Every finding on record at Friendship Village of South Hi

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to immediately report and investigate a resident's allegation, in response to allegations of abuse, neglect, exploitation, or mistreatment for one of eight residents (Resident R1). This was identified as past non-compliance. Findings include: Review of facility policy RISKWATCH (ABILITY) Incident/Accident Occurrence Reporting System reviewed 1/29/26, indicated the incident types listed included (alleged abuse, includes allegations of team member to resident abuse or complaints of rough handling, equipment related incidents involving a resident, and injury of unknown origin) must be entered completely and accurately, whether they involve a resident or visitor, vendor or any other guest in the community. The licensed nurse, if a nurse responds, or if not the first responder is responsible for entering all reports prior to the end of shift and close to the time of the incident as possible. For our licensed health entities, documentation occurs on the 24- hour report and, as per change of condition standards, the resident is placed on alert monitoring and documentation. Review of the clinical records, resident was admitted to the facility on [DATE] and discharged on 3/11/26. Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 2/25/26, indicated the diagnoses of, diagnosis traumatic subdural hematoma (collection of blood in the brain due to head trauma), displaced fracture of seventh cervical vertebra (break of a bone in the neck), and traumatic brain injury (damage to the brain from an external force injury, affecting how the brain works). During a clinical record review, a progress note from Registered Nurse (RN) Employee E1 dated 3/7/26 at 11:19 a.m., indicated Resident R1 reported last night during care when he was being boosted in bed his head hit the headboard and is now c/o (complaint of) increased numbness and tingling to LFA (left forearm), 1st and 2nd finger. Positive sensation throughout with pins and needles to LUE (left upper extremity), R (right) hand and bilateral feet. No obvious injury to head or c/o increased pain. CTO (cervical-thoracic orthosis brace intact, missing foam piece underneath bottom portion. Review of Resident R1s plan of care for indicated resident has potential/actual impairment cervical collar and impaired mobility use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. During an interview on 3/31/26, at 12:46 p.m. the Nursing Home Administrator confirmed the resident, and family reported the event to the nursing staff on 3/7/26 without staff making a report. A report and investigation was conducted per facility policy and in accordance with state law on 3/16/26 after the family had emailed administration at the facility with concerns related to the 3/7/26 event. On 3/17/26, the facility initiated a plan of correction that included:Staff in-service education related to reporting alleged abuse, neglect, injury of unknown origin and other reportable events completed on 3/30/26.Audits initiated on 3/18/26 for daily documentation of incidents and accidents completed through 3/31 and will continue. During interviews with three direct care staff on 3/31/26, it was confirmed that all staff interviewed had received staff in-service education on reporting alleged abuse, neglect, injury of unknown origin and other reportable events. During an interview on 3/31/26, at 2:20 p.m., the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to immediately report and investigate a resident's allegation, in response to allegations of abuse, neglect, exploitation, or mistreatment. This was identified as past non-compliance. 28 Pa Code: 201.14 (a)(c) Responsibility of licensee. 28 Pa Code: 201.18 (e)(1)(2) Management. 28 Pa Code: 201.29 (a)(c) Resident Rights. 28 Pa Code: 211.12 (a)(c)(d)(1) Nursing services.

Based on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to make accessible grievance boxes to residents on three of three locations, nursing units (Dogwood, Pinewood, and Specialty Care).Findings include: A review of the facility policy Resident and Family Grievances reviewed 8/13/25, support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. The Centers for Medicare & Medicaid Services (CMS) does not specify exact height requirements for grievance boxes in skilled nursing facilities. However, CMS mandates that grievance procedures be accessible to all residents, including those with disabilities, in compliance with the Americans with Disabilities Act (ADA). In Pennsylvania, the Department of Health incorporates by reference the federal requirements outlined in 42 CFR Part 483, Subpart B, which pertain to long-term care facilities. These regulations emphasize the importance of accessibility but do not provide additional specifications regarding grievance box placement. To ensure accessibility, the ADA Standards for Accessible Design recommend that operable parts, such as slots on grievance boxes, be mounted between 15 and 48 inches above the floor. This range accommodates individuals using wheelchairs and ensures usability for a broad range of residents. During an observation on 9/30/25, at 10:30 a.m., the grievance boxes were not accessible on nursing units (Dogwood, Pinewood, and Specialty Care). The grievance boxes had been mounted at approximately 55 inches (Dogwood), 61 inches (Pinewood), and 60 inches (Specialty Care) above the floor, out of the reach of residents in wheelchairs. The Specialty Care unit had an armchair blocking access to the grievance box. During rounds on 10/1/25, at 8:30 a.m. the Nursing Home Administrator and surveyor measured the height of the grievance boxes on nursing units (Dogwood, Pinewood, and Specialty Care) and confirmed the grievance boxes had been mounted at approximately 55 inches (Dogwood), 61 inches (Pinewood), and 60 inches (Specialty Care) above the floor, out of the reach of residents in wheelchairs. The Specialty Care unit had an armchair blocking access to the grievance box. During an interview on 10/1/25, at 8:40 a.m. the Nursing Home Administrator confirmed the facility failed to make grievance boxes accessible to residents in three of three locations, nursing units (Dogwood, Pinewood, and Specialty Care). 28 PA Code: 201.18(e)(4) Management. 28 PA Code: 201.29(a)(b)(c) Resident rights.

