Every finding on record at Cliveden Nursing and Rehabilitation Center

Based on review of facility policy, review of clinical records, observations, and staff and resident interviews it was determined that the facility failed to ensure residents received necessary behavioral health services for one of 33 residents reviewed (Resident R36).Findings Include:Review of facility policy on consultations, review date June 2026, revealed residents should receive necessary medical services as ordered by the attending physician or designee. Per the facility policy, all consultations must be ordered by the attending physician or designee. The nurse will initiate consultation per facility practice and consultant services will be provided in the facility when possible.Further review of facility policy on consultations revealed nursing staff will document all actions in the medical record including a consultation order, date and time resident went to appointment, recommendations and follow up, and communication with resident and resident representative.Review of Resident R36's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of major depressive disorder (mood disorder characterized by low mood, a feeling of sadness, and a general loss of interest in things), anxiety disorder (intense, excessive, persistent worry or fear), and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).Review of Resident R36's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated December 18, 2025, revealed section D0150 (Resident Mood Interview) A. Little interest or pleasure in doing things was coded yes, B. Feeling down, depressed, or hopeless was coded yes, C. Trouble falling or staying asleep, or sleeping too much was coded yes, D. Feeling tired or having little energy was coded yes.Resident R36's clinical record revealed a physician order for bupropion 100 milligrams (mg) one time per day for major depressive disorder, that was ordered December 8, 2025, and discontinued April 29, 2026. Further, the physician ordered Trazodone on April 29, 2026, for major depressive disorder.Continued review of Resident R36's clinical record revealed a physician order dated December 8, 2025, for Psychiatry consult - Evaluation, Treatment, and Follow-up as Recommended.Review of Resident R36's clinical record revealed the psychiatry consult ordered December 8, 2025, was not fulfilled until May 8, 2026.Review of Resident R36's clinical record revealed a psych note dated May 8, 2026, that revealed Resident R36 was seen for complaint of low mood.Observation on June 10, 2026, at 10:49 a.m. revealed that Resident R36 appeared sad and non-engaging with interview. Interview with Regional nurse, Employee E8, conducted on June 12, 2026, at 11:35 a.m. confirmed that there was an order dated December 8, 2025, to obtain a psychiatry consultation for Resident R51. Regional nurse, Employee E8, further confirmed Resident R36 was not seen by psych until May 8, 2026 (5 months after the consult was ordered). 28 Pa. Code 201.14 (a) Responsibility of licensee.28 Pa. Code 201.21 (c) Use of outside resources.28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of clinical records and staff interview it was determined that the facility failed ensure clinical records were maintained with complete and accurate documentation for one of 33 residents reviewed (Resident R132). Findings Include:Review of Resident R132's clinical record revealed the resident was admitted to the facility on [DATE].Interview on June 9, 2026, with Resident R132 revealed the resident stated he/she was upset due to not having their wound treatment completed last Saturday and Thursday. Resident R132 stated that he/she is supposed to receive wound treatment three times a week and he has not been. Observation of the dressing on Resident R132's right leg revealed a dressing dated June 8, 2026. The dressing was soiled with blood that soaked through to the resident's sheets. Review of Resident R132's clinical record revealed a physician order dated March 26, 2026, to cleanse right posterior calf with wounder cleanser, apply calcium alginate, ABD (highly absorbent, multi layer dressing), and wrap with kling. The physician order dated March 26, 2026, also indicated to Cleanse left posterior calf with wounder cleanser, apply calcium alginate, ABD, and wrap with kling (type of gauze).Review of Resident R132's treatment administration record for June 2026, revealed the order for wound care was not signed out as completed June 4 and June 6. Interview on June 12, 2026, at 1:11 p.m. with the wound care nurse, Employee E7 revealed that he/she completed wound care treatment for Resident R132 on June 4, 2026, but confirmed it was not documented. The wound care nurse, Employee E7, could not confirm or explain why Resident R132's treatment was not signed out on June 6, 2026. 28 Pa. Code 211.5(f) Clinical records28 PA. Code 211.10 (d) Resident care policies

Based on review of facility policy, review of facility documentation, review of clinical records, and staff interview it was determined that the facility failed to ensure residents were free from abuse for one of 33 residents reviewed (Resident R57).Findings Include:Review facility Abuse Policy, reviewed June 2025, revealed abuse and neglect exist in many forms and to varying degrees. Per the policy abuse is defined as the willful infliction of injury and reasonable confinement intimidation or punishment with resulting physical harm, pain or mental anguish. Physical abuse includes hitting, slapping, pinching, and kicking it also includes controlling behavior through corporal punishment.Review of Resident R57's clinical record revealed that Resident R57 was admitted to the facility on [DATE], and has a diagnosis of bipolar disorder (also known as manic depression, a mood disorder that brings severe high and low moods and changes in sleep, energy, thinking, and behavior) and schizophrenia (mental illness associated with loss of reality contact, delusions and hallucinations)Review of Resident R57's progress note dated April 9, 2026, written by Licensed Nurse, Employee E10, that revealed while the employee was completing documentation, Resident R57 began to shout curse words and attempted to spit at Licensed Nurse, Employee E10. Per documentation, Resident R57 was not easily directed but eventually returned to his/her room.Review of the facility documentation revealed an abuse investigation for an incident that occurred on April 9, 2026, when Licensed Nurse, Employee E10, threw a cup of soda at Resident R57.Review of facility documentation revealed a statement by Licensed Nurse, Employee E10, that revealed on April 9, 2026, at approximately 10:45 p.m. Resident R57 spit on Employee E10. Further review of the statement revealed Licensed Nurse, Employee E10, admitted to throwing his/her drink at Resident R57 in response to being spit on.Continued review of the facility investigation revealed that the allegation of abuse was substantiated and Licensed Nurse, Employee E10, was terminated for throwing a beverage at Resident R57.Interview on June 12, 2026, at 10:50 a.m. with the Director of Nursing, Employee E2, confirmed that Licensed Nurse, Employee E10, admitted to having thrown a cup of soda at Resident R57.Further interview on June 12, 2026, at 10:50 a.m. with the Director of Nursing, Employee E2, revealed that Licensed Nurse, Employee E10, was subsequently terminated after the investigation substantiated abuse. 28 Pa. Code 201.29 (a) Resident rights.

Based on review of facility policy, review of clinical records, observation, and interview with staff, it was determined that the facility failed to development and implement comprehensive care plans for two of 33 residents reviewed (Resident R9 and R98). Findings Include: Review of policy titled Baseline Care Plan, Comprehensive Care Plan and Ongoing Care Plan Updates, revised October 1, 2024, revealed, the facility will follow a uniform process for initiating comprehensive care plans and ensuring care plans are updated to reflect the resident's status. Continued review of facility policy revealed the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's needs that are identified in the comprehensive assessment. Review of clinical documentation revealed Resident R98 was admitted to facility on July 8, 2022, and had a diagnosis of hemiplegia and hemiparesis (paralysis or reduced ability to move or weakness of one side of the body following a stroke), critical illness polyneuropathy (an acute condition/complication of severely ill patients that causes muscle weakness and wasting), and need for assistance with personal care. Continued review of clinical documentation revealed Resident R98 has a BIMS (Brief Interview of Mental Status) score of 13, indicating intact cognition. Review of Resident R98's comprehensive care plan revised May 17, 2023, revealed Resident R98 is part of restorative program related to contracture (shortening and stiffening of soft tissues, such as muscles, tendons, and ligaments), with interventions for a right elbow splint and right resting hand splint. Observation on June 10, 2026, at 10:16 a.m. revealed Resident R98 was in bed, and his/her right wrist/arm was contracted with no splint in place. A black brace was observed to be sitting on the end table. Continued observations on June 11, 2026, at 11:13 a.m. revealed Resident R98 was in his/her wheelchair in the hallway, without the brace or splint in place on right wrist. Interview on June 11, 2026, at 11:15 a.m. with Resident R98 revealed the resident was not wearing the brace because it didn't work. Interview on June 12, 2026, at 9:53 a.m. with the Director of Rehabilitation, Employee E14, revealed Resident R98 independently removes the brace sometimes. Continued review of Resident R98's clinical records reveal no care plan was developed related to Resident R98's refusals of wearing the brace/splint. During an interview with the Director of Nursing, Employee E2, on June 12, 2026, at 11:48 a.m. it was discussed Resident R98 lacked a care plan for refusal of brace. Review of resident R9's clinical record revealed the resident was admitted to the facility on [DATE], and has a diagnosis of Post Traumatic Stress Disorder (PTSD - a mental health condition triggered by experiencing or witnessing a traumatic event, leading to severe anxiety, flashbacks, and emotional distress) and Dementia with agitation (a condition where individuals with dementia become restless, irritable, or aggressive due to changes in brain function, often triggered by confusion, discomfort, or environmental stressors). Review of Resident R9's clinical record revealed no documented evidence a comprehensive care plan was developed related to dementia with agitation or post-traumatic stress disorder. Interview on June 12, 2026, at 10:15 a.m. with Regional Nurse, Employee E8, confirmed no comprehensive care plan was developed for dementia with agitation or PTSD for Resident R9. 28 Pa Code 211.10 (a) Resident care policies. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policy, review of clinical records, observation, and interview with staff, it was determined that the facility failed to ensure the resident environment was free of accident/hazards for two of 33 residents reviewed (Residents R32 and R51). Findings Incldue: Review of Resident R51's clinical records revealed Resident R51 was admitted to the facility on [DATE] and has diagnoses of marasmic kwashiorkor (a severe, life-threatening type of malnutrition), atherosclerosis of native arteries of bilateral legs (build up of plaque or fatty deposits inside the arteries of both legs), difficulty in walking, and muscle weakness. Continued review of Resident R51's clinical record revealed the resident has a BIMS (Brief Interview for Mental Status) score of 9, indicating moderate impairment of cognition. Review of facility documentation submitted to state survey agency revealed on September 24, 2025, Resident R51 had a fall in his/her wheelchair while being transported in a van by contract transport company coming back from an appointment. When the van driver, Employee E11, came to a stop, Resident R51 tipped backward and hit the back of his/her head. Resident R51 remained strapped in the wheelchair as it tipped backwards. Continued review of facility documentation revealed a statement by van driver, Employee E11, dated September 24, 2025, that revealed the employee may have forgotten to put the front straps on the resident's wheelchair to hold it in place when securing Resident R51 into the van. Van Driver, Employee E11, reported that as the van proceeded through a light on a hill, Resident R51's chair was pulled backwards by the back straps. Resident R51 subsequently fell backwards, hitting his/her head. Review of Resident R51's clinical record revealed a nursing progress note dated September 24, 2025, that revealed upon a physical assessment (after returning to the facility after the above noted incident) Resident R51 was noted with a lump to the back of the head with a small amount of bleeding. Resident R51 was subsequently transferred to the hospital for evaluation. Review of incident report completed by the transport company dated September 24, 2025, revealed upon a review of video footage from the van interior, it was determined and confirmed that Van Driver, Employee E11, failed to properly secure Resident R51 in the van. Per the incident report, Resident R51 was initially strapped in by the van driver x2 versus x4. Interview with Director of Nursing, Employee E2, on June 12, 2026, at approximately 11:00 a.m. confirmed the above incident with Resident R51. Review of the facility policy titled, Administering Medications revised October 2025 revealed medications shall be administered in a safe and timely manner, and as prescribed. If a drug is withheld, refused or given at a time other than the scheduled time, staff should document in the electronic health record per protocol. The resident's responsible party, if applicable, and Attending Physician will be made aware. Continued review of facility Administering Medications revealed residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. Review of resident R32's clinical record revealed that the resident was admitted to the facility on [DATE], and had a diagnosis of muscle weakness, anxiety disorder (a group of mental health conditions defined by intense, excessive, and persistent worry or fear about everyday situations), major depressive disorder (a serious mental health condition causing persistent sadness, hopelessness, and a loss of interest in activities), hyperlipidemia (high levels of fats in the blood), and Type 2 Diabetes (a chronic condition where your body either resists the effects of insulin or doesn't produce enough of it to maintain normal glucose levels). Observations on June 9, 2026, at 10:00 a.m. during a tour of the second-floor nursing unit revealed Resident R32 had medications left in a plastic cup at the bedside. Observations on June 9, 2026, at 10:05 a.m. with Unit Manager, Employee E4, confirmed Resident R51 had a clear, plastic cup that contained 6 pills at bedside. Unit Manager, Employee E4, confirmed Resident R32 does not self-administer medications, and the medications should not have been left at bedside. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.10 (d) Resident Care Policies. 28 Pa. Code 211.12 (d)(5) Nursing Services.

