Every finding on record at Edenbrook South

Based on observation, and staff interview, it was determined that the facility failed to serve food at safe and appetizing temperatures on one of four hallways (East Hall).Findings include: Observation of tray line in the main kitchen on July 6, 2026, from 11:32 AM to 12:05 PM revealed the following: Employee 1 (dietary aide) was preparing the lunch meal trays. The reach in refrigerator was beside the steam table, and the door was propped open during the entire meal service. The reach in refrigerator contained milk, juice, and yogurt. The temperature of the reach in refrigerator was 67.1 degrees Fahrenheit. The ice cream was stored in a plastic bin filled with cold water. Employee 1 finished the East Hall meal cart at 12:05 PM and the meal cart was delivered to the nursing unit. Staff began passing trays immediately and passed the last resident food tray at 12:17 PM. The surveyor began testing the food temperatures of the test tray with the following results: The milk was 60.8 degrees Fahrenheit and was warmThe ice cream was 53.1 degrees Fahrenheit and melted These findings were reviewed with the Nursing Home Administrator and Director of Nursing on July 6, 2026, at 3:30 PM. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

Based on observations and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner, maintain equipment in a sanitary condition, and prepare food items in accordance with professional standards in the facility's main kitchen and store a resident's tube feed in a safe and sanitary location on one of four nursing units reviewed (North Hall Nursing Unit, Resident 11). Findings include: Initial tour of the facility's main kitchen with Employee 9, Dietary Director, on February 8, 2026, at 9:10 AM revealed the following: A hand-washing sink was starting to detach from the wall. A section of wall behind the dishwasher had flaking paint. A temperature booster box for the dishwasher located on the floor adjacent to the dishwasher was observed to be leaking water from underneath the unit. Employee 9 revealed this unit started leaking recently and a work order (a system used to keep track of maintenance work requests) was placed. A refrigerator contained a pitcher of a brown colored liquid and a yellowish colored liquid. The items were not labeled. A facility placed date on the yellowish colored liquid was unreadable. A lid on a garbage receptacle had an extensive build-up of dried stains and food debris. An unlabeled plastic cup was observed on a small table near the spices. The cup contained a liquid and plastic lid. Employee 9 revealed that it was sanitizer for the kitchen thermometer. Another refrigerator contained a small stainless-steel pan with tin foil. There were no dates or labels on the pan. This refrigerator also contained a container with what Employee 9 identified as diced peppers. There were no labels or dates on the pan. A refrigerator adjacent to the tray line preparation area contained multiple small glasses of liquid drinks that were not labeled or dated. There were multiple unlabeled small plastic containers that contained cooked eggs. Review of a maintenance work order provided by facility staff for the leaking booster box under the dishwasher observed as noted above revealed a creation date of February 8, 2026, at 10:38 AM, after the observation occurred. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on February 9, 2026, at 2:10 PM. Observation of Resident 11's room on February 8, 2026, at 11:03 AM, February 9, 2026, at 12:23 PM, and February 10, 2026, at 10:33 AM revealed there was a box stored directly on the floor of Resident 11's room with six containers of Osmolite (tube feeding formula). Reviewed the above findings with the Nursing Home Administrator and Director of Nursing on February 10, 2026, at 2:40 PM, who confirmed to prevent the potential for contamination, the tube feeding formula should not be stored directly on the floor. 483.60(i)(1)-(2) Food safety requirementsPreviously cited deficiency 1/24/25 28 Pa. Code 201.14(a) Responsibility of licensee

Based on observation and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to maintain a clean and safe environment on three of four nursing units (South, East and West, Residents 2, 8, 9, 29, and 85). Findings include: Observation of Resident 2's room on February 8, 2026, at 11:30 AM and on February 9, 2026, at 12:30 PM revealed the left side bathroom door frame had a chip of wood out of it, a chip of wood out of the bathroom door near the bottom corner, and a scrape down to the wood, horizontally around the middle of the inside of his room door. There was loose dirt behind the door to his room. It was also noted that the floor was dirty from the doorway to the resident's bed with loose dirt and a hazy dull streak indicating where feet had tracked. Observation of Resident 29's room on February 9, 2026, at 12:41 PM revealed loose dirt on the floor with pieces of paper. It was also noted that Resident 29's first and third dresser drawer handles were hanging down on one side. She indicated that they had been that way for a while. Observation of Resident 85's room on February 10, 2026, at 1:30 PM revealed dust and dirt noted to the right as you enter the room. The cove base was noted to be coming off in the corner to the right as you entered her room. The door to her room was marred with chips of wood out near the bottom. The Nursing Home Administrator and the Director of Nursing were made aware of the above noted environmental concerns for Residents 2, 29, and 85 during a meeting on February 11, 2026, at 9:35 AM. Observation of the resident lounge at the end of the East Hall Nursing Unit on February 8, 2026, at 12:31 PM revealed four ceiling lights that had a significant accumulation of debris in the protective covers. Observation of Resident 8's room on February 8, 2026, at 2:45 PM revealed a large brown colored stain on the corner ceiling tile located above the resident's recliner. A concurrent interview with Resident 8 revealed the stain was from a previous leak in the roof. The above information for the resident lounge and Resident 8 were reviewed in a meeting with the Nursing Home Administrator on February 10, 2026, at 10:56 AM. Interview with Resident 9 on February 8, 2026, at 1:13 PM revealed concerns related to a leak in the roof at the corner of his room. The resident stated that the leak initiated about a week prior and was described as a waterfall but had since slowed to a trickle. Concurrent observation revealed that a large commercial sized round yellow garbage bin on a wheeled base was sitting in the corner of Resident 9's room. Further inspection revealed that one of the tiles from the drop ceiling above the garbage bin was removed, exposing a pipe that was dripping into the garbage bin. The garbage bin was noted to be 5 inches from being filled with clear liquid. Two additional resident room sized trash bins were noted to be partially filled with clear liquid to the left of the yellow bin. On the floor to the right of the large garbage bin was a white towel that appeared to have been left on the floor wet, but was now dried and wrinkled, with yellowing edges. Observation on February 9, 2026, at 9:07 AM and again on February 10, 2026, at 10:05 AM revealed the state of the above-mentioned items in Resident 9's room to be unchanged. Resident 9's room environment was discussed with the Nursing Home Administrator and the Director of Nursing on February 10, 2026, at 2:45 PM. 483.10(i)(1)-(7) Safe/clean/comfortable/homelike EnvironmentPreviously cited 1/24/25 28 Pa. Code 201.14(a) Responsibility of licensee

Based on clinical record review, review of select facility policies and procedures, and staff and responsible party interview, it was determined that the facility failed to obtain appropriate documentation for a device used as a physical restraint for one of one resident reviewed for restraint use (Resident 6).Findings include: The policy entitled Physical Restraints, last reviewed without changes September 9, 2025, reveled physical restraints are only used when they are used appropriately to treat a resident's medical symptoms and to promote an optimal level of function for the resident. If an adaptive device is being used an Adaptive Equipment assessment will be completed by a licensed nurse or therapist to determine if the device is limiting the resident's freedom of movement or normal access to one's body. If device is found to be limiting movement, the Restraint Assessment will be completed. The least restrictive device should be used with documentation of all other alternatives tried prior to the implementation of a restraint. An order for the use of restraint will be received from the physician which includes medical symptoms for use, frequency of use, type of restraint, release protocols, and a plan for reduction. Notification to the residents and/or family of the risks of physical restraints and documentation of informed consent/education on use must be obtained anytime there is a restraint applied. The resident's care plan will be updated with the use of a restraint. A restraint review should be completed at least quarterly with updates if applicable. Clinical record review revealed the facility admitted Resident 6 on September 4, 2021, with diagnoses including cerebral palsy. Review of Resident 6's most recent quarterly MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated December 30, 2025, revealed staff assessed Resident 6 using a trunk restraint daily. Review of previous MDS assessments dated November 2, and August 25, 2025, revealed nursing staff also assessed Resident 6 as utilizing a trunk restraint daily. Review of Resident 6's clinical record revealed a Restraint Use/ assessment dated [DATE], noting staff assessed Resident 6 for the use of a harness and seatbelt for use in her wheelchair. The assessment revealed Resident 6 is at a significant risk of serious or fatal injury if a fall should occur out of chair due to her diagnosis of cerebral palsy, epilepsy, and having an extrapyramidal movement disorder and severe cognitive impairment. The only previous restraint assessment was completed February 26, 2025. Interview with Resident 6's family on February 10, 2026, at 2:20 PM revealed that staff utilize the seat belt/harness restraint when they are feeding Resident 6. Resident 6's family explained when staff feed Resident 6 her wheelchair is in the upright position and her restraint is utilized, and when she is seated in the hallway her wheelchair is tilted/reclined. Further review of Resident 6's clinical record revealed there was no physician order, or plan of care addressing Resident 6's restraint. These findings were reviewed with the Nursing Home Administrator and Director of Nursing on February 9, 2026, at 2:38 PM. Further interview with the Nursing Home Administrator and Director of Nursing on February 11, 2026, at 9:38 AM confirmed there was no documentation of monthly assessments, a physician order, or a plan of care addressing Resident 6's restraint until after surveyor questioning. 