Every finding on record at Centennial Healthcare and Rehabilitation Center

Based on review of facility documentation, observations, and staff interviews it was determined that the facility failed to ensure safe and secure storage of all medications for three of three nursing units (Second, Third, Fourth Floor). Findings Include: Review of facility documentation revealed a June 2026 temperature log for the second-floor nursing unit medication refrigerator. The temperatures of the medication refrigerator were only documented twice. No temperature monitoring was documented for the remaining days of the month. Observations on June 29, 2026, inside the medication refrigerator on the fourth-floor nursing unit revealed it was operating at an excessively low temperature, with multiple medications observed to be encased in ice. Licensed nurse, Employee E7, confirmed the condition of the medications and removed/discarded affected medications due to potential compromised integrity of the medications. The refrigerator thermometer was observed to be malfunctioning/incorrect, contributing to inaccurate temperature monitoring. Observations on June 30, 2026, inside the medication refrigerator on the third-floor nursing unit revealed the refrigerator was unplugged and inoperable. Refrigerated medications were subsequently relocated and stored in the resident refrigerator in the room adjacent to medication storage room. The refrigerator to which the medications were relocated, was observed to contain food and beverages being stored for the residents. This refrigerator was not designated exclusively for medication storage and posed a risk for contamination and improper storage conditions. During an interview on June 30, 2026, Unit Manager, Employee E17, confirmed the refrigerator was inoperable, due to a nonfunctioning electrical outlet and acknowledged that medication should not have been stored in resident refrigerator. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to provide necessary respiratory care and services for one of 31 residents reviewed (Residents R35).Findings Include: Review of the facility policy titled, Oxygen Therapy Policy dated January 2026 states, Policy Statement- This policy is to instruct on how to treat hypoxemia, decrease work of breathing and decrease myocardial work in patients requiring supplemental oxygen therapy due to respiratory or cardiac insufficiency. Further review of the facility policy states, Procedure 1. Follow Standard Precautions 2. Verify the physician's order (should include liter flow, type of oxygen delivery device). Further review of the policy states, Oxygen Equipment Maintenance- Oxygen equipment will be maintained in a clean, safe, and functional condition according to facility policy and the manufacturer's guidelines. A tour of the third-floor nursing unit on June 29, 2026, at 11:10 a.m. revealed Resident R35's oxygen machine was observed to be visibly soiled with speckles of gray substance on the back of the filter and on the machine. Review of Resident R35's clinical record revealed no physician order for oxygen. Follow-up observations on June 30, 2026, at 10:00 a.m. revealed housekeeping aide, Employee E16, was in the room cleaning off the oxygen machine. Housekeeping Aide, Employee E16, confirmed Resident R35's oxygen machine was dirty and therefore staff was cleaning it. When asked how often they are cleaned Housekeeping Aide, Employee E16, was unsure. Interview on June 30, 2026, at 1:42 p.m. Maintenance Director, Employee E10, provided the surveyor with monthly Concentrator Checklists last completed on June 4, 2026. Maintenance Director, Employee E10, stated that the filter's and machines are cleaned once a month and in between nursing is supposed to notify maintenance/housekeeping if they need additional cleaning. Review of Resident R35's care plan revealed no care plan in place for maintenance of the oxygen machine. Interview held with licensed nurse, Employee E14, on July 1, 2026, at 11:00 a.m. confirmed Resident R35 did not have a physician order for oxygen prior to June 30, 2026. 28 Pa Code 211.12(d)(1) Nursing services. 28 Pa Code 211.12(d)(5) Nursing services.

Based on review of facility policy and observations it was determined that the facility failed to implement and maintain effective infection control practices related to feeding assistance for two of 31 residents reviewed (Residents R20 and R165).Findings Include: Review of the facility policy titled, Assistance with Meals last revised December 2025 states, Policy Statement- Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Review of the facility policy titled, Handwashing/Hand Hygiene Policy last updated September 2024 states, Policy Statement- This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Further review of the facility policy states, Indications for Hand Hygiene: 1. Hand hygiene is indicated:.d. after touching a resident e. after touching the resident's environment. Review of Resident R165's nutrition assessment dated [DATE], states, Interventions: 1:1 feed. Review of Resident R20's physician orders revealed an order, Provide 1:1 feeds initiated on April 15, 2026. Observation was made of the dining room on the third floor on June 29, 2026. During observation a nurse aide Employee, E15, was seen at 12:33 p.m. assisting both Resident R20 and Resident R165 with feeding. Nurse aide, Employee E15, would feed one resident with their fork and then feed the second resident with their fork without completing hand hygiene in between. 28 Pa Code 201.14 (a) Responsibility of licensee. 28 Pa Code 211.12 (d)(5) Nursing services.

Based on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that arbitration agreements granted residents the right to rescind the agreements within 30 calendar days of signing it, for three of three residents reviewed (Residents R33, R68 and R187). Findings include: A Binding Arbitration Agreement is a legal process where parties in a dispute agree to have a neutral third party decide their case instead of a judge or jury. The arbitrators decision is final, and the parties usually cannot appeal it. Review of the Arbitration Agreement for Resident R33, revealed, This Agreement may be cancelled by written notice sent by certified mail to the Facility's Administrator within thirty (30) calendar days of the Resident's date of admission. If alleged acts underlying the dispute occur before the cancellation date, this Agreement shall be binding with respect to those alleged acts. The Agreement was signed by Resident R33 on June 10, 2026. Review of the Arbitration Agreement for Resident R68, revealed, This Agreement may be cancelled by written notice sent by certified mail to the Facility's Administrator within thirty (30) calendar days of the Resident's date of admission. If alleged acts underlying the dispute occur before the cancellation date, this Agreement shall be binding with respect to those alleged acts. The Agreement was signed by Resident R68 on June 11, 2026. Review of the Arbitration Agreement for Resident R187, revealed, This Agreement may be cancelled by written notice sent by certified mail to the Facility's Administrator within thirty (30) calendar days of the Resident's date of admission. If alleged acts underlying the dispute occur before the cancellation date, this Agreement shall be binding with respect to those alleged acts. The Agreement was signed by Resident R187 on June 25, 2026. Interview on June 30, 2025, at 2:15 p.m. the above was reviewed with the Nursing Home Administrator, that the facility's Arbitration Agreements did not meet the regulatory requirement of allowing residents to rescind the agreement within 30 days of signing the agreement. The Nursing Home Administrator confirmed that the Arbitration Agreements provided to residents stated that they had 30 days from their date of admission, not 30 days from them signing the agreement. 28 Pa Code 201.14(a) Responsibility of licensee

