Every finding on record at Gettysburg Center

Based on facility policy review, clinical record review, review of select facility documentation, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to provide adequate supervision to prevent accidents with eating for one of four residents reviewed (Resident 4), which resulted in actual harm as evidenced by Resident 4 choking and suffering death.Findings include: Review of facility policy, titled NSG107 Emergency: Medical Response, dated November 14, 2025, revealed, in part, Response to medical emergencies will be acted upon within the scope of practice of the licensed nursing staff. The employee who first witnesses or is first on-site of a medical emergency, that is trained, will initiate immediate action including cardiopulmonary resuscitation (CPR) as appropriate, basic first aid, and summon for assistance. A licensed nurse will assume the role of the Medical Emergency Leader until the arrival of advanced medical personnel (e.g., Emergency Medical Services (EMS)/Paramedics), ensuring all actions are guided by current clinical standards, physician/provider orders (including advanced directives/code status), and Center protocols. Review of Resident 4's clinical record revealed that he was admitted to the facility on [DATE], with diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), dysphagia (difficulty swallowing), cognitive communication deficit (a group of disorders that affect a person's ability to communicate which can cause difficulty with understanding or producing language and nonverbal communication skills such as gestures and facial expressions), and need for assistance with personal care. Review of Resident 4's physician orders revealed an order for a regular texture liberalized diet and standard thin liquids consistency. Supervision and out of bed for all regular texture meals and snacks, dated May 8, 2026; and Do Not Resuscitate/Full Treatment, dated April 22, 2026. Review of Resident 4's Speech Therapy Treatment Encounter Note dated May 7, 2026, revealed that Resident 4 attempted to eat the tea bag from his mug while being supervised by the Speech Therapist. The Speech Therapist educated Resident 4 that they were not intended to be eaten. Review of Resident 4's Speech Therapy Treatment Encounter Note dated May 8, 2026, revealed that Resident 4's diet was upgraded to regular texture with thin liquids. He must be supervised and out of bed for all regular texture meals and snacks. Review of Resident 4's Speech Therapy Treatment Encounter Note dated May 11, 2026, revealed that Resident 4 required verbal prompting to alternate solids and liquids. Review of Resident 4's Speech Therapy Treatment Encounter Note dated May 12, 2026, revealed that Resident 4 needed multiple cues and reminders to initiate eating and became easily distracted by external visual and auditory stimuli. Review of Resident 4's Speech Therapy Discharge summary dated [DATE], indicated section titled Discharge Recommendations and Status that it is recommended the patient use the following strategies during oral intake: rate modification, bolus size modification, solid/liquid alternation, sitting upright and out of bed. SLP (Speech Language Pathologist) recommends patient is supervised during all meals for safety. Pt is discharged on a regular texture diet with thin liquids. Further review of Resident 4's clinical record progress notes revealed a nurse's note written by Employee 8 (Registered Nurse) dated June 4, 2026, at 5:30 PM, which indicated Employee 8 was summoned to one of the dining areas due to a resident having an emergency and, upon entering, Employee 8 observed Resident 4's face and neck to be light blue in color and unresponsive. Nursing staff rendering CPR. The note further indicated that Employee 8 attempted to administer artificial breaths four times and attempted to clear Resident 4's mouth of undigested food unsuccessfully. The note further indicated that Emergency Medical Services arrived at the facility and after they received report from Employee 8, they contacted their medical command physician who directed that resuscitation efforts be stopped. Resident 4 was pronounced deceased at 5:45 PM. Review of facility provided incident report for Resident 4 dated June 4, 2026, at 5:25 PM, indicated that at approximately 5:25 PM, a nurse aide heard a yell for help from the South Sub-dining room. When the nurse aide ran back to the dining room, she saw Resident 4 sliding out of his wheelchair and hitting the back of his head on the floor before she could reach him. The report further indicated that when the nurse aide reached Resident 4, she observed him to be unresponsive with blue lips. This nurse aide was later identified as Employee 9. Review of facility provided witness statements for Resident 4's choking incident revealed a statement from Employee 8 (Registered Nurse Supervisor), undated, which indicated that he was summoned to the South sub-dining room for a resident emergency. He said that when he arrived Resident 4 was light blue in color in his face and across his neck on the floor of the dining room unresponsive. Employee 8's statement further indicated that another Registered Nurse was giving CPR compressions, and that when the AED was applied it advised no shock, advised continue CPR. Employee 8 then obtained a bag-valve-mask (a hand-held device commonly used to provide ventilation to patients who are not breathing or not breathing adequately) and started to provide artificial respirations but was unsuccessful. Employee 8 then repositioned Resident 4 and tried again with no success. Employee 8 then assessed Resident 4's mouth and found thick undigested rice and meat. Employee 8 again attempted to provide artificial respirations without success. Employee 8 was relieved by Employee 10 (Licensed Practical Nurse) to provide airway management while Employee 8 prepared paperwork for emergent transfer. Employee 8's statement indicated that Emergency Medical Services arrived at 5:44 PM and they notified their Medical Commander who directed that resuscitation efforts be stopped. Resident 4 was pronounced deceased at 5:45 PM. Review of facility provided witness statements for Resident 4's choking incident revealed a statement from Employee 9 (Nurse Aide) which indicated that on June 4, 2026, at approximately 5:15 PM, she was assisting another resident with his meal, and that Resident 4 was seated beside her in his wheelchair eating his meal. She indicated that she then left the dining room to assist in passing trays in a hallway and that Resident 4 was fine when she left. Employee 9's statement then indicated that she was away less than 10 minutes when she heard someone yelling Help! Help! Employee 9 indicated that she ran back to the dining room, and she saw Resident 4 slide off his wheelchair backwards onto the floor, hitting the back of his head. Employee 9 indicated that she ran over to Resident 4 and checked his pulse, but she did not feel any, and she then called for Employee 10 (Licensed Practical Nurse) to call Code Blue and Employee 11 (Registered Nurse). Employee 9 further indicated that while Employee 10 was retrieving the crash cart, another employee called 911 and Employee 12 (Nurse Aide) attempted to remove food from Resident 4's mouth. Employee 9 indicated that she then began performing abdominal thrusts until Employee 11 arrived and started performing CPR. Review of facility provided witness statements for Resident 4's choking incident revealed a statement from Employee 10 (Licensed Practical Nurse) dated June 4, 2026, which indicated that she had just finished delivering medications to a resident and had returned to her medication cart when Employee 9 (Nurse Aide) yelled for her to come to the sub dining room. Employee 10 indicated that Resident 4 was lying flat on his back and was unresponsive and that she called out for Employee 11 (Registered Nurse) and instructed someone to call Employee 8 (Registered Nurse Supervisor). She indicated that Employee 11 started CPR while Employee 10 checked Resident 4's code status, retrieved the AED and applied pads. Employee 10's indicated that other nursing staff arrived from north hall and assisted with chest compressions and ventilation with bag-valve mask until EMS arrived. Review of facility provided witness statements for Resident 4's choking incident revealed a statement from Employee 11 (Registered Nurse), undated, which indicated that at approximately 5:15 PM, a nurse aide alerted a nurse on to an emergency in the dining room and that nurse responded immediately finding Resident 4 on the floor. Employee 11's statement further indicated that Resident 4 was unresponsive, without a pulse and not breathing and that CPR was initiated immediately and continued until EMS personnel arrived and assumed care. During a staff interview with the Director of Nursing (DON) on June 11, 2026, at 2:18 PM, she indicated that ad no documentation that Employee 9 or Employee 12 were trained in performing abdominal thrusts, mouth sweeps, or CPR. During a staff interview with the Nursing Home Administrator (NHA) on June 11, 2026, at 2:22 PM, she confirmed that Resident 4 was left unsupervised while eating and choked. During a staff interview with Employee 8 on June 11, 2026, at 2:45 PM, he indicated that Resident 4 had received the correct meal, which was a regular diet with thin liquids. Employee 8 confirmed that Resident 4 was eating in the dining room unsupervised when the choking incident occurred. Employee 8 indicated that he assisted in providing resuscitation efforts until EMS arrived. Review of information reported by the DON on June 10, 2026, revealed that the coroner's preliminary report of cause of death is accidental death due to choking. The coroner stated that it may take 4-6 weeks until the final autopsy report is available. Review of facility provided plan to correct the identified issue revealed the following:1) Quality Assurance Performance Improvement committee was held on June 5, 2026, to review event and develop correction plan.2) Nursing staff to complete competency for Heimlich Maneuver/Obstructive Airway initiated June 6, 2026.3) Nursing staff re-education on signs and symptoms of choking initiated on June 6, 2026.4) DON/designee to conduct initial audit of nursing staff to confirm active CPR certification, which was completed on June 8, 2026, with no concerns identified.5) DON/designee will conduct audit of CPR certification of five random nursing staff weekly for four weeks and then monthly for two months to ensure active CPR certification.6) Nursing staff statements were obtained from all shifts regarding any observations or concerns with swallowing, coughing, or difficulty eating for Resident 4, which was documented as on-going and no statements were provided.7) DON/designee to conduct initial audit of all residents who require supervision with meals per Speech Therapy to confirm staff are providing supervision and care plan matches which was completed June 8, 2026, with no concerns identified.8) DON/designee will conduct an audit of all dining rooms to ensure staff supervision during meals weekly for four weeks then monthly for two months. 9) Nurse Practice Educator to re-educate nurse aides regarding scope of practice regarding CPR versus Obstructive Airway Management guidelines.10) Ongoing audit results will be monitored through the Quality Assurance Performance Improvement committee for further review and recommendations.11) Compliance date June 8, 2026. Random interviews with five nurses and three nurse aides on June 11, 2026, revealed they were provided with written and verbal education and signed the Employee Training Sign-In Sheets. Observation of lunch meal on June 11, 2026, between 12:25 PM and 1:20 PM, revealed at least one nursing staff member was always present during meal in the South Sub-dining room. During a final staff interview with the NHA and DON on June 11, 2026, at 2:50 PM, the NHA again acknowledged that Resident 4 was eating in the dining room unsupervised when the choking incident occurred. The facility failed to provide adequate supervision for Resident 4 while he was eating, which resulted in him experiencing actual harm of a choking incident resulting in death. 201.4(a) Responsibility of licensee.201.18(b)(1)(3) Management.211.10(d) Resident care policies.211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policy review, clinical record reviews, review of select facility documentation, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to revise a resident's care plan to provide adequate supervision with eating for one of four residents reviewed (Resident 4), which resulted in actual harm as evidenced by Resident 4 choking and suffering death.Findings include: Review of facility policy titled OPS416 Person-Centered Care Plan, dated September 15, 2025, revealed, in part, 6. Care plans will be 6.1 Communicated to appropriate staff, patient, representative, family; 6.2 Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals. Review of Resident 4's clinical record revealed that he was admitted to the facility on [DATE], with diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), dysphagia (difficulty swallowing), cognitive communication deficit (a group of disorders that affect a person's ability to communicate which can cause difficulty with understanding or producing language and nonverbal communication skills such as gestures and facial expressions), and need for assistance with personal care. Review of Resident 4's physician orders revealed an order for a regular texture liberalized diet and standard thin liquids consistency. Supervision and out of bed for all regular texture meals and snacks dated May 8, 2026. Review of Resident 4's Speech Therapy Discharge summary dated [DATE], indicated section titled Discharge Recommendations and Status that it is recommended the patient use the following strategies during oral intake: rate modification, bolus size modification, solid/liquid alternation, sitting upright and out of bed. SLP (Speech Language Pathologist) recommends patient is supervised during all meals for safety. Pt is discharged on a regular texture diet with thin liquids. Review of Resident 4's care plan failed to reveal any interventions that he was to be supervised with meals or snacks or the specific strategies to utilize as indicated in his Speech Therapy Discharge Summary. Further review of Resident 4's clinical record progress notes revealed a nurses note written by Employee 8 (Registered Nurse) dated June 4, 2026, at 5:30 PM, which indicated Employee 8 was summoned to one of the dining areas due to a resident having an emergency and upon entering Employee 8 observed Resident 4's face and neck to be light blue in color and unresponsive. Nursing staff rendering CPR. The note further indicated that Employee 8 attempted to administer artificial breaths four times and attempted to clear Resident 4's mouth of undigested food unsuccessfully. The note further indicated that Emergency Medical Services arrived at the facility and after they received report from Employee 8, they contacted their medical command physician who directed that resuscitation efforts be stopped. Resident 4 was pronounced deceased at 5:45 PM. Review of facility provided witness statements for Resident 4's choking incident revealed a statement from Employee 9 (Nurse Aide) which indicated that on June 4, 2026, at approximately 5:15 PM, she was assisting another resident with his meal, and that Resident 4 was seated beside her in his wheelchair eating