28 Pa. Code: 211.8(e) Use of restraints. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide the highest practicable care for one of 19 residents reviewed for advance care planning (Resident 11), and one of three residents reviewed for skin conditions (Residents 3). Findings include: Observation of Resident 3 on February 8, 2026, at 12:48 PM revealed that the skin on his cheeks and forehead was reddened and he had white flaking skin noted to his forehead, cheeks, and eyebrows. Many white flakes were also noted to be around the collar of the resident's shirt. Observation of Resident 3 on February 9, 2026, at 9:19 AM revealed the skin on his cheeks and forehead was reddened and he had white flaking skin noted to his forehead, cheeks, and eyebrows. Clinical record review for Resident 3 revealed a medical progress note dated [DATE], which stated the resident has some dried skin on face. No further documentation could be identified regarding the dry skin. The above information related to Resident 3 was reviewed with the Nursing Home Administrator and the Director of Nursing on February 10, 2026, at 2:45 PM. Observation of Resident 11 on February 8, 2026, at 11:03 AM revealed he was in bed sleeping, with a tube feeding hung at his bedside. Interview with Resident 11 on February 9, 2026, at 12:23 PM revealed he does not want his tube feeding. Clinical record review revealed the facility admitted Resident 11 on [DATE]. Review of Resident 11's physician orders revealed a current order for enteral feedings, initiated [DATE]. Review of a POLST (Physician Orders for Life Sustaining Treatment, a medical order that communicates a patient's wishes for end of life) dated [DATE], signed by Resident 11 indicated that he did not want artificial hydration or nutrition. Resident 11's POLST was updated [DATE], noting he continues to not want hydration and artificial nutrition by tube. Further review of Resident 11's clinical record revealed a physician assistant progress note dated [DATE], noting a discussion with Resident 11 regarding advance care planning and Resident 11 requested a do not resuscitate order (cardiopulmonary resuscitation (CPR) would not be attempted if the resident stopped breathing) with limited additional interventions, including no antibiotics, hydration, or artificial nutrition by tube. Reviewed the above findings for Resident 11 with the Nursing Home Administrator and Director of Nursing on February 10, 2026, at 2:33 PM. Further discussion with the Nursing Home Administrator and Director of Nursing on February 11, 2026, at 9:38 AM, revealed that the facility spoke to Resident 11 and he wants to discuss discontinuing his tube feeds with his physician. The facility failed to provide the highest practical care to Resident 11 related to his advance care planning. 483.25 Quality of CarePreviously cited deficiency [DATE] and [DATE] 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on employee personnel record review and staff interview, it was determined that the facility failed to complete a performance evaluation of each nurse aide at least once every 12 months for three of three nurse aides reviewed (Employees 1, 2, and 3).Findings include: The facility noted the following hire dates for three employees reviewed for performance evaluations (EPR, employee performance review): Employee 1's hire date of September 21, 2022.Employee 2's hire date of May 1, 2019.Employee 3's hire date of September 29, 2021. A request to review the annual performance evaluations revealed no documented evidence that the facility completed performance evaluations for Employees 1, 2, and 3 (nurse aides) at least once every 12 months. Employees 1 and 3's last performance evaluations were December 5, 2024. Employee 2's last performance evaluation was November 20, 2024. Interview with the Nursing Home Administrator and Director of Nursing on February 10, 2026, at 2:23 PM confirmed that performance evaluations were not completed annually on the three employees requested. 28 Pa. Code 201.19 (2) Personnel policies and procedures

Based on observation and resident and staff interview, it was determined that the facility failed to secure medications on two of four nursing units (West and North, Resident 11).Findings include: Observations of Resident 11's room on the North nursing unit on February 8, 2026, at 11:20 AM, February 9, 2026, at 9:45 AM, and February 10, 2026, at 10:52 AM, revealed a container of Normal Saline Solution (used to restore or maintain fluid volume, especially when oral intake is not possible), on the resident's bedside stand with an expiration date of February 19, 2022. The above findings for Resident 11 were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on February 10, 2026, at 2:30 PM. Observation of the North nursing unit medication cart on February 11, 2026, at 8:15 AM revealed the cart was in use by Employee 8, licensed practical nurse, during a medication pass. Observation of this medication cart revealed the following: There were several unsecured and unidentified medications found in the bottom of two of the drawers that included: five round white-colored pills; a blue/green colored capsule; a green oblong tablet; a white oblong tablet; a round, brown-colored pill; a round, yellow-colored pill; and half an oblong, white-colored tablet. The above findings were reviewed in a meeting with the Nursing Home Administrator on February 11, 2026, at 9:47 AM. Observation on the [NAME] nursing unit on February 8, 2026, at 12:17 PM revealed the [NAME] nursing unit medication cart parked along a wall in the hallway near the nursing station. Residents were observed ambulating in the hallway by the cart. The cart was unattended and unlocked. The surveyor was able to open the cart and access resident medications within the cart. Concurrent interview with Employee 12, licensed practical nurse, confirmed that this medication cart should have been locked before it was left unattended. Observation on the North nursing unit on February 9, 2026, at 3:00 PM revealed the North nursing unit treatment cart parked along a wall near the nursing station as residents were ambulating in the hallway by the cart. The cart was unattended and unlocked. The surveyor was able to open the cart and access resident medicated treatments and medical supplies. Concurrent interview with Employee 8, licensed practical nurse, confirmed that this treatment cart should have been locked before it was left unattended. The above medication storage and security concerns related to the [NAME] nursing unit medication cart, and the North nursing unit treatment cart were reviewed with the Nursing Home Administrator and the Director of Nursing on February 10, 2026, at 2:45 PM. 483.45(g)(h)(1)(2) Label/store Drugs and BiologicalsPreviously cited deficiency 2/16/24 and 1/24/25 28 Pa. Code 211.9 (a)(1)(k) Pharmacy services 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on clinical record review, review of select facility policies and procedures, and resident and staff interview, it was determined that the facility failed to determine a resident's capability to self-administer their medications for one of 19 residents reviewed (Resident 22).Findings include: The facility policy entitled Medication Self Administration, last reviewed without changes September 9, 2025, revealed the resident shall have a screen completed by a licensed nurse to determine factors that may impact the safe administration of medications. Residents who have been deemed appropriate to self-administer medications independently or with supervision/cueing or after set-up, shall have a physician order to do so. The screen will be re-evaluated quarterly and more frequently as clinically indicated. Medications to be self-administered shall be secure in a locked area in the resident's room or stored in the medication cart for provision to the resident to self-administer. Any significant change in the resident's condition will be promptly reported to the Director of Nursing and/or the resident's attending physician with rescreening for self-administration performed to ensure self-administration of medications is still safe. The resident will be provided with a medication administration record to document the self-administration medications. Proper documentation of self-administration will be reviewed and used as a factor to determine continued self-administration at the next review. The self-administration of medications will be care planned with interventions specific to the individual resident. Clinical record review revealed the facility admitted Resident 22 on January 5, 2026. Review of Resident 22's physician orders revealed the following orders: Dialysis Monday, Wednesday, Friday, with a chair time of 11:00 AM, transported by Step van, and dietary to provide lunch, initiated on January 9, 2026. Renvela (medication used to control high phosphorus levels in adults with chronic kidney disease on dialysis) tablet 800 milligrams (mg), three tablets by mouth three times a day, initiated on January 8, 2026. Interview with Resident 22 on February 8, 2026, at 1:47 PM revealed that she goes out of the facility to dialysis three days a week. Resident 22 stated that she takes her lunch and a large white pill to take with her to dialysis. Review of Resident 22's clinical record on February 8, 2026, revealed no evidence of a Self-Administration Screen, or physician order for Resident 22 to self-administer her Renvela. The facility did not complete a Self-Administration Screen until February 9, 2026, after the surveyor's questioning. The facility did not get an order for Resident 22 to self-administer her Renvela medication on dialysis days until February 9, 2026, after the surveyor's questioning. The above findings for Resident 22 were reviewed during a meeting with the Nursing Home Administrator and Director of Nursing on February 9, 2026, at 2:30 PM. The Nursing Home Administrator confirmed that Resident 22 was not assessed to self-administer her medication until after surveyor questioning. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on observations and staff interview, it was determined that the facility failed to ensure residents' rights to secure confidential personal and medical information in the facility's main lobby, one of four nursing units (North Hall Nursing Unit) and three of 19 residents reviewed (Residents 11, 53, and 60).Findings include: Observation of hallway in the area located in front of Nurse Station 1 at the end of the North Hall Nursing Unit on February 8, 2026, at 12:10 PM revealed a facility binder on the wall titled Pennsylvania Department of Health Survey Book. The binder contained the results of recent surveys of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. Observation of the facility's main lobby area on February 8, 2026, at 1:38 PM revealed a facility binder on the wall titled Pennsylvania Department of Health Survey Book. The binder contained the results of recent surveys of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. Review of the contents of these binders revealed that the facility placed the full health survey letters and complaint deficiency letters (letters sent to administration after a survey) into the binder. Further review of the binders revealed a deficiency letter and associated Statement of Deficiencies (Form CMS-2567) for a survey on February 16, 2024. The letter noted the full name and associated specific resident identifiers for Residents 11 and 60. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on February 8, 2026, at 1:40 PM. Observation of a medication pass with Employee 8, licensed practical nurse, on the North Hall Nursing Unit on February 11, 2026, at 8:12 AM revealed a medication cart with a plastic garbage receptacle attached to the side. The garbage receptacle contained an empty medication card with a prescription label attached containing Resident 53's name, and dosing instructions for mycophenolate mofetil oral capsules (a medication used to prevent organ rejection after transplant and treatment of autoimmune diseases). An interview with Employee 8 on February 11, 2026, at 8:12 AM revealed that the medication card with the attached identifying information for Resident 53 should not be thrown away in the regular trash. Employee 8 informed that the resident identifiers on the medication card should be torn off and placed in the shredder bin located near the nurse station. The above information for Resident 53 was reviewed in a meeting on February 11, 2026, at 9:47 AM. The facility failed to ensure the right to privacy of their personal and medical information for Residents 11, 53, and 60. 28 Pa. Code: 201.18(e)(1) Management

Based on clinical record review and staff interview, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman upon transfer to the hospital for three of six residents reviewed for hospitalizations (Residents 3, 6, and 36).Findings include: Review of Resident 3's clinical record revealed they were transferred to the hospital on November 5, 2025, December 13, 2025, and January 30, 2026. There was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman regarding Resident 3's transfer to the hospital on November 5, 2025, December 13, 2025, or January 30, 2026. Review of Resident 6's clinical record revealed that the facility transferred her to the hospital from [DATE] to 26, 2025. There was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman regarding Resident 6's transfer to the hospital on December 23, 2025. Review of Resident 36's clinical record revealed they were transferred to the hospital on November 6, 2025, and November 22, 2025. There was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman regarding Resident 36's transfer to the hospital on November 6, 2025, or November 22, 2025. Interview with the Nursing Home Administrator and Director of Nursing on February 11, 2026, at 10:04 AM confirmed the above findings for Resident 3, 6, and 36. The facility failed to notify the Office of the State Long-Term Care Ombudsman upon transfer to the hospital for Residents 3, 6, and 36. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights

Based on clinical record review and staff interview, it was determined that the facility failed to ensure assessments accurately reflected a resident's status for 3 of 19 residents reviewed (Residents 29, 70, and 22). Findings include: Clinical record review for Resident 29 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated January 9, 2026, that indicated section C of the assessment (cognitive patterns) was documented with dashes indicating Resident 29 was not assessed for cognitive status. Further clinical record review for Resident 29 revealed a quarterly MDS assessment dated [DATE], that indicated she was assessed as having no cognitive impairment with a BIMS (Brief Interview for Mental Status) of 15, (a score of 13-15 is intact cognition). Interview with Resident 29 on February 9, 2026, at 11:45 AM revealed her to be alert and oriented with no noticeable cognitive deficits. Interview with the Nursing Home Administrator on February 9, 2026, at 2:00 PM confirmed that Resident 29 was cognitively intact. She indicated that the social service director who is responsible for completing section C of the MDS went out on leave and they did not realize Resident 29's section C assessment was not done until the assessment reference date had passed, so they had to code Resident 29's cognitive status as not assessed The facility failed to accurately assess Resident 29's cognitive pattern for the MDS assessment as noted above. Clinical record review for Resident 70 revealed a quarterly MDS dated [DATE], that indicated Section C of the assessment (cognitive patterns) was documented in all areas as not assessed. Further clinical record review for Resident 70 revealed a Discharge Return Anticipated MDS assessment dated [DATE], that indicated multiple areas of Section C documented by staff as not assessed. Further clinical record review for Resident 70 revealed a quarterly MDS assessment dated [DATE], that indicated the resident was assessed as having a BIMS of 13. Interview with Resident 70 on February 9, 2026, at 10:35 AM revealed the resident to be alert and with no noticeable cognitive deficits and answered questions appropriately. The above information for Resident 70 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on February 9, 2026, at 2:10 PM. The Nursing Home Administrator revealed that the staff member responsible for completing section C of the MDS went on leave and the facility did not realize Resident 70's Section C assessment was not completed until the assessment reference date had passed, so the facility had to code Resident 70's cognitive status as not assessed. The facility failed to accurately assess Resident 70's cognitive pattern for the MDS assessments as noted above. Clinical record review for Resident 22 revealed an admission MDS dated [DATE], that indicated section C of the assessment (cognitive patterns) was documented with dashes indicating Resident 22 was not assessed for cognitive status. Interview with Resident 22 on February 8, 2026, at 11:45 AM revealed her to be alert and oriented with no noticeable cognitive deficits. The above findings for Resident 22 were reviewed with the Nursing Home Administrator and Director of Nursing on February 9, 2026, at 2:28 PM. The facility failed to accurately assess Resident 22's cognitive pattern for the MDS assessments as noted above. 