Every finding on record at Cedar Hill Healthcare and Rehabilitation Center

Based on review of facility documents, clinical record review and staff interview, it was determined that the facility failed to initiate a thorough investigation for allegations of misappropriation of property for four of seven residents (Resident R57, R112, R115, and R119).Findings include: Review of the facility's Abuse Reporting and Investigation policy last reviewed 7/1/26, indicated the facility will thoroughly investigate all reports of suspected or alleged abuse (mental, physical, sexual, involuntary seclusion or misappropriation of resident property), neglect or exploitation. Review of the admission record revealed that Resident R57 was admitted to the facility on [DATE]. Review of the facility's grievance log dated August 2026, indicated on 8/19/26, Resident R57 reported a concern of missing $25 dollars. Resident placed money on bedside table and left room for a while. The money was not located. Review of the admission record revealed that Resident R112 was admitted to the facility on [DATE]. Review of the facility grievance log dated June 2026, indicated on 6/5/26, Resident R112 reported a concern of missing $35 dollars. Review of the admission record revealed that Resident R115 was admitted to the facility on [DATE]. Review of the facility grievance log dated May 2026, indicated on 5/14/26, Resident R115 reported a concern of missing $54 dollars. Review of the admission record revealed that Resident R119 was admitted to the facility on [DATE]. Review of the facility grievance log/concern dated April 2026, indicated on 4/10/26, Resident R119 reported a concern of missing $75 dollars and on 4/13/26, reported a concern of missing $50 dollars. Interview on 9/2/26, at 8:30 a.m. the Director of Nursing and Nursing Home Administrator were unable to produce investigations for the misappropriation of property grievances listed, and confirmed the facility failed to initiate a thorough investigation for allegations of misappropriation of property for four of seven residents (Resident R57, R112, R115, and R119). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1) Management.28 Pa. Code: 201.20(b) Staff development.28 Pa. Code: 211.10(c)(d) Resident care policies.

Based on review of facility policy, clinical record review, reports submitted to the State, and staff interview, it was determined that the facility failed to report allegations of abuse and/or neglect in the required timeframe for five of seven residents (Residents R4, R57, R112, R115, and R119).Findings include: Review of facility policy Abuse Reporting and Investigation dated 7/1/26, indicated the Department of Health will be notified of the alleged event by the Administrator or designee via the Electronic Reporting System per regulation. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/20/26, indicated diagnoses of anxiety, depression, and need for assistance with personal care. Review of a physician order dated 7/29/26, indicated to cleanse coccyx (tailbone) with NSS (normal sterile saline), apply Alginate (a high absorbent wound dressing) and cover with a foam dressing every day shift for wound care. During an interview on 8/31/26, at 9:58 a.m. Resident R4 stated, Licensed Practical Nurse (LPN) Employee E1 changed my dressing this morning, she said the dressing that was on my wound was dated for Friday the 28th. It is supposed to be changed daily; it wasn't done on Saturday or Sunday. Review of Resident R4's August 2026 Treatment Administration Record (TAR) indicated the ordered treatment to the coccyx wound was documented as completed on 8/29/26, and 8/30/26, during the day shift (7 a.m. - 3 p.m.). During an interview on 9/1/26, at 12:29 p.m. LPN Employee E1 stated, Yes, when I changed Resident R1's dressing yesterday morning the dressing on the wound was dated for Friday the 28th. I reported that to the Nursing Home Administrator (NHA), the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) at 7:49 a.m. on Monday. Review of incidents submitted to the State Agency on 9/1/26, at 12:32 p.m. did not include Resident R4's allegation of neglect on 8/31/26. During an interview on 9/1/26, at 12:40 p.m. the NHA confirmed that the facility failed to report an allegation of neglect in the required timeframe for Resident R4. Review of the admission record revealed that Resident R57 was admitted to the facility on [DATE]. Review of the facility's grievance log dated August 2026, indicated on 8/19/26, Resident R57 reported a concern of missing $25 dollars. Resident placed money on bedside table and left room for a while. The money was not located. Review of the admission record revealed that Resident R112 was admitted to the facility on [DATE]. Review of the facility grievance log dated June 2026, indicated on 6/5/26, Resident R112 reported a concern of missing $35 dollars. Review of the admission record revealed that Resident R115 was admitted to the facility on [DATE]. Review of the facility grievance log dated May 2026, indicated on 5/14/26, Resident R115 reported a concern of missing $54 dollars. Review of the admission record revealed that Resident R119 was admitted to the facility on [DATE]. Review of the facility grievance log/concern dated April 2026, indicated on 4/10/26, Resident R119 reported a concern of missing $75 dollars and on 4/13/26, reported a concern of missing $50 dollars. Review of incidents submitted to the State Agency on 9/2/26, at 8:00 a.m. did not include reports for the allegations of misappropriation of property for Residents R57, R112, R115, and R119 as required. Interview on 9/2/26, at 8:30 a.m. the Director of Nursing confirmed the facility failed to report allegations of misappropriation of property for four of seven residents (Residents R57, R112, R115, and R119). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(3)(e)(1) Management.

