Every finding on record at Emerald Nursing and Rehabilitation

Based on review of facility policy and procedure, clinical record review, and staff interviews, it was determined the facility failed to provide adequate urinary catheter care for four of six residents reviewed (Residents 6, 8, 28, and 47) resulting in actual harm for three of six residents who contracted urinary tract infections requiring subsequent hospitalizations (Resident 6, 28 and 47).Findings include: Review of the facility's policy, Catheter Care, Urinary (revised September 2014), revealed documentation of catheter care should be documented in the resident's medical record. This documentation should include the date and time catheter care was given, the name of the staff providing the catheter care, and all assessment data obtained during catheter care. Review of Resident 6's Physician Orders revealed the resident was admitted to the facility on [DATE], with a suprapubic catheter (tube inserted through a small abdominal incision directly into the bladder to drain urine when the urethra is blocked or unusable). Review of Resident 6's clinical progress notes revealed a general note dated October 31, 2025 (12:40 a.m.) indicating Resident c/o (complained of) rib pain and requested to be sent out he said he believes he has an infection.notified supervisor, supervisor came down and assess and said we will continue to monitor in an hour. Further review of Resident 6's progress notes revealed a nursing note dated October 31, 2025, at 12:57 a.m. indicating assessed resident and spoke with him about pain in the ribs and wanting to be sent out to the hospital. His vitals are stable; LPN gave him tramadol for his pain. Explained I could not send him out just because he wanted to go to the hospital, I need a legitimate reason to ask a doctor to send him out, right now there is no reason. I told him give it time for his pain medicine to take effect and would revisit the situation in an hour. Further review of Resident 6's progress notes revealed a general note dated November 1, 2025, at 12:59 p.m. indicating order received from on call to transfer to [local ER] for eval (evaluation) relating to supra pubic cath(catheter) serosanguinous (pink-to-light-red watery fluid) drainage and emesis (vomiting). Review of Resident 6's hospital documentation dated November 1, 2025, revealed patient presented with low suprapubic output, blood tinged leakage and pus around SPT (suprapubic tube), and pus/gross hematuria (blood and urine) within the tubing as well. He had suprapubic abdominal pain and vomiting.urology consulted and exchanged the SPB in ED (emergency department). Resident 6 was admitted to the hospital with a diagnosis of Sepsis (life-threatening medical emergency caused by the body's extreme, dysfunctional response to an infection, leading to potential tissue damage, organ failure, and death) secondary to CAUTI (catheter associated urinary tract infection). Review of Resident 6's physician orders since admission failed to reveal an order for catheter care. Review of Resident 6's task administration record failed to reveal documentation of catheter care being completed since admission of April 2025. The facility failed to provided catheter care to Resident 6's suprapubic catheter increasing his risk for urinary tract infection causing actual harm when Resident 6 was admitted to the hospital on [DATE], due to sepsis secondary to CAUTI. Interview with the Nursing Home Administrator and the Director of Nursing on May 1, 2026, at 11:30 a.m. confirmed there was no order or documented evidence Resident 6 received catheter care per policy for the suprapubic catheter since admission. Review of Resident 28's Census revealed an admission to the facility on September 28, 2025. Review of Resident 28's admission summary dated [DATE], at 3:34 a.m. stated Resident 28 currently utilizing an indwelling catheter continent of bladder secondary to catheterization (a flexible tube inserted into the bladder to drain urine, typically used for retention, post-surgery, or monitoring output). Further review of Resident 28's clinical record revealed progress note dated October 30, 2025, at 8:15 a.m. indicating, Resident yelling in pain, stated that 'nurses are not flushing' his catheter and that this has caused a lot of pain in his bladder Tylenol given .(RN and LPN) irrigated (pushed sterile water) catheter. Further review of Resident 28's clinical progress notes revealed a nursing note dated October 30, 2025, at 11:00 a.m. revealed, Resident continues with pain after Tylenol was given penis cleaned Foley (catheter)was removed and writer observed pus (yellow fluid) in and around catheter .the physician was notified. Review of Resident 28's physician's orders revealed an order dated October 30, 2025, for urinalysis (non-invasive diagnostic test used to detect urinary tract infections [UTIs]) and to administer ciprofloxacin (antibiotic) 250 mg (milligrams) to be administered two times per day for possible urinary tract infection. Further review of Resident 28's clinical progress notes dated October 30, 2025, at 7:13 p.m. indicated this writer successfully inserted an indwelling catheter. Further review of Resident 28's progress notes revealed a nursing note dated October 31, 2025, at 4:03 p.m. indicating, (physician) made aware of positive (has a UTI) UA (urinalysis) results. Further review of Resident 28's progress notes revealed nursing note dated November 13, 2025, at 4:44 a.m., indicating, Resident 28 heard curing (crying) in pain coming from residents' room Resident 28 had labored breathing and Foley catheter had sediment almost totally occluding (blocking) it and Foley insertion site had yellow pus around it .order from doctor given to send to emergency room for evaluation and treatment related to pain at bladder/insertion site. Further review of Resident 28's progress notes revealed nursing note dated November 13, 2025 at 3:16 p.m. ICU (Intensive Care Unit) nurse has indicated he is being admitted for sepsis (life-threatening medical emergency caused by the body's extreme, dysfunctional response to an infection, leading to tissue damage, organ failure, and potential death). Review of Resident 28's progress notes revealed nursing note dated November 17, 2025, at 3:34 p.m. indicating Resident 28 returned from hospital, new medication orders placed. Review of Resident 28's progress notes revealed nursing note dated December 2, 2025, at 3:33 p.m. indicating Doctor made aware of yellowish discharge around Foley insertion site, urinalysis, culture and sensitivity (test to determine the type of bacteria present and what antibiotics it is suspectable to) and PO (oral) antibiotics ordered. Further review of Resident 28's progress notes revealed nursing note dated December 5, 2025, at 11:53 a.m. indicating, patient was sent out to hospital via ambulance .was assessed this morning related to pain in his penis area .presented with redness around the tip of penis with extreme amount of yellowish drainage .pain was rated 10/10 (extreme) .resident. Further review of Resident 28's progress notes revealed nursing note dated December 23, 2025, at 11:50 a.m. indicating, Resident 28 complained of 10 out of 10 pain at the insertion site scrotum (an external sac of skin between the legs and behind the penis) was red and swollen .provider was notified and gave order to send to ER (Emergency Room). Further review of Resident 28's progress notes revealed a nursing progress note dated December 27 at 11:08 a.m. indicating writer notified MD of readmission. Further review of Resident 28's progress notes revealed nursing progress note dated January 29, 2026, at 6:31 a.m. indicating, Resident 28 had 500 cc (cubic centimeters) of hematuria (blood in urine) in Foley. Further review of Resident 28's progress notes revealed a nursing progress note dated January 29, 2026 (12:55 p.m.) indicating MD gave order for culture and sensitivity. Further review of Resident 28's progress notes revealed a nursing progress note dated February 1, 2026, at 2:42 p.m., stating Resident has Klebsiella (bacteria) in urine culture greater than 100,000, order to give Cipro (antibiotic) 500mg PO twice a day for seven days. Additional review of Resident 28's progress notes revealed nursing progress note dated March 30, 2026 (9:33 p.m.) indicating Resident 28 noted to have cola-colored urine attempted to notify MD. Further review of Resident 28's progress notes revealed a nursing progress note dated March 31, 2026 (3:22 p.m.) indicating spoke with (MD) new order for Cipro 250mg BID (twice a day) times 7 days. Further review of Resident 28's progress notes revealed a nursing progress note dated April 8, 2026, at 9:48 p.m. indicating, resident complained of pain from his Foley this nurse cleaned the head of the penis and the tubing from catheter as there was crusty drainage on them. Review of Resident 28's physician orders revealed an order dated April 10, 2026, for Bactrim (antibiotic) 800-160mg (milligrams) to be administered twice a day for seven days. Further review of Resident 28's progress notes revealed an alert progress note dated April 11, 2026 at 7:50 a.m., indicating, approximately 2:17 a.m. resident went to hospital due to his genital area being inflamed and swollen, foley was being coming dislodged, tried replacing it and it would not go in .resident sent out to (local hospital) per provider orders. Further review of Resident 28's progress notes revealed a nursing progress note dated April 11, 2026, at 9:41a.m. indicating Resident returned from (local emergency room) status post (after) Foley reinsertion at 8:24 a.m. Review of Resident 28's physician orders since admission on [DATE], failed to reveal an order for catheter care. Review of the Resident 28's task administration record failed to reveal documentation of catheter care being completed since admission. Interview with the Nursing Home Administrator on April 23, 2026, at 12:14 p.m. confirmed the clinical record did not contain documented evidence of catheter care for Resident 28 since admission to the facility. The facility failed to provide catheter care to Resident 28 resulting in multiple urinary tract infections as well as hospitalization for urinary tract infections resulting in actual harm to Resident 28. Review of Resident 47's Physician Orders revealed the resident was admitted to the facility on [DATE]. Further review of Resdient 47's Physician Orders revealed an order dated August 9, 2025 for a foley catheter. Review of Resident 47's progress notes revealed a general note dated November 26, 2025 at 4:53 a.m. indicating, resident with c/o (complaints of) discomfort and pain in abd (abdomen) and penis, requested a PRN (as needed) foley flush with saline (push sterile water into the tube). Upon attempting to flush the resident Foley, a blockage/resistance was found. The supervisor then advised me to follow the residents order & change the Foley catheter completely. After completing a Foley catheter change, the resident is still unable to void (urinate). Bladder scan (noninvasive, painless ultrasound procedure used to measure the volume of urine in the bladder and determine if it is emptying completely) 1211 cc (cubic centimeters) found. ABD hard and distended (visibly swollen, firm, or stretched belly caused by internal pressure). MD aware awaiting instructions. Further review of Resident 47's progress notes revealed general note dated November 26, 2025 (5:15 a.m.) indicating Residents MD/on call physician requested for resident to be sent to hospital. Review of Resident 47's hospital discharge record dated December 1, 2025, revealed the resident was admitted to ICU (intensive care unit) with a diagnosis of septic shock from ESBL (antibiotic resistant infection) Klebsiella (bacteria that causes UTIs) and E.coli (bacteria) bacteremia from complicated UTI/cauti present on admission. Review of Resident 47's physician orders since admission failed to reveal an order for catheter care. Review of Resident 47's task administration record failed to reveal documentation of catheter care completed since admission. The facility failed to provided catheter care to Resident 47's Foley catheter increasing his risk for urinary tract infection causing actual harm when Resident 47 was admitted to the hospital on [DATE], due to septic shock from ESBL (antibiotic resistant infection) Klebsiella (bacteria that causes UTIs) and E.coli (bacteria) bacteremia from complicated UTI/cauti present on admission. Interview with the Nursing Home Administrator and the Director of Nursing on May 1, 2026, at 11:30 a.m. confirmed there was no order or documented evidence Resident 47 received catheter care for the Foley catheter since admission, as facility policy indicates. Review of Resident 8's progress notes revealed admission Summary Notes dated March 4, 2026, at 6:37 p.m. indicating continent of bladder secondary to catheterization. Review of Resident 8's physician orders revealed an order dated March 5, 2026, for a Foley catheter. Review of Resident 8's physician orders since admission failed to reveal an order for catheter care. Review of Resident 8's task administration record failed to reveal documentation of catheter care completed from March 4, 2026, when the resident returned from the hospital until it was discontinued on April 20, 2026. Interview with the Nursing Home Administrator and Director of Nursing on May 1, 2026, at 11:30 a.m. confirmed there was no order or documented evidence Resident 8 received catheter care as directed by facility policy. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services Previously cited 4/19/2024, 5/30/2024, 5/22/2025, 7/16/2025, 8/4/2025, 12/22/2025, 2/4/2026, 3/27/2026

Based upon observation and interview, it was determined that the facility failed to ensure appropriate sanitization monitoring and documentation was completed for daily dishwasher sanitization for one of one dishwasher observed.Findings include:Observation of the facility dishwashing machine located in the kitchen on April 20, 2026, at 10:00 a.m. revealed the dishwashing machine to be running.Interview with Employee E6 on April 20, 2026, at 10:00 a.m. revealed the dishwasher water temperature to be 125 degrees.Review of the dishwasher log on April 20, 2026, at 10:00 a.m. revealed the log to be completed.Observation during a second visit to the kitchen on April 22, 2026, at 10:15 a.m. revealed the dishwasher to be running.Interview with Employee E6 on April 22, 2026, at 10:15 a.m. revealed that no test strips were immediately available to test the sanitization of the water coming out of the dishwasher.Upon locating test strips, the water was tested and revealed to be greater than 100 PPM (parts per million).Review of the dishwasher sanitization log on April 22, 2026, at 10:15 a.m. revealed that the sanitization was tested during the cleaning of breakfast dishes.Interview with Employee E6 on April 22, 2026, at 10:15 a.m. revealed Employee E6 had completed the log for the breakfast dishes.Observation of the dishwasher sanitization log revealed that the entire day was completed on April 22, 2026, at 10:15 a.m.Interview with Food Service Director Employee E7 confirmed that employees are to test the sanitization of the dishwasher during each meal and to complete the log after the completion of the testing of the sanitization of the water.This interview further confirmed that the log was inappropriately completed ahead of the meals on April 22, 2026, and therefore no adequate sanitization was tested during each meal. 28 Pa. Code 211.6(f) Dietary ServicesPreviously cited 5/22/2025

Based on review of clinical records and interview with staff, it was determined that the facility failed to notify the office of the state long term care ombudsman of emergency transfers for four of eight residents reviewed (Residents 2, 5, 8, and 9). Findings include: Review of Resident 2's progress note of January 7, 2026, revealed that the resident was seen by the wound nurse practitioner (NP) and was noted to have a painful, red lump to the incision line. NP recommended to reach out to wound center and or surgeon. An additional note on January 7, 2026, revealed that a representative from the surgical group suggested that the resident be sent to the emergency department. Resident was admitted for left above the knee amputation cellulitis (bacterial infection of the deep skin layers). Review of facility documentation failed to reveal evidence that the State Ombudsman's office was notified of Resident 2's transfer and admission to the hospital. Review of Resident 5's progress note of January 9, 2026, revealed that 911 was activated to take Resident 5 to the hospital for treatment and evaluation of crushing chest pain. An additional note on January 11, 2026, revealed that Resident 5 was admitted to the hospital for congestive heart failure exacerbation. Review of facility documentation failed to reveal evidence that the State Ombudsman's office was notified of Resident 5's transfer and admission to the hospital. Review of Resident 8's progress note of February 16, 2026, revealed that Resident 8 was admitted to the hospital with a diagnosis of osteomyelitis. Review of facility documentation failed to reveal evidence that the State Ombudsman's office was notified of Resident 8's transfer and admission to the hospital. Review of Resident 9's progress note of December 27, 2025, revealed that the resident was experiencing respiratory distress, hypoxia (low oxygen levels), productive cough, and was using abdominal muscles to breath. Resident appeared cyanotic (bluish or purplish discoloration of the skin, lips, or mucous membranes caused by low oxygen saturation in the blood. Resident was transferred to the hospital. Progress note of December 29, 2026, revealed that the resident was admitted to the hospital for respiratory failure with hypoxia. Interview with Employee E5 on April 23, 2026, at 1:00 p.m. confirmed that the above residents were not on the list provided to the State Ombudsman's office. 483.15 Admission, Transfer, and Discharge Previously cited 5/22/25 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 12/22/25, 8/4/25, 5/22/25

