Every finding on record at Edenbrook of Yeadon

Based on clinical record review, facility policy, facility documentation, and staff interviews, it was determined the facility failed to ensure Resident R1 was free from abuse. Resident R1 was included in a social media post in which he was photographed from behind, partially exposing his buttocks and without a shirt. The image also contained profanity. A reasonable person in Resident R1's position would likely feel humiliated by having such a photograph taken and posted on social media without consent. Posting this image of a cognitively impaired Resident R1 caused harm. This deficiency was cited as past noncompliance. (Resident R1).Findings include:Review of the facility policy titled, Policy and Procedure Vulnerable Adult Abuse and Neglect Prevention revised 03/25/2025, revealed it is the policy of the facility to provide residents a safe environment that is free from harm. Further, it is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, neglect, mistreatment or exploitation. Review of facility policy Policy and Procedure Social Media, revised 01/29/2025, revealed staff should Refrain from using social media while on work time or on equipment we provide unless it is work-related as authorized by your manager and consistent with the [Equipment/Computer Usage Policy]/ Further review of facility policy revealed staff should not use legal facility name email addresses to register on social networks, blogs or other online tools utilized for personal use.Observations conducted on 07/01/2026 at 11:38 a.m., revealed Resident R1 was pacing in his/her room without a shirt, and pants were partially down, exposing part of his/her buttocks, similar to what was depicted in the social media post. Nurse aide, Employee E9, was present in the room and asked Resident R1 to put on a shirt. Resident R1 took the shirt and walked into the hallway, placing it onto his/her body and continued pacing back and forth on the nursing unit. Resident R1 did not respond to the surveyor's greeting and continued to walk the hallway. Nurse aide, Employee E9 reported Resident R1 is nonverbal and exhibits behaviors such as removing his shirt, walking without clothing on upper body, and pants partially pulled down. Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Schizophrenia (mental health condition that may result in a mix of hallucinations, delusions, and disorganized thinking and behavior), Autistic Disorder (neurodevelopmental and repetitive behavior), Anxiety Disorder (intense, excessive, persistent worry or fear ), personal history of other mental and behavioral disorder, unspecified symptoms and signs involving cognitive functions and awareness (confused), and Major Depressive Disorder (mood disorder characterized by low mood, a feeling of sadness, and a general loss of interest in things ).Review of Resident R1's Comprehensive Minimum Data Set Assessment (MDS-periodic assessment of a resident's needs) dated 05/14/2026, revealed a Brief Interview for Mental Status (BIMS) not recorded indicating the resident was unable to participate in the assessment due to severe cognitive impairment., Review of the comprehensive care plan dated 11/30/2020, revealed Resident R1 had wandering/pacing related to change in environment, cognitive impairment-autism. The goal included encouraging Resident R1 to rest throughout the day and to wander only within certain boundaries, specifically down the hall to his room entrance and back into his room. The interventions were to attempt to minimize excess stimulation. Review of facility documentation submitted April 6, 2026, revealed on April 5, 2026, at approximately 5:30 - 6:00 p.m. the facility was made aware an agency certified nurse aide (CNA), Employee E3, posted an image of a resident on social media earlier in the day. Nuse aide, Employee E3, was put on Do Not Return (DNR) status from the nursing agency and an investigation was initiated. Review of the facility investigation revealed on April 5, 2026, the alleged perpetrator, Nurse Aide, Employee E3, was scheduled to work the 7:00 a.m. to 3:00 p.m. shift. Nurse aide, Employee E3, had previously worked one other shift at the facility on January 2, 2026. Further review of facility investigation revealed on April 5, 2026, Nurse aide, Employee E4, was at home around 5:20 p.m. when a social media image post (posted by nurse aide, Employee E3) was brought to his/her attention. The image included profanity across the picture and showed Resident R1 in the main unit hallway, facing away, with his/her buttocks partially exposed and without a shirt. The social media post was time stamped 10:12 a.m. on Aoril 5, 2026, during Nurse aide, Employee E3's shift. Further review of documentation revealed, nurse aide, Employee E4, notified facility management of the social media post. Nurse aide, Employee E3, was placed on Do Not Return (DNR) status pending the outcome of the investigation. The facility notified the resident's physician, Resident's Representative, Department of Health (DOH), Department of State and police. Resident R1 was assessed; there were no negative outcomes, as Resident R1 was unaware the photo was taken and remained at his baseline. Education was initiated to nursing staff. Further review of facility investigation revealed the facility substantiated the allegation of abuse related to the social media posted photograph of Resident R1. Review of Employe E4, nurse aide's, written statement dated 04/06/2026 revealed around 5:20 p.m. as we were having dinner, family member told me look your job is going viral on social media with a resident held naked walking down the hallway. So when I proceeded to look at her phone I noticed [Resident R1] was recorded walking half naked down the hallway. I reported ASAP through phone to my unit manager. Review of written statement by Employee E2, Director of Nursing dated 04/06/2026, revealed On 04/05/2026 around 5:30-5:45 p.m. I was notified that a picture was posted of one of our residents on social media by an agency CNA that worked at the facility that morning. The picture did not show resident's face or any other resident's identifier. I immediately informed the NHA and notified the scheduler to DNR [do not return] the CNA on all agency platforms, when I went to look on the CNA's social media account so that I can report, the picture was already removed. Review of the written statement by the CNA, Employee E3, who was named as the alleged perpetrator, revealed the following: 'I am writing to formally address a matter that appears to involve a misunderstanding. I am not sure where the mix-up may have occurred; however, I want to make it absolutely clear that I would never treat any resident improperly or engage in any action that would compromise my professional responsibilities. I take my role and ethical obligations very seriously and would not put my career at risk under any circumstances. If there are specific concerns or details that need to be reviewed, I am more than willing to cooperate fully to help clarify the situation and resolve any confusion.' Interview conducted on 07/01/2026 at approximately 10:00 a.m. with Nursing Home Administrator (NHA), Employee E1, and Employee E2 (DON), who revealed on 04/06/2026 local police were notified and police report was filed regarding the investigation. In addition, Resident R1's representative, physician, Department of State, and adult protective services were all notified about the incident. Employee E1 (NHA), and Employee E2 (DON), revealed the post does not identify Resident R1 nor the facility. It was further stated the facility provided emotional support to Resident R1, but the resident did not exhibit any negative effects related to the incident. Interview on 07/01/2026 at 11:47 a.m., with the licensed nurse, Employee E10, reported Resident R1 is nonverbal, non aggressive, and exhibits behaviors such as pacing and walking in his room or in the hallway. Resident R1 is able to follow directions but is unable to speak; Resident R1 has a low, soft voice and able to say yes or no. Resident R1 has a history of removing shirt, pants, socks, and other clothing, particularly when preparing to lie down in bed. Resident R1 is currently prescribed Lorazepam (anti-anxiety medication) 2 mg (milligram) every 8 hours and Risperidone (anti-psychotic medication) 2 mL (milliliter) twice daily at 9 a.m. and 5 p.m. Telephone interview on 07/01/2026 at 1:45 p.m., with the facility's medical director, Employee E18, stated that Resident R1 did not experience any negative effects related to the incident, due to cognitive impairments. The facility stated that they were not able to fully identify Resident R1 as the individual in the social media post because the image showed only the resident's back, with no facial features or name visible. However, during the surveyor's observations, on all units, on July 1, 2026, no other residents were found with the same physical characteristics. When the surveyor arrived on Resident R1's unit, Resident R1 was observed walking without a shirt, pants partially pulled down, exposing part of his/her buttocks, consistent with the image in the post. The facility did not identify any other resident for comparison besides Resident R1. Review of the facility's action plan revealed the following information: The involved CNA, Employee E3, was immediately removed from resident care and placed on Do Not Return (DNR) status. The facility conducted an investigation immediately upon identification of the allegation. A review of the employee's social media activity was completed to determine the scope of the incident. No additional residents were identified as being affected. The facility completed a comprehensive review of the employee's social media activity and resident assignments. Nursing leadership reviewed resident interviews, observations, and clinical records as indicated. The investigation determined no additional residents were impacted by the deficient practice. The scheduler, nursing supervisor and all staff were re educated on the facility's staffing procedures to ensure agency staff are no longer automatically scheduled by external staffing agencies. The nursing supervisor and scheduler received education on the social media policy and the abuse, neglect, and exploitation policy. The interdisciplinary team will complete audits of staff knowledge and compliance with the Abuse Prevention and Exploitation and social media policies. Audits will be conducted daily for 2 weeks, weekly for 4 weeks, and monthly for 3 months. Audit results will be reviewed during the facility's QAPI (Quality Assurance Performance Improvement) meetings. Any identified concerns will result in immediate corrective action, re education, and additional monitoring until sustained compliance is achieved. Based on the completed corrective actions and monitoring, the deficient practice was determined to be past noncompliance effective as of April 10, 2026. Facility education records and subsequent audits were verified as complete. Staff were interviewed to confirm completion of education on the facility's policies regarding resident privacy, social media use, and protection of resident dignity. Additional staff interviews were conducted to verify compliance with the plan of correction. No continuing concerns were identified through record review, staff interviews, or observation.The facility failed to ensure Resident R1 was free from mental abuse when a staff member posted a partially naked photograph of the resident, including profanity, on a public social media platform, causing harm to Resident R1 as a reasonable person would not consent to such social media posts.28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management

Based on Observations, review of clinical record, and interview with staff and residents, it was determined that the facility did not ensure dignity and privacy was maintained for one resident who had an audiology consult in a public activities area for one of 36 residents (Resident R13). Findings include:Review of Resident R13's April 2026 physician orders included the following diagnosis: diabetes (a group of diseases that affect how the body uses blood sugar/glucose; depression; chronic kidney disease ( a condition in which the kidneys are damaged and gradually lose their ability to function properly over time), and hypertension (high blood pressure).During an observation on April 22, 2026 at 11:00 a.m. the resident was observed sitting in the activity office on the 2nd floor. The resident was observed sitting in the room receiving an audiology assessment. The audiologist was also sitting next to the resident with her computer on the desk. Observed in the room with the resident and audiologist were two barbers/beauticians were talking and transporting residents in and out of the room for hair care services. In addition to the residents being brought in and out of the room for services, three employees were observed coming in and out of the room for work related purposes, and at a later time the three employees were observed standing in the doorway of the activity office, having a conversation.During a discussion with the Activity Director (Employee E17) at 11:10 a.m. on April 22, 2026, it was discussed that the audiologist was conducting the resident's hearing assessment in the activity's room. During a discussion with the Nursing Home Administrator (NHA) on April 22, 2026 at 11:15 a.m. the NHA and acknowledged that she was aware of the above-referenced incident regarding resident R1.

Based on review clinical record, review of facility documents, facility investigations, facility policy and interview with staff and residents, it was determined that the facility did not ensure that residents were free from misappropriation of resident property related to narcotic diversion for one of 36 residents (Resident R14). This deficiency was identified as Past Non-compliance.Findings include:Review of facility policy on Controlled Substance Management with most recent revision date of August 7 2024, revealed that under section Policy: to provide guidance for record keeping receipt handling storing and disposal of control substances in accordance with federal state DEA (Drug Enforcement Agency) and board of pharmacy regulations under section Storage and Inventory, #1 store medications listed in schedules II, III, IV and V under double lock separate from other medications. #2 when a controlled medication is administered, the details of the administration should be documented on the accountability record. #a. date/time of administration #b. amount of medication administered #c. amount of medication remaining in the container #d. signature of nurse administering the dose. #3 conduct an inventory of all controlled medications at each shift or when keys are surrendered to another license nurse.Review of event details reported by the facility through the Department of Health on December 23 2025 revealed that on December 20 2025, misappropriation of resident property occurred related to oxycodone hydrochloride factual description of the event detail revealed that facility was notified by staff LPN that during narcotic count she noticed a discrepancy for Resident R14 for his oxycodone 5 milligrams. Description of follow up action revealed that an investigation was conducted and the investigation concluded that a diversion was substantiated.Further review facility investigation documents revealed that a PB22 report form for investigation of alleged abuse neglect misappropriation of property was completed by the facility for misappropriation of resident property description of event revealed as follow: on Monday December 22, 2025, at approximately 4:00 PM the facility was notified about the discrepancy in the narcotic logbook on the 2nd floor cart. Licensed nurse Employee E15 identified the miscount and notify the supervisor on December 20 2025 and the agency nurse Employee E16 signed out three PRN (as needed) 5 milligram oxycodone for Resident R14 which was not signed out in PCC, The starting count was sixteen pills, three were signed out, one pill was administered leaving the count at thirteen with two pills unaccounted for. The incident was reported to the Department of State, The Department of Health, and the [NAME] police. Resident R14 was interviewed which revealed that resident was not in pain at the time of the incident and did not request for pain medication.The facility initiated a facility wide staff education conducted, a quality assurance performance improvement on medication administration policy, physician completed a complete review of all narcotic logs and review of all PRN and narcotics discontinued and narcotics not being used per administration policy.Interview with Director of Nursing Employee E2 conducted on May 22, 2026, at 8:54 AM revealed that the facility conducted a complete and thorough investigation on the incident. Further Employee E2 revealed that Resident R14 never requested for the Oxycodone and was not in pain.Further the director of nursing revealed that 29 of 30 full time licensed nurses and 11 of 11 agency licensed nurses were educated on controlled drugs accountability and medication administration policy, QAPI was conducted and is still on going.Further employee 2 revealed that the plan of correction was completed and fully implemented on December 29, 2026. 28 Pa. Code 201.18(b)(2) resident's personal property28 Pa. Code 201.29(c) Resident's rights

