Every finding on record at Cranberry Place

Based on review of facility policy, facility documentation and clinical record, and resident and staff interviews, it was determined that the facility failed to ensure that one of two residents reviewed (Resident R1) was free of neglect during care which resulted in actual harm of a fracture of left femoral neck (hip fracture). This deficiency is cited as past non-compliance. Findings include: Review of facility policy Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, last reviewed January 2026, indicated all reports of resident abuse (including injuries of unknown origins), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019 indicated that a Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions:13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of Resident R1's admission record indicated that Resident R1 was admitted to the facility 3/15/23. Review of Resident R1's Minimum Data Set (MDS - an assessment tool used to facilitate the management of care) assessment dated [DATE], indicated diagnoses of quadriplegia, gastroesophageal reflux disease (chronic condition where stomach acid flows back into the esophagus), and hyperlipidemia (condition that causes high levels of lipids, or fats, in the blood). Review of Section C: Cognitive Patterns indicated Resident R1 had a BIMS score of 15, cognitively intact. Review of Section GG - Functional Abilities - Mobility, Question GG0170A indicated the resident was coded at a 01 for dependent, helper does all of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. Review of Resident R1's Kardex (documentation system that allows nurses to organize and reference key patient information essential for their care plans) revealed Resident R1's bed mobility: x 2 assist. Review of Resident R1's care plan revealed a focus for ADL self-care performance deficit, initiated 4/3/25, updated 4/8/26 indicating Bed Mobility: assist x 2. Review of Resident R1's clinical record nursing progress note dated 4/1/26, at 3:23 p.m., revealed writer was alert by Nurse Aide that resident (R1) had slid off the side of her bed. Upon entering room resident (R1) was sitting on the floor, leaning with her back against nightstand and legs straight out and her head to the left, on a pillow against the mattress of her bed. Resident (R1) stated that she slid off her bed while Nurse Aide was providing care. Assessed no injuries. Redness to left upper back where she was leaning on nightstand. Assisted back to bed with hoyer lift and 3 staff. Resident (R1) complained of increased pain to left leg. Unit Manager present assisting with transfer back to bed. Notified physician services and confirmed orders for x-rays of the left leg. Notified resident (R1) and sister of fall and new orders. Further review of Resident R1's clinical record nursing progress note dated 4/2/26, at 12:11 a.m., revealed Resident (R1) transferred to hospital for evaluation and possible treatment related to post fall altered mental status, decreasing blood pressure, and increased heart rate. Resident (R1) transported via stretcher accompanied by two EMS (Emergency Medical Service) personnel. Appropriate parties aware including physician and supervisor. Further review of Resident R1's clinical record nursing progress note date 4/2/26, 4:15 a.m., revealed writer called hospital for an update on resident (R1), and nurse stated that resident (R1) was admitted to hospital for altered mental status and a left femoral neck fracture. Review of facility provided witness statement dated 4/1/26, revealed Resident R1 was interviewed by Unit Manager (UM) Employee E1 stating she (Resident R1) is unable to tell me what happened, other than she slipped off the bed. In a follow-up interview by UM Employee E1 with Resident R1 after Resident R1 was assessed and placed back into bed, indicated Resident R1 stated she (R1) slid between NA Employee E2 and the bed and she (R1) did not know how. She (R1) was insistent she did not hot her head but she (R1) was confused and seeing a man with a mustache carrying balloons. She (R1) was not able to clearly state what or how she rolled from the bed. Review of facility provided witness statement dated 4/1/26, provided by Nurse Aide (NA) Employee E2 stated I (NA Employee E2) was in (Resident R1's) room checking the resident. (NA Employee E2) was told another aide (NA) would be coming in shortly to assist me. (NA Employee E2) rolled the resident towards me and noted a bowel movement. (NA Employee E2) went to look behind me for a towel or other item to perform some degree of care whilst waiting for help. In that time, the resident (R1) slid off the bed in front of me in such a way where there was no way for me to catch her. (NA Employee E2) immediately scanned the resident (R1) for obvious wounds or bleeding before finding a nurse to do an assessment. During the fall, (NA Employee E2) did all (NA Employee E2) could to prevent it (rolling resident (R1) towards caregiver, actively looking for 2nd person to assist). Review of facility submitted investigation report dated 4/10/26, at 5:00 p.m., revealed upon investigation, it was determined that the assigned NA did not follow resident's (R1) Kardex instructions for required bed mobility assistance. The care plan indicated the need for additional support during transfers and repositioning. Failure to adhere to the established care plan directly contributed to the incident. The allegation was substantiated. During an interview on 4/30/26, at 1:35 p.m., Resident R1 revealed that she doesn't remember much about the incident other than she tried to make her head not hit her dresser and hit her hip instead. During an interview on 4/30/26, at 2:30 p.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that NA Employee E2 failed to provide appropriate bed mobility assistance to Resident R1 resulting in neglect during care. The facility failed to ensure that Resident R1 was free of neglect during care resulting in actual harm of a fracture of left femoral neck (hip fracture) due to providing improper bed mobility assistance. This deficiency is cited as past non-compliance. On 4/1/26, the facility initiated a plan of correction that included:The resident involved was immediately assessed following the incident, and appropriate medical evaluation and monitoring were conducted.The involved staff member received immediate re-education and corrective counseling on proper transfer techniques and strict adherence to care plans requiring two-person assistance. The incident was reviewed with nursing leadership to reinforce expectations regarding resident safety and compliance with care plans. Nursing staff have been re-educated on safe transfer procedures, including the requirement to wait for assistance when indicated in the care plan. Reinforcement of facility policy that prohibits single-person transfers when a two-person assist is required. Increased supervisory rounds by nursing leadership to ensure compliance with transfer protocols. Implementation of visual or care plan alerts (as applicable) to clearly identify residents requiring two-person assistance. Nursing supervisors/designee will conduct random audits of staff during transfers to ensure compliance.Audits will occur weekly for four weeks, then monthly thereafter, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee.Any observed noncompliance will result in immediate re-education and corrective action as appropriate. The facility was back in compliance on 4/22/26. Interviews with nine nurse aides confirmed they received education on bed mobility and location of communicated information specific to resident care. All staff interviewed acknowledged understanding of bed mobility education and where to find resident specific information related to assistance with care. During an interview on 4/30/26, at 2:30 p.m., the NHA and DON confirmed that the facility failed to ensure that one of two residents reviewed (Resident R1) was free of neglect during care which resulted in actual harm of a fracture of left femoral neck (hip fracture). 28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 201.29(a)(c) Resident Rights28 Pa. Code 211.10(c)(d) Resident Care Policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical records, facility documentation, and resident and staff interviews, it was determined that the facility failed to provide adequate supervision and implement effective mobility interventions to promote resident safety, resulting in a preventable accident and actual harm when the resident received a fracture of the left femoral neck (hip fracture), for one of two residents reviewed (Resident R1). This deficiency is cited as past non-compliance. Findings include: Review of facility policy Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, last reviewed January 2026, indicated all reports of resident abuse (including injuries of unknown origins), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Review of facility policy Resident Mobility and Range of Motion, last reviewed January 2026, indicated residents with limited mobility will receive appropriate care and services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable.As part of the resident's comprehensive assessment, the nurse will identify the resident's:b. Current mobility status (per current MDS assessment tool), including his or her ability to:(1) Move to and from the lying position;(2) Turn and move side-to-side in bed;(3) Change body positions;(4) Transfer to and from bed or chair; and(5) Walk. Review of Resident R1's Minimum Data Set (MDS - an assessment tool used to facilitate the management of care) assessment dated [DATE], indicated diagnoses of quadriplegia, gastroesophageal reflux disease (chronic condition where stomach acid flows back into the esophagus), and hyperlipidemia (condition that causes high levels of lipids, or fats, in the blood). Review of Section C: Cognitive Patterns indicated Resident R1 had a BIMS score of 15, cognitively intact. Review of Section GG - Functional Abilities - Mobility, Question GG0170A indicated the resident was coded at a 01 for dependent, helper does all of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. Review of Resident R1's Kardex (documentation system that allows nurses to organize and reference key patient information essential for their care plans) revealed Resident R1's bed mobility: x 2 assist. Review of Resident R1's care plan revealed a focus for ADL self-care performance deficit, initiated 4/3/25, updated 4/8/26 indicating Bed Mobility: assist x 2. Review of Resident R1's clinical record nursing progress note dated 4/1/26, at 3:23 p.m., revealed writer was alert by Nurse Aide that resident (R1) had slid off the side of her bed. Upon entering room resident (R1) was sitting on the floor, leaning with her back against nightstand and legs straight out and her head to the left, on a pillow against the mattress of her bed. Resident (R1) stated that she slid off her bed while Nurse Aide was providing care. Assessed no injuries. Redness to left upper back where she was leaning on nightstand. Assisted back to bed with hoyer lift and 3 staff. Resident (R1) complained of increased pain to left leg. Unit Manager present assisting with transfer back to bed. Notified physician services and confirmed orders for x-rays of the left leg. Notified resident (R1) and sister of fall and new orders. Further review of Resident R1's clinical record nursing progress note dated 4/2/26, at 12:11 a.m., revealed Resident (R1) transferred to hospital for evaluation and possible treatment related to post fall altered mental status, decreasing blood pressure, and increased heart rate. Resident (R1) transported via stretcher accompanied by two EMS (Emergency Medical Service) personnel. Appropriate parties aware including physician and supervisor. Further review of Resident R1's clinical record nursing progress note date 4/2/26, 4:15 a.m., revealed writer called hospital for an update on resident (R1), and nurse stated that resident (R1) was admitted to hospital for altered mental status and a left femoral neck fracture. Review of facility provided witness statement dated 4/1/26, revealed Resident R1 was interviewed by Unit Manager (UM) Employee E1 stating she (Resident R1) is unable to tell me what happened, other than she slipped off the bed. In a follow-up interview by UM Employee E1 with Resident R1 after Resident R1 was assessed and placed back into bed, indicated Resident R1 stated she (R1) slid between NA Employee E2 and the bed and she (R1) did not know how. She (R1) was insistent she did not hot her head but she (R1) was confused and seeing a man with a mustache carrying balloons. She (R1) was not able to clearly state what or how she rolled from the bed. Review of facility provided witness statement dated 4/1/26, provided by Nurse Aide (NA) Employee E2 stated I (NA Employee E2) was in (Resident R1's) room checking the resident. (NA Employee E2) was told another aide (NA) would be coming in shortly to assist me. (NA Employee E2) rolled the resident towards me and noted a bowel movement. (NA Employee E2) went to look behind me for a towel or other item to perform some degree of care whilst waiting for help. In that time, the resident (R1) slid off the bed in front of me in such a way where there was no way for me to catch her. (NA Employee E2) immediately scanned the resident (R1) for obvious wounds or bleeding before finding a nurse to do an assessment. During the fall, (NA Employee E2) did all (NA Employee E2) could to prevent it (rolling resident (R1) towards caregiver, actively looking for 2nd person to assist). Review of facility submitted investigation report dated 4/10/26, at 5:00 p.m., revealed upon investigation, it was determined that the assigned NA did not follow resident's (R1) Kardex instructions for required bed mobility assistance. The care plan indicated the need for additional support during transfers and repositioning. Failure to adhere to the established care plan directly contributed to the incident. The allegation was substantiated. During an interview on 4/30/26, at 1:35 p.m., Resident R1 revealed that she doesn't remember much about the incident other than she tried to make her head not hit her dresser and hit her hip instead. During an interview on 4/30/26, at 2:30 p.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that NA Employee E2 failed to provide adequate supervision and implement effective bed mobility interventions to promote resident safety for Resident R1, resulting in the resident receiving a hip fracture. The facility failed to ensure that Resident R1 was provided adequate supervision resulting in actual harm when the resident received a hip fracture, due to providing improper bed mobility assistance. This deficiency is cited as past non-compliance. On 4/1/26, the facility initiated a plan of correction that included:The resident involved was immediately assessed following the incident, and appropriate medical evaluation and monitoring were conducted.The involved staff member received immediate re-education and corrective counseling on proper transfer techniques and strict adherence to care plans requiring two-person assistance. The incident was reviewed with nursing leadership to reinforce expectations regarding resident safety and compliance with care plans. Nursing staff have been re-educated on safe transfer procedures, including the requirement to wait for assistance when indicated in the care plan. Reinforcement of facility policy that prohibits single-person transfers when a two-person assist is required. Increased supervisory rounds by nursing leadership to ensure compliance with transfer protocols. Implementation of visual or care plan alerts (as applicable) to clearly identify residents requiring two-person assistance. Nursing supervisors/designee will conduct random audits of staff during transfers to ensure compliance.Audits will occur weekly for four weeks, then monthly thereafter, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee.Any observed noncompliance will result in immediate re-education and corrective action as appropriate. The facility was back in compliance on 4/22/26. Interviews with nine nurse aides confirmed they received education on bed mobility and location of communicated information specific to resident care. All staff interviewed acknowledged understanding of bed mobility education and where to find resident specific information related to assistance with care. During an interview on 4/30/26, at 2:30 p.m., the NHA and DON confirmed that the facility failed to provide adequate supervision and implement effective mobility interventions to promote resident safety, resulting in harm when the resident received a hip fracture, for one of two residents reviewed (Resident R1). 28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 201.29(a)(c) Resident Rights28 Pa. Code 211.10(c)(d) Resident Care Policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of clinical record, and staff interviews it was determined that the facility failed to identify and or review a change in therapy recommendations for one of three residents (Resident R1). Review of clinical record indicated Resident R1 was admitted on [DATE]. Review of clinical record MDS (minimum data set - a periodic assessment of resident needs) dated 2/8/26, indicated diagnosis of diabetes mellitus, left femur fracture and end stage renal disease (kidneys no longer work well and you need dialysis or a transplant to survive). Review of facility provided documents revealed on 3/5/26 NA was getting Resident R1 up for dialysis. During a transfer of assist x 1 stand and pivot, Resident R1 lost balance and fell. Most recent Kardex indicated Resident R1 is a sit to stand x 2. Xray completed, Resident R1 sent out to the hospital with right distal radius fracture. During an interview on 4/1/26, at 10:30 a.m. Assistant Director of Nursing (ADON) Employee E1 indicated that Resident R1 has been working with therapy, transfer status was changed, but it did not make it to the Kardex or Care Plan. ADON Employee E1 stated therapy gives a paper change of status to nursing. During an interview on 4/1/26, at 1:00 p.m. Nursing Home Administrator confirmed that the facility failed to address or implement therapy instructions for Resident R1 as required. 28 Pa. Code 201.18 (e ) Management28 Pa. Code 211.10(c )(d) Resident care policies

