Every finding on record at Edison Manor Nursing & Rehabilitation Center

Based on review of facility policy and Resident Council Minutes, observations and staff and resident interviews, it was determined that the facility failed to provide a safe and homelike environment for residents for two of two nursing care units (Second and Third floor nursing care units).Findings include: Review of a facility policy entitled, General/Routine Environmental Cleaning and Disinfection Policy dated 9/2/25, revealed, Proper cleaning and disinfecting of environmental surfaces is necessary to break the chain of infection. Cleaning refers to the removal of visible soil from surfaces through the physical action of scrubbing with detergents/surfactants and rinsing with water; Process for Environmental cleaning and disinfection includes: Cleaning and disinfection of environmental surfaces immediately if surface(s) are visibly soiled. Daily cleaning and disinfection for high touch surfaces in resident rooms; Household surfaces should be cleaned on a regular basis, when spills occur, and when surfaces are visibly soiled (floors, tabletops, resident care areas, dining rooms, common areas, shared shower rooms and bathrooms, hair salons, activities, etc.) Review of three months of Resident Council Meeting notes revealed: 6/29/26: Residents shared concern of occasional need to request housekeeping service including floor mopping and trash removal. 7/27/26: Concern with consistency of room cleaning and timely replenishment of supplies. Observations on 8/11/2026, between 10:30 a.m. and 1:00 p.m. of the Second and Third floor nursing care units revealed the following: Second Floor:room [ROOM NUMBER] - When standing inside room and closing door, met resistance and door would not close. When letting go of the door, it would spring back open on its own. room [ROOM NUMBER] - Door would not close completely leaving approximately a one-inch gap. room [ROOM NUMBER] - Door would not close completely to allow it to latch. During an interview on 8/11/26, at 11:24 a.m. Certified Nursing Assistant (CNA) Employee E1 and Licensed Practical Nurse (LPN) Employee E2 confirmed that the door to room [ROOM NUMBER] would not shut and when attempting to shut it and let the door go, it would spring back open. During an interview on 8/11/26, at 11:34 a.m. Regional Registered Nurse (RN) and Assistant Director of Nursing (ADON) confirmed that the doors to room [ROOM NUMBER], 224, and 222 were not closing and latching as required. Third floor:room [ROOM NUMBER]-D: head of bed was covered with a personal blanket, no sheets. room [ROOM NUMBER]-D: thick layer of dirt and debris on the floor noted between the bed and dresser. room [ROOM NUMBER]-D no fitted sheet covering entire mattress, sheet noted only covering the ordered perimeter overlay that did not extend over the entire mattress. room [ROOM NUMBER]-D and W- dirt, dust, and debris under both beds in the room. Resident bathroom door missing a threshold and had a hole located in the bottom left corner. Resident bathroom with broken towel bar-left side of towel bar contained an anchor screw sticking out covered by a disposable glove. Observations of Resident R6 in the third-floor hallway on 8/11/26, at 11:39 a.m. revealed Resident R6 sitting in his/her wheelchair. Resident R6's wheelchair was observed to have a thick layer of food like substance laying on the frame of the wheelchair and a dried liquid substance running down the right side of the wheelchair base. Further observation revealed the left armrest was ripped and there was a rip to the left side of the back cushion exposing the foam padding. During an interview on 8/11/26, at 11:40 a.m. CNA Employee E3 revealed that some beds are not made because there are not always enough fitted sheets for the larger mattresses. During an interview on 8/11/26, at approximately 12:15 p.m. the ADON confirmed that there was food like substance on Resident R6's wheelchair base and wheelchair frame, the left armrest was torn and the left side of the back cushion was torn. He/she also confirmed that the wheelchair should be clean and in good repair. The ADON further confirmed that beds in rooms [ROOM NUMBERS] were without sheets covering the entire mattresses, and rooms [ROOM NUMBERS] contained dirt and debris on the floors and room [ROOM NUMBER] had a hole in the bathroom door and the towel rack in the bathroom was broken. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(2.1) Management 28 Pa. Code 211.12(d)(3) Nursing services

Based on review of facility policies and clinical records and staff interview, it was determined that the facility failed to transcribe and act upon physician orders for medications ordered at time of admission for one of three residents reviewed (Resident R2) and failed to follow physician's orders regarding laboratory (blood and urine) orders for two of five residents reviewed (Residents R7 and R9). Findings include: Facility policy entitled admission re-admission Process dated 9/2/25, revealed the process included review of orders; physician verification of orders noted, transmitted to pharmacy, and transcribed to the electronic medication administration record/treatment administration record (eMAR/eTAR). Facility policy entitled Documentation of New or Changed Physician/Prescriber Orders dated 9/2/25, revealed facility should provide new admission order to pharmacy using a completed and reconciled physicians order sheet, telephone order sheet, or an electronically transmitted medication order; Facility should ensure all resident information is complete and accurate, has been reconciled and is verified by physician/prescriber before faxing or transmitting orders to the pharmacy: authorized facility staff should enter new electronic medication orders in the electronic medication ordering system as soon as they are received. Resident R2's clinical record revealed an admission date of 7/17/26, with diagnoses that included cerebral infarction (a condition where a part of the brain is damaged or dies due to a lack of blood supply), hyperlipidemia (high cholesterol), and high blood pressure Resident R2's transfer orders received upon admission revealed an order for Doxycycline (type of antibiotic) 100 mg (milligrams) 1 capsule daily with no stop date. Resident R2's facility physician orders (orders that are transcribed by the facility into the resident's electronic medical record) dated 7/17/26, lacked evidence of an order for Doxycycline 100 mg capsule, one capsule daily, therefore Resident R1 did not receive the Doxycycline 100 mg from 7/17/26, through 8/13/26. Review of Resident R2's progress notes revealed a provider evaluation dated 7/21/26, that stated Ophthalmologic (eye specialist) evaluation identified a left upper eyelid chalazion/hordeolum (bump or cyst that forms on the eyelid) associated with Demodex blepharitis (eye condition caused by an overgrowth of mites living in the eyelashes and oil glands), treated with warm compresses and doxycycline 100 mg daily through July 28, 2026. During an interview on 8/14/26, at 9:45 a.m. the Registered Nurse Assessment Coordinator (RNAC) confirmed that Resident R2's order for Doxycycline 100 mg was not transcribed from his/her transfer orders into his/her medication record on admission and subsequently Resident R2 was not administered the ordered medication. Resident R7's clinical record revealed an admission date of 2/13/25, with diagnoses that included Anemia (a reduction in red blood cells resulting in symptoms such as fatigue and weakness), Diabetes (a health condition caused by the body's inability to produce enough insulin), and High Blood Pressure. Resident R7's clinical record revealed a physician's order dated 1/8/26, for CBC with diff (Complete Blood Count with Differential is a blood test that measures overall blood cell counts) and a physician's order dated 1/19/26 for CDC with diff and CMP (Comprehensive Metabolic Panel is a blood that that measures 14 different substances to give your healthcare provider a picture of your overall physical health). Further review of Resident R7's clinical record lacked evidence of the 1/8/26, and 1/19/26, ordered blood test being completed as ordered. Resident R9's clinical record revealed an admission date of 10/14/25, with diagnoses that included diabetes, Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), and high blood pressure. Resident R9's clinical record revealed the following: a physician's order dated 3/18/26, for CBC with diff and CMP; a physician's order dated 4/15/26, for CBC with diff, CMP, Sed Rate ((Erythrocyte Sedimentation Rate is a blood test that measures how quickly red blood cells settle in a tube, indicating inflammation in the body), ANA Screen (antinuclear antibodies is a blood test that detects antinuclear antibodies, which can indicate autoimmune disease), and CRP (C-Reactive Protein is a blood test that measures the level of inflammation in your body, helping to detect infections, autoimmune conditions, and cardiovascular risk); a physician's order dated 4/17/26 for Uric Acid (a blood test that measures the amount of uric acid in your bloodstream to help diagnose conditions like gout, and kidney stones among other things); and a physician's order dated 6/9/26 for UA (Urinalysis - a diagnostic test that examined urine to detect various substances and assess overall health. Often used to diagnose conditions like urinary tract infections) and C&S (culture and sensitivity is a medical diagnostic test used to identify and quantify the microorganisms present and determine their sensitivity to various antibiotics to guide appropriate treatment) if indicated. Further review of Resident R9's clinical record lacked evidence of the 3/18/26, 4/15/26, 4/17/26, or 6/9/26, ordered blood tests and/or urine tests being completed as ordered. During a telephone interview on 8/14/2026, at 12:49 p.m. the Director of Nursing confirmed that Resident R7 and R9's clinical records lacked evidence of all required blood and/or urine tests being completed as ordered. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.9(a)(1) Pharmacy services

Based on review of facility policy, pharmacy contract/agreement, clinical records, and facility documents and staff interviews, it was determined that the facility failed to obtain ordered medications in a timely manner for one of three residents reviewed (Resident R1).Findings include: Review of a facility policy entitled admission re-admission Process dated 9/2/25, revealed the process included review of orders; physician verification of orders noted, transmitted to pharmacy, and transcribed to the electronic medication administration record/treatment administration record (eMAR/eTAR). Review of a facility policy entitled Documentation of New or Changed Physician/Prescriber Orders dated 9/2/25, revealed facility should provide new admission order to pharmacy using a completed and reconciled physicians order sheet, telephone order sheet, or an electronically transmitted medication order; authorized facility staff should enter new electronic medication orders in the electronic medication ordering system as soon as they are received; If the medication is needed before the next scheduled delivery and is not available in the emergency medication supply, facility staff should: fax or transmit the order to the pharmacy, notify the pharmacy of the exact time by which the medication is needed. Resident R1's clinical record revealed an admission date of 6/17/26, with diagnoses that included epilepsy (a brain condition that causes seizures[a sudden uncontrolled burst of electrical activity in the brain]), Rett Syndrome (genetic disorder that affects brain development), and muscle weakness. Resident R1's eMAR revealed:Physician's order dated 6/18/26 for Alprazolam (a medication used to treat anxiety)1mg (milligram)tablet, administer one tablet twice a day and documentation of missed doses on 6/18/26, 6/19/26, 6/20/26, 6/21/26,6/22/26, 6/24/26, 6/25/26, 6/26/26, 6/29/26 and 6/30/26, due to drug not available. During an interview on 8/13/26, at 10:30 a.m. the Registered Nurse Assessment Coordinator (RNAC) revealed that Resident R1 was admitted to the facility on [DATE], all of his/her meds transmitted from computer program to the pharmacy on admission on [DATE] but the Alprazolam that was entered on 6/18/26 did not transmit over to the pharmacy until 6/30/26. The RNAC further revealed that the nurse that entered the orders is no longer at the facility and it is unclear as to why this medication order did not transmit to the pharmacy. During an interview on 8/13/26, at 1:00 p.m. the RNAC confirmed that there was a delay in receiving the above medication for Resident R1 from the pharmacy that was ordered on 6/18/26 until 6/30/26. