Every finding on record at Deer Meadows Rehabilitation Center

Based on observations and an interview with staff, it was determined that the facility did not ensure that garbage and refuse was properly disposed. Finding Include: Observations were made of the facility's loading dock on, August 18, 2026, at 11:30 a.m. with the Food Service Director. Upon first entering the loading dock/dumpster area on the first tier was a wooden chair, two PVC bins (normally used for dirty laundry), and six wooden pellets. Stepping down to the area of the trash bins was a pile of trash with cups, lids, liquids on the ground. Per the Food Service Director, the trash company had recently taken the dumpster and will be returning the dumpster within an hour. Left in its place was loose trash consisting of cups, lids etc. A few feet away from the same area was a thick yellow sludge 3-4 feet x 3-4 feet wide. Two dumpsters were seen in the same area. The Food Service Director stated the kitchen uses the dumpster to the left for boxes. On the ground next to that dumpster was an uncontained bag of trash. The dumpster to the right had a recliner chair, a PVC shower bed, wooden pellets. The entire area had a strong stench and appeared unkept. 28 Pa. Code 201.18 (b)(3) Management 28 Pa. Code 207.2 (a) Administrator's responsibility

Based on review of clinical records, review of facility documentation, review of facility policy, and interviews with resident and staff it was determined that the facility failed to ensure each resident is treated with dignity and respect when providing care for one of 35 resident records reviewed (Resident R25).Findings include: Review of the facility's policy titled, Resident Rights revised July 2023, states, Employees shall treat all residents with kindness, respect, and dignity. Resident R25 was admitted to the facility April 25, 2025, diagnosed with Rheumatoid arthritis (a chronic autoimmune disease-causing inflammation of the joints). Review of Resident R25's care plan revealed the resident had a pulmonary embolism (blood clot in lungs) that caused difficulty breathing and to ensure the resident with proper body alignment for optimal breathing, dated April 28, 2025. The resident had a self-care deficit that required two people to assist the resident using a mechanical lift (Hoyer Lift) for transfers, dated May 5, 2025. The resident had a psychosocial well-being problem related to potential, PTSD (post-traumatic stress disorder) due to a report of physical abuse on May 5, 2026. Interventions included supportive care for talk therapy and meeting one on one with Social Services. Review of Resident R25's nursing progress notes dated May 5, 2026, stated the resident was upset and crying when the resident stated that when the resident was in her Geri chair (a chair used for long-term comfort and therapeutic positioning), the nurse aide (NA, Employee E18) was rough and pushed the resident's Geri chair too hard, and the resident's leg hit the cabinet. Interview with Resident R25 on August 19, 2026, at 2:00 pm stated, I was sitting in my wheelchair waiting for the aides to transfer me with the Hoyer. One of the aides (Nurse Aide (NA) Employee E18) came in my room with an attitude, she didn't say much. For some reason as she was getting me ready for the Hoyer, she kept jerking my chair around. I said, What are you doing!? Then she forcefully pushed me, while I was in my chair, so hard that my wheelchair went into my tall dresser in front of me and then my right leg hit the bureau next to it. It really hurt. I told the NA to leave the room, but she wouldn't. Instead, she was trying to justify her actions. She wouldn't leave until a nurse told her to leave my room. Interview with licensed practical nurse (LPN) Employee E12 on August 21, 2026, at 3:30 p.m. stated, I heard the resident yelling and screaming telling the aide to get out. It's not like the resident, if you look at her chart she never causes anyone any problems. She was so upset she couldn't stop crying and I started crying with her. The LPN's witness statement stated, The resident is normally quiet, not aggressive. The resident stated that the aide became aggressive and pushed her chair into the dresser which caused the resident to hit her leg on the dresser. Review of facility documentation revealed a witness statement from the second aide, NA Employee E14 that came to Resident R25's room to assist in the resident's transfer with NA Employee E18. NA Employee E14 heard Resident R25 yelling at NA Employee E18 saying how rough she was. The NA heard the other NA raise her voice at the resident being defensive asking the resident, 'How was I rough with you?' The NA stated that when the NA was adjusting the Geri chair she (NA E18) wasn't gentle and she was rushing. 28 Pa. Code 201.29 (a) Resident rights

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure that resident preferences were honored related to choice of dining location for one of 35 resident records reviewed (Resident R14). Findings include: Review of Resident R14's clinical record the resident was admitted to the facility on [DATE], is alert and oriented, and has a diagnosis heart disease. On August 19, 2026, at 12:08 p.m. on the ground floor, A unit dining room Resident R14 was observed in a wheelchair being pushed by Nurse aide (NA) Employee E13 yelling, I don't want to eat here I want to eat in my room! But the NA continued to place the resident at a table ignoring the request. During an interview with Nurse aide, Employee E13, on August 20, 2026, at 1:02 PM the NA was asked why the resident was made to eat in the dining room when the resident made it clear he/she wanted to eat in his/her room. The NA said the aides are told to get the residents out of bed because if we don't it looks like we aren't doing our jobs, The surveyor asked even when the resident refuses? The NA, Employee E13, stated that the resident eventually stopped complaining. Interview with Resident R14 on August 20, 2026, at 1:30 PM confirmed he/she did not want to eat in the dining room and prefers to eat in his/her room. 28 Pa. Code 201.29(a) Resident rights

Based on observations, review of facility documents and interviews with residents and staff, it was determined that the facility failed to ensure that foods were served at appropriate temperatures and that pureed foods were appropriately seasoned and served in a visually appealing way, for two of eight nursing units observed ([NAME] Ground floor Section C unit and [NAME] First floor Section C unit). Findings include: Interview on August 18, 2026, at 1:06 p.m. Resident R60 stated that the food was cold. Interview on August 18, 2026, at 1:10 p.m. Resident R210 stated that the food was cold. Interview on August 18, 2026, at 1:50 p.m. Resident R4 stated that the food was inedible. Review of the menu posted revealed that for August 18, 2026, the lunch meal was apple spice pork roast with gravy, bowtie pasta, capri vegetables and chilled pears. The alternate meal was oven fried chicken, mashed potatoes and parslied cauliflower. Review of the menu extensions for pureed diets revealed the lunch meal was pureed apple spice pork roast, pureed capri vegetables, pureed bowtie pasta and pureed chilled pears. Continued observation of the lunch meal on August 18, 2026, at 2:12 p.m. revealed Residents R50 and R77 received total feeding assistance from Employee E5, licensed nurse, and E6, nurse aide. Both residents received pureed meals consisting of a runny white pureed substance, a runny green pureed substance and mashed potatoes. The pureed white and green substances lacked form and swirled together on the plate. Interview with Employees E5 and E6 revealed that the pureed meal was not appetizing in appearance. Review of the menu posted revealed that for August 19, 2026, the lunch meal was country meatloaf with ketchup glaze, lyonnaise potatoes, corn o'brian and pineapple tidbits. The alternate meal was baked macaroni and cheese, carrots and steamed rice. Review of the menu extensions for pureed diets revealed the lunch meal was pureed country meatloaf with ketchup glaze, pureed lyonnaise potatoes, pureed carrots and pureed pineapple. A test tray of the regular and pureed lunch meals was conducted on August 19, 2026, on the [NAME] first floor C unit with Employee E7, Dietary Manager. Tray line was observed in the kitchen at 11:50 a.m. and the food truck was followed up to the nursing unit at 11:59 a.m. The food was sampled after all the trays had been distributed to residents at 12:16 p.m. The regular meal plate contained meatloaf with ketchup glaze, lyonnaise potatoes, corn o'brian and pineapple tidbits. Coffee and milk were also sampled. The coffee was 135 degrees Fahrenheit and the milk was 50 degrees. The meatloaf was 124 degrees, the lyonnaise potatoes were 127 degrees, the corn o'brian was 121 degrees and the pineapple was 49 degrees. The pureed meal that was served consisted of runny pureed meatloaf, mashed potatoes, an unidentified runny green vegetable and applesauce. Employee E7 was unsure what the green vegetable was. The pureed meatloaf was 124 degrees Fahrenheit, the mashed potatoes were 130 degrees and the green vegetable was 125 degrees. The pureed meatloaf and pureed green vegetable lacked form and swirled together on the plate. The pureed meatloaf and pureed green vegetable also had a taste and texture of food thickener, which was unappealing. The pureed meatloaf was bland, unseasoned and did not have the same flavor as the regular meatloaf. The pureed green vegetable was bland and unseasoned. The mashed potatoes did not have the same seasoning or flavor of the lyonnaise potatoes. Interview with Employee E7, Dietary Manager, at the time of the observation, confirmed that the foods didn't taste hot, that the pureed meatloaf and pureed green vegetable were unseasoned and that the appearance of the pureed foods was runny and not appetizing. 28 Pa Code 201.14(a) Responsibility of licensee28 Pa Code 211.6(a) Dietary services

