Every finding on record at Edenbrook North

Based on observation, and staff and resident family interviews, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, comfortable, orderly, and homelike environment located in the Central Supply Room, an outdoor storage area behind the dumpsters, and on one of three nursing units (Nursing Units 1; Residents 48, 36, 12, and 84).Findings include: Observations on April 21, 2026, at 7:55 AM revealed the central supply room, which houses a deep freezer and refrigerator for the kitchen, as well as facility supplies, was noted to have a blackened floor around the refrigerator and the freezer. There was dust and debris, in addition to leaves noted on the floor around the entrance area. A wooden pallet on the floor was observed on a blackened floor with dust and debris, including rolled up blue disposable gloves under the pallet. Concurrent observation revealed an area located outside, behind the dumpsters under an awning, with a large pile of furniture items. Included in the pile were two wooden bed frames, a metal bed frame, multiple mattresses, two wooden chairs with cushions on the chairs, and bedside tables. During an interview with Employee 2, Maintenance Director, on April 21. 2026, at 8:05 AM, he stated that the area located behind the dumpsters was an additional storage area, and the items were to be brought back in and used for the residents if needed. Observation on April 21, 2026, at 10:34 AM on the third floor revealed a pair of sneakers, a balled-up pair of gloves, and a blanket, were sitting on the air-conditioning unit located behind chairs at the upper end of the hallway. Observations on April 22, 2026, at 9:18 AM revealed the sneakers, gloves, and blanket were still sitting on the air-conditioning unit behind chairs. Observations on April 21, 2026, at 11:10 AM in the dining room/sunroom area on the third floor revealed the following: A hole in the wall to the left at shoulder height that had a phone jack wire extending four inches from the wall off the entrance to the dining room. The same dining room wall to the left was noted to have multiple splash/drip stains to the lower half of the wall, below the chair rail. There was a balled-up paper towel observed on top of the soda machine in the dining area. The sunroom had four empty wheelchairs in the room with a deflated air mattress on top of them. There was a large purse and a sweater located on one of the wheelchairs. A table in the sunroom had an empty, sealed plastic lunch container with empty ketchup packets and a plastic spoon noted inside. The sunroom ceiling around the windows and the walls were observed to have cobwebs with small dead insects scattered throughout the cobwebs. Cobwebs, debris and dead insects were also noted lining the windowsill. Multiple dark colored objects were observed inside both light fixtures in the sunroom ceiling. The air-conditioning unit in the sunroom was noted to have broken drywall and peeling paint around the top and to the right side of the unit. The above environment concerns regarding the central supply room, outdoor storage, and third floor nursing unit were reviewed during an interview with the Nursing Home Administrator and the Director of Nursing on April 22, 2026, at 2:00 PM. Observation of Resident 48's room on April 22, 2026, at 10:11 AM revealed there was a pile of clothes on the floor in her closet. Observation of Resident 36 and 12's room on April 21, 2026, 11:52 AM revealed there were piles of clothes, as well as hygiene items on the floor of Resident 36 and 12's closets. Interview with Resident 84's family on April 21, 2026, at 2:42 PM revealed that she visits two to three times a week and Resident 84's closet always has clothes on the floor. Observation of Resident 84's closet with her family at this time revealed there were three shirts and a pair of pants on the floor of Resident 84's closet. The above environmental concerns for Residents 48, 36, 12, and 84 were reviewed during a meeting with the Nursing Home Administrator and Director of Nursing on April 22, 2026, at 2:00 PM 483.10(i)(1)-(7) Safe/clean/comfortable/homelike EnvironmentPreviously cited deficiency 4/4/2025 28 Pa. Code 201.18(b)(3)(e)(2.1) Management

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to implement interventions to promote acceptable parameters of nutrition for three of seven residents reviewed (Residents 7, 84, and 82).Findings include: Clinical record review for Resident 82 revealed that the facility admitted the resident on February 13, 2026. Further review of Resident 82's clinical record revealed the following weight assessments: February 13, 2026, 110.0 poundsFebruary 24, 2026, 107.0 poundsMarch 2, 2026, 107.0 poundsMarch 11, 2026, 101.0 pounds (a 9-pound, 8% severe weight loss in less than 30 days)March 17, 2026, 100.6 poundsApril 1, 2026, 98.0 pounds Clinical record review revealed a weight change note written by Employee 4, dietitian, dated March 12, 2026, with recommendations to add a house shake. Resident 82 had continued weight loss documented on March 17, 2026, and April 1, 2026. No further review of Resident 82's nutritional status could be identified in the clinical chart. The above findings were reviewed with the Nursing Home Administrator and the Director of Nursing on April 23, 2026, at 2:00 PM. During an interview with Employee 4 on April 24, 2026, at 9:00 AM, they indicated that they had not reviewed Resident 82's weight loss because their name was closer to the end of the alphabet. Clinical record review revealed the facility admitted Resident 84 on August 13, 2025, weighing 170.4 pounds. Interview with Resident 84's family on April 21, 2026, at 2:37 PM revealed that Resident 84 had lost a ton of weight since her admission to the facility. Interview with Resident 84's family revealed that Resident 84 has no issues eating food the family brings in from home but stated that the facility does not serve Resident 84 food according to her preferences. Further review of Resident 84's clinical record revealed the following weight assessments:November 6, 2025, 160.3 poundsDecember 3, 2025, 143.0 poundsDecember 9, 2025, 140.6 pounds (a 19.7-pound, 12.28 percent severe weight loss in a month) Review of a quarterly assessment completed on November 19, 2025, by Employee 4 noted that Resident 84's food and fluid intakes decreased when compared to her prior nutritional review and indicated that Resident 84 met the criteria for being at risk of malnutrition. There were no nutritional interventions added at this time. A weight change note dated December 10, 2025, confirmed Resident 84 had a 19.7-pound, 12.3 percent weight loss in a month, and there were no new nutritional interventions added. Interview with Employee 4 on April 24, 2026, at 10:21 AM, confirmed that no new nutritional interventions were added after the identified December 9, 2025, severe weight loss. Clinical record review revealed the facility admitted Resident 7 on March 27, 2024. Further review of Resident 7's clinical record revealed the following weight assessments: October 2, 2025, 178.8 poundsNovember 3, 2025, 153.8 pounds (a 25-pound, 13.98 percent severe weight loss in a month)November 3, 2025, 154.4 pounds (reweight) Review of a quarterly assessment completed on October 30, 2025, Employee 4 noted Resident 7's food and fluid intake was decreased when compared to the prior nutrition review. Employee 4 noted Resident 7's skin was intact, with no edema noted. A weight change note dated November 4, 2025, confirmed Resident 7's weight was down 24.4 pounds, 13.6 percent weight loss in one month, and there were no new nutritional interventions added. Interview with Employee 4 on April 24, 2026, at 10:07 AM confirmed that no nutritional interventions were added after Resident 7's severe weight loss on November 3, 2025. Employee 4 stated that Resident 7 was on two diuretic medications. Employee 4 confirmed she assessed Resident 7 as having no edema on October 30, 2025, and indicated there were no changes to Resident 7's diuretic medications. The above findings for Residents 84 and 