Every finding on record at Edinboro Manor

Based on observations, review of facility policies and documents, and staff interviews, it was determined that the facility failed to provide housekeeping services necessary to maintain a clean environment and clean equipment for two of four resident halls (Resident rooms 32, 34, 35, 38, 40, 41, 43 on C Hall and rooms 56, 57, 58, 59, 60, and 62 on D Hall).Findings include: Review of facility policy entitled Equipment Cleaning and Maintenance dated 12/3/25, indicated IV and enteral poles clean poles thoroughly Review of policy entitled Housekeeping and Maintenance Services dated 12/3/25, indicated Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping residents' care equipment clean. Review of facility Daily resident room cleaning and disinfecting checklist indicated toilet cleaned/disinfected inside and outside, dust mop/mop floor, IV/tube feed poles cleaned and disinfected, and list any maintenance repairs. Review of facility wheelchair cleaning schedule indicated that wheelchairs are to be cleaned per schedule and initial when completed. Observations on 1/12/26, between 12:20 p.m. - 4:00 p.m., and on 1/13/26, between 9:30 a.m. - 10:30 a.m., of resident rooms on C unit revealed: room [ROOM NUMBER]- an IV pole with a thick yellow dried liquid substance covering the base, under the bed a large amount of gray fluffy substance. room [ROOM NUMBER]- an IV pole with a yellow dried liquid substance covering the legs. room [ROOM NUMBER]- a wheelchair with food crumbs on the seat cushion, a white dried liquid substance running down the legs of the wheelchair and under both beds a large amount of fluffy gray substance. room [ROOM NUMBER]- a wheelchair with chunks of food stuck to the cushion, and under both beds a large amount of gray fluffy substances. room [ROOM NUMBER]- a wheelchair with pieces of vinyl covering on the armrest peeling off, a second wheelchair with a cushion that had a large brown stain and the vinyl cover peeling off, under both beds a large amount of fluffy gray substance, food crumbs against the walls and paper and used tissue lying on the floor. room [ROOM NUMBER]- a wheelchair with pieces of vinyl covering on the armrest peeling off, chunks of food on the floor, and a large amount of gray fluffy substance under both beds. room [ROOM NUMBER]- chunks of food on the floor, a hole in the wall behind the bed with plaster dust on the floor, a dark brown ring in the toilet bowl and a large amount of gray fluffy substance under both beds. Observations on 1/12/25, between 1:35 p.m. - 4:25 p.m., and on 1/13/25, between 9:05 a.m. - 10:30 a.m. of resident rooms on the D Hall revealed: room [ROOM NUMBER]- a partially empty bottle of shampoo, a red plastic bag, and an accumulation of a moderate amount of dust under one bed, and moderate amount of potato chips/crumbs, a white and green box, and a moderate amount of dust under and around the other bed. The garbage can was overflowing with a plastic dessert container, pop bottle, and paper. The raised toilet seat had a brown substance smeared on top and around the front, and there was a bark brown ring between the raised and standard toilet seats. room [ROOM NUMBER]- a used washcloth on the floor under the sink, a clear plastic cup under the wheel of the bed, and a moderate amount of dirt and debris accumulated under and around the bed. room [ROOM NUMBER]- a clear plastic cup and thick coating of solid gray substance under the top left corner of the bed, and an accumulation of a moderate amount of dust and debris under one bed. Under the other bed was a brown wrapper and an accumulation of a moderate amount of dust. The raised toilet had a bark brown ring between the raised and standard toilet seats, and there was brown substance smearing around the front of the raised seat. room [ROOM NUMBER]- a used tissue and an accumulation of dust and debris under one bed. A blue, a green, and a brown M&M under the other bed, and an accumulation of dust and debris. room [ROOM NUMBER]- an accumulation of dust under the bed and black shaped ring (unknown material) under the bed. room [ROOM NUMBER]- an empty Dorito bag and an accumulation of dust under the bed. During an interview on 1/13/26, at 10:35 a.m. the Nursing Home Administrator confirmed the condition of the C Hall and D Hall rooms, and the wheelchairs/cushions were not clean and in good repair. He/she also confirmed that the resident rooms and wheelchairs should be clean and in good repair. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(2.1) Management 28 Pa. Code 207.2(a) Administrator's responsibility

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to have complete and accurate documentation regarding skin check/wound documentation for one of six residents reviewed with wounds (Resident R9), and one of nine residents receiving enteral feedings (liquid nutrition delivered through a flexible tube inserted through the stomach wall into the digestive tract) (Resident R94). Findings include: Review of facility policy entitled Documentation, dated 12/03/25, revealed The Manor will provide a complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care. Review of Resident R9's clinical record revealed an admission date of 1/17/23, with diagnoses that included cancer of the pancreatic duct, chronic pain syndrome, diabetes, Parkinson's disease and high blood pressure. The clinical record revealed that on 12/18/25, Resident R9's skin/wound note revealed that Resident R9 had open areas on the left glute and right calf, open areas have been resolved. Skin check notes dated 12/21/25, 12/29/25 and 1/08/26, all indicated that Resident R9 had Stage 3 pressure ulcers (full thickness skin loss) to the left glute and the right calf. During an interview on 1/13/2026, at 9:25 a.m. the Director of Nursing (DON) confirmed that Resident R9's clinical record documentation for the skin check's on the above dates were inaccurate and that the wounds were resolved on those dates. Resident R94's clinical record revealed an admission date of 12/10/25, with diagnoses including stroke, malnutrition, difficulty swallowing, presence of a gastrostomy (g-tube-artificial opening into the stomach to administer nutritional supplement), and prostate cancer. Resident R94's clinical record revealed the following physician's orders dated 12/10/25: document the total intake of enteral feeding and water flushes through the g-tube every shift; flush g-tube with 20-30 mL (milliliters) of water before and after administration of medication; Iso-Source (nutritional supplement) 1.5 at 55 mL/hour through the g-tube every shift; and free water flushes of 100 mL every four hours for hydration. A nutrition progress note dated 12/18/25, indicated that Resident R94 was to receive a total of 1210 mL of feeding and 919 mL of free water in 24 hours. A physician's order dated 12/19/25, identified to disconnect the feeding for up to two hours to allow for personal care (down at 10:00 a,m. and restarted at 12:00 p.m.) Review of Resident R94's medication administration record revealed omitted and inconsistent documentation of the amount of nutritional feeding and water administered through his/her g-tube each shift, and failure to ensure that Resident R94 received the recommended 1210 mL of enteral feeding and 919 mL of free water in 24-hour period. During an interview on 1/15/2026, at 9:30 a.m. the DON confirmed that documentation of nutritional feeding totals and free water was not complete and accurate to ensure that Resident R94 was receiving the required nutrition and hydration. 