Based on review of facility policy, review of facility grievances, resident interviews, and staff interviews, it was determined that the facility failed to ensure that residents are free from misappropriation of property for four of four residents (Resident R57, R112, R115, and R119).Findings include: Review of the facility's Abuse Protection policy last reviewed 7/1/26, indicated the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporate punishment, involuntary seclusion, neglect, and misappropriation of property. Review of the admission record revealed that Resident R57 was admitted to the facility on [DATE]. Review of the facility's grievance log dated August 2026, indicated on 8/19/26, Resident R57 reported a concern of missing $25 dollars. Resident placed money on bedside table and left room for a while. The money was not located. Review of the admission record revealed that Resident R112 was admitted to the facility on [DATE]. Review of the facility grievance log dated June 2026, indicated on 6/5/26, Resident R112 reported a concern of missing $35 dollars. Review of the admission record revealed that Resident R115 was admitted to the facility on [DATE]. Review of the facility grievance log dated May 2026, indicated on 5/14/26, Resident R115 reported a concern of missing $54 dollars. Review of the admission record revealed that Resident R119 was admitted to the facility on [DATE]. Review of the facility grievance log/concern dated April 2026, indicated on 4/10/26, Resident R119 reported a concern of missing $75 dollars and on 4/13/26, reported a concern of missing $50 dollars. Interview on 9/2/26, at 8:30 a.m. the Director of Nursing and Nursing Home Administrator confirmed the facility failed to ensure that residents are free from misappropriation of property for four of four residents (Resident R57, R112, R115, and R119). 28 Pa. Code: 211.12 (d)(1)(5) Nursing services.28 Pa. Code: 201.29(a) Resident rights.

Based on review of documents submitted to the State agency and staff interviews it was determined that the facility failed to notify the State agency of a change in the facility's Medical Director at the time of the change.Findings include: Review of the facility's data indicated Medical Director Employee E4 was the Medical Director effective 7/1/26. During an interview on 8/31/26, at 9:53 a.m. the Nursing Home Administrator (NHA) indicated that Medical Director Employee E5 no longer worked at the facility and was replaced with Medical Director Employee E4. Interview on 8/31/26, at 9:55 a.m. the NHA confirmed that the facility failed to notify the State agency of a change in the facility's Medical Director at the time of the change. 28 PA Code: 201.14(a) Responsibility of licensee.

Based on review of facility policy, facility documents, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of four residents reviewed (Resident R4).Finding include: Review of facility policy Abuse Protection dated 7/1/26, indicated each resident has the right to be free from abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safety adequate, and appropriate services, treatment of care, including but not limited to: nutrition, medication, therapies, and activities to daily living. The absence of reasonable accommodations of individual needs and preferences may result in resident neglect. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/20/26, indicated diagnoses of anxiety, depression, and need for assistance with personal care. Review of a physician order dated 7/29/26, indicated to cleanse coccyx (tailbone) with NSS (normal sterile saline), apply Alginate (a high absorbent wound dressing) and cover with a foam dressing every day shift for wound care. During an interview on 8/31/26, at 9:58 a.m. Resident R4 stated, Licensed Practical Nurse (LPN) Employee E1 changed my dressing this morning, she said the dressing that was on my wound was dated for Friday the 28th. It is supposed to be changed daily, it wasn't done on Saturday or Sunday. Review of Resident R4's August 2026 Treatment Administration Record (TAR) indicated the ordered treatment to the coccyx wound was documented as completed on 8/29/26, and 8/30/26, during the day shift (7 a.m. - 3 p.m.). During an interview on 9/1/26, at 12:29 p.m. LPN Employee E1 stated, Yes, when I changed Resident R1's dressing yesterday morning the dressing on the wound was dated for Friday the 28th. I reported that to the Nursing Home Administrator (NHA), the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) at 7:49 a.m. on Monday. During an interview on 9/1/26, at 12:40 p.m. the DON confirmed that LPN Employee E1 had reported Resident R4's dressing was not changed on 8/29/26, and 8/30/26, and the facility was conducting an investigation at that time. During an interview on 9/3/26, at 10:50 a.m. the DON stated, We have identified three Alleged Perpatrators (APs) involved. Two of the nurses signed off the dressing prior to performing the treatment. One nurse was sent home early due to staffing and had signed off the treatment and stated she forgot to tell the nurse taking over that she had not done the dressing yet. We interviewed Resident R4 and she stated she kept telling staff to come back later to do the dressing change. Review of a witness statement dated 9/1/26, indicated Resident R4 stated, Resident R4 stated that she didn't even realize her coccyx treatment wasn't done for 3 days until wound nurse told her. Resident stated there are times that the nurse will come in to do her treatments and she tells them she doesn't want it done at that time and will tell the nurses to come back. She doesn't remember if she told them that this weekend but will tell them that often. Resident R4 stated that she may forget to remind them or the nurse will forget to come back. Due to resident's schedule, wound treatment moved to 11 p.m. - 7 a.m. shift per resident's personal preference. Review of a written interview dated 9/1/26, with Registered Nurse (RN) Employee E8 indicated, RN Employee E8 does not remember if she completed the treatment. Did do colostomy care on resident. Resident R4 did not ask for treatment to be done or remind RN Employee E8. RN Employee E8 had a busy day dealing with another resident that was removing dressings and was confused. Review of an undated staff witness statement completed by LPN Employee E6 stated, On 8/28/26 I was the nurse assigned to Resident R4. Early in the shift I offered to change her dressing. Resident said