7 were reviewed with the Director of Nursing on April 24, 2026, at 11:03 AM. The facility failed to implement interventions to promote acceptable parameters of nutrition for Residents 84 and 7. S483.25(g)(1) Maintains acceptable parameters of nutritional statusPreviously cited 4/4/25 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility documentation, facility policies and procedures, observation, clinical record review, and review of personnel training records, it was determined that the facility failed to ensure specific competencies necessary to care for resident needs for one of one resident reviewed for intravenous access concerns (Resident 119, Employees 5, 6, 7, 8, 9, and 10).Findings include: The State Operations Manual, Appendix PP, Guidance to Surveyors for Long Term Care Facilities, 483.71(c)(1) Facility Assessment, stipulates that the facility must use the facility assessment to inform staffing decisions to ensure that there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through resident assessments and plans of care. The Facility Assessment Tool reviewed during the onsite survey, last reviewed March 31, 2026, revealed that the Resident Support/Care Needs list included types of care the resident population could require and that could be provided. The list noted that specific care or practices for medications required awareness of any limitations of administering medications that residents need by the following routes of administration: oral, nasal, buccal (cheek), sublingual (under the tongue), topical, subcutaneous (under the skin/injection), rectal, intravenous (stipulated peripheral or central lines), intramuscular, inhaled, vaginal, ophthalmic (eye), etc. The facility holds a structured orientation for new hires. During this orientation the staff receive education and competencies on the necessary requirements. If identified, additional training would be provided. Annually, the facility evaluates the educational needs, including competencies, that are needed for staff. The facility policies entitled, Peripherally Inserted Central Line Catheter (PICC), Dressing Change for Vascular Access Devices, and Maintaining Patency of Peripheral and Central Vascular Access Devices, last reviewed March 1, 2026, did not include measures the facility would implement to ensure necessary staff competencies related to PICC line care and use. The facility policy entitled, Maintaining Patency of Peripheral and Central Vascular Access Devices, last reviewed March 1, 2026, noted that if scope of practice regulations do not allow LPNs to flush intravenous catheters and if there is no 24-hour registered nurse coverage in the building, flush protocols may vary to allow for heparin (intravenous anticoagulant medication) flushing by a registered nurse once a day. According to, Pennsylvania Code, Title 49, Chapter 21, Functions of the LPN, an LPN (licensed practical nurse) may perform only the IV (intravenous) therapy functions for which the LPN possesses the knowledge, skill, and ability to perform in a safe manner. Clinical record review for Resident 119 revealed that the facility admitted her on April 18, 2026. Nursing documentation dated April 18, 2026, at 11:28 AM revealed that Resident 119 arrived at the facility for ongoing antibiotic therapy related to her right knee replacement that became infected. admission physician orders dated April 18, 2026, for Resident 119 included the use of the following: PICC line (a long, flexible tube inserted into a vein in the arm that reaches a large central vein near the heart, used for long-term intravenous treatments; the line requires careful care and monitoring for complications including bleeding, infection, and blood clots) to right upper extremityCeftriaxone Sodium (antibiotic) 2 gram intravenously in the afternoon for knee infection Review of Resident 119's Medication Administration Record and Treatment Administration Record (electronic documentation completed by licensed staff to attest to the administration of medications and treatments) dated April 2026 revealed that Employee 5 (licensed practical nurse, LPN), Employee 6 (LPN), Employee 7 (LPN), and Employee 10 (registered nurse), documented that they administered Resident 119's intravenous Ceftriaxone Sodium medication. Employees 8 (LPN) and 9 (LPN) documented that they flushed Resident 119's PICC line with normal saline on their shift. Interview with the Director of Nursing on April 24, 2026, at 8:15 AM confirmed that the facility had no licensed staff competencies completed related to the use of PICC lines. 28 Pa. Code 201.19(7) Personnel policies and procedures 28 Pa. Code 201.20(a)(6)(d) Staff development 28 Pa. Code 211.12(d)(1) Nursing services

Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to monitor target behaviors and potential side effects for psychotropic medication use for two of five residents reviewed for medication regimen concerns (Residents 3 and 6). Findings include: The facility policy entitled, Psychotropic Medication, last reviewed March 1, 2026, revealed that the purpose of the policy was to provide guidance for the psychopharmacologic drug treatment for a resident with a specific condition, including but not limited to dementia and other cognitive disorders, and/or behaviors as documented in the resident's clinical record. An assessment must be conducted to identify specific behaviors/symptoms, potential causative factors and recommendations for managing identified behaviors. The medical record documentation must reflect the specific behaviors/symptoms and the resident's response to non-pharmacological interventions to manage the behaviors/symptoms. After implementation of psychotropic medication, behavior/symptoms and medication side-effects will be monitored and documented. Clinical record review for Resident 6 revealed active physician orders for the following psychotropic medications: Lorazepam (Ativan, an antianxiety medication) 0.5 mg (milligrams) every 12 hours as needed for agitation until April 23, 2026. ABH Gel (Combination topical medication that includes Lorazepam 1 mg, Benadryl (over-the-counter antihistamine that can induce drowsiness) 12.5 mg, and Haldol (an antipsychotic which helps regulate mood, behavior, and thought processes) 1 mg) to wrist topically in the morning for agitation. Resident 6's clinical record did not contain evidence that the facility implemented ongoing monitoring of target behavior symptoms for the use of the antianxiety or antipsychotic medications. Resident 6's clinical record did not contain evidence that the facility implemented ongoing assessment for potential side effects from the use of antianxiety or antipsychotic medications. Review of Resident 6's plans of care developed by the facility to address Resident 6's care needs revealed no interventions related to the use of antianxiety or antipsychotic medications. Interview with the Director of Nursing on April 24, 2026, at 10:04 AM confirmed that the facility had not added Resident 6's antipsychotic and antianxiety medications to her plans of care. The facility could not provide evidence of ongoing tracking of behavioral interventions and the monitoring of potential side effects for the antipsychotic and antianxiety medications. Clinical record review for Resident 3 revealed active physician orders for Aripiprazole (an atypical antipsychotic medication), 2 mg at bedtime for mood regulation. Resident 3's clinical record did not contain evidence that the facility implemented ongoing monitoring of target behavior symptoms for the use of antipsychotic medications. Resident 3's clinical record did not contain evidence that the facility implemented an ongoing assessment for potential side effects from the use of antipsychotic medications. Review of Resident 3's plans of care developed by the facility to address Resident 3's care needs revealed no interventions related to the use of antipsychotic medications. Interview with the Director of Nursing on April 24, 2026, at 12:35 PM confirmed that the facility had not added Resident 3's antipsychotic medication to her plans of care. The facility could not provide evidence of ongoing tracking of behavioral interventions and the monitoring of potential side effects for the antipsychotic medication. 