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.9(a)(1)(4) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and documentation, clinical records, and resident and staff interviews, it was determined that the facility failed to implement sufficient safety interventions and supervision to prevent elopement (unauthorized leave from the facility). This failure placed residents at the facility in an Immediate Jeopardy situation for one of four residents reviewed who were at risk for elopement from the facility (Resident R1). Findings include: Review of the facility policy entitled, Elopement Unauthorized Absence Policy, dated 9/02/25, defined elopement as leaving the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. The policy also indicated that the facility would: identify residents with potential and/or actual risk factors for elopement and protect the residents through development and implementation of safety interventions. Resident R1's clinical record revealed an admission date of 8/03/23, with diagnoses that included encephalopathy (generalized dysfunction of the brain), stroke, Bipolar disorder (chronic mental health condition characterized by extreme mood swings, alternating between high-energy manic or hypomanic episodes and deep depressive lows), and Epilepsy (chronic neurological disorder characterized by recurrent, unprovoked seizures caused by sudden, excessive electrical discharges in brain cells). Review of an elopement assessment completed on 3/17/26, indicated that Resident R1 was at risk for elopement. Review of a care plan entitled, At risk for injury related to elopement/wandering dated 9/15/25, included interventions to apply a Wander guard bracelet (wearable devices designed for senior care facilities to prevent residents with cognitive impairments from wandering off), check placement, functioning, and skin integrity, and follow facility elopement procedures. A Brief Interview for Mental Status (BIMS) dated 2/06/26, indicated he/she had a score of 10 (moderately impaired cognition). Review of facility documentation dated 4/14/26, revealed the following information: A witness statement typed by the Nursing Home Administrator (NHA) dated 4/14/26, indicated that Employee E2 pulled in the parking lot, heard an alarm; opened the door to stairwell; observed Resident R1 in the doorway; walked with Resident R1 to the parking lot and Employee E1 stayed with Resident R1 while he/she got the nurse.A witness statement typed by the NHA dated 4/14/26, indicated that Resident R1 walked down the long hallway to the door at the end of the hall and went down the stairs; got to the end of the stairwell; while trying to decide which way to go some b**** stopped [Resident R1] before he/she could go anywhere and turned him/her in; and took him/her back upstairs.A handwritten witness statement from Employee E3 dated 4/14/26, indicated he/she observed Resident R1 walking around his/her room; did not realize Resident R1 had left the floor; when the nurse returned from smoking 45 minutes later, he/she proceeded to go down stairs; observed the clear plastic lock box over the elevator button was unlocked; when he/she arrived on the Second Floor staff had been alerted that Resident R1 was outside; he/she returned to upstairs and notified Resident R1's nurse who continued to pass medications; he/she then went outside to assist in getting Resident R1 back inside.A handwritten witness statement from Employee E4 dated 4/14/26, indicated he/she did not witness Resident R1 getting out of the building.A handwritten witness statement from Employee E5 dated 4/14/26, indicated during last rounds he/she was notified Resident R1 was found outside the facility.A handwritten witness statement from Employee E6 dated 4/14/26, indicated that he/she was notified by kitchen staff that a resident wearing a helmet was outside; Employee E6 last observed Resident R1 sitting at nurse's station 45 minutes prior; wander guard did not go off.A handwritten witness statement from Employee E7 dated 4/14/26, around 5:30 a.m. revealed a kitchen worker came to the floor and voiced there was a resident outside; exited outside followed by a maintenance worker; observed Resident R1 standing in the parking lot talking to a housekeeper; Resident R1 stated to Employee E7 that he/she walked down the stairs; wander guard was in place and alarmed when resident came in the door.Employee E1 provided a written statement to the surveyor dated 4/14/26, indicated that he/she arrived at work 5:25 a.m.; observed Resident R1 by the first floor elevator; taking items to the garage then stopped at the smoking area to smoke; observed a car pulling into the parking lot and stood to put out his/her smoke; observed Resident R1 by the roll-off dumpster; as he/she approached Resident R1 the staff who had pulled in (Employee E2) also approached Resident R1; together they engaged in conversation with Resident R1; Employee E2 went to alert nursing staff that Resident R1 was in the parking lot; Employee E1 alerted his/her supervisor that Resident R1 was in the parking lot. During an interview on 4/16/26, at 7:10 a.m. Employee E7 confirmed he/she was alerted by laundry that Resident R1 was outside at 5:30 a.m. He/she went down and with the assistance of maintenance staff were able to get him/her back inside. The 3rd floor nurse did not respond. Employee E8 had stated throughout the shift that he/she was upset about being the only nurse on 3rd floor that night. When Resident R1 was brought back inside, the Wander guard system alarmed. Resident R1 stated to Employee E7 that he/she went down the stairs.Interview on 4/16/26, at 7:20 a.m. revealed Employee E9 was working on the 2nd floor and was alerted by housekeeper that Resident R1 was found in the parking lot by maintenance.Interview on 4/16/26, at 7:25: a.m. with Resident R1 revealed that he/she walked to end of the hall and the door was unlocked, he/she just pushed on it, there was no alarm, so went down the stairs, saw cars outside, then went outside. Resident R1 also stated that there wasn't an alarm on that door either, because if an alarm goes off you stop dead in your tracks. Resident R1 continued to state during the interview that there were a couple people who came up to him/her and next thing they knew there were lots of people there.Interview on 4/16/26, at 7:30 a.m. revealed Employee E1 confirmed that the only doors with Wander guard alarms are the main front door, smoking door, and the second-floor sliding door on ground level that goes to the side parking lot. Employee E1 stated that he/she got here about 5:20-5:25, entered the building and saw Resident R1 by the elevators on the ground floor. He/she punched in and went back to the maintenance garage/office to unload their personal belongings and went to have a smoke. At that time, he/she realized they didn't have a lighter and saw the nurse from 3rd floor outside smoking by the main entrance and asked them for a light. He/she went over to the smoking area near the dumpster to finish smoking. Employee E1 saw a car pull into the lot, put out the smoke, and went back into the maintenance garage. When he/she came back out, the 3rd floor nurse was gone, and then saw a housekeeper approaching Resident R1 from the parking lot near the roll off dumpster area. Employee E1 told the housekeeper to go get nursing staff while he/she waited with Resident R1. After the incident, Employee E1 and another maintenance staff did a walk-through of all the doors and found: 1)the dining room door to the outside was propped open with a rock and 2) the door at the end of the long hall on the third floor was not closed tightly and latched (stairwell that leads directly down to the area where Resident R1 was found). Employee E1 confirmed that he/she has found the locked box securing the elevator button on third floor unlocked and open when he/she comes into work at 5:30-6:00. Employee E1 provided a photocopy of the handwritten statement that was provided to facility administration. During an interview on 4/16/26, at 7:45 a.m. Employee E2 stated that when he/she was walking toward the building Resident R1 came out of the darkness on the sidewalk from between the building and dumpster area that leads to the back of the building. Employee E2 verbalized [Resident R1] scared the crap out of me because I didn't see [Resident R1] until he/she stepped out of the dark. At that same time, Employee E2 saw Employee E1 coming from the maintenance garage area. Employee E1 stayed with Resident R1 while he/she went to second floor and told nursing. Employee E2 confirmed he/she was not asked to provide a written statement about the incident. Employee E2 confirmed that he/she has found the lock box at the third-floor elevator unlocked and open, and the door propped open that leads to the laundry on and off since starting employment at the facility. During an interview on 4/16/26, at 7:53 a.m. Employee E10 confirmed that he/she has found the lock box at the third floor elevator unlocked and open, and the door propped open that leads to the laundry several times when he/she comes to work at six a.m. Observations on 4/16/26, between 7:30 a.m. and 7:45 a.m. revealed the laundry room door propped open and a rock lying against the window frame near the dining room glass door. Observations and Interview on 4/16/26, at 8:00 a.m. with Employee E11 confirmed that the locking mechanism and door handle for the door leading from the housekeeping hallway was broken and unable to be locked to prevent entry into the housekeeping hallway; the laundry room door from the housekeeping hallway is not locked when he/she leaves because the next shift that comes in doesn't have a key and is told by the supervisor that they don't have a key either; the door from the laundry room to the outside also has a broken handle is unable to locked from the inside to prevent exit. Employee E11 confirmed that it is possible for a resident to get into the housekeeping hallway, through the unlocked laundry room door and outside through the unsecured laundry door to the outside of the building. Documents provided by the facility on 4/16/26, and dated 4/14/26, revealed that an elopement drill was conducted with day shift staff; and an elopement in-service was conducted with 35 facility staff on 4/15/26.Review of clinical records for four residents (Residents R1, R2, R3, and R4) identified as elopement risks revealed that elopement assessments were completed on 4/14/26.During an interview on 4/16/26, at 11:40 a.m. the NHA did not consider the incident with Resident R1 an elopement, and had no other documents to provide the surveyor. An Immediate Jeopardy (IJ) situation was identified to the NHA on 4/16/26, at 2:21 p.m. and the IJ template was provided to the NHA, related to Resident R1's elopement from the facility. The NHA was made aware that Immediate Jeopardy existed for the facility's failure to ensure implementation of all safety measures to prevent elopement for residents in the facility and an immediate action plan was requested.On 4/16/26, at 5:30 p.m. an acceptable immediate action plan was approved which included the following interventions:Resident #1 was immediately assessed and assisted back to his unit with no injury. Wanderguard in place and functioning properly by floor nurse.WanderGuard/Watchmate functionality verified by maintenance department immediately following incident on 4/14/2026 by 7am.All unsecured doors were immediately closed and secured following incident by maintenance department on 4/14/2026 by 7am.Resident #1 physician notified with no new orders at 8:55am on 4/14/2026. Resident #1 is his own responsible party.Elopement risk residents reviewed by IDT team and ensured that careplans and orders were in place and elopement binders were up to date on 4/14/26 by 10am.Door ajar alarm placed on identified doors that was propped open on 4/14/2026 by 12pm.Elopement drill completed by staff for education purposes on 4/14/2026 by 2pm.All objects able to be used to prop doors open were removed from door areas on 4/16/2026 by 3pm.All residents (4) at risk for elopement careplans and orders were reviewed and updated, if necessary, by IDT team by 4/16/2026.All staff education on door security, door propping, door codes, elevator lock box and elopement prevention beginning on 4/16/2026 prior to the start of there next shift; prn and agency staff will be educated via phone prior to the start of their shifts.Staff instructed to report malfunctioning doors immediately to maintenance director/NHA.After review of facility documentation, observations, and staff interviews, the implementation of the above stated action plan was confirmed on 4/17/26, at 2:21 p.m. and the NHA was informed that the Immediate Jeopardy situation was removed.28 Pa. Code 201.14(a) Responsibility of Licensee28 Pa. Code 201.18(b)(1)(3) Management28 Pa. Code 201.18(e)(1) Management28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of clinical records, facility documents, facility policy, and staff and resident interviews, it was determined that the facility failed to complete a thorough investigation regarding an elopement for one of four residents reviewed (Resident R1).Findings include:A facility policy entitled, Pennsylvania Resident Abuse Policy dated 9/02/25, indicatedThe facility will investigate all allegations of neglect immediately and report all such allegations to the Administrator (NHA) and the NHA will immediately begin an investigation.The facility defines neglect as the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or coercion.Once the Nursing Home Administrator (NHA) and Director of Nursing (DON) are notified, an investigation of the allegation will be conducted.Conduct interviews with the resident, and all witnesses.Witnesses include anyone who witnessed or heard of the incident, anyone who came in close contact with the resident the day of the incident (including other residents).Obtain written statements from the resident, if possible, and each witness.Evidence of the investigation should be documented.A final report will be submitted to applicable state agency, after the investigation is completed, but no later than five working days after the alleged occurrence.Review of facility documents provided on 4/16/26, revealed evidence that Resident R1 eloped from the facility on 4/14/26, at approximately 5:30 a.m.During an interview on 4/16/26, at 7:25: a.m. Resident R1 stated that he/she walked to end of the hall and the door was unlocked, he/she just pushed on it, there was no alarm, so he/she went down the stairs, saw cars outside, so went outside. There wasn't an alarm on that door either, because if an alarm goes off you stop dead in your tracks. There were a couple of people who came up to him/her and next thing he/she knew there were lots of people there.Review of witness statements provided by the facility on 4/16/26, and dated 4/14/25, revealed lack of handwritten statements from all staff involved in the incident.Interviews with staff on 4/16/26, between 6:45 a.m. and 9:30 a.m. confirmed that not all witnesses were required to submit a handwritten witness statement at the time of the elopement and that Resident R1 was observed to have eloped from the facility on the above stated date and time.There was no evidence that the facility thoroughly investigated Resident R1's elopement in the required time frame following the incident which occurred on 4/14/26, or two days prior to the on-site survey.28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 211.12(d)(5) Nursing services

