Every finding on record at Embassy of Saxonburg

Based on review of facility policies, employee file review, observations, and staff interviews it was determined that the facility failed to prohibit and prevent retaliation, as defined at section 1150B(d)(1) and (2) of the Social Security Act for five of fifteen staff members (Terminated Employees E1, E2, E3, E4, and E5) (Staff interviews to remain confidential).Findings Include: Review of the United States Social Security Act, Section 1150B indicated that:(d) Additional Penalties for Retaliation.-(1) In general.-A long-term care facility may not-(A) discharge, demote, suspend, threaten, harass, or deny a promotion or other employment-related benefit to an employee, or in any other manner discriminate against an employee in the terms and conditions of employment because of lawful acts done by the employee; or(B) file a complaint or a report against a nurse or other employee with the appropriate State professional disciplinary agency because of lawful acts done by the nurse or employee, for making a report, causing a report to be made, or for taking steps in furtherance of making a report pursuant to subsection (b)(1).(2) Penalties for retaliation.-If a long-term care facility violates subparagraph (A) or (B) of paragraph (1) the facility shall be subject to a civil money penalty of not more than $200,000 or the Secretary may classify the entity as an excluded entity for a period of 2 years pursuant to section 1128(b), or both.(3) Requirement to post notice.-Each long-term care facility shall post conspicuously in an appropriate location a sign (in a form specified by the Secretary) specifying the rights of employees under this section. Such sign shall include a statement that an employee may file a complaint with the Secretary against a long-term care facility that violates the provisions of this subsection and information with respect to the manner of filing such a complaint. Review of the facility-provided Employee Handbook effective 4/1/20, indicated under the section entitled Disciplinary Procedures Disciplinary actions remain in effect for a twelve-month rolling calendar period. Review of the facility-provided Employee Handbook effective 4/1/20, indicated under the section entitled Policy for Detecting and Preventing False Claims and Statements, Including Whistleblower Protections:Disciplinary ActionIf it is determined that an employee has violated these policies, then disciplinary action will be taken, up to and including termination of employment. This applies to a failure to timely and fully report violations, and for interfering with another person's attempt to report. Anti-Retaliation[Facility] prohibits any retaliatory action against an employee for making a good faith report of a violation of this policy to [facility] or any government agency. During an observation on 6/25/26, at 12:41 p.m. of a staff lounge area a posting was displayed relating to the reporting of possible abuse and neglect of nursing home residents. The posting stated, An LTC (long-term care) facility cannot punish or retaliate against you for lawfully reporting a crime under this law. Examples of punishment or retaliation include firing/discharge, demotion, threatening these actions. During the survey conducted onsite on 6/22/26, and 6/23/26, 15 staff members were interviewed by the State Survey Agency surveyor, with only two interviews not being interrupted by the Nursing Home Administrator, the Interim Director of Nursing, or the social services employee (whose office was being utilized). On 6/23/26, a staff member stated to the surveyor that a paper with a phone number had been placed by the surveyor's computer who would like to speak to the surveyor. Upon observation, there was not a paper with a phone number present. Conversation with the staff member confirmed she had asked a nurse to place the phone number there. During an interview with the staff member who wanted to speak to the surveyor, they stated that the Interim Director of Nursing had called them and wanted to know why the staff member wanted to speak to the surveyor. Subsequently, the staff member contacted the surveyor again to inform the surveyor that they had been terminated for professionalism. The staff member stated that they had been terminated via a voicemail, and when they called into the facility and asked for a reason why they had been terminated, had been told, We will get back to you on that. The staff member stated additional staff members had been terminated. On 6/25/26, the surveyor returned to the facility and requested a list of names for the staff members that had been terminated, or would be terminated, since the survey began on 6/22/26. The facility administration provided a list of six staff members. The employee files were requested for those staff members. Review of the personnel files for the six listed employees revealed: Terminated Employee E1: No disciplinary actions in the previous 12-month rolling calendar present. One performance evaluation completed, revealed all sections were documented as meets expectations or exceeds expectations. Terminated Employee E2: One disciplinary action in the previous 12-month rolling calendar present, for attendance. Last two performance evaluations revealed all sections were documented as meets expectations or exceeds expectations. Terminated Employee E3: One disciplinary action in the previous 12-month rolling calendar present, for not taking a meal break. No performance reviews were present. Terminated Employee E4: Performance section of the personnel file was empty. No performance reviews or disciplinary actions were present. Terminated Employee E5: No disciplinary actions in the previous 12-month rolling calendar present. Last two performance evaluations revealed all sections were documented as meets expectations or exceeds expectations. Terminated Employee E6: No disciplinary actions present. One performance evaluation completed, revealed all sections were documented as meets expectations or exceeds expectations. During an interview on 6/25/26, the Nursing Home Administrator (NHA) was asked the reasons for the terminations. Terminated Employee E1: Reason provided was professionalism. NHA stated that Employee E1 had refused to complete an admission on a new resident. When asked if there was information documented in the personnel file about Employee E1 refusing to complete the admission, the NHA confirmed that there was not. Terminated Employee E2: Reason provided was professionalism. NHA stated that Employee E2 had been aggressive with the NHA, and the Regional Human Resources staff member had to speak to her. When asked if there was information documented in the personnel file about Employee E2 being counseled by the Regional Human Resources staff member, the NHA confirmed that there was not. Terminated Employee E3: Reason provided was professionalism. NHA stated that several infractions were brought to her attention and stated that Employee E3 incited a verbal riot. When asked if there was information documented in the personnel file about Employee E3's infractions or the verbal riot, the NHA confirmed that there was not. Terminated Employee E4: Reason provided was professionalism. NHA stated Employee E4 also incited a verbal riot. When asked if there was information documented in the personnel file about Employee E4's behavior, the NHA confirmed that there was not. Terminated Employee E5: Reason provided was professionalism and job abandonment. NHA stated Employee E5 called off of work knowing that there was not sufficient staff for the residents. During this interview, the Nursing Home Administrator confirmed that the sixth employee was not being terminated. Confidential interviews completed during the survey included the following information:Staffing has been horrible. They make up names and numbers on the schedule. All day light called off because they cannot handle this. One nurse has over 30 residents. We keep telling them, they don't care. On 6/11/26, about eleven residents did not get medications. Stated she was told Interim DON took her phone number to the office. She said she was being grilled as to why she wanted to speak to the surveyor. Staffing has been a big issue, they are taking no effort to fix. Sometimes only 2-3 aides on the floor. Management doesn't care, they just leave it unsafe. It isn't possible to do all of the showers. I can have 15-20 residents. It's hard enough to be overwhelmed and we have Regional Director of Operations and the (Interim Director of Nursing) yelling at us. Many times when they are in the building and won't help. Confirmed she feels retaliated against. When asked about staffing, stated, There is a problem. There is not enough. Over a year ago, it was wonderful, but about six months ago it started dropping. Call lights are long. We are doing so much, it has been a very bad effect. Residents are waiting to be changed, especially if they need two people, because there is no one to help. It is very hard to give showers. It's scary, I don't know what I am coming into. I've had 20 residents; I'm running until my body gives out. I will just cry. At this point, NA became tearful and apologetic. I feel guilty, I don't want to leave, but I don't know what to do. I feel helpless. People getting fired. It seems to be a cluster of things since you guys came. We went without Agency for so long, and it hurt the facility for so long and now it is a retaliation with people that are making complaints. Yesterday, a nurse and CNA, I think she was a CNA got fired. Yesterday there is somebody from corporate, she is standing in as the DON and the like head person. [Interim DON] told me along with somebody else literally to our faces, if we don't start keeping our mouths shut, the place will be shut down and we will all be out of a job and that they are weeding out everybody and I don't know what she meant by that, but it wasn't in any good tone or way, it's somehow got worse and right now, this week, there's agency, and we're stressed about losing our jobs. There was so much talk yesterday and so much going on it's hard to remember everything, it was keep your mouth closed and the more people complain that to the state the worse this is going to be. [Interim DON] said, Whoever calls the state will be immediately terminated. This was yesterday around 3 right after the nurse was escorted out like she was a criminal. Nothing was said or talked about why she was getting escorted out, she told them she was calling somebody about the staffing and this was retaliation. I'm afraid to speak to [Surveyor] at work, she's very nice but it's just because of the retaliation that's going on. Afraid for my job. Everything else is out in the open with our staffing and stuff .I hope that Agency continues so we are not so horribly staffed. More times than 1 where it was there by myself with 55+ patients and a dozen times or more it was just the 2 of us. I've never been in that situation. I don't want to leave the facility. I hope that something can be resolved for everybody, including the residents .and now the tension is horrible, it's not good for anybody. Stated that the facility is very short staffed. Has had 18 residents on her own. When asked what care isn't being done, stated they would like to be able to complete more rounds, give showers as needed, and be able to respond to call lights more quickly. Stated also that some residents aren't getting treatments because there are not nurse aides available to assist rolling patients to do dressing changes. Stated they were present on 6/11/26, and the social services employee working as a nurse was very stressed out, she's constantly being pulled. When asked about staffing, stated, There is none. It's just a lot. Nurses just as bad as the CNAs. Stated they have worked many 18 hour days, had 18-21 residents at a time. Stated residents are not getting sufficient showers, up in time for appointments, or being gotten out of bed for activities. Stated there they are unable to train new staff because they have to work so fast to get their job duties done due to having too many residents. Didn't come to work on 6/11/26 due to unsafe staffing. It's been bad for a while. This week they have two CNAs scheduled on shift. Stated residents are not getting regular showers, snacks are not getting passed. They are being touched only once or twice per shift. Confirmed that wound treatments are not being completed due to lack of staffing. It's horrible. I have 15-18 per day. Stated residents are not receiving showers regularly. Stated they were told by administrative staff, All you guys do is complain, complain. Why don't you do something about it. The last two weeks have been horrid. Stated that Interim Director of Nursing stated if they found out you called the state it is immediate termination with no warning. You have to call the corporate number first. Stated Interim Director of Nursing said she knows who is calling state. It's rough here. During an interview on 6/25/26, at approximately 1:30 p.m. the Regional Director of Operations and the Nursing Home Administrator were made aware that facility failed to prohibit and prevent retaliation for five of fifteen staff members. 28 Pa. Code: 201.14(a)(c) Responsibility of Licensee.