Based on review of facility policy, documents, clinical record review, resident, and staff interviews, it was determined that the facility failed to make certain that necessary care and services were provided for thirteen of twenty-four residents (Resident R1, R6, R34, R50, R60, R123, R500, R501, R502, R503, R505, R506, and R507). Findings include: Review of facility policy Activities of Daily Living (ADL), Supporting reviewed 8/13/25, indicated resident will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment During a group interview, on 9/29/25 at approximately 1:30 p.m., when asked, Do you get the help and care you need without waiting a long time? Does staff respond to your call light timely? consensus from the group was no. Residents (R500, R501, R502, R503, R505, R506, and R507) verbalized frustration with the wait times, residents stated, some staff are quick to respond and some just don't seem to try very hard. Residents reported they experienced wait times of 40 minutes to more than an hour. Review of resident council minutes revealed on 1/8/25 and 8/14/25 residents expressed concerns over long wait times for assistance. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/30/25, indicated diagnoses of malignant neoplasm of colon (cancerous tumor in the colon), diabetes mellitus (high blood sugar), and hyperlipidemia (high level fats in the blood), a BIMS of 15. Section GG 130 Self Care personal hygiene indicates resident requires setup or clean up assistance (helper sets up or cleans up). Section GG 130 Functional Abilities transfer/mobility indicates resident requires Substantial/maximal assistance (helper does more than half the effort). During an interview on 9/30/25, at approximately 1:00 p.m. Resident R1 stated wait times for assistance after pushing your call light can take 20 minutes, 40 minutes, or more at times. Review of Resident R1's call light audit between the dates of 9/24/25 through 9/30/24, revealed call light times equal to or greater than 20 minutes. - 9/29/25 call light event 28 minutes. - 9/30/25 call light event 35 minutes. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of Resident R6's Minimum Data Set (MDS-a periodic assessment of care needs) dated 8/5/25, indicated diagnoses of high blood pressure, dysphagia (difficulty swallowing) and dementia (group of diseases and illnesses that affect your thinking, memory, reasoning, personality, mood and behavior). During an interview on 9/29/25, at approximately 10:30 a.m. Resident R6 stated wait times for assistance after pushing call light system seems to take a while, feels like I have waited for 30 minutes or longer. Review of Resident R6's call light audit between the dates of 9/24/25 through 9/30/24, revealed call light times equal to or greater than 20 minutes. 9/26/25 call light event times: 24 minutes 9/29/25 call light event times: 23 minutes 32 minutes Review of the clinical record indicated Resident R50 was admitted to the facility on [DATE]. Review of Resident R50's Minimum Data Set (MDS-a periodic assessment of care needs) dated 7/23/25, indicated diagnoses of diabetes (blood sugar is too high or too low), rheumatoid arthritis (chronic condition that causes pain, swelling and irritation in the joints), radiculopathy of cervical and lumbar regions (compression or irritation of nerves in the neck and lower back causing pain, numbness and weakness in arms, legs, hips and buttocks). During an interview on 9/29/25, at approximately 10:40 a.m. Resident R50 stated wait times for assistance after pushing call light system seems to take a while, feels like I have waited for at least 30 minutes or longer, even as long as an hour or more. Review of Resident R50's call light audit between the dates of 9/24/25 through 9/30/24, revealed call light times equal to or greater than 20 minutes. 9/24/25 call light event times: 23 minutes 1 hour 24 minutes 1 hour 33 minutes 48 minutes 9/25/25 call light event times: 25 minutes 21 minutes 9/27/25 call light event times: 26 minutes 28 minutes 29 minutes 9/29/25 call light event times: 31 minutes - Review of the clinical record indicated Resident R34 was admitted to the facility on [DATE]. Review of Resident R34's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/16/25, indicated diagnoses of a hip fracture (break in the thigh bone), diabetes mellitus (high blood sugar), and hyperlipidemia (high level fats in the blood), a BIMS of 15. Section GG 130 Self Care personal hygiene indicates resident is dependent with toileting, showers, and lower body dressing (helper does all of the effort). Section GG 130 Functional Abilities transfer/mobility indicates resident requires Substantial/maximal assistance (helper does more than half the effort). During an interview on 9/30/25, at approximately 1:10 p.m. Resident R34 stated wait times for assistance after pushing your call light seem to take a while, I know I have waited a few occasions much more than 20 minutes to get a response. Review of Resident R34's call light audit between the dates of 9/24/25 through 9/30/24, revealed call light times equal to or greater than 20 minutes. - 9/25/25 call light event times 1 hour 47 minutes 36 minutes - 9/26/25 call light event times 20 minutes 22 minutes 48 minutes - 9/27/25 call light event time 26 minutes - 9/29/25 call light event time 22 minutes Review of the clinical record indicated Resident R123 was admitted to the facility on [DATE]. Review of Resident R123's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/30/25, indicated diagnoses of a parkinson's disease (progressive movement disorder), diabetes mellitus (high blood sugar), and first digit hallux amputation (surgical removal of the toe), a BIMS of 3. Section GG 130 Self Care personal hygiene and Section GG 130 Functional Abilities transfer/mobility information was in the process of updating at the time of review and not available. During an interview on 9/30/25, at approximately 1:00 p.m. Resident R123 family stated they have experienced wait times longer than 20 minutes when using the call light for assistance. Family stated it seems closer to a 40-minute wait time for assistance after pushing his call light too often. Review of Resident R123's call light audit between the dates of 9/24/25 through 9/30/24, revealed call light times equal to or greater than 20 minutes. - 9/25/25 call light event times 25 minutes - 9/26/25 call light event times 34 minutes 42 minutes 43 minutes - 9/27/25 call light event time 50 minutes - 9/29/25 call light event time 22 minutes Review of the clinical record indicated Resident R60 was admitted to the facility on [DATE]. Resident R60 was unavailable for an interview as she had been discharged from the facility on 9/23/25. Review of Resident R60's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/30/25, indicated diagnoses of a hip fracture (break in the thigh bone), hypertension (high blood pressure), and hyponatremia (abnormally low sodium), a BIMS of 14. Section GG 130 Self Care personal hygiene indicates resident is partial/moderate assistance with toileting, showers, and lower body dressing (helper does all of the effort). Section GG 130 Functional Abilities transfer/mobility indicates resident requires Substantial/maximal assistance (helper does more than half the effort) with bed and chair mobility. During a review of the facility grievance's revealed on 9/18/25, Resident R60 filed a grievance related to call light response/wait time. The call light log revealed a wait time of 36 minutes. During an interview on 10/1/25, at approximately 2:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to make certain that necessary care and services were provided for thirteen of twenty-four residents (Resident R1, R6, R34, R50, R60, R123, R500, R501, R502, R503, R505, R506, and R507). 28 Pa. Code: 211.12(1) Nursing services. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12 (2)(5) Nursing services.

