Every finding on record at Crestview Center

Based on observation and interviews with residents and staff, it was determined that the facility failed to maintain an effective pest control program related to flying insects on two of three nursing units observed (North Unit, and East Unit). Findings Include: On July 28, 2026, at 12:37 p.m., an interview was conducted with Resident R77 while she/he was eating lunch in room [ROOM NUMBER]. During the interview, flies were observed flying around the resident's lunch tray. Resident R77 reported that she/he had informed the nursing staff about the flies the previous day. The observation was confirmed by Employee E6, the maintenance director, who was present in the room. Observations on July 28, 2026, from 10:26 a.m., through July 28, 2026, at 12:26 p.m. of North Unit, revealed there were flying insects that resembled house flies in the Resident Rooms, room numbers 115, 117, and 123. On July 28, 2026, at the time of the observation of flies in each resident rooms, the findings were confirmed with Residents R81, R139, R148, and R158. Observations on July 31, 2026, from 9:25 a.m., through July 28, 2026, at 10:24 a.m. of North Unit, revealed there were flying insects that resembled house flies in the Resident Rooms, room numbers 115, 117, 123, and 127. Interview on July 31, 2026, at 10:24 a.m., with Licensed Nurses, E7, and E8, confirmed the findings. 28 Pa Code 201.14 (a) Responsibility of licensee. 28 Pa Code 201.18 (a) Management.

Based on interviews and the review of facility documentation, it was determined that the facility failed to ensure that a complete and thorough investigation was conducted related to a bruise of unknown origin for one out of 30 residents reviewed (Resident R31).Findings include: Review of the facility's policy. Abuse Prohibition, with a revision date of November 15, 2025, stated that injuries of unknown source will be investigated to determine if abuse or neglect is suspected. Continued review of the policy indicated that an investigation will be initiated within 24 hours of an abuse, and that it will be thoroughly documented. Review Resident R31's clinical record revealed the resident has the following diagnoses: hypertension (high blood pressure); adult failure to thrive (characterized by weight loss, decreased appetite, poor nutrition, functional disability, cognitive impairment, and increased vulnerability resulting from underlying medical, psychiatric, functional, or social conditions); dementia (a term that describes a group of symptoms affecting memory, thinking and social abilities, and interfere with an individual's daily life), and repeated falls. Review of the Resident R31's Quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated July 10, 2026, indicated that the resident is cognitively impaired. Review of a nursing note dated June 8, 2026, at 9:36 a.m. stated that a bruise was found on the Resident R31's forearm, described as a bluish bruise noted on dorsal aspect of left forearm. Review of the facility investigation indicated that the bruise was found by the resident's assigned nurse aide (Employee E16) who was assigned to the resident on June 8, 2026, during the 7:00 a.m. through 3:00 p.m. nursing shift. Employee E16 notified the licensed nurse (Employee E8). Review of the investigation did not show evidence that any other nurses on any other shifts prior to the discovery of the bruise on June 8, 2026, at 9:30 a.m. were interviewed regarding anything that they may have witnessed, observed, overheard, or know of something that would have provided any additional insight/information on the investigation regarding the Resident R31's bruise of unknown origin. Review of the investigation indicated that nurse aides and one licensed nurse were interviewed and worked on the following dates and shifts:worked June 5th 7-3 licensed nurse, Employee E8worked June 6th 7-3 nurse aide, Employee E17worked June 7th 11-7 nurse aide, Employee E18worked June 7th 7-3 nurse aide, Employee E17worked June 8th 7-3 licensed nurse, Employee E8worked June 8th 7-3 nurse aide, Employee E16worked June 8th 7-3 nurse aide, Employee E19worked June 8th 3-11 nurse aide, Employee E19 Continued review of facility documentation and the investigation did not show evidence that any other nurse aides who may have worked and were not assigned to the resident were interviewed on any other shifts prior to June 8, 2026, to see if they may have witnessed, observed, overheard, or know of something that would have provided any additional insight/information on the investigation regarding the Resident R31's bruise of unknown origin. In addition, review of the investigation did not show evidence that the facility interviewed any other department employees, such as the activity department to see if the resident participated and/or was present in any activity during the days prior to the discovery of the bruise of unknown origin. There was no documented evidence that staff members of the activity department were interviewed to see if they may have witnessed, observed, overheard, or know of something that would have provided any additional insight/information on the investigation regarding the Resident R31's bruise of unknown origin. Continued review of the investigation also did not show evidence that other departments such as therapy (e.g. physical therapy, occupational therapy) were at least interviewed to see if the resident participated in any therapy activities at any time on or prior to the discovery of the bruise of unknown origin. There was no documented evidence that staff members of the therapy department were interviewed to see if they may have witnessed, observed, overheard, or know of something that would have provided any additional insight/information on the investigation regarding the Resident R31's bruise of unknown origin. During an interview with the Director of Nursing (DON) on August 3, 2026, at 2:230 p.m. The investigation was reviewed and it was discussed with the DON that there were missing interviews from nursing staff who worked shifts prior to the June 8, 2026, discovery of the bruise of unknown origin for the resident to ensure a complete and through investigation. It was also discussed that no additional staff from other departments were interviewed that they resident may have contact with prior to the discovery of the bruise on June 8, 2026, to ensure a complete and through investigation 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.29 (c) Resident rights. 28 Pa. Code 211.10 (d) Resident care policies.

Based on interviews and the review of clinical records, it was determined that the facility failed to ensure that a physician was notified of a resident weight gain for one out of 30 residents reviewed (Resident R70). Findings include: Review of Resident R70's clinical record included the following diagnoses: dementia (a group of symptoms affecting memory, thinking and social abilities), post-traumatic stress disorder (a mental health condition that's caused by an extremely stressful or terrifying by either being part of it or witnessing it); anxiety (intense, excessive and persistent worry and fear about everyday situations), history of alcohol abuse, and cardiomyopathy (a condition that causes the heart to have a harder time pumping blood to the rest of the body, can lead to symptoms of heart failure and other serious heart conditions). Review of Resident R70's Comprehensive Minimum Data Set Assessment (MDS-a periodic assessment of a resident's needs) dated May 2, 2026, indicated that the resident was cognitively impaired. Continued review of Resident R70's clinical record revealed a physician order dated May 6, 2026, for the physician to be notified of a weight gain of greater than 2 pounds in 1 day or 5 pounds in a week in the morning: Notify the provider if: gain>2lbs in 1 day, or 5lbs in a week in the morning. Review of the resident's weight for the following dates indicated that when the weight was taken, the resident had a weight increase of over 2 pounds: The resident's weight recorded by nursing staff on May 8, 2026, indicated that the resident's weight was recorded as 152.6. Review of the resident's weight on May 9, 2026, was recorded as being 155.4, indicating a 2.8-pound weight gain since it was recorded on May 8, 2026. The resident's weight recorded by nursing staff on May 14, 2026, indicated that the resident's weight was recorded as being 154.2 pounds. The resident's weight on May 15, 2026, was recorded by nursing staff as being 157.2, indicating a 3-pound weight gain since it was recorded on May 14, 2026. The resident's weight recorded by nursing staff on July 1, 2026, indicated that the resident's weight was recorded as being 153.7 pounds. Review of the resident's weight on July 2, 2026, was recorded as being 158 pounds, indicating a 4.3-pound weight gain since it was recorded on July 1, 2026. Continued review of the clinical record did not show evidence that the physician was notified regarding any of Resident R70's weight gains to ensure the implementation of any additional interventions should they have been needed to be put in place as a result of the weight increase. During an interview with the Director of Nursing (DON) on July 31, 2026, at 2:52 p.m. the DON confirmed that there was no documentation to show evidence that the facility notified the physician of the resident's weight increase, as ordered. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa Code 211.12 (d)(5) Nursing services.

Based on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan for three of 30 Residents reviewed (R4, R10, R14). Findings include: Review of the Facility Policy and Procedure on Person Centered Care Plan, revised on September 15, 2025, indicated that the Center must develop and implement a person-centered care plan for each Resident consistent with patient rights, measurable objectives and timeframes to meet a Resident's medical, nursing and mental and psychosocial needs and all services that meet professional standards of quality. It also stated that a comprehensive, individualized care plan will be developed within seven (7) days after completion of the comprehensive assessment (admission, annual, or significant change in status) and review and revise the care plan after each assessment. A review of the clinical record for Resident R14 revealed an admission date of September 2, 2025, with a diagnosis of post traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing a terrifying event). A review of the psychiatry progress note dated July 27, 2026, for Resident R14 indicated a diagnosis of PTSD. The clinical record did not identify any triggers or the reason the resident has PTSD. A review of the comprehensive care plan dated September 3, 2025, for Resident R14 did not reveal a care plan addressing the PTSD diagnosis. On July 30, 2026, at 12:34 p.m., an interview was conducted with Resident R14. The resident reported that, due to being a firefighter, his/her triggers for PTSD include hearing people argue and waiting a long time for care to be provided. The resident additionally stated that he/she becomes triggered after waiting approximately four hours for a nurse and by hearing arguing. A review of the clinical record for Resident R10 revealed an admission date of October 24, 2025, with a diagnosis of post traumatic stress disorder (PTSD). A review of the comprehensive care plan dated November 5, 2025, for Resident R10 did not reveal a care plan addressing the PTSD diagnosis. On July 31, 2026, at 10:40 a.m., an interview with Resident R10 revealed that the PTSD diagnosis was related to a car accident that occurred 20 years ago. Resident R10 stated that he/she does not feel safe getting into a car and becomes fearful and sweaty when watching movies that involve car accidents or when in environments that remind him/her of such events. On July 29, 2026, at 12:23 p.m., the Director of Nursing confirmed that Resident R10 and Resident R14 have PTSD diagnoses; however, no care plan has been developed to address their triggers. Review of Resident R4's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included Post Traumatic Stress Disorder (PTSD). Review of R4's Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated June 19, 2026, revealed that R4 has active diagnosis of Post Traumatic Stress Disorder. Review of the care plan for Resident R4 reveled that there were no focus, outcomes (goals), and interventions, care- planned for treating Post Traumatic Stress Disorder. On July 31, 2026, at 10:26 a.m., interview with the DON confirmed the above findings. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.10 (d)(5) Nursing services.