Based on review of clinical records, observations, and staff interview, it was determined that the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for four of five residents (Resident R6, R16, R26, and R44).Findings include: The facility policy Pressure Ulcer Prevention and Management dated 3/13/26, indicated the facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 4/22/26, included diagnoses of paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease), multiple sclerosis (a disease that affects central nervous system), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Section M: Skin Conditions, indicated Resident R6 was at risk of pressure ulcer development, and at the time of the assessment had one Stage IV pressure ulcer (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) and two Stage III pressure ulcers (full-thickness skin and tissue loss). Review of Resident R6's Braden Scale assessments dated 4/25/26, indicated Resident R6 was at high risk for pressure ulcer development. Assessment completed on 6/5/26, indicated Resident R6 was at low risk for pressure ulcer development. Review of a wound nurse practitioner report dated 6/23/26, revealed the presence of a Stage IV pressure ulcer on the right ischium, a Stage IV pressure ulcer on the coccyx, and a Stage III pressure ulcer on the left ischium. Review of physician orders dated 4/29/26-6/2/26, 6/5/26-6/9/26, and 6/10/26, indicated for staff to cleanse and reapply a dressing to Resident R6's coccyx wound daily. Review of the Treatment Administration Record (TAR) for May and June 2026 failed to indicate that dressing changes were completed on the following dates (Resident R6 was present in the facility for all dates, no refusals of wound care documented): 5/2/26, 5/5/26, 5/12/26, 5/19/26, 6/2/26, 6/9/26, 6/11/26, 6/13/26, 6/17/26, 6/22/26, and 6/26/26. Review of physician orders dated 4/29/26-6/2/26, 6/5/26-6/9/26, indicated for staff to cleanse and reapply a dressing to Resident R6's posterior thigh wounds daily. Orders dated 6/10/26, indicated to cleanse left thigh and reapply a dressing and to cleanse right ischium and reapply a dressing. Review of the TAR for May and June 2026 failed to indicate that dressing changes were completed on the following dates (Resident R6 was present in the facility for all dates, no refusals of wound care documented): 5/2/26, 5/5/26, 5/12/26, 5/19/26, 6/2/26, 6/9/26, 6/11/26, 6/13/26, 6/17/26, 6/22/26, and 6/26/26. Review of the clinical record indicated Resident R16 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and muscle wasting. Review of Section M: Skin Conditions, indicated Resident R16 was at risk of pressure ulcer development, and at the time of the assessment had no pressure ulcers. Review of Resident R16's Braden Scale assessments dated 6/7/26, indicated Resident R16 was at moderate risk for pressure ulcer development. Review of a wound nurse practitioner report dated 6/23/26, revealed the presence of a facility acquired Stage III pressure ulcer on the left buttock, a Stage III facility acquired pressure ulcer on the right buttock, and an unstageable (obscured full-thickness skin and tissue loss) pressure ulcer on the coccyx. Review of physician orders dated 6/3/26-6/14/26, indicated for staff to cleanse and reapply a dressing to Resident R16's left and right buttocks wounds daily. Review of physician orders dated 6/17/26, indicated for staff to cleanse and reapply a dressing to Resident R16's left and right buttocks wounds every other day. Review of the TAR for June 2026 failed to indicate that dressing changes were completed on the following dates (Resident R16 was present in the facility for all dates, no refusals of wound care documented): Documentation on 6/10/26, 6/11/26. 6/5/26, was coded to view the progress note. Review of the associated progress notes failed to indicate if the dressing change was completed. Review of the clinical record indicated Resident R26 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of multiple sclerosis, high blood pressure, and neurogenic bladder (bladder problems due to disease or injury of the nervous system involved in the control of urination). Review of Section M: Skin Conditions, indicated Resident R6 was at risk of pressure ulcer development, and at the time of the assessment had one Stage IV pressure ulcer and two Stage III pressure ulcers. Review of Resident R26's Braden Scale assessments dated 5/14/26, indicated Resident R26 was at moderate risk for pressure ulcer development. Review of a wound nurse practitioner report dated 6/23/26, revealed the presence of a Stage IV pressure ulcer on the coccyx. Review of a physician order dated 4/22/26-5/14/26, indicated for staff to cleanse and reapply a dressing to Resident R6's coccyx wound daily. Review of physician orders dated 5/14/26-5/26/26, indicated for staff to cleanse and apply a wound vac dressing to Resident R6's coccyx wound daily. Review of a physician order dated 5/27/26-6/10/26, 6/10/26-6/17/26, 6/17/26-6/24/26, indicated for staff to cleanse and reapply a dressing to Resident R6's coccyx wound daily. Review of the TAR for May and June 2026 failed to indicate that dressing changes were completed on the following dates (Resident R26 was present in the facility for all dates, no refusals of wound care documented): 5/5/26, 5/12/26, 5/14/26, 5/19/26, 5/26/26, 5/28/26, 6/1/26, 6/4/26, 6/10/26, 6/11/26, and 6/24/26. Documentation on 5/1/26, 5/16/26, 5/29/26, 6/20/26, was coded to view the progress note. Review of progress note dated 5/1/26, at 1:01 p.m. indicated Resident R26 was out for an appointment. No further notes indicated if the dressing change was completed upon her return. Review of the associated progress note dated 5/16/26, at 11:55 a.m. indicated Resident R26 was out of bed. No further notes indicated if the dressing change was completed. Review of the associated progress note dated 5/29/26, at 1:47 p.m. indicated Not able to get to it this shift. Review of the associated progress note on 6/20/26 failed to indicate if the dressing change was completed. Review of the clinical record indicated Resident R44 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of lymphedema (the build-up of fluid in soft body tissues), high blood pressure, and coronary artery disease (CAD, damage or disease in the heart's major blood vessels). Review of Section M: Skin Conditions, indicated Resident R6 was at risk of pressure ulcer development, and at the time of the assessment had three Stage II (Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis) pressure ulcers. Review of Resident R44's Braden Scale assessments dated 4/28/26, indicated Resident R44 was at low risk for pressure ulcer development. Review of a wound nurse practitioner report dated 6/23/26, revealed the presence of two facility acquired Stage II pressure ulcers on the right thigh. Review of physician orders dated 5/13/26-6/17/26, indicated for staff to cleanse and reapply dressings to Resident R44's left and right daily. Review of physician orders dated 6/17/26, indicated for staff to cleanse and reapply dressings to Resident R44's left and right twice daily. Review of the TAR for May and June 2026 failed to indicate that dressing changes were completed on the following dates (Resident R44 was present in the facility for all dates, one refusal of wound care documented was documented on 6/8/26): 5/14/26, 5/21/26, 5/22/26, 5/25/26, 5/28/26, 5/29/26, 6/11/26, 6/13/26, 6/14/26, 6/15/26, 6/18/26 daylight, 6/21/26 evening, 6/22/26 evening. Documentation on 6/20/26, was coded to view the progress note. Review of the associated progress note on 6/20/26 failed to indicate if the dressing change was completed. During an interview on 6/25826, at 10:06 a.m. the Medical Director confirmed that she was not notified by facility staff about wound treatments not being completed. During an interview on 6/25/26, at approximately 1:30 p.m. the Regional Director of Operations and the Nursing Home Administrator confirmed the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for four of five residents. 28 Pa. Code: 211.10(c)(d) Resident Care Policies.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, resident observations, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 16 of 20 residents interviewed and/or observed (R3, R4, R5, R6, R10. R16, R17, R26, R30, R32, R39, R46, R47, R48, R49, and R50).Findings include: Review of the facility policy Sufficient Nursing Staffing Policy dated 3/13/26, indicated it is the policy of this facility to maintain staffing practices that are consistent with federal regulations, state law, and professional standards of practice, while supporting safe and effective care. During an observation on 6/22/26, at 7:38 a.m. Resident R30's call light was observed to have been alarming for approximately ten minutes. At 7:39 a.m. a nurse aide walked by without looking into room to ensure resident safety. During an observation on 6/22/26, at 7:43 a.m. the Regional Director of Operations answered the call light. During an interview on 6/23/26, at approximately 2:00 p.m. Resident R46 was noted to be malodorous. When asked if there was sufficient facility staffing, stated, Not to hear them talk about it. During an observation on 6/23/26, at approximately 2:03 p.m. Resident R3 was noted to have long, unclean fingernails. During an interview on 6/23/26, at approximately 2:30 p.m. when asked if the facility maintained sufficient staff to provide resident care, Resident R48 stated, They need more. Observation at this time revealed Resident R48 to have dirty fingernails and unclean clothing on. During an interview on 6/23/26, at 3:33 p.m. Resident R10 stated that sometimes there is not enough staff. During an interview on 6/23/26, at approximately 4:00 p.m. when asked if the facility maintained sufficient staff to provide resident care, Resident R16 stated, Not all the time. When asked about call light response, stated, It depends on how many people are working. During an observation on 6/23/26, at 4:17 p.m. Resident R49 was observed to have long, unclean fingernails. Resident R49 stated, They took me to PT (physical therapy) and brought me back to the place where they watch TV and I was stuck there. My doctor said not to stay in my wheelchair a long time. I just got back into bed just now. During an interview on 6/23/26, at 4:20 p.m. Resident R50 was asked if he felt the facility maintained sufficient staff for resident care, and he began to laugh. Resident R50 stated, The staff are good, but there's not enough. During an observation on 6/23/26, at approximately 4:30 p.m. Resident R4 was noted to have facial hair, and greasy, unbrushed hair. During an interview on 6/23/26, at 4:32 p.m. Resident R17 was asked if she remembers a day when she did not receive her medications, and responded, It did happen. Got some of them it was very late. When asked if she felt the facility maintained enough staff to provide resident care, Resident R17 stated, Less recently, over the weekend wit was really bad. Resident R17 confirmed she had to provide assistance to her roommate over the weekend due to a lack of staff. During an interview on 6/23/26, at approximately 4:40 p.m. when asked if the facility maintained sufficient staff to provide resident care, Resident R6 stated, No. When asked about call light response she stated that it can be a couple hours. When asked if she received her showers, Resident R6 stated, If there is only three people they won't do your shower at all. The other day, I have a colostomy bag, it was getting full. I told somebody, they never came back. I told two people it was going to bust. It did, it was all over me, it was very messy. When asked about the party she had scheduled, she stated she had arranged with her family to celebrate her birthday and Father's Day for her husband, but here were no aides at all. I called my daughter and told her we have to cancel it because there's no one to get me out of bed. It was disturbing. During an interview on 6/23/26, at approximately 4:51 p.m. when asked if the facility maintained sufficient staff to provide resident care, Resident R26 stated, Oh no When asked if she received her showers, Resident R26 stated, Sometimes you get them, but there have been times there is not enough staff. During an interview on 6/23/26, at approximately 4:55 p.m. Resident R5 was asked if she remembers a day when she did not receive her medication, and responded, Yes. When asked if she felt the facility maintained sufficient staff to care for residents, Resident R5 responded No, and exaggeratedly shook her head negatively. When asked about call light response, Resident R5 stated, I push the button through the night because I went in my pants and they never did come. They put a diaper on me and forget about me. I need two people. I have to wait a long time for two people. I thought I was going to poop myself this morning. When asked if she received her showers, Resident R5 laughed. During an interview on 6/23/26, at 5:02 p.m. Resident R39 was asked if she remembers a day when she did not receive her medications, and responded, Yes. They didn't have no help, I kept telling them I have a bad heart. When asked if she felt the facility maintained enough staff to provide resident care, Resident R39 stated, Sometimes. When asked about call light response, Resident R39 stated, Sometimes they don't even come in period. they never respond. We sit here day and night in pee and poop. When asked if she consistently received her showers, Resident R39 shook her head negatively and stated, No. You get a bed bath when they feel like it, and I mean when they feel like it. During an interview on 6/23/26, at approximately 5:05 p.m. Resident R47 was asked if she remembered a day when she did not receive her medication, and she responded, Yes, it did happen. Resident R47 stated she did not receive her morning medication until approximately 1:00 p.m. Resident R47 further stated, I'm not supposed to go to the bathroom by myself but if I didn't, I would never go. I feel not seen and not heard. Am I even worth it, it makes me feel like nothing. During an interview on 6/23/26, at approximately 5:15 p.m. when asked if he remembered a day that he did not receive his medications, Resident R32 stated he got most of them but they were received very late. When asked if the facility maintained sufficient staff for resident care, he stated, Maybe not. When asked about call light response times, Resident R32 stated, sometimes they are all too busy with somebody else. When I urinate in the bottle because I don't' get to get to the bathroom, I hit that (call light) and some of them, they don't' come fast. Sometimes in the morning they don't come. That guy in the bed next to me starts to yell out, I need help. I need to go to the bathroom. Observation at this time revealed Resident R32 to have a brown substance under his fingernails. During confidential interviews completed between 6/22/26, through 6/25/26, revealed: Staffing is horrible. They make up numbers and no one is here. Confirmed that all nursing staff called off on 6/21/26, because they can't handle this. One nurse has over thirty (residents). We keep telling them and they don't care. On the eleventh (6/11/26), eleven or more residents did not get their medications. [Nurse] worked over 24 hours; [Nurse] worked over 20 hours. Stated that the staff do not have time to give showers and stated that the shower book is being documented as if they are given. There is no time to interact with the residents. They get them up and dressed, and they are done. Staff member confirmed the facility is still taking new admissions.Stated they have not come due to unsafe staffing. Stated, It's been bad for a while. This week they have only two CNAs (nurse aides) scheduled. Stated that due to low staffing showers are not getting done, snacks are not being passed, resident are being touched only once or twice per shift, wound treatments are not being done due to lack of staffing, and housekeeping staff have to assist in passing meal trays. Staff member confirmed the facility is still taking new admissions.It's rough here.It's horrible and confirmed she often has 15-18 residents per day on daylight shift. Stated showers are not getting done and that call light response times are long, but they are doing their best.Confirmed she has called off due to lack of staffing and not wanting to be the only nurse aide for approximately 60 residents. Stated she was told by administrative staff, All you do is complain, complain. Why don't' you do some thigh about it? Stated, The last two weeks have been horrid. Staff member confirmed the facility is still taking new admissions.When asked if they felt there was enough staff working at the facility, stated Sometimes enough, sometimes not. The weekend was a disaster. Environmental Services staff helped by passing out and collecting trays for breakfast and lunch. They answered call lights, but there was not much they could do, Sunday (6/21/26) was the worst I have seen it.There is a problem. There is not enough. Over a year ago, it was wonderful, but about six months ago it started dropping. Call lights are long. We are doing so much, it has been very bad. Residents are waiting to be changed, especially if they need two people, because there is no one to help. It is very hard to give showers. It's scary, I don't know what I am coming into. I've had 20 residents, I'm running unit my body gives out. I will just cry. At this point, NA became tearful and apologetic. I feel guilty, I don't want to leave, but I don't know what to do. I feel helpless. During an interview on 6/22/26, at approximately 3:00 p.m. Registered Nurse (RN) Employee E1 confirmed she worked from 6/20/26, at 9:17 a.m. until 6/21/26, at 9:12 a.m. Stated she was supposed to leave at 1:30 a.m., but could not leave as there was no other registered nurses. Stated when she punched in, there were only two nurse aides presents. Registered Nurse Employee E1 confirmed she was both the RN Supervisor and a cart nurse. Stated that even though there was not sufficient staff, she received an admission at approximately 1:30 a.m. During an interview on 6/25826, at 10:06 a.m. the Medical Director confirmed that she was aware of the staffing deficiencies at the facility. The Medical Director stated that while the troops have been rallied, she stated that the facility has not been effective in implementing changes. During an interview on 6/25/26, at approximately 1:30 p.m. the Regional Director of Operations and the Nursing Home Administrator confirmed the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 16 of 20 residents interviewed and/or observed. 28 Pa. Code: 201.20(a)(c)(d) Staff Development28 Pa. Code: 211.12(c)(d)(1)(2)(5) Nursing Services

Based on review of clinical records, facility policy, and staff and resident interviews, it was determined that the facility failed to ensure the complete and timely administration of a prescribed medications for 48 of 59 residents (Resident R1 through R48).Findings include: Review of facility policy Medication Administration dated 3/13/26, indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so il this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review of the Medication Admin Audit Report dated 6/11/26, indicated: Resident R1 had six medications ordered to be administered at 8:00 a.m., that were documented as administered at 3:32 p.m. Resident R2 had four medications ordered to be administered at 7:00 a.m. and two medications ordered to be administered at 8:00 a.m., that were documented as administered at 10:09 a.m. Resident R3 had two medications ordered to be administered at 7:00 a.m., that were documented as administered at 10:51 a.m. Resident R4 had nine medications ordered to be administered at 7:00 a.m., that were documented as administered at 10:22 a.m. Resident R5 had 17 medications ordered to be administered at 8:00 a.m., that were documented as administered between 11:18 a.m. and 11:30 a.m. Resident R6 had 14 medications ordered to be administered at 8:00 a.m., that were documented as administered at 8:40 a.m. and 8:41 a.m. Resident R7 had one injectable medication ordered to be administered at 8:00 a.m., that was documented as administered at 9:41 a.m. Resident R8 had 13 medications ordered to be administered at 8:00 a.m., that were documented as administered between 10:29 a.m. and 10:31 a.m. Resident R8 had one medication to be administered at 12:00 p.m. that was documented as administered at 3:26 p.m. Resident R9 had six medications ordered to be administered at 8:00 a.m., that were documented as administered at 9:22 a.m. Resident R8 had one medication to be administered at 12:00 p.m. that was documented as administered at 2:28 p.m. Resident R10 had six medications ordered to be administered at 8:00 a.m., that were documented as administered at 10:54 a.m. Resident R11 had five medications ordered to be administered at 7:00 a.m., that were documented as administered at 9:01 a.m. Resident R12 had three medications ordered to be administered at 7:00 a.m., that were documented as administered at 8:58 a.m. Resident R13 had five medications ordered to be administered at 7:00 a.m., that were documented as administered at 8:56 a.m. Resident R14 had six oral medications ordered to be administered at 8:00 a.m., that were documented as administered at 11:42 a.m. and 11:43 a.m. Resident R14 had two ophthalmic medications ordered to be administered at 8:00 a.m., that were documented as administered at 3:29 p.m. Resident R15 had 16 medications ordered to be administered at 7:00 a.m., that were documented as administered at 9:40 a.m. and 9:41 a.m. Resident R16 had two medications ordered to be administered at 12:00 p.m. that were documented as administered at 2:18 p.m. Resident R17 had 13 medications ordered to be administered at 7:00 a.m., that were documented as administered at 1:37 p.m. Resident R17 had three medications ordered to be administered at 12:00 p.m. that was documented as administered at 3:25 p.m. Resident R18 had eleven medications ordered to be administered at 8:00 a.m., that were documented as administered at 9:39 a.m. and 9:40 a.m. Resident R18 had one ophthalmic medication ordered to be administered at 12:00 p.m., that was documented as administered at 2:28 p.m. Resident R19 had two medications ordered to be administered at 8:00 a.m. that were documented as administered at 10:36 a.m. Resident R20 had five medications ordered to be administered at 7:00 a.m., that were documented as administered at 1:00 p.m. Resident R21 had two medications ordered to be administered at 7:00 a.m. that were documented as administered at 9:46 a.m. Resident R22 had 14 medications ordered to be administered at 8:00 a.m., that were documented as administered at 9:44 a.m. Resident R22 had one medication ordered to be administered at 12:00 p.m. and one to be administered at 1:00 p.m., both documented as administered at 2:24 p.m. Resident R23 had three medications ordered to be administered at 8:00 a.m., that were documented as administered at 10:27 a.m. Resident R23 had one medication ordered to be administered at 12:00 p.m. that was documented as administered at 3:25 p.m. Resident R24 had seven medications ordered to be administered at 7:00 a.m. that were documented as administered at 8:13 a.m. Resident R24 had one medication ordered to be administered at 12:00 p.m. that was documented as administered at 2:38 p.m. Resident R25 had four medications ordered to be administered at 8:00 a.m., that were documented as administered at 9:52 a.m. Resident R26 had eight medications ordered to be administered at 7:00 a.m. that were documented as administered at 8:39 a.m. and 8:40 a.m. Resident R26 had two medications ordered to be administered at 12:00 p.m. that were documented as administered at 2:39 p.m. Resident R27 had eleven medications ordered to be administered at 8:00 a.m., that were documented as administered at 9:06 a.m. Resident R27 had one medication ordered to be administered at 12:00 p.m. that was documented as administered at 2:20 p.m. Resident R28 had four medications ordered to be administered at 8:00 a.m., that were documented as administered at 11:39 a.m. Resident R29 had ten medications ordered to be administered at 8:00 a.m., that were documented as administered at 9:16 a.m. Resident R29 had four medications ordered to be administered at 12:00 p.m. that were documented as administered between 2:26 p.m. and 2:28 p.m. Resident R30 had one medication ordered to be administered at 7:00 a.m. and twelve medications ordered to be administered at 8:00 a.m., and one medication that was ordered to be administered at 12:00 p.m., that were documented as administered at 3:36 p.m. Resident R31 had nine medications ordered to be administered at 7:00 a.m., that were documented as administered at 3:23 p.m. Resident R32 had ten medications ordered to be administered at 8:00 a.m., one medication ordered to be administered at 11:00 a.m., and one medication that was ordered to be administered at 12:00 p.m., that were documented as administered at 3:31 p.m. and 3:32 p.m. Resident R33 had four medications ordered to be administered at 7:00 a.m., that were documented as administered at 11:33 a.m. Resident R34 had ten medications ordered to be administered at 7:00 a.m., that were documented as administered at 8:35 a.m. and 8:36 a.m. Resident R33 had one medication ordered to be administered at 11:00 a.m., that was documented as administered at 2:41 p.m. Resident R35 had five medications ordered to be administered at 8:00 a.m., that were documented as administered at 9:43 a.m. Resident R36 had 15 medications ordered to be administered at 8:00 a.m., that were documented as administered at 9:55 a.m. Resident R35 had one medication ordered to be administered at 12:00 p.m., that was documented as administered at 2:45 p.m. Resident R37 had six medications ordered to be administered at 7:00 a.m., that were documented as administered at 11:18 a.m. Resident R38 had seven medications ordered to be administered at 7:00 a.m., that were documented as administered at 9:40 a.m. Resident R38 had two medications ordered to be administered at 12:00 p.m. that were documented as administered at 2:28 p.m. Resident R39 had five medications ordered to be administered at 7:00 a.m., that were documented as administered at 11:57 a.m. Resident R39 had one medication ordered to be administered at 7:00 a.m. and 12:00 p.m. that were documented as administered at 3:30 p.m. and 3:21 p.m. Resident R40 had ten medications ordered to be administered at 7:00 a.m., that were documented as administered at 12:17 p.m. and 12:18 p.m. Resident R41 had two medications ordered to be administered at 7:00 a.m. that were documented as administered at 10:17 p.m. Resident R41 had twelve medications ordered to be administered at 8:00 a.m., that were documented as administered at 10:18 a.m. Resident R41 had one medication ordered to be administered at 12:00 p.m., that was documented as administered at 3:18 p.m. Resident R42 had four medications ordered to be administered at 8:00 a.m., that were documented as administered at 10:46 a.m. Resident R42 had one medication ordered to be administered at 11:00 a.m., that was documented as administered at 3:27 p.m. Resident R43 had two medications ordered to be administered at 7:00 a.m., that were documented as administered at 3:22 p.m. Resident R44 had twelve medications ordered to be administered at 7:00 a.m., that were documented as administered at 8:21 a.m. Resident R45 had ten medications ordered to be administered at 8:00 a.m., that were documented as administered at 9:26 a.m. Resident R46 had eleven medications ordered to be administered at 7:00 a.m., that were documented as administered at 10:49 a.m. Resident R46 had one medication ordered to be administered at 12:00 p.m. and one medication ordered to be administered at 1:00 p.m., that were documented as administered at 3:18 p.m. Resident R47 had six medications ordered to be administered at 8:00 a.m., that were documented as administered at 1:30 p.m. and 1:32 p.m. Resident R47 had two medications ordered to be administered at 12:00 p.m. and one medication taht was ordered to be administered at 2:00 p.m. that were documented as administered at 3:24 p.m. Resident R48 had five medications ordered to be administered at 7:00 a.m., that were documented as administered at 1:01 p.m. Resident R49 had six medications ordered to be administered at 7:00 a.m., that were documented as administered at 8:09 a.m. Resident R49 had two medications ordered to be administered at 12:00 p.m., that were documented as administered at 2:44 p.m. During an interview on 6/25826, at 10:06 a.m. the Medical Director confirmed that she was not notified by facility staff about missing and/or late medications on 6/11/26. During an interview on 6/25/26, at approximately 1:30 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure the complete and timely administration of a prescribed medications for 48 of 59 residents. 28 Pa. Code 201.14 (a) Responsibility of Licensee28 Pa. Code 211.9 (a)(1)(d) Pharmacy services28 Pa. Code 211.10 (c) Resident Care Policies28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of facility documents, clinical records, and staff interview, it was determined that the facility failed to make certain that medical records on each resident are completely and accurately documented.Findings Include:Review of the Medication Administration Audit Report for 6/11/26, indicated Licensed Practical Nurse (LPN) Employee E2 provided the following medications and treatments between 2:00 p.m. and 4:00 p.m.-83 oral medications-2 topical medications-7 injected medications-1 intravenous medication-6 inhaled medications-4 ophthalmic medications-4 blood sugar assessments-8 nutritional supplements provided-1 tuberculosis test assessed-29 pain assessments-6 skilled nursing assessments-3 whole body skin assessments-2 vital sign assessments-1 weight assessment During an interview on 6/25/26, at 12:50 p.m. LPN Employee E1 confirmed she did not provide all of the medications and treatments. LPN Employee E2 stated LPN Employee E3 had also provided some of the medications and treatments. LPN Employee E2 stated that she was told by the former Director of Nursing to just sign off on them since they were given. LPN Employee E2 stated, I did what I was told to do. Who am I to question the Director of Nursing? During an interview on 6/25826, at 10:06 a.m. the Medical Director confirmed that she was not notified by facility staff about medications not being received on 6/11/26. During an interview on 6/25/26, at approximately 1:30 p.m. the Nursing Home Administrator and the Regional Director of Operations confirmed that the facility failed to make certain that medical records on each resident are completely and accurately documented. 28 Pa. Code: 211.5(f)(g)(h) Clinical records.