his meal. She indicated that she then left the dining room to assist in passing trays in a hallway and that Resident 4 was fine when she left. Employee 9's statement then indicated that she was away less than ten minutes when she heard someone yelling Help! Review of facility provided plan to correct the identified issue revealed the following:1) Quality Assurance Performance Improvement committee was held on June 5, 2026, to review event and develop correction plan.2) DON/designee to conduct initial audit of all residents who require supervision with meals per Speech Therapy to confirm staff are providing supervision and care plan matches which was completed June 8, 2026.3) Nursing staff educated on signs and symptoms of choking; identification of residents in need of eating in supervised areas; sub-dining rooms need to be supervised during meals and nursing staff are to remain until last tray has been collected completed June 5-6, 2026.4) DON/designee will conduct an audit of all dining rooms to ensure staff supervision during meals weekly for four weeks then monthly for two months.5) Ongoing audit results will be monitored through the Quality Assurance Performance Improvement committee for further review and recommendations.6) Compliance date June 8, 2026. Random interviews with five nurses and three nurse aides on June 11, 2026, revealed they were provided with written and verbal education and signed the Employee Training Sign-In Sheets. Observation of lunch meal on June 11, 2026, between 12:25 PM and 1:20 PM, revealed at least one nursing staff member was always present during the meal. During a staff interview with the Nursing Home Administrator on June 11, 2026, at 2:22 PM, she confirmed that Resident 4 was left unsupervised while eating and choked. During a staff interview with Employee 8 on June 11, 2026, at 2:45 PM, he indicated that Resident 4 had received the correct meal which was a regular diet with thin liquids. Employee 8 also confirmed that Resident 8 was unsupervised in the dining room when the choking incident occurred. During a final staff interview with the NHA and Director of Nursing on June 11, 2026, at 2:50 PM, the NHA acknowledged that Resident 4's care plan was not revised to include the Speech Therapy recommendations which included supervision at all times when eating. She stated, It was in his orders. The facility failed to revise Resident 4's care plan. The resident was not supervised while eating which resulted in actual harm of a choking incident resulting in death. 201.4(a) Responsibility of licensee.201.18(b)(1)(3) Management.211.10(d) Resident care policies.211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policy review, clinical record review, review of facility investigation documentation, review of hospital documentation, and resident and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure that each resident receives adequate supervision and assistance to prevent accidents based on individual needs for one of four resident's reviewed (Resident 1), which resulted in actual harm for Resident 1 as evidenced by a closed fracture of left hip. Findings include: Review of facility policy, titled Safe Resident Handling/Transfer Equipment last revised January 15, 2026, read, in part, Safe Resident Handling involves the use of assistive devices to ensure that patients can be transferred safely and that care providers avoid performing high risk patient handling tasks. Staff will complete training and demonstrate competency in the use of safe resident handling equipment. Review of Resident 1's clinical record revealed diagnoses that included fracture of unspecified part of neck of left femur, abnormalities of gait and mobility (unusual patterns of walking or movement), and history of falling. Review of Resident 1's comprehensive care plan revealed a focus area for Resident requires assistance/is dependent for activities of daily living care, with an intervention for Transfers with assist of two and FWW (front-wheeled walker) with a start date of June 21, 2024. Review of Resident 1's Kardex (nurse aid reference for resident information) stated Transfers with assist of two and FWW, with a start date of June 21, 2024. Review of Resident 1's clinical record revealed a nursing progress note on April 14, 2026, that read, in part, Resident was found sitting on the floor on her buttocks. Resident stated she could not handle her weight while holding on to the nightstand as usual and she lost her balance and sat on the floor. Resident complaining of left hip excruciating pain, resident is unable to move the leg. Certified Registered Nurse Practitioner notified and advised that we send residents to the ER. Review of facility investigation revealed [Resident 1] was being provided incontinence care by [Employee 1 (Nurse Aide)] while standing and holding on to her night stand as she typically does. She was wearing non-skid socks on her feet. Her legs became weak and she sustained a fall on her buttocks. [Resident 1] did not hit her head. Review of statement written by the Nursing Home Administrator (NHA) on April 15, 2026, titled Roommate Statement revealed Interviewed [Resident 2] regarding [Resident 1's] fall last evening. She stated she was in the room at the time of [Resident 1's] fall. She reported that one aide transferred [Resident 1] at bedtime and she fell. Review of email correspondence of statement written by Employee 1 read, in part, I assisted [Resident 1] to stand beside the nightstand in order to change her brief and help her into bed. Immediately after removing her soiled brief, I attempted to dispose of it in the trash behind me. Before I could fully react, the resident began to fall backward. I was unable to catch her in time, and she landed on her buttocks. She began expressing pain shortly after. Review of Resident 1's transfer nurse aide task read Transfers with assist of two and FWW further review revealed the task was signed yes by Employee 1 to indicate two people assisted with Resident 1's transfer the evening of her fall on April 14, 2026, despite his statement that he transferred her from her chair to her nightstand by himself. Review of Resident 1's hospital paperwork revealed she was admitted to the hospital on [DATE], following a fall resulting in a closed left hip fracture. The Resident had a surgical repair to her hip on April 15, 2026, and she was discharged back to the facility on April 19, 2026. Interview with the NHA on April 22, 2026, at 10:54 AM, she revealed she would expect residents to be transferred per their proper transfer status. During an onsite visit on April 22, 2026, at 10:17 AM, the NHA provided the facility's plan of correction that was put into place as a result of the facility's investigation into the fall. QAPI met on April 15, 2026, to review the incident and develop an immediate plan of action, which included the following: Provider/Responsible party notification- 4/14/26Investigation initiated- 4/14/26NA (Nurse Aide) placed on administrative leave during investigation- 4/14/26Staff re-educated on abuse prohibition- 4/15/26Staff re-educated on sate resident handling/transfer equipment- 4/15/26Nursing staff re-educated on Sate Resident Handing Program 4/15/26An initial audit of current residents conducted to ensure current transfer status is accurate and included in the care plan and Kardex- 4/15/26Re-educate NAs, including agency on checking residents Kardex prior to start of shift 4/15/26DON (Director of Nursing)/designee to complete an audit of agency NA orientation to validate completion- 4/16/26 Review of the Plan of correction revealed an initial audit was completed for all residents on April 15, 2026, to ensure current transfer status is included in the care plan and Kardex (care guide), weekly audits were conducted to ensure five randomly selected residents current transfer status were accurate and included in the care plan and Kardex, and weekly audits were conducted to ensure nursing staff were performing transfers properly per their assessments, as per their corrective action plan. In addition, a weekly audit was completed to ensure all contracted nursing staff had received orientation to the facility to validate completion. During an interview with the NHA on April 22, 2026, at 11:42 AM, she revealed that contracted nursing staff are supposed to receive a packet for orientation to the facility that includes a center tour and general information, policies and procedures (including safe resident handling), and various other pertinent information. The packet is signed by the contracted staff before the start of their first shift. She further revealed the audit indicated that eight out of 13 new contracted staff did not receive the education prior to their shift; Employee 1 was on the list that he did not complete orientation. Prior to the abbreviated survey, the facility failed to ensure each resident the right to be free from neglect, resulting in harm for Resident 1 as evidenced by a closed fracture of left hip. The facility's plan of correction was reviewed during the survey. Review of facility documentation revealed that on April 16, 2026, the facility had completed education for staff and audits to ensure compliance. During the abbreviated survey on April 22, 2026, staff interviews, resident interviews, resident record review, and observations revealed no concerns with falls or staff using the correct transfer status. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3)(e)(1) Management

Based on facility policy review, clinical record review, review of facility investigation documentation, review of hospital documentation, and resident and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure each resident the right to be free from neglect for one of four residents reviewed (Resident 1), which resulted in actual harm for Resident 1 as evidenced by a closed fracture of left hip.Findings include: Review of facility policy, titled Abuse Prohibition last reviewed on November 14, 2025, read, in part, Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/patient property, and exploitation of all residents. Neglect is defined as the failure, indifference, or disregard of the Center, its employees, or service, providers to provide care, comfort, safety, goods, and services, to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This includes the failure to implement an effective communication system across all shifts for communicating necessary care and information between Center staff, patient, practitioners, and patient representatives. Review of Resident 1's clinical record revealed diagnoses that included abnormalities of gait and mobility (unusual patterns of walking or movement), and history of falling. Review of Resident 1's comprehensive care plan revealed a focus area for Resident requires assistance/is dependent for activities of daily living care, with an intervention for Transfers with assist of two and FWW (front-wheeled walker), with a start date of June 21, 2024. Review of Resident 1's Kardex (nurse aid reference for resident information) stated Transfers with assist of two and FWW, with a start date of June 21, 2024. Review of Resident 1's clinical record revealed a nursing progress note on April 14, 2026, that read, in part, Resident was found sitting on the floor on her buttocks, complained of excruciating pain and unable to move her left leg. Resident stated she could not handle her weight while holding on to the nightstand as usual and she lost her balance and sat on the floor. Resident complaining of left hip excruciating pain, resident is unable to move the leg. Certified Registered Nurse Practitioner notified and advised that we send resident to the ER. Review of facility investigation revealed [Resident 1] was being provided incontinence care by [Employee 1 (Nurse Aide)] while standing and holding on to her nightstand as she typically does. She was wearing non-skid socks on her feet. Her legs became weak and she sustained a fall on her buttocks. [Resident 1] did not hit her head. Review of statement written by the Nursing Home Administrator (NHA) on April 15, 2026, titled Roommate Statement revealed Interviewed [Resident 2] regarding [Resident 1's] fall last evening. She stated she was in the room at the time of [Resident 1's] fall. She reported that one aide transferred [Resident 1] at bedtime and she fell. Review of email correspondence of statement written by Employee 1 read, in part, I assisted [Resident 1] to stand beside the nightstand in order to change her brief and help her into bed. Immediately after removing her soiled brief, I attempted to dispose of it in the trash behind me. Before I could fully react, the resident began to fall backward. I was unable to catch her in time, and she landed on her buttocks. She began expressing pain shortly after. Review of Resident 1's transfer nurse aide task read Transfers with assist of two and FWW further review revealed the task was signed yes by Employee 1 to indicate two people assisted with Resident 1's transfer the evening of her fall on April 14, 2026, despite his statement that he transferred her from her chair to her nightstand by himself. Further review of Resident 1's transfer nurse aide task revealed that Employee 1 cared for Resident 1 on April 6 and 7, 2026, and signed that the Resident 1 required an assist of two and FWW and the task was marked as completed. Review of Resident 1's hospital paperwork revealed she was admitted to the hospital on [DATE], following a fall resulting in a closed left hip fracture. The Resident had a surgical repair to her hip on April 15, 2026, and was discharged back to the facility on April 19, 2026. Interview with the NHA on April 22, 2026, at 10:54 AM, she revealed she would expect residents to be transferred per their proper transfer status. During an onsite visit on April 22, 2026, at 10:17 AM, the NHA provided the facility's plan of correction that was put into place as a result of the facility's investigation into the fall. QAPI met on April 15, 2026, to review the incident and develop an immediate plan of action, which included the following: Provider/Responsible party notification- 4/14/26Investigation initiated- 4/14/26NA placed on administrative leave during investigation- 4/14/26Staff re-educated on abuse prohibition- 4/15/26Staff re-educated on sate resident handling/transfer equipment- 4/15/26Nursing staff re-educated on Sate Resident Handing Program 4/15/26An initial audit of current residents conducted to ensure current transfer status is accurate and included in the care plan and Kardex- 4/15/26Re-educate NAs, including agency on checking residents Kardex prior to start of shift 4/15/26DON (Director of Nursing)/designee to complete an audit of agency NA (Nurse Aide) orientation to validate completion- 4/16/26 Review of the Plan of correction revealed an initial audit was completed for all residents on April 15, 2026, to ensure current transfer status is included in the care plan and Kardex (care guide), weekly audits were conducted to ensure five randomly selected residents current transfer status were accurate and included in the care plan and Kardex, and weekly audits were conducted to ensure nursing staff were performing transfers properly per their assessments, as per their corrective action plan. In addition, a weekly audit was completed to ensure all contracted nursing staff had received orientation to the facility to validate completion. During an interview with the NHA on April 22, 2026, at 11:42 AM, she revealed that contracted nursing staff are supposed to receive a packet for orientation to the facility that includes a center tour and general information, policies and procedures (including safe resident handling), and various other pertinent information. The packet is signed by the contracted staff before the start of their first shift. She further revealed the audit indicated that eight out of 13 new contracted staff did not receive the education prior to their shift; Employee 1 was on the list that he did not complete orientation. Prior to the abbreviated survey, the facility failed to ensure each resident the right to be free from neglect, resulting in harm for Resident 1 as evidenced by a closed fracture of left hip. The facility's plan of correction was reviewed during the survey. Review of facility documentation revealed that on April 16, 2026, the facility had completed education for staff and audits to ensure compliance. During the abbreviated survey on April 22, 2026, staff interviews, resident interviews, resident record review, and observations revealed no concerns with neglect. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3)(e)(1) Management