not yet. I also was dealing with two residents on my hall, actively as a fall risk. I was sent home early and during my charting I signed off the dressing. Can't remember if I passed it on in report. Review of Resident R4's August TAR indicated LPN Employee E6 signed off the ordered coccyx wound dressing as completed during the day shift on 8/28/26. Review of Resident R4's August 2026 TAR indicated RN Employee E8 signed off the ordered coccyx wound dressing as completed during the day shift on 8/29/26. Review of a staff witness statement dated 8/30/26, completed by RN Employee E7 stated, Asked patient about changing her dressing. She wanted me to come back later. I forgot to re-adjust the MAR (Medication Administration Record), to mark she refused at that time. Review of Resident R4's August TAR indicated RN Employee E7 signed off the ordered coccyx wound dressing as completed during the day shift on 8/30/26. During an interview on 9/3/26, at 10:50 a.m. the DON confirmed that the facility failed to ensure that Resident R4 were free from neglect. 28 Pa. Code: 201.14(a) Responsibility of licensee28 Pa. Code: 201.18(b)(1) Management.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policies, clinical records, facility documents, and staff interviews it was determined that the facility failed to identify a perimeter mattress (a specialized mattress that incorporates built-in edge support to create a raised, cushioned, or air-filled rail round the perimeter of the bed) as a possible restraint, failed to identify a pommel cushion (a wheelchair seat cushion with a raised center used to prevent forward sliding) and failed to assess the functional status of the individual resident to determine if the use of a perimeter mattress and pommel cushion is a restraint for one of four residents (Resident R13).Findings include: Review of facility policy Restraints dated 7/1/26, indicated physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Review of the clinical record indicated Resident R13 was admitted to the facility on [DATE]. Review of Resident R13's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/24/26, indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and need for assistance with personal care. Review of a physician order dated 7/24/26, indicated perimeter defining mattress. Review of a physician order dated 7/30/26, indicated transfers with assist of 1. Positioning: OOB (out of bed) to standard wheelchair with pommel cushion. B (bilateral - both sides) leg rests for transport only. Review of Resident R13's comprehensive care plan dated 4/23/25, indicated the resident has an ADL (activities of daily living) self care performance deficit related to limited mobility and cognitive deficits related to CVA (cerebrovascular accident - a stroke). Interventions include positioning: OOB to standard wheelchair with pommel cushion. Bilateral leg rests for transport only. Review of Resident R13's comprehensive care plan dated 4/24/26, indicated the resident is risk for falls. Interventions include hospice to provide bolster mattress (a type of perimeter mattress) for bed positioning. During an observation on 8/31/26, at 9:21 a.m. Resident R13 was observed lying in bed and the mattress had bilateral raised edges on the top and bottom portions. Resident R13's wheelchair was observed to have a pommel cushion on the seat. Review of Resident R13's clinical record failed to identify any assessments or ongoing evaluations for the usage of a perimeter mattress and pommel wheelchair cushion. During an interview on 9/3/26, at 10:05 a.m. the Director of Nursing confirmed that the facility failed to identify a perimeter mattress and a pommel cushion as a possible restraint and failed to assess the functional status of the individual resident to determine if the use of a perimeter mattress and pommel cushion is a restraint for Resident R13. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, reports submitted to the State, clinical record review, and staff interview, it was determined that the facility failed to implement written policies and procedures to ensure an allegation of neglect was reported in the required timeframe for one of four residents (Resident R4).Findings include: Review of facility policy Abuse Protection dated 7/1/26, indicated our abuse prevention program provides policies and procedures that govern, as minimum: reporting/response - the reporting and filing of accurate documents relative to incidents of abuse; reporting to State agencies as required, analyze and implement necessary changes to prevent future occurrences of abuse. Review of facility policy Abuse Reporting and Investigation dated 7/1/26, indicated the Department of Health will be notified of the alleged event by the Administrator or designee via the Electronic Reporting System per regulation. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/20/26, indicated diagnoses of anxiety, depression, and need for assistance with personal care. Review of a physician order dated 7/29/26, indicated to cleanse coccyx (tailbone) with NSS (normal sterile saline), apply Alginate (a high absorbent wound dressing) and cover with a foam dressing every day shift for wound care. During an interview on 8/31/26, at 9:58 a.m. Resident R4 stated, Licensed Practical Nurse (LPN) Employee E1 changed my dressing this morning, she said the dressing that was on my wound was dated for Friday the 28th. It is supposed to be changed daily, it wasn't done on Saturday or Sunday. Review of Resident R4's August 2026 Treatment Administration Record (TAR) indicated the ordered treatment to the coccyx wound was documented as completed on 8/29/26, and 8/30/26, during the day shift (7 a.m. - 3 p.m.). During an interview on 9/1/26, at 12:29 p.m. LPN Employee E1 stated, Yes, when I changed Resident R1's dressing yesterday morning the dressing on the wound was dated for Friday the 28th. I reported that to the Nursing Home Administrator (NHA), the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) at 7:49 a.m. on Monday. Review of incidents submitted to the State Agency on 9/1/26, at 12:32 p.m. did not include Resident R4's allegation of neglect on 8/31/26. During an interview on 9/1/26, at 12:40 p.m. the NHA confirmed that the facility failed to implement written policies and procedures to ensure an allegation of neglect was reported in the required timeframe for Resident R4. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(3)(e)(1) Management.

Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility one of two residents (Resident R8).Findings include: Review of facility policy Splint dated 7/1/26, indicated upon a physican order, a splint may be used to immobilize, support, and protect and injured body part. Splints are applied per physician order. Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE]. Review of Resident R8's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/22/26, indicated diagnoses of high blood pressure, stroke (occurs when blood supply to the brain is blocked or when a blood vessel bleeds in the brain), and hemiplegia (paralysis on one side of the body). Review of a physician order dated 8/26/26, indicated to apply c-grip splint to left hand as tolerated. Review of Resident R8's care plan dated 8/28/26, indicated the resident has ADLS (Activities of Daily Living) performance deficit due to contracture and left side hemiplegia (paralysis of left side of body). Interventions included to wear c-grip splint to left hand as tolerated, remove for hygiene and check for skin integrity. During an interview and observation on 8/31/26, at 11:50 a.m. Resident R8 was observed lying in bed without a c-grip splint to the left hand. Resident R8 stated she was unsure where it is and that it was last worn a few weeks ago when asked the last time she worn the splint. During an observation on 9/1/26, at 11:31 a.m. Resident R8 was observed lying in bed without a c-grip splint to the left hand. During an observation on 9/2/26, at 10:16 a.m. Resident R8 was observed lying in bed without a c-grip splint to the left hand. Review of Resident R8's clinical record failed to include documentation that the resident refused or did not tolerate the c-grip splint on 8/31/26, and 9/1/26. During an interview on 9/2/26, at 10:18 a.m. Registered Nurse, Employee E2 confirmed Resident R8's c-grip splint was not available and was not applied as ordered. During an interview on 9/2/26, at 10:20 a.m. information was disseminated to the Nursing Home Administrator that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility one of two residents (Resident R8). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility documents, record review, and resident and staff interviews it was determined that the facility failed to provide a resident environment free of accidental hazards for one of two residents (Resident R33).Findings include. Review of the facility's admission Agreement indicated that residents have the right to a safe, clean, comfortable and homelike environment including but not limited to receiving treatment and supports for daily living safely, and ensuring that the physical layout of the facility maximizes resident independence and does not pose a resident safety risk. Review of Resident 33's clinical record indicated that he was admitted to the facility on [DATE]. Review of Resident R33's clinical record revealed a progress note dated 12/16/26, that stated the following: Resident went out at about 9 am today for an appointment. Resident went out via wheelchair van. Resident did not make it to the appointment as the driver reported that this resident slid to the edge of his chair and needed help to be pulled back therefore, she called 911. This resident reports that he slid to the edge of his chair with his knees wedged between the seat in front of him causing some pain and discomfort to his knees, left knee slightly red nothing observed to the right knee. Resident voiced that when the ambulance arrived there was two officers and two ambulance attendees that laid him on the floor in order to us a Hoyer lift (a medical transfer device used to safely lift and move people). Review of the facility document Fall Investigation date 12/16/26, stated Resident being transported to appointment. Resident reported that the driver hit the brakes and he slid to the edge of his chair with his knees wedged against seat. X-rays completed and were negative. Review of Resident R33's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/10/26, indicated diagnoses of high blood pressure, muscle weakness, and age-related physical debility. During an interview on 9/2/26, at 10:04 a.m. Resident R33 recounted the above incident that occurred on 12/16/26, and added that the wheelchair van has two different positions to place a wheelchair; one is closer to the back of the van, and the other is closer to the front of the van. Resident stated that he was placed towards the front to of the van directly behind the van seats, and that wheelchair was secured to the floor so that it would not move during transport. He was restrained in the wheelchair via a lap belt. He stated that no leg rests were placed on his wheelchair prior to leaving the facility. When the driver hit the brakes, I slid underneath the seatbelt. My a** was on the floor and my knees were up against my chest. I was pushed up against the seat in front of me. The driver couldn't get me up so she called 911, and the cops couldn't help me either, so they called Fire and Rescue, who got me up with a Hoyer lift. The whole ordeal lasted about 20-30 minutes. During an interview on 9/2/26, at 11:26 a.m. Rehab Director Employee E10 stated that all wheelchairs are issued with leg rests, and they are utilized to prevent injuries. If a resident can self-propel their wheelchair, the leg rests are placed in a holder on the back of the wheelchair, and they should be placed in position on the wheelchair before someone pushes them in their wheelchair. If the leg rests were on for this appointment, they may not have prevented him from sliding, but they would have stopped him from going all the way down to the floor. During an Interview on 9/2/26, at 10:24 a.m. the Nursing Home Administrator confirmed the facility failed to provide a resident environment free of accidental hazards for one of two residents. 28 Pa. Code 201.14(b) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management.28 PA Code: 201.29(a) Resident rights.