Based on interviews and the review of clinical records, it was determined that the facility failed to ensure that one resident with a diagnosis of congestive heart failure was properly assessed after a 27.4-pound weight gain in a two-month time period, for one out of 29 residents reviewed (Resident R3).Findings include:Review of the facility's Resident Height and Weight policy with a revision date of January 7, 2025 indicated that all residents will be weighed upon admission and subsequently as the policy directs to provide a baseline and ongoing record for monitoring stability of weight as an indicator of nutritional status and medical condition over a period of time. The policy also stated that any weight change of 5lbs or more will be retaken and if a reweight verifies a significant, unplanned weight change, this is communicated to the resident's physician, power of attorney, dietician, and any others deemed necessary by the disciplinary team. Continued review of the policy indicated that the weight change will be assessed and reviewed by the dietician in cooperation with the disciplinary team, and appropriate interventions will be implemented, reviewed and revised as needed. Review of the April 2026 physician orders for Resident R3 include the following diagnosis: Congestive Heart Failure (COPD-a progressive lung disease that makes it difficult to breath); diabetes (a condition defined by persistently high levels of sugar/glucose) in the blood) ; chronic pulmonary edema (a condition caused by too much fluid build-up in the lungs, making it difficult for an individual to breath, and oftentimes due to cardiogenic causes such as congestive heart failure), and congestive heart failure ( occurs when the heart muscle doesn't pump blood as well as it should, causing fluid can build up in the lungs, and shortness of breath).Review of the resident's monthly weight from December documented the resident as weighing 186 pounds. Review of the resident's monthly weight for January 9, 2026 included a weight of 198 pounds, which is a significant weight gain of 12 pounds in a month, and a +6.5% significant weight gain for the resident with a diagnosis of congestive heart failure.Review of a clinical note written by the dietician (Employee E25) dated January 10, 2026, at 1:29 p.m. indicated that the resident's weight on January 9, 2026 was 198 pounds, with a 6.5% weight and 12 pounds weight gain since the previous month. The clinical note from the dietician stated that a reweight was requested. Review of the clinical record did not show evidence that a reweight was completed. Review of a physician's note dated January 27, 2026 at 11:22 p.m. documented that the resident was seen for a routine follow up. Resident's weight gain from January 9, 2026 was not acknowledged/addressed by the physician in the above referenced routine follow up. Continued review of the resident's weight record indicated that the resident's weight was documented as being 213.4 pounds on February 6, 2026, which is an additional 15.4 pound weight gain for the resident with a diagnosis of congestive heart failure, a total weight gain of 27.4 pounds since December 8, 2025, and a total significant weight gain of +15% for a resident with congestive heart failure. Review of a clinical note written by the dietician on February 7, 2026 at 11:08 a.m. indicated that the dietician acknowledged the above referenced weight gain. Review of a clinical note written by the dietician on February 7, 2026 at 11:20 a.m. documented that the dietician notified the physician and the nursing supervisor of the resident's weight change. Continued review of the clinical record did not show evidence of what the physicians response was regarding the additional weight gain for the resident with congestive heart failure, to ensure the weight gain was acknowledged, and any additional care and services, or interventions, if ordered, by the physician, were implemented for the resident. During a discussion with the facility's Medical Director on April 23, 2026 at 2:00 p.m. concerns regarding the physician not acknowledging/assessing the resident's weight gain in January and in February to determine whether any additional interventions were needed was discussed.

Based on observation, review of clinical record, and interview with staff, it was determined that the facility did not ensure that residents receiving a tube feeding was placed in proper position to avoid aspiration for one resident (Resident R2).Review facility policy on two feeding Revealed that under section purpose to provide guidelines to ensure safe and effective administration of medications administered via Interlube under section procedure number 5 ensure head of bed is elevated unless contraindicated.Review of resident R2S clinical record revealed that resident R2 was admitted to the facility on [DATE], with diagnosis of but not limited to Dysphagia and get stressed and Gastrostomy Status.Review of Resident R2's MDS minimum data set significant change assessment dated [DATE], section K0520. Nutritional Approaches revealed that Resident R2 was on Feeding tube (PEG percutaneous Endoscopic Gastrostomy- A flexible tube Inserted through the abdomen into the stomach to deliver nutrition, fluids and medications directly).Review of Resident's R2's care plan revealed that Resident R2 requires tube feeding r/t (related to) dysphagia/tracheostomy, and vegetative state. Resident R2 needs the HOB (head of bed) elevated during and thirty minutes after tube feed.Observation of Resident R2 conducted on April 20, 2026, at 1:14 PM revealed that Resident R2 was in bed with tubing connected to feeding pump running at 60 milliliters/hour Further, the head of Resident R2's bed was not elevated, Resident R2 was lying flat on bed. Further observation revealed that Resident was coughing with gurgling sound. Resident R2's tracheostomy mask was on Resident R's right side of face.Further observation revealed yellowish-beige colored substance mixed with mucous was on Resident R2's chest and on lower part of Resident R2's tracheostomy dressing.Further observation revealed that specks of the yellowish beige substance were also on the inside surface of the tracheostomy mask and on the inside of corrugated tubing connected to the tracheostomy mask.Staff were alerted by surveyor, and licensed nurses Employees E5, E6 and E7 responded. Employee E7 stopped the feeding and proceeded to assess the resident, while Employee E5 elevated the head of Resident R2's bed.Interview with Employee E7 conducted at the time of the observation confirmed that a yellowish-beige colored substance mixed with mucous was on chest, below the tracheostomy site, inside of the tracheostomy mask and in the inside of the corrugated tubing. Further, Employee E7 stated she will order x-ray to rule out aspiration.Interview with Employee E5 conducted at the time of the observation confirmed that Resident R2 was receiving feeding via feeding tube while the head of bed of Resident R2's was not elevated and that Resident R2 was lying flat on bed.Further interview with Employee E5 revealed that the facility's policy was that the head of the bed should be elevated for all residents receiving tube feeding. Review of progress note dated April 20, 2026, time stamped15:00 revealed: This RN assessed this resident and noted with copious secretions, and coughing out with some undigested TF (tube feeding). Resident head kept elevated, TF (tube feeding) stopped as per protocol. Another nurse was called in the room to assist with trach care, suctioning and repositioning res. Stat CXR ordered by MD to r/o aspiration PNA (pneumonia). RP (responsible party) made aware. 28 Pa. Code 211.12(d)(1) Nursing services28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 201.18(b)(1) Management responsibility

Based on observation, interviews with staff, and review of clinical records, facility documentation, and policy it was determined that the facility did not implement an effective infection control program related to use of Personal Protective Equipment (PPE) and wound care for two of thirty-six residents observed (Resident R2 and Resident R5).Findings include: Review facility policy on Isolation Precaution with a most recent revision date of May 8, 2024, revealed that under section Purpose: To establish transmission-based precaution for residents who are suspected or confirmed to have communicable diseases/infections that can be transmitted to others. Under section Procedure: #1 Transmission based precaution will be used when transmission cannot reasonably be prevented by standard precaution alone. Under section Contact Precaution: #1 Implemented for residents suspected of or confirmed to be infected with a communicable disease that can be transmitted by direct contact with a resident or indirect contact with environment services/equipment in the resident's environment #3 prior to entering the isolation room the following steps are required: #a. perform hand hygiene and apply gloves and gown prior to entering room. #c. Remove gloves and perform hand hygiene before leaving room.Review of resident R2's clinical record revealed that Resident R2 was admitted to the facility on [DATE], with diagnosis of but not limited to Dysphagia and Gastrostomy Status.Review of Resident R2's MDS minimum data set significant change assessment dated [DATE], section K0520. Nutritional Approaches revealed that Resident R2 was on Feeding tube (PEG percutaneous Endoscopic Gastrostomy (A flexible tube Inserted through the abdomen into the stomach to deliver nutrition, fluids and medications directly).Review of Resident's R2's care plan revealed that Resident R2 requires tube feeding r/t (related to) dysphagia/tracheostomy, and vegetative state. Resident R2 needs the HOB (head of bed) elevated during and thirty minutes after tube feed.Observation conducted on April 20, 2026, at 1:12 PM revealed that Resident R2 for Enhance Barrier Precaution and Contact Precaution posted outside the resident's bedroom door. Observation of Resident R2 conducted on April 20, 2026, at 1:14 PM revealed that Resident R2 was in bed with tubing connected to feeding pump running at 60 milliliters/hour Further, the head of Resident R2's bed was not elevated, Resident R2 was lying flat on bed. Further observation revealed that Resident was coughing with gurgling sound. Resident R2's tracheostomy mask was on Resident R2's right side of face.Further observation revealed yellowish-beige colored substance mixed with mucous was on Resident R2's chest and on lower part of Resident R2's tracheostomy dressing.Employees E6 was notified by surveyor, Employee E6 then went to Resident's R2's room to check on Resident R2 without wearing PPE. Employee E6 then came out of the room, at the same time, surveyor also alerted Employee E7 of the situation and surveyor and Employee E7 donned PPE and entered Resident R2's room to check on Resident R2. Employee E6 also started to put on PPE and followed surveyor and Employee E7 to Resident R2's room.Employee E7 proceeded stop Resident R2's tube feeding and assesses Resident R2. Employee E5 then instructed Employee E6 to get a pulse oximeter. Employee E6 then left the room without removing her PPE and went to the medication cart located in the hallway around the corner from Resident R2's room.Interview with Employee E7 conducted at the time of the observation confirmed Resident R2 was on contact precaution. Further, Employee E7 also confirmed that Employee E6 left the room to retrieve a pulse oximeter from the medication cart located in the hallway around the corner from Resident R2's room without removing the PPE that she was wearing inside Resident R2's room. Further, Observation conducted on April 21, 2026, at 9:33 AM revealed that Resident R5's room had a signage for Enhance Barrier Precaution and Contact Precaution posted outside the door. Further PPE supplies were in a drawer outside of Resident R5's room. Further observation revealed that hospice nurse Employee E27 was going in and out of Resident R5's room without PPE. Interview with Employee E27 conducted at the time of the observation together with licensed nurse Employee E5 revealed that Employee E27 was the hospice aide Employee E5 who was in Resident R5's room Further interview with Employee E27 revealed that she was not aware that she had to wear a PPE and thought that the contact precaution was only for bed A. Employee E5 informed Employee E27 that Employee E27 has to put on PPE before entering Resident R5's room. Interview with Employee E5 confirmed that Employee E28 was in Resident R2's and Resident R5's room without wearing PPE and confirmed that Employee E27 did not know that she had to wear PPE when entering their room. 28 Pa. Code 211.10 (a)(c) Resident care policies28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, observations, and interview with staff and residents, it was determined that the facility did not ensure that residents were free from neglect one of 5 residents reviewed. This deficiency is cited as past non-compliance. (Resident R3)Clinical record review revealed that Resident R3 was admitted to the facility on [DATE], with diagnoses including, but not limited to rheumatoid arthritis (a chronic condition in which the immune system attacks the lining of joints, causing pain, inflammation, stiffness, and potential deformity), and Huntington's Disease (an inherited, fatal disorder that causes progressive breakdown of nerve cells in the brain).Review of facility incident report revealed that during continence care on January 9, 2026, Resident R3 was repositioned by nurse aide, Employee E3, who then slid with her pillow to the floor. Continued review of the report revealed that the identified probable cause of the fall was that the plan of care was not followed (requires 2 person assist with bed mobility) [sic]. Review of the written statement of nurse aide, Employee E3 revealed that she had not utilized a second person for care because I couldn't find help.everybody was with [their] clients. And I didn't want to wait cause she was wet.On February 12, 2026, the Nursing Home Administrator, employee E1, presented documentation indicating that the facility had initiated a plan of correction on January 9, 2026, related to neglect and following the plan of care for resident safety.Review of the facility's Plan of Correction documentation revealed the following: 1. Resident [R3] was assessed for injury on 1/9/26, with no injury noted. X-rays were ordered and results were negative on 1/12/26.2. Current residents that require 2-person assistance for bed mobility were reviewed by nurse managers to ensure it is reflected accurately on the Kardex, completed on 1/13/26.3. Nursing staff were educated on neglect/abuse and following the Kardex to provide the appropriate level of assistance starting on 1/14/26. Completion of education was achieved on 1/16/26.4. Abuse questionnaire will be completed daily for 2 days. Audits will continue weekly x 4 weeks, and monthly x 3 months. IDT (Interdisciplinary Team) will bring results to QAPI (Quality Assurance Improvement Plan) for continued monitoring.Interview with Nursing Home Administrator, Employee E1 on February 12, 2026, at 12:15 p.m. revealed that Nurse aide, Employee E3 had been placed on administrative leave during the investigation and had been terminated when the facility substantiated abuse.The facility alleged a date of compliance with this plan of correction of January 16, 2026.Facility education record and subsequent audits were verified for completion. Staff were interviewed to verify education of facility policies on abuse and neglect, as well as appropriate assistance levels during care. Random staff and resident interviews were conducted to verify compliance with the plan of correction. QAPI records reviewed to verify ongoing monitoring. Residents were observed receiving care with appropriate numbers of staff assisting. No continuing concerns were identified through record review, interview or observation.This deficiency was cited as past non-compliance. 28 Pa Code 201.18(b)(1) Management28 Pa Code 211.12(d)(5) Nursing Services

Based on observation and interview with staff, it was determined that the facility failed to maintain sanitary, and comfortable environment on one of two nursing floors observed. (1st Floor) Findings include:Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnosis of but not limited to Schizophrenia (mental disease characterized by loss of reality). Review of Resident R1's MDS section C0500 BIMS (brief interview of mental status) revealed a score of 11 suggesting that Resident R1 had moderately impaired cognition. Observation of the first-floor unit conducted on August 6, 2025, at 9:10 AM reveled that the ice machine located between the nurse's station and room [ROOM NUMBER] had water leaking on the floor. Further, a white towel and a blue gown was on the floor in front of the ice machine. Further observation revealed that parts of the flooring in front of the ice machine had been peeled off with the understructure exposed. Observation of the back of the ice machine revealed that the floor behind the ice machine had water pooling. Further, specks of black substance on the floor and on the wall to the right of the ice machine was also observed. Observation conducted in room [ROOM NUMBER] revealed that Resident R1 was in the room sitting next to his bed wearing a gown. Observation of the environment inside room [ROOM NUMBER] reveled that, immediately next to the door to the right was a plastic drawer containing PPE (personal protective equipment). Next to the drawer containing PPE's was the yellow attention/caution sign which was propped against the wall. Further observation revealed that the floor to the right next to the doorway where the plastic bin containing PPE was located extending to the middle half of the length of the wall was wet. Further, the wet floor was covered with white sheets. Observation of the bathroom in room [ROOM NUMBER] revealed that the toilet water tank did not have a cover. Further observation revealed dried up dark brown (dark chocolate colored) substance caked on the toilet seat. Further the toilet bowl was filled with feces and tissue paper. Interview with Resident R1 conducted at the time of observation revealed that Resident R1 did not respond to surveyor.Interview with Director of Environmental Services, Employee E3 conducted on August 5, 2025, at 10:06 AM revealed that he was just made aware that the ice machine on the first floor was broken again. Further interview with Director of Environmental Services, Employee E3 confirmed that the first-floor ice machine has been leaking periodically since he started working here 3 months ago. Further Employee E3 revealed that on June 13, 2025, it was reported that the ice machine was leaking and was fixed the same day and on July 23, 2025, a work order was in place due to ice machine leaking again and was fixed on July 28, 2025. Interview with interview with unit manager Employee E4 conducted on August 5, 2025, at 10:17AM revealed that the ice machine on the first floor has been leaking on and off for the past 2 months. Further, Employee E4 was also aware that the water has seeped into room [ROOM NUMBER]. 28 Pa. Code 202.28(b)(3) Management