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of two residents sampled with facility-initiated transfers (Resident R1).Findings include: Review of facility policy Transfer and Discharge Notice dated 2,2026, indicated resident or representative are notified prior to transfer or discharge. Documentation will be completed in medical record. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/5/26, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking), and high blood pressure. Review of the clinical record indicated Resident R1 was transferred to the hospital on 1/15/26, and did not return to the facility. Review of Resident R1's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. During an interview on 3/4/26, at 2:45 p.m. the Director of Nursing confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of two residents sampled with facility-initiated transfers (Resident R1). 28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights.

Based on a review of facility policies, observations and staff interviews it was determined that the facility failed to properly label and date food products, failed to maintain sanitary conditions in the ice machine, failed to properly restrain hair, failed to verify proper sanitizing strength in the 3-compartment sink in the Main Kitchen (Main Kitchen), and failed to properly monitor refrigerator temperatures in three of three nursing unit kitchenettes (North, East, and West) which created the potential for food borne illness. Findings Include: Review of the facility policy Food Receiving and Storage last reviewed January 2026, and previously reviewed indicated that all foods in the refrigerator or freezer will be covered, labeled, and dated. Food items and snacks kept on the nursing units must be kept below 41 degrees at the nurse's station and must be labeled with the resident's name, the item and the use by date. Refrigerator must have a working thermometer and be monitored for temperature. Review of the facility policy Food Storage Guidelines last reviewed January 2026, stated that all food supply is marked with the date the item was received by the department. Review of the facility policy Cleaning and Sanitizing last reviewed January 2026 indicated that team members maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. Review of the facility policy Personal Hygiene Guidelines last reviewed January 2026, indicated that hair nets and caps are to be worn at all times. During an observation and interview on 1/28/26, at 10:10 a.m. in the Main Kitchen walk-in freezer, a bag of Asian blend vegetables, a bag of squash, and a bag of ravioli had no received date on the packages, and an opened bag of squash was not dated with the date that it was opened, which was confirmed by Dining Services Director (DSD) Employee E18. During an observation and interview on 1/28/26, at 10:12 a.m. in the Main Kitchen Dry storage, an opened bag of egg noodles was not dated with the date that it was opened, which was confirmed by DSD Employee E18. During an observation and interview on 1/28/26, at 10:15 a.m. in the Main Kitchen, the ice machine was found to have a black substance on the inside of the lid to the machine, and was confirmed by DSD Employee E18. During an observation and interview on 1/28/26, at 10:18 a.m. in the Main Kitchen, the 3- Compartment sink Temperature and Sanitizer Report log for January 2026 was left blank and did not record any wash temperatures or sanitizer solution concentrations for any breakfast, lunch, or supper meals during the month of January, which is a total of 82 missed opportunities, and was confirmed by DSD Employee E18. During an observation and interview on 1/28/26, at 11:03 a.m. in the Main Kitchen during tray line, the DSD Employee E18, and Dining Services Supervisor Employee E19, were noted to have the front portion of their hair uncovered by a hair net, and was confirmed by DSD Employee E18. During an observation and interview on 1/30/26, at 10:45 a.m. in the North Hall Kitchenette, two yogurts were noted to have no label with resident name or date, and was confirmed by Licensed Practical Nurse Employee E4. Review of the facility documents Refrigerator Inspection Log for January 2026 on 1/30/26, from 10:45 a.m. through 11:00 a.m., revealed that the North Unit was missing documentation for temperature checks for 19 of 29 days (1/3/26, 1/4/26, 1/9/26, 1/10/26, 1/12/26, 1/13/26, 1/14/26, 1/15/26, 1/16/26, 1/17/26, 1/18/26, 1/19/26, 1/20/26, 1/21/26, 1/24/26, 1/25/26, 1/26/26, 1/27/26, and 1/29/26). The East Unit was missing documentation for temperature checks for seven of 29 days (1/1/26, 1/17/26, 1/18/26, 1/21/26, 1/22/26, 1/23/26, and 1/29/26. The [NAME] Unit was missing documentation for temperature checks for seven of 29 days (1/7/26, 1/8/26, 1/21/26, 1/22/26, 1/23/26, 1/27/26, and 1/28/26). During an interview on 1/30/26, at 11:00 a.m. The Nursing Home Administrator confirmed that the facility failed to properly monitor refrigerator temperatures on three of three nursing units (Nort, East, and West). 28 Pa. Code 201.14(a)Responsibility of licensee.28 Pa. Code 201.18(b)(1) Management.

Based on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for three of three crash carts (West Unit, North Unit, and East Unit).Findings include: Review of facility Emergency Crash Cart Checklist stated the emergency crash cart (a wheel container carrying equipment for use in emergency resuscitations) always needs to be ready for emergencies. Complete this checklist at least weekly and after each use to ensure readiness. [NAME] an X next to each item indicating it is present, clean, in working order, and not expired. Review of facility Crash Cart Daily Signature Log stated to complete this form daily to ensure that the emergency crash cart is in order and ready to use in case of emergency. During an observation on [DATE], at 10:10 a.m. of the [NAME] Unit crash cart revealed the following expired supplies:Two (2) intravenous secondary tubing sets, expired [DATE]Two (2) intravenous short-term kits, expired [DATE]Four (4) 21-gauge blood collection needle and tubing sets, expired [DATE]Five (5) 23-gauge blood collection needle and tubing sets, expired [DATE]Nine (9) povidone-iodine (a broad-spectrum antiseptic used for skin disinfection) swab sticks, expired [DATE]. During this observation, a clipboard was located on top of the crash cart with a Crash Cart Daily Signature Log for [DATE]. Review of the check list sheet documentation failed to reveal that the cart was checked on [DATE], [DATE], [DATE], [DATE], and [DATE]. During an interview on [DATE], at 10:29 a.m. Licensed Practical Nurse (LPN) Employee E3 confirmed the above observations and that the facility failed to make certain equipment was in safe operating condition for the [NAME] Unit crash cart.During an observation on [DATE], at 10:38 a.m. of the North Unit crash cart revealed the following expired supplies:One (1) 21-gauge blood collection needle and tubing set, expired [DATE]One (1) StayFIX fixation device (a needleless catheter securement device that prevents migration, movement, and accidental removal of a catheter), expired [DATE].One (1) nonconductive suction tubing set (tubing connected to a suction device), expired [DATE]. During an interview on [DATE], at 10:53 a.m. LPN Employee E4 confirmed the above observations and that the facility failed to make certain equipment was in safe operating condition for the North Unit crash cart. During an observation on [DATE], at 11:00 a.m. of the East Unit crash cart revealed the following expired supplies:Two (2) intravenous short-term kits, expired [DATE]Four (4) povidone-iodine swab sticks, expired [DATE]Adult nonrebreather (a medical device used to deliver high concentrations of oxygen during emergencies) mask and tubing kit, expired [DATE] During an interview on [DATE], at 11:15 a.m. Registered Nurse Employee E5 confirmed the above observations and that the facility failed to make certain equipment was in safe operating condition for the East Unit crash cart. During an interview on [DATE], at 2:39 p.m. information was disseminated to the Director of Nursing that the facility failed to make certain that equipment was in safe operating condition for three of three crash carts (West Unit, North Unit, and East Unit). 28 Pa. Code: 201.14(a) Responsibility of licensee.