Based on a review of facility policy, observations, and staff interview, it was determined that the facility failed to make sure that medical supplies and medications were properly stored and/or disposed of in two of three medication rooms (Secure Care Unit and Dogwood Unit). Findings include: Review the facility policy Medication Labeling and Storage dated 8/13/25, indicated, If the facility has discontinued, outdated, or deteriorated medications or biologicals the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. During an observation of the Secure Care Unit nursing unit medication room on 9/30/25, at approximately 1:15 p.m. the following was observed: -(9) calcium alginate dressings with an expiration date of 5/18/24.-(1) Nasopharyngeal swab set with an expiration date of 8/19/25.-(9) Gelling fiber dressings with an expiration date of 11/2022.-(1) Dressing retention sheet roll with an expiration date of 03/2024.-(1) Latex Foley catheter with an expiration date of 4/28/23.-(1) Container of anti-fungal powder with an expiration date of 5/1/25.-(2) Sponge swabs with an expiration date of 04/2025.-(1) Bottle of povidone iodine solution with an expiration date of 12/2024.-(1) Vacutainer with an expiration date of 6/8/24.-(1) Vacutainer with an expiration date of 3/5/24.-(25) packets of Bacitracin zinc ointment with an expiration date of 09/2021. During an observation of the Dogwood nursing unit medication room on 9/30/25, at approximately 1:40 p.m. the following was observed: -(1) Contact layer dressing with an expiration date of 11/2022.-(1) Nasopharyngeal swab set with an expiration date of 1/7/25.-(1) 1ml syringe with an expiration date of 12/31/2023.-(1) Safety needle with an expiration date of 04/2020.-(1) Safety winged collection set with an expiration date of 7/15/24. Under the sink in the Dogwood medication room the following was observed:-Hearing aides for Resident R201, who discharged from the facility in June of 2022.-Hearing aides for Resident R202, who discharged from the facility in July of 2020.-Cell phone for Resident R203, who discharged from the facility in October of 2022.-(10) pairs of eyeglasses-(8) cans of energy drinks-(6) flashlights-Bag of rosary beads, folding cell phone, and other miscellaneous articles. During an interview on 9/30/25, at approximate 2:30 p.m. the Director of Nursing confirmed that the facility failed to make sure that medical supplies and medications were properly stored and/or disposed of in two of three medication rooms. 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1)(e)(1) Management.28 Pa. Code: 211.9 (a)(1) Pharmacy services.28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services.

Based on review of facility policies and documents, clinical record review, and staff interviews, it was determined that the facility failed to protect residents from neglect that resulted in the actual harm of a skin tear that required 17 sutures for one of three residents (Resident R3). Findings include: Review of the facility policy Abuse, Neglect, and Exploitation dated 8/13/25, indicated, The facility will provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse common to collect, exploitation and misappropriation of resident property. Neglect was defined as, As the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the facility policy Activities of Daily Living, Supporting dated 8/13/25, indicated, Appropriate care and services will be provided for residents who are unable to carry out ADLs (Activities of Daily Living) independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with:a) Hygiene b) Mobility c) Elimination d) Dining e) Communication Review of the clinical record indicated Resident R3 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 8/27/25, included diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), heart failure (a progressive heart disease that affects pumping action of the heart muscles) and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Section GG: indicated that Resident R3 was dependent on staff ( Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for Chair/bed-to-chair transfer. Review of a physician order dated 8/24/25, indicated Pt (patient) to transfer with assist of 2. Review of Resident R3's plan of care for Potential/actual skin impairment intervention dated 8/22/25, indicated Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Review of Resident R3's Kardex (document that outlines the patients' ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) utilized by nurse aide staff dated 9/18/22, indicated Transfer with assist x2. NWB to LLE (non-weight bearing to left lower extremity). Review of a progress note dated 9/19/25, at 3:45 p.m. indicated, CNA (nurse aide) told this nurse that resident got a deep skin tear on right lower leg she noticed after transferring her from wheelchair to bed and pants were off. This nurse went into room and seen large deep skin tear on right shin area with moderate amount of blood dripped down resident's leg. Resident states she felt her leg rub on something when she was being transferred from wheelchair to bed but it did not hurt. She noticed her leg was bleeding after her pants were taken off after getting into bed. Cleaned right shin wound with saline and measured it. Bleeding was stopped right after arriving into room. Skin tear is shaped like a 90 degree angle; one side 4.5cm, the other side 5cm, 1cm wide, and 1cm deep with a fatty flap of skin. This nurse had 2 other nurses assess skin tear and recommended she be sent to hospital. [Physician] and daughter notified. Skin tear was cleaned with saline and dressed with Xeroform (fine mesh gauze), 4x4's, and wrapped with Kerlix (absorbent rolled bandage). Resident had no complaints of pain or discomfort. Alert and vitals stable. Review of facility submitted information dated 9/20/25, indicated that on 9/19/25, CNA transferred patient from wheelchair to bed, went to get a gown for the patient and noted a skin tear to right lateral shin, notified nursing. RN (registered nurse) supervisor assessed and right lateral skin tear measuring 4.5cm x 5cm x 1cm, exposure of adipose tissue. Cleansed right lateral shin with nss, applied xeroform and covered with pressure dressing. Pt is a 2-assist transfer and was transferred with 1 assist. CNA was sent home and not to return until investigation completed. Upon investigation, it noted that while pt was being transferred hit her right shin off of wheelchair leg rest holder as it aligns with skin tear to right lateral shin. No sharp areas noted to bed frame. MD notified and ordered to send patient to hospital for evaluation. Daughter notified. APS (Adult Protective Services) notified at 440pm. Pt returned from hospital at approximately 11:49 pm with 17 sutures and a wound care orders. Review of an employee statement written by NA Employee E4 dated 9/19/24, indicated, On Friday, September 19, 2025 I went into [Resident R3's] room to answer her call light. She wanted to get in bed so I stood her up. She pivoted then sat on the bed. I put her feed in then went to get a nightgown. When I came back she showed me the skin tear and said get the nurse. She was not aware how it happened and I was not aware she hit her leg on anything. Review of a facility submitted Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property dated 9/29/25, included the information, CNA received 1:1 (one on one) training prior to the start of her shift on understanding the importance of checking a residents transfer status prior to attempting to transfer a resident. CNA was also educated on safe transfers. Review of a Team Member Counseling Notice dated 9/24/25, indicated, On 9/19 you entered a room to assist a resident back to bed. Prior to transfer you failed to check transfer status on Kardex. During transfer, which you performed as a 1 person assist, resident obtained a skintear. Resident was a 2 person assist for transfers as noted Kardex. During interviews completed on 10/1/25, Nurse Aides Employees E2, E5, and E6 were all able to appropriately describe how to access a resident's required transfer status. During an interview on 10/1/25, at approximately 2:00 p.m. the Nursing Home Administrator confirmed the facility failed to protect residents from neglect that resulted in the actual harm of a skin tear that required 17 sutures for one of three residents. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(e)(1) Management.28 Pa. Code: 207.2(a) Administrator's responsibility.28 Pa. Code: 211.10(d) Resident care policies