Based on review of facility provided documents, clinical records and staff interviews, it was determined that the facility failed to ensure that a resident's legal surrogate (power of attorney) was provided access to medical records for one of two residents (Resident R51).Findings include: Review of the clinical record revealed that Resident R51 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 12/10/25, included diagnoses of neurogenic bladder (bladder problems due to disease or injury of the nervous system involved in the control of urination), anemia (too little iron in the body causing fatigue), and history of a stroke. Review of information submitted to the state survey agency on 6/12/26, indicated that a request for patient health information was submitted on 12/19/25. We reached out to the custodian on 12/31/2025. The custodian submitted incomplete records on 01/04/2026.From 01/21/2026 through 05/26/2026, we made multiple attempts to contact the custodian via phone calls, voicemails, and a HIPAA (Health Insurance Portability and Accountability Act of 1996) Violation Notice. Despite these efforts, the requested records remain outstanding. To date, the [facility] still has not released the records without any valid justification for such delay. Review of Resident R51's electronic medical record failed to reveal information related to the request for medical records. Review of an electronic communication dated 6/24/26, at 12:16 p.m. indicated the facility closed record failed to reveal information related to the request for medical records. During an interview on 6/25/26, at approximately 1:20 p.m. the Regional Director of Operations confirmed the request was received by a previous Nursing Home Administrator. The Regional Director of Operations confirmed the facility's legal department approved the release of information, but that the medical records had not been provided to the requestor by the facility. During an interview on 6/25/26, at approximately 1:30 p.m. the Regional Director of Operations and the Nursing Home Administrator confirmed the facility failed to ensure that a resident's legal surrogate (power of attorney) was provided access to medical records for one of two residents. 28 Pa. Code 201.14(b) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(2)(3) Management.

Based on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were completed in the required time frame for six of 24 residents (Resident R3, R6, R27, R15, R17, R20, and R37).Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2025, indicated that an admission MDS assessment was to be completed no later than 14 days following admission, and annual MDS assessment was to be completed no later than Assessment Reference Date (ARD). Resident R3 had an admission date of 4/20/26, with an MDS completion date of 5/15/26. Resident R6 had an Annual MDS ARD of 4/22/26, with an MDS completion date of 5/13/26. Resident R15 had an Annual MDS ARD of 4/2/26, with an MDS completion date of 6/4/26. Resident R17 had an admission date of 3/20/26, with an MDS completion date of 4/3/26. Resident R20 had an Annual MDS ARD of 4/22/26, with an MDS completion date of 5/13/26. Resident R37 had an admission date of 4/6/26, with an MDS completion date of 4/21/26. During an interview on 6/23/26, at approximately 5:30 p.m. the Regional Director of Operations confirmed that the facility failed to make certain that MDS assessments were completed in the required time frame for six of 24 residents. 28 Pa. Code: 211.5(f) Clinical records.

Based on review of facility policy, facility documentation, clinical records, staff and resident representative interview, it was determined that the facility failed to protect a cognitive impairment resident (Resident R1) from non-consensual sexual contact by Closed Record Resident CR2 (Resident CR2) who had a history of sexually inappropriate behaviors with Resident R1. This failure resulted in an Immediate Jeopardy situation for one of 58 residents, when Resident CR2 was found exposing genitals to Resident R1, and Resident R1's hands were on Resident CR2's genitals. Findings Include: Review of facility policy Abuse, Neglect, and Exploitation dated [DATE], indicated that abuse can be identified as verbal, physical, mental, and sexual. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves establishing a safe environment that supports, to the extent possible, a resident's consensual; relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to sexual contact will be made. The facility will make efforts to ensure all residents are protected from abuse, during and after an investigation of abuse. Examples include but are not limited to:Responding immediately to protect the alleged victim and integrity of the investigation. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed. Increased supervision of the alleged victims and residents. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. Providing emotional support and counseling to the resident during and after the investigation as needed. Review of Resident R1's clinical record indicated that she was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated [DATE], indicated diagnoses of Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior) dementia (a decline in cognitive function that interferes with daily life), and bipolar disorder (a mental condition marked by alternating periods of elation and depression). Further review of MDS Section C- Cognitive Patterns, C0500 BIMS Summary Score indicated Resident R1 scored a 9, moderately impaired. Review of Resident R1's care plans dated [DATE], indicated she had impaired cognition for daily decision making. Review of Resident CR2's clinical record indicated that he was admitted to the facility on [DATE]. Review of Resident CR2's MDS dated [DATE], indicated diagnoses of high blood pressure, kidney disease, and age-related cognitive decline. Further review of MDS Section C- Cognitive Patterns, C0500 BIMS Summary Score indicated a score of 14, cognitively intact. Review of a written statement from Registered Nurse (RN) Employee E2 dated [DATE], indicated the following: [Resident CR2] went into [Resident R1's] room at approximately 3:25 p.m. and was bent over resident who was in bed. His hand (right) was under her covers near her breasts. He [Resident CR2] was bent over her face with his face. Later at approximately 5:30 p.m. he was back in the room bent over [Resident R1] with his hand under her covers near her breasts. Review of Resident R1's clinical progress note dated [DATE], at 10:00 a.m. was labeled Late Entry, and stated that Resident R1 had a fall in her room the evening of [DATE]. Shortly after her fall, a male resident [Resident CR2] entered resident's room to check on her to see if she was okay. Staff saw male resident in [Resident R1's] room and thought they saw his hands under her bed sheets near her chest area. Both residents deny any touching occurred. It was made known at the time of this report to this writer that this male resident and Resident R1 are friends and he normally pushes her to dining/activities and they visit together/eat meals together in dining room. Staff have witnessed the two residents kiss one another. [Resident R1] and male resident were kept separate and rooms are already a distance away from one another. Families of both residents were notified as well as physician. RN supervisor did skin assessment of [Resident R1]. Male resident was interviewed immediately, and he stated they are friends and have kissed but no touching. RN supervisor also spoke with [Resident R1]. [Resident R1] states they are in a friendly relationship, have kissed but not touched. Both residents feel safe around one another and in the facility. Both families have been consulted with to see their preferences for intervention as well so that we are considering residents' rights. [Resident R1's] family specifically stated they want their mom to be happy and have meaningful relationships, however, until they can meet the male resident, they would like some boundaries put into place: no kissing, touching or private visiting in each other's rooms. This writer spoke to both residents regarding the boundaries put into place for right now, but that they could continue to eat meals together in the dining room and go to activities together. Nursing staff and Medical Director/Physician present and informed of boundaries to follow as well so that it is monitored. Both residents' care plans updated accordingly. Review of Resident R1's care plan dated [DATE] stated Resident desires to have a meaningful relationship with another resident. The following activities have been consented upon by both residents involved and/or guardians of listed residents: residents may go to meals and activities with male resident; no private in-room visits until family has had time to meet male resident; family wants mom to have meaningful relationships and for her to be happy. Review of Resident CR2's clinical progress note dated [DATE], at 10:54 a.m. stated the following: [Resident CR2] was with [Resident R1] coming up the hall from breakfast, this resident attempted to follow Resident R1 into her room, I informed this resident that he could not go into her room because she was going to lay down, this resident stated ok, but then went to kiss [Resident R1] on the lips, i informed this resident that he could not do this at this time and he stated like hell I can't I again told him and he said watch me and leaned down and kissed [Resident R1] on the lips. Review of Resident CR2's clinical progress note from Former Nursing Home Administrator (FNHA) Employee E3 dated [DATE], at 9:55 p.m. stated the following: Was notified by staff that constant re-direction is not working with resident. He continues to go into female resident's [Resident R1] room, witnessed by staff, and when asked to leave the room, gets angry. Starting at 9:30 p.m., resident is being placed on a 1-on-1 (direct supervision at all times from a dedicated assigned employee). This writer spoke to aides and RN supervisor of instruction. Doctor also notified. Should resident continue to not follow direction on specific boundaries put in place, discussions of a 30-day discharge will be had. A review of Resident CR2's clinical record conducted on [DATE], failed to reveal that CR2 had been placed on 1-1 supervision as indicated in the note above. Review of Resident R1's clinical progress note dated [DATE], at 10:03 p.m. stated Notified by nurse aide that resident (R1) had a bruise of unknown origin on the underside of her right breast. Upon assessment 5 cm (centimeter) round, reddish colored bruise noted. When questioned resident stated that she had a fall a couple days ago, she described herself slipping down out of her chair, unsure if her breast was injured at that time. She does not recall any other incident at this time. Denies pain/discomfort. Review of Resident CR2's clinical progress note dated [DATE], at 12:14 p.m. stated Resident was non-compliant with not kissing or touching Resident R1 after lunch today. He was again redirected by Nurse Aide (NA). Review of Resident CR2's clinical progress note dated [DATE], at 12:31 p.m. stated When confronted by nurse aide, this resident became angry that he was informed again that they are not allowed to kiss, he then went up to his room and [Resident R1] went to her room. Review of Resident R1's Physician's progress note dated [DATE], at 8:05 p.m. stated the following: New issue for resident has developed where she has created a friendship with a male resident that has created new challenges in terms of boundaries, the male resident wanting to cross personal boundaries, Resident (R1) is not against but needing to protect both residents. Family has been notified. Review of documentation provided by the facility revealed that Resident CR2 was placed on 15-minute checks on [DATE], whereas staff had to document that they observed him every 15 minutes to ensure his whereabouts. Review of Resident CR2's clinical progress note dated [DATE], at 2:07 p.m. stated the following: Resident (CR2) and [Resident R1] coming up the hallway when I looked up and noted [Resident CR2] to be kissing [Resident R1] in front of her room, DON (Former Director of Nursing Employee E4) also witnessed kissing. Review of Resident CR2's chart revealed that a diagnosis of dementia was added on [DATE]. Review of documentation provided by the facility on [DATE], stated the following: Male resident (CR2) walked in Female Resident R1's room pulled pants down and Female Resident (R1) touched him. Housekeeper walked into the room and summoned nurse to room. He (CR2) was seen in the hall 5 mins (minutes) prior. Male Resident (CR2) placed on one to one (supervision) and remains on it. Review of a written statement from Housekeeping Employee E5 dated [DATE], stated [Resident CR2] was leaning over the bed. His hand was under the blankets [of Resident R1]. Notified the LPN (Licensed Practical Nurse Employee E6) and she went down to the room. Review of a written statement from LPN Employee E6 dated [DATE], stated Was charting when housekeeping came up to me and said, 'You may want to get that male resident out of [Resident R1's] room.' I went to [R1's] room and saw [Resident CR2] standing at the top of her bed with his pants slightly down and [Resident R1] was holding on to his penis. I said to [Resident CR2] 'You need to come with me. You know you are not permitted in [Resident R1's room].' He fixed his pants and walked up the hall with me. I then went to the DON (Director of Nursing) DON, and I went to the Administrator. Review of Resident CR2's clinical record revealed a note from Social Services dated [DATE], that stated This writer and the administrator (NHA) called resident's POA (power of attorney- giving authority to another person to act in all legal or financial matters on another person's behalf) to inform him of the interaction between the resident and a female resident. POA states that it may be one sided and that she [Resident R1] may have invited him in. Try to explain that cognitively that is not a possibility. And also stated that Administrator explained that the facility would like to transfer him to another facility unless he would prefer for resident to discharge home, and Administrator tried to explain the situation and that it was for the safety of the residents. Review of Resident CR2's clinical record failed to reveal that his care plan was updated to include the incident on [DATE]. Review of Resident CR2's clinical record revealed that he was discharged to home with family on [DATE]. During an interview on [DATE], at 10:45 a.m. NA Employee E7 stated that she was Resident R1's nurse aide on [DATE] when Resident CR2 was in her room with his pants down and Resident R1 was touching Resident CR2's penis. NA Employee E7 stated Staff found male resident with his pants down. I had only seen them previously holding hands and kissing, did not see the event that day. I was on a break. I'm glad I didn't see anything, I washed her hands real good afterwards. During an interview on [DATE], at 11:25 a.m. Housekeeping Employee E5 confirmed that she had seen Resident CR2 in Resident R1's room on [DATE]. I saw his hand under her covers near her groin area. I asked him, 'What are you doing?' and he moved his hand and I left to get help. Housekeeping Employee E5 added that she had not seen this behavior before but I didn't feel it was appropriate and so she reported it. During an interview on [DATE], at 11:43 a.m. LPN Employee E6 confirmed that she was the nurse assigned to Resident R1 on the day of the [DATE] incident, and that Resident CR2 was on 15-minute checks at the time of the event. Fifteen minutes is a long time to check in between when someone is ambulatory (able to move about freely). I was told by Housekeeping that [Resident CR2] was in [Resident R1's] room, I saw him [Resident CR2] at the head of the bed with, pants down and she (Resident R1) was holding on to his penis. I told him he needed to come with me now, he came willingly. He isn't allowed in her room. Housekeeping said his hand was underneath her blankets. He (Resident CR2) is the Former DON (Employee E4's) uncle and she knew of all the kissing that had happened before and she would say 'This is cute'. She (Former DON Employee E4) didn't take it seriously, which I feel is a conflict of interest. She's [Resident R1] very child-like, not all there. He (Resident CR2) knows what he is doing because he can go to her room. Her (Resident R1) family didn't want him near her. They were not giving the blessing of the relationship. I've known her (Resident R1) for nine years. She isn't capable of making her own decisions, she has Alzheimer's. State Agency asked LPN Employee E6 if either resident had seen by psychiatric services after the incident on [DATE], to which she replied No. During an interview on [DATE], at 1:40 p.m. the NHA stated that he was the NHA at the time of the incident on [DATE], and that he ensured that the facility placed Resident CR2 on one-to-one supervision after the [DATE] incident to prevent further situations. The NHA also stated that Resident CR2 was the uncle of Former DON Employee E4 and described it as a conflict of interest in reference as to how the previous incidents were handled. During an interview on [DATE], at 8:35 a.m. the NHA confirmed that Resident R2 had not received any 15-minute checks, or one-on-supervision until [DATE], when every 15-minute checks began, and on [DATE] when the one-on-one supervision began. During an interview on [DATE], at 8:47 a.m. the NHA confirmed that the last psychiatric evaluation for Resident R1 was on [DATE], and that the last psychiatric evaluation for Resident CR2 was on [DATE], and that there had not been any referrals for either resident for follow up after the [DATE] incident. NHA also confirmed that individuals with Alzheimer's, and dementia cannot consent to sexual activity. On [DATE], at 9:30 a.m. the Immediate Jeopardy template was provided to the facility administration, and a Corrective Action Plan was requested. State Agency called Resident R1's Representative for interview. Representative unavailable, left message to return phone call. During an interview on [DATE], at 10:58 a.m. LPN Employee E8 stated she had been assigned to one-on-one visits with Resident CR2 after the incident on [DATE], and described it as It was the most boring eight hours of my life, and stated that resident was compliant with the direct supervision and did not display any behaviors or attempts to find Resident R1. During an interview on [DATE], at 11:12 a.m. NA Employee E9 stated that she had also been assigned to one-on-one supervision with Resident CR2 and stated that He never gave me a hard time, and was easily redirected. Review of Resident CR2 revealed no behaviors or sexual advances had occurred after one-on-one supervision was implemented on [DATE]. On [DATE], at 3:07 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Resident CR2 has been discharged from facility on [DATE]. Resident R1 has been placed on the Psych list to be seen on [DATE], via video visit. Medical doctor is completing a physical assessment on [DATE]. Resident R1's Care plan was updated on [DATE], to include:Encourage resident to express any feelings of fear. Document any abnormal behaviors or moods. A full house audit of interviewable residents was completed by Social Services by [DATE]. Residents were interviewed regarding witnessing or experiencing abuse. No interview reflected abuse of any nature, all residents know who to report abuse should they ever experience or witness it. Non-interviewable residents were assessed by the DON/designee by [DATE] for signs or symptoms of fear trauma, neglect or abuse of any nature. No assessments reflected abuse of any nature, all residents remained at psychosocial baseline. No residents were deemed to have an immediate need to be added to the psychiatry list scheduled for [DATE]. Any future residents will be added to that list if needed. All [NAME]'s law checks were validated on [DATE], all residents have one present and uploaded to their chart. Facility will continue to run sex offender checks prior to admission.30 days of progress notes were reviewed on [DATE] by Regional Director of Clinical operations and none were reflective of any other resident witnessing or experiencing abuse. Abuse and Neglect policy was reviewed by Administrator on [DATE] and deemed current and appropriate. Administrator and Director of Nursing were educated by Regional Director of Clinical Operations on [DATE].Nursing staff will be educated on changes in mood or cognitive changes. Social Worker will be educated on [NAME]'s Law Checks. On unwanted aggressive/sexual behaviors.Social Worker will be educated on identifying resident fears. Beginning [DATE], Director of Nursing/designee will review progress notes five times per week to ensure no unwanted behaviors have occurred and update plans of care as deemed necessary if applicable should any reflect behaviors. Beginning on [DATE], Director of Nursing/designee will interview or assess ten residents weekly to ensure all remain free of abuse or unwanted behaviors. Audits will continue for four weeks. Results will be reviewed by QAPI (Quality Assurance and Performance Improvement) to determine further needs of audits. Review of residents at IDT (interdisciplinary team) Clinical will be completed by the Director of Nursing, or designee, at morning meeting five days per week to identify any aggressive behaviors identified. During a telephonic interview on [DATE], at 5:51 p.m. Resident R1's Representative stated that family was aware of the relationship between Resident R1 and Resident CR2, and replied She should have never been left alone with him. He should have never touched her. and replied She is not able to make these decisions when State Agency asked about consenting to a physical relationship. She hasn't had any relations with men since her husband died eight to ten years ago. I can't believe that she would want this to happen. We were okay with them eating lunch together, but the touching is different. You know he [Closed Record Resident CR2] is the Director of Nursing's (Former DON Employee E4) uncle? Makes you question how the whole thing was handled. Review of facility documents, and clinical documentation on [DATE] revealed the following: Resident CR2 was discharged on [DATE] Resident R1 was evaluated by psychiatric services and medical doctor on [DATE].Resident R1's [DATE] Psychiatric evaluation indicated that BIMS score is now a 5 which is indicative of severe cognitive impairment. Resident R1 care plan was updated.30 out of 30 verbal residents were interviewed for abuse concerns, and 29 out of 29 non-interviewable residents were assessed for abuse concerns with both a physical skin check as well as an assessment of behaviors. No new concerns identified.59 out of 59 residents were verified to have had [NAME]'s Law screening completed. However, 36 were not completed until Plan of Correction was implemented on [DATE].Abuse policy was reviewed.30 days of progress notes verified as being reviewed by staff for potential concerns regarding abuse. No new concerns identified.75 of 81 employees received education on abuse and/or changes in mood or cognitive changes/identifying fears and [NAME] Law checks as appropriate. The remaining staff are to be educated before the beginning of their next shift.18 employees were interviewed who verified that they received the appropriate education. Audits to begin on [DATE]. Additionally, facility developed a screening tool for Sexual Urges and screened 30 out of 30 verbal residents for potential concerns with inappropriate sexual behaviors. During an interview on [DATE], at 10:37 a.m. Dietary Employee E10 confirmed that she received education on abuse. When State Agency asked if residents with dementia could consent to sexual activity, she said No. But isn't that obvious? During an interview on [DATE], at 11:39 a.m. Social Worker Employee E11 confirmed that residents with dementia cannot provide consent for sexual activities, and neither can their families. I don't think she (Resident R1) really did get what was happening. She is like a giggly teenager, she's childlike. The Immediate Jeopardy was lifted on [DATE], at 12:20 p.m. when the action plan implementation was verified. During an interview on [DATE], at 1:45 p.m. information was disseminated to the NHA that the facility failed to protect a cognitively impaired resident (Resident R1) from non-consensual sexual contact by Resident CR2 who had a history of sexually inappropriate behaviors with Resident R1 on [DATE], [DATE], [DATE], [DATE], and [DATE]. This failure occurred when the following concerns were not addressed: The facility failed to initiate one-on-one supervision on [DATE], when Former NHA Employee E3 indicated that constant re-direction was not effective to protect Resident R1 and that one-on-one supervision should begin. The facility failed to adhere to Physician's guidance documented on [DATE], that Male resident wanting to cross personal boundaries, Resident (R1) is not against but needing to protect both residents. The facility failed to ensure that Former DON Employee E4's relationship to Resident CR2 was not a factor in implementing any interventions to protect Resident R1. The facility failed to honor Resident R1's family's wishes to not have any kissing, touching, or private visiting between Resident R1 and Resident CR2 as per documentation on [DATE]. The facility failed to provide a timely medical and psychiatric evaluation for Resident R1 after incident on [DATE]. As the above inappropriate, sexual contact would reasonably cause anyone to have psychosocial harm, it can be determined that the reasonable person in these residents' position would have experienced severe psychosocial harm- dehumanization, and humiliation- as a result of sexual abuse. (Resident R1) The above failures resulted in an Immediate Jeopardy situation for one of 58 residents, when Resident CR2 was found exposing his genitalia to Resident R1, who had her hand placed on Resident CR2's genitalia on [DATE]. During an interview on [DATE], at3:35 p.m. the DON confirmed that the facility failed to investigate the bruise on Resident R1's breast that was described in [DATE], to rule out if it was obtained from a fall or from the incident on [DATE], when Resident CR2 was found with his hand on her breast area. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.10 (d) Resident care policies