28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the residents' representative received written notice of transfer and written notice of the facility bed-hold policy at the time of transfer for one of four residents reviewed for hospitalizations (Resident 1).Findings include: Clinical record review for Resident 1 revealed nursing documentation dated January 11, 2026, at 3:54 AM that Resident 1 was requesting to go to the ER (emergency room) to be evaluated. Resident 1 was transferred to the ER on [DATE], at 4:02 AM and admitted for pneumonia and COPD (chronic obstructive pulmonary disease, a progressive lung disease that makes it difficult to breath). There was no evidence to indicated Resident 1 was provided a written notice of transfer or bed hold information at the time of transfer. Further review revealed Resident 1's was provided and acknowledged a bed hold and transfer notice on January 12, 2026, the day after her transfer to the hospital. There was no documented evidence that the facility provided a copy of the bed hold and transfer notice to Resident 1's responsible party. Interview with the Nursing Home Administrator on April 24, 2026, at 2:45 PM, confirmed that the facility did not provide Resident 1 with a written notice of transfer and bed hold information at the time of transfer nor provide Resident 1's responsible party with a copy of the written transfer or bed-hold notices. 28 Pa. Code 201.14(a) Responsibility of license

Based on clinical record review and staff interview it was determined that the facility failed to ensure assessments accurately reflected residents' status for two of 23 residents reviewed (Residents 6 and 9).Findings include: Clinical record review for Resident 6 revealed an admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated September 4, 2025, that indicated she had range of motion impairment only to one of her upper extremities. A significant change MDS assessment dated [DATE], again assessed her as having range of motion impairment only to one of her upper extremities. A quarterly MDS assessment dated [DATE], assessed that Resident 6 had range of motion impairments to her upper extremity and lower extremity on one side. A quarterly MDS assessment dated [DATE], again assessed her has having range of motion impairments to her upper extremity and lower extremity on one side. Interview with the Director of Nursing and Employee 3 (registered nurse assessment coordinator) on April 24, 2026, at 1:11 PM revealed that the facility determined Resident 6's MDS assessments of September 4, 2025, and November 21, 2025, were incorrect; that Resident 6 should have been coded as lower extremity range of motion impairments on all MDS assessments. The interview indicated that Resident 6 entered the facility with the range of motion deficits and she did not develop a decline as was indicated by the MDS assessments reviewed above. Clinical record review for Resident 9 revealed nursing documentation dated January 23, 2025, at 2:51 PM that Resident 9 arrived from the hospital where she was admitted after she was found with symptoms of left lower extremity and left upper extremity weakness. Nursing documentation dated January 23, 2025, at 8:58 PM revealed that Resident 9 was diagnosed with an acute ischemic right MCA stroke (CVA, brain blood flow interruption that affects the right middle cerebral artery leading to left-sided weakness). Resident 9 had left-sided weakness, confusion, and hallucinations. A quarterly MDS dated [DATE], and a significant change MDS dated [DATE], assessed Resident 9 as having no range of motion impairments. A quarterly MDS dated [DATE], assessed that Resident 9 had upper and lower extremity range of motion impairments on one side. A significant change MDS assessment dated [DATE], assessed Resident 9 had no range of motion impairments. A quarterly MDS assessment dated [DATE], assessed that Resident 9 had upper and lower extremity range of motion impairments on one side. The surveyor requested documentation of the facility's response to Resident 9's decline in range of motion as assessed by her MDS assessments dated December 3, 2025, and March 18, 2026, during an interview with the Nursing Home Administrator and the Director of Nursing on April 22, 2026, at 2:30 PM. Nursing documentation dated April 22, 2026, at 5:02 PM (following the surveyor's questioning) revealed that the facility submitted a modification of Resident 9's February 16, 2026, MDS assessment as it was incorrectly coded to have no impairments with her range of motion when she had impairments on one side due to her CVA diagnosis. Interview with the Director of Nursing on April 24, 2026, at 1:11 PM confirmed that staff incorrectly coded Resident 9's February 16, 2026, MDS assessment. 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and resident and staff interview it was determined that the facility failed to provide the resident and their representative with a summary of the baseline care plan within 48 hours of admission for two of 23 residents reviewed (Residents 119 and 120). Findings include: Clinical record review for Resident 120 revealed that the facility admitted him on April 7, 2026. admission physician orders dated April 7, 2026, for Resident 120 included the use of the following: Supplemental oxygen at three liters per minute continuously every shiftFoley catheter (a flexible tube inserted through the penis into the bladder to drain urine) for failed voiding trials (inability to urinate normally after removal of the Foley)Droplet Precautions in place every shift for a diagnosis of human metapneumovirus (isolation precautions that require the use of masks, gowns, gloves, and eye protection due to a contagious virus that causes respiratory infections)Apixaban 2.5 milligrams (Eliquis, an anticoagulant that can prevent blood clotting and result in abnormal bruising and bleeding) every morning and at bedtime Interview with Resident 120 on April 21, 2026, at 1:38 PM indicated that he did not know what goals he needed to achieve before he could return home or if he would utilize home health services after his discharge from the facility. Resident 120 denied that he received a copy of a care plan since his admission to the facility. Resident 120 stated that he entered the facility following a fall and hip fracture at home for which he was hospitalized and had surgery. Resident 120 utilized supplemental oxygen, had an indwelling urinary catheter (Foley), had pressure ulcer injuries to his bilateral heels, and complained of a sore on his buttocks. Review of Resident 120's plans of care did not reveal any entries related to supplemental oxygen use until April 21, 2026. The surveyor reviewed the above concerns that Resident 120 denied knowledge of his plan of care or his goals during an interview with the Nursing Home Administrator and the Director of Nursing on April 22, 2026, at 2:15 PM. Care plan note documentation created by the facility's activity director dated April 22, 2026, at 4:35 PM (following the surveyor's questioning) revealed that he met with Resident 120 on this date to deliver, review, and have him sign the baseline care plan document. The staff provided Resident 120 a copy. Interview with Employee 1 (registered nurse/unit manager/infection preventionist) on April 24, 2026, at 12:19 PM confirmed that Resident 120's baseline care plan did not include the use of supplemental oxygen despite his physician order for, and use of, since his admission to the facility. Clinical record review for Resident 119 revealed that the facility admitted her on April 18, 2026. Nursing documentation dated April 18, 2026, at 11:28 AM revealed that Resident 119 arrived at the facility for ongoing antibiotic therapy related to her right knee replacement that became infected. The documentation indicated that Resident 119 utilized supplemental oxygen. admission physician orders dated April 18, 2026, for