Based on review of facility policy, review of clinical records, obsesrvations, and staff interviews, it was determined that the facility failed to obtain, follow, and clarify physician orders related to medications and skin checks for two of 34 residents reviewed (Resident R84 and R64). Findings Include: Review of facility document titled Administering Medications revised January 22, 2024, revealed medications shall be administered per providers written or verbal orders upon verification of the right medication, dose, root, time and positive verification of resident's identity. Medications may only be administered to the individual in which the medication was prescribed. Review of facility policy titled Physician Orders last revised November 13,2024, revealed the policy is to provide guidance to ensure physician orders are transcribed and implemented in accordance with professional standards. Clear and complete orders will be transcribed to the appropriate administration record medication administration record (MAR). Review of Resident 84's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool) dated February 5, 2025, revealed that the resident was admitted to the facility on [DATE] , and had diagnoses including cerebrovascular accident (stroke, when blood flow to the brain is interrupted, leading to brain damage) heart failure (chronic condition when the heart does not pump enough blood to meet the body's needs), hypertension (high blood pressure, medical condition where the pressure in the blood vessels is too high) and depression ( a mental health is what our characterized by persistently depressed mood or loss of interest and activities, causing significant impairment in daily life). Review of Resident R84's physician orders revealed an order dated January 10, 2025, for the medication MIDODRINE HCL (medication used to treat low blood pressure) oral tablet 2.5 milligrams with directions to give one tablet by mouth every eight hours for hypotension hold for SBP (systolic blood pressure, the force of blood pushing against your artery walls during the hearts contraction. A normal systolic blood pressure is generally considered to be less than 120 mm hg.) greater than 90. Review of Resident R84's medication administration record and nursing notes revealed that although the order specifically instructed to hold for blood pressure greater then 90, the medication administration record revealed that the medication was administered with documented blood pressure recorded as over 90 SBP (systolic blood pressure). Review of residen'ts MAR for the month of March 2025 revealed the medication order for Midodrine HCL 2.5 to be given every eight hours HOLD for SBP (systolic blood pressure) greater then 90, revealed the following recorded dates that the blood pressures were record above 90 SBP and the medication was administered, not following physician orders. March 11, 2025, Residents 84's blood pressure was recorded at 1:00 a.m. as 120/64, at 9:00 a.m. as 120/64 and at 5:00 p.m. as 110/68; the medication Midodrine was administered at all three times. March 14, 2025, Resident R 84's blood pressure was recorded at 1:00 a.m. as 112/64; the medication Midodrine was administered. March 15, 2025, Resident R84's blood pressure was recorded at 1:00 a.m. as 111/62 and at 9:00 a.m. 110/81 the medication Midodrine was administered at both times. March 16, 2025, Resident R 84's blood pressure was recorded at 9:00 am as 118/94 and the medication Midodrine was administered. March 17, 2025, Resident R84's blood pressure was recorded at 9:00 a.m. as 102/59 and at 5:00 pm as 105/69; the medication Midodrine was administered both times. March 18, 2025, Resident R84's blood pressure was recorded as 110/68, the medication Midodrine was administered. March 19, 2025, Resident R84's blood pressure was recorded at 1:00 am as 127/69 and at 9:00 a.m. as 122/94. The medication Midodrine was administered both times. March 24, 2025, Resident R84's blood pressure was recorded as 112/68 the medication Midodrine was administered. Review of residents MAR for the month of April 2025 revealed the medication order for Midodrine HCL 2.5 to be given every eight hours HOLD for SBP (systolic blood pressure) greater then 90, reveal the following recorded dated that the blood pressures were record above 90 SBP and the medication was administered, not following physician orders April 5, 2025, Resident R84's blood pressure was recorded at 9:00 am as 104/90 and at 5:00pm as 130/81 the medication Midodrine was administered both times. April 6, 2025, Resident R84's blood pressure was recorded at 9:00 am as 125/74 the medication Midodrine was administered. April 7, 2025, Resident R84's blood pressure was recorded at 9:00 am as 104/90, the medication Midodrine was administered. April 12, 2025 Resident R84's blood pressure was recorded at 1:00 am as 112/67and at 09:00 am as 104/90, the medication Midodrine was administered both times. April 14, 2025, Resident R84's blood pressure was recorded at 9:00 am as 122/66, the medication Midodrine was administered. April 18, 2025, 4/18 Resident R84's blood pressure was recorded at 1:00 am as 108/79 and at 9:00 am as 104/90 the medication Midodrine was administered both times. April 19, 2025 Resident R84's blood pressure was recorded at 1:00 am as 117/69 and at 9:00am as 104/90 and at 5:00 pm as 100/69 the medication Midodrine was administered all times. April 23, 2025, Resident R84's blood pressure was recorded at 1:00a.m. as 110/70, and at 9:00 am as 128/69 the medication Midodrine was administered both times. April 24, 2025, Resident R84's blood pressure was recorded at 1:00 am as 118/76, the medication Midodrine was administered. Interview with the Director of Nursing Employee E2, on April 30, 2025, confirmed that the medication was given incorrectly. Continued interview with Employee E2 revealed that the physician has been notified and has acknowledge that the order was entered incorrectly, the order should be HOLD for SBP (systolic blood pressure) greater then 130, greater then 130, reveal the following recorded dated that the blood pressures were record above 90 SBP and the medication was administered, not following physician orders. Review of Resident R64's comprehensive care plan revised April 17, 2025, revealed the resident was at risk for alteration in skin integrity. Further review of Resident R64's comprehensive care plan revised April 17, 2025, revealed the resident was an elopement risk with interventions to apply a wanderguard (safety device place at the ankle) and check per facility policy. Review of Resident R64's physician order summary revealed an order dated May 28, 2024, to check skin integrity of skin surrounding/under roam alert bracelet to ensure there was no breakdown every shift and to further document impairments in a progress note. Observations on April 30, 2025, at 1:30 p.m. revealed Resident R64 had a wanderguard applied to the right ankle. The wander guard appeared to be tight fitting around the resident 's ankle. Observations on April 30, 2025, at 1:45 p.m. with Licensed Nurse, Employee E28, revealed the wanderguard applied to Resident R64's left ankle was too tight to see the skin beneath the wanderguard. Licensed Nurse, Employee E28, needed to cut Resident R64's wander guard off to adequately assess the area under the wander guard. Review of Resident R64's treatment administration record revealed the order to check skin integrity of skin surrounding/under roam alert bracelet was signed out as completed by Licensed nurse, Employee E29. Interview on April 30, 2025, at 2:25 p.m. with Licensed Nurse, Employee E29, confirmed the employee signed out the skin check as completed but was unable to adequately assess the area under the wanderguard because the medical device was too tight due to swelling of Resident R64's ankle. 28 Pa. Code 211.10 (d) Resident care policies.

Based on review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure professional practice standards related to pain management for one of 35 residents reviewed (Resident R260). Findings include: Review of facility policy, Pain Management and assessment dated revised April 27, 2022, revealed that the purpose of the policy is to develop a standardized method for assessing, monitoring, evaluating, managing and documenting pain. Continued review revealed that staff should, Assess and document pain including onset and duration, location, severity, alleviating and aggravating factors, possible causes, and accompanying signs and symptoms. Further review revealed, Non-pharmacological interventions will be attempted prior to use of PRN [as needed] analgesics whenever appropriate. Use of interventions and effectiveness will be documented. Interview on April 28, 2025, at 12:44 p.m. Resident R260 stated that she frequently has pain. Review of Resident R260's care plan, dated April 23, 2025, revealed that the resident was admitted to the facility on [DATE], and has chronic back pain. Review of progress notes for Resident R260 revealed a physician's note, dated April 25, 2025, at 6:11 p.m. which indicated that the resident complains of 8/10 (pain scale of 0 to 10, where 0 is no pain and 10 is the worst pain imaginable) low back pain. The physician conducted a pain and opioid management evaluation and recommended to continue Percocet (opioid pain medication), Tylenol (pain medication) and to monitor for pain and effect on therapy progress. The physician also recommended medication weaning as tolerated and in accordance with current pain management guidelines Review of Resident R260's Medication Administration Records (MARs) for April 2025, revealed a physician's order, dated April 22, 2025, for Tylenol, give 650m.g every six hours as needed for generalized pain. The MAR indicated that no doses were administered. Further review of Resident R260's MARs for April 2025, revealed a physician's order, dated April 22, 2025, for Percocet, 5-325 m.g, give one tablet every six hours as needed for pain. The MAR indicated that the resident received ten doses between April 22 through 29, 2025. Review of eMAR (electronic MAR) notes for Resident R260 revealed that Percocet was administered on April 22, 2025, at 6:45 p.m. There was no indication of onset and duration, location, severity, alleviating and aggravating factors, possible causes, and accompanying signs and symptoms, nor any indication of any non-pharmacological interventions attempted. Continued review of eMAR (electronic MAR) notes for Resident R260 revealed that Percocet was administered on April 23, 2025, at 3:53 p.m. There was no indication of onset and duration, location, severity, alleviating and aggravating factors, possible causes, and accompanying signs and symptoms, nor any indication of any non-pharmacological interventions attempted. Continued review of eMAR (electronic MAR) notes for Resident R260 revealed that Percocet was administered on April 24, 2025, at 12:39 p.m. and 6:41 p.m. There was no indication of onset and duration, location, severity, alleviating and aggravating factors, possible causes, and accompanying signs and symptoms, nor any indication of any non-pharmacological interventions attempted. Continued review of eMAR (electronic MAR) notes for Resident R260 revealed that Percocet was administered on April 25, 2025, at 1:53 p.m. There was no indication of onset and duration, location, severity, alleviating and aggravating factors, possible causes, and accompanying signs and symptoms, nor any indication of any non-pharmacological interventions attempted. Continued review of eMAR (electronic MAR) notes for Resident R260 revealed that Percocet was administered on April 26, 2025, at 7:32 p.m. There was no indication of onset and duration, location, severity, alleviating and aggravating factors, possible causes, and accompanying signs and symptoms, nor any indication of any non-pharmacological interventions attempted. Continued review of eMAR (electronic MAR) notes for Resident R260 revealed that Percocet was administered on April 27, 2025, at 9:03 p.m. There was no indication of onset and duration, location, severity, alleviating and aggravating factors, possible causes, and accompanying signs and symptoms, nor any indication of any non-pharmacological interventions attempted. Continued review of eMAR (electronic MAR) notes for Resident R260 revealed that Percocet was administered on April 28, 2025, at 6:24 p.m. There was no indication of onset and duration, location, severity, alleviating and aggravating factors, possible causes, and accompanying signs and symptoms, nor any indication of any non-pharmacological interventions attempted. Further review of eMAR (electronic MAR) notes for Resident R260 revealed that Percocet was administered on April 29, 2025, at 5:55 p.m. There was no indication of onset and duration, location, severity, alleviating and aggravating factors, possible causes, and accompanying signs and symptoms, nor any indication of any non-pharmacological interventions attempted. Interview on May 1, 2025, at 9:07 a.m. the Director of Nursing revealed that pain location as well as a pain scale for appropriate administration of medications, such as mild, moderate and severe pain with corresponding numeric values, should be included in the physician orders for pain medications and that physician orders should also include non-pharmacological interventions for pain. The Director of Nursing confirmed that Resident R260 orders for pain medications did not include any of the above pain medication standards of practice. 28 Pa Code 211.2(9) Medical Director 28 Pa Code 211.9(a)(1) Pharmacy services 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12 (d)(5) Nursing services

Based on clinical record review and interviews with staff, it was determined that the facility failed to maintain effective communication with a dialysis provider for two of two resident reviewed. (Residents R138, and R38) Findings include: Review of facility policy titled Care of Hemodialysis Resident revised January 28, 2025, revealed the facility will provide an ongoing assessment of residents' condition and will monitor for complication before and after each dialysis treatment. Continued review of this policy revealed that the facility will have an ongoing communication and collaboration with the dialysis facility. Review of Resident R138's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool) dated February 1, 2025, revealed that the resident reentered the facility on January 28, 2025, and had diagnoses' including kidney disease (nephropathy-the kidneys are damaged and cant filter waste, fluids, and toxins from the body), diabetes(chronic disease characterized by abnormal high levels of glucose), and malnutrition (the body does not receive enough nutrients to maintain health). Continued review revealed that the resident required medication insulin, antipsychotics diuretics. Resident 138 was dependent on dialysis (a life sustaining treatment used when the kidneys can no longer filter waste from the blood). On May 1, 2025, Resident R138's communication binder was requested, the binder that contains the resident's information and communication pages between the facility and the dialysis team. Facility staff was unable to be located the communication binder on the nursing unit. Interview with licensed nurse, Employee E25 on May 1, 2025 at 08:24 a.m. revealed that the communication binder was not available, cannot be found on the unit. The communication binder is usually kept with the residents, Employee E25 confirmed that Resident R138's communication binder was not with Resident 138. Review of Resident R38's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool) dated February 26, 2025, revealed that the resident was admitted to the facility on [DATE] , and had diagnoses including kidney failure (renal failure- when your kidneys no longer function), diabetes, and hypertension (high blood pressure). Continued review revealed that the resident required dialysis (a life sustaining treatment used when the kidneys can no longer filter waste from the blood). Review of Resident R38's communication binder on May 1, 2025, at 08:29 a.m. revealed that there was information that needed to be completed on every day of dialysis. The information needed is pretreatment, to be complete by facility nurse which includes resident vitals, medication, labs, any pertinent information signed and dated by facility unit nurse. Continued review revealed that the next part of the communication sheet was to be completed by the dialysis center nurse including any pertinent information, any labs, any medical concerns and to be signed and dated by the dialysis nurse. Further review of this document revealed the final part of communication to be completed by the facility unit nurse with information of post treatment vitals, and symptoms resident may be experiencing and to be signed and dated. Review of Resident 38's dialysis communication binder revealed that on the following days the pages were found to be incomplete, only the pre dialysis was completed with vitals and signature, the dialysis nurse did not complete the form, nor was the form completed after the resident returned to the facility of post dialysis evaluation on April 3, 2025; April 14, 2025; April 22, 2025; April 24, 2025 and April 29, 2025. Interview with Licensed nurse, Employee E25 confirmed the dialysis binder was incomplete with resident assessment information. Employee E25 described the protocol of a resident to leave for dialysis, the nurse will take vitals, document the dialysis communication binder and send the resident with the communication binder to transfer, when the resident returns, the nurse is then to assess the resident, take vitals and document the communication binder. 28 Pa. Code 211.(5)(f )Clinical records 28 Pa. Code code 211.12 (d)(1) Nursing services