Based on facility policy review, personnel file review, and staff interview, it was determined that the facility failed to perform criminal history background checks prior to hire for one of five personnel files reviewed (Employee 10).Findings Include: Review of the facility policy titled Abuse Prohibition, revised November 14, 2025, revealed that The Center will screen potential employees for a history of abuse, neglect, or mistreatment of patients, including attempting to obtain information from previous and/or current employers, and checking with the appropriate licensing boards and registries. Review of the personnel file for certified nursing assistant (CNA) Employee 10 indicated that the employee was hired by the staffing agency on February 9, 2026, and began working at the facility on February 16, 2026, and again on June 22, 2026. Further review indicated that there was no proof of a Pennsylvania State Police background check. An interview was conducted with the Nursing Home Administrator, Employee E1, on July 30, 2026, at approximately 2:30 p.m. Employee E1 provided a Pennsylvania State Police background check that was completed on July 30, 2026. Nursing home administrator, Employee E1, was unable to provide documented evidence that a criminal background check was completed before the employee began working at the facility. 28 Pa. Code 201.18 (b)(1) Management.

Based on interviews and review of clinical records, it was determined that the facility failed to ensure that a resident who lost his dentures was promptly referred to the dentist and failed to ensure there was documentation in the clinical record indicating that the resident was properly assessed to ensure the resident was able to adequately eat and drink, for one out of 30 residents reviewed (Resident R70).Findings include: Review of Resident R70's clinical record revealed the resident has the following diagnoses: dementia (a group of symptoms affecting memory, thinking and social abilities), post-traumatic stress disorder (a mental health condition that's caused by an extremely stressful or terrifying by either being part of it or witnessing it); anxiety (intense, excessive and persistent worry and fear about everyday situations), history of alcohol abuse, and cardiomyopathy (a condition that causes the heart to have a harder time pumping blood to the rest of the body, can lead to symptoms of heart failure and other serious heart conditions). Review of Resident R70's Comprehensive Minimum Data Set Assessment (MDS-a periodic assessment of a resident's needs) dated May 2, 2026, indicated that the resident is cognitively impaired. Review of Resident R70's clinical record revealed a physician order dated October 2, 2022, that revealed Resident R70 wears full upper dentures, and to apply dentures in the morning and remove at night. The physician order specified that the dentures be locked in the nurse's cart at night for safekeeping. Review Resident R70's clinical record revealed various nursing notes from November 1, 2025, through July 31, 2026, that indicated that the resident had lost his/her dentures for at least an 8-month time period. Review of Resident R70's clinical record revealed nursing notes from November 2025 through July 2026 that documented the dentures as either missing or not observed by nursing staff for dates that include, but are not limited to the following: 11/10/25 at 8:46 a.m. denture documented as missing11/1/25 at 9:03 a.m. denture documented as missing12/2/25 at 9:27 a.m. dentures documented as missing12/16/25 at 10:04 a.m. dentures documented as missing 1/19/26 at 9:49 a.m. dentures documented as not being observed on this shift.3/7/26 at 9:16 a.m. no denture was documented3/30/26 at 9:32 a.m. dentures documented as missing4/5/26 at 10:02 a.m. dentures documented as missing4/13/26 at 10:01 a.m. dentures documented as missing5/11/26 at 10:13 a.m. dentures documented as missing5/18/26 at 10:26 a.m. dentures documented as missing6/2/26 at 9:44 a.m. dentures documented as missing6/18/26 at 10:37 a.m. dentures documented as missing7/2/26 at 9:15 a.m. dentures documented as missing7/13/26 at 8:12 a.m. dentures documented as missing7/24/26 at 9:04 a.m. dentures documented as missing7/31/26 at 8:46 a.m. dentures documented as missing Review of Resident R70's clinical record did not show evidence that the facility referred the resident to the dentist after losing his/her dentures. Continued review of the clinical record did not show evidence of what the facility did to ensure that the resident was able to adequately eat and drink as a result of the loss of his dentures. During an interview with the Director of Nursing (DON) on July 31, 2026, at 2:35 p.m. the DON reported that the facility was not aware of how long the dentures has been missing. It was concluded during the interview with the DON that the facility could not produce any evidence that the resident was referred to the dentist after the loss of his/her dentures, and that there was no documentation in the clinical record to show evidence that the resident was properly assessed to ensure that he/she was able to adequately eat and drink after the loss of his/her dentures. 28 Pa. Code 201.29 (a) Resident Rights. 28 Pa Code 211.12 (d)(5) Nursing services.

Based on document review and staff interview, it was determined that the facility failed to ensure notification to the Office of the State Long-Term Care Ombudsman of the transfer or discharge of its residents for one of three closed records reviewed (Residents 165)Findings Include:Review of Resident 2's clinical record revealed an admission date of November 12, 2025.Review of Resident 2's census information revealed a discharge date of May 8, 2026, with the status of leaving against medical advice (AMA).Continued review of Resident 165's closed record revealed no evidence of a notice of transfer or discharge being reported to the Long Term Care Ombudsman.An interview with the Social Worker, Employee E20, on July 31, 2026, at 1:30 p.m., revealed that there was no documentation to validate that notices of transfers or discharges had been sent to, or communicated with, the Office of the State Long Term Care Ombudsman.28 Pa. Code 201.14 (a) Responsibility of licensee

Based on clinical record review, selected facility policies, and staff interviews, it was determined that the facility failed to ensure that a resident's representative was informed of treatment options, as well as the risks and benefits of psychotropic medications, for one of five residents reviewed (Resident 12).Findings include: A review of the facility policy titled Informed Consent Annex A, last reviewed by the facility in June 2025, revealed: Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warning for antipsychotic medications. A clinical record review revealed that Resident 12 was admitted to the facility on [DATE], with diagnoses including unspecified mood disorder and post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing a terrifying event). A review of an admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 4, 2026, revealed that Resident 12 has severely impaired cognition, with a BIMS score of 4. The Brief Interview for Mental Status (BIMS), a tool within the Cognitive Section of the MDS, assesses the resident's attention, orientation, and ability to register and recall new information; a score of 0 through 7 indicates severely impaired cognition. Review of Resident R12's clinical record revealed a physician order dated May 29, 2026, for Seroquel oral tablet 25 milligrams (mg) (an antipsychotic medication used to treat depression), to give 0.5 tablet by mouth once daily for anxiety/agitation for 14 days. Review of Resident R12's clinical record revealed a physician order dated June 16, 2026, for Seroquel 25 milligrams oral tablet, to give one tablet by mouth at bedtime for 30 days for depression (mood disorder characterized by low mood, a feeling of sadness, and a general loss of interest in things). An interview with the Director of Nursing on July 31, 2026, at 11:53 a.m. confirmed that there was no documentation available at the time of the survey indicating that informed consent was obtained prior to the initiation of psychotropic medication for Resident 12. Specifically, there was no documentation showing that the resident's representative was informed of the risks and benefits or offered alternative treatment options. 28 Pa Code 201.29(a) Resident rights. 28 Pa Code 211.10 (a)(c) Resident care policies.

Based on clinical record review, facility policy, facility documentation, and staff interviews, it was determined that the facility failed to ensure residents were free from verbal abuse for one out of 30 residents reviewed (Resident R54). This deficiency was cited as past noncompliance.Findings include: Review of the facility policy titled, Abuse Prohibition revised November 14, 2025, revealed Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/patient (hereinafter patient) property, and exploitation for all patients. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptoms. Review of Resident R54's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) and anxiety (intense, excessive, persistent worry or fear). A review of an admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 2, 2026, revealed that Resident R54 has severely impaired cognition, as evidenced by a BIMS (Brief Interview for Mental Status) score of 3. The Brief Interview for Mental Status (BIMS), a tool within the Cognitive Section of the MDS, assesses the resident's attention, orientation, and ability to register and recall new information; a score of 0 through 7 indicates severely impaired cognition. Review of facility documentation submitted to the State Survey Agency on June 22, 2026, revealed on June 22, 2026, at approximately 12:00 p.m. several students in the facility nurse aide class reported to the social services director that nurse aide, Employee E10, was verbally abusive towards Resident R54. Nurse aide students reportedly observed Employee E10 say shut your ass up while washing Resident R54 in the bathroom. Resident R54 has cognitive impairment and denies having any concerns with the alleged perpetrator and denies anyone using inappropriate language toward him/her. The facility identified the alleged perpetrator as agency nurse aide, Employee E10, and an investigation was started immediately. Review of facility documentation and investigation revealed witness statements were obtained. Review of statement sent via email June 22, 2026, by Nurse Aide, Employee E10, revealed the employee stated on Monday, June 22, 2026, while giving care and assisting the [nurse aide] class, I was showing them how care is provided. While assisting my resident [Resident R54] with getting off the toilet, I instructed him/her to stand up so we could wash his/her private area before putting on the brief and pulling up his/her pants. The students were assisting me with my patient, kindly redirecting him/her to sit in the chair, also in a playful manner. While walking to the bathroom, I saw the class instructor said hello, introduced myself, and asked if I had any tips for first time students. I was letting the students know the right way and the wrong way to provide care, including what is allowed and not allowed in nursing facilities. Review of undated written statement by nurse aide student, Employee E11, revealed the employee reported the following: Employee E10 was using inappropriate language toward Resident R54, saying, shut your ass up. Nurse aide, Employee E10, dropped linen on the floor and continued to wash Resident R54 with the same dirty linen. Employee E10 was being aggressive with the resident. Resident R54 told nurse aide, Employee E10, that she was being aggressive and mean, and the nurse aide, Employee E10, proceeded to tell Resident R54 to shut up, making the resident feel bad. Nurse aide, Employee E10, told the nurse aide students she was going to teach them illegal ways to do things . such as making inserts inside a resident's briefs. Review of written statement by nurse aide student, Employee E12, dated June 22, 2026, revealed the employee reported the following: Resident, R54, was getting a bed bath on the toilet. Resident R54 seemed frantic and showed signs of anxiety. Resident R54 stated she/he was uncomfortable with us being in the bathroom, but nurse aide, Employee E10 kept telling the resident to be quiet and to wash his/her face. Then my classmate and I calmed the resident down, and he/she allowed us to proceed with the wash. The rag was on the floor, and nurse aide, Employee E10, picked it up and proceeded to use it to clean Resident R54's private area. She also was using inappropriate language toward Resident R54. Overall, nurse aide, Employee E10, was being disrespectful and degrading toward Resident R54. Review of written statement by nurse aide student, Employee E15, dated June 22, 2026, revealed the employee reported the following: I witnessed Employee E10 verbally abuse Resident R54. Employee E10 kept telling Resident R54 to shut up, mind his/her own business and that she was there to wash the resident up. Employee E10 kept telling Resident R54 to shut up and pushing him/her. Employee E10 then told Resident R54 she doesn't care that it's not what the resident says. I then walked out. Review of written statement by nurse aide student, Employee E13, dated June 22, 2026, revealed the employee reported the following: I am attending the nurse aide program at the facility . we were on the East Wing helping to pass out trays and observing Employee E10 performing skills. I was in the hallway when Employee E15 walked out of room [ROOM NUMBER]. She looked upset. I asked what happened, and she explained to me what she witnessed. I told her we had to report it, and we went and reported it to the social worker. Further review of facility documentation revealed the nurse aide students then privately reported the above alleged incident to Social Services on June 22, 2026, who in turn notified the Director of Nursing. Review of facility documentation and investigation revealed that allegations of verbal abuse against R54 was substantiated. Observations conducted on July 29, 2026, at 12:52 p.m., revealed Resident R54 was interviewed and was not able to recall the incident on June 22, 2026, or recollection of staff being mean to them. This deficiency was identified as past non-compliance. On June 22, 2026, following the incident, the facility immediately implemented the following corrective actions: Facility investigation was initiated on June 22, 2026. Adult Protective Services (APS), the Department of Health, the emergency contact, and the medical physician were notified on June 22, 2026. The facility's investigation revealed that the allegation of verbal abuse toward Resident R54 was substantiated on June 30, 2026. The staffing agency of the nurse aide, Employee E10, was informed of the substantiated abuse and notified that Employee E10 may not return to the facility. The incident was reported to the State Survey Agency. An emotional support visit was provided for Resident R54 by the Social Services Director, and the resident will continue to receive psychological services. Alert and oriented residents were interviewed regarding verbal abuse or inappropriate comments by staff. The grievances log for the previous three months was reviewed for any alleged reports of verbal abuse; none were identified. The Abuse Education Management Team conducted abuse education staff training, and psychology services were scheduled to follow up. Social Services follow up was planned once per week for four weeks. A resident council meeting, which included Abuse Education, was held on June 24, 2026. An ad hoc QAPI meeting occurred on June 29, 2026. The determination of the investigation was completed on June 30, 2026. Completion of Abuse Prohibition/Reporting Training was achieved as of July 14, 2026. Other actions included interviewing alert residents regarding concerns of verbal abuse. Weekly for four weeks, then monthly for two months, random interviews of five residents with BIMS > 10 on each unit were conducted to identify any potential allegations of verbal abuse. Any identified concerns would initiate an immediate, thorough investigation. The Director of Nursing (DON) or designee would conduct weekly for four weeks, then monthly for two months, random interviews of six staff members to identify any potential concerns or allegations of verbal abuse (including concerns involving residents with dementia or cognitive impairment). Any identified concerns would initiate an immediate, thorough investigation. Monitoring would continue through Quality Assurance and Performance Improvement (QAPI) meetings. Facility education records and subsequent audits were verified as complete. Staff were interviewed to confirm completion of education on the facility's policies regarding resident abuse. Additional staff interviews were conducted to verify compliance with the plan of correction. No continuing concerns were identified through record review, staff interviews, or observation. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1) Management.