Based on review of facility policy, review of clinical records, and staff interview it was determined that the facility failed to implement and monitor interventions consistent with resident needs to maintain acceptable parameters of nutritional status for 3 of 33 residents reviewed (Resident R3, R9, and R14). Findings Include:Review of facility policy Weight Assessment and Intervention revised March 11, 2025, revealed the nursing staff and Dietitian will cooperate to prevent, monitor, and intervene for undesirable weight loss the residents. Any weight change of greater than or less than 5 pounds within 30 days will be retaken for confirmation. Per facility policy, the Dietitian will also review monthly weights by the 10th of the month to follow individual weight trends over time. Negative trends will be assessed and addressed by the Dietitian, whether the definition of Significant Weight Change is met.Review of Resident R3's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of Type 2 Diabetes (a chronic condition where your body either resists the effects of insulin or doesn't produce enough of it to maintain normal glucose levels), Obstructive Pulmonary Disease (a group of conditions that make it difficult to exhale all the air from your lungs), Anxiety Disorder (a mental health condition characterized by excessive, persistent, and disproportionate fear or worry in response to everyday situations), and Muscle Wasting with Atrophy (progressive loss or thinning of muscle tissue).Review of Resident R3's clinical record revealed the sustained a 7.6-pound weight gain from March 5, 2026, to April 10, 2026. Review of Resident R3's clinical record revealed missing weights for the months of May 2026 and June 2026.Review of Resident R9's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of Type 2 Diabetes, Morbid Obesity (a chronic, life-threatening disease defined as having a Body Mass Index (BMI) of 40 or higher, or a BMI of 35 to 39.9 with severe obesity-related health conditions), Anxiety, Muscle Wasting and Atrophy.Review of Resident R9's clinical record revealed the resident sustained a significant weight loss over one month from February 9, 2026 (174.2 pounds) to March 5, 2026 (163.4 pounds) of 6.2%.Further review of Resident R9's clinical record revealed a re-weight of 165.4 pounds was taken on March 7, 2026, to confirm the weight loss. Further review of Resident R9's clinical record revealed no weight was obtained for the months of April 2026 and June 2026.Review of Resident R14s clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of Hypertension (a chronic medical condition in which the force of blood against your artery walls is consistently too high), Anoxic Brain Damage (occurs when the brain is completely deprived of oxygen, leading to rapid brain cell death), Anxiety Disorder, and Aphasia (communication deficit).Review of Resident R14's clinical record revealed the resident sustained a significant weight loss over one month from March 5, 2026 (174.2 pounds) to April 10, 2026 (164.3 pounds) of 5.7%. Further review of Resident R14's clinical record revealed no documented evidence a reweight was obtained to confirm the accuracy of the weight loss on April 10, 2026.Continued review of Resident R14's clinical record revealed no weight obtained for the month of May 2026. Resident R14's next weight was documented on June 5, 2026, of 145.8 pounds, reflecting a weight loss of 18.5 pounds since April 10, 2026.Interview on June 12, 2025, at 9:45 a.m. with Registered Dietitian, Employee E6, revealed a reweight was requested for Resident R14's weight loss on June 5, 2026, but has yet to be completed. Continued interview on June 12, 2026, at 9:45 a.m. with Registered Dietitian, Employee E6 confirmed monthly weights and re-weights are not being is not being completed. Registered Dietitian, Employee E6, reported that monthly weights are due by the 10th of each month.28 Pa Code 211.10 (c) Resident care policies.28 Pa. Code 211.12 (d)(5) Nursing services.