Based on observations, review of facility documents and interviews with residents and staff, it was determined that the facility failed to follow menu extensions related to pureed diets and meals were not served in accordance with posted meal times and meal tickets, for two of eight nursing units observed ([NAME] Ground floor Section C unit and [NAME] First floor Section C unit). Findings include: Observation of the [NAME] Ground C unit on August 18, 2026, at 1:25 p.m. revealed several residents gathered by the nurses station, waiting for lunch to arrive. Six residents stated that they were hungry and wanted to know why lunch was so late. Interview with Employee E5, licensed nurse, confirmed that lunch had not arrived yet to the unit. Observation of the dining room on the [NAME] Ground C unit revealed meal times were posted and indicated that lunch was scheduled to be served on this unit at 12:40 p.m. Continued observation revealed that lunch was not delivered to the [NAME] Ground C unit until 1:51 p.m. Review of the menu posted revealed that for August 18, 2026, the lunch meal was apple spice pork roast with gravy, bowtie pasta, capri vegetables and chilled pears. The alternate meal was oven fried chicken, mashed potatoes and parslied cauliflower. Review of the menu extensions for pureed diets revealed the lunch meal was pureed apple spice pork roast, pureed capri vegetables, pureed bowtie pasta and pureed chilled pears. Continued observation of the lunch meal on August 18, 2026, revealed:Resident R120 did not receive the pork and pears in accordance with the meal ticket;Resident R73 did not receive double portions in accordance with the meal ticket;Resident R10 did not receive ice cream in accordance with the meal ticket. Continued observation of the lunch meal on August 18, 2026, at 2:12 p.m. revealed Residents R50 and R77 received total feeding assistance from Employee E5, licensed nurse, and E6, nurse aide. Both residents received pureed meals consisting of a runny white pureed substance, a runny green pureed substance and mashed potatoes. Interview with Employees E5 and E6 revealed that they did not know what the white and green pureed food items were, and guessed that they were chicken and broccoli. Employees E5 and E6 confirmed that R50 and R77 did not receive the bowtie pasta or the pears. Review of the menu posted revealed that for August 19, 2026, the lunch meal was country meatloaf with ketchup glaze, lyonnaise potatoes, corn o'brian and pineapple tidbits. The alternate meal was baked macaroni and cheese, carrots and steamed rice. Review of the menu extensions for pureed diets revealed the lunch meal was pureed country meatloaf with ketchup glaze, pureed lyonnaise potatoes, pureed carrots and pureed pineapple. A test tray of the regular and pureed lunch meals was conducted on August 19, 2026, on the [NAME] first floor C unit with Employee E7, dietary manager. Tray line was observed in the kitchen at 11:50 a.m. and the food truck was followed up to the nursing unit at 11:59 a.m. The pureed meal that was served consisted of pureed meatloaf, mashed potatoes, an unidentified runny green vegetable and applesauce. Employee E7 was unsure what the green vegetable was and was unsure what the planned menu was for the pureed diet extension. The mashed potatoes did not have the same seasoning or flavor of the lyonnaise potatoes. No pureed carrots were observed on the lunch plate. Employee E7 was unable to explain why the same green vegetable and mashed potatoes were served for lunch on both August 18 and 19, 2026, and that neither foods were in accordance with the planned pureed menu extensions. Employee E7 further confirmed that applesauce was served instead of pureed pineapple. 28 Pa Code 201.14(a) Responsibility of licensee28 Pa Code 211.6(a) Dietary services

Based on observation, clinical record review and interview with staff, it was determined that the facility did not ensure that medications were discarded according to manufacturer instructions for one of six medication carts reviewed (Medication Cart W1 B). Findings include: On August 21, 2026, at 11:35 a.m., during review of the Medication Cart of 'Nursing Unit W1 B' in the presence of a Licensed Nurse, Employee E17, detected a blister pack with remaining 12 tablets of Tramadol HCl Oral Tablet 25 mg, marked for Resident R7, having expiration date as July 20, 2026. Interview with the Licensed Nurse, Employee E17, at the time of the finding, confirmed that the expired medications should have been discarded according to manufacturer instructions, and facility policy. 28 Pa Code 211.9(a)(1) Pharmacy services 28 Pa Code 211.12(d)(5) Nursing services

Based on review of clinical records, review of facility documentation, and interviews with staff it was determined that the facility failed to accurately record a resident's weight to ensure appropriate interventions were implemented for 1 of 35 records reviewed (Resident R13). Findings include: Review of the facility policy, Weight and Height Assessment and Interventions, with a review date of May 2026, indicated that any weight change of greater than or less than 5 pounds within 30 days will be retaken the next day for confirmation with the licensed nurse confirming the reweight. The policy stated that if the weight is verified, nursing will immediately notify the dietician in writing. Review of Resident R13's clinical record revealed the following diagnoses: substance abuse; cerebral infarction (a stroke - brain damage); arthritis (a group of conditions that cause joint pain, stiffness, and inflammation, affecting mobility and quality of life), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident R13's clinical record indicated that on June 5, 2026, the resident's weight was recorded by nursing staff as being 184.5 pounds. The resident's weight on June 25, 2026, was recorded by nursing staff as being 173.6 pounds. Review of a reweight that was completed by nursing staff on June 26, 2026, also recorded the resident's weight as being 173.6, confirming an overall weight loss of 10.9 pounds and a significant weight loss of -5.9% over a 21-day period. Review of Resident R13's clinical record revealed a Registered Dietitian's note dated June 26, 2026, at 11:27 a.m. confirmed weight loss and a request for a re-weight to be completed. Reweight needed to confirm. Continued review of Resident R13's clinical record indicated that a nutritional supplement for the resident to consume one time a day was ordered for the resident on June 26, 2026, and monthly thereafter. Health shake one time a day to address the resident's above-referenced weight loss. Continued review of Resident R13's clinical record indicated that the weights that nursing staff recorded on June 25, 2026, and whose significant weight loss was confirmed on June 26, 20026 were both crossed out by the registered dietician on July 15, 2026, 21 days after the significant weight loss was confirmed and interventions were implemented to address the significant weight loss, which consisted of ordering nutrition supplements for the resident to consume. During an interview with the Registered Dietitian on August 20, 2026, at 9:43 a.m. the Registered Dietitian confirmed that a nutritional supplement was ordered for Resident R13 to consume one time a day and was added to address the resident's recent weight loss that was confirmed on June 26, 2026. During the interview, the Registered Dietitian reported that when she reviewed the resident's weights on July 15, 2026, she determined that the resident's weight loss confirmed on June 26, 2026, was not a true weight loss, and that the determination that it was not a true weight loss was made based on what the facility had in addition to what the hospital weight was. The Registered Dietitian also reported that the scale was broken. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 211.12(d)(1)(3) Nursing services.

Based on review of clinical record, review of facility policy, review of facility documentation, and interviews with resident and staff it was determined that the facility failed to provide adequate assistance during a mechanical lift by failing to evaluate the hazards and risks to prevent an avoidable accident resulting in a fall for one of 35 resident records reviewed (Resident R25). Findings include: Review of the facility policy titled, ADL Care, Resident Transfers, and Mechanical Lifts, revised March 2024 states, Residents who require total assistance with transfer may be transferred with use of a mechanical left. It is used by a trained staff for lifting/transferring residents when assessed as safe and appropriate for resident use based on collaboration between Physical Therapy and nursing as per plan of care. The policy states that before using a left device assess the resident's current condition including physical/cognitive and emotional. Check to make sure the resident's head, neck and back are supported, check the resident's comfort level by asking or observing for signs of pinching or pulling of the skin. Review of facility documentation titled, Mechanical Lift, is a clinical performance evaluation checklist shows the standard steps utilized by staff using mechanical lifts. The checklist instructs to Center sling behind resident and fanfold halfway under resident's body with lower edge of seat slightly below the resident's buttocks. Turn resident toward you, across folded sling. Straighten sling and turn resident on to back ensuring he/she is centered on sling, with lower edge now right below the buttocks (Correct placement permits the resident to be lifted evenly with minimal shifting) Pull the straps up between the resident's legs and cross the straps. Raise the head of bed. (Makes application of lift to sling easier and places resident in the position they will be in when lifted off of bed in sling). Select the shorter shoulder loops and longer leg loops for a more seated position, select longer shoulder loops and shorter leg loops for a more reclined position. Review of Resident R25's clinical record revealed the resident was admitted to the facility April 25, 2025, and has a diagnosis of Rheumatoid arthritis (a chronic autoimmune disease-causing inflammation of the joints). Review of Resident R25's care plan revealed the resident had a pulmonary embolism (blood clot in lungs) that caused difficulty breathing. The care plan included positioning the resident with proper body alignment for optimal breathing, dated April 28, 2025. The resident had a self-care deficit that required two people to assist the resident using a mechanical lift (Hoyer Lift) for transfers, dated May 5, 2025. Review of facility documentation revealed an incident report that stated on June 11, 2026, Resident R25 was being transferred into his/her Geri-chair (a chair used for long-term comfort and therapeutic positioning) by two aides using the Hoyer lift. While the aides were moving the resident in the Hoyer the resident started flailing kicking and saying he/she couldn't breathe. The aides told the resident they were almost finished and close to the chair. The lift titled sideways, rested on a dresser, and the resident was sitting on the floor still in the sling. During an interview, the resident said the Hoyer fell to the side and that the sling pad was under his/her head making it feel like he/she couldn't breathe. Interview with Resident R5 on August 19, 2026, at 2:00 p.m. revealed he/she was in bed with the Hoyer sling under him/her. Resident R5 stated I knew something didn't feel right. I said something to the two aides but instead of stopping and listening to me they continued to transfer me with the Hoyer to my chair. They had the sling too high up near the back of my head so when I was lifted it made my head bend forward and my chin was on my chest, and I felt like I couldn't breathe. When they tried to put me in the chair the chair fell over and I was dropped on the floor. I fell on my left side, and I already had problems with my left knee that made it worse. During an interview with nurse aide (NA) Employee E15 on August 21, 2026, at 11:30 a.m. stated that when Resident R5 was in bed, the resident complained he/she couldn't breathe. Nurse aide, Employee E15, stated she was trying to position Resident R5 in the sling, but the resident had the bed raised and was in a sitting position. Nurse aide, Employee E15, stated she told Resident R5 she couldn't position him/her in the sling with the bed back raised and that he/she needed to lay flat. Nurse aide, Employee E15, stated before starting the transfer, Resident R5's sling was not positioned correctly. Continued interview with NA, Employee E15, revealed Resident R5's head was positioned too far down into the sling; the resident could have been further up in the sling for more head room, but nurse aide, Employee E15, continued with the transfer. When Resident R5 said he/she couldn't breathe and started kicking his/her arms and legs, it made the positioning even worse and Resident R5 slid further down in the sling. Nurse aide, Employee E15, stated that she knew the resident was not positioned properly in the sling and if she could do it again, she would have put the resident back in bed and repositioned the resident. 28 Pa. Code:211.12(d)(1)(5) Nursing services.