Based on review of facility policy, clinical record review, review of Resident Representative concerns, review of facility documents, resident observations, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of four quarters of facility staffing data (Quarter Three), two of three Resident Council Meetings (November 2025, and January 2026), six of seven residents in a Group meeting, one of three months for Grievances (January 2026), and five of ten residents observed (Residents R41, R73, R76, R79, and R151). Findings include: Review of the facility policy Staffing, Sufficient and Competent Nursing dated January 2026, indicated the facility provides sufficient staff numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Review of Payroll Based Journal (PBJ - a mandatory reporting system for nursing homes in which staffing information is reported on a quarterly basis) dated 4/1/25, through 6/3/25, indicated that the facility had excessively low weekend staffing. Review of 'Resident Council Meeting Minutes dated 11/13/25, and 1/8/26, indicated that Multiple residents expressed concern with the length of time it takes for call lights to be answered. Review of Concern and Comment Form dated 1/8/26, indicated during Resident Council Residents expressed dissatisfaction with meal temperatures- receiving cold items, and review of Facility and Investigation and Response dated 1/12/26, in response to this concern, indicated Food carts are delivered to the units and sit for a period of time before trays are passed. Review of Concern and Comment Form dated 1/11/26, indicated You need more staff. One person covering is not enough for half a floor. Taking two- two and half hours to get a patient on a bedpan is not acceptable. Has happened too often, and review of Facility and Investigation and Response dated 1/16/26, in response to this concern stated Investigation conducted related to short staffing allegations at the facility. Reviewed schedules, payroll, ratios and interviews with administration and leadership. The investigation determined that the facility experienced periods of staffing challenges due to ongoing recruitment difficulties and unexpected absences. Review of a Resident Representative Concern dated 1/13/26, indicated that residents Go longer than a week between showers due to insufficient staffing, and Residents are fed cold meals, and Call lights go unanswered. Review of a Resident Representative Concern dated 1/22/26, indicated that During Christmas, they had 1 nurse/aide on the floor to take care of 35 residents. This is completely unacceptable, and My mom's food tray sat in hallway for an hour before I finally went out looking for her food, of course it was ice cold by then During a Resident Group meeting on 1/29/26, at 10:30 a.m. when asked if they felt the facility maintained enough staff to care for resident needs, six of seven residents indicated it depended on the day, the shift, and the number of staff that came to work. Indicated if a resident requires a Hoyer lift (a mechanical lift that moves a body from point A to point B) they would likely not get a shower on days the staff were short because it takes two people to use the equipment. Three of seven residents indicated they have missed showers due to lack of staff. Four of seven residents indicated you can wait for assistance on any given day or shift anywhere from 30 minutes up to two hours. Interview on 1/29/26, at 11:17 a.m. Nurse Aide (NA) Employee E10 indicated showers that all depends on how many staff we have, we need two staff for all the Hoyer lift residents who must stay in bed until we find a second person. During an interview on 1/29/26, at 11:17 a.m. NA Employee E26 stated, Staffing is a problem, can't always do showers, and care gets cut in half, you can't get people out of bed, trays are hard to pass when we're short. You can't be everywhere. Call lights have to wait sometimes. During an interview on 1/29/26, at 11:28 a.m. NA Employee E28 stated when staffing is low, Showers don't get done, we are slow at passing trays, and sometimes call bell take longer. Interview on 1/29/26, at 11:30 a.m. Registered Nurse (RN) Employee E11 indicated staffing has been a real struggle. Interview on 1/29/26, at 11:35 a.m. NA Employee E12 indicated usually the quick showers get done, it's the residents who require a Hoyer for their showers that are missed or wait longest. Interview on 1/29/26, at 11:40 a.m. Licensed Practical Nurse (LPN) Employee E13 indicated it is very hard to get the showers in, especially the Hoyer showers seem to be very bad lately. Review of the admission record indicated Resident R41 admitted to the facility on [DATE]. Review of Resident R41's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/4/26, indicated the diagnoses of high blood pressure, GERD (gastroesophageal reflux disease- when stomach acid frequently flows back into the esophagus causing heartburn), and multiple sclerosis (a disease that affects central nervous system). During an interview on 1/29/26, Resident R41 stated that she is to receive two showers per week but frequently misses showers. Sometimes the girls say they can't give me one due to staffing, but that's not my problem. Review of clinical record revealed Resident R41 is to receive showers every Tuesday and Thursday. Review of Documentation Survey Report conducted on 1/29/26, revealed that Resident R41 did not receive showers on 1/6/26, 1/8/26, and 1/28/26 as indicated. During an interview on 1/29/26, at 1:37 p.m. the Director of Nursing (DON) confirmed that the facility failed to provide showers as scheduled to Resident R41 on 1/6/26, 1/8/26, and 1/28/26 Review of the admission record indicated Resident R73 admitted to the facility on [DATE]. Review of Resident R73's MDS dated [DATE], indicated the diagnoses of atrial fibrillation (irregular heart rhythm), high blood pressure and pancreatic cancer. Review of Resident R73's care plan dated 12/16/25, indicated be sure resident's call light is within reach and encourage the resident to use it for assistance as needed. Resident needs prompt response to all requests for assistance. Observation on 1/29/26, at 11:30 a.m. the monitor at the desk indicated Resident R73's call light had been activated for 17 minutes. Interview on 1/29/26, at 11:31 a.m. Resident R73 indicated they needed a pain pill. The final time the call light was activated was 22 minutes. Review of the clinical record revealed Resident R76 was admitted to the facility on [DATE]. Review of Resident R76's MDS dated [DATE], indicated diagnoses of high blood pressure, aphasia (a language disorder that affects a person's ability to speak, understand, read, and write), and hypokalemia (low levels of potassium in the blood).Review of Resident R76's clinical record revealed the resident is scheduled to have shower every Sunday and Wednesday at 6 a.m. Review of documentation revealed Resident R76 did not receive their shower as scheduled on 1/4/26, 1/11/26, and 1/25/26. During an interview on 1/29/26, at 10:04 a.m. Resident R76 stated, My roommate is supposed to get a shower every Monday and Thursday. She did not get one on Monday, she just finally got one on Wednesday, so now she will not get one today [Thursday]. I have a big mouth; I need to speak up for residents like my roommate who can't always make their needs known.During an interview on 1/29/26, at 10:21 am. Resident R76 stated, The website for the facility says we're supposed to get an hour of care per resident every shift. I'm lucky if I get 15 minutes of care a week. I can do a lot for myself, I have balance issues, I need the staff to help me in the shower room. When I don't get my scheduled showers, they [staff] like to say they don't have enough staff. I tell them it's not my problem, tell your boss to get more staff.Review of the clinical record revealed Resident R79 was admitted to the facility on [DATE]. Review of Resident R79's MDS dated [DATE], indicated diagnoses of aphasia, depression, and lack of coordination.Review of Resident R79's clinical record revealed that the resident is scheduled to have a shower every Monday and Thursday during the 7 a.m. to 3 p.m. day shift. Review of documentation revealed Resident R79 did not receive their shower as scheduled on 1/26/26.During an interview on 1/29/26, at 10:23 a.m. when asked if they receive their showers as scheduled, Resident R79 shook their head no indicating that they do not receive their showers as scheduled. Resident R79 then pointed to a calendar and indicated they are scheduled to receive showers every Monday and Thursday.During an interview on 1/29/26, at 1:41 p.m. the DON confirmed that the facility failed to provider showers as scheduled for Residents R76 and R79. Review of the admission record indicated Resident R151 admitted to the facility on [DATE]. Review of Resident R151's MDS dated [DATE], indicated the diagnoses of atrial fibrillation, high blood pressure, and renal failure (a condition in which the kidneys lose the ability to remove waste and balance fluids). Review of Resident R151's care plan dated 1/26/26, indicated be sure resident's call light is within reach and encourage the resident to use it for assistance as needed. Resident needs prompt response to all requests for assistance. Observation on 1/29/26, at 11:27 a.m. the monitor at the desk indicated Resident R151's call light had been activated for 25 minutes. Interview on 1/29/26, at 11:27 a.m. Resident R151 indicated they needed their indwelling foley catheter (a thin tube in bladder to drain urine) adjusted because something was wrong with it. The final time the call light was activated was 26 minutes. During an interview on 1/29/26, at 11:30 a.m. RN Employee E7 confirmed the monitor at the desk indicated times of 22 minutes and 25 minutes for Resident R151. Interview on 1/29/26, at 2:00 p.m. the DON confirmed the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for or one of four quarters of facility staffing data (Quarter Three), two of three Resident Council Meetings (November 2025, and January 2026), six of seven residents in a Group meeting, one of three months for Grievances (January 2026), and five of ten residents observed (Residents R41, R73, R76, R79, and R151). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(6) Management.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(4)(5)(f.1)(i) Nursing services.

Based on review of professional standards of practice facility polices, observations, clinical records, and staff interview it was determined that the facility failed to make certain that appropriate treatments and services were provided for the use of a foley catheter (thin tube placed in bladder to drain urine) as required for three of seven (Resident R64, R83 and R151). Findings include: Review of the facility policy Catheter Care dated January 2026, indicated the purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Use aseptic technique when handling or manipulating the drainage system. Review the resident's care plan to assess any special needs of the resident. Change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. If the catheter material contributes to obstruction, notify the physician and change the catheter if instructed. Review of the facility policy Dignity dated January 2026, indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Staff are expected to promote dignity and assist residents by helping to keep urinary catheter bags covered. Review of the admission record indicated Resident R64 was admitted to the facility on [DATE]. Review of Resident R64's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/24/25, indicated the diagnosis of diabetes (high sugar in the blood), anxiety, and respiratory failure (lungs can't get enough oxygen). Observation on 1/28/26, at 10:23 a.m. Resident R64's urinary catheter bag (a medical collection device attached to a urinary catheter to safely hold urine outside of the body) was hanging on his bed and failed to have a dignity bag as required. Interview completed on 1/28/26, at 10:26 a.m. Registered Nurse (RN) Employee E22 confirmed the urinary catheter bag failed to have a dignity bag as required and stated, it looks like they forgot to put a cover on it. Review of Resident R64's current physician orders on 1/29/26, failed to include orders for the type of urinary catheter or urinary catheter care. Review of Resident R64's current care plan on 1/29/26, failed to include interventions for the type of urinary catheter or care for the urinary catheter. Interview completed on 1/29/26, at 9:33 a.m. RN Employee E22 confirmed there were no current orders or care-plan in place for the urinary catheter. Review of the admission record indicated Resident R83 was admitted to the facility on [DATE]. Review of Resident R83's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/23/26, indicated the diagnoses of high blood pressure, quadriplegia (paralysis affecting all four limbs) and neurogenic bladder (loss of bladder control). Review of Resident 83's physician order dated 4/16/25, indicated to change catheter as needed. Review of Resident R83's physician ordered dated 1/6/26, indicated indwelling foley catheter (thin tube placed in bladder to drain urine) due to neurogenic bladder. Review of Resident R83's care plan with revision on 8/22/24, indicated resident has an indwelling catheter related to neurogenic bladder, change catheter as per order. Indwelling Foley Catheter size18 French with 5cc balloon (holds tube in place in the bladder). Review of Resident R83's care plan with revision on 3/1/25, indicated Risk for infection related to foley catheter. Manage indwelling catheters to minimize risk of infection. Review of Resident R83's health status note dated 12/28/25, at 8:30 a.m. indicated alerted by resident that her catheter has been leaking since yesterday as her brief has been wet and her drainage bag empty. This nurse withdrew 10milliter (ml) from balloon and advanced catheter with a return of medium yellow drainage. Catheter was flushed with 60ml of sterile water with a return of clear, light-yellow drainage. Resident had no further complaints. Review of the admission record indicated Resident R151 admitted to the facility on [DATE]. Review of Resident R151's MDS dated [DATE], indicated the diagnoses of atrial fibrillation, high blood pressure, and renal failure (a condition in which the kidneys lose the ability to remove waste and balance fluids). Review of Resident R151's care plan dated 1/26/26, indicated resident has an indwelling foley catheter related to urinary retention. Observation and interview on 1/29/26, at 11:27 a.m. Resident R151 indicated they needed their indwelling foley catheter adjusted because something was wrong with it. Resident R151's foley catheter failed to have a dignity bag as required. During an observation and interview on 1/29/26, at 11:30 a.m. Registered Nurse (RN) Employee E7 confirmed the facility failed to make certain that appropriate treatments and services were provided for the use of a foley catheter (thin tube placed in bladder to drain urine) required for two of seven (Resident R64, and R151). Interview completed on 1/31/26, at 11:40 a.m. upon asking the Director of Nursing (DON) what the protocol for a urinary catheter that is found to be leaking replied if a catheter was leaking it would be replaced with a new one. Upon review of the nursing note dated 12/28/25, replied. I believe a new one would have been warranted, they did not follow the facility protocol and confirmed that the facility failed to make certain that appropriate treatments and services were provided for the use of a urinary catheter required for three of seven (Resident R64, R83 and R151). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store medications and biologicals in a safe, secure, and orderly manner for three of four medication carts (North Unit Back Hall, [NAME] Unit Front Hall, and East Unit Front Hall). Findings include: Review of the facility policy Storage of Medications dated January 2026, indicated that medications and biologicals are stored safely, securely, and properly. During an observation on 1/28/26, at 9:31 a.m. of the North Unit Back Hall Medication Cart revealed the following: Resident R23's lantus pen (a prefilled pen that injects long-acting insulin under the skin), no open or expiration date noted. Resident R80's lantus pen, no open or expiration date noted. Resident R146's insulin lispro vial (a rapid-acting insulin, stored in a multi-dose vial), no open or expiration date noted. During an interview on 1/28/26, at 9:35 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed the above observations and that the facility failed to properly store medications in the North Unit Back Hall Medication Cart. Observation of the [NAME] Unit Front Hall medication cart on 1/28/26, at 9:35 a.m. indicated the following medications opened and not dated as required:- cyclosporine eye drops (used for dry eyes)- eye itch relief bottle- albuterol sulfate nebulizer solution (used to make breathing easier) Interview on 1/28/26, at 9:35 a.m. Registered Nurse (RN) Employee E14 confirmed the medications were open and without a date as required. Observation of the East Unit Front Hall medication cart on 1/28/26, at 9:42 a.m. indicated the following medications opened and not dated as required:- budesonide solution (used to make breathing easier) 2 boxes- ipratropium bromide (used to make breathing easier) Interview on 1/28/26, at 9:42 a.m. LPN Employee E15 confirmed the medications were open and without a date as required. Interview on 1/28/26, at 10:00 a.m. the Director of Nursing confirmed the facility failed to store medications and biologicals in a safe, secure, and orderly manner for three of four medication carts (North Unit Back Hall, [NAME] Unit Front Hall, and East Unit Front Hall). 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 211.9(a)(1) Pharmacy services. 28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of policies and clinical records, observations and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs of residents for three of six residents reviewed (Residents R2, R45, and R116). Findings include: Review of the facility policy Goals and Objectives, Care Plans dated January 2026, indicated care plan goals and objectives are defined as the desired outcome for a specific resident problem. Goals and objectives are entered into the resident's care plan so that all disciplines have access to such information and are able to report whether the desired outcomes are being achieved. Review of the facility policy Departmental (Respiratory Therapy)-Prevention of Infection dated January 2026, indicated review the residents care plan to assess for any special circumstances or precaution related to the resident. Review of the admission record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/26/25, indicated the diagnoses of high blood pressure, diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) and respiratory failure (lungs can't get enough oxygen). Section O special treatments, procedures, and programs, E1 tracheostomy care coded as performed while a resident. During an observation completed on 1/28/26, Resident R2 was in bed with a tracheostomy (trach-a surgical opening through the neck into the trachea (windpipe) to help you breathe bypassing your nose, mouth and throat) present. Review of Resident R2's physician order dated 12/22/25, indicated respiratory tracheotomy assessment six times a day. Pre -existing trach – 6 Shiley (size and brand of trach tube). Review of Resident R2's care plan on 1/30/25, failed to include a plan of care for the management and monitoring of the tracheostomy. During an interview completed on 1/30/26, at 11:20 a.m. Registered Nurse Employee E5 confirmed a care plan was not present for Resident R2's tracheostomy care. Review of the admission record indicated Resident R45 was admitted to the facility on [DATE]. Review of Resident R45's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/11/26, indicated the diagnoses of high blood pressure, renal insufficiency (a condition in which the kidneys lose the ability to remove waste and balance fluids), and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident R45's physician order dated 1/14/26, indicated COVID isolation/contact and dropletPrecautions (Staff must wear N95 respirator, protective eye wear, gowns and gloves). Care and services to be provided in the resident's room every shift for infection prevention. Review of Resident R45's care plan on 1/29/26, failed to include a plan of care for the management and monitoring of Covid isolation. Interview on 1/30/26, at 9:00 a.m. Infection Preventionist (IP) Employee E9 confirmed Resident R45's plan of care failed to include a plan of care for the management and monitoring of Covid isolation. Review of the admission record indicated Resident R116 was admitted to the facility on [DATE]. Review of Resident R116's MDS dated [DATE], indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), paraplegia (paralysis of legs and lower body), and anxiety. Review of Resident R116's physician order dated 1/10/26, indicated COVID isolation/contact and dropletPrecautions. Care and services to be provided in the resident's room every shift for infection prevention. Review of Resident R116's care plan on 1/29/26, failed to include a plan of care for the management and monitoring of Covid isolation. Interview on 1/30/26, at 9:00 a.m. Infection Preventionist (IP) Employee E9 confirmed Resident R116's plan of care failed to include a plan of care for the management and monitoring of Covid isolation. Interview on 1/30/26, at 3:00 p.m. the Director of Nursing confirmed that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs of residents for three of six residents reviewed (Residents R2, R45, and R116). 28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12 (d)(5) Nursing Services.