Resident 119 included the use of the following: PICC line (a long, flexible tube inserted into a vein in the arm that reaches a large central vein near the heart, used for long-term intravenous treatments) to right upper extremityCeftriaxone Sodium (antibiotic) 2 gram intravenously in the afternoon for knee infectionSupplemental oxygen at four liters per minute while at rest and eight liters per minute during activity Interview with Resident 119 on April 22, 2026, at 10:31 AM revealed that she denied that she received a copy of a care plan since her admission to the facility. Resident 119 requested that the surveyor look in a folder that she had since her admission to verify that she did not receive the baseline care plan. Resident 119 indicated that she had an intravenous access site in her right bicep area that staff use to administer intravenous antibiotics daily. The surveyor reviewed the above concerns that Resident 119 denied knowledge of her plan of care summary during an interview with the Nursing Home Administrator and the Director of Nursing on April 22, 2026, at 2:15 PM. Social services documentation dated April 22, 2026, at 6:13 PM (following the surveyor's questioning) revealed that the staff met with Resident 119 that afternoon and provided her with her baseline care plan. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide dependent residents with activities of daily living assistance for two of three residents reviewed (Residents 30 and 9).Findings include: Observation of Resident 30 on April 21, 2026, at 2:09 PM revealed several days of stubble (short hair growing back on face). Observation and interview with Resident 30 on April 22, 2026, at 10:59 AM revealed the stubble remained on Resident 30's face and when asked if he would like to be shaved Resident 30 replied sure. Clinical record review for Resident 30 revealed his most recent Quarterly MDS (Minimum Data Set, an assessment completed at specific intervals to determine resident needs) dated February 27, 2026, indicated nursing staff assessed Resident 30 as requiring substantial to maximum assistance for personal hygiene (the ability to maintain personal hygiene, including combing hair, shaving, washing/drying face and hands). There was no documentation indicating staff were providing shaving assistance to Resident 30. Interview with the Nursing Home Administrator and Director of Nursing on April 24, 2026, at 10:57 AM confirmed the above findings for Resident 30. The Nursing Home Administrator confirmed Resident 30 is unable to shave himself and wished to be shaven. Observation of Resident 9 on April 21, 2026, at 12:45 PM revealed her to have long straight hair that appeared oily (not clean). Clinical record review for Resident 9 revealed a quarterly MDS assessment dated [DATE], and a significant change MDS dated [DATE], that assessed Resident 9 as dependent on the substantial/maximal assistance of staff for showering/bathing. A plan of care developed by the facility on October 9, 2025, to address her deficits with performing activities of daily living, reiterated that she required the assistance of staff for bathing/showering. Resident 9's plan of care did not indicate that she refuses bathing assistance. Review of Resident 9's bathing task history revealed the following established schedule for bathing:February 15, 2025, showers Mondays and Thursdays on first shift (7:00 AM to 3:00 PM)April 8, 2026, showers Tuesdays and Fridays on second shift (3:00 PM to 11:00 PM)Review of Documentation Survey Report (electronic documentation completed by nurse aide staff who assist residents to complete care needs) data dated April 2026 revealed that no evidence that staff provided Resident 9 a shower from April 1 through first shift on April 21, 2026, as follows: April 2, 2026, bed bathApril 6, 2026, bed bathApril 10, 2026, bed bathApril 14, 2026, no data for either a bed bath or showerApril 17, 2026, bathing documented as NA (not applicable) The surveyor reviewed the above concerns regarding Resident 9's bathing care during an interview with the Nursing Home Administrator and the Director of Nursing on April 22, 2026, at 2:15 PM. 483.24(a)(2) ADL Care Provided for Dependent ResidentsPreviously cited deficiency 4/4/25 and 3/9/26 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, observation, and staff and resident interview, it was determined that the facility failed to implement the highest practicable care regarding central venous catheters for one of 23 residents reviewed (Resident 119).Findings include: The facility policies entitled, Peripherally Inserted Central Line Catheter (PICC), Dressing Change for Vascular Access Devices, and Maintaining Patency of Peripheral and Central Vascular Access Devices, last reviewed March 1, 2026, did not include measures the facility would implement in a resident's plan of care that to ensure the highest practicable care for the PICC line use (e.g., emergency kit/procedures, staff competencies, limb restrictions). Interview with the Director of Nursing on April 24, 2026, at 8:15 AM confirmed that the facility had no licensed staff competencies completed related to the use of PICC lines. The interview also confirmed that the facility had no policy related to the implementation and documentation of all care interventions necessary for the use of a PICC line as noted above. Clinical record review for Resident 119 revealed that the facility admitted her on April 18, 2026. Nursing documentation dated April 18, 2026, at 11:28 AM revealed that Resident 119 arrived at the facility for ongoing antibiotic therapy related to her right knee replacement that became infected. admission physician orders dated April 18, 2026, for Resident 119 included the use of the following: PICC line (a long, flexible tube inserted into a vein in the arm that reaches a large central vein near the heart, used for long-term intravenous treatments; the line requires careful care and monitoring for complications including bleeding, infection, and blood clots) to right upper extremityCeftriaxone Sodium (antibiotic) 2 gram intravenously in the afternoon for knee infection Interview with Resident 119 on April 22, 2026, at 10:31 AM revealed that she had an intravenous access site in her right bicep area that staff use to administer intravenous antibiotics daily. Resident 119 stated that she reminds staff not to use her right arm for blood pressure assessments as necessary. Observation of Resident 119's right bicep area on the date and time of the interview confirmed the presence of intravenous tubing. Observation of Resident 119 and her room environment on April 22, 2026, at 10:31 AM revealed no signage or indication that caregivers should restrict the use of her right arm (e.g., for blood pressure assessments or venipuncture). Interview with Employee 1 (registered nurse/unit manager/infection preventionist) on April 22, 2026, at 10:44 AM confirmed that there was no indication in Resident 119's room or on her person (e.g., bracelet) to indicate any limb restrictions for her right arm. Employee 1, then, obtained a laminated sign to post above Resident 119's bed to alert caregivers to restrict use of her right arm. Review of Resident 119's clinical record revealed a new physician's order (following the surveyor's questioning) dated April 22, 2026, at 2:45 PM for staff to implement right arm limb restrictions. Review of the plan of care initiated by the facility on April 20, 2026, to address Resident 119's use of intravenous medication and PICC line revealed no intervention to restrict the use of her right arm until April 22, 2026. