Every finding on record at Elizabethtown Nursing and Rehabilitation

Based on observation, review of facility policy, and staff interviews, it was determined that the facility failed to distribute and serve food under sanitary conditions during the lunch meal on June 13, 2026.Findings include: Review of facility policy, titled Employee Hygiene and Sanitary Practices, revised October 2017, read, in part, hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment utensil sand linens. Observation on July 13, 2026, at 12:10 PM, revealed Employee 6 (Dietary Manager) was serving on the tray line without wearing a hair net, and Employee 5 (Director of Dietary and Housekeeping) was observing the tray line and wasn't wearing a beard net. Interview on July 13, 2026, at 12:18 PM, with employee 6 revealed Employee 5's hair net must have fallen off. He provided her with another hair net. Interview with the Director of Nursing on July 14, 2026, at 11:20 AM, it was revealed that hair and facial hair should be covered, and both employees should've been wearing appropriate hair coverings. 28 Pa code 211.6(f) - Dietary Services

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure its residents the right to be informed in advance of the risks and benefits of proposed care of treatment alternatives and options to choose alternative treatments for one of five residents reviewed for psychotropic medications (Resident 27).Findings Include: Review of the facility's policy, titled Psychotropic Medication Use, recently revised April 2026, read, Residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record. The policy continued, Prior to initiating the use of.psychotropic medication, the staff and physician will review, the indications and rationale for the recommendation, the potential risks and benefits, and the resident's right to accept or decline treatment. Review of Resident 27's clinical record revealed diagnoses that included major depressive disorder (also called clinical depression - a chronic mental health condition that can cause ongoing sadness or loss of interest and may affect how a person feels, thinks, sleeps and functions) and hypertension (elevated blood pressure). Review of Resident 27's physician orders revealed the addition of the medication Celexa (a medication used to treat depression) on November 26, 2025, and the medication Buspar (a medication used to treat anxiety and/or depression) on March 13, 2026. Review of the facility's document titled Consent for use of psychotropic medication therapy, revealed none completed/reviewed with Resident 27 prior to the addition of those medications to the medication regimen. An interview with the Director of Nursing, on July 15, 2026, at 12:21 PM, confirmed that the consents for the use of those medications were not found in Resident 27's medical record. 28 Pa. Code 211.12 (d) (5) Nursing services

Based on observations, policy review, and staff interview, it was determined that the facility failed to ensure each resident the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility for one survey results book observed in one resident area (Resident TV lounge).Findings Include: Review of the facility's policy, titled Resident Rights, recently revised April 2026, read, in part, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: examine survey results. An observation on July 15, 2026, at 8:47 AM, in the resident television lounge, revealed the facility's book titled Survey Results, dated 2025. Further observation of the survey book revealed the most recent survey results to be dated June 2025. Review of the facility's survey history since June 2025, revealed abbreviated surveys dated 8/13/25, 12/1/25, 12/10/25, 1/6/26, 1/28/26, 2/12/26, and 6/22/26. The results of those surveys were not available in the facility's survey results book. An observation of the survey results books, at 11:40 AM, presented by the Nursing Home Administrator, revealed the results of the abbreviated survey dated June 22, 2026, was added to the book; however, no other surveys, including the survey dated June 22, 2026, had been available for residents to examine at the time of the observation at 8:47 AM. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on observation and staff interview, it was determined that the facility failed to ensure information on how to file a grievance or complaint includes the contact information of the grievance official that also includes the business address, both mail and email, for one grievance official notice posting within the facility (Television and Dining Room Hallway).Findings Include: An observation of the Grievance Official posted information, on July 13, 2026, at 10:41 AM, revealed the contact information of the facility's appointed Grievance Official (Employee 4) did not include the Employee's mailing address. An interview with the Nursing Home Administration, on July 16, 2026, at approximately 10:00 AM, revealed the mailing address for the Grievance Official was added to the posting and now available for resident information. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a significant change MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident, such as a resident's physical, mental or psychosocial needs) assessment was completed timely after election of hospice care for one of 14 residents reviewed (Resident 18).Findings include: Review of facility policy, titled Comprehensive Assessment and the Care Delivery Process, revised December 2016, read, in part, complete a Minimum Data Set within 14 days after it has been determined that the resident has had a significant change in physical or [NAME] condition. Review of the Resident Assessment Instrument 3.0 User's manual (RAI-a standardized process is the basis for the accurate assessment of each nursing home resident) version 1.20.1 dated August 29, 2025, revealed that the facility must complete a significant change MDS no later than 14 days after the effective date of the election of hospice service. Review of Resident 18's clinical record documented diagnoses that included dementia with severe mood disturbance (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking). Review of Resident 18's census/Payor source documented: admission to the skilled nursing unit on February 10, 2026, on Medicaid PA- AmeriHealth; March 1, 2026, on Medicare A; and April 1, 2026, on Medicaid PA- AmeriHealth. Interview with the Director of Nursing (DON) on July 14, 2026, at 2:00 PM, it was revealed Resident 18 previously resided in Personal Care and was transferred to the hospital. She was admitted to skilled care on February 10, 2026, for a short period, during which time she received therapy services, prior to going back on hospice services. Review of Resident 18's physician orders included: hospice evaluation and treat, order date April 1, 2026; and admit to Serenity Hospice with a diagnosis of Senile Degeneration of the Brain, order date April 30, 2026. Review of Resident 18's significant change MDS dated [DATE], documented in Section O hospice care while a Resident. During an interview with the DON on July 15, 2026, at 10:03 AM, it was revealed that Resident 18 was admitted to Hospice services on April 1st, 2026, and the significant change MDS should've been completed prior to April 22nd, 2026. 28 Pa. Code 201.2(a) Requirements

Based on clinical record review and staff interview, it was determined that the facility failed to ensure the resident assessment accurately reflects the resident's status for one of 14 resident assessments reviewed (Resident 32).Findings Include: Review of Resident 32's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (a progressive lung disease characterized by persistent airflow limitation) and muscle weakness. Review of Resident 32's physician orders revealed an order for the use of oxygen, dated November 8, 2024, that read O2 [oxygen] at 2L [liters] via NC [nasal cannula] every shift. Review of Resident 32's Quarterly Minimum Data Set (MDS- a tool used to assess all areas specific to the resident), dated January 19, 2026, did not include documentation of Resident 32's use of oxygen. An interview with the Director of Nursing, on July 16, 2026, at 10:12 AM, revealed the MDS was modified to include Resident 32's oxygen use. 28 Pa. Code 211.12 (d) (5) Nursing services

Based on observation, policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for two of 14 residents reviewed (Residents 2 and 18). Findings include: Review of the facility's policy, titled Care Plans, Comprehensive Person-Centered, revised April 2026, read, in part, The interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.Review of Resident 2's clinical record revealed diagnoses that included heart failure (a chronic condition where the heart muscle becomes too weak or stiff to effectively pump enough oxygen rich blood to meet the body's needs) and diabetes mellitus (a chronic metabolic disease characterized by consistently high blood sugar). An observation of Resident 2's bed on July 13, 2026, revealed bilateral side rails affixed to the bed.Review of Resident 2's interdisciplinary plan of care revealed none developed to address the Resident's use of the side rails.An interview with the Director of Nursing (DON) on July 15, 2026, confirmed no care plan had been developed to address Resident 2's side rails and confirmed the care plan had been updated to reflect Resident 2's current needs and status. Review of Resident 18's clinical record documented diagnoses that included dementia with severe mood disturbance (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking). Interview with the DON on July 14, 2026, at 2:00 PM., it was revealed Resident 18 previously resided in Personal Care and was transferred to the hospital. She was admitted to skilled care on February 10, 2026, and was skilled for a short period, during which time she received therapy services prior to going back on hospice services. Review of Resident 18's physician orders included: hospice evaluation and treatment, order date April 1, 2026; and admit to Serenity Hospice with a diagnosis of senile degeneration of the brain, order date April 30, 2026. Review of Resident 18's care plan failed to contain a care plan for hospice services. During an interview with the DON on July 15, 2026, at 10:03 AM, it was revealed that Resident 18 was admitted to Hospice services on April 1st, 2026, and there should be a hospice care plan. 28 Pa. Code 211.12(d) Nursing Services