Based on interviews, it was determined that the facility failed to ensure that a resident's/family member's grievance regarding was properly addressed for one out of 30 residents reviewed (Resident R151).Findings include: Review of the facility's Grievance/Concern policy with a revision date of October 15, 2024, indicated that concerns may be registered by telephone, mail, office visit, or direct outreach to staff, or with the National Compliance Department, and that upon receipt of the grievance/concern, the Grievance/Concern Form will be initiated by the staff member receiving the concern. Continued review of the policy stated that upon receipt of the Grievance/Concern Form, the Administrator or designee will taken actions that includes, but not limited to, documenting the grievance/concern on the Grievance Concern Log, and notifying the Administrator and the appropriate department manager. Continued review of the policy indicated that once the department manager is aware of the grievance, he/she will take steps that include, but not limited to contacting the person filing the grievance to acknowledge receipt, investigate the grievance, take corrective actions if needed, and offer a written resolution of the grievance which will include pertinent findings or conclusions regarding the grievance, statement on whether the grievance was confirmed or not confirmed, and any corrective actions the facility may have taken. Review of Resident R151's clinical record revealed the following diagnoses: quadriplegia (a symptom of paralysis that affects a person's limbs and body from the neck down); anoxic brain damage (a condition in which the brain loses oxygen supply for a period of time, which results in serious, permanent brain damage), and lack of coordination. Review of information received by the State Survey Agency on July 8, 2026, revealed a concern was filed that Resident R151 was being assisted getting ready for bed by two nurse aides on July 7, 2026, when the nursing supervisor burst into the room while the resident was not clothed and took his/her Hoyer pad (a pad utilized in transferring an individual who requires the use of a mechanical lift). The information received by the State Survey Agency also indicated that the nursing supervisor was described as being rude and unprofessional and could be more accommodating. Continued review of the information submitted to the State Survey Agency indicated that the complainant left a voicemail on the Director of Nursing (DON) voicemail regarding the incident and received no follow up on how it was addressed. Interview on July 31, 2026, at 12:37 p.m., with Resident R151 and his/her family member (resident representative) confirmed the above concerns. The resident representative revealed that a voicemail was left for the Director of Nursing regarding the above concerns and that there was no follow-up to the reported concerns. The resident representative indicated that she spoke with the Director of Nursing regarding the above concerns and told the Director of Nursing she left her a voicemail regarding the incident involving Resident R151 and the nursing supervisor. The resident representative stated that the Director of Nursing told her she didn't know what she was talking about and did not listen to the voicemail messages yet. Review of facility documentation and grievance concern book did not show any evidence that a grievance was filed related to the above referenced incident, that the Director of Nursing was reportedly aware of. the complaint was reviewed. During the interview, both the resident and her mother reiterated what was in the original complaint. The resident's mother also reiterated that she left a voicemail regarding the above referenced concern on the voicemail of the DON but received no follow up on what was done. The resident's mother reported that she spoke with the DON about the incident and told her that she also left her a voicemail message, regarding the incident involving the nurse supervisor and her daughter. During the interview the daughter stated that the DON reportedly told her that she did not know what she was talking about, as she did not listen to her voicemail messages yet. During an interview with the Director of Nursing, on July 31, 2026, at 10:12 a.m. the DON reported that she was aware of the above incident and received a voicemail from Resident R151's family member. During the interview, the DON confirmed that there was no documented evidence to support that prompt efforts were made to resolve the resident's concern/grievance received by voicemail regarding the July 7, 2026, incident. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 201.29 (a) Resident rights.

Based on review of clinical records, facility documentation, and interview with staff, it was determined the facility failed to ensure appropriate assessment of PRN (as needed) pain medication administration for two of two residents reviewed for pain management (Resident R2 and R18).Findings include: Review of Resident R2's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis of type 2 diabetes mellitus (condition that affects how to body uses insulin and sugar), chronic pain syndrome, and polyneuropathy (nerve disease caused by damage to the nerves). Review of Resident R2's physician order revealed an order for Tramadol HCL 50 mg 2 tablets every 6 hours as needed for pain. Review of Resident 's Medication Administration Record (MAR) for the month of July revealed the resident received PRN Tramadol with no documented pain level documented on the following dates: July 1, 2026July 2, 2026July 5, 2026July 6, 2026July 8, 2026July 9, 2026July 14, 2026July 20, 2026July 25, 2026July 26, 2026July 28, 2026 Review of Resident R2's pain assessments, nursing notes, and MAR documentation revealed there was no documented pain level assessment prior to administration of the PRN Tramadol. Review of Resident R18's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis of hemiparesis (one-sided muscle weakness) following cerebral infarction (stroke - blood clot in an artery of the brain) affecting left nondominant side, nondisplaced intertrochanteric fracture of left femur, and muscle weakness. Review of Resident R18's physician order revealed an order for Oxycodone-Acetaminophen 5-325 mg tablet PRN every 6 hours for moderate-severe pain. Review of Resident 's Medication Administration Record (MAR) for the month of July revealed the resident received PRN Oxycodone with no documented pain level on the following dates: July 11, 2026July 14, 2026 July 26, 2026 Review of Resident R18's pain assessments and MAR documentation revealed there was no documented pain level assessment prior to administration of the PRN Oxycodone. Interview on July 30, 2026, at 9:50 a.m. with Employee E2, Director of Nursing, confirmed the pain levels were not documented prior to administration of Resident R2's and R18's pain medication. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d)(1) Nursing services.

Based on review of clinical records, facility policy, and staff interview, it was determined that the facility failed to ensure the resident was assessed after a significant weight loss for one of two residents reviewed for weight loss (Resident R138). Review of facility policy Weights and Heights, revised 2026, revealed Patients are weighed upon admission and/or re-admission, then weekly for four weeks and monthly thereafter. Further review of facility policy revealed significant weight change will be reviewed by the licensed nurse. The license nurse will notify the physician and dietitian of significant weight changes, notify the physician of dietitian recommendations, notify the patient/patient representative of the weight change and dietitian recommendations, and document notifications and any ordered nutritional interventions. Clinical record review revealed Resident R138 was admitted to the facility on [DATE], with a diagnosis of Parkison's disease (progressive neurological disorder that primary affects movement), schizophrenia (serious mental health condition that affects how people, think, feel, and behave) and chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs). Further review of Resident R138's clinical record revealed the following notable weights documented:- 2/13/26: 203.2 pounds (lbs) mechanical lift- 3/1/26: 177.2 lbs mechanical fit- 3/18/26: 171.6 lbs mechanical lift Review of Resident R75's clinical record revealed a nutritional assessment was completed on March 10, 2026, and order for 4 weeks weight monitoring and reassess. Further review of Resident R138's clinical record revealed a re-weigh was not completed until March 18, 2026, in which the resident lost an additional 5.6 lbs. Interview on July 29, 2026, at 10:40 a.m. with Employee E9, Dietitian, confirmed Resident R138 was not assessed until 8 days after a significant weight loss was noted and a re-weigh was not completed until approximately 2 weeks later after the initial weight loss. 28 Pa. Code 211.12(d)(5) Nursing Services

