Every finding on record at Graduate Post Acute

Based on review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility did not ensure that allegations of abuse and neglect were reported immediately to the Pennsylvania Department of Health for 5 of 26 residents reviewed (Resident R6, R20, R47, R216, R217).Findings Include: A review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating revised September 2022, revealed All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Furthermore, Immediately is defined as (a.) within two hours of an allegation involving abuse or result in serious bodily injury; or (b.) within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Review of facility policy Identifying types of Abuse, revised September 2022, revealed Neglect/ Deprivation of Goods and Services by Staff - 1. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. 2. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident requires but the facility fails to provide them and this has resulted in (or may result in) physical harm, pain, mental anguish or emotional distress. 3. Neglect includes cases where the facility's indifference to or disregard for resident care, comfort or safety results in (or could have resulted in) physical harm, pain, mental anguish or emotional distress. Further review of facility policy Identifying types of abuse, revealed Mental abuse is the use of verbal or non-verbal conduct which causes (or has the potential to cause) the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Interview with Employee E1, Director of Nursing, on July 28, 2026, at 12:52 p.m., surveyor reviewed findings from interview with Resident R6 including following statement, I was just calling Medicare to them not to pay this place because they are not taking proper care of me. Resident feels mistreated by nursing assistants and states that they are emotionally aggressive. I ran the call bell earlier and no one would answer so I started yelling and the nurse walked in and said stop yelling and then left the room again without helping me or asking what I need. Resident stated, I am legally blind and the aides will walk into my room very quietly and when i see a flash of their clothes or shadow I will say are you just going to stand there and they will respond I just wanted to see if you could see me or not. I have reported this to the nurse manager, and nothing has been done. I rang my bell a while ago to tell them to change me and I still have yet to be changed. Furthermore, during an interview with Employee E1, Director of Nursing on July 28, 2026, at 12:52 p.m., surveyor reported the following observation findings: Observation of Resident R6 on July 28, 2026, at 11:45 a.m. revealed soiled gown with multiple stains down the front and the smell of feces. Observation of Resident R6 pushed call bell on July 28, 2026, at 12:09 p.m. to request to be cleaned up, noted feces soiled diaper. Observation of Employee E19, Licensed Practical Nurse entering room at 12:15 p.m. to administer resident's medication, stated I will get your Nursing assistant to change you. At this time, Employee E19, Licensed Practical Nurse turned off call bell light. Observation of resident R6 on July 28, 2026, at 12:45 p.m. revealed resident had remained unchanged. Interview with Resident R6 on July 28, 2026, at 12:45 p.m. revealed no one had come back into the room at any point to attempt to change the resident. Review of facility investigation on July 29, 2026, at approximately 11:00 a.m., revealed facility filed Resident R6's concerns under a grievance report with category of Care concern. Under investigation revealed When patient was asked if he/she received any ADL (activity of daily living) care during the morning he/she stated No, I did not patient was asked if he/she had used the call bell and notified the staff that he/she needed to be changed- patient stated he/she did use the call bell and never received care. Review of facility documentation and information submitted to the State Survey Agency revealed no documented evidence that Resident R6's allegations of abuse and neglect were reported to the State Survey Agency within 24 hours after the allegation was made. During an interview on July 29, 2026, at 10:15 a.m., the Director of Nursing, Employee E1, was questioned if 50 minutes is an appropriate amount of time for a resident to remain in a soiled, feces filled diaper before receiving care? Director of Nursing, Employee E1, responded, No but what do you want us to do, the staff was caring for other residents. Director of Nursing, Employee E1, confirmed that facility did not interpret Resident R6's allegations as abuse or neglect, and confirmed that it was not reported to the State Survey Agency. Review of facility grievances revealed multiple grievances with categories of Customer Service/ Interaction or Care concern. Resident R20's grievance dated July 2, 2026, with category of Care Concern, revealed We have received a grievance for the above referenced member regarding the care that was provided at your facility. The grievance states the following: The member has expressed overall dissatisfaction regarding the care received at the above- listed facility; the member stated the overnight staff has been treating her unfairly and not providing the level of care she needs. The member stated that the staff is refusing to administer her ordered pain medication on time and has expressed frustration regarding the care received. Review of Resident R20's grievance file revealed no reference regarding the allegation of neglect. Review of facility documentation and information submitted to the State Survey Agency revealed no documented evidence that Resident R20's allegations of neglect were reported to the State Survey Agency as required. Resident 47's grievance dated July 9, 2026, with category of Customer Service/ Interaction, revealed Patient stated that around 7 p.m. he/she rang the call bell and asked for a pain pill. At 7:30 p.m., he/she spoke to the aide and asked for his/her medication and to tell the nurse. The aide stated that he/she did tell the nurse. The nurse came in and said, I'm by myself. Review of Resident R47's grievance revealed no reference regarding the allegation of neglect. Review of facility documentation and information submitted to the State Survey Agency revealed no documented evidence that Resident R47's allegations of neglect was reported to the State Survey Agency as required. Resident R216's grievance (filed by a family member) dated June 26, 2026, with category of Customer service/ Interaction, revealed Last night I was unable to make contact with my husband. I called continuously before finally being told that the phone system is compromised. Yesterday I bathed my husband at 11 a.m. Then I was told the bell was not working, they gave him a little bell, but he is in room [ROOM NUMBER] all the way away from the nurses' station. Then he's shaking it and nobody responds. At 8:20 p.m. he asked for a blanket. The aide came in the room and left back out, around 9 p.m. she returned but never got the blanket. Nobody changed his pull up since I had changed him at 11 a.m. His bed was wet and needed to be changed. Review of Resident R216's grievance file revealed no reference regarding allegations of neglect. Review of facility documentation and information submitted to the State Survey Agency revealed no documented evidence that Resident R216's allegations of neglect were reported to the State Survey Agency as required. Resident R217's grievance dated June 26, 2026, with category of Customer Service/ Interaction, revealed My call bell in my room and bathroom is not working. They gave me a small bell, but when I ring it, nobody responds. On June 24, 2026, nobody checked on me from 3 p.m. until 2 a.m. This morning I was sleeping; the nurse left my pills on the table and just left out. She didn't wake me up or anything. Review of Resident R217's grievance file revealed no reference regarding allegations of neglect. Review of facility documentation and information submitted to the State Survey Agency revealed no documented evidence that Resident R276's allegations of neglect were reported to the State Survey Agency as required. Interview with Social Work Director, Employee E5, on July 30, 2026, at 11:00a.m., revealed a definition for neglect as failure to provide care or services timely. After reviewing Resident R216's grievance, Employee E5 stated that would be considered a sign of neglect, if a resident did not get care. After reviewing Resident R217's grievance, Employee E5 stated They were not tending to his/her needs, so I would consider this neglect. Interview with Unit Manager, Employee E23, on July 30, 2026, at 11:30 a.m., revealed neglect is something that is willful or intentionally done. Interview with Employee E1, Director of Nursing, on July 30, 2026, at 12:10 p.m., revealed that for an allegation of neglect to be considered neglect, and not a care concern, it would have to be intentionally not provide services and the resident would have to specifically express that they feel neglected. Director of Nursing, Employee E1, confirmed the above incidents involving Resident R6, R20, R47, R216, and R217). 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1) Management. 28 Pa. Code 211.12 (c) Nursing services.

