Every finding on record at Embassy of Park Avenue

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure that the attending physician documented required visits by writing, signing, and dating a physician progress note for each visit for six of six residents reviewed (Residents R4, R7, R8, R9, 10, and R11) and failed to ensure that the physician signs and dates all orders during each of his/her visits for one of size residents reviewed (Resident R11). Findings include: A facility Policy entitled Physician Visit and Physician Delegation dated 3/5/26, revealed The physician should see the Resident within 30-day of initial admission to the facility, The physician should date, write, and sign a progress note for each visit and The physician should sign and date all orders except for the flu and pneumococcal vaccines. Resident R4's clinical record revealed an admission date of 11/1/25, with diagnoses that included Osteoarthritis (Occurs when protective cartilage that cushions the ends of the bones wears down over time leading to pain, stiffness, and reduced mobility. Commonly affected joints include the hands, knees, hips, and spine), Congestive Heart Failure (CHF - a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply causing blood and fluids collect in your lungs and legs over time), and Atrial Fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications). Resident R4's clinical record revealed a physician progress note dated 1/12/26, and not again until 6/2/26, a period of 141 days. Resident R7's clinical record revealed an admission date of 4/23/26, with diagnoses that included Diabetes (a health condition caused by the body's inability to produce enough insulin), Osteoarthritis, and CHF. Resident R7's clinical record lacked evidence of a physician progress note being completed until 6/2/26, a period of 40 days after admission. Resident R8's clinical record revealed an admission date of 5/18/24, with diagnoses that included A-Fib, High Blood Pressure, and Cervical disc Disorder with Myelopathy (A condition in which degeneration or injury to one or more intervertebral discs in the next [cervical spine] leads to compression or irritation of the spinal cord resulting in myelopathy, which is a disorder of the spinal cord that affects motor, sensory, and autonomic functions). Resident R8's clinical record revealed a physician progress note dated 2/16/26, and not again until 6/2/26, a period of 106 days. Resident R9's clinical record revealed an admission date of 6/6/25, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), Transient Ischemic Attack (TIA - occurs when there is a brief interruption of blood flow to a part of the brain, leading to symptoms similar to those of a stroke that are temporary, typically lasting only a few minutes to a maximum of 24-hours), and High Blood Pressure. Resident R9's clinical record revealed a physician progress note dated 1/5/26, and not again until 6/2/26, a period of 148 days. Resident R10's clinical record revealed an admission date of 1/7/25, with diagnoses that included CHF, A-Fib, and Parkinson's Disease (a movement disorder of the nervous system that may result in tremors, stiffness, slowing of movement, and trouble with balance that worsens over time). Resident R10's clinical record revealed a physician progress note dated 3/19/26, and not again until 6/1/26, a period of 74 days. Resident R11's clinical record revealed an admission date of 12/24/25, with diagnoses that included Protein Calorie Malnutrition (occurs when the body does not receive enough protein and energy [calories] to maintain normal tissue structure and function. It can result from inadequate dietary intake, increased nutrient requirements, or conditions that impair nutrient absorption such as chronic illness), CHF, and A-Fib. Resident R11's clinical record revealed a physician progress note dated 2/16/26, and not again until 6/1/26, a period of 106 days. Resident R11's clinical record revealed his/her admission orders weren't signed by the physician until 2/2/26, which is 40 days after his/her admission to the facility. During an interview on 6/9/26, at 2:24 p.m. the Director of Nursing confirmed that Resident R4, R7, R8, R9, R10, and R11's clinical records lacked evidence of the required physician progress notes at the time of review and that Resident R11's physician orders were not signed at the time of or within thirty days of admission as required. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.2 (d)(8) Medical director 28 Pa. Code 211.5 (f)(ii)(iv) Medical records

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure the physician alternated required resident visits with the nurse practitioner or physician's assistant for four of six residents reviewed (Residents R4, R8, R9, and R10). Findings include: A facility Policy entitled Physician Visit and Physician Delegation dated 3/5/26, revealed The physician should assign alternate physician or physician extender to make visits as appropriate by State Law and At the option of the physician, required visits in SNF's (skilled nursing facilities) after the initial visit, may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner, or clinical nurse specialist that is acting within scope of practice defined by State law and under the supervision of the physician. Resident R4's clinical record revealed an admission date of 11/1/25, with diagnoses that included Osteoarthritis (Occurs when protective cartilage that cushions the ends of the bones wears down over time leading to pain, stiffness, and reduced mobility. Commonly affected joints include the hands, knees, hips, and spine), Congestive Heart Failure (CHF - a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply causing blood and fluids collect in your lungs and legs over time), and Atrial Fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications). Resident R4's clinical record revealed physician progress notes signed by the nurse practitioner dated 12/8/25, and 1/12/26. The clinical record lacked evidence of progress notes being alternated between the physician and the nurse practitioner as required. Resident R8's clinical record revealed an admission date of 5/18/24, with diagnoses that included A-Fib, High Blood Pressure, and Cervical disc Disorder with Myelopathy (A condition in which degeneration or injury to one or more intervertebral discs in the next [cervical spine] leads to compression or irritation of the spinal cord resulting in myelopathy, which is a disorder of the spinal cord that affects motor, sensory, and autonomic functions). C Resident R8's clinical record revealed physician progress notes signed by the nurse practitioner dated 10/13/25, 12/18/25, and 2/16/26. The clinical record lacked evidence of progress notes being alternated between the physician and the nurse practitioner as required. Resident R9's clinical record revealed an admission date of 6/6/25, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), Transient Ischemic Attack (TIA - occurs when there is a brief interruption of blood flow to a part of the brain, leading to symptoms similar to those of a stroke that are temporary, typically lasting only a few minutes to a maximum of 24-hours), and High Blood Pressure. Resident R9's clinical record revealed physician progress notes signed by the nurse practitioner dated 11/24/25, and 1/5/26. The clinical record lacked evidence of progress notes being alternated between the physician and the nurse practitioner as required. Resident R10's clinical record revealed an admission date of 1/7/25, with diagnoses that included CHF, A-Fib, and Parkinson's Disease (a movement disorder of the nervous system that may result in tremors, stiffness, slowing of movement, and trouble with balance that worsens over time). Resident R10's clinical record revealed physician progress notes signed by the nurse practitioner dated 12/8/25, 1/8/126, 1/21/26, 2/16/26, and 3/19/26. The clinical record lacked evidence of progress notes being alternated between the physician and the nurse practitioner as required. During an interview on 6/9/26, at 2:24 p.m. the Director of Nursing confirmed that Resident R4, R8, R9, and R12's clinical record lacked evidence of alternating visits between the physician and nurse practitioner as required. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.2 (d)(8) Medical director 28 Pa. Code 211.5 (f)(ii)(iv) Medical records

Based on review of facility policies, facility records, observations, and resident and staff interviews, it was determined that the facility failed to ensure meals were prepared and served in accordance with planned menus and failed to note or update menu changes and notify residents of a change to the posted menu for five of 18 residents interviewed (Residents R7, R11, R16, R24 and R25).Findings include: Review of a facility policy dated 8/29/25, entitled Menu change policy revealed To ensure that all menu changes within the skilled nursing facility support resident preferences, nutritional adequacy, regulatory compliance, and safe food-service operations; any change to the posted or planned menu must be intentional, documented, and communicated to residents and staff; substitutions must be of equal nutritional value and meet resident preferences and dietary restrictions; menu changes require documentation on the monthly menu substitution log; menu changes must be communicated to the dietary staff during pre-meal huddles, nursing staff, residents via menu board or general communication. Interviews on 2/18/26, between 11:30 a.m. and 5:30 p.m. with Residents R7, R11, R16, R24 and R25 revealed that they have lately received foods that were not on the menu and were not notified of the changes prior to being served. Interview with LPN Employee E3 on 2/23/26, at approximately 11:00 a.m. revealed that he/she has noticed some food substitutions on resident trays at mealtimes without the kitchen advising the nursing staff or residents of the changes. During a confidential interview on 2/18/26, at approximately 10:00 a.m. it was revealed that cabbage was provided to 12-15 residents last week due to running out of the brussels sprouts and that the residents were not notified of the food substitution. It was also revealed that some food items ordered were not received at the facility. As a result there have been necessary substitutions to the menu due to those items not received and residents aren't notified of those changes. During a confidential interview on 2/19/26, at 11: 00 a.m. it was revealed that food is ordered twice a week for the facility and over the last few weeks, items ordered have been removed or substituted. Cream of broccoli soup was on the menu for dinner 2/23/26 with an anticipated delivery date of 2/19/26. The soup was not delivered as ordered and subsequently ordered again. Substitutions have to be made to the menu due to items not being received and without resident notification. During a confidential interview on 2/18/26, at 3:00 p.m. it was revealed that substitutions to the menu have been made over the last few weeks due to not receiving needed food items that were ordered. Mashed potatoes were served in place of biscuit mix for pot pie and pears instead of apples for dessert. Menus were not updated and residents not notified of the changes. During a follow-up confidential interview on 2/23/26, at 10:35 a.m. it was confirmed that the facility failed to follow planned menus, complete documentation on the monthly menu substitution log, update the menus, or alert residents of changes in the menu. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.6(a) Dietary services