Based on review of clinical records, and staff and resident interviews it was determined that the facility ensure residents received shower as scheduled for one of 31 residents reviewed (Resident R23).Findings include: Review of Resident R23's clinical record revealed that the resident was admitted to the facility on [DATE], and has diagnoses of Conversion Disorder (a condition in which a person experiences real physical symptoms that are not explained by neurological disease or other medical conditions and are not under voluntary control) and obstructive pulmonary disease (a progressive lung disease characterized by persistent airflow limitation). Further review of Resident R23's clinical record revealed the resident has a BIMS (Brief Interview for Mental Status) score of 15, reflecting intact cognition. Review of Resident R23's comprehensive care plan revealed the resident has an ADL (Activities of Daily Living) self-care performance deficit with impaired balance, muscle weakness, and spondylosis (degenerative spinal condition). Per the care plan, Resident R23 requires one staff participation with bathing. The care plan did not include details of a bathing time preference. During an interview with Resident R23 on June 29, 2026 (Monday), at 10:00a.m. the resident reported he/she last received a shower on June 24, 2026 (Wednesday), and his/her scheduled showers are Wednesdays and Saturdays. Resident R23 reported he/she was not provided a shower on Saturday June 27, 2026. Review of Resident R23's bathing record from June 13, 2026, to June 27, 2026, revealed no documented evidence a shower was provided on June 27, 2026, but documented as not applicable. Interview with Licensed Nurse Employee, E14, on July 1, 2026, at 12:45p.m., Employee E14 did not know what not applicable meant and could not verify if Resident R23 did or did not have a shower or was offered a shower on June 27, 2026. Further interview with Licensed nurse, Employee E14, on July 1, 2026, at 2:15p.m., Employee E14 reported that he/she contacted Nurse Aide, Employee E11, [Resident R23's assigned nurse aide from 6/27/26] who stated that Resident R23 was offered a shower on June 27, 2026, but Resident R23 refused to have it done because it was offered after 4:00 p.m. Review of Resident R23's clinical record revealed no documentation of refusal. Interview with Director of Nursing, Employee E2, on July 2, 2026, at 10:30a.m., reported that Nurse Aide Employee E11 was busy and could not offer Resident R23 a shower by 4p.m. and Resident R23 prefers to have shower by 4p.m. 28 Pa. Code 201.29(j) Residents Rights 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of facility policy, clinical record review, observation, and interviews with staff and residents, it was determined that the facility failed to provide resident care and treatment in accordance with standards of professional practice and physician orders for two of 31 residents reviewed (Resident R182 and R176). Findings Include: Review of the facility policy, Charting and Documentation Change, revised July 2021, indicated that treatments and services performed must be documented in the resident's medical record. Record review revealed Resident R176 was admitted to the facility on [DATE], with diagnoses including flaccid hemiplegia affecting the right dominant side (paralysis of the right side of the body), muscle weakness, and sepsis (a serious infection affecting the whole body). Review of Resident R176's physician orders revealed an order dated March 3, 2026, to apply TED (compression stockings) to the right lower extremity during the day for edema (characterized by swelling in the extremities) and remove them at bedtime. Review of Resident R176's June 2026 Medication Administration Record (MAR) indicated the treatment had been documented as completed on June 30, 2026. Subsequent observation on June 30, 2026, revealed Resident R176 was not wearing the physician-ordered TED/compression stocking on the right lower extremity. Interview on June 30, 2026, with Unit Manager, Employee E14, confirmed Resident R176 TED/compression stocking was not in place. During interview, Unit Manager E14 confirmed the treatment had been signed as completed on the MAR by the 11:00 p.m. to 7:00 a.m. nurse; however, Resident R176's TED/compression stocking was not in place on June 30, 2026, as documented. Review of facility policy titled, Residents Change in Condition Policy, updated July 2022, revealed that The Nurse Supervisor/Charge Nurse will notify the resident's Attending or on-call provider when there has been .a significant change in vital signs from the resident's baseline with clinical symptoms. Review of the American Heart Association document Blood Pressure Categories, dated September 2025, revealed that a systolic blood pressure greater than 180 is considered severe hypertension and requires medical attention. Review of clinical records revealed that resident R182 was admitted to the facility on [DATE], with diagnoses including, but not limited to, chronic kidney disease (progressive condition where the kidneys gradually lose function over time), hypertension (high blood pressure), type 2 diabetes (characterized by insulin resistance and high blood sugar levels), and heart failure (the heart is not pumping as well as it should). Further review of Resident R18's records revealed that on April 30, 2026, at 9:24 a.m., a blood pressure reading of 198/89 was recorded in the resident's record. Progress notes, assessments, and other clinical records were reviewed, and no record could be found to indicate that the elevated blood pressure was communicated to the physician. During an interview with employees E1, the Nursing Home Administrator, and E2, the Director of Nursing, on July 2, 2026, at 11:03 a.m., employee E2 stated that a blood pressure reading over 150 is an issue and a clinical symptom, and that the physician should have been notified. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of facility policy, observations, and interviews with staff, it was determined that the facility failed to maintain an environment free of accidents and hazards related to medications for two of three nursing units observed (Second floor and Third floor). Findings include: Review of facility policy titled, Administering Medications revised June 2025 states, Medications are administered in a safe and timely manner, and as prescribed. Medications, both prescription and non-prescription, shall be administered under the orders of the attending physician, or the physician's designee. Continued review of policy stated, .8. The individual administering the medication will follow the 5 rights of medication administration and checking the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Further review of the facility policy Administering Medications stated, .15. For residents not in their rooms or otherwise unavailable to receive medication on the medication pass, the Medication Administration Record may be flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medication. During a tour of the second-floor nursing unit on June 29, 2026, at 10:20 a.m. a plastic medication cup was noted on Resident R52's bedside table containing several pills. The nurse for the hall was located and asked about the medications left at bedside. Interview on June 29, 2026, at approximately 10:20 a.m. Licensed Nurse, Employee E3 stated he/she was unsure about medications being left on Resident R52's bedside table. Licensed nurse, Employee E3, and Unit Manager, Employee E4, confirmed observations of medications left on Resident R52's bedside table. Further interview on June 29, 2026, at approximately 10:20 a.m. Licensed Nurse, Employee E3, denied leaving medications at bedside and stated Resident R52 came to the doorway where morning medications were administered. Interview on June 29, 2026, at 10:30 a.m. with Unit Manager, Employee E4, confirmed at 10:30 a.m. that medications were left on Resident R52's bedside table. Unit Manager, Employee E4, counted ten pills in the plastic cup. Unit Manager, Employee E4, confirmed that medications should never be left bedside for residents. During the tour of the third floor on June 30, 2026, at 11:24 a.m., observation of a small round white pill was found in the doorway of Resident R118's room. Licensed Nurse, Employee E7, was located at the nurse station and confirmed the finding of a loose pill on the floor. 28 Pa. Code 201.18 (b)(3) Management. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on observation and staff interview, it was determined that the facility failed to follow infection control procedures during medication administration to one of one resident observed during medication pass. (Resident R127)Findings Include: Review of an undated facility policy entitled Infection Control Policy revealed that under section Policy #1. The infection control nurse, in conjunction with the Quality Assurance committee, has responsibility for overall infection control in the building. Under section Purpose In order to provide maximum protection to residents, visitors, and personnel from pathogenic microorganisms and infectious diseases, methods of prevention and control shall be implemented. Medication administration observation conducted on August 12, 2025, at 10:56 AM revealed that the Licensed nurse, Employee E15 was in the process of administering medications to Resident R127. Further observation revealed that two white tablets were on top of the medication cart. Interview with Licensed nurse, Employee E15, conducted at the time of the observation revealed that the two tablets on top of the medication cart were two tablets of Gabapentin. Further, Employee E15 confirmed that that she placed the two tablets of Gabapentin on top of the medication cart because she was preparing to crush it before administering it to Resident R127 Further observation reveled that the nurse proceeded to crush the medication and proceeded to administer the crushed medication to Resident R127 via PEG tube (percutaneous endoscopic gastrostomy tube- a tube placed through the abdomen into the stomach used to provide nutrition and medications). 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on observation, clinical records review and staff interview, it was determined that the facility failed to ensure that residents clinical records were completed related to oxygen therapy for one of 31 resident records reviewed. (Resident R127)Findings Include: Review of facility policy titled Oxygen Therapy dated February 10, 2010, revealed that under section Policy: It is the policy of the facility that oxygen therapy is administered per physician's order or as an emergency measure util a physician order is obtained. Under section Steps to administer oxygen # 12. Document the procedure in the medical record. Review of Resident R127 revealed that Resident R127 was admitted to the facility on [DATE], with a diagnosis of Peripheral Vascular Disease (poor circulations of the extremities). Review of physician's order revealed an order for Oxygen at 2 liters n/c (nasal canula) PRN (when needed) every shift, notify MD if oxygen is less than 94% as needed for SOB (shortness of breath). Observation on initial tour of the unit conducted on August 11, 2025, revealed that Resident R127's was on oxygen concentrator via nasal canula. Interview with Licensed nurse, Employee E13 confirmed that Resident R127 was on 2 liters of Oxygen. Observation conducted during wound care on August 13, 2025, at 10:00 AM revealed that resident was on oxygen via nasal cannula at 2 liters/minute via nasal cannula Follow-up observation conducted on August 15, 2025, at 12:02PM revealed that resident was on Oxygen at 2 liters/minute. Review of August 2025 Treatment Administration Record revealed that there were no initials indicating that oxygen was administered to Resident R127 28 Pa Code 201.18 (b)(1) Management28 Pa. Code 211.10 (c) Resident care policies28 Pa. Code 211.12 (c)(d)(1)(3) Nursing services