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of select facility policy and procedures, observation, clinical record review, and resident and staff interview, it was determined that the facility failed to ensure an environment free from potential accident hazards for one of one resident reviewed regarding smoking (Resident 1). Findings include: Review of the policy entitled Smoking and E-Cigarettes last reviewed on March 9, 2022, indicates that smoking will only be permitted in posted designated areas, and that smoking is prohibited in all other areas. The policy does not indicate where smoking materials should be stored when not in use. Review of Resident 1's smoking agreement dated May 2, 2022, indicated that smoking and lighting material will be kept in a designated area and not in the resident's possession, items will be labeled and clearly identified per resident, and at the end of the smoking period the materials will be collected and returned to their appropriate location. Review of Resident 1's clinical record revealed a Smoking Assessment completed on February 13, 2026, indicating that nursing staff assessed her as being able to continue smoking without incident. The assessment indicated that the facility would be storing her lighter and cigarettes. This Smoking Assessment also noted Resident 1 was informed/educated regarding smoking policy. Interview of Resident 1 on April 23, 2026, at 9:25 AM, revealed that she knows she is to smoke in the designated smoking area outside of the facility. Resident 1 reported she always has her cigarettes and lighter on her and does not return them to the appropriate location as stated in the smoking agreement and assessment. Observation of Resident 1 on April 23, 2026, 10:58 AM, revealed her to be smoking on the concrete next to the red brick pillar, and not in the designated smoking area of the facility. Interview with Resident 1 on April 23, 2026, at 12:00 PM, revealed that her smoking materials, cigarettes and lighter, are in her purse attached to her rolling walker and not at the nursing station. Interview with Nursing Home Administrator and Director of Nursing on April 23, 2026, at 2:10 PM, confirmed the above findings for Resident 1. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to implement the administration of supplemental oxygen per the physician's order for one of one resident reviewed for oxygen concerns (Resident 120).Findings include: Observation of Resident 120 on April 21, 2026, at 2:04 PM revealed him to be in his room with supplemental oxygen administration via a room concentrator set to two liters per minute. Observation of Resident 120 with Employee 8 (licensed practical nurse) on April 23, 2026, at 10:09 AM revealed that Resident 120 supplemental oxygen room concentrator was set to 1.5 liters per minute. Clinical record review revealed an active physician's order dated April 7, 2026, for staff to administer supplemental oxygen continuously at three liters per minute every shift. Review of Resident 120's plans of care developed by the facility to address Resident 120's care needs revealed no entries related to supplemental oxygen use until April 21, 2026. Interview with Employee 8 on April 23, 2026, at 10:26 AM confirmed active physician orders for Resident 120 instructed staff to maintain supplemental oxygen administration at three liters per minute; there were no physician orders for staff to titrate (lower) the liter flow. Employee 8 stated that she had not obtained Resident 120's vital signs (that would include an assessment of his oxygen saturation, pulse oximetry) as of the date and time of the interview. The surveyor reviewed the above concerns regarding Resident 120's supplemental oxygen use during an interview with the Director of Nursing on April 24, 2026, at 8:15 AM. 483.25(i) Respiratory/tracheostomy Care and SuctioningPreviously cited deficiency 4/4/25 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to offer, provide education regarding the benefits, risks, and potential side effects, or administer a COVID immunization for two of five residents reviewed for immunizations (Residents 30 and 36).Findings include: The policy entitled Covid-19, last reviewed without changes March 1, 2026, revealed the facility will conduct education, surveillance, and infection control and prevention strategies to reduce the risk of transmission of COVID-19. Due to the constantly changing and fluid nature of the virus, the facilities will monitor, follow, and implement recommendations and guidelines in accordance with the Centers for Disease Control and Prevention (CDC), CMS, and the state Department of Health to include identification and isolation Of any suspected cases. The facility will encourage everyone to remain up to date with all recommended COVID-19 vaccine doses. Clinical record review for Resident 30 revealed that the facility admitted him on May 19, 2022. Review of Resident 30's immunization history revealed that he did not receive a COVID (a contagious respiratory illness caused by a virus) vaccine since July 23, 2024. Resident 30's clinical record contained no additional information that the facility offered or administered Resident 30 a COVID immunization after July 2024. Clinical record review for Resident 36 revealed that the facility admitted her on July 9, 2021. Review of Resident 36's immunization history revealed that she refused a COVID vaccine on June 30, 2022. Resident 36's clinical record contained no additional information that the facility offered, or provided education regarding the benefits, risks, and potential side effects with the COVID vaccine after June 2022. Interview with Employee 1 (infection preventionist) on April 23, 2026, at 12:51 PM confirmed the above findings for Residents 30 and 36. The surveyor reviewed the above concerns regarding Resident 30 and 36's COVID-19 immunizations during a meeting with the Nursing Home Administrator and Director of Nursing on April 23, 2026, at 2:00 PM. 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate and report to the appropriate agencies an injury of unknown origin and an allegation of potential misappropriation of resident property for one of two records reviewed (Resident CR2). Findings include: The current facility policy entitled Vulnerable Adult Abuse and Neglect Prevention, revealed the facility will follow the federal guidelines dedicated to the prevention of abuse and timely and thorough investigations of an allegation. Upon receiving a complaint of an alleged maltreatment, the Nursing Home Administrator and Director of Nursing must be notified immediately, and they will coordinate an investigation, which will include completion of witness statements. All parties involved including staff, residents, or visitors who were potentially involved, or observed the alleged incident, are to be interviewed. If it appears that the maltreatment may involve a crime, immediately notify the police. The facility will notify the resident's responsible party, as well as physician as soon as possible. The investigation and written findings are completed and reviewed with the Administrator, Director of Nursing, and Director of Social Services. A plan for further action is determined with input from appropriate personnel. The facility must report to the state agency no later than 24 hours if the alleged violation involves neglect, misappropriation of resident property, or exploitation and involves not serious bodily injury. The policy entitled Injury of Unknown Origin, last reviewed without changes on February 1, 2025, revealed it is the policy of the facility to immediately investigate all injuries of unknown origin to determine the cause, ensure resident safety, and comply with federal and state reporting requirements, including mandatory notifications to the Department of Health. Review of documentation provided by the facility revealed that Resident CR2's responsible party sent Employee 1 (social worker) an email on January 28, 2026, questioning what happened to Resident CR2 to cause the serious bruising to his left arm. The email included pictures of the bruising to Resident CR2's arm. Review of Resident CR2's clinical record revealed there was no documentation of Resident CR2's bruising to his left arm. Interview with the Nursing Home Administrator and Director of Nursing on March 9, 2026, at 7:48 PM revealed the facility did not complete a thorough investigation into Resident CR2's injury of unknown origin due to Resident CR2 stating that he scratched himself. Review of Employee 2's (licensed practical nurse) statement revealed she asked