Based on review of facility policy, documents clinical record and staff interviews, it was determined that the facility failed to make certain a resident was free from the use of physical restraints without a physical restraint order for one of eight residents reviewed (Resident R7).Finding include: Review of facility policy, Resident Rights, reviewed 8/13/25, indicated the resident should be free from mental and physical abuse, and free from chemical and physical restraints, except in emergencies or as authorized in writing by his/her physician. This authorization will be for a specific and limited period of time or whenever necessary to protect the resident from injury to him/herself or to others. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2023, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:-13-15: cognitively intact-8-12: moderately impaired-0-7: Severe impairment Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Minimum Data Set (MDS-federally mandated assessment of a resident's abilities and care needs) dated 9/10/25, included diagnoses of Alzheimer's (progressive disease that destroys memory and other important mental functions). high blood pressure and radiculopathy of lumbar region (compression or irritation of a nerve in the lower back causing pain, numbness, or weakness in the leg, hip or buttocks). Review of Section C: Cognitive Patterns, Question C0500 BIMS Summary Score revealed Resident R7 's score to be 3. Review of Resident R7's orders revealed no order placed for bed to be placed against wall. Review of Resident R7's plan of care revealed no documentation for medical reason or goal of bed being placed against wall. Review of Resident R7's progress notes revealed no documentation of reason/explanation for bed to be placed against the wall. During an interview with the Assistant Director of Nursing (ADON) on 10/1/25, at 1:55 p.m. it was confirmed that the facility failed to make certain a resident was free from the use of physical restraint without a physician's order for one of eight residents reviewed. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(a)(c)(d) Resident rights.

Based on clinical record review, facility policy, and staff interview, it was determined that the facility failed to ensure that resident's medication regime was free from unnecessary psychotropic (substances that act on the brain to alter cognition, perception, and mood) medication for one of eight residents (Resident R7).Finding include: Review of the facility policy Use of Psychotropic Medication, dated 8/13/25, indicated that residents receive psychotropic medication when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or team members convenience, which would deem it a chemical restraint. Adequate indications for use refers to identified, documented clinical rationale for administering medication that is based on assessment of the resident's condition and therapeutic goals after any other treatments have been deemed clinically contraindicated. For psychotropic medications, without documentation in the record explaining that the practitioner has determined that other treatments have been deemed clinically contraindicated the indication for use is inadequate. Adverse consequence refers to unwanted, unintended, or dangerous effects that a drug may have, such as impairment or decline in an individuals' s mental or physical condition or functional or psychosocial status. Psychotropic medications are not prescribed or given on a PRN (as needed) basis unless medication is necessary. PRN orders for psychotropic medications are limited to 14 days. Review of the clinical record indicated Resident R7 was admitted on [DATE], and readmitted on [DATE]. Review of Resident R7's Minimum Data Set (MDS-a periodic assessment of care needs) dated 9/10/25, indicated diagnoses of Alzheimer's (a progressive disease that destroys memory and other important mental functions), high blood pressure and radiculopathy of lumbar region (compression or irritation of nerves in the lower back causing pain, numbness, or weakness to leg, hip or buttocks). Review of Resident R7's physician order dated 7/20/25 through 9/2/25, indicated to administer Seroquel (Quetiapine-a psychotropic medication that can be used to treat various mental and mood conditions, including schizophrenia, bipolar disorder, and major depressive disorder), 12.5mg every twelve hours PRN (as necessary) for agitation in the order summary exceeding the 14 day order. On 8/22/25, order was written for Seroquel 12.5mg to give every day at bedtime for depression and Seroquel 12.5mg every 12 hours PRN for agitation related to depression. On 9/15/25, Seroquel was reordered 12.5mg PRN for agitation due to family request for medication, there is no documented behaviors identified in the progress notes during this time frame. During an interview on 10/1/25, at approximately 2:00 p.m. the Assistant Director of Nursing confirmed that the facility failed to ensure that the residents medication regime was free from unnecessary psychotropic medication for one of eight residents (Resident R7). 28 Pa. Code 211.2(d)(3) Medical Director 28 Pa. Code 211.10(a) Resident care policies.