Based on observation, interviews with staff and review of facility policy it was determined that the facility failed to ensure that food items were stored prepared and served according to professional standards.Findings include: Review of facility policy on food storage dating and labeling with the most recent review date of April 2026 reveal that under section POLICY-Sufficient storage facilities are provided to keep foods safe, wholesome and appetizing. Food is stored in an area that is clean, dry and free from contaminants. Food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Under section Procedure: #1. Dry storage rooms must be well ventilated. All storage areas should have adequate illumination with temperature and humidity controls to prevent condensation of moisture and growth of molds. # 3. Food items will be stored on shelves, with heavier and bulkier items stored on lower shelves. # 8. All stock must be rotated with each new order received. Rotating stock is essential to ensure the freshness and highest quality of all foods. a. Old stock is always used first (first in - first out method). b. Supervise the person designated to put stock away to make sure it is rotated properly. c. Food should be dated as it is placed on the shelves. d. Date marking to indicate the date or day by which a ready-to eat, potentially hazardous food should be consumed, sold or discarded will be visible on all high risk food (see chart on next page). e. Foods will be stored and handled to maintain the integrity of the packaging until ready for use. (Food stored in bins may be removed from its original packaging.) # 12. Perishable food such as meat, poultry, fish, dairy products, fruits, vegetables and frozen products must be frozen or stored in the refrigerator or freezer immediately after receipt to ensure nutritive value and quality. Refrigeration temperatures should be thermostatically controlled to maintain food temperatures at or below 41 F and freezer temperatures to keep food frozen solid. # 13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 5 days or discarded. (Also see policy on Use of Leftovers in this section.) # 14. Refrigerated Food Storage: a. All refrigerator units are kept clean and in good working condition at all times. b. PHF/TCS foods must be maintained at or below 41 F unless otherwise specified by law. Periodically take temperatures of refrigerated foods to assure temperatures are maintained at or below 41 F. Temperatures for refrigerators should be between 35-39 F. Thermometer should be checked at least two times each day. Check for proper functioning of the unit at the same time. c. Every refrigerator must be equipped with an internal thermometer. f. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable) or discarded. g. All foods should be stored to allow air circulation. h. Refrigerated foods should be stored upon delivery and careful rotation procedures should be followed. 15. Frozen Foods: a. All freezer units are kept clean and in good working condition at all times. b. Frozen foods must be maintained at a temperature to keep the food frozen solid. Temperatures for the freezer should be cold enough to keep food frozen solid and should be checked at least two times each day. Check for proper functioning of the unit at the same time. Periodically, check the firmness of foods in the freezer to assure temperatures are maintained to keep food frozen solid. d. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. All foods should be checked so as to show no negative outcome (e.g., freezer burn, foods dried out, foods with a change in color). e. All foods should be checked for signs of negative outcome. (freezer burn, foods dried out) f. All foods will be stored to allow adequate air circulation. g. All food items should be stored upon delivery and careful rotation procedures should be followed. Observation of a storage room located in the facility's basement on May 14, 2026, at 11:58AM, in the company of with Business Office Manager, Employee E4 revealed that the room was full of food items such as boxes of chips, candies, packs of water, and soda. Further observation of the storage room also revealed other nonfood items such as unopened Amazon bag. Further, food was stored in random areas of the storage room. Observation of the storage room located in the facility's basement on May 14, 2026, at 11:58 a.m. in the company of Employee E4 revealed three opened honey mustard sauce on a shelf in the storage room outside of the refrigerator. Two of the honey mustard sauce had a best by date of November 22, 2025, and one had a best by date of November 9, 2025. Further the container of the honey mustard sauce indicated Refrigerate after opening. Observation of the refrigerator in the storage room located next to the conference room revealed that the refrigerator was packed with food items. A box of fresh eggs, an open box containing 16 fresh eggs, open salad dressings Pickles whipped cream open soda bottles open mustard bottles open ketchup bottles, a blue plastic container with blue cover containing a grayish brown unknown material. Further, observation of the refrigerator revealed two salted butter with a best by date of September 17, 2024. There was dried up materials on the bottom of the refrigerator and on the shelves. Observation of the top freezer of the refrigerator revealed that the freezer was packed with frozen food items. Freezer contained 2 containers of ice cream and a box of fruit ice pops behind it further a blue bowl loosely covered with aluminum foil containing dried up brownish material was on top of the ice cream further, the bowl did not have a date on it. Further, loose ice pops with no dates affixed to them were at the bottom of the freezer. Further, two bags of undated frozen brown material in a large zip-lock bags were on top of the loose ice pops. Further, the shelves of the freezer door contained 2 packs of sausages. Further observation revealed that the bottom of the freezer had a dried-up brownish-reddish substance. There was no thermometer observed in the freezer. Interview with Business Office Manager, Employee E4 conducted at the time of the observation revealed that Employee E4 conducts a fund raiser on a regular basis involving the sale of sausages, bread, chili cheese and sour kraut. Further, Employee E4 revealed that the kitchen was aware of the sausage sale but was not involved with the process and that Therapeutic Recreation and a few nursing employees help cook and serve during the event. Further interview with Employee E4 also revealed that she purchases all the food items and she brings them in the morning of the sale. Further Employee E4 revealed that if she buys the food items ahead of time, she brings the food items in and places them in the refrigerator located in the storage area. Further, Employee E4 revealed that on the day of the fundraising sale, a hot dog roller grill (A machine used to cook hot dogs on rotating cylinders) is set up in the dining room and the sausages are then cooked there. Further, Employee E4 revealed Kitchen staff are not involved during the sale event. Further interview with Employee E4 revealed that food temperatures are not checked at any time during the storage and cooking of the food items. Further, Employee E4 also revealed that the refrigerator temperature was not checked regularly for proper temperature storage of food. Further, Employee E4 revealed that there were no temperature logs, refrigerator check logs and other documented evidence that the temperature of the refrigerator was monitored, food items were regularly monitored. Interview with Director of Therapeutic Recreation Employee E6 conducted April 14, 2026, at 11:42AM revealed that the Therapeutic Recreation department is not in charge with the fundraising involving the sale of sausages, bread, chili cheese and sauerkraut. Further EmployeeE6 revealed that the role of the Therapeutic Recreation during the event is to help cook and serve the food. Further, Employee E6 revealed that Therapeutic Recreation Department was not involved with the purchase and storage of the food items used during the fundraiser. Interview with Dietary Director, Employee E5 conducted on April 14, 2026, at 1:30 PM revealed that the kitchen was not involved in the food storage and food preparation process for the fundraising event conducted by Business Office Manager Employee E4. Further, Employee 5 revealed that Employee E4 is responsible for purchasing, storing, preparing, cooking, sale and serving the food to residents and staff. Further Dietary Director, Employee E5 revealed that moving forward the kitchen will be responsible for purchasing storing the food items used for the fundraising. Interview with Regional Nurse Employee E3 conducted on April 14, 2026, at 1:53PM during a follow-up observation of the refrigerator and freezer in the storage room confirmed that the refrigerator contained open soda bottles, open mustard bottles open ketchup bottles, a blue plastic container with blue cover containing a grayish brown unknown material, two salted butter with a best by date of September 17, 2024, dried up substance on the bottom of the refrigerator and on the shelves and that the freeze contained an undated blue bowl loosely covered with aluminum foil containing dried up brownish material was on top of two ice cream container, loose ice pops with no dates affixed to them, two bags of undated frozen brown material in a large sized zip-lock bags on top of the loose ice pops, the bottom of the freezer had a dried up brownish/reddish material and that the freezer did not have a thermometer. 28 Pa. Code 201.18(b)(3)(2.10 Management