Based on observation, review of clinical records and staff interview, it was determined that the facility failed to ensure that oxygen was administered in accordance with physician orders for one of one resident observed in oxygen therapy. (Resident R167)Findings Include: Review of facility policy entitled Oxygen Therapy dated February 10, 2010, revealed that under section Policy: It is the policy of the facility that oxygen therapy is administered per physician's order or as an emergency measure util a physician order is obtained. Review of Resident R167's clinical record revealed that resident was admitted to the facility on [DATE], with the diagnosis of Chronic Obstructed Pulmonary Disease (COPD). Review of physician's order dated July 4, 2025, reveled an order to administer Oxygen at 3L (liters)/min via nasal cannula continuously every shift Review of MDS (minimum data set- a federally required resident assessment conducted at a specific interval) dated May 3, 2025, revealed that resident was on oxygen. Review of Resident RT167's care plan revealed that resident has altered respiratory status/Difficulty Breathing related to COPD. Date Initiated: 01/08/2025. The intervention listed included to administer oxygen @ 2LNC (nasal cannula) to maintain SaO2 (saturated oxygen levels) at or above 92%. Observation on Resident R167 conducted on August 11, 2025, at 10:20AM revealed that resident was oxygen concentrator via nasal canula at 2.5 liters/ minute. Interview with resident conducted at the time of observation revealed that he was on oxygen at 3 liters/minute. Further resident revealed that he gets short of breath sometimes. Interview with licensed nurse Employee E14 conducted at the time of the observation revealed that nurse read the oxygen concentrator flow meter standing up at 3 liters/ minute. Nure rechecked the oxygen level at eye level and confirmed that oxygen reading was 2.5 liters. Employee E14 adjusted the level to 3 liters/minute. Interview with DON (Director of Nursing) Employee E2 conducted on August 13 at 2:05 PM revealed that oxygen gauge should be read at eye level. 28 Pa. Code 211.12(d)(5) Nursing services