Based on review of facility policies and documents, clinical record review, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent falls that resulted in the actual harm of a skin tear that required 17 sutures for one of three residents (Resident R3). This was identified as past non-compliance. Findings include: Review of the facility policy Activities of Daily Living, Supporting dated 8/13/25, indicated, Appropriate care and services will be provided for residents who are unable to carry out ADLs (Activities of Daily Living) independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with:a) Hygiene b) Mobility c) Elimination d) Dining e) Communication Review of the clinical record indicated Resident R3 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 8/27/25, included diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), heart failure (a progressive heart disease that affects pumping action of the heart muscles) and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Section GG: indicated that Resident R3 was dependent on staff ( Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for Chair/bed-to-chair transfer. Review of a physician order dated 8/24/25, indicated Pt (patient) to transfer with assist of 2. Review of Resident R3's plan of care for Potential/actual skin impairment intervention dated 8/22/25, indicated Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Review of Resident R3's Kardex (document that outlines the patients' ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) utilized by nurse aide staff dated 9/18/22, indicated Transfer with assist x2. NWB to LLE (non-weight bearing to left lower extremity). Review of a progress note dated 9/19/25, at 3:45 p.m. indicated, CNA (nurse aide) told this nurse that resident got a deep skin tear on right lower leg she noticed after transferring her from wheelchair to bed and pants were off. This nurse went into room and seen large deep skin tear on right shin area with moderate amount of blood dripped down resident's leg. Resident states she felt her leg rub on something when she was being transferred from wheelchair to bed but it did not hurt. She noticed her leg was bleeding after her pants were taken off after getting into bed. Cleaned right shin wound with saline and measured it. Bleeding was stopped right after arriving into room. Skin tear is shaped like a 90 degree angle; one side 4.5cm, the other side 5cm, 1cm wide, and 1cm deep with a fatty flap of skin. This nurse had 2 other nurses assess skin tear and recommended she be sent to hospital. [Physician] and daughter notified. Skin tear was cleaned with saline and dressed with Xeroform (fine mesh gauze), 4x4's, and wrapped with Kerlix (absorbent rolled bandage). Resident had no complaints of pain or discomfort. Alert and vitals stable. Review of facility submitted information dated 9/20/25, indicated that on 9/19/25, CNA transferred patient from wheelchair to bed, went to get a gown for the patient and noted a skin tear to right lateral shin, notified nursing. RN (registered nurse) supervisor assessed and right lateral skin tear measuring 4.5cm x 5cm x 1cm, exposure of adipose tissue. Cleansed right lateral shin with nss, applied xeroform and covered with pressure dressing. Pt is a 2-assist transfer and was transferred with 1 assist. CNA was sent home and not to return until investigation completed. Upon investigation, it noted that while pt was being transferred hit her right shin off of wheelchair leg rest holder as it aligns with skin tear to right lateral shin. No sharp areas noted to bed frame. MD notified and ordered to send patient to hospital for evaluation. Daughter notified. APS (Adult Protective Services) notified at 440pm. Pt returned from hospital at approximately 11:49 pm with 17 sutures and a wound care orders. Review of an employee statement written by NA Employee E4 dated 9/19/24, indicated, On Friday, September 19, 2025 I went into [Resident R3's] room to answer her call light. She wanted to get in bed so I stood her up. She pivoted then sat on the bed. I put her feed in then went to get a nightgown. When I came back she showed me the skin tear and said get the nurse. She was not aware how it happened and I was not aware she hit her leg on anything. Review of a facility submitted Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property dated 9/29/25, included the information, CNA received 1:1 (one on one) training prior to the start of her shift on understanding the importance of checking a residents transfer status prior to attempting to transfer a resident. CNA was also educated on safe transfers. Review of a Team Member Counseling Notice dated 9/24/25, indicated, On 9/19 you entered a room to assist a resident back to bed. Prior to transfer you failed to check transfer status on Kardex. During transfer, which you performed as a 1 person assist, resident obtained a skintear. Resident was a 2 person assist for transfers as noted Kardex. On 9/22/25, the facility initiated a plan of correction that included: One on one reeducation and return demonstration of all nurse aide competencies with NA Employee E4. Education to all nursing staff in the use of the Kardex. Education to all nursing staff on safe transfer procedures. Weekly audits of resident transfers to ensure correct transfer status was used. Information collected presented at Inter-disciplinary team meetings. Review of facility provided documents revealed the plan of correction was completed on 9/29/25. During an interview on 10/1/25, at approximately 2:00 p.m. the Nursing Home Administrator confirmed the facility failed to provide adequate supervision to prevent falls that resulted in the actual harm of a skin tear that required 17 sutures for one of three residents. This was identified as past non-compliance. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(e)(1) Management.28 Pa. Code: 207.2(a) Administrator's responsibility.28 Pa. Code: 211.10(d) Resident care policies.