Based on review of facility policy, resident clinical records, reports submitted to the State, and staff interview, it was determined that the facility failed to report allegations of sexual abuse for two of three sampled resident records (Resident R1 and Closed Resident Record CR2).Findings include: Review of the facility provided policy titled Abuse, Neglect, and Exploitation dated 3/13/26, indicated that abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish. Abuse includes deprivation by an individual, including caretaker of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. It includes verbal, physical or sexual abuse. Sexual Abuse is non-consensual sexual contact of any type with a resident. The facility will have written procedures including reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes. Report immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Review of Resident R1's admission record indicated she was admitted on [DATE]. Review of Resident R1's MDS assessment (Minimum Data Set: MDS - a periodic assessment of care needs) dated 4/21/26, indicated she had diagnoses that included COPD (chronic obstructive pulmonary disease: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and dementia (a chronic or persistent disorder of mental processes caused by brain disease or injury associated with memory disorders, personality changes, and impaired reasoning). Review of Resident R1's care plans dated 8/22/25, indicated she had impaired cognition for daily decision making. Review of Resident R1's clinical nurse notes dated 4/7/26, indicated staff have witnessed the two (Resident R1 and Closed Resident Record CR2) kiss one another. Resident R1 and Closed Resident Record CR2 were kept separate and rooms are already a distance away from one another. Families of both residents were notified as well as physician. RN supervisor did skin assessment of Resident R1. Closed Resident Record CR2 was interviewed immediately, and he stated they are friends and they have kissed but no touching. RN supervisor also spoke with Resident R1 and she stated they are in a friendly relationship, have kissed but not touched. Review of Resident R1's clinical nurse notes indicated no concerns on 4/25/26 related to kissing. Review of Closed Resident Record CR2's admission record indicated he was admitted on [DATE]. Review of Closed Resident Record CR2's MDS assessment dated [DATE], indicated she had diagnoses that included age related cognitive decline, chronic kidney disease (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and changes in urination), hypertension (a condition impacting blood circulation through the heart related to poor pressure) and anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry). Review of Closed Record Resident CR2's clinical progress note dated 4/9/26, at 10:54 a.m. stated the following: [Closed Record Resident CR2] was with [Resident R1] coming up the hall from breakfast, this resident attempted to follow Resident R1 into her room, I informed this resident that he could not go into her room because she was going to lay down, this resident stated ok, but then went to kiss [Resident R1] on the lips, i informed this resident that he could not do this at this time and he stated like hell I can't I again told him and he said watch me and leaned down and kissed [Resident R1] on the lips. Review of Closed Record Resident CR2's clinical progress note dated 4/13/26, at 12:31 p.m. stated When confronted by nurse aide, this resident became angry that he was informed again that they are not allowed to kiss, he then went up to his room and [Resident R1] went to her room. Review of Closed Resident Record CR2's care plan dated 4/20/26, indicated Resident R2 had been observed displaying sexually inappropriate behavior that included kissing. Review of Closed Resident Record CR2s clinical nurse note dated 4/25/26, indicated Resident R1 and Resident R2 were coming up the hallway when staff observed and noted Closed Resident Record CR2 to be kissing Resident R1 in front of her room, DON (Director of Nursing) also witnessed the kissing. Review of alleged abuse allegations submitted to the State field office did not include the sexual abuse incident involving Resident R1 and Closed Resident Record CR2 on 4/25/26. During an interview on 5/27/26, at 1:40 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to report allegations of sexual abuse for incident on 4/25/26, involving Resident R1 and Closed Resident Record CR2 as required. During an interview on 6/1/26, at 3:35 p.m. the DON confirmed that the facility failed to report allegations of sexual abuse for the incidents on 4926, and 4/13/26, involving Resident r1 and Closed Record Resident CR2 as required. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 201.18 (b) (1) (e) (1) Management.28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.

Based on a review of a job description, facility and clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA), and Director of Nursing (DON) did not effectively manage the facility to make certain that residents were free from abuse and failed to make certain the facility implemented its abuse policies, creating an immediate jeopardy situation.Findings include: The job description for the NHA and DON specified the primary purpose of the job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities to assure that the highest degree of quality care can be provided to our residents at all times. Based on the findings in this report that identified that the facility failed to effectively manage the facility to make certain that residents were free from abuse and failed to make certain the facility implemented its abuse policies, resulting an immediate jeopardy situation. The facility failed to provide fundamental principal that apply to treatment and care provided to facility residents. The facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, and facility policies. 28 Pa Code 201.14(a) Responsibility of licensee.28 Pa Code 201.18(b)(1)(e)(1) Management.

Based on review of facility policy, closed resident records, business office documents, and staff interview it was determined that the facility failed to convey funds credited to a resident's family for one of three closed resident records (Closed Resident Record CR3).Findings include: The facility Resident trust fund policy dated 1/16/26, indicated that the facility shall establish and maintain a system that ensure full, complete and separate accounting of each residents' account funds. Review of Closed Resident Record CR3's admission record indicated she was admitted to the facility on [DATE]. Review of Closed Resident Record CR3's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 9/21/25, indicated she had diagnoses upon admission that included lung cancer, diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), and hyperlipidemia (elevated lipid levels within the blood). Review of Closed Resident Record CR3's clinical nurse note dated 10/30/25, indicated staff called to Resident CR3's room by family stating they think she is gone. Staff assessed her and Resident CR3 was without apical pulse for a full minute, no respirations, pupils fixed and dilated. Resident CR3 has ceased to breathe at 9:28am. Hospice and DON notified. Daughter and son-in-law present at time of death and condolences given. Review of facility business office documents dated 5/28/26, indicated Closed Resident Record CR3 had a credit of $650 owed to her family. Review of Closed Resident Record CR3's clinical records and business office records did not indicate a credit issued to Resident CR3's family. During an interview on 5/28/26, at 11:56 a.m. Business office manager (BOM) Employee E1 confirmed that the facility failed to convey funds credited to a Closed Resident Record CR3's family as required. 28 Pa. Code 211.5(d) Clinical records. 28 Pa Code: 201.18(e)(1) Management.

Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to conduct a thorough investigation involving an allegation of resident abuse for two of three sampled resident records (Resident R1 and Closed Resident Record CR2).Findings include: Review of the facility provided policy titled Abuse, Neglect, and Exploitation dated 3/13/26, indicated that abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish. Abuse includes deprivation by an individual, including caretaker of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. It includes verbal, physical or sexual abuse. Sexual Abuse is non-consensual sexual contact of any type with a resident. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include: identifying staff responsible for the investigation; exercising caution in handling evidence that could be used in a criminal investigation; investigating different types of alleged violations; identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and providing complete and thorough documentation of the investigation. Review of Resident R1's admission record indicated she was admitted on [DATE]. Review of Resident R1's MDS assessment (Minimum Data Set: MDS - a periodic assessment of care needs) dated 4/21/26, indicated she had diagnoses that included COPD (chronic obstructive pulmonary disease: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and dementia (a chronic or persistent disorder of mental processes caused by brain disease or injury associated with memory disorders, personality changes, and impaired reasoning). Review of Resident R1's care plans dated 8/22/25, indicated she had impaired cognition for daily decision making. Review of Resident R1's clinical nurse notes dated 4/7/26, indicated staff have witnessed the two (Resident R1 and Closed Resident Record CR2) kiss one another. Resident R1 and Closed Resident Record CR2 were kept separate and rooms are already a distance away from one another. Families of both residents were notified as well as physician. RN supervisor did skin assessment of Resident R1. Closed Resident Record CR2 was interviewed immediately, and he stated they are friends and they have kissed but no touching. RN supervisor also spoke with Resident R1 and she stated they are in a friendly relationship, have kissed but not touched. Review of Resident R1's clinical progress note dated 4/10/26, at 10:03 p.m. stated Notified by nurse aide that resident (R1) had a bruise of unknown origin on the underside of her right breast. Upon assessment 5 cm (centimeter) round, reddish colored bruise noted. When questioned resident stated that she had a fall a couple days ago, she described herself slipping down out of her chair, unsure if her breast was injured at that time. She does not recall any other incident at this time. Denies pain/discomfort. Review of Resident R1's clinical nurse notes indicated no concerns on 4/25/26 related to kissing. Review of Closed Resident Record CR2's admission record indicated he was admitted on [DATE]. Review of Closed Resident Record CR2's MDS assessment dated [DATE], indicated she had diagnoses that included age related cognitive decline, chronic kidney disease (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and changes in urination), hypertension (a condition impacting blood circulation through the heart related to poor pressure) and anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry). Review of Closed Record Resident CR2's clinical progress note dated 4/9/26, at 10:54 a.m. stated the following: [Closed Record Resident CR2] was with [Resident R1] coming up the hall from breakfast, this resident attempted to follow Resident R1 into her room, I informed this resident that he could not go into her room because she was going to lay down, this resident stated ok, but then went to kiss [Resident R1] on the lips, i informed this resident that he could not do this at this time and he stated like hell I can't I again told him and he said watch me and leaned down and kissed [Resident R1] on the lips. Review of Closed Record Resident CR2's clinical progress note dated 4/13/26, at 12:31 p.m. stated When confronted by nurse aide, this resident became angry that he was informed again that they are not allowed to kiss, he then went up to his room and [Resident R1] went to her room. Review of Closed Resident Record CR2's care plan dated 4/20/26, indicated Closed Resident Record CR2 had been observed displaying sexually inappropriate behavior that included kissing. Review of Resident R2's clinical nurse note dated 4/25/26, indicated Resident R1 and Closed Resident Record CR2 were coming up the hallway when staff observed and noted Closed Resident Record CR2 to be kissing Resident R1 in front of her room, DON (Director of Nursing) also witnessed the kissing. Review of alleged abuse allegations documents investigated by the facility did not include evidence of a thorough abuse investigation. The records did not include witness statements, residents' assessments, other resident interviews, and notification to the families involving the incident with Resident R1 and Closed Resident Record CR2 on 4/25/26. During an interview on 5/27/26, at 1:40 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to conduct a thorough investigation involving an allegation of resident abuse that occurred on 4/25/26, for Resident R1 and Closed Resident Record CR2 as required. During an interview on 6/1/26, at 3:25 p.m. the DON confirmed that the facility failed to conduct a thorough investigation involving allegations of resident abuse that occurred on 4/9/26, 4/10/26, and 4/13/26, for Resident R1 and Closed Record Resident CR2 as required. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.10 (c)(d) Resident Care policies.28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of the facility's job descriptions, observations, and staff interviews, it was determined that the facility failed to ensure the consistent services of a full-time Director of Nursing (40 or more hours a week) in the facility.Findings Include: Review of the facility provided Director of Nursing (DON) job description, signed and dated 12/22/25, indicated that the DON position purpose was, to plan, organize, develop, and direct the overall operation of the Nursing Service Department in accordance with current federal, stated, local standards, guidelines, and regulations that govern the facility, and as may be directed by the Administrator and the Medical Director, to ensure the highest level of quality care is maintained at all times. Job duties include assist the designated Infection Control Coordinator, monitor the planning, conducting, and scheduling of timely in-service training classes, ensure that a sufficient number of licensed practical and/or registered nurses and nurse aides are scheduled and working during all shifts. Information reported to the State Department of Health indicated that the Director of Nursing started at the facility on 12/22/26. During an interview on 4/22/26, at 9:58 a.m. the Director of Nursing stated Monday to Friday during daylight shift she completes DON duties and cannot be on a medication cart. The DON indicated she acts as RN Supervisor and DON two to three times a week and sometimes is assigned a medication cart. The DON stated it's hard to do all the things. It was indicated she typically works 12 to 16 hours, 6-7 days a week. The DON confirmed she is also responsible for nursing education and Infection Preventionist. During an interview on 4/23/26, at 8:57 a.m. the DON was observed working on the floor and stated she was assigned to work as an aide for daylight shift. During an interview and observation on 4/23/26, at 9:17 a.m. Resident R2 was calling out for help while the DON was assisting surveyors. The DON yelled across the hallway to the resident that she'll be right there. The DON confirmed she was assigned the C Wing Hallway and was providing direct resident care. During an interview on 4/23/26, at 10:04 a.m. Licensed Practical Nurse (LPN) Social Worker, Employee E5 confirmed she was assigned to a cart on C Wing and the DON is working as the nurse aide. It was indicated the DON works on the medication cart sometimes. During an observation on 4/23/26, at 10:11 a.m. the DON was observed providing care to Resident R2. During an interview on 4/23/26, at 11:32 a.m. the Nursing Home Administrator and confirmed the facility failed to ensure the consistent services of a full-time Director of Nursing (40 or more hours a week) in the facility. 28 Pa Code 201.3 Definitions.28 Pa Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(e)(6) Management.28 Pa. Code 211.12(b)(c)(d) Nursing Services.

