Every finding on record at Complete Care at Harston Hall LLC

Based on interviews and the review of clinical records, it was determined that the facility failed to assess the request for an accommodation of need for one of two residents reviewed (Resident R1). Findings include: Review of Resident R1's clinical record revealed the resident has the following diagnoses hypertension (high blood pressure); cerebral infarction (stroke - brain damage); diabetes (a group of diseases that affect how the body uses blood sugar/glucose); anxiety (intense, excessive and persistent worry and fear about everyday situations) and dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). Review of facility documentation indicated that Resident R1 fell in the hallway, next to the nurse's station, when the resident stood up from the chair that she was sitting in and walked away. Continued review of facility documentation regarding the fall indicated that Resident R1 was sent out to the hospital on August 23, 2026, where it was found that Resident R1 sustained a left humerus fracture (a broken left arm). Review of Resident R1's nursing notes indicated that the resident returned to the facility the following day, August 24, 2026. Interview with Resident R1's representative on August 28, 2026, at 11:26 a.m. revealed on August 25, 2026, after Resident R1's readmission to the facility, the family requested for the resident to have a bed alarm (alerting devices intended to monitor a resident's movement. The devices emit an audible signal when the resident moves in certain ways). Resident R1's representative reported he/she was informed by the Director of Nursing that a bed alarm is considered a restriction. Resident R1's representative expressed concern regarding Resident R1's fall and the desire for a bed alarm, as the representative believes it could be beneficial for Resident R1. Review of Resident R1's clinical record revealed no documented evidence an evaluation was completed to assess the appropriateness of the bed alarm, per the resident's daughter's request. Review of Resident R1's clinical record failed to contain documented evidence that the resident's physician was included in the evaluation. During an interview with the Director of Nursing (DON) on August 28, 2026, at 1:30 p.m. the Director of Nursing reported that she spoke with Resident R1's representative on August 25, 2026, regarding her request for Resident R1 to have a bed alarm in response to the fall and subsequent fracture. During the above referenced interview, the DON reported that she informed Resident R1's representative that the bed alarm is considered a restraint, and it not something that the facility would utilize as an intervention to prevent the resident from falling. It was confirmed with the DON during the above referenced interview that despite the facility informing the daughter of its practice to not utilize devices such as bed alarms, the facility did not evaluate the appropriateness of the bed alarm, as a result of the resident's daughter's request for it to be utilized for her mother. Continued interview with the DON it was discussed if there were any other interventions that the facility could use in lieu of the bed alarm that the daughter requested for her mother (e.g.15 minute checks, etc.), and the DON reported that there was no other interventions discussed with the daughter that could be utilized in place of the bed alarm to address the daughter's concern of her mother falling out of bed. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement Enhanced Barrier Precautions for one of two residents reviewed who had a midline catheter and an indwelling urinary Foley catheter (Resident R4). Findings include: A review of the facility policy titled Enhanced Barrier Precautions, last revised on February 25, 2025, revealed that Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce the transmission of multidrug-resistant organisms through the targeted use of gowns and gloves during high-contact resident care activities. The policy further revealed that the facility may use EBP for residents who do not have a chronic wound or indwelling medical device but are infected or colonized with a multidrug-resistant organism considered epidemiologically important. In addition, the policy revealed that an order for Enhanced Barrier Precautions is to be obtained for residents with wounds, including chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers, and/or indwelling medical devices, including central lines, urinary catheters, feeding tubes, tracheostomy or ventilator tubes, hemodialysis catheters, PICC lines, and midline catheters, even if the resident is not known to be infected or colonized with a multidrug-resistant organism. A review of Resident R4's clinical record revealed an admission date of September 23, 2019, with diagnoses including sepsis (a life-threatening condition caused by the body's extreme response to an infection). A review of physician orders revealed an order dated April 17, 2026, for a midline catheter for intravenous (IV) fluids, and an order dated January 23, 2026, for Enhanced Barrier Precautions for ESBL colonization, Foley catheter, and wound care during day and night shifts for infection control, with instructions to ensure signage was visible outside the room and personal protective equipment was available. On April 20, 2026, at 1:30 p.m., an observation conducted with Licensed Nurse, Employee E11, revealed a sign posted outside Resident R4's room stating Enhanced Barrier, providing guidance that anyone providing direct care was required to wear a gown and gloves when touching Resident R4. Employee E11 was asked to provide assistance in observing the resident's midline catheter for IV fluids. Employee E11 donned gloves and proceeded to touch the resident's arm while showing the surveyor the midline catheter, including the appropriately dated dressing; however, Employee E11 did not don a gown while providing direct care to Resident R4. On April 21, 2026, at 2:28 p.m., observation confirmed that Resident R4 had a midline catheter and an indwelling Foley catheter, both of which required staff providing direct care or handling the devices to wear a gown and gloves in accordance with the facility's Enhanced Barrier Precautions policy. 28 Pa. Code 211.10 (d) Resident care policies.28 Pa. Code 211.12 (d)(5) Nursing services.

Based on observations, clinical record review, facility documentation, and staff interviews, it was determined that the facility failed to ensure that one (1) of twenty-two (22) residents reviewed was free from physical restraint. (Resident R57).Findings include: Review of facility policy titled Restrain Free Environment, last revised 3/24/26, states, It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of physical or chemical restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of such restraints, and further defines Physical Restraint as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily and that restricts freedom of movement or normal access to one's body, including but not limited to applying leg or arm restraints, hand mitts, soft ties, or vests the resident cannot remove; using bed rails to prevent voluntary exit from bed; tightly tucking sheets or fastening clothing to restrict movement; placing a chair or bed close enough to a wall to prevent rising; placing a resident on a concave mattress to prevent independent exit; holding down a resident in response to behavioral symptoms or during care when resistive; placing a resident in an enclosed framed wheeled walker they cannot exit; and using a position change alarm that discourages movement due to fear of triggering the alarm. Review of the clinical record revealed Resident R57 was admitted to the facility on [DATE], with diagnoses of parkinsonism (brain condition that causes slow movements, rigidity and tremors) , dementia (progressive degenerative disease of the brain), difficulty in walking, muscle weakness, adult failure to thrive, and age-related osteoporosis without current pathological fracture (low bone density related to aging, which makes bones weaker and more fragile). Review of the MDS (Minimum Data Set - Assessment of Resident Care Needs) dated December 17, 2025, revealed that the resident had moderate cognitive impairment in decision-making skills. On April 20, 2026, at 11:24 p.m., observation revealed Resident R57 sitting in the hallway across from the nursing station next to the elevators in a Geri chair reclined at 90 degrees, yelling, Move me, move me. The resident had a tray table positioned in front of him, blocking access. Resident R57 was asked to attempt to move the tray table forward and was observed pushing it to allow access; however, he stated, I can't. Observation revealed that the side table wheels were positioned between the Geri chair wheels, effectively locking the resident in the chair and preventing him from exiting independently. A licensed nurse, Employee E9, who was sitting at the nursing station, yelled, Resident R57, come on, you can get out, then approached and removed the wheeled side table from underneath the resident's chair. When the surveyor requested that staff not intervene, Employee E9 stated, He can't get out, and pulled the side table away, confirming that Resident R57 was unable to exit the chair independently. On April 21, 2026, Resident R57 was observed sleeping throughout the day. On April 22, 2026, at approximately 12:18 p.m., Resident R57 was observed sitting in a wheelchair by the nursing station, which provided him the ability to propel himself. An unidentified staff member approached, unlocked the wheelchair brakes, and transported Resident R57 to the dining room. Resident R57 was then observed sitting at the dining table preparing to eat lunch. The surveyor requested observation of whether Resident R57 was able to propel himself away from the dining table independently; however, Resident R57 was unable to move himself away from the table. At that time, the Rehabilitation Director, Employee E10, entered the dining room and reported that Resident R57 was able to self-propel approximately 30 feet; however, if the wheelchair brakes were locked, Resident R57 was unable to unlock them independently. Employee E10 pointed out that the wheelchair brakes were currently locked and confirmed that Resident R57 was unable to unlock the brakes or move himself away from the dining table without staff assistance. Resident R57 required staff assistance to unlock the wheelchair brakes to self-propel. On April 23, 2026, at approximately 11:00 a.m., an additional observation was conducted with the Director of Nursing, Employee E2, and the Administrator, Employee E1. It was confirmed that Resident R57 had no need for physical restraints, and there was no physical restraint evaluation or physician order for a physical restraint. It was further confirmed that Resident R57 requires staff assistance to unlock the wheelchair brakes in order to self-propel. It was additionally discussed that on April 20, 2026, Resident R57 was observed in a situation involving a physical restraint, as he was unable to exit the Geri chair. The side table wheels were positioned between the Geri chair wheels, effectively locking the resident in the chair and preventing independent exit. A tray table was also positioned in front of the resident, blocking access. 28 Pa. Code 201.12(d)(1) Nursing services. 28 Pa. Code 211.8(e)(f) Use of restraints.