Based on review of the clinical records and staff interview, it was determined that the facility failed to provide documentation that a physician provided a rationale for a medication regimen review (MRR) for one of five residents (Residents R7). Findings include: Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of Resident R7's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/19/26, indicated diagnoses of anxiety, depression, and psychotic disorder. Review of Resident R7's physician order dated 10/13/25, indicated to administer ZyrTEC (medication used to treat allergies) oral tablet 10 milligram (mg), one tablet by mouth two times a day for allergies. Review of Resident R7's physician order dated 10/14/25, indicated to administer loratadine (medication used to treat allergies) oral tablet 10 mg, one tablet in the morning for allergies. Review of Resident R7's MRR dated 12/31/25, indicated concurrent use of Zyrtec and loratadine may be considered duplicated therapy. Please document rationale if continuing present therapy. A further review revealed the physician signed the MRR on 1/7/26, and indicated the therapeutic suggestions were not accepted. The physician failed to provide a reason for not accepting. A review of Resident R7's clinical record failed to include a rationale for the physician not accepting pharmacy recommendations and a rationale documented for continued use. Interview on 9/2/26, at 1:36 p.m. the Director of Nursing confirmed that the physician failed to provide a rationale for Resident R7's continued use of Zyrtec and loratadine. The DON confirmed the facility failed to ensure medication regimen reviews (MRR) were completed as required for one of five residents (Residents R7). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.5(f) Medical records.28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of manufacuter guidelines, clinical record review, observations, and staff interviews, it was determined that the facility failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R30).Findings Include: Review of Clorox Bleach Germicidal Disinfectants usage guideline states to wait for the contact time of three minutes. Review of the clinical record indicated Resident R30 was admitted to the facility on [DATE]. Review of Resident R30's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/25/26, indicated diagnoses of high blood pressure, malnutrition, and stage three pressure ulcer (a full-thickness skin injury that extends through the dermis into the subcutaneous fat). Review of a physician order dated 9/2/26, indicated to cleanse coccyx with vashe (a topical wound care solution designed to cleanse, disinfect, and promote healing of a wound), lightly pack with vashe moistened gauze and cover with dry dressing. During a dressing change observation on 9/2/26, from 9:33 a.m. to 9:55 a.m. Wound Care Licensed Practical Nurse (LPN) Employee E1 failed to maintain the Clorox's bleach wipes contact dwell time of three minutes prior to applying supplies on top of the treatment cart and placing a barrier on the resident's bedside table. Wound Care Nurse, LPN, Employee E5 packed Resident R30's wound with her finger. During an interview on 9/2/26, at 9:57 a.m. Wound Care LPN, Employee E1 confirmed the Clorox bleach wipes dwell time was three minutes and confirmed she failed to adhere to the dwell time. Wound Care, LPN, Employee E1 confirmed the facility failed to prevent cross contamination during a dressing change for Resident R30. During this interview on 9/2/26, at 9:58 a.m. the Director of Nursing confirmed that the facility failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R30). 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1)(e)(1) Management.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.

Based on review of facility policy, observation and staff interview it was determined that the facility failed to properly contain and dispose of garbage in one of two outside dumpsters to prevent the potential for rodent and insect infestation (left dumpster).Findings include: Review of facility policy Dispose of Garbage and Refuse dated 7/1/26 indicated that all garbage and refuse will be collected and disposed of in a safe manner. The Dining Services Director coordinates with the Director of Maintenance to ensure that the area surrounding the exterior dumpster area is maintained in a manner free from rubbish or other debris. Appropriate lids are provided for all containers. During an observation and interview of the facility's outdoor trash receptacles on 8/31/26, at 9:15 a.m. Food Service Director Employee E9 confirmed that bags of garbage were piled higher than the top of the dumpster, preventing the lid of the dumpster from being closed . 28 Pa. Code 201.18(b)(3) Management.

Based on review of facility policy, clinical records, observations, and staff interviews, it was determined that the facility failed to timely document insulin administration for two of four residents (Resident R5 and R99).Findings include: Review of the facility policy Medication Administration last reviewed 1/27/26, indicated medications are administered at the time they are prepared. E-MAR documentation of medication orders includes the date and time of administration. Documentation is done immediately after the administration and/or refusal of the medication or attempt. Review of the clinical record revealed Resident R5 was admitted to the facility on [DATE], with diagnoses of high blood pressure, anxiety, and diabetes (occurs when your blood sugar (glucose) is too high. It develops when your pancreas doesn't make enough insulin or any at all). Review of Resident R5's care plan dated 11/16/20, indicated the resident has diabetes and to administer medication as ordered by doctor. Observe for side effects and effectiveness. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/19/26, indicated diagnoses were current. Review of Resident R5's physician order dated 6/30/26, indicated to administer Humalog KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro-a rapid-acting insulin used to control blood sugar) at 6:30 a.m. Inject as per sliding scale. During an interview and observation on 9/1/26, at 9:22 a.m. Resident R5's insulin was observed not signed off in the electronic record. LPN, Employee E3 stated I didn't have a chance to sign it off yet. It was indicated the medication was already administered. Licensed Practical Nurse (LPN), Employee E3 confirmed he failed to timely document insulin administration for Resident R5. Review of the clinical record revealed Resident R99 was admitted to the facility on [DATE], with diagnoses of high blood pressure, anxiety, and diabetes. Review of Resident R99's care plan dated 1/28/25, indicated the resident has diabetes. Review of Resident R99's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/3/26, indicated diagnoses were current. Review of Resident R99's physician order dated 3/17/26, indicated to administer Novolog Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart-a rapid-acting insulin used to control blood sugar) at 8:00 a.m. Inject as per sliding scale. During an interview and observation on 9/1/26, at 9:12 a.m. Resident R99's insulin was observed not signed off in the electronic record. It was indicated the medication was late. Licensed Practical Nurse (LPN), Employee E3 stated the insulin was already administered, and he failed to immediately document after administration in the clinical record. During an interview on 7/31/26, at 9:28 a.m. information was disseminated to the Director of Nursing and Nursing Home Administrator that the facility failed to timely and accurately document insulin administration for two of four residents (Resident R5 and R99). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.5(f) Medical records.28 Pa. Code: 211.12(d)(3)(5) Nursing services.