Based on interviews with resident and facility staff, review of resident and facility documentation and policy it was determined that the facility did not ensure one resident was free from verbal and mental abuse during two incidents for 39 resident records reviewed (Resident R116).Findings include:Review of the facility policy and procedure. Last revised on October 2022, for Abuse of Residents states. It the facility's policy that acts of physical, verbal, psychological and financial abuse directed against residents are absolutely prohibited. The policy defines verbal abuse as to any use of oral written or gestured language that included disparaging and derogatory terms to residents and their families, or within hearing distance to describe residents, regardless of their age, ability to comprehend or disability. The same policy states, Mental abuse, includes, but not limited to resident humiliation intimidation threatening demeanor, harassment and threats of punishment or withholding a treatment, services, or privileges.Resident R116 was admitted to the facility on [DATE], with diagnosed with Multiple Sclerosis (an immune system eats away at the protective covering of nerves), Fibromyalgia (a chronic condition causing widespread musculoskeletal pain, and fatigue), bipolar (mood swings), and clinically documented alert, oriented and had the cognitive ability to make autonomous choices.Review of an event report received from the Director of Nursing (DON) dated January 2, 2025, revealed reported staff to resident verbal abuse between Resident R116 and a Nurse Aide (NA), Employee E3. The resident reported the NA was was rude accusing the resident of ringing the call bell for her roommate. The resident stated that the aide's tone of voice was rude, and aggressive at the time of the encounter.Review of the facility investigation with Resident R116 on August 15, 2025, confirmed on December 31, 2024, at 7:30 p.m. Resident R116, heard NA, E3 talking to R116's roommate in a very Rude and aggressive manner because the roommate's call light was on. Resident R116 explained that the resident's, roommate, Resident R159 tried telling the aide she didn't remember turning on the call bell. Resident R116 said the roommate may have fallen back to sleep and forgotten. Resident R116 stated that the NA angrily said to roommate, ‘I guess your roommate did it, because I heard about her.' Resident R116 said she sat up at the end of the bed to see who said that about her and told the NA she shouldn't talk that way. Resident R116 said the NA threw the curtain at her and hit her. The resident told the NA that she hit her with the curtain, and she was being rude. Resident R116 stated she got very upset and started shaking. The resident said she cried and wanted the NA to leave her room, but she wouldn't, so the resident left the room and screamed for help. Per the witness statement from Licensed Practical Nurse (LPN) Employee E 4, the nurse heard the resident screaming and went to see what was going on. Resident R116 told Employee E4 she did not like how the care nurse (E3) treated her and wanted her out of her room. Review of the witness statement from NA, E3 stated, She (Resident R116) wanted me out of her room, I ignored her and continued care. Review of the roommate's witness statement, facility deemed alert and oriented, Resident R159 stated The C.N.A. (NA E3) came in my room yelling and accusing me of turning on my call bell. My roommate, (Resident R116) told the NA she shouldn't be talking that way to me and they exchanged words. The NA whipped the curtain hitting my roommate. She (R116) was very upset, and I could hear it in her voice. She went yelling for help and people came to see what was going on. The aide was being disrespectful for no good reason. Everything my roommate reported is true. On January 27, 2025, the Director of Nursing reported an allegation of verbal abuse when Resident R116 alleged a NA called the resident a derogatory name.Review of the incident with Resident R116 on August 15, 2025, stated in the middle of the night she heard one of the residents calling out for help. The resident said she got up and saw an aide in the hallway sitting in a chair. The resident stated, I tried to explain to the aide that the resident needed help and hoped she would check on her. Instead, she told me to mind my own business and called me poor white trash. Resident R115 said she immediately went to the front desk and told the nurse. Review of the investigation revealed the DON conducted a telephone interview with the licensed practical nurse (LPN) Employee E5 who worked on the Resident R115's unit that night on the 11-7 shift. LPN told the DON that she heard commotion and went to see what was going on. It was documented in the LPN's witness statement that Resident R116 told the LPN twice that she (the NA) called her white trash. The same witness statement revealed the DON asked the LPN if this was reported to the supervisor. The LPN replied, ‘No, she (the supervisor) defused the situation and corrected the C.N.A. regarding calling names or arguing with residents. The same investigation included a witness statement from a resident that stated he heard the lady across the hall yelling for help. Another resident witness statement stated he did hear the lady screaming for help and he heard the lady across the hall (R116) calling for a nurse to come to help. Resident R116's roommate confirmed R116 left the room and was trying to get the lady next door some help.Review of Resident R116 psychological progress note dated January 28, 2025, it was noted in the clinician's notes that the nurse manager told the clinician a staff member made an inappropriate comment towards the resident and was suspended. The clinician asked during the therapy session how Resident R116 was feeling after the incident. and Resident R116 stated, ‘She was feeling better and expressed being concerned about another resident who was yelling and that the resident likes helping and supporting others.' It was also noted that the clinician praised her efforts and that She did nothing wrong.

Based on interviews with resident and staff, review of clinical records, facility documentation and policy it was determined that the facility failed to complete a thorough investigation to rule out verbal and mental abuse for one resident during two incidents with staff of 39 resident records reviewed ( Resident R116). Findings includeReview of the facility policy and procedures, revised on, October 2022 titled, Abuse of Residents states. It the facility's policy that acts of physical, verbal, psychological and financial abuse directed against residents are absolutely prohibited. The policy defines verbal abuse as to any use of oral written or gestured language that included disparaging and derogatory terms to residents and their families, or within hearing distance to describe residents, regardless of their age, ability to comprehend or disability. The same policy states, Mental abuse, includes, but not limited to resident humiliation intimidation threatening demeanor, harassment and threats of punishment or withholding a treatment, services, or privileges. The same policy further states that the Administrator/Director of Nursing/designee will conduct an investigation to include but not limited to interview any witnesses to the incident, the resident, staff members on all shifts having contact with the resident during the period of the alleged incident. The same policy states, The Administrator/Director of Nursing is responsible to receive and investigate all alleged violations timely, thoroughly, and objectively.Resident R116 was admitted to the facility on [DATE], with diagnosed with Multiple Sclerosis (an immune system eats away at the protective covering of nerves), Fibromyalgia (a chronic condition causing widespread musculoskeletal pain, and fatigue), bipolar (mood swings), and clinically documented alert, oriented and had the cognitive ability to make autonomous choices.Review of a facility reported event dated January 2, 2025, revealed an allegation of staff to resident verbal abusive behavior by a staff member, (NA), Employee E3 to Resident R116. Interview, on August 15, 2025, at 2:00 p.m. with the Director of Nursing (DON) confirmed the above to be true but thought the allegation was unsubstantiated because the perpetrator, Nurse Aide Employee E3 since resigned from working at the facility. On January 27, 2025, the Director of Nursing reported an allegation of verbal abuse when Resident R116 alleged a NA called the resident a derogatory name, [NAME] Trash. The DON concluded in the investigation that the facility was, Unable to substantiate the allegation of verbal abuse. No one else heard the encounter staff nor resident. The roommate and 3 other residents were interviewed and did not voice and care (sic) concerns nor did they hear the encounter and (The resident's name) is Being followed by psych.During an interview with the DON on August 15, 2025, at 2:00 p.m. the DON confirmed the DON knew the names of the perpetrator and the supervisor who disciplined the staff member but both witness statements were omitted from the investigation.