28 Pa. Code 211.5(f)(xiii)(ix) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, review of facility policy, and staff interview, it was determined that the facility failed to implement measures to prevent the potential for cross contamination (transfer of germs from one location to another) for a gastric feeding tube (a medical device used to provide nutrition and/or medications when a person cannot swallow or take anything by mouth) for one of three residents observed regarding feeding tubes (Resident R3).Findings include: Review of facility policy entitled Tube Feedings dated 12/3/25, indicated Cover the end of the feeding tube with its plug or cap to prevent leakage and contamination of the tube and Store clean equipment away from potential sources of contamination. Review of policy entitled Housekeeping and Maintenance Services dated 12/3/25, indicated Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping residents' care equipment clean and properly stored. Review of Resident R3's clinical record revealed an admission date of 11/3/23, with diagnoses that included multiple sclerosis (a disease where the body's immune system attacks the nerves which can cause vision problems, muscle weakness, numbness, feeling tired, difficulty thinking and bowel and bladder dysfunction), chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), and respiratory failure (a condition where your lungs don't exchange air properly). Review of Resident R3's physician orders revealed an order dated 1/25/24, for enteral feed Nurten 1.5 (type of feeding formula) at 65 cc (cubic centimeters) per hour via pump to provide 1300 daily volume and 1905 calories per day to be down from 8:00 a.m. to 12:00 p.m. daily. Observations on 1/13/26, at 9:38 a.m. and again at 10:15 a.m. revealed Resident R3's tube feeding connection (the part that connects to the resident's gastric feeding tube) was hanging over his/her feeding tube pump and the feeding tube connection was not covered. During an interview on 1/13/26, at 10:15 a.m. the Director of Nursing confirmed that the feeding tube connection was hanging over the feeding pump uncovered and that the feeding tube connection should be covered when it is not connected to Resident R3's gastric feeding tube. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to promote cleanliness and help prevent the spread of infection regarding respiratory care equipment for one of one residents reviewed for respiratory care (Resident R3).Findings include: Review of policy entitled Oxygen Concentrators dated 12/3/25, indicated If there are external cabinet filters present, these are to be cleaned weekly. Review of Resident R3's clinical record revealed an admission date of 11/3/23, with diagnoses that included multiple sclerosis (a disease where the body's immune system attacks the nerves which can cause vision problems, muscle weakness, numbness, feeling tired, difficulty thinking and bowel and bladder dysfunction.), chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), and respiratory failure (a condition where your lungs don't exchange air properly). Review of Resident R3's physician orders revealed an order dated 8/7/25, for titrate (to adjust the flow rate of the oxygen) O2 (oxygen) to maintain sats (saturation) at or greater than 90 percent every shift. Observation on 1/12/26, at 12:05 p.m. and 2:30 p.m. revealed an oxygen concentrator with a large amount of fluffy white substance covering the filters. Observation on 1/13/26, at 9:30 a.m. revealed the large amount of fluffy white substance remained on the filters of the oxygen concentrator. During an interview on 1/13/26, at 10:15 a.m. the Director of Nursing confirmed that there was a large amount of fluffy white substance on Resident R3's oxygen concentrator filters and also confirmed that the filters should be clean. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies and clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current care and services for one of 24 residents reviewed (Resident R10).Findings include: Review of facility policy entitled Care Plan Policy dated 12/3/25, revealed Periodically reviewed and revised by a team if qualified persons after each assessment. Review of facility policy entitled Care Plan Revision dated 12/3/25, revealed The Interdisciplinary Team must update and review the care plan: At least Quarterly, in conjunction with the required quarterly MDS (Minimum Data Set-periodic assessment of resident care needs) assessment. Resident R10's clinical record revealed an admission date of 6/10/25, with diagnoses that included diabetes (a health condition that caused by the body's inability to produce enough insulin), intellectual disabilities (limitations to cognitive functioning and skills), and chronic heart failure. Review of Resident R10's admission MDS dated [DATE], Section H - Bladder and Bowel category H0400. Bowel Continence was marked 2 Frequently Incontinent, the Quarterly MDS dated [DATE], Section H - Bladder and Bowel category H0400. Bowel Continence was marked 0 Always Continent, and the Quarterly MDS dated [DATE], Section H - Bladder and Bowel category H0400. Bowel Continence was marked 0 Always Continent. Review of Resident R10's 30-day task record revealed he/she was always continent of bowel. Review of Resident R10's care plan for bowel created on 6/23/25, with a target date of 3/10/26, indicated Resident R10 was frequently incontinent of bowel. During an interview on 1/15/26 at 9:40 a.m. the Director of Nursing confirmed that Resident R10's bowel care plan was not reviewed/revised to reflect current resident care and that care plans should be reviewed and revised as necessary. 