Based on review of facility meal tray test form, review of resident council meeting minutes, review of the menu and select facility recipes, observations, completion of one meal test tray, and resident and staff interviews, it was determined that the facility failed to provide foods that are palatable, attractive, and at appetizing temperatures.Findings include: Review of the form, titled Resident Tray Assessment, revealed the standard optimal temperature for hot entree, starches, and vegetables at point of service is greater than 130 degrees. Interview with Resident 2 on April 13, 2026, at 11:35 AM, revealed she dislikes the food and it is always served cold. Interview with Resident 4 on April 13, 2026, at 11:37 AM, he stated the food is cold. Interview with Resident 6 on April 13, 2026, at 11:46 AM, she stated the food is usually cold and the plates are not hot. Review of resident council meeting minutes on February 24, 2026, revealed residents had concerns with the dietary department that the food is cold. Review of facility menu on April 13, 2026, revealed the main lunch meal consisted of Salisbury Steak with Mushroom Gravy, Scalloped Potatoes, Vegetable Blend, and Angel Food Cake. Interview with Employee 1 (Regional Foodservice Director) on April 13, 2026, at 12:09 PM, revealed there was a work order for the electrical socket next to the steam table in the kitchen, so the staff had to plug in the plate warmer elsewhere in the kitchen and then unplug it and bring it over to the tray line for meal service. Observation in the main kitchen on April 13, 2026, at 12:14 PM, revealed the plate warmer was next to the tray line meal service but it was not plugged in and the plates in the warmer were not warm. A test tray was completed on April 13, 2025, at 12:28 PM, with Employee 1 that included the Salisbury Steak with Mushroom Gravy, Scalloped Potatoes, Vegetable Blend, and Angel Food Cake. The test tray was placed on a meal cart and delivered to South Hall with other trays being delivered at that time. Employee 3 took temperatures of the food items at the time the test tray was served for evaluation. At that time, the Salisbury steak had a highest recorded temperature of 109 degrees Fahrenheit (F); the scalloped potatoes had a highest recorded temperature of 127 degrees F; and the vegetable blend had a recorded highest temperature of 109.2 degrees F. The Salisbury steak was a plain hamburger patty topped with gravy and was dry in appearance and taste, and the scalloped potatoes were made with diced potatoes and tasted bland. Review of the recipe provided for the Salisbury steak revealed it called for finely chopped garlic, onions, and peppers to be mixed in a mixer bowl with ground beef, eggs, and breadcrumbs. Review of the recipe provided for scalloped potatoes revealed it called for fresh peeled and sliced potatoes as well as various spices, onions, and parmesan cheese. During an interview with Employee 1 on April 13, 2025, at 12:39 PM, he revealed the facility had potatoes available to slice for the scalloped potatoes but the cook used diced potatoes instead. Interview with Employee 2 (Maintenance Director) on April 13, 2025, at 1:08 PM, revealed he received a work order for the outlet in the kitchen on March 7, 2026, and completed the replacement on March 9, 2026. It was determined that the plate warmer was incompatible with that socket, but the kitchen employees can plug it into a different socket, where it can still reach while sitting directly next to the steam table. He further revealed he had that discussion with Employee 1 and Employee 3 (Dietary Manager) at the time of the socket replacement, and that they verbalized understanding and stated that utilizing the other outlet would not affect normal operations. During an interview with the Nursing Home Administrator (NHA) on April 13, 2026, at 3:19 PM, the surveyor revealed the concern with food palatability, the test tray results, as well as concerns with recipes being followed and improper use of the plate warmer. The NHA revealed they are working to improve meal service. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility temperature logs, email correspondence, and resident and staff interviews, it was determined that the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety at one of two meals reviewed. Findings include: During an interview with Resident 4 on April 13, 2026, at 11:37 AM, he revealed he was served a peanut butter and jelly sandwich with chips and pudding at lunch yesterday because he heard the turkey was raw. During an interview with Resident 6 on April 13, 2026, at 11:46 AM, she revealed she heard the turkey was undercooked at lunch yesterday so she had a peanut butter and jelly sandwich. Review of facility food temperature log for April 12, 2026, revealed food temperatures failed to be recorded for breakfast and lunch that day. During an interview with Employee 1 (Regional Dietary Manager) on April 13, 2026, at 12:42 PM, revealed he arrived at the facility around 2:00 PM yesterday and the Registered Nurse (RN) supervisor was in the kitchen helping make peanut butter and jelly sandwiches because they felt that the turkey was not properly cooked. He then tested the turkey in the steam table and it was at 169 degrees F (Fahrenheit- unit of measure), but it was already on the steam table for a while. He revealed a nurse aide took a picture of the turkey on her phone and showed it to him, and based on the picture, it did appear undercooked to him. He further revealed upon interviews with staff and residents, it was determined no one was served or consumed the undercooked turkey. Interview with Employee 3 (Dietary Manager) on April 13, 2026, at 1:47 PM, he revealed he cooked two turkey breasts for lunch yesterday, and he pulled them from the oven and sliced into one and noticed it was undercooked, so he put them both back into the oven. He further revealed he later took the temperature of one of the breasts at 183 degrees F but did not temp the other one and did not record the temperatures. He revealed shortly into meal service, four meal trays came back to the kitchen, two were untouched, and two had been cut into, and they appeared to be undercooked. Email correspondence between the Director of Nursing and Employee 5 (RN Supervisor) on April 12, 2026, revealed, issue with lunch: turkey was raw. Residents had seen the raw turkey so they did not want to eat it, even when cooked stuff came to floor. Got them peanut butter and jelly sandwiches with chips. Interview with Employee 4 (Registered Dietitian) on April 13, 2026, at 2:03 PM, revealed she heard that the turkey was potentially undercooked at lunch yesterday, but she was not aware of anyone who actually consumed the turkey. Interview with Employee 5 on April 13, 2026, at 2:11 PM, revealed Employees 6 and 7 (Nurse Aides) noticed the turkey was pink when they started slicing into the breast meat during set-up assistance, so they immediately removed the trays and stacked them up on the meal cart to show her. Employee 5 then went back to the kitchen with the trays and helped make peanut butter and jelly sandwiches in the kitchen. She further revealed residents were then offered turkey that was cooked to the proper temperature or a peanut butter and jelly sandwich with chips and pudding. During an interview with the Nursing Home Administrator (NHA) on April 13, 2026, at 3:19 PM, the surveyor revealed the concern with the temperatures not recorded at breakfast and lunch the day prior, and the overall concern with food safety and lunch yesterday. The NHA revealed that the facility is working towards improving meal service. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to monitor hydration status to ensure proper hydration for one of two residents reviewed for hydration (Resident 11).Findings include: Review of facility policy, titled Fluid Restriction, dated October 2022, revealed, in part, The Nursing services will be responsible for tracking and documenting the total volume consumed in accordance with facility policy. Further review of facility provided policy failed to include any guidance regarding measures that nursing staff should take if a resident exceeds their ordered fluid restrictions. Review of Resident 11's clinical record revealed diagnoses that included acute on chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats, causing the heart to be unable to pump an adequate amount of blood to the body) and hypertensive heart and chronic kidney disease with heart failure (a medical condition that develops from prolonged, poorly managed high blood pressure, which causes progressive damage in both the heart and kidneys). Review of Resident 11's physician orders revealed an order for regular/liberalized diet with 1500 cc fluid restriction: 800 cc from dietary and 700 cc from nursing, dated August 22, 2025. Review of Resident 11's care plan revealed a focus for Resident exhibits or is at risk for dehydration as evidence by fluid restriction/insufficient intake, dated March 23, 2025; and Resident is at nutritional risk requires therapeutic diet history of decreased oral intake, dated March 26, 2025. Interventions included, but were not limited to, offer small amounts of fluids frequently dated March 23, 2205; fluid restriction per order: 1500 ml (dietary offers 800 ml via meals) and offer/encourage fluids of choice within fluid restriction parameters, both dated March 26, 2025. Review of Resident 11's nurse aide Kardex (care plan) revealed a special instruction that Resident 11 was on fluid restrictions, but no additional information or directions were included. Review of Resident 11's dietary tray ticket revealed that Resident 11 was on a fluid restriction of 1500 ml per day and that Resident 11 could receive a maximum of 240 ml with each meal. Review of Resident 11's Medication Administration Records from August 1, 2025, through March 17, 2026, revealed the following:September 2025- Resident 11 exceeded her allotted nursing fluids on September 1 and 16, 2025.October 2025- Resident 11 exceeded her allotted nursing fluids on October 1, 13, 24, 29, and 31, 2025.November 2025-Resident 11 exceeded her allotted nursing fluids on November 2, 4, 6, 9, 10, 11, 21, and 22, 2025.December 2025-Resident 11 exceeded her allotted nursing fluids on December 16, 22, 25, and 30, 2025.January 2026-Resident 11 exceeded her allotted nursing fluids on January 3, 5, 6, 7, 13, 21, 27, and 28, 2026.February 2026-Resident 11 exceeded her allotted nursing fluids on February 5, 6, 10, 11, 16, 23, and 24, 2026.March 2026- Resident 11 exceeded her allotted nursing fluids on March 7, 8, 9, 10, 16, and 17, 2026. Review or Resident 11's clinical record failed to reveal any documentation that Resident 11's physician was made aware of her exceeding her ordered nursing fluid restrictions. Further review of Resident 11's clinical record failed to reveal any documentation of fluids Resident 11 consumed from her meal trays from August 1, 2025, through March 17, 2026, and, therefore, Resident 11's total fluid consumption in each 24-hour period was not determined. During a staff interview with the Nursing Home Administrator and Director of Nursing (DON) on March 19, 2026, at 11:00 AM, the DON confirmed that there was no documentation of what fluids Resident 11 consumed with her meals. She indicated that nurse aides would report to the nurse the amount of fluids they provided to a resident. She confirmed that there was no dietary fluid intake recorded with Resident 11's meal intake documentation. She confirmed that Resident 11 did exceed allotted nursing fluids on occasions and that there was no documentation to show that all Resident 11's fluids were totaled for each 24-hr period. She confirmed that she would expect staff to follow a resident's ordered fluid restrictions and to follow-up with the physician when exceeded. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policy reviews, observations, and staff interviews, it was determined that the facility failed to properly label medications in one of three medications carts reviewed (South Wing Hall C cart); and failed to discard expired medications in two of three medication carts observed (South Hall B and C carts).Findings include: Review of facility policy, titled Storage of Medication, dated January 2025, revealed, in part, Medications and biologicals are stored properly, following manufacturer or provider pharmacy recommendations to keep their integrity and to support safe, effective drug administration. Note the date on the label for insulin vials and pens when first used. Review of facility policy appendix Medications with Shortened Expiration Dates, dated 2007, revealed that Lispro insulin should be discarded 28 days after opening. Observation of the South Wing B Hall medication cart on March 17, 2026, at 12:12 PM, with Employee 4 (Registered Nurse) revealed an opened haloperidol 1 ml single dose vial, which had no resident name or date indicated on the vial. The vial was laying loose in the plastic bin with insulin pens. During an immediate staff interview with Employee 4, Employee 4 confirmed that the vial was not labeled or dated and that it should have been discarded when used since it was a single dose vial. Observation of the South Wing C Hall medication cart with Employee 5 (Licensed Practical Nurse) on March 17, 2026, at 12:20 PM, revealed a lispro insulin belonging to Resident 74 which was dated as being opened on February 16, 2026; and a Lantus insulin pen belonging to Resident 5, which was opened, but not dated. The pharmacy label indicated that the Lantus pen had been dispensed from the pharmacy on March 13, 2026. During an immediate staff interview with Employee 5, Employee 5 confirmed that Resident 74's insulin pen was beyond the 28-day expiration date and should have been discarded. Employee 5 also confirmed that Resident 5's Lantus insulin pen should have been dated with an open date and indicated that she may have been the nurse that opened it and failed to date it. During a staff interview with the Nursing Home Administrator and the Director of Nursing (DON) on March 18, 2026, at 12:11 PM, the DON confirmed that she would expect medications to be labeled and stored properly, and that she expected discarded medications to be discarded when expired according to policy or manufacturer guidelines. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.9(a)(1) Pharmacy services.