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that resident assessments accurately reflected the resident's status for one of 24 residents reviewed (Resident 2).Findings include:Review of Resident 2's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) of March 22, 2026, section N0350 - Insulin, indicated that the resident was receiving insulin on one day in the last seven days Further review of the physician's orders and Medication Administration Record revealed no evidence that the resident received insulin during the assessment lookback period.Interview with licensed staff, E4, on April 23, 2026, at 1:35 p.m. confirmed that the assessment was coded inaccurately.28 Pa. Code 211.5(f) Clinical records

Based on review of facility policy, review of clinical records and interview with staff, it was determined that the facility failed to obtain accurate weights and verify weights to maintain acceptable parameters of nutritional status for one of 24 residents reviewed (Resident 31).Findings include:Review of facility policy, Weight Assessment and Intervention revised September 2008, revealed that any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. Review of Resident 31's weights revealed a weight of 131.0 pounds on December 2, 2025, and 111.0 pounds on January 8, 2026 indicating a loss of 20 pounds or 15.3%. Further review of the clinical record revealed that no reweight was obtained. Resident 31's weight was recorded as 113.0 pounds on January 15, 2026, and 125.0 pounds on January 20, 2026, indicating a gain of 14 pounds or 12.6% with no reweight obtained. Next weight of 116.0 pounds was obtained on February 3, 2026, indicating a loss of 9 pounds or 7.2% with no reweight obtained. Interview with Employee E4 on April 23, 2026, at 1:00 p.m. confirmed that Resident 31's weights were not being verified for accuracy. 483.25 Nutrition/Hydration Status MaintenancePreviously cited 5/22/25 28 Pa. Code 211.12(d)(1)(3)(5) Nursing servicesPreviously cited 5/22/25

Based upon review of facility policy and procedure and observation, it was determined that the facility failed to ensure medications were administered following facility infection prevention protocol for one of two residents observed (Resident 1).Findings include:Review of facility policy and procedure titled Administering Medications revealed Staff follows established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation preventions, etc.) for the administration of medications, as applicable.Observation of medication administration on April 22, 2026, at 9:00 a.m. revealed Licensed Employee E3 cut open medication pill packets and spill the medications onto the top of the medication cart. Licensed Employee E3 picked up the medications off of the top of the medication cart and placed them in a medication cup and administered them to Resident 1.The above information was conveyed to Licensed Employee E4 and the Nursing Home Administrator on April 23, 2026, at 1:00 p.m. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing ServicesPreviously cited 5/22/2025, 7/16/2025, 8/4/225, 12/22/2025, 2/4/2026, 3/27/2026

Based on observations and interviews with residents and staff, it was determined that the facility failed to post the name, address, and telephone number of the State Survey Agency on two of two units (Station 2 and Station 3).Findings include:Observations on all days of the survey on both units revealed no posting of the contact information for the State Survey Agency. An interview with residents during a group interview on April 21, 2026, at 1:00 p.m. revealed that the residents were not aware of a posting containing the contact information for the State Survey Agency. Interview with the Nursing Home Administrator on April 23, 2026, at 12:50 p.m. confirmed that there was no posting of the State Survey Agency contact information on the nursing units. 28 Pa. Code 201.14(a) Responsibility of licenseePreviously cited 12/22/25, 8/4/25, 5/22/25

Based on observations and interviews with residents and staff, it was determined that the facility failed to post the results of the most recent Department of Health survey in a place readily accessible to residents for two of two units (Stations 2 and 3).Findings include:Observations during all days of the survey revealed a posting that the state survey results were available in the lobby.Interview with residents during a group meeting on April 21, 2026, at 1:00 p.m. revealed that they were not aware of the location of the state survey results. The residents also revealed that they do not have access to the lobby and the elevator to the lobby requires a code.Interview with the Nursing Home Administrator on April 23, 2026, at 12:50 p.m. confirmed that the survey results were only located in the lobby which is not readily accessible to the residents.28 Pa. Code: 201.14(a) Responsibility of licensee.Previously cited 12/22/25, 8/4/25, 5/22/25

Based on review of clinical records, and staff interviews, it was determined that the facility failed to ensure physician's orders were followed for one three of five residents reviewed resulting in actual harm to one, resident Resdient1. (Resident 1, 2, and 3).Findings include: Review of Resident 1's quarterly Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated November 27, 2025, revealed the resident was cognitively intact; dependent on staff for daily care needs, and had a diagnosis of Chronic diastolic (congestive) Heart Failure (CHF-progressive condition where the heart cannot pump blood effectively, causing blood to back up and fluid to accumulate in the lungs and body). Review of Resident 1's physician's orders revealed an order dated November 22, 2025, for Torsemide (medication used to treat high blood pressure and fluid retention caused by congestive heart failure) 120 mg (milligrams) by mouth twice a day for CHF (congestive heart failure). Further review of Resident 1's physician's orders, revealed an order dated January 23, 2026, to obtain weight one time a day every Monday, Wednesday, and Friday for congestive heart failure. Weigh every Mon, Wed, Fri. Notify provider weight gain > (greater than) 2 pounds overnight or 5 pounds in one week. Notify daughter of any weight refusals. Review of Resident 1's nursing progress note dated February 6, 2026, (12:07 p.m.) revealed: NP (nurse practitioner) notified of patient abdominal discomfort order to give Zofran 4mg 1 tab (tablet) PO (by mouth) Q (every) 6 hours prn (as needed) nausea. Resident informed of order but requested to go to hospital for evaluation and treatment NP notified gave order to go to hospital for evaluation and treatment. 911 called at 12 noon, EMS (emergency management services) arrived at 1212 pm with stretcher to take resident to hospital for treatment. Review of Resident 1's nursing progress note dated February 6, 2026, (2:11 p.m.) revealed, Resident c/o (complains of) pain and discomfort in the stomach. Resident c/o that (he/she) felt nausea and 'needed to go to the hospital.' RN (Registered Nurse) supervisor immediately notified of the situation. Resident's vital signs stable BP (blood pressure): 106/64, O2 (oxygen level): 96%, HR (heart rate):70, R (respirations):18, T (temperature): 97.6. Resident transported to hospital, POA (Power of Attorney) notified by RN supervisor. Resident's afternoon insulin held before going to hospital. Review of Resident 1's hospital provider notes, dated February 6, 2026, revealed Resident 1 had a previous admission in November of 2025 for similar presentation. Required Lasix drip and discharged on increased torsemide dose of 120 mg twice daily. Review of Resident 1's hospital discharge records dated February 18, 2026, revealed Resident 1 was ordered to continue oral torsemide 120 mg twice a day. Review of Resident 1's February 2026 MAR (Medication Administration Record) revealed an order dated February 19, 2026, for Torsemide Oral Tablet 20 mg; give 20 mg by mouth two times a day for CHF. Review of Resident 1's Cardiology follow up appointment consult report dated February 26, 2026 reveal a hand written note from the Nurse Practitioner indicating: needs BMP (Basic Metabolic Panel is a test measuring key substances in the blood that assess metabolism, fluid balance, and kidney function) weekly, should be on 120 mg of torsemide but since (he/she) has only been getting 20 twice a day (BID). increase to 60 mg BID. Please weigh them daily. Review Resident 1's March TAR (Treatment Administration Record) revealed the following documented weights: February 27, 2026: 191 pounds and March 2, 2026: 187 pounds. Further review of the TAR revealed no other weights recorded from February 26, 2026, through March 4, 2026. Review of Resident 1's dietary progress note, dated March 4, 2026, at 12:53 p.m., revealed a weight warning, current weight reflects a 7.8% weight change x 90 days. Provider is aware and increased torsemide per progress notes.will make nursing aware of weight changes and add Juven BID (twice daily) to promote nutrition and healing. Further review of Resident 1's nursing progress notes dated March 5, 2026, at 1:39 p.m. revealed Resident 1 refused to attend an appointment outside the facility for an IV diuresis (procedure to treat severe edema or swelling caused by excess fluid accumulation). The provider was notified and an order was received for STAT (as soon as possible) BMP and MAG (test to measure magnesium levels in the blood). Further review of Resident 1's nursing progress notes dated March 6, 2026, at 11:21 a.m. revealed: per DON (director of nursing) resp. (respiratory) assessment completed. Lungs sta [sic] bilaterally pulse ox (test to determine how much oxygen in the blood) 97% pulse 70 no respiratory distress pulse 20 edema noted plus 2 (moderate swelling where pressure leaves a dimple in the skin that rebounds within 15 seconds). Review of Resident 1's nursing progress notes dated March 6, 2026 at 11:21 a.m. revealed the facility received the following abnormal blood test results from the BMP: Glucose 318 (normal range = 65-140), BUN 43 (normal range = 8-23), CR 0.55, (normal range = 0.60 – 1.10) CAL 8.1 (normal range = 8.6 – 10.3), MAG 1.7 (normal range = 1.8 – 2.7). Further review of Resident 1's progress note revealed the provider was notified and ordered nursing to encourage fluids due to dehydration and to increase torsemide to 80 mg twice a day with blood pressures every shift for three days. This order was entered on March 7, 2026, and review of Resident 1's March 2026 MAR revealed the resident received the ordered doses on March 7, 2026, and March 8, 2026 and Resident 1 attended an outside appointment for IV diuresis on March 9, 2026 but did not receive the third dose of torsemide due to being out of the facility at the appointment. Review of Resident 1's cardiac provider visit records dated March 9, 2026, revealed Resident 1 was to increase torsemide to 80 mg twice a day, obtain a BMP and Magnesium blood test, and weigh every morning before breakfast. Call your doctor or nurse practitioner for weight gain greater than 2 pounds overnight or 5 pounds in one week and/or worsening shortness of breath, and/or worsening swelling in the legs or belly. Review of Resident 1's weights revealed on March 11, 2026, a weight of 194.4 pounds, on March 13, 2026, a weight of 193 pounds, and March 16, 2026, a weight of 194.4 pounds. Review of Resident 1's progress notes revealed a dietary note dated March 16, 2026, (6:31 a.m.) for an additional weight warning of a 5% gain. Weekly weight taken M/W/F related to CHF.fluid retention likely the cause of these shifts. Will continue to monitor and make nursing aware and follow up as nutritionally indicated. Further review of Resident 1's progress notes revealed a nursing entry dated March 17, 2026 (10:26 p.m.) Staff reported weeping edema (severe form of swelling where fluid seeps through the skin) from b/l (bilateral) LEs (lower extremities). Resident denies pain or discomfort, noted in Dr.'s communication book. Further review of Resident 1's nursing progress notes dated March 18, 2026, at 11:17 a.m. revealed: Resident reassessed after previous shift reported fluid overload symptoms. Report received that the resident's bilateral lower extremities are weeping, and that the resident has had a 5 point increase in weight gain. Head to toe assessment done: .3 + pitting edema (moderate to severe swelling where pressure leaves a dimple that remains for up to 60 seconds after pressure is released) noted on bilateral lower extremities. Upper extremities have multiple discoloration, with an open area around the right forearm. Vital signs are unremarkable: 98%, and 97.0 degrees Fahrenheit. The provider was notified - see new orders. Further review of nursing progress notes dated March 18, 2026, (12:08 p.m.) revealed Provider was contacted by another staff member and orders were for BLE (bilateral lower extremity) US (ultrasound) and blood work (not specified) in the am (morning). Further review of nursing progress notes dated March 18, 2026, (2:37 p.m.) revealed: Spoke with resident's POA (power of attorney), regarding US that is ordered. POA is OK with resident not having US done. POA also stated that resident's cardiology's office was called by family and updated. Further review of nursing progress notes dated March 18, 2026, 3:03 p.m. revealed: Spoke with family, who spoke with the heart group. The provider would like to see resident tomorrow, POA made appt (appointment) for 1345 (1:45 p.m.) tomorrow. Further review of Resident 1's nursing progress dated March 19, 2026, 2:52 p.m. revealed: Received cardiology office that resident is being sent to ED (Emergency Department) secondary to fluid volume overload. Review of hospital admission records dated March 20, 2026, revealed Resident 1 was admitted to the hospital for monitoring and treatment with a diagnosis of acute on chronic CHF. These findings were shared with the Nursing Home Administrator and Director of Nursing at approximately 4:00 p.m. on March 24, 2026. The facility failed to implement medication orders and failed to monitor resident's weight as ordered resulting in increased symptoms of Resident 1's CHF including edema and weight gain resulting in actual harm when Resident 1 was admitted to the hospital on [DATE], for treatment. Review of Resident 2's physician order dated March 17, 2026, revealed an order for Oxycodone HCL 5 mg (An opioid pain-relief medicine used to relieve moderate to severe pain). Give one tablet by mouth every eight hours for three days. The start date was March 17, 2026, at 2:00 p.m. Review of Resident 2's March 2026 Medication Administration Record (MAR) revealed the medication was not administered to the resident on the following dates and times: March 19, 2026, at 6:00 a.m., March 19, 2026, at 2:00 p.m., and March 20, 2026, at 6:00 a.m. Review of Resident 2's nursing progress notes dated March 19, 2026, at 2:00 p.m., revealed: medication held due to resident being hard to arouse, pulse ox (Spo2-blood oxygen saturation-normal range 95%-100%) 86% pulse 68, resp (respirations)18, b/p (blood pressure) 104/64, supervisor aware. Further review of Resident 2's clinical record revealed no documentation indicating a reason Resident 2's ordered Oxycodone was not administered on March 19, 2026, at 6:00 a.m., and March 20, 2026, at 6:00 a.m. Review of Resident 2's clinical record revealed no documented evidence the physician was notified of Resident 2's change in condition (low SpO2 and difficulty to arouse/awaken) on March 19, 2026, at 2:00 p.m., and not notified of the Oxycodone not being administered on the dates mentioned above. Interview with the Director of Nursing (DON), conducted on March 27, 2026, at 3:00 p.m. revealed Resident 2 missed the Oxycodone ordered three times, and the physician was not notified of the resident's change in condition or the missed medications. Review of Resident 2's wound consult dated March 18, 2026, revealed the following: left lower leg cellulitis (deep infection of the skin caused by bacteria), present on admission, measuring 15 x 17 x .10 cm., full thickness with 70% eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like), and serosanguinous (type of wound drainage that is a combination of blood and serum) drainage. The treatment order was to cleanse the left lower leg with soap and water, pat dry, apply Betadine (antiseptic solution used to treat minor cuts, scrapes, and burns by killing bacteria) twice daily, then leave wound open to air. Right lower leg cellulitis is present on admission, measuring 15 x 38 x 0.1 cm (centimeter), full thickness, with 90% eschar, moderate serosanguinous. The treatment order was to cleanse the right lower leg with Acetic Acid 1% (A colorless, organic liquid with a pungent, vinegar-like smell), apply Xeroform (sterile, non-adherent, petrolatum-based mesh dressing impregnated with 3% bismuth tribromo phenate used to cover wounds and promote healing), bordered dressing every other day, and as needed. Review of Resident 2's physician orders revealed there was no order for wound care to the right leg of Acetic Acid and Xeroform. Further review of the physician orders revealed an order for Betadine for the left leg wound dated March 18, 2026. Review of Resident 2's March 2026 Treatment Administration Record (TAR) revealed the ordered wound treatment of Betadine to the left leg was not transcribed on the March TAR. Review of Resident 2's physician order dated March 20, 2026, revealed an order to cleanse the bilateral lower extremity open areas with normal saline solution, apply Hydrogel (water based wound care treatment) to the open wounds with swab, cover with bordered foam (absorbent foam dressing with adhesive border), and wrap with kerlix (gauze) and Tubi grips (compression bandage) every other day and as needed. Review of Resident 2's March 2026 TAR revealed the above ordered Hydrogel treatment was not completed as ordered for the resident's bilateral legs from March 20, 2026, until March 26, 2026 when there was a new order for wound care that was completed as ordered. The order of March 20, 2026 was not transcribed into the resident's TAR. Review of Resident 2's nursing progress notes dated March 20, 2026, and March 23, 2026, revealed Resident 2 was taking off the leg dressing. Neither progress note indicated what treatment/dressing was administered as a replacement to the resident's legs or what the dressing was that Resident 2 was removing. During an interview with the Director of Nursing on March 27, 2026, at 3:00 p.m. revealed the DON could not provide an explanation why Resident 2's wound order was not followed as ordered or what treatments were placed when Resident 2 removed the dressing on March 20, 2026 and March 23, 2026. Interview with the corporate nurse Employee E4 conducted on March 27, 2026, at 4:00 p.m., revealed the facility's EMR (electronic medical record) system had some changes with transcribing the order into the resident's TAR, which caused issue. Review of Resident 3's history and physical dated December 19, 2025, revealed the resident had a lower left leg wound with hematomas (bruise), which required surgical intervention of incision and drainage. The resident was also diagnosed with Cellulitis and Lymphedema (chronic condition that causes swelling in the body's tissue). Review of Resident 3's wound physician consult dated December 24, 2025, revealed the resident had an unstageable wound (obscured full-thickness skin and tissue loss) to the left calf that measures 4.3 x 4.8 x 0.2 cm with 11 o'clock 1.1 cm. tunneling (deep wound that develops narrow, channel-like pathways beneath the skin surface), with moderate serosanguinous drainage. The treatment order was to cleanse the wound with normal saline, apply Wound Vac (NPTW-Negative Pressure Wound Therapy- therapeutic technique using a vacuum dressing system to promote healing in acute or chronic wounds) at 125 mmHg (millimeters of mercury) continuous three times per week and as needed. Review of Resident 3's nursing progress notes dated December 30, 2026, 2:36 p.m., revealed resident came back from a wound center appointment with an order to discontinue the wound vac. Review of Resident 3's physician order dated January 2, 2026, revealed a new wound treatment order to cleanse left lower leg with soap and water, apply Prisma (sterile wound dressing composed of collagen, oxidized regenerated cellulose and silver) and Calcium alginate (biodegradable wound treatment derived from brown seaweed) every Tuesday and Friday then apply Profore (multi-layer compression bandage)from toes to knees. Review of Resident 3's weekly skin assessment dated [DATE], and January 7, 2026, revealed: Skin intact- No. However, further review of the same skin assessments failed to reveal an assessment was completed on resident 3's left calf wound. Review of Resident 3's clinical record failed to reveal documentation of a weekly skin assessment on the resident's left calf wound was done on January 14 and January 21, 2026. Interview with the Director of Nursing on March 27, 2026, confirmed Resident 3's left calf wound was not assessed from December 31, 2025, until January 21, 2026. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on observation and staff interview, it was determined that the facility failed to ensure residents were provided with a clean and homelike environment for one of three bathrooms observed (Resident 2's bathroom). Findings: An observation was conducted in Resident 2's bathroom on March 27, 2026, at 12:10 p.m., in the presence of licensed nurse Employee E3. The observations revealed the following: dried brown substances in front of the toilet bowl; brown substances in the toilet bowl; two used towels in the sink; one used drawsheet, a used gown, and a wet washcloth with brown stains on the bathroom floor; and a garbage can overflowed with used incontinent briefs. An interview with Employee E3 was conducted on March 27, 2026, at 12:15 p.m. Employee E3 confirmed that the resident's bathroom smelled of urine. The above findings were conveyed to the Nursing Home Administrator on March 27, 2026, at 3:00 p.m. The facility failed to ensure Resident 2's bathroom was maintained clean. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management