Based on review of facility policy, observations and staff and resident interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment by not maintaining an acceptable water temperature for two of three units (North Unit and South Unit).Findings Include: Review of the facility policy Resident Environment last reviewed 2/16/26, indicates the facility will provide an environment that is safe, clean, comfortable, and homelike. Review of the facility policy Water Temperature last reviewed 2/16/26, indicates water distribution systems shall be designed and arranged to provide potable hot and cold water at hot and cold-water outlets at all times. Review of the facility provided grievance log on 4/28/26, revealed two concerns about the hot water temperatures. On 2/25/26, a resident filed a concern about the hot water temperatures. The facilities corrective action was water in shower rooms checked; temperatures within range, the resident was notified by maintenance to try when not all the stalls are in use, resident happy with outcome. On 4/20/26, a resident daughter filed a concern there was no hot water. The facilities corrective action was the daughter stated the information is received from roommate. Water temperature is above 100. During an interview completed on 4/28/26, at 10:52 a.m. upon asking Registered Nurse (RN) E3 concerning the hot water replied we did have the system replaced about one to two weeks ago. It happened over a weekend and they came in, we had hot water on the other side. During an interview completed on 4/28/26, at 11:03 a.m. upon asking Licensed Practical Nurse (LPN) Employee E5 concerning the hot water temperatures replied, they replaced the entire system 2 weeks ago, It has been fantastic. We only lost for the one side of the building. The subacute side was used for showers and filling basins. During an interview completed on 4/28/26, at 11:06 a.m. upon asking Nurse Aid (NA) Employee E6 concerning hot water replied some say it's not hot enough, it has gotten better over the last few weeks, we used the shower on the other side During an interview completed on 4/28/26, at 11:10 a.m. upon asking Housekeeper Employee E7 concerning hot water replied we were missing hot water for a while, I can't remember when, its ok now we have it. During an interview completed on 4/28/26, at 11:14 a.m. upon asking NA Employee E8 concerning hot water replied, we had it fixed a few weeks ago, we used the other side to get hot water. During an interview completed on 4/28/26, at 11:16 a.m. upon asking NA Employee concerning hot water replied, not now, in the past we had issues about two weeks ago we couldn't give showers we used the other floor it is good now. During an interview completed on 4/28/26, at 11:20 a.m. upon asking LPN Employee E10 concerning the hot water temperatures replied about 2 weeks ago the other side did not have hot water, they used the subacute side for showers and to provide hot water. It has since been fixed. During an interview completed on 4/28/26, at 11:39 a.m. with the Nursing Home Administrator (NHA) it was revealed that the one boiler was having issues, and the facility had it repaired the NHA stated we always had water it was not completely shut off the water was just not warm enough Upon requesting temperature logs for the time period when the water temperatures weren't warm enough revealed that the temperatures were not logged/monitored. During an interview completed on 4/28/26, at 11:50 a.m. Maintenance Employee E2 stated we weren't getting the temperatures that were needed, so there was lukewarm water on the North and South units. The subacute unit was not affected. For showers they would use the subacute side. Basins were being filled and provided that way. It was on a Friday afternoon until Tuesday morning a couple of weeks ago. Two of the three units did not have readily available hot water in the rooms. No temperatures were taken, the water felt cool. During a facility tour and observation with Maintenance Director Employee E2 on 4/28/26, between approximately 11:53 a.m. and 12:25 p.m. resident rooms were observed to have the following hot water temperatures for bathing: -The hot water temperature of the resident room [ROOM NUMBER]'s sink registered at 98.6 degrees Fahrenheit. -The hot water temperature of the resident room [ROOM NUMBER]'s sink registered at 98.6 degrees Fahrenheit. -The hot water temperature of the resident room [ROOM NUMBER]'s sink registered at 98.2 degrees Fahrenheit -The hot water temperature of resident room [ROOM NUMBER]'s sink registered at 95.2 degrees Fahrenheit -The hot water temperature of resident room [ROOM NUMBER]'s sink registered at 97.2 degrees Fahrenheit -The hot water temperature of resident room [ROOM NUMBER]'s sink registered at 96.8 degrees Fahrenheit. -The hot water temperature of resident room [ROOM NUMBER]'s sink registered at 95.8 degrees Fahrenheit. -The hot water temperature of the resident room [ROOM NUMBER]'s sink registered at 96.4 degrees Fahrenheit. -The hot water temperature of the resident room [ROOM NUMBER]'s sink registered at 95.3 degrees Fahrenheit. -The hot water temperature of the North Hall shower room registered at 94.8 degrees Fahrenheit. -The hot water temperature of the South Hall shower room registered at 99.0 degrees Fahrenheit. -The hot water temperature of the subacute shower room registered at 98.0 degrees Fahrenheit. During an interview completed on 4/28/26, at 11:53 a.m. upon asking Resident R2 in room [ROOM NUMBER]-W concerning the hot water temperature replied, for about a week they were low, when I got to go back into the shower it was warmer, they had it fixed. During an interview completed on 4/28/26, at 12:00 p.m. upon asking Resident R3 in room [ROOM NUMBER] concerning the water temperature replied, I just started getting showers again, it felt warmer. During an interview completed on 4/28/26, at 12:03 p.m. upon asking Resident R4 in room [ROOM NUMBER]-D concerning the hot water temperature replied, it has to run quite a bit, gets lukewarm not as hot as I would like it. During an interview completed on 4/28/26, at 12:15 p.m. upon asking Resident R5 in room [ROOM NUMBER]-W concerning the water temperature replied, I took a cold shower this morning, it was not enjoyable I couldn't wash my hair, I might try to do it in the sink, I don't know yet. During an interview completed on 4/28/26, at 12:15 p.m. upon asking Resident R6 in room [ROOM NUMBER]-D if the water was warm replied barely. During an interview completed on 4/28/26, at 12:30 p.m. Maintenance Employee E2 stated I'm still adjusting the boiler we have two units now. The company did a good job I was impressed with the time; they came in right away. Water was available just not the hot water on the one side. They turned off the water for a short period of time. My goal is to get the hot water temperatures to around 107 to 108 degrees Fahrenheit and that the facility failed to provide a clean, safe, comfortable, and homelike environment by not maintaining an acceptable water temperature for two of three units (North Unit and South Unit). 28 Pa. code: 201.14 (b) Responsibility of licensee.28 Pa Code: 201.18 (e)(1)(2) Management.28 Pa Code: 201.29 (a)(c) Resident Rights.