Based on observation, document review, and staff interview, it was determined that the facility failed to follow the diet extension sheets to provide a menu to meet the needs and preferences of residents on a regular diet for 79 of 79 residents reviewed on a regular diet.Findings include: Review of the facility provided diet manual, titled Diet and Nutrition Care Manual, Reviewed February 16, 2026, revealed, the regular diet should provide adequate nutrients as recommended by the Dietary Guidelines and National Research Council by using these guidelines to provide three balanced meals and up to three snacks daily. Observation of the lunch meal service on March 17, 2026, at 11:51 AM, revealed residents on a regular diet being served rotini pasta salad with a 3-ounce scoop. Review of diet extension sheets for the lunch meal to be served on March 17, 2026, revealed that residents on a regular diet are to be served 1/2 cup (4 ounces) of rotini pasta salad. Interview with the Nursing Home Administrator on March 18, at 11:50 AM, revealed that she would expect resident meals to be prepared and served in accordance with the menus that have been approved by the dietician and physician. Pa code 211.6(a)(b) - Dietary Services

Based on observations, clinical record review, facility policy reviews, and staff interviews, it was determined that the facility failed to ensure staff implement infection control policies to prevent the spread of infection for one of one dressing changes observed (Resident 92); for storage of medications on one of three medication carts observed (South Wing C Hall); and for medication administration in one of two medication administration observations (Employee 5). Findings Include: Review of facility policy, titled IC308 Enhanced Barrier Precautions, revised November 14, 2025, revealed that Enhanced Barrier Precautions expands on the use of gown and gloves beyond anticipated blood and body fluid exposures, focusing on use of gown and gloves only during high contact patient care activities that have been demonstrated to result in the transfer of MDROs (Multi Drug Resistant Organisms) to the hands and clothing of healthcare personnel, even if blood and body exposure is not anticipated. Review of facility policy, titled Section 7.11 Medication Administration Eye Drops, dated January 2026, revealed that gloves are recommended to protect both patient and provider from transmission of infectious agents and staff are to perform hand hygiene and don (apply) gloves prior to administering eye drops. Review of Resident 92's clinical record revealed diagnoses that included pressure ulcer of the right buttock, stage 4 (severe wounds that extend through the skin and underlying tissues, exposing muscle, tendon, and bone, and require immediate medical attention) and dementia (a syndrome characterized by a decline in cognitive function). Review of Resident 92's physician orders revealed an order for, Infection precautions - enhanced barrier, starting January 31, 2026. Review of Resident 92's care plan revealed a care plan focus area of, Resident is at risk for MDRO colonization/infection due to chronic wounds, revised November 18, 2025, with an intervention of, Enhanced Barrier Precautions: Use gown and gloves when performing high-contact activities: dressing, bathing and showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of a device (e.g. central line, urinary catheter, feeding tube, tracheostomy, or ventilator), wound care(any skin opening requiring a dressing), created January 23, 2026. Observation of Employee 1 (Registered Nurse) on March 18, 2026, at 9:41 AM, revealed Employee 1 completed ordered wound care on Resident 92's sacral pressure ulcer. Employee 1 failed to wear a gown at any time during the dressing change. Interview with the Nursing Home Administrator (NHA) on March 19, 2026, at 11:30 AM, revealed that she would expect employees to use appropriate personal protective equipment. Observation of the South Wing C Hall medication cart with Employee 5 (Licensed Practical Nurse) on March 17, 2026, at 12:20 PM, revealed that Employee 5 had her jacket stored in the bottom drawer of the medication cart along with medications. During an immediate interview with Employee 5, she confirmed that her jacket should not be in the medication cart. During a staff interview with the NHA and the Director of Nursing (DON) on March 18, 2026, at 12:11 PM, the DON confirmed that staff personal items should not be stored in medication carts. Observation of Employee 5 administering medications to Resident 127 on March 18, 2026, at 9:15 AM, revealed that she took Resident 127's inhaler and antibiotic eye drops in their boxes into the Resident's room and sat them directly on his overbed table. Employee 5 failed to apply gloves prior to administering Resident 127's antibiotic eye drops. In addition, Employee 5 failed to wear gloves when applying Resident 127's lidocaine patch. After administering Resident 127's medications, Employee 5 returned the inhaler and eye drop boxes to the medication cart and placed them in the drawer of the cart. During an immediate interview with Employee 5 after completing Resident 127's medication administration, Employee 5 confirmed that she should have placed a clean barrier on Resident 127's overbed table before setting the medication boxes down. She also confirmed that she should have worn gloves when administering the eye drops and applying the lidocaine patch. During a staff interview with the NHA and DON on March 18, 2026, at 12:11 PM, the DON confirmed that Employee 5 should have worn gloves when administering Resident 127's eye drops and applying his lidocaine patch. She also confirmed that Employee 5 should have placed a clean barrier under the medication boxes. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policy review, observation, clinical record review, and staff and resident interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of 22 residents reviewed (Resident 92). Findings include: Facility provided policy, Medication Administration, General Guidelines; dated January 2025, failed to reveal any expectation of employees giving medications to remain with the resident and observe the resident take the medication.Review of the Pennsylvania Nursing Practice Act, Chapter 21.145. Functions of the LPN (Licensed Practical Nurse). The LPN administers medication and carries out the therapeutic treatment ordered for the patient in accordance with the following: The LPN may accept a written order for medication and therapeutic treatment from a practitioner authorized by law and by facility to issue orders for medical and therapeutic measures.Review of Resident 92's clinical record revealed diagnoses of gastro esophageal reflux disease without esophagitis (disease (GERD) characterized by typical acid reflux symptoms-heartburn and regurgitation) and peripheral vascular disease (a slow, progressive circulation disorder involving blood vessel damage, narrowing, or blockages outside the heart and brain).Observation of Resident 92 on March 17, 2026, at 10:20 AM, revealed the resident sitting in bed. On her overbed table there were eight pills {identified as aspirin 81 mg (nonsteroidal anti-inflammatory drug) , bupropion ER 150 mg (antidepressant), bupropion ER 300 mg, Calcitriol 0.5 mcg (vitamin D3), Vitamin B12 500 mcg- 2 tablets, Metoprolol 50 mg (blood pressure medication), and Senna 8.5 mg (laxative)}. Interview with Resident 92 at that time revealed that Employee 2 (Licensed Practical Nurse) had left them there with her to take after she was finished with her breakfast.Review of Resident 92's physician orders failed to reveal a physician's order for self-administration of medication.Review of Resident 92's Care Plan failed to reveal a care plan for self-administration of medication.Review of Resident 92's clinical record failed to reveal an evaluation of Resident 92 for self-administration of medication.Interview with the Nursing Home Administrator on March 18, 2026, at 1:00 AM, revealed that Resident 92 should not have had her medications left at her bedside. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to provide care and services necessary to maintain adequate personal hygiene and grooming for care-dependent residents for two out of 10 residents reviewed (Residents 1 and 3).Findings Include: Review of Resident 1's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and chronic obstructive pulmonary disease (a group of lung diseases that cause ongoing inflammation and narrowing of the airways, leading to difficulty breathing). Review of Resident 1's Kardex (a concise, portable document used to record and organize essential patient information) revealed that it is important for the Resident to choose between a tub bath, shower, bed bath or sponge bath. Review of Resident 1's clinical record revealed a shower task indicating Resident 1's shower days are on Mondays and Thursdays. Further review of the task revealed on August 28, 2025; September 4, 8, and 11, 2025, it was marked not applicable, indicating the Resident did not receive a shower on those days. Review of Resident 3's clinical record revealed diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and hypertensive heart disease (problems with your heart that can develop if you have high blood pressure). Review of Resident 3's comprehensive care plan revealed a focus area where the Resident stated it is important that he has the opportunity to engage in daily routines that are meaningful relative to their preferences; with an intervention to include that it is important to the Resident to choose between a tub bath, shower, bed bath or sponge bath, both created on August 29, 2025. Review of Resident 3's clinical record revealed a shower task indicating Resident 3's shower days are on Mondays and Fridays. Further review of the task revealed on August 29, 2025; September 5, 8, 15, 19, and 22, 2025, it was marked not applicable, indicating the Resident did not receive a shower on those days. During an interview with Nursing Home Administrator on September 24, 2025, at 1:40 PM, she revealed that if a resident refused to get a shower on their shower days, she would expect it to be marked as a refusal instead of not applicable. 28 Pa Code 211.12(d)(1)(3)(5)Nursing services.28 Pa. Code 201.29(j) Resident rights.