Based on review of clinical records, facility policy, facility documentation, and interviews with residents and staff, it was determined the facility failed to ensure one of four residents reviewed was free from sexual abuse, resulting in psychosocial harm including being diagnosed with Post Traumatic Stress Disorder (Resident R1). This deficiency was identified as past noncompliance. Findings include: Review of facility policy titled, Abuse Prohibition revised 2025, revealed abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental or psychosocial well-being. Instances of abuse of all patients, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Sexual Abuse is a non-consensual sexual contact of any type with a patient. It includes but is not limited to sexual harassment, sexual coercion, or sexual assault. Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on [DATE], with diagnoses of Hemiplegia and Hemiparesis following cerebral infarction (paralysis/weakness on one side of the body commonly resulting from a stroke), Aphasia (disorder that affects how you communicate), Major Depressive Disorder, and generalized anxiety disorder. Review of Resident R1's Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated April 25, 2026; revealed the resident had a Brief Interview for Mental Status (BIMS - tool used to assess cognitive function and orientation) score of 14, indicating the resident was cognitively intact. Review of facility investigation dated May 25, 2026, revealed on May 25, 2026, at 8:50 a.m. Resident R1 reported to the Speech Therapist that nurse aide, Employee E1, kissed him/her and asked if he/she wanted a massage. Social Services Director was notified and interviewed Resident R1 further. Resident R1 reported in the morning of May 25, 2026, approximately between 2:00 a.m. and 3:00 a.m. that nurse aide, Employee E1, kissed him/her on the lips twice, called him/her beautiful and asked if he/she wanted a massage. Resident R1 consented to back massage but after massaging resident's back, nurse aide, Employee E1, began touching the resident's breasts and genital area. Resident R1 denies any penetration. Resident R1 reports he/she only consented to the massage but not the kissing. Further review of facility investigation, dated May 27, 2026, revealed email communication between Director of Nursing, Employee E2, and Nurse Aide, Employee E1. Nurse Aide, Employee E1, admitted to kissing Resident R1 on the forehead twice and telling the resident he/she is beautiful to show respect and courtesy. Nurse aide, Employee E1, reported while providing incontinence care a massage was offered and cream was applied to Resident R1's back and breasts because his/her skin was reddened. Additional review of facility investigation revealed the facility concluded the allegation of sexual abuse to be substantiated due to non-consensual kissing. Interview conducted with Resident R1 on July 1, 2026, at 8:56 a.m., observed Resident R1 became very emotional when discussing the incident which occurred on May 25, 2026. Resident R1 revealed on May 25, 2026, at approximately 3:30 a.m. Nurse Aide, Employee E1, entered the room while he/she was asleep and woke him /her up to provide incontinence care. After incontinence care was provided Nurse Aide, Employee E1, sat on Resident R1's bed, called him/her beautiful, and kissed the resident twice on the lips. Resident R1 told Nurse Aide, Employee E1, no, no then Nurse Aide, Employee E1, offered Resident R1 a massage to which the resident agreed due to past trauma and feeling pressured. Resident R1 stated Nurse Aide, Employee E1, massaged his/her back, then asked the resident to turn over and grabbed both breasts and touched genital area. Resident R1 told Nurse Aide, Employee E1, to stop which he/she did, then exited the room. Further interview with Resident R1 revealed he/she now has severe nightmares since the incident, and the incident has caused him/her to feel not whole and now don't know how to be a person. Review of Resident R1's social service progress note, dated May 25, 2026, revealed Resident observed emotionally distressed following a reported traumatic experience. Resident appeared anxious, tearful, and emotionally overwhelmed during assessment. Resident verbalized feelings of fear, discomfort, and sadness related to the incident. Review of Resident R1's psychiatry note, dated May 25, 2026, revealed (Resident R1) appeared quiet and somewhat tearful during the encounter. The patient disclosed that he/she was sexually assaulted by a male aide a few nights ago and reported inappropriate physical contact. Resident R1 stated that this event has resurfaced memories of prior sexual trauma from earlier in life, contributing to increased emotional distress. Further review of Resident R1's psychiatry note revealed the resident was diagnosed with post-traumatic stress disorder (PTSD) on May 26, 2026. Interview with Employee E2, Administrator, on July 1, 2026, at 10:30 a.m. confirmed the facility substantiated the incident based on admission by Nurse Aide, Employee E1 to behavior of non-consensual kissing Resident R1's forehead. On May 25, 2024, following the incident, the facility immediately implemented the following corrective actions:-On May 25, 2026, trauma informed care plan initiated for Resident R1. -On May 25, 2026, nurse assessment was completed with Resident R1's permission. -On May 25, 2026, the nurse aide [Employee E1] was placed on administrative leave immediately. The conclusion of the investigation on June 5, 2026, revealed a notice was sent to Employee E1's nursing agency indicating the nurse aide (Employee E1) could not return to the facility, or any sister facility due to a Do Not Return (DNR) status because of the findings of the investigation. -On May 25, 2026, emotional support provided by social services director. -On May 25, 2026, alert and oriented residents interviewed regarding inappropriate behavior/touching. -On May 25, 2026, resident with BIMS <10 assessed for s/s of sexual abuse. -On May 26, 2026, abuse training and trauma informed care training was provided to staff. -Social services to follow up 3x per week x2 weeks, then weekly 2x, then PRN (as needed) to monitor signs or symptoms (s/s) of depressed mood or signs of trauma. - Initial audits of residents completed- alert residents interviewed regarding care, residents with BIMS <10 (Less than 10) assessed for s/s of sexual abuse (Completed May 25, 2026). - Designee will conduct interviews of two residents with BIMS >10 Weekly x4, then monthly x 2 on each unit to identify any potential allegations of sexual misconduct. - Designee will conduct random interviews with two family members for residents with BIMS < 10 weekly x4, then monthly x 2 on each unit to identify any potential allegations of sexual misconduct. - The Director of Nursing or designee will conduct random interviews weekly x 4, then monthly x2, of 5 staff to identify any potential concerns or allegations of sexual misconduct. -Will continue to monitor through QAPI meetings (Quality Assurance and Performance Improvement). Review of clinical records, in service training sign-in sheets, interviews with residents and staff, and audits conducted confirmed the plan of correction was implemented. The facility alleged date of compliance was June 8, 2026. The facility failed to ensure Resident R1 free from sexual abuse, resulting in psychosocial harm including being diagnosed with Post Traumatic Stress Disorder (Resident R1). This deficiency was identified as past non-compliance. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1) Nursing services

Based on review of clinical records an interview with staff, it was determined that the facility failed to ensure that a physician's order was in place before administering oxygen for one of ten residents observed (Resident R1).Findings include: Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on [DATE], with diagnosis of but not limited to Centrilobular Emphysema (chronic lung disease). Review of progress note dated November 30, 2025, at 10:00 p.m. written by licensed nurse Employee E3 revealed a change in condition. At the time of evaluation resident/patient vital signs, weight and blood sugar were: Blood Pressure 92/43 (normal blood pressure 110/80) , Pulse: 90 (normal pulse 60 per 100 beats per minute) - RR (respiration rate):18.0 (normal 30 to 60 breath per minute)-Temperature: T 99.5 (normal body temperature 97.-95.5 degrees Fahrenheit), Weight: 91.2 pounds, Pulse Oximetry: O2 89.0 % ([NAME] oxygen level 95%-100%) - Method: Room Air. Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: Relevant medical history is: COPD Dementia, Functional Status Evaluation: General weakness, Respiratory Status Evaluation: Shortness of breath. Nursing observations, evaluations, and recommendations are: Resident is very weak/tired this shift. She is SOB (short of breath) at times, with decreased pulse ox and a low-grade temp. Placed on 2L(liters) O2(oxygen) with positive results. Her appetite is poor and fluids are encouraged. Spoke with Nurse Practitioner 1 Employee E4 who said that patient will be seen on rounds by Nurse practitioner 2 Employee E5. Review of resident R1's Medical Practitioner Note (Physician/NP) note dated December 1, 2026, at 9:05PM revealed Resident seen for follow up - staff reported increased weakness and decreased PO (oral) intake over the weekend as well as needing supplemental oxygen 2/2 low SpO2 at 89%. Further review of Resident R1's progress notes revealed the following notes: on December 2, 2025, at 12:01PM Respiratory: No shortness of breath noted. Humidification: Yes. Oxygen via nasal cannula; on December 2, 2026, at 10:19PM Respiratory: No signs of difficulty breathing. No shortness of breath noted. Humidification: Yes. Oxygen via nasal cannula; n December 6, 2026, at 12:27PM Respiratory: No signs of difficulty breathing. Humidification: Yes. Oxygen via nasal cannula. Interview with Employee E2 conducted on May 7, 2026, at 11:24 AM confirmed that oxygen was administered to Resident R1 on November 30, 2025, December 2, 2025, and December 6, 2025, without a physician's order. Further interview with Employee E2 revealed that that a physician's order is needed in order to administer oxygen. Further, Employee E2 revealed that there should have been a physician's order for oxygen before the nurse's administered oxygen to Resident R1. Further interview with Employee E2 revealed that the facility did not have a policy related to oxygen administration. 28 Pa. Code 211.10 (c) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of clinical records an interview with staff it was determined that the facility failed to ensure that residents who have a change in clinical status were evaluated by a provider. For one of ten residents observed (Resident R1)Findings include: Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on [DATE], with diagnosis of but not limited to Centrilobular Emphysema (chronic lung disease). Review of progress note dated November 30, 2025, at 10:00 p.m. written by licensed nurse Employee E3 revealed a change in condition. At the time of evaluation resident/patient vital signs, weight and blood sugar were: Blood Pressure 92/43 (normal blood pressure 110/80) , Pulse: 90 (normal pulse 60 per 100 beats per minute) - RR (respiration rate):18.0 (normal 30 to 60 breath per minute)-Temperature: T 99.5 (normal body temperature 97.-95.5 degrees Fahrenheit), Weight: 91.2 pounds, Pulse Oximetry: O2 89.0 % ([NAME] oxygen level 95%-100%) - Method: Room Air. Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: Relevant medical history is: COPD Dementia, Functional Status Evaluation: General weakness, Respiratory Status Evaluation: Shortness of breath. Nursing observations, evaluations, and recommendations are: Resident is very weak/tired this shift. She is SOB (short of breath) at times, with decreased pulse ox and a low-grade temp. Placed on 2L(liters) O2(oxygen) with positive results. Her appetite is poor and fluids are encouraged. Spoke with Nurse Practitioner 1 Employee E4 who said that patient will be seen on rounds byNurtse Practitioner 2 Employee E5. Further review of Resident R1's clinical record revealed that there was no documentation by Nurse Practitioner 1 Employee E4 related to Resident R1's change in condition that was reported to her by licensed nurse Employee E3. Further, there was no documented evidence that Nurse Practitioner 1 Employee E4 had addressed Resident R1's change in status and Oxygen saturation of 89.0%. Review of Resident R1's physician's orders dated December 1, 2026, at 12:36PM revealed an order for: STAT Chest X-ray: 2-view for cough, weakness. Review of Chest XC-ray results and conclusion dated December 1, 2026, at 4:38PM revealed Bilateral patchy infiltrates. Review of Resident R1's Medical Practitioner Note (Nurse Practitioner 2), Employee E5 note dated December 1, 2026, at 9:05PM revealed Resident seen for follow up - staff reported increased weakness and decreased PO (oral) intake over the weekend as well as needing supplemental oxygen 2/2 low SpO2 at 89%. Review resident R1's progress note dated December 7, 2025, at 6:10PM revealed that Resident R1 was admitted to local hospital with diagnoses of B/L (bilateral) pneumonia (infection that inflames the air sacs of one or both lungs), UTI (urinary tract infection), leukocytosis, hyponatremia low sodium in the body). Interview with Director of Nursing Employee E2 conducted on May 7, 2026, at 11:24 AM, confirmed that Nurse Practitioner 1 Employee E4 did not address Resident R1's change of status and did not have any documentation after licensed nurse Employee E3 notified Employee E4 of Resident R1's change in status and oxygen saturation of 89%. Licensed nurse Employee E3, Nurse Practitioner 1 Employee E4 and Nurse Practitioner 2 Employee E5 were not available for interview. 28 Pa. Code 211.12(d)(5) Physician services