483.20(g), F641, Accuracy of AssessmentsPreviously cited 1/24/25 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff and resident interview, it was determined that the facility failed to implement a comprehensive, person-centered care plan regarding a diagnosis for PTSD (Post-Traumatic Stress Disorder, a mental health condition triggered by experiencing or witnessing a traumatic event, leading to severe anxiety, flashbacks, and emotional distress) for one of 19 residents reviewed (Resident 9).Findings Include: During an interview with Resident 9 on February 8, 2026, at 1:38 PM, the resident stated he was diagnosed with PTSD related to a history of childhood sexual trauma. Clinical record review for Resident 9 revealed that the resident was diagnosed with PTSD on March 8, 2025. Review of Resident 9's current comprehensive plan of care (a summary of a resident's personal health, nursing, and psychological well-being needs and how they can be met) included two stated goals; I will remain comfortable and safe in my environment, and I will not have episodes of crisis. There were two listed interventions including, Discuss feelings of anger with resident, and I want to stay in contact with my friends/family. The care plan did not describe what individualized interventions would assist Resident 9 to remain comfortable within their environment. The care plan did not describe what an episode of crisis looks like for the resident or how to address these episodes with the resident to achieve these stated goals. The above information regarding the care plan was reviewed with the Nursing Home Administrator and the Director of Nursing on February 10, 2026, at 2:45 PM. 28 Pa. Code 211.10. (a) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, clinical record review, and resident family and staff interview, it was determined that the facility failed to provide a dependent resident with activities of daily living assistance for one of four residents reviewed (Resident 11).Findings include: Observation of Resident 11 on February 8, 2026, at 12:58 PM revealed he was sleeping in bed and his hair appeared long (shoulder length) and disheveled. Interview with Resident 11 on February 9, 2026, at 1:52 PM revealed that he wished to have his hair cut. Concurrent interview with Resident 11 on February 10, 2026, at 10:15 AM revealed Resident 11 again stated a desire to have his hair cut, indicating he was not sure why it was taking so long. The findings for Resident 11 were reviewed with the Nursing Home Administrator and Director of Nursing on February 9, 2026, at 2:30 PM. They were unable to provide an explanation as to why Resident 11 has not received a haircut for an extended period. Review of social service documentation dated February 9, 2026, at 6:00 PM revealed social worker asked Resident 11 if he would like a haircut, and Resident 11 voiced yes. There was no evidence that the facility offered, or Resident 11 refused to have his hair cut. 483.24(a)(2) ADL Care Provided for Dependent ResidentsPreviously cited deficiency 1/24/25 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, observation, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide appropriate treatment and services for a resident who is fed by enteral (feeding tube) means to prevent potential complications for one of one resident reviewed for tube feeding concerns (Resident 36).Findings include: Review of facility policy titled Policy & Procedure Tube Feeding: Continuous Tube Feeding last reviewed on September 9, 2025, states under step 7 of the procedure to elevate the head of the bed at least 30 degrees during feeding and for 30 to 60 minutes after feeding unless contraindicated. Observation of Resident 36 on February 8, 2026, at 12:20 PM revealed the presence of a feeding tube (G-tube, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications; also known as a PEG tube) connected to a feeding pump (a mechanical device used to pump fluids and a specialized liquid nutrition source referred to as feed, through a G-tube at a pre-set rate). A concurrent observation of the feeding pump revealed that the feeding pump was actively administering feed through the residents feeding tube while Resident 36 was in bed, with the bed laying in a flat position. Observation of Resident 36 on February 9, 2026, at 9:10 AM revealed that the feeding pump was actively administering feed through the residents feeding tube while Resident 36 was in bed, with the bed laying in a flat position. Clinical record review revealed that Resident 36 had an active physician's order dated March 3, 2024, to elevate the residents HOB (head of bed) while the tube feed is running and for one hour after the feed is completed every shift for preventing aspiration (food or liquid entering the airway/lungs). The above information was reviewed with the Nursing Home Administrator and the Director of Nursing on February 10, 2026, at 2:25 PM. 28 Pa. Code 211.10(a)(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing service

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to store respiratory care equipment in a sanitary manner on one of four nursing units (South, Resident 33) and provide respiratory care consistent with professional standards of practice for one of two residents reviewed for respiratory concerns (Resident 4).Findings include: Observation of Resident 33's bedside table on February 8, 2026, at 12:24 PM revealed a nebulizer machine (a compressor device that converts liquid medication into a fine mist, allowing for easier inhalation into the lungs) with nebulizer tubing (a removable, flexible hose that connects the nebulizer machine to the liquid medication cup, allowing air to flow through and convert liquid medication into a mist for inhalation) and a nebulizer mask with a medicine cup (a breathing mask worn over the nose and mouth connected to the medicine cup, which ensures that the aerosolized medicine is adequately inhaled) on the table. The mask appeared to be coated in a slightly opaque white colored film, and the medicine cup had dried droplets of liquid noted to the inside of the medicine cup. Observation of Resident 33's bedside table on February 9, 2026, at 12:10 PM again revealed a nebulizer machine with attached nebulizer tubing and a nebulizer mask and medicine cup on the table. The mask continued to appear to be coated in a slightly opaque white colored film, but the medicine cup was noted with droplets of liquid to the inside of the medicine cup. Concurrent observation of the bedside table revealed food debris/crumbs, a dried drop of a red liquid, and a spoon that appeared to have been previously used. The above findings regarding the condition of Resident 33's nebulizer machine was discussed with the Nursing Home Administrator and the Director of Nursing on February 10, 2026, at 2:45 PM. Clinical record review revealed the facility admitted Resident 4 on January 21, 2022, with diagnosis of chronic obstructive pulmonary disease (COPD). A diagnosis of chronic respiratory failure with hypoxia (insufficient oxygen supply) was added April 25, 2025. A physician's order initiated on July 1, 2024, instructed staff to administer Resident 4 continuous oxygen at two liters per minute (LPM) by nasal cannula (medical tubing that delivers supplemental oxygen directly to the nose). Observation of Resident 4 on February 8, 2026, at 10:52 AM and 2:51 PM revealed she was seated in her wheelchair with her oxygen being administered at three LPM. Observation of Resident 4 on February 10, 2026, at 9:49 AM revealed she was seated in her wheelchair with her oxygen being administered at one LPM. The above information for Resident 4 was reviewed with the Nursing Home Administrator and the Director of Nursing on February 10, 2026, at 2:30 PM. 483.25(i) Respiratory CarePreviously cited 1/24/25 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility documentation and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of residents with wound vacs for four of four employees reviewed (Employees 4, 5, 6, and 7). Findings include: Clinical record review revealed the facility admitted Resident 3 on November 20, 2025. A physician order dated January 13, 2026, revealed nursing staff are to apply a wound vac (a therapy that uses a device to decrease air pressure on a wound) to Resident 3's sacral area wound using black foam and setting to 125 mmhg (millimeters of mercury). A request for nursing staff competencies for Resident 3's wound vac revealed the facility was unable to provide any competencies related to wound vacs for Employees 4 and 5 (licensed practical nurses) and Employees 6 and 7 (registered nurses). The findings were reviewed with the Nursing Home Administrator and Director of Nursing on February 11, 2026, at 9:44 AM. They confirmed the facility could provide no documentation that ensured Employees 4, 5, 6, and 7 had specific competencies and skill sets to care for Resident 3's needs listed above. 483.35(a)(3)(4)(d) Competent Nursing StaffPreviously cited deficiency 1/24/25 28 Pa. Code 201.20 (a) Staff Development

Based on clinical record review and staff interview, it was determined that the facility failed to obtain and provide medications for one of 19 residents reviewed (Resident 20). Findings include: Clinical record review for Resident 20 revealed that the facility admitted her on June 16, 2017. Further clinical record review revealed that she had diagnoses of bipolar disorder (a mental health disorder characterized by intense mood swings, ranging from extreme highs to deep lows), psychotic disorder with hallucinations (a loss of contact with reality, characterized by hearing voices, seeing things, or feeling sensations that are not there), restlessness and agitation, generalized anxiety disorder (a mental health condition characterized by chronic, excessive, uncontrollable worry), and vascular dementia with agitation (triggered by brain damage from reduced blood flow to the brain causing cognitive decline with behaviors of increased motor activity, restlessness, irritability, and aggression). Review of Resident 20's medication administration record (MAR) for December 2025, revealed that Resident 20 was to receive one milliliter of Lorazepam (a medication used to treat anxiety) 0.5 milligrams (mg) per milliliter (ml) gel topically two times a day. Resident 20's MAR for December 2025, revealed that the medication was not administered on December 25-26, 2025, at 8:00 AM or 8:00 PM, and it was not administered on December 27, 2025, at 8:00 AM due to the medication not being available. Clinical record review for Resident 20 revealed a progress note dated December 25, 2025, at 8:27 AM that indicated Lorazepam 0.5 mg/ml Gel was not available and they were awaiting pharmacy delivery of the medication. A progress note dated December 25, 2025, at 9:45 PM revealed that the facility was waiting on delivery of Resident 20's Lorazepam 0.5 mg/ml Gel. A progress note dated December 26, 2025, at 8:08 AM revealed that Resident 20's Lorazepam 0.5 mg/ml Gel was unavailable. The writer indicated that the medication was ordered last week and pharmacy would be called. A progress noted dated December 26, 2025, at 1:16 PM indicated that the writer called the pharmacy but was unable to get an answer as to whether the medication had been shipped. A progress note dated December 27, 2025, at 4:18 AM revealed that the pharmacy was called and the representative stated that the medication was not reordered but they would fill the medication now and send it on the next pharmacy run between 9:00 AM-12:00 PM. A pharmacy order status report dated February 10, 2026, provided by the facility revealed that the Resident 20's Lorazepam 0.5/ml Gel was reordered on December 15, 2025, but the pharmacy only sent enough for eight doses. The medication was not reordered again until December 27, 2025, after Resident 20 missed 5 doses. An email dated February 10, 2026, at 12:19 PM, provided by the pharmacy to the facility indicated that Resident 20's Lorazepam refill request was received by them on December 27, 2025, at 4:00 AM (after hours). The email indicated that the pharmacy filled and shipped the medication on December 27, 2025. An interview with the Director of Nursing and Nursing Home Administrator on February 11, 2026, at 9:30 AM confirmed the noted information related to the unavailability of Resident 20's Lorazepam 0.5 mg/ml gel. The facility failed to ensure Resident 20 received her physician ordered medications as noted above. 