Based on facility policy review, observations and staff interviews it was determined the facility failed to provide PPE and signage for residents who require enhanced barrier precautions for one of six residents reviewed. (Resident 1)Findings Include:Review of facility policy titled Enhanced Barrier Precautions, effective March 2024, revealed EPB (enhanced barrier precautions) are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO (multi-drug resistant organism) colonization .Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE (personal protective equipment) required .PPE is available outside of the resident rooms.Observation of Resident 1 on February 4, 2026 at approximately 12:05PM revealed the resident had an indwelling urinary catheter (a flexible tube inserted into the bladder to continuously drain urine into an external bag). Further observations revealed there was no PPE in the room and there was no sign for EBP.Two Licensed Practical Nurses E2 and E3 confirmed the lack of signage on February 4, 2026, at approximately 2:45PM.These findings were relayed to the Nursing Home Administrator and the Director of Nursing on February 4, 2026, at 3:30 p.m.28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services

Based on review of facility policies and documentation, clinical record reviews, and interviews with staff, it was determined the facility failed to provide adequate supervision to one of twelve residents reviewed (Resident R1) who was inaccurately assessed as a low risk for elopement. This failure resulted in Resident R1 exiting nursing unit via the elevator and walking out the front entrance doors. The facility was not aware Resident R1 was missing until the resident's daughter called and informed the facility Resident R1 had walked to her house crossing multiple busy streets. This failure placed the resident at high risk for injury and was identified as an Immediate Jeopardy of past non-compliance. (Resident R1)Findings include: Review of facility policy, titled, wandering and elopements, revealed the facility will identify residents who are at risk of unsafe wandering and strive to prevent while maintaining the least restrictive environment for residents. Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on [DATE], with the following diagnosis; Parkinson's disease with dyskinesia, without mention of fluctuations (movement disorder of the nervous system that worsens over time); neurocognitive disorder with Lewy bodies (a progressive neurodegenerative disorder characterized by the accumulation of Lewy bodies in the brain, leading to cognitive decline, movement issues, and various other symptoms); muscle weakness (generalized); and difficulty in walking. Review of Resident R1's [NAME]-Elopement Assessment/Evaluation completed on admission dated September 16, 2025, revealed that the facility incorrectly completed the assessment by stating the resident does not have dementia resulting the resident being identified as low risk for wandering instead of moderate risk for elopement. Review of Resident R1's admission MDS (Minimum Data Set- periodic assessment of resident's care needs) completed on September 21, 2025, revealed the resident was assessed with a BIMS (Brief Interview for Mental Status) score of 10. A score of 10 indicates moderate cognitive impairment. Review of facility investigation provided by the facility revealed a timeline dated November 5, 2025. The following is the summary of the timeline: Between 11:00 a.m. and 12:00 p.m. Resident R1 was observed twice by nursing assistant (NA) Employee E1 trying to enter the elevator on the second floor. Employee E1 removed Resident R1 but did not report Resident R1's exit seeking behaviors to her supervisors. Between 12:00 p.m. and 12:30 p.m. registered nurse, Employee (E2) removed Resident R1 from the elevator twice and redirected (him/her) to own room. Employee E2 did not report Resident R1's exit seeking behaviors to her supervisors. At 2:00 p.m. NA Employee E3 observed Resident R1 standing in front of the elevator. Employee E3 redirected Resident R1 back to own room. Employee E3 did not report Resident R1's exit seeking behaviors to the supervisors. Between 2:00 p.m. and 2:15 p.m. licensed Employee E4 was sitting in her car in the facilities parking lot located in a lot across the street from the front entrance and observed Resident R1 walking out of the facility. Employee E4 believed the resident was on leave of absence (LOA) due to observing another individual walking out of the facility at the same time. Employee E4 watched Resident R1 walk up the street by self. Employee E4 did not report her observations to her supervisor. At 2:30 p.m. Resident R1's daughter called the facility to report Resident R1 had left the facility and walked to her house by (himself/herself). Resident R1 was returned to the facility at 6:05 p.m. by (his/her) daughter. Interview conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on December 22, 2025, at 6:15 p.m. revealed Resident R1 followed an unidentified visitor onto the elevator and exited the facility walking alongside the individual; the NHA revealed the resident's proximity to the visitor led a receptionist and Employee E4 to presume the resident was leaving with a family member. Additionally, the NHA and DON confirmed Resident R1's elopement risk assessment was not completed accurately. Based on the above findings, an Immediate Jeopardy to the safety of the resident was identified for failure to accurately complete an elopement assessment and to provide adequate supervision of a resident who was actively exhibiting exit seeking behaviors. The resident went missing on November 5, 2025. The facility was not aware Resident R1 was missing until Resident's daughter called the facility to report Resident R1 was at her house. An Immediate Jeopardy template (document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator and Immediate Jeopardy was called on December 22, 2025, at 6:49 p.m. The facility provided a Plan of Correction on December 22, 2025, for submission and it was approved at 7:00 p.m. The plan of correction was as follows:a. The Nursing Administration reviewed all resident' electronic health records for accurate elopement/wandering evaluations- completed November 5, 2025.b. Elopement books found at the reception desk, and every unit were reviewed to ensure that all resident's identified as elopement risks were current, and resident's identifiers were available. - completed November 5, 2025.c. Sign posted at reception notifying visitors of the LOA process- completed November 5, 2025. d. Staff were educated on routine resident checks, the wandering and elopement policy, and the wander management and elopement prevention policy. 90% of staff will be educated by November 6, 2025. The remainder were educated prior to the start of their next shift.e. RN (registered nurse) Supervisors/Unit managers were educated on the completion of headcounts of all residents compared to the midnight census and the immediate reporting of any discrepancy to the Director of Nursing (DON). 90% of staff will be educated by November 6, 2025. The remainder will be educated prior to the start of their next shift. f. Staff educated on the LOA process. 90% of staff were educated by November 6, 2025. Remainder were educated prior to the start of their next shift. g. The reception staff were educated on the facility visitor badge protocol, visitor badge process, resident leaves of absence, and signing residents out. 90% of staff were educated by November 6, 2025. The remainder were educated prior to the start of their next shift. h. Staff were educated on the elopement/missing person policy and procedure including the elopement code announcement to notify staff in the center, search on the premises and the surrounding areas, and notification processes. 90% of staff were educated by November 6, 2025. The remainder were educated prior to the start of their next shift. i. Staff were educated on elopement drills including the frequency of drills and expected responses. 90% of staff were educated by November 6, 2025. The remainder were educated prior to the start of their next shift. j. The training regarding elopement were added to the general orientation schedule for new employees- completed November 6, 2025. k. An elopement drill was completed on November 6, 2025. l. The elevator and keypads were assessed. Elevator keypad code changed. Additional training provided to staff related to not providing keypad codes to visitors and/or residents. 90% of staff were educated by November 7, 2025. The Remainder were educated prior to the start of their next shift.m. Elopement/wandering evaluation updated as needed. REview of facility documentation revealed the facility completed implementation of the action plan on November 9, 2025. On December 22, 2025, the implementation of the action plan was verified. Eleven staff members were interviewed from various units and departments. Facility staff were able to answer questions on recognizing signs of exit seeking behaviors and who to report them to, missing resident response, how often are elopement assessments completed, LOA process, Visitor badges, signing out resident process.Following the verification of the completion of the immediate action plan the Immediate Jeopardy was lifted on December 22, 2025, at 7:15 p.m. and the Immediate Jeopardy situation was determined to exist at the facility from the time of the elopement on November 5, 2025, until the completion of the action plan on November 9, 2025.The facility failed to ensure appropriate supervision of a resident, exhibiting exit seeking behavior and who exited the door of the facility to cross multiple busy streets to arrive at a family member's home. Facility staff were unaware of resident's elopement until the family member contacted the facility. The deficient practice is being cited as past non compliance. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 201.18(e)(1) Management28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1)(5) Nursing services28 Pa. Code 211.12(d)(2) Nursing services

Based on the review of clinical records, job descriptions, review of facility policy, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure the safety of one of twelve residents reviewed (Resident R1) with a diagnosis of Dementia who eloped from the facility. This failure resulted in an Immediate Jeopardy situation for Resident R1. (Resident R1)Findings Include:Review of the job description for the Nursing Home Administrator (NHA) states, Position Summary-this position is responsible to establish and maintain systems that are efficient and effective to operate the nursing home in a manner to safely meet resident's needs in accordance with federal, state and local regulations. Also, develop and maintain systems that are effective and efficient to operate the facility in a financially sound manner.Further review of the NHA job description revealed, Essential Duties and Responsibilities-. Develop, maintain and implement operational policies and procedures to meet residents need in compliance with federal, state and local requirements. Determine the personnel requirements of the facility in collaboration with Department Managers and hire or arrange for sufficient staff to provide for sound resident care and implement the facility policies and procedures.Review of the job description for the Director of Nursing (DON) states, Position Summary- The Director of Nursing functions as the administrative authority for the Department of Nursing. This Director will be responsible for the organization and oversight of all nursing operations and for the supervision of care for all residents at the facility. Further review of the DON job essential requirements revealed, must possess the ability to plan, organize, develop, implement and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality of care.The findings in this report identified the facility failed to maintain the safety of the residents from elopement by ensuring elopement assessments were completed correctly and residents exhibiting behaviors for elopement were prevented from leaving the facility without proper supervision.Refer to F68928 Pa Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 201.18(b)(3) Management