Based on review of facility records and job descriptions, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to make certain that proper supervision and elopement prevention interventions were effectively implemented in the facility.Findings include:The NHA's job description revealed that the NHA's primary purpose is to lead, direct, and manage the overall operations of the community in accordance with policies and procedures; current federal, state, and local standards, guidelines and regulations that govern the community. To organize, develop and direct resources to maintain the highest degree of quality care is maintained for each resident at all times.The DON's job description specified that the DON is responsible to organize, develop, manage, and direct the overall operations of the Nursing Department in accordance with current federal, state and local standards, guidelines and regulations that govern the community. Work directly with the Administrator and the Medical Director to ensure the highest degree of quality of care is maintained for each resident at all times.The findings in this report identified that the facility failed to consistently supervise and maintain all safety interventions to prevent elopement for their residents, and the NHA and the DON failed to fulfill their essential job duties to ensure that the federal and state guidelines and regulations were followed. Refer to F68928 Pa. Code 201.14(a) Responsibility of Licensee28 Pa. Code 201.18(a) Management28 Pa. Code 201.18(b)(1)(3) Management28 Pa. Code 201.18(e)(1) Management28 Pa. Code 211.12(c) Nursing Services28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on observations and staff and resident interviews, it was determined that the facility failed to provide a homelike environment for residents for two of two nursing care units (Second and Third floor nursing care units). Findings include: Observations on 3/9/2026, between 12:00 p.m. and 1:00 p.m. of the Second and Third floor nursing care units revealed the following: Stock of clean linen on the Second floor nursing care unit revealed no wash cloths, no bed sheets, no towels for use. Observations of the clean storage room on the second floor had no stock available of bedding supplies. Stock of clean linen on the Third floor nursing care unit revealed one cart to have only 1 sheet, 3 pillow cases, zero towels and zero wash cloths for use. Observation of the Third floor clean storage room revealed no further supply of linens for use. Observations of rooms on the Third floor revealed:room [ROOM NUMBER] window: bed was not made, no sheetsroom [ROOM NUMBER] window: bed not made, no sheets room [ROOM NUMBER] no fitted sheet on bed just a flat sheetroom [ROOM NUMBER] bed not made, no fitted sheet, just a flat sheet on bed. During an interview on 3/9/26, at 12:43 p.m. the Registered Nurse Supervisor revealed that beds are not made because there are no linens to use until they come from the laundry room. Observation of the laundry room was conducted on 3/9/26 at approximately 12:55 p.m. revealed that only one washing machine was in functioning use at the time of observation. There was one employee working in the laundry room to sort, wash, dry, fold, and redistribute all linens. At the time of observation, there were 2 wash cloths, 3 towels, 4 sheets and 4 fitted sheets stocked and cleaned for use. There was a load of laundry in the washer and 3-4 bags of laundry that needed sorted in the chute to be separated and washed. Observation of the clean linen cart at 1:00 p.m. on 3/9/26, revealed that there was not enough clean wash cloths, towels, fitted sheets, and flat sheets available for a census of 103 residents at the time of onsite complaint investigation. During an interview with the Nursing Home Administrator on 3/9/26, at approximately 2:30 p.m. it was confirmed that there was not enough clean wash cloths, towels, and bed linens at the time of observation for the 103 residents currently residing in the facility. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(2.1) Management 28 Pa. Code 211.12(d)(3) Nursing services

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in one of one main kitchens and failed to monitor resident's personal refrigerators for temperatures for one of two residents reviewed with personal refrigerators (Resident R78). Findings include: Review of a facility policy entitled Storage of Refrigerated Foods Policy dated 9/2/25, indicated that Perishable foods will be stored in order to maximize food safety and quality. and Refrigerated, TCS (time / temperature control for safety) foods, prepared and held for more than 24 hours will be marked to indicate the date the food will be consumed or discarded. Review of a facility policy entitled Food Brought in From Outside the Facility with a policy review date of 9/2/25, indicated that, Resident room refrigerators: The refrigerator where the food will be stored will have an internal thermometer. Units will maintain safe internal temperature in accordance with state and federal standards for safe food storage temperatures. Temperatures should be monitored and recorded daily. Designated employees will check and record date, refrigerator temperature(s), and initials daily on tracking sheets for all refrigerators and freezers. Facility did not have policy to indicate how they will handle perishable foods with Best if used by/Before, Sell-By, Use-By, and Freeze-By dates. Tour of main kitchen on 1/10/26, between 10:20 a.m. and 10:50 a.m. revealed the following: Walk-in refrigerator had a container of French Onion Soup with a prepared date of 12/30/25, and use by date of 1/4/26; 17 half pint cartons of chocolate milk with a sell by date of 1/3/26; Reach-in refrigerator had a half full five pound container of sour cream with a best by date of 12/30/25, a half full five pound container of coleslaw with a use by date of 12/26/25, and a half full five pound container of egg salad with a use by date of 1/6/26. During an interview on 1/10/26, at 10:39 a.m. Dietary Manager confirmed that the French Onion Soup was six days past the use by date and the 17 cartons of chocolate milk were seven days past the sell by date. During an interview on 1/10/26, at 10:43 a.m. Dietary Manager confirmed that the sour cream was 11 days past the best by date, coleslaw was 15 days past the use by date, and the egg salad was four days past the use by date. During an interview on 1/12/26, at approximately 10:30 a.m. the Regional Director of Clinical Services confirmed the facility policy did not indicate how the facility would handle perishable foods regarding the best by date, sell by date, and use by date. During an interview and observation with Resident R78 on 1/10/26, at approximately 1:30 p.m. it was observed that Resident R78 had a personal refrigerator to store food items. Resident R78 gave permission for the surveyor to open the refrigerator and observe it for safe storage of food items. Upon observation, it was noted that there were food items in the refrigerator. Upon observation there was no thermometer present to determine the temperature of the refrigerator for safe storage of food items, and no recorded temperatures noted. During an interview with the Nursing Home Administrator (NHA) and the Regional Director of Clinical Services on 1/10/26, at 3:30 p.m. it was confirmed that there should be thermometers in each personal refrigerator and temperatures should be recorded in the resident chart by the designated employee. During an interview with the NHA on 1/11/26, at approximately 3:30 p.m., it was confirmed that there was no thermometer in Resident R78's personal refrigerator and no temperatures recorded in Resident R78s charting monitoring the personal refrigerator for safe storage of items. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(2.1) Management

Based on observations, review of facility policy, and staff interview, it was determined that the facility failed to maintain a clean, homelike environment for one of 20 residents rooms reviewed (Resident R5). Findings include: Review of a facility policy entitled, General/Routine Environmental Cleaning and Disinfection Policy dated 9/2/25, revealed, Proper cleaning and disinfecting of environmental surfaces is necessary to break the chain of infection. Cleaning refers to the removal of visible soil from surfaces through the physical action of scrubbing with detergents/surfactants and rinsing with water; Process for Environmental cleaning and disinfection includes: Cleaning and disinfection of environmental surfaces immediately if surface(s) are visibly soiled. Daily cleaning and disinfection for high touch surfaces in resident rooms; Household surfaces should be cleaned on a regular basis, when spills occur, and when surfaces are visibly soiled (floors, tabletops, resident care areas, dining rooms, common areas, shared shower rooms and bathrooms, hair salons, activities, etc.) Review of Resident R5's clinical record revealed an admission date of 1/29/25, with diagnoses that included respiratory failure (a condition where you don't get enough oxygen or you get too much carbon dioxide in your body), persistent vegetative state ( a severe brain injury condition where a person is awake, but shows no signs of awareness), and diabetes (a health condition caused by the body's inability to produce enough insulin). Observations of Resident R5's room on 1/11/26, at approximately 8:50 a.m. revealed a dried washcloth on the floor at the foot of the bed, alcohol wipe wrappers, and a clear plastic syringe lid under the bed by the foot controls. Further observations revealed a white, dry substance on the floor next to Resident R5's bed and in front of the oxygen concentrator. Observations of Resident R5's room on 1/11/26, at approximately 2:00 p.m. revealed the same dried washcloth remained on the floor at the foot of the bed; alcohol wipe wrappers, and a clear plastic syringe lid remained under the bed by the foot controls. Further observations revealed a white, dry substance remained on the floor next to Resident R5's bed and in front of the oxygen concentrator; and a white, dry substance on the front and back of the oxygen concentrator. Observations of Resident R5's room on 1/12/26, at approximately 11:00 a.m. revealed the same dried washcloth remained on the floor at the foot of the bed, alcohol wipe wrappers, and a clear plastic syringe lid remained under the bed by the foot controls. Further observations revealed a white, dry substance remained on the floor next to Resident R5's bed and in front of the oxygen concentrator; and a white, dry substance remained on the front and back of the oxygen concentrator. During an interview on 1/12/26, at 11:20 a.m. the Regional Director of Clinical Services confirmed the dried washcloth on the floor at the foot of the bed; alcohol wipe wrappers, and a clear plastic syringe lid under the bed by the foot controls. He/she also confirmed that there was a dried white liquid substance on the floor next to Resident R5's bed and on the front and back of Resident R5's oxygen concentrator. He/she confirmed that residents' rooms should be kept clean. 28 Pa. Code 201.14 (a) Responsibility of Licensee 28 Pa. Code 201.18 (e) (2.1) Management