Based on observations and a staff interview, it was determined the facility failed to post information for Adult Protective Services (APS) as required in the building. Findings include: The facility must post, in a form and manner accessible and understandable to residents, resident representatives; a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit. Observations conducted on 9/30/25, at approximately 10:30 a.m., in the building, revealed the facility did not have any elements of the State Agency or APS contact information (agency name, address, email, and phone number) as required, posted or accessible to residents or resident representatives. During rounds and an interview, on 10/1/25, at approximately 8:30 a.m., with the Nursing Home Administrator (NHA), the (NHA) confirmed the facility failed to post information for Adult Protective Services (APS), as required in the building. 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 201.18(e) Management.

Based on observations and a staff interview, it was determined that the facility failed to display (for residents and/or their responsible person) written information on how to apply for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid as required, in the building. Findings include: The facility must display written information in the facility, and provide to residents and applicants for admission, oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. During observations completed on 9/30/25, at approximately 10:30 a.m. in the building, it was revealed that the facility failed to include information on how to apply for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid. During rounds and an interview, on 10/1/25, at approximately 8:30 a.m., with the Nursing Home Administrator (NHA), the (NHA) confirmed the facility failed to display (for residents and/or their responsible person) written information on applying for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid as required, in the building. 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 201.18(e) Management.

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to revise/update care plans for two of eighteen residents to accurately reflect the current status of the resident (Resident R7 and R32). Finding include:Review of the facility policy Care Plans, Comprehensive Person-Centered dated 8/13/25, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Review of the clinical record indicated Resident R7 was admitted on [DATE], and readmitted on [DATE].Review of Resident R7s Minimum Data Set (MDS-a periodic assessment of care needs) dated 9/10/25, indicated diagnoses of Alzheimer's (a progressive disease that destroys memory and other important mental functions), high blood pressure and radiculopathy of lumbar region (compressed or irritated nerves in lower back causing pain, numbness or weakness in the leg, hip or buttock).Review of Resident R7's order summary revealed no order was placed for bed to be up against the wall.Review of Resident R7's plan of care failed to include goals and interventions related to Resident R7 having their bed placed against the wall creating a physical restraint on one side.Review of the clinical record indicated Resident R32 was admitted to the facility on [DATE]. Review of Resident R32's MDS dated [DATE], indicated diagnoses of non-Alzheimer's dementia, high blood pressure, and depression. Review of resident R32's care plan with a revision date of 1/9/2025, revealed the resident is totally dependent on staff for oral care. Review of Resident R32's progress notes from the Registered Nurse dated 2/15/25 and 2/16/25, indicate oral care not performed resident is independent. Review of Resident R32's Survey Report V2 Personal Hygiene combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers) for the months of July through August of 2025 revealed no documentation of service performed and assistance level required on the following dates: July 2, 3, 4, 6, 7, 8, 11, 13, 17, 19, 20, 21, 22, 23, 25, and 27th August 3, 6, 15, 19, 25, and 26th September 3, 8, 9, 10, 18, 19, 20, and 25thDuring an interview on 9/29/25, at approximately 2:00 p.m. Resident R34's family stated resident is unable to do her own oral care and it doesn't seem like Resident R34 has mouth care done daily or routinely. Resident 34 confirmed she doesn't get oral care daily.During an interview on 10/1/25, at approximately 2:00 p.m. the Director of Nursing and Nursing Home Administrator confirmed the facility failed to revise/update care plans for two of eighteen residents.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.28 Pa. Code 211.11(e) Resident Care Plan.

Based on review of facility documents, personnel in-service training records, and staff interview, it was determined that the facility failed to provide documented training on the Quality Assurance and Performance Improvement (QAPI) Program for facility staff.Findings include: Review of the Facility Assessment dated 7/4/25, included in the list of staff training topics QAPI. Review of facility provided education documentation failed to include related to the facility QAPI program. During an interview on 10/1/25, at approximately 11:00 a.m. the Nursing Home Administrator was made aware of the surveyor's inability to find education related to the QAPI program, and was requested to confirm if any other education provided QAPI education or if possibly a class was named that it did not reveal it additionally provided QAPI education. The facility was unable to provide additional information. During an interview on 10/1/25, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide documented training on the QAPI Program for facility staff. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development.

Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to provide the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for four of nine residents reviewed (Resident 40, R42, R61, and R63). Findings include: A review of the facility Advance Directives 10/1/24 and 1/4/24, indicated the resident has the right to formulate an advance directive, including the right to accept or refuse medial or surgical treatment. A review of the medical record indicated Resident R40 was admitted to the facility on [DATE], with diagnoses that included diabetes, anxiety and high blood pressure. A review of the clinical record failed to reveal an advanced directive or documentation that Resident R40 was given the opportunity to formulate an Advanced Directive. A review of the medical record indicated Resident R42 was admitted to the facility on [DATE], with diagnoses that included high blood pressure, muscle weakness and repeated falls. A review of the clinical record failed to reveal an advanced directive or documentation that Resident R42 was given the opportunity to formulate an Advanced Directive. A review of the medical record indicated Resident R61 was admitted to the facility on [DATE], with diagnoses that included dementia (group of thinking and social symptoms that interferes with daily functioning), anxiety, high blood pressure and muscle weakness. A review of the clinical record failed to reveal an advanced directive or documentation that Resident R61 was given the opportunity to formulate an Advanced Directive. A review of the medical record indicated Resident R63 was admitted to the facility on [DATE], with diagnoses that included dementia, anxiety, high blood pressure and a history of falling. A review of the clinical record failed to reveal an advance directive or documentation that Resident R63 was given the opportunity to formulate an Advance Directive. During an interview on 10/4/24, at approximately 9:20 a.m. DON and NHA confirmed that the clinical record did not include documentation that Resident R40, R42, R61, and R63 were afforded the opportunity to formulate Advanced Directives. 28 Pa. Code: 201.29(b)(d)(j) Resident rights.