Based on review of facility policy, review of clinical records, and interviews with staff it was determined the facility failed to ensure a resident received the necessary services and treatment to prevent pressure ulcers for one of 35 resident records reviewed (Resident R5).Findings include: Review of the facility policy titled, Risk Assessment and Prevention, revised October 2023 states that the facility will strive to ensure that a resident entering the Facility without pressure ulcers/pressure injuries (PU/PI) does not develop pressure ulcers/injuries unless the resident's clinical condition demonstrates unavoidable skin breakdown. Prevention of pressure ulcers/injuries (PU/PI) requires early identification of at-risk residents and the implementation of prevention strategies: 1. Identify residents at risk for developing pressure ulcers/injuries (PU/PI) and initiate an early prevention program. 2. Implement appropriate strategies/plans to: a. Attain/maintain intact skin b. Prevent complications c. Promptly identify or manage complications d. Involve the resident and Responsible Party in decisions. 3. Implement cost-effective strategies/plans that prevent and treat pressure ulcers/injuries. 4. A skin assessment will be completed upon admission. Braden/Norton Assessments will be completed on admission and weekly x4 after admission, quarterly, annually and with significant changes. Interventions based on assessment will be implemented and care planned. Review of Resident R5's clinical record revealed the resident was admitted to the facility on [DATE], and has diagnoses of heart disease, schizophrenia (mental illness associated with loss of reality contact, delusions and hallucinations), cognitive communication deficit, and unspecified intellectual disabilities. Review of Resident R5's admission MDS (an assessment of resident needs) dated December 30, 2026, assessed the resident as dependent (the resident does none of the effort to complete the activity) for toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement), and is dependent on staff for showers/bathing, personal hygiene, bed mobility (roll left and right), chair/bed-to-chair transfer, and toilet transfers. The same MDS assessed the resident as frequently incontinent (having no control) of bowel and bladder. Review of Resident R5's care plan for risk of pressure ulcer injury dated December 26, 2025, had interventions that included monitoring the skin, preventative skin care and the use of barrier cream. Due to the resident being dependent on staff for bed mobility further review of the resident's clinical chart revealed no evidence the facility developed appropriate strategies/plans to prevent the resident from pressure injury. On January 6, 2026, Resident R5 was assessed with a deep tissue injury on the resident's right heel measuring 3.0 x 4.5. It was only after the pressure injury was found that the facility included intervention for the resident to wear heel boots to offload the heels and for staff to turn and reposition the resident every two hours to prevent pressure to the boney areas. The above was confirmed with the Assistant Director of Nursing on August 21, 2026 at 10:00 a.m. that the facility failed to have interventions in place to prevent Resident R5 from pressure injuries. 28 Pa. Code:211.12(d)(1)(5) Nursing services.

Based on interviews and the review of clinical records, it was determined that the facility failed to ensure residents received care and services needed for residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of 35 residents reviewed (Resident R161).Findings include: Review of Resident R161's clinical record revealed the resident was admitted into the facility on October 1, 2025, with diagnoses that included the following: anxiety disorder (a condition that causes fear, worry and a constant feeling of being overwhelmed); substance abuse (the harmful or hazardous use of psychoactive substances, including alcohol, prescription medications, and illegal drugs, that negatively impacts health, relationships, and daily functioning), and cerebral infarction (a stroke - brain damage). Review of a nurse practitioner's admission note dated October 2, 2025, at 9:23 p.m. stated that Resident R161 was admitted into the facility from the hospital for care and rehabilitation services. Review of the nurse practitioner's admission note indicated Resident R161 has a history of substance abuse and was treated for aspiration pneumonia and a stroke while in the hospital when he/she presented with left sided vision loss and left side weakness. Continued review of the nurse practitioner's admission note indicated that the resident's follow up appointment with the neurologist, related to the recent stroke, was scheduled for December 19, 2025. Review of a nursing note dated April 29, 2026, at 6:56 p.m. written by Employee E19 (licensed nurse) stated that the resident was observed returning back into the building with his/her roommate's mother. Continued review of the nursing note stated that the resident was educated by the Unit Manger that he/she cannot go outside to smoke with his roommate's mother since she is not facility staff. The nursing note also stated that the roommate's mother disagreed with what the Unit Manager said, went in Resident R161's room with Resident R161, and shut the room door for approximately 10-15 minutes with Resident R161 inside the room. Continued review of the nursing note indicated that once the resident's roommate's mother left Resident R161's room the resident appeared to be heavily sedated, slumped over, leaning forward in his/her geri chair and slow to arouse. Residents were told to sit up or get in bed for safety measures. he refused to get in bed, put a pillow on his side table and leaned on that instead. Continued review of the nursing note indicated that the resident's vital signs were taken, were within normal limits, and the Unit Manager was notified. Review of a nursing note dated April 30, 2026, at 8:39 a.m. indicated that Resident R161 was still being monitored for behaviors, and that the resident slept through the current shift, slumped over in chair and not easily aroused at times with head hanging off to the side of bedside table. Resident noted about to fall out of chair and falls prevented several times by staff. When awaken by Nurse to take medications, resident would be awake for a minute then fall back to sleep. Drunken behavior noted with talking in slurred speech at times when name called, no pain or discomfort noted. Will monitor. Continued review of a nursing note dated April 30, 2026, at 11: 37 a.m. indicated that the unit manager notified the nurse practitioner, and that a new order was given for drug testing to be completed on the resident. Continued review of a nursing note dated April 30, 2026, at 11:37 a.m. indicated that the unit manager notified the nurse practitioner, and that a new order was given for drug testing to be completed on Resident R161. Review of the Preliminary Drug Screen Result Form, Review of the a Preliminary Drug Screen Result Form indicated that drug test was administered by Employee E4 (licensed nurse) on April 29, 2026, and on April 30, 2026, and the results of both tests were negative. Review of Resident R161's nursing notes did not show evidence that any other follow-up was initiated by the facility regarding any other additional clinical assessments completed to rule out any other sources of the resident's symptoms related to his change in condition that the resident started exhibiting after his roommate's sister left (e.g. observed as having slurred speech, heavily sedated, slumped over, leaning forward in his geri chair, slow to arouse, having falls prevented several times by staff, and the drunken behavior that nursing staff documented the resident as having) to ensure that appropriate care, services, treatment needed could be provided to the resident. During an interview with licensed nurse (Employee E19) on August 20, 2026, at 2:30 p.m. the resident's nursing note from April 29, 2026, at 8:39 a.m. was reviewed, and the licensed nurse reiterated that Resident R161 and his roommate's sister were outside smoking together, and after they returned to the unit, Resident R161 and his roommate's sister went to Resident R161's room and the licensed nurse saw Resident R161's roommate sister shut the door after they both entered. The licensed nurse reported that she noticed Resident R161's change in condition after Resident R161's roommate's sister left the facility, and that she told the Unit Manager what she observed after Resident R161's sister left the facility. During a discussion with the Director of Nursing on August 22, 2026, at 2:45 p.m. it was discussed that there were no additional follow-up after the negative drug testing was completed by the facility to identify any additional source(s) of the resident's symptoms that the resident was presenting, During the above-mentioned discussion with the Director of Nursing, it was confirmed that there was no investigation completed by the facility regarding the change in Resident R161's condition that was observed by nursing staff following visitation with the resident's roommate's sister on April 29, 2026. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 211.10 (c) Resident care policies 28 Pa. Code 211.12 (d)(5) Nursing services