Based on clinical record review, review of facility policy, and staff interviews, it was determined that the facility failed to obtain a physician's order for the use of a restraint following application of an emergency restraint for one of one individuals reviewed for restraint use (Resident 4).Findings include:Review of facility policy, Restraints: Use of, revised June 15, 2022, revealed, Emergency restraints may be used: As a last resort to protect the safety of the patient and others if patient's unanticipated violent or aggressive behavior places self or others in imminent danger. The order for the use of the restraint must be obtained from the physician/advanced practice provider either during the application of the restraint or immediately after the restraint has been applied. Supporting documentation must reflect what the patient was doing and what happened that presented the imminent danger.Review of Resident 4's clinical record revealed diagnoses that included Parkinson's Disease (movement disorder of the nervous system that worsens over time) and dementia, severe with psychotic disturbance (decline in cognitive functioning that affects memory, thinking and social abilities, significantly interfering with everyday life).Review of Resident 4's nursing progress note dated August 11, 2025, revealed, Called toward room, in hallway, by [nurse aide] in hall stating 'the patient is going to hit the girl in this room.' Upon entering room, patient was being asked to sit down in chair at bedside and began striking out at Staff. Patient continued growing more agitated with staff despite quiet verbal redirection and patience offered. This writer intervened to deflect patient's aggressive advances toward staff and protect patient with the assistance of two others. Patient fighting against chair, proceeded to try scratching, gripping, head butting and biting at those in his vicinity. Staff preserved safety to the patient and their peers despite the aggressive and violent outbursts. Patient verbalizing threats towards Staff and demand he be released from position. Educated patient on steps needed to release from position however, patient persistently posturing with flat affect, lacking insight, and judgment while thrashing.Respirations and pulse slightly elevated due to agitation, patient shows no signs or symptoms of distress. Circulation and skin integrity monitored throughout interaction without deviation from baseline.While interaction was taking place, supervisory staff stepped in to call for outside help. EMS [Emergency Medical Services] was contacted via 911. EMS arrived on scene to survey situation and upon seeing patient's aggression, called for assistance from state police. Wife entered room and offered to help facilitate de-escalation, paramedics told her to stay back for safety. When [State Police] arrived on scene, background of the situation was relayed to officers, and intramuscular ketamine [anesthetic] was administered by paramedic to patient's left thigh. Staff was cycled slowly to be replaced by officers and paramedics to facilitate ease of transfer to stretcher. Upon patient's exit from the unit, one on one processing and active listening provided to patient's wife at bedside.Review of Employee 7's (Nurse Aide) witness statement dated August 11, 2025, revealed, in part, I was called to assist fellow CNA [certified nurse aide] with [Resident 4]. When walking [Resident 4] was already irritable and not following commands when I went closer to him he then lunged forward pinning me on to the bed. Fellow CNA called for help [Resident 4] still wasn't following commands and still was very aggressive .no way to console him or de-escalate. Employee 7 was helping to hold his knees down until Employee 2 [Registered Nurse] came in.Review of Employee 9's (Nurse Aide) witness statement dated August 11, 2025, revealed, in part, [Resident 4] was getting up from his bed. I assisted him by bringing his wheelchair, but he wouldn't sit down. The nurse was walking past and I asked her for help but one of the aides came in to help assist as we told [Resident 4] to have a seat in his chair cause we didn't want him to fall. He pushed the other aide down to this bed and held her down. We tried to tell him we were there to help but he kept holding her down to the bed .Nurse and aides came to assist but he became aggressive.Review of Employee 10's (Registered Nurse) witness statement dated August 11, 2025, revealed, in part, I was alerted by CNA screaming down the A hall that they needed help with [Resident 4]. I go in the room and see [Resident 4] pinning one of the CNAs on the bed. As another aide attempts to take him off her, but as she tries to get him off her he tries to throw punches at them. We attempted to get him to sit on the chair, but he continued to throw punches and kick with both legs at all staff members. As he continues his aggression I call [practitioner] and get order to send to ER [Emergency Room]. When Employee 10 entered room [Employee 8 (Nurse Aide)] had Resident's left wrist. [Employee 13 (Licensed Practical Nurse)] had right wrist. They sat him down on chair. He began kicking staff so Employee 2 was holding his right thigh down to keep him from kicking.Review of Employee 11's (Licensed Practical Nurse) witness statement dated August 11, 2025, revealed, in part, I was down C Hall when [Employee 9] came down the hall stating they need help with [Resident 4]. She said he was trying to punch staff. When I entered the room [Employee 8] was holding [Resident 4's] left arm, [Employee 2] was assisting trying to hold his legs down as he was trying to kick staff and [Employee 13] was holding his right arm. He continued to try to kick, bite, and punch staff. I assisted holding his right forearm as he continued to try to punch staff, kick and turn his head to bite Ambulance crew arrived then [State Police] who after [Resident 4] was administered IM [Intramuscular] medication in his left thigh by the ambulance crew directed us one by one out of the room.Review of Resident 4's physician orders failed to reveal an order allowing use of physical restraint either before or immediately following the aforementioned incident.During an interview with the Director of Nursing on August 13, 2025, at 1:33 PM, she confirmed that no order for application of a physical restraint was obtained for Resident 4.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.8 (d) Use of restraints.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy, clinical record review, facility documents, and resident and staff interviews, it was determined the facility failed to ensure that residents were free from any significant medication errors for one of four residents reviewed (Resident 1). Findings include:Review of facility policy, Medication Administration last revised January 2025, stated, medications are administered as prescribed in accordance with manufacturers specifications, good nursing principles and practices and only by persons legally authorized to do so. # 9. The individual administering medications verifies medication is correct three (3) times before administering the medication.When pulling the medication package from med cart.When dose is prepared.Before dose is administered.# 10. Residents are identified before medication is administered using at least two resident identifiers. Methods of identification may include: a. Check identification band. b. Check attached to medical record photograph. c. Verify resident identification with other nursing care center personnel.Note: the resident's room number or physical location is not used as an identifier.Review of the admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included hypertension (elevated blood pressure) and dysphagia (difficulty swallowing).Review of Resident 1's quarterly MDS (minimum data set- standardized assessment tool to gather comprehensive information about residents' functional capabilities, health status, and care needs) completed May 5, 2025, revealed a BIMS (brief interview of mental status) of 15, indicating intact cognition.Review of a select documents revealed Resident 1 reported to her daughter that Employee 1 (Registered Nurse) on July 31, 2025, at 2:00 AM, entered her room, where she resides with her spouse who is hospice status. Resident 1 said she was asleep, and Employee 1 placed a syringe in the corner of her mouth. Resident 1 immediately woke up and said no, no, no that is my husband's medication. Resident 1 reported that she was able to taste some of the medication before the syringe was removed. Resident 1 reported that Employee 1 pulled the syringe out of her mouth, turned around, and inserted the same syringe into her husband's mouth and administered the Morphine (opioid). Resident 1 reported the event to nursing on July 31, 2025, at 7:00 AM. Resident 1 notified her daughter in the evening of the event on July 31, 2025.Resident 1 was interviewed by Employee 2 (Registered Nurse) on July 31, 2025, at 9:30 AM, after Employee 12 (Registered Nurse) informed her that Resident 1 needs to talk with her because the night shift nurse tried to give her husband's liquid medication.Resident 1 was interviewed again on August 1, 2025, after family of Resident 1 came to the nurse's station and questioned Employee 2 why their mother received their dad's medication and what was being done about it. Employee 2 informed the family that she didn't realize the syringe went into her mouth when she interviewed Resident 1 on July 31, 2025. Employee 2 reported to the Director of Nursing (DON) on August 1, 2025, after interviewing Resident 1 for more details about the syringe and it being placed in her mouth. The DON completed an Individual Performance Improvement Plan on August 1, 2025, and had Employee 1 sign it. The form is marked Unsatisfactory Job Performance.This Surveyor interviewed Resident 1 on August 13, 2025, at 11:00 AM, and requested that she review the event that occurred on July 31, 2025. Resident 1 stated that she was awoken on July 31, 2025, at 2:00 AM, by a syringe being placed in the corner of her mouth by Employee 1, a male nurse. She said she yelled no, no, no that's my husband's medication. Resident 1 added that her husband receives liquid Morphine every 4 hours with a syringe for his hospice care. Resident 1 confirmed that she was able to taste some of the medication. Resident 1 said the nurse removed the syringe from her mouth and immediately turned toward her husband in the next bed and administered the medication to her husband with the same syringe. Resident 1 was asked if she reported the event and she said she reported that morning about 7:00 AM, because no one approached her about the event. Resident 1 said she wasn't sure if it was reported by the male nurse. Resident said staff took her blood pressure on July 31, 2025, at 10:30 AM, and it was 100/60, (confirmed in clinical record) which was low per Resident 1. Resident 1 added that she didn't urinate for about 6-8 hours, which she said was unusual for her, but denied any pelvic pressure. (Note: a side effect of morphine is urinary retention and reduced arterial blood pressure). Resident 1 said was able to attend activities and had no complaints of discomfort.During an interview with Resident 1's daughter on August 13, 2025, at 11:15 AM, the daughter stated that she was never notified about the event until Resident 1 called and informed her in the evening on July 31, 2025.During an interview with the Nursing Home Administrator (NHA) on August 13, 2025, at 11:45 AM, she confirmed that Employee 1 never reported the medication error with Resident 1. A statement written August 1, 2025, by Employee 1 failed to admit syringe entered Resident 1's mouth, but did admit to approaching Resident 1 and that Resident 1 stopped him. The NHA stated that Employee 1 no longer works at the facility. There was no record of the physician being notified of the event.28 Pa Code: 201.18 (b)(1)(3) Management28 Pa Code: 211.10 (d) Resident care policies

Based on policy review, clinical record review, as well as resident, resident family member, and staff interviews, it was determined that the facility failed to maintain professional practices that support infection prevention and control for one of four residents reviewed (Resident 1).Findings include: A review of the facility policy, titled Infection Control Policies and Procedures, last revised February 24, 2025, stated, Centers will record incidents identified under the Infection Prevention and Control Program (IPCP) and the corrective actions taken. Breaches in Practice are failures in infection control practices, such as non-compliance.Reports from staff, patients, or families on any healthcare associated infection or spread of disease due to possible errors in infection prevention or control Centers for Disease Control states all single-dose syringes should never be used for more than one patient and is a breach in practice.Review of the admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included hypertension (elevated blood pressure) and dysphagia (difficulty swallowing).Review of Resident 1's quarterly MDS (minimum data set- standardized assessment tool to gather comprehensive information about residents' functional capabilities, health status, and care needs) completed May 5, 2025, revealed a BIMS (brief interview of mental status) of 15, indicating intact cognition.Review of select documents revealed Resident 1 reported to her daughter that Employee 1 (Registered Nurse) on July 31, 2025, at 2:00 AM, entered her room, where she resides with her spouse who is hospice status. Resident 1 said she was asleep, and Employee 1 placed a syringe in the corner of her mouth. Resident 1 immediately woke up and said no, no, no that is my husband's medication. Resident 1 reported that she was able to taste some of the medication before the syringe was removed. Resident 1 reported that Employee 1 pulled the syringe out of her mouth, turned around, and inserted the same syringe into her husband's mouth and administered the Morphine (opioid).Resident 1 reported the event to nursing on July 31, 2025, at 7:00 AM. Resident 1 notified her daughter in the evening of the event on July 31, 2025.During an interview with Resident 1's daughter on August 13, 2025, at 11:15 AM, the daughter stated that she was never notified about the event until Resident 1 called and informed her in the evening on July 31, 2025. Resident 1's daughter was also concerned about the syringe being placed in her dad's mouth due to a current infection Resident 1 was receiving antibiotics to treat.A review of Resident 1's clinical record revealed the Resident was diagnosed with bacterial sinusitis and was currently receiving Cefuroxime Axetil (antibiotic that treats bacterial infections) 500 milligrams twice a day for 7 days, effective July 29, 2025.During an interview with the Nursing Home Administrator (NHA) on August 13, 2025, at approximately 1:00 PM, the NHA agreed that the syringe should have been discarded after being inserted into Resident 1's mouth and the event should have been reported by Employee 1. The NHA added that Employee 1 no longer works at the facility.28 Pa Code: 201.18 (b)(1)(3) Management28 Pa Code: 211.10 (d) Resident care policies