Based on review of facility policies, observations, and resident and staff interviews, it was determined that the facility failed to implement dignified feeding practices and to maintain resident dignity for seven of 18 residents interviewed (Residents R7, R8, R9, R15, R16, R24, and R25).Findings include: Review of facility policy entitled Resident Environmental Quality dated 8/29/25, revealed It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents. Review of facility policy entitled Paper Products in the Dietary Department dated 8/29/25, revealed To ensure safe, sanitary, and high-quality food service operations by prohibiting the use of paper products (e.g., paper plates, bowls, cups, and disposable utensils) within the dietary department. This policy supports infection control, regulatory compliance, cost management, and resident dignity. Paper products are not permitted for use in food preparation, plating, or service within the dietary department except in approved emergency situations. Review of Resident Council meeting minutes and food committee minutes from 12/30/25, revealed resident concerns of food is cold and sometimes hard. Interviews on 2/18/26, between 11:30 a.m. and 5:30 p.m. with Residents R9, R16, R24 and R25 revealed that they have been receiving meals in Styrofoam containers on occasion for the last few weeks and the food is often cold as a result. The residents identified above revealed they are aware meals were being served in Styrofoam containers at dinner a few times this week due to a water issue, but unaware why meals were served in Styrofoam for the past few weeks on occasion. Resident R8 indicated that when meals are served in a disposable container, they are cold and not worthy of eating, so he/she typically orders out. Resident R8 stated, When I see a disposable container coming, I just order out. Interviews with Resident R15 on 2/19/26, at 12:00 p.m. and Resident R7 on 2/19/26, at 2:30 p.m. revealed that meals have been served in Styrofoam containers more often, and food is cold and does not taste good. Interviews on 2/18/26, between 2:00 p.m. and 5:30 p.m. with Licensed Practical Nurses (LPN) Employees E2 and E3, and interviews on 2/19/26, between 11:30 a.m. and 3:00 p.m. with LPN Employees E1, E5, and Certified Nursing Assistants (CNA) Employees E4 and E6 revealed evening and weekend meals have been served on Styrofoam quite a few times in the last few weeks. Interviews on 2/18/26, between 11:00 a.m. and 4:00 p.m. with [NAME] Employees E6 and E10 revealed that Styrofoam has been used sometimes for the dinner meals mainly due to staffing. Interview with Nursing Home Administrator (NHA) and Director of Nursing (DON) on 2/19/26, at 3:30 p.m. confirmed that Styrofoam containers have been used on occasion for the past few weeks for resident's meals. 28 Pa. Code 201.29 (a) Resident rights

Based on a review of facility policy, clinical and facility records, and resident and staff interviews, it was determined that the facility failed to provide a shower/bath as resident preference for seven of 13 residents reviewed (Residents R8, R9, R19, R20, R21, R22, and R23). Findings include: A facility policy entitled Personal Care Procedure dated 8/29/25, revealed it is the policy of this facility to provide/assist resident care and hygiene to each resident based on their individual status and needs. This includes such things as baths/showers (may be a bed bath), oral care (mouth care, denture care) resident grooming and peri-care/catheter care. Our residents are different in terms of how much resident care they can do their own. Some residents: can take care of their own resident care needs without our help, others need a little help, some need a lot of help with this care, and still others can do nothing on their own and are dependent on staff to provide all of their resident care to them. Independent Residents - provide privacy, and assist as needed. (May need help with setting up supplies, or to reach body parts. Self-care and independence should be encouraged but not forced. Bath/showers may be given at any time the resident chooses. They may be done in the morning, before bed or any other time of the resident's preference. A shower may only be necessary 2-3 times per week if the resident choose this. More showers can be given per resident request. A bed bath should be given on days a resident does not get a shower per their preference. Residents who are incontinent of urine and/or stool and those that perspire a lot may need to be given personal hygiene more than once a day. Refusals - If resident refuses care, encourage but don't threaten or force. Re-offer care at a later time. Attempt to identify reason for refusal - modify schedule or procedure when possible when medical/safety parameters to honor resident preferences. Keep responsible party aware of patterns of refusal. Resident R8's clinical record revealed an admission date of 6/16/25, with diagnoses that included epilepsy (a chronic neurological disorder that involves unprovoked recurring seizures), Crohn's disease (a chronic inflammatory bowel disease), cerebral infarction (a life threatening medical emergency where blood flow to part of the brain is blocked causing brain tissue to die), monoplegia of upper limb following cerebral infarction (loss of muscle function of one arm caused by cerebral infarction). Resident R8's clinical record revealed that during 1/21/26, through 2/19/26, he/she was offered a shower/bath on 1/23/26, 1/30/26, 2/10/26, and 2/13/26. An interview with Resident R8 on 2/18/26, at 12:30 p.m. revealed he/she would like to have a shower everyday but would be satisfied with one twice weekly, which is his/her schedule. Resident R8 indicated he/she has not received a shower since last Friday 2/13/26, but should have received a shower on Tuesday 2/17/26. Resident R8 stated, I would love to get a shower every day. I can do it myself, but not allowed for safety reasons. I got myself in trouble when I was on the other unit, when I showered by myself. The showers were in our rooms. Resident R8 was observed with greasy hair. Resident R9's clinical record revealed an admission date of 7/19/22, with diagnoses that included atrial fibrillation (an irregular and often rapid heart rhythm), diabetes mellitus (a chronic disease that affects how blood sugar is regulated resulting in high levels in the blood stream), morbid obesity (severely overweight resulting in chronic health conditions), and cardiac heart failure (a condition when the heart cannot pump enough blood allowing fluid to build up in the lungs and body). Resident R9's clinical record revealed that during 1/21/26, through 2/19/26, he/she was offered a shower/bath on 1/21/26, 1/25/26, 2/08/26, 2/11/26, and 2/15/26. An interview with Resident R9 on 2/18/26, at 12:15 p.m. revealed he/she should receive his/her shower on Sundays and Wednesdays, however, did not receive his/her shower on Wednesday 2/18/26, due to no hot water situation/available in the facility. A review of facility documentation for showers for 2/18/26, revealed Resident R9 refused. An interview with Resident R9 on 2/19/26, at 12:30 p.m. revealed Resident R9 did not refuse his/her shower on 2/18/26. Further review of residents to receive showers/baths on 2/18/26, revealed Residents R19, R20, R21, R22, and R23 did not receive a shower/bath, but received a bed bath instead due to no hot water situation/available indicated by Certified Nursing Assistant (CNA) Employee E11 during an interview on 2/18/26, at 11:45 a.m. and Licensed Practical Nurse (LPN) Employee E12 during an interview on 2/18/26, at 12:00 p.m. Interview on 2/18/26, at approximately 1:00 p.m. with the Maintenance Director further confirmed that hot water was available for above noted residents' showers/baths. Interview with the Nursing Home Administrator (NHA) on 2/19/26, at 2:15 p.m. confirmed Residents R9, R19, R20, R21, R22, and R23 did not receive their shower/bath on 2/18/26, per each residents' preference. Interview with the Director of Nursing (DON) on 2/19/26, at 2:30 p.m. further confirmed that Resident R9 should have received a bath/shower at least twice weekly per his/her preference, and the facility lacked evidence that Resident R9 received a bath/shower twice weekly per his/her preference. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12 (d) (1)(5) Nursing services

Based on review of facility policy, observations, and staff interview, it was determined the facility failed to properly maintain safe operation of essential equipment in the main kitchen and prevent excessive buildup of frost in the walk-in freezer. Findings include: Review of facility policy entitled Freezer with a policy review date of 8/29/25, indicated that all walk-in freezers shall be cleaned at least every six months; remove excess ice build-up; report any damage or any need of repair to the Maintenance Department. Observations of the walk-in freezer in the Main Kitchen on 2/18/26, at 10:30 a.m. revealed areas with an accumulation of ice including on the ceiling that extended out from the condenser to the other side of the walk-in-freezer, as well as multiple areas on the floor by the entrance to the freezer. Ice accumulation was observed on frozen food item boxes on the top of the shelves to the right and left of the entrance door. Condenser coils were observed frozen in ice. During an interview on 2/18/26, at the time of observation, the Dietary Manager confirmed that there was an accumulation of ice to include on the ceiling that extended out from the condenser to the other side of the walk-in-freezer, as well as multiple areas on the floor by the entrance to the freezer; ice accumulation was observed on frozen food item boxes on the top of the shelves to the right and left of the entrance door; and condenser coils were observed frozen in ice, and that the ice should be removed. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3) Management28 Pa. Code 201.18(e)(2.1) Management