Based on clinical record review, policy review, and resident and staff interviews, it was determined that the facility failed to ensure the comprehensive care plan is reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, for two of 14 resident records reviewed (Residents 5 and 32).Findings Include: Review of the facility's policy, titled Care Plans, Comprehensive Person-Centered, revised April 2026, read, in part, The interdisciplinary team must review and update the care plan, when there has been a significant change in the resident's conditions, when the desired outcome is not met. Review of Resident 5's clinical record revealed diagnoses that included hidradenitis suppurativa (a chronic inflammatory skin disease characterized by painful, recurring bumps, abscesses, and deep-draining tunnels) and atrial fibrillation (irregular and rapid heart rate). Clinical record review also revealed Resident 5 had an indwelling bladder catheter for wound healing since admission to the facility on April 18, 2026. Review of Resident 5's physician orders revealed the indwelling bladder catheter was discontinued July 3, 2026. A review of Resident 5's care plan on July 14, 2026, revealed the care plan for the catheter remained in place. During an interview with the Director of Nursing (DON) on July 15, 2026, the DON confirmed the catheter care plan should have been discontinued on July 3, 2026, when the catheter was removed. Review of Resident 32's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (a progressive lung disease characterized by persistent airflow limitation) and muscle weakness. Review of Resident 32's interdisciplinary plan of care revealed a care plan developed that read [Resident 32] has potential for short term status . Will be discharged when able. The care plan was recently revised on August 26, 2025. An interview with Resident 32 on July 13, 2026, at 10:41 AM, revealed she was not working on a discharge plan and was not able to return to the community. During an interview with the DON, on July 15, 2026, at 1:59 PM, revealed Resident 32's discharge planning care plan should have been closed, when recently reviewed, as the Resident is now long-term care status. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on observation, policy review, and staff interview, it was determined that the facility failed to ensure that a resident who needs respiratory care is provided with such care that is consistent with professional standards of practice for one of two residents reviewed for oxygen use (Resident 3). Findings Include: Review of the facility's policy section, titled Resident Care Policies, in relation to respiratory care, recently reviewed April 2026, read, in part, The facility.must assure that the resident care policies and procedures for respiratory care and services, are developed, according to professional standards of practice. Also, The policies and procedures, based on the type of respiratory care and services provided, may include, but are not limited to: Oxygen services, including the safe handling, humidification, cleaning, storage, and dispensing of oxygen. Review of Resident 3's clinical record revealed diagnoses that included acute respiratory failure (a sudden life-threatening condition where the lungs cannot provide enough oxygen to the blood or remove carbon dioxide efficiently) and muscle weakness. Review of Resident 3's Treatment Administration Record, dated July 2026, read, Change O2 [oxygen] tubing and filter weekly every night shift every Saturday. An observation of Resident 3's oxygen concentrator equipment on July 13, 2026, at 10:46 AM, revealed no date written on the oxygen tubing or any bag attached to the machine indicating the date of the most recent change of the tubing or the filter. An interview with the Director of Nursing, on July 15, 2026, at 1:31 PM, confirmed Resident 3's oxygen tubing and filter did not have a date when last changed by the nursing staff. 28 Pa. Code 211.12 (d) (1) (5) Nursing services

Based on policy review, staff interviews, and clinical record reviews, it was determined that the facility failed to maintain complete and accurate medical records for three of 14 clinical records reviewed (Residents 2, 5, and 42).Findings Include: Review of the facility's policy, titled Weight Assessment and Intervention, reviewed April 2026, read, in part, Weights will be recorded in each unit's weight record chart or notebook and in the individuals' medical record. Review of Resident 2's clinical record revealed diagnoses that included heart failure (a chronic condition where the heart muscle becomes too weak or stiff to effectively pump enough oxygen rich blood to meet the body's needs) and diabetes mellitus (a chronic metabolic disease characterized by consistently high blood sugar). Review of Resident 2's physician orders summary revealed the Resident to require a fluid restriction with limited daily intake of fluids due to chronic heart failure. The summary also revealed an order for daily weights at 6:00 AM due to chronic heart failure. Review of Resident 2' s June 2026 Treatment Administration Record (TAR) revealed no documentation of daily weights on June 2, 6, 7, 8, 20, and 21, 2026. Review of Resident 2's July 2026 TAR revealed no documentation of daily weights on July 6, 7, 9, 12 and 13, 2026. An interview with the Director of Nursing (DON) on July 16, 2026, at 10:33 AM, revealed an acknowledgement of the weights not documented in Resident 2's clinical record and an ongoing review of the facility's process of documenting in the weight book as well as the TAR per physician order. Review of Resident 5's clinical record revealed diagnoses that included hidradenitis suppurativa (a chronic inflammatory skin disease characterized by painful, recurring bumps, abscesses, and deep-draining tunnels) and atrial fibrillation (irregular and rapid heart rate). Clinical record review also revealed Resident 5 had an indwelling bladder catheter for wound healing since admission to the facility on April 18, 2026. Review of Resident 5's physician orders revealed the indwelling bladder catheter was discontinued during the AM of July 3, 2026. A review of Resident 5's progress notes revealed staff continued to document the indwelling bladder catheter was in place with all skilled progress notes written daily from the evening of July 3, 2026, until July 15, 2026. A review of the task section of the clinical record revealed catheter care continued to be documented daily until July 15, 2026. During an interview with the DON on July 16, 2026, at 10:00 AM, the DON confirmed that the catheter was removed July 3, 2026, and the skilled progress notes and task documentation are inaccurate since the catheter was removed. Review of facility policy, titled Tube Feeding, revised November 2018, read, in part, check Enteral tube placement every four hours and prior to feeding or medication administration. Elevate head of the bed 30 degrees during tube feeding and at least one hour afterwards. Monitor resident for signs and symptoms of respiratory distress during enteral feeding and medication administration. Review of Resident 42's clinical record documented diagnoses that included acute respiratory failure (lungs can't adequately supply oxygen to the blood), pneumonitis (inflammation of lung tissue), and Parkinson's disease (a progressive disorder of the central nervous systems that affects movement). Review of Resident 42's physician orders included: Isosource 1.5 at a rate of 55 milliliters(ml)/hour for 24 hours, free water flush 25 ml every hour, and 60 ml water flush with medications via PEG tube (Percutaneous Endoscopic Gastrostomy- a flexible feeding tube inserted directly through the abdominal wall into the stomach to deliver liquid nutrition and hydration), start date July 9, 2026; enteral feed check placement before each feeding and during medication pass, start date July 9, 2026; head of bed to 30 to 45 degrees at all times during feeding and for at least 30 to 40 minutes after the feeding is stopped, start date July 9, 2026; and Isosource 1.5at a rate of 70 ml/hour for 18 hours, free water flush 200 ml every 6 hours, and 60 ml flush with medications, start date May 21, 2026, and discontinue June 24, 2026. Review of Resident 42's July 2026 Medication Administration Record (documentation of administered medications, treatments or nursing interventions) failed to contain documentation of PEG tube placement or that the head of the bed being elevated. Review of progress note dated July 12, 2026, at 12:13 PM, documented tube feed Isosource 1.5 at 70 ml/hour, off from 8:00 AM - 2:00 PM, tolerating tube feeding. Email communication with the DON on July 17, 2026, at 11:35 AM, it was revealed that the physician order to check Enteral feed placement before each feeding and medication administration was entered into the electronic record as for your information and, therefore, didn't trigger for nursing to document on the medication administration record. It was confirmed it should be documented on the MAR. It was also revealed that the progress note, dated July 12, 2026, at 12:13 PM, documented the incorrect tube feeding rate. No further information was provided regarding documentation to ensure the head of the bed was elevated. 28 Pa. Code 211.5 (f) (viii) (ix) Medical records28 Pa. Code 211.12 (d) (5) Nursing services