Resident CR2 about the bruises on his arm and he stated he scratched himself and denied anyone grabbing him. Review of Employee 3's (registered nurse) statement revealed she assessed Resident CR2's arm on January 28, 2026, noting a large bruise to his upper forearm. There was no assessment of Resident CR2's bruise in his clinical record, including the size, or color to determine the age of the injury. Review of Resident CR2's weekly skin check completed by facility staff on January 28, 2026, revealed no skin issues. The facility failed to thoroughly investigate and report to the appropriate authorities Resident CR2's bruises to rule out abuse, neglect, or prevent further injuries. Interview with the Nursing Home Administrator and Director of Nursing on March 9, 2026, at 9:03 PM confirmed there was no documentation in Resident CR2's clinical record regarding his injury of unknown origin on January 28, 2026, no assessment of the bruises, or a thorough investigation into the cause of the bruising. Review of Resident Family Grievances provided by the facility revealed a grievance filed by Resident CR2's responsible party on January 15, 2026, noting Resident CR2's prescription glasses were stolen in October, and now personal prescription glasses that the responsible party left at his bedside are now stolen. Resident CR2's responsible party stated the eyeglass case was in his room, but not his glasses. Employee 1(social worker) noted that Resident CR2's responsible party used the words stolen. The grievance investigation noted Employee 1 sent Resident CR2's responsible party a consent for Resident CR2 to be seen by the in-house vision provider. A resolution dated February 5, 2026, revealed the facility requested reimbursement for Resident CR2's glasses when seen by in-house vision provider on the next visit. Further review of Resident CR2's clinical record revealed no investigation into the allegation of the potential misappropriation of Resident CR2's glasses. Interview with the Nursing Home Administrator and Director of Nursing on March 9, 2026, at 8:57 PM confirmed the above findings for Resident CR2. The facility failed to complete an investigation, obtain witness statements, notify law enforcement, or notify Department of Health related to Resident CR2's responsible party's allegation of a potential misappropriation of resident property. 483.12 (b) Development and Implementation of Abuse PolicyPreviously cited deficiency 4/4/25 and 11/8/25 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)(c) Resident rights

Based on clinical record review, and staff interview, it was determined that the facility failed to provide a dependent resident with activities of daily living assistance for one of two residents reviewed (Resident CR2).Findings include: Clinical record review revealed the facility admitted Resident CR2 on October 8, 2025. Review of Resident CR2's most recent MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated January 14, 2026, noted staff assessed Resident CR2 as dependent on staff for oral hygiene (the ability to use suitable items to clean teeth). Review of Resident CR2's Kardex (documentation system used by staff to organize and reference key resident information essential for resident care) revealed he is to have his teeth brushed twice daily. Review of Documentation Survey Report (electronic documentation completed by nurse aide staff for the completion of ADL care) from January 1 to February 11, 2026, revealed there was no documentation that staff assisted Resident CR2 with oral hygiene twice daily on 18 of 41 days reviewed. There was no documentation indicating staff were providing oral hygiene assistance twice daily to Resident CR2. The findings were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on March 9, 2026, at 9:15 PM 483.24(a)(2) ADL Care Provided for Dependent ResidentsPreviously cited deficiency 4/4/25 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate and report to the appropriate agencies an injury of unknown origin and potential neglect for one of seven records reviewed (Resident CR1).Findings include:The policy entitled Injury of Unknown Origin, last reviewed without changes on February 1, 2025, revealed it is the policy of the facility to immediately investigate all injuries of unknown origin to determine the cause, ensure resident safety, and comply with federal and state reporting requirements, including mandatory notifications to the Department of Health. The nurse discovering or notified of the injury must perform an assessment including pain, location, size, color, and pattern of injury. The attending physician or on-call provider will be notified promptly for evaluation and treatment orders. The facility will remove the resident from potential harm if indicated and ensure supervision until the resident's safety is assured. The Director of Nursing and Nursing Home Administrator will be notified immediately. The responsible party will be notified promptly of the injury and findings. If abuse, neglect, or misappropriation is suspected, the incident must be reported within two hours if there is serious bodily injury, or within 24 hours to the Department of Health. The Director of Nursing or designee initiates a root cause investigation reviewing staffing assignments, supervision, and the environment. Interviews with residents, staff, and potential witnesses and review of recent events will be completed. The Director of Nursing or designee with evaluate potential abuse, neglect, or accident-related causes, including the abuse coordinator when abuse cannot be ruled out. The facility will complete and submit investigation results within five business days to the Department of Health. Closed clinical record review revealed the facility admitted Resident CR1 on October 29, 2020. Nursing documentation dated October 12, 2025, at 10:08 AM revealed hospice was contacted for further instructions on Resident CR1's condition with bruising to her forehead. Documentation at 10:17 AM revealed the certified nurse practitioner noted that Resident CR1's forehead was raised and discolored, she also noted a bruise to Resident CR1's right hand. Documentation dated October 13, 2025, at 12:35 AM noted Resident CR1's bruising on her forehead had moved under her left eye. Review of the facility investigation dated October 12, 2025, at 6:00 AM revealed that Resident CR1 was found with a discolored area and swelling on her forehead on October 11, 2025 (second shift). Resident CR1 stated she fell and was picked up off the floor. The registered nurse assessed and found erythema (redness or discoloration of skin) on her forehead. Review of Employee 1's (nurse aide) witness statement dated October 12, 2025, indicated yesterday when Employee 1 was giving Resident CR1 a shower he saw a bruise around her head and hand, but did not report it immediately. Employee 1 noted in the morning when he was washing her up, the bruise got worse, so he notified the licensed practical nurse. When the nurse asked Resident CR1 what happened Resident CR1 said she fell yesterday, but she could not remember who picked her up. Further review of Resident CR1's clinical record revealed a significant change MDS (Minimum Data Set, an assessment completed at specific intervals to determine resident care needs) dated September 26, 2025, noting staff assessed Resident CR1 as dependent on staff for all activities of daily living. Interview with the Director of Nursing on November 8, 2025, at 1:37 PM confirmed these findings. She stated it is the facility policy for staff to report all injuries of unknown origin at the time of identification. The facility failed to thoroughly investigate and report to the appropriate authorities Resident CR1's bruises to rule out neglect or prevent further injuries.28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)(c) Resident rights