Based on a review of facility documents, information from the State Ombudsman Office and staff interviews it was determined that the facility failed to notify the State Ombudsman Office of resident transfers and discharges for four plus years ( 9/19 through 12/19. 1/20 through 12/20, 1/21 through 12/21, 1/22 through 12/22, 1/23 through 12/23 and 1/24 through 9/24) as required. Findings include: A request to review facility documents on 10/3/24, of the facility's compliance in notifying the State Ombudsman Office revealed that the facility failed to provide documented evidence of notifying the the State Ombudsman Office of resident transfers and discharges for the time period of 9/19 through 9/24. A review of information on 8/1/24, provided by the State Ombudsman Office revealed that the facility failed to notify the State Ombudsman Office of transfers and discharges as required since 8/2019. During an interview on 10/3/24, at 3:25 p.m. the Nursing Home Administrator confirmed that the facility failed to report resident transfers and discharges to the State Ombudsman Office for a 4 plus year period from 9/19, through 9/24, as required. PA Code: 201.29(f)(g) Resident rights.

Based on review of facility policies, review of Centers for Disease Control (CDC) guidelines for Legionella (bacterium that causes Legionnaires Disease found in pipes and heating systems) Control, the facility's infection control tracking logs for water management and staff interviews, it was determined that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella within the facility. Findings include: Review of the facility policy Health Center Prevention and Control of Legionella last reviewed on 1/27/23, indicated that an interdisciplinary effort will be employed to prevent and control Legionella in the health centers. The environmental services department will be responsible for maintenance of the facility water sources. They will complete random testing of at least three water supply sources twice per year unless more frequent testing is deemed necessary. Review of the facility testing provided did not include any Legionella or any other water pathogens being tested for within the last year as required. During an interview on 10/12/23, at 1:48 p.m., the Nursing Home Administrator confirmed that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella and /or other potential water pathogens within the facility. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management.

Based on review of facility policy, clinical records, facility investigation reports, a progress note and staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards for residents who were at risk for falls for one of eight residents (Residents R58). Findings include: Review of the facility policy Incident/ Accident Occurrence Reporting System last reviewed on 1/27/23, indicated that the facility electronic reporting system is in place to assist staff to report incidents for tracking. All incidents are to be investigated and witness statements obtained and the licensing entities notified if required. Review of the clinical record indicated that Resident R58 most recent re-admission to the facility on [DATE], with diagnoses which included dementia with behaviors, psychotic disturbance, mood disturbance and anxiety. A MDS dated [DATE], indicated the diagnoses remained current. Review of Resident R58's plan of care indicated use of a wheeled walker and assist of one or two staff if agitated. Review of Resident R58's current Physician orders indicated the same ambulation order as identified above. Review of a progress note dated 8/28/23, indicated that Resident R58 was ambulating with a Nurse Aide in his room and lost his balance and fell against his dresser causing abrasions to his right back and left mid back requiring a treatment. During an interview on 10/11/23, at 12:20 p.m., the DON confirmed the incident was not investigated to determine if proper assistance was utilized which could have potentially prevented incident. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1) Management. 28 Pa. Code: 207.2(a) Administrator's responsibility. 28 Pa. Code: 211.10(d) Resident care policies.

Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to investigate an injuries of unknown origin for three of nine residents (Resident R7, R42, and R43) and failed to investigate an actual allegation of neglect for one of nine residents (R56). Findings include: Review of the facility policy Incident Reports, last reviewed on 3/1/22, indicated that all incidents, unusual occurrences, and injuries will be documented on an incident/accident form. Review of the facility Resident Abuse/Neglect/Exploitation and Reporting Requirements, last reviewed on 3/1/22, with previous review date of 2/28/21, indicated that each resident has a right to be free from abuse, neglect and exploitation. and the facility will provide an environment free from all types of abuse, neglect and exploitation by all persons. Any reports or suspicions will be fully investigated. Indicators of abuse include cuts, lacerations, puncture wounds, bruises, welts, discolorations, any injury which has not been properly cared for, poor skin condition or hygiene, etc. All team members once reported must write a statement related to the incident, report to their immediate supervisor. Review of a progress note dated 10/29/22, indicated that Resident R7 developed a bruise of his left upper arm. During an interview on 11/28/22, at 12:24 p.m., Assistant Director of Nursing (ADON) Employee E16 confirmed that the facility failed to investigate a bruise of Resident R7's upper arm to rule out potential for abuse. Review of a progress note dated 8/2/22, indicated that Resident R42 was pulled from the dining table and developed a skin tear which required cleansing and an island dressing. A site of the injury was not clearly identified. Review of the Treatment Record dated 8/1/22 through 8/31/22 indicated a treatment to Resident R42's left arm with saline cleansing and Xeroform (petroleum embossed dressing for non-sticking) and a dry dressing until healed, this treatment was discontinued on 8/23/22, 21 days later. During an interview on 1/28/22, at 3:31 p.m., the Director of Nursing (DON) confirmed a full investigation was not completed to rule out the potential for abuse for Resident R42 while being pulled from the dining table. Review of a progress note dated 7/18/22, indicated that while Resident R43 was being showered, the Nurse Aide identified his right pinky toe was red, his big toe had a raised area and his right wrist had a bruise. During an interview on 11/28/22, at 12:18 p.m., the ADON Employee E16 confirmed that the bruise of Resident R43's wrist or the redness and swelling of Resident R43's toes was not fully investigated to rule out the potential of abuse. Review of a progress note dated 10/30/22, indicated that Resident R56's daughter had requested the resident have her morning care done very early so the resident can eat breakfast. The note indicated that Resident R56 reported that she was upset that she could not eat breakfast that day because she was wet and was told she could not be changed until trays were passed. The note indicated that the nurse aide told the LPN, who wrote the note. During an interview on 11/28/22, at 2:30 p.m. the DON confirmed that the facility failed to investigate the allegation of neglect. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1) Management.