Based on observation, staff interview, and record review, the facility failed to ensure implementation of a fall prevention intervention for 1 of 22 resident reviewed. (Resident R52)Findings include:Review of Resident R52's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including Essential (Primary) Hypertension (high blood pressure), Anxiety Disorder (persistent nervous feelings), and history of falling (past falls reported). On April 21, 2026, at 8:45 am, on the 3rd floor, during observation of a medication pass with Licensed Nurse Employee E16, the surveyor observed a sign posted on Resident R52's wall that read, Floor mats need to be placed at all times. Further observation revealed no floor mats in place on the floor next to the resident's bed. One floor mat was found standing against the wall, under the posted sign; no mats were positioned on either side of the bed.On April 21, 2026, at 8:47 am, Licensed Nurse, Employee E16 confirmed that the floor mats were not in place at the time of observation. The nurse retrieved the mat from the wall and placed one floor mat on the left side of the bed. Further review of Resident R52's care plan on April 21, 2026, at 10:43 AM revealed an intervention for bilateral floor mats at all times, initiated on 12/11/2024. 28 PA. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, observations and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for one of two sampled residents (Residents R58)Findings include: A review of the facility policy titled Oxygen Policy, last revised on January 7, 2025, revealed, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. A review of Resident R58's clinical record revealed an admission date of October 11, 2019, with diagnoses including chronic obstructive pulmonary disease (COPD- a progressive lung disease that causes airflow limitation). A physician's order dated June 3, 2025, revealed, Oxygen at 2 liters via nasal cannula continuously during day and night shifts. Review of the resident's comprehensive care plan, last revised on April 14, 2025, revealed, The resident has COPD, with a goal that the resident will be free of signs and symptoms of respiratory infections through the review date, and an intervention of Oxygen at 2 liters via nasal cannula continuously. On April 20, 2026, at 1:44 p.m., an observation was conducted with Licensed Nurse, Employee E11, who confirmed that Resident R58's oxygen was set at 3 liters, which was inconsistent with the physician's order. On April 21, 2026, at 2:04 p.m., an observation was conducted with the Director of Nursing, Employee E2, and Regional Nurse, Employee E3, who confirmed that Resident R58's oxygen was set at 1 liter, which was also inconsistent with the physician's order of 2 liters continuously. 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, facility policy, and interview with staff, it was determined the facility failed to ensure pain medication was administered in accordance with the physician's order for two of two residents reviewed for pain management. (Resident R 7 and Resident R16) Findings include: Review of Resident R16's clinical record revealed Resident R16 was admitted to the facility on [DATE] with a diagnosis of congestive heart failure (condition where the heart can't pump blood as well as it should), type 2 diabetes mellitus ((insufficient production of insulin, causing high blood sugar), pain in left shoulder. Review of Resident R16's clinical record revealed physician's order, dated November 10, 2025, for Tramadol 50 milligrams to be given every 6 hours as needed for severe pain, pain scale 7-10. Review of Resident R16's April 2026 Medication Administration Record (MAR) revealed that the as needed pain medication Tramadol 50 mg was administered out of the parameter ordered by the physician as follows:April 1, 2026- Pain level 3April 2, 2026- Pain level 5April 3, 2026- Pain level 3April 5, 2026 Pain level 5April 13, 2026- Pain level 4April 16, 2026- Pain level 5April 22, 2026- Pain level 0 Interview on April 22, 2026, at 12:10 p.m. with Regional Director of Nursing, Employee E3, confirmed Resident R16's pain medication was not administered in accordance with physician's order. Review of facility policy Pain Management, revised on September 1, 2025, revealed the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Under section Pain Management and Treatment number seven (h) Opioid treatment for acute pain, subacute pain, and chronic pain will be prescribed and dosed in accordance with current professional standards of practice and manufacturer guidelines to optimize their effectiveness and minimize their adverse consequences.During an interview with the Regional Director of Nursing Employee E3 and Assistant Director of Nursing Employee E2 on April 22, 2026, at 10:30 am confirmed Resident R 7 and Resident R 16's pain medication was not administered in accordance with physician orders.Review of Resident R7's clinical record revealed, Resident R7 was admitted to the facility on [DATE] with a diagnosis of displaced intertrochanteric fracture of left femur sequela, traumatic compartment syndrome and contusion of left thigh.Review of Resident R7's Medication Administration Record for April 2026 revealed that the as needed pain medication Oxycodone 5 milligrams every six hours for severe pain (7-10) was administered out of the parameters ordered by the physician as follows:April 17,2026 at 1:54 pm Pain level 7April 18,2026 at 7:41 am Pain level 6 April 20,2026 at 5:01 pm Pain level 6April 21,2026 at 9:50 am Pain level 6 28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12(d)(1) Nursing services

Based on review of clinical records, facility documentation, and interview with resident and staff, it was determined the facility failed to ensure necessary dental services were arranged and followed up for one of six residents reviewed. Findings include: Review of Resident R102's clinical record revealed the resident was admitted to the facility on [DATE] with a diagnosis of dementia (decline in cognitive function that interferes with daily life), type 2 diabetes (insufficient production of insulin, causing high blood sugar), and peripheral vascular disease (condition where blood vessels outside the heart-usually in the legs-become narrowed or blocked, reducing blood flow). Interview on April 20, 2026, at 11:00 a.m. with Resident R102 revealed the resident does not have dentures and had requested dentures several times. Review of R102's dental consult, dated March 17, 2025, revealed the dentist recommended impressions for full upper and lower dentures in 3 weeks. Review of Resident R102's dental consult, dated July 30, 2025, revealed the resident was evaluated and expressed a desire to obtain dentures. The consultation indicated the need for follow-up to address the resident's request for dentures. Review of Resident R102's clinical record revealed no evidence that the facility arranged for or followed up on dental services to obtain dentures following the consult. Interview on April 21, 2026, at 11:15 p.m. with Administrator, Employee E1, confirmed there was no documentation about further dental consults for Resident R102. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, review of facility policy, and interview with staff, it was determined the facility failed to ensure that there was an adequate emergency food supply available. Findings include: Findings include Review of facility policy on April 20, 2026, at 1:15 p.m. revealed the facility is required to maintain, at all times, a minimum three-day supply of nonperishable and perishable staple food items sufficient to implement its emergency menu. Inventory must be physically present, organized, and readily accessible to ensure continuity of meal service during emergencies. During a tour of the dietary department on April 20, 26 at 9:37am in the company of Food Service Manager, Employee E18, the surveyor requested documentation of the facility's three- day emergency food service plan and corresponding inventory. Review of the three-day emergency menu was provided for review. A physical inventory of available food supplies was then completed and compared against the three-day emergency menu. Interview with Food Service Manager, Employee E18 confirmed there was not enough emergency food supply for three days available at the time of the observation. Employee E18 stated during interview that a food order could be obtained within 24 hours. Observation of the Food Emergency Storage on April 21, 2026, 9:45 am revealed the emergency supply did not have enough emergency food supply for 3 days available at the time of observation. 28 Pa. Code 201.18(b)(3) Management

Based on observation and staff interview, it was determined that the facility failed to maintain proper food temperatures during meal service on one of two nursing units. (3rd Floor)Findings include: Observations conducted on April 22, 2026, at 11:10 AM, of the lunch meal delivery to the 3rd floor nursing unit revealed that the meal tray cart was loaded in the kitchen at 11:34 a.m. At 11:37 AM, the meal cart arrived on the 3rd floor for meal distribution. On April 22, 2026, at 11:45 AM, test tray temperatures were obtained in the presence of the Food Service Director (Employee E14). The following temperatures were recorded:Pork chop: 127 FSpinach: 131 [NAME] juice: 51 [NAME] April 22, 2026, at 11:50 AM, the Food Service Director, Employee E14 confirmed the recorded temperatures and acknowledged that the pork chops and spinach were below the required hot holding temperature of 135 Fahrenheit (F). Employee E14 also confirmed the red juice temperature exceeded the recommended cold holding temperature of 41 F. 28 Pa Code 201.18(b)(3) Management

Based on observations and staff interviews, it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of three nursing units reviewed (3rd Floor Medication Cart).Findings include: During an observation on April 22, 2026, at 12:04 p.m. the license nurse, Employee E14 confirmed Medication Cart that was assigned to license nurse, Employee E15 which revealed to be left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information. Employee E15 was not in the hallway nor near her medication cart. During an observation on April 22, 2026, at 12:33 p.m., the Rehabilitation Director, Employee E10, confirmed that a medication cart assigned to Licensed Nurse, Employee E15, was left unattended with the computer screen open, displaying identifiable resident information visible to any passerby, exposing personal and confidential medical information. Employee E15 was not present in the hallway or near the medication cart at that time. When Employee E15 returned to the medication cart, she confirmed that Resident R40's information was displayed on the screen while the computer had been left unattended. During the conference meeting, the Director of Nursing, Employee E2, and Regional Nurse, Employee E3, confirmed that nurses are required to lock their computer screens when leaving the medication cart unattended. It was further confirmed that Licensed Nurse, Employee E15, had already reported to the Director of Nursing that the computer was left unattended with Resident R40's medical information displayed on the screen while the nurse was in another resident's room. During an observation on April 22, 2026, at 12:04 p.m. the license nurse, Employee E14 confirmed Medication Cart that was assigned to license nurse, Employee E15 which revealed to be left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information. Employee E15 was not in the hallway nor near her medication cart. Employee E14 was inside a resident room administering medication 28 Pa. Code 211.5(b) Medical records

Based on observations, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, homelike environment for one of five resident rooms observed. (room [ROOM NUMBER]).Findings include:An initial tour of the facility on January 20, 2026 at 10:30am, revealed the following observations.Observation of facility room [ROOM NUMBER] revealed phone jack with face plate missing and wires hanging from wall.Further observation of room [ROOM NUMBER] revealed multiple stained ceiling tiles.Observation of facility room [ROOM NUMBER] bathroom revealed broken tiles in bathtub, exposing holes in wall around faucet.Interview with Employee E1, Assistant Director of Nursing on January 20, 2025 at 10:45am, confirmed the above findings. 28 Pa. Code: 201.29(j)(k) Resident rights.28 Pa. Code: 207.2(a) Administrator's responsibility.

Based on review of facility policy, review of resident clinical records, and interview with resident and staff, it was determined the facility fail to ensure physician orders were followed related to the administration an anticoagulant medication for one of 12 residents reviewed. (Resident R1)Findings include: Review a facility policy titled Reconciliation of Medication on admission revised July 2017, revealed the purpose of this procedure is to ensure medication safety by accurately accounting for a residence medication, including drug names, dosages, roots, and frequencies, upon emission or remission to the facility. Proper medication reconciliation is essential to prevent unintended omissions, duplications, or dosing errors that may occur during transitions of care. Medication and reconciliation involve comparing the medications a resident was taking prior to admission with those ordered upon admission. This comparison must include both prescription and over the counter medications and should reflect an accurate and complete list that specifies the drug name, dosage, root, frequency, and the indication for each medication. To complete this process staff must gather necessary documentation including the medication reconciliation form, the discharge summary from the referring facility, the emission order sheet, and any prescription or supplement information provided by the resident or their families during the medication history interview. For readmission, the most recent Medication Administration Record (MAR) should also be reviewed. Once all sources have been collected, the staff should compile a complete list of medications from the discharge summary, medication history, previous MAR (if applicable) and admission orders. Each medication should be listed with the corresponding dosage, root, frequency, and reason for use. Compiled list must be carefully reviewed to identify any discrepancies such as missing medications, changes in dosage, or differences in root or frequency. All findings, actions taken, and communication with providers must be clearly documented to ensure continuity of care and to support safe medication practice throughout the residence day in the facility. Review of Resident R1's Minimum Data Set (MDS- resident assessment) dated September 30, 2025, revealed Resident R1 was admitted to the facility on [DATE], with a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. Continue review of Resident R1's clinical record revealed the resident's diagnoses of peripheral vascular disease vascular disease (disorders that affect the blood vessels outside of the heart and brain), chronic heart failure (heart failure often just called CHF happens when the heart can't pump blood effectively this can lead to a fluid buildup in the lungs and other parts of the body) ,acute ischemic heart disease (a sudden reduction in blood flow to the heart muscle often caused by a blockage in the coronary arteries, Coronary artery disease (blood vessels that supply the heart with blood become narrowed or blocked this usually happens due to the build up of plaque), cardiomyopathy (disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), endocarditis (an infection of the inner lining of the heart usually involving the heart valves, and anxiety (a feeling of worry nervousness or unease often about an imminent). Review of Resident R1's July, 2025 through September 2025 physician orders revealed that the resident was order the anticoagulant medication Eliquis (Apixaban) 5 mg to be administered twice daily. Review of the resident's Medication Administration Record (MAR) revealed that the resident had an order to hold Eliquis for an upcoming surgery on July 14, 2025. Continue review of MAR's from July-September 2025 revealed that on July 14, 2025 was the last day the resident received Eliquis 5mg. The next administration of the medication Eliquis until September 26, 2025. Review of the hospital discharge orders for the following dates revealed that the resident was to continue the medication Eliquis as follows:7/22/25: Discharge orders indicated the resident was to continue Eliquis.8/4/25: Discharge orders specified Eliquis 5 mg to be continued.9/26/25: Discharge orders indicated Eliquis 5 mg twice daily. Interview with Director of Nursing, Employee E2 on October 3, 2025, at 2:10 p.m. confirmed that the medication Eliquis had not been administered to the resident for approximately nine weeks. Employee E2 stated that, to her knowledge, the medication was discontinued prior to the resident's surgery on July 17, 2025 and was never re-entered into the electronic health record or reordered thereafter. Interview with. Licensed nurse, Employee E3 on October 6, 2025, acknowledged it was her responsibility to verify all medications post-hospitalization, but the order for Eliquis was unintentionally missed. She further explained that standard protocol involves confirming medications with hospital staff during discharge and again upon the resident's return. 28 Pa Code 211.12(c)(d)1) Nursing services