Based on review of facility documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to maintain accurate documentation of arbitration agreements for five of six arbitration agreements reviewed (Residents R37, R122, R48, R136 and R410). Findings include: Binding Arbitration Agreements are agreements by which the parties agree to submit to arbitration (private process where disputing parties agree that another individual can make a decision about the dispute after receiving evidence and hearing arguments) to resolve disputes between them within a defined legal relationship. The decision is final and can be enforced by court. Review of facility documentation dated March 20, 2025, revealed a list of Residents who are currently residing in the facility that have entered into a binding arbitration agreement on or after 9/16/2019: Residents R150, R37, R122, R48, R136 and R410 were selected for review from the list. On May 1, 2025, at 10:30 a.m. arbitration agreements for Residents R150, R37, R122 and R410 were provided for review. The Nursing Home Administrator revealed that arbitration agreements for Residents R48 and R136 were not available because those residents did not have signed arbitration agreements. Review of arbitration agreements for Residents R37, R122 and R410 revealed that none of the agreements were dated and that all three had initials from the residents' family members in the signatures section of the agreement. The rest of the forms for Residents R37, R122 and R410 were blank/incomplete. Interview on May 1, 2025, at 10:20 a.m. Employee E3, assistant administrator, stated that the arbitration agreements for Residents R37, R122 and R410 were completed by her in person with the resident's family members present. Employee E3, assistant administrator, stated that Residents R37, R122 and R410's family members all agreed to the arbitration agreements. Employee E3, assistant administrator, confirmed that there were no dates or signatures on the forms and was unable to explain why the forms were not filled out properly. Interview on May 1, 2025, at 10:48 a.m. the Nursing Home Administrator stated that Residents R37, R122 and R410 did not have binding arbitration agreements with the facility. The Nursing Home Administrator stated that the provided list of residents who have entered into binding arbitration agreements with the facility was incorrect, that the facility's tracking system was wrong and that she needed to create a new list. Employee E3, assistant administrator, stated that she misspoke during her earlier interview and was unable to explain why she stated that she reviewed the arbitration agreements in person with Residents R37, R122 and R410's family members, that she said they agreed to the arbitration agreements and that now she did not know if they agreed to the arbitration agreements. The Nursing Home Administrator confirmed that it was unclear if the arbitration agreements for Residents R37, R122 and R410 were agreed to or not and that the forms were incomplete. 28 Pa Code 201.14(a) Responsibility of licensee

Based on review of facility policy, review of clinical records, and staff and family interviews, it was determined that the facility failed to ensure resident representatives had the opportunity to participate in the care planning process for one of 35 residents reviewed (Resident R31). Findings Include: Review of facility policy Care Conference revised June 20, 2023, revealed the purpose of the policy is to provide interdisciplinary communication with the resident and/or legal representative for purposes of the development of an individualized comprehensive plan of care. The resident and/or their representative will receive communication in advance of the scheduled care conference. Review of Resident R31's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 15, 2025, revealed the resident had diagnoses of dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), anxiety (intense, excessive, persistent worry or fear), and depression (mood disorder characterized by low mood, a feeling of sadness, and a general loss of interest in things). Continued review of the MDS revealed Resident R31 scored a 7 on the Brief Interview for Mental Status (BIMS - used to assess cognitive function) assessment, reflecting severe cognitive impairment. Review of Resident R31's comprehensive care plan revised April 8, 2025, revealed Resident R31 was alert and oriented x 1 (oriented to person) and was totally dependent on staff to anticipate her needs for socialization and activities involvement related, but not limited, to dementia, physical limitation, and hearing impairment. Interview on April 29, 2025, at 1:30 p.m. with Resident R31's representative revealed this individual had concerns regarding social stimulation/activities for Resident R31. Further interview revealed Resident R31's representative was not invited to participate in the care planning process and was subsequently not provided with a copy of Resident R31's comprehensive care plan. Review of Resident R31's clinical record revealed a care plan note dated January 3, 2025, that a care review was completed for Resident R31. The care plan note indicated that Resident R31 refused to participate and that Resident R31's daughter had been in to visit on January 2, 2025. Further review of Resident R31's care plan note dated January 3, 2025, revealed no documented evidence that Resident R31's representative was given advanced notice of the care plan meeting, was invited to participate, or was given a copy of Resident R31's care plan. Interview on May 1, 2025, at 9:35 a.m. with Social Services Director, Employee E26, confirmed there was no documented evidence that Resident R31's representative was invited to participate in the care plan meeting and further confirmed there was no documented evidence that Resident R31's representative was provided with a copy of the care plan. 28 Pa. Code 211.10 (a) Resident care policies.

Based on observations and staff interview, it was determined that the facility failed to maintain a clean and homelike environment in resident care areas and dining experience for one of four nursing units observed (Main Unit). Findings Include: Observations on April 28, 2025, at 11:08 a.m. revealed Resident R95's breakfast tray, with leftover food on the tray, was left on the windowsill in the dining room on the Main Unit. Continued observations in the dining room on the Main Unit revealed the railing on the wall was broken. Further observations on April 28, 2025, at 12:35 p.m. as resident's gathered in the dining room to have lunch on the Main Unit revealed Resident R95's breakfast tray was still left on the windowsill. Observations were confirmed by Registered Nurse, Employee E6. Observations on April 28, 2025, at 12:45 p.m. revealed broken floor tiles in the shower room on the Main Unit. Observations on April 28, 2025, at 12:49 p.m. in Resident R16's room revealed the wallpaper behind the bed was peeling, the privacy curtain was stained, and there was a brown substance splattered in the corner behind the bed where the baseboard and wall meets. Observations on April 28, 2025, at 1:39 p.m. revealed Resident R4's headboard was broken off and propped on the floor next to the resident's bed. Observations on April 29, 2025, at 12:42 p.m. revealed the first food truck with meal trays was delivered to the Main Unit. Observations revealed staff did not begin to set residents up for lunch (setting out place mats, applying clothing protectors) until 12:49 p.m. Continued observations revealed staff did not begin to pass lunch trays until 12:55 p.m., 13 minutes after lunch was delivered to the unit. Continued observations on April 29, 2025, at 12:55 p.m. revealed the floors were dirty with food items spilled from breakfast. Resident R150 was observed to be sitting barefoot in the dining room with scrambled eggs beneath her feet. Further observations on April 29, 2025, during the lunch time meal in the dining room on the Main Unit revealed residents were served individual milk cartons on the lunch trays. Nursing staff was observed to be pouring the contents of the milk cartons into small, plastic, disposable cups. Observations made during the lunch time meal service on April 29, 2025, were confirmed by Registered Nurse, Employee E6. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on review of facility policies, review of facility documentation, clinical record review and interviews with residents and staff, it was determined that the facility failed to ensure that residents were free from verbal abuse, for two of four residents reviewed for abuse (Residents R135 and R361). Findings include: Review of facility policy, Vulnerable Adult Abuse and Neglect Prevention dated revised February 25, 2025, revealed that abuse includes, Conduct which is not an accident or therapeutic conduct as defined in this section, which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to, the following . use of repeated or malicious oral, written, or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, use of repeated or malicious oral, written, or derogatory, humiliating, harassing, or threatening language. Review of Resident R135's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool) dated October 21, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), encephalopathy (damage or disease that affects the brain) and contractures (permanent shortening of a muscle or joint). Continued review revealed that the resident required substantial/maximal assistance with toileting hygiene, personal hygiene and rolling in bed. Further review revealed that the resident was occasionally incontinent of bowel and bladder. Interview on April 28, 2025, at 10:28 a.m. Resident R135 stated that he needs help with toileting and that staff used profanity towards him when he asked for help. Review of facility documentation submitted to the Pennsylvania Department of Health on December 16, 2024, revealed that a nurse aide went into Resident R135's room and that the resident and the staff member had a verbal altercation. The facility substantiated the verbal altercation as an allegation of abuse. Review of grievances revealed a grievance, filed by Resident R105, undated, which indicated that he witnessed that a staff member did not want to assist Resident R135 with continence care and that the staff member and Resident R135 used profanity towards each other. Review of facility documentation related to the incident revealed a witness statement, written by Resident R105, undated, which stated, 11-7 shift aide came in to change [Resident R135]. She told resident he was not wet. Resident said he knows his body and he was wet. I know when I'm wet (he said again). Aide showed resident his brief. That he was not wet. That's when the argument started. They was cussing at each other going back and forth. She said she was going to get her husband. Resident was gonna get his people (somebody). Using profanity to each other motherf***, kiss my ***, etc. The nurse came in afterwards. Said he wasn't wet. And resident got mad about that also. A lot of profanity going around. But staff member did use offensive words (cursing) at resident. Continued review of facility documentation related to the incident revealed a written statement from Resident R135, undated, which stated, On Monday December 16, 2024, around 4am he asked [Employee E12, nurse aide] to change his brief, she responded that it has already been changed. They had a verbal altercation with curse words and she threatened to get her husband to come to the facility. Continued review of facility documentation related to the incident revealed an interview witness statement from Resident R135, dated December 16, 2024, which stated, Resident stated that around 4am during the 11pm-7am shift, he was involved in a verbal altercation with [Employee E12, nurse aide] the nurse aide assigned to his room. Resident stated the when the nurse aide came into his room, she said 'I've already changed you 3 or 4 times.' The resident then told her that he knows when he has urinated and has a bowel movement and he needed to be changed again. He also said that sometimes he sweats a lot and need to be changed head to toe for that reason. According to the resident, the nurse aide checked him and stated, 'you're not wet.' The resident said that he told the nurse aide that he was wet and needed to be changed. The nurse aide then responded with 'you peed in the bed.' The resident went on to tell her that he did not urinate in the bed because he has a urinal that he uses. The resident stated that at that point, that is when the nurse aide started cursing at him and told him, 'I'm from South Philly' and 'I will get my man to beat your a**.' The resident then said that he replied with 'I don't care where you're from, but I am from North Philly and I will beat you and your man the f*** up.' There was some more back and forth arguing and cursing from both parties and eventually the nurse aide left. Interview on April 30, 205, at 11:22 a.m. Resident R105 stated that he remembered the incident that occurred on December 16, 2024. Resident R105 reviewed his grievance and written statement and confirmed these documents to be true as written. Resident R105 confirmed that he heard Employee E12, nurse aide, curse and threaten Resident R135. Interview on April 30, 2025, at 11:46 a.m. the Nursing Home Administrator confirmed that the allegation of verbal abuse by Employee E12, nurse aide, towards Resident R135, was substantiated based on Resident R105's statement and the resident is a credible witness. Continued interview revealed that Employee E12, nurse aide, was terminated from employment at the facility due to the substantiated allegation. Review of Resident R361's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool) dated February 12, 2025 , revealed that the resident was admitted to the facility on [DATE] , and had diagnoses including cerebrovascular accident( stroke , when blood flow to the brain is interrupted, leading to brain damage) heart failure (chronic condition when the heart does not pump enough blood to meet the body's needs) and depression (a mental health is what our characterized by persistently depressed mood or loss of interest and activities, causing significant impairment in daily life). Continued review revealed that the resident required minimal assistance with toileting hygiene, personal hygiene and rolling in bed. Further review revealed that the resident was occasionally incontinent of bowel. Resident R361 has a Bims (Brief interview of mental status) Score of 15 indicating intact cognition. Review of facility documentation submitted to the Pennsylvania Department of Health on April 25, 2025, revealed that a nurse aide went into Resident R361's, the resident asked the aide to help clean him, the aide refused with verbal altercation. The facility substantiated the verbal altercation as an allegation of abuse. Continued review of facility documentation related to the incident revealed an interview witness statement from Resident R361, dated April 20, 2025, which stated, I had a bm (bowel movement) accident. I asked my aide to help clean me up. She replied, I'm not wiping you're a**. Another aide overheard the comment, and she came in and cleaned me out I also informed the nurse of what happened. Interview on April 30, 2025, at 11:46 a.m. the Nursing Home Administrator confirmed that the allegation of verbal abuse by Employee E21, nurse aide, towards Resident R361, was substantiated. Continued interview revealed that Employee E21, nurse aide, was terminated from employment at the facility due to the substantiated allegation. 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.29(a)(c) Resident rights 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(c) Nursing services 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, review of clinical records, observations, and staff interview, it was determined that the facility failed to ensure residents were free from physical restraint for one of 34 residents reviewed (Resident R310). Findings Include: Review of facility policy Physical Restraints revealed physical restraints are only used when they are used appropriately to treat the resident's medical symptoms and to promote an optimal level of function for the resident. A restraint may never be used for the purpose of discipline or staff convenience. Per the facility policy, a physical restraint includes all devices and practices that restrict freedom of movement or normal access to one's body. Review of Resident R310's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated March 2, 2025, revealed the resident had severe cognitive impairment, had impairment in functional limitation in range of motion to the upper and lower extremities, and required substantial/maximal assistance with mobility to roll left and right. Further review of Resident R310's quarterly MDS dated [DATE], revealed the resident had diagnoses of dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), hemiplegia (weakness) or hemiparesis (paralysis), and difficulty in walking. Review of Resident R310's comprehensive care plan revised September 11, 2024, revealed the resident was at high risk for falls related to confusion and gait dysfunction. Observations on April 28, 2025, at 11:15 a.m. revealed Resident R310 was in bed with a wedge positioned under the sheets on the resident's right side and the left side of the bed was pushed up against the wall. Observations of Resident R310's positioning was confirmed on April 28, 2025, at 11:23 a.m. by Registered Nurse, Employee E6. Interview on April 28, 2025, at 11:23 a.m. with Registered Nurse, Employee E6, revealed the wedge was used to help position the resident and offload pressure from the sacrum. Further interview with Registered Nurse, Employee E6, confirmed Resident R310's bed should not have been pushed against the wall as it can act as a restraint. Review of Resident R310's entire clinical record revealed no documented evidence the resident had a physical restraint assessment or an order by the physician to push Resident R310's bed against the wall. 28 Pa. Code 211.10 (d) Resident care policies.