Based on observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner and maintain the environment in a safe and sanitary condition in the facility's main kitchen. Findings included: Observation of the facility's main kitchen with Employee 2, dietitian, on April 1, 2025, at 8:30 AM revealed the following: A mobile rack holding bowls had various debris on the base and felt greasy to touch. Two floor drains had an extensive amount of debris in them. The perimeter of the grease trap in the floor of the dishwasher area had an extensive build-up of debris, including food debris. A windowsill had a build-up of dust, a dead bug, and a discarded potato chip. A storage room adjacent to the main kitchen contained a refrigerator and freezer that held resident food items. The facility was unable to provide a history of temperature monitoring on these units. An interview with the Nursing Home Administrator on April 2, 2025, at 2:43 PM confirmed that facility staff are unable to find documented temperature monitoring for these units. A review of tray line food temperatures provided revealed no documented temperatures for the following dates: March 2, 8, 9, 15, 29, 2025 (breakfast) March 2, 7, 8, 15, 29, 2025 (lunch) March 2-22; March 24-29, 2025 (dinner) The facility failed to provide any additional documentation that the food temperatures were documented by staff for the dates reviewed. The above information was reviewed in a meeting with the Nursing Home Administrator on March 3, 2025, at 3:00 PM. 483.60 (i) Food prepare, distribute, and serve -sanitary/safety Previously cited 5/23/24 28 Pa. Code 201.14(a) Responsibility of licensee

Based on observation and staff and resident interview, it was determined that the facility failed to assist a resident to retain and use personal possessions on three of three nursing units (First, Second, and Third Floor Nursing Units; Residents 2, 19, 22, 64, 88, 92, 106, and 121). Findings include: Interview with Resident 22 on April 1, 2025, at 12:49 PM revealed that she could not locate a few pairs of pants and three shirts. Observation of the facility laundry on April 4, 2025, at 11:05 AM revealed that there was a large plastic laundry bin in the dirty laundry area that was stacked full of bagged dirty personal laundry and extended/overflowed 3.5 feet above the top of the plastic laundry bin. Further observation revealed that there were nine large bins identified for the first, second, and third floor nursing units in the clean laundry area that were stacked full of clean laundry that belonged to Residents 2, 19, 22, 64, 88, 92, 106, and 121. The clean bin of clothes was sitting for at least four days and the clothes were not distributed to the residents for their use. The facility failed to ensure that residents had access to their personal clothing timely after laundering by the facility. Interview with Employee 3, housekeeping supervisor, on April 4, 2025, at 11:05 AM, and the Nursing Home Administrator on April 4, 2025, at 12:13 PM confirmed the observation. 28 Pa. Code 201.18(f) Management 28 Pa. Code 201.29(c.3)(4) Resident rights

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to assist dependent residents with bathing and/or personal hygiene for 7 of 14 residents reviewed (Residents 2, 21, 88, 92, 96, 117, and 121). Findings include: Interview with Resident 2 on April 1, 2025, at 1:30 PM revealed that she did not receive her shower four times in February 2025, and two times in March 2025. She also indicated that she had missed showers in January but did not provide the number of showers she missed. Clinical record review for Resident 2 revealed that she did not receive her scheduled showers on January 19, 26, and 31, 2025. Review of Resident 2's clinical documentation for February 2025, revealed that she did not receive her scheduled showers on February 25, 2025. Review of Resident 2's clinical documentation for March 2025, revealed that she did not receive her scheduled showers on March 4 or 11, 2025. Review of Resident 2's current MDS (Minimum Data Set, an assessment completed at intervals by the facility to determine care needs of the resident) dated February 10, 2025, revealed that she required substantial/maximal assistance (the person helping lifts or holds trunk or limbs and provides more than half the effort with bathing/showers) with bathing. Observation of Resident 21 on April 1, 2025, at 11:51 AM revealed he entered the community room for lunch. His hair was disheveled and appeared greasy. Clinical record review for Resident 21 revealed that his scheduled shower days were Monday and Thursdays on dayshift. Review of Resident 21's task documentation for February 2025, revealed that he only had his hair washed two times, February 11 and 20, 2025. Review of Resident 21's task documentation for March 2025, revealed that he only had his hair washed on March 3, 2025. Observation of Resident 96 on April 1, 2025, at 11:46 AM revealed she was sleeping in a chair in the community room. Her hair appeared disheveled and greasy. Clinical record review for Resident 96 revealed task documentation for February and March 2025, that indicated she only had her hair washed on February 25, 2025, and March 5, and 8, 2025. Further clinical record review for Resident 96 revealed task documentation that indicated she did not have a bath or shower on February 12, 15, 19, or 22, 2025, and March 12, 15, 19, 22, and 26, 2025. Resident 96's scheduled bath days were Wednesday and Saturday dayshift. Resident 96's most recent MDS dated [DATE], revealed that she was coded as dependent (staff does all the effort. Resident does none of the effort to complete the activity) for bathing. The above noted bathing concerns for Residents 2, 21, and 96 were addressed with the Nursing Home Administrator on April 3, 2025, at 12:45 PM. Interview with Resident 121's family voiced concerns that sometimes upon visiting, the resident's hair seems dirty and the family was unsure if the resident was getting bathed. A review of the census for Resident 121 revealed that the resident was admitted to the facility on [DATE]. Clinical record review for Resident 121 revealed an admission MDS that noted facility staff assessed the resident as having a BIMS (Brief Interview for Mental Status) of 4, which indicated cognitive impairment. Further review of Resident 121's MDS revealed the resident required substantial maximal assistance to shower and bathe self. Clinical record review for Resident 121 revealed a task list (located in the electronic health record where staff document specific care related events for a resident) that noted bathing on Monday and Thursday 3 PM to 11 PM. Further review of the bathing task for Resident 121 for March and April 2025, revealed staff documented one bed bath (basin or sink bath) as completed on March 8, 2025. The staff documented the resident as refusing bathing on March 20, 2025. The following dates were marked NA to note non-applicable: March 17, 24, 27, and 31, 2025. Further review of the clinical record revealed no evidence was documented to indicate Resident 121 refused a bath, there was a wound or injury preventing a bathing, or any other rationale other than the refusal on March 20, 2025. There was no evidence that staff reapproached Resident 121 after he refused bathing on March 20, 2025. The information on Resident 121 was reviewed with the Nursing Home Administrator on April 3, 2025, at 12:37 PM. Clinical record review revealed the facility admitted Resident 88 on May 19, 2022. A review of Resident 88's most recent MDS dated [DATE], indicated nursing staff assessed Resident 88 as requiring substantial to maximum staff assistance with bathing. A review of Resident 88's task documentation for the last three months revealed Resident 88 only received seven showers. There were eight days that the staff documented NA (not applicable), and Resident 88 did not receive his shower. Further review of Resident 88's clinical record revealed that Resident 88's bathing preference was identified as showers twice a week. Clinical record review revealed the facility admitted Resident 92 on December 13, 2023. A review of Resident 92's most recent quarterly MDS dated [DATE], indicated nursing staff assessed Resident 92 as dependent on staff for bathing. A review of Resident 92's task documentation for