Based on review of facility policy 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 20 residents reviewed (Resident R8).Findings include: Review of facility policy entitled Comprehensive Care Planning Policy dated 9/2/25, indicated that An interdisciplinary plan of care will be established and updated as indicated for every resident in accordance with state and federal regulatory requirements. And The care plan is reviewed on an ongoing basis and revised as indicated by the resident's needs, wishes or change in condition. At a minimum this will occur with each comprehensive and quarterly assessment in accordance with Resident Assessment Instrument (RAI) requirements. Resident R8's clinical record revealed an admission date of 2/15/21, with diagnoses that included stroke (occurs when blood flow to the brain is blocked or a blood vessel inside or on the surface of the brain bursts causing brain cells to die often times, but not always leading to permanent disabilities), bipolar disorder (a mental health condition where you experience extreme mood swings that include emotional highs and lows. It causes significant shifts in mood, energy, activity levels, and concentration, affecting a person's overall functioning), and dementia (loss of cognitive functioning affecting a person's memory and behaviors). Resident R8's physician's orders dated 7/2/25, revealed an order to discontinue Seroquel (Antipsychotic Medication (type of medications used to treat psychosis related conditions such as Dementia, Bipolar, Schizophrenia), 25 milligram (mg) daily. Further review revealed no additional orders for any antipsychotic medications. Resident R8's clinical record revealed a care plan started on 5/30/24, and reviewed on 10/24/25, with a problem Resident receives antipsychotic medication. During an interview on 1/12/26, at 2:43 p.m. the Regional Director of Clinical Services confirmed that Resident R8 was no longer receiving any antipsychotic medications, and his/her care plan was not updated to reflect their current status. 28 Pa. Code 211.5(f)(i) 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 records, and staff interview, it was determined that the facility failed to maintain complete and accurate documentation for two of 20 residents reviewed (Residents R5 and Closed Record CR91).Findings include: Review of a facility policy entitled Enteral Feeding Tube Policy dated 9/2/25, indicated Flush tube according to physician direction. Review of a facility policy entitled Dietary Enteral Nutrition Care Policy dated 9/2/25, indicated The use of an enteral nutrition tube has a major impact on a resident and his or her quality of life. Enteral nutrition tubes will be utilized only after assessment determines that the clinical condition of the resident makes the use of the feeding tube medically necessary. Review of a facility policy entitled Resident Change in Condition dated 9/2/25, indicated The Physician/Provider and Resident/Family/Responsible Party will be notified when there has been a significant change in the resident's physical/emotional/mental condition. Review of a facility policy entitled Post Mortem Care Policy dated 9/2/25, indicated Document postmortem care, time body was released and to whom and complete the inventory of personal effects nothing final disposition of everything listed: transported with resident, sent home with family/representative, left on resident's body, or retained by the facility. No policy provided by the facility regarding documentation. Review of Resident R5's clinical record revealed an admission date of 1/29/25, with diagnoses that included respiratory failure (a condition where you don't get enough oxygen or you get too much carbon dioxide in your body), persistent vegetative state ( a severe brain injury condition where a person is awake, but shows no signs of awareness), and diabetes (a health condition caused by the body's inability to produce enough insulin). Resident R5's clinical record revealed a physician's order dated 11/28/25, for enteral feeding, Free Water: Administer 200 cubic centimeter (cc) of water four times per day (QID) for total of 800cc/day. Flush tube with 60cc free water before and 30cc free water between meds. (Record amounts every shift); a physician's order dated 12/17/25, for Diabetisource AC at 100 ml per hour continuous via gastric tube x 20 hours (Up at 12:00 a.m., down at 8:00 p.m. or when total amount infused. Total volume 2000ml per day. Day =1200ml, Night=800ml). Review of documentation of water flushes for Resident R5 from 12/1/25, through 1/10/26, under the medication administration record revealed Resident R5 received less than the ordered 200 cc of water flush QID (not counting medication flushes) fifteen times. Documentation also revealed that facility lacked any evidence of water flushes four times. Review of documentation of formula intake for Resident R5 from 12/17/25, through 1/10/26, under the medication administration record revealed Resident R5 received less than the ordered 2000 ml of formula per day eighteen times, and more than the ordered 2000 ml of formula per day one time. During an interview on 1/11/25, at 2:45 p.m. the Regional Director of Clinical Services confirmed that Resident R5's clinical record contained incomplete and inaccurate documentation related to his / her tube feeding formula and water flushed. Resident CR91's clinical record revealed an admission date of 10/3/25, with diagnoses that included sepsis (a reaction to an infection that causes extensive inflammation throughout the body, potentially leading to tissue damage, organ failure, and even death), cerebral palsy (a brain disorder that appears in infancy or early childhood, permanently affecting body movement and muscle coordination. It is caused by changes in the developing brain that disrupts its ability to control movement and maintain posture and balance), and Non-ST Elevation Myocardial Infarction (NSTEMI – a type of heart attack characterized by a partial blockage of an artery that leads to a lack of blood flow to the heart muscle). Resident CR91's clinical record progress note dated 10/20/25, at 9:10 a.m. revealed Call to PCMA regarding elevated Temp, face flushed, decreased oral intake and lethargy. A progress note dated 10/20/25, at 11:00 a.m. revealed New Orders received PRN (as needed) Tylenol every 6 hours, STAT chest x-ray, and lab in the morning. A progress note dated 10/20/25, at 9:34 p.m. revealed Resident ceased to breath at 2118 (9:18 p.m.), the RN called the sister and notified her about the brother's demise. The body is to be discharged to funeral home. A progress note dated 10/20/25, at 9:45 p.m. revealed Placed a phone call to Funeral Home, provided required information, a crew will be here shortly, the body is ready to be picked up. Resident CR91's clinical record lacked evidence of assessment of Resident CR91's condition between 10/20/25, at 9:10 a.m. and 10/20/25, at 9:34 p.m. when Resident CR91's sister was notified of his/her passing. Resident CR91's clinical record also lacked evidence of physician notification of his/her death, physician order to release body to the funeral home, and information regarding when he/she was released from the facility to the funeral home and if any belongs were sent with him/her at the time he/she was released to the funeral home. During an interview on 1/13/26, at 1:43 p.m. the Director of Nursing confirmed that Resident CR91's clinical record lacked any evidence of assessment of Resident CR91 on 10/20/25, between 9:10 a.m. and 9:34 p.m. when Resident CR91's sister was notified of his/her passing, physician notification of his/her death, physician order to release the body and when Resident CR91 was actually released to the funeral home and if any of his/her belongings were sent with him/her. 28 Pa. Code 211.5(f)(ii)(iii) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to ensure that the call bell system was adequately working for one of one residents reviewed (Resident R49). Findings include: Review of the facility policy entitled, Call Light Resident Communication System Policy with a policy review date of 9/2/2025 , revealed that it is the policy of the facility to provide residents with a means of communicating with staff. A call system is installed in each resident room and toilet/bath areas. The facility responds to resident needs and requests. Observation in Resident R49's room revealed the call bell system in the corridors did not illuminate when resident call bell button was pressed. There was also no signal to the front desk area that the call light was activated. Resident R49 revealed that there are constantly long wait times when he/she calls for help of over 60 minutes and last night nobody came to assist him/her at all.During an observation and interview on 1/10/26, at approximately 1:00 p.m. the Maintenance Director confirmed that call bell button for Resident R49 was not functioning and needed replaced.During an interview on 1/10/26, at approximately 3:30 p.m. the Nursing Home Administrator confirmed that the call light button for Resident R49 was not functioning and needed replaced preventing Resident R49 from alerting staff for assistance. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1) Management

Based on review of facility policy, pharmacy contract/agreement, clinical records, and facility documents and staff interviews, it was determined that the facility failed to obtain ordered medications in a timely manner for two of four residents reviewed (Residents R3 and R4). Findings include: A facility policy entitled New Admission/readmission Process revised on 3/19/25, revealed the process included review of orders; physician verification of orders noted, transmitted to pharmacy, and transcribed to the electronic medication administration record/treatment administration record (eMAR/eTAR). Pharmacy contract/agreement effective 7/01/24, included: all controlled substance orders should be communicated to the pharmacy as follows: If the medication is needed before the next scheduled delivery, facility staff should indicate the exact time by which the medication is needed; If the controlled substance is needed before the pharmacy can make arrangements for a timely delivery, the facility should fax a request to remove a controlled substance from the emergency medication supply to the pharmacy. Resident R3's clinical record reviewed an admission date of 5/15/25, with diagnoses that included Type 2 Diabetes (chronic condition where the body either doesn't produce enough insulin or can't properly use the insulin it produces, leading to high blood sugar levels), lumbago with sciatica (irritation, inflammation, pinching or compression affect one or more nerves that run down your lower back and into your legs), depression, and difficulty walking. Resident R3's eMAR revealed: -Bupropion (antidepressant) missed dose on 5/16/25, due to drug not available. -CoQ-10 (supplement helps with migraines, heart failure and high blood pressure) missed doses on 5/19/25, 5/20/25, 5/22/25, 5/24/25, and 5/27/25, due to drug not available. -Prednisone (steroid) missed dose on 5/16/25, due to drug not available. -Tresiba (anti-diabetic) missed dose on 5/16/25, due to drug not available. -Adult multivitamin gummies missed doses on 5/16/25, 5/19/25, 5/20/25, 5/22/25, 5/24/25, and 5/27/25, due to drug not available. -Baclofen (muscle relaxant) missed dose on 5/22/25, due to drug not available. Resident R4's clinical record revealed an original admission date of 1/29/25, with diagnoses that included respiratory failure, persistent vegetative state (condition in which a person is awake but lacks awareness of themselves or their surroundings), tracheostomy (surgical hole through the neck and into the windpipe to help air/oxygen reach the lungs), paranoid schizophrenia (subtype of schizophrenia [a chronic mental health disorder characterized by significant disturbances in thought, perception, and behavior] that includes intense delusions, and hallucinations, particularly auditory ones, where individuals may hear voices that aren't real), and gastrostomy (tube inserted through the wall of the abdomen directly into the stomach). Resident R4's eMAR revealed: -Atropine sulfate (drug used to block nerve stimulation of muscles and glands to reduce excessive saliva production or tracheal/bronchial secretions, especially when a person has difficulty swallowing) missed dose on 5/15/25, due to drug not available. -Cipro (antibiotic) missed dose on 5/07/25, due to drug not available. -Cefepime (antibiotic) missed dose on 5/04/25, due to drug not available. -Diazepam (treats anxiety, seizures, muscle spasms or twitches) missed doses on 5/22/25 (twice), 5/23/25, 5/28/25 (twice), due to drug not available. During an interview on 6/18/25, at 4:00 p.m. the Nursing Home Administrator (NHA) confirmed that when Resident R3 was admitted to the facility on [DATE], at approximately 7:00 p.m. staff sent the medication orders to the pharmacy at 10:21 p.m. (too late for the routine nighttime delivery on 5/16/25, 11-7 shift); the pharmacy processed the orders on 5/16/25, at 8:37 a.m. (too late for the routine afternoon delivery on 5/16/25, 7-3 shift), therefore Resident R3's medications were not delivered to the facility until the routine nighttime delivery on 5/17/25, 11-7 shift. Interview on 6/18/25, at 4:00 p.m. the NHA confirmed that there was a delay in receiving the above medications for Residents R3 and R4 from the pharmacy due to a lack of instruction in the pharmacy policy/contract for staff and obtaining non-controlled medications before the routine pharmacy delivery time, and that staff failed to request (from the pharmacy) access to the controlled emergency medication supply in the facility. The NHA also confirmed there is no listed alternate pharmacy for the facility to obtain medications needed in an urgent situation. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.9(a)(1)(4) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of clinical records and facility documents, and staff interview, it was determined that the facility failed to follow physician's orders for eight of 13 residents reviewed (Residents R1, R2, R3, R5, R10, R11, R12 and Resident R17). Findings include: During wound dressing observations on 3/26/25, from 8:45 a.m. through 9:30 a.m. with Licensed Nurse Employee E1, the daily wound dressings for Residents R1, R2, R3, R5, R10 and R12 were noted to be absent. During this time, Licensed Nurse Employee E1 confirmed the absence of the wound dressings and that the dressings were to be changed and reapplied daily. A review of these resident's clinical records revealed each had physician's orders to change and apply a new wound dressing daily. Additionally, review of R17's clinical record revealed that the resident was cognitively intact and physician's orders for daily wound dressing changes were present. Resident R17 also verified that staff failed to complete daily wound dressing changes as physician ordered. During interviews on 3/26/25, from 8:45 a.m. through 11:35 a.m. cognitively intact Residents R2, R3, R10, and R12 verified that they were to have wound dressings changed daily, but that the staff rarely changed the dressings daily. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and documents, and resident and staff interviews, it was determined that the facility failed to ensure that the residents are able to voice their concerns at the meetings, and that the meeting concerns are recorded for timely follow-up and resolutions to resident concerns for seven of seven Resident Council attendants (Residents R9, R14, R56, R62, R67, R73, and R85). Findings include: Review of a facility policy entitled Resident Council Policy dated 9/2024, indicated that the Life Enrichment Director or designee may attend the Resident Council Meeting to act as a liaison between the group and the facility if requested by the Council. Any additional facility personnel will attend the meeting upon request of the residents. The Activity Director will attempt to accommodate the resident recommendations to the extent practicable and provide follow-up to the Resident Council. Resident Council will document minutes of each meeting along with attendance on the Resident Council Meeting Minutes Form. Resident issues or concerns will be documented on the Resident/Family Concern Form and forwarded to the facility Administrator for the appropriate follow-up. If a particular resident is voicing a concern versus a group concern, the resident may or may not include their name. Once the respective department has addressed the Resident/Family Concern and document the outcome, the form is returned to the Life Enrichment Director to file with the Resident Council Minutes. Resident Council minutes from 10/28/24, revealed no concerns with administration, nursing, dining services, maintenance, laundry, social services, therapy, business office, life enrichment. Food committee-residents stated they would like to have different snacks available. We now have more option for snack now *Nutri grain bars *Fig bars. Resident Council minutes from 11/25/24, revealed resolutions old business-Review of Previous Meeting, Outstanding Issues and Resident Council Departmental Response Forms Resolutions from last meeting (from the concern forms): Administration issue/concern: No issues. Resolution: No concern. Nursing issue/concern: Cellphones in hallways. Resolution: No issues, residents stated they have not been seeing staff on their phones. Dining Services issue/concern: Resolution: No issues residents stated they enjoy eating in the dining room. Maintenance issue/concern: No issues. Laundry issue/concern: Resolution: No issues. New Business Administration-Residents stated the administrator is great. Nursing-No concerns. Residents stated staffing is better, aids should knock before entering rooms stated residents. Most aids do knock on the doors. Dining Services-Residents stated they enjoy eating in dining room. Maintenance-Residents stated he is great, doing a great job, no complaints. Laundry-no concerns resident stated there not missing any items this month. Social Services-no concerns. Therapy-Residents stated therapy is good at what they do. Business office-No concerns. Food Committee-residents stated they're happy to now get chef salads as a substitute. Resident Council minutes from 12/30/24, revealed resolutions old business-Review of Previous Meeting, Outstanding Issues and Resident Council Departmental Response Forms Resolutions from last meeting (from the concern forms): Administration issue/concern: No issues. Nursing issue/concern: Cellphones use in hallways. Resolution: No cell phone use in hallways. Dining Services issue/concern: Residents stated they want more residents to eat in the dining area. Resolution: We have more residents eating in dining area at this current time. Maintenance issue/concern: No issues. Laundry issue/concern: No issues. New Business Administration-No concerns. Residents stated the administrator is doing great. Nursing-No concerns. Residents stated staffing is better. Call lights are getting better. Resident did state there is some use of cell phones in hallways staff mostly agency aids. Dining Services-no concerns residents enjoy eating in dining room. Residents stated there are more residents that come down to dining area feels like family eating together. Maintenance-No concerns. Residents are sad to see him leave. Laundry-No concerns. Residents stated laundry is not an issue this month. Social Services-No concerns. Therapy-No concerns. Residents state therapy is great. Business office-No concerns. Life Enrichment-Residents would like to change evening bingo times. Life enrichment director will work on doing that. Food Committee-No complaints for food committee residents stated food is good. During a Resident Council meeting on 1/07/25, between 1:00 p.m. and 1:35 p.m., seven resident council attendants (Residents R9, R14, R56, R62, R67, R73, and R85) elicited concerns that their Resident Council monthly meeting concerns are not followed up by each department. Residents further indicated they never hear back from the facility and/or see any positive resolution from their concerns. Residents revealed in the past three months (October, November, and December of 2024) concerns for call bell response times (times revealed by residents ranged between 30 minutes and one hour time period for staff to respond to a call bell), snack availability (residents revealed that snacks are not available often, either the dietary department does not supply them to the floors and/or staff state there are none available and will not bring any to the residents' rooms), food quality, palatability, and temperature of resident meals, linen and resident care supplies availability (residents revealed wash cloths, towels, sheets, paper towels, soap, and incontinence products are not available daily) and housekeeping do not clean their rooms often enough due to lack of staff, .were voiced each month and not addressed by the facility and/or resolutions communicated back to the Resident Council residents. During an interview on 1/07/25, at 3:00 p.m. the Activity Director revealed that no concerns, other than some dietary issues, were ever mentioned by the residents in the past three months of Resident Council (October, November, and December of 2024). During an interview on 1/08/25, at 3:00 p.m. the Social Services Director revealed that no concerns from Resident Council were provided to him/her to follow up with each department for the past three months (October, November, and December of 2024). The Nursing Home Administrator indicated on 1/08/25, at 2:10 p.m. that the Social Services Director would be the facility person to follow up on Resident Council concerns. Review of Resident Council meeting notes from October, November, and December 2024, revealed a lack of evidence of resident contribution and/or participation in the Resident Council meetings and evidence regarding how the facility responded to any resident concerns. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (e)(1)(4) Management

Based on review of facility policy, staff and resident interviews and observations, it was determined that the facility failed to provide adequate housekeeping services to maintain a clean and sanitary environment for 14 of 94 resident rooms (Rooms 207, 209, 210, 217, 220, 223, 224, 226, 303, 307, 310, 319, 321, and 325 ), and for one of two dining rooms. Findings include: Facility policy, General/Routine Environmental Cleaning and Disinfection Policy dated 9/2024, revealed proper cleaning and disinfecting of environmental surfaces is necessary to break the chain of infection. Cleaning refers to the removal of visible soil from surfaces through the physical action of scrubbing with detergents/surfactants and rinsing with water. Process for Environmental cleaning and disinfection includes: working from clean to dirty; working from top to bottom. Cleaning and disinfection of environmental surfaces immediately if surface(s) are visibly soiled. Daily cleaning and disinfection for high touch surfaces in resident rooms. Household surfaces should be cleaned on a regular basis, when spills occur, and when surfaces are visibly soiled (floors, tabletops, resident care areas, dining rooms, common areas, shared shower rooms and bathrooms, hair salons, activities, etc). Horizontal surfaces with infrequent hand contact (e.g., windowsills and hard-surface flooring) in routine patient care areas require cleaning on a regular basis, when soiling or spills occur, and when a patient is discharged from the facility. Cleaning of walls, blinds, and window curtains is recommended when they are visibly soiled. Interviews with Residents R9, R56, R62, R67, R73, and R85 on 1/07/25, at 1:00 p.m revealed the residents feel the facility and their rooms are unsanitary and not cleaned sufficiently and/or often enough. Observations on 1/06/25, from 11:25 a.m. through 2:30 p.m. of resident rooms revealed the following: Rooms 220, 223, 224 and 226: the floors were dirty with dried stains, debris, trash and what appeared to be food particles. The bathroom of room [ROOM NUMBER] was noted to be without toilet paper. Observations on 1/06/25, 1/07/25, and 1/08/25, at approximately 11:30 a.m of room [ROOM NUMBER] revealed a lancet (a small medical device that releases a needle to prick the skin and obtain a blood sample), medication cup, used band-aid, gauze with blood stain, and a wound vac strap laying on the floor under and near the window bed. A dried brown liquid was also observed on the wall and floor near the window bed. Observations of room [ROOM NUMBER], on same dates as noted above, revealed brown stains on the privacy curtain, and room [ROOM NUMBER] with a lancet, nebulizer, and a yellowish-brown dried liquid under the resident's bed by the door. The Nursing Home Administrator (NHA) confirmed the above observations in rooms [ROOM NUMBER] on 1/08/25, at 11:55 a.m. that were unsanitary, and the rooms were not cleaned sufficiently. Review of housekeeping form entitled housekeeping resident room checklist, which all housekeeping staff fill out ensuring all rooms get cleaned and stocked completely, revealed that housekeeping staff should refill paper towels and soap dispensers. Observations on the second floor east hall resident care area on 1/06/25, at about 4:15 p.m. revealed that 2 east hallway hand sanitizer dispensers were empty. Observation of room [ROOM NUMBER] restroom revealed no paper towels or toilet paper, room [ROOM NUMBER] had no soap in the soap dispenser, room [ROOM NUMBER] had no paper towels or toilet paper, and room [ROOM NUMBER] had no paper towels. During an interview with Licensed Practical Nurse Employee E2, at the time of the observations, it was confirmed that the restrooms observed and hallway hand sanitizer were not stocked with the supplies for resident use. Observations of the 3rd floor east hall resident care area on 1/07/25, at about 9:30 a.m., revealed that the 3 east hallway hand sanitizer dispensers were empty. Observation of room [ROOM NUMBER] restroom revealed no paper towels in the dispenser, room [ROOM NUMBER] had no toilet paper or paper towels, and room [ROOM NUMBER] had no paper towels. During an interview with Registered Nurse Employee E3 at the time of observations, it was confirmed that the restrooms observed and hallway hand sanitizer dispensers were not stocked with the supplies for resident use. An interview conducted with the NHA 1/08/25, at approximately 2:30 p.m. revealed that supplies should be stocked for resident use in resident rooms, restrooms, and resident care areas. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(2.1) Management