Based on interviews and the review of clinical records, it was determined that the facility failed to ensure that a person-centered plan of care was developed for a resident who the facility documented as hoarding items in her room for 1 out of 2 residents reviewed (Resident R1). Findings include: Review of the March 2026 physician orders included the following diagnosis: seizures; anxiety (intense, excessive and persistent worry and fear about everyday situations);chronic obstructive pulmonary disease (COPD-a term used to describe a group of lung diseases that cause airflow blockage and breathing-related problems), and multiple sclerosis (a neurological illness that affects the brain and spinal cord). During an observation in the resident's room on March 6, 2026 at 11:00 a.m. the resident was observed lying in her bed with an abundance of items surrounding her entire room overcrowding both her and her roommate's drawers side by side each other on the left side of the resident's side of the room. The piles on both drawers were reportedly those of Resident R1 despite the items being on both drawers pilled up, leaving her roommate (Resident R2) with no room on top of her drawer. Items of Resident R1 were also observed on the floor area surrounding Resident R1's bedroom area on the heating unit, bedside table, a chair and a bedside dresser on the right side of the resident's bed, all with a number of items piled on top of each other in the room that she shares with another female resident. The items consisted of, but were not limited to stuffed animals, papers and pocketbooks. Piles of items in the resident's room were so compacted, and items that items in-between the piles could not be made out without lifting the piles of items up. During an interview with Resident R1 on March 6, 2026, at 11:00 a.m. Resident R1 reported during this survey that her room was junky because she has had items that have gone missing since she has been at the facility in 2021. During a visit on March 6, 2026, at 1:00 p.m. to Resident R1's room on March 6, 2026 1:00 p.m. with the Director of Nursing (DON) that she shares with her roommate, the condition of Resident R1's side of the room was discussed and observed. During a discussion with the DON on March 6, 2026, at 1:35p.m DON discussed that the resident did have hoarding behaviors. Concerns regarding Resident R2 having to be resident in a room with a description such as the above were also discussed during the above discussion. Review of the resident's current person-centered plan of care plan documents that the resident has hoarding behaviors [name of resident] has a behavior problem of hoarding, and that the goal was for the resident to have no evidence of behavior problem hoarding by the next care plan review date but there were no interventions on the care plan outlined as to how this goal would be achieved in order for the resident to address this care area and assist the resident with the care and services that she may need (e.g behavioral health treatment; assistance with a storage area; prioritizing; assisting resident with going through the items in her room and determine which items should be thrown out, put in storage, etc, involvement of family, friends as support). During an interview with the Director of Nursing on March 6, 2026 at 12:36 p.m. the resident's plan of care for hoarding behaviors having no interventions was reviewed and discussed with the DON. 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c(1) )Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on observations and staff interviews, it was determined that the facility failed to ensure that a resident received showers as scheduled for one of two residents reviewed (Resident R2).Findings include: Review of the facility policy, Activities of Daily Living (ADL's) with a review date of December 2024 indicated that it was the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring that all staff, across all shifts and departments, understands the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided a are person-centered, an honor and support each resident's preferences, choices, values and beliefs. Review of Resident R2's March 2026 physician orders included the diagnoses of seizure disorder; anxiety (intense, excessive and persistent worry and fear about everyday situations); chronic obstructive pulmonary disease (COPD-a term used to describe a group of lung diseases that cause airflow blockage and breathing-related problems), and multiple sclerosis (a neurological illness that affects the brain and spinal cord). Review of the resident's significant change Minimum Data Set Assessment (MDS- periodic assessment of a resident's needs) dated January 21, 2026 documented the resident as awake, alert and oriented. During an interview with Resident R2 on March 6, 2026 at 11:00 a.m. the resident reported that she had not had a shower since May 5, 2025 due to being told that the facility no longer had a bariatric shower bed with a size that was able to accommodate her. The resident reported that she prefers to take a shower on her scheduled shower days, which are on Wednesdays and Saturdays between the hours of 3:00 p.m. through 11:00 p.m. Review of the resident's bathing record from February 5, 2026-March 6, 2026 included documentation that the resident had not had a shower at any time during the specified time period, and was only given bed baths on the days that her showers were scheduled. Review of Resident R2's person-centered plan of care included a plan of care for the resident's adl's (activites of daily living) [resident name] has an ADL self-care performance deficit, with the goal of the resident approving/maintaining her current level of function in adl's. The interventions related to this care area included that the resident prefers showers on Wednesday and Saturday. evening, and that she requires the assistance of 1 person with bathing and showering. During a discussion with the Director of Nursing (DON) on March 6, 2026, at 1:35p.m it was discussed with the DON that the resident's bathing record documented by the resident's assigned nurse aide on the assigned shower days, did not show evidence that the resident was provided with a shower on those designated days. 28 Pa.Code 201.29(j) Resident 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 staff interview and clinical record review, it was determined that the facility failed to ensure that residents were free from misappropriation of personal property when narcotic medications were stolen/diverted for two of two clinical records reviewed. (Resident R1 and Resident R2).Findings include:A review of the facility's policy titled Abuse (Revised June 1, 2025) defines abuse as: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services necessary to maintain physical, mental, and psychosocial well-being. Continued review of the policy defines misappropriation of resident property as: The deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Review all facility policy titled Drug Buster dated May 2,2023 revealed only authorized licensed nursing pharmacy personnel should have access to controlled substances maintained on the premises. Before destroying controlled substances, medication must be counted for accuracy and verified by two licensed nurses. Both nurses must sign the disposition of narcotics section of the narcotic record verifying the accurate count and method of disposition. The narcotic record must not be discarded it remains a part of the resident's permanent medical record.Review of facility policy titled Controlled Substance Log Dated April 24, 2023, and last revised August 2025, revealed the facility shall comply with all laws regulations and other requirements related to receiving, handling, storage, disposal, and documentation of Scheduled ll and other controlled substances. Follow the index page to perform a complete count of all scheduled II to IV controlled drugs at the change of shifts or at any time in which narcotic keys are surrendered from one licensed nurse staff to another. The count must be performed by two licensed nursing staff per state regulation; the two licensed nursing staff must be those who are relinquishing and accepting the narcotic keys. Both licensed nursing staff participating in the count must confirm the inventory page reflects the quality of drugs present in the container, verify the amount remaining as noted in the amount left column of each inventory page, do not fold pages, one page is full and narcotic completed destroyed highlighted narcotic page and correlating line on the index sheet, both licensed nurses sign the shift count page in the Controlled Substance books to acknowledge the completion of the shift count.Review of facility documentation submitted to the Department of Health revealed that on July 31, 2025, at approximately 2:00 PM, a Licensed nurse, Employee E3 identified a discrepancy involving the medications of Resident R1 and Resident R2. Two medications were reported missing. At the time of discovery, Resident R2 had been discharged from the facility on July 30, 2025, while Resident R1 remained at the facility. According to the nurse's testimony, the overnight nurse administered only one narcotic during her shift. Suboxone (a medication used to treat opioid dependence) was last administered at 6:00 AM and documented both in the narcotic count book and the electronic medication administration record (eMAR). Resident R2's Oxycodone (opioid pain medication) was last administered prior to her discharge on [DATE]. During the shift change, the overnight Licensed nurse, Employee E 4 conducted a medication count with the oncoming 7:00 AM-3:00 PM Licensed nurse, Employee E 3. Both nurses confirmed that the narcotic count was complete and accurate at the time of the 7:30 AM handoff. A review of Resident R1's admission Minimum Data Set (MDS- a mandatory periodic resident assessment tool), dated August 4, 2025, revealed that the resident was admitted to the facility on [DATE] with the diagnoses of Viral Hepatitis (an infection that causes liver inflammation), Rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the bloodstream), and Pulmonary Fibrosis (a chronic lung disease in which damaged and scarred lung tissue makes breathing difficult). Continued review of the clinical record revealed that the resident experienced frequent pain and received anticoagulant therapy. The Brief Interview for Mental Status (BIMS) score was 15, signifying that the resident's cognitive function is intact.Review of Resident R1's physician orders revealed an order dated July 28, 2025, for Buprenorphine HCL-Naloxone (Suboxone) Sublingual film 8-1 was prescribed to give one film sublingually every 8 hours for opioid withdrawal.Review of Resident R1's medication administration record (eMAR) revealed on July 30, 2025 Suboxone was administered at 6:00 a.m., 2:00 p.m. and 10:00 p.m. and on July 31, 2025, Suboxone was administered at 6:00 a.m. and 10:00 p.m. The medication was not documented as administered at 2:00 p.m. The medication was signed off by Licensed nurse Employee E3, and it was documented that the medication was not available.Review of Resident R2's quarterly Minimum Data Set (MDS- a mandatory periodic resident assessment tool) date May 5, 2025, revealed that Resident R 2 was admitted into the facility on January 28, 2025, with diagnosis of amputation (removal of a limb). Resident was discharged from the facility on July 31, 2025.Review of Resident R2's clinical record and physician orders revealed a prescription dated July 28, 2025, for Oxycodone 5 milligrams (mg) oral tablets. The order directed to administer 2.5 mg by mouth every 12 hours as needed for moderate pain. Review of Resident R2's eMAR revealed that Resident R2 was administered the pain medication daily until discharge July 28, 2025.Review of facility investigation revealed Resident R1 received immediate pain management as prescribed. Nursing staff were interviewed, the local police department was notified, A full audit of the narcotic inventory across all six (6) medication carts was conducted, revealing no additional discrepancies and replacement medications were reordered from the pharmacy. The on-call provider was informed accordingly. The investigation has concluded. While the facility was unable to obtain sufficient evidence to substantiate the involvement of the named individual, it was confirmed that the medications were indeed missing. The facility has covered the cost of the replacement medication.During interviews conducted on September 2, 2025, at 10:15 a.m. and 12:04 p.m., the Director of Nursing (DON), Employee E2 reported that the investigation determined the missing medications were linked to an agency nurse, Employee E4, who had worked two shifts at the facility. Licensed Nurse, Employee E4 manipulated the narcotic count sheets, leading to inaccurate medication counts. As a result, the facility placed Employee E4 on a Do Not Return list. Continued interview with DON, Employee E2 revealed that there were a total of ten oxycodone tablets and nine suboxone pills missing. A full audit of all medication carts was conducted by the DON, Employee E2 and no additional discrepancies were identified. The DON, Employee E2 confirmed that education was provided to staff, and relevant policies were revised to prevent future occurrences. 28 Pa Code 201.14 (a)(b) Responsibility of licensee28 Pa. Code 201.18 (b)(1)(2)(3) Management

Based on facility policy, interviews, and record reviews, the facility failed to conduct a thorough investigation into an allegation of drug misappropriation and to protect residents from misappropriation of controlled substances for two of two residents reviewed. (Residents R1 and R2)Findings include:Review of Facility Policy titled Abuse (Revised [DATE]) defines abuse as: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services necessary to maintain physical, mental, and psychosocial well-being.Continued review of the policy defines misappropriation of resident property as: The deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. The facility policy further states that all reports of abuse, neglect, exploitation, and misappropriation must be promptly and thoroughly investigated. When a crime is suspected, staff must preserve evidence and handle materials carefully to avoid compromising any potential criminal investigation. Review of facility documentation submitted to the Department of Health revealed that on [DATE], at approximately 2:00 PM, a licensed nurse Employee E3 identified a discrepancy involving the medications of Resident R1 and Resident R2. Two medications were reported missing. At the time of discovery, Residents R2 had been discharged on [DATE], while the other remained admitted . According to the nurse's testimony, the overnight nurse administered only one narcotic during her shift. Suboxone (a medication used to treat opioid dependence) was last administered at 6:00 AM and documented both in the narcotic count book and the electronic medication administration record (eMAR). Resident R2's Oxycodone (opioid pain medication) was last administered prior to her discharge on [DATE]. During the shift change, the overnight licensed nurse, Employee E4 conducted a medication count with the oncoming 7:00 AM-3:00 PM Licensed nurse Employee E3. Both nurses confirmed that the narcotic count was complete and accurate at the time of the 7:30 AM handoff. Review of Facility's Investigation revealed three staff statements were obtained, a basic audit of all six medication carts was completed, revealing no additional discrepancies. Continued review of facility investigation included, medical provider notified, replacement medications were ordered, and the local police department was notified. However, the investigation lacked critical elements: No Inventory Reconciliation was documented/performed, there were no documented medication counts included, no waste documentation was provided, interviews were conducted with only three employees not all staff who had access to the medication cart, and the exact count and accounting of the missing drugs were not documented, the missing medications (9 Suboxone films and 10 Oxycodone tablets) were only mentioned during interviews and were not documented in the investigation report. Review of Licensed nurse, Employee E5 (Nursing Supervisor) written statement dated [DATE], stated that on [DATE], during the 11 PM-7 AM shift, a resident expired at 5:33 AM. The charge nurse, Employee E4, was instructed to secure the deceased resident's medications. The nurse claimed the only medication present was one full blister pack of Lisinopril, and no discrepancies were reported at that time.Review of Licensed nurse, Employee E3 's written statement dated July31, 2025, reported that she conducted a medication count with the morning nurse and did not recall counting Oxycodone or Suboxone. When this discrepancy was noticed, the Director of Nursing (DON) was immediately notified.Review of Licensed nurse, Employee E4's written statement dated [DATE], indicated proper narcotic counts were conducted at the start and end of shift. The only narcotic administered was one dose of Suboxone at 6:00 AM.Review of employee E 4 Personnel File revealed that the license was verified as current and the criminal background check was marked as pending. Nursing Home Administrator (Employee E1) provided the completed background check only after it was requested by the surveyor.Review of provided medication carts audit revealed the audit documentation included basic charting of dates, locations, insulin vial status, presence of loose pills, and need for follow-up, but did not include any actual narcotic counts.Interview with Director of Nursing, Employee E 2 on [DATE], at 10:20 a.m. revealed that the Investigaton determined that licensed nurse Employee E4 was responsible for the missing medications. This employee is not an employee of the facility but an agency nurse. She has worked at the facility twice. Employee E2 concluded that the nurse manipulated the pages of the narcotic book to indicate an inaccurate about of medication that were counted. This overnight nurse was not charged but noted on a do not return list of the facility. Continued interview with Employee E2 revealed that he conducted a full audit of all medication carts and determined no other medication were missing. Education was given to employees, and policy were altered going forward. Employee E2 confirmed that the provided documents of the medication audits were incomplete the documents did not reflect the actual count of medication, and no other staff were interviewed. Further interview with this employee indicated that the investigation was determined completed but documentation was not included. 28 Pa. Code 211.9(a)(1) Pharmacy Services 28 Pa. Code 201.149A) Responsibility of Licensee 28 Pa. Code 201.18(a)(j)(4) Management