Based on review of clinical records, observations, review of facility policy and interviews with residents, it was determined that the facility failed to ensure a resident was treated with dignity and respect during wound care for one of 12 residents reviewed (Resident R1). Findings include: Review of Facility policy titled Clean dressing change, date implemented September 1, 2024, under Policy explanation and Compliance Guidelines, step 1 states Explain the procedure to the resident and screen for privacy. Review of Resident R1's clinical record revealed resident was admitted to facility on August 13, 2025, with the diagnosis of Sepsis (infection in the blood stream), Paraplegia (paralysis on the lower half of the body), and Pressure Ulcer of Left Buttocks. Review of Resident R1's Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) dated September 11, 2025, revealed that the resident has a BIMS (Brief interview for Mental Status) score of 15 indicating that resident cognitively intact. Observation of Resident R1's wound care with Employee E4, Licensed Practical Nurse on September 17, 2025, at 12:30pm revealed resident left with exposed buttocks after perineal care, for approximately 2 minutes, while staff prepared for dressing change. Observed multiple unnamed staff members entering and exiting room without introduction or providing the resident with privacy.Interview with Resident R1 on September 17, 2025 at 12:45pm, revealed that this experience happens often when care is being provided and it makes him feel very uncomfortable. People come and go while I am getting care, I don't know who they are, they do not introduce themselves, sometimes it someone dropping off a tray, other times it is housekeeping. It's uncomfortable when I am exposed and have no privacy and it doesn't seem like anyone cares. 28 Pa. Code: 201.18(b)(2) Management.28 Pa. Code: 201.29(j) Resident's rights.

Based on a review of facility policies, facility documentation, review of clinical records and interviews with residents and staff, it was determined that the facility failed to conduct a thorough investigation related to potential resident abuse and/or neglect related to a grievance for one of 12 residents reviewed. (Resident R2)Findings include:Review of facility policy titled Abuse, Neglect and Exploitation, implemented on September 1, 2025, revealed It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Further review revealed definition of Mental Abuse includes, but is not limited to, humiliation, harassment, threat of punishment or deprivation. Mental abuse also includes abuse that is facilitated or caused by nursing home staff taking or using photographs or recording in any manner that would demean or humiliate a resident(s). Mistreatment- means inappropriate treatment or exploitation of a resident Verbal abuse- means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Further review revealed, under section V. Investigation of alleged Abuse, Neglect and Exploitation, An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigation include: Identifying staff responsible for the investigation; Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); Investigating different typers of alleged violations; Identifying and Interviewing all involved persons, including the alleged victims, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent and cause; and providing complete and thorough documentation of the investigation. Review of Resident R2's clinical record revealed that resident was admitted to the facility on [DATE], with the diagnosis of End Stage Renal Disease. Review of Resident R2's Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) dated August 20, 2025, revealed that the resident has a BIMS (Brief interview for Mental Status) score of 15 indicating that resident was cognitively intact. Review of facility grievance revealed concern form dated August 26, 2025 with letter attached signed by Resident R2's family. Letter revealed At approximately 8:50pm, I received a call from my mother, [Resident R2]. She was very upset. She told me that an aide/orderly had treated her poorly and she was very hurt. She asked the aide to help her get in the chair so that she could use the bathroom. The aide told her no and that she had to get in the bed. She asked again and was told the same thing. Shortly after being put in the bed, my mom had an accident. When the aide returned and found that she had soiled herself, her tone was demeaning and she said, This is just a mess! (In a mean tone). My mom also said that she was very forceful while changing her. This is unacceptable. My Mom said that she felt hurt and embarrassed. She should not be made to feel this way and my family would like to know what the consequence will be for this behavior. We need to know that she is safe and cared for while in this facility, we are officially requesting an apology from this worker and assurance that this will not happen again. Sincerely, The family of [Resident R2] Request for incident investigation on September 17, 2025 at 1:30pm revealed no documented evidence of investigation completed. Further review of grievance form dated August 26, 2025, revealed that Employee E5 Nurse Aide (CNA) was identified. Employee E5 was provided education on customer service and perineal care on August 28, 2025. Interview with Employee E2, Director of Nursing confirmed no documented evidence of investigation completed regarding the concern of abuse and neglect. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.29 (a) Resident rights

Based on observations of the food and nutrition services department, it was determined that foods were not being stored, prepared, distributed and served in accordance with professional standards for food service safety. Findings include: Observations on March 22, 2025 of the main kitchen where foods and beverages were stored, prepared and assembled for distribution and service to the residents revealed that the low temperature dish machine was not fully functioning since March 14, 2025. The director of dietary service could not demonstrate with the use of litmus test strip that the hypochlorite was registering an acceptable 50 ppm (parts per million) to effectively sanitize the dishes, utencils, pots, pans, cups, bowls, plates and trays for resident and dietary staff use. Interview with the Director of Dietary Services, Employee E15 revealed that the main kitchen operation had been waiting on a customized part (squeeze tube and rinse assembly metal connector) for the mechanics of the dish machine, since March 14, 2025. All of the dome lids and plate holders contained a white film like substance, which the Director of Dietary Services reported was calcium and magnesium deposits from the hard water (water high in mineral content) usage. The Director of Dietary Services reported that there was no water softener in operation inside the food and nutrition services department. The flooring in the dish room area was water damaged and in need of repair. The grouting surrounding the floor drain and throughout the dish room was warn away leaving the grooves between the ceramic floor tiles with constant stagnant water and food debris. Ceramic floor tiles were missing and broken that were near the floor drain. The flooring in the dish room underneath the dish machine contained a build up of food debris, sludge and moist dirt. The basic white drop ceiling tiles above the dish machine area contained dried food debris that was splattered across the ceiling. The white drop ceiling tiles above the hot food cooking (gas stove, grill and oven) and preparation area contained a film of grease. The tiles were observed to be light yellow instead of white there original color. The wall area behind the dish machine across the lip of the flight type dish machine and its' attachment to the wall, contained a black substance resembling mold. Observations on March 22, 2025 of the alcove that was adjacent to the dish machine and ice machine revealed that there was piping in this area that was not funneled to the floor drain. A constant flowing of water was noted on the floor in this area along with a white green and black tinged film. The wall area where the pipe was attached was water damaged. The plaster board was damp and cracking. The walk-in refrigerator unit was heavily soiled. The walls and floors of this refrigerator contained a build-up of dirt, food spillage and white film-like substances. The air circulation fan screens were soiled with dust, dirt. The large metal food storage racks were soiled with sticky food pieces. The shelving was also soiled with dirt and rust. The lighting inside this walk-in refrigerator unit was dull; making the refrigerator not easily cleanable. The reach-in refrigerator and reach-in freezer units were not function. The Director of Dietary Services, Employee E15, reported that it has been for several months without the use of the reach-in refrigerator or freezer units. The preparation sink was leaking water onto the flooring while dietary staff were using it to prepare foods. The steam table was leaking water onto the flooring tray line assembly. Dietary staff were using bins to collect the water as it leaked from the sinks and steam table unit inside the main kitchen. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3)(e)(1)(2.1)(3) Management

Based on review of facility provided documentation and interview with staff, it was determined that facility did not ensure annual performance evaluation was completed for three nurse aides out of three nurse aides' trainings reviewed (Employee E21, E22 and E23) Findings include: Review of facility policy titled Required Training Certification and Continuing Education on Nurse Aides, revised in 2024, indicates that the facility will provide at least 12 hours of in-service training annually, based on the employment date, not calendar year. Review of facility provided performance evaluations on Thursday, April 25, 2025, revealed that nurse aides, Employees E21, E22 and E23 did not have any 12 hours of in-service training. Interview with Development Coordinator on April 25, 2025, at 1:40 p.m, confirmed that there was no 12 hours of in-service training annually. 28 Pa Code 201.19(2) Personnel policies and procedures