Based on review of clinical records, review of MDS (minimum data set- a federally required resident assessment completed at a specific interval) assessments, review of MDS schedules, review of MDS submission records and interview with staff, it was determined that the facility failed to complete the required Quarterly MDS assessments within the required timeframe (at least every 92 days) for 5 of 29 residents reviewed (Resident R30, R81, R7, R163, and R177). Findings include: Review of facility policy on MDS (Minimum Data Set - federally mandated resident assessment and care screening) Completion and Submission Time Frames With the most recent revision date of October 2023, revealed that under section Statement: Our facility will conduct and submit resident assessments in accordance with current federal and state submission time frames. Under section Policy Interpretation and Implementation: #1. the assessment coordinator or designee is responsible for ensuring resident assessments are submitted to CMS internet quality improvement evaluation system or iQIES in accordance with current federal and state guidelines. #2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. Review of Resident R30's MDS schedule revealed that a quarterly assessment dated [DATE], was not completed and is currently in progress. Further review of Resident R30's MDS schedule revealed that the quarterly assessment dated [DATE], was 29 days overdue. Review of Resident R81's MDS schedule revealed that a quarterly assessment dated [DATE], was not completed and is currently in progress. Further review of Resident R81's MDS schedule revealed that the quarterly assessment dated [DATE], was 23 days overdue. Review of Resident R7's MDS schedule revealed that a quarterly assessment dated [DATE], was not completed and is currently in progress. Further review of Resident R7's MDS schedule revealed that the quarterly assessment dated [DATE], was 22 days overdue. Review of Resident R163's MDS schedule revealed that a quarterly assessment dated [DATE], was not completed and is currently in progress. Further review of Resident R163's MDS schedule revealed that the quarterly assessment dated [DATE], was 22 days overdue. Review of Resident R177's MDS schedule revealed that a quarterly assessment dated [DATE], was not completed and is currently in progress. Further review of Resident R177's MDS schedule revealed that the quarterly assessment dated [DATE], was 22 days overdue. Interview with facility's RNAC (registered nurse assessment coordinator) Employee E8 conducted on July 30, 2026, at 10:45 AM confirmed that Resident R30's quarterly assessment dated [DATE], Resident R81's quarterly assessment dated [DATE], Resident R7's quarterly assessment dated [DATE], Resident R163's quarterly assessment dated [DATE], and Resident R77's quarterly assessment dated [DATE], were not yet completed and were currently in progress. Follow-up interview with Employee E8 conducted on July 30, 2026, at 1:20PM revealed that Resident R30's quarterly assessment dated [DATE], Resident R81's quarterly assessment dated [DATE], Resident R7's quarterly assessment dated [DATE], Resident R163's quarterly assessment dated [DATE], and Resident R77's quarterly assessment dated [DATE], were not completed because the facility did not have a social worker to complete the social worker's section of the MDS. Interview with Regional Clinical Coordinator Employee E12 conducted on July 30, 2026, at 1:20PMconfirmed that the facility did not have a Social Worker to complete the MDS assessments. Interview with facility's Assistant Administrator conducted on July 30, 2026, at 1:25PM confirmed that the facility did not have a social worker to complete the MDS and that she has been helping out with the completion of the MDS. 23 Pa. Code 211.12 (d)(1) Nursing services.

