Every finding on record at Crawford Care Center

Based on review of facility policies, clinical records, facility documents, observations, and staff interview, it was determined that the facility failed to implement sufficient monitoring and supervision to prevent elopement (when a resident leaves a safe care setting without staff knowledge) and failed to adequately implement search procedures related to an elopement. This failure placed residents at the facility in an Immediate Jeopardy situation for one of one residents reviewed (Resident R1). Findings include: Review of facility policy entitled Elopements and Wandering Residents dated 1/22/26, indicated This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement., implementing interventions to reduce hazards and risk. and Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the residents care plan and communicated to appropriate staff. Adequate supervision will be provided to help prevent accidents or elopements. Resident R1's clinical record revealed an admission date of 5/11/26, with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), delusional disorder (a mental health condition that includes delusions a false belief based on an incorrect interpretation of reality), and hypertension (high blood pressure). Review of Resident R1's admission records sent from the hospital indicated that Resident R1 was sent to the hospital due to increasing paranoid delusions [false beliefs that one is being threatened or harmed] in association with his/her dementia which has been a problem in the past. The hospital physician indicated that Resident R1 was admitted to the hospital for new onset of A-Fib (atrial fibrillation-irregular heartbeat) however the physician indicated that Resident R1 needed more supervision than what he/she was being provided at home due to his/her worsening dementia. Review of Resident R1's wandering risk assessment dated [DATE], indicated that he/she was a moderate risk for wandering. Review of Resident R1's plan of care revealed no plan of care for wandering/elopement. Review of Resident R1's progress notes revealed the following notes:admission progress note dated 5/11/26, indicating Resident R1 was alert and oriented on arrival but short time after arrival unable to relate info about him/herself. His/her level of orientation varied from moment to moment.Progress note dated 5/13/26, revealed Resident R1's Brief Interview for Mental Status (BIMs - a short cognitive screening tool to assess a person's orientation and short-term memory) score was a 9 (8-12 moderately impaired the person shows clear memory or thinking deficits and needs help with complex task).Progress note dated 5/13/26, at 1:59 p.m. indicated the Resident R1 was banging on the window trying to get through it. He/she was brought out in the hall in his/her wheelchair, and he/she was angry and yelling at staff that he/she was being held against his/her will.Progress note dated 5/14/26, at 10:00 a.m. indicated that Resident R1 was noted to be outside the building leaning against a tree waving at traffic at approximately 9:50 a.m. He/she was visibly confused and unstable while walking back to the building with staff. He/she was saying help me, help me, I do not want to be here I want to go home. He/she was wearing pajama pants and a sweatshirt with non-skid socks and no shoes. Interview on 5/20/26, at 10:45 a.m. with Nursing Assistant (NA) Employee E1 revealed that he/she said On 5/14/26, I was giving a bed bath to another resident and heard an alarm going off. I thought it was a bathroom bell going off so I went out into the hall to check the alarm. I heard an alarm and seen a light blinking. I went down the hall and realized it was the exit door. I looked out the door and did not see anyone, so I went back to finish providing care. He/she also said, when I received report that morning, I was told that the resident was trying to climb out his/her window. Interview on 5/20/26, at 11:00 a.m. with Social Service Director revealed he/she was in the conference room on 5/14/26, getting ready for a 10:00 a.m. care plan meeting for Resident R1 when he/she saw a person outside leaning against a tree and waving at cars. The Director of Nursing (DON) and Social Service Director went outside and found Resident R1 leaning against a tree very close to the highway and assisted him/her back into the building. Interview on 5/20/26, at 1:00 p.m. with the DON revealed that on 5/14/26, around 10:00 a.m. he/she was in the conference room for a care plan meeting, and a person was seen outside. He/she and the Social Service Director went outside and found Resident R1 leaning against a tree waving at cars. He/she stated that when they got to Resident R1 that a state trooper pulled up to see if everything was alright. He/she then stated that they assisted Resident R1 back into the facility. The DON revealed that she was unaware of Resident R1 trying to climb out his/her window the night before. The DON confirmed that the resident left the facility without any staff knowledge. Interview on 5/20/26, at 3:25 p.m. with the Nursing Home Administrator (NHA) and Licensed Practical Nurse Assessment Coordinator revealed that the exit door alarm was never turned off until the Maintenance Director turned it off. They revealed that no other staff came outside to assist with Resident R1 until Resident R1 was on his/her way back into the facility. Interview on 5/20/26, at 3:50 p.m. with the Maintenance Director, revealed that the alarms on the exit doors have to be turned off by a key. He/she stated that the only staff that have access to the key to turn off the exit door alarms are the Nursing Supervisor and him/herself. The Maintenance Director further stated that after Resident R1 was brought back into the facility he/she went to ensure the door alarm was functioning. When they got to Resident R1's hall he/she could hear an alarm going off. He/she stated that they shut off the exit door alarm which was never shut off throughout the incident. Observation on 5/20/26, at 10:30 a.m. of the hall the exit door that was sounding on 5/14/26, revealed that the exit door was approximately 75 feet from the highway. Further observations revealed Resident R1 had walked approximately 500 feet from his/her hall exit door and crossed the parking lot to a tree which was approximately 10 feet from the highway. Observations on 5/20/26, at 11:00 a.m. with the Social Service Director revealed that the tree that Resident R1 was leaning against was approximately ten feet from the highway. Review of information submitted by the facility to the Department of Health revealed the elopement incident of 5/14/26, was not reported until 5/20/26. Review of elopement incident investigation dated 5/14/26, revealed the following information from three staff statements: The first statement from staff revealed Resident R1 was in his/her room refusing medication when he/she was last observed and staff were with another resident providing care when Resident R1 left the building. The second statement indicated that Resident R1 was sitting on his/her bed the last time he/she was seen. The third statement indicated that Resident R1 refused his/her medications and was sitting on their bed talking about wanting to go home. During an interview on 5/20/26, at 1:00 p.m. the DON confirmed that the Resident R1 left the facility without any staff knowledge on 5/14/26, and also confirmed that the facility failed to properly supervise Resident R1 and failed to respond appropriately related to the exit door alarm, by going outside of the facility and looking thoroughly. On 5/20/26, at 3:52 p.m. the NHA was made aware that Immediate Jeopardy existed for one of one residents in the facility and that a corrective action plan was required. The IJ template was provided to the NHA at that time. On 5/20/26, at 6:16 p.m. an acceptable corrective action plan was approved which included the following interventions:All Current staff will be immediately educated on properly and timely responding to door alarms. Staff that are currently in the facility will immediately be educated on Elopement and Wandering Policies. Any employee not currently in the facility will be educated within 24 hours prior to them working or the next time they are scheduled to work in the facility if it is over 24 hours.All current residents not on the locked unit will immediately have a new elopement assessment completed.All new admissions will be assessed for the risk of Wandering and Elopement. Those at risk will either be moved to the locked unit or provided with a wander guard.The facilities Elopement binder will be updated immediately on every resident assessed as a risk resident for elopement with current informationAll resident care plans for residents at risk for elopement will be updatedThe Maintenance Supervisor and Maintenance Staff will be educated to ensure proper working conditions of the facility door alarms.The Maintenance Dept. will check all doors to ensure all doors with alarms are functioning properly and document their tests.The Maintenance Dept. will check all wander-guard devices to ensure they are in proper working order and functionalityThe facility will conduct an Elopement drill immediately after educating the current in-house staff to ensure staff's prompt responsiveness. The facility will conduct an AD HOC QAPI on 5/21/26. On 5/21/26, between 12:45 p.m. and 3:20 p.m. review of staff education, new elopement assessments, new admissions, elopement binder, resident care plans, door test documentation, wander-guard function, elopement drill, AD HOC QAPI, and staff interviews confirmed the facility implemented the above stated action plan. On 5/21/26, at 3:35 p.m. NHA and DON were informed that the Immediate Jeopardy had been lifted. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(c)(d)(1)(5)(3) Nursing services

Based on review of facility records and job descriptions, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to implement sufficient monitoring and supervision to prevent an elopement.Findings include: The job description for the NHA revealed that the NHA's purpose is to establish and maintain systems that are effective and efficient to operate the facility in a manner to safely meet resident needs in compliance with federal, state, and local requirements. The primary functions and responsibilities of the nursing home administrator include overseeing staff, personal, financial matters, medical care, medical supplies, and facilities. The job description for the DON revealed that the DON's primary purpose is to provide nursing management, set resident care standards for all direct care providers and provide complete supervision and management for the nursing department. The primary functions and responsibilities of the DON include setting resident care standards in accordance with acceptable current standards of care in order to provide the high quality care to residents, develop and implement policies, and supervise and manage all aspects of the nursing department. Based on the findings in this report that identified the facility failed to properly supervise a resident and failed to respond appropriately to an elopement, the NHA and the DON failed to fulfill their essential job duties to ensure that the Federal and State guidelines and Regulations were followed. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure the physician alternated required resident visits with the nurse practitioner or physician's assistant for 16 of 24 residents reviewed (Residents R2, R3, R5, R7, R9, R11, R12, R13, R14, R39, R42, R55, R58, R60, R61, and R94). Findings include: Facility policy entitled Physician Visits and Physician Delegation dated 1/22/26, revealed The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by physician or physician delegate as appropriate by state law and At the option of the physician, required visits in SNFs (skilled nursing facilities), after the initial visit, may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist that is acting within scope of practice defined by State law and under the supervision of the physician. ' Resident R2's clinical record revealed an admission date of 12/4/24, with diagnoses that included chronic obstructive pulmonary disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), bipolar disorder (a mental health condition where you experience extreme mood swings that include emotional highs and lows. It causes significant shifts in mood, energy, activity levels, and concentration, affecting a person's overall functioning), and hypertension (high blood pressure). Resident R2's clinical records revealed physician progress notes signed by the nurse practitioner dated 6/26/25, 8/29/25, 10/20/25, 1/8/26, and 2/12/26. The clinical record lacked evidence of progress notes being alternated between the physician and nurse practitioner as required. Review of Resident R3's clinical record revealed an admission date of 7/26/24, with diagnoses that included Parkinson's (a chronic and progressive movement disorder that causes shaking, slows a person's ability to move and worsens over time), vascular dementia (a disease that affects short term memory and the ability to think logically), and hypertension. Resident R3's clinical records revealed physician progress notes signed by the nurse practitioner dated 5/29/25, 7/31/25, 10/10/25, 11/13/25, and 1/16/26. The clinical record lacked evidence of progress notes being alternated between the physician and nurse practitioner as required. Resident R5's clinical record revealed an admission date of 3/16/18, with diagnoses that included hypertension, major depressive disorder, and insomnia (difficulty sleeping). Resident R5's clinical records revealed physician progress notes signed by the nurse practitioner dated 9/11/25, 11/20/25, and 1/22/26. The clinical record lacked evidence of progress notes being alternated between the physician and nurse practitioner as required. Resident R7's clinical record revealed an admission date of 7/23/25, with diagnoses that included sleep apnea (a sleep disorder that causes breathing to stop and start multiple times during sleep), COPD, and diabetes (a health condition caused by the body's inability to produce enough insulin). Resident R7's clinical records revealed physician progress notes signed by the nurse practitioner dated 9/4/25, 10/2/25, 11/6/25, 1/16/26, and 2/19/26. The clinical record lacked evidence of progress notes being alternated between the physician and nurse practitioner as required. Resident R9's clinical record revealed an admission date of 10/6/21 with diagnoses that included end stage renal disease (ESRD - when the kidneys have permanently lost their ability to function effectively), anemia (a reduction in red blood cells resulting in symptoms such as fatigue and weakness), and diabetes. Resident R9's clinical records revealed physician progress notes signed by the nurse practitioner dated 5/29/25, 7/31/25, 9/24/25, 12/15/25, and 2/26/26. The clinical record lacked evidence of progress notes being alternated between the physician and nurse practitioner as required. Resident R11's clinical record revealed an admission date of 5/8/25, with diagnoses that included sleep apnea, diabetes, and hypertension. Resident R11's clinical records revealed physician progress notes signed by both the physician and nurse practitioner dated 6/26/25, 7/31/25, 9/4/25, 11/13/25, and 1/16/26. The physician notes were not clear defined as to who actually saw Resident R11. Review of Resident R12's clinical record revealed an admission date of 12/24/25, with diagnoses that included Parkinson's (a chronic and progressive movement disorder that causes shaking, slows a person's ability to move and worsens over time), drug induced retention of urine (a condition where a person is unable to fully empty their bladder because of a medication), and hyperlipidemia (high cholesterol). Resident R12's clinical records revealed physician progress notes signed by the nurse practitioner dated 12/15/25, 1/16/26, and 2/19/26. The clinical record lacked evidence of progress notes being alternated between the physician and nurse practitioner as required. Review of Resident R13's clinical record revealed an admission date of 3/13/24, with diagnoses that included Alzheimer's disease (brain disorder that slowly destroys memory, thinking skills, and, over time the ability to carry out the simplest tasks), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and hyperlipidemia (high cholesterol). Resident R13's clinical records revealed physician progress notes signed by the nurse practitioner dated 7/3/25, 9/4/25, 11/13/25, and 1/22/26. The clinical record lacked evidence of progress notes being alternated between the physician and nurse practitioner as required. Resident R14's clinical record revealed an admission date of 11/27/23, with diagnoses that included muscle wasting and atrophy (loss of muscle tissue resulting in decreased size and strength), weakness, and hypertension.Resident R14's clinical records revealed physician progress notes signed by the nurse practitioner dated 9/11/25, 11/20/25, and 1/29/26. The clinical record lacked evidence of progress notes being alternated between the physician and nurse practitioner as required. Resident R39's clinical record revealed an admission date of 1/9/25, with diagnoses that included anxiety, insomnia, and hypertension.Resident R39's clinical records revealed physician progress notes signed by the nurse practitioner dated 8/14/25, 10/2/25, 11/6/25, 1/8/26, and 1/22/26. The clinical record lacked evidence of progress notes being alternated between the physician and nurse practitioner as required. Resident R42's clinical record revealed an admission date of 4/26/24, with diagnoses that included COPD, dementia, and anxiety.Resident R42's clinical records revealed physician progress notes signed by the nurse practitioner dated 9/11/25, 11/20/25, and 1/22/26. The clinical record lacked evidence of progress notes being alternated between the physician and nurse practitioner as required. Review of Resident R55's clinical record revealed an admission date of 3/10/25, with diagnoses that included hypertension, emphysema (a chronic lung condition that causes shortness of breath due to lung damage), and hyperlipidemia.Resident R55's clinical records revealed physician progress notes signed by the nurse practitioner dated 6/26/25, 9/4/25, 11/13/25, and 2/26/26. The clinical record lacked evidence of progress notes being alternated between the physician and nurse practitioner as required. Review of Resident R58's clinical record revealed an admission date of 9/11/24, with diagnoses that include Alzheimer's disease, hypertension, and chronic kidney disease (a disease that affects the kidney's ability to filter waste products and extra fluid from the body). Resident R58's clinical records revealed physician progress notes signed by the nurse practitioner dated 6/26/25, 9/4/25, 11/13/25, and 1/22/26. The clinical record lacked evidence of progress notes being alternated between the physician and nurse practitioner as required. Resident R60's clinical record revealed an admission date of 10/2/1018, with diagnoses that included Alzheimer's disease, diabetes, and dementia. Resident R60's clinical records revealed physician progress notes signed by the nurse practitioner dated 5/29/25, 7/31/25, 10/10/25, 12/15/25, and 2/19/26. The clinical record lacked evidence of progress notes being alternated between the physician and nurse practitioner as required. Resident R61's clinical record revealed an admission date of 1/23/25, with diagnoses that included hypertension, atrial fibrillation (irregular heartbeat), and major depressive disorder. Resident R61's clinical records revealed physician progress notes signed by the nurse practitioner dated 8/14/25, 10/16/25, 12/29/25, and 2/26/25. The clinical record lacked evidence of progress notes being alternated between the physician and nurse practitioner as required. Resident R94's clinical record revealed an admission date of 10/6/21, with diagnoses that included COPD, sleep apnea, and hypertension. Resident R94's clinical records revealed physician progress notes signed by the nurse practitioner dated 5/29/25, 7/31/25, 8/14/25, 9/18/25, 10/10/25, 12/15/25, and 1/16/26. The clinical record lacked evidence of progress notes being alternated between the physician and nurse practitioner as required. During an interview on 4/30/26, at 10:46 a.m. the Director of Nursing confirmed that Residents R2, R3, R5, R7, R9, R12, R13, R14, R39, R42, R55, R58, R60, R61, and R94's clinical records lacked evidence of alternating visits between the physician and nurse practitioner as required and Resident R11's clinical lacked evidence that they were definitely seen by their physician between 6/26/25, and 1/16/26. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.2 (d)(8) Medical director 28 Pa. Code 211.5 (f)(ii)(iv) Medical records

Based on review of a facility policy, observations, and staff interview, it was determined that the facility failed to maintain sanitary operations in the main kitchen and failed to ensure that food was stored in accordance with standards for food safety in the main kitchen and three resident pantries reviewed (Units 100/200, 200/300, and 400/500).Findings include: Review of policy entitled Date Marking for Food Safety dated 1/22/26, indicated The food shall be clearly marked to indicate the date or day by which food shall be consumed or discarded. The discard date or day may not exceed the manufacturer's use-by-date, or four days, whichever is earliest. The date of opening or preparation counts as day 1. Review of facility policy entitled Environment dated 1/22/26, indicated The Dining Service Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. Review of facility policy entitled Equipment dated 1/22/26, indicated All non-food contact equipment will be cleaned and free of debris. Observations during tour of the kitchen on 4/27/26, between 10:35 a.m. and 10:55 a.m. with the Dietary Manager of the walk-in freezer revealed several metal containers all covered with aluminum foil with the name of the item and the date the item was placed in the metal container written on each one. The first container was labeled rolls with a date of 4/6/26, second was labeled chili with a date of 4/8/26, third was labeled sprouts with a date of 3/28/26, fourth was labeled pumpkin with a date of 2/5/26, and fifth was labeled roll ups with a date of 1/20/26. In the walk-in refrigerator was a container of garlic with a best by date of 4/4/26, in the reach in refrigerator was an open container of cottage cheese with a best buy date of 4/24/26, in the second reach in refrigerator was a container of cottage cheese with a best buy date of 4/24/26. During an interview with the Dietary Manager on 4/27/26, at the time of observations, he/she said that all the items in the metal pans should be used within fourteen days from the date that was written on the foil. He/she confirmed that the items in the metal pans, the containers of cottage cheese, and the container of garlic should have all been discarded. Observation on 4/27/26, at 12:26 p.m. of a pantry on unit 100/200 used for residents revealed an open container of 2.0 Cal med pass (a supplement given to residents during medication administration) with an open date of 4/23/26. During an interview on 4/27/26, at the time of observations with Licensed Practical Nurse Employee E1, he/she confirmed that the med pass was dated open on 4/23/26, which was beyond its use by date and should have been discarded. Observations on 4/27/26, between 12:30 p.m. and 12:35 p.m. of a pantry on unit 300/400 used for residents revealed an open box of mini wheats with a best buy date of 10/19/24, an open box of cheerios with a best by date of 10/22/25, a can of ravioli with an expiration date of 6/18/25, and an open container