Based on observations of the food and nutrition services department, reviews of policies and procedures and interviews with staff and residents, it was determined that the facility failed to ensure that foods and drinks were being served palatable, attractive and at safe and appetizing temperatures during meal times for the residents. (Third floor, noon meal) Resident council (Residents R37, R36, R81, R84, R89, and R31) Findings include: A review of the facility's policy titled resident test tray assessment dated April, 2025 indicated that hot food entrees and vegetables were to be served at a temperature of 130 degrees Fahrenheit and all cold foods and beverages were to served at 45 degrees Fahrenheit. The temperatures were established to ensure safety and resident satisfaction at point of service, with the foods and fluids prepared by the food service department. On April 22, 2025, at 12:54 p.m., an interview was conducted with Resident R15, who stated that the food at the facility is terrible. Observation of the resident's plate revealed that only a piece of bread, juice, and ice cream had been consumed from the lunch tray. Observations of the tray line assembly area in the main kitchen , where foods are prepared for delivery to the nursing unit revealed that cold food items (sandwiches: cheese, turkey and cheese and turkey salad platters) were not being held cold. The time and temperature sensative food items were placed on an open cart in the middle of the main kitchen and held throughout the meal trayline preparation for delivery to the nursing units. Interview with the director of dietary services, Employee E15 at 11:30 a.m., on April 23, 2025 revealed that since the food service equipment was broken (reach-in refrigerator unit); we have not been able to hold the prepared cold food items under refrigeration. Observations of the lowerator (heated pellet drop in dispenser unit) at 11:30 a.m., on April 23, 2025 revealed that this piece of food service epuipment was not fully functioning. One of the drop in dispenser units was not warm. The pellets were cool to touch. The other two dispensers were not hot; that was the pellets were lifted out of the dispensers with out using the handle that was designed for lifting hot pellets with ease. The internal temperature of the heated pellet drop in dispenser unit ranges from 250 to 290 degrees Fahrenheit when fully operational. Dietary staff were required to use gloves or a handle to lift the pellet and place it in the pellet holder on the residents' meal trays during tray line and assembly of foods and drinks. Observations of the steam table located in the main kitchen of the dietary services department revealed that it was not fully operational. The dietary staff had to have a large bucket to catch and contain the constant leaking of the water place inside the wells of the unit. The dietary cooks were documenting hot food holding temperatures of 145 degrees Fahrenheit for hot foods. Observations of the built in steam table located in the bistro part of the dietary services department on the first floor of the facility revealed that two of the four wells in that unit were not fully functioning. A test tray evaluation was completed on the Third floor nursing unit with the director of dietary service, Employee E15, during the noon meal service for the residents on April 23, 2025. Observations of the noon meal service on the third floor nursing unit revealed that hot food and cold fodd items were not being served to the residents at appetizing temperatures. A test tray was evaluation on the April 23, 2025 during the noon meal service on the third floor revaled a glazed ham glazed 3 ounces was planned on the menu however only a two ounce potion was given. The temperature of the glazed ham at point of service was 115 degrees Fahrenheit. The vegeatables planned on the menu were steamed cabbage and baked sweet potatoes. The temperature of the foods tested at 116 degrees Fahrenheit. The dessert planned on the menu was a cranberry crunch bar. The residents were served angel food cake with cranberry sauce. The angel food cake and cranberry sauce was slanted side ways and attempted to be portioned in a small bowl. The director of dietary services said that the dietary staff ran out of small cake plates. The drinks were coffee milk and fruit punch. The time temperature sensative milk was served at 60 to 67 degrees Fahrenheit. The foods and fluids served on April 23, 2025 were not appetizing, attractive, portion specific or at safe satisfying temperatures for the residents. The facility policy for point of service temperatures were have hot food served at 130 degrees Fahrenheit and cold foods to be served at 45 degrees Fahrenheit. During a resident council meeting on April 24, 2025, at 10 a.m. on the second floor with six residents, (Residents R37, R36, R81, R84, R89, and R31) who were identified as being alert and oriented, reported that food is served cold, uncooked meat, overcooked vegetables, fish served very smells and not getting night snacks. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

Based on observations and staff interview, it was determined that the facility failed to address the care needs of a resident when answering call bells for one of 23 residents reviewed (Resident R29), and did not ensure sufficient staffing was maintained on a daily basis for all nursing units. (2nd and 3rd floors) Findings include: During a resident council meeting on April 24, 2025, at 10:00 a.m. with six residents, (Residents R37, R36, R81, R84, R89, and R31) who were identified as being alert and oriented, reported that call bells were not answered in a timely manner and staff were coming in and turn off the call bells without providing assistance. On April 24, 2025, at 11:07 a.m., an observation was made of Resident R29 lying flat in bed. The resident, who is non-verbal and communicates using head nods and facial expressions, clearly indicated a desire to be transferred into her wheelchair. The surveyor recommended the use of the call bell, and Resident R29 pressed it at 11:08 a.m. On April 24, 2025, at 11:11 a.m., Licensed Nurse, Employee E6 responded to the call. Upon entering the room, Licensed Nurse, Employee E6 asked the resident what she needed. Resident R29 pointed to her wheelchair, indicating she wanted to be transferred. Licensed Nurse, Employee E6 informed her that she had been changed and that her assigned nurse aide would be in to assist with the transferring the resident out of bed. Licensed Nurse, Employee E6 then turned off the call bell and exited the room. On April 24, 2025, at 11:22 a.m., the surveyor observed Nurse aide, Employee E24 walking through the hallway and asked whether she had been notified of Resident R29's need for a transfer. Nurse aide, Employee E24 reported that she had not been informed and stated her role was to provide transport and respond to call bells. Interview with Nurse aide, Employee E25, who was also present in the hallway near the room where Resident R29 lived stated that she had not been informed of the resident's need and that Resident R29 was not part of her caseload. The surveyor proceeded to the nursing station, where approximately four staff members were seen conversing. Licensed Nurse E6 was observed working at the computer. Employee E6 explained that the nurse aid assigned to Resident R29 was occupied with cleaning another room and stated, she's unable to do everything. Shortly thereafter, Employee E25 volunteered to assist and called upon Employee E24 to help. Resident R29 was transferred to her wheelchair at 11:26 a.m. Since the call bell was turned off by Employee E6 and there was no further indication that Resident R29 needed help. On April 24, 2025, at 2:55 p.m. an interview was conducted with the Administrator, Employee E1 who confirmed that staff members should not be turning off the call bells without ensuring that the resident's needs are addressed. Review of nursing care staffing levels revealed that the facility failed to meet the state required minimum number of 3.2 care hours per patient per day (PPD) on five of 21 days reviewed (February 9, 14 and 15, 2025, and April 20 and 22, 2025), and did not meet the state required minimum Nurse Aide staffing ratios on 13 of 21 days reviewed (February 9-15, 2025, and April 18-20, and 22-24, 2025). In an interview with the staffing coordinator, employee E33, on April 24, 2025, at 2:30 p.m., she confirmed that the staffing levels did not meet state minimum requirements and stated that the facility was always understaffed. 28 Pa Code 211.12(d)(4) Nursing services 28 Pa Code 211.12(f.1)(3)(4) Nursing services 28 Pa Code 211.12(i)(2) Nursing services 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(a)(3) management

Based on review of clinical records, and interviews with staff and residents, it was determined that the facility did not ensure that residents were free of misappropriation of resident property related to diversion of narcotic medication for two of 24 residents records reviewed (residents R69 and R262). Findings include: Review of clinical documentation for Resident R69 revealed that she was admitted to the facility on [DATE], and had diagnoses including of dementia (progressive degenerative disease of the brain), chronic pain and arthritis (join inflamation). Conintued review of the resident's clinical record revealed that the resident signed on to receive hospice care in February 2024. Review of Resident R69's [DATE] physican orders revealed an order obatined dated [DATE], for Morphine sulphate .20MG (milligrams)/ML .give 0.25 ml by mouth every four hours as needed for pain. Review of her most recent MDS (Minimum Data Set, a periodic assessment of resident care needs) section C, Cognitive Patterns, dated [DATE], revealed that the resident had a BIMS (Brief Interview for Mental Status, an assessment of orientation and memory recall) score of 9 out of 15, indicating moderate impairment. Review of clinical documentation for Resident R262 revealed that she was admitted to the facility on [DATE], and had diagnoses including, but not limited to, dementia, chronic pain and arthritis. Further review showed that she signed on for hospice care on [DATE]. A physician order, dated [DATE], was noted which stated, Morphine sulphate .20MG/ML .give 0.25 ml by mouth every 6 hours as needed for SOB (shortness of breath)/pain. Review of records also revealed that the resident had died on [DATE]. Review of a facility reported incident from [DATE], revealed that on that date, licensed nurse Employee E32, upon administering a dose of morphine to resident R262, noted that the color of the liquid in the bottle was a paler blue than usual. She also noted a mint-like smell to the liquid, and that the bottle cap was incorrect. On further investigation, it was noted by the facility that the color, smell, and bottle cap were all consistent with the facility house stock mouthwash. An investigation was initiated, and all liquid morphine in the facility was reviewed for signs of tampering. The morphine bottle for resident R69 was also found to be altered in color and to have a minty smell. No other morphines were noted to appear to be tampered with. An email dated [DATE], stated that independent laboratory testing confirmed that the concentration of the morphine for resident R262 was 3.88 MG/ML, confirming that it had been diluted. Interview with Resident R69 on [DATE], at 1:15 p.m. revealed that she felt that her pain management had been adequate and that she did not suffer an increase in pain related to the morphine diversion. At the time of the interview, the resident was alert and oriented. Interview with the Nursing Home Administrator, Employee E1, and the Director of Nursing, Employee E2, on [DATE], at 2:30 p.m. confirmed that the Morphine for Residents R69 and R262 had been misappropriated. Employee E1 stated that all nurses with access to the medication had been tested for opiates; all nurses tested negative. He further stated that the local police department had been contacted but had declined to investigate the matter. 28 Pa. Code 201.14(a)(b) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(2)(3) Management 28 Pa. Code 201.29(a) Resident rights

Based on facility policy and observations, it was determined that the facility failed to provide a sanitary, clean, comfortable, homelike environment for one out the two units observed. (Third floor nursing unit). Findings include: A review of the policy titled Home Environment revised on July 1, 2024, under the Policy Guidelines #3 Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. On April 22, 2025, at 12:51 p.m. observation of room [ROOM NUMBER]B had a significant urine smell. On April 24, 2025, an observation of room [ROOM NUMBER]A revealed that Resident R10, who had passed away on April 22, 2025, had not had her room cleaned or cleared. Her personal belongings remained in place, including her reclining chair, which, according to Licensed Nurse Employee E6, was broken and being used to store random items. The items included ankle protectors and uncovered pillows. Both bedside dressers were covered with a noticeable layer of dust. Resident R10 had two dressers, and behind one of them, a broken television was stored alongside additional ankle protectors. Dried-out flowers were also present, contributing to dirt and debris on the floor and on top of the television stand. Observations conducted of room [ROOM NUMBER], revealed that four bedside dressers were dusty, tray tables had visible food spills, and the windowsills were also dusty and had not been cleaned. These findings were confirmed by Licensed Nurse Employee E6. On April 25, 2025, at approximately 10:30 a.m., a meeting with the Administrator, Employee E1, it was confirmed that housekeeping staff are not consistently maintaining resident rooms, including regularly dusting dressers and wiping tray tables. On April 25, 2025, at 2:30 p.m., a second observation was conducted with the Housekeeping Supervisor, Employee E4, who confirmed that room [ROOM NUMBER]A had not been cleaned or sanitized since the passing of Resident R10 on April 22, 2025. 28 Pa. Code 201.18(b)(1) Management