Based on observations of care and treatments, clinical record review, interviews with residents and staff, and reviews of policies and procedures, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet the resident's medical, nursing and mental and psychosocial needs identified in the comprehensive assessment for two of 31 residents reviewed. (Resident R116 and R180). Findings includeReview of the facility's policy titled, Care plan Policy revised March 2024, states the interdisciplinary team (IDT) is responsible for the development of resident care plans. Each resident's care plan is consistent with the resident's right to participate in the development and implementation of his or her plan of care including the right to participate in the planning process, request revisions, see the care plan and sign it after significant changes are made. The same policy states that care plan interventions are chosen based on relevant clinical data and decision making. Resident R116 was admitted to the facility on [DATE], with diagnoses of Multiple Sclerosis (an immune system eats away at the protective covering of nerves), Fibromyalgia (a chronic condition causing widespread musculoskeletal pain, and fatigue), bipolar (mood swings), and clinically documented alert, oriented and had the cognitive ability to make autonomous choices.Review of Resident R116 care plan dated January 3, 2025, revealed the resident had behavior problem related to making false allegations against staff. Review of Resident R116's nursing progress notes revealed January 4, 2025, the resident was noted without any moods or behaviors. Nurse Practitioner's note, dated, January 17, 2025, stated, The resident is calm, Bipolar diagnosis is stable and mild. Review of the January 24, 2025, activities note, noted Resident R116 More involved during group, and Comes to all group programs, enjoys socializing with the activity team and her neighbors, continues to participate in special events, helping others, socializing with peers/staff. Review of Resident R116 psychological progress note dated January 28, 2025, noted that the nurse manager told the clinician a staff member made an inappropriate comment towards the resident and was suspended. The clinician asked during the therapy session how Resident R116 was feeling after the incident. and Resident R116 stated, ‘She was feeling better and expressed being concerned about another resident who was yelling and that the resident likes helping and supporting others.' It was also noted that the clinician praised her efforts and that She did nothing wrong. The Director of Nursing on August 15, 2025, at 4;00 p.m. was asked to show documentation and evidence of Resident R116 making false allegations against staff. The DON stated she was accused of making false allegations from her prior institution but failed to show evidence nor evidence this occurred at the facility. Furthermore, during an interview with Resident R116 on August 15, 2025, at 1:00 p.m. stated she was not told nor signed any revisions to her care plan related to making false allegations against staff and stated this was not true. A review of the facility policy titled care plans dated March 2024 revealed that the interdisciplinary team was responsible for the development of resident care plans. The team was responsible for developing, implementation and revision of a comprehensive person-center care plan that included measurable objectives and timetables to meet each resident's physical, psychosocial and functional needs. The policy also indicated that the person-centered care plan was based on the comprehensive assessment. The interdisciplinary care team includes the attending physician, licensed nursing staff, members of the food and nutrition services, the resident and/or resident's representative and other staff to meet the resident's needs.Clinical record review for Resident R180 revealed a comprehensive assessment (MDS-an assessment of care needs) dated April 29, 2025, revealed that this resident had difficulty communicating some words or finishing thoughts and that cueing was required to complete recall. The assessment also indicated that Resident R180 required partial/moderate assistance of a staff member with toileting (the ability to maintain perineal hygiene, adjust clothes before and after having a bowel movement. The assessment also indicated that Resident R180 required partial/ moderate assist of a staff member for sit to stand (the ability to come to a standing position from sitting in a chair wheelchair or side of bed). The assessment indicated that for chair to bed/bed to chair transfers Resident R180 required supervision or touching assist (the staff member provides verbal cues and/or touching steadying and/or contact guard assistance as resident completes the activity). The assessment said that Resident R180 was frequently incontinent of bowel. A diagnosis of non-Alzheimer's Dementia and difficulty walking was assessed for Resident R180. Clinical record review revealed a social worker's assessment and progress note for Resident R180 dated May 3, 2025, that indicated the resident was not cognitively intact scoring a BIMS (brief interview for mental status) of 10.Clinical record review revealed a nurse practitioner's assessment of Resident R180's cognition as fluctuating between confusion and alertness. Clinical record and care plan review revealed that the interdisciplinary team did not develop and implement a person-centered care plan for Resident R180 related to incontinence of bowel. There was no individualized toileting schedule assessed and/or implemented for this resident. There were no measures developed and implemented for Resident R180's need for partial/moderate assistance of a staff member for toileting (the ability to maintain perineal hygiene, adjust clothes before and after having a bowel movement). Clinical record review revealed a care plan listing diagnoses of dementia, impaired balance and decreased functional mobility for Resident R180. The care plan indicated staff supervision for transfers. Resident R180 required staff supervision or assistance for all transfers. Interviews were conducted with nursing staff (Employees E6, E7, E8, E9, E10 and E11) at various times, throughout the survey dated August 11, 2025, through August 14, 2025. The nursing staff who were familiar with the activities of daily living for Resident R180 reported that the resident was independent (requiring no staff assist, cueing or supervision with all transfers into and out of the adjoining bedroom/bathroom for toileting during the months of March, April and May 2025. 28 PA. Code 211.10(a)(b)(c)(d) Resident care policies28 PA. Code 211.12(b)(c)(d)(1)(2)(3)(5) Nursing services28 PA. Code 211.5(b)(f)(ii)(iii)(vii)(ix) Medical records