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident/resident representative of the resident transfer, in writing, to include the following: the reason for the transfer or discharge, date of transfers, location of transfer, statement of the resident's appeal rights, and name, address (mailing and email) and telephone number of the Office of the State Long Term Care Ombudsman; and failed to provide the resident/resident representative written notice of the bed hold policy at time of transfer for four of four residents reviewed for hospitalizations (Residents 10, 23, 32, and 43). Findings include: Review of facility policy, Transfer or Discharge Documentation, revised December 2016, read, in part, an appropriate transfer notice will be provided to the resident and/or legal representative. Review of facility policy Bed-Hold and Return to Facility Policy and Procedure, initiated 2015, read, in part, before the resident is transferred to a hospital, the Facility must provide written information to the resident or resident representative, which specified the duration of the bed-hold and the reserve bed payment Review of facility Bed Hold Agreement, revised December 2008, read in part, the resident/resident representative was informed of the bed-holding policy and the basic per-diem rate and are to elect whether they wish to hold the bed or not. Review of Resident 10's clinical record revealed diagnoses that included wedge compression fracture (a type of compression fracture that occurs when vertebrae collapses and creates a wedge shape) unspecified fall and unsteadiness on feet. Review of Resident 10's clinical record revealed he was transferred out of the facility and admitted to the hospital on [DATE]. Further review of Resident 10's clinical record failed to reveal notation that a bed hold notice or transfer notice were provided to the Resident or the Resident Representative at the time of the hospitalization. Interview with the Director of Nursing (DON) on June 18, 2025, at 9:50 AM, revealed that it was the responsibility of nursing staff to be completing and sending the notices, but they were not competing them, and she would expect for them to be completed and sent upon hospital transfers. Review of Resident 23's clinical record revealed diagnoses that included hypertension (elevated/high blood pressure) and anxiety disorder (mental health disorder characterized by excessive worry or fear). Review of Resident 23's clinical record revealed that on May 8 and 30, 2025, Resident 23 was transferred to a hospital emergency department after a medical change in condition. Review of available documentation revealed the facility did not provide Resident 23, nor Resident 23's Representative, with notices nor the facility's bed hold policy upon transfer to the hospital for the aforementioned dates. Review of Resident 32's clinical record revealed diagnoses that included acute on chronic systolic congestive heart failure (a specific type of heart failure that occurs in the left ventricle and the ventricle cannot contract normally when the heart beats) and acute respiratory failure with hypoxia (the inability of the respiratory system to meet the oxygenation requirements of the body). Review of Resident 32's clinical record revealed that he was transferred and admitted to the hospital on [DATE], secondary to complaints of chest pain and shortness of breath. Review of Resident 32's clinical record revealed a progress note dated May 16, 2025, at 9:48 AM, that indicated the facility's bed hold policy was reviewed with Resident 32's Representative and that she agreed to hold the bed, but review of the clinical record failed to reveal a copy of the bed hold notice was reviewed with Resident 32's Representative. Further review of the clinical record also failed to reveal the presence of a notice of transfer for his May 16, 2025, hospital transfer or documentation that the transfer notice was provided to Resident 32 or his representative. During a staff interview with the DON on June 18, 2025, at 10:20 AM, she confirmed that hospital transfer notices to the responsible party and bed hold notices were not completed as nursing was not aware they needed to complete the notices. Review of Resident 43's clinical record revealed transfers to the hospital on March 6, 2025, and April 11, 2025; Resident payor source was Medicare A. Review of Resident 43's clinical record failed to include a notice of transfer to the Resident Representative, and bed hold notice for the aforementioned dates. Interview with the DON on June 18, 2025, at 10:20 AM, revealed hospital transfer notices to the responsible party and bed hold notices were not completed, nursing wasn't aware they needed to complete the notices. 28 Pa. Code 201.14(a) Responsibility of Licensee

Based on policy review, observations, clinical record review, and resident and staff interviews, the facility failed to review and revise the resident plan of care for five of 13 residents reviewed (Residents 2, 19, 26, 27, and 30). Findings include: Review of facility policy, Comprehensive Person-Centered Care Plans, revised December 2016, read, in part, the care plan will include services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, and incorporate risk factors associated with identified problems. Assessments of residents are ongoing, and care plans are revised as information about residents and the resident's condition changes. The interdisciplinary team must review and update the care plan. Review of Resident 2's clinical record diagnoses that included depression (feelings of severe despondency and dejection), anxiety disorder (a feeling of worry nervousness or unease), intellectual disabilities (a condition characterized by significant limitations in both intellectual function and adaptive behavior), post-traumatic stress disorder (a mental disorder that develops from experiencing a traumatic event), cerebral palsy ( a group of neurological disorders that affect movement and posture causing activity limitations), and encephalopathy (brain disease, damage or disorder that impacts brain structure or function). Review of Resident 2's physician orders included apixaban 5 milligrams by mouth two times a day for deep vein thrombosis (a serious condition that occurs when a blood clot forms in a deep vein), start February 4, 2025, and discontinued May 27, 2025; and admission to Serenity Hospice on May 27, 2025, due to sarcopenia (muscle disease that involves a progressive loss of muscle mass, strength, and function). Review of Resident 2's care plan documented anticoagulant therapy to treat: At risk for adverse effects, date Initiated February 25, 2025, and revised on April 10, 2025. Further review of the care plan failed to document a plan of care for hospice. During an interview with the Director of Nursing (DON) on June 17, 2025, at 10:36 AM, it was revealed that the care plan should have been updated prior to June 16, 2025, to include hospice services. Interview with the DON on June 18, 2025, at 10:13 AM, it was revealed that the care plan should be updated quarterly and as needed. Review of Resident 19's clinical record revealed diagnoses that included anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and need for assistance with personal care. Review of Resident 19's care plan revealed an active focus area of At risk for loss of range of motion related to physical limitations with an intervention for Restorative Splint/Brace: Sling to right upper extremity to be worn at all times. May remove for care and skin checks, last revised May 14, 2025. Further review of Resident 19's care plan revealed an active focus area of Self-care deficit related to physical limitations, with in intervention for transfers: extensive assistance of 1, last revised April 25, 2025. Observation of Resident 19 on June 16, 2025, at 10:19 AM, revealed he was walking without assistance and did not have a sling on his right arm. Observations of Resident 19 on June 16, 2025, at 11:04 AM, and June 17, 2025, at 9:53 AM, failed to reveal he was wearing a sling on his right arm. Interview with Resident 19 on June 17, 2025, at 9:54 AM, revealed he no longer needs to wear a sling on his arm. Review of Resident 19's physician orders revealed he had an order for resident may perform pulleys with range of motion of right shoulder, advance to weight bearing as tolerated in 2 weeks on June 2, 2025, with a start date of May 19, 2025. Interview with the DON on June 18, 2025, at 10:12 AM, revealed that Resident 19 has not needed the sling since he went to weight bearing as tolerated, he no longer requires extensive assistance with transfers, and she would expect his care plan to be updated. Review of Resident 26's clinical record revealed diagnoses that included at risk for malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it gets), dysphagia (difficulty swallowing), and muscle weakness. Review of Resident 26's care plan revealed an active focus area for infection of urinary tract, with a start date of April 8, 2025. Interview with the DON on June 18, 2025, at 10:12 AM, revealed Resident 26 does not have an active urinary tract infection, and she would expect care plans to be reviewed and revised as needed. Review of Resident 27's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), anxiety disorder, and delusional disorder (type of psychotic disorder; a delusion is an unshakable belief in something that is untrue). Review of Resident 27's care plan revealed a care plan focus that indicated she was at risk for adverse effects related to use of antianxiety (anxiolytic) medication, dated March 31, 2024. Review of Resident 27's clinical record revealed that she was not receiving an antianxiety medication. During a staff interview with the DON on June 18, 2025, at 10:40 AM, she confirmed that Resident 27's care plan should have been revised when the antianxiety medication was discontinued. She indicated that the care plan was most likely not revised because the wrong indication for use was utilized for Resident 27's antidepressant medication. Review of Resident 30's clinical record documented diagnoses that included dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking), dysphagia (difficulty swallowing), transient ischemic attack (a temporary interruption of blood flow to the brain), and left wrist fracture with routine healing. Observation in Resident 30's room revealed she was dressed, in bed with a perimeter mattress, and no cervical collar observed. Review of Resident 30's physician orders included: cervical collar except during meals: skin and circulation check every shift, start date November 20, 2024, and discontinued December 16, 2024; and cervical collar at all times except meals, start weaning collar over a 2-week period if no neck pain, every shift, start date December 16, 2024, discontinued December 30, 2024. Review of Resident 30's care plan included activities of daily living self-care deficit related to fractures and history of TIA, initiated October 15, 2024, with interventions that included cervical collar on at all times (patient has a C1/neck fracture) initiated October 15, 2024, and revised on November 21, 2024. Review of Resident 30's progress notes included on January 13, 2025, out to Neuroscience surgery, new order to discontinue neck collar, follow up as needed. During an interview with the DON on June 17, 2025, at 10:36 AM, it was revealed that the care plan should have been updated to remove the cervical collar prior to June 16, 2025. 42 CFR 483.21(b)(2) Comprehensive Care Plans 28 Pa. Code 211.12(d)(2)(3)(5) Nursing services