Based on the review of clinical records, facility policies and procedures, resident's financial information, facility investigation and resident and staff interviews, it was determined that the facility failed to ensure that the residents where free from misappropriation and exploitation of property related to the unauthorized access of Resident R1's financial information, theft of money from resident's bank account, unauthorized purchase on resident's account, and receiving monetary assistance by the facility staff. Facility staff failed to report the alleged violation in a timely manner. This failure resulted in an Immediate Jeopardy situation to Resident R1 who experienced financial loss, mental health decline, and psychosocial harm for one of three residents reviewed. This was identified as past non-compliance. (Resident R1) Findings Include: Review of facility policy Program for Prevention of Abuse, Neglect, Exploitation and Misappropriation dated January 2024, revealed that Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; b. other residents; consultants; volunteers; staff from other agencies; family members; legal representatives; friends; visitors; and/or any other individual. Develop and implement policies and protocols to prevent and identify: abuse or mistreatment of residents; a. neglect of residents; and/or b c. theft, exploitation or misappropriation of resident property. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Investigate and report any allegations within timeframes required by federal requirements Protect residents from any further harm during investigations. Review of facility policy, Resident Rights dated January 2023 revealed, Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility, These rights include the resident's right to: a. dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation. e. self-determination. g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States: h. be supported by the facility in exercising his or her rights: i. exercise his or her rights without interference, coercion, discrimination or reprisal from the facility. r. manage his or her personal funds, or have the facility manage his or her funds (if he or she wishes). Review of current Employee Hand book revealed that Employee Conduct and Ethics: All employees are expected to have the highest level of integrity. Employees may not solicit or accept gratuities, gifts, or loans from patients or residents, their families or visitors. In the case where a gratuity is forced upon you, it must immediately be given to your department head or supervisor who will return. SOLICITATION AND DISTRIBUTION Soliciting or accepting gifts, cash, cash equivalents, payments, services, vacations, pleasure trips, or any favors from referral sources, suppliers, vendors, or any other person, firm or corporation that does or seeks to do business with the Company is strictly prohibited. In addition, employees should not borrow, hold money, or agree to cash checks on behalf of a patient, resident, family member, visitor, or employee. Solicitation by employees in resident care areas for any reason is strictly prohibited. Solicitation by employees in non-resident care areas while on working time is strictly prohibited. Collections for charitable purposes shall be considered solicitations for the purposes of this policy, unless approved by management. Employees participating or assisting in solicitation that violates this policy are subject to disciplinary action, up to and including termination. Review of MDS (Minimum Data Set-Assessment of Resident care needs) for Resident R1 dated May 9, 2024, revealed that the resident was admitted to the facility on [DATE]. Further review of the MDS revealed that the resident had a BIMS (Brief Inter for Mental Status) score of 12, which indicated that the resident's cognitive status was moderately impaired. Review of facility investigation dated July 31, 2024 revealed that resident had requested charge nurse to open his phone and look at (online retailer) charge, first nurse not able to open, called second nurse to open (online retailer) account. Nurse told resident there was a maternity dress, (an electronic phone pen) and a glasses case ordered. Resident stated he did not order them, further investigation found there were multiple other charges. Charge nurse reported to administrator. Further review of facility investigation revealed that after discussion with resident it was discovered that activity aide had made purchases on account, after meeting with activity aide, she admitted to the charge, she was suspended, during the investigation a second activity aide went to resident and believed to have cleared his phone of charges, followed by a dietary aide who then took resident phone and erased further information, both the activity aide and dietary aide were suspended. On August 1, 2024, facility staff met with resident again in the morning and had a new bank statement, found charges to multiple sites the resident did not make and then admitted to 3 employees who would order him food and then proceeded to use cash app, online food delivery service, online taxi booking service and online retailer store account for themselves. The investigation of misappropriation of property was substantiated and the facility terminated the activity aides. The dietary aide was terminated for accepting a monetary gift, and the facility concluded that the allegations was unsubstantiated for misappropriation. One nurse aide was terminated for accepting monetary gifts and was unsubstantiated for misappropriation. The police came in spoke with resident and took copies of all information. The information was sent to detectives to investigate. Review of statement from Employee E4, Nurse Aide, on August 6, 2024, revealed that she received $500.00 from Resident R1 when she told him she was going on vacation and she would be off. Another day the resident sent the nurse aide $700.00 dollar to do something nice for her and asked her to go get her hair done. It was revealed that the employee gave him her cash app id for resident to transfer the money. Employee admitted that she understood accepting money from resident was wrong. Review of facility investigation revealed that Nurse aide Employee E4, received a total gift of $1,200.00 dollars from residents account to employee's cash app account. Further review revealed that the employee was terminated for accepting monetary gifts from a resident which is against facility policy. Review of statement from Activity aide, Employee E5, , on August 6, 2024, stated Resident R1 gifted a maternity dress last Wednesday or Thursday. She never asked him to buy her the dress, he surprised her with it last week, it was still in the amazon packaging. Review of facility investigation revealed that nurse aide, Employee E7 reported that the staff in question (Employee E5) used his card. Employee E7 stated she felt that he did not want Employee E5 get in trouble because she was pregnant. She looked into April 2024 bank statement and found $954.00 in charges. Review of facility investigation revealed that on May 29, 2024, Resident R1 account was used to transfer a $100.00 and $200.00 on June 27, 2024, to Employee E5, Activity Aide. Further review of the investigation revealed that After reviewing resident bank statements, cash apps, (online grocery store), online taxi service rides, after review with resident and reviewing each charge, it was determined that [Employee E5, Activity Aide] was using resident bank card on multiple occasions, purchasing clothing, shoes, many food deliveries, online taxi service rides-lift, and trips to inhouse soda and vending machines. Discussion with employee she admitted to using the apps and his card paying for all of the purchases. At this time, it is still undetermined if employee had resident bank information on her phone or if all transactions were done through resident phone. Employee E5 did admit to purchasing items on resident account. Review of statement from Employee E6, Dietary Aide, on August 6, 2024, stated the employee used cash app to herself, for $20.00, she stated she went to resident and asked for $20.00 to get an uber ride home after work. She states she gave resident the $20.00 in exchange. Employee E6 stated she heard Resident R1 stated a nurse or aide might have taken money from him. Review of facility investigation revealed that on June 17, 2024, Resident R1 account was used to transfer a $700.00 and $20.00 at two different times to Employee E6, Dietary Aide. Further review of facility investigation revealed that on July 1, 2024, Resident R1's account was used to transfer $100.00 dollars to Employee E8, Activity Aide's son's account. Further review revealed that after full review of bank statements, witness statements and accused statements, the accusation of misappropriation of resident funds have been substantiated. Employee E8 was terminated. Review of facility investigation related to Employee E9, Business Office Manager, dated July 31, 2024, revealed that the employee was suspended for suspicion of involvement in the case of misappropriation and later terminated for opening resident's mail. Further review of the investigation revealed that the Resident R1 was in administrator office reviewing charges on his phone account and Employee E9, Business Office Manager brought in an opened bank statement and handed it to the resident stating that he should pay attention to the second page of the bank statement. Employee E9, Business Office Manager was interviewed by the administrator, and she stated she accidentally opened the statement and saw suspicious charges. Employee E9, Business Office Manager was suspended due to suspicion of involvement in this case. Continued review of the investigation revealed that the facility did not establish how long Employee E9, Business Office Manager kept the bank statement to herself, or she accessed any other bank statement which could have helped resident to identify unauthorized charges early. Review of facility investigation related to Nurse aide, Employee E10, revealed that resident had disclosed that Employee E10 had taken $5,000.00 from his social security account. Facility was unable to verify at the time. Review of facility investigation related to Activities Director, Employee E11, revealed that from multiple interviews with all staff involved it was determined Employee E11, was aware of the theft and misappropriation activity within the department and did not report to administrator, and he contacted suspended staff during investigation. Review of a statement by social service department July 31, 2024, revealed that she interviewed the Charge nurse, Employee E12 looked into Resident R1's account and showed online retailer store purchase of maternity dress which resident did not recognize but stated the dress could be for Employee E5 who was pregnant. Review of Resident R1's bank statement from May 2024 to July 2024 revealed that there were online taxi booking service transaction on the following days: July 10, 2024- $9.02 July 11, 2024- $13.18 July 16, 2024- $15.31, $6.05 July 17, 2024- $15.92, $14.12 July 18, 2024- $9.00 July 19,- $8.91, $9.98, $14.36 July 22, 2024- $36.60 July 27, 2024- $14.76 July 29, 2024- $17.57 Review of Resident R1's bank statement from May 2024 to July 2024 revealed that there were multiple transactions to two different online food delivery services on the following days: July 1,2024- $54.84, $97.98, $60.30, $9.16 July 5, 2024- $26.61, $48.64, $5.03, $4.34, $36.20, $26.61, $48.64 July 6, 2024- $120.13, $41.41 July 8, 2024- $120.13, $41.41 July 10, 2024- $40.61, $4.17, $35.86, $29.18 July 12, 2024- $11.58, $12.24, $26.72 July 15, 2024 -$28.68, $18.98, $54.56, $42.74, $31.03 July 17, 2024- $24.45, $15.92, $14.01, $33.77 July 19, 2024- $23.39, $27.36, $27.05, $27.23 July 20, 2024- $35.45, $17.01 July 22, 2024- $51.03, $57.54 July 24, 2024- $14.75, $15.54 July 25, 2024- $21.95, $40.14, $34.10 July 26, 2024- $23.70, $40.14, $43.03, $55.25, $21.89 July 29, 2024- $16.21 July 31, 2024- $15.75, $35.21 Review of Resident R1's bank statement from May 2024 to July 2024 revealed that there were purchase to an online grocery delivery service on the following days: July 1, 2024 - $31.05, $60.03, $97.99, $95.87, $70.58, $31.67 July 2, 2024 - $33.94, $25.96 July 3, 2024- $32.65 July 4, 2024- $72.99 July 5, 2024- $52.60, $72.99 July 8, 2024- $52.60 July 9, 2024- $42.34, $70.86 July 10, 2024- $39.44, $32.79, $105.6, $31.67 July 11, 2024, 2024- $30.18, $61.43 July 12, 2024- $139.67, $32.39, $9.00, $5.94, $24.45 July 13, 2024- $28.12, $24.45 July 14, 2024- $28.12, July 15, 2024- $164.11 July 16, 2024- $75.75, $144.10, $104.00, $144 July 17, 2024- $46.92 July 18, 2024- $67.07 July 19,- $51.92, $67.07 July 21, 2024- $137.72, July 22, 2024- $31.07, $101.53, $136.50, $100, $25.00, $2.18 July 23, 2024- $106.57, $31.31, $40.50 July 24, 2024- $34.00, $60.90, $1.25, July 25, 2024- $37.27 July 27, 2024- $57.74 July 29, 2024- $45.20, $80.00, $8.64, $28.29, $62.98 July 30, 2024- $134.95, $49.90 July 31, 2024- $27.22, $27.99 Telephone bill pay for the following days, July 2, 2024- $251.13 July 26, 2024- $200.00 July 25, 2024- $57.03 Review of Resident R1's bank statement from May 2024 to July 2024 revealed that there were lingerie, clothing, and beauty retailer purchases on: July 5, 2024 - $6.70 July 10, 2024- $7.82 July 17, 2024- $56.46 July 28, 2024- $36.20 Review of bank statement for June 2024 revealed there were 32 transactions for a food delivery service ranging between $72.00- $240.00. There were several food delivery transactions, cell phone bill payments, and electronic online purchases. Review of available bank statement for May 22 to May 31, 2024 revealed there were 12 transactions on for a food service delivery including transactions in the amount ranging from $64.00- $247.00, and $89.00. The bank statement also reflected several transactions for food delivery. Review of available bank statement for April 11, 2024 to April 19, 2024, revealed there were 10 transactions for food delivery service between the amounts of $50.00- $101.00. Review of available bank statement for March 2024, revealed there were purchases for a lingerie retail store on March 5, 2024- $38.17, March 14, 2024- $42.53; March 16, 2024-$27.30, March 17, 2024- $47.61, March 19, 2024- $38.70, March 21, 2024-$53.99, March 23, 2024-$75.59, March 24, 2024- $56.99, and March 26, 2024-$32.33. There were seven food delivery transactions. Grocery delivery for purchases of $55.74, $38.89, $21.69, $33.80, and $16.98. Three taxi trips purchased of $23.12, $38.00, $21.97 and a purchase of $16.98 for a department store. Review of bank statement for February 2024, revealed that there was a cash app transfer on February 3, 2024 of $15.00 in addition to online grocery purchase of $21.59 and $32.06, cash app transfer of $20.00, cell phone bill payment of $56.00, for a lingerie store of $31.84, and $32.33. Several food delivery transactions which were on the same day and online taxi services of $10.69, $9.98, $8.33, $8.34, $7.97, $10.57, $8.97, $35.89, $23.07, $14.66, and cash app transfers of $20.00. Interview with Resident R1 on August 15, 2024, at 10:30 a.m. stated staff emptied my 2 bank accounts and tricked me and broke my trust. There is $23,0000, left in my account but it was over $40,000 back in March 2024 and April, 2024. He stated he gave $500.00 and $700.00 to an aide when she told him she was struggling and her situation. Resident stated he was paralyzed on one side so he could not hold the phone properly and order stuff from the phone, so he asked the activity aides to help him out. He stated they teamed up and conspired against him to steal his money. He stated he would ask them to order food for him, but they would take his phone and order groceries, trips, clothes, and food for themselves. He stated he lost over $10,000 but he don't know the actual amount. One staff might have took $5000 once. Resident stated he was more depressed and could not trust any staff or anyone, as they were taking advantage of him. Resident stated there were other staff who were aware of the theft but did not report it to him or others or they did not try to stop it. Resident stated he was not receiving the statements for a long time, he used to receive it every month. He stated activity staff who was responsible to give the mails to him were taking the mail and hiding or destroying the mails. Continued interview with resident stated he orders food from outside once daily but usually around $30- $40 at the maximum. He stated he once it a while orders groceries but usually ranges $30 or under. Resident stated he did not recognize the multiple charges to the electronic food delivery service, most of the electronic food purchases especially the ones over $30.00, online taxi services and purchases to a lingerie store. Resident stated the only valuable items in his room were his tablet and cell phone, other items such as clothes and other stuff did not cost much money. Resident stated when he realized the theft, it messed him up and he was upset. Resident stated they were my friends, he thought they were the last person that would do it. It affected his sleep, activities and social life. He stated he did not go out to activities as much he used to, he stated he was not sleeping well at night. Resident stated now that the whole facility knows this he was embarrassed to face other residents and staff. Resident stated he was a Veteran and he had PTSD (Post Traumatic Stress Disorder). Resident stated he got a sum of money from the Veteran's Administration for PTSD settlement. Resident stated staff stole money from that settlement and now if he sees those staff he was afraid if it would trigger PTSD for him. Resident stated he could not buy food or other stuff from outside from July 31, 2024, because of the hold on the account. Resident stated he needed services from psychologist. Interview with the Nursing Home Administrator on August 15, 2024, at 12:00 p.m. stated 2 activity staff and one dietary staff used resident's money to purchase items for themselves. One activity staff admitted to the purchase. Administrator stated most of the transactions from online grocery store, and online food delivery service online grocery service, were not authorized by the residents. Administrator stated resident orders food everyday once but not more than once usually, resident might use vending machine once or twice but not up to 10 times as shown in the statement. Administrator stated activity staff were responsible for delivering the mail and packages for the residents, so it was easy for them to hide or remove residents mail or packages. Administrator confirmed that the facility failed to protect resident's money. Administrator also confirmed that the resident now experiences emotional distress, embarrassment and distrust because of the theft. Review of psychiatric progress note for Resident R1 dated August 13, 2024 revealed that the resident has been upset about fraudulent activity with his bank. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on August 15, 2024, at 2:55 p.m. The facility failed to ensure that the residents where free from misappropriation and exploitation of property related to the unauthorized access of Resident R1's financial information, theft of money from resident's bank account, unauthorized purchase on resident's account, and receiving monetary assistance by the facility staff for over six months (February 2024, March 2024, April 2024, May 2024, June 2024 and July 2024). Facility staff failed to report the alleged violation in a timely manner. This failure resulted in harm to Resident R1 who experienced financial loss, mental health decline, and psychosocial harm. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator on August 15, 2024, at 2:55 p.m. The facility's corrective action plan included the following interventions: On 07/31/2024 facility was notified that Resident R1 had unauthorized charges on his online retailer account. The facility immediately began an investigation. Action: The threat to Resident R1 was identified and Employees E5 and E6 were suspended and removed from the building. Resident bank debit card was closed and access to his account was closed on 8/1/24. The facility was able to receive statements. Action: Employees E5, E6, E7 were suspended on 7/31/24, followed by termination for misappropriation. Action. The facility revised the facility policy to include protection of resident's financial information. Action: All staff were educated on the facility policy that include Abuse, Neglect. Exploitation and use and protection of resident's financial information by 8/1/24 Action: Facility conducted audits 'to ensure protection of resident fund and property on 8/1/24. NHA/designee will audit funds/ daily x 3 days, weekly x 4 weeks and monthly x 4 months. Results-reported to QAPI. This deficiency was identified as Immediate Jeopardy past non-compliance. Interviews were conducted with activity staff, nurse aides, licensed nursing staff, Registered Nurses and other staff regarding education related to Abuse, Neglect. Exploitation and use and protection of resident's financial information. Staff stated that they received sufficient education from the facility related to Abuse, Neglect. Exploitation and use and protection of resident's financial information. Nurses verbally demonstrated knowledge of Abuse, Neglect. Exploitation and use and protection of resident's financial information. The facility's action plan was accepted on August 15, 2024 at 5:00 p.m. and identified as past non-compliance. 28 Pa. Code 201.14(a)(b) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(2)(3) Management 28 Pa. Code 201.29(a) Resident rights