483.45 Pharmacy ServicesPreviously cited June 4, 2025 28 Pa. Code 211.9 (k) Pharmacy services 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent on one of four nursing units (North Nursing Unit; Residents 75 and 94). Findings include: The facility's medication error rate was 11.54 percent based on 26 medication opportunities with three medication errors. Review of Resident 75's current physician orders revealed an order dated September 24, 2025, for Potassium Chloride (potassium supplement) ER (extended release) oral tablet 20 mEq (milliequivalent); give 1 tablet by mouth two times a day, dissolve in small amount of fluid for slurry. Observation of Resident 75's medication administration on February 8, 2026, at 8:37 AM revealed that Employee 10, licensed practical nurse, crushed the Potassium Chloride ER tablet and placed it in pudding with additional crushed medications to administer to Resident 75. Employee 10 did not prepare the Potassium Chloride ER as ordered. Drugs.com (an online comprehensive source of drug information) states do not chew, break, or crush the medication. Review of Resident 75's current physician orders revealed an order dated March 25, 2025, for Calcium 600 plus D plus Minerals (a calcium and vitamin supplement) oral tablet chewable 600-400 mg (milligrams) - unit (international units) (calcium carbonate-vitamin D with minerals); give 1 tablet by mouth one time a day for supplement. Observation of Resident 75's medication administration on February 10, 2026, at 8:35 AM revealed that Employee 8, licensed practical nurse, prepared the medications prior to administration. This preparation included one Calcium 600 plus Vit D3 (a house stock medication containing Calcium 600 mg and Vitamin D 5 mcg (micrograms). Five mcg is the equivalent of 200 units of Vitamin D which was not the concentration of the medication ordered for the resident. Employee 8 then proceeded to administer the medication to Resident 75. Resident 75's medication administration concerns were reviewed with the Nursing Home Administrator and the Director of Nursing on February 10, 2026, at 2:45 PM. Review of Resident 94's current physician orders revealed an order dated August 28, 2023, for Calcium 600 plus D plus minerals oral tablet 600-400 milligrams-unit (calcium carbonate - vitamin D with minerals); give one tablet by mouth two times a day for calcium deficiency. Observation of Resident 94's medication administration pass on February 11, 2026, at 8:10 AM revealed that Employee 8, licensed practical nurse, prepared the medications prior to administration. This preparation included one Calcium 600 plus Vit D3 (a house stock medication containing Calcium 600 mg and Vitamin D 5 mcg). The medication only contained 200 units of Vitamin D and not the 400 units ordered. Employee 8 then proceeded to administer the medication to Resident 94. An interview with Employee 8 on February 11, 2026, at 11:00 AM confirmed that the Vitamin D dose in the house stock medication did not match the dose specified in the physician order for Resident 94. The Nursing Home Administrator and Director of Nursing were notified of the findings for Resident 94 on February 11, 2026, at 11:03 AM. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of select facility policies and procedures, observation, and staff and resident interviews, it was determined that the facility failed to ensure an environment free from the potential spread of infection on one of eight residents reviewed for infection control (Resident 22).Findings include: The facility policy entitled Isolation Precautions, last reviewed without changes September 9, 2025, revealed contact precautions will be implemented for residents suspected or confirmed to be infected with a communicable disease/infection that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces/equipment in the resident's environment. Residents should be placed in a private room when available. Prior to entering the isolation room, the following steps are required: perform hand hygiene and apply gloves and gown prior to entering room, while providing direct resident care, wear gloves and wash hands after coming into contact with infectious material, remove gloves and perform hand hygiene before leaving room. Clinical record review revealed the facility admitted Resident 22 on January 5, 2026. Interview with Resident 22 on February 8, 2026, at 12:35 PM revealed that she came to the facility from the hospital due to Clostridioides difficile (c-diff, a bacterium that causes diarrhea and inflammation of the colon). Review of Resident 22's physician's orders revealed an order for contact precautions for c-diff initiated January 5, 2026. Observation of Resident 22 on February 8, 2026, at 1:20 PM revealed Employee 11 (laundry aide) entered Resident 22's room to put Resident 22's laundry away. Employee 11 wore gloves but did not don (put on) a gown. Observation of Resident 22 on February 8, 2026, at 1:25 PM revealed Employee 10 (licensed practical nurse) entered Resident 22's room and administered Resident 22 her medications. Employee 10 wore gloves but did not don a gown. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on February 9, 2026, at 3:07 PM, who confirmed staff are to wear gloves and gowns when entering a resident's room on contact precautions. 483.80(a)(1)(2)(4)(e)(f) Infection Prevention and ControlPreviously cited deficiency 1/24/25 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of employee personnel and education records and staff interviews, it was determined that the facility failed to ensure that each nurse aide received 12 hours of in-service training annually for one of three nurse aides reviewed (Employee 1).Findings include: Review of Employee 1's, nurse aide, personnel record revealed that the facility hired her on September 21, 2022. The surveyor requested training records for Employee 1 during an interview with the Nursing Home Administrator and the Director of Nursing on February 9, 2026, at 2:38 PM. Review of training records provided by the facility for Employee 1 on February 10, 2026, revealed that Employee 1 completed only 3.35 hours of in-service education in the last year. Interview with the Director of Nursing and the Nursing Home Administrator on February 11, 2026, at 9:44 AM confirmed the above findings for Employee 1, and were unable to provide any further documentation indicating Employee 1 received 12 hours of in-service training annually. 28 Pa. Code 201.19(7) Personnel policies and procedures 28 Pa. Code 201.20(a)(6)(d) Staff development

Based on review of select facility policies, facility documentation, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents were free from neglect for one of five residents reviewed resulting in actual harm (Resident 1, East Hall Nursing Unit). This deficiency is cited as past noncompliance. Findings include: The current facility policy entitled Abuse, revealed that they identified neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect occurs when the facility was aware of, or should have been aware of, goods or services that a resident requires but the facility fails to provide them to the resident, that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. Neglect includes cases where the facility's indifference or disregard for resident care, comfort, or safety, resulted in or could have resulted in physical harm, pain, mental anguish, or emotional distress. A covered individual is anyone who is an owner, operator, employee, manager, agent, or contractor of the facility. Willful is defined in the definition of abuse and means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. It is the facility policy that each resident will be free from abuse. Residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. Clinical record review for Resident 1 revealed that on April 14, 2024, at 7:05 PM Employee 1, licensed practical nurse (LPN), documented a concern (was broken) with the facility's bladder scanner when she attempted to bladder scan Resident 1 per his physician's order to determine the amount of urine in the bladder if his (urine) output was less than 250 cubic centimeters (cc). Employee 1 documented Resident 1's urine output for the evening shift was 200 cc. At 8:30 PM, Employee 1 documented that she held Resident 1's physician ordered Lantus insulin 10 units. Resident 1's blood sugar was 104 mg/dl (milligrams/deciliter) at the time the insulin was held. Review of Resident 1's physician orders revealed no parameters (i.e., hold if less than 