Based on observations as well as resident and staff interviews, it was determined that the facility failed to maintain a safe, comfortable, and home-like interior one of two nursing units (2nd floor). Findings include: The grievance log documented on May 4, 2025, environmental concerns pertaining to lack of cleanliness in the building and overflowing trash. Observation in Resident 8's room on July 14, 2025, at 2:25 PM: the trash can at the sink was overflowing; one package of wipes under Resident 8's bed and brown food crumbs on the floor around the bed; a white powdery film on the night stand (able to be wiped away with a paper towel); the baseboard to the right of the door had a dried brown substance; behind the door were 2 enabler bars, a dusty blue foam square cushion and a headboard from Resident 8's bed; and the windowsill contained a white film and dried watermarks around the plants. Resident 8 stated that her room has not been cleaned by housekeeping since July 10th, and nursing staff have not emptied the trash can at the sink. Observation with the Nursing Home Administrator on July14, 2025, at 3:00 PM the environmental concerns remained as stated above, and the Nursing Home Administrator confirmed the room needed to be cleaned. At that time Resident 15, Resident 8's roommate, confirmed that housekeeping has not cleaned their room since July 10th. Observation in Resident 16's room on July 14th, 2025, at 2:57 PM. On the floor in front of her closet was a soiled pair of pants and a bag containing a soiled brief, crumbs of food on the floor near her bed, and seven dried red stain/marks on the privacy curtain; and in the bathroom the toilet contained a brown substance around the entire inside of the bowl and urine and wipes were inside the toilet, three light brown pieces of unknown substance were on the floor to the left side of the toilet. Resident 16 stated that her room is not cleaned daily. Observation and interview with the Nursing Home Administrator on July 14, 2025, at 3:21 PM the environmental concerns remained as stated above, and the Nursing Home Administrator confirmed the room needed to be cleaned. Observation in Resident 13's room on July 14, 2025, at 2:51PM food crumbs were on the floor around his bed and on the bilateral floor mats. The mats also contained a white film. Observation and interview with the Nursing Home Administrator on July 14, 2025, at 3:24 PM the environmental concerns remained as stated above, and the Nursing Home Administrator confirmed the room needed to be cleaned. Observation in Resident 14's room on July 14, 2025, at 2:51PM under the bed were torn tissues, three empty clear plastic cups, one black hanger, and a pink bin. On the floor in the bathroom was a used tissue, a urinal, tan crumbs, the baseboard contained a brown film, and the floor tiles were lifted to the left of the toilet; there was a strong urine odor. Observation and interview with the Nursing Home Administrator on July 14, 2025, at 3:24 PM the environmental concerns remained as stated above, and the Nursing Home Administrator confirmed the room needed to be cleaned. Observation on July 14, 2025, at 2:55 PM the floor inside and outside the chapel and down Sunshine Way contained black wheelchair marks, dried brownish grey patches, and light brown food crumbs. Observation and interview with the Nursing Home Administrator at 3:20 PM the floor remained as stated above, and the Nursing Home Administrator stated that she would find out if housekeeping had cleaned the area that day (it was later noted that the area was not cleaned and there was a call off in housekeeping). Observation on July 15, 2025, at 9:00AM in the chapel on the second floor the air conditioning wall unit to the left had 5 dried dark brown smudge marks on the control panel. Of the three units in that room none of them were operational (the ambient temperature in the room was comfortable). The middle window had a dead vine growing up through the window into the building from the outside of the building. Interview with the Nursing Home Administrator on July 15, 2025, at 10:00 AM it was revealed that a work order would be submitted. 28 Pa. Code 201.18 (b)(1)(3)(e)(2.1) Management

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for two of 6 resident clinical records reviewed (Residents 2 and 6).Clinical record review of Resident 2 documented diagnoses that included: metabolic encephalopathy (a brain disorder caused by a chemical imbalance in the blood stemming from an underlying illness or organ dysfunction), diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), obesity, frequent falls, chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe), atrial fibrillation (irregular, often rapid heart rate that causes poor blood flow), dysphagia (difficulty swallowing), congestive heart failure (the heart can't pump enough blood to meet the body's need), and shortness of breath. Review of Resident 2's Medication Administration Record (MAR- documentation of administration of physician orders) pertaining to NovoLog Flex Pen Subcutaneous (under the skin) Solution Insulin aspart (a rapid acting insulin) Inject as per sliding scale: if 151 - 200 = 3 units; 201 - 250 = 5 units; 251 - 300 = 8 units; 301 - 350 = 10 units; 351 - 400 = 12unit and if >400 give 15 units and notify MD, with meals related to diabetes mellitus, start date May 6, 2025. Vitals and MAR documented blood sugar was above 400 ml/dl on the following dates: 431 ml/dl on May 25th at 6:20 PM; and 446 ml/dl on May 30th at 5:15 PM. Further clinical record review documented 14 units of aspart insulin was administered on May 25th at 6:20 PM and the supervisor was made aware. There was no documentation aspart insulin was administered on May 30th or that the physician was notified. Progress notes failed to document that the physician was notified on the 25th or 30th. Interview with the Director of Nursing on July 15, 2025, at 3:15 PM revealed that physician orders should be followed. Review of Resident 6's clinical record documented diagnoses that included muscle weakness, abnormalities of gait, and right knee pain. Interview with Resident 6 on July 15, 2025, at 8:30 AM it was revealed she sustained a fall several weeks ago and sustained a brush burn on her left forearm near her elbow. She stated at the time of the fall the facility placed a bandaged over the area but never cleaned it. No one looked at the area for three days, so she requested to have the area cleaned and rebandaged. Observed a white bandaged date marked July 13, on 3-11 shift. Progress note dated July 3, 2025, at 1:43PM documented Resident 6 was participating in an outside activity when she fell to the ground and sustained a skin tear on the left lower arm. No documentation that the physician was notified, or treatment orders were obtained. Further review of Resident 6's clinical record failed to include physician orders for a treatment to Resident 6's left arm. During an interview with the Director of Nursing on July 15, 2025, at 3:15 PM it was revealed that the resident should have a standard order for the aforementioned dressing and treatment. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(1) Nursing services

Based on clinical record review, observations, and staff interviews it was determined that the facility failed to maintain adequate personal hygiene and grooming of residents' dependent on staff for assistance with incontinence care for two of 15 resident s reviewed (Residents 12, and 16).Review of resident council meeting minutes documented:June 19, 2025, call bells are taking over an hour to be answered, staff turning off call bells without helping the resident or stating they'll be back and never return, Nursing Assistants sitting at the nursing desk on their phone on 2nd and 3rd shift, ear buds in during care. The expectation was for call bells to be answered in 10-20 minutes.May 15, 2025, call bells are not being answered or are being turned off without resident's needs being met (mainly 3rd shift), and ear buds are worn during care. Discussed calling down to the receptionist if call bells are being ignored and to Nursing Home Administrator over the weekend and calling the Director of Nursing or the Nursing Home Administrator in real time to report Nursing Assistants.April 17, 2025, residents are waiting hours in soiled clothing and bedding before call bells are answered, 3rd shift not doing their job causing 1st and 2nd shift to fall behind. Interviews with multiple Residents on July 15, 2025, between 2:00 and 3;00 PM it was revealed extended call bell wait times for incontinence care. Resident 4 stated there were times she has waited over 20 minutes for the call bell and eventually she has taken herself to the restroom, however she has difficulty backing her wheelchair out of the restroom. Resident 8 stated she has waited two hours for her call bell to be answered. It was also revealed that she is a heavy sleeper and if they don't wake her on night shift she remains in a soiled brief for hours. She prefers to get out of bed into her wheelchair for an hour or two each day however she is hesitant to do so because she is left in her chair well into the next shift. Resident 15 revealed staff turn off call bell and don't respond to the resident needs. Observations on July 15, 2025, at 2:50 PM at the second-floor nursing station there were two Nurses and three Nursing Assistants; two of the Nursing Assistants were utilizing their personal cell phones. The two Nurses and the other Nursing Assistant were utilizing facility computers. Review of Resident 12's clinical record documented diagnoses that included urge incontinence, and dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking). Further review of the clinical record documented a care plan intervention for a toileting program: bladder retraining; toilet upon rising, before bed, after each meal, & as needed based on resident's needs, initiated April 8, 2025. Observation of Resident 12's room on July 14th at 2:19 PM the call bell was on, and both residents were sleeping. The call bell was off at 2:57 PM and interview with Resident 12 revealed the staff must have come and turned the call bell off and it was revealed that she needed to use the restroom. The call bell was turned back on at 3:00 PM and staff provided assistance at 3:22 PM. Review of Resident 16's clinical record documented diagnoses that included displaced fracture right lower leg, anxiety, abnormalities of gait, history of falling. Further review of the clinical record documented a care plan focus area for urinary incontinence related to impaired mobility, initiated June 24, 2025; interventions included provide assistance with toileting or provide incontinent care as needed, initiated June 24, 2025. Observation of Resident 16's room on July 14th, 2025, at 2:42PM the call bell was on and resident 16 was sitting in her wheelchair with her back to the door. The call bell was off at 2:57 PM. Interview with Resident 16 at 2:57 PM revealed that staff came in and turned the call bell off and didn't assist her with incontinence care. The Resident stated her brief was soiled and required assistance to lay down in bed. It was also revealed that if she soils her brief over night she has to wait until morning for her brief to be changed, and she prefers to be woken up for her brief to be changed. The night prior, she was left in a soiled brief for three hours. Observation with the Nursing Home Administrator on July 14, 2025, at 3:20 PM at the second-floor nursing station there were two Nurses and three Nursing Assistants; two of the Nursing Assistants were utilizing their personal cell phones. The two Nurses and the other Nursing Assistant were utilizing facility computers. During an interview with the Nursing Home Administrator on July 14, 2025, at 3:30 PM it was revealed the expectation is for call bells to be answered within 10 to 20 minutes and incontinence care should be provided timely. 28 Pa code 211.12.(d)(1)(5) Nursing services

Based on facility policy review, observations, and staff interview, it was determined that the facility failed to store food and beverages and utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen. Findings include: Review of facility policy, titled Food Storage last reviewed [DATE], read, in part, It is the policy of this facility that food storage areas be maintained in a clean, safe, and sanitary manner. Food storage areas should be clean at all times. All perishable food items shall be labeled with the name of the product and an 'opened date' after opening product. Food items should be closed to air to prevent decline of quality in product and cross contamination. Open should be discarded after 5 days. A food storage audit shall be conducted on a weekly basis by dietary manager or designee. All expired foods shall be discarded immediately upon finding. Scoops are not to be stored in containers with food products such as flour, sugar, and thickener, etc. Scoops are to be stored in a separate container with a lid or in a closed Ziploc bag. All scoops are to be washed on a weekly basis or when product is switched out. Observation in the dry storage area on [DATE], at 10:13 AM, revealed one bottle of honey thick orange juice with a best by date of [DATE]. Observation in the reach-in freezer in the dry storage area on [DATE], at 10:16 AM, revealed two packs of waffles not labeled with the name of the product or use by date; two open packages of waffles not labeled with the name of the product or an open date; and one pack of fish patties open, not labeled with the name of the product or an open date, and left open to air. Observation in the main kitchen on [DATE], at 10:17 AM, revealed one container of flour with a scoop stored inside; and one container of sugar with a scoop stored inside. Observation in the milk reach-in refrigerator on [DATE], at 10:18 AM, revealed two containers of milk with a sell by date of [DATE], and a water bottle and a soda bottle belonging to kitchen staff members. Further observation in the milk reach-in refrigerator on [DATE], at 10:19 AM, revealed the bottom of the refrigerator was heavily soiled with liquid and dried milk. Interview with the Nursing Home Administrator on [DATE], at 10:12 AM, revealed it was the facility's expectation that expired items are discarded, foods items are labeled and dated per facility policy, and food items and kitchen equipment are stored, cleaned, and utilized in accordance with professional standards. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.6(f) Dietary services