Based on observation, clinical records review and staff interview, it was determined that the facility failed to ensure that a resident on oxygen therapy was assessed for the need of oxygen for one of 31 resident records reviewed. (Resident R127)Findings Include: Review of facility policy titled Oxygen Therapy dated February 10, 2010, revealed that under section Policy: It is the policy of the facility that oxygen therapy is administered per physician's order or as an emergency measure util a physician order is obtained. Under section Steps to administer oxygen # 12. Document the procedure in the medical record. Review of Resident R127 revealed that Resident R127 was admitted to the facility on [DATE], with a diagnosis of Peripheral Vascular Disease (poor circulations of the extremities). Review of physician's order revealed an order for Oxygen at 2 liters n/c (nasal canula) PRN (when needed) every shift, notify MD if oxygen is less than 94% as needed for SOB (shortness of breath). Observation on initial tour of the unit conducted on August 11, 2025, revealed that Resident R127's was on oxygen concentrator via nasal canula. Interview with Licensed nurse, Employee E13 confirmed that Resident R127 was on 2 liters of Oxygen. Observation conducted during wound care on August 13, 2025, at 10:00 AM revealed that resident was on oxygen via nasal cannula at 2 liters/minute via nasal cannula Follow-up observation conducted on August 15, 2025, at 12:02PM revealed that resident was on Oxygen at 2 liters/minute. Review of resident R127's clinical record revealed no documented evidence that Resident R127 was assessed for the need for Oxygen. 28 Pa Code 201.18 (b)(1) Management28 Pa. Code 211.10 (c) Resident care policies28 Pa. Code 211.12 (c)(d)(1)(3) Nursing services

Based upon interviews with staff, review of residents' records, and facility policy it was determined the facility failed to determine one resident with a substantial weight loss was reweighed in a timely manner for one of 39 resident records reviewed (Resident R99) Findings includeReview of the facility's policy titled, Weight and Weight Change Management not dated states, Residents with a suspected weight change (per MDS guidelines) will have a reweigh completed in a timely manner. Review of Resident R99 weights reveal on July 17, 2025, a weight of 140.6 lbs. and on July 23, 2025, was 133.6 lbs. calculating a substantial weight loss per MDS guidelines, of 4.98% in six days. Further review of Resident R99 clinical record revealed the facility failed to re-weigh the resident in a timely manner. This was confirmed with the registered dietician on August 12, 2025, who confirmed the substantial change in weight loss should have been reweighed and was not done.

Based on interviews with staff, reviews of clinical records and policies and procedures, observations of resident care and treatment, it was determined that for one of 31 residents reviewed, the facility failed to administer and use its' resources effectively and efficiently to maintain the highest practicable physical, mental and psychosocial well-being of each resident. (Resident R180). Findings Include: A review of the facility's policy titled incident and accident dated July 2025, revealed the facility was responsible to complete a report of all accidents/incidents for each resident. The facility was responsible for investigation of the incident/accident for each resident to determine the risk factors that contributed to the event. The facility was also responsible to ensure that the resident's environment was free of accident hazards as possible. The policy said that the interdisciplinary team would develop a care plan to ensure that the resident's environment was free of accident hazards as possible. The policy indicated that the completed investigation and review by the director of nursing would be forwarded to the medical director and administrator. The policy said that the medical director shall be consulted about the conclusion of the incident/accident investigation as desired. Interview with the director of nursing Employee E2 and the administrator Employee E1 at 2:30 p.m., on August 13, 2025, confirmed that they were aware of the incident/accident that occurred on May 7, 2025, for R180; whereby the resident was found lying on the floor in the bedroom/adjoining bathroom. The administrative staff (Employees E1 and E2) confirmed that there was no care plan developed and implemented for bowel incontinence, individualized toileting schedule, toileting and staff supervision or touching assistance with all transfers for Resident R180. Interview with the medical director, Employee E12 at 11:00 a.m., on August 14, 2025, revealed that on May 7, 2025, Resident R180 was sent to the hospital emergency room for a brain bleed or ischemic stroke and fall. The physician also reported that the cause of the fall was determined in the emergency room on May 7, 2025, when Resident R180 was assessed and diagnosed with an acute large intraparenchymal hemorrhage (a type of stroke that occurs when blood from a ruptured blood vessel leaks into the brain tissue.) and hydrocephalus. The physician explained that this intraparenchymal hemorrhage was a progressive neurological disease that occurs when abnormal amyloid proteins build up in the brain's blood vessels causing them to leak. The physician also said that Resident R180 had a history of cerebral amyloid angiopathy and prior intracranial parenchymal hemorrhages in 2018. Interview with Employees R1 and R2 at 11:30 a.m., on August 14, 2025, confirmed that they did not conduct and record a complete and thorough investigation into the incident/accident that occurred on May 7, 2025, for Resident R180. The administrative staff failed to use its' resources effectively to identify the root cause of the fall on May 7, 2025, for Resident R180 by consulting with the medical director as stipulated in the facility's policy for investigation of incidents and accidents to ensure a safe environment for residents. 28 PA. Code 211.10(a)(b)(c)(d) Resident care policies28 PA. Code 211.12(d)(1)(2)(3)(5) Nursing services28 PA. Code 201.14(a) Responsibility of licensee28 PA. Code 201.18(b)(1)(3)(e)(1)(3) Management