28 Pa. Code 211.5(f)(iii) Medical records 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical record, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for one of 24 residents reviewed (Resident R10) and failed to ensure that a baseline care plan was developed and implemented within 48 hours that included the minimum healthcare information necessary to provide proper care for one of 24 residents reviewed (Resident R110). Findings include: A facility policy entitled, Care Plan Policy dated 12/3/25, revealed .A baseline care plan will be developed within 48 hours of admission.Residents will have the opportunity to discuss their goals including their preferences for advances care planning. Resident R10's clinical record revealed an admission date of 6/10/25, with diagnoses that included diabetes (a health condition that caused by the body's inability to produce enough insulin), intellectual disabilities (limitations to cognitive functioning and skills), and chronic heart failure. Resident R10's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R10 and/or his/her representative. Resident R110's clinical record revealed an admission date of 7/8/25, with diagnoses that included heart failure, chronic obstructive pulmonary disease (a disease that obstructs air flow from the lungs), and anxiety. Resident R110's clinical record lacked evidence that a baseline care plan was developed within 48 hours that included the minimum healthcare information necessary to provide proper care. During an interview on 1/14/26, at 1:38 p.m. the Director of Nursing confirmed that the clinical record for Resident R10 lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R10 and/or his/her representative upon admission to the facility and that the clinical record for Resident R110 lacked evidence that a baseline care plan was developed within 48 hours that included the minimum healthcare information necessary to provide proper care. 28 Pa. Code 201.18 (b)(1) Management

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for one of four residents reviewed (Residents R6).Findings include: Review of facility policy entitled Admission, Transfer, Discharge, and Room Change dated 12/3/25, indicated The Manor is required to provide sufficient preparation and orientation to resident to ensure safe and orderly transfer. Review of Resident R6's clinical record revealed an admission date of 1/13/16, with diagnoses that included diabetes (a health condition that is caused by the body's inability to produce enough insulin), chronic kidney disease (a disease that affects the kidney's ability to filter waste products and extra fluid from the body), and hypertension (high blood pressure). Resident R6's progress notes revealed a note dated 9/27/25, indicating transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. During an interview on 1/14/26, at 1:32 p.m. the Director of Nursing confirmed that Resident R6's clinical record lacked evidence that the necessary clinical information was provided to the receiving healthcare provider upon transfer and when the transfers occurred clinical information should have been provided to the receiving healthcare provider. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c.3) (2) Resident rights

Based on review of clinical records and facility policy, and staff interview, it was determined that the facility failed to provide evidence that a gradual dose reduction (GDR) was attempted and a clinical rationale for the continued use of a psychoactive (affecting the mind) medication for one of five residents reviewed for psychoactive medications (Resident R4). Findings include: Review of policy entitled Psychotropic Drugs dated 12/3/25, revealed residents that use psychotropic drugs receive gradual dose reduction. and A physicians note indicating that the use of the drug, or continued use of the drug is clinically appropriate, and the reason why. Review of Resident R4's clinical record revealed an admission date of 10/8/22, with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically) and delusional disorder (a mental disease that includes delusions a false belief based on an incorrect interpretation of reality). Resident R4's clinical record revealed a physician's order dated 7/12/24, for Aripiprazole (medication to treat behavioral disturbance in dementia) two milligrams by mouth one time a day. The clinical record lacked evidence of an attempt of a GDR and/or rationale for continued use. During an interview on 1/14/26, at 11:50 a.m. the Director of Nursing confirmed that Resident R4's physician's order for Aripiprazole lacked evidence of a GDR attempt or a clinical rationale for continued use. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of clinical records, and staff interview, it was determined that the facility failed to assure physician's orders and resident's Physician Order for Life Sustaining Treatment (POLST- a legal document specifying the resident/responsible party choices regarding life-sustaining treatments) were consistent for one of 24 residents reviewed (Resident R96). Findings include: Resident R96's clinical record revealed an admission date of [DATE], with diagnoses including ankylosing spondylitis of the mid-lower back (inflammatory arthritis that affects the spine, causing stiffness and pain), chronic obstructive pulmonary disease (COPD- group of lung diseases that make it hard to breathe and get worse over time), respiratory failure, irregular heartbeat, and kidney disease. Resident R96's clinical record contained: a physician's order dated [DATE], for a code status of Do Not Resuscitate (instructing healthcare providers not to perform cardiopulmonary resuscitation [CPR- emergency treatment that's done when someone's breathing or heartbeat has stopped] if a patient's heart or breathing stops).a POLST dated [DATE], which indicated that Resident R96 wished to have CPR performed if he/she has no pulse and is not breathing.During an interview on [DATE], at 12:56 p.m. the Director of Nursing confirmed that Resident R96's physician's order and POLST were not consistent with eachother. 28 Pa. Code 201.18 (b)(1)(e)(1) Management28 Pa. Code 201.29(a) Resident rights28 Pa. Code 211.5(f)(i)(vii) Medical records