of ginger bread cookies with an expiration date of 4/16/26. Observations on 4/27/26, between 12:35 p.m. and 12:39 p.m. of a pantry on unit 500/600 used for residents revealed and in the cabinet was a clear plastic bag with no name or date and what appeared to be a large amount of cooked French toast. During an interview on 4/27/26, at the time of observations the Director of Nursing (DON) confirmed that the open box of mini wheats, open box of cheerios, can of ravioli, and the open container of gingerbread cookies were beyond their use by dates and should have been discarded. The DON also confirmed that the clear plastic bag of what appeared to be French toast should not be stored in the cabinet and should have been discarded. Observation of the kitchen on 4/27/26, between 10:35 a.m. and 10:55 a.m. revealed white, gray, black and brown substances on the floors under the sink, under the stove, under the pan rack, and there was a small brush lying on the floor beside the sink. There was a large amount of food crumbs behind the pot rack, under the sink, under the prep table, and under the stove. Observations of the dishwasher room revealed a thick white substance covering the front of the dishwasher, the sides of the dishwasher where the dishes exit, and the top of the dishwasher revealed crumbling chunks of a white substance. Further review revealed metal wheeled carts covered in a thick white substance. Observation on 4/28/26 between 11:00 a.m. and 11:30 a.m. revealed the white, gray, black and brown substances on the floors under the sink, stove, and under the pan rack, and the small brush lying on the floor beside the sink remained. The large amount of food crumbs behind the pot rack, under the sink, under the prep table, and under the stove remained. The thick white substance covering the front of the dishwasher, the sides of the dishwasher where the dishes exit, and the top of the dishwasher the crumbling chunks of a white substance remained. The metal wheeled cart covered in a thick white substance remained. During an interview on 4/28/26, at the time of observations with the Dietary Manager, he/she confirmed the kitchen floors under the sink, stove, and under the pan rack had white, gray, black and brown substances, and there was a small brush lying on the floor beside the sink. He/she also confirmed that there was a large amount of food crumbs behind the pot rack, under the sink, under the prep table, and under the stove. He/she confirmed that the dishwasher had a thick white substance covering the front and the exit sides and that there were crumbling chunks of a white substance on the top of the dishwasher. He/she also confirmed that the kitchen floors, dishwasher and metal carts should be clean. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policies, clinical records, and staff interview it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day), and failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for five of five residents reviewed (Residents R2, R3, R5, R7, and R56). Findings include: Facility policy entitled Bed-Hold Notice dated 1/22/26, indicated that It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave. The policy further revealed In the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed-hold policies to the resident and/or the resident representative within 24 hours. The facility will document multiple attempts to reach the resident's representative in cases where the facility was unable to notify the representative. The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or representative in the resident's file and/or medical record. and The facility will provide this information to all facility residents, regardless of their payment source. Facility policy entitled Transfer and Discharge (including AMA [against medical advice]) dated 1/22/26, indicated that for a transfer to another provider, for any reason, the following information must be provided to the receiving provider: contact information for the practitioner responsible for care of resident, resident representative information, advanced directive, information necessary to meet the resident's needs, special instructions and/or precautions for ongoing care, and care plan goals. Resident R2's clinical record revealed an admission date of 12/4/24, with diagnoses that included chronic obstructive pulmonary disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), bipolar disorder (a mental health condition where you experience extreme mood swings that include emotional highs and lows. It causes significant shifts in mood, energy, activity levels, and concentration, affecting a person's overall functioning), and hypertension (high blood pressure). Resident R2's progress notes revealed notes dated 8/9/25, 8/20/25, 12/24/25, 1/13/26, and 3/6/26, indicating transfers to the hospital. Resident R2'2 clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. The clinical record also lacked evidence indicating that he/she and/or their representative were provided with a copy of the bed-hold policy upon transfers on 8/9/25, 8/20/25, 12/24/25, 1/13/26, and 3/6/26. Resident R3's clinical record revealed an admission date of 7/26/24, with diagnoses that included Parkinson's (a chronic and progressive movement disorder that causes shaking, slows a person's ability to move and worsens over time), vascular dementia (a disease that affects short term memory and the ability to think logically), and hypertension. Resident R3's progress notes revealed notes dated 8/14/25, 11/1/25, and 4/13/26, indicating transfers to the hospital. Resident R3's clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. The clinical record also lacked evidence indicating that Resident R3 and/or his/her representative were provided with a copy of the bed-hold policy upon transfers on 8/14/25, 9/26/25, 11/1/25, 2/11/26, and 4/13/26. Resident R5's clinical record revealed an admission date of 3/16/18, with diagnoses that included hypertension, major depressive disorder, and insomnia (difficulty sleeping).Review of Resident R5's progress notes revealed notes dated 12/12/25, and 1/11/26, indicating transfers to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. His/her clinical record also lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfers on 12/12/25, and 1/11/26. Resident R7's clinical record revealed an admission date of 7/23/25, with diagnoses that included sleep apnea (a sleep disorder that causes breathing to stop and start multiple times during sleep), COPD, and diabetes (a health condition caused by the body's inability to produce enough insulin). Resident R7's progress notes revealed notes dated 12/14/25, indicating transfers to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. His/her clinical record also lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfers on 12/14/25. Review of Resident R56's clinical record revealed an admission date of 9/13/2024, with diagnosis that included but not limited to Dementia (a decline in cognitive function including memory, language, problem solving and thinking), Macular degeneration (vision loss affecting the central vision needed. Damage to the macula in the retina) of both eyes, Anxiety, and cognitive communication deficit. Review of Resident R56's progress notes revealed notes dated 1/12/2026, indicating transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. His/her clinical record also lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfers on 1/12/2026. During an interview on 4/29/26, at 3:14 p.m. the Director of Nursing confirmed that Residents R2, R3, R5, R7, and R56, clinical records lacked evidence that the necessary clinical information was provided to the receiving healthcare provider and lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfer. He/she also confirmed when the transfers occurred clinical information should have been provided to the receiving healthcare provider and bed hold policy should have been provided to the resident/representative upon transfer. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c.3) (2) Resident rights

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure that the attending physician documented required visits by writing, signing, and dating a physician progress note for each visit for 12 of 24 residents reviewed (Residents R2, R3, R5, R11, R13, R14, R25, R39, R42, R58, R60, and R94).Findings include: Facility policy entitled Physician Visits and Physician Delegation dated 1/22/26, revealed The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by physician or physician delegate as appropriate by state law, Date, write, and sign a progress note for each visit and A physician visit is considered timely if it occurs no later than 10 days after the date the visit was required. Resident R2's clinical record revealed an admission date of 12/4/24, with diagnoses that included chronic obstructive pulmonary disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), bipolar disorder (a mental health condition where you experience extreme mood swings that include emotional highs and lows, causing significant shifts in mood, energy, activity levels, and concentration, affecting a person's overall functioning), and hypertension (high blood pressure). Resident R2's clinical record revealed the last documented physician progress note was 2/12/26. The clinical record lacked evidence of any physician progress notes being completed between 2/12/26, and 4/30/26, which is 7 days past the 10-day grace period for the required visit. Review of Resident R3's clinical record revealed an admission date of 7/26/24, with diagnoses that included Parkinson's (a chronic and progressive movement disorder that causes shaking, slows a person's ability to move and worsens over time), vascular dementia (a disease that affects short term memory and the ability to think logically), and hypertension. Resident R3's clinical record revealed the last documented physician progress note was 1/16/26. The clinical record lacked evidence of any physician progress notes being completed between 1/16/26, and 4/30/26, which is 33 days past the 10-day grace period for the required visit. Resident R5's clinical record revealed an admission date of 3/16/18, with diagnoses that included hypertension, major depressive disorder, and insomnia (difficulty sleeping).Resident R5's clinical record revealed the last documented physician progress note was 1/22/26. The clinical record lacked evidence of any physician progress notes being completed between 1/22/26, and 4/30/26, which is 27 days past the 10-day grace period for the required visit. Resident R11's clinical record revealed an admission date of 5/8/25, with diagnoses that included sleep apnea (a sleep disorder that causes breathing to stop and start multiple times during sleep), diabetes (a health condition caused by the body's inability to produce enough insulin), and hypertension. Resident R11's clinical record revealed the last documented physician progress note was 1/16/26. The clinical record lacked evidence of any physician progress notes being completed between 1/16/26, and 4/30/26, which is 36 days past the 10-day grace period for the required visit. Review of Resident R13's clinical record revealed an admission date of 3/13/24, with diagnoses that include Alzheimer's disease (brain disorder that slowly destroys memory, thinking skills, and, over time the ability to carry out the simplest tasks), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and hyperlipidemia (high cholesterol). Resident R13's clinical record revealed the last documented physician progress note was 1/22/26. The clinical record lacked evidence of any physician progress notes being completed between 1/22/26, and 4/30/26, which is 27 days past the 10-day grace period for the required visit. Resident R14's clinical record revealed an admission date of date of 11/27/23, with diagnoses that included muscle wasting and atrophy (loss of muscle tissue resulting in decreased