Based on review of facility documents, resident group meeting, clinical record review, observation and staff interview, it was determined that the facility failed to accommodate the call bell needs for 19 of 19 residents in Resident Council on 1/8/26, two of seven Group residents on 1/29/26, and one of seven residents observed (Resident R41).Findings include: Review of the facility policy Accommodation of Needs dated January 2026, the facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independence functioning, dignity and well-being. Review of the facility document Resident Council Meeting Minutes dated 1/8/26, indicated that during Resident Council Residents unanimously expressed that staff do not leave their call bells in reach. During a Resident Group meeting on 1/29/26, at 10:30 a.m. two of seven Group residents indicated call bells are not always left within their reach. They put it where we can't reach it. This happens a lot. Review of the admission record indicated Resident R41 admitted to the facility on [DATE]. Review of Resident R41's Minimum Data Set (MDS- a periodic assessment of care needs) dated 1/4/26, indicated the diagnoses of high blood pressure, GERD (gastroesophageal reflux disease- when stomach acid frequently flows back into the esophagus causing heartburn), and multiple sclerosis (a disease that affects central nervous system). Review of Resident R41's care plan intervention dated 8/7/24, indicated to be sure that resident's call light is within reach and encourage resident to use it for assistance as needed. During an observation and interview on 1/29/26, at 9:35 a.m. Resident R41 was observed lying in bed with a call bell beside her head, clipped to her pillow. State Agency (SA) asked Resident R41 how she activates her call bell, and resident explained that she is unable to move her arms, so she has to use her head to activate the call bell. Resident R41 then moved her head vigorously from side to side but was not able to reach the call bell with her head. Resident R41 stated I can give myself whiplash and still not reach it. I need my pillow to be slide over to the left, so the light is closer. During an interview and observation on 1/29/26, at 9:36 a.m. Nurse Aide (NA) Employee E26 entered Resident R41's room, and assisted with moving the resident's pillow to the left. Resident R41 was then able to activate the call light. NA Employee E26 confirmed that Resident R41 was unable to activate call light when it was in the original position. During an interview on 1/29/26, at 2:36 p.m. the Nursing Home Administrator confirmed that the facility failed to accommodate call bell needs for 19 of 19 Resident Council residents, two of seven Group residents, and 1 of seven residents observed (Resident R41). 28 Pa. Code 201.14(a) Responsibility of license28 Pa. Code: 211.10(d) Resident care policies28 Pa. Code: 211.12(d)(1)(5) Nursing services

Based on clinical record review and resident and staff interview, it was determined that the facility failed to promote a multidisciplinary approach with care conferences for four of seven resident's reviewed (Resident R5, R10, R40, R119). Findings include: Review of the clinical record indicated Resident R5 was admitted [DATE]. Review of Resident R5's MDS (minimum data set a periodic review of assessment needs) dated 10/15/25, indicated diagnosis of heart failure (when the heart muscle can't pump enough blood to meet the body's needs) and CAD (coronary artery disease - narrowing or blockage of your coronary arteries). Review of Resident R5's Interdisciplinary Care Plan Conference sign in sheet dated 10/22/25, included the following disciplinary: social service, dietary, therapy with the resident and family member in attendance. Review of Resident R5's Interdisciplinary Care Plan Conference sign in sheet failed to include nursing. Review of clinical record indicated Resident R119 was admitted to the facility on [DATE], with diagnoses that included progressive multiple sclerosis (disease that causes breakdown of the protective covering of nerves), bacteremia (bacteria in the bloodstream) and urinary tract infection. Review of Resident R199's Minimum Data Set (MDS-a mandated assessment of a resident's abilities and care needs) assessment, dated 1/3/26, indicated the diagnoses remain current. Progress dated 12/30/25 indicated nursing unavailable during care conference meeting. Review of clinical record indicated Resident R10 was admitted to the facility on [DATE], with diagnoses that included atrial fibrillation ( irregular heart rhythm), heart failure and hypertension. Review of Resident R10's Minimum Data Set (MDS-a mandated assessment of a resident's abilities and care needs) assessment, dated 12/24/25, indicated the diagnoses remain current. Progress dated 7/8/25 and 1/28/26 indicated nursing unavailable during care conference meeting. Review of clinical record indicated Resident R40 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease ( ongoing lung condition caused by damage to the lungs), anxiety and cellulitis (spreading skin infection). Review of Resident R40's Minimum Data Set (MDS-a mandated assessment of a resident's abilities and care needs) assessment, dated 12/18/25, indicated the diagnoses remain current. Progress dated 12/17/25 indicated nursing unavailable during care conference meeting. During an interview on 1/31/26 at 10:00 a.m. Director of Nursing confirmed there was no nursing in attendance at the care conferences as required. 28 Pa. Code 211.12(d)(3) Nursing services

Based on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for three of five residents (Resident R7, R9 and R56). Findings include: Review of the facility policy Trauma-Informed and Culturally Competent Care dated January 2026, indicated to guide staff in providing care that is culturally competent and trauma informed in accordance with professional standards of practice. To address the needs of trauma survivors by minimizing triggers and /or re-traumatization. Develop individualized care plans that address past trauma in collaboration with the residents and family, as appropriate. Identify and decrease exposure to triggers that may retraumatize the resident. Review of the facility policy Goals and Objectives, Care Plans dated January 2026, indicated care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Care plan goals and objectives are defined as the desired outcome for a specific resident problem. Review of the admission record indicated Resident R7 was admitted to the facility on [DATE]. Review of Resident R7's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/23/25, indicated the diagnosis of quadriplegia (paralysis of all four limbs), anxiety, and depression. Observation completed on 1/28/26, at 9:57 a.m. a sign was noted on the outside of Resident R7's door. The sign stated, do not knock. Review of Resident R7's care plan on 1/30/26, indicated that Resident R7 had a history of trauma that affects him negatively. Resident was shot by a gun several times but failed to identify what the triggers were and how to avoid them. Review of the admission record indicated Resident R9 was admitted to the facility on [DATE]. Review of Resident R9's MDS dated [DATE], indicated the diagnosis of quadriplegia (paralysis affecting all four limbs), neurogenic bladder (loss of bladder control) and anemia (low iron in the blood). Observation completed on 1/28/26, at 9:57 a.m. a sign was noted on the outside of Resident R9's door. The sign stated, do not knock. Review of Resident R9's care plan on 1/30/26, indicated that Resident R9 had a history of trauma that affects him but failed to identify what the triggers were and how to avoid them. Interview completed on 1/28/25, at 10:01 a.m. Registered Nurse (RN) Employee E22 confirmed that both Resident R7 and Resident R9 have do not knock signs on the outside of their doors and stated, they are both gunshot victims and loud noises are a trigger for them. Review of the admission record indicated Resident R56 was admitted to the facility on [DATE]. Review of Resident R56's MDS dated [DATE], indicated the diagnosis of hemiplegia (paralysis affecting one side of the body), anxiety and depression. Review of Resident R56's care plan on 1/30/26, indicated that the resident has a history of trauma that affects her but failed to identify what the triggers were and how to avoid them. During an interview completed on 1/30/26, at 11:30 a.m. Registered Nurse RN Employee E5, confirmed that Resident R56's care plan failed to identify what the triggers were and how to avoid them. RN Employee E5 stated when she transferred over, we were told she is not to have male caregivers and that is also not included on the care plan. RN Employee E5 also confirmed that Residents R7 and R9 also did not have care plans that identified any triggers and how to avoid them. During an interview completed on 1/30/26, at 11:55 a.m. upon asking Social Service Employee E8, how triggers are identified for residents who have had trauma stated, we ask the resident if they have any triggers, if they tell us then we will put it on the care plan. During an interview completed on 1/30/26, at 3:00 p.m. the Director of Nursing confirmed that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for three of five residents (Resident R7, R9 and R56). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1) Management