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for one of one resident reviewed for dialysis (Resident 23). Findings Include: Review of facility policy, titled End Stage Renal Disease, Care of a Resident with, last reviewed on March 31, 2025, read, in part, Residents with end stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. Education and training of staff includes, specifically: the type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis. The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. Review of Resident 23's clinical record revealed diagnoses that included ESRD (failure of kidney function to remove toxins from blood) and dependence on renal dialysis (an artificial process for removing waste products and excess fluids from the body that is needed when the kidneys are not functioning properly). Review of Resident 23's clinical record revealed she has been receiving dialysis treatments since 2022, and revealed an active physician order for dialysis three times per week at an outside facility. Further review of Resident 23's physician orders revealed an active order for Dialysis Precautions: No blood draws, injections, or blood pressure from left arm. Review of Resident 23's comprehensive care plan revealed an active focus area for renal insufficiency (compromised kidney function) with an intervention for, Do not take blood pressure or blood specimens from left arm and coordinate dialysis care with the dialysis treatment facility. Review of Resident 23's blood pressure measures revealed it was documented that they were taken in the left arm nine times since July 12, 2024 Review of select dialysis communication forms (a form utilized to facilitate communication of assessment data between a dialysis center and a nursing care facility), revealed none were provided for the following dates that Resident 23 attended dialysis: February 5 and 12, 2025; March 5, 12, 19, and 26, 2025; April 9, 11, 18, 21, 23, 25, 28, and 30, 2025; and May 5, 7, 9 and 12, 2025. . During an interview with the Director of Nursing on May 21, 2025, at 10:19 AM, she revealed the blood pressures that were documented in the left arm were likely documentation errors, however, staff education will be implemented to ensure blood pressures are not taken in Resident 23's left arm. She further revealed she was unable to locate the missing dialysis communication forms from Resident 23's clinical record, and she would expect them to be completed and available for review. 28 Pa Code 211.5(f) Medical records 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of select facility documentation and staff interview, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least once every 12 months for four of five nurse aides reviewed (Employee 7, 8, 9, and 10). Findings include: Review of select facility documentation revealed a list of nurse aides that had worked at the facility for greater than a year; Employees 6, 7, 8, 9, and 10 were selected from the list to review their last annual nurse aide performance evaluations. During an interview with the Director of Nursing on May 22, 2025, at 9:54 AM, she revealed she was unable to locate annual evaluations in the past 12 months for Employees 7, 8, 9, and 10; and she would expect them to be available and located in their employee files. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews (MRRs) were completed at least once a month by a consultant pharmacist and responded to in a timely manner by the attending physician or prescriber for four of five residents reviewed for unnecessary medications (Resident's 14, 23, 30, and 46). Findings include: Review of facility policy, titled Medication Regimen Review (Monthly Report), without revision date, revealed, The consultant pharmacist reviews the medication regimen of each resident at least monthly. Recommendations are acted upon by the facility staff and or prescriber. Review of Resident 14's clinical record revealed diagnoses that included hypertensive heart disease (a condition where heart problems develop due to prolonged high blood pressure) and chronic kidney disease (a progressive condition where the kidneys gradually lose their ability to filter waste and excess fluid from the blood). Review of Resident 14's electronic medical record failed to reveal any monthly pharmacy reviews completed for Resident 14's medications in August 2024 and November of 2024. Interview with the Director of Nursing (DON) on May 22, 2025, at 10:45 AM, revealed that they would expect a pharmacy review of Resident 14's medications would be completed monthly. Review of Resident 23's clinical record revealed diagnoses that included type 2 diabetes mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), end stage renal disease (failure of kidney function to remove toxins from blood)2, and dependence on renal dialysis (an artificial process for removing waste products and excess fluids from the body that is needed when the kidneys are not functioning properly). Review of Resident 23's electronic medical record failed to reveal monthly pharmacy reviews completed for Resident 23's medications in July and August 2024, as well as in April 2025. Review of Resident 23's September 2024 pharmacy recommendation failed to reveal it was responded to by facility staff and or a prescriber. During an interview with the DON on May 22, 2025, at 10:14 AM, she revealed Resident 23 follows with psychiatry services, and was seen on September 25, 2024, where they responded to the recommendation to attempt a dose reduction on a psychotropic medication she was prescribed; however, she would expect the physician would have responded to the recommendation that they were going to defer the recommendation to psychiatry services. She revealed the other two recommendations on Resident 23's September 2024 MRR were not responded to, that they were recommended again on the December 2024 MRR, and she was unable to locate a physician response to the December 2024 MRR. She further revealed her expectation that pharmacy reviews are completed monthly and responded to appropriately. Review of Resident 30's clinical record included diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things), hypertension (high blood pressure), and anxiety disorder (a persistent feeling of worry, nervousness, or unease). Review of Resident 30's electronic medical record failed to reveal monthly pharmacy reviews were completed for Resident 30's medications in July 2024 and August 2024. During an interview with the DON on May 22, 2025, at 10:14 AM, she revealed she would expect that pharmacy reviews are completed monthly and responded to appropriately. Review of Resident 46's clinical record included diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning) and severe protein-calorie malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it gets). Review of Resident 46's electronic medical record failed to reveal monthly pharmacy reviews were completed for Resident 30's medications in July 2024 and August 2024. During an interview with the DON on May 22, 2025, at 10:14 AM, she revealed she would expect that pharmacy reviews are completed monthly and responded to appropriately. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of facility policy, clinical record and facility documentation, observations, resident and staff interview, it was determined that the facility failed to ensure that one of two residents reviewed was provided with adequate supervision to prevent accidents which resulted in actual harm to Resident 1 sustaining a fall, requiring transfer to the hospital via emergency medical services and the diagnosis of a fracture involving the neck of the right humerus (long bone of the upper arm). Findings include: Review of facility policy, Safety and Supervision of Residents, revised July 2017, revealed the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Review of Resident 1's clinical record included diagnoses of, but not limited to, Malignant Neoplasm (cancer) of the kidney and Muscle Weakness. Review of Resident 1's current care plan revised April 28, 2023, identified the resident was at moderate risk for falls related to prior falls, weakness, renal cell cancer, COPD (chronic obstructive pulmonary disease - chronic inflammatory lung disease that causes obstructed airflow from the lungs), Hypertension (high blood pressure), Spinal Stenosis (abnormal narrowing of the spinal canal), Anemia (deficiency of red blood cells), vitamin D deficiency, seizures, and Depression. The care plan also indicated that the resident had an ADL (activities of daily living) self-care performance deficit related to fatigue, renal cell cancer, COPD, HTN, spinal stenosis, anemia, and depression with an intervention indicating that the resident required 1 staff to turn and reposition in bed. Review of physician's orders dated February 2, 2024, indicated resident had an air mattress to the bed. Review of Resident 1's annual MDS (Minimum Data Set - periodic assessment of resident needs) dated May 3, 2024, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, indicating the resident was cognitively intact. The MDS assessment also revealed that the resident required the extensive assistance of two persons for bed mobility. Review of Resident 1's fall risk assessment dated [DATE], revealed a score of 55, indicating that the resident was at high risk for falling. Review of physician's progress note of May 15, 2024, revealed resident slipped out of bed - hit right elbow - no LOC [loss of consciousness] and sustained a skin tear to the right elbow. Review of Resident 1's nurses note of May 15, 2024, at 10:59 a.m. revealed UM [unit manager] made this writer aware about resident had fall. this writer came to resident's room and seen resident on the floor between her dresser and her bed. resident said this happen when CNA rolled her on her on her left side, there was no pink pad under me so she told me to stay right there, and went out to the room to get pad and i felt unsteady and try to reached out to the dresser so i could steady myself and then i went down to the floor on my right side. Neuro checks initiated, vitals were taken and entered in PCC [Point Click Care - electronic medical record]. resident assessed by RN [registered nurse], OPTUM CRNP [certified registered nurse practitioner] and [attend physician]. resident had skin tear on right elbow, resident C/O [complained of] pain 10/10 to her left knee. PRN [as needed] pain medication given. N/O [new order] for X-ray given by MD. Review of nurses note of May 15, 2024, at 3:06 p.m. indicated x-ray result was negative for any fractures. Review of Resident 1's clinical record including nurses note of May 16, 2024, at 5:58 a.m. revealed right arm x-ray done at 11:00 p.m. Review of clinical record of Resident 1's interdisciplinary note of May 16, 2024, at 8:58 a.m. indicated CRNP made aware of acute right humeral neck fracture. Further review of Resident 1's nurses note of May 16, 2024, at 9:52 a.m. revealed resident sent out to the hospital related to right humeral neck fracture. Additional nursing note at 3:12 p.m. indicated resident was back from the hospital with a sling and orders to follow up with orthopedic surgery. Review of orthopedic surgery consult of May 20, 2024, revealed resident seen for right proximal humerus fracture with recommendations to continue the sling, not use the right upper extremity for transfers, and follow up in two weeks. Review of Employee E3's statement obtained on May 15, 2024, revealed I was doing care on resident, stepped out room to get pad for her. came back patient was on fall [sic]. she told me she was reaching for dresser when falling. Observation on May 30, 2024, at 10:00 a.m. revealed Resident 1 lying in bed with right arm in sling and right hand with edema (swelling) elevated on pillow. Interview with Resident 1 on May 30, 2024, at 10:00 a.m. revealed staff was changing resident and had forgotten the incontinence pad. Resident 1 revealed he/she was on his/her left side when staff left the room to retrieve a pad from the laundry cart. Resident 1 indicated he/she became unsteady, reached for the dresser, and rolled out of the bed onto the right side. Resident 1 stated that he/she continues to have pain, especially when turned on the right side. Review of physician's orders included an order for Oxycodone HCl 5 milligrams (mg) one tablet every eight hours as needed for moderate pain and Oxycodone HCl 10 mg one tablet every eight hours as needed for severe pain. Review of Resident 1's May 2024 Medication Administration Record (MAR) revealed that prior to the fall from May 8-14, 2024, the resident received Oxycodone HCl 5 mg twice and did not receive any Oxycodone HCl 10 mg. Further review of the May 2024 MAR revealed that from May 15-30, the resident received Oxycodone HCl 5 mg twice and received Oxycodone 10 mg HCl 18 times. Interview with the Nursing Home Administrator on May 30, 2024, at 12:30 p.m. revealed the staff should not have left the resident unsupervised while retrieving supplies. The facility failed to ensure Resident 1 was provided with supervision which resulted in actual harm to Resident 1 sustaining a fall, requiring transfer to the hospital via emergency medical services and the diagnosis of a fracture to the right humerus. 28 Pa. Code: 211.5(f) Clinical records Previously cited 4 /19/24 28 Pa. Code: 211.10(d) Resident care policies 28 Pa. Code: 211.12(d)(1) Nursing services 28 Pa. Code: 211.12(d)(5) Nursing services

Based on observation, review of facility policies and select documents provided by the facility, and staff interviews, it was determined the facility failed to maintain an infection control program by failing to follow infection control guidelines from the Centers for Disease Control and Prevention (CDC) and the Pennsylvania Department of Health (PA-DOH) to reduce the spread of infection and prevent cross-contamination during the COVID-19 pandemic. This failure placed the facility in an Immediate Jeopardy situation for one of four residents reviewed (Resident R1). Findings include: A review of Pennsylvania Department of Health 2020-PAHAN-526-09-17- ADV Point-of-Care [MEDICATION NAME] Testing for [DIAGNOSES REDACTED]-CoV-2 in Long-term Care Facilities revealed: Testing of symptomatic residents- If an [MEDICATION NAME] test is positive, and no quality assurance issues are identified, no confirmatory test is necessary. Conduct contact tracing, notifications, and quarantine/isolation of exposed persons. Further review revealed that if a confirmatory RT-PCR test is collected within 48 hours (preferably collect within 24 hours), individuals should be assumed infectious until the confirmatory test results are completed. A review of the information from the Centers for Disease Control and Prevention site titled, Interim Guidance for [MEDICATION NAME] Testing for [DIAGNOSES REDACTED]-CoV-2, updated on December 20, 2020, revealed: If Symptomatic -> tested (+) [MEDICATION NAME] -> Consider Infected with [DIAGNOSES REDACTED]- CoV-2. A review of the Pennsylvania Department of Health 2020-PAHAN-530-10-07-ADV Long-term Care Facility Guidance for Testing and Cohorting: Response to an Outbreak and Residents with Exposure to COVID-19 revealed, that for a resident who develops symptoms consistent with COVID: Test for COVID-19 immediately; while awaiting the result, move to a private room or remove roommate from the current room. Consider roommate exposed. Keep residents in the current Zone if they are in an Exposed Zone. If the symptomatic resident is in an Unexposed Zone, move to the Exposed Zone in a private room; and If test positive, move to COVID (+) zone. A review of the facility's policy and procedure titled, Coronavirus (COVID-19) PPE (Personal Protective Equipment) & Cohorting Policy and Procedure, undated revealed that the facility follows current guidelines and recommendations for the prevention and control of the Coronavirus. Procedure #9 revealed: Residents that develop signs and symptoms of COVID should be moved to the Yellow zone and tested for COVID. If the result is COVID (+) the resident should be moved to the Red zone. If the result is COVID (-) they should still stay on the yellow zone for 10 days. A review of Resident CL1's admission notes dated January 13, 2021, at 1:40 p.m. revealed that the resident was admitted to the facility for a [DIAGNOSES REDACTED]. A review of Resident CL1's hospital records revealed a negative COVID-19 test result on January 13, 2021, at 3:33 a.m. A review of Resident R1's admission assessment dated [DATE], at 4:40 p.m. revealed that the resident was admitted to the facility for a right acetabular fracture (A break in the socket portion of the ball-and-socket hip joint), and heart failure. A review of Resident R1's hospital records revealed a negative COVID-19 test result on January 13, 2021, at 11:48 a.m. A review of the facility census and an interview with the Director of Nursing (DON) on January 25, 2021, at 1:00 p.m. revealed that Resident CL1 and Resident R1 were both in the same room. A review of Resident CL1's progress notes dated January 17, 2021, at 9:45 p.m. revealed that the resident had a temperature of 100.6 F (normal body temperature range from 97F - 99F), had a loose nonproductive cough, rhonchi (an abnormal breath sound characterized by a low-pitched breath sound) in posterior bilateral lower lobes. Further review of the same notes revealed that the resident had also reported a sore throat. A [DIAGNOSES REDACTED]-COV-2 (COVID -19 [MEDICATION NAME]) rapid test (this test detects protein fragments specific to the Coronavirus) was administered with a positive result. A new order to obtain [DIAGNOSES REDACTED]-COV-2 (COVID-19) PCR testing (this test detects genetic material that is specific to [MEDICAL CONDITION] and can detect [MEDICAL CONDITION] within days of infection), and a chest X-ray to rule out pneumonia (an infection that inflames air sacs in one or both lungs) was obtained. A review of the progress note for Resident CL1, dated January 18, 2021, at 2:32 p.m. revealed an alert charting due to a positive COVID rapid test. A review of the same note revealed the resident was running a low-grade fever this shift and complained of dry, nonproductive cough at the end of the shift. A review of the progress note for Resident CL1, dated January 19, 2021, at 4:01 p.m. revealed that the resident was moved to a room on the COVID unit with his belongings, two days after the resident had exhibited symptoms related to COVID and testing positive for COVID [MEDICATION NAME] (rapid) test. A review of the progress notes dated January 19, 2021, at 10:35 p.m. revealed that the Nursing Home Administrator (NHA) was informed that the resident's COVID PCR test was positive. The resident was already in isolation, Red Zone. The resident and the responsible party were notified. An interview with the NHA and the Director of Nursing (DON) on January 25, 2021, at 1:00 p.m. revealed that when Resident CL1 exhibited symptoms related to COVID-19 and tested positive for the COVID-19 [MEDICATION NAME] (rapid test) test on January 17, 2021, a PCR test was ordered and obtained. Resident CL1 remained in the room with Resident R1. The NHA stated that Resident CL1 was not separated from Resident R1 despite showing symptoms and testing positive for COVID [MEDICATION NAME] (rapid) test because the facility was waiting for the COVID PCR test. The NHA further stated that the COVID Rapid test might be false-positive and transferring Resident CL1 might expose other residents. The NHA stated that while waiting for the test, precautions were implemented by pulling the divider curtain and ensuring that staff was wearing and changing personal protective equipment (PPE), in between caring for the residents. A review of Resident R1's progress notes dated January 18, 2021, at 5:20 a.m. revealed the resident's [DIAGNOSES REDACTED]-COV-2 (COVID-19) PCR testing was completed. A review of the progress notes dated January 19, 2021, at 4:01 p.m. revealed that Resident R1 was moved to a room in a COVID unit with all belongings. A review of the progress notes dated January 19, 2021, at 10:35 p.m. revealed that the NHA was notified that Resident R1's COVID PCR test was positive, and the resident was on the COVID isolation, Red Zone. A review of the Nurse Practitioner's Progress Notes dated January 19, 2021, at 7:23 p.m. revealed that as per nursing, Resident R1 had been exposed to COVID 19, has a cough and intermittent fevers. He has rapidly tested negative for COVID. A review of Resident R1's clinical records, progress notes, and vital signs revealed that Resident R1 had a documented temperature of 101.1F on the day of his/her admission on January 13, 2021, at 5:10 p.m. [MEDICATION NAME] (a medication to treat mild pain and fever) was administered and the temperature went down to 99.4 F. There was no other documentation of elevated temperature and no documentation/assessment that the resident had cough until January 19, 2021, as documented by the NP. Clinical records review also failed to reveal when the Rapid test for Resident R1 was done. An observation was conducted on January 25, 2021, at 11:00 a.m. and Resident R1 was observed in an isolation room on a COVID unit. An interview with the DON on January 25, 2021, at 11:50 a.m., was conducted and stated that when a resident showed symptoms related to COVID, a COVID [MEDICATION NAME] (rapid test) will be done. If positive, the resident will be moved to the COVID unit immediately and the roommate will be tested for COVID [MEDICATION NAME] (rapid) test. An interview with the Medical Director on January 25, 2021, at 2:00 p.m. was conducted. The Medical Director confirmed that Resident CL1 should have been moved and separated from Resident R1 upon showing symptoms and testing positive for COVID [MEDICATION NAME] test. The above was conveyed with the DON on January 25, 2021, at 11:45 a.m. and the DON agreed that Resident CL1 should have been separated from Resident R1 upon exhibiting symptoms related to COVID and testing positive for COVID [MEDICATION NAME] (Rapid) test. The facility failed to implement timely infection control measures related to COVID-19 for Resident CL1 and Resident R1 that resulted in Resident R1 who tested positive for COVID -19 after exposure to a symptomatic roommate who tested positive for COVID-19 on January 17, 2021, who remained in the same room with Resident R1 for two days, and was not immediately moved to a COVID-19 unit. An immediate jeopardy situation was identified, and the Nursing Home Administrator was notified and provided the immediate jeopardy template on February 9, 2021, at 4:52 p.m. for the facility's failures to ensure implementing infection control timely, and proper cohorting to control and potentially mitigate the spread of COVID-19 in the facility. The facility submitted and completed an immediate action plan which included: Immediate education to all staff regarding cohorting of residents, utilization of different zones (Green Yellow, Red) in response to test results and in accordance with the PA HAN 530. Upon resuming resident testing, any positive residents will be moved to the Red Zone (located on the 3rd floor behind a barrier). Upon needing more rooms, the Red Zone will be extended to include additional six more rooms. A dedicated Red Zone, Yellow Zone, and Green Zone were already established and designated since November 22, 2020, and staff had already been educated at that time. If a resident showed any signs and symptoms of COVID, they will be tested per POC and followed up with a PCR test. Upon the result of the POC test, if positive, the resident will be immediately moved to a Red Zone Room. If the result is negative, the resident will be immediately moved to a Yellow Zone until the PCR test results. The roommate of the positive resident will be moved to a Yellow Zone room. The DON/designee will audit that (+) COVID or suspected (+) COVID residents were moved to specific areas timely, for one month, ending on March 8, 2021. This action plan was accepted on February 9, 2021, at 8:18 p.m. On February 10, 2021, a review of documentation was completed of employee (including agency staff), education regarding cohorting of residents, and appropriate zone placement. Observations of different zone areas and placement of residents according to symptoms, COVID test result and exposure; clinical records reviewed on timely and appropriate implementation of isolating and cohorting of residents based on symptoms and COVID test result; Staff were interviewed to confirm that education was received and could verbalize knowledge and comprehension on appropriate and timely placement to appropriate zones of residents showing symptoms, testing positive, and had a possible exposure; audits reviewed, indicating no resident with new symptoms and positive COVID test. The Immediate Jeopardy was lifted on February 10, 2021, at 12:07 p.m. after confirmation the immediate action plan was implemented, and the Nursing Home Administrator was informed the residents were no longer in Immediate Jeopardy. 42 CFR 483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 9/27/19 28 Pa. Code 211.12(c)(5) Nursing services. Previously cited 11/23/20, 9/27/19 28 Pa. Code 211.12(a)Nursing services. Previously cited 11/23/20 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 9/27/19