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to properly store, label and date food items in the Main kitchen which created the potential for food borne illness.Findings include: Review of the facility policy Dating for Food Storage dated 3/16/26, and previously dated 1/21/26, indicated that when receiving foods from delivery, assure the foods are packaged with a shipping label. If the food item is removed from the original packaging/box from shipment, the item must have a date marked that it was received. In addition to labeling, dating items requires special attention. All foods that require time and temperature control should be labeled with the following: common name of food, date the food was made, use by date. If the food is not used within the days allowed to be held it must be discarded. Items that are being stored in the freezer must be labeled, dated, sealed in the same manner and may store for the period of time per guidelines. During a observation in the Main Kitchen in the walk-in freezer on 4/20/26, at 10:10 a.m. the following was observed: an opened bag of tater tots with no label, or date marked to indicate what date it was opened, two bags of frozen noodles that were not labeled, or marked with a received date, three grocery bags of ice cream cups with no label or receive date, a plastic container of kielbasa and sauerkraut that had the lid off-center (not sealed) with a use-by date of 4/10/26. During an observation in the Main Kitchen I stand-up freezer on 4/20/26, at 10:16 a.m. a bag of potatoes was observed with no label, or receive date. During an interview on 4/20/26, at 10:19 a.m. Kitchen Manager Employee E6 confirmed the above findings, and stated that the ice cream was brought in by a resident's family and it would not fit into the freezer in the nursing unit that is provided for resident use. Kitchen Manager Employee E6 informed that storing resident food in the freezer is not appropriate as chain of custody of the food and food safety is not guaranteed. Kitchen Manager Employee E6 confirmed that the facility failed to properly label, date, and store food items that created a potential for food borne illness. 28 Pa. Code: 201.18(b)(1) Management.28 Pa. Code: 201.14(a) Responsibility of licensee.

Based on review of facility policy, personnel records and staff interviews, it was determined that the facility failed to complete annual performance evaluations for four of five nursing staff (Nurse Aide (NA) Employees E10, E11, E12, and E13).Findings include: Review of facility Employee Performance Evaluations policy dated 3/16/26, indicated all employees receive timely, fair, and consistent performance evaluations. After 90 days, performance evaluations are conducted annually. Review of NA Employee E10's personnel record indicated a hire date of 2/7/24. Last employee performance evaluation was dated 6/20/24. Review of NA Employee E11's personnel record indicated a hire date of 10/30/23. Last employee performance evaluation was dated 11/11/24. Review of NA Employee E12's personnel record indicated a hire date of 2/29/24. Last employee performance evaluation was dated 8/7/24. Review of NA Employee E13's personnel record indicated a hire date of 6/22/23. Last employee performance evaluation was dated 6/24/24. Review of personnel records did not include an annual performance evaluation based on the date of hire for NA Employees E10, E11, E12, and E13. During an interview on 4/22/26, at 9:20 a.m. Human Resource Employee E4 stated, We are behind in evaluations and are trying to get caught up, and confirmed that the facility failed to complete annual performance evaluations for four of five nursing staff personnel records (Employees E10, E11, E12, and E13). 28 Pa Code: 201.20 (a)(b)(d) Staff development.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of three residents sampled with facility-initiated transfers (Residents R1), and failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for one of three residents (Resident R1).Findings include: Review of facility policy Transfer and discharge date d 3/16/26, and previously dated 1/21/26, indicated that for transfer to another provider, for any reason, the following information must be provided to the receiving provider: contact information of the practitioner who is responsible for the care of the resident; resident representative information, including contact information; advance directive information; and all other information necessary to meet the resident's needs. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/31/26, indicated diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and chronic pain. Review of the clinical record indicated Resident R1 was transferred to the hospital on 3/19/26, and returned to the facility on 3/23/26. Review of Resident R1's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. Review of Resident R1's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the Office of Long-Term Care Ombudsman for the hospitalization on 3/19/26. During an interview on 4/23/26, at 9:16 a.m. the Director of Nursing confirmed that there was no evidence that the necessary information was communicated to the receiving health care institution or provider upon transfer. During an interview on 4/23/26, at 11:43 a.m. the Nursing Home Administrator confirmed that the facility failed to provide documented evidence that the Office of the State Long-Term Care Ombudsman was notified upon transfer to the hospital for one of three residents (Resident R1) 28 Pa. Code: 201.14(a)Responsibility of licensee.28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights.

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that discharge documentation was on record for one of three closed resident records (Closed Resident Record R64).Findings include: Review of facility policy Transfer and discharge date d 3/16/26, and previously dated 1/21/26, indicated that for transfer to another provider, for any reason, the following information must be provided to the receiving provider: contact information of the practitioner who is responsible for the care of the resident; resident representative information, including contact information; advance directive information; and all other information necessary. Review of Closed Resident Record R64's admission record indicated she was admitted on [DATE]. Review of Closed Resident Record R64's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 8/24/25, indicated she had diagnoses that included hyperlipidemia (elevated lipid levels within the blood), hypertension (a condition impacting blood circulation through the heart related to poor pressure), dysphagia (difficulty swallowing), and macular degeneration (a vision impairment affecting the macula). Review of Closed Resident Record R64's care plans dated 8/20/25, indicated to notify doctor of discharge plans, and staff will work with resident to facilitate safe discharge. Review of Closed Resident Record R64's clinical nurse note dated 9/12/25, indicated Closed Resident Record R64 discharged at this time with son to Assisted living facility. Scripts sent too , and discharge paperwork sent with son. Review of Closed Resident Record R64's clinical nurse notes, physician orders, and physician assessment documents did not include an order to discharge to Assisted Living/ Personal care. During an interview on 4/23/26, at 10:10 a.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to ensure that discharge documentation was on record for Closed Resident Record R64's including an physician order to discharge to Assisted Living as required. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.29 (a)(c)(2) Resident rights.

Based on review of a resident representative's concern, and staff interview, it was determined that the facility failed to ensure that residents have the right to communication and access to persons and services inside the facility. for one of two residents (Resident R64).Findings include: Review of a Resident Representative concern dated 3/17/26, stated that a bill was received on behalf of her mother (Resident R64) who was a resident at the facility. The Resident Representative had questions, and concerns with her bill, and stated: I called them and they don't answer their phone. I went in and spoke to a young girl, and I told her the problem and gave her my name and phone number, and nobody ever got back to me. If this is a legitimate bill, then why can't they explain why we owe this amount? During an interview on 4/22/26, at 2:49 p.m. the Nursing Home Administrator (NHA) stated that the Business Office Manager that would be able to explain the bill no longer worked at the facility, and that the NHA is now handling these concerns. However, the NHA was not made aware that the Resident Representative needed to speak with someone regarding billing, therefore she had not addressed these concerns. NHA noted that failure to return phone calls and answer questions failed to ensure that residents have ease with communication to persons inside the facility. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(1) Management.28 Pa. Code: 201.29(a)Resident Rights.

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide documentation that residents or resident representatives were given the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for two of three residents reviewed (Resident R4 and R5).Findings include: Review of facility Residents' Rights Regarding Treatment and Advance Directives policy dated 3/16/26, indicated that the facility will support and facilitate a resident's right to request, refuse or discontinue medical or surgical treatment and to formulate advance directives. On admission, the facility will determine if the resident has executed an advance directive and if not, determine whether the resident would like to formulate an advance directive. The facility will provide the residents or resident representative information on formulating advanced directives. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/7/26, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), high blood pressure, and anxiety. Review of the clinical record failed to reveal an advanced directive or documentation that Resident R4 was given the opportunity to formulate an Advance Directive. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/12/26, indicated diagnoses of high blood pressure, chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), and paraplegia (partial or complete paralysis of the lower half of the body). Review of the clinical record failed to reveal an advanced directive or documentation that Resident R5 was given the opportunity to formulate an Advance Directive. During an interview on 4/22/26, at 12:30 p.m. Social Worker Employee E5 stated, I don't have it documented anywhere, and confirmed that the facility failed to provide documentation that residents or resident representatives were given the opportunity to formulate an advance directive for two of three residents reviewed (Resident R4, and R5). 28 Pa. Code: 201.29(b) Resident rights.

Based on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to notify the physician of a change in condition for one of three residents (Resident R1).Findings include:Review of facility policy Notification of Changes dated 3/16/26, and previously dated 1/21/26, indicated that the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. This may include a significant change in the resident's physical, mental or psychosocial. condition such as deterioration in health, and a transfer or discharge of the resident from the facility. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/31/26, indicated diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and chronic pain. Review of the clinical record revealed a progress note dated 3/19/26, that stated Resident R1's daughter requested that resident be sent to the emergency room as she was having difficulty breathing. Resident was found sitting in her wheelchair on oxygen, audible wheezing heard. Updated daughter on resident's condition, and requested she be sent to the emergency room. Review of Resident R1's clinical record did not reveal that the change of condition and hospital transfer were communicated to the physician. During an interview on 4/23/26, at 11:43 a.m. the Nursing Home Administrator confirmed that the facility failed to notify the physician of a change in condition that required hospitalization. 28 Pa. Code: 211. 12(d)(1) Nursing services.