Based on resident interviews and observations, it was determined that the facility failed to provide sufficient nursing staff to promote the physical and mental well-being and meet the needs of nine of 24 residents interviewed (Residents R149, R19, R226, R9, R56, R67, R62, R73, and R85). Findings include: During interviews on 1/06/25, from 10:05 a.m. through 1:00 p.m. revealed that Residents R149, R19 and R226 expressed concerns of poor call bell response times, indicating that they often had to wait nearly an hour after activating the call bell, to have their needs met. Obervations on 1/06/25, at 2:17 p.m. revealed an activated call light for Resident R226. The call light remained unaddressed until 2:30 p.m. During interview at 2:25 p.m., Resident R226 stated they activated the call light as they had been left on a bedpan which was causing considerable discomfort while waiting for assistance. At this time, staff members were observed seated at the nursing station where the call bell system was alarming audibly and visually lighted. Interviews during the Resident Council meeting on 1/07/25, between 1:00 p.m. and 1:30 p.m., revealed six out of seven alert and oriented residents in attendance with concerns related to staff not responding to their call bells timely. Resident R62 indicated that it could take 45 minutes for his/her call bell to be answered and, staff are typically outside or near his/her door due to he/she can hear them. Resident R9 indicated that he/she will wait for 30 minutes to receive incontinence care after placing his/her call bell on. Resident R9 further indicated if he/she does not get his/her call bell answered by the end of dayshift, it could take longer due to the new shift coming on. Residents R56, R67, R73, and R85 indicated they wait 30 minutes when their call bell is placed on to be responded to by staff. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(4)(5) Nursing services

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to follow acceptable infection control practices regarding enhanced barrier precautions (EBP) for two of two resident units (200 and 300 units). Findings include: A facility policy, Transmission-Based Precautions and Isolation Policy, dated 9/2024, revealed Enhanced Barrier Precautions (EBP) - EBP are intended to prevent transmission of multi-drug resistant organisms (MDROs) via contaminated hands and clothing of healthcare workers to high risk residents. EBP are indicated for high contact care activities for residents with chronic wounds and indwelling devices (such as central lines, urinary catheters, and trachs) and for all those colonized or infected with a MDRO currently targeted by the CDC. Other MDROs may be included at the discretion of the facility Infection Control Committee unless required by state guidance. Observations on 1/07/25, at 12:05 p.m. revealed Certified Registered Nurse Practitioner (CRNP) completing a wound assessment in Resident R42's room without donning (putting on) a gown. An interview with the Infection Control Licensed Practical Nurse (LPN) confirmed the CRNP should have donned the appropriate Personal Protective Equipment (PPE), gowns and gloves, prior to entering Resident R42's room to provide the assessment and care due to Resident R42 being in EBP for having a chronic stage four (full thickness loss of skin and bone exposed) coccyx pressure ulcer and foley catheter (tubing entering the bladder to drain urine). Observations on 1/06/25, at 12:45 p.m. and 1/07/25, at 12:00 p.m., revealed no PPE available at the doorway or in the hallways for EBP for room [ROOM NUMBER] (resident with a foley catheter and chronic wound), room [ROOM NUMBER] (resident with colostomy-artificial opening from the colon that permits passage of intestinal contents), room [ROOM NUMBER] (resident with foley catheter), 324 (resident with foley catheter). An interview on 1/07/25, at 12:10 p.m. with Nursing Assistant Employee E2 confirmed the facility did not have PPE readily available for staff to utilize for residents that are in EBP. During an interview on 1/07/25, at 2:10 p.m. the Director of Nursing confirmed that employees should be wearing appropriate PPE, such as gloves and gowns, when providing care for residents who are in EBP, and the PPE should be readily available. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to comprehensively assess pressure ulcers/injuries (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one of 21 residents reviewed (Resident R42). Findings include: A facility policy Pressure Injury Prevention and Treatment Policy dated 9/2024, revealed Residents admitted with existing pressure injuries will receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection. New pressure injuries will not develop unless the individual's clinical condition demonstrates that they were unavoidable. Pressure injuries identified will be assessed initially and at least weekly thereafter, until closed. All assessments will include the following elements: Location and stage [Stage one-nonblanchable redness of an area. Stage Two-shallow open ulcer with a red or pink wound bed without slough or bruising. Stage Three-full thickness tissue loss, subcutaneous fat may be visible but bone, tendon, or muscle is not exposed and slough (yellow, white, or gray material that can be dry or moist and is a result of dead cells and bacteria accumulating in a wound) may be present but does not hide the depth of tissue loss. Stage 4-full thickness loss with exposed bone, tendon, or muscle. Unstageable-slough and/or eschar (dead tissue that eventually will fall off from the skin), pressure ulcer known but not stageable due to coverage of wound bed by slough and/or eschar]. (if pressure injury), Size (perpendicular measurements of the greatest extent of length and width of the ulceration) depth and the presence, location and extent of any undermining of tunneling/sinus tract, Exudate if present: type (such as purulent/serous), color, odor and appropriate amount, Pain, if present: nature and frequency (e.g., whether episodic or continuous), Wound bed: Color and type of tissue/character including evidence of healing (e.g., granulation [new tissue that forms in the body during the healing process of wounds] tissue, maceration [process of softening or breaking down]) as appropriate, Any evidence of infection. Resident R42's clinical record revealed an admitted [DATE], with diagnoses that included osteomyelitis of left ankle (inflammation of ankle bone caused by infection), gangrene (dead tissue caused by an infection or lack of blood flow), bacteremia (bloodstream infection), and urinary tract infection. Resident R42's hospital records dated 5/28/24, revealed Resident R2 had a stage three pressure injury to the coccyx (a small triangular bone at the base of the spinal column) with assessment documented as 2 cm diam [centimeter diameter], 0.2 cm deep with areas of scattered moist yellow and tan slough on red base small amt serous [clear or slightly yellow fluid] tan drainage, wound located with in bright red macerated, weeping skin, solid redness with macules [a flat, distinct discolored area of skin less than 1 cm wide] and papules [a small, raised, solid pimple or swelling] around the edges. Resident R42's clinical record for the day of admission to the facility, 6/05/24, revealed Resident R42's pressure injury to the coccyx assessment documented as Stage 2 to Coccyx 1.5 cm x 0.5 cm. Resident R42's clinical record dated 6/11/24, by a Certified Registered Nurse Practitioner (CRNP) revealed Resident R42's pressure injury to the coccyx/sacrum assessment documented as Stage/Severity: Unstageable, Wound Status: Present on Admission, Odor Post Cleansing: None, Size: 7 cm x 7 cm x 0.1 cm. Calculated area is 49 sq cm. Wound Base: 50-74% granulation, 50-74% eschar, Wound Edges: Attached, Periwound: Macerated, Exudate: Moderate amount of Serosanguineous [drainage containing blood and serum, the clear liquid part of blood]. During an interview on 1/09/25, at 10:40 a.m. the Infection Control Licensed Practical Nurse (ICLPN) confirmed the facility failed to accurately assess and document Resident R42's coccyx on admission to the facility 6/05/24. The ICLPN further confirmed Resident R42's coccyx wound was inaccurately documented as a stage two pressure ulcer, and lacked a comprehensive assessment of the pressure injury as noted prior, Stage 2 to Coccyx 1.5 cm x 0.5 cm, due to the resident was documented with a stage three coccyx pressure ulcer with macerated, weeping skin and macules, papules around the edges at the hospital prior to admission. 28 Pa. Code 211.5 (f)(ii)(iii)(ix) Medical records 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records and facility policy, observations, and staff interviews, it was determined that the facility failed to properly reorder and store medications for two of eight residents reviewed during medication pass observations (Residents R72 and R73). Findings include: Review of the facility policy entitled Medication Shortages/Unavailable Medications last revised 8/01/2024, revealed that upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication form the pharmacy. If the medication shortage is discovered at the time of medication administration, facility staff should immediately notify the pharmacy. Resident R72's clinical record revealed an admitted [DATE], with diagnoses that included history of falls, fracture of the left femur, and aftercare for joint replacement therapy. R72 had a physician's order for Oxycodone (pain medication) 5 milligrams (mg) every 6 hours as needed for pain with a start date of 10/14/24, and last administered 11/04/24. Observation of medication administration on 1/06/25, at 3:55 p.m. revealed that Licensed Practical Nurse (LPN) Employee E2 attempted to obtain oxycodone for Resident R72 for pain upon resident request. Upon attempting to administer oxycodone per order, there was no medication card in the cart to fulfill the order. During an interview at that time, LPN Employee E2 confirmed that there was no medication card, the medication would have to be obtained through the Omnicell machine. The last time the medication was administered per record was 11/04/24, and the order was not resubmitted to the pharmacy for use. Resident R73's clinical record revealed an admitted [DATE], with diagnoses that included Type 2 Diabetes (a long term condition in which the body has trouble controlling blood sugar levels due to the pancreas not making enough insulin), depression, heart failure, and history of a cerebral infarction (blocked blood flow to the brain causing brain tissue to die). R73 had a physician's order for Furosemide (medication to help excrete fluids) 20 mg by mouth daily. Observation of medication administration on 1/07/25, at 9:15 a.m. revealed that Registered Nurse (RN) Employee E3 attempted to administer Furosemide 20 mg per physician's order during morning routine medication pass. The medication cart did not contain Furosemide for resident use and the medication was not reordered from the pharmacy after the last medication was administered. During an interview at that time, RN Employee E3 confirmed that there was no medication card for Furosemide because it was not reordered from the pharmacy after the last pill was given from the card. The medication would have to be obtained through the Omnicell machine. During an interview on 1/08/25, at approximately 1:30 p.m. the Director of Nursing, and Nurse Supervisor confirmed that the medications were not reordered from the pharmacy as they should have been and were not available for use as required in the medication carts for Residents R72 and R73. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policies, clinical records, and facility documentation and staff interviews it was determined that the facility failed to provide Cardiopulmonary Resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after [CONDITION(S)]) as required for one of one residents reviewed who had requested that CPR be administered in the event that they became unresponsive with no pulse. Resident R1 became unresponsive and pulseless, facility staff did not administer CPR to Resident R1 as required. This failure placed 44 of 85 residents (Residents R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39, R40, R41, R42, R43, and R44), that had requested to have CPR administered if they became unresponsive and pulseless, at a high risk for death and resulted in an Immediate Jeopardy situation. This deficiency is cited as past non-compliance. Findings include: Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a POLST (Pennsylvania Orders for Life-Sustaining Treatment) dated [DATE], stated, FIRST follow these orders, THEN contact physician, Certified Registered Nurse Practitioner or Physician Assistant. This is an Order Sheet based on the person's medical condition and wishes at the time the orders were issued. Everyone shall be treated with dignity and respect. The POLST was signed by both the physician and Resident R1 and Section A revealed that CPR/attempt resuscitation was to occur when no pulse and no breathing were present. The facility Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a facility policy entitled Cardiopulmonary Resuscitation (CPR) last revised [DATE], indicated that CPR will be provided to all residents/patients who experience cardiopulmonary arrest unless one or more of the following is present: a valid advanced directive or POLST requesting withholding of CPR; a properly executed and witnessed Do Not Resuscitate (DNR) order; documented verbal wishes by the resident/surrogate decision maker indicating the desire to be a DNR but physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of information submitted by the facility dated [DATE], revealed the following: on [DATE], at 2:00 a.m. Nurse Aide (NA) Employee E2 provided Resident R1 with fresh ice water and observed that Resident R1 was asleep and covered Resident R1 with a blanket which he/she rejected; at 3:30 a.m. NA Employee E3 entered Resident R1's room to perform personal hygiene and observed Resident R1 laying in bed on his/her side with vomitus on his/her face, hands, hair, and clothes, and attempted to verbally and tactically awaken Resident R1 unsuccessfully, and went to retrieve the RN Supervisor; RN Employee E1 listened to Resident R1 with a stethoscope and felt his/her chest and attempted to obtain a pulse on the wrist and neck, and responded that Resident R1 was gone, NA Employee E2 entered the room and RN Employee E1 repeated to NA Employee E2 that Resident R1 was gone. Further review of documentation submitted by the facility revealed that RN Employee E1 observed that Resident R1 was found covered in vomit, no pulse, no respirations, the physician was notified, and Resident R1 was cold and blue, Resident R1's code status was not checked, and CPR was not initiated. During an interview on [DATE], at 11:00 a.m. the Nursing Home Administrator (NHA) and DON confirmed that RN Employee E1 did not obtain Resident R1's code status and that RN Employee E1 should have sought that information and started CPR as Resident R1 was listed as a Full Code. The facility failed to promptly initiate CPR in accordance with the resident's wishes and professional standards of nursing to a resident who had requested CPR upon admission, had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The NHA and DON were notified of the Immediate Jeopardy situation on [DATE], at 5:20 p.m. An Immediate Plan of Correction was requested. The Immediate Plan of Correction was provided by the NHA and DON on [DATE], at 5:20 p.m. which was accepted at 5:20 p.m. This deficiency is cited as past non-compliance The facility implemented their corrective action plan on [DATE] that included: 1. Identify all residents current/active code status. 2. Educate licensed staff on initiating CPR, verification of code status prior to initiating CPR and overall code process. 3. Immediately following the event (in the morning of [DATE]), the facility's NHA and DON completed an audit of current resident's code statuses and an audit of facility deaths in the last 30 days to ensure 100% compliance. 4. Immediately following the event (in the morning of [DATE]) and continuing on each resident care unit for each shift over 24 hours, all licensed nursing staff received continuing education on initiating CPR, verification of resident's code status, over-all code (CPR) process, and mock codes on each resident care unit for each shift over 24 hours, responsibilities to know and adhere to resident's advanced directives/POLST/code status elections. Licensed staff not scheduled to report to the facility on [DATE], participated in phone education/reviews and follow-up education was completed as needed with staff upon entry to the facility. 5. Effective [DATE], weekly audits on in-house deaths will be conducted to ensure resident code statuses are followed for the next three months. 6. Effective [DATE], mock code will be conducted weekly on each shift for four weeks then monthly for three months. 7. On [DATE], a Quality Assurance Plan for Improvement meeting was held by the facility to review the events occurring that morning and formulate the above stated plan of action. On [DATE], the Immediate Jeopardy was lifted at 5:20 p.m. after ensuring the Immediate Plan of Correction had been implemented and compliance achieved. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a)(b)(1)(2)(e)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 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 maintain a sanitary kitchen for all residents creating an Immediate Jeopardy (IJ) situation for one of one kitchens. Findings include: The Kitchen Sanitation and Cleaning Schedules policy, dated 2/10/21, indicated that Food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. During an interview on 8/2/21, at 10:00 a.m., the Director of Maintenance (DOM), disclosed that on the afternoon of Thursday, 7/29/21, he was notified that there was a leak in the facility kitchen ceiling. Upon investigation, it was determined that there was a leak in a toilet on the floor above the kitchen. He indicated that at that time, he placed a bead of caulk at the base of the toilet and intended to complete the repair on the following Monday, 8/02/21. Observations of the kitchen on 8/02/21, between 10:00 a.m. and 10:45 a.m., revealed the following: A crack in the ceiling with a gray dish bin on the floor directly below the cracked ceiling that contained brown/tanish colored liquid in it and was near the food tray line area. Observations also revealed a drip of liquid from the ceiling onto one of the food tray delivery carts. The floors under and behind the equipment and in corners were dirty with food items and dirt. There was a cart with bowls of cereals dated 6/23/21, and two open bags of cereal with no open date on them. The seven of seven food tray delivery carts all had a build up of debris and were sticky to touch. The Dietary Manager Employee E1 indicated that the carts are to be sanitized after each meal and demonstrated the process by spraying a cart down with the sanitizer and wiping it, removing a large amount of black/ brown substance from the cart. Dietary Manager Employee E1 on 8/02/21, at 10:40 a.m. confirmed that the food delivery carts had not been cleaned or sanitized. The kitchen's walls, floors and pan storage shelving had particles of food on them. There was a large standing fan by the dish machine area with a large amount of dust and debris accumulated on it. Observation of the dry storage area revealed a dented can of mushrooms and a dented can of chocolate pudding on the shelves. During an interview on 8/02/21, at 10:50 a.m. Dietary Employee E2 confirmed that on 7/29/21, around 5:30 p.m. the ceiling had a crack in it and there was water coming out of it and that staff had placed a gray dish bin on the floor below the leak and it had about a half inch of brown/tan liquid. On 8/02/21, at 3:10 p.m. the Nursing Home Administrator (NHA) was informed that Immediate Jeopardy was identified in the kitchen as related to the cracked ceiling dripping toilet water around the tray line area. The first immediate action plan for kitchen sanitation was received on 8/02/21, at 4:25 p.m.; the second revision was received on 8/02/21, at 5:30 p.m. The immediate action plan was accepted on 8/02/21, at 5:48 p.m. The plan included: 1. Water was shut off from upstairs toilet at 11:15 am as the identified area of the possible leak. 2. Plastic occlusive Barrier placed at 11:20 to isolate the area in the kitchen to eliminate contamination. 3. Deep cleaned the affected equipment started at 11:21 and completed at 11:31 before tray service. 4. Removed the affected toilet at 1:00 pm. 5. Replaced the bolt ring flange at 1:40 pm 6. New wax ring was placed and toilet was reattached and tightened down at 1:45 pm. 7. Water was turned back on and toilet was cycled 4 times to ensure seal was set at 2:00 pm. 8. 2x2 section of affected ceiling section was cut out in affected area at 1:50 pm 9. Verified that there was no leak under the ceiling 2:15 pm 10. Dry wall was replaced at 3:00 pm. 11. Maintance Director was educated from the RDCS on proper way to fix a toilet leak 4:40 pm. 12. Ad HOC QAPI held to inform of the incident and remedies identified 6:00 pm. 13. Kitchen deep clean completed by 9:00 pm August 2, 2021. Audit all the toilets in the facility to ensure they are secure and no visible leaks this will be completed by 5:15 pm August 2, 2021. Three times a week for four weeks the maintenance director or designee will check five toilets on each floor to ensure secure and no leaks, then two times a week for four weeks to be completed by August 6, 2021. NHA or designee will audit four work orders completed weekly for four weeks by the maintenance department ensure completed, then two work orders a week for four weeks to ensure completed accurately by August 6, 2021. Dietary staff will be educated to immediately notify the NHA of any leaks and to remove food from the affected area. Licensed nursing staff will be educated to monitor for GI illness and to notify the DON if GI illness identified. Monitor all residents for GI illness from 7/29/21. No GI illness identified as of 8/2/21. Audits for GI illness will be conducted daily on all residents for one week to ensure there is no development of GI illness. The IJ was subsequently lifted on 8/03/21, at 1:45 p.m. when the plan was confirmed to be fully implemented and all kitchen areas were deemed safe to store and serve food. 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 policy and procedures, and staff interviews, it was determined that the facility failed to implement sufficient monitoring interventions and supervision to prevent elopement (unauthorized leave from the facility). This failure placed residents at the facility in an Immediate Jeopardy situation for two of three residents reviewed who eloped from the facility (Closed Residents CR1 and CR2). Findings include: Review of the facility policy entitled, Elopement/ Unauthorized Absence Policy, dated 10/03/2019, defined elopement as leaving the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. The policy also indicated that the facility would: conduct an elopement assessment for each resident on admission, quarterly and as needed; identify residents receiving a score of four or more as at risk; have prompt interventions for residents identified as at risk; notify the physician of the risk and recommended interventions; notify the responsible party; and place a picture and face sheet in a binder kept in an area accessible by staff. Resident CR2's clinical record revealed an admitted [DATE], with diagnoses including [CONDITION(S)] (progressive nervous system disorder that affects movement), [CONDITION(S)] Disorder (mental illness that brings severe high and low moods and changes in sleep, energy, thinking, and behavior), [CONDITION(S)] (serious mental disorder in which people interpret reality abnormally), and cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information, responding accurately, understanding jokes or metaphors, or following directions). A Minimum Data Set (MDS-a periodic assessment of resident care needs) dated 9/17/2020, identified Resident CR2 with a Brief Interview for Mental Status (BIMS) score of 15 and cognitively intact. Review of progress notes revealed the following documentation: - On 11/29/2020, at 11:06 a.m. Resident CR2 was anxious all night; swinging and got down the elevator to the first floor; and was attempting to get out the doors; noted he/she was hitting the chair with his/her fist; thought his/her mother and father are downstairs to take him/her to a mental hospital today to lock him/her away; he/she stated he/she is going to jail for killing them. - On 12/01/2020, at 11:37 a.m. therapy staff observed Resident CR2 attempting to open a window and jump out of it. Resident CR2 stated he/she was trying to escape the facility and stated that Resident CR2 had made multiple attempts in the past few days to exit the building. An elopement assessment completed on 12/01/2020, (after his/her attempt to crawl out the window) resulted in a score of eight (high risk). An elopement care plan was initiated on 12/01/2020, which included interventions of 1:1 (one-on-one), every 15-minute or every 30-minute monitoring for safety if applicable; use distraction; and Wanderguard (electronic band programmed to alarm when the resident approaches an outside door) if applicable. Review of Resident CR2's progress notes revealed the following documentation: - On 12/03/2020, at 1:47 p.m. the Interdisciplinary Team (IDT) identified Resident CR2 as an elopement risk, he/she verbalized wanting to leave, and that staff would continue with the Wanderguard. - On 12/06/2020, at 9:22 a.m. Resident CR2 refused medications, was agitated, anxiously walked up and down the hallways, and was unable to be redirected. - On 12/06/2020, at 9:45 a.m. Resident CR2 eloped from the facility and was returned by staff at approximately 10:00 a.m. Review of information dated 12/06/2020, submitted by the facility, revealed the following information: .At 9:45 a.m. the resident was seen sitting at the nurse's station in his/her wheelchair a few minutes later the empty wheelchair was sitting at the nurse's station. Staff immediately checked resident's room to determine if he/she had returned to his/her room or bathroom. The resident was not in either area Wandergard system alarming at this time on first floor resident had been identified as an elopement risk . There was no evidence that Resident CR2's safety interventions to prevent elopement of a 1:1 or every 15-minute, or every 30-minute monitoring between 12/01/2020, and 12/06/2020, had occurred prior to Resident CR2's elopement from the facility. The December 2020 Treatment Administration Record (TAR) identified to check placement and functioning of the