Based on facility policy, observations and staff interviews, it was determined that the facility failed to provide an environment that ensured personal privacy for one of one resident during a wound care obvservation (Resident R32) and confidentiality of clinical records for residents on one of three nursing units (Pine Nursing Unit). Findings include: Review of the facility policy Confidentiality of Information and Personal Privacy last reviewed on 3/1/22, indicated that the facility will protect and safeguard personal privacy and confidentiality of all resident personal and medical records. During an observation on 11/29/22, at 8:20 a.m., the Pine medication cart was placed at nurses station with the computer screen open revealing resident personal information and two papers with resident names, room numbers and personal medical information lying on top for any passerby to see. Licensed Practical Nurse (LPN) Employee E13 was behind a curtain inside a resident room. During an interview on 11/29/22, at 8:25 a.m., LPN Employee E13 confirmed that she had left the computer screen open and her resident papers uncovered allowing resident personal and medical information for any passerby to see. During an observation on 11/29/22, at 11:31 a.m., while Registered Nurse(RN) Employee E14 was performing a dressing change on Resident R32, Nurse Aide (NA) Employee E15 knocked on closed door but did not wait for response before entering room allowing for any passerby to look into room as Resident R32's privacy curtain was not pulled. During an interview on 11/29/22, at 11:33 a.m. RN Employee E14 confirmed that NA Employee E15 should not have entered without waiting for a response and allowed any passerby to see into Resident R32's room, not allowing personal privacy. 28 Pa. Code: 201.29(j) Resident rights. 28 Pa. Code: 211.5(b) Clinical records.

Based on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, comfortable and homelike environment for three out of eight resident rooms (Rooms 101, 104, and SC8). Findings include: The facility Quality of Life-Homelike environment policy last reviewed on 3/1/22, indicated that residents are provided with a safe, clean, comfortable and homelike environment. During a tour on 11/28/22, at 2:30 p.m. Environmental Services Supervisor Employee E2, observations found the following: -room [ROOM NUMBER] was observed unlocked, unoccupied and with no assigned resident. room [ROOM NUMBER] had no bed, no bed frame, no television, three large boxes of incontinence supplies, four large boxes of cups, one large box of Kleenex, five large boxes of gloves, five large boxes of wipes. -room [ROOM NUMBER] was observed unlocked, unoccupied and with no assigned resident. room [ROOM NUMBER] had four oxygen concentrators, four fall mats, a linen cart, two mattresses, and three wheelchairs. During an interview on 11/29/22, at 2:39 p.m. Environmental Services Supervisor Employee E2, confirmed that the facility failed to provide a clean, comfortable and homelike environment for three out of eight resident rooms (Rooms 101, 104, and SC8). During a tour on 11/30/22, at 9:40 a.m. Licensed practical nurse (LPN) Employee E4, observations found the following: -Room SC8 was observed unlocked, unoccupied and with no assigned resident. Room SC8 had a metal bed frame with no mattress on it, a clean linen cart, five wheeled walkers, one rollator, and one wheelchair. During an interview on 11/30/22, at 9:40 a.m. LPN Employee E4, confirmed that the facility failed to provide a clean, comfortable, and homelike environment for SC8. 28 Pa. code: 207.2 (a) Administrator's Responsibility.

Based on a review of facility policy, observations, and staff interviews, it was determined the facility failed to notify residents/resident representatives of their right to file anonymous grievances through postings in prominent locations throughout the facility, provide grievance forms for anonymous grievances, and provide grievance collection boxes for anonymous grievances in three of three units (Dogwood Lounge, Pine Hall and the Special Care Unit). Findings include: Review of facility policy titled Health Center Resident Grievance (Complaint) Policy last reviewed on 11/22/22, indicated the community's health center Nursing Home Administrator will assign a Grievance official who is responsible for overseeing the Grievance process. Review of facility policy titled Grievance Procedure last reviewed 3/1/22, indicated an anonymous concern/complaint can be made by completing a a form and placing it in the concern box located in the Dogwood Lounge. During an observation on 11/28/22, at 9:20 a.m. the Dogwood Unit grievance form wall bin did not contain grievance forms for filing an anonymous grievance. During an interview on 11/28/22, at 9:25 a.m. Activities staff Employee E5 confirmed grievance forms for anonymous grievances were not available in the Dogwood Lounge. During an observation on 11/30/22, at 8:55 a.m. the Pine Hall Unit did not have a grievance procedure posting, grievance forms, or a grievance collection box available to file an annoymous grievance. During an interview on 11/30/22, at 9:10 a.m. Nursing Assistant Employee E6 confirmed the Pine Hall Unit did not have a grievance procedure posting, grievance forms, or a grievance form collection box available to file an anonymous grievance. During an observation on 11/30/22, at 9:10 a.m. the Special Care Unit did not have a grievance procedure posting, grievance forms, or a grievance collection box available to file an annoymous grievance. During an interview on 11/30/22, 9:10 a.m. Licensed Practical Nurse Employee E4 confirmed the Special Care Unit did not have a grievance procedure posting, grievance forms, or a grievance form collection box available to file an anonymous grievance. During an interview on 11/30/22, at 10:00 a.m. Social Service Director and Grievance Official Employee E7 confirmed the facility failed to notify residents/resident representatives of their right to file anonymous grievances through postings in prominent locations throughout the facility, provide the grievance forms for anonymous grievances, and provide grievance collection boxes for anonymous grievances in 3 of 3 units (Dogwood Lounge, Pine Hall and the Special Care Unit). 28 Pa. Code: 201.29(i) Resident rights.