Based on employee handbook review, review of select facility documentation, and staff interview, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least once every 12 months for five of five nurse aides reviewed (Employees 1, 2, 3, 4, and 5). Findings include: Based on facility document, titled Employee Handbook effective June 6, 2023, read, in part, All employees will be subject to a written annual rating and evaluation by the department supervisor based on his/her anniversary date. This evaluation will be reviewed with the employee by the supervisor at the time of presentation for the employee's signature. Review of select facility documentation revealed a list of nurse aide's that had worked at the facility for greater than a year, which included: Employee 1 had a hire date of December 26, 2023; Employee 2 had a hire date of April 1, 2020; Employee 3 had a hire date of May 21, 2018; Employee 4 had a hire date of May 6, 2024; and Employee 5 had a hire date of April 15, 2002. Interview with the Director of Nursing on June 17, 2025, at 1:31 PM, revealed she routinely speaks with staff members about their performance, however, the formal process for annual performance evaluations was not in place at that time. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on Resident Assessment Instrument (RAI - a standardized approach for applying a problem identification process in nursing homes, adopted to examine nursing home quality and to improve nursing home regulation), clinical record review, and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 13 residents reviewed (Residents 2, 26, and 27). Findings included: Review of RAI Version 3.0 dated October 2024, pages N1 - 11, read, in part, N0415 high risk drug classes: is taking - check if the resident is taking any medication by pharmacological classification during the last 7 days or since admission. Indication noted 1 is checked if there is an indication noted for all medications in the drug class. Review of Resident 2's clinical record diagnoses that included depression (feelings of severe despondency and dejection), anxiety (a feeling of worry nervousness or unease), intellectual disabilities (a condition characterized by significant limitations in both intellectual function and adaptive behavior), post-traumatic stress disorder (PTSD - a mental disorder that develops from experiencing a traumatic event), cerebral palsy (a group of neurological disorders that affect movement and posture causing activity limitations), and encephalopathy (brain disease, damage or disorder that impacts brain structure or function). Review of Resident 2's physician orders included apixaban 5 milligrams by mouth two times a day for deep vein thrombosis (DVT - a serious condition that occurs when a blood clot forms in a deep vein), start February 4, 2025, and discontinued May 27, 2025. Review of Resident 2's significant change MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) dated June 7, 2025, documented yes for taking AC and indication noted. Interview with the Director of Nursing (DON) on June 18, 2025, at 12:23 PM, it was revealed that the significant change MDS was incorrect, and the care plan should've been updated to reflect the anticoagulant was discontinued. Review of Resident 26's clinical record revealed diagnoses that included at risk for malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it gets), dysphagia (difficulty swallowing), and muscle weakness. Review of Resident 26's clinical record revealed she had a significant weight loss of 11% from April 8, 2025, to May 2, 2025. Review of Resident 26's Medicare 5 Day MDS with ARD (assessment reference date - last day of the assessment period) of May 7, 2025, revealed under Section K0300. Weight Loss: Loss of 5% or more in the last month or loss of 10% or more in last 6 months, Resident 26 was marked No or unknown. Interview with the DON on June 18, 2025, at 10:13 AM, revealed the aforementioned MDS was coded in error and she would expect MDS assessments to be coded accurately. Review of Resident 27's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and delusional disorder (type of psychotic disorder; a delusion is an unshakable belief in something that is untrue). Review of Resident 27's Quarterly MDS with ARD of September 26, 2024, indicated in Section N. Medications that she had received an antipsychotic medication on a routine basis and that she had not had a gradual dose reduction. Review of Resident 27's clinical record revealed that her antipsychotic medication dose had been reduced by her physician on September 11, 2024. Review of Resident 27's Annual MDS with the assessment reference date of May 2, 2025, indicated in Section N. Medications that she was coded as receiving antianxiety and anticonvulsant medications. Review of Resident 27's clinical record revealed that she had not received any antianxiety or anticonvulsant medications. During a staff interview with the DON on June 18, 2025, at 12:29 PM, she confirmed that the MDS's were coded in error and that modifications were completed. 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, observation, staff and resident interviews, and facility policy review, it was determined that the facility failed to develop a baseline plan of care for one of two residents reviewed for new admission (Resident 95). Findings include: Review of facility policy, titled Care Plans - Baseline, last reviewed January 15, 2025, revealed it stated, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission The interdisciplinary team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs . Review of Resident 95's clinical record revealed diagnoses that included history of venous thrombosis (blood clot formation) and embolism (blood clot that travels through the circulatory system and blocks blood flow through a vessel) and hypertension (elevated/high blood pressure). Review of Resident 95's clinical record revealed that Resident 95 was admitted to the facility on June, 8, 2025. During an interview with Resident 95, Resident 95 was observed wearing a lidocaine patch to her right knee. When asked about her right knee, Resident 95 stated she had chronic pain in her right knee. Review of Resident 95's physician orders revealed the Resident was receiving meloxicam (prescription non-steroidal anti-inflammatory medication), and the lidocaine 4% (topical pain medication) for right knee pain. Review of Resident 95's baseline plan of care revealed no care plan for pain. Review of Resident 95's physician orders revealed Resident 95 also received an anticoagulant medication (medication that decreases the clotting ability of the blood). Review of Resident 95's baseline care plan revealed no care plan was initiated for the use of an anticoagulant medication. During a staff interview on June 17, 2025, at approximately 10:30 AM, Director of Nursing revealed that Resident 95's baseline care plan should have included a care plan for pain and anticoagulant use. 28 Pa code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, review of select facility fall reports, clinical record review, and staff interviews, it was determined that the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents and failed to conduct thorough fall investigations for one of two residents reviewed for falls (Resident 10). Findings include: Review of facility policy, titled Falls and Fall Risk, Managing last reviewed on January 25, 2025, read, in part, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try and prevent the resident from falling and try to minimize complications from falling. Resident conditions that may contribute to the risk of falls include lower extremity weakness. Review of Resident 10's clinical record revealed diagnoses that included wedge compression fracture (a type of compression fracture that occurs when vertebrae collapses and creates a wedge shape) unspecified fall and unsteadiness on feet. Review of facility fall report dated February 21, 2025, revealed Nursing Description: Registered Nurse (RN) was called to resident's bathroom by licensed practical nurse, per nurse aide (NA), NA was transferring resident from wheelchair to toilet, resident was unable to turn right lower extremity and requires to be lowered to the floor by nurse aide. Was witnessed and resident did not hit his head. Review of facility fall report dated March 18, 2025, revealed Nursing Description: During transfer with staff [Resident 10] was lowered to the floor. Review of Resident 10's comprehensive care plan revealed staff was to use a sit to stand (sts) lift for transfers at the time of Resident 10's fall on February 21, 2025, and March 18, 2025. Interview with the Director of Nursing (DON) on June 18, 2025, at 9:22 AM, revealed the NA in the fall report from February 21, 2025, was not utilizing the sts lift at the time of Resident 10's fall, and that in response she did a verbal education with that nurse aide, and the following month she did an education with all nursing staff. She further revealed staff was not utilizing the sts lift at the time of Resident 10's fall on March 18, 2025, and that Employee 14 (Registered Nurse) did not notify the DON of the fall that morning per facility protocol, so a proper investigation was not conducted, including gathering witness statements. During a follow-up interview with the DON on June 18, 2025, at 12:21 PM, revealed she was unable to find any witness statements associated with the fall on February 21, 2025, and she would expect witness statements to be available for review. Review of facility fall report dated April 21, 2025, detailed a fall sustained by Resident 10 that evening. The intervention noted in response to the fall read, Staff to offer to get resident out of bed for supper at the start of shift. Review of Resident 10's comprehensive care plan failed to reveal the fall intervention had been added to Resident 10's care plan. During an interview with the DON on June 18, 2025, at 12:56 PM, revealed she was adding the fall intervention to Resident 10's care plan, and she would expect his care plan to be updated. 28 Pa Code 201.18(b)(1) Management 28 Pa Code 211.12(c)(d)(1)(3)(5) Nursing Services