Based on the review of professional standards of practice, facility policy, clinical records, observation, and interviews with staff and resident, it was determined that the facility failed to make certain that residents received the necessary services to prevent/treat pressure ulcers (injuries to the skin and underlying tissue resulting from prolonged pressure to the skin) for two of three residents (Residents R83 and R156). Findings include: Review of the facility policy Physician Orders last reviewed January 2026, indicated that orders must be carried out as written and within the timeframe specified. Review of the admission record indicated Resident R83 was admitted to the facility on [DATE]. Review of Resident R83's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/23/26, indicated the diagnoses of high blood pressure, quadriplegia (paralysis affecting all four limbs) and neurogenic bladder (loss of bladder control). During an observation completed on 1/28/26, at 11:11 a.m. Resident R83 was in bed Prafo boots (boots that stabilize the ankle and foot helping mange muscle weakness, foot drop and ankle/foot anomalies while removing pressure from the heel to prevent pressure ulcers) were visualized to her bilateral lower extremities. During an observation completed on 1/28/26, at 1:18 p.m. Prafo boots were visualized on both bilateral lower extremities. During an observation and interview completed on 1/28/26, at 2:15 p.m. upon asking Resident R83 concerning the schedule for the boots, stated if I am in bed they go on in the morning and then my bunny boots (medical foot supports designed to prevent heel and toe pressure injuries that provides cushioning and positioning flexibility while allowing air circulation to reduce skin irritation and promote comfort) go on at 5:00 p.m. I keep track and let the staff know when it is time to change them. Review of resident R83's physician orders on 1/29/26, failed to include orders or a schedule for Resident R83's Prafo and bunny boots. During an interview completed on 1/29/26, at 12:12 p.m. Registered Nurse RN Employee E5 confirmed there were not any current physician orders or schedule for Resident R83's Prafo and bunny boots. Review of the admission record indicated Resident R156 was admitted to the facility on [DATE]. Review of Resident R156's MDS dated [DATE], indicated the diagnoses of high blood pressure, malnutrition (lack of nutrients in the body), and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of Resident R156's clinical record revealed a physician's order dated 12/25/25, to wash coccyx (tailbone) and peri area/groin twice daily with soap and water and apply zinc based barrier cream (a protective cream that helps to prevent skin irritation and breakdown in a moist environment) report any decline in wound care, two times a day (morning shift, and evening shift). Review of Resident R156's Treatment Administration Record (TAR) indicated that Resident R156 did not receive the above treatment on 12/26/25 on the evening shift. During an interview on 1/30/26, at 9:48 a.m. the Director of Nursing confirmed that the facility failed to provide pressure ulcer prevention treatments as ordered for Resident R156. Interview on 1/30/26, at 3:00 p.m. the Director of Nursing confirmed that the facility failed to make certain that residents were monitored, assessed, and received the necessary services to prevent pressure ulcers/wounds from developing for two of three residents (Residents R83 and R156). 28 Pa. Code 211.10(c)(d) Resident care policies28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of clinical records and staff interview, it was determined that the facility failed to obtain a physician order for a wander guard for one of one resident (Resident R40) and failed to obtain a physician order for a colostomy for one of one resident (Resident R59).Findings include: Review of facility policy Physician Orders dated January 25, indicated the facility maintains a system for receiving, documenting, verifying, and carrying out physician orders. Review of the admission record indicated Resident R59 was admitted to the facility on [DATE], with diagnoses that included peripheral vascular disease (circulatory condition characterized by narrowed blood vessels), sepsis and anemia. Review of Resident R59''s Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/3/25, indicated the diagnoses remain current. Review of most recent plan of care for Resident R59 indicates the need for colostomy management. Review of Resident R59's physician's orders dated 1/12/26 revealed no orders for a colostomy. Review of the clinical record indicated Resident R40 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (progressive lung disease characterized by persistent respiratory symptoms and airflow limitation, atrial fibrillation (irregular and often rapid heart rhythm) and anxiety. Review of Resident R40's annual MDS assessment (minimum data assessment)- periodic assessment of resident care needs) dated 12/18/25, indicated the diagnosis remained current. Review of Resident R40's nurse progress dated 1/13/26 indicated wander guard placed on right ankle. Review of Resident R40s most recent physician orders indicate no order for wander guard. During an interview on 1/30/26, at 1:12 p.m. Director of Nursing confirmed there was no physician order for the wander guard or colostomy as required. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for two of four residents (Resident R8 and R34).Findings include: Review of the facility policy Administering Medications through a Small Volume Handheld Nebulizer dated January 2026, indicated the purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. When treatment is complete, turn off nebulizer, rinse and disinfect the nebulizer equipment according to facility protocol. When equipment is completely dry, store it in a plastic bag with the resident's name and date on it. Review of the admission record indicated Resident R8 was admitted to the facility on [DATE]. Review of Resident R8's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/19/25, indicated the diagnosis of respiratory failure (lungs can't get enough oxygen), Parkinson's disease (progressive brain disorder that causes muscle stiffness, slowed movement and balance issues) and aphasia (a communicative disorder that affects the ability to speak and understand). Review of Resident R8's physician orders dated 10/13/25, indicated average volume assured pressure support (AVAPS-used to treat obstructive sleep apnea) every night shift. During an observation completed on 1/28/26, at 10:46 a.m. Resident R8's AVAPS mask was hanging on an IV pole next to his bed not stored in a bag as required. During an interview completed on 1/28/26, at 10:47 a.m. Registered Nurse (RN) Employee E21 confirmed the AVAPS mask was hanging on the IV pole and not stored in a bag as required. RN Employee E21 stated sometimes the nurse aids take it off and don't put it in a bag. Review of the admission record indicated Resident R34 was admitted to the facility on [DATE]. Review of Resident R34's MDS dated [DATE], indicated the diagnosis of heart failure (heart doesn't pump the way it should), obstructive sleep apnea (breathing stops during sleep) and hyperlipidemia (high fat in the blood). Review of Resident R34's physician orders dated 1/8/26, indicated Ipratropium-Albuterol solution 3 milliliter (ml) inhaled via nebulizer every four hours as needed. During an observation completed on 1/28/26, at 10:56 a.m. Resident R34's nebulizer was sitting on the bedside table not stored in a bag as required. During an interview completed on 1/28/26, at 11:01 a.m. Licensed Practical Nurse (LPN) Employee E20 confirmed the nebulizer was sitting on the bedside table and was not stored in a bag as required. Review of Resident R34's physician orders dated 1/8/26, indicated continuous positive airway pressure (CPAP-a machine that delivers continuous air pressure while you sleep) at bedtime. The order failed to have the settings for the device. Review of Resident R34's current care plan on 1/30/26, failed to have interventions for the CPAP machine. During an interview completed on 1/30/26, at 11:22 a.m. Registered Nurse (RN) Employee E5 confirmed the orders for the CPAP machine did not include the settings and the care plan failed to have interventions for the CPAP. During an interview completed on 1/30/26, at 3:00 p.m. the Director of Nursing confirmed that the facility failed to provide appropriate respiratory care for two of four residents (Resident R8 and R34). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility documents, clinical record review and staff interview the facility failed to provide sufficient and timely social services to meet the resident needs for one of three residents reviewed (Resident R33).Findings include: Review of facility policy dated 01/26, Referrals, Social Service indicated Social services personnel shall coordinate most resident referrals with outside agencies. Social services will document the referral in the resident's medical record. Review of facility documentation Social Worker job description indicated responsibilities document assessment, clinical team meeting minutes, and community resource referrals. Review of the clinical record indicated resident R33 was admitted [DATE]. Review of Resident R33's MDS (minimum data set a periodic review of assessment needs) dated 12/18/24, indicated diagnosis of heart failure and CAD. Review of Resident R33 clinical record psychiatric evaluation note dated 9/24/25, indicated Resident R33 says his mood is unchanged and he is still frustrated that he is still unable to find a facility closer to home and he feels like a prisoner at Cranberry. Review of Resident R33 clinical record psychiatric evaluation note dated 1/7/26, indicated Resident R33 says his mood is unchanged and he is still frustrated that he is unable to go home or to another facility another facility with better liberty. He realizes people are working on it but he is frustrated. Just frustrated that he is stuck in this prison. Review of Resident R33 clinical record progress notes indicated the last referrals regarding housing and placement outside of the nursing care facility were dated July of 2025. During an interview on 1/31/26, at 12:13 p.m. Social Service Director Employee E8 confirmed that the facility has not sent out any referrals for other nursing care facilities, and that the facility failed to provide sufficient and timely social services to meet the resident needs for Resident R33. 28 Pa. Code 201.14(b)Responsibility of licensee.28 Pa. Code 211.16(a)(1) Social services.

Based on review of clinical records, and staff and resident interviews, it was determined that the facility failed to ensure that a dental appointment was scheduled for one of six residents reviewed (Resident R59). Findings include:Review of the admission record indicated Resident R59 was admitted to the facility on [DATE]. Review of Resident R59''s Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/3/25, indicated diagnoses of peripheral vascular disease (circulatory condition characterized by narrowed blood vessels), sepsis and anemia. Documentation by the facility's contracted dental provider dated 11/21/25, indicated Resident R59 potentially has extraction(s) that are surgical in nature, need to consult with an Oral MaxillofacialSurgeon. Review of Resident R59's progress notes dated 11/25/25 indicated received list of oral surgeons from 360 care/ Social work director, calls placed to several to schedule for resident's teeth removal. During an interview on 1/30/26, at 1:30 p.m. Unit Manager Employee E27 stated there has not been an appointment set up and it could take up to two years because Resident R59 needs to be transported via stretcher. During an interview on 1/30/26, at 2:00 p.m. the Nursing Home Administrator confirmed the facility failed to obtain dental services for Resident R59 as required. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services28 Pa. Code 211.15(a) Dental Services.

Based on review of facility policy, clinical record review, and staff interview it was determined that the facility failed to identify parameters for heart medication for one of three residents (Resident R5).Findings include: Review of facility policy Pharmacy Services Overview dated 01/26, indicated: Pharmaceutical services consist of: a. The process of receiving and interpreting prescriber's orders; acquiring, receiving, storing, controlling, reconciling, compounding, (e.g. intravenous antibiotics), dispensing, packaging, labeling, disturbing, administering, monitoring responses to, using and/or disposing of all medications, biologicals, chemicals;The provision of medication related information to health care professionals and residents;The process of identifying, evaluation, and addressing medication -related issues including the prevention and reporting of medication errors; andThe provision, monitoring and/or the use of medication -related devices.The facility shall contract with a licensed consultant pharmacist to help it obtain an maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements. Review of facility policy Pharmacy Services Overview dated 01/26, indicated: Screen new medications for orders for key parameters including appropriate indications proper dose and duration, correct route of administration, potential for adverse consequences including medication interactions, possible duplicative therapy. Review of facility documentation carvedilol:Indications: Hypertension, HF (ischemic or cardiomyopathic) with digoxin, diuretics, ace inhibitors. Left ventricular dysfunction after MI. Action Therapeutic Effect Decreased HR and BP Improved cardiac output, slowing of the progression of HF and decreasing the risk of death.Assessment Monitor BP and HR frequently during dose adjustment and periodically during therapy. If HR is down to <55 bpm, decrease dose.Implementation:PO take HR before administration. If <50 bpm or if arrythmia occurs hold therapy. Review of the clinical record indicated Resident R5 was admitted [DATE]. Review of Resident R5's MDS (minimum data set a periodic review of assessment needs) dated 10/15/25, indicated diagnosis of heart failure (when the heart muscle can't pump enough blood to meet the body's needs) and CAD (coronary artery disease - narrowing or blockage of your coronary arteries). Review of Resident R5 clinical record MAR (medication administration record - a record of a resident's medication) for November 2025 indicated: 11/21/25 to 11/30/25:Carvedilol Oral Tablet 6.25MG (Carvedilol)Give 1 tablet by mouth twotimes a day for HTN-Start Date-11/21/2025 0900Review of Resident R5 clinical record MAR December 2025 indicated:Carvedilol OralTablet 6.25 MG(Carvedilol)Give 1 tablet bymouth two times [NAME] for HTN-Start Date-11/21/2025 0900Review of Resident R5 clinical record MAR January 2026 indicated:Carvedilol OralTablet 6.25 MG(Carvedilol)Give 1 tablet bymouth two times [NAME] for HTN-Start Date-11/21/2025 0900 Review of the MAR from 11/21/25 to 11/30/25, and 12/25 and 1/1/26 to 1/23/26 failed to include parameters for carvedilol. Review of the MAR for January 2026 failed to identify parameters until 1/23/26. During an interview on 1/31/26, at 11:43 a.m. DON (Director of Nursing) confirmed that the facility failed to follow manufactures guidelines and identify parameters for heart medication for Resident R33. 28 Pa. Code 201.14 (a) Responsibility of licensee28 Pa. Code 211.9 (a)(1) Pharmacy services

Based on a review of facility policy, clinical records, incident investigations, and staff interviews, it was determined that the facility failed to ensure that residents are free from misappropriation of property for one of five residents (Resident R155).Findings include: Review of the facility policy Recognizing Signs and Symptoms of Abuse/Neglect dated January 2026, indicated all types of resident abuse, neglect, exploitation, or misappropriation of resident property are strictly prohibited. Review of the clinical record indicated that Resident R155 admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 12/9/25, indicated diagnoses of peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), high blood pressure, and seizure disorder (a person experiences abnormal behaviors, symptoms and sensations, sometimes including loss of consciousness). Section C0500 indicated a Brief Interview for Mental Status (BIMS - is a screening test that aids in detecting cognitive impairment) score of 13 - cognitively intact. Review of facility provided information dated 1/13/26, at 12:00 p.m. indicated Resident R155 was admitted to the hospital on [DATE]. On 1/14/26, Resident R155 contacted the facility, stating they were looking for their wallet and passport that was left at the facility. Resident R155's son claims that a bank card, social security card, and military ID (identification) were all in this wallet. During the investigation two nurses indicated remembering the wallet and passport. Both nurses relayed that they last seen the grey bag locked in the narcotic drawer on the west unit back hall narcotic box for safe keeping. Said medication cart was searched, surrounding area including the nurses' station, medication room and patient's room with no success in locating the grey bag. Interview on 1/30/26, at 12:54 p.m. Social Services Director Employee E8 indicated Resident R155's spouse was in the hospital and the son needed Resident R155's wallet for his mother's funeral, his debit card, passport, and his military ID for when the dad dies, he'll need it for the funeral. We investigated it. The last person who saw it was in the narcotic drawer on the [NAME] Unit. We were unable to locate it. Interview on 1/30/26, at 1:00 p.m. the Director of Nursing confirmed the facility was unable to locate Resident R155's personal property and that the facility failed to ensure that residents are free from misappropriation of property for one of five residents (Resident R155). 28 Pa. Code: 211.12 (d)(1)(5) Nursing services.28 Pa. Code: S 201.18(b)(2) Management