Based on observations, review of clinical records and interviews with residents and staff, it was determined that the facility failed to ensure that appropriate language translation services were in use for one resident and did not ensure that resident nails were appropriately cared for, for two of 35 residents reviewed (Resident R14 and R113). Findings include: Review of the facility policy for nail care revised March 2024 states Nail Care will be provided on shower days and as necessary. It is the policy of this facility to clean and trim fingernails and toenails in order to: 1. Provide cleanliness. 3. Provide comfort. 4. Prevent skin injury problems. Review of Resident R14 clinical record the resident was admitted to the facility on [DATE], is alert and oriented, and has a diagnosis of heart disease. Reviewing the physician orders with Resident R14 on August 18, 2026, at 12:30 p.m., in response to a wound on the resident's chest wall, Resident R14 said it was from scratching the area with his/her nails. It was observed that the resident had long nails and appeared dirty with a dark colored substance under them. The resident stated he/she has been waiting a while for someone to cut them and said he/she does not like them long. Interview with Nurse Aide (NA) Employee E13 on August 20, 2026, at 1:00 p.m. stated he/she was aware the resident's nails were long and dirty and the aides are responsible to maintain the resident's nail care. Interview on August 19, 2026, at 9:38 a.m. Resident R113 stated that he/she speaks Cambodian. Resident R113 tried to express concerns regarding the food, but was unable to communicate any further due to the communication barrier. Resident R113 stated that he/she would prefer to use language translation services. Observation at the time of the interview revealed no communication devices were readily available for Resident R113. Interview on August 19, 2026, at 12:38 p.m. Employee E11, licensed nurse, confirmed that Resident R113 speaks Cambodian. Employee E11 stated that the facility has an electronic tablet with translation available, but was unaware of any staff using it. Employee E11 was unable to show the surveyor the tablet device. Employee E11 stated that they were unaware of any other language translation services available for use at the facility. Employee E11 confirmed that he/she had never used language communication services to speak to Resident R113. Interview on August 19, 2026, at 2:40 p.m. the Director of Nursing revealed that the facility has information for language translation services via phone with a live interpreter posted at nurses stations and that it should also be posted in residents' rooms for any resident that needs language translation services. Review of Resident R113's admission MDS (Minimum Data Set – a mandatory periodic resident assessment tool), dated June 30, 2026, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including cancer and malnutrition. Review of Resident R113's care plan, dated June 23, 2026, revealed that no care plan was developed related to the resident's language communication needs. An interview was conducted with the use of a live language interpreter, on August 20, 2026, at 9:45 a.m. with Resident R113. Resident R113 stated that no language translation services have been used by any staff since his/her admission to the facility. Resident R113 stated that it was difficult being at the facility because no one here can communicate with me, nobody understands what I want. Resident R113 stated that he/she would like to use language translation services while at the facility. Interview on August 20, 2026, at 10:10 a.m. Employee E8, nurse aide, stated that he/she only speaks English with Resident R113 because the resident is able to say a few words and express very basic needs. Continued interview confirmed that Employee E8 had never used language communication services to speak to Resident R113. 28 Pa. Code 211.12(d)(1)(3)(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 on orthopedic device use for two of 35 residents reviewed (R137, R168). Findings include: Review of the Facility Policy on Care Planning Process and Care Conference reviewed on May 2025 and May 2026, indicated that, to foster the philosophy of the facility, in compliance with Federal and State Regulations and in accordance with HIPAA Regulations (HIPAA stands for the Health Insurance Portability and Accountability Act of 1996. It is a United States federal law created to keep an individual's private medical information safe and secure), the facility will develop a comprehensive, resident centered care plan for each resident/patient. The care plan is a working tool that provides a profile of the needs of the individual resident/patient; the resident/patient care plan will be available for use by staff caring for the resident. Review of Resident R137's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included Catatonic Disorder due to Known Physiological Condition (a neuropsychiatric syndrome characterized by abnormal movement, behavior, and responsiveness), and Aphasia (loss of ability to understand or express speech, caused by brain damage). Review of physician order for R137, dated January 17, 2025, indicated an order for Patient to wear blue splint on Left elbow daily. Put on after morning care and remove after 2 hrs. Check skin and report any changes to charge nurse. Review of physician order for R137, dated March 14, 2025, indicated an order for Bilateral Elbow guards for skin protection, every shift. Review of Resident R137's clinical record revealed no documented evidence a comprehensive care plan was developed to include a focus, outcomes (goals), and interventions, for Resident R137's orthopedic devices. Interview on August 20, 2026, at 2:15 p.m., with the Director of Nursing confirmed the above findings. Review of Resident R168's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included Dysarthria (motor speech disorder), Hemiplegia and Hemiparesis Affecting Right Dominant Side (Hemiparesis is weakness on one side of the body, while hemiplegia is complete paralysis on one side of the body), and Dysphagia (swallowing difficulty). Review of physician order for R168, dated April2, 2026, indicated an order to apply Bilateral Heel Boots on at all times every shift. Review of physician order for R168, dated July 29, 2026, indicated an order to apply splint to right hand after morning care one time a day for Restorative Nursing Program and remove per schedule. Review of Resident R168's clinical record revealed no documented evidence a comprehensive care plan was developed to include a focus, outcomes (goals), and interventions, for Resident R168's heel boots and splint. Interview on August 21, 2026, at 1:27 p.m., with the Director of Nursing confirmed the above findings. 28 Pa Code 211.10 (c) Resident care policies 28 Pa Code 211.12(d)(5) Nursing services

Based on observations and interviews with residents and staff, it was determined that the facility failed to maintain a comfortable and homelike environment related to linens for one resident (Resident R73) and dining room repair for one of eight units observed ([NAME] unit). Findings include: Interview on August 18, 2026, at 1:35 p.m. Resident R73 stated that the bed sheets were raggedy. Observation on August 18, 2026, at 1:46 p.m. revealed a that there was a large hole in Resident R73's bedsheet, exposing the mattress. Resident R73 stated that the sheets were just changed this morning. Interview on August 18, 2026, at 2:08 p.m. Employee E5, licensed nurse, confirmed the large hole in Resident R73's bed sheet. Employee E5 also stated that the bed linens were just changed this morning and doesn't know why a staff member would use bed linens with holes in them. During a tour on the locked memory care unit, 2 [NAME], on August 19, 2026, at 10:42 a.m., it was observed that there were three areas in the dining room where large areas of wallpaper were peeling off the wall. In an interview with the Assistant Director of Nursing, Employee E3, on August 21, 2026, at 10:30 a.m., it was confirmed that the unit was in need of a refresh, including the wallpaper in the dining room. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on review of the clinical record, and staff and resident interviews it was determined that the facility failed to ensure that informed consent was obtained prior to administering a drug test to a resident for one out of 35 residents reviewed (Resident R161). Findings include: Review of the facility policy Illegal Drug Possession and Us, with a creation date of July 28, 2026, stated that the possession, use, distribution, or sale of illegal drugs or controlled substances without a valid prescription is prohibited on facility property. Continued review of the policy indicated that the facility will respond promptly to suspected or confirmed incidents in accordance with specific State and Federal regulations. Review of Resident R161's clinical record included the following diagnoses: anxiety disorder (intense, excessive, persistent worry or fear), cerebral infarction (a stroke - damage to the brain), and substance abuse (the harmful or hazardous use of psychoactive substances, including alcohol, prescription medications, and illegal drugs, that negatively impacts health, relationships, and daily functioning). Review of Resident R161's clinical record revealed a nursing note dated April 29, 2026, at 6:56 p.m. stated that the resident was observed returning back into the building with his/her roommate's mother. Continued review of the nursing note stated that the resident was educated by the Unit Manger that he/she cannot go outside to smoke with the roommate's mother since she is not facility staff. The nursing note also stated that the roommate's mother disagreed with what the Unit Manager said, went in Resident R161's room with Resident R161, and shut the room door for approximately 10-15 minutes with Resident R161 inside the room. Continued review of the nursing note indicated that once the resident's roommate's mother left Resident R161's room the resident appeared to be heavily sedated, slumped over, leaning forward in his/her geri chair and slow to arouse. Residents were told to sit up or get in bed for safety measures. Resident R161 refused to get in bed, put a pillow on his/her side table and leaned on that instead. Continued review of the nursing note indicated that Resident R161's vital signs were taken, and the Unit Manager was notified. Review of a nursing note dated April 30, 2026, at 8:39 a.m. indicated that the resident was still being monitored for behaviors, and that the resident slept through the current shift, slumped over in chair and not easily aroused at times with head hanging off to the side of bedside table. Resident noted about to fall out of chair and falls prevented several times by staff. When awaken by Nurse to take medications, resident would be awake for a minute then fall back to sleep. Drunken behavior noted with talking in slurred speech at times when name called. No pain or discomfort noted. Will monitor. Continued review of a nursing note dated April 30, 2026, at 11: 37 a.m. indicated that the unit manager notified the nurse practitioner, and that a new order was given for drug testing to be completed on the resident. Continued review of a nursing note dated April 30, 2026, at 11:37 a.m. indicated that the unit manager notified the nurse practitioner, and that a new order was given for drug testing to be completed on the resident. Review of the a Preliminary Drug Screen Result Form, indicated that drug test was administered by Employee E4 (licensed nurse) on April 29, 2026 and on April 30,2026, Continued review of the clinical record and the Preliminary Drug Screen Form did not show evidence that that informed consent was obtained prior to the administration of the drug tests to ensure that the resident was informed about why the facility felt it was needed, to ensure that the resident understood the risk, benefits and any alternatives to the drug test that may or may not be offered, and to ensure that the resident was provided with the right to agree or to refuse the administration of the drug test. During an interview with the licensed nurse, Employee E4, on August 20, 2026, at 9:15 a.m. the licensed nurse confirmed that no information in the clinical record or on the Preliminary Drug Screen Result Form could be produced to show evidence that informed consent was obtained from Resident R161 prior to the administration of the drug tests. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa Code 201.29 (c.3)(1)(2) Resident rights. 28 Pa Code 211.12 (d)(5) Nursing services.