Based on facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to provide a physician ordered nutritional supplement, per physician's order, for two of four residents reviewed for nutritional status (Residents 2 and 26), and failed to notify the physician of significant weight changes for two of four residents reviewed for nutritional status (Residents 10, and 26). Findings include: Review of facility policy, titled Weight Policy last reviewed January 25, 2025, read, in part, The Registered Dietitian will review the medical record of residents with significant weight changes. Dietary interventions will be recommended as needed. All significant weight changes will be reported to the physician. Review of facility policy, titled Medication Administration last reviewed January 25, 2025, read, in part, Medications are administered in accordance with prescriber orders. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR (Medication Administration Record) space provided for the drug and dose. Review of Resident 2's clinical record diagnoses that included depression (feelings of severe despondency and dejection), anxiety (a feeling of worry nervousness or unease), intellectual disabilities (a condition characterized by significant limitations in both intellectual function and adaptive behavior), post-traumatic stress disorder (a mental disorder that develops from experiencing a traumatic event), cerebral palsy ( a group of neurological disorders that affect movement and posture causing activity limitations), and encephalopathy (brain disease, damage or disorder that impacts brain structure or function). Weight history for Resident 2 revealed a 10-pound weight loss from May to June of 2025; May 6th 95 pounds, and June 6th 84 pounds. Review of Resident 2's physician orders included house supplement after meals 90 milliliters three times a day, starting March 6, 2025, and Remeron 7.5 milligrams at bedtime for poor appetite starting May 20, 2025, and discontinued June 6, 2025. Review of Resident 2's April 2025 Medication Administration Record (MAR- documentation of medication administered per physician orders) for house supplement documented X or 0 on the 14th and 26th at 1:00 PM, and 27th at 9:00 AM, 1:00 PM, and 6:00 PM. Review of progress notes revealed the house supplement was not available on April 14th, 26th, and 27th, 2025. Progress notes failed to document the physician was notified that the supplement was not available. May 2025 MAR for house supplement documented an X, NA, or 0 on the 17th at 1:00 PM and 6:00 PM; 22nd and 23rd at 9:00 AM, 1:00 PM, and 6:00 PM; 24th at 1:00 PM; and 25th, 29th, 30th and 31st at 6:00 PM. Review of progress notes revealed the house supplement was not available on May 17th, and 18th, 2025. Progress notes failed to document the physician was notified that the supplement was not available. June 2025 MAR for house supplement documented an X, or 0 on the 1st at 1:00 PM; 4th at 1:00 PM and 6:00 PM; 10th at 1:00 PM; and 13th at 6:00 PM. Interview with Employee 6 (Registered Nurse) on June 17, 2025, at 12:10 PM, revealed that the house supplement is Med Pass 2.0 or 2 Cal HN. Observation with Employee 6 on June 17, 2025, at 12:11 PM, in the medication room and nourishment pantry (in the cabinet and refrigerator) there was no Med pass 2.0 or 2 Cal HN. Observation in central supply and interview with Employee 6 and Employee 7 (Director of Dietary/Housekeeping) revealed there was no house supplement. Per Employee 7, the house supplement should be with the delivery that was due that. Surveyor stated that there was no house supplement available on the nursing unit and that residents scheduled to receive after lunch or this afternoon may not receive it; Employee 7 stated that he would call a sister facility to obtain the supplement. Observation with the Director of Nursing (DON) on June 17, 2025, at 12:57 PM, there was one 8-ounce container of med pass 2.0 in the one medication cart; the other medication cart didn't have a supply. Observation with the DON on June 17, 2025, at 1:04 PM, in the medication room after the supply order arrived, there were 2 cases (12- 32 ounce) med pass 2.0. It was also revealed that the supply company will deliver what they have whether it is med pass 2.0 or 2 Cal HN and in whatever packaging, 32 oz containers or 8 oz containers. Supplies are delivered every two weeks on Tuesday, however if the facility requires additional supplies, an additional delivery will be made. Interview with DON June 17, 2025, at 2:32 PM, it was revealed the physician should be notified if the supplement wasn't available or administered. Review of Resident 10's clinical record revealed diagnoses that included wedge compression fracture (a type of compression fracture that occurs when vertebrae collapses and creates a wedge shape) unspecified fall, and unsteadiness on feet. Review of Resident 10's weight measures revealed he had a significant weight loss of 10.1% in one month from February 5, 2025, to February 26, 2025. Review of Resident 10's clinical record failed to reveal physician notification of the significant weight loss. Interview with the DON on June 18, 2025, at 10:15 AM, revealed the dietitian emails weight loss notifications to the DON and nurse unit manager to notify the physician, but they thought she was notifying him separately, so they did not send the weight loss notifications to the doctor. She further revealed moving forward the doctor will be copied on the email sent to the DON and unit manager for review. Review of Resident 26's clinical record revealed diagnoses that included at risk for malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it gets), dysphagia (difficulty swallowing), and muscle weakness. Review of Resident 26's clinical record revealed she had a significant weight loss of 11% from April 8, 2025, to May 2, 2025. Review of Resident 26's clinical record failed to reveal physician notification of the significant weight loss. Review of Resident 26's physician orders revealed an order for House Supplement every evening shift 120mL daily, with a start date of May 2, 2025. Review of Resident 26's May 2025 MAR for house supplement documented NA (not available) on May 6, 14, 15, 19, 20, 27, and 30, 2025. Review of Resident 26's June 2025 MAR for house supplement documented NA (not available) on June 5 and 9-11, 2025. On June 16, 2025, it was marked 9 for other/see progress notes. Review of Resident 26's nursing progress notes failed to reveal documentation the physician was notified that the supplement was not available on the aforementioned dates, and the progress note linked to the MAR on June 16, 2025, read not available. Interview with DON on June 17, 2025, at 2:32 PM, revealed the physician should be notified of significant weight losses and if the supplement wasn't available to administer. Further revealed is that they did had the supplement in one of the medication carts on the evening of June 16, 2025, so staff should have communicated supplies between medication carts and administer the supplement if it was available. 28 Pa. Code 211.12(d)(3) Nursing services

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to complete a timely assessment for trauma, and then develop and implement an individualized person-centered care plan to render trauma-informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder (PTSD) for one of one resident reviewed with PTSD (Resident 2). Findings include: Review of facility policy, Trauma Informed Care, revised March 2019, read, in part, nursing staff are trained on screening tools, trauma assessment, and how to identify triggers associated with re-traumatization. Implement universal screening of residents for trauma. Review of Resident 2's clinical record diagnoses that included depression (feelings of severe despondency and dejection), anxiety (a feeling of worry nervousness or unease), intellectual disabilities (a condition characterized by significant limitations in both intellectual function and adaptive behavior), PTSD (a mental disorder that develops from experiencing a traumatic event), cerebral palsy ( a group of neurological disorders that affect movement and posture causing activity limitations), and encephalopathy (brain disease, damage or disorder that impacts brain structure or function). Review of Resident 2's hospital Discharge summary dated [DATE], documented PTSD. Review of the Centers for Medicare and /Medicaid Services form 802 (matrix- a list of all current residents and to note pertinent care categories) Resident 2 was documented for PTSD. Further review of the clinical record failed to reveal a screening for a history of trauma, documentation, or care planning per facility policy related to trauma-informed care. Review of Resident 2's care plan failed to reveal Resident 2's diagnosis, symptoms, or triggers related to the diagnosis of PTSD. Interview with the Director of Nursing on June 18, 2025, at 10:30 AM, it was revealed the facility doesn't complete a trauma assessment due to it not being available in the electronic record, and the facility does have a form to complete the assessment. It was also revealed the Social Worker will be tasked with completing the trauma informed care assessment. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services