size and strength), weakness, and hypertension.Resident R14's clinical record revealed the last documented physician progress note was 1/29/26. The clinical record lacked evidence of any physician progress notes being completed between 1/29/26, and 4/30/26, which is 20 days past the 10-day grace period for the required visit. Review of Resident R25's clinical record revealed an admission date of 2/15/26, with diagnoses that included COPD, anxiety, and hypertension. Resident R25's clinical record revealed the last documented physician progress note was 2/19/26. The clinical record lacked evidence of any physician progress notes being completed between 2/19/26, and 4/30/26, which is 30 days past the 10-day grace period for the required visit. Resident R39's clinical record revealed an admission date of 1/9/25, with diagnoses that included anxiety, insomnia, and hypertension.Resident R39's clinical record revealed the last documented physician progress note was 1/22/26. The clinical record lacked evidence of any physician progress notes being completed between 1/22/26, and 4/30/26, which is 27 days past the 10-day grace period for the required visit. Resident R42's clinical record revealed an admission date of 4/26/24, with diagnoses that included COPD, dementia, and anxiety.Resident R42's clinical record revealed the last documented physician progress note was 1/22/26. The clinical record lacked evidence of any physician progress notes being completed between 1/22/26, and 4/30/26, which is 27 days past the 10-day grace period for the required visit. Review of Resident R58's clinical record revealed an admission date of 9/11/24, with diagnoses that included Alzheimer's disease, hypertension, and chronic kidney disease (a disease that affects the kidney's ability to filter waste products and extra fluid from the body). Resident R58's clinical record revealed the last documented physician progress note was 1/22/26. The clinical record lacked evidence of any physician progress notes being completed between 1/22/26, and 4/30/26, which is 27 days past the 10-day grace period for the required visit. Resident R60's clinical record revealed an admission date of 10/2/1018, with diagnoses that included Alzheimer's disease, diabetes, and dementia. Resident R60's clinical record revealed the last documented physician progress note was 1/29/26. the clinical record lacked evidence of any physician progress notes being completed between 1/22/26, and 4/30/26, which is 9 days past the 10-day grace period for the required visit. Resident R94's clinical record revealed an admission date of 10/6/21, with diagnoses that included COPD, sleep apnea, and hypertension. Resident R94's clinical record revealed the last documented physician progress note was 1/16/26. The clinical record lacked evidence of any physician progress notes being completed between 1/16/26, and 4/30/26, which is 36 days past the 10-day grace period for the required visit. During an interview on 4/30/26, at 10:46 a.m. the Director of Nursing confirmed that Residents R2, R3, R5, R11, R13, R14, R25, R39, R42, R58, R60, and R94's clinical records lacked evidence of the required physician progress notes at the time of review. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.2 (d)(8) Medical director 28 Pa. Code 211.5 (f)(ii)(iv) Medical records

Based on review of facility policy and clinical record and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 24 residents reviewed (Resident R11).Findings include: Facility policy entitled Comprehensive Care Plans date 1/22/26, indicated It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Resident R11's clinical record revealed an admission date of 5/8/25, with diagnoses that included Sleep Apnea (a sleep disorder that causes breathing to stop and start multiple times during sleep), Diabetes (a health condition caused by the body's inability to produce enough insulin), and High Blood Pressure. Resident R11's physician's orders dated 5/9/25, revealed CPAP (Continuous Positive Airway Pressure - CPAP machine that delivers a steady stream of pressurized air through a mask worn over the nose and/or mouth which keeps the airway open and ensure consistent oxygen flow) nightly for sleep apnea. Review of Resident R11's comprehensive plan of care failed to reveal a care plan for the use of his/her CPAP. During an interview on 4/29/26, at 2:59 p.m. the Registered Nurse Assessment Coordinator confirmed that Resident R11's comprehensive plan of care did not include a care plan for the use of his/her CPAP and should have. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure physician's orders and residents Physician Order for Life Sustaining Treatment (POLST- a legal document specifying the resident/responsible party choices regarding life-sustaining treatments) were consistent for one of 24 residents reviewed (Resident R123).Findings include: Review of facility policy entitled Communication of Code Status dated [DATE], indicated When an order is written pertaining to a resident's presence or absence of an Advance Directive, the directions will be clearly documented in designated sections of the medical record. Review of Resident R123's clinical record revealed an admission date of [DATE], with diagnoses that include hypertension (high blood pressure), parkinsonism (a syndrome with symptoms of tremors, stiff muscles, and slow and difficult movement because of disease of the nervous system), and chronic kidney disease (a disease that affects the kidney's ability to filter waste products and extra fluid from the body). Review of Resident R123's clinical record revealed a physician's order dated [DATE], indicating DNR (Do Not Resuscitate). Review of Resident R123's POLST revealed CPR (Cardiopulmonary Resuscitation - emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest). During an interview on [DATE], at 1:50 p.m. with Licensed Practical Nurse Employee E2, he/she revealed that during an emergent situation the staff refer to the physician's orders in the computer to determine resident life sustaining wishes. During an interview on [DATE], at 1:55 p.m. the Director of Nursing confirmed that Resident R123's physician orders and POLST were not consistent with one another. He/she also confirmed that the resident's physician's order and POLST should match. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.5(f)(i)(vii) Medical records 28 Pa. Code 211.10(c) Resident care policies

Based on review of facility policies, clinical records, and staff interview, it was determined that the facility failed to follow physician's orders related to a medication gradual dose reduction (GDR-lowering a high-risk medication to determine if a person can function safely on a lower dose) and failed to administer pain medication timely resulting in a delay in treatment for two of 24 residents reviewed (Residents R3 and R5).Findings include:Facility policy entitled, Consulting Physician/Practitioner Orders dated 1/22/26, revealed .For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will:Call the attending physician to verify the order.Document the verification order by entering the order and the time, date, and signature on the physician order sheet.Follow facility procedures for verbal or telephone orders including: noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record.Review of Resident R3's clinical record revealed an admission date of 7/26/24, with diagnoses that included Parkinson's (a chronic and progressive movement disorder that causes shaking, slows a person's ability to move and worsens over time), vascular dementia (a disease that affects short term memory and the ability to think logically), and hypertension (high blood pressure).Resident R3's clinical record revealed a psychiatry progress note dated 2/24/26, to reduce Quetiapine (antipsychotic mind-altering medication) to 25 mg (milligrams) po (by mouth) every HS (hour of sleep), reassess in two weeks.Resident R3's medication administration records for February, March, and April 2026 lacked evidence that Quetiapine was reduced and reassessed as ordered.Review of Resident R3's active and discontinued physician orders for Quetiapine revealed all orders were for 50 mg by mouth one time a day.During an interview on 4/29/26, at 3:14 p.m. the Director of Nursing confirmed that the facility failed to follow physician's orders related to Resident R3's Quetiapine GDR order. Review of Resident R5's clinical record revealed an admission date of 3/16/18, with diagnoses that included hypertension, major depressive disorder, and insomnia (difficulty sleeping).Review of Resident R5's medication administration record revealed that a new order was entered dated 12/11/25, at 5:30 p.m. for Oxycodone (an opioid used to treat moderate to severe pain) 5 mg every six hours as needed for severe pain. This was in addition to his/her existing order dated 11/20/2018, for Oxycodone 5 mg one time a day for back pain.Resident R5's pain scale (a numerical scale used to determine a person's pain level with zero indicating no pain and a 10 being the worst pain ever) revealed on 12/10/25, all pain assessments revealed his/her pain was a zero, on 12/11/25, his/her pain was documented as a zero, three, six, zero, and zero, and on 12/12/25, his/her pain was documented as a six, five, one, six, 10, seven, and 10. Resident R5 started to have severe pain on 12/11/25, at 2:13 p.m. An order for Oxycodone 5 mg every six hours for severe pain was available on 12/11/25, at 5:30 p.m. and he/she did not receive his/her first dose until 12/12/25, at 4:46 a.m. almost 12 hours after the order was received.During an interview on 4/29/26, at 2:06 p.m. the Director of Nursing confirmed that there was a delay in treatment related to Resident R5 and confirmed the Oxycodone 5mg as needed medication should have been provided to Resident R5 earlier to address their pain. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f)(i)(x) Medical records

Based on review of facility policies and clinical record and staff interview, it was determined that the facility failed to review and/or revise resident care plans for one of 24 residents reviewed (Resident R11). Findings include: Facility policy entitled Comprehensive Care Plans' dated 1/22/26, revealed The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Facility policy entitled Care Plan Revisions Upon Status Change dated 1/22/26, revealed The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a change. And The care plan will be updated with new or modified interventions. Resident R11's clinical record revealed an admission date of 5/8/25, with diagnoses that included Sleep Apnea (a sleep disorder that causes breathing to stop and start multiple times during sleep), Diabetes (a health condition caused by the body's inability to produce enough insulin), and High Blood Pressure. Resident R11's care plan for problem area of Respiratory included an intervention for Oxygen concentrators 3 liters via nasal canula or face mask. Resident R11's physician's orders revealed an order dated 12/25/25 to discontinue oxygen at 3 liters via nasal cannula. During an interview on 4/29/26, at 2:50 p.m. the Registered Nurse Assessment Coordinator (RNAC) confirmed that Resident R11's oxygen was discontinued on 12/25/25, and that his/her care plan was not updated to reflect this change. The RNAC confirmed this intervention should have been resolved. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, facility documents, and facility meal schedule, observations, and resident and staff interviews, it was determined that the facility failed to ensure that alternate meals were served comparable to normal mealtime in accordance with resident preference and request for two of 24 residents (Residents R55 and R123).Findings include: Review of facility policy entitled Dining and Food Preferences dated 1/22/26, revealed The alternate meal and/or beverage selection will be provided in a timely manner. Review of facility meal schedule revealed that the scheduled time for lunch delivery starts at 11:00 a.m. and the last delivery is at 1:15 p.m. which identified that tray line would not be completed until 1:15 p.m. Observations on 4/27/26, and 4/28/26, revealed a sign on the dining services door indicating Alternate meals will be made at the end of tray line. Tray line does not stop! During an interview on 4/27/26, at approximately 12:45 p.m. Resident R55 stated, I have asked for an alternate meal, and it has taken over 30 minutes to get it, and it was only a peanut butter sandwich. I was told that I would have to wait until tray line was done before I would get the sandwich. During an interview on 4/27/26, at approximately 1:00 p.m. Resident R123 and his/her representative stated, We asked for a grilled cheese sandwich in place of [Resident R123's] meal and was told that we would have to wait until tray line was completed. They also stated that it took over 30 minutes to get the grilled cheese sandwich and that all the other residents were done eating their meals by the time Resident R123 received his/her sandwich. During an interview on 4/28/26, at 11:30 a.m. the Dietary Manager confirmed that an alternate meal would not be made until tray line was completed. During an interview on 4/30/26, at 11:24 a.m. the Nursing Home Administrator confirmed that when a resident requests for an alternate meal that it should be prepared and delivered timely. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policy, clinical records, observations, and staff interview, it was determined that the facility failed to provide appropriate urinary catheter (tubing inserted into the bladder to drain urine into a bag) care to help prevent urinary tract infections for one resident reviewed for catheter care (Resident R12).Findings include: Review of facility policy entitled Indwelling Catheter Use and Removal dated 1/22/26, revealed If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that include but are not limited to: Insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures. Review of Resident R12's clinical record revealed an admission date of 12/24/25, with diagnoses that include Parkinson's (a chronic and progressive movement disorder that causes shaking, slows a person's ability to move and worsens over time), drug induced retention of urine (a condition where a person is unable to fully empty their bladder because of a medication), and hyperlipidemia (high cholesterol). Review of Resident R12's care plan dated 4/8/26, for indwelling catheter revealed an intervention If resident is in a low bed, place foley [catheter] collection bag into a privacy bag then store that bag in a basin. Observations on 4/27/26, at 12:13 p.m. and again at 2:11 p.m. revealed Resident R12 lying in bed with their foley collection bag not in a privacy bag and was sitting on the floor. Observations on 4/28/26, at 9:33 a.m. and again at 1:20 p.m. revealed Resident R12 sitting in their wheelchair and the foley collection bag was not in a privacy bag and was sitting on the floor. During an interview on 4/28/26, at 1:45 p.m. the Director of Nursing confirmed that Resident R12's foley collection bag was not in a privacy bag and was sitting on the floor. He/she also confirmed that Resident R12's foley collection bag should not be sitting on the floor. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 211.10(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 interview, it was determined that the facility failed to provide evidence that pharmacist medication regimen reviews were reviewed and signed by a physician prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for one of one residents reviewed (Resident R109). Findings include: Review of facility policy entitled Psychotropic Medication Use Process Auditing Chart Review with an annual policy review of 1/22/2026, revealed is there a practitioner's order documented for the psychotropic medication. Are orders for antipsychotic medications only time limited to 14 days? If it needs to be extended, has the practitioner evaluated the resident and documented on the resident prior to writing the new PRN order? Review of Resident R109's clinical record revealed an admission date of 4/30/25, with diagnoses that included Cerebrovascular disease affecting right dominant side (a group of conditions that affect blood vessels and blood circulation to the brain, restricting oxygen and often causing strokes), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), aphasia (a language disorder caused by damage to the brain), and major depressive disorder. Review of Resident R109's physician's orders revealed an order for Lorazepam (anti-anxiety) 0.5 milligrams (mg) by mouth every four hours PRN for anxiety. Review of Resident R109's medication regimen reviews and medication administration record revealed that the PRN Lorazepam was to be reviewed on 12/29/2025, 1/28/2026, and 2/24/2026 and lacked evidence that the physician reviewed and signed the regimen reviews. The medication regimen reviews revealed that 12/29/2025, was unsigned and that 1/28/2026, and 2/24/2026 were not signed off for reorders until 3/27/2026. The order was changed to an indefinite duration after 3/27/26. During an interview on 4/30/26, at 10:50 a.m. the Nursing Home Administrator and Director of Nursing confirmed that Resident R109's clinical record lacked evidence that medication regimen reviews were signed reviewed and signed by the physician for PRN psychotropic medication Lorazepam. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for two of 12 residents reviewed (Residents R12 and R7).Findings include: Facility policy entitled Baseline Care Plan dated 1/22/26, indicated A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. The summary shall include, at a minimum, the following: The initial goals of the resident, a Summary of the resident's medications and dietary instructions, and Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. And The person providing the written summary of the baseline care plan shall: Obtain a signature from the resident/representative to verify that the summary was provided and Make a copy of the summary for the medical record. Resident R12's clinical record revealed an admission date of 12/24/25, with diagnoses that included Parkinson's (a chronic and progressive movement disorder that causes shaking, slows a person's ability to move and worsens over time), drug induced retention of urine (a condition where a person is unable to fully empty their bladder because of a medication), and hyperlipidemia (high cholesterol). Resident R12's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R12 and/or his/her representative. During an interview on 4/29/26, at 1:45 p.m. the Director of Nursing (DON) confirmed there was no evidence that a written summary of the baseline care plan and order summary were provided to Resident R12 and/or his/her representative. Resident R7's clinical record revealed an admission date of 7/23/25, with diagnoses that included Sleep Apnea (a sleep disorder that causes breathing to stop and start multiple times during sleep), Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), and Diabetes (a health condition caused by the body's inability to produce enough insulin). Resident R7's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R7 and/or his/her representative. During an interview on 4/29/26, at 3:27 p.m. the DON confirmed there was no evidence that a written summary of the baseline care plan and order summary were provided to Resident R7 and/or his/her representative. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of clinical records and Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), and staff interviews it was determined that the facility failed to ensure that MDS assessments accurately reflected the status of three of 27 residents reviewed (Residents R7, R11, and R120).Findings include: MDS instructions for section A2105 Discharge Status indicated to select the two-digit code that corresponds to the resident's discharge status. MDS instructions for section O0100b Special Treatments, Procedures, and Programs while a resident indicated to check all of the following treatments, procedures, and programs that were performed while a resident of this facility and within the last 14-days. Instructions for section O0110G1 Non-Invasive Mechanical Ventilator indicated to Code any type of CPAP (a machine that delivers a steady stream of pressurized air through a mask worn over the nose and/or mouth which keeps the airway open and ensure consistent oxygen flow.) or BiPAP ( machine that delivers pressurized air through a mask worn over the nose and/or mouth to help keep the airway open and improv oxygen intake while reducing carbon dioxide buildup by delivering a higher pressure while inhaling and a lower pressure while exhaling) respiratory support devices. Instructions for section O0110G3 CPAP indicated to Check if the non-invasive mechanical ventilator support was a CPAP. Resident R7's clinical record revealed an admission date of 7/23/25, with diagnoses that included Sleep Apnea (a sleep disorder that causes breathing to stop and start multiple times during sleep), Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), and Diabetes (a health condition caused by the body's inability to produce enough insulin). Resident R7's physician's orders dated 9/16/25, revealed CPAP via nasal mask at bedtime. Review of the September 2025, December 2025, and March 2026 Treatment Administration Records (TAR) revealed Resident R7 utilized his/her CPAP nightly. Resident R7's quarterly MDS with an Assessment Reference Date (ARD) of 9/15/25, significant change MDS with an ARD of 12/19/25, and quarterly MDS with an ARD of 3/21/26, Section O0110G1 Non-Invasive Mechanical Ventilator were coded as No. Resident R11's clinical record revealed an admission date of 5/8/25, with diagnoses that included Sleep Apnea, Diabetes, and High Blood Pressure. Resident R11's physician's orders dated 5/9/25, revealed CPAP nightly for sleep apnea. Review of the May 2025, August 2025, November 2025, and February 2026 TARs revealed Resident R11 utilized his/her CPAP nightly. Resident R11's admission MDS with ARD 5/14/25, quarterly MDS with ARD of 8/14/25, and quarterly MDS with ARD of 11/14/25, Section O0110G1 Non-Invasive Mechanical Ventilator were coded as No. During an interview on 4/29/26, at 2:56 p.m. Registered Nurse Assessment Coordinator (RNAC) confirmed that Resident R7 and R11's MDS's Section O0110G1 was coded inaccurately and should have been coded as Yes. Resident R120's clinical record revealed an admission date of 2/6/26, with diagnoses that included Gastroesophageal reflux disease (GERD - happens when stomach acid flows back up into the esophagus and causes heartburn), Anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and History of Urinary Tract Infections. Resident R120's clinical record progress note dated 2/7/26, revealed he/she left the facility with a family member to go home against medical advice. Resident R120's admission / Discharge - Return Not Anticipated MDS with an ARD of 2/7/26, section A2105 Discharge Status was coded as 04 - Short-Term General Hospital (acute hospital). During an interview on 4/30/26, at 1:57 p.m. the RNAC confirmed that Resident R120's MDS Section A2105 was coded inaccurately and should have been coded as 01. Home/Community. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f)(ix) Medical records