Based on review of clinical records and interviews with resident and staff, it was determined that the facility failed to ensure one resident with unwanted sexual behavior received adequate supervision to prevent wandering for three resident records reviewed (Resident R1).Findings include:Review of Resident R1 clinical records revealed the resident was last admitted to the facility on [DATE], and has diagnoses of unspecified psychosis (a mental health condition involving impaired thinking, altered perception, hallucinations, delusions, or disorganized behavior), adjustment disorder ( excessive behavioral responses to identifiable stressors, leading to impairment in daily functioning), with anxiety and depressed mood, unspecified dementia (cognitive decline), with behavioral disturbances.Review of Resident R1 clinical record revealed a nursing note dated May 19, 2026, that stated Resident R1 was found in Resident R2's room. Resident R2 was sitting on the edge of the bed and Resident R1 was standing in front of the resident. Due to Resident R1 showing Increased anxiety, pacing around unit, and non-compliant with re-directions the resident was placed on 1:1 supervision (a single staff member provides continuous, close oversight of one individual to ensure safety, support, and individualized attention) due to this continued behavior.Review of Resident R1 clinical record revealed a nursing note dated May 28, 2026, that revealed nursing staff continued to provide 1:1 supervision due to Unwanted sexual behaviors and that the resident was observed by staff pacing floors and walking away from the staff member providing 1:1 supervision.Further review of Resident R1 clinical records revealed on June 14, 2026, Resident R1 was found again in Resident R2's room. The nursing progress note indicated Resident R1 had, Pants down to knees and underwear on, standing near Resident R2 bed. Immediately the nursing aide (NA), Employee E3, assigned to provide 1:1 supervision for Resident R1, removed Resident R1 from Resident R2's room.Review of Resident R1 physician orders dated June 2, 2026, revealed during the time Resident R1 was found in Resident R2 room, the 1:1 supervision was still in force and required due to the resident's behaviors.Interview with nurse aide, Employee E3, on June 29, 2026, at 12:30 p.m. indicated he/she knew Resident R1 needed 1:1 supervision, but stated, I needed to use the restroom. Instead of asking a staff member for assistance, the nurse aide, Employee E3, stated, I left Resident R1 near the nursing station and used the bathroom. I was so fast I was only 1-2 minutes in the bathroom. When I was finished, I saw the resident was gone. I immediately went to Resident R2 room, near the nursing station, and found Resident R1 standing there in his underwear with his/her trousers down.Interview with the Assistant Director of Nursing, Employee E2, on June 29, 2026, confirmed Nurse aide, Employee E3, failed to provide Resident R1 with adequate 1:1 supervision. 28 Pa. Code 211.10 (d) Resident care policies.28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of facility policy, review of facility documentation, and interviews with residents and staff it was determined that the facility failed to conduct a complete and through investigation related to potential verbal abuse for one out of two residents reviewed (Resident R1). Findings include:Review of the facility policy Abuse Policy-Prevention and Management, revised September 8, 2022, indicated that the facility will begin the investigation process immediately upon notification of the incident and will prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. Continued review of the policy indicated that upon receiving an incident or suspected incident of resident abuse, neglect, misappropriation of resident property, or injury of an unknown source, the Administrator/DON/designee will conduct an investigation to include, but not limited to: completing paperwork for investigation of abuse, neglect, misappropriation; interviewing the person(s) reporting the incident; interviewing any witnesses to the incident; interviewing the resident if able; interviewing staff members on all shifts who had contact with the resident during the period of the alleged incident; interviewing the resident's roommate, family members, and visitors as applicable, and interviewing other residents to which the accused employee provides care or services. Review of Resident R1's June 2026 physician orders included the following diagnoses: arthritis (the swelling and tenderness of one or more joints), morbid obesity, and anemia (a blood disorder that happens when you don't have enough red blood cells, or your red blood cells don't work as they should). Review of information submitted to the State Survey Agency on May 5, 2026, indicated a concern related to the care and services provided by Nurse Aide, Employee E3, regarding Resident R1.During an interview with Resident R1 on June 3, 2026, at 1:30 p.m. the resident spoke of a previous time he/she felt mistreated by Nurse Aide, Employee E3. Resident R1 reported that when speaking with another nurse aide in his/her room the Nurse Aide, Employee E3, entered the room. Resident R1 stated that the Nurse Aide, Employee E3, raised his/her voice at the resident, was speaking in a manner that was disrespectful, and was accusing Resident R1 of speaking bad about him/her to the other nurse aide in the room. Continued interview with Resident R1 on June 3, 2026, at 1:30 p.m., the resident reported that he/she did not like the way Nurse Aide, Employee E3, spoke to him/her when entering the room. Resident R1 stated the above referenced incident was reported to the Unit Manager, Employee E4. Resident R1 further reported nothing was done about it, as no one ever followed up with him/her regarding the outcome.During an interview on June 4, 2026, at 10:15 a.m. with Unit Manager, Employee E4, it was reported that in December 2025 or January 2026, Resident R1 made him/her aware of the above referenced incident between Resident R1 and Nurse Aide, Employee E3.Continued interview on June 4, 2026, at 10:15 a.m. Unit Manager, Employee E4, reported that he/she cannot recall what Employee E3 told her at the time of the incident. Unit Manager, Employee E4, reported that he/she did not interview the other nurse aide in the room or anyone else (such as other staff or residents) regarding the above referenced incident that Resident R1 reported regarding Nurse Aide, Employee E3. 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 review of clinical records, interviews with staff, review of facility investigation and review of facility policies, it was determined that the facility failed to ensure that one of nine residents reviewed received proper assistance during transfer from chair to bed, which resulted in a fall incident and a skin tear to the left leg. (Resident R1)Findings Include:Review of facility policy titled, Fall Prevention and Management with a date of January 12, 2023, states, The interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. Determining causal factors leading to a resident fall is necessary to provide consistent intervention to help prevent further occurrences. Further review of the facility policy revealed, Implement goals and interventions with input from resident/family if able for inclusion in the interdisciplinary Plan of Care based on individual needs after attempting to determine possible causes. Communicate interventions to the care giving teams and family/responsible party. Review of facility policy titled, ADL-CARE- MOBILITY AND RESORATIVE MOBILITY PROGRAM (Transfers) (Bed Mobility) with a date of March 12, 2024 states, All care provided to a resident must be within the context of the resident's care plan which provides for appropriate care and services for the resident related to mobility needs, such as transfers, bed mobility, and amputation with prosthetic device. Review of Resident R1's clinical record revealed an admission date of September 18, 2024, with diagnosis of, Parkinsons disease (progressive disease of the central nervous system characterized by tremors, muscle weakness and unsteady gait). Review of Resident R1's Comprehensive Care Plan, revised on September 9, 2023, indicated I have an ADL (Activities of Daily Living) care deficit related to decreased activity, wound, back pain, CVA (Cerebrovascular accident, also known as a stroke). Interventions included Transfer status: I require use of the mechanical lift with 2 staff members during all transfers. Review of Resident R1's nursing notes dated February 7, 2026, revealed that the resident BIMS (Brief Interview of Mental Status) was completed and the resident was assessed with a score of 14 indicating that the resident was cognitively intact. Continued review of nursing notes dated February 16, 2026, revealed that around 10:20 pm. The CNA (nurse aide) Notified to me that the resident was a fall while transferring to bed. Went to the room and assessed the resident. Resident was found sitting on the floor with the left knee bleeding. Resident was observed with a skin tear in Left knee, 6cm x 6 am Pressure applied to stop the bleeding and left knee was coered with pressure dressing. Resident was stable. CRNP . and daughter . Notified. Daughter asked to send resident to [local hospital]. Left knee skin tear noted and bleeding, pressure initially and clean the skn tear wtih NSS ([NAME] saline solution) Pat dry apply moist saline gauze . cover with kerlx. Vital signs .Resident is stable at this time. Review of facility investigation dated February 16, 2026, Resident had fall while transferring resident to bed. Charge nurse immediately responded and observed resident sitting on the floor with a skin tear on left knee, pressure dressing applied. Review of Employee E2, Nursing Assistant's statement dated February 18, 2026, After completing peri-care on resident, standing using walker, we begin to ambulate to the bed. Leaving from the recliner chair, resident did well walking until resident's left knee gave out causing resident to fall. During the fall I obtained a firm grip and slowly assisted resident to the floor. Review of Resident R1's hospital record, dated February 17, 2026, Wound approximately 8cm x 8cm avulsion laceration left knee with partial skin approximation. Visible open area pink with serosanguineous drainage. Skin flap with some dusky discoloration. Steri-strips anchoring skin flap. Just placed by orthopedics. Review of Employee E2, Nursing Assistant's counseling record Employee E2 didn't follow the care plan for a 2 person assist transfer for Resident R1 on 2/16/2026 at 10:15p.m. It caused resident to lose her balance and the C.N.A. to lowered her to the floor to the left knee and caused a skin tear. 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(d)(1)(5) Nursing services