Based on observations, review of facility policy, staff interviews, and the review of clinical records, it was determined that the facility failed to ensure that medications were administered on time, as ordered by the physician for 3 out of 3 residents reviewed (Resident R1, R2 and R3). Findings include: Review of the facility policy, Medication Administration and Disposition, with a revision date of June 2023 indicated that medications must be administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). During an observation on March 12, 2025 st 10:50 a.m. Employee E3 (licensed nurse) was observed standing at her medication cart, and confirmed that she was still administering medications to residents and that she had some rooms in 219-233, in addition to other rooms in which she still had to administer medications. Employee E3 reported that she did not start medication administration because she got into work later. Review of March 2025 physician orders for Resident R1 included diagnoses of respiratory failure (a condition in which an individual does not have oxygen or too much carbon dioxide in your body; atrial fibrillation (an irregular and often very rapid heart rhythm); heart failure (a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply); chronic obstruction pulmonary disorder (COPD-a lung condition that limits airflow an oxygen exchange). Continued review of the resident's March 2025 physician orders included medications and treatments that included, but were not limited to the following: Eliquis Oral Tablet - give 1-2.5 milligram (mg) tablet by mouth every 12 hours (9:00 a.m. and 9:00 p.m.) for the treatment of atrial fibrillation. Buspirone HCl Oral Tablet- give 1-10 mg tablet by mouth one time a day (9:00 a.m.) for anxiety, forgetfulness. Symbicort Inhalation Aerosol 160-4.5 MCG/ACT (Budesonide- Formoterol Fumarate Dihydrate)-1 puff inhale 1 puff orally every 12 hours (9:00 a.m. and 9:00 p.m.) for shortness of breath. During an observation of medication administration on March 12, 2025 at 11:10 a.m. Employee E3 was observed administering 9:00 a.m. physician ordered medication to Resident R1 which included, but not limited to the administration of the above referenced medications, Symbicort Inhalation Aerosol; Buspirone HCl Oral Tablet; and Eliquis Oral Tablet. Review of the March 2025 physician orders for Resident R2 included, but not limited to the following diagnosis: diabetes (a condition that happens when your blood sugar/glucose) is too high); and chronic obstruction pulmonary disorder (COPD-a lung condition that limits airflow an oxygen exchange) and epilepsy (a brain disorder that causes recurring seizures). Continued review of the resident's March 2025 physician orders included medications and treatments that included, but not limited to the following: Levetiracetam : 1-750 milligram (mg) tablet of the medication to be administered by mouth every 12 hours (9:00 a.m. and at 9:00 p.m) for treatment of the resident's epilepsy. Lidocaine External Cream, 4%: cream to be applied to the resident's right arm every 12 hours (9:00 and 9:00 p.m.) for mild pain. Docusate Sodium Capsule: 1-100 mg capsule to be given by mouth 2 times a day (9:00 a.m. and 5:00 p.m.) for constipation. Metformin HC Tablet: 1-500 mg tablet given by mouth 2 times a day times a day for diabetes. During an observation of medication administration on March 12, 2025 at 11:29 a.m. Employee E3 was observed administering medication to Resident R2, which included, but not limited to the above referenced 9:00 a.m. physician ordered medications, levetiracetam; Lidocaine External Cream; Calcium Carbonate; Docusate Sodium and Metformin. During an observation on March 12, 2025 st 11:00 a.m. Employee E4 (licensed nurse) was observed standing at his medication cart, and confirmed that he was still administering medications to residents. Employee E4 reported that Resident R3's medications still needed to be administered. Review of the March 2025 physician orders for Resident R3 included, but not limited to the following diagnosis: chronic kidney disease (gradual loss of kidney function); hypertension (high blood pressure); convulsions (uncontrollable muscle contractions that can happen during or without seizures). Continued review of the resident's March 2025 physician orders included medications and treatments that included, but were not limited to the following: Lacosamide: 1-150 mg tablet taken orally two times a day (9:00 a.m. and 5:30 p.m.) for convulsions Levetiracetam: 1-500 mg tablet to be administered by mouth every 12 hours (9:00 a.m. and at 9:00 p.m.) for treatment of convulsions. Eliquis Oral Tablet: give 1-5 mg tablet by mouth every 12 hours (9:00 a.m. and 9:00 p.m. for Atrial fibrillation During an observation of medication administration on March 12, 2025 at 11:19 a.m. Employee E4 was observed administering 9:00 a.m. physician ordered medications to Resident R3 which included, but was not limited to the above referenced medications, Lacosamide, Levetiracetam, and Eliquis. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of clinical records, interview with staff and review of facility policy, it was revealed that the facility did not ensure revision were made to the PASRR (Pre-Admission Screening and Resident Review) application to include mental health diagnoses for four out of 34 residents reviewed. (Resident R62, R88. R26, R23) Findings include: Review of the undated facility policy titled PASSR policy and procedure revealed that all residents reguardless of payer source would have a PASSR form completed. The policy indicated that any resident with mental health disorder would have a complete and accurate PASSR done and referral made for a level II PASSAR, if necessary. The policy also indicated that all residents with newly evident serious mental health disorder, intellectual disability, or a related condition with a significant change in status were required to have a PASSR completed and screening done. The policy indicated that this screening would determine the PASSR level II documentation and screening, if necessary. Review of Resident R62's PASRR completed on September 29, 2021, indicated that Resident R62 did not have a mental health condition or suspected mental health condition, other than dementia, that may lead to a chronic disability. Review of R62's clinical record revealed admitted [DATE]. Clinical record review for Resident R62 revealed that the resident developed a medical diagnosis during the nursing home stay of delusional disorder, anxiety disorder and major depressive disorder, May 27, 2024. Review of Resident R88's PASRR completed on July 3, 2017, indicated that Resident R88 did not have a mental health condition or suspected mental health condition, other than dementia, that may lead to a chronic disability. Review of R88's clinical record revealed admitted [DATE]. Clinical record review for Resident R88 revealed that the resident developed medical diagnoses during the nursing home stay of delusional disorder on June 8, 2024. Review of Resident R26's PASRR completed on January 24, 2019, indicated that Resident R26 did not have a mental health condition or suspected mental health condition, other than dementia, that may lead to a chronic disability. Review of R26's clinical record revealed admitted [DATE]. Clinical record review for Resident R26 revealed that the resident developed medical diagnoses during the nursing home stay of bipolar disorder on April 16, 2019, mood disturbance on February 8, 2019, major depressive disorder on June 8, 2024 and anxiety disorder on June 8, 2024. Review of Resident R23's PASRR completed on January 2, 2009, indicated that Resident R23 did not have a mental health condition or suspected mental health condition, other than dementia, that may lead to a chronic disability. Review of R23's clinical record revealed admitted [DATE]. Clinical record review for Resident R236 revealed that the resident developed medical diagnoses during the nursing home stay of anxiety dosorder on March 25, 2024, delusional disorder on March 25, 2024 and major depressive disorder on March 25, 2024. Interview with the facility administrator, Employee E1 at 10:30 a.m., on October 31, 2024 confirmed that the PASSR forms for Residents: R62, R88, R26 and R23 lacked complete and documentation and were not reflective of each resident's current mental health conditions. 28 PA Code 211.10 (c) Resident Care Policies 28 PA Code 211.5(f)(ii)(iv)(vi)(ix) Medical records