Based on review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated transfers to the hospital and that a resident's representative was made aware of a facility-initiated transfer in writing, for two of two clinical records reviewed. Resident R37 and Resident R119. Findings Include: Interview with Facility Administrator Employee E1 conducted on May 1, 2025 at 2:24pm revealed that the facility does not have a policy on discharge notification. Review of Resident R119's clinical record revealed that resident was admitted to the facility on [DATE], with diagnoses of but not limited to Cerebral Atherosclerosis, Poly-osteoarthritis. Further review of Resident R119's clinical record revealed that Resident R119 was transferred to a local hospital on February 9, 2025, and was readmitted to the facility on [DATE]. Review of Resident R37's clinical record revealed that resident was admitted to the facility on [DATE], with diagnoses of but not limited to cardiovascular disease, gastrostomy status. Further review of resident R37's clinical record revealed that Resident R37 was transferred to a local hospital on February 9, 2025, and was readmitted to the facility on [DATE]. Upon request, the facility was not able to produce a copy of a written notification to resident and the resident's representative(s) of Resident R37's transfer to the hospital and the reasons for the move in a language and manner they understand and proof that the facility sent a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. Interview with Employee E18 Medical Records Director conducted on April 1, 2025, at 11:03 a.m. revealed that the facility did not send a written notification to the resident and the resident's representative(s) of transfers or discharges and the reasons for the move. Employee E18 further revealed that she did not send letters to the Office of the State Long-Term Care Ombudsman. Interview with Employee E4 ADON (Assistant Director of Nursing) conducted on May 1, 2025, at 11:29 a.m. revealed she did not send letters to the family/resident representatives notifying them of transfers or discharges. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(2) Management

Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to develop a person-centered comprehensive care plan related to behaviors for one of 35 residents reviewed (Resident R135). Findings include: Review of facility policy, Care Plan - Baseline and Comprehensive dated revised June 20, 203, revealed that care plans will be developed to ensure that each resident receives care individualized to him or herself and that goals and approaches for care are communicated to all parties including caregivers, the resident, and the resident's representative. Review of Resident R135's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool) dated October 21, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures) and encephalopathy (damage or disease that affects the brain). Review of progress notes for Resident R135 revealed a behavior note, dated January 23, 2025, at 3:02 p.m. which indicated that the resident began yelling, screaming and using foul language. The note continued that the resident acted like he wanted to jump out of bed. Continued review of progress notes for Resident R135 revealed a psychiatric (mental health) provider note, dated January 27, 2025, at 8:58 a.m. for follow up on mood and behavior. The resident was reported to have increased anxiety and agitation. The mental health provider recommended to start Hydroxyzine three times per day for anxiety/agitation and to monitor the resident for increased anxiety. Continued review of progress notes for Resident R135 revealed a mood/behavior note, dated January 28, 2025, at 12:49 p.m. which indicated that the resident got upset with staff was using foul language and threatening to get everyone fired. The note continued that the resident and staff remained safe during the situation. Continued review of progress notes for Resident R135 revealed a behavior monitoring note, dated February 7, 2025, at 6:48 p.m. which indicated that the resident had multiple behaviors noted and was observed yelling obscenities. Review of nurse aide documentation of behavior monitoring from April 1, 2024, through April 30, 2025, for Resident R135 revealed the that resident exhibited behaviors on five days, and included attention seeking, screaming at others and yelling out. The documentation revealed that the resident's behaviors interfered with providing care to the resident and created a disruptive environment. Continued review revealed that on one of the days with behaviors, staff implemented an intervention of redirection and that the resident's behavior was unchanged despite the intervention. On three of the days when the resident exhibited behaviors, interventions were not implemented and were documented as not applicable. Review of Resident R135's care plan, dated April 17, 2025, revealed that no care plan was developed related the resident's behaviors and that no interventions for staff to use when the resident exhibits behaviors were developed. Interview on April 30, 2025, at 11:35 a.m. Employee E14, nurse aide, revealed that she frequently provides care to Resident R135 and that the resident cusses me out everyday. Employee E14, nurse aide, stated that she has to wait for the resident to calm down and reapproaches the resident at a later time to provide care. Interview on April 30, 2025, at 2:20 p.m. Employee E15, licensed nurse, confirmed that no care plan was developed for Resident R135 related to his behaviors. Continued interview confirmed that nurse aide documentation noted that the resident has ongoing behaviors and that no interventions in response to the resident's behaviors were implemented. 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 clinical records, observations, and staff interview, it was determined that the facility failed to timely provide feeding assistance for a dependent resident for one of 34 residents reviewed (Resident R78). Findings Include: Review of facility policy Activities of Daily Living (ADLs) revealed the facility will provide care and services for eating, assistance with feeding or preparation of meals. Based on the assessments, a personalized care plan is created and outlines the level of assistance needed for activities of daily living. Review of Resident R78's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated March 7, 2025, revealed the resident had severe cognitive impairment and required substantial/maximal (helper does more than half the effort) assistance with eating (the ability to bring food to mouth). Review of Resident R78's comprehensive care plan revised May 1, 2025, revealed the resident had an activities of daily living self-care performance deficit related to contractures to the left upper and lower extremities, communication deficit, and impaired mobility. Continued review of Resident R78's comprehensive care plan revised May 1, 2025, revealed the resident had potential for altered nutritional status related to need for assistance with eating. Observations on April 28, 2025, revealed food carts with the lunch trays were delivered from the kitchen to the Main Unit from 1:00 p.m. to 1:12 p.m. Interview on April 28, 2025, at 1:40 p.m. with nurse aide, Employee E30, confirmed Resident R78 required 1:1 feeding assistance and staff were just beginning to feed the resident at 1:40 p.m., 30-40 minutes after the lunch trays were delivered. Observations on April 29, 2025, revealed food carts with the lunch trays were delivered from the kitchen to the Main Unit from 12:45 p.m. to 1:00 p.m. Observations on April 29, 2025, at 1:34 p.m. revealed Resident R78 was in bed and the resident's lunch tray was placed on the tv stand across the room. Observations revealed the lunch tray was untouched at this time. Observations on April 29, 2025, at 1:50 p.m. revealed nursing staff just began to assist Resident R78 with eating, 50-60 minutes after the lunch trays were delivered. Observations on April 30, 2025, revealed food carts with the lunch trays were delivered from the kitchen to the Main Unit from 1:00 to 1:15 p.m. Interview on April 30, 2025, at 1:30 p.m. with nurse aide, Employee E30, revealed Resident R78 was still waiting to be fed. Further observations on April 30, 2025, at 1:57 p.m. revealed Resident R78 was in bed and was still waiting to be assisted with lunch. Interview on April 30, 2025, at 1:57 p.m. with Unit Manager, Employee E5, confirmed Resident R78 had still not yet been assisted with lunch. 28 Pa. Code 211.10 (d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility documents, review of clinical records, observations, and staff interviews, it was determined that the facility failed to implement both group and individual activities to meet the needs of each resident for 15 of 39 residents on the Main Nursing Unit (Resident R31, R78, R51, R71, R21, R142, R88, R4, R111, R133, R125, R131, R117, R64, and R150). Findings Include: Review of the April 2025 Activities Calendar revealed on April 29, 2025, Coffee & Chat was scheduled for 10:00 a.m. and Fun & Fit Exercise was scheduled for 11:15 a.m. on the Main Nursing Unit. Observations on April 29, 2025, at 9:45 a.m. revealed Resident R21, R88, R125, R64, and R131 were sitting in the dining room with no music and no television. These residents were observed to be sitting quietly with no stimulation. Follow up observations on April 29, 2025, at 11:45 a.m. revealed Residents R51, R71, R21, R142, R88, R4, R111, R133, R125, R131, R117, R64, and R150 were sitting in the dining room with only the television on and no stimulating/engaging activities. Interview on April 29, 2025, at 12:11 p.m. with nurse aide, Employee E31, revealed the Coffee & Chat activity scheduled for 10:00 a.m. consisted of just passing coffee out to the residents and leaving the room. Continued interview revealed the Fun & Fit Exercise was not held at 11:15 a.m. as scheduled on the activities calendar. Review of Resident R31's quarterly activities assessment dated [DATE], revealed the resident was totally dependent on staff to anticipate her needs for socialization and activities involvement related to dementia and physical limitations. Further review of the activities assessment revealed Resident R31 would benefit in having one to one beside activity for sensory stimulation. Review of Resident R78's quarterly activities assessment dated [DATE], revealed the resident was totally dependent on staff to anticipate all his needs related to dementia and physical limitations. Further review of the activities assessment revealed Resident R78 would benefit in having one to one bedside visit 2 times per week with staff from the activity department for 20-30 minutes, or as tolerated by the resident. Interview on May 1, 2025, at 12:26 p.m. with Activities Director, Employee E32, confirmed Resident R31 and R78 required one to one bedside visits for activity and sensory stimulation as the resident's are mostly bed bound and do not attend group activities. Review of one-to-one activity documentation provided by the Activities Director, Employee E32, revealed Resident R78 only had three documented one- to one bedside activity documented for the month of April 2024. There was no documented evidence that one- to- one beside activities were completed prior to April 2025. Continued review of one-to-one activity documentation provided by the Activities Director, Employee E32, revealed no documented one-to-one bedside activity for Resident R31 prior to March 2025. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on observations, review of facility policies, facility documentation and interviews with staff, it was determined the facility failed to ensure water temperatures in the central shower room and resident bathroom sinks were maintained at a safe temperature for one of four nursing units observed (TCU Nursing Unit). This failure placed residents on the TCU Nursing Unit at risk for serious injury from a burn and resulted in an Immediate Jeopardy situation. Findings include: Review of facility policy titled, Water Temps - Bathing dated February 1, 2025, revealed, It is the policy of this facility to provide a safe and comfortable temperature for residents during bathing and procedures to protect them from avoidable injury whenever possible. The facility will monitor domestic hot water temperatures prior to bathing/showering residents and testing will be conducted on a routine basis by the Maintenance Department. Domestic hot water ideally will be maintained at 105 degrees to 110 degrees Fahrenheit. Acceptable range is 100-110 degrees. Continued review of the facility policy, under subsection titled, Procedure revealed, Water temperature will be checked using the digital bath temperature reading prior to immersing a resident in water, using water from a shower, or using hot water for the purpose of bathing or soaking. Hot water temperatures exceeding 110 degrees Fahrenheit or less than 100 degrees Fahrenheit will be reported immediately to the Charge Nurse or designee. The Charge Nurse or designee will notify the Maintenance Department and communicate the situation to all unit staff. Signs should be posted in the affected areas, such as 'Caution-Hot Water' or 'Do Not Use-Hot Water', until the situation has been corrected. Observation of the TCU Nursing Unit, on March 5, 2025, at 10:45 a.m. with Employee E6, Maintenance Assistant, revealed hot water from the hand sink in the Central Shower Room was 121.2 degrees Fahrenheit and hot water from the shower stall was 121.1 degrees Fahrenheit. Employee E6, Maintenance Assistant, immediately left the TCU Nursing Unit to check the hot water tank in the boiler room. Observation conducted on March 5, 2025 at 10:50 a.m. revealed in room [ROOM NUMBER] on the TCU Nursing Unit, the hot water from the resident hand sink in the bathroom was 123.8 degrees Fahrenheit. Observation of the boiler room on March 5, 2025, at 10:53 a.m. with Employee E6, Maintenance Assistant, revealed the thermostat on the hot water tank that supplies water to the TCU Nursing Unit was set to 135 degrees Fahrenheit and the temperature of the water inside the hot water tank was 160 degrees Fahrenheit. Interview conducted at the time of the observation, with Employee E6, Maintenance Assistant, revealed when Employee E6 first came down to check the hot water tank, that the thermostat was set at 150 degrees Fahrenheit and he turned it down to 135 degrees Fahrenheit. Employee E6, Maintenance Assistant, stated that this hot water tank supplies hot water to all of the resident rooms, shower room, and care areas on the TCU Nursing Unit. Interview on March 5, 2025, at 11:14 a.m. Employee E8, agency nurse aide, revealed that she gave Resident R4 a shower in the TCU Central Shower Room that morning. Continued interview revealed that she did not use a thermometer to check the water temperature prior to giving the resident a shower. Further interview revealed that Employee E8, agency nurse aide, was unable to state what the safe water temperature range should be when bathing a resident. Interview on March 5, 2025, at 11:16 a.m. Employee E9, nurse aide, revealed that she gave Resident R5 a shower in the TCU Central Shower Room that morning. Continued interview revealed Employee E9 did not use a thermometer to check the water temperature prior to giving the resident a shower. Further interview revealed Employee E9, nurse aide, was unable to state what the safe water temperature range should be when bathing a resident. Interview on March 5, 2025, at 11:20 a.m. Employee E10, nurse aide, revealed that she gave Resident R6 a shower in the TCU Central Shower Room that morning. Employee E10, nurse aide, proceeded to enter the TCU Central Shower Room and provide a demonstration of how to use the thermometer in the shower stall. Employee E10, nurse aide, stated that she adjusted the water temperature for comfort and that she did not put the hot water on all the way, so she was unaware the hot water was excessively hot. Observation conducted at the time of the interview, revealed the hot water temperature reading from the shower stall in the TCU Central Shower Room was 122.3 degrees Fahrenheit. Further interview with Employee E10, nurse aide, revealed that she was assigned to work on the TCU Nursing Unit that shift. Employee E10, nurse aide, stated that four residents in her assignment, Residents R7, R8, R6 and R9, were able to independently use the hand sinks in their rooms. Interview on March 5, 2025, at 11:30 a.m. with Employee E11, nurse aide, revealed that she was assigned to work on the TCU Nursing Unit that shift. Continued interview revealed Employee E11 was unable to state what the safe water temperature range should be when bathing a resident. Further interview, Employee E11, nurse aide, stated that three residents in her assignment, Residents R10, R11 and R12, were able to independently use the hand sinks in their rooms. Based on the above findings, Immediate Jeopardy to the safety of the residents on the TCU Nursing Unit, was identified to the Nursing Home Administrator on March 5, 2025, at 1:18 p.m. for failure to ensure that safe hot water temperatures were maintained not to exceed 110 degrees Fahrenheit. The Nursing Home Administrator was provided with the Immediate Jeopardy Template (document which included information necessary to establish each of the key components of immediate jeopardy) and an immediate action plan was requested. On March 5, 2025, at 4:55 p.m. the facility provided the following corrective action plan: - At 11:52 a.m. the facility turned off the hot water valve to TCU unit when they were alerted about the high temperatures on TCU. - Adjustments were made after the system was flushed. Hot water maintained and did not exceed 110 degrees. The plumber who was onsite assisting with a different work order and was called to assess and make recommendations. - The facility checked the sink temperature in every room on the TCU after the hot water valve was turned back on. - There were no additional high temps identified. -The facility water temperature policy will be reviewed to ensure that safe processes for monitoring water temperatures have been fully developed. - 80% of employee list that were working on the day and evening shift were educated on the water temperature policy including acceptable water temperature ranges (100-110 degrees) and appropriate methods to check water temps. Methods include: - Water temperature will be checked using a thermometer reading prior to immersing a resident in water, using water from a shower, or using hot water for the purpose of bathing or soaking. - Hot water temperatures exceeding 110 degrees Fahrenheit or less than 100 degrees Fahrenheit will be reported immediately to the Charge Nurse or designee. - If the water feels excessively warm or out of range. - Regular maintenance checks to ensure the plumbing system is functioning properly and temperature limits are being adhered to. - Staff for future shift (11-7) will be educated at the beginning of shift. Additional 10% staff will be virtually educated to total of 100% staff education compliance by March 6, 2025. - The plumber is scheduled for a follow-up visit on March 6, 2025, proactively to ensure the adjustments that were made were effective. - The Maintenance staff or designee will complete temp audits hourly for the next 24 hours. The team will continue to monitor water temps daily until further direction of QAPI Committee. - A random sampling of employee interviews to ensure that they are knowledgeable on how to identify and respond to elevated water temperatures. Audits will occur daily until further direction of the QAPI Committee. - The Medical Director was updated on this Correction and Removal-Abatement Plan as well as occurrences of which this plan pertains. Monitoring will be initiated and completed by the Administrator and/or designee as indicated above. Any discrepancies identified during completion of these audits will be immediately addressed. All audits, reviews and interviews will be forwarded to the Center's QAPI (Quality Assurance Performance Improvement) Committee to identify patterns and trends of noncompliance and to determine if further action is necessary. Frequency of continued audits will be determined at that time. If issues are identified, re-education will be completed. If any trends are identified, systems will be assessed to determine effectiveness. A plan will be developed, and revision will be made as deemed necessary. Interviews conducted on March 5, 2025, between 2:06 p.m. and 2:46 p.m. with day shift nursing staff, and between 4:21 p.m. and 4:44 p.m. with evening shift nursing staff, verifying the implementation of the immediate action plan. Nursing staff were able to verbalize the facility's water policy, including that water temperatures should not exceed 110 degrees Fahrenheit, what to do if water temperatures were found to be too hot, and how to check water temperatures. The hot water on the TCU Nursing Unit at residents' hand sinks and in the Central Shower Room were tested and verified that they did not exceed 110 degrees Fahrenheit. Maintenance and Supervisory staff were observed checking water temperatures and completing audit logs. Water temperature logs were reviewed and revealed appropriate water temperatures. Following verification of the implementation of the immediate action plan, review of water temperature logs and review of staff education documentation, the Immediate Jeopardy was lifted on March 5, 2025, at 5:20 p.m. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.18(b)(3) Management 28 Pa Code 205.63(c) Plumbing and piping systems required for existing and new construction 28 Pa Code 211.12(d)(5) Nursing services