Based on observation, facility policy review, and staff interviews, it was determined that the facility failed to ensure opened vials were labeled in accordance with currently accepted professional principles for one of one medication rooms reviewed. Findings include: Review of facility policy, titled Medication Labeling and Storage, last reviewed January 15, 2025, revealed subsection five of Medication Labeling, stated, Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. During observation of the facility medication storage room on June 17, 2025, revealed two of two vials of tuberculosis purified protein derivative solution (PPD - used to determine resident or staff exposure or infection with tuberculosis) were opened with no opened date written on the vial or the box that contained the vial. During a staff interview directly after the observation, Employee 9 (Licensed Practical Nurse) confirmed that the two vials appeared accessed and that there were no open dates on the two vials of the PPD solution. During a staff interview on June 18, 2025, at approximately 10:30 AM, Director of Nursing confirmed that the open dates should have been documented on the PPD solution. 29 Pa code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure clinical records were complete and accurately documented for one of 13 residents (Resident 8). Findings include: Review of facility policy, titled Attending Physician Responsibilities; with a last review date of January 15, 2025, revealed, in part, Each attending physician will be responsible for providing appropriate, timely, and pertinent documentation; At each visit, the attending physician will provide a progress note (written, typed, or electronic) in a timely manner for placement in the medical record. The note should either be written or entered at the time of the visit or, if dictated or otherwise prepared after the visit, should be returned to the facility for placement on the chart within a week. Review of Resident 8's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure) and fractures of the bilateral fibula (the smaller bone located in the lower leg). Review of Resident 8's clinical record on June 17, 2025, failed to reveal any physician progress notes since her admission to the facility. During a staff interview with the Director of Nursing (DON) on June 17, 2025, at approximately 1:45 PM, she indicated that she would look for the physician progress notes. On June 18, 2025, at approximately 10:00 AM, the DON provided physician progress notes dated March 18, 21, and 25, 2025. She said that she had texted Resident 8's physician requesting progress notes be sent to the facility. She indicated that these were the only three progress notes she had received and that she was still awaiting the others to be sent. During a staff interview with the Nursing Home Administrator (NHA) and the DON on June 18, 2025, at 12:11 PM, the DON indicated that Resident 8's physician dictates his notes, then his office types them up, and then the notes are faxed via email to a general email account at the facility for staff to print. She said that there was no clear process as to who would be responsible to print the notes and place on resident charts. She also indicated that Resident 8's physician is not timely with providing his notes for the Resident records. She further confirmed that she was yet to receive any additional progress notes for Resident 8 from her physician and could not state when Resident 8 was seen by her physician. During a final interview with the NHA and DON on June 18, 2025, at 12:28 PM, both confirmed that they had no additional documentation to provide and that they would expect physician progress notes to be on a resident's chart within 7 days as the facility policy states. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.5(f)(iv) Medical records 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on policy review, state professional standards, clinical record review, document review, and staff interviews, it was determined that the facility failed to ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services for each resident, resulting in the absence of a Registered Nurse in the facility to assess and pronounce a resident who was found with no pulse or respirations (Resident 4). This failure placed all residents who reside at the facility requiring services from a Registered Nurse in an Immediate Jeopardy situation (34 residents). Findings Include: Review of the Pennsylvania Nursing Practice Act for Licensed Practical Nurses (LPN), Chapter 21.145. revealed Functions of the LPN. (a) The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgement based on preparation, knowledge, experience in nursing and competency. The LPN participates in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place. (1) An LPN shall communicate with a licensed professional nurse and patient's healthcare team members to seek guidance when the patient's care needs exceed the licensed practical nursing scope of practice. Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing Chapter 21, Subchapter A, Section 21.11 states The registered nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse Collects complete and ongoing data to determine nursing care needs. A Registered Nurse under the act of [DATE] (P.L. 317, No. 69), 1 known as The Professional Nursing Law, who are involved in direct care of a patient shall have the authority to pronounce death as determined under the act of [DATE] (P.L. 1401, No. 323) known as the Uniform Determination of Death Act, in the case of death from natural causes of a patient who is under the care of a physician or certified registered nurse practitioner when the physician or certified registered nurse practitioner is unable to be present within a reasonable period of time to certify the cause of death. Professional nurses shall have the authority to release the body of the deceased to a funeral director after notice has been given to the attending physician or certified registered nurse practitioner, when the deceased has an attending physician or certified registered nurse practitioner, and to a family member. Review of the facility's policy, titled Discharging a Resident to the Mortuary revised [DATE], reads, in part, The resident must be declared legally dead in accordance with state law [either direct or indirect pronouncement by a Licensed Physician]. Review of Resident 4's interdisciplinary plan of care revealed diagnoses that included morbid obesity and chronic diastolic congestive heart failure. Review of Resident 4's interdisciplinary progress notes dated [DATE], at 12:04 AM, revealed documentation by Employee 5 (LPN- Licensed Practical Nurse) that reads, Employee 6 (NA - Nurse Aid) provided care to resident [Resident 4] at 22:30 [10:30 PM]. At that time she was alert, oriented, and offering no c/o [no complaints of] discomfort or pain. After providing care, the [nurse aide] exited the room and began charting. The progress notes continue Approximately 10 minutes later [nurse aide] heard the resident's roommate calling. He went into the room to offer assistance and observed the resident as nonresponsive. The nurse aide alerted the charge nurse [ Employee 5 ] who could not find a pulse, observed no breathing, and could not detect a heartbeat using a stethoscope. Employee 5 is an LPN and does not have the credentials to assess and pronounce a resident deceased . An interview with Employee 5 on [DATE], at 8:21 AM, revealed after Resident 4 was found with no pulse and no respirations, he placed calls to the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Nursing Home Administrator (NHA). The interview revealed all calls went unanswered. Employee 5 stated he proceeded to place a call to the coroner's office as he was unable to contact facility administration. Employee 5 stated the coroner's office dispatched the local police and emergency services personnel to the facility for assistance. The interview also revealed that the facility had no Registered Nurse (RN) scheduled on the evening shift in order to assess and pronounce Resident 4 to be deceased . The facility designated the DON to be the on-call RN for the night shift. The on-call RN is expected to be able to come to the facility within 30 minutes if RN services are needed. The DON and ADON did not come to the facility throughout the night shift despite Employee 5's efforts to contact them for needed assistance. Employee 5 also stated the facility's NHA made contact with Employee 4 (RN) from the facility's sister facility, who presented to the facility around 7 AM to assess and pronounce Resident 4 to be deceased . Employee 5 stated Resident 4 remained in her room at the facility at the end of his shift, when he left the facility at approximately 7:30 AM. An interview with Employee 4 on [DATE], at 5:21 PM, revealed he received a call from the NHA a little after 6 AM on [DATE], with a request to present to the facility as Employee 5 could not get a hold of the DON or the ADON in order to pronounce Resident 4 as deceased . The interview also revealed Employee 4 was not the on-call RN or scheduled to work at the facility during the night shift following Resident 4's passing on [DATE], at approximately 10:40 PM. Review of employee files revealed that Employee 4 was not an employee of the facility on [DATE]. An interview with the NHA, on [DATE], at 9:35 AM, regarding the circumstances surrounding the death of Resident 4 and subsequent actions following her death, revealed Employee 4 to be on call and proceeded to the facility to assess and pronounce Resident as deceased . The interview revealed no information regarding Employee 5's difficulties in contacting the DON, ADON, or NHA. The interview did not reveal any information regarding Employee 5 contacting the coroner, nor the local police and emergency personnel presenting to the facility for assistance as stated during the interview with Employee 5. An interview with the DON on [DATE], at approximately 4:00 PM, revealed she was not on duty on the evening of [DATE], as she was ill and would be unavailable for facility staff to reach her for assistance. The facility did not have a RN working the evening shift on [DATE]. The facility also did not have a RN available to present to the facility to assess a Resident who was found without a pulse or respirations. This failure resulted in Resident 4 laying in bed, deceased , from 10:30 PM until the following day, some time after 7:30 AM; when a RN came to the facility and received an order to pronounce the Resident and release the body to the funeral home. The Nursing Home Administrator (NHA 2) and the DON were notified of the concern regarding the lack of RN coverage on the 3 PM-11 PM evening shift on [DATE], and were provided the Immediate Jeopardy template at 5:06 PM on [DATE]. An immediate action plan was requested at that time. On [DATE], at 6:59 PM, the facility's immediate action plan was accepted, which included: - All licensed staff will be educated on requirement for On-Duty RN for 7 AM-3 PM and 3 PM-11 PM shifts, and on call RN for 11 PM-7 AM with the ability to be at the facility within 30 minutes. NHA or designee will in-service on each shift for licensed staff by [DATE]. - All licensed staff will be educated to proper procedure for handling call-offs and need to obtain RN coverage. NHA or designee will in-service on each shift for licensed staff by [DATE]. - Facility will immediately contract with staffing agency for RN use. COO signed a contract with a staffing agency on [DATE]. - NHA to audit schedule daily. NHA or designee will audit daily RN Coverage and RN On-Call Coverage. - On-call RN to be designated daily. There will be a calendar/schedule posted at the nurses' station. On [DATE], at 12:55 PM, the Immediate Jeopardy was lifted during an on-site survey after ensuring that the immediate action plan had been implemented. 28 Pa. Code 211.12 (a)(c)(d)(1)(4)(5) Nursing Services 28 Pa. Code 201.18 (b)(1)(3)(e)(1)(2)(3)(6) Management 28 Pa. Code 201.14(a) Responsibility of licensee

