the facility. The daughter-in-law signed Resident R1 out on the facility's Release of Responsibility for LOA. RN1 stated, during the above noted interview, that on November 25, 2011, she received a call from Resident R1's daughter-in-law saying that he was getting worse, and that she thought she had given him too much potassium. The daughter-in-law told RN1 that the family was going to bring him back to the facility. RN1 advised her to take him to the hospital. Following the conversation, RN1 said she looked in Resident R1's medication drawer and found the [MEDICATION NAME] that was supposed to have been sent with him on the LOA. RN1 said she then reported this to her supervisor and the Director of Nursing (DON). Review of IDPN dated November 25, 2011, indicated that Resident R1 was admitted to the hospital with [REDACTED]. Review of hospital records dated November 25, 2011, revealed that Resident R1 was admitted to the intensive care unit with a [DIAGNOSES REDACTED]. During an interview on November 29, 2011, at 1:45 p.m., the ManorCare Regional Director of Operations confirmed that the [MEDICATION NAME] should have been sent with Resident R1 on LOA and was not and that the facility sent twice as much potassium as was necessary. 28 Pa. Code 211.12 (a)(c) Nursing services. 28 Pa. Code 211.12 (d)(1)(5) Nursing services. Previously cited 12/10/11, 7/25/11, and 11/17/11 28 Pa. Code 211.12 (d)(3) Nursing services. Previously cited 12/10/11 and 11/17/11

Based on review of clinical records and facility documents and interview with staff, it was determined that the facility failed to ensure that staff provided adequate supervision for two of six residents (Residents R2 and R3) reviewed. Findings include: Review of Resident R3's Minimum Data Set quarterly assessment dated [DATE], identified that she required extensive assistance from two persons for transfers and was at risk for falls. Her [DIAGNOSES REDACTED]. An Occupational Therapy Positioning Evaluation completed on May 16, 2011, included the use of a Rock n Go style wheelchair (wheelchair that has a rocking motion). Her care plan reviewed on May 17, 2011, included the use of anti-roll back device to wheelchair. Her current physician's orders [REDACTED]. Progress notes dated June 21 at 3:00 a.m. and June 22, 2011, at 2:00 a.m., reported that she had been sitting in the Rock 'n' Go chair and attempted to stand up from her chair and leaned forward in the chair multiple times and was put to bed at this time. Between June 29-July 5, 2011, Resident R3 was identified to have multiple episodes of skin tears on her left shin. On July 5, 2011, the Interdisciplinary Care Plan team reviewed the skin alterations to her left shin which were obtained during transfers and obtained an order for [REDACTED]. Progress notes dated July 9, 2011, at 9:30 p.m., reported that she was found on the floor in the dining room on her right side. Her right arm was extended, right leg was flexed and left leg extended. She was emergently transferred and admitted to the hospital for a fractured right hip and clavicle (collarbone). Review of staff statements revealed the following: Licensed Practical Nurse (LPN) 1 reported that Resident R3 was in her chair, pushed up to the table with the brakes on at 8:00 p.m. on July 9, 2011. She stated that the day shift had reported (on July 10, 2011) that she had been restless and was throwing her legs over the side of the chair. LPN 1 saw the resident on the floor on her right side but she 'was some distance from her chair' which was still at the table where it was. Nurse Aide (NA) 2 reported that she had seen Resident R3 about 20-30 mins. prior to her fall seated in her chair at the table. She also noted that she has seen her at other times try to stand up from her chair or throw her legs over the side arms. NA 1 reported that she had seen Resident R3 less than 10 mins. prior to her fall. She stated that the activity staff said she had been "antsy" all day and needed a lot of extra attention. When she was found on the floor she was about 5 feet away from her chair, "...like she walked away from the chair and then fell ." Observations on July 21, 2011, at 1:50 p.m., revealed that residents in the dining room cannot be seen from the nurses station. There was no evidence that the facility provided increased supervision for Resident R3 who had displayed recent unsafe behaviors to ensure that the resident was safe from falls. Review of Resident R2's June 30, 2011, physician's orders [REDACTED]. Progress notes dated June 21, 2011, reported that she required extensive assistance of two persons with the Stand Aid. On June 22, 2011, resident's right hand was pinched while using the Stand Aid. Interdisciplinary Care Plan review on June 24, 2011, reviewed the blood blister to the palm of her right hand which was pinched in lift during a transfer on June 22, 2011 and staff were reducated on using the lift for transfers. Subsequent progress notes dated July 4, 2011, at 10:30 a.m., reported that Resident R2 had swelling and bruising from right upper arm across her chest to under her left breast (14 centimeters (cm) by 51 cm.) and swelling concentrated at right upper chest (24 cm by 20 cm) with firmness of right upper chest and that Physician 1 was called. At 10:45 a.m., Resident R3 was noted to have some confusion, using the call bell more frequently and making unusual requests for her and that Physician 1 would be updated. A physician's orders [REDACTED]. later). The high abnormal results were reported to Physician 1 at 3:15 p.m. who ordered Vitamin K 10 mg now and to discontinue the Coumadin. Progress notes at 6:15 p.m., reported that the Vitamin K was given as ordered (at 3:30 p.m.) as well as Tylenol for the resident's complaint of pain in her right chest area and that bruising and swelling continues. At 11:30 p.m., Resident R2 was pale and that the purple bruising and hematoma on her right upper chest continued. Her heart rate was 118 beats/minute and she was assessed by RN 2 at midnight. RN 2 reported that the resident's blood pressure was lower, her heart rate was higher and her blood oxygen level ranged from 77-85% (normal over 90%), contacted Physician 1 and emergently transferred the resident to the hospital. Hospital records dated July 5, 2011, reported a hematoma in right chest wall that extended to her mid-flank and left breast. Review of the facility's Mechanical Lift procedure reviewed March 2010 included that it is advisable to have two staff members present to stabilize and support the resident. Review of the facility's investigation into Resident R2's bruising revealed that Nurse Aide 3 had transferred Resident R2 with the Stand Aid to and from the bathroom and back to bed alone, without the help of another person for any of the transfers. Nurse Aide 3 was counseled on July 4, 2011, and instructed that she must always transfer residents in lifts of any type with two staff persons. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. Previously cited 12/10/10 28 Pa. Code: 211.10 (d) Resident care policies. Previously cited 12/10/10 28 Pa. Code: 211.11 (a) Resident care plan. Previously cited 12/10/10 28 Pa. Code: 211.12 (d)(1)(5) Nursing services. Previously cited 12/10/10