Based on observations, review of facility policies and International Plumbing Code, and staff interviews it was determined that the facility failed to safely store food containers, and prepare, serve and store food in a safe and sanitary manner in the main kitchen; failed to prevent the potential for cross contamination (transfer of harmful substances or disease-causing organisms to food from unclean hands or objects) during food preparation; and failed to maintain safe storage of ice for residents for one of one ice machines located in the kitchen. Findings include: Review of the International Plumbing Code Chapter Eight dated 2018, revealed that devices that store ice and that discharge to the drainage system shall be provided with protection against backflow, flooding, fouling, contamination and stoppage of the drain; and when equipment discharges potable clear water waste (fit for human consumption) to the building drainage system, the discharge shall be through an indirect pipe by means of an air gap. A facility policy entitled Equipment dated 1/16/25, indicated that all equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials; all food contact equipment will be cleaned and sanitized after every use; and all non-foods contact equipment will be clean and free of debris. A facility policy entitled Food Storage: Cold Foods dated 1/16/25, indicated that all foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. A facility policy entitled Food Storage: Dry Goods dated 1/16/25, indicated that all packaged and canned food items will be kept clean, dry, and properly sealed. Observations on 4/14/25, at 10:55 a.m. and 12:21 p.m. of the facility main kitchen revealed: -A clear plastic square container with an orange/red liquid in the cooler and was not labeled and/or dated. -The drain hose leading from the ice machine storage bin to the floor drain lacked the required air gap between the hose and the floor drain, and the side of ice machine was splattered with dried food. -There was wet stacking and food crumbs between stored metal steam table inserts. -Opened and unsealed bags of sugar and flour on the bottom shelf in the dry storage area. -Food crumbs in the bottom of the clean utensil storage bins. -Dietary staff rolling silverware in paper napkins without gloves and touched eating end of the silverware when transferring items from the dishwasher basket to the utensil tray. -The floor of two ovens inside were covered in black substance, scattered with moderate amount of food pieces and crumbs. During interviews on 4/14/25, at 10:55 a.m. and 12:21 p.m. the Dietary Manager confirmed that all opened food items should have a date and be sealed properly; equipment should be cleaned between uses; pans should not be stored/stacked wet and food crumbs should be cleaned up; staff should not touch silverware/clean eating surface with bare hands; ovens should be cleaned regularly; and there should be an air gap between the drain hose of the ice machine and floor drain. Interview on 4/14/25, at 3:30 p.m. with the Dietary Manager also confirmed there was no schedule for cleaning of kitchen appliances. Interview on 4/15/25, at 11:00 a.m. with the Director of Operations in Dietary confirmed there should be an air gap between the ice machine storage bin's drainage hose and the floor drain to prevent organism transfer from the floor and/or drain pipes to the ice machine drain hose. 28 Pa. Code 211.6(f) Dietary services 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for five of 13 residents reviewed (Residents R3, R18, R30, R64, and Closed Record CR110). Findings include: Review of facility policy entitled Baseline Care Plan dated 1/16/25, indicated A written summary of the baseline care plan shall be provided to the resident and representative . and This will be provided by completion of the comprehensive care plan. Review of Resident R3's clinical record revealed an admitted [DATE], with diagnosis that included anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and hypertension (high blood pressure). Resident R3's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R3 and/or his/her representative. Review of Resident R18's clinical record revealed an admitted [DATE], with diagnoses that included dementia (a disease of the brain that affects decision making, mood, and behaviors), diabetes mellitus (a disease affecting how blood sugar is used and regulated throughout the body), gout (a type of arthritis that causes severe swelling and pain in the joints), and polyneuropathy (a nerve disorder affecting the nerves from the spinal cord to the skin, muscles, glands, and internal organs). Resident R18's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R18 and/or his/her representative. Review of Resident R30's clinical record revealed an admitted [DATE], with diagnoses that included anxiety, obstructive sleep apnea (a condition when a person repeatedly stops and starts breathing when they are sleeping), and hypertension. Resident R30's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R30 and/or his/her representative. Review of Resident R64's clinical record revealed an admitted [DATE], with diagnosis that include chronic obstructive pulmonary disease (condition when your lungs do not have adequate air flow), anxiety, and hypertension. Resident R64's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R64 and/or his/her representative. Review of Resident CR110's clinical record revealed an admitted [DATE], with diagnoses that included cellulitis of lower limbs (a bacterial skin infection of lower legs characterized by redness, swelling, and pain), polyneuropathy, diverticulitis (an infection or inflammation in one or more small pouches in the digestive tract), and Radiculopathy (a disease of the root of a nerve, such as from a pinched nerve or a tumor). Resident CR110's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident CR110 and/or his/her representative. During an interview on 4/16/25 at 1:30 p.m. the Director of Nursing confirmed that the clinical record of Residents R3, R18, R30, R64, and CR110 lacked evidence that a written summary of the baseline care plan and order summary were provided the resident and/or his/her representative upon admission to the facility. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 201.18 (b)(1) Management

Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to provide oxygen according to physician's orders and failed to promote cleanliness and help prevent the spread of infection for four of 25 residents reviewed for respiratory services (Residents R30, R44, R48, and R64). Findings include: A facility policy dated 1/16/25, entitled Oxygen Concentrator revealed the purpose of the policy is to establish responsibilities for the care and use of oxygen concentrators. An oxygen concentrator is a medical device that extracts oxygen from room air by filtering out or separating the nitrogen from the oxygen. The oxygen passes through a filter system and is then stored within the device for delivery based on the flow meter setting. Care of the Concentrator. Filters on concentrators to be cleaned weekly. The main body cabinet should be dusted when needed and can be wiped clean with a damp cloth and mild household cleaner if necessary. Change oxygen tubing and mask/cannula weekly and as needed. Change humidifier bottle when empty, every seventy-two hours . Resident R44's clinical record revealed an admitted [DATE], with diagnoses that included Parkinsonism (a group of brain conditions that cause slowed movements, stiffness, and tremors), vascular dementia (a condition that affects the blood vessels and blood flow of the brain resulting in changes to memory, thinking, and behavior), and chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe). Resident R44's clinical record revealed a physician's order dated 2/08/25, for oxygen at 3 liters per minute (lpm) continuous for COPD. Observations on 4/15/25, at 11:05 a.m. and 4/16/25, at 9:55 a.m. revealed Resident R44 lying in bed with oxygen being delivered via nasal cannula at 3 lpm. The concentrator was observed dusty and with a dried white and brown substance down the front and on the sides. During an interview on 4/17/25, at 10:30 a.m. Licensed Practical Nurse (LPN) Employee E3 confirmed that Resident R44's concentrator filter was missing to the back of the concentrator, the filter inside the concentrator contained a dusty gray substance, and the concentrator itself was dusty with a dried substance noted down the front and sides. LPN Employee E3 further confirmed that the concentrator did not appear to be cleaned weekly and that it was missing a filter. Review of Resident R30's clinical record revealed an admitted [DATE], with diagnosis that include Anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), Obstructive Sleep Apnea (a condition when a person repeatedly stops and starts breathing when they are sleeping), and Hypertension (high blood pressure). Review of Resident R30's physician's orders revealed an order dated 1/31/25, for oxygen 2 lpm via nasal cannula (oxygen tubing that has prongs that go into the nostrils and loops around the ears to secure in place to ensure adequate oxygen delivery). Observations on 4/14/25, at 12:20 p.m., 1:50 p.m., and 2:50 p.m. revealed Resident R30 lying in bed with oxygen being administered via nasal cannula at 2 lpm. Observation of Resident R30's nasal canula revealed it lacked a date. Further observations revealed a humidification water bottle connected to the oxygen concentrator dated for 4/5/25. Review of resident R64's clinical record revealed an admitted [DATE], with diagnoses that included COPD, anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and hypertension (high blood pressure). Review of Resident R64's physician's orders revealed an order dated 2/10/25, for oxygen at 2 lpm via nasal cannula as needed to keep oxygen saturation above 90%. Observations on 4/14/25, at 12:25 p.m., 1:55 p.m. and 2:50 p.m. revealed Resident R64 lying in bed with oxygen being administered via nasal cannula at 2 lpm. Observation of Resident R64's nasal canula revealed it lacked a date. Further observations revealed a humidification water bottle connected to the oxygen concentrator dated for 4/6/25. During an interview on 4/14/25, at 2:50 p.m. the Assistant Director of Nursing (ADON) confirmed that the date on Resident R30's humidification water bottle was 4/5/25, and the date on Resident R64's humidification water bottle was 4/6/25. He/she confirmed that Resident R30 and Resident R64's nasal cannulas were lacking a date. He/she also confirmed that the humidification water bottles and the nasal cannulas should be changed weekly. Resident R48's clinical record revealed an admitted [DATE], with diagnoses that included polyosteoarthritis (a form of arthritis that affects multiple joints at the same time), dementia, and dizziness. Observation on 4/14/25, at 3:05 p.m. revealed a nebulizer (small machine that turns liquid medicine into a mist that can be easily inhaled) with a mask dated 3/15/25, in Resident R48's room. Resident R48 confirmed that he/she was not aware it was laying on his table stand and does not remember having one. Further review of Resident R48's clinical record lacked evidence of a physcian's order and/or a care plan for a nebulizer, and there was no evidence in his/her departmental progress notes (3/14/25, to present) of requiring a nebulizer. During an interview on 4/15/25, at 10:27 a.m. LPN Employee E5 confirmed the nebulizer machine on Resident R48's stand was dated for 3/15/25, and that there was no current order for the nebulizer and that he/she does not ever remember Resident R48 having them ordered. 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.10(c) Resident care policies