Based on facility policy review, clinical record review, facility documentation review, and staff interview, it was determined the facility failed to ensure each resident is free from neglect, which resulted in actual harm as evidenced by displaced hardware securing a fracture for one of three residents reviewed (Resident 3). Findings include: Review of facility policy, titled OPS 300 Abuse Prohibition with a last revision date of October 24, 2022, revealed Neglect is defined as the failure, indifference, or disregard of the Center, its employees, or service providers to provide care, comfort, safety, goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of Resident 3's clinical record revealed diagnoses that included chronic kidney disease (longstanding disease of the kidneys leading to renal failure), atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating of the upper chamber of the heart), and history of falling. Review of Resident 3's care plan revealed an intervention for provide resident/patient with extensive assist of 2 for bed mobility, dated March 12, 2024. Review of Resident 3's clinical record progress notes revealed a note dated March 15, 2025, at 7:46 AM, that indicated around 5:40 AM the Resident was noted to be on the floor, was complaining of left knee pain, right hip pain, and worsening left arm pain. The Resident rated all her pain 10/10, unable to move lower extremities and left arm, and the left knee warm to touch. The note indicated that Resident 3's provider was made aware and orders were given for x-rays of both hips, pelvis, both knees, and left forearm; as well as orders for an additional pain medication and to hold their anticoagulant (blood thinning) medication for two days. The note further indicated that Employee 4 (agency nurse aide) said, she was trying to change resident when she rolled out the opposite side of bed and landed with her feet touching the ground first. Further review of Resident 3's progress notes revealed a note dated March 15, 2025, at 12:04 PM, that indicated that the x-ray revealed an appliance in Resident 3's left arm with an abnormality noted. The note further indicated that Resident 3's provider was made aware and an order was given to transport Resident 3 to the hospital. Review of Resident 3's x-ray report dated March 15, 2025, revealed that there was a sideplate and screws bridging a distal humerus fracture. A screw in the sideplate is broken and the distal portion of the sideplate is no longer attached to the humerus. Review of facility provided investigation witness statement from Employee 4 dated March 15, 2025, revealed that Employee 4 was providing care, and she had Resident 3 on her side but she rolled off I grabbed her, but she still fell. Review of the facility reported incident, revealed that the facility suspended Employee 4 immediately at time of Resident 3's fall. The report also confirmed that Employee 4 neglected to follow Resident 3's care plan by failing to provide extensive assist of 2 people for bed mobility and failed to properly turn and reposition Resident 3 toward them while providing care, which resulted in Resident 3 falling out of bed and experiencing actual harm as evidenced by displaced hardware securing a fracture requiring a transfer to the hospital for treatment. The facility terminated the contract for Employee 4. Review of facility provided training information revealed that in December 2024, the facility completed education with nursing staff on resident safety during turning and repositioning, and objectives included ability to quickly identify potential safety issues prior to turning resident; how to safely turn and reposition a resident; and identify ways to prevent injury during turning and repositioning. Employee 4 had signed the Employee Training Sign-In Sheet as an attendee. During a staff interview with the Nursing Home Administrator (NHA) and Employee 1 on March 20, 2025, at 10:51 AM, the NHA confirmed that she would expect staff to follow a resident's care plan. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1)(e)(1) Management 28 Pa. Code 201.29 (a) Resident rights 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on facility policy review, clinical record review, facility incident report investigation review, facility training records, and staff interview, it was determined that the facility failed to ensure that residents received adequate assistance to prevent accidents, which resulted in harm as evidenced by displaced hardware securing a fracture for one of two residents reviewed for falls (Resident 3). Findings include: Review of facility policy, titled NSG215 Falls Management, with a last revised date of March 15, 2024, revealed Interventions to reduce risk and minimize injury will be implemented as appropriate; and 2. Implement and document patient-centered interventions according to individual risk factors in the patient's plan of care. Review of Resident 3's clinical record revealed diagnoses that included chronic kidney disease (longstanding disease of the kidneys leading to renal failure), atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating of the upper chamber of the heart), and history of falling. Review of Resident 3's care plan revealed an intervention for provide resident/patient with extensive assist of 2 for bed mobility, dated March 12, 2024. Review of Resident 3's clinical record progress notes revealed a note dated March 15, 2025, at 7:46 AM, that indicated around 5:40 AM the Resident was noted to be on the floor, was complaining of left knee pain, right hip pain, and worsening left arm pain. The Resident rated all her pain 10/10, unable to move lower extremities and left arm, and the left knee warm to touch. The note indicated that Resident 3's provider was made aware and orders were given for x-rays of both hips, pelvis, both knees, and left forearm; as well as orders for an additional pain medication and to hold their anticoagulant (blood thinning) medication for two days. The note further indicated that Employee 4 (Agency Nurse Aide) said she was trying to change resident when she rolled out the opposite side of bed and landed with her feet touching the ground first. Further review of Resident 3's clinical record progress notes revealed a note dated March 15, 2025, at 12:04 PM, that the x-ray revealed an appliance in Resident 3's left arm with an abnormality noted. The note further indicated that Resident 3's provider was made aware and an order was given to transport Resident 3 to the hospital. Further review of Resident 3's clinical record progress notes revealed a note dated March 15, 2025, at 3:46 PM, that indicated Resident 3 was admitted to the hospital with a displaced fracture of left humerus. Review of Resident 3's x-ray report dated March 15, 2025, revealed that there was a sideplate and screws bridging a distal humerus fracture. A screw in the side plate is broken and the distal portion of the sideplate is no longer attached to the humerus. Review of facility provided investigation witness statement from Employee 4 dated March 15, 2025, revealed that Employee 4 indicated she was providing care, and she had Resident 3 on her side but she rolled off; I grabbed her, but she still fell. Review of facility provided investigation witness statement from Resident 3 dated March 15, 2025, revealed that Employee 4 had pushed her too hard and she fell out of the bed. Resident 3 further indicated that the bed was in high position and that Employee 4 had kept pulling the sheets and the Resident got closer to the edge of the bed and slid out of the bed, onto the floor. Review of facility provided investigation witness statement from Resident 4, the roommate of Resident 3, dated March 15, 2025, indicated that Resident 4's bed was in the high position and although Resident 4 did not see Resident 3 fall; she heard her fall. Review of facility provided investigation information confirmed that Employee 4 was providing care and turning and repositioning alone and that she had rolled Resident 3 away from her, resulting in Resident 3 rolling out of bed onto the floor. During a staff interview with the Nursing Home Administrator (NHA) and Employee 1 on March 20, 2025, at 10:51 AM, the NHA confirmed that she would expect staff to follow a resident's care plan and follow proper care techniques to prevent accidents. 201.4(a) Responsibility of licensee 201.18(b)(1)(e)(1) Management 211.10(c)(d) Resident care policies 211.12(d)(1)(2)(5) Nursing services

Based on facility policy review, clinical record reviews, facility incident report review, hospital records review, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for two of 16 residents reviewed (Residents 1 and 5). Findings include: Review of facility policy, titled NSG115 Physician/ Advanced Practice Provider (APP) Notification, with a last revision date of December 16, 2024, revealed, in part, Upon identification of a patient who has a change in condition, abnormal laboratory values, or diagnostic tests, a licensed nurse will: perform appropriate clinical observations, collect pertinent patient information, and report to physician/Advanced Practice Provider (APP); complete the eInteract Change in Condition UDA and determine if the change in condition requires immediate or non-immediate notification, and notify physician/APP as applicable. Review of Resident 1's clinical record revealed diagnoses that included hypertension (high blood pressure), bradycardia (heart rate lower than 60 beats per minute), and chronic pain syndrome. Review of Resident 1's progress notes revealed a note written by Employee 8 (Registered Nurse [RN]) dated March 1, 2025, at 3:49 PM, that indicated Resident 1's family was at the bedside requesting that Resident 1 be transferred to the hospital right away because of confusion, low blood pressure, and unrelieved pain. Review of Resident 1's Medication Administration Record revealed that she received oxycodone on March 1, 2025, at 1:41 PM, for a pain level of 10; and received Tylenol at 2:30 PM for continued pain level of 8. Review of Resident 1's vital signs documentation for March 1, 2025, at 3:25 PM, revealed a temperature of 96.7 degrees Fahrenheit (normal 98.6 degrees Fahrenheit), a pulse rate of 76 (normal 60-100), a respiratory rate of 22 per minute (normal 16-20 per minute), a blood pressure of 77/50 (normal 120/80), and an oxygen saturation of 93% on room air (normal 95-100%). Review of Resident 1's clinical record progress notes revealed a note written by Employee 6 (RN), who was Resident 1's assigned nurse for that shift, dated March 1, 2025, at 3:50 PM, that noted Resident 1 had increased weakness, pain medicine not effective after administering her as needed oxycodone and Tylenol, her blood pressure was low, Resident 1's son was visiting and requesting her to be sent to the hospital for evaluation and treatment, the nurse practitioner was made aware, and the ambulance arrived at 3:50 PM. Review of Resident 1's progress notes revealed a note written by Employee 8 dated March 1, 2025, at 9:00 PM, that indicated Resident 1 had been admitted to the hospital with diagnoses of septic shock (life threatening condition caused by a severe localized or system-wide infection that requires immediate medical attention), acute kidney injury (an abrupt disruption in kidney function), and a urinary tract infection. Review of facility provided incident report documentation revealed that Resident 1's son contacted the facility and reported concerns regarding Employee 5's (Agency RN Supervisor) actions and Resident 1's care on March 1, 2025. The son notified Employee 5 of Resident 1's change in condition and requested that she be sent to the hospital, Employee 5 rolled her eyes and stated that Resident 1 did not need to go to the hospital. Review of facility provided incident report documentation revealed a statement written by Employee 5 dated March 10, 2025, that indicated she was unaware of any situation or incident involving Resident 1 on March 1, 2025. Further review of Resident 1's progress notes failed to reveal any documentation that Employee 5 completed a nursing assessment of Resident 1 when she was notified of the change in her condition, or that Resident 1's physician was made aware of the changes at time they were initially noted. Review of facility provided incident report documentation revealed a statement written by Employee 6, undated, that Resident 1's son had approached her about his mother's condition as he thought something was off and that she seemed worse than she was 2 weeks ago. Employee 6 indicated that she did tell Resident 1's son that she had administered a narcotic pain medication about an hour prior and that she had also just administered Tylenol right before his arrival. Employee 6 notified Employee 5 of Resident's son's request. Employee 6 indicated that she overheard Employee 5 tell Resident 1's son she had no clinical indications to send her to the hospital. Further review of the incident report revealed a statement written by Employee 8, dated March 7, 2025, that indicated on March 1, 2025, she arrived on the nursing unit at approximately 3:15 PM. Employee 8 said she greeted Employee 5 who was leaving the nursing station. Employee 7 indicated that Employee 5 told her that there was not much going on in the building except a lady wanting to go to the hospital. Employee 8 indicated that she spoke to Employees 6 and 7, and Employee 7 told her that Resident 1's blood pressure was 78/40 and that she was experiencing a change in mental status. Employee 8 indicated that she immediately began calling 911. Review of Resident 1's hospital records revealed that she arrived at the emergency room on March 1, 2025, at 4:20 PM, and that she had a temperature of 86.9 degrees Fahrenheit, a pulse rate of 44, a respiratory rate of 27 per minute (normal 16-20 per minute), a blood pressure of 79/43, and an oxygen saturation of 87% on 10 liters of oxygen. She was noted to be in acute distress, mildly confused, very fatigued and lethargic, and able to move all extremities with generalized weakness noted. During a staff interview with the Nursing Home Administrator (NHA) and Employee 1 (RN) on March 20, 2025, at 10:50 AM, the NHA indicated that she was not comfortable stating whether Employee 5 should have sent Resident 1 to the hospital when the Resident and her son requested since she was not present to visualize Resident 1's status. When asked if Employee 6 should have notified Resident 1's physician and sent her to the hospital as requested by Resident 1 and her son, the NHA indicated that Employee 6 had followed the chain of command. Review of Resident 5's clinical record revealed diagnoses that included hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting left non-dominant side, Type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and severe protein-calorie malnutrition (malnutrition caused when not enough proteins and calories are consumed). Review of Resident 5's clinical record progress notes revealed a note written by a LPN dated March 9, 2025, at 10:05 PM, that indicated Resident 5 had refused her medications and had multiple episodes of nausea and vomiting on evening shift. Review of Resident 5's clinical record progress notes revealed a note written by a LPN dated March 10, 2025, at 10:50 AM, that indicated Resident 5 had refused her medications and was complaining of feeling nauseous. Review of Resident 5's clinical record progress notes revealed a note written by a LPN dated March 10, 2025, at 4:59 PM, that indicated Resident 5 had refused her medications and was complaining of general malaise (a general feeling of being ill or having no energy which can be an indefinite feeling of debility or discomfort, or a sign of an illness). Review of Resident 5's physician orders failed to reveal any medication orders to treat her nausea or vomiting. Review of Resident 5's meal intakes revealed that no meal intakes were documented after March 9, 2025, at 4:30 PM. Further review of Resident 5's clinical failed to reveal any documentation that the LPNs had notified a RN of Resident 5's refusal of medications, nausea, vomiting, and malaise; that Resident 5 was assessed by a RN; or that Resident 5's physician was made aware of her nausea, vomiting, malaise, and medication refusals. During a staff interview with the NHA and Employee 1 on March 20, 2025, at 10:50 AM, Employee 1 indicated that the LPNs should have notified a RN of Resident 5's condition, and a RN should have completed an assessment and notified the physician as applicable. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c)(d) Resident Care Policies 28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing Services