Based on review of clinical records, facility policy, and staff interview, it was determined the facility failed to timely identify and implement interventions to ensure that Resident R1 did not develop pressure ulcers. This failure resulted in actual harm to Resident R1 who developed an unstageable sacral pressure ulcer requiring hospitalization for one of two residents reviewed (Resident R1). Findings include: Review of the facility policy Skin Integrity and Wound Management, revised 2025, revealed staff are to perform comprehensive initial and ongoing assessments of factors affecting skin integrity, develop care plans reflective of assessment findings, and implement as well as revise interventions as needed to prevent skin breakdown. The policy further revealed staff are responsible for identifying residents at risk and implementing appropriate prevention and treatment interventions. Review of Resident R1's clinical record revealed resident was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure with Hypoxia (long term condition where the lungs cannot provide enough oxygen to the blood), type 2 Diabetes Mellitus (chronic condition where the body doesn't use insulin properly, causing high blood sugar overtime) and Vascular Dementia (type of dementia caused by problems with blood flow to the brain, usually from strokes or damaged blood vessels). Review of Resident R1's comprehensive care plan, initiated February 19, 2026, revealed Resident as being at risk for skin breakdown. Interventions included application of barrier cream, observation of skin for signs and symptoms of breakdown, evaluation of localized skin issues, and weekly skin checks. Review of Resident R1's Braden Scale (assessment of resident's level of risk for development of pressure ulcers), dated February 19, 2026, revealed a score of 13, indicating the resident is at moderate risk for pressure ulcer development. Review of Resident R1's Minimum Data Set (MDS - federally mandated resident assessment and care screening), dated February 27, 2026, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment. Further review of Resident R1's MDS assessment, dated March 2, 2026, revealed the resident was dependent on staff for bed mobility, including rolling left and right, and transfers. Further review of the MDS assessment revealed the resident was incontinent bladder. Review of Resident R1's nursing skin assessment notes, dated February 19, 2026, through February 24, 2026, revealed that the resident had no skin breakdown to the sacral area (lower part of the back, just above the buttocks). Review of Resident R1's skin assessment note dated February 25, 2026, revealed the development of an unstageable pressure injury to the sacral area, described as covered with slough and/or eschar and identified as facility acquired. Review of Resident R1's nursing progress note, dated February 26, 2026, revealed the sacral wound had deteriorated, and measured length (cm - centimeter): 7.15 x width (cm): 8.96 x depth (cm): 0.1 with slough and eschar (dead tissue that forms in wounds) present, seropurulent (mix of clear serous fluid and pus, often signaling early infection or inflammation) drainage, and odor noted after cleansing. Additional wounds were observed on the resident's right foot. The physician documented concern for ischemic (condition related to blood flow) changes, noting absent pulses in the lower extremities, and ordered transfer to the hospital for urgent evaluation. Review of Resident R1's nursing note, dated February 27, 2026, revealed the resident was admitted to the hospital with a diagnosis of a sacral wound on this date. Resident R1's sacral wound measured length (cm): 12 x width (cm): 11 x depth (cm): 0.1. Review of Resident R1's hospital records, dated February 28, 2026, revealed Initial skin assessment on admission to [facility] reportedly showed no open or reddened areas. On February 20, (she/he) was evaluated for a possible fungal infection in the right 4th-5th toes. Later, staff identified a sacral wound not previously documented on admission, described as unstageable. Within 24 hours, the sacral wound reportedly worsened significantly. The following information as reported by facility nurse practitioner; Resident R1's initial skin assessment reportedly showed no open areas or redness. Staff later identified a sacral wound on February 25, 2026, that had not been present or documented upon admission, which was described as unstageable. Within 24 hours, the sacral wound reportedly worsened significantly, and additional wounds developed on the resident's right foot. The resident was evaluated by the physician, who expressed concern for vascular etiology and recommended urgent hospital evaluation. Further review of Resident R1's hospital records revealed, upon evaluation in the emergency department, the physical examination was notable for an open sacral wound with purulent, foul-smelling drainage, as well as discoloration of the toes. Review of witness statements provided by the facility revealed non licensed staff, nurse aide Employee E2, on February 25, 2026, provided Resident R1 with a bed bath during the 3:00 p.m.-11:00 p.m. shift after complaints of Resident R1's bottom hurting. Further review of Nurse aide, Employee E2's witness statement revealed I called the nurse and we turned and saw plaster, removed it, it was a hole on her bottom, Review of Employee E3, Licensed Practical Nurse, witness statement, dated February 26, 2026, revealed Employee E3 worked on February 24, 2026 from 7:00 p.m.-7:00 a.m. and did not observe skin injury/wound or observe any interventions in place for Resident R1 (turning reposting devices) during her shift. Interview conducted on March 16, 2026, at 11:15 a.m. with the Director of Nursing (DON), Employee E1, confirmed, there were no interventions in the resident's care plan to addressing turning and repositioning of the resident. Resident R1 was provided a standard mattress; which is pressure redistribution mattress which considered standard. DON stated staff do turn and reposition but that it is not always documented. Review conducted of Resident R1's clinical record failed to reveal documentation/tasks/intervention of resident being turned/repositioned to prevent a sacral pressure ulcer. The facility failed to timely identify and implement interventions to ensure that Resident R1 did not develop pressure ulcers. This failure resulted in actual harm to Resident R1 who develop an unstageable pressure ulcer, requiring hospitalization for further evaluation and treatment. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services