Based on staff interviews, clinical record review, and policy review, it was determined that the facility failed to ensure an allegation of exploitation of resident's property was reported to the facility's Nursing Home Administrator in accordance with requirements. The facility failed to protect one of three sampled residents (Resident R1) from exploitation of resident's property by three perpetrators which resulted in an Immediate Jeopardy situation to Resident R1 who experienced financial loss, mental health decline, and psychosocial harm. This was identified as past non-compliance. (Resident R1) The findings include: Review of facility policy Program for Prevention of Abuse, Neglect, Exploitation and Misappropriation dated January 2024, revealed that Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; b. other residents; consultants; volunteers; staff from other agencies; family members; legal representatives; friends; visitors; and/or any other individual. Develop and implement policies and protocols to prevent and identify: abuse or mistreatment of residents; a. neglect of residents; and/or b c. theft, exploitation or misappropriation of resident property. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Investigate and report any allegations within timeframes required by federal requirements Protect residents from any further harm during investigations. Review of facility investigation dated July 31, 2024 revealed that resident had requested charge nurse to open his phone and look at (online retailer) charge, first nurse not able to open, called second nurse to open (online retailer) account. Nurse told resident there was a maternity dress, (an electronic phone pen) and a glasses case ordered. Resident stated he did not order them, further investigation found there were multiple other charges. Charge nurse reported to administrator. Review of facility investigation related to Activities Director, Employee E11, revealed that from multiple interviews with all staff involved it was determined Activities Director, Employee E11, was aware of the theft and misappropriation activity within the department and did not report to administrator, and he contacted suspended staff during investigation. Review of statement from Employee E5, Activity Aide, dated July 31, 2024, revealed that she received gift from Resident R1 but did not report it to the facility administrator or designee. Review of statement from Employee E6, Dietary Aide dated August 6, 2024, revealed that she received money from Resident R1 on June 16, 2024 and overheard Resident R1 mentioning a Nurse Aide or a nurse might have took money from him. Further review of the statement revealed But because I didn't know what the situation or proof of anything I didn't pay it any mind. Review of statement from Employee E4, Dietary Aide dated August 6, 2024, revealed that she received a total of $1,200.00 from Resident R1 but did not report it to facility the administrator or designee. Further review facility investigation revealed that several staff was aware of the allegation prior but did not report it to the Nursing Home Administrator. Interview with the Nursing Home Administrator on August 15, 2024, at 12:00 p.m. stated business office manager opened resident's personal bank statements and saw questionable charges but did not report it until questioned few days later. Review of facility investigation revealed that on May 29, 2024, Resident R1 account was used to transfer a $100.00 and $200.00 on June 27, 2024, to Employee E5, Activity Aide. Further review of the investigation revealed that After reviewing resident bank statements, cash apps, (online grocery store), online taxi service rides, after review with resident and reviewing each charge, it was determined that [Employee E5, Activity Aide] was using resident bank card on multiple occasions, purchasing clothing, shoes, many food deliveries, online taxi service rides-lift, and trips to inhouse soda and vending machines. Discussion with employee she admitted to using the apps and his card paying for all of the purchases. At this time, it is still undetermined if employee had resident bank information on her phone or if all transactions were done through resident phone. Employee E5 did admit to purchasing items on resident account. Review of statement from Employee E6, Dietary Aide, on August 6, 2024, stated the employee used cash app to herself, for $20.00, she stated she went to resident and asked for $20.00 to get an taxi ride home after work. She states she gave resident the $20.00 in exchange. Employee E6 stated she heard Resident R1 stated a nurse or aide might have taken money from him. Nursing Home Administrator stated it appeared Employee E11 was aware of misappropriation but did not report it timely. Nursing Home Administrator stated some of the nurse aides and activity staff was aware of the misappropriation but did not report it timely. Interview with Resident R1 on August 15, 2024, at 10:30 a.m. stated staff emptied my 2 bank accounts and tricked me and broke my trust. There is $23,0000, left in my account but it was over $40,000 back in March 2024 and April, 2024. He stated he gave $500.00 and $700.00 to an aide when she told him she was struggling and her situation. Resident stated he was paralyzed on one side so he could not hold the phone properly and order stuff from the phone, so he asked the activity aides to help him out. He stated they teamed up and conspired against him to steal his money. He stated he would ask them to order food for him, but they would take his phone and order groceries, trips, clothes, and food for themselves. He stated he lost over $10,000 but he don't know the actual amount. One staff might have took $5000 once. Resident stated he was more depressed and could not trust any staff or anyone, as they were taking advantage of him. Resident stated there were other staff who were aware of the theft but did not report it to him or others or they did not try to stop it. Resident stated he was not receiving the statements for a long time, he used to receive it every month. He stated activity staff who was responsible to give the mails to him were taking the mail and hiding or destroying the mails. Resident stated when he realized the theft, it messed him up and he was upset. Resident stated they were my friends, he thought they were the last person that would do it. It affected his sleep, activities and social life. Resident stated he was a Veteran and he had PTSD (Post Traumatic Stress Disorder). Resident stated he got a sum of money from the Veteran's Administration for PTSD settlement. Resident stated staff stole money from that settlement and now if he sees those staff he was afraid if it would trigger PTSD for him. Resident stated he could not buy food or other stuff from outside from July 31, 2024, because of the hold on the account. Resident stated he needed services from psychologist. Interview with the Nursing Home Administrator on August 15, 2024, at 12:00 p.m. stated 2 activity staff and one dietary staff used resident's money to purchase items for themselves. One activity staff admitted to the purchase. Administrator stated most of the transactions from online grocery store, and online food delivery service online grocery service, were not authorized by the residents. Administrator stated resident orders food everyday once but not more than once usually, resident might use vending machine once or twice but not up to 10 times as shown in the statement. Administrator confirmed that the facility failed to protect resident's money. Administrator also confirmed that the resident now experiences emotional distress, embarrassment and distrust because of the theft. Review of psychiatric progress note for Resident R1 dated August 13, 2024 revealed that the resident has been upset about fraudulent activity with his bank. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on August 15, 2024, at 2:55 p.m. The facility failed to ensure that an allegation of exploitation of resident's property was reported to the facility's Nursing Home Administrator which resulted in actual harm to Resident R1 who experienced financial loss, mental health decline, and psychosocial harm. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator on August 15, 2024, at 2:55 p.m. The facility's corrective action plan included the following interventions: On 07/31/2024 facility was notified that Resident R1 had unauthorized charges on his online retailer account. The facility immediately began an investigation. Action: The threat to Resident R1 was identified and Employees E5 and E6 were suspended and removed from the building. Resident bank debit card was closed and access to his account was closed on 8/1/24. The facility was able to receive statements. Action: Employees E5, E6, E7 were suspended on 7/31/24, followed by termination for misappropriation. Action. The facility revised the facility policy to include protection of resident's financial information. Action: All staff were educated on the facility policy that include Abuse, Neglect. Exploitation and use and protection of resident's financial information by 8/1/24 Action: Facility conducted audits 'to ensure protection of resident fund and property on 8/1/24. NHA/designee will audit funds/ daily x 3 days, weekly x 4 weeks and monthly x 4 months. Results-reported to QAPI. This deficiency was identified as Immediate Jeopardy past non-compliance. Interviews were conducted with activity staff, nurse aides, licensed nursing staff, Registered Nurses and other staff regarding education related to Abuse, Neglect. Exploitation and use and protection of resident's financial information. Staff stated that they received sufficient education from the facility related to Abuse, Neglect. Exploitation and use and protection of resident's financial information. Nurses verbally demonstrated knowledge of Abuse, Neglect. Exploitation and use and protection of resident's financial information. The facility's action plan was accepted on August 15, 2024 at 5:00 p.m. and identified as past non-compliance. 28 Pa. Code 201.14(a)(b) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(2)(3) Management 28 Pa. Code 201.29(a) Resident rights