Based on clinical record review, review of facility policy and staff interview, it was determined that the facility failed to identify, monitor and treat pressure ulcers for two out of 10 residents reviewed, which resulted in actual harm to Resident B17. (Resident B7 and B17). Findings include: Review of the facility policy entitled Pressure Ulcer Report (revised 1-12) revealed that the facility would accurately document on each identified pressure ulcer and ensure that appropriate treatment is consistently applied. Review of Resident B7's clinical medical record revealed that the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident B7's clinical medical record revealed that upon admission on June 16, 2015 the resident had no skin issues documented. Review of June 2015 physician's orders revealed that on June 27, 2015 the physician was notified of the following: Noted slit at coccyx, scant blood noted, resident reports this has happened before. Tender only to touch. Would you consider: cleanse area with normal saline solution, cover with duoderm and change every 3 days and as needed). Review of the clinical medical record reveal no documented evidence that the above treatment was initiated until July 3, 2015 (7 days later) when it was documented on the July 2015 treatment administration record (TAR) that the above order was administered. Review of Resident B7's clinical medical record revealed the next following nursing note that addressed the new skin issue was on July 7, 2015 from the wound nurse stating the area on the coccyx was now a Stage 2 (ulcer involving the loss of the top layers of the skin) pressure ulcer measuring 4 by 0.5 by less than 0.1 centimeters with 100% granulation tissue (healing tissue on the surface of a wound). The nursing note also stated that permission was asked to the resident to be evaluated by the wound physician and there was no change in the present treatment. Review of Resident B7's clinical medical record revealed that Resident B7 was seen by the wound physician for the first time on July 14, 2015 and his documentation indicated, Stage 3 pressure ulcer on lower midline sacrum 5 days in duration, 3.2 by 0.9 by 0.2 centimeters, 50% granulation tissue and 50% necrotic (dead) tissue, debrided. Review of the documentation revealed a pressure ulcer that progressed from a slit area, to a Stage 3 (full thickness skin loss involving the epidermis) pressure ulcer with necrotic (dead tissue) tissue in a 2 week period . Interview with the Nursing Home Administrator and the Director of Nursing on December 2, 2015 at 10:30 a.m. did confirm the lack of documentation in regard to the initiation of the treatment to the open area on Resident B7's coccyx area. Review of Resident B17's comprehensive (MDS) assessment dated [DATE] (periodic resident assessment used to identify care needs) revealed that the resident was at risk for skin breakdown and pressure ulcer development. Review of the resident nursing notes dated April 24, 2015 revealed that the resident was seen on wound rounds on that date for an unstageable deep tissue injury ( discolored or blood-filled blister due to damage of underlying skin due to damage of underlying soft tissue from pressure) on the right heel which was blue/purple in color and documented as measuring 1 centimeter round. Review of the weekly body check documentation included the wound identification on April 24, 2015 however the time identified in the clinical record nursing note was 9:10 p.m. which would be after wound rounds. The wound was identified on the weekly body check dated April 24, 2015 as an unstageable right heel wound - eschar, slough (devitalized tissue covering the wound). Review of the treatment administration record for April 2015 revealed that [MEDICATION NAME] cream was documented as being applied to the right heel twice a day from April 1 through April 24, 2015 however there was no documentation of the timely identified of a right heel wound by the nursing staff. An interview with the Director of Nursing on December 3, 2015 at approximately 9:00 a.m. revealed that she was unsure when the wound was first identified and could not explain how the resident was scheduled for wound rounds if the wound had not been identified previously. Further there was no documentation in the clinical record relating the size or measurements of the wound or the date and time of identification. The facility failed to timely identify the development of an unstageable pressure ulcer on Resident B17's right heel which resulted in actual harm to Resident B17. 28 Pa. Code: 211.5(f)Clinical records Previously cited 11/15/2015, 10/23/2015, 8/4/2015, 3/25/2015, 1/30/2015 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 11/15/2015, 10/23/2015, 3/25/2015, 1/30/2015

Based on a review of clinical record and staff interview, it was determined that the facility failed to monitor that sufficient fluids intake was maintained to ensure proper hydration for one of two residents reviewed, resulting in actual harm to one of two residents reviewed. (Resident A1) Findings include: Review of Resident A1 ' s nurses notes dated February 5, 2015 stated the resident was admitted [DATE] via ambulance. Review of Resident A1 ' s [DIAGNOSES REDACTED]. Review of the resident's admission comprehensive minimum data set (MDS- assessment of resident care needs and status) dated February 12, 2015 identified the resident with severe cognitive impairments and requiring extensive assistance of two people for eating. Review of the swallowing evaluation completed on February 6, 2015 confirmed that the resident was assessed with [REDACTED]. Review of the dietary assessment completed February 6, 2015 revealed that the resident was admitted to the facility on [DATE] with an admission weight of 159 pounds. The dietary fluid needs of the resident were assessed as 1300-1560 cc of fluids and 1300-1560 calories daily. The resident was identified with difficulty chewing and swallowing due to the [DIAGNOSES REDACTED]. Review of the resident's plan of care stated that the resident was to maintain good/stable weight with good intakes by mouth at all meals and adequate hydration to prevent complications. The resident was to be offer fluids throughout the day in addition to fluids offered at meal to maintain adequate hydration and 8 ounces of nectar water three times a day between meals. Review of nursing documentation dated February 12, 2014 noted that the resident ' s appetite was poor to fair. Nursing notes dated February 14, 2015 stated the resident refused to eat stating that she did not like it. Nurses ' notes dated February 15, 2015 stated the resident refused meals and that they were too thick. Nurses ' notes dated February 16, 2015 at 10:15 a.m. stated the resident refused all morning medication and stated that the "they make me cough". On February 16, 2015 at 3: 00 p.m. it was noted that the resident refused breakfast and only ate two bites of lunch. On February 16, 2015 it was documented that the physician was notified of the resident poor appetite and sad expression. Review of physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. Review of the laboratory report revealed that there was no evidence that the complete blood count, and the complete metabolic panel were obtained. Interview with the Director of Nursing on March 18, 2015 at 2:30 p.m. indicated that per the 24 hour nursing report and laboratory request form, the resident refused to have the blood test completed. There was no documented evidence that the facility communicated to the physician that the blood work was not able to be obtained due to resident refusal. Further review of nursing documentation revealed that on February 15, 2015 at 9:45 a.m. the resident spit out all medications and at 2:00 p.m. the resident vomited. On February 18, 2015 the resident continued with poor appetite and refused all morning medication by holding the medications in her mouth and then spitting them out. On February 19, 2015 nursing notes stated that the resident was taking fluids but in small amounts. There was no other documentation on the clinical record beside the nursing note of February 19, 2015 regarding the resident fluid intake. Review of the meal consumption records from February 12, 2015 through February 20, 2015 revealed the following percentages for meal consumption: on February 12, 13, 16, 17, 19 and 20, 2015, the resident consumed 5-10 % of breakfast and did not consumed any breakfast on February 18, 2015. The resident only consumed 10% of the lunch meal on February 13, 16, 17, and 19, 2015 and did not consumed any of the lunch meal on February 12, 15, and 18, 2015. On February 12, 14, 15, 16, 17, 18, 19, and 2015 the resident did not consume any of the dinner meal. Interview with the Director of Nursing on March 18, 2015 at 2:30 p.m., confirmed that there was no record of the fluid intake consumed by the resident and that the only records available were the meal consumption records. Review of physician notification dated February 17, 2015 noted that nursing notified the physician that the resident was gagging on foods and medications. There were no further orders given by the physician at this time. On February 19, 2015 at 11:27 a.m. the physician was again notified that the resident was not eating, spitting out the food, and taking fluids but not in very large amounts. Review of a physician order [REDACTED]. A review of the hospital admission documentation on March 20, 2015 revealed the [DIAGNOSES REDACTED]. Review of Resident A1 comprehensive metabolic panel obtained on February 20, 2015 at the hospital revealed a BUN (blood, urea, nitrogen) level of 70 milligrams per deciliter (normal range 8-23 milligrams per deciliter) and a creatinine level of 2.7 milligrams per deciliter (normal range 0.8-1.3 milligrams per deciliter) which are indicator of dehydration. There was no evidence that the resident had been assessed for the refusal to eat pureed foods and nectar thick liquids. There was no evidence that the resident's fluid intake had been monitored or that the physician was timely notified of the resident ' s refusals to eat pureed foods and drink nectar thick fluids in order to maintain the resident ' s hydration needs and avoid dehydration and other complications. The resident was hospitalized 15 days after admission to the facility with a [DIAGNOSES REDACTED]. 28 Pa Code: 201.18(b)(1) Management Previously cited 01/30/15 28 Pa. Code: 211.5(f) Clinical records Previously cited 01/30/15 28 Pa Code: 211.10(c) Resident care policies Previously cited 01/30/15 28 Pa Code: 211.12(d)(1)(5) Nursing services Previously cited 01/30/15