the last three months revealed Resident 92 only received four showers and staff documented that Resident 92 refused her shower four times. There was no evidence that staff reapproached Resident 92 after they refused bathing to re-attempt. Further review of Resident 92's clinical record revealed that Resident 92's bathing preference was identified as showers twice a week. Clinical record review revealed the facility admitted Resident 117 on February 6, 2025. A review of Resident 117's admission MDS dated [DATE], indicated nursing staff assessed Resident 117 as requiring partial to moderate staff assistance (staff lifts, holds, or supports trunk or limbs, but provides less than half the effort). A review of Resident 117's task documentation since admission revealed Resident 117 only received four showers, and staff documented that Resident 117 refused his shower four times. There was no evidence that staff reapproached Resident 117 after they refused bathing to re-attempt. Further review of Resident 117's clinical record revealed that Resident 117's bathing preference was identified as showers twice a week. The above information for Residents 88, 92, and 117 was reviewed during an interview with the Nursing Home Administrator and the Director of Nursing on April 3, 2025, at 2:30 PM. The facility failed to provide assistance for bathing assistance for residents' dependent on staff assistance. 483.24(a)(2) ADL Care Provide for Dependent Residents Previously cited deficiency 9/19/24 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered pain medications for one of one resident reviewed (Resident 108) Findings include: Review of Physiopedia's and Wikipedia's definition of the numeric pain rating scale (parameters) from zero to 10 indicated that no pain was identified as zero, mild pain was identified as one to three, moderate pain was identified as four to six, and severe pain was identified as seven to 10. Clinical record review for Resident 108 revealed physician's orders for the following pain medications: Ordered on February 14, 2025, and discontinued on March 11, 2025, Oxycodone 5 mg (milligrams) 2 tablets PO (by mouth) every 4 hours PRN (as needed) for severe pain 7-10. Review of Resident 108's February and March 2025 MAR (medication administration record, a form to document medication administration) revealed that staff did not document a level of pain on the following dates and times: Oxycodone (for moderate to severe pain) 5 mg 2 tablets PO every 4 hours PRN for severe pain 7-10. February 21, 2025, at 8:05 AM, 1:19 PM, and 4:00 PM, no pain level February 22, 2025, at 2:41 AM, no pain level February 23, 2025, at 4:33 PM and 9:03 PM, no pain level February 24, 2025, at 4:00 PM, no pain level February 28, 2025, at 8:30 PM, no pain level March 2, 2025, at 8:11 PM, no pain level March 3, 2025, at 8:24 PM, no pain level March 8, 2025, at 12:42 AM and 5:28 PM, no pain level March 9, 2025, at 9:00 PM, no pain level March 10, 2025, at 10:51 AM and 7:47 PM, no pain level Staff did not administer Resident 108's pain medications according to the physician ordered pain scale level(s). The above information was reviewed during an interview with the Director of Nursing on April 3, 2025, at 9:20 AM. 483.25(k) Pain Management Previously cited 5/23/24 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to implement appropriate enhanced barrier transmission-based precautions for three of 24 residents reviewed (Residents 2, 67, and 106) Findings include: Review of the memo entitled Enhanced Barrier Precautions (EBP, gown and glove use) in Nursing Homes to Prevent the Spread of Multi-drug Resistant Organisms (MDRO, bacteria that are resistant to some antibiotics) released by the Center for Medicaid and Medicare Services (CMS) on March 20, 2024, with an implementation date of April 1, 2024, revealed that nursing care facilities are to use EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care. Review of the facility policy titled, Enhanced Barrier Precautions, reviewed without changes on March 27, 2025, revealed that it is the policy of the facility that EBP, in addition to standard contact precautions (refer to the infection prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis or presumed infection status), will be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring MDROs such as a resident with chronic wounds requiring a dressing, indwelling medical devices, or residents with infection or colonization (when a germ or microbe is found on or in the body but does not cause symptoms or disease) with an MDRO. Further review of the policy revealed that EBP refers to an infection control intervention designed to reduce transmission of MDROs that employs targeted gown and glove use during high contact resident care activities (dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, assisting with toileting, device care, wound care). The policy noted that EBP will not only focus on residents with an infection or colonization with an MDRO, but it will also address residents at risk for developing or becoming colonized. EBP require gown and glove use for residents with a novel or targeted MDRO or any resident with a wound or indwelling medical device during specific high-contact care activities. Clinical record review for Resident 106 revealed the resident has bilateral heel pressure ulcers. The resident has current orders for wound care and antibiotic treatment related to the pressure ulcers. There was no evidence in the clinical record to indicate that Resident 106 was on any type of enhanced barrier precautions or any type of isolation for the wound. Observation of Resident 106's room on April 3, 2025, at 1:10 PM revealed no evidence that the resident was on EBP (no sign indicating EBP precautions, no personal protective equipment (PPE) in the room or at the doorway to don (put on and use), or any sign placed that instructed to see the nurse prior to care Observation of Resident 106's wound care on April 3, 2025, at 1:10 PM revealed Employee 4, licensed practical nurse, and Employee 5, registered nurse, entered the resident's room and performed wound care to the resident's bilateral heels, which included a dressing change. There was dark colored wound drainage noted on the bed sheet of the resident's bed under the resident's heels. The staff did not wear gowns during the high contact activity of wound care with noted drainage. The above information for Resident 106 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on April 3, 2025, at 2:15 PM. Clinical record review for Resident 2 revealed a urinalysis dated March 18, 2025, that indicated she had ESBL (extended-spectrum beta-lactamase an enzyme found in some strains of bacteria that can't be killed by many of the antibiotics doctors use to treat infections) in her urine. Resident 2 was then hospitalized from March 19 to 25, 2025. There was no evidence in her clinical record that EBP was initiated upon her return from the hospital. Observation of Resident 2's room on April 1, 2025, at 1:30 PM revealed no evidence that EBP was initiated. The above information for Resident 2 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on April 3, 2025, at 2:00 PM. Clinical record review for Resident 67 revealed current physician orders for a Foley (urinary) catheter to straight drainage every shift for a diagnosis of bilateral obstructive uropathy (blockage of the urinary system). Observation on April 1, 2025, at 10:41 AM and 12:48 PM, April 2, 2025, at 12:47 PM and 12:53 PM, and April 3, 2025, at 8:41 AM of the hallway outside Resident 67's room revealed that there was no enhanced barrier precaution signage to indicate the need to utilize PPE (personal protective equipment, to prevent infectious disease transmission) and /or the necessary PPE available outside Resident 67's room though they had an indwelling medical device (Foley urinary catheter). The above information was reviewed during an interview on April 3, 2025, at 3:11 PM with the Nursing Home Administrator and the Director of Nursing. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services