Based on facility policy, clinical records and staff interview, it was determined that the facility failed to develop a care plan for two of three residents (Resident R1 and R97) to accurately reflect the current status of the resident. Findings include: Review of the facility policy “Care Plan” last reviewed 4/2/25, indicated the facility’s interdisciplinary team will develop a comprehensive care plan for each resident. The residents’ care plan shall be developed upon admission and implemented as soon as possible thereafter and describe the services that are to be furnished to attain or maintain the residents’ highest practical physical, mental and psychosocial well-being. A review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. A review of the Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 6/9/25, indicated the diagnoses of high blood pressure, depression and diabetes (high sugar in the blood). A review of Resident R1’s physician orders dated 7/18/25, indicated insulin Lispro (fast acting) subcutaneous solution cartridge 100 UNIT/milliliter (ml) inject as per sliding scale with meals resident has a Libre (Continuous Glucose System) and self-check with phone nurse to document. A review of Resident R1’s physician orders dated 7/18/25, indicated insulin Glargine (long acting) subcutaneous solution inject 34 units subcutaneously at bedtime resident has Libre and self-check with phone nurse to document. A review of Resident R1’s physician orders dated 8/13/25, indicated free style Libre 3 sensor inject 1 application every 15 days for diabetes monitoring. A review of Resident R1’s current care plan failed to include interventions for Libre. A review of the clinical record indicated Resident R97 was admitted to the facility on [DATE], with diagnoses that included atrial fibrillation (irregular heartbeat where the heart's two upper chambers, the atria, quiver and beat too fast instead of contracting properly), hypertension and type 2 diabetes mellitus. A review of Resident R97's quarterly MDS dated [DATE], indicated the diagnosis remained current. A review of Resident R97's physician orders dated 8/20/25, indicated Tresiba FlexTouch Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Degludec) Inject 30 unit subcutaneously in the morning for DM2 resident has libre (continuous glucose monitoring) and self-checks. A review of Resident R97's current care plan revealed no care plan for the libre. During an interview on 8/28/25, at 1:30 p.m. Nursing Home Administrator confirmed the facility failed to revise the care plan for Resident R97 as required. During an interview completed on 08/28/25, at 1:44 p.m. the Director of Nursing confirmed that the facility failed to implement a care plan for Resident R1’s Libre system and that the facility failed to develop a care plan for two of three residents (Resident R1 and R97) to accurately reflect the current status of the resident. 28 Pa. Code: 211.11(d) Resident Care Plan

Based on a review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident representative of the start of a new antibiotic for one of three residents (Resident R136).Findings include: Review of the facility policy Notification of Change of Condition: Responsible Party/Guardian last reviewed 4/2/25, indicated the responsible party or guardian is to be notified of changes in condition or occurrences. The nurse must document the name of the person notified, the date and time in the nurse's notes. Review of the clinical record indicated that Resident R136 was admitted to the facility on [DATE]. Review of Resident R136's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/20/25, included diagnoses of high blood pressure, depression and heart failure (the heart doesn't pump the way it should). Review of Resident R136's physician orders dated 6/18/25, indicated Keflex oral capsule (treats bacterial infection) give 500 milligrams (mg) three times a day for cellulitis right hip for 7 days. Review of Resident R136's physician progress notes dated 6/18/25, indicated asked by staff to see the patient. Resident R136 has a right lateral thigh redness with tenderness. Clinically it looks like cellulitis. Will treat with the Keflex for one week and reevaluate. Review of Resident R136's progress notes failed to include notification of Resident R136's representative of the start of the new antibiotic. During an interview completed on 08/27/2025, 12:22 p.m. the Nursing Home Administrator confirmed that the facility failed to notify the resident representative of the start of a new antibiotic for one of three residents (Resident R136). 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: 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on a review of facility policy, Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS - a periodic assessment of care needs) accurately reflected the resident's status for two of three residents (Resident R4 and R84).Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set Assessments dated October 2024, indicated the following instructions: Section O: Special Treatments, Procedures, and Programs, indicated to document what services and treatments were performed while a resident of the facility and within the last 14 days. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's MDS dated [DATE], indicated diagnoses of end stage renal disease (kidneys no longer function), high blood pressure and diabetes (high sugar in the blood). Section O Special treatments section J1- Dialysis, failed to be checked performed while a resident. Review of physician orders dated 7/30/25, indicated that resident R4 is scheduled for dialysis on Monday, Wednesday and Friday 10:00 a.m. to 2:00 p.m. Review of Resident R4's current care plan indicated Resident R4 needs dialysis related to renal failure. During an interview completed on 8/27/25, at 11:30 a.m. Registered Nurse Assessment Coordinator (RNAC) Employee E3 confirmed that Resident R4's MDS dated [DATE], Section O Special treatments section J1- Dialysis, failed to be checked performed while a resident. Review of the clinical record indicated Resident R84 was admitted to the facility on [DATE]. Review of Resident R84's MDS dated [DATE], indicated diagnoses of diabetes (high sugar in the blood), high blood pressure and dependence on supplemental oxygen. Section O Special treatments section C1- Oxygen Therapy failed to be checked performed while a resident. Review of Resident 84's physician orders dated 6/27/25, indicated oxygen at 4 liters per minute continuously via nasal cannula (device used to deliver oxygen through the nose) every shift. Review of Resident R84's current care plan indicated oxygen therapy dependence on supplemental oxygen. During an interview completed on 8/27/25, at 2:30 p.m. RNAC Employee E3 confirmed that Resident R84's MDS dated [DATE], Section O Special treatments section C1- oxygen therapy, failed to be checked performed while a resident and that the facility failed to ensure the MDS accurately reflected the resident's status for two of three residents (Resident R4 and R84). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.5(f) Medical records.