Based on a review of medical records and staff interviews it was determined that the facility failed to develop and implement care plans for two of eight residents reviewed regarding intravenous (IV) and ostomy care. (Resident R7 and R8.) Findings include: A review of Resident R7's clinical record revealed that the resident was admitted to the facility on [DATE], with a colostomy. Interview with Resident R7 on August 13, 2025, at 11:00 a.m. revealed that the resident was receiving colostomy care each day. Further review of Resident R7's medical record revealed no comprehensive care plan for the care of his colostomy. A review of Resident R8's clinical record revealed that the resident was admitted to the facility on [DATE], with an IV. Interview with Resident R on August 13, 2025, at 11:15 a.m. revealed that the resident had an IV for medication to prevent infection to his wounds. An interview with the Director of Nursing on August 13, 2025, at 1:20 p.m. confirmed that there was no care plan to address resident R7's colostomy care or Resident R8's IV care. 28 Pa. Code 211.12 (d)(5) Nursing services

Based on review of facility documentation and staff interview, it was determined that the facility failed to ensure that licensed nursing staff had the proper competencies including intravenous (IV) care and ostomy care for four of four licensed nurse training records reviewed (Employees E4, E5, E6 & E7). Findings include:Review of the provided facility policies did not reveal any policy related to nursing competencies.Review of training records provided did not reveal competencies requested including IV care for Employees E4 and E5, and ostomy care for Employees E4, E5, E6 and E7.Interview with the Director of Nursing on August 13, 2025, at 1:15 p.m. confirmed that there was no documentation available to review to show that the selected licensed nursing staff had been evaluated for competency in ostomy care, and that Employee E6 and E7 had no IV competency documented. 28 Pa. Code: 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on observations, and staff and resident interviews. it was determined that the facility failed to maintain a comfortable environment for one of three nursing units observed (3rd floor lounge). Findings Include: A tour of the facility was conducted on June 26, 2025, at approximately 10:30 a.m. with Maintenance Director, Employee E3, to monitor the temperatures of the building and resident care areas. Temperatures taken by Maintenance Director, Employee E3, on June 26, 2025, at 11:15 a.m. in the 3rd floor multipurpose room revealed temperatures reached up to 84 degrees. Temperature of the room felt hot, humid, and uncomfortable. Observations on June 26, 2025, at 11:15 a.m. in the 3rd floor multipurpose room revealed about 20 residents were gathered in the room and were being supervised by nurse aide, Employee E4. Interview with nurse aide, Employee E4, revealed these residents required supervision due to fall risks. Nurse aide, Employee E4, was observed to be sitting in a chair amongst the resident's drinking a cold, iced coffee. Further observations revealed 16 residents (Resident R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17) were sitting without any kind of beverage. Nurse aide, Employee E4, confirmed the residents did not have water and would get a pitcher of water and ice to begin passing beverages. Further observations on June 26, 2026, at 11:15 a.m. revealed Resident R1 looked uncomfortable with a clammy/sweaty appearance. During an interview with Resident R1 the resident confirmed being uncomfortable due to the warm temperature of the room. Interviews with Resident R2 and R3 reported feeling hot and uncomfortable due to the temperatures of the room. 28 Pa Code: 201.14 (a) Responsibility of licensee.

Based on review of facility policy, facility documentation, review of clinical records, and staff interviews, it was determined that the facility failed to conduct a complete and thorough investigation related to abuse/neglect and misappropriation of resident property for three of four residents reviewed (Resident R303, R90 and R108.). Findings Include: Review of facility policy Abuse, reviewed December 2024, revealed misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. It is the policy of the facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. Investigation regarding misappropriation should consist of, but not limited to, an interview with any witnesses to the incident, a search of resident room (with resident permission), interviews with the resident's roommate, family members, and visitors, a root-cause analysis of all circumstances surrounding the incident. Review of Resident R303's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 5, 2025, revealed the resident was cognitively intact, assessed by a Brief Interview for Mental Status (BIMS) score of 15. Review of documentation submitted to the Survey State Agency on February 20, 2025, revealed that Resident R303 reported that on February 15, 2025, nurse aide, Employee E16, allegedly stole $100 from the resident's purse while the nurse aide was in the room to provide care. Resident R303 subsequently provided the Nursing Home Administrator, Employee E1, with a copy of the receipt for the money Resident R303 withdrew from the ATM. Review of facility documentation revealed a statement dated February 20, 2025, by nurse aide, Employee E16, who denied stealing Resident R303's money. Nurse aide, Employee E16, was subsequently suspended pending an investigation. Interview on June 12, 2025, at 12:07 p.m. with the Director of Nursing, Employee E2, revealed no investigation was available for the allegations of misappropriation of resident's property. Review of facility documentation revealed no evidence that the facility obtained interviews with any witnesses to the incident, a search of the resident room (with resident permission), interview with family members or visitors, or interviews with resident's roommate or residents under the care of the same nurse aide in question. Interview on June 12, 2025, at 2:00 p.m. with the Nursing Home Administrator, Employee E1, revealed the statement by nurse aide, Employee E16, was all that was available for the investigation of misappropriation for Resident R303's allegedly stolen money. Review of the June 2025 physician orders for Resident R90 included the following diagnoses: dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities); muscle weakness and lack of coordination. Review of the resident's Quarterly Minimum Data Set Assessment (MDS-periodic assessment of a resident's needs) dated September 13, 2024 indicated that the resident was severely cognitively impaired. Review of a reportable incident submitted to the State Survey Agency on October 16, 2024 indicated that on October 15, 2024 at approximately 3:30 p.m. Resident R90 fell out of her wheelchair in the hallway outside her room and was found lying on her left side. Continued review of the resident's fall report indicated that the resident was found on the floor in the hallway lying on her left side, and that the resident was unable to provide a description of what happened. Review of the fall report provided by the facility did not show evidence that the facility conducted a complete and through investigation (e.g. interviews with any staff members or residents who may have been present; no information on who found the resident on the floor )to rule out abuse/neglect. During an interview on June 12, 2025, at 12:07 p.m. with the Director of Nursing, Employee E2, revealed no investigation was available for the above referenced incident. Review of the June 2025 physician orders for Resident R108 included the following diagnoses: osteoarthritis of the knee; lack of coordination; morbid obesity; muscle weakness and difficulty walking. Review of the resident's Quarterly Minimum Data Set Assessment (MDS-periodic assessment of a resident's needs) for the resident dated October 28, 2024 indicated that the resident was awake, alert and oriented. Review of a reportable incident submitted to the State Survey Agency on October 30, 2024 indicated that on October 29, 2024, the resident sustained a fall while transferring from her bed to the wheelchair while using a mechanical lift with two nurse aides. Continued review of the reportable incident indicated that the sling broke during the transfer causing the resident to slide down in the sling and onto the floor. The resident was subsequently sent out to the hospital and treated for a left thumb sprain. The reportable incident also indicated that staff were interviewed, resident were interviewed, and that abuse was ruled out, and staff was able to confirm that the sling was connected correctly to the lift. Review of the information related to the investigation that was provided by the facility did not show evidence of a complete and through investigation to rule out abuse/neglect. The facility could not produce any interviwed regarding the incident from the nurse aides, other nursing staff, or the resident. It was also unknow if the facility investigated to ensure that the sling that the reportedly two nurse aides were utilizing during the transfer was the correct sling size for the resident's weight. During an interview on June 12, 2025, at 12:07 p.m. with the Director of Nursing, Employee E2, revealed no investigation was available for the above referenced incident. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.29 (a) Resident rights.