Wanderguard as an unscheduled other order, however did not include a method for staff to identify that they had checked the Wanderguard as ordered. During an interview on 3/04/2021, at 2:45 p.m. Licensed Practical Nurse (LPN), Medical Records Employee E1 confirmed there was no evidence for 1:1, every 15-minute, or every 30-minute monitoring, and checking placement and functioning of the Wanderguard on the TAR between 12/01/2020, and 12/06/2020. During an interview on 3/04/2021, at 4:02 p.m. the Nursing Home Administrator (NHA) confirmed there was no evidence for 1:1, every 15-minute, or every 30-minute monitoring, and checking placement and functioning of the Wanderguard on the TAR between 12/01/2020, and 12/06/2020. The facility failed to implement identified interventions to prevent Resident CR2's elopement from the facility on 12/06/2020. Resident CR1's clinical record revealed an admitted [DATE], with diagnoses that included being unsteady on feet, muscle weakness, multiple chemical dependencies, [CONDITION(S)], [CONDITION(S)] (bacteria in the blood), and pneumonia (infection in the lung). Resident CR1's clinical record contained an admission elopement assessment completed on 2/24/2021, with a score of six (high risk). Further review revealed a physician's order dated 2/24/2021, for a Wanderguard and check for placement and functioning every shift. Resident CR1's MDS dated [DATE], identified a BIMS of 15, cognitively intact. Review of progress notes revealed the following documentation: - On 2/24/2021, at 1:00 p.m. the admission nursing assessment identified that Resident CR1 was alert to person, place, and time, was independent with functioning, was exit seeking near exit door after being requested to go into room, and that the Wanderguard bracelet is intact and functional. - On 2/24/2021, at 3:46 p.m. a progress note stated that Resident CR1 was very agitated coming out of his/her room, leaving the isolation area, trying to get on the elevator, and was not redirected easily. - On 2/24/2021, at 4:06 p.m. a Social Services progress note stated that Resident CR1 was pacing short hall on 2nd floor causing outside door to alarm, the cause of the alarm activation was reviewed with Resident CR1 and he/she was agreeable and voiced understanding, and that Social Services placed Resident CR1's picture and demographic sheet in elopement books on 1st, 2nd and 3rd floors and initiated a care plan. An elopement care plan reviewed on 3/5/2021, did not identify the use of the Wanderguard or to check for its placement and functioning every shift. Interventions included: activities to keep occupied, calmly redirect resident, divert resident attention, and relocate resident to a different area. The February 2021 TAR lacked evidence that Resident CR1's Wanderguard was checked for placement and functioning for three out of 11 shifts prior to the date of elopement on 2/28/2021. Resident CR1's clinical record lacked further evidence regarding monitoring his/her exit seeking behaviors between 2/24/2021, and 2/28/2021. There was no evidence of implementation of the care plan interventions. Review of information dated 2/28/2021, submitted by the facility, identified the following information: Resident had left the facility unauthorized and without notifying staff. The Wanderguard had been torn/cut off and left on a tray table .A search of the facility grounds was conducted and staff noted a homemade rope extending out a third floor window and down the side of the building. Upon inspection, it was determined that the resident had cut/torn a bath blanket into strips then tied them together and either repelled or lowered himself to ground level. When the window was inspected it was determined that the resident had broken the window stop from the metal frame either by slamming the window against it or with an object. The window stop was still intact and found on the window ledge. The window screen was kicked out. The resident did not return to the facility. Resident CR1 was exhibiting exit seeking behaviors and the facility failed to implement the appropriate supervision and interventions to prevent him/her from eloping on 2/28/2021. An Immediate Jeopardy (IJ) situation was identified to the NHA on 3/11/2021, at 8:10 p.m. and the IJ template was provided to the NHA, related to Resident CR2 and Resident CR1's elopements from the facility. The NHA was made aware that Immediate Jeopardy existed for the facility's failure to ensure implementation of all supervision and safety measures to prevent elopement for residents in the facility and an immediate action plan was requested. On 3/11/2021, at 11:54 p.m. an acceptable immediate action plan was approved which included the following interventions: 1. On 2/28/2021, the Administrator and Maintenance Director fixed the window in the room that the resident went out unauthorized and inspected all other windows in the facility to ensure that all safety stops were intact. 2. On 2/28/2021, the facility completed an unusual occurrence report. An investigation was started immediately, and root cause completed. Statements were obtained from employees on duty. 3. To identify other like residents, on 2/28/21 the DON/designee completed a house-wide audit of elopement assessments of all and ensure that the elopement binders are updated. 4. On 2/28/2021, an elopement drill was conducted, and will be conducted every shift within the 24 hrs. The facility will conduct a weekly elopement drill for four weeks then quarterly per policy. 5. On 2/28/2021, the Social Worker or designee will review and update care plans for high elopement risk residents. All elopement risks will be reviewed by the Medical Director and only residents identified as continued risk with a past elopement will have an order for 15-minute checks as needed when a risk deemed. 6. On 2/28/2021, the therapy/speech department reviewed all residents Brief Interview for Mental Status (BIMS) and updated care plans as needed. 7. On 2/28/2021, to prevent this from recurring, the Director of Nursing and designee provided education to all staff re: elopement policy, admission care plan meeting, and BIM scores on admission. Initiated again on 3/11/21, and continue prior to employees starting their shift. 8. On 2/28/2021, the Activity Director completed an emergency resident council meeting room-to-room and informed residents that they would need to complete a Leave of Absence (LOA) to leave the facility if going on a pass. 9. On 2/28/2021, that facility conducted a whole house BIMS re-assessment. Beginning 3/11/21, the Interdisciplinary Team (IDT) will monitor BIMS scores every week for four weeks, then monthly for three months to ensure that the facility maintains compliance. 10. All elopement care plans were updated on 2/28/21, will be reviewed weekly at IDT meetings and updated as necessary. 11. The facility changed the exterior door codes on 3/11/21, and will continue to change every two weeks and document. 12. On 3/11/21, a full house elopement assessment was completed and will be completed once per week for four weeks, then monthly times three months. 13. Education of nursing staff and managers if a resident expresses a want to leave the facility, notify the resident of their right to discharge against medical advice (AMA), notify the physician, family, and appropriate authorities, have the resident sign the AMA and discharge was completed 3/11/21, and continue prior to employees starting their shift. 14. Education of nursing staff on order entry scheduling was initiated on 3/11/21, and education will continue prior to employees starting their shift. 15. Placed AMA documents at both nurse's stations and the front lobby on 3/11/21. 16. An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held on 2/28/21, with Medical Director and IDT. 17. On 3/11/21, any further every 15-minute checks will be directed by the physician. 18. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations. After review of facility documentation, observations, and staff interviews, the implementation of the above stated action plan was confirmed on 3/12/2021, at 3:40 p.m. and the NHA was informed that the Immediate Jeopardy situation was removed. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.11 (d) Resident Care Plan 28 Pa. Code 211.12 (d) (5) Nursing Services

Based on review of facility policy, clinical records, an incident report, and staff interview, it was determined that the facility failed to provide a safe transfer in a manner that protected a resident from injury. The incident resulted in actual harm for one of nine residents reviewed (Resident R3). Findings include: The facility, Resident Abuse policy dated 3/4/16, indicated that neglect means the failure to provide the goods and services necessary to avoid physical harm, mental anguish, or mental illness. The Minimum Data Set assessment (MDS-a periodic assessment of resident care needs) dated 8/7/16, indicated that Resident R3 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. (a disease of the nervous system characterized by tremors, muscular weakness and slowness of movement), and anxiety. MDS Section G0110B Transfer, was coded 3/3, which indicated that he/she requires the extensive assistance of two staff to get in and out of bed and in and out of a wheelchair. Section G0110C and D, Walk in Room or Corridor, was coded 8/8, which indicated that the resident was not ambulatory. MDS Section C0200-C0500 Brief Interview for Mental Status was coded 13 of 15, which indicated that the resident is cognitively intact. The physician restatement order dated 9/4/16, indicated that Resident R3 was to transfer with the assist of two with or without a rollator (wheeled) walker. Review of information dated 9/16/16, submitted by the facility, disclosed an incident that occurred on 9/16/16, at 1:45 p.m. The report revealed that Nurse Aide (NA), Employee E5, performed a one person transfer of Resident R3 from his/her wheelchair to the bed instead of the physician ordered two person assist dated 9/4/16. During the transfer Resident R3 sustained a jagged laceration (a deep cut or tear in the skin) with exposure of adipose (fat) tissue to the right calf. The witness statement of NA Employee E5 dated 9/16/16, indicated that the resident complained about her leg and upon inspection noted a wound and the nurse was notified. The resident stated that her leg slid during the transfer and hit the bed frame. The incident required a transfer to the hospital for repair with seven whip sutures (sutures that allow for swelling). Resident R3 required pain medication and an anti-anxiety medication prior to being transferred to the hospital. During an interview on 10/5/16, at 2:15 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that Employee E5 failed to provide a safe transfer that resulted in actual harm to Resident R3. 28 Pa. Code: 201.18 (b)(1) Management. Previously cited 9/11/15. 28 Pa. Code: 201.18 (b)(2)(3) Management. 28 Pa. Code: 201.29 (a) (c) (d) Resident rights. 28 Pa. Code: 211.10 (d) Resident care policies. Previously cited 9/11/15. 28 Pa. Code: 211.12 (d) (5) Nursing services. Previously cited 10/17/14, 9/11/15 and 4/6/16.

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to provide adequate supervision and assistive devices to prevent injury during a transfer, for one of nine residents reviewed (Resident CR23). Findings include: Review of facility policy entitled, "Safe Lifting and Movement of Residents" dated 7/23/10, indicated that mechanical lifting devices shall be used for all heavy lifting, except during emergency situations or unavoidable circumstances; for all other reasons, manual lifting is not permitted. The clinical record indicated that Resident CR23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-a periodic assessment of care needs) dated 4/30/10, indicated that Resident CR23 required the assistance of two staff for transfers and suffered a fall in the past 31 - 180 days. A physician order [REDACTED]. A reportable event submitted to the State Survey Agency dated 9/29/10, indicated that on 9/26/10, at 3:00 p.m., staff noted Resident CR23 to have pain, swelling, and bruising of both knees, and that an investigation was being completed to determine the cause of the injury. As a result of the investigation, Nurse Aide (NA) Employee E2, in a written statement dated 10/2/10, indicated that on 9/26/10, Employee E2 walked into the resident's room and found Resident CR23 kneeling on the floor. Employee E1, a NA, stated that he, "tried to lift (the resident) but had to lower the resident to the floor." A Radiology Report dated 9/29/10, indicated that Resident CR23 had an acute fracture of the left femur (large bone in the upper leg) with displacement. During an interview on 10/7/10, at 11:25 a.m., the Nursing Home Administrator and the Director of Nursing confirmed that the staff performed an unsafe transfer without two staff members present or the use of the Hoyer lift on 9/26/10, resulting in injury to Resident CR23. Cross Refer to F224. 28 Pa. Code: 201.18(b)(1) Management. Previously cited 2/13/09, 8/26/09. 28 Pa. Code: 201.29(a)(c)(d)(j)(m) Residents rights. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. Previously cited 4/6/09, 2/13/09, 1/22/10, 4/14/10. 28 Pa. Code: 211.12(d)(3) Nursing services. Previously cited 2/13/09, 8/26/09.