Based on review of facility policies, documents and clinical records and staff interviews, it was determined that the facility failed to protect residents from abuse and neglect which resulted in actual harm of abandonment and mental anguish for one of three residents (Resident R1) and resulted in actual harm of a tibial plateau fracture (a break in the upper tibia, the lower leg bone below the knee, that affects the knee joint) for one of three residents (Resident R3). Findings include: The facility's policy Abuse and Neglect - Clinical Protocol dated August 2024, indicated abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Also includes Neglect defined as the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Review of the facility's Job Description for Driver dated May 2004, indicated the duties and responsibilities of the Driver include driving residents to and from scheduled appointments using a company van, car, and/or bus. Maintains confidentiality and privacy of community/resident records and communicates with dignity and respect. Review of facility policy Activities of Daily Living dated August 2024, indicated appropriate care and services will be provided for residents who are unable to carry out ADLs (activities of daily living) independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking); c. Elimination (toileting); d. Dining (meals and snacks); and e. Communication (speech, language, and any functional communication systems). Review of admission record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/24/25, indicated the diagnoses of diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), hypertension (the force of the blood against the artery walls is too high), and renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids). Section C0500 indicated a Brief Interview for Mental Status (BIMS - is a screening test that aides in detecting cognitive impairment) score of 15. The distribution indicated 13-15 as cognitively intact. Review of Resident R1's care plan dated 3/21/25, indicated resident will have safe leave of absence. Review of facility provided documentation dated 3/25/25, at 3:21 p.m. indicated the facility received a voice mail from Resident R1's niece with concerns regarding Resident R1's ride to the hospital for a CT scan (a medical imaging technique that uses X-rays to create detailed images of the inside of the body) this morning. Resident R1 was alone with the driver, and it was fine on the way there, but on the way back the Driver Employee E1 took her from the hospital in Shadyside, and Resident R1 reported seeing signs for Murrysville and Monroeville. Driver Employee E1 then took Resident R1 to a neighborhood, pulled up to a house and left Resident R1 alone in the van for five to ten minutes and went into the house. Driver Employee E1 then came out of the house with a sandwich, and then returned her to Cranberry. It didn't sound good to the niece, but Resident R1 was terrified. Review of Driver Employee E1's witness statement dated 3/26/25, at 11:00 a.m. indicated he took Resident R1 to the hospital for an appointment. Once done, the driver headed back to the facility. The driver stopped at his personal house because he had forgotten his driver's license. He also realized that he left his personal house that morning without his breakfast sandwich or diabetic (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) medication and then ate the sandwich. Review of the Nursing Home Administrator's interview with Driver Employee E1 dated 3/26/25, at 10:48 a.m. indicated the Driver Employee E1 reported everything went well. When asked if when he picked Resident R1 up after the appointment, did he go anywhere else? Driver Employee E1 admitted he stopped at home for his wallet. When asked if he also grabbed a sandwich, he replied that he did and apologized. Review of Social Worker (SW) Employee E2's interview with Resident R1, dated 3/25/25, indicated the resident stated on the way back from the doctor's appointment, she noticed signs for Monroeville, Murrysville, and Ohio turnpike, that the trip was taking longer than on the way to the appointment. She didn't know what was happening. She didn't know if she was being kidnapped, was the driver stealing the van? Resident R1 stated she was scared and didn't know what to do. Then Driver pulled into a house, in a questionable neighborhood and left her alone in the van for five minutes. Stated she was frightened. Reported the driver returned with a sandwich. Interview on 4/1/25, at 10:00 a.m. Resident R1 indicated I was so terrified. I wasn't going to say anything, but the therapist asked me what took so long at the appointment because they expected me back sooner. I started seeing all these signs of places we did not pass on the way there. I was so scared; I didn't dare say a word. I wondered if I was being kidnapped or the driver was perhaps stealing the van with me in it. I saw signs for McKeesport. He locked the wheelchair in but didn't put my belt on. He didn't say a word to me. Parked in this alley, left me there without saying anything, and went into a house. I didn't know where I was, when or if he was going to come back. I'm still terrified about it. Finally, about five to ten minutes later the driver came back, didn't say a word to me, and was eating a sandwich. When asked if she asked the driver any questions, Resident R1 indicated No, I didn't dare say a word, I was too afraid. Interview on 4/1/25, at 10:30 a.m. the Nursing Home Administrator and Director of Nursing indicated they fired Driver Employee E1. Indicated they were mortified of the driver's behavior. They verified that Resident R1 was terrified from the experience and would always have an escort to any outside appointment moving forward. They indicated they were grateful nothing happened to Resident R1 while she was unattended in the van, in the alley, in a questionable, unknown neighborhood. Review of the admission record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's MDS dated [DATE], indicated the diagnoses of End Stage Renal Disease (kidneys cease to function on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), coronary artery disease (narrow arteries decreasing blood flow to heart), and hypertension (the force of the blood against the artery walls is too high). Review of Resident R3's care plan dated 3/3/25, indicated resident requires two staff members assistance using mechanical lift (machine that moves residents from point A to point B) for transfers. Review of facility provided documentation dated 3/22/25, at 8:00 p.m. indicated during a therapy session Resident R3 reported pain in her left knee. The session was stopped, the nurse and physician were notified. Resident R3 reported she twisted it over the weekend. X-rays were ordered and found a fracture of the left tibial plateau. Review of Resident R3's progress notes dated 3/24/35, at 4:54 p.m. indicated weekly fall review meeting held on 3/24/25. Resident R3 had a fall in the resident room on 3/21/25, due to an unassisted transfer. No injuries observed at the time of the incident. Physician and family notified. Kardex (a summary of care needs) reviewed. The resident requires assistance of two staff members using the mechanical lift for transfers. She is being screened this week under Part B therapy services. Review of Physical Therapist (PT) Employee E6's witness statement dated 3/26/25, indicated upon evaluation for a Physical Therapy scan Resident R3 reported severe (eight out of ten) pain in left knee. Resident had pain with palpation (touch) on left side of knee, pain with range of motion, and weight bearing. A Lidocaine (pain medication) patch located on the front of the left knee. Reported to nursing. Resident reported she twisted her knee when transferring back to bed over the weekend and stated nursing was aware. Review of Employee E7's witness statement dated 3/26/25, indicated Resident R3 could not remember how she was transferred but was certain that it was with only one person named NA Employee E14. Indicated her foot did not get caught but was in pain when she hit the bed. Review of SW Employee E2's interview with Resident R3's unidentified roommate indicated roommate reported on Saturday, 3/22/25, heard her roommate Resident R3 scream as facility aide was transferring her either from bed to the chair or chair to the bed. Roommate reported she heard Resident R3 scream, My knee, my knee, my knee. Roommate reported she told NA Employee E14 to go slowly. NA Employee E14 replied to roommate I can do it. Mind your business. It's none of your business. Review of interview on 3/26/25, at 12:00 p.m. indicated the Director of Nursing interviewed NA Employee E14 who responded she transferred Resident R3 by herself from her wheelchair to her bed. She reported that during the transfer, Resident R3's leg got caught on the wheelchair. NA Employee E14 indicated after the transfer, she realized that Resident R3 was probably a transfer assist of two staff members, but she was not sure what resident's transfer status was at the time the transfer was completed. Review of Physician Employee E8's evaluation dated 3/27/25, at 12:24 p.m. indicated Resident R3 had knee pain and X-ray was ordered and found to have left lateral tibial plateau fracture. Resident R3 was seen in the emergency room , brace was placed and is non-weight bearing to left lower extremity. Resident R3 is now on Norco (pain medication) for pain. Resident R3 is tearful this morning due to the pain. She received the medication just prior to the physician's visit. Review of facility provided education dated 1/13/25, indicated a signed education by NA Employee E14 that stated my signature acknowledges that I know how to access the Kardex, how to identify a resident's transfer status and bed mobility status and that I understand that not following the Kardex is considered resident neglect. Review of the Five Why Analysis provided by the facility dated 3/26/25, indicated define the problem: Resident R3 has a left tibial plateau fracture. Why did this happen? NA Employee E14 transferred Resident R3 incorrectly and did not follow the Kardex. NA Employee E14 admitted she did not bother to look at the Kardex. Interview on 4/1/25, at 9:33 a.m. NA Employee E5 indicated I've asked the aides to show me, so they know how to find the Kardex. Interview on 4/1/25, at 9:50 a.m. NA Employee E10 indicated We look on the Kardex for how many are needed for transfer, or if they're a new admission I'll ask the nurse who got report from the hospital. Interview on 4/1/25, at 9:51 a.m. NA Employee E11 indicated The Kardex. Even agency aides have access to the Kardex for transfer status. Interview on 4/1/25, at 9:56 a.m. NA Employee E12 indicated We look on the Kardex for the transfer status or ask someone who knows them. Interview on 4/1/25, at 9:58 a.m. NA Employee E13 indicated We look on the computer for the transfer status. Interview on 4/1/25, at 1:00 p.m. the Director of Nursing confirmed NA Employee E14 was removed from the schedule and separated from employment due to not following the resident's plan of care resulting in a serious injury to Resident R3. Telephonic interview on 4/3/25, at 10:30 a. m. the Nursing Home Administrator confirmed the facility failed to protect residents from abuse and neglect which resulted in actual harm of abandonment and mental anguish for one of three residents (Resident R1) and resulted in actual harm of a tibial plateau fracture for one of three residents (Resident R3). 28 Pa. Code 201.14(a)(c) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.29(a) Resident Rights. 28 Pa. Code 211.10(a)(d) Resident care policies. 28. Pa. Code. 211.12(d)(1)(2)(5) Nursing Services.