Based on review of clinical records and resident and staff interviews, it was determined that the facility failed to ensure that physician visits were conducted at least once every 60 days for three of three residents reviewed (R15, R19, and R26). Findings include: Interview on 4/15/25, at 1:35 p.m. with Resident R15 revealed that he/she had not seen their physician since his/her prior physician had stopped coming to the facility. He/she expressed that he/she has only seen the nurse practitioner. Interview on 4/15/25, at 2:00 p.m. with Resident R19 revealed that he/she has only seen a nurse practitioner since their last physician stopped coming to the facility, which was sometime last summer. Interview on 4/14/25, at 12:15 p.m. with Resident R26 revealed that he/she has not seen their physician since his/her prior physician stopped coming to the facility. He/she expressed that the last time they saw their physician was sometime last summer. He/she expressed that they have only seen the nurse practitioner. Interviews on 4/15/25, at 2:00 p.m. during resident council meeting revealed four out of five residents attending expressed that they have not seen a physician since their previous physician stopped coming to the facility. They also expressed that they have only seen a nurse practitioner. Review of Resident R15's clinical record revealed a physician note dated 7/18/24, from resident's previous physician. The resident's clinical record lacked evidence of physician visits between August 2024 through December 2024. Further review revealed physician notes from 1/16/25, 3/13/25, and 4/10/25. All three visit notes were signed by both the nurse practitioner and the physician. The physician notes were not clear definitely as to who actually saw Resident R15. Review of Resident R19's clinical record revealed a physician note from 7/18/24, from resident's previous physician. The resident's clinical record lacked evidence of physician visits between August 2024 through December 2024. Further review revealed physician notes from 1/16/25, 3/13/25, and 3/26/25. All three visit notes were signed by both the nurse practitioner and the physician. The physician notes were not clear definitely as to who actually saw Resident R19. Review of Resident R26's clinical record revealed a physician note from 7/18/24, from resident's previous physician. Resident's clinical record lacked evidence of physician visits between August 2024 through December 2024. Further review revealed physician notes from 1/16/25, 2/20/25, 3/20/25, and 4/3/25. All four visit notes were signed by both the nurse practitioner and the physician. The physician notes were not clear definitely as to who actually saw Resident R26. During an interview on 4/17/25, at 1:00 p.m. the Assistant Director of Nursing (ADON) confirmed that the physician and the nurse practitioner come to the facility for visits on different days. The ADON also confirmed that there was no evidence of who made visits on the dates on the physician visit's documentation and that Resident R15, R19, and R26's clinical records had no evidence that they were definitely seen by their physician between August 2024 and December 2024. He/she also confirmed that all residents should be seen by their physician every 60 days. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.5(f)(ii)(vii) Medical records

Based on review of facility policy, observation and staff interview, it was determined that the facility failed to ensure that waste was properly contained in dumpsters or compactors with lids or otherwise covered, and the garbage storage area was maintained in a sanitary condition to prevent the potential of harborage and feeding of pests for one of one garbage storage areas. Findings include: A facility policy entitled Disposal of Garbage and Refuse dated 1/16/25, indicated that refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or cover; containers and dumpsters shall be kept covered when not being loaded; dumpsters shall be emptied according to the facility contract and garbage should not accumulate or be left outside the dumpster. Observation on 4/14/25, at 1:35 p.m. revealed four plastic rolling carts in proximity of the facility loading dock were overflowing with garbage bags. Three of the plastic carts contained clear unsealed garbage bags of cans with food remaining in a number the cans, and one plastic cart contained black and clear bags of garbage with dietary and housekeeping waste. During an interview on 4/14/25, at 2:02 p.m. the Director of Maintenance and the Nursing Home Administrator confirmed that the cart of dietary and housekeeping garbage was more than one days' worth, and that the bags containing the cans should have been loaded into the dumpster and not left sitting by the dock. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management

Based on observations, review of facility policies and documentation, and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program by failing to follow infection control guidelines from the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections and prevent cross-contamination during the COVID-19 pandemic. This failure placed the facility in an Immediate Jeopardy situation for 20 of 20 residents reviewed (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, and R20). Findings include: Review of the Pennsylvania Department of Health COVID-19 Infection Control and Outbreak Response Toolkit for Long-Term Care Version 1.1 dated February 2024, and expanded from infection prevention and control guidance from the Centers for Disease Control and Prevention (CDC) for nursing homes and Long-Term Care Facilities revealed the following: During the Outbreak: COVID-19 Outbreak Management and Control Measures included: 1.Identify and Isolate First Case. a. Isolate with transmission-based precautions (TBP) on COVID-19 Care Unit in accordance with most up-to-date isolation guidance or provide source control to positive resident and isolate in room (ideally residents should be placed in a single-person room). b. Place TBP signs on the door to indicate to those entering the COVID-19 Care Unit/room of the personal protective equipment (PPE) requirements when providing care to residents with COVID-19. c. Ensure all required PPE is available including N95 or higher-level respirator, gowns, gloves, and eye protection and is worn. d. Reinforce core infection prevention practices among residents, visitors, and healthcare personnel (HCP) including hand hygiene, appropriate use of PPE, environmental cleaning, and disinfection. 2.Identify Additional Cases and Exposures. a. Exposed asymptomatic residents and HCP should be tested with a series of up to three viral tests. b. Determine approach (contact-tracing, unit-based, facility-based). c. Identify exposures because of close contact. d. Test exposures immediately (but not within 24 hours of exposure) and if negative, another test at 48 hours, and if negative another test 48 hours later. Evaluation and Monitoring of Residents included: Older adults with COVID-19 may not show common symptoms such as fever or respiratory symptoms, and it is important to assess for other symptoms such as: 1. Fever or chills 2. Cough 3. Shortness of breath 4. Fatigue 5. Muscle or body aches 6. Headache 7. New loss of taste or smell 8. Sore throat 9. Congestion or runny nose 10. Nausea or vomiting 11. Diarrhea With identification of any COVID-19 symptoms, implement prompt isolation and further evaluation for COVID-19 infection. During an interview on 7/31/24, at 11:50 a.m. the Infection Preventionist (IP) confirmed that the facility does not COVID-19 test residents unless they present with a fever, and that the facility follows, PAHAN 741, New Respiratory Virus Guidance (General Guidance for Community Settings) dated 3/15/24, which indicated to refer to CDC guidance and that fever is listed at the top of the symptom list, and that residents must have a fever before any other symptoms are considered to testing. During an interview on 8/01/24, at 1:37 p.m. the Director of Nursing (DON) and Assistant Director of Nursing (ADON), confirmed the facility only tests for COVID when the resident presents a fever, and that residents are isolated and watched, and that the facility follows CDC guidance by testing for COVID-19 when a resident presents with a fever. Review of facility policy provided to the surveyor on 8/01/24, entitled, [NAME] Care Center COVID-19 (revised 11/01/23), included: 1.Residents with suspected COVID-19: a. Place the resident in a single-person room, or cohort with other simultaneously identified known COVID-19, exposures or symptoms and remain in their current location pending test results. b. Initiate TBP per CDC. c. PPE-N95 or higher respirator, eye protection, gown, and gloves. d. Roommates of residents confirmed COVID-19 are considered to have close contact. 2.Residents who have close contact to someone with COVID-19 will have a series of three viral test, immediately (but not earlier than 24 hours after exposure), and, if negative, again in 48 hours after the first negative test, if negative, again in 48 hours after the second negative test. 3.Residents with confirmed COVID-19 infection a. Place resident in a single person room, door should remain closed if safe, or cohort with other residents with the same respiratory pathogen. b. Initiate TBP (N95 or higher respirator, eye protection, gown, and gloves). c. Resident will remain in their room during this time. 4.Symptomatic testing of residents who have signs or symptoms of COVID-19 as soon as possible and placed on TBP pending test results. Review of clinical records and facility documents revealed: Resident R1 was readmitted from the hospital on 7/26/24, with COVID-19, and remained with roommate Resident R2 who tested positive on 7/28/24, and experienced a fever and cough. Resident R3 tested positive on 7/28/24, and experienced cough, lethargy, increased confusion, and nausea, and remained with roommate Resident R4 who was not tested and discharged to home on 7/30/24. Resident R5 tested positive on 7/28/24, and experienced a fever, cough, lethargy, nausea and vomiting, and remained with roommate Resident R6 who tested positive on 8/01/24, and experienced fatigue. Resident R7 experienced difficulty breathing, and lethargy on 7/20/24, and requested to be sent to the hospital where he/she tested positive, and his/her roommate (Resident R8) was tested on [DATE], and was negative. Resident R9 tested positive on 7/30/24, and experienced a fever, increased confusion, rambling speech, and remained with roommate Resident R10 who tested negative on 8/02/24, and who was asymptomatic. Resident R11 experienced low oxygen saturations, was difficult to arouse, productive cough on 7/24/24, and family requested to be sent to the hospital where he/she tested positive, and his/her roommate (Resident R12) was tested on [DATE], and was negative and asymptomatic. Resident R13 tested positive on 7/28/24, and experienced a fever, cough, lethargy, and increased confusion, and remained with roommate Resident R14 who tested negative on 7/28/24, and experienced a fever, cough, lethargy, and nausea, and tested negative again on 8/01/24. Resident R15 experienced lethargy, disorientation, confusion, on 7/19/24, and on 7/26/24, and was sent to the hospital and diagnosed with COVID-19, his/her roommate (Resident R16) tested positive on 7/28/24, and experienced a fever, cough, lethargy, and nausea. Further review of clinical records revealed: On 7/27/24, Resident R17 experienced lethargy, cough, cyanosis (bluish color), wheezing, and fever and was not tested for COVID-19. On 7/25/24, Resident R18 experienced abnormal lung sounds and cough, and continued to exhibit respiratory symptoms and lethargy and was not tested for COVID-19. On 7/16/24, Resident R19 experienced lethargy, headache, nasal congestion, sore throat, harsh cough, and continued through 7/23/24, and was not tested for COVID-19. On 7/17/24, Resident R20 experienced headache, sore throat, cough, and continued through 7/23/24, and was not tested for COVID-19. Observations on 8/01/24, between 12:10 p.m. and 12:25 p.m. revealed COVID positive resident Rooms 201, 202, 203, 104, 110, 108, 109, and 107 lacked signage indicating the presence of a respiratory infection and the necessary precautions and lacked provision of appropriate PPE upon entry into COVID positive resident rooms. During an interview on 8/01/24, at approximately 12:30 p.m. Registered Nurse Employee E1 confirmed the lack of signage and provision of PPE at COVID positive resident rooms, and that not all staff wear N95's when entering COVID positive resident rooms. During an interview on 8/01/24, at 2:45 p.m. the ADON confirmed that COVID positive resident rooms lacked signage, and the provision of PPE. The DON and ADON were made aware that an Immediate Jeopardy (IJ) existed for 12 of 12 residents in the facility on 8/01/24, at 4:32 p.m. and a corrective action plan was requested and the IJ Template was provided. On 8/01/24, at 6:43 p.m. an acceptable corrective action plan was approved which included the following interventions: 1. Appropriate signage and PPE were immediately placed by the entry of the COVID-19 positive rooms. 