Based on policy, employee files, facility documents, staff interviews, it was determined that the facility failed to ensure all staff had a criminal background check prior to working in the facility for one of seven staff members (Social Worker, Employee E1). The facility failed to identify incidents of abuse/neglect, and timely report and investigate allegations of abuse/neglect for one of six residents (Resident R1). The facility put other residents at risk for abuse/neglect from the Nursing Home Administrator (NHA) and Licensed Practical Nurse LPN), Employee E2, by allowing the staff members to continue to work after abuse/neglect occurred. This failure created an immediate jeopardy situation.Findings include: Review of the facility provided policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property review date of 1/21/26, indicated This facility will not tolerate Abuse, Neglect, and Exploitation of its residents or the Misappropriation of Resident Property. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish. Abuse includes deprivation by an individual, including caretaker of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. It includes verbal abuse, physical abuse, and mental abuse. It is the policy of the facility to undertake background checks of all employees and to retain on file applicable records of current employees regarding such checks. The check must be completed prior to hiring a new employee. All alleged violations involving abuse and neglect will be investigated. Facility staff should immediately report allegations to the administration and Department of health. In cases where crime is suspected, staff should report the dame to law enforcement. Residents interested in family members, or other people may contact members of the administration or the facility's nursing staff at any time with concerns related to abuse and neglect. A person may also file a grievance. After notification, an investigation of the alleged violation will be conducted. Interview and obtain statements from the residents, the accused, and all witnesses. Evidence of the investigation should be documented. In the case of staff abuse, the facility will follow the procedure for discipling or dismissing an employee, depending upon the circumstances and results of the investigation. It is the policy of the facility that each of its own operated homes treat all residents with kindness, respect and in a manner that is at all times free from any form of abuse, neglect, misappropriation of property, exploitation, or mistreatment. To protect our residents, each of our homes will implement procedures in the areas of screening, training, prevention, identification, investigation, protection, reporting/response and corrective action. The facility has developed and implemented personnel and other policies to ensure that all staff are qualified and meet all regulatory standards for hire. In addition, we screen our employed contracted prior to employment, Employed staff, upon hire and at least annually through in-service education will receive training on issues related to abuse prohibition and prevention. We provided adequate supervision of our staff to identify inappropriate behaviors and to ensure that care/services are provided safely and as needed. We provide appropriate information to our staff of those residents with potential for aggressive behavior. Abuse and neglect will be identified through various methods such as reports from employed or contracted staff, utilization of resident incident reports, review prior incidents and any patterns of staff behaviors. Allegations involving residents, visitors, employees, or any other person must be reported to the Administrator or Director of Nursing (DON) immediately. The Administrator or DON will notify the Department of Health via electronic reporting system within 24 hours of the incident and complete an on-line PB-22 if directed to do. The County Area Agency on Aging will be contacted and a verbal report of allegation of abuse will be submitted within 24 hours of the event. All written reports shall include, at a minimum, the name and age of the resident, address of resident representative, address of the home, nature of the alleged offense, and any specific comments or observations that are directly related to the alleged incident and individuals involved. All investigation will be conducted thoroughly and will attempt to gather as much information as possible. If a specific employee is suspected of abuse of a resident, the home shall immediately implement a plan of supervision or, where appropriate, reassignment, suspension or where appropriate, reassignment, suspension or termination of employment of the employee. The Elder Justice Care Act requires each owner, operator, employee, manager, agency, or contractor of a nursing home facility (a covered individual) to report any responsible suspicion of a crime no later than (2) hours after forming the suspicion. In addition to reporting all obligations described above, covered individuals must report any reasonable suspicion of a crime to the Department of Health and to the local police serving the community where the resident is receiving care. Review of Social Worker, Employee E1 employee file on 3/12/26, at 2:26 p.m. revealed a hire date of 1/27/26. Review of Social Worker, Employee E1's criminal background check revealed it was completed on 3/12/26. During an interview on 3/12/26, at 3:05 p.m. the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the facility failed to ensure all staff had a criminal background check prior to working in the facility for one of seven staff members (Social Worker, Employee E1). Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE], with diagnoses of acquired absence of left leg above knee, acquired absence of right leg above knee, and opioid dependence. Review of Resident R1's Minimum Data Set (MDS - mandated assessment of a resident's abilities and care needs) dated 1/20/26, revealed the diagnoses were current. Section C- Cognitive Pattern Brief Interview for Mental Status (BIMS) revealed a score of 15, cognitively intact. During an interview on 3/13/26, at 8:45 a.m. Resident R1 started on 3/11/26, he experienced abuse/neglect from LPN, Employee E2 and the Nursing Home Administrator. Resident R1 stated he does not feel safe while the NHA is in the facility. Resident R1 stated he wrote a letter detailing the events and provided it to RN Supervisor, Employee E3, the only person I trust that same day. Resident R1 stated the facility did nothing and didn't investigate, and the alleged perpetrators continued to work. During an interview on 3/13/26, at 8:57 a.m. Certified Occupation Therapy Assistant (COTA), Employee E5 stated he entered the facility five minutes after the incident took place. COTA, Employee E5 stated I mean it's unbelievable, especially with it being the NHA, he's supposed to set the tone. COTA Employee E5 stated the NHA continued to work the remainder of the day on 3/11/26. It was indicated the NHA is intimidating and he was aggressive with an ombudsman that came in. He has a short fuse, shouldn't be in that role. COTA, Employee E5 stated Social Worker, Employee E1 is the NHA's wife, it's all a cover up, they all came from the same place and revealed the DON is married to the Director of Maintenance, Employee E4. During an interview on 3/13/26, at 9:15 a.m. the Director of Maintenance, Employee E4 confirmed he had to remove the NHA out of the resident's room to deescalate the situation on the morning of 3/11/26, and the NHA continued to work that day. Review of facility incidents failed to include the allegation of abuse/neglect that occurred to Resident R1 on 3/11/26. Review of information submitted to the State Agency on 3/11/26, and 3/12/26, failed to include Resident R1's incident of abuse/neglect. During an interview on 3/13/26, at 9:23 a.m. the Director of Nursing stated she was working on a cart on 3/11/26, when she was notified Resident R1 was screaming and wanting to speak with her. The DON stated the NHA was coming into the facility and asked him to see the resident. When asked how the facility was protecting Resident R1 from the alleged perpetrators, the DON indicated the NHA does not go down the hall where Resident R1 resides, that the NHA separates himself from the hall all together. The DON stated the NHA reached out to corporate. The DON stated, I knew about the verbal altercation, that's why we reached out to corporate, we were told not to call police by corporate. I know we had to do things, but corporations told us that is not what we do. The DON confirmed LPN, Employee E2 and the NHA continued to work in the facility and were not suspended. The DON confirmed the facility failed to timely report, investigate, notify the appropriate agencies, and protect residents from abuse/neglect from recurring for Resident R1. The DON stated I know what we had to do, corporation told me no. During an interview on 3/13/26, at 10:04 a.m. the Director of Nursing (DON) stated the NHA was just suspended, pending investigation. A total of two days, after the alleged abuse/neglect occurred to Resident R1. Review of Resident R1's letter dated 3/11/26, stated on Wednesday, 3/11/26, I am reporting 7:00 a.m. to 8:30 p.m. verbal and attempted physical abuse from the NHA and feel unsafe with him around. It was revealed that a HIPPA violation of personal information was being yelled at in the hall by the same person. There are multiple witnesses. The names of witnesses were not provided to protect against retaliation, the jobs, and safety. Will be reporting to police if something is not done for threats to safety and health. It was indicated LPN, Employee E2 on same day and time was giving middle finger behind curtain, basically telling me to f*ck myself and when called out about it she did it to my face, thinking it was joke. It was revealed RN, Employee E3 was made aware of the incident involving NHA and LPN, Employee E2 on 3/11/26. During a phone interview on 3/13/26, at 10:09 a.m. Registered Nurse, Employee E3 confirmed Resident R1 gave her a written concern on 3/11/26, regarding the abuse/neglect that took place. RN, Employee E3 stated I have it in my work bag. RN, Employee E3 stated When I came into work on Wednesday, I did hear other staff and the DON talking about this. RN, Employee E3 stated I wasn't sure who to give it to, didn't want to give it to NHA since it was against him. RN, Employee E3 stated I want to help out, I just don't know where to go with it. On 3/13/26, at 1:31 p.m., Interim NHA, Employee E12 and the DON were made aware of Immediate Jeopardy (IJ) related to implementation of the facility's abuse policy. The Interim NHA, Employee E12 was provided with the IJ Template, the facility failed to ensure all staff had a criminal background check prior working in the facility for one of seven staff members (Social Worker, Employee E1). The facility failed to identify incidents of abuse/neglect, and timely report and investigate allegations of abuse/neglect for one of six residents (Resident R1). The facility put other residents at risk for abuse/neglect from the Nursing Home Administrator and Licensed Practical Nurse, Employee E2, by allowing the staff members to continue to work after abuse/neglect occurred. A corrective action plan was requested. On 3/13/26, at 5:02 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action:-Root cause of this Immediate Jeopardy is that staff failed to follow facility abuse policy. -3/13/26, Resident R1 will be assessed for adverse outcomes related to abuse/neglect allegation from 3/11/26. Resident offered coping and trauma support by RN Supervisor or designee on 3/13/26. -Facility would ensure appropriate services are provided to residents if adverse outcomes occurred from abuse/neglect on 3/13/26 by Mobile DON or designee. -Assess all residents for abuse/neglect via assessment or interview on 3/13/26, by Mobile DON or designee for indications of fear, trauma or abuse/neglect. -Physician/POA if applicable will be notified of any adverse findings and medical record updated. Care plans will be reviewed and updated as appropriate by Mobile DON or designee by 3/13/26. -Facility would ensure appropriate services are provided to residents if adverse outcomes occurred from abuse/neglect. Will also be reported to appropriate agencies on 3/13/26, by Mobile DON or designee. -All residents will be assessed or interviewed on 3/13/26, by Mobile DON or designee, including head to toe skin assessments, and findings will be documented in residents' medical records. The attending physicians will be notified of any negative results. Facility would ensure appropriate services are provided to residents if adverse outcomes occurred from abuse/neglect. -Interview staff by Regional Director of Operation or designee by 3/16/26, for allegations of abuse/neglect that have not been reported in the last 30 days. 30 days of incidents will be reviewed by Mobile DON or designee by 3/16/26, to ensure no incidents occurred that went unreported. If incidents are noted that meet criteria, they will be immediately reported. -Review the Abuse/Neglect Policy and deemed appropriate and what to do if alleged perpetrator is DON or NHA, update if needed. Included in staff education will include corporate compliance number for staff to utilize should the DON/NHA be involved or feel uncomfortable reporting to facility leadership. -All house staff and will be re-educated by 3/16/26, Regional Director of Operations or designee on the abuse/neglect policy and will include corporate compliance number for staff to utilize should the DON/NHA be involved or feel uncomfortable reporting to facility leadership. -Regional Director of Operations or designee will educate HR or designee that criminal background checks are to be completed prior to hire. All staff HR files will be audited by HR or designee by 3/16/26, to ensure all background checks are present. Should a file be found without a criminal background check on 3/13/26, employee will not return to work until one is completed. -Audits will be conducted for 4 weeks starting 3/16/26, for HR files to ensure all criminal background checks are in existing employee files and all new hires will be audited to ensure a criminal background check is completed prior to start date. -Audits will be conducted starting 3/16/26, for resident's care needs to ensure no abuse or neglect is identified 3-5 residents 3x a week for 4 weeks. 5 days a week nursing documentation will be reviewed by Mobile DON or designee to ensure no incidents occurred that were unreported to administration. -Review all audits and policy changes related to immediate jeopardy at Ad Hoc QA meeting on 3/16/26. -Upon completion of audits, QAPI committee will review all findings. Resident R1 was assessed on 3/13/26. No adverse outcomes related to abuse/neglect allegation from 3/11/26 reported. Resident care plan was updated to offer emotional support and coping as needed. No adverse outcomes were noted for Resident R1. Resident R1 was offered emotional support and care plan was updated. 52/52 residents were assessed for abuse/neglect. 27/52 Residents with BIMS of 12 or higher were interviewed and reports of abuse/neglect were identified/ 25/52 Residents with BIMS of 11 or lower were assessed for indications of fear, trauma, or abuse/neglect. 0/52 Residents had no indication of abuse/neglect that has occurred. 0/52 Residents were identified with any adverse findings. No adverse outcomes noted from abuse/neglect. Facility reported Resident R1's abuse/neglect on 3/13/26 and notified the appropriate agencies such as police and Area on Agiing (AAA) on 3/13/26. No further abuse/neglect incidents were identified that required reporting. 58/68 Staff were interviewed for allegations of abuse and neglect that had not been reported in last 30 days. Staff failed to indicate any other abuse/neglect concerns other than the incident that occurred on 3/11/26, with resident R1. No new incidents were identified. Remaining 10/68 staff will be interviewed prior to start of next shift. Abuse policy was reviewed by Interim NHA, and revisions included the compliance hotline number to call if facility leadership is alleged perpetrators. 59/68 in-house staff were educated on abuse, reporting, and the compliance hotline number if leadership is involved in allegation. During in-person interviews conducted on 3/14/26, 17/17 staff members confirmed they were educated on abuse, reporting, and the compliance hotline number if leadership is involved in allegation. During phone interviews conducted on 3/14/26, from 10:40 a.m. to 11:09 a.m. 11/11 staff members confirmed they were educated on abuse, reporting, and the compliance hotline number if leadership is involved in allegation. Facility continues to educate staff via Carefeed, telephone, and in person prior to the start of their next shift. HR Director was educated on 3/13/26, that criminal background checks must be completed prior to the start date. Audit of 68/68 staff employee files revealed all background checks were completed. No further files were found without background checks. Starting 3/16/26, the HR Director will conduct weekly audits to ensure all criminal background checks are in existing employee files and all new hires are screened before starting date. Facility will conduct audits starting on Monday, 3/16/26, for resident care needs to ensure no neglect/abuse is identified 3-5 residents 3x a week for 4 weeks. 5 days a week nursing documentation will be reviewed by Mobile DON or designee to ensure no incidents occurred that were unreported to administration. Facility will review audits in monthly QAPI committee meeting. The Immediate Jeopardy was lifted on 3/14/26, at 12:13 p.m. when the action plan implementation was verified. During an interview on 3/14/26, at 1:37 p.m. the Director of Nursing and Interim NHA, Employee E12, confirmed the facility failed to ensure all staff had a criminal background check prior working in the facility for one of seven staff members (Social Worker, Employee E1). The facility failed to identify incidents of abuse/neglect, and timely report and investigate allegations of abuse/neglect for one of six residents (Resident R1). The facility put other residents at risk for abuse/neglect from the Nursing Home Administrator and Registered Nurse, Employee E2, by allowing the staff members to continue to work after abuse/neglect occurred. This failure created an immediate jeopardy situation. 28 Pa. Code 201.14(c) Responsibility of licensee.28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policy, clinical records, staff and resident interviews, it was determined that the facility failed to ensure that residents were free from mental and verbal abuse which caused a resident to experience severe psychosocial harm (embarrassment, humiliation) because of the abuse (Resident R1). This situation created an Immediate Jeopardy situation for one of six residents reviewed (Resident R1). Findings Include: Review of the facility provided policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property review date of 1/21/26, indicated This facility will not tolerate Abuse, Neglect, and Exploitation of its residents or the Misappropriation of Resident Property. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish. Abuse includes deprivation by an individual, including caretaker of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. It includes verbal abuse, physical abuse, and mental abuse. In the case of staff abuse, the facility will follow the procedure for discipling or dismissing an employee, depending upon the circumstances and results of the investigation. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE], with diagnoses of acquired absence of left leg above knee, acquired absence of right leg above knee, and opioid dependence. Review of Resident R1's Minimum Data Set (MDS - mandated assessment of a resident's abilities and care needs) dated 1/20/26, revealed the diagnoses were current. Section C- Cognitive Pattern Brief Interview for Mental Status (BIMS) revealed a score of 15, cognitively intact. Review of Resident R1's care plan dated 8/12/24, indicated to encourage verbalization of feelings and fears through active listening. Review of Resident R1's physician order dated 12/9/25, indicated to administer 10 mg, oxycodone HCl oral tablet, every four hours related to opioid dependence. It was indicated to administer at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8 p.m. During an interview on 3/13/26, at 8:45 a.m. Resident R1 stated on 3/11/26, he was requesting his pain medications and Licensed Practical Nurse (LPN), Employee E2 refused to give him his medication. It was indicated when LPN, Employee E2 told him she wouldn't help, he began yelling and screaming for help. The Nursing Home Administrator (NHA) threatened to have my a** kicked and to be physically harmed. Resident R1 stated the NHA came down and told me, I sound like an idiot, and if I had legs he would beat my a** right now. Resident R1 indicated the NHA was screaming out his medical history and the Director of Maintenance E4 had to pull and remove the NHA out of his room twice. Resident R1 stated he does not feel safe while the NHA is in the facility. The resident said there were multiple witnesses and he felt embarrassed and humiliated. Later, when LPN, Employee E2 entered the resident's room she flicked me off behind the curtain and when I confronted LPN, Employee E2, did it to my face, thinking it was a joke. Resident R1 stated he wrote a letter detailing the events and provided it RN Supervisor, Employee E3, the only person I trust. Resident R1 stated the facility did nothing and didn't investigate. During an interview on 3/13/26, at 8:48 a.m. Resident R3 confirmed she observed the altercation between the NHA and Resident R1. It was indicated the NHA physically threatened Resident R1. It was indicated the NHA mentioned his medical information and said he knows he's an addict. Resident R3 stated the Director of Maintenance, Employee E4 had to carry him away twice. Resident R3 stated it was by far the worst thing I witnessed, and I was a social worker. Review of Resident R3's MDS dated [DATE], Section C-Cognitive Pattern Brief Interview for Mental Status (BIMS) revealed a score of 15, cognitively intact. During an interview on 3/13/26, at 8:54 a.m. Resident R4 was asked if she witnessed an incident on the morning of 3/11/26. Resident R4 indicated she was eating breakfast in her room, with her tray in front of her when she heard yelling and screaming. Resident R4 indicated the yelling lasted for about 20 minutes. During an interview on 3/13/26, at 8:55 a.m. Resident R13 was asked if he witnessed an incident on the morning of 3/11/26. Resident R13 stated he was in his room eating breakfast at the time and he heard commotion and yelling. It was indicated the yelling went on for about 20 minutes. Resident R13 stated, It was a bit ridiculous, sounded like someone was fighting the way they were exchanging words. During an interview on 3/13/26, at 8:57 a.m. Certified Occupation Therapy Assistant, Employee E5 stated he entered the facility five minutes after the incident took place. COTA, Employee E5 stated I mean it's unbelievable, especially with it being the NHA, he's supposed to set the tone. COTA Employee E5 stated the NHA continued to work the remainder of the day on 3/11/26. It was indicated the NHA is intimidating and he was aggressive with an ombudsman that came in. COTA, Employee E5 stated He has a short fuse, shouldn't be in that role. During an interview on 3/13/26, at 9:15 a.m. the Director of Maintenance, Employee E4 confirmed he had to remove the NHA out of the resident's room to deescalate the situation. During an interview on 3/13/26, at 9:23 a.m. the Director of Nursing (DON) stated she was working on a cart on 3/11/26, when she was notified Resident R1 was screaming and wanting to speak with her. The DON stated the NHA was coming in to the facility and asked him to see the resident. The DON confirmed the facility failed to protect Resident R1 from verbal abuse, which caused a resident to experienced severe psychosocial harm (embarrassment, humiliation) because of the verbal abuse. During an interview on 3/13/26, at 9:37 a.m. LPN, Employee E2 indicated on 3/11/26, Resident R1 started screaming for his medications and she notified him his pain medication was scheduled every four hours. The resident kept screaming, and LPN, Employee E2 said I never even stepped foot into room. LPN, Employee E2 stated she told Resident R1 your pain administration is every four hours, I can take an hour before or after. LPN, Employee E2 stated he kept screaming, and I simply told him, the ball is in your court so if you want to keep screaming, I don't have to come in. LPN, Employee E2 indicated she told the resident until you calm down, I am not coming in. LPN, Employee E2 stated I went outside to cool down, I was shaky, I went outside to smoke a cigarette. It was indicated the NHA came into the facility, and she notified him of the situation, and stated she told him I am not entering room until he calms down. It was indicated you could hear Resident R1 screaming, having behaviors, and cursing. LPN, Employee E2 indicated she was trying to tell Resident R1 people were still sleeping. LPN, Employee E2 stated she gathered info about pain medication, then continued with med pass. It was indicated the NHA knocked on door frame and opened Resident R1's door a little more to try to converse with him, and Resident R1 started screaming. LPN, Employee E2 was asked what was witnessed, and stated I put my headphone in and was listening to one of my podcasts, zoning it all out. It was indicated the NHA and Resident R1 were screaming, the NHA was telling him he needed to calm down, and the Director of Maintenance arrived and stuck around. LPN, Employee E2 indicated she entered Resident R1's room to try to get him to calm down. LPN, Employee E2 stated I said, listen I am preparing your meds, so we are done with the situation, it's not late one hour before one hour after. It was indicated Resident R1 apologized. LPN, Employee E2 stated I said regardless, you don't talk to human beings like that. When asked how long the interaction with the NHA and Resident R1 went on for, LPN, Employee E2 responded, It felt like an eternity, maybe 10-15 minutes. LPN, Employee E2 was asked if she gave Resident R1 the middle finger on 3/11/26 and responded, I may have. Review of Resident R1's letter on 3/13/26, dated 3/11/26, stated on Wednesday, 3/11/26, I am reporting 7:00 a.m. to 8:30 p.m. verbal and attempted physical abuse from the NHA and feel unsafe with him around. It was revealed that a HIPPA violation of personal information was being yelled at in the hall by the same person. There are multiple witnesses. The names of witnesses were not provided to protect against retaliation, the jobs, and safety. Will be reporting to police if something is not done for threats on safety and health. It was indicated LPN, Employee E2 on same day and time was giving middle finger behind curtain, basically telling me to f**ck myself and when called out about it she did it to my face, thinking it was joke. Will be reporting to police if something is not done for threats on safety and health. During a phone interview on 3/13/26, at 10:09 a.m. Registered Nurse (RN), Employee E3 confirmed Resident R1 gave her a written concern on 3/11/26, regarding the abuse/neglect that took place. RN, Employee E3 said I have it in my work bag. Here is what he said, and I did hear it from several other employees that worked that day. It was indicated the only time the resident acts out is if he is not getting his medications on time, everyone knows he likes to get meds on time, very particular. RN, Employee E3 stated I really like Resident R1, he likes to joke, he has a funny personality. RN, Employee E3 stated From what I heard, it was pretty bad. On 3/13/26, at 1:31 p.m., Interim NHA, Employee E12 and the DON were made aware of Immediate Jeopardy (IJ) related to the facility, which failed to ensure that residents were free from mental and verbal abuse which caused a resident to experienced severe psychosocial harm (embarrassment, humiliation) because of the abuse (Resident R1). This situation created an Immediate Jeopardy situation for one of six residents reviewed (Resident R1). On 3/13/26, at 5:02 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action:-Root cause of this Immediate Jeopardy is that staff failed to follow facility abuse policy. -3/13/26, Resident R1 will be assessed for adverse outcomes related to abuse/neglect allegation from 3/11/26. Resident offered coping and trauma support by RN Supervisor or designee on 3/13/26. -Facility would ensure appropriate services are provided to residents if adverse outcomes occurred from abuse/neglect on 3/13/26 by Mobile DON or designee. -Assess all residents for abuse/neglect via assessment or interview on 3/13/26, by Mobile DON or designee for indications of fear, trauma or abuse/neglect. -Physician/POA if applicable will be notified of any adverse findings and medical record updated. -Care plans will be reviewed and updated as appropriate by Mobile DON or designee by 3/13/26. -Facility would ensure appropriate services are provided to residents if adverse outcomes occurred from abuse/neglect. Will also be reported to appropriate agencies on 3/13/26, by Mobile DON or designee. -All residents will be assessed or interviewed on 3/13/26, by Mobile DON or designee, including head to toe skin assessments, and findings will be documented in residents' medical records. The attending physicians will be notified of any negative results. Facility would ensure appropriate services are provided to residents if adverse outcomes occurred from abuse/neglect. -Interview staff by Regional Director of Operation or designee by 3/16/26, for allegations of abuse/neglect that have not been reported in the last 30 days. 30 days of incidents will be reviewed by Mobile DON or designee by 3/16/26, to ensure no incidents occurred that went unreported. If incidents are noted that meet criteria, they will be immediately reported. -Review the Abuse/Neglect Policy and deemed appropriate and what to do if alleged perpetrator is DON or NHA, update if needed. Included in staff education will include corporate compliance number for staff to utilize should the DON/NHA be involved or feel uncomfortable reporting to facility leadership. -All house staff and will be re-educated by 3/16/26, Regional Director of Operations or designee on the abuse/neglect policy and will include corporate compliance number for staff to utilize should the DON/NHA be involved or feel uncomfortable reporting to facility leadership. -Audits will be conducted starting 3/16/26, for resident's care needs to ensure no abuse or neglect is identified 3-5 residents 3x a week for 4 weeks. 5 days a week nursing documentation will be reviewed by Mobile DON or designee to ensure no incidents occurred that were unreported to administration. -Review all audits and policy changes related to immediate jeopardy at Ad Hoc QA meeting on 3/16/26. -Upon completion of audits, QAPI committee will review all findings. Resident R1 was assessed on 3/13/26. No adverse outcomes related to abuse/neglect allegation from 3/11/26 reported. Resident care plan was updated to offer emotional support and coping as needed. No adverse outcomes were noted for Resident R1. Resident R1 was offered emotional support and care plan was updated. 52/52 residents were assessed for abuse/neglect. 27/52 Residents with BIMS of 12 or higher were interviewed and reports of abuse/neglect were identified. 25/52 Residents with BIMS of 11 or lower were assessed for indications of fear, trauma, or abuse/neglect. 0/52 Residents had no indication of abuse/neglect that has occurred. 0/52 Residents were identified with any adverse findings. Resident R1's care plan was reviewed and updated on 3/13/26, to include interventions of offering coping and support as needed when resident is dealing with difficult situations. No adverse outcomes noted from abuse/neglect. Facility reported Resident R1's abuse/neglect on 3/13/26, and notified the appropriate agencies such as police and AAA on 3/13/26. 0/52 Residents had no indication of abuse/neglect that has occurred, no other reports were indicated. 58/68 Staff were interviewed for allegations of abuse and neglect that had not been reported in last 30 days. Staff failed to indicate any other abuse/neglect concerns other than the incident that occurred on 3/11/26, with resident R1. No new incidents were identified. Remaining 10/68 staff will be interviewed prior to start of next shift.Abuse policy was reviewed by Interim NHA, and revisions included the compliance hotline number to call if facility leadership is alleged perpetrators. 59/68 in-house staff were educated on abuse, reporting, and the compliance hotline number if leadership is involved in allegation. During in-person interviews conducted on 3/14/26, 17/17 staff members confirmed they were educated on abuse, reporting, and the compliance hotline number if leadership is involved in allegation. During phone interviews conducted on 3/14/26, from 10:40 a.m. to 11:09 a.m. 11/11 staff members confirmed they were educated on abuse, reporting, and the compliance hotline number if leadership is involved in allegation. Facility continues to educate staff via Carefeed, telephone, and in person prior to the start of their next shift. Facility will conduct audits starting on Monday, 3/16/26, for resident's care needs to ensure no abuse or neglect is identified 3-5 residents 3x a week for 4 weeks. 5 days a week nursing documentation will be reviewed by Mobile DON or designee to ensure no incidents occurred that were unreported to administration for resident care needs to ensure no neglect/abuse is identified. Facility will review audits and policy changes at Ad Hoc QA meeting that will be conducted on Monday, 3/16/26, inclusive of all IDT people and staff. Upon completion of all audits, the facility will review audits in monthly QAPI committee meeting. The Immediate Jeopardy was lifted on 3/14/26, at 12:13 p.m. when the action plan implementation was verified. During an interview on 3/14/26, at 1:37 p.m. the Director of Nursing and Interim NHA, Employee E12, confirmed the facility failed to ensure that residents were free from mental and verbal abuse which caused a resident to experience severe psychosocial harm (embarrassment, humiliation) because of the abuse (Resident R1). This situation created an Immediate Jeopardy situation for one of six residents reviewed (Resident R1). 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(d)(1)(3)(e)(1) Management.