Based on review of facility policy, facility documentation, and staff interviews it was determined that the facility failed to implement appropriate tracking and surveillance of infection for five of five months of infection surveillance data reviewed. (January 2025 through May 2025) Findings Include: Review of facility policy Surveillance, June 2025, revealed The ongoing, systematic collection, analysis, and interpreta1ion of health data essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those who need to know. The Infection Preventionist will monitor new infections and antibiotic. The Infection Preventionist is encouraged to map out the HAI onto a facility map monthly to rule out concerns/ patterns with care givers. The surveillance sheet will capture the following information : o Name o Room o Unit o Indication where acquired o CAI = community-acquired infection o HAI = hospital-acquired infection o NHAI = nursing home-acquired infection o Other Nosocomial = acquired in another health care setting o New infections/ ABT use o Signs/ Symptoms o Onset Date o Type of Infection o Antibiotic (HAI and community acquired) o Prescribing Physician o Dose o Start and End date o Total Days o X-Ray/ Labs Results o Cultures o Organism identified o Date of Culture (if applicable) o Cultures ordered during stay o Cultures results during stay o ESBL, Cdiff, MRSA, VRE, CRE o Indicate Diagnostic Tool Used o Whether criteria were met A request was made to Director of Nursing, Employee E2 for infection tracking of the facility on June 10, 2025. Review of facility infection tracking for the month of January 2025 revealed that the facility had 11 infections for the month of January 2025. 10 of those infections were facility acquired. The tracking did not include signs and symptoms or stop dates for the antibiotics. Review of January 2025 pharmacy order report revealed that the facility had 15 residents/infections with antibiotics ordered which was not consistent with facility tracking form. Review of facility infection tracking for the month of February 2025 revealed that the 2nd floor had 2 infections for the month of February. Both of those infections were facility acquired. The tracking did not include signs and symptoms or stop dates for the antibiotics. There was no tracking available for 3rd floor. Review of February 2025 pharmacy order report revealed that the facility had 5 residents/infections with antibiotics ordered which was not consistent with facility tracking form. Review of facility infection tracking for the month of March 2025 revealed that the 3rd floor had 3 infections for the month of March 2025. All three of those infections were facility acquired. The tracking did not include signs and symptoms or stop dates for the antibiotics. Review of February 2025 pharmacy order report revealed that the facility had 5 residents/infections with antibiotics ordered which was not consistent with facility tracking form. Review of March 2025 pharmacy order report revealed that the facility had 14 residents/infections with antibiotics ordered which was not consistent with facility tracking form. Review of facility infection tracking for the month of April 2025 revealed that the facility had 5 infections for the month of April. 3 of those infections were facility acquired. The tracking did not include signs and symptoms or stop dates for the antibiotics. Review of April 2025 pharmacy order report revealed that the facility had 13 residents/infections with antibiotics ordered which was not consistent with facility tracking form. Review of facility documentation revealed that no infection tracking for were available for May 2025. Review of May 2025 pharmacy order report revealed that the facility had 12 residents/infections with antibiotics ordered which was not consistent with facility tracking form Interview with Employee E2, Director of Nursing on June 11, 2025, at 2 p.m. confirmed that the facility did not have complete infection surveillance including the tracking of signs and symptoms. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a review of facility documentation, facility policies and staff interviews, it was determined that the facility failed to maintain an effective antibiotic stewardship program that includes a system that includes antibiotic use protocols and a system to effectively monitor antibiotic usage for 10 of 10 months of antibiotic stewardship program data reviewed. (January 2025, February 2025, March 2025, April 2025, and May 2025). Findings Include: A review of CDC (Centers for Disease Control and Prevention) guidelines, The core element of Antibiotic Stewardship for Nursing Homes, revealed that Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. 1. Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.2 The Centers for Disease Control and Prevention (CDC) recommends that all acute care hospitals implement an antibiotic stewardship program (ASP) and outlined the seven core elements which are necessary for implementing successful ASPs.2 CDC also recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use. Nursing homes monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions. Data on adherence to antibiotic prescribing policies and antibiotic use are shared with clinicians and nurses to maintain awareness about the progress being made in antibiotic stewardship. Clinician response to antibiotic use feedback (e.g., acceptance) may help determine whether feedback is effective in changing prescribing behaviors. Integrate the dispensing and consultant pharmacists into the clinical care team as key partners in supporting antibiotic stewardship in nursing homes. Pharmacists can provide assistance in ensuring antibiotics are ordered appropriately, reviewing culture data, and developing antibiotic monitoring and infection management guidance in collaboration with nursing and clinical leaders. Identify clinical situations which may be driving inappropriate courses of antibiotics such as asymptomatic bacteriuria or urinary tract infection prophylaxis and implement specific interventions to improve use. Perform reviews on resident medical records for new antibiotic starts to determine whether the clinical assessment, prescription documentation and antibiotic selection were in accordance with facility antibiotic use policies and practices. When conducted over time, monitoring process measures can assess whether antibiotic prescribing policies are being followed by staff and clinicians. Track the amount of antibiotic used in your nursing home to review patterns of use and determine the impact of new stewardship interventions. Some antibiotic use measures (e.g., prevalence surveys) provide a snap-shot of information; while others, like nursing home initiated antibiotic starts and days of therapy (DOT) are calculated and tracked on an ongoing basis. Selecting which antibiotic use measure to track should be based on the type of practice intervention being implemented. Interventions designed to shorten the duration of antibiotic courses, or discontinue antibiotics based on post-prescription review (i.e., antibiotic time-out), may not necessarily change the rate of antibiotic starts, but would decrease the antibiotic DOT. Review of facility policy, Antimicrobial Stewardship Program, dated February 2025 revealed that Since antimicrobials are frequently over or inappropriately prescribed, a concerted effort to decrease or eliminate inappropriate use can make a big impact on resident safety and the reduction of adverse events. Antimicrobial stewardship consists of coordinated interventions aimed at treating infections while promoting appropriate antimicrobial use. The practice of antimicrobial stewardship requires commitment, leadership, communication, and actions informed by best practice guidelines and defined protocols. In compliance with the current Centers for Medicare and Medicaid Services (CMS} Requirements of Participation for infection control in long-term care facilities, this Antimicrobial Stewardship Policy outlines how the facility will address this important health care issue. Actions Prescription record keeping. Dose, duration, route, and indication of every antimicrobial prescription MUST be documented in the medical record for every resident, regardless of prior prescriptions or documentation elsewhere (e .g., in medical record of a discharging facility). Notation of this information should be made on the day that an in-house prescription is written or on the day that a resident returns to the facility on an antimicrobial prescribed elsewhere. Records will be reviewed monthly to assess compliance with this require ent swell as prescription appropriateness for the individual resident, site, and type of infection. Assessment of residents suspected of having an infection. Provider will utilize the Pennsylvania Patient Safety Reporting (PA-PSRS} Criteria when considering initiation of antimicrobials for suspected infections including; urinary tract infections, respiratory tract infections, gastrointestinal infections, skin and soft tissue infections and device related blood stream infections. Antimicrobial time-out. At 72 hours after antimicrobial initiation or first dose in the facility, each resident will be reassessed for consideration o l antimicrobial need, duration, selection, and de-escalation potential. At this time, laboratory testing results, response to therapy, resident condition, and facility needs (e . , outbreak situation) will be considered. Completion of an antimicrobial time out must be recorded in the resident record. Review of facility antibiotic stewardship/surveillance data provided by the facility during the survey revealed that the facility only completed 10 resident infection review from January 2025 to June 2025. Review of January 2025 pharmacy order report revealed that the facility had 15 residents/infections with antibiotics ordered which was not consistent with facility tracking form. Review of February 2025 pharmacy order report revealed that the facility had 5 residents/infections with antibiotics ordered which was not consistent with facility tracking form. Review of March 2025 pharmacy order report revealed that the facility had 14 residents/infections with antibiotics ordered which was not consistent with facility tracking form. Review of April 2025 pharmacy order report revealed that the facility had 13 residents/infections with antibiotics ordered which was not consistent with facility tracking form. Review of May 2025 pharmacy order report revealed that the facility had 12 residents/infections with antibiotics ordered which was not consistent with facility tracking form. Interview with Employee E2, Director of Nursing on June 11, 2025, at 2 p.m. confirmed that the confirmed that the facility antibiotic stewardship program did not include use protocols for antibiotics, did not include complete review of facility antibiotic orders to determine the appropriateness of the antibiotics and a system to effectively monitor antibiotic usage and a tracking of symptoms. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records and staff interviews, it was determined that the facility failed to offer and/or provide the influenza and pneumococcal immunization for three of five residents reviewed (Resident R117, R295, R32, R62, and R95). The findings include: Review of the clinical record for Resident R117 revealed the resident was admitted to the facility on [DATE]. Resident was [AGE] years old. Review of R117's immunization records revealed no evidence that the resident received the pneumococcal vaccine, or the facility offered the pneumococcal vaccine. Facility did not offer or administer influenza vaccine. Review of the clinical record for Resident R295 revealed that the resident was [AGE] years old. Review of R295's immunization records revealed no evidence that the resident received the pneumococcal vaccine, or the facility offered the pneumococcal vaccine. Review of the clinical record for Resident R32 revealed that the resident was [AGE] years old. Review of R32's immunization records revealed no evidence that the resident received the pneumococcal vaccine, or the facility offered the pneumococcal vaccine. Review of the clinical record for Resident R62 revealed the resident was admitted to the facility on [DATE]. Resident was [AGE] years old. Review of R62's immunization records revealed no evidence that the resident received the pneumococcal vaccine, or the facility offered the pneumococcal vaccine. Facility did not offer or administer influenza vaccine. Review of the clinical record for Resident R95 revealed that the resident was [AGE] years old. Review of R95's immunization records revealed no evidence that the resident received the pneumococcal vaccine, or the facility offered the pneumococcal vaccine. 28 Pa Code: 201.14 (a ) Responsibility of licensee 28 Pa Code: 201.12 (d)(1) Nursing services

Based staff interviews, review of facility policy and the review of the clinical record, it was determined that the facility failed to ensure that a resident received proper notification for a room change, and failed to ensure that the resident had the opportunity to refuse a room change for 1 out of 29 residents reviewed (Resident R11). Findings include: Review of the facility policy, Room Change/Roommate Assignment, dated April 1, 2022 indicated that changes in room or roommate assignment shall be made when the facility deems it necessary or when the resident requests the change. Changes in room or roommate assignment shall be made when the facility deems it necessary or when the resident requests the change. The policy also stated that prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g., residents or their representatives (sponsors)) will be given advance notice of such change. Continued review of the policy indicated that he notice of a change in room or roommate assignment may be oral or in writing, or both, and will include the reason(s) for such change. Review of the June 2025 physician orders for Resident R11 included the following diagnoses epilepsy; hypertension (high blood pressure) and muscle weakness. During an interview Resident R11 on June 10, 2025 at 10:30 a.m. the resident reported he was told that he had to move from the st floor because the first floor was only for short term residents. The resident reported that he told the facility that he did not want to move. I told them that I did not want to move. Review of the resident's clinical record revealed a Roommate Change-Advanced Notification form dated April 23, 2025 indicating that on the above referenced date, the resident was moved from the1st floor to the 3rd floor on April 23, 2025 and that the reason for the room change was switch from skilled unit to long-term care unit. Review of a nursing note dated April 23, 2025 at 1:04 p.m. indicated that the resident was transferred from the 1st floor to the 3rd floor on the above referenced date. Review of the clinical record did not show evidence that the resident received advanced notice of the room changed (prior to April 23, 2025) and instead, was notified the same day that the room change occurred. Review of the clinical record also did not show evidence that the resident was allowed the opportunity to refuse the room change to the 3rd floor. During a discussion with the Director of Nursing on June 13, 2025 at 12:15 p.m. , it was discussed that there was no evidence in the clinical record that the resident received advanced notice of his room change that occurred on April 23, 2025, and there was no evidence that the resident was provided with the right to refuse the room change to the 3rd floor. The facility failed to ensure prior written notification was provided to Resident R11 and failed to ensure that the resident was provided with the opportunity to refuse the room change. 28 Pa. Code 201.14(a) Responsibility of licensee 29 Pa. Code 201.29(d) Resident rights 29 Pa. Code 201.29(j) Resident rights