Based on review of clinical records, observations, and staff interview, it was determined that the facility failed to ensure that a resident with limited range of motion received physician ordered treatment and services to prevent further decrease in range of motion for one of six residents reviewed (Resident R27). Findings include: Review of Resident R27's clinical record revealed an admitted [DATE], with diagnoses that included flaccid hemiplegia affecting left non-dominant side (a condition where a person is paralyzed and unable to move one side of their body), diabetes (a health condition caused by the body's inability to produce enough insulin), and hypertension (high blood pressure). Review of Resident R27's physician's orders revealed an order dated 12/26/24, for left resting hand splint everyday/shift for left hand support; splint on during waking hours; skin to be checked frequently for signs of irritation or breakdown; may remove for hygiene. Observations on 1/28/25, at 12:45 p.m. and again at 2:45 p.m. revealed Resident R27 lying in bed without a left resting hand splint (a splint placed on the hand to help with contractures) to his/her left hand and the left resting hand splint was observed laying on Resident R27's bedside table. Observations on 1/29/25, at 8:40 a.m. and again at 1:00 p.m. revealed Resident R27 was sitting in his/her wheelchair in the lounge without a left resting hand splint to his/her left hand and the left resting hand splint was observed in Resident R27's room laying on the bedside table. Observations on 1/30/25, at 9:20 a.m. and again at 10:45 a.m. revealed Resident R27 was sitting in his/her wheelchair in the lounge without a left resting hand splint to his/her left hand and the left resting hand splint was observed in Resident R27's room laying on the bedside table. During an interview on 1/30/25, at 10:45 a.m. the Director of Nursing confirmed that Resident R27 did not have a left resting hand splint on his/her left hand per physician's orders. He/she also confirmed that Resident R27 should have his/her left resting hand splint on per physician's orders. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of clinical records and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for two of 23 residents reviewed (Residents R110 and R112). Findings include: Resident R110's clinical record revealed an admitted [DATE], with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), and chronic obstructive pulmonary disease (condition when your lungs do not have adequate air flow). R110's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R110 and/or his/her representative. Resident R112's clinical record revealed an admitted [DATE], with diagnoses that included dementia hypertension (high blood pressure), and hyperlipidemia (high cholesterol). R112's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R112 and/or his/her representative. During an interview on 1/30/25, at 1:59 p.m. the Director of Nursing confirmed that the clinical records of the residents listed above lacked evidence that a written summary of the baseline care plan and order summary were provided to the resident and/or his/her representative upon admission to the facility. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to develop a splint care plan for one of 23 residents reviewed (Resident R27). Findings include: Review of facility policy entitled Comprehensive Care Plan dated 12/18/24, indicated. The Manor will develop a comprehensive person centered care plan for each resident . and Periodically reviewed and revise . Review of Resident R27's clinical record revealed an admitted [DATE], with diagnoses that included flaccid hemiplegia affecting left non-dominant side (a condition where a person is paralyzed and unable to move one side of their body), diabetes (a health condition caused by the body's inability to produce enough insulin), and hypertension (high blood pressure). Review of Resident R27's physician's orders revealed an order dated 12/26/24, for left resting hand splint every day/shift for left hand support; splint on during waking hours; skin to be checked frequently for signs of irritation or breakdown; may remove for hygiene. Review of Resident R27's care plans revealed no evidence of a care plan for a left resting hand splint. During an interview on 1/30/25, at 10:45 a.m. the Director of Nursing confirmed that there wasn't a care plan for Resident R27's left resting hand splint. He/she also confirmed that a care plan should have been developed for Resident R27's left resting hand splint. 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.10(c)(d) Resident care policies

Based on review of clinical records and facility policies, and staff interview, it was determined that the facility failed to show evidence of having resident care plan conference meetings or invitation to care plan meetings for one of 23 residents reviewed (Resident R106) Findings include: Review of facility policy entitled Comprehensive Care Plan dated 12/18/24, indicated Residents will have the opportunity to discuss their goals for care . Review of facility skills competency checklist entitled Resident Service Coordinator dated 12/18/24, indicated Demonstrates knowledge of the 72 hours care conference and care planning process. Review of Resident R106's clinical record revealed an admitted [DATE], with diagnosis that include chronic obstructive pulmonary disease (condition when your lungs do not have adequate air flow), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and hypertension (high blood pressure). Review of Resident R106's clinical record lacked evidence that he/she and/or resident representative had been invited/attended a care plan conference meeting. During an interview on 1/28/25, at 2:14 p.m. Resident R106 disclosed that he/she had not attended and/or been invited to a care plan conference meeting. During an interview on 1/31/25, at 10:00 a.m. with Social Services Coordinator Employee E3, he/she confirmed there was no evidence that Resident R106 and/or his/her representative had attended and/or had been invited to a care plan conference meeting since Resident R106 was admitted to the facility. During an interview on 1/31/25, at 10:20 a.m. the Director of Nursing confirmed there was no evidence that Resident R106 and/or his/her representative had attended and/or had been invited to a care plan conference meeting. 28 Pa. Code 211.5(f)(ii) Medical records 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies, manufacturer's guidelines, observations, and staff interviews, it was determined that the facility failed to store controlled schedule II-V medications (medications that may be abused or cause addiction that are closely monitored due to high risk of diversion) in a separately locked permanently affixed compartment and failed to ensure that medications were properly dated when opened in the main medication room, and failed to ensure an expired medication was discarded in a timely manner in one of two medication carts reviewed (A-Wing Cart). Findings include: Review of a facility policy entitled Vials and Ampules of Injectable Medications dated [DATE], indicated that, The date opened is recorded by the first person to use each multidose vial. Prior to each use, the solution in multidose vials is inspected for unusual cloudiness, precipitation, or foreign bodies. The rubber stopper is inspected for deterioration. Multi-dose vials expire 28 days after initial use, unless otherwise indicated by the manufacturer. Review of a facility policy entitled Medication Storage in the Facility dated [DATE], indicated that, Outdated, contaminated, or deteriorated