Based on a review of clinical records and interviews with staff, it was determined that the facility failed to provide an abuse free environment which resulted in actual harm to Resident R2 who was grabbed by the throat by another resident and sustained bruising to neck and chest, a skin tear to left elbow and bleeding from the upper lip for one of 12 clinical records reviewed. (Resident R2). Findings include: A review of Resident R2's clinical record revealed that the resident was admitted to the facility on [DATE], from the hospital with a [DIAGNOSES REDACTED]. The condition occurs when there is not enough insulin in the body), diabetes (failure of the body to produce insulin), and dementia (progressive disease of the brain, resulting in loss of reality contact). The resident was alert with confusion and forgetfulness. Review of Resident R13's clinical record revealed that the resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Symptoms may include delusions, hallucinations, depressed episodes, and manic periods of high energy.) [MEDICAL CONDITION] (a mental health condition that causes extreme mood swings that include emotional highs or lows). Suicidal ideation (thoughts of self harm), adjustment disorder (a group of symptoms such as stress, feeling sad or hopeless, and physical symptoms that can occur after you go through a stressful life event, and agitation.) A review of Resident R13's quarterly Minimum Data Set MDS-a periodic review of the residents needs), dated November 13, 2019, revealed that the resident was severely cognitively impaired in decision making skills. A review of Resident R13's care plan titled The resident exhibits, or has the potential to exhibit physical/verbal behaviors related to cognitive loss/dementia, psychiatric disorder ([MEDICAL CONDITION]), throwing objects: including televisions, bedding, belongings, hitting , scratching staff and residents, dated February 18, 2019. The goal listed is the resident will not harm others. Interventions include : observe for non-verbal signs of aggression, provide a calm environment and remove the resident from the environment. A review of information dated December 13, 2019, submitted by the facility revealed that Resident R13 had returned from a doctor appointment and was sitting in her wheelchair in the hallway when Resident R2 walked past the resident . Resident R13 reached out and grabbed Resident R2 by the throat, Resident R13's wheelchair tipped over pulling both residents to the floor. The nursing staff responded and separated both residents. The police were called and responded. Resident R2 was examined by the nurse practitioner, the resident was found to have redness and bruising to neck and chest, a skin tear to left elbow and bleeding from the upper lip. Resident R13 was found to have a skin tear to the stomach. Both residents received first aid treatment. Resident R2 requested to go to the hospital for evaluation and Resident R13 was sent to the hospital for a Geri-psychological evaluation. Further review of Resident R2's clinical record revealed a note titled Encounter Summary Details, dated December 13, 2019, documented by the nurse practioner. Note stated resident seen and evaluated today status [REDACTED]. The patient is seen in her room, visibly upset and shaken. Patient noted pain to left elbow with abrasions, upper lip with bleeding, neck and chest have multiple scratch marks. Patient thinks she hit her head but is unsure, but does have pain in the head during exam. The patient will be sent to hospital due to blood thinning medications. The patient was able to explain incident, stating she was pulled over the other residents' wheelchair onto the ground where the other resident was holding her neck and clothing. Physical exam of Resident R2, noted three small abrasions to left elbow, mid upper lip laceration with minimal bleeding and multiple scratch marks to neck and chest with no bleeding. The resident heart rate is elevated likely secondary to recent assault . The resident was experiencing anxiety, reassurance given. A review of a witness statement by Employee E5, the unit clerk, documented on December 13, 2019, revealed that Resident R2 was at the nurse station asking for paper on her way to the elevator. Resident R13 was sitting in her wheelchair in the hallway, and grabbed Resident R2's shirt and pulled her in and grabbed her by the throat and pulled her to the ground. Resident R13 would not take her hands off of Resident R2's throat. It took myself and other staff to get her off. Resident R13 fell out of her wheelchair and was also on top of Resident R2. A review of licensed nursing staff, Employee E13's , witness statement dated December 13, 2019, revealed that on December 13, 2019, I was in the medication room when I heard the staff yelling my name. I came out of the medication room and saw Resident R2 and Resident R13 on the floor in the hallway. I intervened trying to separate Resident R13's hand from Resident R2's shirt. A review of Employee E14's, nursing assistant, witness statement dated December 13, 2019, stated that I was on transport with Resident R13 from a doctor appointment. During the transport she became irrational and began swinging the seatbelt at the driver. We arrived at the facility and I left the resident in front of the nurses station. I got about 15 feet away and heard her yelling. I turned around and saw that she (Resident R13) had Resident R2 on the floor with her (Resident R13) hands around Resident R2's neck. Myself and a few of my co-workers had to separate them. Further review of facility documentation dated December 13, 2019, revealed that Resident R2 stated the lady in the wheelchair attacked me and Resident R13 stated I did it on purpose because I don't want to be here, I want to be in a psychiatric facility. The cops should come and arrest me and send me to jail. Summary of investigation stated that the root cause was related to Resident R13's psychiatric condition. Corrective action stated the facility is in the process of locating another appropriate facility for Resident R13 related to her behavioral issues. A review of Resident R13's chart revealed documentation titled, Encounter summary details, dated December 2, 2019, documented by the physician, stated neurological the resident is awake but is confused and forgetful and she shows poor insight. The resident was sent to the hospital today, December 2, 2019, for agitated episode. She was unable to be re-directed by this physician or staff. She has a history of violent outbursts. She was sent to the hospital for possible admission to the psychiatric facility. The patient was physically abusive to staff and threatening towards the other residents. The resident was deemed stable in the emergency room and sent back to the facility. She has had multiple hospitalization s for uncontrolled mood instability and violent behavior. She can go from sitting in a wheelchair to standing and lifting a television. A review of medication management assessment (a psychiatric visit) dated December 3, 2019, revealed that the resident was being seen for combative behavior. Assessment: the resident hit another resident yesterday with out a known trigger. She was sent to the hospital and later discharged with no change to medication. The resident does not show remorse at the incident and states I want to move to another facility. The resident has labile moods. No suicidal thoughts. No worsening in depression or anxiety. Attention seeking remains. Delusions and psychotic thoughts are present. An interview with the Nursing Home Administrator and the Director of Nursing on December 19, 2019, at 3:00 p.m. confirmed that they are aware of Resident R13's violent behavior. The facility failed to provide an a abuse free environment for Resident R2 who was grabbed by the throat by another resident and sustained bruising to neck and chest, a skin tear to left elbow and bleeding from the upper lip 28 Pa. Code 201.14 (a) Responsibility of licensee previously cited 8/15/18 28 Pa. Code 201.18 (a)(1) Management 28 Pa. Code 211.12 (d)(5) Nursing services previously cited 8/15/18