Based on observation, review of clinical record, review of facility policies, interview with staff and resident, it was determined the facility failed provide tracheostomy care consistent with professional standards of practice for one of one resident observed. This failure resulted in an Immediate Jeopardy situation for Resident R130 who was decannulated, experienced respiratory and emotional distress and potential death. (Resident R130) Findings include: Review facility, policy title Tracheostomy dated April 1, 2022, revealed that under section Policy Statement it was stated that it was the policy of the corporation to establish standards for the care and maintenance of tracheostomy tubes. Following these standards will assist in maintaining a patent airway, reduce the risk of this for nosocomial infection, and help to prevent excoriation, breakdown, and infection of surrounding skin. Under section Procedure Trach care is performed every shift (TID-three times a day) and as needed. Partial trach care does not include inner cannula changes. Inner cannulas are changed during trach care every night shift. #3. Daily trach care does not include trach tie changes unless needed. Trach ties are routinely changed every Tuesday (day shift) and Friday (night shift) and as needed. #5. e. Clean the top surface of the faceplate as necessary using sterile NSS (normal saline solution) and 4x4's, f. Remove the inner cannula, g. Place new sterile inner cannula into trach. h. place new drainage sponge under trach flanges. Review of the undated facility policy and procedure for Accidental Decannulation Responsestated under the section purpose: establish a standardized procedure for responding to accidental decannulation to ensure patient safety and effective management of the situation. Under section Scope: This policy applies to all healthcare professionals involved in the care of patients with tracheostomies within the facility. Under section Policy: Healthcare professionals must follow the outlined procedure to ensure the patient is stabilized and the tracheostomy tube is reinserted promptly and safely. Under section procedure. #1. Visualize Tracheal Stoma: Ensure the stoma is patent if the stoma has closed. All oxygen and other inhaled therapies must be delivered via mask to the nose and or mouth. #2 Determine Trach Tube Size: Establish if the same size or smaller trach tube must be inserted. #3. Stabilize Patient: Ensure the patient is stabilized from a respiratory standpoint. Administer oxygen ventilation via patent airway (stoma, mask, etcetera) if the patient is in distress. #4. Alert Additional Staff. Call for additional assistance from staff. #10. Insert Obturator: Remove the inner cannula from the trach tube and insert the obturator. #11 Apply Lubricating Gel: Apply water based lubricating gel to the tip of the obturator and distal end of the tracheostomy tube. #18 Accompany the Patient: Accompany that patient until stabilized, ensuring good oxygen saturation, respiratory rate, heart rate, and assessment of any respiratory or cardiovascular distress. Review the facilities tracheostomy care competency checklist reveal that The employee demonstrates skills and competence in the following: #1 physicians order is checked prior to beginning of treatment. #2 Privacy is provided to resident. #3. Explain procedure to resident even if unresponsive. #4 Perform hand hygiene. #5 Apply pulse oximetry and monitor as needed. Number six. Dawn face mask, gown and goggles and splashing is anticipated. #7 [NAME] sterile gloves. #8 Suction inner cannula. #9 Remove. Oxygen source #12. Remove and dispose gloves. #14 Perform hand hygiene. #15 Don's sterile gloves. #16 Clean stoma site and face plate, swivel neck plate of outer cannula with cotton tip applicator and sterile gauze 4X4's moistened with normal saline. Using each applicator once moving from the stoma outward. Disposable inner cannulas should not be cleaned and reused as per manufacturer's recommendations. Disposable inner cannulas should be replaced every shift with tracheostomy care. Review of Resident R130's clinical record revealed that Resident R130 was admitted to the facility on [DATE], with diagnoses of Cerebral Infarction due to unspecified occlusion or stenosis of the left middle cerebral artery, Cognitive Communication Deficit, Hemiplegia and Hemiparesis (weakness to one side of the body) following Cerebral Infarction (stroke) affecting right dominant side, aphasia (disorder that affects communication) following cerebral infarction, Chronic respiratory failure with hypoxia (low oxygen), chronic respiratory failure with hypercapnia (elevated carbon dioxide levels), chronic obstructive pulmonary disease (process that causes decreased ability of the lungs to perform), obesity and tracheostomy (tube inserted through the neck to assist breathing) status. Review of Resident R130's quarterly Minimum Data Set (MDS- assessment of resident's care needs) dated May 3, 2024, section C0500 BIMS (Brief interview for mental status) revealed that Resident R130 scored 12 which indicated that Resident R130 was moderately impaired in cognition. Review of section O (Special treatments and procedures) 0110, C1(oxygen), D1(suctioning), E1(tracheostomy care) confirmed that Resident R1 received oxygen, was suctioned, and received tracheostomy care. Review of Section G (ADL-activities of daily living) reveled that Resident R130 required extensive assistance in bed mobility and transfer and required supervision with eating. Review of Resident R130's February 2024 physician's order revealed an order obtained February 6, 2024 for Shiley#8 (a tracheostomy tube) IC85 cuffed DIC (disposable inner cannula) obtained on March 28, 2024, order for Trach care daily and PRN (as needed), remove and dispose of inner cannula. Replace with new inner cannula every day shift for reduce risk of infection and as needed. Continued review of physician's orders revealed an order obtained on February 8, 2024 to change O2 (oxygen) and trach tubing weekly every night shift every Wednesday and to check and change trach ties during 11-7 shift on Monday and Thursday, every night shift. Further review of Resident R130's physician orders revealed an order for the following respiratory treatments: Pulmicort Suspension 0.5 MG/2ML (Budesonide) 3 ml (milliliters) inhale orally via nebulizer every 12 hours for SOB (shortness of breath) supplementary. Documentation Codes: Pre and Post Tx (treatment) Lung Sounds C = Clear O = Other (see progress note) Pre and Post Tx - P, R and O2 Sat results MNS -Rinse and expectorate after each use -Start Date-June 12, 2024. Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML1 application inhale orally every 6 hours for SOB-Start Date-February 7, 2024. Acetylcysteine Inhalation Solution 20 % (Acetylcysteine) 4 ml via trach every 6 hours as needed for SOB-Start Date-February 6, 2024. Tracheostomy care observation conducted on June 25, 2024, at 12:36 p.m. with Licensed nurse, Employee E14 and Unit Manager, Employee E15, with Resident R130's husband in the room, revealed that Employee E14 started to set-up the tracheostomy care supplies on top of Resident R130's overbed table. After setting up the overbed table with the tracheostomy care supplies, Employee E14, proceeded to remove the gauze from around Resident R130's stoma. Employee E14 then proceeded to untie the tracheostomy tie from the flange, discarded the trach tie and proceeded to remove the entire tracheostomy tube out. Employee E14 proceeded to remove the inner cannula from the tracheostomy tube and place the tracheostomy tube on a gauze on top of the overbed table. Employee E14 proceeded to wipe off secretions from the inner cannula. Nurse Manager Employee E15 was talking to Resident R130's husband who was standing close to the door. Further observation revealed that the privacy curtain was not drawn and Resident R130 was visible from where the husband and Nurse Manager, Employee E15 were standing. Observation of Resident R130 after she was decannulated revealed that Resident R130 started to slowly raise her hand started waving while looking towards the Employee E14, then towards Employee E15 and to the observing surveyor. Resident R130 then started to frantically waive her hand and repeatedly hit her chest with her hand, started to flail her hand around and started to appear in distress. The resident's face was in a panic state, eyes wide open and started mouth something. Further Resident R130's started to become flushed. (Resident R130 could not make any vocal sounds). Surveyor then informed Licensed nurse, Employee E14 and Nurse Manager, Employee E15 that Resident R130 looked like she was not able to breathe. Nurse Manager, Employee E15 asked Resident R130 if she was OK and if she could breathe. The resident shook her head and continued to flail her hands around. Nurse manager, Employee E15 then instructed Licensed nurse, Employee E14 to re-insert the tracheostomy tube. Licensed nurse, Employee E14 then picked up the trach tube and said: I have to clean this first. Nurse Manager, Employee E15 instructed Licensed nurse, Employee E14 again to insert tracheostomy tube back. Licensed nurse, Employee E14 then proceeded to re-insert the trach tube into the stoma. Further observation revealed that the tracheostomy tube was re-inserted without using an obturator, but Licensed nurse, Employee E14 was able to successfully re-insert the tracheostomy tube. Immediately after the tracheostomy tube was re-inserted into the stoma, Resident R130 started coughing violently. Resident R130 started to slowly calm down and stopped flailing her hands around after the tube was re-inserted but continued to cough for several minutes. Licensed nurse, Employee E14 then suctioned Resident R130 and wiped off copious secretions coming from the trach. Licensed nurse, Employee E14 then started preparing a respiratory treatment for Resident R130's, administered Resident R130's respiratory treatment via nebulizer without changing her gloves. Further, Licensed nurse, Employee E14 was then observed rummaging through Resident R130's drawers without changing her gloves. Interview with Licensed nurse, Employee E14 revealed that she was looking for tracheostomy tie. Licensed nurse, Employee E14 eventually found the tracheostomy tie and secured the tracheostomy tube. Licensed nurse, Employee E14, then adjusted Resident R130's bed by pressing on the panel at the foot of the bed without changing her gloves. Licensed nurse, Employee E14 then changed the gloves and continued to clean the inner cannula with a wet gauze and re-inserted the inner cannula. Interview conducted at the time of the observation with Licensed nurse, Employee E14 revealed that this was not the first time she performed a trach care and that she was just nervous and does not like to be watched which caused her to make the mistakes. Interview with Director of Nursing, Employee E2 conducted on June 25, 2024, at 2:05 p.m. revealed that only the Respiratory Therapist and the Pulmonologist can remove the tracheostomy tube and that Licensed nurse, Employee E14 was only supposed to clean the outside of the trach and change the dressing and should not have removed the tracheostomy tube. Further, Licensed nurse, Employee E14 revealed that Resident R130's inner cannula was disposable and should have been discarded and replaced with a new one instead of being re-inserted. Interview with Resident R130 conducted on June 27, 2024, at 11:12 a.m. revealed that resident did not have a Passy Muir (speaking valve) on and was not able to speak. When asked where the Passy Muir was, she shook her head and pointed at her trach. When asked if she remembered what happened the day before, Resident R130 nodded her head. When asked if she was scared, Resident R130 nodded her head. Follow-up interview with Resident R130 conducted on June 27, 2024, at 11:32 a.m. with Speech therapist, Employee E23 confirmed that Resident R130 did not have her Passy Muir on, and that resident was not able to produce a vocal sound and not able to speak. Observation of Resident R130's bedside tabletop drawer revealed an unopened plastic containing a Passy Muir. Resident R130 was asked if she remembered what happened the other day, she nodded, when asked if she was scared during the incident the other day resident nodded. Based on the above findings an Immediate Jeopardy situation was identified to the Nursing Home Administrator on July 3, 2024 at 11:08 a.m. for the failure of the faciltiy to provide tracheostomy care to a resident in accordance with professional standards of practice. This failure resulted in Resident R130 being decannulated and experiencing respiratory and emotional distress An Immediate Jeopardy template was provided to the Nursing Home Administrator. The facility developed the following approved action plan: -The tracheostomy appliance was reinserted on June 25, 2024. Resident was assessed by Nurse Practitioner and Pulmonologist on June 25, 2024. Resident was stable with no physical distress noted. - Employee involved in the incident was suspended pending investigation on June 25, 2024. -Current residents with tracheostomy care needs were assessed on June 25, 2024, to ensure equipment was present and tracheostomy was in place and stable. -In service was initiated on June 25, 2024, with licensed staff in the building and is ongoing. Facility is at 84%. 100% staff educated will be completed on July 3, 2024. -The facility has been conducting 5 weekly observations of tracheostomy care being completed. Facility will review during facility's monthly QAPI (quality assurance performance improvement). Facility conducted observations of five residents on June 25, 2024, with no negative findings noted. Facility conducted observations of five residents on June 27, 2024 with no negative findings noted. Facility conducted observations of five residents on July 1, 2024, with no negative findings noted. -Facility Policy titled Tracheostomy Care was reviewed and revised on July 3, 2024. Review of the facility documentation revealed the facility's action plan was immediately initiated, observation of tracheostomy care on three residents with tracheostomy (Residents R5, R81, R167) revealed that the physician's orders were followed, and tracheostomy care was performed according to standard of practice. Interview with nine day shift nursing staff and five evening shift nursing staff conducted on July 3, 2024, from 2:52 p.m. to 4:10 p.m. to assess staff knowledge on tracheostomy care and responses to an emergency decannulation revealed that all fourteen staff interviewed were knowledgeable on tracheostomy care, responses to an emergency decannulation. Immediate Jeopardy was lifted on July 3, 2024, at 4:20 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 PA. Code 210.18(1) Management 28 Pa. 211.10 (c)(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on observation, review of clinical record, review of facility documentation, review of facility policies and interviews with resident and staff, it was determined that the facility failed to ensure that residents were free from neglect during provision of care for one of nine residents reviewed. (Resident R1). This failure resulted in actual harm to Resident R1, who sustained a fall resulting in actual harm, transfer to the hospital and was diagnosed with a left femur fracture. (Resident R1) Findings Include: Review of the facility's policy titled Abuse revised October 24, 2022, revealed that abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychological well-being. Instances of abuse of all residents, irrespective of any mental or physical condition cause physical harm, pain or mental anguish. Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, including Muscle Wasting and Atrophy (the decrease in size and wasting of muscle tissue), Post-Traumatic Hydrocephalus (a serious complication that follows a traumatic brain injury), History of Falling, and Idiopathic Neuropathy (Nerve damage interferes with the functioning of the peripheral nervous system; when the cause cannot be determined, it is called idiopathic neuropathy). A review of the Comprehensive Minimum Data Set ( MDS-a periodic review of a resident's assessment and care needs), dated September 3, 2023, revealed a BIMS (Brief Interview for Mental Status- a brief screening tool that aids in detecting cognitive impairment) Score of 15, indicating that Resident R1's cognition was intact. Further review of the MDS revealed that R1 needed two persons' physical assistance with staff for transfer to move between surfaces including to and from bed, chair, wheelchair, and some aspects of toilet use. A review of R1's care plan, revised on September 7, 2023, revealed that Resident R1 had limited physical mobility, and that Resident R1 needed two person assist via Hoyer Lift (mechanical device that is utilize to move a person from one surface to another). Review of information submitted to the Department of Health on October 19, 2023, revealed that Resident R1 was lowered to the floor while transferring into the shower chair. Residents stated her left leg twisted and she heard a pop as she was being assisted into the chair .Resident was assessed; pain identified to left lower extremity. 911(Emergency Medical Services) was called and resident was taken to ED (Emergency Department) where she was diagnosed with a left femur fracture. Interview on October 30, 2023, at 11:14 a.m., Resident R1 stated that on October 17, 2023, she was assisted by one nurse aide to the shower chair, and she was placed at the tip of the chair, then she tipped to the floor and fell . Review of Resident R1's nursing notes completed by Employee E7, a Registered Nurse, dated October 17, 2023, indicated as follows: At 17:25 (5:25 p.m.), my attention was called to this resident room regarding incident. On arrival, resident met lying in bed in semi [NAME] position but appears to be in pain/discomfort. On inquiry, resident verbalized, 'I fell while being transferred from wheelchair to shower chair in the shower room while about taking shower, my left knee twisted and heard a pop, it's no one's fault, I'm in pain, I want to go to the hospital'; transfer was being carried out by a Certified Nursing Assistant (CNA) with a sit to stand Hoyer. On assessment, pain 10/10, resident denied hitting her head, no skin alteration noted, left knee appear swollen. Vital signs Within Normal limits. 911 called. MD made aware, Responsible Party self. Resident transferred to ER (emergency room ). Review of witness statement dated October 17, 2023, by a Nurse Aide, Employee E8, on October 17, 2023, revealed that Employee E8 was transferring Resident R1 to the shower chair in the shower room was with another aide. The Patient in the shower room. The other aide got a call about her patient needing help. I felt I was okay to finish helping the patient [Resident R1] transfer. So, I told her (the other CNA), it was okay and that I would be fine. When I continued to transfer the patient [Resident R1], the shower chair tilted, and the patient was in an awkward position. So, I called for help from a nurse aide, and he came into help get her [Resident R1] upright, and more comfortable, but the lift had her leg struck, and she [Resident R1] complained that her knee hurt. Then we called for more assistance and the Nurse came in along with another staff member. Review of witness statement dated October 17, 2023, by Employee E9, Nurse aide, indicated as follows: I was standing at the door of the shower room and asked if the CNA needed help; the CNA said 'No, I don't'. Interview conducted with Nurse aide, Employee E9, on October 30, 2023, at 12:34 p.m., revealed the same information: I was standing at the door of the shower room and asked if the CNA needed help; the CNA said 'No, I don't'; and that she did not witness the fall. Review of witness statement dated October 17, 2023, by Nurse aide, Employee E10, revealed My coworker called me for help, to get [Resident R1] off the floor in the shower room. My coworker and charge nurse assisted with the transfer to the wheelchair to the room. Review of hospital records of Resident R1, dated October 19, 2023, indicated an X-ray result of medially displaced angulated comminuted left femoral distal shaft fracture. Review of Medical Practitioner's note, dated October 29, 2023, indicated [Resident R1] was admitted to hospital status post fall, had a closed comminuted intertrochanteric fracture of left femur. Underwent left femur fracture repair. An interview with the Director of Nursing on October 30, 2023, at 2:20 p.m., confirmed that the facility failed to provide adequate supervision and assistance to prevent fall to Resident R1. The facility failed to ensure a resident was free from neglect during the provision of care by transferring the resident from the wheelchair to the shower chair with the assistance of one staff. This failure resulted in actual harm to Resident R1 who sustained a fall resulting in actual harm, transfer to the hospital and was diagnosed with a left femur fracture. (Resident R1) 28 Pa Code 211.10(d) Patient care policies 28 Pa Code 211.12 (c) Nursing Services 28 Pa Code 211.12 (d)(3) Nursing Services 28 Pa Code 211.12 (d)(5) Nursing Services