medication and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, returned to ICP, and reordered from the pharmacy, if current order exists. Manufacturer's guidelines for Tubersol PPD (solution used for tuberculosis testing upon admission and for employment), indicated that vials which are entered and in use for 30 days should be discarded. Manufacturer's guidelines for Humalog insulin (a fast-acting insulin used to manage blood sugar levels in people with diabetes), indicates that after opened vials and pre-filled pens should be discarded after 28 days. Observation on [DATE], at 12:13 p.m. of the main medication room refrigerator revealed several vials of controlled scheduled II-V medications in two separately locked containers that were attached to a removeable shelf, therefore they were not permanently affixed to the refrigerator and an opened vial of Tubersol PPD without an open date, therefore the staff were unable to determine the discard date. During an interview at that time Licensed Practical Nurse (LPN) Employee E1 confirmed that the controlled scheduled II-V medications should be stored in a separately locked permanently affixed compartment, and not attached to a removeable shelf and also confirmed that the opened Tubersol PPD vial lacked an open date, and staff were unable to determine the discard date. Observation on [DATE], at 3:18 p.m. of the A-Wing medication cart revealed an open injector pen of Humalog insulin with an open date of [DATE], therefore the medication was expired. During an interview at that time LPN Employee E2 confirmed that the injector pen of Humalog insulin was expired and should have been discarded. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and facility documentation, observations, resident and staff interviews, it was determined that the facility failed to make certain residents were aware of the procedure for filing a concern/grievance (written or verbal, the procedure to file a grievance anonymously), and make certain concern forms are easily located and accessible to all residents and/or representatives on four of four nursing units (A, B, C, D). Findings include: Review of the facility policy entitled, Grievance Policy last reviewed 12/14/23, indicated that: all persons will be provided with an opportunity to present their complaints through a formal grievance procedure; the grievance procedure will be reviewed with all residents at the time of admission, and posted in the Manor; if filing a written grievance, the forms are located in the Administrator's office, must be submitted in writing and signed by the resident or person filing the grievance on behalf of the resident, and lacked guidance related to filing an anonymous grievances. Observation on 2/12/24, at 11:00 a.m. revealed a green sample grievance form in flip chart at the entrance with a round wooden table blocking access to the chart, and no blank forms for resident use, or a box to anonymously place completed grievance forms. During an interview on 2/13/24, at 10:15 a.m. Resident Council Members confirmed that they tell someone if they have a complaint, and do not know if there is an official form or where to get it. During an interview on 2/14/24, at 1:11 p.m. the Nursing Home Administrator confirmed there was no postings of grievance procedures and no way for residents/family to anonymously submit a grievance. 28 Pa. Code 201.29(a)(b)(c) Resident rights 28 Pa. Code 201.18(e)(4) Management

Based on review of facility policy, and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen according to physician's orders for one of four residents reviewed for respiratory care and failed to follow physician's orders related to oxygen equipment for one of four residents reviewed for respiratory care (Residents R45 and R57). Findings include: Review of a facility policy entitled, Disposable Supply Changes dated 12/14/23, indicated that Guidelines of when disposable supplies for medical equipment need changed for infection control purposes. Disposable supplies need to be dated when changed And Oxygen Cannulas (a thin tube with two prongs that fits into the resident's nostrils to deliver oxygen), Oxygen Supply Lines (tubing that connects from the oxygen source to the nasal cannula), and Oxygen Humidifier Bottles) plastic bottles filled with distilled water used to humidify oxygen) should be changed weekly or prn (as needed). Resident R45's clinical record revealed an admitted [DATE], with diagnoses that included heart disease, irregular heartbeat, difficulty speaking and swallowing and hypertension. There was no evidence in the clinical record of a physician's order for supplemental oxygen. Observations on 2/12/24, at 3:57 p.m. and 2/13/24, at 8:39 a.m. revealed Resident R45 sitting in a wheelchair in his/her room with supplemental oxygen via nasal canula (a thin tube with two prongs that fits into the resident's nostrils to deliver oxygen) set a 2 LPM (liters per minute). During an interview on 2/12/24, at 4:39 p.m. Registered Nurse (RN) Employee E2 confirmed that Resident R45 had oxygen in place at 2 LPM. Observation on 2/14/24, at 10:10 a.m. revealed Resident R45 sitting in wheelchair in D Hall with supplemental oxygen via nasal canula attached to a portable tank set at 2 LPM . During an interview at that time RN Employee E1 confirmed that Resident R45 was wearing supplemental oxygen, there was no physician's order and that it was applied in response to an episode of respiratory distress on 12/14/23, and staff failed to obtain a physician's order. Resident R57's clinical record revealed an admitted [DATE], with diagnoses that included Chronic Obstructive Pulmonary Disease, (COPD - a condition that obstructs air flow in the lungs with symptoms of difficulty breathing, coughing and shortness of breath), pneumonia, and Heart Failure (a progressive heart disease that affects pumping action of the heart muscles, causing fatigue and shortness of breath). Resident R57's clinical record revealed a physician's order dated 1/6/23, indicating to Change O2 [oxygen] tubing and supply bag weekly . Change water jug (bottle) weekly. Review of Resident R57's treatment records for February 2024, revealed that Resident R57's oxygen tubing and water bottle was last changed on February 9, 2024. Observations on 2/12/24, at 2:30 p.m. and on 2/14/24, at 8:35 a.m. revealed Resident R57 lying in bed in his/her room with supplemental oxygen on. Resident R56's oxygen tubing had a piece of tape on it indicating it was last changed on 2/4/24, and the water bottle had 2/6/24 written on the top. During an interview on 2/14/24, at 8:42 a.m. Licensed Practical Nurse (LPN) Employee E5 confirmed that the oxygen tubing was dated 2/4/24, and was not changed per physician's orders and the water bottle was dated 2/6/24, and was not changed per physician's orders. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of admission packet and facility documents, observations, and resident and staff interviews, it was determined that the facility failed to post the results of the most recent survey results in a place readily accessible to residents on four of four units (Units A, B, C, D). Findings include: The Admission Notice Packet presented on admission by the facility and posted on entrance and in the survey result book are the Resident Rights. Sec.1919(c)(1) Examination of Survey Results in the admission packet stated the survey results must be made available for your examination by the facility in a place readily accessible to you. Observation on 2/12/24, at 11:00 a.m. an unknown female (later identified by staff as being from Medicaid) was working on a laptop in the resident library, and remained until approximately 4:00 p.m. Observation on 2/13/24, at 8:15 a.m. an unknown female (later identified by staff as the Certified Registered Nurse Practitioner- CRNP) was working on a laptop in the resident library, and remained until approximately 3:00 p.m. Interview on 2/13/24, at 3:00 p.m. with the Nursing Home Administrator (NHA) confirmed who the above visitors were there working in the library. Observation on 2/13/24, revealed a sign located in a glass enclosed case in the facility entrance indicated that the survey results were located in the resident library. Interviews on 2/13/24, at 10:00 a.m. with Resident Council Members confirmed that they did not know where the survey results were located, and stated they assumed they were in the front office. Upon being informed that the survey results were located in the resident library, Resident Council Members confirmed that they do not have access to the resident library on most days, and that there is often someone in there working. Observation on 2/14/24, at approximately 8:45 a.m. five corporate consultants were working in the resident library until surveyors left the building at 3:45 p.m. Interview on 2/14/24, at 1:08 p.m. with the NHA confirmed the presence of individuals working in the resident library. Interview on 2/14/24, at 1:36 p.m. with the NHA identified that the survey results binder was not located in the resident library and was not able to state where it was. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a) Management

Based on review of clinical records and staff interviews, it was determined that the facility failed to accurately code the Minimum Data Set (MDS-periodic assessment of resident care needs) for one of 23 residents reviewed (Resident R59). Findings include: Review of facility policy entitled Resident Assessment Policy dated 12/14/23, indicated Accuracy of assessment. The assessment will accurately reflect the resident's status. Resident R59's clinical record revealed an admitted [DATE], with diagnoses that included chronic kidney disease (a disease that affects the kidney's ability to filter waste products and extra fluid from the body), dependence of renal dialysis (a mechanical treatment that helps remove extra fluid and waste products from the blood when the kidneys are not able to), and diabetes (condition of improper blood sugar levels). Review of Resident R59's clinical record revealed a physician's order dated 1/29/24, that identified that the resident was ordered to go to dialysis on Monday, Wednesday, and Friday at 7:30 a.m. Review of Resident R59's Care Plans revealed a care plan with a focus that indicated I am receiving dialysis services related to kidney failure and chronic kidney disease stage five, with a care plan creation date of 2/15/21. Review of the MDS dated [DATE], Special Treatments, Procedures, and Programs Section O0100 revealed to check all of the following treatments, procedures, and programs that were performed during the last 14 days. Documentation on the MDS for O0100 while a resident under J Dialysis revealed it was answered no. During an interview on 2/14/24, at 1:42 p.m. the Registered Nurse Assessment Coordinator (RNAC) confirmed that the resident was currently receiving dialysis. The RNAC also confirmed that Section O0100 of the MDS dated [DATE], was incorrectly coded for Resident R59 regarding receiving dialysis. 28 Pa. Code 201.14 (a) Responsibility of Licensee

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to fully investigate an incident with injury in a timely manner for one of 24 residents reviewed (Resident R81). Findings include: Review of a facility policy entitled, Accidents and Incidents dated 12/14/2023, indicated that, all accidents and/or incidents occuring on Manor premises involving residents must be investigated. Review of Resident R81's clinical record revealed an admitted [DATE], with diagnoses that included dementia, history of falling and abnormalities of gait and mobility. Review of Resident R81's clinical record revealed a progress note dated 9/20/2023, that identified Resident R81 was lying on his/her back on the floor with feet towards the door and a large amount of bloody drainage noted on the floor and Resident R81's clothes. Resident R81 was assessed with a head laceration to posterior scalp. An order was received from the physician to transfer Resident R81 to the hospital. Review of Resident R81's clinical record and incident documentation revealed a lack of evidence that a full investigation was completed. Further review of the clinical record lacked evidence of interviews from staff present at the time of the incident or handwritten statements from staff. During an interview on 2/15/2024, at 11:00 a.m. the Nursing Home Administrator confirmed that there was not a complete investigation completed on Resident R81's unwitnessed incident with injury, and also confirmed that all incidents should be investigated which included obtaining written statements. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, review of facility policy, and staff interviews, it was determined that the facility failed to provide housekeeping services necessary to maintain a clean environment on one of four units (B Unit). Findings include: Review of facility policy entitled Housekeeping and Maintenance Services dated 12/14/23, indicated The Manor will provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior. Observations on 2/12/24, between 12:40 p.m. - 12:48 p.m., 2/13/24, 9:30 a.m. - 9:39 a.m., and on 2/14/24, at 8:20 a.m. - 8:30 a.m. revealed in room [ROOM NUMBER] a white/brown substance on the floor to the right side of the resident's bed, a white substance on the floor to the left side of the resident's bed, pieces of paper under the bed and under the nightstand, and a large amount of gray fluffy substance over the floor of the resident room, under the resident's bed and covering the flat surfaces of the bed frame. Observations on 2/12/24, between 12:40 p.m. - 12:48 p.m., 2/13/24, 9:30 a.m. - 9:39 a.m., and on 2/14/24, at 8:20 a.m. - 8:30 a.m. revealed in room [ROOM NUMBER] a round quarter-size brown object under bed two, a large amount of gray fluffy substance over the floor of the resident room, and under both resident beds and covering the flat surfaces of both bed frames. In the resident bathroom observation of a brown dry substance on the floor to both sides of the toilet. Observations on 2/12/24, between 12:40 p.m. - 12:48 p.m., 2/13/24, 9:30 a.m. - 9:39 a.m., and on 2/14/24, at 8:20 a.m. - 8:30 a.m. revealed in room [ROOM NUMBER] a crumpled up facial tissue under bed one, a large amount of gray fluffy substance over the floor of the resident room, and under both resident beds and covering the flat surfaces of both resident's bed frames. Observations on 2/12/24, between 12:40 p.m. - 12:48 p.m., 2/13/24, 9:30 a.m. - 9:39 a.m., and on 2/14/24, at 8:20 a.m. - 8:30 a.m. revealed in room [ROOM NUMBER] empty candy wrappers under bed one, paper from dressing supplies under bed one, a used band aide stuck to the floor between bed one and bed two, a large amount of gray fluffy substance over the floor of the resident room, and under both resident beds and covering the flat surfaces of both bed frames. During observations with the Nursing Home Administrator on 2/14/24, at 9:00 a.m. he/she confirmed that Resident Rooms 48, 51, 55, and 61 were not appropriately cleaned. He/she also confirmed that resident rooms should be clean. During observations with Housekeeping Employee E4 on 2/14/24, at 9:15 a.m. he/she confirmed that the above resident rooms on B Unit were not appropriately cleaned. He/she also confirmed that resident rooms should be clean. 28 Pa. Code 201.14 (a) Responsibility of Licensee

Based on a review of facility policy and facility records, observations, and staff interviews, it was determined that the facility failed to maintain safe storage of perishable foods, safe preparation/service of foods, and a sanitary kitchen for all residents creating an Immediate Jeopardy situation for one of one kitchens. Findings include: Review of the facility policy entitled, Storage of Perishable Foods dated 12/15/22, indicated that All perishable goods are refrigerated at the appropriate temperature and in an orderly and sanitary manner. A reliable thermometer shall be provided in a clearly visible position placed inside each refrigerator and freezer close to the door. It is the responsibility of the A.M. and P.M. cook to read and record temperatures. Floor in walk-in refrigerator to be cleaned daily; shelves washed weekly, floor in freezer to be cleaned weekly. Frozen foods stored in recommended temperatures as -10 degrees to -0 degrees. Margarine and eggs are to be stored in packing cartons. Prepared or leftover foods should be stored tightly covered, clearly labeled, dated, and used within 3 days or discarded. Review of the facility policy entitled, Preparation and Holding of Foods dated 12/15/22, indicated that During preparation, food is protected from contamination, and growth of any pathogenic organisms. Bacterial growth is inhibited by holding cooked foods at temperatures of 135 degrees Fahrenheit (F). A thermometer must be available and able to probe thin meats. Temperatures can be measured by inserting a clean calibrated thermometer into the center of foods. Temperatures of each food should be taken at each meal. Review of the facility policy entitled, Food Temperatures dated 12/15/22, indicated that At point of service in the kitchen, all cold foods are served at 41 degrees F or below and all hot foods are served at 135 degrees F or higher. Temperatures are taken and recorded for each meal for all hot and cold foods. Foods allowed to remain at temperatures above 41 degrees and below 135 degrees for a period of two (2) hours must be discarded. Review of the Job Description for Cook for the Nutrition Services Department, provided on 3/1/23, indicated that The Position Summary: Prepares meals according to the daily menu and diet specifications in order to ensure successful completion of daily meal service operations. On 2/28/23, at 11:30 a.m. Registered Nurse (RN) Supervisor Employee E6 was instructed by facility administration to give the initial tour of the dietary department. At the start of the initial tour, the RN Supervisor Employee E6 disclosed that on the evening of Sunday, 2/26/23, he/she cooked the dinner meal, which included grilled cheese, hamburgers, tomato soup, carrots, and mashed potatoes and gravy, due to no dietary cook available. RN Supervisor Employee E6 also indicated he/she had no previous dietary training and did not temp any food items prior to serving the food to the resident population on 2/27/23. He/She verbalized, We just wanted to get hot food out to the residents, so they had something to eat. During the initial tour on 2/28/23, between 11:30 a.m. and 11:45 a.m. observations revealed the following: It was identified that the walk-in freezer was not functioning and food items such as, ice cream and waffles, in the freezer were soft. No internal thermometer was located in the freezer, due to numerous boxes stored on the floor and scattered in an unorganized manner throughout the entire freezer area. Two thermometers were observed on the outside of the freezer, one being a dial thermometer with 40 degrees F observed on it, and the other thermometer was off and blank. A few of the food items in the boxes on the floor were pizza, wax beans, and hot dogs. A box of chicken was observed open with the chicken exposed freely with no date or label to acknowledge when the box was opened. The fans were off in the freezer, and the freezer appeared to be thawing due to moisture dripping from the entire roof of the freezer. In the front corner of the walk-in refrigerator, a soiled mop head was observed on the floor somewhat covering a yellow-colored dried substance. Unpasteurized eggs were observed loosely stored on a plate in the refrigerator. A cookie also was observed laying on the floor. Ceiling fans in the dietary area were observed to be dirty and brown in color. Soiled dark, brown-colored mop heads were located on the floor of the dietary area including the food prep area and dishwashing area. During an interview on 2/28/23, at approximately 11:40 a.m. the RN Supervisor Employee E6 confirmed that the walk-in freezer was not functioning, and food was observed soft and unfrozen. He/She also confirmed unsanitary and unsafe conditions with food boxes stored on the floor, open chicken with no date and/or label to acknowledge when it was opened, a cookie laying on refrigerator floor, eggs stored loosely on a plate in the refrigerator, a