Based on review of clinical records, review of facility documentation and review of facility policies and interviews with staff, it was determined that the facility failed to provide adequate supervision to one resident who expressed suicidal ideation. Additionally, the facility failed to maintain a safe environment which resulted in actual harm to the resident who cut himself with scissors and was emergently transferred to the hospital for one of 26 residents reviewed (Resident R153). Finding Include: Review of facility policy Suicide Precautions revised on (MONTH) 02, 2014 revealed that For patients who exhibit actual/potential suicidal behavior: 1. One-on-one, 24-hour supervision by either family member or nursing staff member. 2. Limit/Restrict mobility throughout the center. 3. Notify maintenance to secure the windows. 4. Search patient's room and remove objects that may potentially be used for self-harm. 1 Sharp items such as knives, razors, pens, nail clippers, scissors, etc. 2 Hazardous liquids. 3 Other items such as electrical cords, straps, belts, plastic bags and clothing that could be used for self- destruction. 5. Use disposable dinnerware and utensils. Review of the clinical record for Resident R153 revealed that the resident was admitted to the facility on (MONTH) 21, 2019 with [DIAGNOSES REDACTED]. Continued review of the clinical record revealed a med option (Psychiatric services) assessment dated (MONTH) 28, 2019 which indicated that Resident R153 was a [AGE] year-old male who had been paralyzed from a motor vehicle accident. Review of the Minimum Data Set (MDS-periodic assessment of resident's care needs) dated (MONTH) 28, 2019 revealed that the resident had a BIMS (Brief Interview for Mental Status-a screening assessment to aid in in determining cognitive impairment) score of 15 which indicated that resident's cognitive status was intact. Review of hospital records dated (MONTH) 19, 2019 revealed that prior to the hospital admission the resident was in a behavioral rehab. Review of a social service progress note dated (MONTH) 27, 2019, at 2:48 p.m. revealed that Resident R153 expressed feeling of harming himself in the fear of being in a nursing home for the rest of his life. Resident R153 expressed the goal of discharge to community as he did not want to live in nursing facility for the reminder of his life. Review of physician order [REDACTED]. Review of a med option assessment dated (MONTH) 28, 2019 revealed that Resident R153 reported on going suicidal ideation but presently denies, continue q 15 min check as Resident R153 sounded very hopeless, even though he presently denies any suicidal ideation. Review of Minimum Data Set (MDS-periodic assessment of resident's care needs) dated (MONTH) 28, 2019 revealed a mood interview question, Thoughts that you would be better of dead or of hurting yourself in some way and the resident responded Yes with frequency of 7-11 days (half or more of the days assessed). Further review of mood interview question revealed that the resident responded Yes to feeling down, depressed, or hopeless with frequency of 12-14 days (nearly every day). Review of a nursing progress note for Resident R153 dated (MONTH) 30, 2019 at 9:30 p.m. revealed that when the resident was encouraged to verbalize feelings, the resident stated I don't want to end up living in here like other people. Review of clinical record revealed a physician note dated (MONTH) 1, 2019. Further review of the physician note revealed that it was entered into the system on (MONTH) 2, 2019 at 7:47 p.m., seven hours after Resident R153 attempted suicide. The physician noted indicated that will discontinue q 15 min check. Nursing and staff to monitor any change in behavior or mood closely. Review of entire clinical record did not reveal any evidence that this order was ever communicated to nursing staff before Resident R153's suicide attempt. Review of the clinical record Q-15 min check for Resident R153 revealed that the resident started on q 15 min-check on (MONTH) 27, 2019 at 3 p.m. and continued until (MONTH) 2, 2019 at 7 a.m. There was no evidence in the clinical record that staff continued q 15 min check after 7 a.m. on (MONTH) 02, 2019. Review of physician orders [REDACTED].> R153 did not reveal any evidence that the active physician order [REDACTED].>Interview with the director of nursing on (MONTH) 25, 2019 at approximately 2 p.m. confirmed that the clinical record did not contain a physician order [REDACTED]. Review of the facility investigation dated (MONTH) 02, 2019 revealed that at 12:00 p.m. Resident R153 was found sitting up minimally responsive with a fixed gaze. A large pool of blood was noted to resident's right thigh with evidence of injury to the right thigh. Further review of the investigation revealed that pressure was applied to the injured area, high flow oxygen was administered, and intravenous fluids were also administered. Resident R153 gradually became conscious and stated I did this to myself, I will do it again. Resident was transferred to the hospital by 9-1-1 emergency medical service. Resident R153 handed over a pair of scissors to the staff which he stated he used to inflict the injury to himself. Review of a progress note dated (MONTH) 02, 2019 by Employee E3, RN unit manager, revealed that Resident R153 stated the scissors he used to inflict the injury were brought into the facility and that he had them in his possession since admission. Review of social worker progress note dated (MONTH) 02, 2019 revealed that the resident had the scissors in his backpack. Review of facility document Inventory of Personal effect for Resident R153 revealed an inventory list did not include the pair of scissors and resident's backpack which the resident stated was where he kept the scissors. Review of clinical records for Resident R153 did not reveal any evidence that the resident's room was searched for potential objects which could use for self-harm after Resident R153 expressed suicidal ideation on (MONTH) 28, 2019, as per the facility's policy. Interview with director of nursing on (MONTH) 25, 2019 at approximately 2 p.m. confirmed that facility staff did not search the resident's room or belongings after the resident made the threat of self-harm. Further review of clinical records did not reveal any evidence that Resident R153 was provided with disposable dinnerware and utensils after resident made the statement of [MEDICAL CONDITION] on (MONTH) 28, 2019. Interview with director of nursing on (MONTH) 25, 2019 at approximately 2 p.m. confirmed that the clinical record contained no documented evidence that disposable dinnerware and utensils were provided. The facility failed to provide adequate supervision to one resident who expressed feelings of self-harm and failed to maintain a safe environment to the resident who expressed suicidal ideation which caused actual harm to the resident who cut himself with scissors. Free of Accident Hazards/Supervision/Devices 42 CFR(s): 483.25 (d)(1)(2) 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 8/15/18 28 Pa. Code 201.18(b)(1)(3)(e)(3) Management Previously cited 8/15/2018 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.11(d) Resident care plan Previously cited 8/15/19 28 Pa. Code 211.12(c)(5) Nursing services Previously cited 8/15/18 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 8/15/2018

Based on a review of clinical records, facility documentation and interviews with facility staff, it was determined that the facility failed to provide adequate supervision and monitoring to ensure the safety of a resident identified as a fall risk which resulted in actual harm for one of six residents reviewed (Residents CL-1). Findings include: A review of Resident CL-1's clinical record revealed hospital transfer instructions, dated 04/19/2016, from a local hospital, which identified Resident CL-1 as a Fall Risk, and that Resident CL-1 was being sent to the facility for strengthening after her hospital stay (which was from 04/06/2016 to 04/19/2016) and then to an acute rehabilitation facility (an aggressive inpatient Physical and Occupational Therapy facility) so she could learn to apply her prosthesis (an artificial limb) and walk independently again. Further review of Resident CL-1's clinical record revealed an admission Minimum Data Set assessment (MDS - a periodic assessment of needs) dated 04/26/2016, which identified Resident CL-1 as alert and oriented, and requiring extensive assistance by two or more staff members for bed mobility and toileting. This MDS also identified resident CL-1 as weighing 336 pounds and having a fall within the last month. A review of Resident CL-1's plan of care initiated 04/20/2016, identified the resident as a fall risk and the resident was at risk for an alteration in functional mobility related to an amputation (removal of a limb or a section of a limb) of the left leg below the knee. This plan of care also identified that Resident CL-1 required assistance for activities of daily living (ADL's-washing, bathing toileting, etc.) due to a recent hospitalization and her decreased mobility. An initial Physical Therapy (PT) evaluation dated 04/20/2016, noted that Resident CL-1 was admitted to the facility with generalized weakness and impaired mobility skills. A PT summary for the dates of service from 04/20/2016 through 05/19/2016, identified Resident CL-1 as having an old left BKA (below the knee amputation). A review of facility documentation dated 05/21/2016, at 10:30 a.m. revealed that Resident CL-1 was found on the floor next to her bed lying on her back with her head at the bottom of the bed and her foot at the head of the bed. Employee E6, the Registered Nurse, who completed this facility documentation, noted that Resident CL-1 was also incontinent at the time of the fall and Resident CL-1 stated that she was repositioning herself at the time of the fall. Employee E5, Nurse Aide, who was caring for Resident CL-1 at the time of the fall, wrote in her, Accident/Incident Witness Intervention Tool, dated 05/21/2016, that she left Resident CL-1 lying on her left side and she went to get more wash cloths. There was no further documentation to review at the time of the survey to clarify how long the resident was left lying on her left side, the side of her amputation. An interview with both the Nursing Home Administrator and the Director of Nursing on 06/24/2016, at 12:15 p.m. confirmed that the facility did not know how long the resident was left unattended and lying on her left side. An X-ray report attached to the facility documentation dated as completed on 05/21/2016, at 3:05 p.m. revealed that Resident CL-1 suffered a fracture at the end of her left femur (large bone of the upper leg from the hip to the knee), the side of her amputation. The facility failed to provide adequate supervision and monitoring to ensure the safety of a resident identified as a fall risk by leaving the resident, with an amputation of the left leg, unattended and sustained a fall that resulted in a fracture of the left leg. 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(1) Management Previously cited 08/05/15 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.11(c) Resident care plan Previously cited 08/05/15 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 08/05/15, 09/09/14