2. Roommates of all residents that tested positive for COVID-19 will be immediately tested if they have not yet been tested . 3. Residents will be moved to the appropriate rooms with COVID-19 positive residents separate from residents that are not COVID-19 positive. 4. The facility will then test all residents for COVID-19 to ensure we are cohorting the residents as appropriate. 5. Upon plan approval all staff will be educated on proper PPE and signage for rooms that have COVID-19 residents. The nursing staff will be educated on the infection control policy. 6. Upon plan approval the staff that are currently in the facility will immediately be educated on these policies. Any employees not currently in the facility will be educated prior to the start of their next scheduled shift. 7. Monitoring will continue for all residents with signs and symptoms of COVID-19. Testing will be performed immediately when signs and symptoms are identified. Roommates will be tested as well. Appropriate signage and PPE will be placed immediately. 8. The DON or designee to audit a. all residents who are symptomatic each day during morning clinical meeting. b. all newly diagnosed residents for proper signage and PPE upon diagnosis. c. facility staff compliance with isolation and PPE directives three times a week on random shifts during the outbreak. 9. the facility will hold ad hoc QAPI to address COVID-19 outbreak in facility to ensure proper adherence to state guidelines and directives. 10. The facility will provide education to all management staff including the facility infection preventionist regarding proper signage, PPE, and measures to be implemented during COVID-19 outbreak in the facility. The corrective action plan was verified as implemented and the Immediate Jeopardy was removed on 8/02/24, at 2:16 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, and facility documentation and resident and staff interviews, it was determined that the facility failed to provide necessary precautionary measures to maintain resident safety and prevent injury during transport in a wheelchair resulting in actual harm of a fractured tibia for one of 18 residents reviewed (Resident R9). Findings include: Review of facility policy entitled Assistive Devices and Equipment dated 1/18/23, indicated, Residents, family, and visitors are trained, as indicated, on the safe use of equipment and devices and Staff practices-staff are required to demonstrate competency on the use of devices and equipment and are available to assist and supervise residents as needed. Review of the clinical record revealed that Resident R9 was admitted to the facility on [DATE], with diagnoses that included avulsion of the left and right eye (loss of eyesight), history of pulmonary embolism (blood clot in the lung), gout (pain and swelling in joints), hypertension (high blood pressure), and abnormalities of gait and mobility. Review of the Minimum Data Set (MDS-a federally mandated standardized assessment process conducted to plan resident care) assessment dated [DATE], revealed a BIMS (Brief Interview for Mental Status-a tool used to assess cognitive function) with score of 15, that indicates intact cognition. Review of the past 30 days of Resident R9's tasks which is used by the Nursing Assistants (NA) to provide care and document on residents indicated that from 5/16/23-6/14/23, Resident R9's Ambulation/Locomotion task was non-ambulatory. Uses wheelchair with pressure relief cushion, back cushion, calf pad, leg rests always on for transport. Review of the initial facility incident report dated 5/17/23, revealed a staff description that Resident was being pushed down the hallway by aide and resident's left foot was pulled under wheelchair. Resident R9's description of the event was that staff pushed her knee up against something and believes her knee was twisted. Facility incident report also included staff statements at the time of the incident which all revealed that the leg rests were not on the wheelchair at the time of the incident. Review of nursing progress notes revealed on 5/18/23, at 11:08 a.m. a STAT (immediate) x-ray of the left lower extremity, from the hip to foot and pelvis was ordered. The results were called in to the Certified Nurse Practitioner on 5/18/23, at 4:08 p.m. which indicated that Resident R9 had a left acute non-displaced proximal fracture, new orders were received at this time. Interview with Resident R9 on 6/13/23, at approximately 11:30 a.m. revealed that he/she was being pushed in his/her wheelchair without the leg rests on to get a shower. He/she expressed that he/she always wants the leg rests on the wheelchair because he/she is blind. Resident R9 expressed that his/her left leg was run into something and got caught, which broke his/her shin. He/she revealed that when this happened, he/she hollered out in pain and asked to be placed back into bed. During an interview on 6/14/23, at 1:00 p.m. the Director of Nursing (DON) confirmed the wheelchair leg rests are always to be on the resident's wheelchair during transport. The DON confirmed that during the Resident R9's transport on 5/17/23, wheelchair leg rests were not in place and the resident sustained a fractured left tibia. The DON confirmed that Resident R9 always insists that the leg rest are always in place. 28 Pa. Code 211.12 (d)(3)(5) Nursing services 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policy, facility documentation and the clinical record and staff interview, it was determined that the facility failed to assess a resident in response to a change in condition, resulting in harm, for one of three residents reviewed (Resident CR2). Findings include: The facility policy titled, Change in Resident Condition, dated 1/21/2015, indicated that in response to a resident's change in condition, staff should promptly notify the Registered Nurse Manager, the resident, his or her attending physician and representative (family) of significant changes in the resident's physical, mental, psychosocial or medical condition. The admission record revealed that Resident CR2 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. The facility incident investigation documentation, dated 6/14/2015, revealed that on 6/8/2015, at 5:30 a.m., Resident CR2 experienced a change in condition, did not respond to verbal stimuli or touch and that night shift Licensed Practical Nurse (LPN) Employee E1, stated that he/she and a nurse aide were unable to obtain a blood pressure. The facility incident investigation documentation, dated 6/14/2015, indicated that Resident CR2's medication was held on 6/8/2015, at 6:00 a.m., as documented by night shift LPN Employee E1, the resident was, not responding appropriately to administer the medication and that Resident CR2 was lethargic and barely responding. A witness statement completed by night shift Registered Nurse Manager Employee E3, on 6/16/2015, stated that on 6/8/2015, at approximately 6:15 a.m., she received a phone call from night shift LPN Employee E1 indicating that Resident CR2's urine output was low for the shift and that the resident had not been eating or drinking well the last few days and, not once during this conversation was any reference made to the decline in Resident CR2's cognitive state. A witness statement completed by day shift LPN Employee E2, in the investigation indicated that the resident was administered eye drops on 6/8/2015, at 7:20 a.m., and the resident opened his/her eyes and looked at me. The clinical record lacked evidence that Resident CR2 was assessed by a professional nurse in response to the change in condition. The facility Weights and Vitals Summary form for Resident CR2, indicated that the last blood pressure was taken on 6/7/2015, at 2:52 p.m. A nurses' note, dated 6/8/2015, at 8:36 a.m., indicated that Resident CR2 arrived at a wound clinic appointment with the skin cool to touch and unresponsive. Resident CR2 was sent to the emergency room . A nurses' note dated 6/8/2015, at 10:59 a.m., revealed that Resident CR2 was admitted to the Intensive Care Unit with a [DIAGNOSES REDACTED]. A nurses' note dated 6/12/2015, at 6:17 a.m., indicated that Resident CR2 had ceased to breathe at 2:35 a.m. in the hospital. The Event Reporting System (ERS) report submitted to the state survey agency, dated 6/26/2015, indicated that septic shock was not present as a [DIAGNOSES REDACTED]. During an interview on 7/8/2015, at 2:00 p.m., the Director of Nursing confirmed that there was no documentation in Resident CR2's clinical record regarding the change in the resident's condition, that the physician was not notified of the change in condition and that no assessment was done in response to the decline. During an interview on 7/8/2015, at 2:45 p.m., Resident CR2's physician confirmed that he/she was not notified of the change in condition, was unaware that the staff were unable to obtain a blood pressure and stated that Resident CR2 had multiple medical issues and a poor prognosis prior to this event and that the cause of death was [MEDICAL CONDITION]. 42 CFR 483.25 Provide Care/Services For Highest Well Being. Previously cited 02/27/2015. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 02/27/2015.

Based on review of clinical records and facility policies and staff interviews, it was determined that the facility failed to maintain an environment free of accident hazards for one of one sampled residents (Resident CR1), resulting in actual harm. The findings include: The admission record indicated that Resident CR1 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The care plan, dated [DATE], indicated that Resident CR1 would receive ground meat with gravy for all meals and only "soft easy to chew foods". The name card included on the lunch tray indicated that Resident CR1 required "ground meat with gravy." The dietary "Accuracy of Tray Line" policy, dated [DATE], stated that each tray would be checked to ensure that foods were served as listed on the menu and that problems with tray accuracy would be resolved immediately. The nursing "Nutrition/Feeding" policy, dated [DATE], indicated that staff would "identify the resident's tray by checking the name card" and "provide beverages as indicated." The policy failed to instruct nursing staff to check the tray for proper diet. The dietary menu and diet extension sheet for [DATE], indicated that Resident CR1 and others with a physician order [REDACTED]. The incident/accident report, dated [DATE], indicated that on [DATE], at 12:15 p.m., Resident CR1 choked while eating lunch and died . During an interview on [DATE], at 11:10 a.m. Director of Nutritional Services Employee E1 stated that on [DATE], Resident CR1 received a whole hot dog for lunch, rather than the required ground meat. During an interview on [DATE], at 2:25 p.m., Registered Nurse (RN) Employee E1 stated that Nurse Aide Employee E3 reported that Resident CR1 was choking, that RN Employee E1 retrieved string beans and a piece of hot dog from Resident CR1's mouth and was unable to revive Resident CR1. During an interview on [DATE], at 2:30 p.m., Nurse Aide Employee E4 stated that he/she provided Resident CR1 with her lunch tray on [DATE], and did not check the tray to confirm that the proper diet was served. 28 Pa. Code 211.6(c)(d) Dietary services. 28 Pa. Code 211.12(d)(3)(5) Nursing services. Previously cited [DATE], [DATE]. 28 Pa. Code 201.18(a)(d) Management. Previously cited [DATE].