Based on review of a facility policy, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in a resident pantry in two of four refrigerators reviewed (Rehab Unit and North Unit). Findings include: Review of facility policy entitled Use and Storage of Food Brought in by Family or Visitors, dated 8/29/25, revealed that The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator; The prepared food must be consumed by the resident within 3 days; If not consumed within 3 days, food will be thrown away by facility staff; All items not maintained are subjected to being thrown away if not removed by the resident and/or resident representative. Observations on 12/8/25, at 11:57 a.m. of a refrigerator in the Rehab Unit used for residents revealed three single serve containers of cottage cheese with a resident name and expiration date of 11/24/25, and one can of Celsius-Retro Vibe drink without a resident name or date. During an interview on 12/8/25, at the time of observation, Registered Nurse Employee E1 confirmed that food items in the resident refrigerator contained items that were not labeled as required, and/or items that were expired. Observations on 12/8/25, at 3:45 p.m. of a refrigerator in the North Unit used for residents revealed one bottle of orange juice with a resident name and expiration date of 6/15/25, and one bottle of Hazelnut coffee creamer with a resident name and expiration date of 11/15/25. During an interview on 12/8/25, at the time of observation, Nursing Assistant Employee E2 confirmed that food items in the resident refrigerator contained items that were expired. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policies, observations, and resident and staff interviews, it was determined that the facility failed to implement dignified feeding practices and to maintain resident dignity and respect by serving meals in a timely manner to individuals seated at the same table for two of two dining areas observed (North and Haven). Findings include: Review of facility policy entitled Dining Experience Policy dated 10/28/24, indicated All residents seated at the same table should be served before moving to another table. Review of facility policy entitled Safe and Homelike Environment dated 10/28/25, indicated In accordance with residents' rights, the facility will provide a . comfortable and homelike environment . Observations of the afternoon meal in the North and Haven dining rooms on 4/9/25, between 12:40 p.m. and 1:00 p.m. revealed the following. On 4/9/25, at 12:40 p.m. there was a table in the north dining room with five residents seated together around the table. Four residents were consuming their meals while one resident without their meal, watched the others eat. The last resident at the table was served at 12:50 p.m. and began eating his/her meal. At that time, the four other residents finished their meals and had left the table. On on 4/9/25, at 12:55 p.m. there was a food cart being delivered to Haven dining room. In the dining room were four different tables with residents seated together. The first table had four residents seated together and one resident had consumed his/her meal and the other three were just being served their meals. The second table had two residents seated together and one resident had consumed their meal and the other one was just being served their meal. The third table had four residents seated together and one resident had consumed their meal and the other three had not been served yet. The fourth table had three residents seated together and one resident had consumed their meal and was leaving the table. The other two residents had not been served their meals yet. During an interview on 4/9/25, at 1:10 p.m. Nursing Assistant Employee E1 stated the first meal cart was delivered at 12:35 p.m. He/she confirmed that residents that were seated at the same table together and were not served at the same time. He/she also confirmed that some residents had consumed their meals and were leaving the dining room. Interviews on 4/9/25, between 10:00 a.m. and 1:00 p.m. with Resident's R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10, confirmed they received meals in Styrofoam containers several days a week and the food is often cold as a result. Residents listed above revealed they are aware meals were being served in Styrofoam containers as a result of dietary staffing shortages. Interview on 4/9/25, at 11:40 a.m. with Resident R11's family member revealed that they eat at the facility with Resident R11 several days a week. They confirmed that meals are served in Styrofoam containers several days a week and the food is often cold as a result. Interview on 4/9/25, at 12:50 p.m. with Dietary Aide Employee E2 revealed that dietary uses Styrofoam containers due to not having enough staff in the dietary department. Interview on 4/9/25, at 12:20 p.m. with the Dietary Manager Employee E3 revealed that the dietary department is not staffed adequately. He/she also revealed that meals are served in Styrofoam containers when the dietary department is not staffed adequately. Interview on 4/9/25, at 1:30 p.m. with the Dietary Manager Employee E3 confirmed that Styrofoam containers are used for resident's meals due to staffing in the dietary department. He/she also confirmed that residents sitting at the same table for meals should be served at the same time. Refer to F802 Sufficient Dietary Support Personnel 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of facility policy and clinical record, and staff interviews, it was determined that the facility failed to notify the resident's physician and emergency contact timely regarding a change in condition for one of 13 residents reviewed (Resident R1). Findings include: The facility policy entitled Notification of Responsible Party and Physician Procedure, dated 10/28/24, indicated that the nurse should notify the Primary Care Physician when a resident has a significant change in clinical status such as a decline in condition, new/worsening symptoms, new/change in pain status The nurse or designee will notify the responsible party regarding change in the resident's clinical status The clinical record revealed that Resident R1's initial admitted was 1/17/23, with diagnoses including nstemi myocardial infarction (a serious heart attack causing damage related to a reduced blood supply to the heart), type II diabetes (when the body does not use insulin properly with poor blood sugar control), and muscle weakness. The clinical record progress notes revealed that on 1/25/25, at 12:38 a.m. Resident R1 was a little off and had slurred speech. The physician and emergency contact were not notified of these changes in condition timely. During an interview on 4/11/25, at approximately 9:30 a.m. the Director of Nursing and Nursing Home Administrator confirmed that the physician and emergency contact should have been contacted and it should have been documented in the clinical record at the time of the slurred speech. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, review of facility records, and resident and staff interviews, it was determined that the facility failed to provide sufficient staff to carry out the functions of the food and nutrition services in the kitchen. Findings include: Review of facility policy entitled Safe and Homelike Environment dated 10/28/25, indicated In accordance with residents' rights, the facility will provide a . comfortable and homelike environment . Review of four weeks of dietary schedule lacked evidence that the appropriate number of trained dietary staff were scheduled each day. Review of grievances revealed that residents going to dialysis did not have meal trays ready for residents to consume before going to dialysis. Review of Resident Council meeting minutes and food committee minutes from 3/25/25, revealed resident concerns of food is warm or not hot. Interviews on 4/9/25, between 10:00 a.m. and 1:00 p.m. with Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10 revealed that they are receiving meals in Styrofoam containers several days a week and the food is often cold as a result. Residents identified above revealed they are aware meals were being served in Styrofoam containers as a result of dietary staffing. Interview on 4/9/25, at 11:40 a.m. with Resident R11's family member revealed that they eat at the facility with Resident R11 several days a week. They confirmed that meals are served in Styrofoam containers several days a week and the food is often cold as a result. Interview on 4/9/25, at 12:50 p.m. with Dietary Aide Employee E2 revealed that dietary uses foam containers due to not having enough staff in the dietary department. He/she expressed that there have been several shifts that there had only been a cook and one dietary aide working. Interview on 4/9/25, at 12:20 p.m. with the Dietary Manager Employee E3, revealed that the dietary department is not staffed adequately. He/she revealed there have been shifts when there are only two staff working in the dietary department. He/she also revealed that meals are served in Styrofoam containers when the dietary department is not staffed adequately. Interview on 4/9/25, at 1:30 p.m. with the Dietary Manager Employee E3, confirmed that Styrofoam containers are used for resident's meals due to staffing in the dietary department. He/she also confirmed that residents sitting at the same table for meals should be served at the same time. Interview on 4/11/25, at 10:50 a.m. with the Nursing Home Administrator (NHA) he/she confirmed that staffing levels in the dietary department should be one cook and three dietary aides for each shift. Refer to F550 Resident Rights 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

Based on review of clinical records and facility policy and staff interviews, it was determined that the facility failed to notify the resident's representative of a change in condition and/or treatment for one of 24 residents reviewed (Resident R30). Findings include: The facility policy entitled Notification of responsible party and physician procedure dated 10/28/24, revealed Goal: The facility makes reasonable attempts to assure that responsible party and physician are notified and kept aware of a resident's condition, changes in orders, acute situations, lab/x-ray results, significant change in status, incidents that effect a resident's status or transfer from the facility to hospital, another agency or a change in residence. The responsible party will also be notified of incidents and accidents regarding the resident, medication error, change in medication/treatment, labs/x-rays/tests and results or transfer out of the facility. Documentation: Notification and attempts to notify the physician, responsible party and third party vendors should be documented. The DON/ADON [Director of Nursing/Assistant Director of Nursing] should be kept aware of unsuccessful notification attempts. Resident R30's clinical record revealed an admitted [DATE], with diagnoses that included unstageable pressure ulcer of right hip (a type of wound covered by slough or dead/blackened tissue), diabetes mellitus (a disease when the body has trouble controlling blood sugar and using it for energy), weakness, and chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe). Resident R30's clinical record revealed a physician's order dated 11/12/24, for Voltaren External Gel 1% (Diclofenac Sodium Topical), Apply to knees, elbows typically every 6 hours as needed for pain 2 grams. Resident R30's progress notes dated 11/12/24, indicated that x-ray (a type of radiation imaging that creates pictures of the inside of your body) results were reviewed with the Certified Registered Nurse Practitioner (CRNP) and an order was received for Voltaren gel 2 grams every six hours as needed for pain. The clinical record lacked evidence that Resident R30's representative was notified of CRNP's orders/treatment change and x-ray findings dated 11/12/24. An interview with Resident R30's representative on 11/19/24, at 1:00 p.m. revealed the facility does not always update him/her of new orders and/or test results. On 11/22/24, at 1:00 p.m. the DON confirmed the facility did not notify Resident R30's representative of the new orders/treatment change and x-ray findings dated 11/12/24. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12 (d)(1)(5) Nursing services