Based on clinical record reviews, review of facility documentation and interviews with staff, it was determined the facility failed to ensure Resident R1 was free from neglect related to failing to provide wound treatment in accordance with physician orders. This failure resulted in actual harm for Resident R1 who developed an infection of the left foot surgical site, for one of nine residents reviewed. This deficiency was cited as past non-compliance. (Resident R1). Findings include: Review of facility policy titled Abuse Prohibition, revised November 14, 2025, indicates Neglect is defined as the failure, indifference, or disregard of the center, its employees, or service providers to provide care, comfort, safety, goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This includes the failure to implement an effective communication system across all shifts for communicating necessary care and information between center, patient, practitioner and patient representative. Review of facility policy titled Skin integrity and wound management revised September 15, 2025, indicates the A comprehensive initial and ongoing nursing assessment of intrinsic and extrinsic factors that influence skin health, skin/ wound impairment, and the ability of a wound to heal will be performed. The plan of care for the patient will be reflective of assessment findings from the comprehensive patient assessment and wound evaluation. Staff will continually observe and monitor patients for changes and implement revisions to the plan of care as needed, furthermore for surgical wound, follow specific orders from the surgeon. Review of Resident R1's clinical record revealed that resident was admitted to the facility on [DATE], with diagnosis of orthopedic aftercare for a left fibula (leg) fracture. Review of Resident R1's MDS (Minimum Data Set- assessment of resident care needs), dated January 8, 2026, revealed a BIMS (Brief Interview of Mental Status) score of 14, indicating resident is cognitively intact. Review of Resident R1's care plan developed, December 20, 2025, indicated Resident at risk of skin breakdown related to occasional refusals of wound care, decreased activity and has actual skin breakdown: left ankle surgical wound. Interventions include providing wound care as ordered. Continued review of Resident R1's care plan dated, revealed a care plan, initiated December 22, 2025, which revealed patient is at risk for MDRO (Multi Drug Resistant Organism) colonization/infection due to wounds. Interventions include enhanced barrier precautions (are infection control measures using targeted gown and glove use during high-contact care activities to prevent the spread of multidrug-resistant organisms (MDROs). Review of Resident R1's physician order, dated December 20, 2025, revealed Change dressing every 3 days. Dress the wound with Xeroform (sterile, non-adherent wound dressing made of fine mesh gauze coated in a petrolatum blend), gauze, cling and ace bandage. Order discontinued on February 13, 2026. Review of Resident R1's Orthopedic Surgery Note, dated January 29, 2026, The wound looks fantastic. There are no open wounds and there is no evidence of infection. Swelling is improved; incisions are well-healed. Continue local wound care as per the wound care team at her facility however her wound does look very good at this time. Review of Resident R1's nursing note, by Employee E3, Registered Nurse, dated February 12, 2026, revealed New skin issue: Left foot surgical incision swollen and inflamed with scant amount of purulent drainage noted. Review of Resident R1's skin assessment dated [DATE], revealed that a surgical wound on the left shin Length (cm): 12.02 Width (cm): 3.41 Depth (cm): 0.1 Area (cm2): 23.23. Left foot surgical incision swollen and inflamed with scant amount of purulent drainage noted. Review of facility documentation submitted to the State Survey Agency dated February 13, 2026, revealed On February 12, 2026, at approximately 2:00 p.m. the daughter of Resident R1 met with the DON (Director of Nursing) and Unit Manager regarding concerns with care. The daughter believes the dressing on a surgical wound on (resident) left foot is not being changed and treatments are not being done as ordered by physician. The daughter believes the foot looks swollen and inflamed. Continue review of facility documentation dated February 13, 2026, submitted to the State Survey Agency, revealed On February 12, 2026, resident had an active order for left ankle wound treatment to be completed every 3 days. The treatment in place was dated February 1, 2026. According to e-TAR (Electronic treatment administration record), it was documented as completed on February 3, 2026, and February 6, 2026. On February 9, 2026, it was documented as a refusal. The nurse assigned to [Resident R1] on February 3, 2026, and February 6, 2026, admits to signing it out without completing it. The surgical wound was assessed by her attending physician on February 13, 2026, and she was started on antibiotics for signs and symptoms of wound infection. Allegation of neglect was substantiated. Review of Resident R1's nursing note, by Employee E3, Registered Nurse, dated February 13, 2026, revealed Change of Condition: physician notified, resident started on Cephalexin Capsule 500 milligrams (mg). Wound care order changed to daily. Review of Resident R1's nursing note, Employee E3, Registered Nurse, dated February 13, 2026, revealed Resident's left foot surgical site assessed at bedside by Employee E4 Physician. Continue Cephalexin for 7 days as prescribed. Further review of Resident R1's physician order, dated February 13, 2026, revealed Left ankle surgical wound: cleanse with wound cleanser, pat dry, apply xeroform then wrap with kling, every day shift and as need for soilage or displacement. Review of Resident R1's physician order, dated February 13, 2026, revealed on order for an antibiotic Cephalexin Capsule 500mg Give 1 capsule by mouth every 6 hours for wound infection for 7 days. Review of facility's February 2026 Infection Control Log revealed, Resident R1 obtained a facility acquired infection, onset date of February 13, 2026, left foot wound treated with Cephalexin Capsule 500mg. Review of facility's investigation, revealed an interview statement with Resident R1, dated February 13, 2026, which indicated the resident stated It has been a while (since the last dressing change). I think that nice male nurse on the weekend was the last to do it. Review of facility investigation revealed an interview statement with Employee E5, Registered Nurse, dated February 13, 2026, revealed I got to be honest, I didn't do them. I have a bad habit of signing them out and writing them down to complete, but I must have gotten side-tracked those days. Continue review of facility investigation revealed that Employee E5, Registered Nurse, dated February 13, 2026, revealed I had [Resident R1] on February 3, 2026, and on February 6, 2026, as my resident. I signed out the dressing change prior to completing the task. On February 3, 2026, when I went to her room she was dressed and eating. My intention was to return later that day. On February 6, 2026, I once again signed out the task prior to completion. There were several activities happening on another unit when I looked for (resident) in (his/her) room. Unfortunately, I became very busy later that afternoon and it slipped my attention. Interview with Employee E1, Director of Nursing, on March 11, 2026, at approximately 2:00 p.m. confirmed the above findings and further confirmed the allegation of neglect was substantiated. This deficiency was identified as actual harm past non-compliance for the facility failure to ensure Resident R1's was free of neglect related not providing wound treatment in accordance with physician orders. This failure resulted in actual harm to Resident R1 who sustained a wound infection of the left foot. On March 11, 2026, the Nursing Home Administrator presented documentation, indicating that the facility initiated a plan of correction on February 13, 2026, to address the failure to provide surgical wound treatment not completed per the physician orders, which resulted in Resident R1 sustaining an infection of the surgical wound. The facility alleged compliance date of March 5, 2026. Facility plan of correction included the following:The facility notified the physician and responsible party of treatment not being completed as ordered.The facility revaluated Resident R1's wound by physician.The facility initiated an investigation into neglect.The facility placed nurse on administrative leave during investigation.The facility re-educated licensed nurses on Abuse and Neglect Policy.The facility re-educated licensed nurses on Skin integrity and Wound Management Policy with the focus of following MD orders.The facility re-educated licensed nurses on change in condition policy.The facility conducted an initial audit of current residents' treatment records to ensure treatments were completed and documented as per MD order.The facility conducted an initial audit of current residents with wounds, had their dressings observed to verify the treatment was completed as per the MD order.The facility to have DON (Director of Nursing)/ designee to conduct random audits weekly for 4 weeks, the monthly for 2 months of resident treatment administration records to verify treatments were completed and documented as per the physician order. The DON or designee will conduct random observations of 5 residents with wounds weekly for 4 weeks, then monthly for 2 months, to verify treatments were completed as per physician order. Results of the audits will be presented at QAPI (Quality Assurance Performance Improvement) meetings for review. Interviews with nursing staff on March 11, 2026, confirmed that they had all been in-serviced on reviewing and following the physician orders, skin integrity and wound care policy, abuse and neglect policy. Review of nursing education and audit results for resident treatment administration completed. This deficiency was identified as past non-compliance. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on clinical record reviews, review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that Resident R1 was providing wound treatment in accordance with physician orders. This failure resulted in actual harm for Resident R1 who developed a wound infection of the left foot surgical site for one of nine residents reviewed. This deficiency was cited as past non-compliance. (Resident R1).Findings include: Review of facility policy titled Skin integrity and wound management revised September 15, 2025, indicates the A comprehensive initial and ongoing nursing assessment of intrinsic and extrinsic factors that influence skin health, skin/ wound impairment, and the ability of a wound to heal will be performed. The plan of care for the patient will be reflective of assessment findings from the comprehensive patient assessment and wound evaluation. Staff will continually observe and monitor patients for changes and implement revisions to the plan of care as needed, furthermore for surgical wound, follow specific orders from the surgeon. Review of Resident R1's clinical record revealed that resident was admitted to the facility on [DATE], with diagnosis of orthopedic aftercare for a left fibula (leg) fracture. Review of Resident R1's MDS (Minimum Data Set- assessment of resident care needs), dated January 8, 2026, revealed a BIMS (Brief Interview of Mental Status) score of 14, indicating resident is cognitively intact. Review of Resident R1's care plan dated developed December 20, 2025, indicated Resident at risk of skin breakdown related to occasional refusals of wound care, decreased activity and has actual skin breakdown: left ankle surgical wound. Interventions include providing wound care as ordered. Review of Resident R1's care plan developed December 22, 2025, indicated patient is at risk for MDRO (Multi Drug Resistant Organism) colonization/infection due to wounds. Interventions include Enhanced barrier precautions (are infection control measures using targeted gown and glove use during high-contact care activities to prevent the spread of multidrug-resistant organisms (MDROs). Review of Resident R1's physician order, dated December 20, 2025, revealed Change dressing every 3 days. Dress the wound with Xeroform, gauze, cling and ace bandage. Order discontinued on February 13, 2026. Review of Resident R1's Orthopedic Surgery Note, dated January 29, 2026, The wound looks fantastic. There are no open wounds and there is no evidence of infection. Swelling is improved; incisions are well-healed. Continue local wound care as per the wound care team at her facility however her wound does look very good at this time. Review of facility documentation submitted to the State Survey Agency dated February 13, 2026, revealed On February 12, 2026, at approximately 2:00 p.m. the daughter of Resident R1 met with the DON (Director of Nursing) and Unit Manager regarding concerns with care. The daughter believes that the dressing on a surgical wound on her left foot is not being changed and treatments are not being done as ordered by physician. The daughter believes the foot looks swollen and inflamed. Review of Resident R1's nursing note, by Employee E3, Registered Nurse, dated February 12, 2026, revealed New skin issue: Left foot surgical incision swollen and inflamed with scant amount of purulent drainage noted. Review of Resident R1's skin assessment dated [DATE], revealed that a surgical wound on the left shin Length (cm): 12.02 Width (cm): 3.41 Depth (cm): 0.1 Area (cm2): 23.23. Left foot surgical incision swollen and inflamed with scant amount of purulent drainage noted. Review of Resident R1's nursing note, by Employee E3, Registered Nurse, dated February 13, 2026, revealed Change of Condition: Physician notified, Resident started on Cephalexin Capsule 500 milligrams (mg). Wound care order changed to daily. Continued review of Employee E3, Registered Nurse, nursing note, revealed Resident's left foot surgical site assessed at bedside by Employee E4, Physician. Continue Cephalexin for 7 days as prescribed. Further review of Resident R1's physician order, dated February 13, 2026, revealed Left ankle surgical wound: cleanse with wound cleanser, pat dry, apply xeroform then wrap with kling, every day shift and as need for soilage or displacement. Review of Resident R1's physician order, dated February 13, 2026, revealed on order for the antibiotic Cephalexin Capsule 500mg Give 1 capsule by mouth every 6 hours for wound infection for 7 days. Review of facility's February 2026 Infection Control Log revealed Resident R1 obtained a facility acquired infection, onset date of February 13, 2026, left foot wound treated with Cephalexin Capsule 500mg. Review of facility's investigation, revealed an interview statement with Resident R1, dated February 13, 2026, which indicated that the resident stated It has been a while (since the last dressing change). I think that nice male nurse on the weekend was the last to do it. Review of facility investigation revealed an interview statement with Employee E5, Registered Nurse, dated February 13, 2026, revealed I got to be honest, I didn't do them. I have a bad habit of signing them out and writing them down to complete, but I must have gotten side tracked those days. Review of facility investigation, statement from Employee E5, Registered Nurse, dated February 13, 2026, revealed I had [Resident R1] on February 3, 2026, and on February 6, 2026, as my resident. I signed out the dressing change prior to completing the task. On February 3, 2026, when I went to her room she was dressed and eating. My intention was to return later that day. On February 6, 2026, I once again signed out the task prior to completion. There were several activities happening on another unit when I looked for her in her room. Unfortunately, I became very busy later that afternoon and it slipped my attention. Review of facility documentation submitted to the State Survey Agency, dated February 13, 2026, revealed On February 12, 2026, resident had an active order for left ankle wound treatment to be completed every 3 days. The treatment in place was dated February 1, 2026. According to ETAR (Electronic treatment administration record), it was documented as completed on February 3, 2026, and February 6, 2026. On February 9, 2026, it was documented as a refusal. The nurse assigned to Resident R1 on February 3, 2026, and February 6, 2026, admits to signing it out without completing it. The surgical wound was assessed by her attending physician on February 13, 2026, and she was started on antibiotics for signs and symptoms of wound infection. Interview with Employee E1, Director of Nursing, on March 11, 2026, at approximately 2:00 p.m. confirmed the above findings. This deficiency was identified as actual harm past non-compliance for the facility failure to ensure that Resident R1 was provided wound treatment in accordance with physician orders. This failure resulted in actual harm for Resident R1 who developed a wound infection of the left foot surgical site. This deficiency was cited as past non-compliance. On March 11, 2026, the Nursing Home Administrator presented documentation, indicating that the facility initiated a plan of correction on February 13, 2026, to address the failure to provide surgical wound treatment not completed per the physician orders, which resulted in Resident R1 sustaining an infection of the left foot surgical site. The facility alleged compliance date of March 5, 2026. Facility plan of correction included the following:The facility notified the physician and responsible party of treatment not being completed as ordered.The facility revaluated Resident R1's wound by physician.The facility initiated investigation for neglect.The facility placed nurse on administrative leave during investigation.The facility re-educated licensed nurses on Abuse and Neglect Policy.The facility re-educated licensed nurses on Skin integrity and Wound Management Policy with the focus of following MD orders.The facility re-educated licensed nurses on change in condition policy.The facility conducted an initial audit of current residents' treatment records to ensure treatments were completed and documented as per MD order.The facility conducted an initial audit of current residents with wounds, had their dressings observed to verify the treatment was completed as per the MD order.The facility to have DON (Director of Nursing)/ designee to conduct random audits weekly for 4 weeks, the monthly for 2 months of resident treatment administration records to verify treatments were completed and documented as per the physician order. The DON or designee will conduct random observations of 5 residents with wounds weekly for 4 weeks, then monthly for 2 months, to verify treatments were completed as per physician order. Results of the audits will be presented at QAPI (Quality Assurance Performance Improvement) meetings for review. Interviews with nursing staff on March 11, 2026, confirmed that they had all been in-serviced on reviewing and following the physician orders, skin integrity and wound care policy, abuse and neglect policy. Review of nursing education and audit results for resident treatment administration completed. This deficiency was identified as past non-compliance. 28 Pa. Code 201.14(a) Responsibility of Licensee28 Pa. Code 201.18(b)(1)(e)(1) Management28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on review of clinical records, observation, and staff and resident interviews, it was determined that the facility failed to ensure timely assessment, identification, and documentation of a change in condition related to skin integrity for one of four residents reviewed (Resident R1).Review of facility policy Skin Integrity and Wound Management, revised 2025, revealed the nursing assistant will observe skin daily and report any changes or concerns to the nurse. The licensed nurse will:- Evaluate any reported or suspected skin changes or wounds;- Document newly identified skin/wound impairments as a change in condition; -Document skin/wound findings on the 24-hour Report;-Perform and document skin inspection on all newly admitted /readmitted patients weekly thereafter and with any significant change of condition.Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on [DATE] with a diagnosis of brain neoplasm (brain tumor), epilepsy (brain condition that causes recurring seizures), and cortical blindness (total or partial loss of vision caused by brain damage to the occipital cortex).Review of Resident R1's most recent Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairmentInterview with Resident R1's family member on January 22, 2025 at 11:20 a.m., revealed Resident R1 had an unexplained bruise on his/her right inner forearm.Review of Resident R1's clinical record revealed Resident R1 was transferred to the hospital on January 02, 2025 and was re-admitted to the facility on [DATE].Review of Resident R1's re-admission skin assessment, dated January 05, 2025, revealed no documentation of the presence of a bruise to Resident R1's right inner forearm.Review of Resident R1's clinical record revealed weekly skin assessments/wound care treatment were performed on the following dates:January 05, 2026January 08, 2026January 12, 2026January 14, 2026January 15, 2026January 20, 2026Review of Resident R1's physician orders revealed an order, dated January 05, 2025, for geri sleeve (protects sensitive thin skin from tears and abrasions) to be applied to left arm and to remove for skin check/treatment/hygiene.Observation of Resident R1 on January 22, 2026 at approximately 12:30 p.m. with Director of Nursing, Employee E1, present revealed Resident R1 with geri sleeve on his right and left arm. Director of Nursing, Employee E1, then performed a skin assessment on Resident R1's right lower inner forearm and identified a fading bruise. Interview on January 22, 2025 at 1:45 p.m. with Director of Nursing, Employee E1, confirmed there was no documentation that identified the bruise to Resident R1's inner forearm.28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services