Based on observations, resident and staff interviews, it was determined that facility failed maintain a safe, clean comfortable and home like environment for residents of one of three nursing units. (Third floor) Findings Include: Observation of Third floor nursing unit on June 10, 2025, at 9:45 AM revealed there was a strong odor of urine throughout the South unit hallway. Observation of Third floor nursing unit on June 10, 2025, at 9:52 AM revealed there was a strong odor of urine throughout the [NAME] unit hallway. Interview with the Licensed Practical Nurse, Employee E23, on June 9, 2025, at 9:52 AM confirmed that there was strong odor of urine on both hallways. Employee E3 stated it could be from staff changing the residents. A follow up tour of the south hallway on June 10, 2025, at 10:00 AM revealed that there were no residents receiving incontinence care. Observation of Third floor nursing unit on June12, 2025, at 10:41 AM revealed there was strong odor of on the [NAME] hallway. Observation of the Third-floor dining room on June11, 2025, at 10:35 AM revealed that there was trash on the floor, liquid spill on the floor and table. There were breakfast trays sitting on the table. Residents were observed sitting in the dining room and watching TV at the time of the observation. Interview with the Housekeeping Director, Employee E24, on June 12, 2025, at 10:52 AM confirmed that there was strong odor on the third-floor hallway. He stated facility cleaned the rooms, but the odor still kept coming. He stated staff sprayed the hallway but it only lasted for 15 min and the odor comes back. 28 Pa Code: 201.14 (a) Responsibility of licensee.

Based on observation, review of medical records, review of facility documentation and facility policy and interviews with staff, it was determined that the facility failed to ensure that one of four residents reviewed were protected from neglect. This resulted in actual harm to resident (Resident CL1) who sustained a fracture hip related to a fall. Findings include: Review of a facility policy titled Abuse and Neglect and dated (MONTH) 9, (YEAR), revealed that residents have the right to be free from abuse and neglect in accordance with State and Federal regulations. Continued review of the policy revealed that the facility defined neglect as the failure to provide goods and services necessary to avoid physical harm. Review of an undated facility policy titled Fall Risk Assessment revealed that residents who are at risk for falls are identified and proper preventative measures are taken to minimize their risk, promote safety, improve quality of nursing care, and ensure resident needs are met in a timely manner. Review of medical records for Resident CL1 revealed diagnoses, including but not limited to, repeated falls, fall from chair, lack of coordination and [MEDICAL CONDITION] (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain). Further review of medical records for Resident CL1 revealed that on (MONTH) 25, 2019, the resident had fallen while left unattended in the bathroom. The medical records further indicated that the resident had sustained a fractured left hip following her fall. Review of Resident CL1's care plans revealed the resident required the physical assistance of one staff member to transfer (move from one area to another). Additionally, the care plan indicated that the resident required close monitoring when going to the bathroom because she would attempt to get up by herself. The care plan further indicated that close monitoring would avoid the resident trying to ambulate by herself. Interview with the Nursing Home Administrator (NHA) and the Assistant Director of Nursing (ADON) on (MONTH) 16, 2019, at 11:00 a.m. regarding their investigation into Resident CL1's [MEDICAL CONDITION] revealed that on (MONTH) 25, 2019, Employee E8, NA (nurse's assistant), took Resident CL1 to the toilet and left her alone on the toilet. Then shortly thereafter, Resident CL1 activated the call bell for assistance and Employee E11, LPN, responded to the call bell. The ADON stated that Employee E11 told the resident to wait for assistance while she went to find a NA to help her mobilize the resident. Shortly after Employee E11 left Resident CL1's room, Employee E7, NA, heard a scream and ran to the resident's room to find her lying on the floor. Review of the facility investigation into Resident CL1's fall revealed a witness statement by Employee E8, NA, which noted, When I went in the room she stated she needed to use the bathroom. I put her on the toilet and when she was finish she put the light on to the bathroom. A witness statement from Employee E11, LPN, revealed that at or around 12:00 p.m. Resident CL1's call bell was going off. Resident stated 'I'm done now', I said OK, I will get someone to help you. As I was coming out room Employee E12, NA, was walking pass (sic) me and I said she was done in the bathroom. Employee E12, NA, stated 'she goes back and forth'. At or around 12:20 p.m. I was alerted by Employee E7, NA, that the resident was on the floor. A witness statement provided by Employee E7, NA, revealed that when coming off the elevator the resident was screaming and I went to the room and resident was on the bathroom floor and I notified the nurse. Continued review of the facility investigation into Resident CL1's fall on (MONTH) 25, 2019, revealed a statement made by the resident. The resident stated, in response to the question did you report this to anyone? that I told you (Employee E11, LPN), you said you was getting someone. Interview with the NHA and ADON on (MONTH) 16, 2019, at 1:00 p.m. revealed the statement from Employee E11, LPN, where she stated she (Resident CL1) goes back and forth meant that the resident was able to self-ambulate between the toilet and the wheelchair independently. The ADON revealed that Employee E11, a licensed nurse, took the advice of Employee E12, a nursing assistant that the resident was capable of walking independently. The ADON confirmed that no employees returned to help resident CL1 or to explain that she would not receive help after being told to wait by Employee E11, LPN. Interview with Employee E8, NA, on (MONTH) 16, 2019, at 1:57 p.m. in the presence of the NHA, DON, ADON and the Director of Human Resources (DHR), confirmed that the employee took Resident CL1 to the toilet at 11:50 a.m. on (MONTH) 25, 2019. Employee E8 stated in interview, normally, I would stay with her in the bathroom by the door. I was the only one on the floor and had dirty linen, so I went to the linen chute. Interview with the NHA and DON on (MONTH) 16, 2019, at 4:00 p.m. confirmed that the Nursing Assistant (Employee E8) who placed Resident CL1 on the toilet and the Licensed Practical Nurse (Employee E11) who responded to Resident CL1's call bell both had the opportunity to follow Resident CL1's care plan and remain with the resident while she was on the toilet to prevent her from self-ambulating. Continued interview with the DON on (MONTH) 16, 2019, at 4:00 p.m. revealed, I should have reported this as neglect in reference to Resident CL1 obtaining a [MEDICAL CONDITION] following her fall on (MONTH) 25, 2019. The facility failed to follow the care plan for one resident which resulted in the resident experiencing harm and being neglected by two employees and Freedom from Abuse and Neglect CFR(s): 483.12(a)(1) - Previously cited 04/17/18 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 10/06/18, 07/31/17 28 Pa. Code 201.14(e) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management Previously cited 10/06/18, 06/19/18, 04/17/18, 10/13/17, 07/31/17 28 Pa. Code 201.18(b)(3) Management Previously cited 10/06/18, 04/17/18, 07/31/17 28 Pa. Code 201.18(e)(1) Management Previously cited 10/06/18 28 Pa. Code 201.29(c) Resident rights Previously cited 10/06/18 28 Pa. Code 201.29(d)(j) Resident rights Previously cited 08/08/18, 10/13/17 28 Pa. Code 211.10(d) Resident care policies Previously cited 07/31/17 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 08/08/18, 04/17/18, 10/13/17, 07/31/17 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 06/19/18 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 10/06/18, 08/08/18, 06/19/18, 04/17/18, 10/13/17

Based on review of clinical records and investigative reports, as well as staff interviews, it was determined that the facility failed to provide an environment that was free from accident hazards for residents who were at risk for falls for one of twelve residents reviewed (Resident 3), resulting in a fall with fractures for the resident. Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated (MONTH) 28, (YEAR), indicated that the resident required extensive assistance with daily care tasks and had [DIAGNOSES REDACTED]. An incident report for Resident 3, dated (MONTH) 18, (YEAR), indicated that the resident was found on the floor in the hallway in front of the vending machine room. The resident stated that she fell out of her wheelchair while trying to wheel herself into the vending machine room. She was transferred back into her wheelchair, complained of pain to the left clavicle (collar bone) and shoulder, and was transferred to the hospital and diagnosed with [REDACTED]. The resident was referred to therapy for wheelchair management and mobility, and a therapy referral to the restorative nursing program, dated (MONTH) 20, (YEAR), indicated that the resident was to use an Evolution chair (a specialized wheelchair that improves mobility and independence for individuals at risk of falling out of standard wheelchairs) for wheelchair mobility. An incident report and nursing note for Resident 3, dated (MONTH) 12, (YEAR), at 3:20 p.m. and 11:13 p.m., respectively, indicated that the resident was found on the floor in front of her wheelchair in her room. She stated that she slid out of her wheelchair and was having right hip pain. The physician was notified and ordered x-rays, which showed a fractured right hip. The resident was transferred to the hospital, and a nursing note, dated (MONTH) 21, (YEAR), revealed that she had surgical repair of her right [MEDICAL CONDITION] on (MONTH) 13, (YEAR). An occupational therapy note for Resident 3, dated (MONTH) 12, (YEAR), at 4:52 p.m. revealed that the resident was assisted back into her Evolution chair after she fell out of a standard wheelchair. She was not able to tolerate standing secondary to reported pain in the knee and hip. The note indicated that prior to the fall, Certified Occupational Therapy Assistant 2 was going to transfer the resident into the Evolution chair, when she was found on the floor. Interview with the Therapy Director on (MONTH) 6, (YEAR), at 12:55 p.m. revealed that when the therapist went to Resident 3's room to provide treatment, he saw that the resident was in a standard wheelchair. He left the resident's room to get her Evolution chair and when he returned she was on the floor. She confirmed that Resident 3 should have been in an Evolution chair. An interview with the Director of Nursing on (MONTH) 6, (YEAR), at 2:35 p.m. revealed that on (MONTH) 12, (YEAR), Resident 3 was in a standard wheelchair when she returned from the beauty shop and fell and fractured her right hip. Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) - Previously cited 07/31/17, 08/09/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 07/31/17, 08/09/16 28 Pa. Code 201.18(b)(1) Management Previously cited 06/19/18, 04/17/18, 10/13/17, 07/31/17, 08/09/16 28 Pa. Code 201.18(b)(3) Management Previously cited 04/17/18, 07/31/17, 08/09/16 28 Pa. Code 201.18(e)(1) Management Previously cited 08/09/16 28 Pa Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 08/08/18, 06/19/18, 04/17/18, 10/13/17, 07/31/17, 09/06/16, 08/09/16