Based on review of facility policy and clinical records, observations, and staff and resident representative interviews, it was determined the facility failed to ensure that residents with indwelling catheters (a tube inserted into the bladder to facilitate urine drainage) receive proper care and services to help prevent infections for two of nine residents reviewed with indwelling catheters (Residents R19 and R79). Findings include: A facility policy entitled, Catheter Care dated 10/28/24, revealed it is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. Resident R19's clinical record revealed an admitted [DATE], with diagnoses that included cerebral infarction (a condition where blood flow to the brain is blocked resulting in brain tissue death), aphasia (a language disorder that affects a person's ability to communicate), neuromuscular dysfunction of bladder (a condition that affects bladder control typically from a brain, spinal cord, or nerve problem), and urinary tract infection (UTI). Observation on 11/20/24, at 11:00 a.m., revealed Resident R19's catheter drainage bag uncovered and laying on the floor beside the bed. During an interview on 11/21/24, at approximately 1:00 p.m. Resident R19's resident representative revealed that Resident R19 recently was hospitalized for a UTI. Resident R79's clinical record revealed an admitted [DATE], with diagnoses that included encephalopathy (a term for any brain disease that alters brain function or structure caused by infection, tumor, or stroke ), dementia, weakness, retention of urine, and history of UTI. Observation on 11/20/24, at 10:23 a.m., revealed Resident R79's catheter drainage bag uncovered and laying on the floor beside the bed. During an interview with Nursing Assistant Employee E1 on 11/20/24, at 10:25 a.m., it was confirmed that Resident R79's catheter bag was laying on the floor beside the bed without a catheter bag cover on it. During an interview on 11/21/24, at 2:14 p.m. the Director of Nursing confirmed that Resident R19 and R79's catheter bag should be covered and not lay on the floor and/or touch an unclean surface due to risk for infection. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of facility policy, observations, and staff interview, it was determined the facility failed to properly maintain safe operation of essential equipment in the main kitchen and prevent excessive build up of frost in the walk-in freezer. Findings include: Review of facility policy entitled, Cleaning Instructions: Freezer with a policy review date of 10/28/24, revealed that the freezer will be defrosted as needed (when the frost is greater than 1/4 inch thick and according to the cleaning schedule). Observations of the walk-in freezer in the Main Kitchen on 11/19/24, at 12:45 p.m. revealed areas with an accumulation of ice including on the ceiling that extended out from the condenser to the other side of the walk-in-freezer, as well as multiple areas on the floor by the entrance to the freezer. Water and ice was observed dripping and freezing on frozen food item boxes on the top of the shelves. Condenser coils were observed frozen in ice. During an interview on 11/20/24, at 12:00 p.m. the Dietary Manager confirmed that there was an accumulation of ice to include on the ceiling that extended out from the condenser to the other side of the walk-in-freezer, as well as multiple areas on the floor by the entrance to the freezer. Water and ice was observed dripping and freezing on frozen food item boxes on the top of the shelves. Condenser coils were observed frozen in ice. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(2.1) Management

Based on observations, review of facility policy and clinical record, and staff and resident interviews, it was determined that the facility failed to safely transfer a resident using a mechanical lift for one of one residents reviewed (Resident R9). Findings include: Review of a facility policy entitled Safe Resident Handling/Transfers revised 6/01/24, revealed that two staff members must be utilized when transferring residents with a mechanical lift. Resident R9's clinical record revealed an admitted [DATE], with diagnoses that included Rheumatoid Arthritis (condition where the body's immune system attacks its own tissue, typically in the hands and feet, and causes painful swelling), Lymphedema (tissue swelling caused by any type of problem that blocks the drainage of lymph fluid, most commonly affects the arms or legs), lack of coordination, weakness, and abnormal gait and mobility. Resident R9's Kardex (documentation system that provides information regarding necessary resident care) included special instructions to utilize a sit-to-stand lift to transfer to power wheelchair, and his/her task indicated he/she was non-ambulatory and included sit-to-stand lift to transfer to power wheelchair. Observation on 7/18/24, at 11:53 a.m. revealed Nurse Aide (NA) Employee E1 lowered Resident R9 into the power wheelchair without the assistance of a second staff member. During an interview on 7/18/24, at 11:54 a.m. NA Employee E1 would not confirm utilizing the sit-to-stand lift without the assistance of another staff member. During an interview on 7/18/24, at 11:57 a.m. NA Employee E2 confirmed that he/she did not assist NA Employee E1 with operating the sit-to-stand lift to place Resident R9 into his/her power wheelchair. During an interview on 7/18/24, at 12:00 p.m. Resident R9 confirmed that usually there are two staff, but today the aide did not get help to use the lift. During an interview on 7/18/24, at 12:10 p.m. Licensed Practical Nurse Employee E3 confirmed that staff are supposed to have two people when using the mechanical lifts. During an interview on 7/18/24, at 12:39 p.m. the Assistant Director of Nursing confirmed that all mechanical lifts are to have two staff to operate at all times. During an interview on 7/18/24, at 2:45 p.m. the Nursing Home Administrator also confirmed that mechanical lifts require two staff to operate. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(c)(d) Resident Care Policies 28 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 serve food that was palatable for taste and temperature for four of four units. Findings include: On 12/9/23, and 12/10/23, during resident interviews, the following residents had complaints regarding their meals: Residents R2, R13, R28, R33, R36, R90, and R100 expressed frustration that their meals were not palatable because the food was cold when delivered by staff. Residents R24, R31, R66, R79, R92, and R103 expressed frustration that their meals were not palatable because the food is cold and is either undercooked or overcooked most of the time. Observations on 12/11/23, from 11:25 a.m. through 12:25 p.m. revealed the menu/meal consisted of breaded sliced beef, noodles, and green beans. Observation on Havenwood Unit further revealed the following regarding that some residents received overcooked / burnt slices of breaded beef that the residents were unable to cut: Resident R28 questioned, What is this black thing on my plate? and asked nursing staff to get him/her a new piece of meat. Resident R66 stated This meat, if that is what you call it, is not edible. Resident R66 was then asked if he/she would like something else to eat, they stated they would just eat the noodles and beans and declined a new piece of beef or alternate. During an interview on 12/11/23, at 12:52 p.m. the Dietary Director confirmed that the slice of beef was overcooked and was not able to be cut or eaten. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policy and clinical records, and staff interview it was determined that the facility failed to develop a comprehensive care plan for one of 24 residents reviewed (Resident R94). Findings include: Review of facility policy entitled Comprehensive Care Plans dated 1/4/23, stated It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . to meet a resident's medical, mental, and psychosocial needs that are identified in the resident's comprehensive assessment. Resident R94's clinical record revealed an admitted [DATE], with diagnoses that included Kidney Cyst (fluid-filled pouches found on the kidney), Benign Prostatic Hyperplasia (BPH - an enlarged prostate), and Leakage of urine from Nephrostomy Catheter (a tube that drains urine directly from the kidneys into a drainage bag). Resident R94's clinical record revealed a Bowel and Bladder Evaluation form dated 11/10/23, that identified Resident R94 as having bilateral nephrostomies. The clinical record lacked evidence that a care plan had been developed to address Resident R94's nephrostomy tubes. During an interview on 12/11/23 at 2:50 p.m. the Assistant Director of Nursing confirmed that a care plan had not been developed to address Resident R94's nephrostomy tubes. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on observations, and staff interview, it was determined that the facility failed to ensure that a safe, clean, comfortable homelike environment was maintained related to resident's wheelchair for one of four units observed (Rehabilitation Unit). Findings include: Observation on 12/10/23, at 11:24 a.m. revealed Resident R115's protective covering on the bilateral armrest of his/her wheelchair was cracked exposing some of the foam and had duct tape wrapped around them. During an interview on 12/10/23, at 11:27 a.m. Licensed Practical Nurse (LPN), Employee E2 confirmed that Resident R115 had a damaged wheelchair armrest with cracked protective covering and duct tape around them. Observation on 12/10/23, at 11:40 a.m. revealed Resident R94's protective covering on the bilateral armrest of his/her wheelchair was cracked, peeling, and torn exposing the foam. During an interview on 12/10/23, at 11:50 a.m. LPN Employee E1 confirmed that Resident R94 had damaged wheelchair armrests with cracked, peeling, and torn protective covering. 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policy and clinical records, observations, and resident and staff interviews, it was determined that the facility failed to ensure that residents with limited range of motion received physician ordered treatment and services to prevent further decrease in range of motion for one of 24 residents reviewed (Resident R13). Findings include: Review of the facility policy entitled Resident Mobility and Range of Motion, dated 1/4/23, indicated that Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. Resident R13's clinical record revealed an admitted [DATE], with diagnoses that included hemiplegia (paralysis/limited use of one side of the body) due to a stroke, muscle weakness and dementia (a disorder of mental processes). Resident R13's clinical record revealed a physician's order dated 5/31/23, that identified Apply Right hand roll Splint with a.m. care and remove with p.m. care to facilitate contracture management. The clinical record lacked documentation that Resident R13 was utilizing the right-hand roll splint. Observations on 12/9/23, at 1:40 p.m., on 12/10/23, between 12:00 p.m. and 3:00 p.m. and on 12/11/23, at 2:20 p.m. revealed that Resident R13 was in his/her chair watching TV and did not have the right-hand roll splint on. During an interview on 12/11/23, at 2:20 p.m. when Resident R13 was asked about his/her splint, Resident R13 stated that he/she lost it and needed it. During an interview on 12/11/23, at 2:50 p.m. the Director of Nursing confirmed that Resident R13 was not wearing the right-hand roll splint as ordered. 28 Pa. Code 211.10 (d) Resident care policies 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa. Code 201.18 (b)(1) Management