Based on observation, staff interview, review of the facility policy, and clinical records review, it was determined that the facility failed to appropriately and comprehensively assess residents skin, and failed to develop and implement measures and treatment in a timely manner for three of four residents reviewed (Residents R1, R2, and CL2). The failure to develop a care plan timely with interventions to prevent pressure ulcer formation of a resident identified at risk for pressure ulcer resulted in actual harm to Resident R1 in the development of an intact blood blister to the left heel. The failure to accurately assess, develop and implement preventative measures, and skin treatment resulted in actual harm to Resident CL1 evidenced by the development of a pressure dark purple area to coccyx (commonly referred to as a tail bone) and open area to right hip. Findings include: A review of the facility policy titled, Pressure Ulcer/Skin Breakdown-Clinical Protocol, last revised on April 2007, revealed that the physician and staff will examine the skin of a new admission for ulcerations or indication of a Stage 1 pressure (the skin appears reddened and does not blanch (turn white when pressed and then return to red or pink indicating good blood flow)) area that had not yet ulcerated at the surface. Further review of the same policy revealed that the nurse shall assess and document/report the following: Full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue. An interview with the Director of Nursing (DON), on January 27, 2021, at 11:30 a.m. revealed that on admission, residents are assessed by a Registered Nurse (RN) from head to toe. Any skin issues will be measured and documented. The physician and the responsible party will be notified, treatment orders will be ordered, and will be referred to the wound doctor. Also, a care plan will be developed and updated, and weekly skin checks will be completed. A Review of Resident R1's clinical record revealed [DIAGNOSES REDACTED]. A review of the resident's Admission assessment dated [DATE], at 4:40 p.m. revealed that the resident was admitted to the facility on [DATE]. A review of the same assessment revealed that the resident did not have skin issues upon admission. A note on the same assessment revealed refuses to move BLE (Bilateral Lower Extremities) b/c (because) of pain in the right pelvis. A review of the resident's Braden Assessment (a tool used to determine risk factors for pressure sore development) completed on January 13, 2021, revealed that the resident was bedfast and was completely immobile placing the resident at-risk for a pressure sore. A review of the resident's Admission Minimum Data Set (MDS- an assessment tool used to facilitate the management of care) dated January 20, 2021, revealed that the resident had moderate cognitive impairment and required extensive two people assistance with repositioning in bed. Clinical records review failed to reveal that a care plan with interventions to prevent pressure ulcer formation was developed for Resident R1 until January 21, 2021, eight days after identifying that the resident was at risk for pressure ulcer formation. A review of the resident's January 2021 Medication Administration Record [REDACTED]. A review of the same MAR indicated [REDACTED]. Further review of the clinical records failed to reveal documented evidence that the body audit was completed on January 20, 2021. A review of the progress note dated January 23, 2021, at 4:15 p.m. revealed that the resident's left heel had a flat blood blister 5.0 x 3.0 centimeters, no drainage, skin fragile, cushion dressing applied with heel protector foam. Pillow placed to offload left heel. An observation on January 27, 2021, at 10:00 a.m. revealed Resident R1 had a wound on the left heel, flat intact dry blister, 80-90% black in color. An interview with licensed nurse Employee E5 on January 27, 2021, at 10:00 a.m. revealed that she was an agency nurse and was not familiar with the resident yet. An interview with the DON on January 27, 2021, at 11:30 a.m. revealed that the care plans were not completed and updated because the nurse who was doing the care plan resigned. The DON stated that she is currently doing the care plans. The facility failed to develop and implement measures in a timely manner, to prevent the development of a pressure ulcer to Resident R1, who was assessed to be at risk for developing pressure sores, resulting in actual harm in developing a blood blister to the left heel. A review of Resident CL2's [DIAGNOSES REDACTED]. A review of the Admission Assessment Notes dated January 7, 2021, at 4:00 p.m. revealed a skin assessment completed as follows: Site: coccyx, Type: pressure, Measurement: 1.5 x0.5 x 0.01, Stage: N/A. A review of the Weekly Skin/Body Check completed on January 7, 2021, at 4:01 p.m. revealed Site: Coccyx, Type: Pressure, Measurement: 1.5 x 0.5 x 0.01, Stage: N/A. Further review of the same assessment revealed a note indicating a small red area 0.5 cm left of gluteal (group of three muscles that make up the buttocks), near Coccyx. Clinical records review failed to reveal that the physician was notified of the identified skin impairments on admission and that a treatment order was made. A review of the hospital records, skin assessment dated [DATE], revealed that the resident's coccyx was red nonblanchable (when the area is pressed it does not turn white), sinus (narrow opening or passageway extending from a wound underneath the skin that results in dead space with potential for abscess formation), but no drainage noted. A review of the Braden Scale Assessment completed on January 7, 2021, at 4:01 p.m. revealed that the resident was moderately at risk for developing pressure ulcers. A review of the resident's MDS dated [DATE], revealed that Resident CL2 was cognitively intact. A review of the same MDS revealed that the resident was at risk for developing a pressure ulcer, occasionally incontinent of urine (no or insufficient voluntary control), usually incontinent of the bowel, and required extensive two people assistance with bed mobility and toileting. A review of the resident's care plans failed to reveal that a plan of care with interventions was developed upon identifying Resident CL2's skin impairments on admission and risk for further skin impairments. A review of the progress notes dated January 13, 2021, at 2:27 p.m. revealed Supervisor made aware open area found on resident's right hip. Applied foam dressing for now. Clinical records review failed to reveal a complete assessment of the identified open area to the right hip. Clinical records review also failed to reveal that the physician was notified and that an order was made for the identified area to the right hip and there was no documented evidence that the right hip open area treatment completed by the nurse on January 13, 2021, was continuously completed. A review of the progress notes dated January 15, 2021, at 11:07 p.m. revealed Assessed pressure area to the coccyx, the area is dark purple in color, no open areas noted, new treatment in place for foam dressing Clinical records review failed to reveal that a comprehensive assessment was completed for the identified dark purple area to the resident's coccyx on January 15, 2021, which includes the stage, and measurements of the skin impairment. A review of the January 2021 MAR indicated [REDACTED]. MAR indicated [REDACTED]. Further review of the treatment order revealed that the treatment did not specify the site to apply the foam dressing. Further review of the January 2021 MAR indicated [REDACTED]. Review of the clinical records did not reveal a reason on why the treatment on January 20, 2021, was not completed. A review of the progress note dated January 21, 2021, indicated writer was unable to complete during the shift will be passed onto oncoming shift, no follow up documentation found. January 2021 MAR indicated [REDACTED]. Clinical records review failed to reveal that the body audit/assessment scheduled for January 20, 2021 was completed. An interview with Employee E6, a nurse aide, on January 27, 2021, at 10:20 a.m. revealed that she/he took care of Resident CL2 but was uncertain regarding the condition of the resident's skin on the back. Employee E6 stated that the nurse was responsible for residents' treatments. Employee E6 stated that most of the nurses currently working on the unit are agency nurses. A review of the resident's active care plan revealed that the facility developed a plan of care with interventions regarding the resident's actual skin impairment on January 27, 2021, 20 days after admission and identification of skin impairment to the coccyx area, and 14 days after identification of the open area to the right hip. The facility failed to appropriately assess, develop and implement measures, and treatment in a timely manner for Resident CL2 resulting in actual harm, the development of an open area to the right hip and progression of a red nonblanchable pressure area to a dark purple pressure area to the coccyx. A review of Resident R2's Admission assessment dated [DATE], at 3:15 p.m. revealed that the resident was admitted to the facility with a [DIAGNOSES REDACTED]. A review of the same records revealed a wound to the coccyx, stage two (ulcer involving loss of the top layers of the skin) with measurements of 6.0 x 5.0 x 0.25. Wound treatment of [REDACTED]. A review of the Weekly Skin/Body Check completed on December 22, 2020, at 2:30 p.m. identified the coccyx wound as unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (dead tissue, yellow, green or tan in color that may be moist and loose in appearance) and eschar (dry, thick, leathery tissue)). A review of the record failed to reveal a comprehensive assessment of the unstageable wound to the coccyx. A review of the physician's order revealed an order on December 31, 2020, to change coccyx treatment to [MEDICATION NAME] (a wound care treatment that works by promoting new tissue formation and wound healing as well as reducing the risk of infection). A review of the Weekly Skin/Body Check completed on January 6, 2021, at 4:47 p.m. revealed that the resident still had an unstageable wound to the coccyx. The documentation failed to reveal a comprehensive assessment of the unstageable wound to the coccyx. A review of the progress note dated January 7, 2021, at 10:34 a.m. revealed that the resident was transferred to the hospital due to right lower leg surgical site not healing as anticipated. A review of the progress note dated January 7, 2021, at 6:01 p.m. revealed that the resident returned from the hospital on January 7, 2021. Further review of the progress note revealed Coccyx with large area of necrotic tissue, green/gray tissue. A review of the wound consult report dated January 14, 2021, revealed a stage four (ulcer involving loss of skin layers, exposing muscle and bone) coccyx ulcer, measuring 7.0x 5.0 x 0.3 cm, 50% thick adherent necrosis, and 50% slough. The wound treatment was changed to Santyl (a [MEDICATION NAME] enzyme that breaks up and removes dead skin and tissues). Progress notes review revealed that the resident was transferred and admitted to the hospital on January 14, 2021, due to right leg surgical wound deterioration. The resident was readmitted to the facility on [DATE]. A review of the resident's clinical records failed to reveal that the resident's coccyx wound was assessed when readmitted to the facility on [DATE]. MAR review [REDACTED]. The above was conveyed to the DON on January 27, 2021, at 11:30 a.m. The DON was unable to give a specific reason as to why the wound assessment of Resident R2 was not completed comprehensively, accurately, and timely. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.12(d)(5) Nursing Services Previously cited 11/23/20, 9/27/19 28 Pa. Code 211.12(c)(d)(1) Nursing Services Previously cited 9/27/19