Based on review of information submitted by the facility, review of clinical records, facility documentation, facility policies and procedures, and interviews with staff, it was determined that the facility failed to provide proper supervision and assistance to provide a safe transfer while using the full mechanical lift that resulted in actual harm of a laceration requiring sutures for one of 24 residents' reviewed (Resident Cl 1). Findings include: Review of facility policy, Transfer Assessment, dated effective or revised 07/15/2015, stated that the facility, is committed to providing a safe environment and establishing safe and effective methods of patient handling techniques based on individual patient needs. The policy also stated that the scope of the policy, covers the procedures by nursing and rehabilitation to assess and determine safe and effective transfer methods for each patient in our care. The policy stated that all nursing staff members, are required to follow the lifting/transfer policy and that the, total dependency lift will be operated by two staff members at all times. Further review of the same policy revealed that when the Mechanical/Passive Lift was utilized for resident transfer, the presence of at least two staff at all times was required during use. Review of the clinical record for Resident Cl 1 revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set assessment (MDS - periodic assessment of resident care needs) dated June 13, 2017, revealed a BIMS (Brief Interview for Mental Status) of 6 which indicated that the resident was severely cognitively impaired. The same MDS assessment also noted that Resident Cl 1 sometimes understood others and was sometimes understood by others. Further review of the quarterly MDS assessment of June 13, 2017, also indicated that the resident was totally dependent on staff for transfers, and resident transfers required the physical assistance of two staff members. Review of Resident Cl 1's nursing care plan titled, resident has an ADL (activities of daily living) self-care performance deficit due to dementia and impaired balance, dated as initiated May 26, 2016, and revised June 13, 2017, revealed that the resident was required to have the, assistance of two staff Hoyer (name brand of a mechanical piece of equipment that assists with transferring a resident from one surface to another, e.g. bed to chair) to transfer. Review of the progress notes for Resident Cl 1 for July 7, 2017, at 12:23 pm written by a licensed nurse stated the resident had a, fall with injuries, lacerations to right forehead and right side of head. The resident's physician was notified and ordered Resident Cl 1 to be transferred to the emergency room . Further review of the progress notes for July 7, 2017, stated that the resident returned to the facility at 2:20 pm and indicated, sutures intact to right forehead and right side of head, open to air. There was no evidence available that documented the measurements of the lacerations on resident's right forehead and right side of head. Also, there was no evidence available that documented the type or number of sutures in place. Review of the hospital documentation of July 7, 2017, revealed that the resident was seen in the, emergency department for a fall and that Resident Cl 1 was to return in 7-10 days to have the sutures removed. During an interview on July 30, 2017, at approximately 10:00 am the Nursing Home Administrator (NHA) confirmed that there was no other documentation available regarding the lacerations to the resident's head. Review of the progress notes for July 7, 2017, completed by a licensed nurse, indicated that the hospital contacted the facility at 3:20 pm and informed the facility that the resident, needed to return to hospital for a CAT scan (an X-ray made using computerized axial tomography) of the knee for a possible fracture. The resident's physician was notified and there was a physician's orders [REDACTED]. Review of the progress notes for July 8, 2017, at 5:18 am stated that Resident Cl 1 was admitted to the hospital with [REDACTED]. During an interview with the NHA on July 30, 2017, at approximately 10:00 am indicated that there was no additional information or documentation received by the facility regarding the resident. Review of the facility investigation dated July 7, 2017, and signed July 11, 2017, stated Employee E6, NA (Nursing Assistant), was transferring Resident Cl 1 from the bed to the geri chair (geriatric reclining chair) using the hoyer (full mechanical) lift. Employee E3, a Registered Nurse, assessed the resident, lying face down on right side of forehead, bleeding from head, laceration noted to right side of forehead and right side of head. Review of Employee E6's written statement dated July 7, 2017, revealed that Employee E6 stated that while giving care to the resident, I placed the resident in the hoyer sling and the hoyer to get the resident up out of bed. Proceeded to lift resident up when the sling came off and let resident go. Employee E6 also stated that Employee E7, a Housekeeper, was in the resident's room at the time. The same statement also indicated that Employee E6 was asked if she was aware of the transfer policy of the facility and answered yes, and also indicated that Employee E6 was asked if she followed the facility policy and answered no. Review of Employee E7's written statement dated July 7, 2017, revealed that Employee E7, a Licensed Nurse, stated that she was called to resident's room by Employee E6. Employee E7 stated that the resident was on the floor with right side of the head on the floor with a, large amount of bleeding from large laceration to right side of forehead. Employee E7's statement then stated that, NA was in process of being transferred from bed to geri chair with hoyer lift. An interview with the NHA on July 28, 2017, at approximately 11:30 am confirmed that Employee E6 was hired on November 19, 1997. A review of the nurse aide in-service records indicated that Employee E6 last completed elder abuse training on May 16, 2017, and Transfer Policy - Mechanical Lift - two person assist in-service training on February 28, 2017. Further review of the nurse aide in-service records also indicated that Employee E6 completed a Clinical Competency/Validation Checklist for Mechanical Lift on May 22, 2016, and was validated as passed by Employee E8, a Licensed Nurse. During the same interview with the NHA on July 28, 2017, at approximately 11:30 am it was confirmed that Employee E6 was terminated from employment by the facility for not following the facility policy with transfers using the full mechanical lift. Review of the information dated July 7, 2017, submitted by the facility revealed an allegation of neglect. Rview of facility documentation dated July 7, 2017, and July 10, 2017, revealed that the facility completed in-service education regarding the proper transfer techniques for use with the full mechanical lift for nursing staff (licensed nurses and NA's). The facility failed to provide an environment free from accident hazards by not providing safe supervision and assistance for resident transfers and resulted in harm to one resident. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 07/10/15, 03/24/16, 06/25/16, 08/09/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 07/10/15, 08/09/16 28 Pa. Code 201.18(b)(1) Management Previously cited 07/10/15, 08/09/16 28 Pa. Code 201.18(b)(3) Management Previously cited 07/10/15, 03/24/16, 08/09/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 07/10/15 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 07/10/15, 03/24/16, 08/09/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 07/10/15, 03/24/16, 08/09/16, 09/06/16

Based on observations of care and services, interviews with staff and residents, reviews of clinical records and pertinent facility documentation, it was determined that the facility failed to provide adequate supervision and assistive devices to prevent accidents and maintain a safe environment for residents resulting in harm to one resident (Resident R106). Findings include: The comprehensive assessment (an assessment of care needs) dated January 21, 2016 for Resident R106 indicated that this resident had severe cognitive impairment, required total assistance of two staff to perform activities of daily living including transfers (how resident moves between surfaces including to or from bed, chair, wheelchair standing position). This assessment also indicated that this resident was not able to walk and was not steady with surface to surface transfers. The assessment also indicated that Resident R106's medications included an antianxiety agent. Nursing progress notes dated January 10, 2016 indicated that Resident R106 had complained of pain to the left ankle. Edema (swelling) and redness were noted to the skin at the ankle. The physician had ordered that an x-ray be completed for Resident R106, based on her signs and symptoms. The x-ray revealed that Resident R106 had a mildly displaced fracture of the left ankle. A review of Resident R106's care planning for transfers revealed that two staff persons were required to use a mechanical lift (resident care equipment) for safe transfers of this resident. A review of the facility's accident/incident investigation form revealed that on January 10, 2016, a nurse, Employee E4 and a certified nursing assistant, Employee E5, transferrred/moved/lifted Resident R106 from the chair to the bed without using the mechanical lift. Resident R106's established care plan, indicated that a mechanical lift was required for safe tranfers for this resident based on the resident's inability to bear weight on the lower extremities. Interview with the Director of Nursing at 10:30 a.m., on March 24, 2016 confirmed that the facility failed to follow Resident R106's established care plan for safe transfers on January 9, 2016, resulting in an injury to the resident's left leg. Observation of Resident R106 at 1:00 p.m., on March 24, 2016 revealed that the resident was wearing a CAM (controlled ankle movement) boot. The orthopedic physician documented on March 10, 2016 that the left ankle was healing slowly and that follow-up was necessary in three weeks. The facility failed to provide adequate supervision and assistive devices to prevent an accident or maintain a safe environment for residents resulting in actual harm to one resident. 28 PA. Code: 211.11(a)(b)(c)(d) Resident care plan 28 PA. Code: 211.12(a)(c)(d)(1)(2)(3)(5)(e) Nursing services