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14 days for one of 24 residents reviewed (Resident R64). Findings include: Review of a facility policy entitled Use of Psychotropic Medications dated 1/4/2023, indicated that PRN orders for all psychotropic drugs shall be used only when the medication is necessary .and for a limited duration 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for PRN order to be extended beyond 14 days, he/she shall document their rationale . Review of Resident R64's clinical record revealed an admitted [DATE], with diagnoses that included diabetes, dementia with anxiety (a disease that affects short term memory, the ability to think logically and causes a person to feel nervous), and hypertension (high blood pressure). Review of Resident R64's medication orders revealed a physician order dated 11/26/23, to administer Ativan (anti-anxiety) 0.5 milligrams (mg) by mouth every eight hours as needed for anxiety. The medication order lacked the required stop date within 14 days or a clinical rational for continuing beyond 14 days. During an interview on 12/11/2023, at 2:08 p.m. the Director of Nursing confirmed that Resident R64's Ativan order lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, observation and staff interview, it was determined that the facility failed to ensure that the garbage and refuse was disposed of properly for two of two dumpsters. Findings include: Review of facility policy entitled Commercial Dumpster Use Policies and Procedures, dated 1/4/23, revealed that, The side and top doors should be closed when the dumpster is not in use. Observation on 12/9/23, at 12:25 p.m. with Kitchen Employee, E3, revealed two dumpsters that had the sliding doors on the side of the dumpster that were open. At the time of the observation, Employee E3 confirmed that the dumpster doors should be closed so that the refuse doesn't spill out and to keep rodents/animals from getting into the dumpsters. During an interview on 12/9/23 at 12:35 p.m. Dietary Director confirmed that the side doors of the dumpster should be closed when the dumpster is not in use. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management