yellow substance spilled on floor of refrigerator with a soiled mop head covering it, and dirty brown ceiling vents observed in dietary food storage area. No logs of freezer and refrigerator temperatures were available to review at initial tour. During an interview on 2/28/23, at approximately 1:00 p.m. the Dietary Cook Employee E5 was unable to provide evidence of final food temperatures for past several days of food items served to the resident population, in addition to daily records of freezer and refrigerator temperatures for the past several days. It was also indicated during the interview that the walk-in freezer was ultimately not functioning for approximately 24 hours due to a breaker being turned off on 2/27/23 in the afternoon, approximately 12:00 p.m. On 2/28/23, at 4:18 p.m. the Nursing Home Administrator (NHA) was informed that Immediate Jeopardy (IJ) was identified in the kitchen related to the facility failed to consistently monitor/document final food temperatures, refrigerator, and freezer temperatures in the main kitchen, and utilized untrained staff to perform food preparation service to residents. The IJ Template was provided to the NHA at that time. The immediate action plan for the kitchen to eliminate the immediate risk for food-borne illness was accepted on 2/28/23, at 6:45 p.m. The plan included: 1. Freezer and fridge monitoring to be completed by NHA or trained designee starting immediately 2/28/23. 2. Starting 3/1/23 will be reviewed daily by NHA or Designee for 14 days and then three times per week for 30 days. 3. Final food temperatures to be completed by Serve Safe Trained PM Cook Immediately on 2/28/23. This will be reviewed by the NHA or designee. 4. Starting 3/1/23 food temperatures will be completed by trained staff and will be reviewed daily by NHA or Designee for 14 days and then three times per week for 30 days. 5. Re-education will be provided to staff scheduled on 2/28/23 on food temps and freezer/fridge temps by Licensed Dietitian. 6. Licensed Dietitian and Administrator will ensure that properly trained staff are performing food preparation service to residents immediately 2/28/23. 7. Administrator or Designee will ensure properly trained personnel are scheduled starting 3/1/23 for all meals. The IJ was subsequently lifted on 3/01/23, at 3:44 p.m. when the plan was confirmed to be fully implemented and all kitchen areas were deemed safe to store and serve food and properly trained personnel were scheduled for all meals. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3)(e)(1)(3) Management 28 Pa. Code 207.2(a) Administrator's responsibility 28 Pa. Code 211.6(d) Dietary services 28 Pa. Code 211.6(f) Dietary services

Based on review of clinical records, facility documentation and staff interview, it was determined that the facility failed to provide services to maintain a safe environment in a bathroom that resulted in actual harm when the resident suffered a laceration (cut) above the right eye that required sutures for one of eight residents reviewed (Resident R1). Findings include: Resident R1's Admission Record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident R1's Minimum Data Set (MDS-periodic review of resident care needs), dated 2/04/19, revealed in Section C1000 that Resident R1's cognitive skills for daily living were moderately impaired (decisions poor; cues/supervision required), and that Section G0300D revealed that balance during transitions and walking for Resident R1 was not steady, only able to stabilize with staff assistance moving on and off toilet. Review of a facility incident report regarding an incident that occurred on 12/12/18, revealed that Resident R1 had a previous unwitnessed fall in the bathroom that was without injury. Resident R1's At Risk for Falls care plan revealed that on 12/12/18, an additional intervention of please do not leave resident unattended when in the bathroom was added. An inservice conducted on (MONTH) 11, 2019, and (MONTH) 12, 2019, revealed that staff were educated Do not leave residents in the bathroom or shower unattended. Nurse Aide (NA) Employee E1 had signed the attendance sheets dated 1/11/19 and 1/12/19. Review of information dated 3/26/19, submitted by the facility revealed an event occurred on 3/26/19, which involved Resident R1 while in the bathroom on the toilet, NA Employee E1 stepped out of the room to grab some supplies for care and Resident R1 fell forward landing on the right side of the front of his/her head and was transferred to the emergency room for evaluation. Review of the hospital emergency room report dated 3/26/19, revealed that Resident R1 suffered a laceration above the right eye and required four sutures. A facility incident report dated 3/26/19, involving Resident R1 revealed that at 7:25 a.m. NA Employee E1 assisted Resident R1 onto the toilet in the bathroom, left the bathroom to get something with Resident R1 unattended. Resident R1 fell during the time unattended. The incident report further stated that the resident had a 2.5 centimeter laceration above the right eye that appeared pretty deep. Resident R1 was transferred to the emergency room for treatment. NA Employee E1's statement revealed that he/she had taken Resident R1 to the toilet in the bathroom and left the resident in the bathroom to get Resident R1's clothes. The current Nursing Assistant Job Description revealed that a nursing assistant will assist residents in all activities of daily living, to include, bathing, dressing, eating, toileting, transferring, personal hygiene and ambulation .refers to and follows resident care plan. During an interview on 3/28/19, at 10:37 a.m. the Director of Nursing confirmed that NA Employee E1 stated that he/she stepped out of the bathroom while Resident R1 was on the toilet and knew the resident should not be left alone while in the bathroom and additionally confirmed that Resident R1 required treatment at the emergency room for a laceration above the right eye that occurred on 3/26/19. The facility investigative conclusion revealed that NA Employee E1 was aware that Resident R1 should not have been left unattended and indicated that NA Employee E1 was hurrying and forgot to gather supplies prior to taking the resident into the bathroom. The facility failed to maintain a safe environment and left Resident R1 unattended in the bathroom which placed the resident at risk for injury. As a result, there was actual harm to the resident who suffered a laceration above the right eye requiring four sutures at the emergency room . 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 10/12/18 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited 11/08/17 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.12(c)(1)(5) Nursing services Previously cited 11/08/17