Based on review of clinical records and interviews with staff, it was determined that the facility failed to ensure that Minimum Data Set (MDS - federally mandated resident assessment and care screening conducted at specific intervals) was completed accurately for five of 26 residents reviewed (Resident R20, R63, R64, R99, and R215).Findings include: Review of facility policy titled Resident Assessments revised in October 2023, revealed A comprehensive assessment of each resident is completed at intervals designated by OBRA regulations and PPS requirements. Data from the Minimum Data Set (MDS) is submitted to the Internet Quality Improvement Evaluation System (IQIES) is required. Further review revealed Information in the MDS assessments will consistently reflect information in the progress notes, plan of care, and resident observations/ interviews. Review of Resident R20's clinical record revealed that Resident R20 was admitted to the facility on [DATE], with diagnosis of joint replacement. Review of Resident Review of Resident R20's quarterly MDS dated [DATE], revealed that section C0100- Should brief interview for mental status be conducted?, indicating yes. Further review of Resident R20's quarterly MDS dated [DATE], revealed that Brief interview for Mental Status (MDS sections C0200, C0300, C0400) were not assessed. Review of Resident R215's clinical record revealed that Resident R215 was admitted to the facility on [DATE]. Review of Resident Review of Resident R215's quarterly MDS dated [DATE], revealed that section C0100- Should brief interview for mental status be conducted?, indicating yes (assessment should be completed). Further review of Resident R215's quarterly MDS dated [DATE], revealed that Brief interview for Mental Status (MDS sections C0200, C0300, C0400) were not assessed. Review of Resident R99's clinical record revealed that Resident R99 was admitted to the facility on [DATE]. Review of Resident Review of Resident R99's quarterly MDS dated [DATE], revealed that section C0100- Should brief interview for mental status be conducted?, indicating yes. Further review of Resident R99's quarterly MDS dated [DATE] revealed that Brief interview for Mental Status (MDS sections C0200, C0300, C0400) were not assessed. Review of Resident R63's clinical record revealed that Resident R63 was admitted to the facility on [DATE], with a diagnosis of Radiculopathy, lumbar region (pinched nerve in lower back). Review of Resident Review of Resident R63's quarterly MDS dated [DATE], revealed that section C0100- Should brief interview for mental status be conducted?, indicating yes. Further review of Resident R63's quarterly MDS dated [DATE] revealed that Brief interview for Mental Status (MDS sections C0200, C0300, C0400) were not assessed. Review of Resident R64's clinical record revealed that Resident R64 was admitted to the facility on [DATE], with diagnosis of Atrial fibrillation (irregular heart rhythm). Review of Resident Review of Resident R64's quarterly MDS dated [DATE], revealed that section C0100- Should brief interview for mental status be conducted?, indicating yes. Further review of Resident R64 quarterly MDS dated [DATE] revealed that Brief interview for Mental Status (MDS sections C0200, C0300, C0400) were not assessed. Interview with Employee E8, Registered Nurse Assessment Coordinator, July 30, 2026, at approximately 1:00p.m., confirmed Brief Interview for Mental status not completed, and assessments do not accurately reflect the medical record for the resident. Interview with Employee E12, Regional Clinical Coordinator, July 30, 2026, at approximately 1:00 p.m. stating we are down a social worker, and some things have fell through the cracks unfortunately. 28 Pa. Code 211.12(d)(1) Nursing Services

Based on review of resident council, review of facility documentation, interviews with staff and residents, it was determined that the facility failed to ensure each resident receives food that is palatable for taste, temperature, and appearance for 20 out of 26 residents reviewed (Residents R24, R39, R46, R213, R93, R101, R157, R89, R134, R208, R57, R204, R131, R3, R23, R13, R102, R135, R42 and R35).Findings include: During the initial tour of the facility beginning on July 28, 2026, at 10:15 a.m. the following resident interviews were obtained: Interview with Resident R24 at 11:15 a.m. revealed that he does not like the meals and that he is upset about not getting meat at breakfast even when the dietitian said he could have it. Interview with Resident R39 at 11:19 a.m. revealed that the food is cold, that they don't give her a menu, that the trays are late, that the food is not appetizing, and she feels she is losing weight. Interview with Resident R46 at 11:24 a.m. revealed that she complained about cold food, and not tasting very good, and that they don't know her preferences and just send her a tray. She said that she wants cold cereal and oatmeal, but they never get it right. Interview with Resident R213 at 11:28 a.m. revealed that the food is horrible, it is not hot and the coffee is lousy too. Interview with Resident R93 at 11:28 a.m. revealed that the food is not great, it is cold and way too salty. Interview with Resident R101 at 11:32 a.m. revealed that he has to be fed and by the time they get to him the food is always cold. Interview with Resident R157 at 11:38 a.m. revealed that he does not like the food especially the eggs which taste like powdered eggs, and they do not send him whole milk. Interview with Resident R57 on July 28, 2026, at 9:05 a.m. reported the food is not good. Interview with Resident R204 on July 28, 2026, at 9:15 a.m. reported that the food is bland. Interview with Resident R131 on July 28, 2026, at 9:30 a.m. reported that the food should be upgraded but resident gets outside food to snack on. Interview with Resident R134 on July 28, 2026, at 9:45 a.m. reported that the food is not good. Interview with Resident R208 on July 28, 2026, at 10:25 a.m. reported that while he is out of his room doing therapy, the staff will deliver his food tray even though Resident R208 will not be back for a while and the food is cold by the time the resident returns to the room. Interview with Resident R3 on July 28, 2026, at 10:45 a.m. reported that the food is bland but resident gets food from the outside to snack on. Interview with Resident R99 on July 29, 2026, at 2:20 p.m. reported that the is super dry and burned. Resident Council was held on July 29, 2026, at 2:00 p.m. In attendance were alert and oriented Residents R23, R13, R102, R135, R42, and R35. All residents reported the food comes either overcooked, undercooked, burned, or cold. The residents also reported that the food trays come late usually and it is not what they wanted or nothing at all. Interview with Director of Social Services Employee E5 on July 30, 20226, at 11:51 a.m. reported that when it comes to food complaints the facility deals with them at the time of the complaint. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b)(3) Management