Based on review of facility policy and clinical record, observation and staff interviews, it was determined that the facility failed to ensure that residents were monitored and adequately assessed to prevent new ulcers from developing, resulting in actual harm of an Unstageable (full-thickness skin and tissue loss) pressure ulcer development of the heel (bottom part of the foot below the ankle) and ankle for one of nine residents reviewed with pressure ulcers (Resident R148). Findings include: Review of facility policy entitled Skin/Wound Care dated 2/16/22, revealed that skin will be observed upon admission and routinely throughout the residents stay and residents will be encouraged / assisted to turn and reposition. The policy also indicated that wounds will be evaluated when they are noted and weekly until resolved. Wounds will be monitored for location, size, (measure length, width, and depth), only pressure ulcers will be staged and to review/revise the resident's individualized care plan for skin treatment and prevention. Review of Resident R148's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of hospital documentation from a local hospital entitled Nurse to Nurse Report Sheet with discharge date [DATE], stated under the skin/wound section Ulcer right ankle foam dressing- slough. Review of Resident R148's facility Admission Assessment with Baseline Care Plan completed on 1/14/22, at 4:39 p.m. by Registered Nurse (RN) Employee E7 indicated no open or pressure areas. A Braden Scale (assessment used to assist in identifying risk of developing a pressure ulcer) dated 1/23/22, revealed a total score of 11 indicating Resident R148 was at a very high risk for developing pressure ulcers due to Resident R148's incontinence, and having limited mobility or inability to make frequent changes in position. Review of Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), with an Assessment Reference Date (ARD) of 1/21/22, section G0100A entitled Activities of Daily Living (ADL) Assistance - Bed Mobility (move to and from lying position, turn side to side, and position body while in bed) was coded as requiring extensive assistance of two staff to complete task. Section M0100A entitled Determination of Pressure Ulcer Injury or Risk - Resident has a pressure ulcer / injury was coded as No. Section M0150 entitled Risk of Pressure Ulcer / Injuries - Is this Resident at risk for developing pressure ulcers/injuries was coded as Yes. Section M1200C entitled Skin and Ulcer/Injury Treatments - Turning and Repositioning program was coded as No. And applications of dressing to feet was coded as Yes. Review of Resident R148's skin care plan dated 1/14/22, revealed interventions that included to encourage Resident [R148] to float heels while in bed and encourage to turn and reposition every two hours and as needed. Review of Resident R148's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility documentation for Resident R148 lacked any evidence of skin assessments with measurements or consult reports from the local wound consultant company until 2/03/22, a period of 21 days after admission. A Skin Grid Pressure sheet dated 2/03/22, revealed a right heel pressure area that measured 3.5 centimeters (cm) x 3.5 cm x 0.2 cm and was Unstageable. The wound was described as draining serosanguineous fluid (watery and bloody fluid) and covered with 50 % slough (loose dead skin) and 50% glandular moderate. This form indicated that this wound was present on admission and indicated that the wound was not a new problem area. A second wound area was also noted with the site of right heel pressure area measuring 0.5 cm x 0.5 cm x 0.0 cm Unstageable. The wound was described as a full-thickness ulceration of the right lateral ankle wound base 100% eschar (dry dark scab or falling away dead skin). A Skin Grid Pressure sheet dated 2/09/22, revealed a right heel pressure area that measured 3.6 cm x 3.6 cm x 0.2 cm and was Unstageable. The wound was described as draining moderate serosanguineous fluid and covered with 75 % slough and 25% glandular moderate. This form indicated that this wound was present on admission and indicated that the wound was not a new problem area. A second wound area was also noted with the site of right lateral heel pressure area measuring 0.6 cm x 0.6 cm x 0.1 cm Stage III ( Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed). The wound was described as a full-thickness ulceration of the right lateral ankle & Reclassified as a Stage III wound with 100% granular (new connective tissue formed on a healing wound). Review of the clinical record revealed that on 2/03/22, a wound consultant assessed Resident R148's right lateral ankle wound indicating follow up assessment as Unstageable and measured 0.5 cm x 0.5 cm x 0.0 cm and the plan indicated discontinue current treatment with new order to cleanse affected area with Normal Saline Solution (NSS) and apply skin prep (protective skin wipe) to wound base twice daily. The second area assessed was an Unstageable wound to the right heel , indicating initial assessment, measuring 3.5 cm x 3.5 cm x 0.2 cm and the plan indicated cleanse with NSS, apply skin prep to periwound (area around wound), apply Santyl (prescription medication that removes dead tissue from the wound allowing it to start to heal) to wound base, apply Calcium Alginate (substance that when combined with wound drainage it forms a gel to help with wound healing by limiting secretions and bacteria), over top and cover with dry dressing. The documentation indicated that Resident R148 came to facility with open wounds to the right lateral ankle and right heel. Review of the wound consultant company documentation for Resident R148 dated 2/09/22, revealed a right lateral ankle wound as Reclassified to a Stage III and measured 0.6 cm x 0.6 cm x 0.1 cm and the plan indicated to discontinue current treatment with new order to cleanse affected area with NSS and apply skin prep to periwound wound and apply [MEDICATION(S)] to wound base and cover with abdominal pad and kling twice daily. The second area assessed was an Unstageable wound to the right heel measuring 3.6 cm x 3.6 cm x 0.2 cm and the plan indicated to discontinue current treatment and new order to cleanse affected area with NSS and apply skin prep to periwound wound and apply [MEDICATION(S)] to wound base and cover with abdominal pad and kling twice daily. The documentation indicated that Resident R148 came to facility with an open wound to the right lateral ankle and right heel. Review of Resident R148's treatment record for January 2022, revealed that Resident R148 had a treatment to the right ankle of Calcium Alginate and dry dressing from 1/21/22, with a discontinue date of 1/29/22, the same treatment order with a start date of 1/30/22, with a discontinue date of 2/02/22, with no evidence of wound assessment including measurements, location, description of the wound and staging. The January treatment record also revealed a treatment order to the right heel of cleanse wound with wound cleanser and apply Xeroform to wound bed and cover with dry dressing start date of 1/30/22 with discontinue date of 2/02/22, with no evidence of wound assessment including measurements, location, description of the wound and staging. Observation of Resident R148's right ankle and heel on 2/17/22, at 1:30 p.m revealed the ankle area to be a scabbed area and the right heel to have an Unstageable ulcer. Interview with Registered Nurse Employee E7 on 2/17/22, at 12:30 p.m. revealed that they observed Resident R148's right ankle with a dressing on it during the admission assessment and failed to measure or assess the area and confirmed that it was documented as no pressure or open areas on Resident R148's admission assessment. During an interview on 2/17/22, at 1:30 p.m. the Director of Nursing confirmed that all resident documentation is contained in the electronic health record, either directly entered or scanned in, and that the facility was unable to locate any documentation to support that Resident R148's right ankle and heel wound was comprehensively assessed per facility policy from date of admission 1/14/22, to 2/03/22, a period of 21 days, and also confirmed that the clinical record lacked consistent documentation regarding Resident R148's right ankle and right heel wound with lack of identification resulting in harm, as evidenced by the wound progression from an intact skin to a Stage III pressure ulcer of the right ankle and a large Unstageable wound to the right heel as assessed by the wound nurse. The facility failed to ensure that Resident R148 was monitored for skin integrity adequately to prevent actual harm of the development of two Unstageable pressure ulcer wounds. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.5 (f) Clinical records 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.11(c)(d) Resident care plan 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure a pressure ulcer was consistently assessed, resulting in actual harm from the unmonitored deterioration of the pressure ulcer, and failed to ensure that wound treatments provided were consistent with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: The facility policy entitled, Pressure Ulcer Identification and Wound Management, dated 3/1/21, indicated that comprehensive assessment of the individual and his or her pressure ulcer informs development of the most appropriate management plan and ongoing monitoring of wound healing. Effective assessment and monitoring of wound healing is based on identification and treatment as described in the assessment. The policy further indicated that pressure ulcers are to be assessed at least weekly, documenting location, stage, size, tissue type, color, peri-wound condition, wound edges, [MEDICATION(S)] tracts/undermining/tunneling (extension of the wound under the skin), and exudate (drainage). Review of Resident R93's 2/2/21, Significant Change Minimum Data Set (MDS - federally mandated periodic assessment of resident care needs) revealed that Resident R93 entered the facility on 8/5/16, had severe cognitive (mental processing) impairment and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS further indicated that Resident R93 was at risk for pressure ulcer development and had a Stage IV pressure ulcer (a full thickness tissue loss with exposed bone, tendon or muscle) of the heel (left). Resident R93's previous MDS, a Quarterly MDS dated [DATE], revealed no evidence of pressure ulcers. Review of Resident R93's physician orders, dated 9/29/20, included an order, originally dated 6/19/20, for Weekly Skin/Wound Evaluation: Nurse to initial and code appropriately. 0=Skin Impairment; 1=Pre-existing Area. 2=New Area (proceed to wound assessment if pressure ulcer/non-pressure ulcer). Every evening shift every Friday. Review of Resident R93's care plan, related to the risk for skin breakdown/pressure ulcer of the heel, included interventions to follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident R93's electronic record indicated that on 12/25/20, Licensed Practical Nurse Employee (LPN) E1 documented in Progress Notes that a large intact blister of the left heel was noted measuring 5 centimeters (cm) in length by 4 cm in width (1.9 inches by 1.5 inches). The Progress Note revealed the doctor was notified and an order obtained to wipe a Skin Prep pad (a product to provide a protective film) over the left heel blister daily, let dry, and loosely apply a foam dressing every day for 30 days. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The record lacked a comprehensive pressure ulcer assessment, or documentation at the time of identification or at the treatment change, related to the condition of the wound or physician rational for the change in treatment. Review of Resident R93's electronic health record included Skilled Progress Notes completed after identification of the blister of the left heel, dated 12/27/20; 12/29/20; 12/30/20; 12/31/20; 1/4/21; 1/6/21; 1/7/21; 1/9/21; 1/12/21; and 1/14/21. The integumentary (skin) section of the skilled documentation, on the identified dates, referenced a pressure ulcer of the left heel and directed to see assessment for further details. There was no evidence of comprehensive wound or skin assessment in the clinical record related to Resident R93's left heel blister on the associated dates of the skilled documentation, or on any other date, prior to 1/19/21 (25 days after wound identification). During interviews on 3/31/21, at 9:45 a.m. Physical Therapy (PT)/Wound Care Employee E2 indicated that he/she observed the blister on Resident R93's left heel in the days after it's identification, but was not involved in the care at that point, and described it as large, and that the surrounding area was darkened, almost like a deep tissue injury. LPN Employee E1, at the same interview, indicated Resident R93's wound progressed from a blister, to an open wound within a few days, and thought that was why the treatment was changed. LPN Employee E1 also indicated that the unit's LPN or wound nurse would complete the daily ordered treatment, unless the therapy department was providing daily wound treatments with electrical stimulation, and indicated that the wound nurse was responsible for the completion of the weekly wound assessment. Upon reviewing the electronic health record, LPN Employee E1 confirmed there was no evidence of the weekly assessments of Resident R93's left heel pressure ulcer between 12/25/20, and 1/19/21, when a wound physician was consulted. The electronic health record included a Wound Nurse - Weekly note, dated 1/20/21, that indicated Resident R93 was seen by a wound physician on 1/19/21 (25 days after discovery), at staff request for open area to the left heel which is a Stage IV pressure ulcer measuring 4.0 cm x 4.0 cm by 0.2 cm with light serosanguinous (lightly colored bloody mixture) drainage, with the wound bed 40% necrotic tissue (eschar - black hard tissue), 20% necrotic (dead) tissue, and 40% muscle, fascia (bands/connective tissue attached to muscle) tissue. The note indicated the wound was anesthetized (numbed) and debrided (cleaning away of dead tissue) by the physician. A Wound Evaluation & Management Summary, dated 1/19/20 and completed by the wound physician, indicated that the plan was to treat the wound with Santyl (a product that removes dead tissue) and [MEDICATION(S)] (an anti-infective ointment) with a dressing every day and that the estimated time for healing was 63 days with continued physician evaluation and intervention. On 1/28/21, the wound doctor, changed the wound treatment order to alternate Santyl ointment (a wound treatment) with [MEDICATION(S)] (an antibiotic) ointment on a daily basis, with a dressing to be completed on the evening shift. On 2/15/21, the wound physician added electrical stimulation treatments (application of electrical current through electrodes placed adjacent to the wound to stimulate cell growth/wound healing) to the Stage IV pressure ulcer (left heel.) Wound physician documentation from 1/28/21, through 3/31/21, directed staff to continue with the alternating daily treatments of Santyl and [MEDICATION(S)] based on visible healing. Observations of wound care to Resident R93's pressure ulcer, with PT/Wound Care Employee E2, conducted on 3/29/21, at 9:30 a.m., revealed a healing Stage IV pressure ulcer to the left heel, the approximate size of a fifty cent piece. PT Wound Care Employee E2, following removal of the electrical stimulation leads, cleansed the wound, applied Santyl Ointment to the wound and dressed the wound per physician order. PT/Wound Care Employee E2 indicated he/she provided wound care, Monday through Friday, in conjunction with electrical stimulation treatments. When questioned about the alternating [MEDICATION(S)] and Santyl treatment orders, PT/Wound Care Employee E2 indicated he/she was unaware of a [MEDICATION(S)] order and always applied Santyl when dressing the wound after treatment. PT/Wound Care Employee E3 indicated the electrical stimulation treatments and wound care he/she provided was documented in a therapy electronic record, not in the nursing record, and was unsure if nursing could view the documentation. Review of the Nursing March Treatment Record revealed documentation to support the application of [MEDICATION(S)] on alternating evening shifts by nursing staff, but not the Santyl order for alternating days. During an interview on 3/31/21, at 1:00 p.m. the Director of Nursing confirmed that all resident documentation is contained in the electronic health record, either directly entered or scanned in, and that the facility was unable to locate any documentation to support that Resident R93's left heel wound was comprehensively assessed per facility policy between identification on 12/25/20, and 1/19/21, resulting in harm, as evidenced by the wound progression from an intact blister to a Stage IV pressure ulcer as assessed by the wound physician. The facility Corporate Nurse, during the same interview, confirmed the documentation in the clinical record did not support that staff consistently implemented treatments to Resident R93's pressure ulcer per physician order. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.5 (f) Clinical records 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.11(c)(d) Resident care plan 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, review of clinical records and policies and procedures, and facility documentation related to an incident, and resident and staff interviews, it was determined that the facility failed to provide adequate supervision to ensure the safety of one of five residents reviewed (Resident R1) utilizing an electric scooter/wheelchair, placing the resident at risk for serious harm during six ([DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]) unsupervised leave of absences (LOA) creating an Immediate Jeopardy (IJ) situation. Findings include: The facility policy titled, Electric/Specialty Wheelchair Policy, dated [DATE], indicated that residents utilizing electric scooters/wheelchairs would be evaluated by the therapy department to determine if the resident can safely use the electric/specialty wheelchair outside on facility property and/or during independent/assisted leaves of absence. The policy further indicated that if unsafe use was identified, including potential harm to self by leaving grounds unsupervised or potential harm to peers, staff and other individuals in the community or facility property/equipment by careless operation, use of the wheelchair may be restricted. The facility policy titled, Leave of Absence Policy (LOA), dated [DATE], indicated that when residents leave the facility, the nurse will initiate the LOA form including destination, telephone number and expected time of return. Upon return, the resident is to sign back in with the charge nurse. The policy also recommends the use of a personal cell phone while on leave. If electric wheelchairs/scooters are used during a LOA, the policy indicates that the resident is to ensure the battery is fully charged and the wheelchair/scooter is to be operated on sidewalks once the road/street is crossed and that residents cross in crosswalks only. Any resident not returning from LOA as scheduled per the policy will be considered absent without official leave and the requirements of an elopement determined by the Nursing Home Administrator (NHA) or Director of Nursing (DON). Resident R1's clinical record revealed an original admission date of [DATE], and current [DIAGNOSES REDACTED]. The clinical record also indicated that Resident R1 was dependent on a manual wheelchair or electric scooter for motion and activity. Resident R1's current electric wheelchair/scooter assessment, conducted by rehabilitation staff on [DATE], stated, not approved for outdoor use. Poor safety awareness. Only approved for use within the building at this time. The clinical record lacked evidence of any other assessments for electric wheelchair use subsequent to that date. Resident R1's current physician orders, dated [DATE], included an order that Resident R1 was permitted to take a leave of absence and included an order, originally signed [DATE], indicating that Resident R1 was, not permitted to drive his/her electric scooter off premises grounds. Interdisciplinary notes, dated [DATE], indicated that Resident R1 signed out of the building at approximately 4:30 p.m. and returned at 6:30 p.m., stating he/she went to the grocery store. A Social services note, dated [DATE], indicated that Resident R1's recent leave of absence was discussed and he/she was encouraged to, take bus next time as it would be a safer route . monitoring continues. A Social services note, dated [DATE], again addressed Resident R1's use of a local bus service to go shopping as, he/she is not allowed to use his/her motorized scooter to go on the road. Resident R1's Sign Out/Off Unit Sheet and clinical documentation revealed that since being assessed as unsafe for use of the electric scooter/wheelchair for outdoor use on [DATE], Resident R1 left the building on 16 occasions; on six of those occasions without evidence of another person in attendance. The log and clinical documentation also lacked information relative to destination on all 16 occasions (destination - shopping), lacked a sign-out time on two occasions and lacked a re-entry time on 12 occasions. The log and clinical record lacked documentation relative to the wheelchair's battery charge/life. The last entry in the Sign Out/Off Unit Sheet revealed Resident R1 signed out of the facility on [DATE], at 3:20 p.m. Facility documentation related to the LOA taken by Resident R1 on [DATE], indicated that on [DATE], at 6:41 p.m. a call was received from 911 that Resident R1 was seen on the road leading to the facility, in the middle of the north bound lane blocking traffic. The documentation further revealed Resident R1 and the electric wheelchair/scooter were returned to the facility by private individuals at 6:51 p.m. During an interview conducted on [DATE], at 1:15 p.m. Resident R1 confirmed leaving the facility on the afternoon of [DATE], after signing out to go buy a phone card and stating that he/she told the facility staff a friend was picking him/her up. Resident R1 stated, they should know better than to believe me and that no one went to the door with me. Resident R1 stated that he/she drove the electric wheelchair/scooter into town and on return to the facility the wheelchair battery ceased to work and stated, after the sidewalk ran out . I was on a hill just near the college and that's where the battery died . I thought it would last but it didn't. During an interview conducted on [DATE], at 1:40 p.m. Social Services Employee E1 indicated that previously in [DATE], Resident R1 left the facility in his/her electric wheelchair/scooter alone to go shopping (traveling via the road from the facility to the local town) after being advised he/she had to go via the local transportation system/bus. During an interview on [DATE], at 2:30 p.m. Nursing Assistant (NA), Employee E2, indicated that on [DATE], while on break around 3:20 p.m. he/she saw Resident R1 headed down the road on his/her electric wheelchair/scooter alone, headed toward town. Employee E2 stated it was reported to the supervising nurse because, I was worried about his/her safety, but I don' t think it went anywhere because the next thing I heard was someone brought him/her back to the facility when the battery on the wheelchair died . Observations of the road leading from the facility to the local town revealed a paved road with a narrow/limited berm extending 1.1 mile from the facility to the onset of an accessible sidewalk. During an interview on [DATE], at 3:45 p.m. the NHA and DON confirmed that Resident R1 left the faciity on [DATE], signing out with staff knowledge and left the facility via the road adjacent to the facility without supervision, documentation of when and where the resident was going, and against physician's orders [REDACTED].>On [DATE], at 4:00 p.m. the NHA was informed that Immediate Jeopardy (IJ) was identified as a result of the facility's failure to appropriately supervise Resident R1 for safe use of the electric wheelchair/scooter and an immediate action plan was requested to assure a system was in place to provide for safe use of electric wheelchairs/scooters for Resident R1 and the four other residents currently approved for their use. An immediate action plan for resident safety related to electric wheelchair/scooter use was received on [DATE], at 6:45 p.m. The plan included an immediate reassessment by the therapy department of all residents currently utilizing electric wheelchairs/scooters for safety, the notification of resident physicians of that reassessment and clarification of orders for use of the wheelchairs/scooters for LOA's, an updated log-out form to include required information relative to the LOA policy and procedure, escorting of residents with electric wheelchairs/scooters to the door for LOA's, re-education of residents impacted by the incident by social services regarding the changes related to electric wheelchair/scooter use, updates to the policies and procedures related to LOA and use of electric wheelchairs/scooters for safety enhancement including battery charging requirements, and re-education of all staff regarding the updated policies and procedures. The IJ was subsequently lifted on [DATE], at 1:20 p.m. when the plan was confirmed to be fully implemented and all residents with electric wheelchairs/scooters were deemed safe for use per assessment and physician order. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 201.18(a)(b)(3) Management 28 Pa. code 201.18(b)(1) Management Previously cited [DATE] 28 Pa. Code 201.18(e)(1) Management Previously cited [DATE] 28 Pa. Code 211.5(f) Clinical records Previously cited [DATE], [DATE] 28 Pa. Code 211.10(d) Resident care policies Previously cited [DATE] 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE]