120 mg/dl) to hold Resident 1's insulin. Review of Resident 1's April 2024 MAR (medication administration record, a form to document medication administration) revealed that Employee 1, LPN, documented that Resident 1 refused his Oxycodone (narcotic) at 12:00 PM and his Fentanyl (narcotic) patch at 12:21 PM. Employee 1 documented that Resident 1 refused his physician ordered Eliquis (blood thinner) and Ensure (dietary supplement) at 5:00 PM, his Oxycodone at 6:00 PM and 10:00 PM, his Lidocaine (pain medication) and Milk of Magnesia (for constipation) at 8:00 PM. There was no other documentation on April 14, 2024, during the day or evening shift that indicated concerns with the health and welfare of Resident 1. On April 15, 2024, at 12:52 AM Employee 3, registered nurse (RN), documented this nurse was alerted to resident (Resident 1) change in condition reported from prior shift per LPN. This nurse assessed for profound AMS (altered mental status), right sided facial droop, decreased mobility, and weakened grasp in RUE (right upper extremity). Febrile 100.9 (degrees Fahrenheit), bradycardic (slow pulse) at 24 BPM (beats per minute), minimally responsive to verbal and tactile stimuli, inappropriate verbal response when able. BP (blood pressure)/HR (heart rate) labile (unstable). This nurse immediately summoned staff support, code blue on standby (Resident 1 was a full code), 911 dispatched. (Medical Director) on-call service physician assistant-certified: made aware and in agreement with transfer. New orders received: transfer to ER (emergency room ) for evaluation and treatment related to AMS, rule out CVA (cerebral vascular accident, stroke), bradycardia (slow pulse), fever. Transferred via EMS (emergency medical services). Paperwork and POLST (code status) surrendered. Will follow up for outcome of transfer. Review of Resident 1's hospital documentation dated April 15, 2024, at 1:09 AM revealed that the ambulance (EMS) called a stroke alert enroute to the hospital as right sided weakness and slurred speech was noted. In the ER, the physician noted a Glasgow Coma Scale (to determine potential brain injury) of 12 (moderate brain injury) and a National Institute of Scale's Stroke Score of 18 (moderate/severe stroke) with bilateral (both) upper and lower extremity (arm/leg) drift, right sided facial droop, dysarthria (weak muscles causing difficulty speaking), and aphasia (loss of ability to understand and/or express speech caused by brain injury), tachycardia (fast pulse) of 100 BPM. Neurology was consulted who recommended admission for an MRI (magnetic resonance imaging) and further stroke workup. Employee 4's, RN, witness statement dated April 17, 2024, revealed that when she arrived tonight at 10:45 PM, Employee 5, RN, informed her that on her previously worked shift (April 14, 2024, 3-11 PM) Employee 1 did not report to her that Resident 1 was having health issues on the entire shift. This was also reported to Employee 4 by Employee 6, LPN. Per Employee 6, Employee 1 informed the 11-7 AM LPNs of the issue with Resident 1 and instructed them to call their supervisor, Employee 3, to have (Resident 1) assessed. Resident 1 was transferred to the hospital and admitted . Review of Employee 5's witness statement dated April 22, 2024, revealed he was discussing pertinent information regarding recent admissions to the hospital with and LPN (Employee 1) that works 3-11 PM frequently on East Hall (Resident 1's unit). I asked when she first noted a change in (Resident 1's) condition. Her response was that she passed the information to oncoming staff/RN. Employee 5 asked why she didn't give this information to the RN during her shift? (Employee 1's) response was that because she doesn't speak to that RN. Employee 5 told Employee 1 that we have to work together regardless. (Employee 1) laughed and said NO. Review of Employee 7's, nurse aide (NA), witness statement dated April 23, 2024, revealed that Resident 1 was sleeping all day and talking slow, like he was high. Resident 1 told Employee 7 he felt like I've been drugged. Employee 1 and (Employee 7) both noticed he was off - something was not right. Employee 7 had to put food into Resident 1's mouth. Employee 7 indicated the Resident 1's face was pale and droopy when (he) first arrived on shift, doing rounds. (Resident 1) was asking all shift to go to the hospital. Employee 7 indicated that Resident 1's roommate also stated that (Resident 1) was not right. Review of Employee 2's, NA, witness statement dated April 23, 2024, revealed NA was not assigned to the resident (Resident 1) on April 14, 2024, and did not provide any care to the resident (Resident 1). The facility re-interviewed Employee 2 on May 3, 2024. Employee 2 revealed that upon initial interview she was asked if she worked/was assigned to (East) Hall, (Resident 1's unit) which she answered yes. Employee 2 indicated that she was not asked about providing care to Resident 1 specifically. Employee 2 then confirmed that she did provide care to Resident 1 on April 14, 2024, during the evening shift. She stated that she did not recognize a change in condition because she rarely works East Hall and last time she worked on the hall was a long time ago. Employee 2 revealed that (she) don't know (Resident 1's) baseline. I thought he was acting normal. Review of the facility's deployment sheet for April 14, 2024, into April 15, 2024, confirmed that Employees 1, 2, 3, 4, 6, and 7 worked on either evening shift on April 14, 2024, or night shift on April 14th into the 15th, 2024. Further review revealed that Employees 2, 4 and 6 are agency staff. Review of a facility implemented plan of correction, signed by facility administration during an Ad Hoc quality assurance (QA) meeting on April 30, 2024, revealed that the facility implemented the following: On April 15, 2024, when notified of Resident 1's concern staff immediately assessed and received orders for evaluation and treatment at the ER. On April 21, 2024, all East Hall residents were screened to ensure that there was not a change in condition that went unreported within the past two weeks (April 7, 2024, to April 21, 2024). On April 25, 2024, and April 26, 2024, facility staff were reeducated on facility policies regarding a change in condition, neglect, and supervision, Ongoing weekly and again monthly after April 17, 2024, facility staff will audit any reports of a change in condition. Audits will be reported to and reviewed by the QA steering committee monthly. After three months of audits are completed, the committee will review the audit findings and determine the frequency of future audits. Ongoing, the facility will educate newly hired employees on facility policies regarding a change in condition, neglect, and supervision. Interview with the Director of Nursing (DON) on April 19, 2024, at 9:17 AM revealed that he was unaware of the concern identified by Employee 4 until April 22, 2024, as Employee 4 had slipped her witness statement under his door. The DON indicated once notified he initiated a facility investigation immediately. Interview on May 2, 2024, at 9:17 AM and on May 2, 2024, 3:30 PM with the Nursing Home Administrator indicated that the facility substantiated their investigation and founded that Employee 1 neglected Resident 1 while in her care. The DON indicated that Employee 1 was terminated. Past non-compliance was determined that the facility failed to ensure a safe environment that was free from neglect from April 14, 2024, through April 26, 2024. 28 Pa. Code 201.18(b)(2)(e)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of select facility policies, clinical record review, and staff interviews, it was determined that the facility failed to prevent neglect that resulted in actual harm, for one of three residents reviewed (Resident CR1). Findings include: The facility practice guide entitled, Patient Protection, Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation Prevention last reviewed November 2016, defines neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The most critical step toward detecting and preventing abuse is acknowledging that no one should be subjected to neglectful behavior. The facility admitted Resident CR1 on September 30, 2009, with a [DIAGNOSES REDACTED]. The closed clinical record review for Resident CR1 revealed that she fell out of bed on May 25, 2017, at 11:00 AM while receiving care. Employee 1, Nurse Aide, positioned Resident CR1 on her right side and then went into the bathroom to empty Resident CR1's bath water. As Employee 1 was coming out of the bathroom she heard Resident CR1 state, I'm going over and Resident CR1 rolled out of bed onto her knees on the floor. Resident CR1's arms were on the bed and she was partially wedged between the bed and night stand. A nursing progress note dated May 25, 2017, at 11:25 AM revealed that Resident CR1 obtained a bruise measuring 15 centimeters (cm) by 15 cm on the resident's left knee and a 7 cm by 15 cm bruise on the right knee. The resident had moderate to severe pain in bilateral knees when palpated (touched) by the nurse. The nursing documentation at 3:31 PM indicated that Resident CR1 also had a skin tear on the left forearm, left shin, and right toe. The facility notified the physician's assistant and he ordered x-rays to both knees and the right foot and a treatment to the skin tears. The x-rays were completed at the facility on May 25, 2017, at 3:37 PM. The x-ray results revealed bilateral distal (just above the knee joint) femur fractures (both thigh bones were broken). Review of Resident CR1's task Kardex (a list of items indicating care required by the resident) revealed that Resident CR1 was an ADL (activities of daily living) Assist, usually two-person total level of assist. Review of Resident CR1's significant change Minimum Data Set (MDS, an assessment completed to determine care needs) dated March 29, 2017, indicated the resident