Based on observations, interviews with staff and residents it has been determined that the facility did not provide one or more rooms designated for resident dining for 4 of 4 floors observed (1st floor, 2nd floor, 3rd floor, and 4th floor). Findings Include: Observation on the 2nd floor on July 28, 2026, at 12:30 p.m. revealed a room with a sign on the wall outside that said dining room. Inside this room were administrative staff working, including the Director of Nursing. There were no residents eating lunch in this room. All residents were eating their lunch in their own rooms. Observation on the 5th floor on July 29, 2026, at 12:30 p.m. revealed two residents sitting in the lobby area in front of the television while the lunch trays were being passed. The residents were talking to the nurse about eating lunch, the nurse said do you want me to get your table, and the nurse aid reported that she had already put the residents lunch tray was in his/her room. The other resident said, I guess I will eat in my room too then. Both residents wheeled themselves to their rooms to eat lunch. Observation on July 28, 2026, through July 31, 2026, on the 2nd, 3rd, 4th, and 5th floors during meal times revealed meals were delivered to resident rooms instead of residents going to dining rooms. Interview with Nurse aide, Employee E15, on July 28, 2026, at 10:50 a.m. reported that the breakfast trays don't come until 10:00 a.m. and confirmed that the residents eat in their rooms and a small few eat in the lobby. Resident Council meeting on July 29, 2026, at 2:00 p.m. revealed that the residents can eat in the lobby of the floor that they reside on but since there are not enough space and/or tables for them to eat, they must eat in their rooms. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on staff and resident interviews, grievance logs, and review of electronic call bell logs, it was determined that the facility failed to ensure that the call bells were answered in a timely manner to provide care and services respectful of each resident's dignity and preferences to promote quality of life for six of 26 residents reviewed (Resident R6, R9, R188, R89, R147, and R208).Findings include: Review of the Call System, Residents policy; policy statement states Residents are provided with the means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. 6- Calls for assistance are answered as soon as possible. Urgent requests for assistance are addressed immediately. Review of facility policy titled Dignity revised in February 2021, revealed Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: a. helping the resident to keep urinary catheter bag covered; b. promptly responding to a resident's request for toileting assistance; and c. allowing residents unrestricted access to common areas open to the public, unless this poses a safety risk for the resident. Review of Resident R188's clinical record revealed resident was admitted to the facility on [DATE], with diagnosis of muscle wasting, and heart failure. Review of Resident R188's MDS (Minimum Data Set- a federally required resident assessment completed at a specific interval) revealed resident BIMS (brief interview for mental status) is a 15, indicating cognitively intact. Interview with Resident R188 on July 28, 2026, at 11:30 a.m. revealed I don't know who is in charge, no one comes to check on me unless they drop off my food or medicine, when I go out to beg for nighttime snacks, it usually takes them forever to get me something and when they do they bring me something, it's crackers, which is nothing. Staff are always on their phones. They don't clean well. Therapy is inconsistent, I haven't seen them since last Tuesday. Review of Resident R9's clinical record revealed resident was admitted to the facility on [DATE]. Observation of Resident R9's room revealed resident's urinary catheter bag did not have privacy cover on it and was visible from the hallway. Interview with Employee E22, Nursing Assistant on July 29, 2026, at 11:28 a.m. confirmed no privacy bag on foley catheter bag. Review of Resident R6 's clinical record revealed resident was admitted to the facility on [DATE], with diagnosis of surgical amputation. Review of Resident R6's MDS (Minimum Data Set- a federally required resident assessment completed at a specific interval) revealed resident BIMS (brief interview for mental status) is a 15, indicating cognitively intact. Interview with Resident R6 on July 28, 2026 at 11:45 a.m. revealed teary-eyed resident stating I was just calling Medicare to them not to pay this place because they are not taking proper care of me. Resident feels mistreated by nursing assistants and states that they are emotionally aggressive. I ran the call bell earlier and no one would answer so I started yelling and the nurse walked in and said stop yelling and then left the room again without helping me or asking what I need. Resident stated, I am legally blind and the aides will walk into my room very quietly and when i see a flash of their clothes or shadow I will say are you just going to stand there and they will respond I just wanted to see if you could see me or not. I have reported this to the nurse manager, and nothing has been done. I rang my bell a while ago to tell them to change me and I still have yet to be changed. Observation of Resident R6 on July 28, 2026, at 11:45 a.m. revealed soiled gown with multiple stains down the front and the smell of feces. Observation of Resident R6 pushed call bell on July 28, 2026, at 12:09 p.m. to request to be cleaned up, noted feces soiled diaper. Observation of Employee E19, Licensed Practical Nurse entering room at 12:15 p.m. to administer resident's medication, stated I will get your Nursing assistant to change you. At this time, Employee E19, Licensed Practical Nurse turned off call bell light. Observation of resident R6 on July 28, 2026, at 12:45 p.m. revealed resident had remained unchanged. Interview with Resident R6 on July 28, 2026, at 12:45 p.m. revealed no one had come back into the room at any point to attempt to change the resident. Interview with Director of Nursing on July 28, 2026 at 12:50 p.m., this surveyor provided notification that resident remained unchanged. Observation of Resident R6 on July 28, 2026 at 12:55 p.m., revealed resident remained unchanged. Resident initiated call bell again at 12:55 p.m. Observation on July 