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and assistance for bed mobility and transfers to prevent accidents which resulted in actual harm of a head injury for one of four residents (Resident R2) and resulted in actual harm a tibial plateau fracture (a break in the upper tibia, the lower leg bone below the knee, that affects the knee joint) for one of four residents (Resident R3). Findings include: Review of the facility policy Accidents and Incidents-Investigating and Reporting, dated August 2024, indicated all accidents occurring on our premises must be investigated and reported to the administrator. Review of facility policy Activities of Daily Living dated August 2024, indicated appropriate care and services will be provided for residents who are unable to carry out ADLs (activities of daily living) independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking); c. Elimination (toileting); d. Dining (meals and snacks); and e. Communication (speech, language, and any functional communication systems). Interview with the Director of Nursing indicated the facility did not have a policy regarding bed mobility. Review of Libre Texts Medicine procedure 12.8.5: Procedure- Turning and Positioning the Patient in Bed, indicated to position yourself on the side of the bed that the patient will be turned to. Review of admission record indicated Resident R2 was admitted to the facility 7/24/24. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs dated 2/19/25, indicated the diagnoses of Alzheimer ' s Disease (a progressive disease that destroys memory and other important mental functions), Neurofibromatosis (a condition that causes tumors to form in the brain, spinal cord, and nerves), and chronic pain (persistent pain that lasts weeks to years). Section G0110 indicated assist of two for bed mobility. Review of Kardex dated 3/7/25, indicated bed mobility assist of one. Review of facility provided document Witnessed Fall with Injury dated 3/8/25, indicated Nurse Aide (NA) Employee E3 called for help. Licensed Practical Nurse (LPN) Employee E4 went into residents' room and found Resident R2 on the floor with the NA holding a washcloth on residents head and blood on the floor. Blood pressure at the time elevated at 177/72. There is a two-inch laceration (a deep cut or tear in the skin that exposes the underlying soft tissue) on resident's head. Resident R2 said she was rolling onto her side to get changed and said, I' m going and then fell on to the floor. Review of facility provided documentation dated 3/8/25, indicated Resident R2 refused transfer to the emergency room and refused family contact be made until morning. Later in the morning around 8:45 a.m., resident agreed to transfer. She was sent to local hospital emergency room that diagnosed a closed head injury and frontal scalp laceration four cm (centimeters), and resident received eight staples to forehead area. Resident sent back to facility with orders for staple removal in ten days. Bed was elevated during the event while care was being performed. Kardex updated to include that resident is to roll towards caregiver during care. Review of Registered Nurse (RN) Employee E5's witness statement dated 3/8/25, indicated according to NA Employee E3, she was changing the resident's brief when the resident rolled over and leaned too far over and fell to the floor before she could catch her. Review of NA Employee E3's witness statement dated 3/8/25, indicated I was changing Resident R1's brief, she rolled over a tiny bit more so I could wash her better. With her head at 30 degrees, she leaned too far over, and her head went first onto the floor. I had my hand on her one hip, as I was cleaning her, I tried to catch her, but she was on the floor before I could stop her from falling. I noticed blood on the floor as I checked on her. I hurried out to the hall and yelled for help, grabbed a washcloth to put pressure on her open head to control the bleeding. Nurses arrived and took over. Review of Resident R2's Report Form for investigation of Alleged Abuse, Neglect, and Misappropriation of property dated 3/10/25, indicated Section VII Actions Taken as: Resident was provided education on rolling towards caregiver for care. NA Employee E3 was educated on rolling resident towards caregiver during incontinence care and reports understanding. Interview on 4/1/25, at 9:11 a.m. Resident R2 indicated about three weeks ago at 3:00 a.m. she had diarrhea and couldn't get up her left leg, it's paralyzed. Resident R2 turned on the right side and said to NA Employee E3 please, just watch my left leg. Resident R1 turned and they were just about done. Resident R2 was turned and said oh my gosh my leg left burning, NA Employee E3 needed to hold the leg. Resident R2 told the aide don ' t let go. NA Employee E3 turned had her hand on Resident R2's leg. NA Employee E3 was on the left side of the bed and rolled Resident R2 away from her toward the door. The side of resident's head was full of blood. Resident had a gash on the top of her head. She had to get eight staples put in her forehead. Interview on 4/1/25, at 1:00 p.m. the Director of Nursing confirmed NA Employee E3 should have rolled Resident R2 towards her body and that NA Employee E3 was educated to roll the resident towards the body, not away. Review of the admission record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's MDS dated [DATE], indicated the diagnoses of End Stage Renal Disease (kidneys cease to function on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), coronary artery disease (narrow arteries decreasing blood flow to heart), and Hypertension (the force of the blood against the artery walls is too high). Review of Resident R3's care plan dated 3/3/25, indicated Resident requires two staff members assistance using mechanical lift (machine that moves residents from point A to point B) for transfers. Review of facility provided documentation dated 3/22/25, at 8:00 p.m. indicated during a therapy session Resident R2 reported pain in her left knee. The session was stopped, the nurse and physician were notified. Resident R1 reported she twisted it over the weekend. X-rays were ordered and found a fracture to the left tibial plateau. Review of Resident R3's progress notes dated 3/24/35, at 4:54 p.m. indicated weekly fall review meeting held on 3/24/25. Resident R3 had a fall in the resident room on 3/21/25, due to an unassisted transfer. No injuries observed at the time of the incident. Physician and family notified. Kardex reviewed. The resident requires assistance of two staff members using the mechanical lift for transfers. She is being screened this week under part B therapy services. Review of Physical Therapist (PT) employee E6's witness statement dated 3/26/25, indicated upon evaluation for a PT scan Resident R3 reported severe eight out of ten pain in left knee. Resident had pain with palpation (touch) left side of knee, pain with range of motion, and weight bearing. A Lidocaine (pain medication) patch located on the front of the left knee. Reported to nursing. Resident reported she twisted her knee when transferring back to bed over the weekend and stated nursing was aware. Review of Employee E7's witness statement dated 3/26/25, indicated Resident R3 could not remember how she was transferred but was certain that it was with only one person named NA Employee E14. Indicated her foot did not get caught but was in pain when she hit the bed. Review of SW Employee E2's interview with Resident R3's unidentified roommate indicated roommate reported on Saturday, 3/22/25, heard her roommate Resident R3 scream as facility aide was turning her either from bed to the chair or chair to the bed. Roommate reported she heard Resident R3 scream, My knee, my knee, my knee. Roommate reported she told NA Employee E3 to go slowly. NA Employee E3 replied to roommate I can do it. Mind your business. It's none of your business. Review of interview on 3/26/25, at 12:00 p.m. indicated the Director of Nursing interviewed NA Employee E14 who responded she transferred Resident R3 by herself from her wheelchair to her bed. She reported that during the transfer, Resident R3's leg got caught on the wheelchair. NA Employee E14 indicated after the transfer, she realized that Resident R3 was probably a transfer assist of two staff members, but she was not sure what resident's transfer status was at the time the transfer was completed. Review of Physician Employee E8's evaluation dated 3/27/25, at 12:24 p.m. indicated Resident R3 had knee pain and X-ray was ordered and found to have left lateral tibial plateau fracture. Resident R3 was seen in the emergency room , brace was placed and is non-weight bearing to left lower extremity. Resident R3 is now on Norco (pain medication) for pain. Resident R3 is tearful this morning due to the pain. She received the medication just prior to the physician's visit. Interview on 4/1/25, at 9:33 a.m. NA Employee E5 indicated I've asked the aides to show me, so they know how to find the Kardex. We always roll toward the body with one person. Interview on 4/1/25, at 9:50 a.m. NA Employee E10 indicated I always roll the resident towards me when asked how to roll a resident in bed by yourself, we look on the Kardex for how many are needed for transfer, or if they're a new admission I'll ask the nurse who got report from the hospital. Interview on 4/1/25, at 9:51 a.m. NA Employee E11 indicated towards you when asked how to roll a resident in bed by yourself and indicated agency aides even have access to the Kardex for transfer status. Interview on 4/1/25, at 9:56 a.m. NA Employee E12 indicated we look on the Kardex for the transfer status or ask someone who knows them. I always roll the patients toward me. Interview on 4/1/25, at 9:58 a.m. NA Employee E13 indicated I'd roll them towards me when asked how to roll a resident in bed by yourself. We look on the computer for the transfer status. Interview on 4/1/25, at 1:00 p.m. the Director of Nursing confirmed NA Employee E14 was removed from the schedule and separated from employment due to not following the resident's plan of care resulting in a serious injury to Resident R3. Interview on 4/1/25, at 1:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to make certain each resident received adequate supervision and assistance for bed mobility and transfers to prevent accidents which resulted in actual harm of a head injury for one of four residents (Resident R2) and resulted in actual harm of a tibial plateau fracture for one of four residents (Resident R3). 28 Pa. Code 201.14(a)(c) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.29(a) Resident Rights. 28 Pa. Code 211.10(a)(d) Resident care policies. 28. Pa. Code. 211.12(d)(1)(2)(5) Nursing Services.

Based on review of facility policy, facility documentation, and staff interviews, it was determined that the facility failed to protect residents from neglect for one of five residents (Resident R1), by failing to follow physicians orders during transfer that resulted in actual harm for Resident R1 of right lower extremity laceration with eleven sutures. Findings include: Review of the United States Code of Federal Regulations (CFR), 42 CFR S483.12. Freedom from Abuse, Neglect, and Exploitation defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of facility policy Abuse Neglect Exploitation dated 1/2/24, indicated that each resident must not be subjected to abuse by anyone. Review of Resident R1's admission record indicated he was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS-periodic assessment of a resident's abilities and care needs) dated 2/28/24, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), anxiety disorder and neurogenic bladder ( lack of bladder control due to brain, spinal cord or nerve problems) Review of Resident R1's plan of care for potential for injury initiated 2/22/24, revealed required assistance of two for transfer. Review of Resident R1's Kardex (document that outlines the patients' ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) utilized by nurse aide staff effective date 2/22/24, revealed required assistance of two for wheelchair mobility, stand pivot assistance of two for transfer, assistance of two for toileting, assistance of two for bed mobility. Review of a progress note written by Registered Nurse (RN) Employee E4 dated 4/9/24, at 7:15 p.m. indicated NA Employee E5 came to this (RN Employee E4) and stated he was transferring resident and noticed a skin tear on her leg. Large skin tear noted to right lower leg. Area has been bandaged before, but this is a new skin tear. She is a 2 assist for transfers. Resident R1 unable to describe event and Employee E5 does not know how it happened, but it was during transfer. Skin tear was 4.5 cm x .5 cm. Cleansed with nss (normal saline solution) and applied dressing. Dr notified. Orders from doctor were to send to ER for evaluation for skin tear to possibly be sutured. Daughter notified of incident. Review of hospital documentation dated 4/9/24, indicated that Resident R1 received an x-ray of right tibia and fibula which revealed no acute abnormalities and no evidence of foreign body. Laceration repair was performed resulting in a total of 11 sutures. Review of an employee statement written by NA Employee E5 dated 4/9/24, stated, I help get in the bed, she stood up and I put her straight on the bed in a sitting potion and lift her legs at the bottom off and lift her in the bed and saw blood running down her leg and called the nurse. NA Employee E5 is currently suspended by the facility and did not answer the phone or return the message left by the State Agency. Review of an employee statement written by Employee E6 dated 4/9/24, stated, I was at the nurses station when a CNA (NA) approached the desk stating a residents leg was bleeding when I went to this Resident room she was laying on the bed lifted her pant leg where I saw the blood coming from and observed a large gash which was bleeding. I called the on call doctor and it was decided she needed to go to the hospital for further eval. Family notified, pt transported by ambulance to emergency room . Review of an employee statement written by Employee E7 dated 4/9/24, stated, I wasn't on the actual conversation regarding what happened. According to (NA), it was during a transfer that the incident happened. Review of facility's investigation revealed an interview with NA Employee E5 dated 4/10/24, was conducted by RN Employee E4, indicated Employee E5 stated he was transferring Resident R1 by himself, when he noticed a new skin tear on her right lower leg, patient is ordered to be an assist x 2 for transfer, bed mobility and care, Employee E5 admits to completing the transfer the independently. During an interview on 4/16/24, at 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to protect a resident from neglect by not following physicians orders during a transfer (Resident R1). 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.29(a)(c)(d)(j) Resident Rights 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(3) Nursing services.

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide adequate supervision of transfers for one of five residents (Resident R1), which resulted in actual harm for Resident R1 of right lower extremity laceration with eleven sutures. Findings include: Review of the facility policy Accidents and Incidents dated 1/4/24, indicated a safe environment will be promoted for all residents, report occurrences appropriately, and review and analyze for the opportunity for preventative measures. Review of Resident R1's admission record indicated he was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS-periodic assessment of a resident's abilities and care needs) dated 2/28/24, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), anxiety disorder and neurogenic bladder ( lack of bladder control due to brain, spinal cord or nerve problems). Review of Resident R1's plan of care for potential for injury initiated 2/22/24, revealed required assistance of two for transfer. Review of Resident R1's Kardex (document that outlines the patients' ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) utilized by nurse aide staff effective date 2/22/24, revealed required assistance of two for wheelchair mobility, stand pivot assistance of two for transfer, assistance of two for toileting, assistance of two for bed mobility. Review of a progress note written by Registered Nurse (RN) Employee E4 dated 4/9/24, at 7:15 p.m. indicated Nurse Aide (NA) Employee E5 came to this (RN Employee E4) and stated he was transferring resident and noticed a skin tear on her leg. Large skin tear noted to right lower leg. Area has been bandaged before, but this is a new skin tear. She is a 2 assist for transfers. Resident R1 unable to describe event and Employee E5 does not know how it happened, but it was during transfer. Skin tear was 4.5 cm x .5 cm. Cleansed with nss (normal saline solution) and applied dressing. Dr notified. Orders from doctor to send to Emergency Department for evaluation for skin tear to possibly be sutured. Daughter notified of incident. Review of hospital documentation dated 4/9/24, indicated that Resident R1 received an x-ray of right tibia and fibula which revealed no acute abnormalities and no evidence of foreign body. Laceration repair was performed resulting in a total of 11 sutures. Review of an employee statement written by NA Employee E5 dated 4/9/24, stated, I help get in the bed, she stood up and I put her straight on the bed in a sitting potion and lift her legs at the bottom off and lift her in the bed and saw blood running down her leg and called the nurse. NA Employee E5 is currently suspended by the facility and did not answer the phone or return the message left by the State Agency. Review of an employee statement written by RN Employee E6 dated 4/9/24, stated, I was at the nurses station when a CNA (NA) approached the desk stating a residents leg was bleeding when I went to this Resident room she was laying on the bed lifted her pant leg where I saw the blood coming from and observed a large gash which was bleeding. I called the on call doctor and it was decided she needed to go to the hospital for further eval. Family notified. Resident was transported by ambulance to the emergency department. Review of an employee statement written by RN Employee E7 dated 4/9/24, stated, I wasn't on the actual conversation regarding what happened, understood that injury occurred during a transfer that the incident happened. During an interview 4/16/24, at 10:00 a.m. NA Employee E1 was asked how she knows where to find the transfer status of a resident. NA Employee E1 stated from the wall unit kardex, paper file or ask. During an interview 4/16/24, at 10:05 a.m. NA Employee E2 was asked how she knows where to find the transfer status of a resident. NA Employee E2 stated kardex on the computer. During an interview 4/16/24, at 10:11 a.m. NA Employee E3 was asked how she knows where to find the transfer status of a resident. NA Employee E3 stated info is on computer or ask. During an interview on 4/16/24, at 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide adequate supervision for transfers for one of five residents, which resulted in right lower extremity laceration with eleven sutures. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.20(b)(1) Staff Development. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan.