Based on review of facility policy, facility provided documents, clinical records, and staff interviews, it was determined the facility failed to ensure a resident was free from mental abuse and intimidation for one of two residents reviewed (Resident R1), which resulted in psychosocial harm and mental anguish related to the reasonable person concept. Findings include: Review of facility's policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 2/19/25, revealed the facility will not tolerate abuse, neglect, and exploitation of its residents. The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, pain or mental anguish. This includes verbal abuse. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2025, indicated that a Brief Interview for Mental Status (BIMS), is a screening test that aids in detecting cognitive impairment). The BIMS total score suggests the following distributions:13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Quarterly MDS (Minimum Data Set, periodic assessment of resident care needs) dated 4/22/25, indicated diagnoses of high blood pressure, Dementia (group of symptoms that affects memory, thinking and interferes with daily life), and Anxiety (feeling of worry, nervousness, or unease). Further review of the MDS assessment revealed question C0500BIMS Summary Score revealed Resident R1's score to be 10, indicative of moderate cognitive impairment. Review of Resident R1's clinical record revealed that a Power of Attorney (giving authority to another person to act in all legal or financial matters on another person's behalf) Form was uploaded into the electronic health record on 3/6/24, and identified Resident R1's son as his/her Power of Attorney (POA). Review of facility [NAME] Statements revealed an invoice was sent to Resident R1 on 5/1/25, with a balance due of $26,827.00, with a duplicate invoice sent to Resident R1's POA on the same date. Further review of facility billing statements revealed additional invoices dated 6/1/25, 7/1/25, and 8/1/25, were also sent with the same outstanding balance. Two copies were sent on each date, one to Resident R1 and the other copy to the resident's POA. Review of written statement dated 6/27/25, revealed a Meeting was held with Assistant Nursing Home Administrator (ANHA) about the approach with Resident R1 on 6/26/25. It was reiterated residents should be pulled into room or private area to discuss personal matters. ANHA did explain she understood she should have pulled resident into the room but the sheriff was adamant and she was nervous in the situation/moment. ANHA was given the customer service policy and educated on proper customer service with residents. Review of employee file revealed that the Assistant Nursing Home Administrator was promoted to Nursing Home Administrator (NHA) on 9/4/25 and will hence forth be identified as NHA. Review of resident representative concern from Former Activities Director Employee E4 dated 10/12/25, revealed the following: On 6/26/25, I personally witnessed NHA accompanied by a sheriff's deputy, verbally and psychologically abusing Resident R1, in the middle of a public hallway. NHA repeatedly told the resident at least seven times that she owed the facility $26,000, stating, 'We issue 30-day notices like candy around here to people who owe money.' The resident was visibly distraught, crying, and repeatedly stated [he/she] did not understand why [he/she] was being held or what the debt referred to. During an interview on 11/12/25, at 9:56 a.m. Resident R1 was unable to verbalize any recounting of the event or of her feelings regarding said event. As resident has a diagnosis of dementia, and a BIMS score of 10, and there was a void of expression of feelings regarding the event, a reasonable person concept was applied to demonstrate the reaction that a reasonable person in the resident's position would have to the same event. During an interview on 11/12/25, at 10:45 a.m. Resident R1's family member stated that the facility had been sending letters to the POA that $26,000 was owed to the facility, and that the POA had paid the bill in full sometime in August 2025. During an interview on 11/12/25, at 11:47 a.m. Employee E1 stated that she was present in the hallway when the above incident occurred. Employee E1 revealed she was concerned about the location this occurred since it was in a public space and the matter appeared to be private in nature. Resident R1 was asked to sign paperwork, and resident appeared confused, and was asking questions. Someone from law enforcement in uniform was there and resident didn't appear to understand, and [he/she] became tearful, I thought it was questionable that resident could have signed [his/her] own papers given [his/her] mental status. Employee E1 stated it was the NHA who confronted Resident R1. During an interview on 11/12/25, at 1:54 p.m. the NHA stated the local sheriff had come in on the day in question with papers. NHA explained Resident R1 had to spend down $26,000 to qualify for Medicaid, and the family wasn't compliant with paying [his/her] bills, therefore the sheriff was serving [him/her] papers for the unpaid balance. The sheriff had come in and asked to be taken to Resident R1's room, and at the time Resident R1 was listed in the medical chart as her own responsible party. The NHA confirmed Resident R1 does have a POA who is authorized to handle resident's bills. During an interview on 11/12/25, at 1:56 p.m. the Former Nursing Home Administrator (FNHA) Employee E2 was asked to provide information that may have been compiled during the investigation of the above incident, and FNHA Employee E2 revealed, I don't think we did an investigation. During an interview on 11/12/25, at 1:57 p.m. The NHA confirmed the facility failed to protect Resident R1 from mental/emotional abuse during the altercation, and this should have been handled with the resident's POA. During an interview via telephone on 11/12/25, at 2:32 p.m. former Director of Nursing, Employee E3 stated that she had not been a witness to the above altercation but was aware of the situation as some employees had voiced their concern over how it happened. Employee E3 revealed she asked employees To fill out a statement if they felt it was abuse to give me the facts. But I got zero statements. During an interview via telephone on 11/12/25, at 3:01 p.m. former Activities Director (AD)Employee E4 stated that he was present in the hallway during the above incident and confirmed the sheriff, the NHA, and Resident R1 were all in the hallway during the conversation. Employee E4 described Resident R1 to be confused and tearful during the altercation. AD Employee E4 stated he filled out a written statement regarding the incident as he felt it to be emotional/mental abuse and slid it underneath Former Director of Nursing Employee E3's door the day of the event. He stated that he was later told by FNHA Employee E2 that the incident would not be considered abuse, and it was implied that if he liked his job he should shut up. During an interview on 11/12/25, at 3:15 p.m., FNHA Employee E2 stated that she spoke to four employees who witnessed the incident and asked them if they felt the incident could be considered abuse and they all said no. FNHA Employee E2 now stated that there is an investigation file, but that it cannot be located at this time but will continue to look for it. During an interview via telephone on 11/12/25, at 4:04 p.m. former Social Worker, Employee E5 confirmed she was a witness to the incident, and it took place in the hallway. She stated Resident R1 had a POA, and that he should have been the one involved and not Resident R1 as [he/she] has dementia. Employee E5 stated the information regarding Resident R1's POA was definitely in the chart. Employee E5 stated that she filed out a witness statement with the details of the event and put it underneath (former Director of Nursing) Employee E3's door the day of the incident. Employee E5 stated the resident was tearful during the incident, and when she saw resident less than an hour later [he/she] was still tearful. Employee E5 stated she had never seen a sheriff come into a facility to handle bills before, and that Resident R1 would absolutely feel intimidated with the sheriff being there. Employee E5 added that about a week after the incident the (former NHA) Employee E2 came into morning meeting and closed the door and told her that she was disappointed with how the witnesses worked together and they accused the NHA of abuse, and If we didn't like it, we could leave. During an interview on11/12/25, at 4:53 p.m. (former NHA) Employee E2 confirmed the investigation file regarding the incident could not be located. During an interview on 11/12/25, at 4:54 p.m. with the NHA, State Agency (SA) read the statement from the above written statement dated 6/27/25, in which the NHA explained that she was nervous in the situation/moment. The NHA confirmed that she was nervous during the altercation. SA asked that if she (NHA) was nervous at the time as a reasonable person, how would she think Resident R1 felt? NHA confirmed that this would also indeed make Resident R1 feel nervous. During an interview on 11/13/25, at 1:02 p.m. Nurse Aide (NA) Employee E6 stated that he is familiar with Resident R1 and would not think [he/she] would be able to pay [his/her] own bills as [he/she] can be confused. NA Employee E6 was not present for the incident, but when he was informed the sheriff came into the building to discuss non-payment of bills, he replied They should have stopped 'em at the door. That makes me vomit. During an interview on 11/13/25, at 1:14 p.m. Employee E1 provided a copy of the written statement that she had provided to Former Nursing Home Administrator Employee E2 right after the incident had occurred. Review of this written statement dated 6/26/25, indicated the following: A discussion was overheard in the hallway that included the resident (Resident R1), a sheriff, and the NHA. The conversation was loud enough for me to hear during a meeting down the hall. Other residents were present in the hallway and listening/observing. I only heard parts of the conversation, which were 'you're not in trouble,' and 'this is a long time coming,' and 'this is what happens to people like you who don't want to pay.' Following the interaction, resident was tearful, but able to be redirected. During an interview on 11/13/2025, at 1:30 p.m. NA Employee E7 stated that she is also familiar with Resident R1 and did not witness the incident but when she was told of the occurrence, NA Employee E7 replied That's humiliating. If that happened to me, I wouldn't want to stay here. During an interview on 11/13/25, at 3:26 p.m. the NHA was asked how the sheriff's office became involved in the bill collection process and after conferring with colleagues for information on the process, stated that the Corporate office sent the account to 'collections', which then gets sent to the sheriff's office, and they (corporate) don't communicate with us to give us a heads up. During an interview on 11/13/25, at 3:50 p.m. the NHA confirmed that the facility failed to protect Resident R1 from mental abuse and intimidation. During an interview on 11/14/25, at 8:37 a.m. a Sheriff's Office Representative stated that for the above incident to occur, The facility would have to file paperwork with an attorney at the County Prothonotary Office to file a civil lawsuit. This is then forwarded to the Sheriff's Office with instructions including the person's name and where to find them. This is done with payment of a fee. When SA told the Sheriff Office Representative that the above resident had dementia and had a POA, the representative replied, We would not expect to go in and deal with a person with dementia, and would have served the POA if we were provided with that information. 28 Pa. Code 201.14(b) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(2)(3) Management.28 Pa. Code 211.10(a) Resident care policies.