Based on observation, review of facility policy, clinical record review and staff interviews, it was determined that the facility failed to ensure that resident assessments accurately reflected resident diagnoses for one of nine residents reviewed. (Resident R148) Finding includes:Review of facility policy titled Social Service Assessment revised March 15, 2024, revealed residents will have a social service assessment completed upon admission, quarterly, annually and with a significant change in condition.Review of Resident R148's clinical record revealed that on October 21, 2024, resident was given the diagnosis of anorexia. Review of Resident R148's care plan last revised on May 28, 2025, revealed that this resident has potential for nutrition hydration risk due to advanced age currently stable nutritionally.Interview with DON Employee E2 on July 3, 2025, at 09:40 a.m. revealed that the diagnosis of anorexia for Resident R148 was not accurate. It is believed that the diagnosis of Anorexia was used for that practitioners visit for the purpose of a billing code and transcribed into residence list of diagnosis in the resident's record. 28 Pa. Code 211.5 (f) Clinical records

Based on interviews with residents and staff, review of clinical records, review of facility policy and review of facility documentation, it was determined that the facility failed to ensure that Resident R5 was free from sexual and physical abuse. This failure resulted in an Immediate Jeopardy situation for Resident R5 whose arm was restrained and was sexually abused by Resident R6 for one of eight residents reviewed. (Resident R5) Findings include: The facility policy titled, OPS300 Abuse Prohibition revised October 24, 2022, stated that the Center prohibits abuse, mistreatment, neglect, misappropriation of resident'/patient property, and exploitation for all patients. This includes, but not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptoms. The Center will implement an abuse prohibition program through the following: Screening of potential hires; training of employees (both new employees and ongoing training for all employees); prevention of occurrences; Identification of possible incidents or allegations which need investigation; Investigation of all incidents and allegations; and reporting of incidents, investigations, and Center response to the results of their investigations. Further, the policy stated, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods and services that are necessary to attain or maintain physical, mental, or psychological well-being. Instances of abuse of all patients, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal Abuse is any use of oral, written, or gestured language that will fully includes disparaging terms to patients or their families or within their hearing distance, regardless of their age, ability to comprehend or disability. Sexual Abuse is a non-consensual sexual contact of any type with patient. It includes but not limited to sexual harassment, sexual coercion, or sexual assault. Review of the July 2022 physician orders revealed Resident R6 was admitted to the facility on [DATE], with diagnoses of coronary artery disease (condition that affect the heart); heart failure (condition that develops when your heart doesn't pump enough blood for the body's needs); peripheral arterial disease (condition in which narrowed arteries reduce blood flow to the arms and legs); stroke (damage to the brain from interruption of its blood supply) and dementia (the loss of cognitive functioning - thinking, remembering, and reasoning). Review of the Resident R6's quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated May 2, 2023, indicated that the resident had a BIMS (Brief Interview of Mental Status) of 13, which indicated that the resident was cognitively intact. Review of Resident R5's June 2018, physician orders revealed Resident R5 was admitted to the facility on [DATE], with diagnoses of arterial fibrillation (an irregular heart rhythm), deep vein thrombosis (formation or presence of a blood clot in a blood vessel), and dementia (the loss of cognitive functioning - thinking, remembering, and reasoning). Review of Resident R5's quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated April 6, 2023, revealed that Resident R5 was severely cognitively impaired, with inability to express ideas and wants, verbally and nonverbally. Review of facility information submitted to the Department of Health on July 6, 2023, revealed that Employee E16 witnessed Resident R6 restraining one of Resident R5's arms while his other hand was observed underneath her gown in her peri-area making fast up/down movements causing Resident R5's gown to move around. Nurse aide, Employee E16 witnessed Resident R5 swinging her arm to stop Resident R6. Review of facility documentation revealed a witness statement by nurse aide, Employee E16, related to an incident involving Resident R5 and Resident R6 that took place on July 6, 2023 at approximately 4:15 p.m. during the 3 p.m.-11:00 p.m. nursing shift. The statement indicated that male Resident R6 was seen with female Resident R5 grabbing on to one arm holding it down while his other hand was under the female resident. Interview with the nurse aide, Employee E16, on July 13, 2023, at 11:45 p.m. confirmed the above-mentioned statement. Employee E16 stated during the interview that on the day of the incident, Employee E16 had stepped away from the dining room for a few minutes to help other residents and when she came back minutes later, Resident R6 was holding her down with one hand and with the other hand in the genital private area. Resident R5 was trying to fight but she couldn't. It's not like she can talk or say anything, or scream. Review of another witness statement by Nurse Unit Manager, Employee E21, dated July 6, 2023, revealed Employee E21 stated that she was aware of a consensual relationship between Resident R6 and another female resident (Resident R12); he referred to her as girlfriend. Employee E21 stated, I have witnessed them holding hands and I have also witnessed a conversation between the two of them regarding going to hotel room. Review of resident R12's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses including hyperlipidemia (an elevated level of lipids in the blood), multiple sclerosis (disease of the central nervous system), and depression (a mood disorder that causes persistent feeling of sadness and loss of interest). Review of Resident R12's quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated May 19, 2023, indicated that the resident had a BIMS (Brief Interview of Mental Status) of 13, which indicated that the resident was cognitively intact. Interview held with the Nursing Home Administrator on July 12, 2023, at approximately 5:30 p.m. revealed the facility staff were aware of a relationship between Resident R6 and Resident R12. During the interview a policy regarding consensual relationships was requested regarding Resident R6 being diagnosed as having a stroke and dementia and Resident R12 being diagnosed as having multiple sclerosis and depression. The Nursing Home Administrator stated that the facility does not have a policy on consensual relationships. Review of a witness statement by nurse aide, Employee E22, indicated that Resident R6 always called staff, baby, honey and is always around talking to Resident R5. Interview with nurse aide, Employee E22 on July 12, 2023, at approximately 6:15 p.m. revealed Resident R6 seemed to gravitate toward the confused residents and always talks to us: honey baby, you love me baby. We tell him: you can't talk to us like that. Further interview with Nurse Manager, Employee E21, at approximately 5:43 p.m. revealed Resident R6 was inappropriately name calling female staff and residents: baby, sweetie pie, and honey. Interview held with nurse aide, Employee E22, and the Nurse Unit Manager, Employee E21 on July 12, 2023, at 5:41 p.m. and 6:15 p.m. revealed Resident R6 and Resident R12 were witnessed kissing a long time ago, by another resident. Further interview with nurse aide, Employee E16, on July 13, 2023, at 11:45 p.m. revealed Resident R6 referred to facility staff members inappropriately, honey boo, sweetie pie, and baby. and was told that it is inappropriate to call the staff members this way. Review of Resident R6's clinical records, including progress notes and care plan, failed to reveal documentation regarding inappropriate verbal behavior or name calling and identifying Resident R12 as a significant other. Review of Resident R12's clinical records including progress notes and care plan failed to reveal documentation identifying Resident R6 as a significant other. During an interview with the facility Administrator, Employee E1, and the Director of Social Services, Employee E26, on July 12, 2023, at approximately 5:30 p.m. a review of care pans for Resident R5, R6, and R12 was conducted. During this interview, it was confirmed that there was no care plan developed regarding inappropriate verbal behaviors and identifying as a significant other, for Residents R6, and R12. Another interview held with the facility Administrator, Employee E1, on July 13, 2023, at 10:40 a.m. confirmed that there is nothing documented in the clinical records, including an individualized care plan for each resident mentioned above. The facility failed to ensure that Resident R5 was free from sexual abuse by Resident R6. Based on the above-mentioned findings, an Immediate Jeopardy to the situation was identified to the Nursing Home Administrator, on July 13, 2023, at 1:14 p.m. for failure to ensure that residents were free from physical and sexual abuse from Resident R6, and that other residents were protected from further abuse. The Immediate Jeopardy template was provided to the Nursing Home Administrator on July 27, 2023, at 2:49 p.m. and an Immediate action plan was requested. On July 13, 2023, at 6:09 p.m. the facility provided the following corrective action plan. 1. An audit will be completed today 7/13/23 by interviewing all residents residing in facility to identify any residents who reported any unwanted sexual overtures (as capable). Employees will be interviewed to identify any witnessed unwanted sexual overtures. 2. The female resident was immediately removed from the male resident by the witnessing nursing assistant and assessed. No injury noted. All cognitively impaired residents on nursing unit had a skin check performed and no unknown injuries were identified. Female resident on unit were interviewed and denied any unwanted contact with make resident. 3. The male resident was placed on a 1:1 and moved to another unit. The 1:1 remains in place. The resident was seen by Psychiatry with medication recommendations called to primary Physician and POA. His care plan has been updated to include inappropriate behaviors towards residents and staff. The female residents care plan will be updated to provide interventions to protect against unwanted behaviors. 4. The sexual abuse policy was reviewed and includes nonconsensual sex and actions including revision to care plan. 5. Staff education was identifying residents with sexually promiscuous behaviors will be immediately initiated with goal of 80% by 7/14 and continue wit each employee before next scheduled shift with goal of 80% by 7/14. 6. Resident care plans will be updated to include any resident with identified sexual overtures and interventions to protect other residents. 7. All audits and Training will be reported to QAPI committee who will determine need for further actions. The implementation of the action plan was verified on July 14, 2023. Interviews conducted with facility staff on July 14, 2023, reported they had all been in-serviced on the resident abuse prohibition policy, recognizing the signs of resident abuse, to whom to immediately report an allegation of resident abuse and actions to be taken related to incident of resident abuse. The Immediate Jeopardy was lifted on July 14, 2023, at 5:51 p.m. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29 (c) Resident rights 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services