28, 2026, at 1:00 p.m., revealed Employee E19, Licensed Practical Nurse and Employee E1, Director of Nursing, entered Resident R6's room and provided incontinence care for resident. Review of the facility documentation entitled, Call Bell Audits, revealed an electronic system that indicates all call bell response times. The response times exceeded fifteen minutes for seven residents between April 2026 to July 2026. On July 26, 2026, at 9:31, room [ROOM NUMBER] waited 22 minutes, on July 25,2026, at 10:23a.m. room [ROOM NUMBER] waited 16 minutes, and at 10:54a.m. room [ROOM NUMBER] waited 18 minutes, and on July 19, 2026, at 12:13 room [ROOM NUMBER] waited 16 minutes, and at 9:47 a.m. room [ROOM NUMBER] waited 24 minutes, and at 2:09 p.m. room [ROOM NUMBER] waited 18 minutes. On June 27, 2026, at 10:35 p.m. room [ROOM NUMBER] waited 20 minutes and on April 26, 2026, at 10:00 a.m. room [ROOM NUMBER] waited 20 minutes. During resident council meeting conducted on July 29, 2026, at 2:00 p.m. residents reported that residents who are further away from the nursing station are having issues with their calls for assistance being answered in a timely manner. Interview with Resident R89 on July 28, 2026, at 9:15 a.m., Resident R89 reports that the facility does not have enough aides to help the residents daily. Interview with Resident R147 on July 28, 2026, at 10:00 a.m., Resident R147 reports the facility needs more staff. Interview with Resident R208 on July 28, 2026, at 10:25 a.m., Resident R208 reports that prior to our arrival to the facility Resident R208 had to wait up 4 hours on one occasion on the bed pan before anyone came to assist him and an 1 1/2 hours another time. Review of the grievance log on July 13, 2026, it was reported to the facility that a resident had to wait some time for a nurse to provide incontinent care to the resident. On July 16, 2026, the facility provided a call bell audit, call bell education, and incontinence care education. Interview with Assistant Administrator E7 on July 31, 2026, at 11:30 a.m. confirmed that anything over 15 minutes is too long for a resident to wait for care, also that calls should be answered within 5 to 10 minutes. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on observations and staff interviews, it was determined that the facility failed to ensure that grievance boxes and forms were available for residents to anonymously submit grievances on 4 of 4 floors observed (2nd, 3rd, 4th, and 5th floor) Findings include: Observations during a tour of the facility and each floor (2nd, 3rd, 4th, and 5th floor) on July 28, 2026, at 9:00 a.m. revealed there were no grievance boxes, no grievances forms, and no posting of ombudsman contact information. Review of facility's policy titled Grievances/Complaints, Filing, 4 - Upon admission, residents are provided with written information on how to file a grievance or complaint. A copy of our grievance/complaint procedure is posted on the resident bulletin board. 5 - Grievances and/or complaints may be submitted orally or in writing and may be filed anonymously. Interview with Licensed nurse (LPN), Employee E19, on July 29, 2026, at 9:18 a.m., reported that he/she was unaware of where the grievance box or grievance forms were located. Interview with Registered Nurse, Employee E14, on July 29, 2026, at 9:20 a.m., reported they the facility uses an online system, and that they do ambassador rounds every day to ensure the residents have a way to communicate any concerns. Employee E14 confirmed that the boxes and forms were taken down due to construction and haven't been put back up. Interview with LPN, Employee E13, on July 29, 2026, at 9:35 a.m., reported that when a resident has a concern that they want to report, the unit manager is notified. Resident Council was conducted on July 29, 2026, at 2:00 p.m., revealed that the short term and/or newly admitted residents do not know how to contact the ombudsman. Interview with Assistant Administrator, Employee E7, on July 31, 2026, at 11:00 a.m. confirmed no grievance boxes, grievance forms, and ombudsman phone numbers were located on four of four floors (2nd, 3rd, 4th, and 5th floor). 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights.

Based on review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to conduct complete and thorough investigations to rule out allegations of abuse and neglect for 4 of 26 residents reviewed (Resident R20, R47, R216, and R217).Findings Include: A review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating revised September 2022, revealed All allegations are thoroughly investigated. The administrator initiates investigations. The individual conducting the investigation as a minimum: (a.) reviews the documentation and evidence (b.)review's the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; (c.) observes the allege victim, including his or her interactions with staff and other residents; (d.) interviews the person(s) reporting the incident; (e.) interviews any witnesses to the incident; (f.) interviews the resident (as medically appropriate) or resident's representative; (g.) interviews the resident's attending physician as needed to determine the resident's condition; (h.) Interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; (i.) interviews the resident's roommate, family members, and visitors; (j.) interviews other residents to whom the accused employee provides care or services; (k.) reviews all events leading up to the alleged incidents; and (l.) documents the investigation completely and thoroughly. Review of facility policy Identifying types of Abuse, revised September 2022, revealed Neglect/ Deprivation of Goods and Services by Staff - 1. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. 2. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident requires but the facility fails to provide them and this has resulted in (or may result in) physical harm, pain, mental anguish or emotional distress. 