Based on observations, clinical record review, and interviews with residents and staff, it was determined that the facility failed to provide adequate supervision to prevent accident hazards for one of nine residents reviewed (Resident R1) who sustained a fall resulting in actual harm, transfer to the hospital and diagnosed with a left femur fracture. (Resident R1) Findings Include: Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, including Muscle Wasting and Atrophy (the decrease in size and wasting of muscle tissue), Post-Traumatic Hydrocephalus (a serious complication that follows a traumatic brain injury), History of Falling, and Idiopathic Neuropathy (Nerve damage interferes with the functioning of the peripheral nervous system; when the cause cannot be determined, it is called idiopathic neuropathy). A review of the Comprehensive Minimum Data Set ( MDS-a periodic review of a resident's assessment and care needs), dated September 3, 2023, revealed a BIMS (Brief Interview for Mental Status- a brief screening tool that aids in detecting cognitive impairment) Score of 15, indicating that Resident R1's cognition was intact. Further review of the MDS revealed that R1 needed two persons' physical assistance with staff for transfer to move between surfaces including to and from bed, chair, wheelchair, and some aspects of toilet use. A review of R1's care plan, revised on September 7, 2023, revealed that R1 had limited physical mobility, and that Resident R1 needed two person assist via Hoyer Lift. Interview on October 30, 2023, at 11:14 a.m., Resident R1 stated that on October 17, 2023, she was assisted by one nurse aide to the shower chair, and she was placed at the tip of the chair, then she tipped to the floor and fell . Review of Resident R1's nursing notes completed by Employee E7, a Registered Nurse, dated October 17, 2023, indicated as follows: At 17:25 (5:25 p.m.), my attention was called to this resident room regarding incident. On arrival, resident met lying in bed in semi [NAME] position but appears to be in pain/discomfort. On inquiry, resident verbalized, 'I fell while being transferred from wheelchair to shower chair in the shower room while about taking shower, my left knee twisted and heard a pop, it's no one's fault, I'm in pain, I want to go to the hospital'; transfer was being carried out by a Certified Nursing Assistant (CNA) with a sit to stand Hoyer. On assessment, pain 10/10, resident denied hitting her head, no skin alteration noted, left knee appear swollen. Vital signs Within Normal limits. 911 called. MD made aware, Responsible Party self. Resident transferred to ER (emergency room ). Review of witness statement, dated October 17, 2023, by a Nurse Aide, Employee E8, on October 17, 2023, revealed that Employee E8 was transferring Resident R1 to the shower chair in the shower room was with another aide. The Patient in the shower room. The other aide got a call about her patient needing help. I felt I was okay to finish helping the patient [Resident R1] transfer. So, I told her (the other CNA), it was okay and that I would be fine. When I continued to transfer the patient [Resident R1], the shower chair tilted, and the patient was in an awkward position. So, I called for help from a nurse aide, and he came into help get her [Resident R1] upright, and more comfortable, but the lift had her leg struck, and she [Resident R1] complained that her knee hurt. Then we called for more assistance and the Nurse came in along with another staff member. Review of witness statement dated October 17, 2023, by Employee E9, Nurse aide, indicated as follows: I was standing at the door of the shower room and asked if the CNA needed help; the CNA said 'No, I don't'. Interview conducted with Nurse aide, Employee E9, on October 30, 2023, at 12:34 p.m., revealed the same information: I was standing at the door of the shower room and asked if the CNA needed help; the CNA said 'No, I don't'; and that she did not witness the fall. Review of witness statement dated October 17, 2023, by Nurse aide, Employee E10, revealed My coworker called me for help, to get [Resident R1] off the floor in the shower room. My coworker and charge nurse assisted with the transfer to the wheelchair to the room. Review of hospital records of Resident R1, dated October 19, 2023, indicated an X-ray result of medially displaced angulated comminuted left femoral distal shaft fracture. Review of Medical Practitioner's note, dated October 29, 2023, indicated [Resident R1] was admitted to hospital status post fall, had a closed comminuted intertrochanteric fracture of left femur. Underwent left femur fracture repair. An interview with the Director of Nursing on October 30, 2023, at 2:20 p.m., confirmed that the facility failed to provide adequate supervision and assistance to prevent fall to Resident R1. The facility failed to provide adequate supervision for one resident who sustained a fall that resulted in the left femur fracture. 28 Pa Code 211.10(d) Patient care policies 28 Pa Code 211.12 (c) Nursing Services 28 Pa Code 211.12 (d)(3) Nursing Services 28 Pa Code 211.12 (d)(5) Nursing Services