Based on interviews with residents and staff, review of clinical records, review of facility policy and review of facility documentation, it was determined that the facility failed to developed a plan of care for a male resident (Resident R6) who was seeking attention from female residents and staff. This failure resulted in Resident R6 engaging in inappropriate sexual contact with a female resident placing Resident R5 and other residents in an Immediate Jeopardy situation for one of eight residents reviewed. (Resident R5) Findings include: The facility policy titled, OPS300 Abuse Prohibition revised October 24, 2022, stated that the facility is to . take steps to revise patients' care plan where indicated if there is a change in the patient's medical, nursing, physical, mental or psychosocial needs or preferences as result of an incident of abuse. Review of the July 2022 physician orders revealed Resident R6 was admitted to the facility on [DATE], with diagnoses of coronary artery disease (condition that affect the heart); heart failure (condition that develops when your heart doesn't pump enough blood for the body's needs); peripheral arterial disease (condition in which narrowed arteries reduce blood flow to the arms and legs); stroke (damage to the brain from interruption of its blood supply) and dementia (the loss of cognitive functioning - thinking, remembering, and reasoning). Review of the Resident R6's quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated May 2, 2023, indicated that the resident had a BIMS (Brief Interview of Mental Status) score of 13, which indicated that the resident was cognitively intact. Review Resident R5's June 2018, physician orders revealed Resident R5 was admitted to the facility on [DATE], with diagnoses of arterial fibrillation (an irregular heart rhythm), deep vein thrombosis (formation or presence of a blood clot in a blood vessel), and dementia (the loss of cognitive functioning - thinking, remembering, and reasoning). Review of Resident R5's quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated April 6, 2023, revealed that Resident R5 was severely cognitively impaired, with inability to express ideas and wants, verbally and nonverbally. Review of facility information submitted to the Department of Health on July 6, 2023, revealed that nurse aide, Employee E16 witnessed Resident R6 restraining one of Resident R5's arms while his other hand was observed underneath her gown in her peri-area making fast up/down movements causing Resident R5's gown to move around. Nurse aide, Employee E16 witnessed Resident R5 swinging her arm to stop Resident R6. Review of facility documentation revealed a witness statement by nurse aide, Employee E16, related to an incident involving Resident R5 and Resident R6 that took place on July 6, 2023 at approximately 4:15 p.m. during the 3 p.m.-11:00 p.m. nursing shift. The statement indicated that male Resident R6 was seen with female Resident R5 grabbing on to one arm holding it down while his other hand was under the female resident. Interview with the nurse aide, Employee E16, on July 13, 2023, at 11:45 p.m. confirmed the above-mentioned statement. Employee E16 stated during the interview that on the day of the incident, Employee E16 had stepped away from the dining room for a few minutes to help other residents and when she came back minutes later, Resident R6 was holding her down with one hand and with the other hand in the genital private area. Resident R5 was trying to fight but she couldn't. It's not like she can talk or say anything, or scream. Review of another witness statement by Nurse Unit Manager, Employee E21, dated July 6, 2023, revealed Employee E21 stated that she was aware of a consensual relationship between Resident R6 and another female resident (Resident R12); he referred to her as girlfriend. Employee E21 stated, I have witnessed them holding hands and I have also witnessed a conversation between the two of them regarding going to hotel room. Interview held with the Nursing Home Administrator on July 12, 2023, at approximately 5:30 p.m. revealed the facility staff were aware of a relationship between Resident R6 and Resident R12. During the interview a policy regarding consensual relationships was requested. Nursing Home Administrator stated that the facility does not have a policy on consensual relationships. Review of witness statement by nurse aide, Employee E22, indicated that Resident R6 always called staff, baby, honey and is always around talking to Resident R5. Interview with nurse aide, Employee E22 on July 12, 2023, at approximately 6:15 p.m. revealed Resident R6 seemed to gravitate toward the confused residents and always talks to us: honey baby, you love me baby. Employee E22 stated that the unit staff would always redirect this inappropriate behavior, we tell him: you can't talk to us like that. Further interview with Nurse Manager, Employee E21, at approximately 5:43 p.m. revealed Resident R6 was inappropriately name calling female staff and residents: baby, sweetie pie, and honey. Interview held with nurse aide, Employee E22, and the Nurse Unit Manager, Employee E21 on July 12, 2023, at 5:41 p.m. and 6:15 p.m. revealed Resident R6 and Resident R12 were witnessed kissing a long time ago, by another resident. Further interview with nurse aide, Employee E16, on July 13, 2023, at 11:45 p.m. revealed Resident R6 referred to facility staff members inappropriately, honey boo, sweetie pie, and baby, and was told that it is inappropriate to call the staff members this way. Review of Resident R6's clinical records, including progress notes and care plan, failed to reveal documentation regarding inappropriate verbal behavior or name calling and identifying Resident R12 as a significant other. Review of Resident R12's clinical records including progress notes and care plan failed to reveal documentation identifying Resident R6 as a significant other. During an interview with the facility Administrator, Employee E1, and the Director of Social Services, Employee E26, on July 12, 2023, at approximately 5:30 p.m. a review of care pans for Resident R5, R6, and R12 was conducted. During this interview, it was confirmed that there was no care plan developed regarding inappropriate verbal behaviors and identifying as a significant other, for Residents R6, and R12. Another interview held with the facility Administrator, Employee E1, on July 13, 2023, at 10:40 a.m. confirmed that there is nothing documented in the clinical records, including an individualized care plan for each resident mentioned above. Based on the above-mentioned findings, an Immediate Jeopardy situation was identified to the Nursing Home Administrator, on July 13, 2023, at 1:14 p.m. for failure to ensure that a plan of care was developed for a male resident (Resident R6) who demonstrated attention seeking behaviors from females, resulting in engaging in inappropriate sexual contact with a female resident. (Resident R5) The Immediate Jeopardy template was provided to the Nursing Home Administrator on July 27, 2023, at 2:49 p.m. and an Immediate action plan was requested. On July 13, 2023, at 6:09 p.m. the facility provided the following corrective action plan. 1. An audit will be completed today 7/13/23 by interviewing all residents residing in facility to identify any residents who reports any unwanted sexual overtures (as capable). Care Plans will be developed for identified residents who exhibit sexual behaviors. 2. The female resident was immediately removed from the male resident by the witnessing nursing assistant and assessed. No injury noted. All cognitively impaired residents on Nursing unit had a skin check performed and no unknown injuries were identified. Female resident on unit were interviewed and denied any unwanted contact with male resident. 3. The Male resident was placed on 1:1 and moved to another unit. The 1:1 remains in place. The resident was seen by Psychiatry with medical recommendations to address sexual disinhibition in Dementia. Recommendations called to primary Physician and POA. His care plan has been updated to include inappropriate behaviors towards residents and staff. 4. The Sexual abuse policy was reviewed ad includes nonconsensual sex and actions including revision and care plan. 5. Staff education on Identifying residents with sexually promiscuous behavior and updated the care plan will be immediately initiated with goal of 80% by 7/14 and continue with each employee before next scheduled shift if unable to be reached by 7/14. 6. Staff Training on identifying and reporting sexually inappropriate behavior exhibited by residents has been initiated with goal of 80% by 7/14 and continue with each employee before next scheduled shift if unable to be reached by 7/14. 7. Residents care plans will be updated to include any resident with identified sexual overtures and interventions to protect other residents. 8. All Audits and training will be reported to QAPI committee who will determine need for further actions. Interviews with 29 staff members from various departments were conducted on July 14, 2023, during the 7:00 a.m. to 3:00 p.m. and 3:00 p.m. to 11:00 p.m. shifts. All staff members reported that they received education regarding identifying and reporting residents with attention seeking behaviors leading to sexual advances and education on care plan completion and updating. Licensed nursing staff, nursing assistants, as well as ancillary staff from various departments including maintenance, housekeeping, and therapy were interviewed. Review of facility plan of action confirmed that the facility completed audits to ensure other residents with attention seeking behaviors were identified and the comprehensive care plans were developed to address behaviors with 100% compliance. Further review of the facility plan of action confirmed all residents were screened to identify if any other residents experienced inappropriate touching and to ensure the residents feel safe. All resident's reported feeling safe and there were no abnormal findings from the skin checks. Review of clinical records for Resident R5 and Resident R6 confirmed care plans were implemented for behaviors and psych consults were completed. Resident R12's care plan was updated for psychosocial aspects related to maintaining an appropriate relationship. The immediate Jeopardy was lifted on July 14, 2023, at 5:51 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10 (d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services