Based on review of facility incident investigations, facility policy, manufacturer's guidelines, clinical record review, resident interview and interviews with staff, it was determined that the facility failed to implement policies to provide ongoing monitoring of equipment and failed to make certain component alarm systems were functioning and clearly audible resulting in actual harm to one resident (Resident R1) and placing eight of eight ventilator dependent residents in Immediate Jeopardy (Residents R1, R2, R3, R4, R5, R6, R7, R8). Findings include: Review of facility policy, Mechanical Ventilator Checks dated 8/24/21, stated that ventilator checks are performed by the respiratory therapist on initial set-up, after any transport, after any request to verify safety/function and every four hours. Accurate records will be maintained to reflect management and functioning of the ventilator. Review of the facility policy Mechanical Ventilation General Guidelines dated 8/24/21 state that: Accepted standards of practice are followed regarding the management and monitoring of mechanical ventilator Ventilator shall be used in strict accordance with manufacturers specifications and Assure that alarms are in place and operational. Review of the manufacturer guidelines of the [NAME] Respironics Trilogy 202 Ventilator dated 12/3/09, states that when using a remote alarm system make sure you fully test the remote alarm connector and cable by verifying that: Annunciated alarms on the ventilator are also annunciated on the remote alarm (pager system); disconnecting the remote alarm cable from the ventilator or from the remote alarm results in an alarm notification at the remote alarm; and the remote alarm should be tested daily. Additionally, the manufacturer guidelines indicate ventilator alarms at the unit are soft- 47 decibels and loud-92 decibels, and Make sure the alarm volume is set loud enough to be heard by the caregiver. Consider the use of a remote alarm. The CDC defines Decibels (dB) as a measurement of sound with common decibels defined as: a soft whisper (30dB); refrigerator hum (40dB); normal conversation (60dB); dishwasher (70dB); city traffic, inside the car (80-85dB); Motorcycle (90dB). Review of the facility policies indicates there was no policy for carrying the ventilator notification pager. Resident R2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS- a periodic assessment of care needs) dated 6/2/22 indicates that the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident R4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . review of the MDS dated [DATE] indicates that the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident R5 was admitted to the facility 6/17/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE] indicates that the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident R6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE] indicates that the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident R7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE] indicates that the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident R8 was admitted the facility on 7/1/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS-an assessment of care needs) dated 7/19/22, indicated the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Facility submitted documents indicated an event on 9/4/22, where Resident R1's ventilator became disconnected from the resident and the resident became unresponsive and required pulmonary resuscitation (manual assist of respirations by staff) and sternal rubbing (aggressive stimulating chest rubs) to regain consciousness. Review of those documents also indicated the ventilator alarms are connected to the wall paging system alarm system were noted to have been activated, but the central pager carried by the respiratory therapist which notifies staff of ventilator issues, was turned off and sitting in a drawer and therefore did not activate. Review of the statement by Respiratory Therapist (RT) Employee E2 as part of the investigation stated: I was in room [another room -room number removed] doing routine care. When I finished, I walked towards the respiratory office and heard Residents R1's vent alarm. I walked in, saw her disconnected from her vent circuit and immediately placed her back on the vent. She was unresponsive. The statement further stated,Vent alarms were on and functioning. The volume was set to soft, Resident R1 asked me to check this, it is not part of our routine vent checks. She was upset it was set to soft as opposed to loud. The alarm cable was found damaged a few hours after this happened and was replaced, I cannot say when it was damaged, but it has happened multiple times in the past . Review of the call transcript of a telephone meeting on 9/8/22 at 9:30 a.m., between facility staff, Resident R1 and Resident R1's family indicated that Resident R1 notified the facility that RT Employee E3 had changed the alarm settings on the ventilator unit in the room to soft without notifying her. Additionally, the cord connecting the ventilator to the central call light system (nurse's station, indicator outside Resident R1's door, and pager system which would flash red and green to indicate it was a ventilator-initiated alert) had been disconnected by a broken clip at the ventilator. The facility acknowledged that the ventilator would alarm to the pager system if the ventilator were to become disconnected from the central call system, but the pager was not in use as it was found sitting in a drawer. During an interview on 9/25/22 at 6:31 p.m., Resident R1 reported being scared at the time of the event and thought she wasn't going to make it. She reported that on the day of the event her [CONDITION(S)] popped off, the ventilator alarmed in the room, and she began trying to do deep breathing to maintain some air. At some point she put on her call light at 9:20 am (noted on facility call light logs at 9:20:11) and sat and waited for staff to respond. As the minutes went by, she stated, oh this isn't good and remembered watching the clock tick to 9:25 a.m. and then lost consciousness. Upon inquiry she reported it was the trifecta of issues that resulted in the event happening and didn't ever want to experience it again. Resident R1 also reported that the cord being disconnected has been an ongoing issue as it gets caught along the bedframe when nurses provide care and has been replaced approximately four or five times since November 2021. Resident R1 reported that RT Employee E3 had turned down her ventilator to low without telling her, and that he told the facility she had asked him to turn it down to which Resident R1 replied, Which I did not. Review of the ventilator generated facility (alarms) activated through the facility call light system from 8/1/22-9/10/22 for Resident R1's room revealed the following (counted in number of alerts during a 24 hour period): 8/1/22: Ventilator associated=29 8/2/22: Ventilator associated= 45 8/3/22 Ventilator associated=5 8/4/22 Ventilator Associated = none no matching calls to display 8/5/22 Ventilator Associated = none no matching calls to display 8/6/22 Ventilator Associated = none no matching calls to display 8/7/22 Ventilator Associated =2 8/8/22 Ventilator Associated =26 8/9/22 Ventilator Associated =24 8/10/22 Ventilator Associated =13 8/11/22 Ventilator Associated =14 8/12/22 Ventilator Associated =15 From 8/13-9/3/22 Ventilator Associated = none no matching calls to display 9/4/22 Ventilator Associated = 20 * day of event. First call 10:00:25 9/5/22 Ventilator Associated =16 9/6/22 Ventilator Associated =11 9/7/22 Ventilator Associated =6 9/8/22 Ventilator Associated =20 9/9/22 Ventilator Associated =64 9/10/22 Ventilator Associated =37 During an interview on 9/25/22, at 6:36 p.m., Respiratory Therapist Employee E5 and E11 reported that they never noticed the ventilator notifications on the call light system was not functioning (flashing red and green and beeping), that they only listen for the ventilator unit alarms directly. During an interview on 9/25/22, at 6:40 p.m., RN Employee E6 reported she was not aware of any problems with Resident R1's ventilator call light alerts any time she has been working and that they always light up with red and green flashing. During an interview on 9/26/22, at 6:41 p.m., RN Employee E7 reported not being aware of any issues with the ventilators alarming and not activating the call light system. During an interview on 9/26/22, at 6:57 p.m., the Nursing Home Administrator confirmed at the time of Resident R1's event, that the ventilator was alarming but the ventilator unit was not signaling the facility call light system, and that during the periods of 8/4/22-8/6/22 and 8/13/22-9/3/22, the staff was not getting visual or auditory notifications in the hallway or nursing desk. Additionally, the pager was not in use, so the staff did not receive the pager notification that the ventilator was not alerting the facility call light system, and on the day of the event, the ventilator unit in the room was set to the soft alarm. The NHA also confirmed that the two staff members working the day of the event were discharged from the facility for not fully checking the ventilators. The NHA and DON were made aware that Immediate Jeopardy existed due to the failure of the facility to follow through with existing policies or lacking policies and procedures to ensure all alarms and protective measures associated with the ventilators were functioning and in use on 9/26/22 at 12:15 p.m., and a corrective action plan was requested; and the IJ template was provided at that time. On 9/26/22 at 4:13 p.m., an acceptable Corrective action plan was approved which included the following interventions: Corrective action taken: Resident R1 suffered no [MEDICATION(S)] effect from the ventilator becoming disconnected. Resident R1 refused to go to the hospital on September 4, 2022. On September 6, 2022, resident had a routine bronchoscope which was clear. The black vent alarm call light cable was replaced on resident R1 ventilator September 4, 2022. The respiratory therapist was instructed on the evening of 9/4/2022 that they must carry the pager with them all times while on duty. The ventilators in use were checked by respiratory therapy on the evening of September 4, 2022, no issues noted on remaining ventilators. The ventilators were checked for alarm settings, all cables and cords were checked to ensure all were properly fitting, the alarms from the ventilator to the wall, above the door and at nurse's station panel were checked and functioning properly. The policy was reviewed and revised by Respiratory Therapy to check ventilators every 6 hours and document. The policy was updated to include the cords on the ventilator to ensure proper connection. Plans of Care reviewed for R1 and updated. The ventilator residents plan of care will be reviewed and updated by 3:30 p. m. on September 27, 2022. The Respiratory Supervisor and or designee will educate the Respiratory Therapists, Nurses, and the Nursing Assistants, on the importance of completing Ventilator checks each shift and re-implementation of the Ventilator Pagers and the policy. Education will be completed by September 27, 2022, by 3:30 p.m No Respiratory or Nursing staff will be working until education is completed. Any Nursing or Respiratory staff that can not be educated in person will be called by phone and educated by the DON or designee within 24 hours and will be followed up with in person training upon returning to work. Ventilator checks will include, alarm checks, checking the call light and pager functionality, all cords are properly attached to the ventilator and the wall unit. Ventilator checks will be reviewed 5 times per week for 1 month, 3 times per week 1 month or until substantial compliance is achieved. Completed check audits will be turned into the Nursing Home Administrator for review. Audit results will be reviewed and discussed at the Quarterly QA Meeting. During an observation and interview on 9/26/22 at 3:21 p.m., Certified Biomedical Equipment Technician Employee E8, the SD memory card from the ventilator associated with Resident R1 was reviewed. The log of events on the ventilator unit which triggered alarms were reviewed from 8/1/22-9/4/22. All dates were noted to have multiple ventilator alarms generated, indicating the ventilator was alarming in the room, but the ventilator generated alerts to the facility call light system from 8/4/22-8/6/22, and 8/13/22-9/4/22 indicated zero alerts no matching calls to display on the facility logs. Additionally, the SD memory card noted that on 9/3/22 at 9:21 p.m., the ventilator alarm setting was changed from loud to soft. The ventilator alarm setting was changed from soft to loud on 9/4/22 at 12:53 p.m., more than three hours after the event involving Resident R1. Certified Biomedical Equipment Technician Employee E8 confirmed the ventilator unit in the room was alarming, but the facility call light logs indicated that the call light system (nurse's station, indicator outside Resident R1's door, and pager system) was not being activated by the ventilator unit. During observations, interviews, and document review the facility in serviced all staff and provided education offsite by telephone. Interviews of staff members in person and by telephone was ongoing and review of signature sheets verified the training sessions and content. The Immediate Jeopardy was removed on 9/27/22, at 12:50 p.m., when the action plan implementation was verified. During an interview on 9/27/22, at 1:21 p.m., the NHA confirmed the facility failed to provide ongoing monitoring of equipment, including ensure component alarm systems are functioning and clearly audible placing all ventilator dependent residents in Immediate Jeopardy and resulted in actual harm to Resident R1. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited: 11/3/21, 2/17/22, 3/15/22, 8/31/22. 28 Pa. Code 201.18(b)(1)Management. Previously cited: 11/3/21, 3/15/22, 8/31/22. 28 Pa. Code 201.18(e)(1) Management. Previously cited: 11/3/21, 3/15/22. 28 Pa. Code 201.20(b)(1) Staff Development. Previously cited: 3/15/22, 8/31/22. 28 Pa. Code: 211.12(d)(3) Nursing services. Previously cited: 8/31/22. 28 Pa. Code: 211.12(d)(5) Nursing services. Previously cited: 3/15/22, 8/31/22.