Based on clinical record review and staff interviews, it was determined that the facility failed to provide a transfer notice to the resident or their representative upon transfer out of the facility, which included the following information: the reason for the transfer or discharge, date of transfer, location of transfer, statement of the resident's appeal rights, and name, address (mailing and email), and telephone number of the Office of the State Long-Term Care Ombudsman for three of three residents reviewed for hospitalization s (Residents 63, 77, and 84). Findings include: Review of the clinical record for Resident 63 on February 19, 2025, revealed clinical diagnoses that included depression disorder (major loss of interest in pleasurable activities, characterized by change in sleep patterns, appetite and or daily routine) and dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability). Further review of Resident 63's clinical record revealed transfers to the hospital on March 28, 2024, to April 1, 2024; July 30, 2024, to August 9, 2024; and January 6, 2025, to January 21, 2025. The surveyor requested copies of the transfer, bed hold, and Ombudsman notification. The Ombudsman notification and bed hold notices were provided, however, the transfer notices provided failed to include a statement of the Resident's appeal rights and the name, address (mailing and email), and telephone number of the Office of the State Long-Term Care Ombudsman. During an interview with the Nursing Home Administrator (NHA) on February 20, 2025, at 10:50 AM, the NHA confirmed that the written transfer notice should include information that is required. Review of Resident 77's clinical record revealed diagnoses that included congestive heart failure (decreased ability of heart to pump blood through out the body) and atrial fibrillation (irregular heartbeat). Review of Resident 77's clinical revealed that Resident 77 was transferred to the hospital after an acute medical change in condition on June 23, 2024. Review of Resident 77's clinical record revealed no evidence that a notice of a transfer letter was provided to Resident 77 or Resident 77's Representative. Review of Resident 77's clinical revealed that Resident 77 was transferred to the hospital after an acute medical change in condition on January 22, 2025. Review of Resident 77's clinical record revealed no evidence that a notice of a transfer letter was provided to Resident 77 or Resident 77's representative. During a staff interview on February 20, 2025, at approximately 1:00 PM, the NHA confirmed that the facility did not provide Resident 77 or Resident 77's Representative with a notice of transfer letter for the transfers to the hospital on June 23, 2024, and January 22, 2025. Review of Resident 84's clinical record revealed diagnoses that included dementia with agitation (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and history of falling. Further review of Resident 84's clinical record revealed that she was transferred to the hospital on January 13, 2025, following a fall with fracture, and was subsequently admitted . Review of Resident 84's clinical record failed to reveal that written notification was provided to her or her representative regarding her transfer to the hospital, which included the following required contents: reason for transfer, effective date of the transfer, location to which the Resident was transferred, a statement of the Resident's appeal rights, and contact information for the Office of the State Long-Term Care Ombudsman. During an interview with the NHA on February 20, 2025, at 12:52 PM, she confirmed that the aforementioned transfer notice was not provided to Resident 84 or her Representative. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1) Nursing services

Based on observations and staff interviews, it was determined that the facility failed to ensure medications were stored in a manner that met professional standards for three of three medication carts observed (North Hall B, North Hall C, and South Hall A medication carts). Findings include: Observations of North B Hall medication cart on February 19, 2025 revealed multiple loose pills (whole and fragmented) and multi-colored granular dust (consistent with crushed/degraded pills) located in the medication cart drawers and in the bottom of the cart under the drawers. It was also observed that a blister-pack of medications was lodged behind the lowest drawer, which had been filled by the pharmacy in April 2024, for a Resident that had been discharged from the facility in April 2024. During a staff interview directly after the aforementioned observation, Employee 3 (Licensed Practical Nurse) revealed that she was unaware of the facility's procedure for cleaning the medication carts. Observations of North C Hall medication cart on February 19, 2025, revealed multiple loose pills (whole and fragmented) and multi-colored granular dust (consistent with crushed/degraded pills) located in the medication cart drawers and in the bottom of the cart under the drawers. Observations of the South A Hall medication cart on February 19, 2025, revealed multiple loose pills (whole and fragmented) and multi-colored granular dust (consistent with crushed/degraded pills) located in the medication cart drawers and in the bottom of the cart under the drawers. During a staff interview on February 19, 2025, directly after the aforementioned observation of South A Hall medication cart, Employee 4 (Licensed Practical Nurse) revealed she was familiar with the facility's procedure regarding cleaning of the medication carts as she was recently hired by the facility. During a staff interview on February 20, 2025, at approximately 1:00 PM, Nursing Home Administrator (NHA) revealed that the facility did not have policy or procedure in place that addressed how often medication carts should be inspected and cleaned. During the interview, the NHA revealed that it was the facility's expectation that medication carts are clean 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and interviews, it was determined that the facility failed to follow the physician's orders for one of 2 residents reviewed (Resident 1) and failed to perform an assessment after a change in condition for one of 2 residents reviewed (Resident 1) resulting in harm. Findings include: Review of the clinical record for Resident 1 on [DATE], at 10:00 a.m. revealed [DIAGNOSES REDACTED]. The clinical record also indicated that Resident 1 had been admitted to the facility following a hospitalization for a trochanteric [MEDICAL CONDITION] femur (a [MEDICAL CONDITION] part of the thigh bone/hip). Review of Resident 1's Comprehensive Admission Minimum Data Set assessment (MDS-an assessment of physical abilities and mental status) revealed that Resident 1's cognitive skills for daily decision making were severely impaired regarding the tasks of daily life. An interview with the Director of Nursing on [DATE], at 1:15 p.m. revealed that the facility doesn't have a specific policy on bowel management and that the staff should follow the physician's orders and notify the physician if the bowel management medications are ineffective in achieving results of a bowel movement. Review of the physician's orders dated [DATE], revealed that the following medications for constipation were ordered to be administered PRN (as needed): Milk of Magnesia (MOM-a medication for constipation) give 30 ml (milliliters = 1 ounce) as needed for constipation if no bowel movement every 3 days. Bisac-Evac Rectal Suppository (also known as [MEDICATION NAME]-a medication for constipation) give 1 suppository rectally every 4 days as needed if the MOM is ineffective. Enema (a treatment used for constipation) use one rectally every 5 days as needed for constipation if the [MEDICATION NAME] is ineffective. Review of Resident 1's bowel movements revealed that she had a bowel movement on [DATE], at 2:12 p.m.; [DATE], at 9:19 a.m.; and on [DATE], at 10:56 a.m. Review of the Medication Administration Record [REDACTED] An interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on [DATE], at 2:30 p.m. confirmed that the staff should have followed the physician's orders. In addition the DON and the NHA confirmed that Resident 1 should have been administered the MOM on [DATE] and the Bisac-Evac Suppository should have been administered on [DATE] because the resident failed to have a bowel movement. Further review of the physician's verbal orders dated [DATE], at 2:00 p.m. revealed that the staff contacted the physician via phone and relayed that Resident 1 was, moaning in pain when her abdomen was palpated (examined by hand), there were hypoactive bowel sounds (unable to hear gurgling of intestinal contents with a listening device), she had a medium bowel movement this morning ([DATE]), she had emesis (vomited) this morning after coughing on her breakfast. The physician's response was to transfer the resident to the Emergency Department for evaluation and treatment. Review of the clinical record for assessment of the resident failed to reveal that any vital signs (temperature, heart rate, blood pressure and respirations) were assessed since [DATE], at 11:28 a.m. There was no evidence that indicated that Resident 1's lung sounds were auscultated (the action of listening to sounds from lungs, typically with a stethoscope, as a part of an assessment). Review of the form titled, Nursing Home To Hospital Transfer Form, dated [DATE], at 2:00 p.m. revealed that the Staff Registered Nurse 1 documented the vital signs at 11:28 a.m. and failed to assess Resident 1 again prior to the transfer to the hospital. The oxygen saturation (a measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry, maximum = 100%) recorded on the form, was 94% oxygen saturation on room air and was obtained on [DATE], at 11:04 a.m. which was three days prior to the date the resident was transferred to the hospital. Review of the emergency room report dated [DATE], revealed that the resident had [MEDICAL CONDITION] (a blood infection) likely due to ischemic bowel (dead intestinal tissue due to lack of blood flow) and the white blood cell (cells in the blood that fight infection, normal is 4,500 to 10,000) count was 25,000 - HI. Resident 1 was intubated (a tube placed into the airway) and connected to a ventilator (a machine designed to move breathable air into and out of the lungs, to provide breathing for a patient who is physically unable to breathe, or breathing insufficiently). Resident 1 died on [DATE]. The hospital report stated the cause of death was septic shock and aspiration pneumonia (an infection that develops due to the entrance of foreign materials into the lungs). An interview with the DON and the NHA on [DATE], at 2:30 p.m. confirmed that the staff should have followed the physician's orders for the bowel protocol and when Resident 1's condition changed, the staff should have notified the physician immediately. The DON and the NHA also agreed that the staff should have performed additional assessments that included vital signs prior to the transport time of 2:00 p.m., instead of using the vital signs taken at 11:28 a.m. and the oxygen saturation value which was obtained three days prior to the date the resident was transferred to the hospital. Further review of the clinical record failed to reveal any contact with the physician related to Resident 1's initial onset of abdominal pain at 11:28 a.m. on [DATE], or regarding the moderate amount of emesis of undigested food that had occurred on [DATE] during breakfast. Interview with the NHA and DON revealed that the physician should have been notified with these events prior to 2:00 p.m. on [DATE] and were unable to provide explanation of why the physician was not contacted earlier. The facility failed to follow the physician's orders when the resident did not have a bowel movement for six days, resulting in abdominal pain, vomiting and hospitalization . Resident 1 subsequently died of septic shock (a condition in which blood pressure falls dangerously. It may occur in patients with serious infections. Very low blood pressure will slow blood flow. Organ failure may occur if the blood flow is too low) and aspiration pneumonia. 42 CFR §483.25 Provide Care/services for Highest Well Being. Previously cited [DATE]. 28 Pa. Code 211.10(a)(c) Resident care policies. Previously cited [DATE] 28 Pa. Code 211.12(c)(d)(3) Nursing services. Previously cited [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited [DATE], [DATE], [DATE]. 28 Pa. Code 211.12(d)(2) Nursing services. Previously cited [DATE]. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE].