Based on review of clinical records, facility policies and review of facility documentation, it was determined that the facility failed to ensure that one of three residents reviewed (Resident R1) was free of neglect during care, which resulted in actual harm to Resident R1 while being transferred via a mechanical lift and sustaining a right knee fracture. Findings include: Review of the facility policy titled Using a Mechanical Lifting Machine states, at least two nursing assistants are needed to safely move a resident with a mechanical lift Types of lifts that may be available in the facility are . sit to stand lifts. Staff was further instructed to document the following in the medical record, names and titles of staff assisting. Review of Resident R1's electronic clinical record revealed the [DIAGNOSES REDACTED]. Review of Resident R1's annual Minimum Data Set assessment (MDS - a mandated assessment of resident care needs) completed on (MONTH) 6, 2019, revealed that the resident was assessed with [REDACTED]. Further review of the MDS assessment indicated that the resident required extensive assist of two people for transfers and had no ambulation capacity. Review of Resident R1's care plan dated (MONTH) 16, 2019, identified the resident with self-care deficit related to physical limitation. Interventions listed on the resident's care plan included the use of a sit-to-stand lift for transfers. Further review of Resident R1's clinical record revealed a nursing note dated (MONTH) 23, 2019, at 11:00 a.m. the resident complained of right knee pain after being transferred from the wheelchair to the bed which happened some time during the week, resident does receive routine pain medication and was given PRN (as needed) Tylenol for pain which seem to help take the edge off, RN (Registered Nurse) assessed right knee and right lower extremity and noted slight swelling to right knee and lower leg which resident does have when she is in her chair .n.o. (new order) for right knee x-ray. Review of nursing documentation dated (MONTH) 24, 2019, at 11:26 a.m. noted the resident's right knee x-ray report was read by another radiologist and states suspicious of distal femur (right knee) fracture re (repeat) x-ray was recommended physcian aware n.o. for STAT (immediate) 2 view right knee x-ray, RP (Responsible Party) .was notified. Review of an x-ray report dated (MONTH) 24, 2019, at 3:11 p.m. confirmed that the resident sustained [REDACTED]. Further review of nursing notes dated (MONTH) 24, 2019, at 3:45 p.m. indicted that the resident's responsible party did not want the resident to have surgery and prefer that an orthopedic doctor review the x-ray report and recommended treatment without the resident being transferred out of the facility. Review of the facility investigation related to the right knee fracture sustained by Resident R1 revealed that the facility confirmed that Resident R1 was transferred either to bed or chair on three separate instances by one nursing assistant via a sit-to-stand lift. Review of a written statement obtained on (MONTH) 24, 2019, during an interview with Resident R1 noted the resident stated that she thinks her leg got hurt during a transfer a few days prior. She was unable to identify staff but stated it isn't someone she really recognized. Review of a written statement by non-licensed nursing agency staff, Employee E2 noted on (MONTH) 21, 2019, Employee E2 transferred Resident R1 from the wheelchair to the bed using the sit-to-stand lift by herself. Review of a written statement by non-licensed nursing agency staff, Employee E3 revealed I transfer (Resident) with one assist on Fri (Friday) to her chair. Review of a written statement by non-licensed nursing agency staff, Employee E4 revealed that Employee E4 transferred Resident R1 into bed utilizing the sit-to-stand by herself on (MONTH) 20, 2019. An interview with the Director of Nursing on (MONTH) 6, 2019, at approximately 3:00 p.m. revealed that the agency staff are educated on the facility policies and procedures and provided proof of education for Employee E2, Employee E3 and Employee E4. The facilty failed to ensure that Resident R1 was free of neglect, which resulted in actual harm to the resident after being improperly transferred from the bed or the chair via the use of a sit-and stand lift resulting in the resident sustaining a right knee fracture. 28 Pa Code 201.14(a) Responsibility of licensee Previously cited 01/14/19 28 Pa Code 201.18(b)(1)(3) Management Previously cited 01/14/19, 03/18/18 28 Pa Code 201.18(e)(1) Management Previously cited 01/14/19 28 Pa Code 201.29(c) Resident Rights 28 Pa Code 211.5(f) Clinical records Previously cited 01/14/19, 03/18/18 28 Pa Code 211.10(d) Resident care policies Previously cited 01/14/19 28 Pa Code 211.11(d) Resident care plan 28 Pa Code 211.12(c) Nursing services Previously cited 01/14/19 28 Pa Code 211.12(d)(1)(5) Nursing services Previously cited 01/14/19, 03/30/18

Based on observation, clinical record review and facility documentation, it was determined that the facility failed to ensure that proper staff assistance was provided to Resident #63 resulting in Resident #63 falling from bed and sustaining a [MEDICAL CONDITION] (bone in upper part of leg). The facility failed to use the required equipment to prevent accidents for two of ten residents reviewed (Resident #50 and Resident #63). Findings include: Review of Resident #63's [DIAGNOSES REDACTED]. Review of Resident #63's Significant Change Minimum Data Set (MDS - periodic assessment of resident needs) dated (MONTH) 28, (YEAR), revealed that the resident required the extensive assistance of two staff members for bed mobility, transfers and toilet use. Further review of Resident #63's MDS revealed Resident #63's balance was assessed as not steady and only able to stabilize with staff assistance. Review of Resident #63's Activities of Daily Living (ADL) care plan revised on (MONTH) 30, (YEAR), identified Resident #63's as having a deficit with activities of daily living related to physical limitations. The interventions included total assist of two for bed mobility. Further review of Resident #63's care plan included the intervention that the resident was to be transferred with the use of a mechanical lift and two person assist. Review of Resident #63's interdisciplinary notes dated (MONTH) 27, (YEAR) at 3:50 a.m. revealed called to assess resident after a witnessed fall. Found resident on the floor on back alert and oriented. Neuro(checks) wnl (within normal limits). ROM (range of motion) performed able to move all extremities with no pain, some discomfort reported on the left leg as normal per patient. No visible injury noted. CNA (nursing assistant) was giving care to patient and patient slid out of bed while (resident) was on (resident's) left side PT (patient) assist by four staff members with hoyer lift (mechanical lift) to bed. Further review of Resident #63's interdisciplinary notes dated (MONTH) 27, (YEAR) at 1:53 p.m. noted Tylenol 325 mg (milligrams) instructed to give 650 mg every six hours as needed for pain . resident needed for back and knee pain due to fall. Further review of Resident #63's interdisciplinary notes dated (MONTH) 27, (YEAR) at 4:30 p.m. revealed received x-ray report of back and left knee. Notified MD (physician), N.O. (new order). Resident #63's physcian ordered the resident to be sent to the local hospital for evaluation. Review of X-Ray report dated (MONTH) 27, (YEAR) revealed ongoing concern for acute fracture. Review of Resident #63's nursing notes dated (MONTH) 27, (YEAR) at 10:12 p.m. noted that the physician indicated not to have the resident transported to the emergency room . Review of Resident #63's nursing notes dated (MONTH) 28, (YEAR) at 11:00 a.m. revealed Resident #63 was transported to the orthopedic practice. Review of the Resident #63's orthopedic consult dated (MONTH) 28, 2019 confirmed the [DIAGNOSES REDACTED]. Review of Resident #63's (MONTH) 28, (YEAR) nursing progress note at 1:25 p.m. revealed Resident is being monitored for pain due to fracturing (resident's) femur during a fall that was witnessed by staff. Resident has had pain off and on, it was alleviated by Tylenol order. Review of the nurse aide, Employee E11, statement obtained by the facility on (MONTH) 27, (YEAR), revealed that the nurse aide indicated, Approximately 4 am, I changed my resident. She was lying on her side; as I instructed the resident to come back to lying on her back I noticed she was rolling opposite direction from me. I was unable to assist her back to the bed upon falling. She did not hit her head, I assisted her to a safe position and yelled for help. Further review of the nurse aide statement revealed that when questioned about the Kardex care instructions (card that provides written instructions of the daily care of a resident), Resident is a two person assist for transfer, which is what I looked at on the Kardex. When asked for interpretation of above statement, Employee E11 responded Resident is a Hoyer lift and two persons assist. An interview with the Nursing Home Administrator and the Director of Nursing on (MONTH) 11, (YEAR) at approximately 1:15 p.m. confirmed that the nurse aide did not follow the personal care recommendations of needing two person assistance for Resident #63. The facility failed to ensure that Resident #63 was provided personal hygiene with the assistance of two staff while in bed which resulted in the resident falling from the bed and sustaining a fractured femur. Review of Resident #50's [DIAGNOSES REDACTED]. Review of Resident #50's quarterly MDS dated (MONTH) 20, (YEAR), revealed Resident #50 required the extensive assistance of two persons for transfer between surfaces including to or from bed, chair, wheelchair and standing position and is totally dependent on two staff persons for bathing. Review of Resident #50's plan of care revealed that Resident #50 required extensive assist of two staff for transfers with a sit-to-stand lift. Review of the facility investigation into the fall incident sustained by Resident #50 revealed a written statement by nursing staff, Employee E12 indicating the resident said he felt off balance, legs started to give out, lowered resident to floor during 2 assist transfer. Review of a second written statement by nursing staff, Employee E13 who was present during the fall incident revealed that resident said he was off balance, legs gave out . lowered him to floor during two ast. transfer. Further review of this documentation revealed that Resident #50's knees buckled and Resident #50 was lowered to the floor without injury. Interview with the Director of Nursing on (MONTH) 14, 2019, at approximately 1:30 p.m. confirmed that the nursing assistants were required to use the sit-to-stand lift at all times when transferring Resident #50. Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) - Previously cited 01/17/17 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 01/17/17 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 03/30/18, 01/17/17 28 Pa. Code 201.18(e)(1) Management Previously cited 01/17/17 28 Pa. 211.11(a) Resident care plan Previously cited 01/17/17 28 Pa. Code 211.12(c) Nursing services Previously cited 01/17/17 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 03/30/18, 01/17/17

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to timely notify the physician and the resident's responsible party of a significant medication error requiring transfer to the hospital due to a change in the resident's condition for one of 15 residents reviewed (Resident B5), which resulted in harm to the resident in the form of a medication error and change in condition. Findings include: Review of the facility policy Change in Condition, undated, indicated that immediate notification should be made to the physician for any symptom, sign or apparent discomfort that is acute or sudden in onset, and a marked change in relation to usual symptoms and signs or unrelieved by measures already prescribed. Review of the nurse supervisor job description indicated that the supervisor, identifies and reports changes in condition to the supervisor, physician, and family. Review of Resident B5's nursing note dated August 11, 2016, at 2:43 a.m. revealed that the resident was given the roommate's medication on the 3-11 shift. The note indicated, Paged on-call doctor two times at 11:30 p.m. and 2:30 a.m. and called (Physician 1's) cell phone at 11:30 p.m. with no answer or return call. At this time resident is lethargic with blood pressure 88/35. Employee E8 texted the Medical Director at 3:48 a.m. with no response. Review of the nursing note dated August 11, 2016, at 6:46 a.m. revealed that the nursing staff spoke with (Physician 1) concerning the medication error and the resident's present condition. The facility then obtained an order from the physcian and the residenmt was sent to the emergency room at the local hospital for evaluation and treatment. The nursing note further stated, Left message for sister to return call. Review of the nursing note dated August 11, 2016, at 8:14 a.m. revealed that Resident B5's sister and power of attorney, returned the call and were informed that the resident received the roommate's medications last evening and that the resident was sent to the hospital. An interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on January 12, 2017, at approximately 11:15 p.m. confirmed that when the physician could not be reached , the NHA or the DON should have been contacted and that the resident should have been sent to the hospital. An interview with the NHA on January 12, 2017, at 12:45 p.m. confirmed that the resident's power of attorney was not notified of the medication error and change in condition until the following morning. The facility failed to timely notify the physician and resident's responsible party of a significant medication error and change in condition which resulted in harm to the Resident B5. 42 CFR 483.10(g)(14) Notify of Changes (Injury/Decline/Room, ETC) Previously cited 08/31/16 28 Pa. Code 211.5(f) Clinical records Previously cited 01/09/15, 02/22/16 28 Pa. Code 211.12(d)(1)(3) Nursing services Previously cited 01/09/15, 02/22/16, 04/05/16, 07/03/16, 08/31/16

Based on review of facility policy, information submitted by the facility, facility documentation, clinical record review and staff interview, it was determined that the facility failed to ensure that one of 15 residents reviewed (Resident B5) received medications ordered by the physician resulting in actual harm to Resident B5 and thereby required transfer and admission to the hospital with a [DIAGNOSES REDACTED]. Findings include: Review of the facility policy, Change in Condition, undated, indicated that immediate notification should be made to the physician for any symptom, sign or apparent discomfort that is acute or sudden in onset, and a marked change in relation to usual symptoms and signs or unrelieved by measures already prescribed. Review of the nurse supervisor job description indicated that the supervisor demonstrates the ability to administer medications timely and according to facility policy and identifies and reports changes in condition to the supervisor, physician, and family. Review of Resident B5's annual Minimum Data Set assessment (MDS - periodic assessment of resident needs) dated July 20, 2016, indicated [DIAGNOSES REDACTED]. Review of Resident B5's vitals (vital signs) summary sheet revealed the following: blood pressure 131/76 mmHg (millimeter of mercury - normal is considered 120/80) and pulse 80 beats per minute (bpm - a normal resting heart rate is between 60 and 100 beats per minute) on August 10, 2016, at 10:30 p.m.; blood pressure 115/55 mmHg and pulse 79 bpm on August 10, 2016, at 12:30 a.m.; amd blood pressure 88/35 mmHg and pulse 64 bpm at 2:30 a.m. Review of Resident B5's progress notes dated August 11, 2016, at 2:43 a.m. revealed, Resident was given roommate's medication on 3-11 shift. Checking vitals every two hours. Paged on-call doctor at 11:30 p.m. and 2:30 a.m. and called (Physician 1's) cell phone at 11:30 p.m. with no answer or return call. At this time resident is lethargic with blood pressure 88/35. Additional review of Resident B5's vitals summary sheet revealed the following: blood pressure 84/50 mmHg and pulse 63 bpm at 4:04 a.m. and blood pressure 82/58 mmHg and pulse 57 bpm at 5:20 a.m. Review of the nursing notes of August 11, 2016, at 6:21 a.m. revealed, resident still lethargic. Vitals still low. Resident does not open eyes to verbal or physical stimuli. Review of a nursing note completed at 6:46 a.m. on August 11, 2016, revealed that the staff spoke with the physician concerning the medication error and the resident's present condition. A new order was received and the resident was sent to the emergency room for evaluation and treatment. Review of Licensed Staff, Employee E6's statement obtained on August 11, 2016, revealed that around 10:15 p.m. on August 10, 2016, Resident B5 was noted to be glassy eyed, eyes rolling back and speech slightly slurred. Review of Licensed Staff, Employee E8's statement obtained on August 11, 2016, revealed that she was made aware of the medication error when she arrived for the 11-7 shift and instructed Licensed Nurse, Employee E7, to notify the physician, which did not occur. Employee E8 attempted to contact Physician 1's cell phone at 11:30 p.m. and left a message. Employee E8 left a message with the physician's office at 12:00 a.m. and 2:30 a.m. Employee E8 texted the Medical Director at 3:48 a.m. with no response. The statement indicated that at 5:45 a.m. the vitals were taken manually and the resident was unresponsive. Physician 1 was called at 6:30 a.m. and gave orders to send the resident to the hospital. The emergency medical technicians arrived, did a sternal rub (technique used to assess consciousness) and the blood pressure was palpable (taken with the pulse, not with a stethoscope) at 100. Review of the hospital discharge instructions dated August 14, 2016, revealed that Resident B5 was admitted to the hospital on August 11, 2016, and discharged from the hospital on August 14, 2016, with a [DIAGNOSES REDACTED]. An interview with the Nursing Home Administrator and the Director of Nursing on January 12, 2017, at 11:15 a.m. revealed that the resident should have been sent to the hospital when the physician was unable to be contacted. The facility failed to ensure that Resident B5 only received the medications that were ordered by the physician which resulted in actual harm to Resident B5, and required a transfer and admission to the hospital with a [DIAGNOSES REDACTED]. Review of the facility policy entitled, Medication and Treatment Administration Guidelines, revised December 2014, revealed that PRN (as needed) pain medications require the evaluation of pain both prior to and after the administration of medications ordered for pain management. Review of the facility policy PAINAD Scale (a tool used to assess the pain level of residents with dementia) dated December 2011, revealed that in using the Numeric Pain Scale, ask the patient to identify how much pain they are having by choosing a number from 0 (no pain) to 10 (the worst pain imaginable). Review of Resident C5's annual MDS dated [DATE], revealed [DIAGNOSES REDACTED]. Review of Resident C5's December 2016 and January 2017 physician's orders revealed orders for [MEDICATION NAME] HCL (a narcotic-like pain reliever) 50 milligrams (mg) every six hours as needed for moderate pain and 100 mg every six hours as needed for severe pain. Review of Resident C5's December 2016 Medication Administration Record [REDACTED]. Additionally, the resident received [MEDICATION NAME] HCL 100 mg once for a pain level of 4, five times for a pain level of 5, 26 times for a pain level of 6, and once for a pain level of 7. Review of Resident C5's January 2017 MAR indicated [REDACTED]. Additionally, the resident received [MEDICATION NAME] HCL 100 mg three times for a pain level of 5, three times for a pain level of 6, and once for a pain level of 7. An interview with the Director of Nursing on January 12, 2017, at 12:35 p.m. indicated that moderate pain would be between 4-6 on the pain scale and severe pain would be between 7-10 on the pain scale; however, there were no parameters in place to direct how the staff would administer the medication based on the pain scale. Review of Resident D4's [DIAGNOSES REDACTED]. Review of Resident D4's September 2016 and October 2016 physician's orders revealed orders for [MEDICATION NAME] (a narcotic pain medication) HCl 20 mg to be administered every four hours as needed for pain. Review of Resident D4's September 2016 MAR indicated [REDACTED]. Review of Resident D4's October 2016 Medication Administration Record [REDACTED]. The facility failed to provide documented evidence that the Resident D4 pain was evaluated prior to the administration of as needed narcotic pain medications. An interview with the Director of Nursing on January 13, 2017, at approximately 11:40 p.m. confirmed that a pain evaluation should have been completed prior to the administration of as needed pain medication. The facility failed to ensure that the physician's orders were clarified or complete to include parameters for administration of pain medications for Residents C5 and D4. 42 CFR 483.24 Provide Care/Services for Highest Well Being Previously cited 2/22/16 28 Pa. Code 211.5(f) Clinical records Previously cited 01/09/15, 02/22/16 28 Pa. Code 211.9(a)(1) Pharmacy services Previously cited 01/09/15, 02/22/16 28 Pa. Code 211.10(c) Resident care policies Previously cited 02/22/16, 04/15/16 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 01/09/15, 02/22/16, 04/05/16, 07/03/16, 08/31/16