Based on observation, staff interview, clinical record review and review of the facility policy, it was determined that the facility failed to provide appropriate assistance with meals for one of three residents (Resident R65). Findings include: Review of the facility policy Flow of Care last reviewed 4/2/25, indicated the flow of care is to be implemented on a continuous basis to promote quality of life with the residents. The charge nurse will be responsible for evaluating compliance with the flow of care expectations to ensure that needs are met on an ongoing basis. Review of the admission record indicated Resident R65 was admitted to the facility on [DATE]. Review of Resident R65's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/14/25, indicated the diagnoses of heart failure (the heart doesn't pump blood as well as it should), atrial fibrillation (irregular heart rhythm), and dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life). Section C0500 - Brief Interview for Mental Status (BIMS - is a screening test that aides in detecting cognitive impairment) indicated a score of 12 - moderately impaired cognition. Review of Resident R65's current care plan on 8/25/25, indicated Special Instructions Staff to cut food into small pieces at mealtimes. During an observation on 8/25/25, at 11:53 a.m. Resident R65's meal ticket indicated that staff is to cut food into small pieces at mealtimes. Resident R65 was observed sitting in a wheelchair at bedside, with a piece of whole chicken breast in both hands attempting to tear it apart with fingers. During an interview on 8/25/25, at 11:54 a.m. Nurse Aide (NA) Employee E6 confirmed Resident R65 had a piece of whole chicken breast in both hands attempting to tear it apart with fingers, and that staff failed to cut the food into small pieces at mealtime as indicated. During an interview on 8/25/25, at 12:00 p.m. the Director of Nursing confirmed the facility failed to provide appropriate assistance with meals for one of three residents (Resident R65). 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical record, facility documents, reports submitted to the State, and staff interview it was determined that the facility failed to report an allegation of neglect for one of three residents (Resident R2).Findings include: Review of facility Abuse Protection policy last reviewed 4/2/25, indicated regardless of how minor an accident or incident may be, it must be reported to the department supervisor as soon as such accident/incident is discovered or when information of such accident/incident has been discovered. The reporting and filing of accurate documents relative to incidents of abuse, reporting to State agencies as required. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/30/25, indicated diagnoses of high blood pressure, cancer, and mood disorder. MDS Section GG-Functional Abilities, GG0130 Self-Care for lower body dressing was coded as a 1, which revealed the resident was dependent with the ability to dress and undress below the waist. Resident R2 does none of the effort to complete the activity. Review of Resident R2's progress note dated 8/19/25, revealed the resident arrived at an appointment with no pants on. It was documented the outside provider notified the facility Resident R2 did not have any pants on. Review of information submitted to the State Agency on 8/19/25, and 8/20/25, failed to include Resident R2's incident of neglect. During an interview on 8/26/25, at 11:45 a.m. the Nursing Home Administrator confirmed the facility failed to identify the incident of Resident R2 arriving to an appointment without pants on 8/19/25, as an allegation of neglect. The Nursing Home Administrator confirmed the facility failed to report an allegation of neglect for one of three residents (Resident R2). 28 Pa Code: 201.14 (a)(c )(e ) Responsibility of management 28 Pa Code: 201.18 (b)(1) (e)(1) Management.

Based on review of facility policies, resident record review, and staff interviews, it was determined that the facility failed to follow professional standards of practice when obtaining physician orders for one of four residents. (Resident R136).Findings include: Review of the facility policy Medication and Treatment Orders last reviewed 4/2/25, indicated telephone or verbal orders must be recorded in the clinical record, under physician orders when received and must be recorded by the nurse receiving the order. Review of the clinical record indicated that Resident R136 was admitted to the facility on [DATE]. Review of Resident R136's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/20/25, included diagnoses of high blood pressure, depression and heart failure (the heart doesn't pump the way it should). Review of Resident R136's nursing progress note dated 5/5/25, indicated Unit Manager (UM) called 3-11 Registered Nurse (RN) supervisor (sup) requested to put in order provided by physician (md) to unit manager for urinalysis with culture and sensitivity (UA/CS) due to increased confusion to determine if urinary tract infection (UTI). Order placed in point click care (PCC), assigned nurse. During an interview completed on 8/27/25, at 10:20 a.m. upon reviewing the nursing progress note dated 5/5/25, the Director of Nursing (DON) confirmed that a Unit Manager gave a RN supervisor a verbal order for a UA/CS and stated they are not a physician and that the facility failed to follow professional standards of practice when obtaining physician orders for one of four residents. (Resident R136). 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: 211.12 (d)(1)(2)(3)(5) Nursing services.