3. Neglect includes cases where the facility's indifference to or disregard for resident care, comfort or safety results in (or could have resulted in) physical harm, pain, mental anguish or emotional distress. Further review of facility policy Identifying types of abuse, revealed Mental abuse is the use of verbal or non-verbal conduct which causes (or has the potential to cause) the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Review of facility grievances revealed multiple grievances with categories of Customer Service/ Interaction or Care concern. Resident R20's grievance dated July 2, 2026, with category of Care Concern, revealed We have received a grievance for the above referenced member regarding the care that was provided at your facility. The grievance states the following: The member has expressed overall dissatisfaction regarding the care received at the above- listed facility; the member stated the overnight staff has been treating her unfairly and not providing the level of care she needs. The member stated that the staff is refusing to administer her ordered pain medication on time and has expressed frustration regarding the care received. Review of Resident R20's grievance file revealed no documented evidence a complete and thorough investigation was conducted to rule out allegations of abuse/neglect. Interview with Director of Nursing, Employee E1, on July 31, 2026, confirmed no further documented evidence of complete investigation was available. Resident 47's grievance dated July 9, 2026, with category of Customer Service/ Interaction, revealed Patient stated that around 7 p.m. she rang the call bell and asked for a pain pill. At 7:30 p.m., she spoke to her aide and asked for her medication and for her to tell the nurse. The aide stated that she did tell the nurse. The nurse came in and said I'm by myself. Review of Resident R47's grievance file revealed no documented evidence a complete and thorough investigation was conducted to rule out allegations of abuse/neglect. Interview with Director of Nursing, Employee E1, on July 31, 2026, confirmed no further documented evidence of complete investigation was available. Resident R216's grievance (filed by family member) dated June 26, 2026, with category of Customer service/ Interaction, revealed Last night I was unable to make contact with my husband. I called continuously before finally being told that the phone system is compromised. Yesterday I bathed my husband at 11 a.m. Then I was told the bell was not working, they gave him a little bell, but he is in room [ROOM NUMBER] all the way away from the nurses' station. Then he's shaking it and nobody responds. At 8:20 p.m. he asked for a blanket. The aide came in the room and left back out, around 9 p.m. she returned but never got the blanket. Nobody changed his pull up since I had changed him at 11 a.m. His bed was wet and needed to be changed. Review of Resident R216's grievance file revealed no documented evidence a complete and thorough investigation was conducted to rule out allegations of abuse/neglect. Interview with Director of Nursing, Employee E1, on July 31, 2026, confirmed no further documented evidence of complete investigation was available. Resident R217's grievance dated June 26, 2026, with category of Customer Service/ Interaction, revealed My call bell in my room and bathroom is not working. They gave me a small bell, but when I ring it, nobody responds. On June 24, 2026, nobody checked on me from 3 p.m. until 2 a.m. This morning I was sleeping; the nurse left my pilled on the table and just left out. She didn't wake me up or anything. Review of Resident R217's grievance file revealed no documented evidence a complete and thorough investigation was conducted to rule out allegations of abuse/neglect. Interview with Director of Nursing, Employee E1, on July 31, 2026, confirmed no further documented evidence of complete investigation was available. Interview with Employee E5, Social Work Director on July 30, 2026, at 11:00a.m., described a definition for neglect as failure to provide care or services timely. After reviewing Resident R216's grievance, Employee E5 stated that would be considered a sign of neglect, if a resident did not get care. If they failed to meet a deadline. After reviewing Resident R217's grievance, Employee E5 stated They were not tending to his/her needs so I would consider this neglect. Interview with Employee E23, Unit Manager on July 30, 2026, at 11:30 a.m., revealed for an allegation of neglect is something that is willful or intentionally done. Interview with Director of Nursing, Employee E1, on July 30, 2026, at 12:10 p.m., revealed that for an allegation of neglect to be considered neglect, and not a care concern, it would have to be intentionally not provide services and the resident would have to specifically express that they feel neglected. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of clinical records, review of MDS (minimum data set- a federally required resident assessment completed at a specific interval) assessments, review of MDS schedules, review of MDS submission records and interview with staff, it was determined that the facility failed to complete comprehensive MDS assessment in a timely manner for 2 of 29 residents reviewed (Resident R107 and R108). Findings include: Review of facility policy on MDS (Minimum Data Set- Federally mandated resident assessment and care screening) Completion and Submission Time Frames With the most recent revision date of October 2023, revealed that under section Statement: Our facility will conduct and submit resident assessments in accordance with current federal and state submission time frames. Under section Policy Interpretation and Implementation: #1. the assessment coordinator or designee is responsible for ensuring resident assessments are submitted to CMS internet quality improvement evaluation system or iQIES in accordance with current federal and state guidelines. #2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. Review of Resident R107's MDS schedule revealed that a comprehensive assessment dated [DATE], was not completed and is currently in progress. Further review of Resident R107's MDS schedule revealed that the comprehensive assessment dated [DATE], was 37 days overdue. Review of Resident R108's MDS schedule revealed that a comprehensive assessment dated [DATE], was not completed and is currently in progress. Further review of Resident R108's MDS schedule revealed that the comprehensive assessment dated [DATE], was 39 days overdue. Interview with facility's RNAC (registered nurse assessment coordinator) Employee E8 conducted on July 30, 2026, at 10:45 AM confirmed that Resident R107's comprehensive MDS assessment dated [DATE], and Resident R108's comprehensive assessment dated [DATE], were not yet completed and were currently in progress. Follow-up interview with Employee E8 conducted on July 30, 2026, at 1:20PM revealed that the Resident R107's comprehensive MDS assessment dated [DATE], and Resident R108's comprehensive assessment dated [DATE], were not completed because the facility did not have a social worker to complete the social worker's section of the MDS. Interview with Regional Clinical Coordinator Employee E12 conducted on July 30, 2026, at 1:20PMconfirmed that the facility did not have a Social Worker to complete the MDS assessments. Interview with facility's Assistant Administrator conducted on July 30, 2026, at 1:25PM confirmed that the facility did not have a social worker to complete the MDS and that she has been helping out with the completion of the MDS. 23 Pa. Code 211.12(d)(1)