required extensive assist of two with bed mobility. Review of Employee 1's statement dated May 25, 2017, confirmed that she had Resident CR1 positioned on the resident's right side and went into the bathroom to empty the basin. Employee 1 confirmed that she provided care to Resident CR1 by herself. The interview that the Director of Nursing conducted on May 26, 2017, revealed that Employee 1 stated she did not look at Resident CR1's Kardex prior to giving her care, but that she knew Resident CR1 required two assist. Review of the facility's investigation into the event revealed that the facility determined that Resident CR1 was morbidly obese, unable to turn or position, was totally dependent and two staff would be required for incontinence care and bathing. Interview with the Nursing Home Administrator and the Director of Nursing on May 31, 2017, at 11:50 AM confirmed that Employee 1 should have had two people to care for this resident and that failure resulted in a fall with bilateral distal femur fractures. The facility failed to provide the necessary care and services to prevent neglect of Resident CR1 resulting in actual harm. 28 Pa. Code 201.18(b)(1) Management Previously cited 9/30/16, 6/7/16, 9/18/15 28 Pa. Code 201.18(b)(2) Management Previously cited 9/30/16 28 Pa. Code 201.18(e)(1) Management Previously cited 9/30/16, 5/3/16, 9/18/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 9/30/16, 6/7/16, 5/3/16, 9/18/15 28 Pa. Code 211.12(d)(5) Nursing Services Previously cited 9/30/16, 6/7/16, 5/3/16, 9/18/15

Based on clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision and assistive devices to prevent serious injury for two of 8 residents sampled (Resident 64 and 65). Findings include: Review of Resident 64's plan of care initiated April 29, 2015, revealed that the facility identified Resident 64 as being at risk for falls. On April 29, 2015, the facility initiated the intervention to provide assistance of one staff member to Resident 64 when she transfers or ambulates to and from the bathroom with her rolling walker. A plan of care dated February 17, 2016, indicates that the facility implemented an intervention to provide assistance with toileting. A Minimum Data Set Assessment (MDS, an assessment tool completed at specific intervals to determine care needs) dated February 9, 2016, indicated that the facility assessed Resident 64 as needing the extensive assistance of one staff member to ambulate and use the toilet. Nursing documentation dated February 28, 2016, at 4:50 PM indicated that nursing staff heard Resident 64 calling for help. Upon entering the room and bathroom, nursing staff observed Resident 64 on the floor in front of the toilet. Nursing documentation dated February 28, 2016, at 10:45 PM indicated that Resident 64 was admitted to the hospital with [REDACTED]. Review of the facility's investigation into Resident 64's fall dated February 28, 2016, revealed a statement from Employee 1, licensed practical nurse, indicating that she entered Resident 64's bathroom when Resident 64 was on the toilet, and that Resident 64's bathroom call light was on (indicating that she needed assistance). Employee 1 indicated in her statement that Resident 64 asked her if the girls were busy? Employee 1 stated that she told Resident 64 that they were across the hall. Employee 1 indicated in her statement that she went back into Resident 64's room a few minutes later to administer medications to her roommate, and the call bell was off (however, Resident 64 was still in the bathroom). A statement from Resident 64 indicated that she attempted to pull up her pants and socks, lost her balance, and fell . Resident 64 never indicated in her statement that she turned the bathroom call light off (as she still needed assistance). The facility failed to provide assistance according to Resident 64's plan of care, which resulted in a fall with multiple fractures. Nursing documentation dated March 3, 2016, at 10:01 PM indicated that Resident 64 returned to the facility at 2:30 PM from the hospital. Both of Resident 64's legs were in casts due to fractures. Resident 64 was complaining of severe pain and requesting Percocet (a narcotic pain reliever to treat moderate to severe acute pain). Resident 64's physician wrote a new order for Coumadin (a blood thinner) until her legs are healed and the casts are removed. Review of Resident 65's clinical record revealed nursing documentation dated February 13, 2016, at 7:45 PM that indicated Employee 2, nurse aide, was assisting Resident 65 to get out of her wheelchair. Resident 65 stood up, lost her balance, fell backwards onto her buttocks, and hit her head on the wall. Review of the facility's investigation into Resident 65's incident dated February 13, 2016, indicated that Employee 2 did not use a gait belt (a belt used around a resident's waist to help stability while ambulating). Resident 65's plan of care dated November 24, 2015, indicated that nursing staff were to use a gait belt for all transfers. Nursing documentation dated February 13, 2016, at 9:55 PM indicated that Resident 65 was complaining of a bad headache and neck pain. Nursing staff obtained a physician's orders [REDACTED]. Resident 65 was diagnosed at the hospital with a compression fracture (collapse of vertebra, small bones that are linked together to form the backbone) of her lumbar spine (lower back). Nursing staff failed to use the appropriate nursing care device when ambulating Resident 65 to prevent a fall and an injury. 483.25(h) Accidents. Previously cited 9/18/15 28 Pa. Code 201.18(e)(1) Management. Previously cited 9/18/15 28 Pa. Code 211.10(d) Resident care policies. Previously cited 9/18/15 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited 9/18/15

Based on clinical record review, review of select facility practice guide flowcharts, and staff interview, it was determined that the facility failed to implement interventions to prevent accidents for two of 19 sampled residents (Residents 53 and 2). Findings include: The document entitled, "Falls Practice Guide Flowchart," last reviewed February 10, 2012, revealed that the facility assesses residents risk for falls, implements a plan to prevent further falls, and periodically evaluates the effectiveness of the plan. Clinical record review for Resident 53 revealed that the facility admitted him on March 16, 2012, with dementia. Nursing documentation indicates that Resident 53 was ambulatory at the time of his admission. Social services notes dated March 30, 2012, revealed that Resident 53's goal is for staff to discharge him to home with local services to assist him and his family with care. Clinical record review revealed that nursing documentation and facility investigation reports indicated that Resident 53 often falls or staff finds him on the floor. Resident 53 fell or staff found him on the floor on the following dates indicating that he is at risk for injury due to his lack of safety awareness: March 18, 21, 23, and 26, 2012; April 1, 25, and 29, 2012; May 7, and 25, 2012; and June 3, 2012. The investigation report dated March 26, 2012, revealed that Resident 53 fell when he transferred himself from his wheel chair. Staff implemented hipsters (soft padding to be worn inside the pants to protect hips) to be worn at all times after this fall to aid in preventing injury to Resident 53's hips. Clinical record review revealed nursing notes dated June 7, 2012, indicating that staff found Resident 53 on the floor in the bathroom with his right leg externally rotated. Staff sent Resident 53 to the emergency room where staff diagnosed him with a right hip fracture. The investigation report dated June 7, 2012, revealed that staff did not place Resident 53's hipsters on him, even though this intervention was intended to help prevent hip injury because they were in the laundry. The report also noted that staff placed smooth socks on Resident 53 at the time of his fall instead of non-skid footwear to help prevent falling. There is no documentation in the nursing notes or care plans that staff are to ensure Resident 53 has non-skid foot wear on at all times to help prevent falls despite his history of falling in the facility. Interview with the Administrator and the Director of Nursing on August 16, 2012, at 2:00 PM, confirmed that staff did not place non- skid foot wear or hipsters on Resident 53 on June 7, 2012, when he fell and fractured his right hip. The Director of Nursing confirmed that the facility has enough hipsters for the residents even if designated hipsters are in the laundry. Observation of Resident 53 from August 15 through August 17, 2012, revealed that he was no longer ambulatory since his right hip fracture on June 7, 2012, and that he is now wheel chair bound. There is no updated documentation by social services indicating if Resident 53 is still capable of returning to his home with his family, as was his original goal since admission. Clinical record review for Resident 2 revealed a 14 day MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment dated [DATE], and a quarterly MDS assessment dated [DATE], that assessed Resident 2's transfer status as requiring extensive assistance of two persons providing physical assistance. Nursing documentation dated May 3, 2012, at 7:27 PM, indicated that while the nurse aide was transferring Resident 2 with a sling lift, the sling mechanism suddenly dropped; lowering the resident quickly towards the floor. The nurse aide yelled for assistance. Resident 2 sustained a, "small brush burn from the sling to her left upper arm." There were no measurements to indicate the extent of the, "brush burn." Review of the facility's investigation of the above incident revealed that the facility determined the first shift staff were having problems with the lift earlier in the day, and informed second shift staff of the problems; however, staff from neither shift took the lift out of service. Witness statements obtained as part of the investigation indicated that the nurse aide providing assistance with the transfer called to a nurse who was outside the door for assistance. The facility did not investigate why only one staff member was performing the transfer when the resident's transfer status required extensive physical assistance of two staff. The facility's investigation also did not include a description of the resident's injury. Interview with the Nursing Home Administrator and Director of Nursing on August 16, 2012, at 3:00 PM, confirmed the investigation findings as noted above for Resident 2. 483.25(h) Accidents. Previously cited 9/30/11 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited 9/30/11