Based on review of facility policy, facility documentation, the clinical record and staff interview, it was determined that the facilty failed to follow the physician's orders [REDACTED]. Findings include: The facility policy titled, Reconciliation of Medications on Admission, dated 4/15/16, stated that Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. The policy instructs the staff to, list all medications from the medication history, the discharge summary, the previous medication administration record (if applicable) and the admitting orders. List the dose, route and frequency for all medications. Review the list carefully to determine if there are discrepancies/conflicts. A review of the admission record revealed that Resident R3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's discharge orders from the hospital, written 12/17/16 and signed by the nursing home physician on 12/22/16, included an order for [REDACTED]. Review of the Medication Administration Record (MAR) revealed that the Levetiracetam was not present on the December 2016 MAR and there was no evidence that it was administered from the time of admission on 12/17/16, at 3:45 p.m. until the time of discharge to the hospital on [DATE], at 2:00 p.m. Facility documentation dated 12/19/16, at 2:00 p.m. indicated, Called to the dining room by staff due to [MEDICAL CONDITION] activity and [MEDICAL CONDITION] activity continued for several minutes and resident (Resident R3) became hypotensive (abnormally low blood pressure) and was sent to the emergency room for evaluation. Hospital records dated 12/28/16, revealed that Resident R3 was admitted to the hospital because of [MEDICAL CONDITION] activity that, per the physician's documentation, occurred because Resident R3 did not receive the Levetiracetam as ordered. During an interview on 12/28/16, at 12:25 p.m. the Director of Nursing confirmed that Resident R3's admission orders [REDACTED]. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 10/19/15, 05/18/16, 08/11/16 28 Pa. code 211.5(f) Clinical records 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(c)(d)(2) Nursing services 28 Pa. code 211.12(d)(1) Nursing services Previously cited 09/25/15, 10/19/15, 05/18/16, 08/11/16, 11/07/16 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 11/07/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 09/25/15, 05/18/16, 08/11/16, 11/07/16