Based on review of clinical record, facility documentation, facility policy, and staff interviews, it was determined the facility failed to ensure that all interventions to prevent fall incidents were in place after Resident R48 was transfer into bed, resulting in actual harm to Resident R48 who fell out of bed and sustained a fractured jaw for one of three residents reviewed for falls. (Resident R48) Findings include: Review of facility policy Fall Prevention and Management, revised 2023, revealed an Avoidable Accident is interpreted as an accident occurred because the facility failed to: - Identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices; and/or - Evaluate and analyze the hazards and risks and eliminate them, if possible, or if not possible, identify and implement measures to reduce the hazards/risks as much as possible; and/or - Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and if not, reduce the risk of an accident; and/or - Monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standards of practice Review of Resident R48's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that include Cerebral Ischemia (insufficient blood flow and oxygen to the brain, which can lead to cell death or irreversible damage), legal blindness, and Anxiety disorder. Review of Resident R48's physician orders, dated December 09, 2024, revealed an order for fall mat to both sides when resident is in bed, move from bedside when out of bed. Review of Resident R48's quarterly Minimum Data Set (MDS- mandated assessment of a resident's abilities and care needs), dated October 03, 2025, revealed Resident R48 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Review of documentation submitted to the State Survey Agency on January 11, 2025, revealed on January 10, 2025, the nurse aide, Employee E19 was assisting Resident R48 with evening care. After nurse aide, Employee 19 transferred resident to bed she took the wheelchair away from the side of the bed towards the door in resident's room to make space for her to assist resident with evening care. Resident was placed at center of the bed. Then suddenly Employee E19 heard the noise and observed the resident lying on the floor. Upon arrival, the charge nurse observed resident lying on the floor beside [his/her] bed. Resident R48 was observed bleeding from [his/her] mouth. Resident was then transferred to ER (Emergency Room) and diagnosed with closed fracture of maxillary bone (break on the upper jawbone). Review of facility investigation, dated January 10, 2025, revealed the charge nurse was alerted by the nurse aide that Resident R48 had a fall in [resident] room. Resident R48 was observed laying on the ground and his/her mouth bleeding. The nurse aide confirmed that she just transferred resident from wheelchair to bed and while she was putting away the chair when Resident R48 fell. Further review of facility investigation revealed a witness statement from agency nurse aide, Employee E19, on January 13, 2025, which indicated the floor mats were not on the floor at the time of the fall. Employee E19 also stated I was still trying to get [resident] ready for bed. After I finish, then I will put the floor mat on the floor before leaving the room. Surveyor efforts to conduct phone interview with agency nurse aide, Employee E19 were unsuccessful. Interview conducted on October 23, 2025, at 12:30 p.m. with Assistant Director of Nursing, Employee E13, confirmed Resident R48 had an order for floor mats to be in place while Resident R48 was in bed. The facility failed to ensure floor mats were in place after Resident R48 was transferred into bed and as indicated in the resident's care plan which resulted in actual harm to Resident R48 who fell out of bed and sustained a fracture of the jaw. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, facility policy, resident and staff interviews, it was determined that the facility failed to maintain the facility in a clean and homelike condition in one of eight nursing units (Dementia Unit 2nd floor). Findings include: Facility Policy titled Housekeeping Operational Manual revised on 11/2024, revealed under Bed Washing and Disinfecting it stated to control odor, to prevent the spread of infections and bacteria and to ensure maximum cleanliness and sanitation for the individual resident. Bed disinfecting is performed on a monthly basis (in conjunction with complete room cleaning).Observations on September 29, 2025, at approximately 11:54 a.m. indicated that Unit Manager, Employee E10, confirmed a strong and heavy odor of urine on the dementia unit between rooms [ROOM NUMBERS].Observations on September 30, 2025, at 12:48 p.m. on the dementia unit near room [ROOM NUMBER] revealed a strong odor of urine. Licensed Nurse Employee E8 confirmed the strong and heavy odor of urine near room [ROOM NUMBER] and in the small hallway leading into the dementia unit.On September 30, 2025, at 12:48 p.m., an interview with a housekeeping staff member, Employee E9, confirmed a strong and heavy urine odor. Employee E9 reported that room [ROOM NUMBER] had been cleaned, but suggested that the flooring may be saturated with urine and may need to be replaced. A certified nursing assistant, Employee E11, reported that she/he had changed the resident residing in room [ROOM NUMBER]. The Unit Manager, Employee E10, also confirmed the urine odor and stated that she would request that the mattress be inspected and replaced if necessary.On October 1, 2025, at 1:06 p.m., there was no detectable urine odor near or inside room [ROOM NUMBER]. The Unit Manager, Employee E10, reported that the mattress in room [ROOM NUMBER] had been replaced.28 Pa. Code 201.18(e)(2.1) Management

Based on observation, review of clinical records, interview with staff and resident, it was determined that the facility failed to ensure that MDS (Minimum Data Set) a federally required resident assessment completed at a specific interval) was completed accurately for one of thirty-five residents reviewed. (Resident R143) Findings include: Rearview of Resident R143's clinical record revealed that Resident R143 was admitted to the facility on [DATE], with diagnosis of but not limited to Chronic Obstructive Pulmonary Disease.Review of Resident Review of Resident R143's quarterly MDS dated [DATE], revealed that section B0200, Hearing was coded as ADEQUATE Review of hearing evaluation dated July 25, 2025, revealed that Resident 143 was seen for an audiometric hearing evaluation. Further, the hearing evaluation revealed moderate - severe hearing loss in both ears. Further review of Resident R143's clinical record, revealed a care plan for Communication Problem r/t Hearing deficit Ability to hear initiated on January 30, 2025. Observation of Resident R143 conducted on September 29, 2025, at 1:15PM revealed that resident was in bed, alert, awake and responsive to surveyor. Further observation during interview with resident revealed that resident was not able to hear surveyor very. Interview with Resident R143 conducted at the time of the observation revealed that Resident R143 was hard of hearing. Further, Resident R143 asked the surveyor to speak louder so she can hear. Further interview with resident revealed that she does not have a hearing aid and that the staff had to talk louder to her in order for her to hear them properly. Interview with Director of Social Worker Employee E5 and Social Worker Assistant Employee E6, conducted on October 23, 2025, at 10:42AM revealed that the MDS dated [DATE], section B0200 (Hearing) was completed by Social Worker Assistant Employee E6 who was a new employee. Further, Employee E5 confirmed that the MDS section B0200 was coded erroneously. Further, Employee [NAME] revealed that they will correct the MDS. 28 Pa. Code 211.12(d)(1) Nursing Services