Based on clinical record review, review of select facility guidelines, and staff interview, it was determined that the facility failed to provide sufficient fluid intake to maintain adequate hydration for one of 19 sampled residents (Resident 25). Findings include: The "Hydration Management Guideline" last reviewed on August 7, 2012, revealed that when the facility assesses a resident with signs and symptoms of dehydration, the facility provides risk reducing interventions, ongoing evaluation of physical symptoms, and evaluates the resident's response to interventions. Clinical record review for Resident 25 revealed that the facility admitted her on February 22, 2012, with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS, an assessment tool completed at specific intervals to determine care needs) dated July 12, 2012, revealed that Resident 25 needs oversight, cueing, and one person physical assistance for eating and drinking. Laboratory tests completed on February 22, 2012, revealed that Resident 25's BUN (Blood urea nitrogen, lab data indicative of assessing hydration status), was normal at 21 milligrams per deciliter (mg/dL, the normal range is 9-23 mg/dL), revealing adequate hydration status. Resident 25's clinical record contained a nutrition assessment dated [DATE], indicating that Resident 25 requires 2781 cubic centimeters (cc) of fluid daily to maintain adequate hydration. Documentation in Resident 25's clinical record dated July 23, 2012, revealed that nursing staff informed Resident 25's physician that she was not voiding as much. Resident 25's physician ordered laboratory tests. The laboratory tests revealed that Resident 25's BUN was now 41 mg/dL indicating a decline in Resident 25's hydration status. Resident 25's physician responded to this decline by discontinuing the physician ordered [MEDICATION NAME] (a diuretic used to treat fluid retention by increasing urine output) 40 milligrams (mg) by mouth daily. On July 30, 2012, nursing staff informed Resident 25's physician that her mucous membranes "are tacky and her skin tents" (signs and symptoms of poor hydration). Nursing staff requested short term intravenous (IV) hydration. Resident 25's physician responded by ordering IV hydration if Resident 25's oral intake was poor. Nursing staff initiated fluid intake recording on July 30, 2012, with the following results: July 31, 2012, 1240 cc fluid. August 1, 2012, 1200 cc fluid. August 2, 2012, 860 cc fluid. August 3, 2012, 225 cc fluid (no recording for evening hours). August 4, 2012, 870 cc fluid. August 5, 2012, 1140 cc fluid. August 6, 2012, 1660 cc fluid (400 from IV fluids at the hospital, or 1260 cc). Resident 25's fluid intake varied from 1500 cc to 2500 cc below her required intake to maintain adequate hydration. There is no evidence in Resident 25's clinical record that the facility informed Resident 25's physician regarding her poor fluid intake or that the facility followed Resident 25's physician order [REDACTED]. On July 31, 2012, Resident 25's physician diagnosed her with pneumonia, placing her on antibiotic therapy. On August 1, 2012, nursing staff informed Resident 25's physician that Resident 25 was experiencing daily loose stools. Resident 25's physician ordered tests and treatment for [REDACTED]. Both pneumonia and[DIAGNOSES REDACTED] have the potential to deplete body fluids. The facility transferred Resident 25 to the hospital on August 6, 2012, as Resident 25 was described as "cold and clammy, with low blood sugars." Laboratory tests at the hospital recorded Resident 25's BUN at 44 mg/dL, indicating further decline in Resident 25's hydration status. Nursing staff documented on August 6, 2012, that Resident 25 returned from the hospital with a [DIAGNOSES REDACTED]. The hospital recommended that Resident 25 begin IV hydration at the facility. The facility started IV hydration for Resident 25 upon her return to the facility. Interviews with the Nursing Home Administrator and the Director of Nursing on August 16, 2012, at 2:30 PM, and August 17, 2012, at 10:00 AM, revealed that there was no evidence that the facility initiated interventions to maintain adequate hydration status for Resident 25, until August 6, 2012, when she returned to the facility from treatment at the hospital for volume depletion. 28 Pa. Code 201.18(b)(1) Management. Previously cited 9/30/11. 28 Pa. Code 211.10 (d) Resident care policies. Previously cited 9/30/11. 28 Pa. Code 211.12 (d)(1)(5) Nursing services. Previously cited 9/30/11. 28 Pa. Code 211.12 (c)(d)(2) Nursing services.

Based on select facility guidelines, clinical record review, and staff interview, it was determined that the facility failed to ensure an environment free of accident hazards for one of 20 residents (Resident 37). Findings include: Review of the facility's guidelines entitled "Conducting Investigations-Skilled Nursing Facility," last reviewed July 13, 2011, revealed that staff is to respond to investigation findings, such as change a plan of care, evaluate processes, and train employees. A facility investigation worksheet revealed that staff is to identify a root cause, update the resident's care plan, and implement new interventions to prevent further incidents. Review of Resident 37's clinical record revealed [DIAGNOSES REDACTED]. Review of an incident report dated May 20, 2010, at 11:00 PM, revealed that Resident 37 notified staff of a 1.3 centimeter (cm) by 0.2 cm dry scab and several red lines/areas on his right forearm. Resident 37 said he injured himself on a hot plate a day or two ago. The facility investigated the incident and determined that Resident 37's injury is from inadvertently touching the hot plate with his arm. The facility intervention indicated for staff to remove the hot plate when Resident 37's meal tray is delivered to his room. Review of Resident 37's Minimum Data Set (MDS, an assessment tool completed at specific intervals to determine care needs) dated August 5, 2011, revealed that Resident 37 has diminished range of motion in his upper and lower extremities. Nursing documentation dated September 22, 2011, at 10:00 AM, revealed that staff did not identify any skin issues during Resident 37's shower. Review of Resident 37's nursing documentation dated September 23, 2011, at 6:40 PM, revealed that he presented with a skin alteration measuring 7 cm by 8 cm with 7 lines of fluid filled, blistered red skin. Staff contacted Resident 37's physician at that time. Staff did not identify the location of the resident's skin alteration. Review of physician order's dated September 23, 2011, revealed an order for [REDACTED]. Staff are to change the dressing twice a day until healed. The incident report dated September 23, 2011, at 6:38 PM, revealed that Resident 37 sustained a burn on his right forearm, which staff noted to have fluid filled areas and redness. Resident 37 revealed, "It must have been from the hot plate, from lunch." The incident report documentation revealed that Resident 37 burned his arm "like before" and that staff served Resident 37 his lunch tray without removing the hot plate, as indicated on the resident's meal ticket. Review of Resident 37's September 23, 2011, incident report revealed that the facility nurse aide (NA) tasks located on the facility's point of care electronic program failed to alert staff to remove Resident 37's hot plate. Employee 1's, NA, statement dated September 23, 2011, at 8:10 PM, indicated that she gave Resident 37 his tray. Employee 1 stated, "I did not remove the hot plate. I know I am supposed to remove it, but I forgot." A staff statement dated September 23, 2011, revealed that at 4:30 PM, Employee 2, NA, provided incontinence care to Resident 37. Employee 2 noticed red marks on Resident 37's right forearm. Employee 2 revealed, "I know we are supposed to take his (Resident 37) hot plate off related to this reason (burning himself)." Review of Resident 37's plan of care revealed an intervention initiated on June 6, 2007, and updated on September 26, 2011, that indicated Resident 37 prefers to eat in his room and staff is to remove the resident's hot plate base with each meal. Interview on September 27, 2011, at 11:15 PM, with the Nursing Home Administrator (NHA), confirmed that Resident 37 burned his arm on a dietary hot plate. Interview on September 28, 2011, at 2:30 PM, with the Director of Nursing (DON) revealed that the facility did not complete a Pennsylvania Bulletin 22 Abuse Report form regarding Resident 37's September 23, 2011, burn. Interview on September 30, 2011, at 8:45 AM, with Employee 1 revealed that Resident 37 has diminished sensitivity in his right arm. Employee 1 confirmed that she forgot to remove Resident 37's hot plate at lunchtime on September 23, 2011. Employee 1 indicated that removing Resident 37's hot plate at meals was not written or documented anywhere, stating, "We just knew we had to remove it." 28 Pa. Code 201.18(b)(1) Management. Previously cited 7/28/11 28 Pa. Code 211.10(a)(d) Resident care policies. Previously cited 8/27/10 28 Pa. Code 211.10(c) Resident care policies. Previously cited 10/27/10 and 8/27/10 28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 7/28/11, 10/27/10 and 8/27/10