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a resident was free from significant medication errors and failed to administer medications as ordered by the physician for constipation for one of 2 residents reviewed (Resident 1) resulting in harm. Findings include: Review of the clinical record for Resident 1 on August 9, 2016, at 10:00 a.m. revealed [DIAGNOSES REDACTED]. The clinical record also indicated that Resident 1 had been admitted to the facility following a hospitalization for a trochanteric [MEDICAL CONDITION] femur (a [MEDICAL CONDITION] part of the thigh bone/hip). Review of Resident 1's Comprehensive Admission Minimum Data Set assessment (MDS-an assessment of physical abilities and mental status) revealed that Resident 1's cognitive skills for daily decision making were severely impaired regarding the tasks of daily life. Review of the physician's orders [REDACTED]. Milk of Magnesia (MOM-a medication for constipation) give 30 ml (milliliters = 1 ounce) as needed for constipation if no bowel movement every 3 days. Bisac-Evac Rectal Suppository (also known as [MEDICATION NAME]-a medication for constipation) give 1 suppository rectally every 4 days as needed if the MOM is ineffective. Enema (a treatment used for constipation) use one rectally every 5 days as needed for constipation if the [MEDICATION NAME] is ineffective. Review of Resident 1's bowel movements revealed that she had a bowel movement on July 22, 2016, at 2:12 p.m.; July 25, 2016, at 9:19 a.m.; and on July 31, 2016, at 10:56 a.m. Review of the Medication Administration Record [REDACTED] An interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on August 9, 2016, at 2:30 p.m. confirmed that the staff should have followed the physician's orders [REDACTED]. Review of the clinical record progress notes (documented events by date and time) for Resident 1 dated July 31, 2016, at 2:00 p.m. stated there was a new physician's orders [REDACTED]. Review of the physician's verbal orders dated July 31, 2016, at 2:00 p.m. revealed that the staff contacted the physician via phone and relayed that Resident 1 was, moaning in pain when her abdomen was palpated (examined by hand), there were hypoactive bowel sounds (unable to hear gurgling of intestinal contents with a listening device), she had a medium bowel movement this morning (July 31, 2016), she had emesis (vomited) the morning of July 31, 2016, after coughing on her breakfast and she did not have a fever. The physician's response was to transfer the resident to the Emergency Department for evaluation and treatment. Further review of the clinical record failed to reveal any contact with the physician related to Resident 1's initial onset of abdominal pain at 11:28 a.m. on July 31, 2016, or regarding the moderate amount of emesis of undigested food that had occurred on July 31, 2016 during breakfast. Interview with the NHA and DON revealed that the physician should have been notified with these events prior to 2:00 p.m. on July 31, 2016 and were unable to provide explanation of why the physician was not contacted earlier. The facility failed to ensure that Resident 1 was free from significant medication errors by not administering medications for constipation, as ordered by the physician resulting in abdominal pain, emesis and hospitalization . 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. Previously cited 6/20/16, 3/31/16, 11/19/15. 28 Pa. Code 211.9(a)(k) Pharmacy services.

Based on clinical record reviews and staff interviews, it was determined the facility failed to implement interventions to assure resident safety during a transfer, resulting in actual harm to one of 4 residents reviewed (Resident 3). Findings Include: Review of the policy titled, Transcription of Orders (transfer of the original order on to another form), with an effective date of June 1, 1996, revealed that, Orders from an authorized licensed independent practitioner are transcribed by a licensed nurse. The purpose of the policy revealed, To communicate all practitioner orders to caregivers regarding patients' care and treatment. Review of the policy titled, Care Plans (instructions on how a resident will be taken care of with interventions, goals and outcomes) revealed practice standards including, The comprehensive care plan is reviewed and revised a minimum of quarterly and as needed to reflect response to care and changing needs and goals. Review of Resident 3's June 2016, physician's orders [REDACTED]. Review of Resident 3's current care plan for ADL'S (Activities of Daily Living - ability to do everyday tasks) created on January 3, 2016, revealed that for lift/transfers/positioning the resident requires a two person assist and a mechanical lift (a device used to transfer a resident from the bed to a chair when they are unable to stand on their own). Further review of Resident 3's clinical record revealed that she required the two assist for transfers with the use of the mechanical lift due to non weight bearing status related to a recent right hip fracture. Review of Resident 3's clinical record revealed a consultation with an orthopedic physician (a physician that specializes in bones, joints and ligaments (connective tissue)) dated May 25, 2016. The physician's recommendations included for Resident 3 to wear the TROM (Total Range of Motion) brace during mobility (purposeful movement). The TROM brace is used for the immobilization and protection of range of motion and can be used to stabilize femoral fractures. Review of the facility's physician Fax-order communication document revealed that Licensed Practical Nurse 1 (LPN 1) communicated the results of the orthopedic physician's recommendations to Resident 3's attending physician. The orthopedic physician's recommendations included for the resident to progress with the use of a walker to 50% weight bearing as tolerated while using the TROM brace and that the resident only needed the TROM brace for mobility. Further review of the document revealed that the document was returned to the facility via Fax and addressed by Resident 3's attending physician with an ok and a signature. According to the Fax document, the order was received by LPN 1 on May 26, 2016 at 5:44 p.m. Review of the facility's, Risk Management System (incident/fall reporting) forms dated May 27, 2016, revealed that Resident 3 was transported to the hospital pursuant to, .being transferred from chair to bed with assist from two NA's (nursing assistants). Resident then stated she needed to go to the bathroom. They then assisted her to get up again this time she complained of sharp knee pain and said she felt a pop. Review of the hospital's preliminary radiology report May 28, 2016, revealed an impression of, oblique (slanted) fracture of the metaphyseal tibia (bone in lower leg). Resident 3's discharge instructions from the hospital also read, You have a break (fracture) of the knee joint . The ongoing investigation of this incident occurring on May 27, 2016 at 7:30 p.m., revealed that Resident 3, was not wearing her brace as ordered for mobility. Further documentation states, NA's (Nurse Aides) stated they were not aware she (Resident 3) was supposed to wear the brace with mobility. Review of the, Witness Interview Record (witness statement) associated with the hospital transfer of Resident 3 on May 27, 2016, revealed that Nursing Assistant 1 commented, I was unaware the resident was no longer a lift and had a brace for mobility. Further review of the Risk Management Summary report revealed corrective action plans for staff to include Sign posted in room to alert staff of changes with mobility. Better communication between NA's and staff recommended An interview on June 20, 2016 at 12:35 p.m., with the Director of Nursing and the Nursing Home Administrator revealed that LPN 1 did not document or relay the new order for the TROM brace to be worn with mobility to the staff providing care to Resident 3. Review of Resident 3's interdisciplinary care plan revealed, TROM brace in place right leg when out of bed and non-weight bearing status (to place no weight on the affected leg) right lower extremity. This intervention was initiated by LPN 1 on May 29, 2016, which was 3 days following the Fax from the physician. Review of Resident 3's current care plan for ADL'S created on January 3, 2016, revealed that this care plan was updated on May 31, 2016, 5 days following the physician's orders [REDACTED]. An interview on June 20, 2016 at 12:35 p.m., with the Nursing Home Administrator and the Director of Nursing revealed an expectation that caregivers would follow the care plan and the ordered treatments for the residents. An interview with the Director of Nursing on June 20, 2016 at 12:35 p.m., revealed an expectation that nursing staff would have informed the nursing assistants of the new order for the TROM brace to be worn during mobility for Resident 3. The facility failed to provide adequate interventions to assure a safe transfer for a resident with a recent fracture, resulting in harm. 42 CFR 483.25 Quality of care Previously cited 3/15/16. 28 Pa. Code 201.18(b)(1) Management. Previously cited 3/31/16, 11/19/15. 28 Pa. Code 211.11(a) Resident care plan. Previously cited 5/18/16, 3/15/16. 28 Pa. Code 211.11(c) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 3/31/16, 3/15/16, 11/19/15, 12/19/14.

Based on a review of clinical records, facility documentation, facility policy and interviews with facility staff, it was determined that the facility failed to develop an appropriate plan of care, provide adequate supervision and monitoring to prevent accidents for three of 16 residents reviewed (Resident 7, 8 and 13). Findings include: Review of the facility's policy for Accidents, Incidents and Adverse Events, dated January 23, 2013 states that its purpose is to define causative/contributing factors and institute preventive measures to avoid further occurrences. Review of Resident 7's clinical record revealed that the resident was admitted to the facility from the Gettysburg Hospital. Review of the hospital's physician progress notes [REDACTED]. Review of the facility's admission nurse's note, dated January 3, 2014 states that the reason for admission is post trauma and/or accident rehabilitation. A fall risk score of 15 was obtained as part of the assessment. Additionally, a Lift-Transfer-Repositioning evaluation was also completed on January 3, 2014 and it indicates that resident can ambulate with assistance and perform greater or 50% of lift/transfer with stand pivot assist and that a gait/transfer belt is required. [DIAGNOSES REDACTED]. The resident's care plan was initiated on January 3, 2014 but did not include a fall care plan. Review of the facility's incident reports dated January 4, 2014, revealed Resident 7 had two falls that day. The first one occurred at 6:35 a.m. when she used her walker to ambulate to the bathroom and fell , sustaining a bruise to her right hip. Intervention was to assist resident in and out of bed and with ambulation, provide safety cues and monitor toilet needs. The second fall occurred at 12:15 p.m. when resident was transferred to the bathroom using her wheelchair and with the assistance of Nurse Aide (NA) 2. After transferring the resident onto the toilet, the NA 2 left the bathroom to go and get clean linen. While NA 2 was gone, the resident attempted to transfer herself out of the bathroom and fell from her wheelchair sustaining a fractured wrist. During an interview with NA 2 on January 15, 2014 at 3:00 p.m., she stated that she was answering Resident 7's call light and had not gotten report on the resident that day so was unaware of the resident's transfer status, use of gait belt or that she had fallen earlier in the day. Review Resident 8 clinical record reveals an admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 8 has a history of multiple falls since admission to the facility. review of the Quality Assurance document dated December 26, 2013 revealed Resident 8 had a fall December 26, 2013 at 11:30 a.m. found Resident 8 sitting on floor in his room with his head against the dresser stand. A skin laceration was noted to the mid parietal (Top of Head) 1 centimeter in length. Review of Resident 8's Plan of Care dated November 23, 2013 revealed a nursing [DIAGNOSES REDACTED]. Intervention put in place November 23, 2014 is do not leave resident in room by himself in wheel chair. During an interview on January 16, 2014 at 11:15 a.m. with the Director of Nursing and Nursing Home Administrator revealed Resident 8 is in wheel chair an move around and do not always know when he is in his room. In an interview with the Director of Nursing on January 16, 2014 at 9:30 a.m., she confirmed that NA 2 should have been aware of the resident's previous fall on January 4, 2014 and that the interventions put into place following the first fall were appropriate despite the resident's previous non-compliance with transfers as she was deemed to be alert and oriented. Clinical record review revealed that Resident 13 was admitted to the facility on [DATE]. At the time of admission, according to the fall assessment, the resident was identified as a mild risk for falls. The admission MDS (Minimum Data Set-a periodic assessment of resident needs) dated December 23, 2013, indicated that the resident was to have a plan of care developed for fall prevention. Review of the incident report dated January 4, 2014 at 4:40 p.m., the resident sustained [REDACTED]. The incident report states that there was "no fall care plan prior to the fall". Review of the resident's plan of care revealed that the fall care plan was developed on January 4, 2014, following the fall. 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.11(a)(c) Resident care plan. 28 Pa. Code: 211.12(d)(5) Nursing services.