Based on review of facility policies, facility documentation and clinical records and staff interview, it was determined that the facility failed to prevent an act of physical abuse by one resident (Resident R16) resulting in harm to another resident (Resident R17). Findings include: The Abuse of Resident policy dated 04/14/2015, revealed that, each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, mistreatment, neglect and misappropriation of property. The admission record revealed that Resident R16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident R16's behavioral care plan, dated 01/05/2015, revealed one-on-one supervision AAT (at all times). The behavioral care plan included: goals to prevent harm to the resident and others, goals to verbalize understanding of the resident's need to control physically aggressive and socially inappropriate behaviors and goals to prevent the resident from entering other residents' rooms when uninvited. According to the care plan, the resident has the potential to demonstrate physical violent behavior by pushing peers, tripping peers and hitting/harming peers when attempting to fist bump. The resident has the potential to take items that belong to others and put the items in his/her room. The resident has had a history of [REDACTED]. Interventions included, but were not limited to: reminding and educating the resident to contact a staff member when a resident comes into his/her room uninvited, assess resident's level of agitation and give space to calm down, calmly guide resident to conversation to positive comments about others, to use calm tones with others, provide physical and verbal cues to alleviate anxiety and encourage and give positive feedback. The annual Minimum Data Set assessment (MDS-a periodic assessment of resident care needs) dated 04/21/2015, indicated that Resident R16 had a Brief Interview for Mental Status (BIMS) score of 15 which indicates independence in decision making and was noted to have an overall presence of behavioral symptoms on 1-3 days during the assessment period. Resident R16 received antipsychotic, antianxiety and antidepressant medications on 7 days of the 7 day assessment period. The annual MDS, dated [DATE], revealed that Resident R17 had a BIMS score of 9, and indicated a behavior of rejection of care that occurred 1-3 days during the assessment period. Resident R17 had [DIAGNOSES REDACTED]. Resident R17 received antipsychotic, antidepressant and anti anxiety medications. Review of a nursing note written by Licensed Practical Nurse (LPN), Employee E1, dated 06/10/2015, revealed that Resident R17 was heard screaming and staff approached the area to find that Resident R16 had grabbed Resident R17 by the throat. Resident R16 choked Resident R17 and then pushed Resident R17 to the floor with both residents falling. Review of the facility investigation dated 06/10/2015, revealed that six staff were interviewed and that there were no staff supervising Resident R16 at the time of the altercation. LPN Employee E1 documented in the facility's investigation report on 6/10/2015, at 3:56 p.m. that Resident R17 had, some red blotches noted to neck and (the resident) was sore. During an interview on 07/16/2015, at 1:10 p.m., Registered Nurse, Employee E2, stated that Resident R16 was to have one-on-one supervision 24 hours a day. During an interview on 07/16/2015, at 10:10 a.m., the Nursing Home Administrator confirmed that there was no supervision at the time of the altercations from witness statements. The facility staff failed to follow the plan of care and adequately supervise Resident R16 to prevent an act of resident to resident physical abuse that resulted in actual harm. 42 CFR 483.13(b), 483.13(c)(1)(i) Free From Abuse/Involuntary Seclusion. Previously cited 10/09/2014 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 10/09/2014, 07/17/2014 28 Pa. Code 201.18(b)(1) Management. Previously cited 10/09/2014, 07/17/2014 28 Pa. Code 211.10(d) Resident care policies. Previously cited 06/24/2015, 07/17/2014 28 Pa. Code 211.12(a) Nursing services. Previously cited 10/09/2014 28 Pa. Code 211.12(c) Nursing services. Previously cited 10/09/2014, 07/17/2014 28 Pa. code 211.12(d)(1) Nursing services. Previously cited 03/26/2015, 10/09/2014, 07/17/2014 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 03/26/2015, 01/29/2015, 12/24/2014, 10/09/2014, 07/17/2014

Based on review of a facility event report, facility records and policies, clinical record review and staff interviews, it was determined that the facility failed to prevent an act of physical abuse by one resident (Resident R18) resulting in harm to another resident (Resident R19). The findings include: An event report submitted to the State Department of Health, dated 9/22/14, detailed an event that occurred on 9/21/14, at 8:00 p.m. The report stated that Resident R18 yelled at Resident R19 and Resident R19 yelled back. Resident R18 then pinned Resident R19 against the wall and punched Resident R19 repeatedly in the face causing harm to Resident R19. The hospital report, dated 9/22/14, revealed that Resident R19 was admitted to the hospital with [REDACTED]. The "Behavior Management" policy, dated 6/20/14, revealed that, "the psychiatrist or psychiatric CRNP (Certified Registered Nurse Practitioner) shall visit the facility every 1-3 weeks and evaluate the residents under the supervision of the psychiatrist." An interdisciplinary team meeting shall be held and the team will identify additional interventions as needed. Recommendations from the meeting will be discussed with the attending physician and the Medical Director will be consulted as needed. The "Resident Abuse and Neglect" policy, dated 6/20/14, stated that, "the facility screens all potential residents prior to admission in an attempt to determine whether the individual's needs can be appropriately addressed and met in the facility and that the facility will not admit individuals who have been determined through the screening process to pose a significant potential for harm to themselves or to others" and "the facility will not admit an individual who has been determined as requiring services that cannot be provided by the facility." Also noted as considered in the admittance process were, "regular and periodic review of incident reports and concerns/complaints for trends within the facility or with individual caregivers." The Admission Record revealed that Resident R18 was admitted to the facility on [DATE], from another long term care facility, with [DIAGNOSES REDACTED]. A Social Service History report, dated 6/03/14, from the previous facility, revealed that Resident R18 had no verbal or physical abuse noted, however, had a long history of having been treated for [REDACTED]. Review of the nursing notes after Resident R18's admission to the facility, indicated that between 6/7/14 and 9/21/14, there were 25 times that agitated and/or aggressive behaviors were displayed by Resident R18. Review of the physician's progress notes, dated 6/11/14 through 9/01/14, indicated no documented evidence that the physician reviewed Resident R18's behaviors or made any recommendations on the treatment of [REDACTED]. During an interview on 10/7/14, at 11:50 a.m., the Director of Nursing (DON) confirmed that the physician's progress notes did not contain information regarding Resident R18's behaviors. The "Clinical Assessment Report- [MEDICAL CONDITION] Medication Evaluation", dated 6/26/14, revealed that Resident R18 was resistive to care at times and combative with staff and recommended a psychiatric consult. A physician's orders [REDACTED]. On 7/10/14, the psychologist again reviewed Resident R18's medications and documented, "will follow in two weeks to monitor behavior" and "an order has been entered for a psychiatric consult and I feel this is very important." On 7/24/14, the psychologist attempted to see Resident R18 again, however, Resident R18 refused to be seen. There was no evidence to indicate that the facility made any further attempts for Resident R18 to be seen by a psychiatrist as the psychologist recommended and the physician had ordered. During an interview on 10/07/14, at 10:50 a.m., the DON confirmed that Resident R18 had not been seen by the psychiatrist. Review of the "resistive to care" care plan for Resident R18, revealed no new interventions created after 7/16/14, however, the nursing notes indicated that behaviors exhibited by Resident R18 continued after that date. Review of the "I use [MEDICAL CONDITION] Medications" care plan indicated two new interventions dated 8/6/14, "residents separated by staff, 1:1, music, TV" and "observe resident for increased signs of agitation and anxiety." There were no further interventions developed after 8/06/14, to address the behaviors that Resident R18 continued to display. During an interview on 10/07/14, at 1:35 p.m., the Social Service Director, Employee E1, confirmed that the care plans had not been updated for Resident R18 after 8/06/14. The facility failed to adequately supervise and implement interventions to prevent an act of resident to residents physical abuse, resulting in harm. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 7/17/14. 28 Pa. Code 201.18(b)(1)Management. Previously cited 7/17/14. 28 Pa. Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing Services Previously cited 7/17/14.