Based on a review of facility policy, information submitted by the facility, review of clinical records and facility documentation and interviews with staff, it was determined that the facility failed to ensure that the residents were free of a significant medication error for one of 15 residents reviewed (Resident B5), which resulted in the resident receiving the wrong medications, became lethargic and required transportation to the hospital. This was identified as a past non-compliance Immediate Jeopardy situation for one resident. Findings include: Review of facility policy titled, Change in Condition, undated, indicated that immediate notification should be made to the physician for any symptom, sign or apparent discomfort that is acute or sudden in onset, and a marked change in relation to usual symptoms and signs or unrelieved by measures already prescribed. Review of facility policy titled, Medication Administration: Medication Pass, dated March 2010, revealed that the nurse when administering medication should identify patient by calling their name, checking identification band, and referring to photo. Review of facility policy titled, Medication and Treatment Administration Guidelines, dated December 2014 revealed that medications are administered in accordance with the following rights of medication administration - right patient, right medication, right dose, right route, right time, right documentation, right of patient to refuse, and right clinical indication. Review of Resident B5's annual Minimum Data Set assessment (MDS - periodic assessment of resident needs) dated July 20, 2016, indicated [DIAGNOSES REDACTED]. Review of information submitted by the facility on August 11, 2016, indicated that Resident B5 received his roommate's medications including [MEDICATION NAME] (a nonsteroidal anti-[MEDICAL CONDITION] drug (NSAID) used to reduce inflammation and pain), Atorvastatin (a cholesterol lowering medication), [MEDICATION NAME] (a muscle relaxer), [MEDICATION NAME] (a [MEDICAL CONDITION] medication), [MEDICATION NAME] (a supplement used to aid in sleep), [MEDICATION NAME] (an antidepressant), [MEDICATION NAME] (an antidepressant with sleep inducing effects), [MEDICATION NAME] (a narcotic-like pain reliever used to treat moderate to severe pain), and [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION] - a disease characterized by [MEDICAL CONDITION]). Review of Resident B5's progress note dated August 11, 2016, at 2:43 a.m. revealed, Resident was given roommate's medication on 3-11 shift. Checking vitals every two hours. Paged on-call doctor at 11:30 p.m. and 2:30 a.m. and called (Physician 1's) cell phone at 11:30 p.m. with no answer or return call. At this time resident is lethargic with blood pressure 88/35. Review of Resident B5's vitals (vital signs) summary sheet revealed the following: blood pressure 131/76 mmHg (millimeter of mercury-normal is considered 120/80) and pulse 80 beats per minute (bpm- normal is considered 60-100 bpm) on August 10, 2016, at 10:30 p.m., blood pressure 115/55 mmHg and pulse 79 bpm on August 10, 2016, at 12:30 a.m., blood pressure 88/35 mmHg and pulse 64 bpm at 2:30 a.m. Review of Resident B5's vitals summary sheet of August 9-11, 2016, revealed the following: blood pressure 84/50 mmHg and pulse 63 bpm at 4:04 a.m. and blood pressure 82/58 mmHg and pulse 57 bpm at 5:20 a.m. Review of the progress note of August 11, 2016, at 6:21 a.m. revealed, resident still lethargic. Vitals still low. Resident does not open eyes to verbal or physical stimuli. Review of a progress note completed at 6:46 a.m. revealed that staff spoke with the physician concerning the medication error and the resident's present condition. A new order was received to send the resident to the emergency room for evaluation and treatment. Review of Licensed Staff, Employee E6's statement obtained August 11, 2016, revealed that around 10:15 p.m. on August 10, 2016, Resident B5 was noted to be glassy eyed, eyes rolling back and speech slightly slurred. Review of Licensed Staff, Employee E8's statement obtained August 11, 2016, revealed that she was made aware of the medication error when she arrived for the 11-7 shift and instructed Licensed Staff, Employee E7, to notify the physician, which did not occur. Employee E8 attempted to contact Physician 1's cell phone at 11:30 p.m. and left a message. Employee E8 left a message with the physician's office at around 12:00 a.m. and 2:30 a.m. Employee E8 texted the Medical Director at 3:48 a.m. with no response. The statement indicated that at 5:45 a.m. the vitals were taken manually and the resident was unresponsive. Physician 1 was called at 6:30 a.m. and gave orders to send the resident to the hospital. The emergency medical technicians arrived, did a sternal rub (technique used to assess consciousness) and the blood pressure was palpable (taken with the pulse, not with a stethoscope) at 100. Review of the hospital discharge instructions revealed that Resident B5 was admitted to the hospital on August 11, 2016, and discharged from the hospital on August 14, 2016, with a [DIAGNOSES REDACTED]. Review of the facility documentation dated August 11, 2016, revealed that Licensed Nurse, Employee E6, prepared medications for Resident B9, but Licensed Nurse, Employee E7, administered the medications to Resident B5. Employee E7 attempted to confirm the resident's name and Resident B5 indicated that he was Resident B9. Employee E7 indicated that the resident was not wearing an identification band and Employee E7 did not look at the resident's picture to confirm identity prior to the medication administration. Interview with the Nursing Home Administrator and Director of Nursing on January 12, 2017, at 11:15 a.m. revealed that the nurse did not confirm the resident's identification by checking the identification band or a picture before administering the medications. They also confirmed that the resident should have been sent out to the hospital when the physician was unable to be contacted. Immediate Jeopardy, past non-compliance, was identified to the Nursing Home Administrator on January 17, 2017, at approximately 2:30 p.m. The past non-compliance Immediate Jeopardy situation was in effect from August 10, 2016, until September 5, 2016. The facility submitted a corrective action plan that included that each licensed nurse would receive education regarding medication administration, documentation compliance, emergency situation education, and completing a medication skills validation checklist. Review of facility documentation showed that the corrective action had been fully implemented and completed by September 5, 2016, at which time, the Immediate Jeopardy situation was removed. The facility failed to ensure that the resident was free of a significant medication error, which resulted in harm to the resident and required a transfer and admission to the hospital with a [DIAGNOSES REDACTED]. 42 CFR 483.45(f)(2) Residents Free of Significant Med Errors Previously cited 2/22/16, 1/9/15 28 Pa. code 211.9(a)(1) Pharmacy services Previously cited 01/09/15, 02/22/16 28 Pa. Code 211.10(c) Resident care policies Previously cited 02/22/16, 04/15/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 04/15/16, 08/31/16 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 01/09/15, 02/22/16, 04/05/16, 07/03/16, 08/31/16

Based on a review of the Pennsylvania Professional Nursing Practice Act, facility policy, clinical record review, facility documentation and staff interview, it was determined that the facility failed to meet professional standards for medication administration by the licensed nursing staff for one of 15 residents reviewed (Resident B5) and resulted in the resident receiving the wrong medications and became lethargic, and required transportation to the hospital. Findings include: The Professional Code, Title 49, Professional and Vocational Standards, Chapter 21.11(b) states that the registered nurse (RN) is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered. Additionally, a licensed practical nurse (LPN) shall follow the written, established policies and procedures of the facility that are consistent with the act. Review of the nurse supervisor job description indicated that the supervisor demonstrates the ability to administer medications timely and according to facility policy and identifies and reports changes in condition to the supervisor, physician, and family. Review of the facility policy, Medication Administration: Medication Pass, dated March 2010, revealed that the nurse when administering medications should identify the patient by calling the name, checking the identification band, and referring to a photo. Review of the facility policy, Medication and Treatment Administration Guidelines, dated December 2014, revealed that medications are administered in accordance with the following rights of medication administration - right patient, right medication, right dose, right route, right time, right documentation, right of patient to refuse, and right clinical indication. Review of Resident B5's nursing note dated August 11, 2016, at 2:43 a.m. revealed that the resident was given the roommate's medication on the 3-11 shift. Review of the facility documentation revealed that Licensed Nurse, Employee E6, prepared medications for Resident B9, but Licensed Nurse, Employee E7, administered the medications to Resident B5. Employee E7 attempted to confirm the resident's name and Resident B5 indicated that he was Resident B9. Employee E7 indicated that the resident was not wearing an identification band and Employee E7 did not look at the resident's picture to confirm identity prior to the medication administration. An interview with the Nursing Home Administrator and the Director of Nursing on January 12, 2017, confirmed that the licensed staff who prepares the medications should be the licensed staff administering the medications to the resident. It was also confirmed that the licensed staff were to confirm the resident's name, check the identification band, and check the resident's picture prior to administering the medications, which did not occur. The facility failed to ensure professional standards of practice were being followed by the licensed nursing staff by failing to prepare and administer medications by the same licensed staff person who was responsible to prepare the medications, by confirming the resident's name, and by checking the resident's identification band and the resident's picture prior to the administration of medications for Resident B5, which resulted in actual harm to Resident B5. Refer to F333. 28 Pa. Code 211.9(a)(1) Pharmacy services Previously cited 01/09/15, 02/22/16 28 Pa. Code 211.9(c) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies Previously cited 02/22/16, 04/15/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 01/09/15, 02/22/16, 04/05/16, 07/03/16, 08/31/16

Based on a clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident was free of a significant medication error for one of 15 residents reviewed (Resident H1). Findings include: Review of Resident H1 ' s medical record revealed an original admitted [DATE] with the [DIAGNOSES REDACTED]. to process insulin causing the blood sugar to increase), [MEDICAL CONDITION], diabetic [MEDICAL CONDITION] (tingling/pain in fingers, toes, limbs due to diabetes), depression, [MEDICAL CONDITION] and significant functional deficits. Review of physician order [REDACTED]. Review of medical record revealed that upon admission to facility on October 13, 2014 the resident was ordered [MEDICATION NAME] 750 mg to take twice a day ([MEDICATION NAME] is used to control [MEDICAL CONDITION]). Resident was sent to local community hospital for treatment of [REDACTED]. He was discharged back to the facility on [DATE] and the [MEDICATION NAME] 750 mg twice a day was to be continued according to the hospital. In addition, [MEDICATION NAME] ([MEDICATION NAME]) 300 mg twice daily ([MEDICATION NAME] is used for [MEDICAL CONDITION] and also to help with pain issues) was started at the hospital and was to be continued at the facility. The nursing staff admitting the resident back to the facility did not receive a physician's order [REDACTED]. There was no nurses ' note to indicate that the physician was informed that these medications were given at the hospital as listed on the hospital transfer sheet. Review of Resident H1 ' s nursing progress note on November 17, 2014 at 8:38 a.m. stated " A loud bang was noted by this nurse as I was administering medications. Upon investigation I entered the bathroom and noted that the resident was having an active [MEDICAL CONDITION] ...The [MEDICAL CONDITION] lasted approximately 2 minutes, resident had all body shaking with muscles rigid, resident unresponsive ...upon evaluation of resident ' s medications, it was also noted that resident did not receive [MEDICATION NAME] 750 mg for a total of 5 doses and did not receive [MEDICATION NAME] 300mg ([MEDICATION NAME]) for a total of 5 doses " . Interview with licensed nurse, Employee E5 on January 7, 2015 at 11:40 a.m. revealed that on November 17, 2014 around 8:30 a.m. Resident H1 was found in his rooms bathroom lying on the floor having a [MEDICAL CONDITION] and was unresponsive. She stated that [MEDICAL CONDITION] was probably caused by the resident not receiving his medication for 4 days (November 14- pm dose, November 15, November 16 and November 17th am dose). She stated that the [MEDICATION NAME] and [MEDICATION NAME] were not started when readmitted back to the facility. Interview with the administrator on January 9, 2015 at 9:45 a.m. revealed that during investigation of what occurred with resident [MEDICAL CONDITION] and fall to floor that the admitting nurse did not receive the orders for the [MEDICAL CONDITION] medications or inform the physician that these medications were given when the resident was hospitalized . Facility failed to ensure resident was free of significant error by failing to ensure that the resident had the [MEDICAL CONDITION] medication ([MEDICATION NAME] and [MEDICATION NAME]) ordered and available for the resident. 28 Pa Code 201.14(a) Responsibility of Licensee 28 Pa. Code:201.18(b)(1) Euro(1) Management 28 Pa Code 211.12(d)(1)(5) Nursing Services Previously cited: 02/19/2014, 07/02/2014