Based on review of facility policy and records, and staff interviews, it was determined that the facility failed to prevent avoidable pressure sore development that resulted in actual harm (stage three pressure sore) for one of four residents reviewed (Resident R1). This was identified as harm for past non-compliance for one resident (Resident R1). Findings include: A review of the facility policy Pressure Ulcer Prevention and Management Program, updated 5/4/21, indicated the facility is committed to providing a comprehensive pressure ulcer prevention and management program to ensure that residents admitted to the facility without pressure ulcers do not develop them unless the individual ' s clinical condition demonstrates they are unavoidable. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggest the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment Review of Resident R1's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R1's MDS dated [DATE], included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Section C: Cognitive Patterns indicated that Resident R1's BIMS score was unable to be assessed due to Resident R1 being rarely/never understood. Review of the Braden Scale for Predicting Pressure Sore dated 11/17/21, indicated that Resident R1 was at moderate risk of pressure sore development. Review of the plan of care updated 1/3/22, indicarted that Resident R1 was at risk for skin impairment related to fragile skin. Review of a physician's progress note dated 12/27/21, at 4:28 p.m. indicated that Resident R1 had fractures in both the medial and lateral malleolus (inner and outer ankle bones). The note further indicated that the family agreed to pain control and an ankle brace. Review of a physician's order dated 1/14/22, at 6:41 a.m. indicated that Resident R1 is to wear a left ankle brace with a tubular dressing at all times, to be removed one time in the morning and one time in the evening for hygiene and skin checks. Review of a nursing note dated 1/24/22, indicated that Resident R1 had a newly acquired wound to her left outer ankle. The wound was documented as a Stage 4 (Full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bone, or supporting structure) with dimensions of 1.9cm x 2.2cm x 0.4cm. The note further indicated that a referral was sent to the therapy department to reevaluate her brace, with Resident R1 to see the wound nurse practitioner. Review of a physician's order dated 1/24/22, indicated for Resident R1 to wear tubular dressing to the left lower leg, removed each shift to check for skin integrity. Review of a skin/wound note dated 1/24/22, at 8:45 p.m. indicated that Resident R1 had an acute Stage 3 (full-thickness skin loss potentially extending into the subcutaneous tissue layer) pressure sore. Review of the Treatment Administration Record (TAR) indicated that prior to the discovery of the newly acquired pressure sore, Licensed Practical Nurse (LPN) Employee E1 was documented as completing the dressing removal and skin checks for morning and evening shift on 1/22/22, morning shift on 1/23/22, and morning shift on 1/24/22. Review of a dietary note on 1/30/22 indicated the recommendation of additional liquid protein for 45 days for healing. During an interview on 2/7/22, at 2:05 p.m. LPN Employee E1 was asked how, if she had removed Resident R1's dressing and performed a skin check, the pressure sore was not noted, even on the day of discovery. LPN Employee E1 stated that she had not completely removed the dressing as ordered, had only lifted it up, out of concern for stability of the ankle. LPN Employee E1 confirmed that the wound occurred in an area that she had not visualized, due to not completely removing the wound dressing, and not having a second staff member assist to immobilize the ankle to allow for full visualization. During an interview on 2/7/22, at 2:25 p.m. the Interim Director of Nursing confirmed that the facility failed to prevent avoidable pressure sore development that resulted in actual harm of a stage three pressure sore for one of four residents. On 1/24/22, the facility initiated education for all direct care nursing staff including Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Nurse Aides (NAs) to ensure that skin issue and skin observation protocols, appropriate notifications, and new skin incident procedures were followed. Nurses were educated regarding thorough skin inspections again at the next all staff meeting to ensure education was understood and retained. This plan included the following: -Facility completed a full head to toe skin assessment of all residents of the facility, no additional findings were noted with like residents. -Facility audited results of the skin assessments for all residents, proactive interventions implemented for residents deemed to be at risk. -Residents records reviewed, modifications added if needed to plan of care related to interventions. -Dietician to review records of all residents with wounds to determine need to add additional dietary interventions. -List of residents determined at risk will be generated and reviewed with IDT team. -All facility nurses educated regarding skin protocol, appropriate notifications, facility skin observation protocols as well as education regarding thorough skin inspections and measures to take if a thorough skin inspection can not be completed. -All direct care staff will be educated regarding new skin issue protocol, appropriate notifications, facility skin observation protocols and new skin incident procedures again at the next all staff meeting to ensure education was understood and retained. -Nurses will be educated regarding thorough skin inspections again at the next all staff meeting to ensure education was understood and retained. -Skin checks will be completed and body inspections will be completed per schedule -All residents determined at risk on admission or readmission will have standing proactive interventions implemented as needed. -All residents admitting or readmitting with splint devices will be reviewed to ensure proper orders. -List of residents determined at risk will be generated and IDT (interdisciplinary team) will view weekly at the facility risk meeting. -All appropriate IDT members will review POC upon admission or readmission. -Upon admission all residents will have proactive interventions added if applicable -Three residents will be audited three times a week for skin observations, appropriate treatments in place if resident has a current skin issue, and proper documentation upon discovery. -All residents with splints will be audited 3 times a week for continued proper documentation. -Three direct care employees will be interviewed per week regarding the education received. -QA nurse will review weekly wound report, and all skin incidents upon occurrence to validate interventions were in place at time of occurrence and plan of care was followed. -All audits will continue for one month and periodically [NAME] as deemed necessary. The facility has demonstrated compliance with the regulation since 1/24/22. During an interview on 2/16/22, at 12:07 p.m. with the DON and ADON, and review of the facility's immediate actions, education, and review of the QAPI monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction and achieved compliance ensuring the prevention of avoidable pressure sore development. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited: 6/26/20, 12/21/20, 10/18/21 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited: 6/26/20, 12/21/20, 8/24/21, 10/18/21 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited: 8/24/21, 10/18/21 28 Pa. Code 211.11(a) Resident care plan. Previously cited: 8/24/21 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited: 12/21/20, 8/24/21, 10/18/21

Based on review of facility policies, clinical records, incident reports, and staff interview, it was determined that the facility failed to provide adequate assistance during a transfer, resulting in actual harm (laceration [cut] to right hand between thumb and second finger) for one of three residents (Resident R35). Findings include: The facility Fall Risks and Prevention Guideline policy last reviewed 5/4/21, indicated the facility, through resident assessment, fall risk assessment and implementation of appropriate intervention, will provide a medical and environmentally safe home for the resident thus ensuring his/her optimum physical, mental, and psychosocial well-being. Review of the medical record indicated Resident R35 was admitted to the facility on [DATE], with diagnoses that included left knee pain, high blood pressure, and a history of falls. Review of the Quarterly Minimum Data Set assessment (MDS- periodic assessment of care needs) dated 4/20/21, Section G, Question G0110: Activities of Daily Living (ADL) Assistance indicated Resident R35 required two plus persons for physical assistance for transfers. Review of the physician orders dated 4/22/19, indicated Resident R35 was to be a transfer with mechanical Spryte lift (a transport assist unit that requires and encourages strength and stability from the patient) and assist of 2 staff. Review of the care plan dated 4/20/21, indicated Resident R35's assistance level was as follows; transfer with mechanical Spryte lift and assist of 1-2; toilet use required 2 staff assistance; transfer required 2 staff; and bed mobility required 2 staff. Review of a fall risk observation tool (a nursing assessment for residents' risk of falling) dated 4/20/21, indicated Resident R35 was at high risk for falling. Review of the progress note dated 7/5/21, at 5:26 p.m., revealed Resident R35 fell while being transferred by Nurse Aide (NA) Employee E13 from the wheelchair to the bed, lost balance, fell and sustained a laceration (cut) to right hand between the thumb and index finger that measured 2.0 cm (centimeters) by 5.5 cm by 0.3 cm that had a moderate amount of bleeding. Review of a physician order dated 7/6/21, revealed the laceration to right hand required daily cleansing and dressing changes over steri-strips (thin adhesive bandages can use them to help close shallow cuts or wounds can use them to help close shallow cuts or wounds). Review of an investigative interview and written statement with NA Employee E13 dated 7/5/21, obtained by the facility during their investigation revealed NA Employee E13 did not use the mechanical Spryte lift or ask additional staff for assistance, NA Employee E13 stated that was his fault he didn't have the assignment sheet with him because he left it on the cart in the hallway and the written statement indicated he was transferring Resident R35 from her chair to the bed when Resident R35 lost balance resulting in NA Employee E13 lowering her to the ground. He stated that he did not have an assignment sheet that stated the Resident R35's transfer status. During an interview on 8/23/21, at 4:30 p.m. with the Assistant Director of Nursing Employee E1 revealed the Nurse Aide assessment sheets were available at the nurses station for all nurse aides at the start of the shift. During an interview on 8/24/21, at 9:45 a.m. with the Assistant Director of Nursing Employee E1 confirmed the facility failed to provide adequate staff assistance during a transfer resulting in actual harm to Resident R35. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (e)(1) Management. 28 Pa Code: 211.10 (c)(d) Resident care policies. 28 Pa Code: 211.11 Resident care plan.

Based on review of observations, facility policies, documentation, and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program by failing to follow infection control guidelines from the Centers for Disease Control (CDC) and the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections and prevent cross-contamination during the COVID-19 pandemic. This failure placed the facility in an Immediate Jeopardy situation for four of eight residents reviewed (Residents R2, R4, R6 and R8). Findings include: Pennsylvania Health Alert Network (PA-HAN) - 530, regarding Long-Term Care Facility Guidance for Testing and Cohorting (for outbreaks and exposure to COVID-19 - a contagious [MEDICAL CONDITION] disease that can cause a variety of symptoms, including breathing problems, fever and cough), dated October 7, 2020, indicated that residents needed to be cohorted to separate units in three zones, based on test results: - COVID-19 positive residents (Red Zone) were residents with a positive test and still within the parameters for transmission-based precautions. - Potentially exposed residents (Yellow Zone) were residents with a negative COVID-19 test who remained asymptomatic but were within 14 days of possible exposure to COVID-19. - Unexposed (Green Zone) were any residents in the facility who were not tested and were thought to be unexposed to COVID-19. - Zones were to be clearly marked with limited access signs or temporary barriers to prevent unnecessary foot traffic to the area Review of Centers for Disease Control (CDC - a national public health agency) guidance Responding to Coronavirus (COVID-19) in Nursing Homes, dated 4/30/20, indicated that residents of nursing homes who have a confirmed COVID-19 infection, regardless of symptoms, should be transferred to a designated COVID-19 care unit. Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for COVID-19 fourteen days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). Exposed residents may be permitted to room share with other exposed residents, if space is not available for them to remain in a single room. Review of the facility policy COVID-19 Separation Quarantine Zones dated 5/4/20, indicated the facility will establish a Separation- Quarantine Zone for increased separation for residents suspected of, presumed to be or have tested positive COVID-19. Types of Units Red Contains residents with confirmed COVID-19. Yellow Contains residents that have been exposed by confirmed positive staff, co-residents, other source or high probability of exposure. Green contains residents that have not had a confirmed or suspected exposure as well as any residents that are recovered On entrance to the facility on [DATE] at 9:18 a.m. the Director of Nursing (DON) confirmed the facility census was 54 residents and all residents were being housed in a facility wide red zone. A facility line listing of residents and staff that are positive for COVID-19 was requested. The DON confirmed the facility failed to maintain an updated line listing of residents and staff. A request for facility floor plan that included documentation on which residents were COVID-19 positive indicated the facility was maintaining all residents in a facility wide red zone and failed to separate residents into quarantine zones. A review of the requested facility line listing for residents and staff that revealed it was not up to date. Information in the first four pages was a not up to date line listing and attached paperwork revealed stationary with a calendar including an advertisement for a funeral home and a pet cremation service, which contained hand written notes including keeping residents in their rooms and pulling curtains between residents. 14 pages of single and double sided papers with resident names and room numbers indicating some had signs and symptoms of illness. Then three more attached additional pages of hand written notes on tracking of employees. Review of daily census information indicated that Resident R1, and R2 in the same room Review of the facility red zone floor plan indicated Resident R1 was positive for COVID-19 on 12/18/20, and R2 was negative for COVID-19. Review of daily census information indicated that Resident R3 and R4 in the same room Review of the red zone facility floor plan indicated Resident R3 was positive for COVID-19 on 12/18/20, and R4 was negative for COVID-19. Review of daily census information indicated that Resident R5 and R6 reside in the same room Review of the red zone facility floor plan indicated Resident R5 was positive for COVID-19 on 12/18/20, and R6 was negative for COVID-19. Review of daily census information indicated that Resident R7 and R8 reside in the same room Review of the red zone facility floor plan indicated Resident R7 was tested for the presence of Covid-19 on 12/8/20, and R6 was negative for COVID-19. During an interview on 12/18/20, at 10:22 a.m. and 11:30 a.m. the Director of Nursing confirmed that the Residents R1, R3, R5 and R7 are positive for Covid19 and are residing in rooms with Residents that are negative for COVID-19. That residents 2, 4, 6 and 8 are currently negative for COVID-19 and are residing in rooms with positive residents. That the furnished red zone layout indicated Resident R7 was tested for COVID-19 on 12/8/20, and is currently positive and the provided layout did not indicate the day of their positive results. That the laboratory results from 12/8/20, were delayed and the facility is not doing onsite Point of Care (POC- on site facility testing for residents to determine if a resident has COVID-19). During an observation of the facility wide red zone on 12/18/20 at 10:58 a.m. the entrance to the residents hallways had a barrier and all 54 residents were housed behind the barrier in the two facility hallways in a facility wide red zone. During an interview on 12/18/20, at 6:00 p.m. the Director of Nursing and Infection Control Registered Nurse reviewed the incomplete line listing provided at entrance. Were provided a Center for Medicare and Medicaid directive dated 8/26/20, then instructed to complete a facility line list as directed on page 9 under the Documentation of Testing requirements. During an interview on 12/18/20, at 6:53 p.m. the Director of Nursing confirmed the facility currently had 24 residents tested positive for COVID-19. The DON and Infection Control Registered Nurse were made aware that Immediate Jeopardy existed for four of eight residents in the facility on 12/18/20, at 8:40 p.m. and a corrective action plan was requested. On 12/19/20, at 12:45 a.m. an acceptable Corrective Action Plan was approved which included the following interventions: 1. The Director of Nursing and RN Supervisors were re-educated on PA HAN 530 related to cohorting of confirmed positive residents, patients under investigation or exposed, and negative residents. 2. The Director of Nursing will establish a red zone that contains COVID-19 positive residents, a yellow zone that contains patients under investigation or residents with a known COVID-19 exposure, and a green zone for residents with a negative residents within the facility to be separated by temporary walls, and with separate Personal Protective Equipment (PPE) at the entrance of each zone. 3. These zones will be identified by signage noting the zone color at the entrance and inside each zone. 4. RNs, LPNs, Housekeeping staff and Aides will be educated prior to their next shift on zone definitions, which residents will occupy zones, transmission based precautions, and proper donning and doffing of PPE at the entrance of each zone. 5. Residents that have been COVID-19 negative, but exposed to COVID-19 positive residents will be tested using Point of Care [MEDICATION NAME] testing tests to determine at this time if they are COVID-19 positive or exposed, and placed in the correct zone of the facility beginning on 12/18/20. 6. Residents zone may be de-escalated as follows and consistent with PA HAN 517 Discontinuation of Transmission Based Precautions following the symptom based strategy - Red zones residents may deescalate to green zone residents if and when all non-severely immunocompromised residents are asymptomatic for 10 days post infection date and when severely immunocompromised residents are asymptomatic for 20 days past initial date of laboratory testing. 7. Temporary wall will be constructed at the border of each zone as noted in the attached floor plan with update resident room assignments as the following room changes will be made 12/19/20: Red Zone will include rooms 34-49, Yellow Zone will include rooms 30-33 on the D hall and rooms 13-27 on the C hall, Green zone will include rooms 9-12. 8. Employees will be assigned to each unit as staffing allows by department. When possible, a staff member will be dedicated to a zone. If a staff member must cross a zone into a different zone, they will change PPE and leave contaminated PPE in the yellow zones for disposal or reuse during the crisis capacity conservation strategy. 9. Housekeeping will don different PPD by zone and clean all assigned rooms in one zone before doffing PPE, donning different PPE, and clean the next zone until all zones have been cleaned as assigned. 10. Crisis capacity staffing strategies are enacted, the facility will operate consistent with the CDC ' s guidance and have COVID-19 negative employees working with COVID-19 negative residents. COVID-19 positive employees working with COVID-19 positive residents, and only cross staff form the green zone, or yellow zone into the red zone when absolutely necessary and only after hand hygiene has been performed and different PPE is donned prior to re-entering the yellow or green zone. 11. Education of all staff within the next 48 hours to include criteria of zones and criteria for removing from isolation precautions. Education for Housekeeping staff to include terminal cleaning of rooms. 12. All previous negative residents will be POC tested tomorrow and audit will be conducted by RN supervisor and compliance of adherence to PPE on zone will be completed every day for 3 weeks and will be audited by Infection Control Nurse or designee. 13. Any further residents that test positive or have COVID-19 exposure will immediately be moved to the appropriate zone within the facility. If a resident's roommate tests positive, exposed roommate will be tested within two days per PA HAN 530. 14. Compliance will be monitored to ensure through the use of walking rounds audits by the Director of Nursing, RN Supervisor, or designee one per shift, daily for the next two weeks, and once weekly throughout the duration of this outbreak with results reported to the quality assurance committee monthly. Observations in the Red Zone with the DON on 12/20/20, at 9:20 a.m. revealed the clean supply room had three boxes of gloves, and 8 boxes of depends on the floor. The soiled utility room had four full tied off red bags on top of garbage cans or on the floor. The clean utility room had boxes of gauze rolls, shampoo caps, wash clothes and elastic bandages on the floor. The ice cooler for passing ice water to residents contained a cup being used as a scoop. The entrance to the Yellow Zone did not contain signage to indicate an it was an entrance to a yellow zone. During an interview on 12/20/20, at 9:41 a.m. the DON and LPN Employees E4 and E14 confirmed that all three of them failed to know if a COVID-19 negative employee could pass medications to a COVID-19 positive resident. The Immediate Jeopardy was removed on 12/20/20, at 3:45 p.m. when the action plan implementation was verified. During an interview on 12/20/20, at 3:30 p.m. the Owner of the facility, DON and Corporate Office Employee E12 were presented information on the facilities failure to follow infection control guidelines from the CDC and the PA DOH to reduce the spread of infections and prevent cross-contamination during the COVID-19 pandemic, which resulted in an Immediate Jeopardy situation. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 6/26/20, 6/20/19. 28 Pa. Code 201.18(b)(1) Management. Previously cited 6/20/19. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 6/20/19. 28 Pa. Code 201.20(a) Staff Development.