Based on review of the facility protocol, review of clinical records, observations and interviews with staff, it was determined that the facility failed to timely identify and provide treatment for [REDACTED]. Findings include: Review of the undated facility Wound Protocol indicated that it's purpose is to prohibit any avoidable decline in wound status and included that staff should consult with dietary if indicated. Review of Resident B8's [DIAGNOSES REDACTED]. Review of the resident's nursing notes revealed that the resident was admitted on [DATE], was at risk for skin breakdown, needed assistance of staff for activities of daily living and for repositioning. Review of the resident's pressure ulcer risk assessments dated November 16 and 23, 2011 revealed that Resident B8 was at low risk for developing pressure ulcers. Review of the wound sheet dated November 22, 2011, revealed that Resident B8 had a Deep Tissue Injury (Purple or maroon localized area of discolored intact skin due to damage of underlying soft tissue from pressure and/or shear) on the right heel, it measured 3 centimeters (cm) round and 0.1 cm deep, with a small amount of serosanguineous drainage (containing blood and serous fluid). There was no documentation of the appearance of the wound base or the peri wound area (side surrounding wound). Wound Documentation dated November 30, 2011, eight days later, revealed that the area on the right heel wound was now a Stage two pressure ulcer (Partial thickness skin loss with a red pink wound bed) that measured 5 cm round with a moderate amount of serosanguineous drainage. There was also no documentation of the appearance of the wound base or the peri wound area (side surrounding wound) at this time. Review of the resident's care plan revealed that there was no care plan in place for pressure ulcer prevention, to assist in the prevention of the development of a pressure ulcer on Resident B8's right heel. Review of dietary documentation dated November 18, 2011, revealed that the resident's hemoglobin and hematocrit were low (9.8/29.7), (normal 12-16 /36-46%) which can potentially delay wound healing. Review of the resident's dietary care plan dated November 18, 2011 revealed for staff to report skin breakdown to the dietician. Review of the resident's record on December 1, 2011, revealed that there was no documented evidence that the resident's skin breakdown was reported to the dietician in order to implement necessary interventions to assist with wound healing. Observation of the resident's pressure ulcer on December 1, 2011, at approximately 1:00 p.m., during wound care revealed that there was a large amount of drainage from the ulcer, the right side of the heel ulcer was opened pinkish/red in color and the left side had loose skin over it which was brownish-black under the loose skin. The observation also revealed that the resident's bed pillow, in the foot area (used to elevate the right foot), and dressing and socks that the resident had on, had a large amount of drainage on it. During the same observation of Employee E7 providing wound care to the resident it was revealed that infection control practices were not followed consistently which made the wound susceptible to infection. Additionally, during the observation of the resident on December 1, 2011, another blistered area, approximately the size of a quarter, purplish black in color, was identified on the resident's left heel. This was a new area that had not been previously identified or documented. Nursing documentation after the observation dated December 1, 2011, revealed that it was a Stage two pressure ulcer (Partial thickness skin loss with a red pink wound bed) in the resident's left lateral heel. It was described as an intact blister one centimeter by one centimeter. Review of the resident's care plan also revealed that there was not a care plan in place to prevent the development of this second pressure ulcer. Interview with the Nursing Home Administrator and the Director of Nursing on December 2, 2011, at 2:30 p.m. confirmed that there were no interventions in place for Resident B8 prior to the development of the pressure ulcer on her right heel and that it was an oversight. The interview also revealed that there was no policy and procedure in place to direct staff in the prevention, identification and proper stagging of pressure ulcers but that there was a wound manual available. The Director of Nursing indicated during the interview that a wound with a darkened area should have been staged as an unstageable pressure ulcer instead of a stage two, as was indicated by employee. Review of Resident C5's admitting orders dated October 20, 2011, included a [DIAGNOSES REDACTED]. Nursing documentation on admission also indicated that the resident had a potential for skin breakdown secondary to immobility related to a [MEDICAL CONDITION] hip. Review of the resident's admission comprehensive assessment revealed that the resident needed extensive assistance of staff for bed mobility and for transfer. Review of the wound sheet for Resident C5 dated November 6, 2011, revealed that the resident had a Stage One pressure ulcer (a reddened area on the skin, when pressed, does not turn white) which measured 1.0 cm x 2.0 cm and a physician's orders [REDACTED]. Licensed staff Employee E7, prior to the observation, indicated that the resident had a Stage one pressure ulcer (a reddened area on the skin, when pressed, does not turn white) on the left heel. Observation of the resident on December 2, 2011, revealed that the resident's left heel had a large amount of serous drainage on the bed, some of which was dry. The wound was noted to be open with no dressing in place to cover it, and had dark brownish discoloration around the wound edge with a little pink area in the medial portion. Review of the resident's wound sheet documention (documentation made after the observation) revealed a Stage two (Partial thickness skin loss with a red pink wound bed) pressure ulcer, 4 centimeters round, large serosanguineous drainage with brown wound edges. This documentation is not consistent with what was observed, as indicated above. Interview with Employee E7 on December 2, 2011, at 9:05 p.m. revealed that the resident would require a new treatment order for wound treatment. Review of the resident's care plan revealed that there was no care plan developed to prevent the pressure ulcer until November 6, 2011, when the resident was identified to have a Stage one pressure ulcer(a reddened area on the skin, when pressed, does not turn white). The facility failed to ensure that adequate and timely care was provided for Resident C5's pressure ulcer and failed to assure that adequate preventive measures were in place, and failed to provide timely necessary care and services to Residents B8 and C5's wound resulting in actual harm to resident B8. . 28 Pa. Code 201.18(b)(1) Management previously cited 5/19/11 28 Pa. Code 201.18(e)(1) Management previously cited 5/19/11 28 Pa. Code 211.5(f) Clinical records previously cited 5/19/11, 1/28/11 28 Pa. Code 211.10(c) Resident care policies previously cited 5/19/11 28 Pa. Code 211.12(d)(1)(5) Nursing services previously cited 5/19/11, 1/28/2011 28 Pa. Code: 211.12(c)(d)(3) Nursing services previously cited 5/19/11

Based on a review of policy and procedure, clinical records, and staff interview it was determined that the facility failed to provide timely and appropriate care to manage one out of three residents reviewed in a manner prevent further breakdown and actual harm to the resident. (Resident: R1) Findings include: A review of the current facility policy for skin review indicated that the facility will identify skin issues in a timely manner with accurate documentation and implementation of facility skin policy and procedure. It further documented that staff will notify the physician and obtain a treatment. A review of Resident R1 March 20, 2011 quarterly assessment indicated that the resident required the extensive assist of two people for all transferring and hygiene needs, and that the resident had no current skin breakdown. Review of the resident's plan of care dated March 22, 2011 indicated that the resident's skin will be adequately managed to prevent skin breakdown and pressure ulcers. The plan of care further documented that the resident's physician would be notified of any skin breakdown. May 2011 physician orders [REDACTED]. A nursing note dated May 8, 2011 documented that the resident was noted to have a reddened bottom and a skin tear to her coccyx. However, there is no evidence that the physician was notified or a treatment was ordered. Another nursing note date May 12, 2011 indicated that the staff informed the nurse of an open area to the gluteal fold. The note further documented that the area was moist in appearance and dark in color with the surrounding skin appearing to have a fungal appearance. Further review of the same note gave no indication that the physician was notified, or that any specific treatment was ordered. Another nursing note dated May 13, 2011 noted that the resident had a Stage IV pressure ulcer ( ulcer that causes full-thickness skin loss with extension into other areas of the body including the muscle, bones, tendons and joint spaces) over her coccyx area with what appeared to look like some eschar (dead tissue that is black in color). The note further documented that the area had a foul odor to it. Review of the wound skin care management sheets dated May 13, 2011 indicated that the pressure ulcer was noted to be 3.0 centimeters by 2.2 centimeters with 75% eschar and macerated (softened) edges. Further review of the record revealed a physician order [REDACTED]. Interview with the Administrator on May 19, 2011 at 12:20 p.m. confirmed that there was no communication to the physician, or order obtained from the physician to manage the area until May 13, 2011. The administrator further confirmed that the area was first discovered as a reddened area with a small skin tear and that according to documentation the area did decline over the next few days. The facility failed to implement timely treatment to the pressure ulcer when it was first discovered, causing decline to the area, and actual harm to the resident. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.5(f) Clinical records previously cited 1/28/11 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)((5) Nursing services previously cited 1/28/2011 28 Pa. Code: 211.12(c)(d)(3) Nursing services