Based on review of facility policy, review of clinical records, and staff interviews, it was determined that the facility failed to develop a baseline care plan that included the minimum information necessary to properly care for a resident related to Alzheimer's Disease within 48 hours of admission for one of one resident reviewed (Resident R195).Findings Include: Facility policy titled Care Planning - Interdisciplinary Team, revised on [DATE], indicates that The interdisciplinary team is responsible for the development of resident care plans. The policy further indicates that 2- Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). Review of Resident R195's clinical record revealed Resident R195 was originally admitted to the facility on [DATE], with a diagnosis of Alzheimer's Disease. Further review of Resident R195's clinical record revealed the resident expired on [DATE]. Review of Resident R195's clinical record revealed no documented evidence a baseline care plan was developed and implemented to include the care and management of Alzheimer's Disease. Further review of the care plan revealed that Resident R195 only had plan of care for pressure ulcers and falls, no plan of treatment for other diagnoses and preferences. Interview on [DATE], at 11:00 a.m. with Assistant Administrator Employee E7 confirmed that the resident baseline care plan was not accurately completed. 28 Pa. Code 211.10 (d) Resident care policies

Based on review of facility policy, review of clinical record, observations, and staff and resident interviews it was determined that the facility failed to provide care and services for a dependent resident for one of 26 residents reviewed (Resident R6). Findings Include: Review of facility policy Identifying types of Abuse, revised on September 2022, revealed Neglect/ Deprivation of Goods and Services by Staff - 1. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. 2. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident requires but the facility fails to provide them and this has resulted in (or may result in) physical harm, pain, mental anguish or emotional distress. 3. Neglect includes cases where the facility's indifference to or disregard for resident care, comfort or safety results in (or could have resulted in) physical harm, pain, mental anguish or emotional distress. Review of Resident R6 's clinical record revealed resident was admitted to the facility on [DATE], with diagnosis of surgical amputation. Review of Resident R6's MDS (Minimum Data Set- a federally required resident assessment completed at a specific interval) revealed resident BIMS (brief interview for mental status) is a 15, indicating cognitively intact, and required assistance with activities of daily living. Interview with Resident R6 on July 28, 2026 at 11:45 a.m. revealed teary-eyed resident stating I was just calling Medicare to them not to pay this place because they are not taking proper care of me. Resident feels mistreated by nursing assistants and states that they are emotionally aggressive. I ran the call bell earlier and no one would answer so I started yelling and the nurse walked in and said stop yelling and then left the room again without helping me or asking what I need. Resident stated, I am legally blind and the aides will walk into my room very quietly and when i see a flash of their clothes or shadow I will say are you just going to stand there and they will respond I just wanted to see if you could see me or not. I have reported this to the nurse manager, and nothing has been done. I rang my bell a while ago to tell them to change me and I still have yet to be changed. Observation of Resident R6 on July 28, 2026, at 11:45 a.m. revealed soiled gown with multiple stains down the front and the smell of feces. Observation of Resident R6 pushed call bell on July 28, 2026, at 12:09 p.m. to request to be cleaned up, noted feces soiled diaper. Observation of Employee E19, Licensed Practical Nurse entering room at 12:15 p.m. to administer resident's medication, stated I will get your Nursing assistant to change you. At this time, Employee E19, Licensed Practical Nurse turned off call bell light. Observation of resident R6 on July 28, 2026, at 12:45 p.m. revealed resident had remained unchanged. Interview with Resident R6 on July 28, 2026 at 12:45 p.m. revealed no one had come back into the room at any point to attempt to change the resident. Interview with Director of Nursing on July 28, 2026 at 12:50 p.m., this surveyor provided notification that resident remained unchanged. Observation of Resident R6 on July 28, 2026 at 12:55 p.m., revealed resident remained unchanged. Resident initiated call bell again at 12:55 p.m. Observation on July 28, 2026 at 1:00 p.m., revealed Employee E19, Licensed Practical Nurse and Employee E1, Director of Nursing, entered Resident R6's room and provided incontinence care for resident. Interview with Employee E1, Director of Nursing on July 29, 2026 at 10:15 a.m., questioned if 50 minutes is an appropriate amount of time for a resident to remain in a soiled, feces filled diaper before receiving care? Employee E1, Director of Nursing responded, No but what do you want us to do, the staff was caring for other residents. 28 Pa. Code 201.29 (c) Resident rights.

Based on review of clinical record, observations, resident and staff interview, it was determined that the facility failed to ensure that residents were monitored during medication administration for 1 of 26 residents observed (Resident R139). Findings include: A review of facility policy on administering medications with the most recent revision date of April 2019 revealed that under section Policy Statement: #1. Only persons licensed or permitted by the state to prepare, administer and document the administration of medications may do so. #2. The director of nursing services supervisors and directs all personnel who administer medications and or have related functions. #4. Medications are administered in accordance with prescriber orders including any required time frame. #28. Residents may self-administer their own medication only if the attending physician in conjunction with the interdisciplinary care planning team has determined that they have the decision-making capacity to do so safely. Review of Resident R139 clinical record revealed that resident R139 was admitted to the facility on [DATE], with diagnosis of but not limited to Unspecified Dementia, and Allergies. Review of Resident R139 physician orders revealed an order for fluticasone propionate suspension 15 MCG/ACT Two sprays in each nostril one time a day for allergies dated May 7, 2024. Observation of Resident R139's room conducted on July 28, 2026, at 11:26AM during the tour of the 3rd floor unit revealed two bottles of fluticasone nasal spray on Resident R139's bed. Further the two bottles of fluticasone nasal spray were labeled with Resident R139's name on them. Interview with resident R139 revealed that one of the nurses gave her the two bottles of fluticasone nasal spray. Interview with licensed nurse Employee E9 conducted at the time of the observation confirmed that there were two vials of fluticasone on resident R139's bed. Employee E9 interviewed resident R139 who also revealed to Employee E9 that a nurse gave her the nasal spray. Employee E9 removed the two vials of nasal spray from Resident R139. 28 Pa. Code 211.12 (d) Nursing services