Based on observations and interviews with facility staff, it was determined that he facility did not ensure to accurately post information regarding daily nurse staffing data as required. Findings include: Observations of posted daily staffing information on October 28, 2024 at 11:45 AM , 2nd floor unit, did not include total hours required, did not include actual hours worked for each shift, excluded call outs and unit. Observations of posted daily staffing information on October 29, 2024 at 1:30 PM, 2nd floor unit, did not include total hours required, did not include actual hours worked for each shift, excluded call outs and unit. Review of posted daily staffing information for October 30, 2024 did not include total hours required, did not include actual hours worked for each shift, excluded call outs and unit. Review of posted daily staffing information for October 31, 2024 did not include total hours required, did not include actual hours worked for each shift, excluded call outs and unit. Reviewed 'daily staffing information,' for week of July 1st, 2024 through July 7th, 2024 - did not include total hours required, did not include actual hours worked for each shift, excluded call outs and unit. Reviewed 'daily staffing information,' for weeks of February 1, 2024 through February 7th, 2024 - did not include total hours required, did not include actual hours worked for each shift, excluded call outs and unit. 28 Pa Code 201.14(a) Responsibility of licensee

Based on clinical record review and staff interview, it was determined that the PASRR-ID (Preadmission Screening and Resident Review Identification) was not appropriately completed for one of 34 residents reviewed (Resident R2). Findings include: The PASRR (Preadmission Screening Resident Review) was created in 1987 through language in the Omnibus Budget Reconciliation Act (OBRA) and it has three goals: to identify individuals with mental illness and/or intellectual disability, to ensure they are placed appropriately, whether in the community or in a nursing facility, and to ensure they receive the services they require for their mental illness or intellectual disability. The PASRR Level 1 must be completed on all persons who are considering admission to a Medicaid certified nursing facility. Review of Resident R2's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including Psychosis (Psychosis is a set of symptoms that cause a person to lose touch with reality, and have difficulty distinguishing what is real and what is not. It can affect people in different ways, and can include Hallucinations: Seeing, hearing, feeling, tasting, or smelling things that aren't there; Delusions: believing things that are untrue, such as thinking someone is trying to harm you; disordered thinking or speaking: speaking quickly or constantly, or switching topics mid-sentence; Ccgnitive symptoms: dfficulty with attention, concentration, and memory; mod changes: sucidal thoughts or behaviors). Review of Resident R2's Pennsylvania Preadmission Screening Resident Review Identification Level I Form (PASRR) which was completed on August 24, 2018. Review of PASRR of R2 indicated; in the Section III A (does the individual have a mental disorder or suspected mental disorder, other than Dementia, that may lead to chronic disability), no Diagnosis was marked, even though R2 was diagnosed with Psychosis. Review of PASRR of R2 also indicated for Section VIII- PASRR LEVEL I Screening Outcome, R2 was not checked off for the outcomes that may or may not lead to chronic disability. Interview on October 28, 2024, at 11:48 a.m., with the Director of Nursing, confirmed the finding. 28 Pa Code 211.5(f) Clinical records 28 Pa Code 211.16(a) Social services

Based on a review of clinical records, facility policies and facility documentation and interviews with staff, it was determined that the facility failed to provide the care necessary to protect one resident from neglect resulting in actual harm and death to one of five residents reviewed (Resident CL1). Findings include: Review of an undated facility policy titled, Freedom From Abuse, Neglect, And Exploitation; And Reporting Crime Policy, revealed that It is the policy of this facility: 1. Not to use verbal, mental, sexual, or physical abuse, Corporal punishment, or involuntary seclusion on any of it's residents. Review of the clinical record for Resident CL1 revealed that the resident had been admitted to the facility on (MONTH) 29, (YEAR), with [DIAGNOSES REDACTED].I. ([MEDICAL CONDITION] Infarction- [MEDICAL CONDITION]) and Right THR (Total Hip Replacement - surgical removal of the hip joint and replacement with an artificial joint) for the treatment of [REDACTED]. Review of facility documentation dated (MONTH) 13, (YEAR), indicated that on (MONTH) 2, (YEAR), Employee E7, Psychologist, had reported to Employee E8, Licensed Nurse, assigned to provide care to Resident CL1, a concern regarding the status of the resident's current medical condition. Further review of facility documentation revealed that after approximately 45 minutes and after making repeated requests to Employee E8 to check on Resident CL1, Employee E7 went to the Unit Manager with her concerns. The Unit Manager immediately went to assess Resident CL1 and subsequently called a STAT code. Continued review of the clinical record for Resident CL1 revealed nurse's notes dated [DATE] ([DATE], (YEAR)), at 9:15 a.m. which revealed that Employee E2, Unit Manager, had been notified by Employee E7, Psychologist, that . resident did not look good and he was SOB (short of breath) and very clammy (skin cool and moist to touch) . Further review of nurses notes dated (MONTH) 2, (YEAR), at 9:20 a.m. revealed that Resident CL1's Accucheck (fingerstick test to measure amount of blood sugar) was four (normal blood sugar level ,[DATE]) and that staff had administered [MEDICATION NAME] (a medication administered by injection to treat extremely low blood sugar levels) to the resident twice. Additional nurse's notes dated (MONTH) 2, (YEAR), revealed that the resident had become unresponsive (Unarousable) and that the resident had no palpable (able to feel the presence of a pulse through the skin) pulse subsequently at 9:25 a.m. a STAT code (urgent call for assistance) was called and CPR (cardiopulmonary resuscitation - emergent medical measures to maintain a person's heart rate and breathing) was initiated. The nurse's notes further indicated that EMTs (Emergency Medical Technicians) had arrived at approximately 9:30 a.m. and took over the CPR but that the resident did not recover and was subsequently pronounced dead at 10:00 a.m. Interview with Employee E2, Director of Nursing, on (MONTH) 16, (YEAR), at 9:15 a.m. confirmed that on (MONTH) 2, (YEAR), Resident CL1 had experienced an acute change in his medical condition. Continued interview with Employee E2 confirmed that Employee E8, licensed nurse had been approached several times that morning by Employee E7, Psychologist, regarding concerns about the resident's current medical condition however; Employee E8 neglected to go check on the resident and assess his condition. The facility neglected to ensure that one resident who had experienced an acute change in his medical condition was seen and assessed in a timely manner resulting in actual harm in the result of death to Resident CL1. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management Previously cited [DATE], [DATE] 28 Pa. Code 201.18(b)(3) Management Previously cited [DATE] 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.5(f) Clinical records Previously cited [DATE] 28 Pa. Code 211.5(g) Clinical records 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited [DATE], [DATE]