Based on the review of facility documentation, clinical records, Safety Data Sheet, facility policies, observations, and interview with staff, it was determined that the facility failed to secure the housekeeping cart and hazardous chemical products and failed to ensure that these products were not accessible to residents in one of eight nursing units. ([NAME] 1 nursing unit). These failures resulted in Resident R1 able to access and drank hazardous chemical product and experienced episodes of emesis. This failure resulted in an Immediate Jeopardy situation for Resident R1 and other residents at risk for serious harm in the [NAME] 1 nursing unit. Findings include: Review of the facility document title Housekeeping Cart Safety undated revealed: 1. Housekeeping carts are never to be left unattended (if you have to leave your cart, it must be placed in the locked housekeeping closet). 2. Housekeeping carts are to be locked at all times. 3. Chemicals are never to be left unattended. 4. Housekeeping carts and Closets are to be checked daily to make sure all equipment is functional. 5. When chemicals aren't being used they must be stored inside the housekeeping cart and it must be locked. 6. All chemicals must be in a properly labeled bottle. Review of facility policy Housekeeping Operational Manual date [DATE], revealed, Chemical and Cleaning Agents: Safety in a healthcare environment is not only limited to accidents and injuries. To provide a safe and hazard free environment all employees must also utilize cleaning chemicals properly and in observance of all safety precautions. All housekeeping employees will be using cleaning chemicals on a regular basis and, to ensure optimum levels of safety, should follow some simple guidelines. Never handle any chemical or cleaning agent without wearing proper personal when protective equipment (always wear gloves, wear goggles and gowns instructed). Follow dilution ratios and mixing instruction exactly according to product specifications. All chemicals and cleaning agents must be stored in labeled containers. Store all chemicals and cleaning agents in designated locked storage areas. Never leave any chemicals or cleaning agents unattended, even for even for a moment. Never allow residents, visitors or untrained employees to handle any chemicals or cleaning agents. Never spray any chemicals or cleaning agents in the presence of residents or visitors. Never spray any chemicals or cleaning agents in the presence of food or beverages. Never mix chemicals or cleaning agents for any reason. Never used. chemicals or cleaning agents in any manner other than that for which they were intended Never consume any chemicals or cleaning agents. Review of Hazard Determination System (HDS) (A system used to rate chemicals and products based on hazard risk level) revealed that a health rating of 0 - minimum hazard 1 - Can cause irritation if not treated 2 - Can cause injury. Requires prompt treatment 3 - Can cause serious injury despite medical treatment 4 - Can cause death or major injury despite medical treatment. Review of SDS (a document that contains detailed information about the safety and health impacting aspects of various substances and products.), sheet for chemical product Sienna revealed that the product use was Neutral Disinfectant Cleaner This product was a registered pesticide. GHS Label Element: Classified as Corrosive which indicated that the chemical damages metal and living tissues on contact. Skin corrosion and serious eye damages. Signal Word: Danger Hazard Statement: May be corrosive to eyes. Cause skin burns, May be harmful if swallowed. Precautionary Statements: Wear protective gloves, splash goggles, face shield and protective clothing. Wash thoroughly after handling. Acute Effects: Eyes: May cause irreversible damage Skin: Causes skin burns, Inhalation: Mists and vapors may be irritating to throat and respiratory tract. Ingestion: Harmful if swallowed. First Aid Measures: Ingestion: Do not induce vomiting, Drink copious amounts of water. Seek medical attention immediately. Hazardous Determination System (HDS): score: Health: 3. (Can cause serious injury despite medical treatment) Review of SDS sheet for chemical product Fusion Pink revealed that the product use was Air freshener/deodorizer GHS Label Element: Classified as Harmful Irritant which indicated that the chemical can cause skin irritation and acute toxicity. Signal Word: Warning Hazard Statement: May cause skin. Precautionary Statements: Wear protective gloves and eye protection. Wash thoroughly after handling. Acute Effects: Ingestion: Maybe irritating to the mouth, throat and gastrointestinal systems. Hazardous Determination System (HDS): score: Health: 1 Review of SDS sheet for chemical product Fusion [NAME] revealed that the product use was Disinfectant Cleaner This product was a registered pesticide. GHS Label Element: Classified as Corrosive which indicated that the chemical damages metal and living tissues on contact. Skin corrosion and serious eye damages. Signal Word: Danger Hazard Statement: Cause eye and skin burns, Causes respiratory tract irritation. May be harmful if swallowed. Precautionary Statements: Wear protective gloves, splash goggles, face shield and protective clothing. Wash thoroughly after handling. Acute Effects: Eyes: Causes burns, inflammation of the eye Skin: Corrosive to skin Ingestion: Harmful if swallowed. May cause burns to mouth throat and stomach. Ingestion may cause erosion of mucous membranes and perforation of the esophagus of stomach. First Aid Measures: Ingestion: Do not induce vomiting, Drink copious amounts of water. Seek medical attention immediately. Hazardous Determination System (HDS): score: Health: 3. (Can cause serious injury despite medical treatment). Review of clinical record for Resident R1 revealed that the resident was admitted to the facility on [DATE], with diagnosis including, dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life) and Wernicke's encephalopathy (a type of brain injury that mostly happens to people who drink a lot of alcohol). Review of Minimum Data Set MDS- (assessment of resident care needs) for Resident R1 dated [DATE], revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 5 which indicated that the resident's cognitive status was severely impaired. Review of care plan for Resident R1 dated [DATE], revealed that Resident R1 had a history of suicidal ideation with intervention to remove all dangerous objects from resident's environment. Review of facility documentation dated [DATE], revealed that the unit had a flood, housekeeping staff left the housekeeping cart by the nurse's station so that the nurses could disinfect appropriately. The cart has a closed locked compartment that contained disinfectant. Resident R1 was observed at 7:30 a.m. with a bottle of disinfectant in her hand close to her mouth. A nursing assistant called the name of resident, ran to her and took the bottle from her. Resident was examined by her physician approximately at 9:30 a.m. with stable vital signs no abnormality. Resident was ambulating on the unit without any adverse effect. At 10:51 a.m. had her weight taken, offered water which she drank with no nausea or vomiting or complaint. At 12 noon she had normal bowel movement, vital signs stable and ambulating in hallway and later sat in the chair in the hallway. At 12:55, nurse went to check on resident for observation and did not see her in her room. She was observed in another room lying in bed unresponsive, Cardio Pulmonary Resuscitation (CPR) was initiated, [DATE] was called for EMS (Emergency Medical Services). EMS continued CPR. The resident was pronounced dead at 1:21 p.m. Review of progress note dated [DATE], revealed that the nurse was called to the floor, he notified that the resident was seen by staff with bottle of Sienna disinfectant in her hands, staff removed bottle from resident. Vital signs stable, no distress noted, no irritation of mouth face or hands, nurse stayed with resident. Nurse called the position control center. Gave name of cleaner and all information form SDS sheet along with label ingredients answered all questions from poison control center. Poison control center said the PH level is between ,d+[DATE] means, non-caustic and ingredients listed are not poisonous no need for medical intervention. Milk given, resident alert and verbal. Physician assessed resident no new orders. Resident was monitored by staff. Review of progress note dated [DATE], at 12:55 p.m. revealed that the resident was found in another resident's room lying on her back flat and unresponsive. No pulse noted and unable to obtain vital signs. CPR-(Cardiopulmonary resuscitation) initiated and 911 called. Review of physician progress note dated [DATE], at 4:31 p.m. revealed that the resident expired. The physician spoke with coroner and agreed on the cause of death as Wernicke's encephalopathy and dementia. Review of facility documentation revealed that an autopsy (a postmortem examination to discover the cause of death or the extent of disease.) was not performed based on physician's discussion with the coroner. Interview with Nursing Assistant, Employee E4, on [DATE], at 10:20 a.m. stated around 7.45 a.m. on [DATE], she was taking another resident to breakfast, when she saw Resident R1 drinking the cleaning liquid Sienna in front of the house keeping cart, which was placed in front of the janitor closet. Employee E4 stated she saw resident lift the open bottle to her mouth and drinking it. Employee E4 further stated that she ran towards her calling her name loudly and snatched it from her there was over half of the solution was left in the container, but it was not full. Employee E4 stated she saw another cleaning product similar shape of Sienna bottle stored unsecured on top of the house keeping cart. She opened the janitor closet which was unlocked at that time and secured cart in the janitor closet. Employee E4 also stated she saw Resident R1 vomit large amount of clear vomitus on top of the breakfast cart around 8:30 a.m. Employee stated nurse was aware of the vomiting. Interview with Nursing Assistant, Employee E5, on [DATE], at 10:39 a.m. stated she was behind Employee E4 when Resident R1 drank the disinfectant liquid. She saw Resident R1 vomit right after she drank the milk. Resident R1 vomited again on top of the breakfast cart around 8:30 a.m. and vomited for the third time at around 10:00 a.m. Employee E5 stated she noticed a change in Resident R1's voice it was like hoarseness. Employee E4 also stated Resident R1 did not eat her breakfast, only drank few sips of liquid and her lunch tray was untouched. Interview with Employee E6, Licensed Nurse, on [DATE], at 10:29 a.m. stated after Resident R1 drank the liquid the resident's vital signs were taken and they were normal. Later in the shift Resident R1 was found unresponsive in another resident's bed. Interview with the Physician, Employee E11, on [DATE], at 1:13 p.m. stated staff showed him a bottle from where the resident was drinking chemical disinfectant. He did not think she drank much from that bottle. However, physician stated he did not know if resident drank any liquid prior to that. He stated that the resident was stable when he assessed her around 9:00 a.m. He verbally ordered the nurse to closely monitor resident by checking vital signs and assessment every 15 to 30 minutes. Interview with Nursing Assistant, Employee E7, on [DATE], at 10:46 a.m. stated she saw the janitor room was little open and the cart was in the hallway next to the door. Employee E7 stated she did not close the door because she thought there was someone in the janitor closet room. Interview with Housekeeping staff, Employee E9, on [DATE], at 10:12 a.m. stated she worked on [DATE], but her shift did not start until 9.00 a.m. She stated the employee from previous day left the cart in the hallway. She stated staff was supposed to lock the cart and store it inside locked janitor closet at the end of their shift. Observation of Employee E8's housekeeping cart located on [NAME] 2 nursing unit revealed that the storage compartment contained two bottle of Sienna multi surface cleaner disinfectant, one bottle of pink fusion, one bottle of pure bright germicidal ultra-bleach liquid, one full bottle of unlabeled bottle. Employee E8 stated it was bleach. Interview with Housekeeping Staff, Employee E8, on [DATE], at 9.58 a.m. stated staff was supposed to store housekeeping carts locked inside the janitor closet room on each floor. Observation of Employee E8's housekeeping cart located on [NAME] 1 nursing unit revealed that the storage compartment contained one bottle of Sienna multi surface cleaner disinfectant, one bottle of soap liquid, one bottle of pure bright germicidal ultra-bleach liquid, one full bottle of unlabeled bottle. Employee E8 stated it was bleach. Observation of the [NAME] 1 nursing unit on [DATE], at 10:01 a.m. revealed Employee E8 opening janitors closet without a key. Observation of the [NAME] 1 nursing unit on [DATE], at 10:06 a.m. revealed that the janitor's closet was unlocked, and the surveyor was able to open it without a key. One bottle of hand sanitizer solution was observed store in the unlocked housekeeping closet. Continued observations revealed that Housekeeping Staff, Employee E8 closed the janitor's closet. It was also observed that [NAME] 1's janitor closet door was not equipped with auto lock, which required to be locked every time it was opened. Interview with Housekeeping Director, Employee E10, on [DATE], at 12:00 a.m. stated on [DATE], he observed the housekeeping cart, where Resident R1 drank the Sienna cleaning solution, had a broken door and it was not closing properly. Employee E10 stated he completed an audit and found another cart with a broken door. Employee E10 stated nurses on the floor had keys to the janitor closet and the carts did not need to stay on the hallway. Employee E10 confirmed that prior to Resident R1 was observe drinking Sienna disinfectant on [DATE], Housekeeping Staff, Employee E11, left the cart in the hallway to clean a flood, which was not needed as the nurses had the keys to the janitor's closet. Employee E10 stated staff should ensure that the cart was locked if unattended. Employee E10 also confirmed that the housekeeping department used harmful chemical and it was a potential hazard to leave it unattended in dementia unit or around residents with dementia. Further review of the facility investigation revealed no evidence that the facility determined the amount of unsecured cleaning supplies available on the housekeeping cart and the amount Resident R1 ingested. It was also revealed that Resident R1 and other residents on the dementia unit had access to the broken housekeeping cart, cleaning chemicals inside the locked compartment of the cart, unsecured cleaning chemicals on top of the cart, and unlocked janitor's closet. Review of facility documentation provided by the facility revealed that on [DATE], there were 5 residents on [NAME] 1 with diagnosis of dementia and 22 residents on [NAME] 2 with diagnosis of dementia, 5 of those residents were ambulatory. Interview with the Nursing Home Administrator on [DATE], at 2:45 confirmed that housekeeping carts and cleaning supplies should not be left unattended, and unsecured housekeeping chemicals on [DATE], created an environment potential to cause serious harm to the residents. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on [DATE], at 4:06 p.m. for the facility's failure to ensure that the resident environment was free of accident hazards, as the facility failed to secure the housekeeping cart and hazardous chemical products and failed to ensure that these products were not accessible to residents in one nursing unit. These failures resulted in Resident R1 able to access and drank hazardous chemical product and experienced episodes of emesis. These failures also placed Resident R1 and other residents in the unit at risk for serious harm including death. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator (NHA) and Director of Nursing (DON) on [DATE], at 4:10 p.m. The facility submitted a written plan of action on [DATE], at 7.12 p.m. and implemented the plan of action which included: 1. All housekeeping carts were inspected on to ensure that all housekeeping locking mechanism are working properly and chemicals are securely locked on [DATE]. No supplies will be on top of the cart. 2. All housekeeping carts removed from the units [DATE], Carts will be stowed in the housekeeping supply room in the basement not accessible to residents. Housekeeping carts when in use and not within housekeeping eyesight the disinfectant compartment will be locked 3. All housekeeping carts inspected [DATE], to ensure locking mechanism are working and locking properly before the carts are taken to the units. If a cart locking mechanism is not locking properly, the cart will be removed from service. Maintenance will be notified to complete repair before the cart is put back in service. Maintenance audited all housekeeping closets to ensure that door locks properly and lock has a self-locking lock on [DATE]. 4. All Healthcare center staff will be educated on the following before the beginning of their shift starting on [DATE]: -Housekeepers will be educated about checking the locking mechanism of the housekeeping carts compartment for disinfectants before taking carts to the unit to ensure that locking mechanism is working properly. Cart will be removed from service immediately if locking mechanism is not locking properly. Maintenance will complete repair before cart is put back in service. -Housekeeping carts will be removed from the unit at the end of the shift and will be stored in the housekeeping supply room in the basement. -Housekeeping carts when in use and not within eyesight of housekeeper must be locked. -Janitor closets will be locked at all times and the lock must be self-locking lock. -Housekeeping chemical bottles will be labelled. -If a bottle does not have a label housekeeping supervisor will be notified, and bottle will be removed. -supervisor will be notified immediately -Inservice will be completed by end of [DATE]. 5. Unit round audit will be completed by NHA or designee daily x 1 week starting [DATE], and then weekly x 4, and then monthly x 3 to ensure housekeeping closet are locked, carts are locked when on the units. Housekeeping director will audit all housekeeping carts for chemical labels to ensure that all chemical are labelled daily x 1 week starting [DATE], then weekly x 4 weeks, then Monthly x 3 months. Results of audits will be submitted to QAPI until substantial compliance is achieved On [DATE], between 1:15 p.m. and at 3:25 p.m. the action plan was reviewed, observation was made of all eight nursing units, janitor's closet and housekeeping carts. All janitor's closets were found to be locked and their locking mechanism working properly. Housekeeping carts were safely stored. Maintenance and safety rounds audits were reviewed. Interviews were conducted with staff to confirm that the in-service education was completed. Following the verification of the immediate action plan the Immediate Jeopardy was lifted on [DATE], at 3:48 p.m. 28 Pa. Code 201.18(b)(1) Management 28 Pa.Code 201.18(b)(3) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.10(d) Resident care policies