Based on review of clinical records, facility documentation, facility Policy and Procedures and interviews with residents and facility staff, it was determined that the facility failed to ensure a safe transfer, provide timely appropriate assessments and supervision for the resident with a change in condition, resulting in actual harm to one of two residents reviewed. (Resident: Cl 1). Findings include: Clinical record review of Resident Cl 1 revealed [DIAGNOSES REDACTED]. The quarterly resident assessment dated [DATE], indicated that the resident was alert, oriented, received extensive assistance with activities of daily living and required a two person assist with transfers with use of a mechanical lift. A review of facility documentation for December 28, 2013 revealed that Employee E4, nursing assistant, initially transferred Resident Cl 1, to the bathroom via Hoyer lift by herself . When the resident was ready to return to bed, Employee E4 requested Employee E2, licensed nurse, to assist with Resident Cl 1, with the Hoyer Lift, when the resident became very weak, uncooperative and had difficulty with utilizing the Hoyer Lift. The nursing assistant obtained the "Sit to Stand Lift". A second nursing assistant, Employee E6, was requested to assist with the transfer at the bedside and observed that the resident was not correctly positioned on the "Sit to Stand Lift"." Employee E6 reported that" the resident's arms were up, the straps were barely under her arms and the resident was slumped over". However, the resident was returned in that condition. A short time later, Employee E6, heard several screams on that wing, but could not determine where the noise came from and went back to her assignment. A further review of facility documentation for December 28, 2013, revealed that later in the shift, nursing assistant, Employee E6, was told by the resident that it was her that screamed out. A review of facility documentation for December 29, 2013, indicated that during an interview with Employee E4, it was revealed that the son had informed the CNA that his Mother had hit her leg on December 28, 2014 and wanted a report for it. Another review of facility documentation for December 28, 2013, revealed a statement from Employee E8, licensed nurse, that Resident Cl 1 reported to the nurse that she hit her leg on the wall while exiting the bathroom about a week ago around lunch time. The resident reported that the leg hurt but she "beared it". Nursing documentation from December 28, 2013 until January 11, 2014 revealed that Resident Cl 1 had informed facility staff of ongoing pain concerns. The combination of pain medication adjustment, treatment for [REDACTED]. At that point, the physician ordered an X-ray on January 10, 2014, which determined that the resident sustained [REDACTED]. Interview with the Administrator, Asst. NHA and the Director of Nursing, on May 9, 2014, at 2:00 p.m., confirmed that facility staff failed to transfer the resident safely, failed to address the concerns that the resident had voiced to them regarding hitting her legs during the transfer, that resulted in a delay into the facility investigation and treatment for [REDACTED]. The facility failed to ensure that facility staff followed the facility Policy and Procedure related to transfer of residents guidelines dated March 20, 2010, by providing a two person assistance for a safe transfer. Interview with the Administrator, on May 9, 2014, confirmed that Employee E4 did not request another CNA to assist her with the initial transfer and placed this resident at risk for injury. The facility failed to adequately identify, correctly assess and consistently monitor this medically compromised resident's concerns causing a delay in treatment for [REDACTED]. Interview with the Administrator, Asst. NHA and the Director of Nursing, on May 9, 2014, at 2:30 p.m., confirmed that facility staff did not address the resident's concerns related to hitting her leg and caused a delay in initiating a complete investigation. 483.13(c) Staff treatment of [REDACTED]. 28 Pa. Code 201.18(a)(b)(1)( Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on interviews with administrative staff, a review of the facility's accident investigation policies and procedures, and hospital and clinical record reviews, it was determined that the facility failed to complete investigations to evaluate the circumstances surrounding the cause of two falls, complete assessments following the falls, and implement interventions to reduce the risk for further falls, for one of two residents reviewed. This lack of assessment and care planning to prevent accidents and injury resulted in actual harm for Resident R1. Findings include: The comprehensive assessment dated [DATE], for Resident R1, indicated that this resident was admitted to the facility on [DATE]. The assessment indicated that this resident was cognitively intact, required extensive assistance of one person for transfers from the bed to the chair, the wheelchair or a standing position. The assessment also indicated that this resident required the use of an assistive device for walking balance. Resident R1's medical [DIAGNOSES REDACTED]. Review of the facility accident investigation form dated November 1, 2012, indicated that this resident left the facility at 10:30 a.m., with the contracted transport company driver. Instead of taking Resident R1 directly to his dialysis treatment center, the driver of the ambulance stopped at a convenience store and allowed the resident to leave the ambulance. While walking outside the store, the resident tripped and fell to the ground. The ambulance driver did not notify the facility or the dialysis unit about the fall. The resident's lower lip was lacerated and appeared bloody. The blood was discovered by the dialysis staff, as the resident was leaving the dialysis unit at 5:00 p.m., to return to the facility. At this time Resident R1 reported to the dialysis staff that he, "fell at Seven Eleven with his ambulance driver." The facility was notified of the fall and injury by the dialysis center staff. The facility administrative staff failed to complete an investigation of the incident which occurred on November 1, 2012, and did not implement measures to prevent further falls with injury for Resident R1. This was confirmed during an interview with the Nursing Home Administrator at 9:30 a.m. on November 7, 2012. On November 2, 2012, at 8:33 a.m., nursing progress notes indicated that Resident R1, "had another fall this morning and was confused." There was no documentation to indicate that the physician had been notified of the resident's fall and neurological change in condition. There was no descriptive information available for review about how the resident fell . There was no documentation to indicate that nursing staff were assessing and monitoring Resident R1 after the fall. The lack of clinical documentation, assessment and monitoring of Resident R1 on November 2, 2012, was confirmed during an interview with the Director of Nursing at 11:15 a.m., on November 7, 2012. An interview with the Director of Nursing on November 7, 2012, at 12:30 p.m., revealed that Resident R1 fell on [DATE], during the 11-7 tour of duty at approximately 7:00 a.m. The Director of Nursing reported that she was given this information during a telephone conversation with a licensed nursing staff member, caring for Resident R1 on the 11-7 tour of duty, who reported this information at 12:00 noon on November 7, 2012. Three hours later at 10:00 a.m. on November 2, 2012, Resident R1 was experiencing shortness of breath, was unresponsive and had an elevated blood pressure. The physician was notified at this time and directed the staff to send the resident to the hospital emergency room for further evaluation. A review of the hospital records revealed that resident R1 was admitted to the hospital at 10:38 a.m. on November 2, 2012. The resident was diagnosed with [REDACTED]. Interview with the Nursing Home Administrator and Director of Nursing revealed that nursing staff failed to complete an investigation report. The Nursing Home Administrator and Director of Nursing were unaware of exactly what had happened on November 1, 2012, or the morning of November 2, 2012, since the facility had not completed either accident investigations. Interviews with administrative staff on November 7, 2012, at 11:30 a.m., revealed that they were trying to contact the 11-7 Unit Manager to obtain information about Resident R1's fall. The facility failed to conduct a complete investigation of the fall that occurred on November 1, 2012. Nursing staff did not assess "what happened" when Resident R1, fell prior to dialysis treatment on November 1, 2012. In addition, the facility failed to complete an investigation into a subsequent fall for Resident R1 on November 2, 2012. A review of the facility policies and procedures for investigation of resident incidents dated March 2011, indicates that the facility is responsible for conducting an investigation which is to include witness statements, critical information that included the date, the time and the place of the fall, and conclusions and recommendations to safeguard residents. The facility's administrative staff did not follow their established policies and procedures for investigation of resident incidents. 28 Pa. Code 201.18(b)(1) Management. Previously cited 09/27/11, 10/02/12. 28 Pa. Code 201.18(e)(1) Management. Previously cited 09/21/12. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 10/02/12. 28 Pa. Code 211.12(c) Nursing services. Previously cited 09/27/11. 28 Pa. Code 211.12(d)(1) Nursing services. previously cited 9/27/11, 1/18/12, 10/02/12 28 Pa. Code 211.12(d)(3)(5) Nursing services. previously cited 9/27/11, 01/18/12, 09/21/12, 10/02/12.

Based on observation, review of clinical documentation, and interviews with staff, it was determined that the facility failed to adequately assess, monitor, implement, and revise appropriate interventions to prevent decline in skin integrity, for three of 30 residents, reviewed resulting in actual harm (Residents R119, R118 and R17). Findings include: Review of Resident R119's clinical record revealed nursing documentation that the resident was admitted to the facility from the hospital on July 31, 2012, with a portion of the resident's right-side skull bone removed from a right [MEDICAL CONDITION] (bleeding in the brain). The resident additionally was nonverbal and had a [MEDICAL CONDITION] (tube inserted through the neck to assist breathing) and feeding tube. Review of the admission Minimum Data Set (MDS - periodic assessment of needs) dated August 7, 2012, revealed that the resident was severely cognitively impaired in decision making, was totally dependent on staff for personal hygiene and bathing, required total assistance of two or more-person assistance from staff for transfers, and was non-ambulatory. Review of the resident's plan of care, initiated on August 2, 2012, revealed that the resident was at risk to develop an alteration in skin integrity, and included interventions such as diet, nutritional supplements, and laboratory studies. Review of a Patient Admission/Readmission Screen, dated August 1, 2012, at 1:05 a.m., for Resident R119 revealed no documentation of skin breakdown or skin alteration on the sacral (lower back) or buttock area. Review of a nursing progress note, dated August 2, 2012, at 10:11 p.m., revealed that the resident was seen by a member of the wound team, and that Resident R119's skin was intact, but was a high risk for/potential for skin breakdown related to incontinence of bowel and bladder, unresponsiveness, and immobility. Review of a Skin Alteration Record for Resident R119 revealed that on September 5, 2012, an open area was documented on the resident's buttock/sacral area, measuring 3.0 cm (centimeters) long by 2.5 cm wide, described as pale, pink tissue with a scant amount of serous (clear) fluid draining from the wound. The skin surrounding the wound was described as reddened and macerated (skin softening related to fluid). Review of nursing documentation revealed that on September 6, 2012, Resident R119 was seen by a wound team member and was found to have an open area on the sacrum, measuring 2.8 cm by 3.0 cm, and was noted with 20% slough (separation of dead tissue from living tissue) with scant amount of drainage. Review of a Nutrition assessment dated [DATE], revealed that the resident required increased protein needs due to history of skin alteration on the sacrum and bilateral (both sides) lower extremities, and that the resident's potassium level on September 11, 2012, was moderately low. The nutritional assessment did not include or recommend interventions of dietary supplements or laboratory studies to assess the resident's compromised nutritional status related to the new sacral wound, or that the physician was notified of the resident's wound and nutritional status. Review of nursing documentation revealed on September 17, 2012, Resident R119 was seen during wound rounds and the open area on the sacrum now measured 3.5 cm by 4.0 cm, and was noted with 90% slough with moderate amount of purulent (creamy white to yellow) drainage. The note also indicated that a wound care/vascular physician was consulted. Review of the wound consultant sheet, dated September 17, 2012, revealed that the sacral wound was described as unstageable (unable to determine the depth of the wound), with a moderate amount of odorous serosanguinous (bloody) drainage, and recommended to monitor the resident's nutrition. The wound consultant sheet also indicated that the resident's left heel was being monitored by facility staff, and recommended to discontinue the use of a Prevalon boot (pressure-reducing device). Further review of the Skin Alteration Record for Resident R119 revealed that on September 29, 2012, the resident's sacral wound was measured to be 6.0 cm long by 6.0 cm wide by 1.0 cm deep, described as slough with a moderate amount of purulent drainage from the wound. Observation of Resident R119's sacral wound, on October 2, 2012, at approximately 9:15 a.m., in the presence of Employee E5, Director of Care Delivery, revealed a sacral wound measuring approximately six cm. long by six cm. wide by one cm. deep, was foul-smelling, and had the appearance of yellow-gray colored tissue inside the wound. Observation of Resident R119, in the presence of Employee E2, Assistant Director of Nursing, on October 2, 2012, at approximately 12:15 p.m., revealed the resident was wearing a Prevalon boot on the left heel. Interview with Employee E2 at the time of the observation confirmed that the resident was wearing the Prevalon boot, and confirmed that the boot should have been discontinued as recommended by the wound care consultant on September 17, 2012. Clinical record review revealed no documentation of the status of Resident R119's deteriorating sacral wound from September 6, 2012, through September 17, 2012, no documentation that the resident's primary physician had been notified of the resident's deteriorating wound, no documentation that the resident's plan of care was reassessed and revised to include a new onset sacral wound as identified by the facility on September 5, 2012, and no documentation that the dietitian reevaluated the resident's possible need for nutritional supplements and lab work related to a deteriorating sacral wound. Interview with Employee E6, on October 2, 2012, at approximately 1:00 p.m., confirmed these findings. Review of Resident R118's clinical record revealed that the resident had [DIAGNOSES REDACTED]. Review of a quarterly MDS dated [DATE], revealed that the resident was severely cognitively impaired in decision making, required extensive, one-person assistance for personal hygiene, required extensive two or more-person physical assistance from staff for transfers, and was non-ambulatory. Review of the resident's plan of care, dated last revised June 16, 2012, revealed that the resident was at risk for alteration in skin integrity related to incontinence, impaired mobility, and [MEDICAL CONDITION] requiring [MEDICAL TREATMENT]. Review of a Skin Alteration Record for Resident R118 revealed that on July 26, 2012, an excoriated area was documented on the resident's right knee area, measuring 1.5 cm long by 2.0 cm wide, described as pale, pink tissue with a scant amount of serous (clear) fluid draining from the wound. Review of nursing documentation revealed that on July 28, 2012, Resident R118 was noted to have an excoriated area on the right side knee area, measuring 1.5 cm by 2.0 cm, and a new physician's orders [REDACTED]. Review of the Skin Alteration Record revealed on July 29, 2012, the resident's right knee area was measured as 4.5 cm by 1.5 cm, described as pale, pink tissue with a scant amount of serous (clear) fluid draining from the wound. On August 30, 2012, nursing documentation indicated that Resident R118 was seen by a wound team member and the right lateral (side) lower leg wound measured 1.7 cm by 2.8 cm, and was described as necrotic (dead tissue/skin that is black in color) noted with a moderate amount of drainage. Further review of the Skin Alteration Record revealed that on September 18, 2012, the right lower extremity wound was measured as 4.0 cm long by 2.8 cm wide by 1.5 cm deep, and described as dark pink/red tissue with serosanguineous drainage. Observation of the right calf wound on September 28, 2012, at 9:30 a.m., revealed the wound to be approximately 4.0 cm long by 3.0 cm wide by 1.5 cm, and beefy red in color. The wound was cleansed with normal saline solution (salt solution-wound cleanser), [MEDICATION NAME] AG (dressing for leg ulcers) was applied, and was dressed with [MEDICATION NAME] (adherent dressing) per physician's orders [REDACTED]. Clinical record review revealed no documentation of the status of Resident R118's leg wound from July 29, 2012, through August 30, 2012, no documentation that the resident's primary physician had been notified of the change in the integrity of the resident's skin, no documentation that the resident's plan of care was reassessed and revised to include a new area of breakdown on the resident's right knee area as identified by the facility on July 26, 2012, and no documentation that an investigation was conducted into how or why this skin area had broken down. Interview with Employee E6, on October 1, 2012, at approximately 2:15 p.m., confirmed these findings. Clinical record review of Resident R17 revealed [DIAGNOSES REDACTED]. The current resident assessment indicated that Resident R17 was alert, oriented and required extensive assistance with activities of daily living. A review of physician's recommendations dated September 20, 2012, indicated that Resident R17 had skin breakdown at the stoma of [MEDICAL CONDITION] and required [MEDICATION NAME] for treatment. A review of the admission facility skin assessment did not identify this skin impairment or follow up treatment. Nursing documentation dated September 22, 2012, noted that Resident R17 was transferred to the hospital for a dislodged Trach, which the facility was unable to replace. The hospital ENT physician described the stoma area as red and moist and to continue using a [MEDICATION NAME] dressing to protect the area. Review of nursing documentation and September 2012 Treatment Administration Record revealed that on September 25, 2012 (five days later), at 10:06 a.m., the resident was observed with a stage III pressure ulcer 1.0 by 4.0 centimeters, with 100% slough under the bottom of [MEDICAL CONDITION] on the neck due to [MEDICAL CONDITION] digging into the area. Upon readmission,the facility failed to assess and monitor Resident R17's hospital acquired tracheal irritation. Additionally, the facility did not follow the hospital's discharge recommendation to apply [MEDICATION NAME] to the tracheal site. There was no evidence that the facility performed Body Audits with showers /bed baths from September 20 to October 2, 2012, which aids in determining deterioration/healing with skin impairment. The facility failed to address specific interventions for the hospital acquired skin impairment to prevent further decline in skin condition for five days since admission. Interview with Employee E4, a Registered Nurse, on October 1, 2012, at 1:00 p.m., confirmed the delay in identification of the tracheal pressure ulcer and putting specific interventions into place to prevent further decline. 28 PA Code: 201.14(a) Responsibility of licensee. Previously cited 9/21/12. 28 PA Code: 201.18(b)(1) Management. Previously cited 9/27/11. 28 PA Code: 211.6(d) Dietary services. 28 PA Code: 211.11(a) Resident care plan. 28 PA Code: 211.12(d)(1) Nursing services. Previously cited 1/18/12 and 9/27/11. 28 PA Code: 211.12(d)(3)(5) Nursing services. Previously cited 9/21/12, 1/18/12 and 9/27/11.