Based on observations and review of clinical and facility documentation and interviews with staff and residents it was determined that the facility did not provide adequate supervision for two of 30 residents reviewed resulting in harm for one resident (Resident R176 and R115). Findings include: Review of Resident R 176's clinical record revealed that the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident's ordered diet is listed as regular control carbohydrates with honey thickened liquids. Review of Resident R176's care plan dated May 7, 2015 revealed that the resident is on a therapeutic diet related to a [DIAGNOSES REDACTED]. Interventions listed state the resident is to use a sippy cup for beverages and a one handled mug with a lid for meals. Also the resident is to be at a 90 degree angle for all meals with frequent supervision. Review of Physician orders [REDACTED]. Review of the clinical documentation revealed the that resident spilled hot tea on her right thigh and left hand around May 27, 2015. Review of Resident R176 clinical record nurse's notes dated May 29, 2015 revealed the area on the right thigh measures 2.7 centimeters by 10.5 centimeters, the left hand was red and tender to the touch and the area measured 18.5 centimeters by 8 centimeters, in addition to a fluid filled blister measuring 5 centimeters by 6.5 centimeters on the side of the hand. Review of a nurse's note dated May 31, 2015 revealed that the physician ordered Keflex (an antibiotic) three times a day for seven days for a possible left hand infection. Further review of nurse's notes revealed the resident's burns were being treated all through June and most of July 2015. Interview with the occupational and physical therapy supervisor, Employee E15, on January 22, 2016 at 11:00 a.m. revealed that Resident R176 was receiving occupational therapy from March 23, 2015 to May 7, 2015 for fine motor coordination, perform hand to mouth feeding, and bi-lateral hand strength. The resident was discharged from occupational therapy on May 7,2015, discharge recommendations included a sippy cup for beverages, mug with lid for meals to reduce risk of spillage. The facility failed to provide adequate supervision to prevent the resident from receiving this burn. This was confirmed by the Director of Nursing On January 22, 2016 at 1:00 p.m. Review of Resident R115's clinical record revealed [DIAGNOSES REDACTED]. Review of facility documentation dated August 30, 2015 revealed that the resident was found on the floor as a result of a self transfer. Review of Resident R115's a nursing progress notes dated October 24, 2015 revealed that the resident was found on the floor as a result of the resident sliding out of bed. Further review of progress notes dated November 16, 2015 revealed that the resident was found on the floor as a result of the resident sliding out of the wheelchair again. Further review of the progress notes dated November 24, 2015 revealed tht the resident was found again on the floor as a result of the resident sliding out of the wheelchair. Further review of the progress notes dated December 27, 2015 revealed that the resident was found on the floor as a result of the resident slid out of the wheelchair. Observation on January 21, 2016 at approximately 3:15 p.m. revealed Resident R115 on a stretcher, being transferred to the hospital, with an ice pack applied to the forehead, which was swollen. Interview with Employee E14 at this time revealed that the resident was found on the floor in the bathroom. Review of facility documentation revealed that Employee E25 placed the resident on the toilet, told the resident to pull the call bell when finished, and when Employee E25 was coming down the hallway, Employee E25 heard the resident call out. The facility failed to provide adequate supervision to prevent further falls and injuries for a resident with a seizure diagnosis, and five previous falls resulting from sliding out of the wheelchair and bed. 28 Pa. Code:201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)Management. Previously cited 2/26/15 and 1/8/14. 28 Pa. Code:201.18(b)(3) Management. 28 Pa. Code.201.18(e)(1)(3)(4) Management.

Based on clinical record review, facility policy and procedures and staff interviews, it was determined that the facility failed to obtain a physician's orders [REDACTED]. Findings include: Review of Resident CL1's closed clinical record revealed that the resident was admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. Review of the nursing admission documentation dated August 18, 2011 at 3:00 p.m., revealed that the resident was awake, alert, non-verbal and on a ventilator continuously. The admission documentation also revealed that the resident had a feeding tube and a urinary catheter, and required a 2 person assist for bed mobility. Nursing documentation dated August 21, 2011, indicated that at 2:30 a.m. the resident was noted with a small amount of bleeding from the [MEDICAL CONDITION] site (a surgical wound over the trachea to provide an airway for the ventilator). Resident was noted again at 5:30 am with fresh blood from [MEDICAL CONDITION] suctioning and that it was increasing. Nursing documentation indicated that the physician was contacted and a message was left. The physician returned the call and gave an order to send the resident to the ER for evaluation. Documentation on the transfer form at the time of the transfer noted there was profuse bleeding coming from the trachea at that time. Hospital documentation indicated that the resident arrived at the emergency room at 7:30 am. on August 21, 2011. A review of the hospital emergency room records revealed that the resident was admitted to the hospital with [REDACTED]. Review of an investigation, dated August 31, 2011, by the facility revealed a statement from the respiratory therapist who was caring for the resident the night of the incident. In the statement the therapist stated that the resident had very thick secretions and could not be suctioned. The therapist then obtained a 'coffalator' (a mechanical device that assists patients in clearing secretions by gradually applying a positive pressure to the airway, then rapidly shifting to a negative pressure through the [MEDICAL CONDITION], which then produces a high expiratory flow rate from the lungs to simulate a cough). The statement then states that the therapist set the machine settings and proceeded to do a treatment on the resident. According to the statement, at that time blood was noted and the coffalator was stopped. A review of the residents physician's orders [REDACTED]. A review of the facility Respiratory Policy and Procedures for Coffalators states that the equipment will be set up with a physician's orders [REDACTED]. The policy also states that documentation is to include date and time of procedure, pre and post assessment, length of treatment, number of maneuvers performed and outcomes in the clinical record. A review of the clinical record did not indicate that any of these items had been documented in the clinical record as required. A review of the clinical record did not indicate that a physician's orders [REDACTED]. An interview with Employee E1 confirmed that a physician's orders [REDACTED]. 28 Pa. Code: 201.18(b)(1) Management Previously cited 2/10/11 28 Pa. Code: 211.11(a)(c) Resident care plans Previously cited 2/10/11 28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services Previously cited 2/10/11