Based on review of clinical record interview with staff and review facility policy it was determined that the facility failed to identify, implement, monitor, and modify interventions for a resident who experienced a significant wight loss for one of 29 residents reviewed (Resident R78). Findings Include: Review of facility policy on Weight Assessment and Intervention revealed that under section Policy Statement: Resident weights are monitored for undesirable or unintended weight loss or gain. Under section Policy Interpretation and Implementation: section Weight Assessment #3 Any weight change of 5% or more since the last weight assessment is retaken. #a. If the weight is verified, nursing will immediately notify the dietician. #5 The threshold for significant unplanned and undesired weight loss will be based on the following criteria #a. 1 month-5% weight loss is significant, Greater than 5% is severe. Under section Evaluation: #1. Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. #2. The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia, weight loss, or increasing the risk of weight loss. Under section Care Planning: #1. Care planning for weight loss or impaired nutrition is multidisciplinary effort and includes the physician, nursing staff, the dietitian, the consultant pharmacist, and the resident or residence legal surrogate. #2. Individualized care plan shall address to the extent possible: # a. The identified causes of weight loss #b. Goals and benchmarks for improvement and #c. Time frames and parameters for monitoring and reassessment. Under section Interventions: #1. Interventions for undesirable weight loss are based on careful consideration. Review of Resident R78 clinical record revealed that Resident R78 was admitted to the facility on [DATE], with diagnosis of but not limited to Benign Prostatic Hyperplasia (enlarged prostate), and Gastrostomy Status (presence of They surgically created opening through the abdominal wall directly into the stomach used to place a fitting tube). Review of Resident R78's nutrition care plan revealed that Resident R78 had nutritional problem or potentialnutritional problem related chronic disease, need for enteral nutrition, history of significant weight changes, and advanced age. Review of resident R78 MDS (minimum data set - a federally required resident assessment completed at a specific interval) dated April 13,2026, reveal that under section K0520. Nutritional Approaches, B. Feeding tube (e.g., nasogastric or abdominal (PEG) was coded as having a feeding tube. Review of Resident R78's weight record revealed that on July 9, 2026, Resident R78's weight was 135.0 Lbs. (pounds). Further review of Resident R78's weight record revealed that on July 23, 2026, Resident R78's weight was 113.2 Lbs. Further, weight record revealed a WARNING indicating Comparison Weight 7/9/2026, 135.0 Lbs., -16.1%, -21.8 Lbs. Further review of Resident R78's weight record revealed that there was no documented evidence that Resident R78 was reweighed on July 23, 2026, to confirm the significant weight loss of 12.1% Review of Resident R78's clinical record revealed no documented evidence the significant weight loss sustained on July 23, 2026, of -16.1% in 14 days, was reviewed and addressed by the Registered Dietitian. Interview with ADON (assistant director of nursing) Employee E2 conducted on July 30, 2026, at 10:40 a.m., confirmed Resident R78 was not reassessed by the Registered Dietitian following the significant weight loss. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on observation, a review of facility documentation and staff and resident interviews, it was determined the facility failed to ensure that there was no more than 14 hours between substantial evening meal and breakfast the following day.Finding include: Observation on July 28, 2026, at 9:30 a.m. during initial tour of the kitchen revealed tray-line was still running for breakfast. An interview with the Food Service Director on July 28, 2026, at 9:30 a.m. confirmed that the tray-line was still running for breakfast. A review of facility's scheduled meal times revealed meal times greater than 14 hours between dinner and breakfast for the first cart as follows: 7/1/26 was 4:15 PM for dinner, 7/2/26 was 8:26 AM for breakfast = 16 hours and 11 minutes. 7/2/26 was 4:49 PM for dinner, 7/3/26 was 8:27 AM for breakfast = 15 hours and 38 minutes. 7/3/26 was 4:52 PM for dinner, 7/4/26 was 8:26 AM for breakfast = 15 hours and 34 minutes. 7/4/26 was 4:35 PM for dinner, 7/5/26 was 8:32 AM for breakfast = 15 hours and 57 minutes. 7/5/26 was 4:25 PM for dinner, 7/6/26 was 8:30 AM for breakfast = 16 hours and 05 minutes. 7/6/26 was 4:42 PM for dinner, 7/7/26 was 8:32 AM for breakfast = 15 hours and 50 minutes. 7/7/26 was 4:39 PM for dinner, 7/8/26 was 8:30 AM for breakfast = 15 hours and 51 minutes. 7/8/26 was 4:47 PM for dinner, 7/9/26 was 8:30 AM for breakfast = 15 hours and 43 minutes. 7/9/26 was 4:25 PM for dinner, 7/10/26 was 8:30 AM for breakfast = 16 hours and 05 minutes. 7/10/26 was 4:35 PM for dinner, 7/11/26 was 8:30 AM for breakfast = 15 hours and 55 minutes. 7/11/26 was 4:34 PM for dinner, 7/12/26 was 8:30 AM for breakfast = 15 hours and 56 minutes. 7/12/26 was 4:30 PM for dinner, 7/13/26 was 8:28 AM for breakfast = 15 hours and 58 minutes. 7/15/26 was 4:45 PM for dinner, 7/16/26 was 8:28 AM for breakfast = 15 hours and 43 minutes. 7/16/26 was 4:25 PM for dinner, 7/17/26 was 8:28 AM for breakfast = 16 hours and 03 minutes. 7/17/26 was 4:33 PM for dinner, 7/18/26 was 8:22 AM for breakfast = 15 hours and 49 minutes. 7/18/26 was 4:35 PM for dinner, 7/18/26 was 8:30 AM for breakfast = 15 hours and 55 minutes. 7/19/26 was 4:35 PM for dinner, 7/20/26 was 8:33 AM for breakfast = 15 hours and 58 minutes. 7/20/26 was 4:26 PM for dinner, 7/21/26 was 8:28 AM for breakfast = 16 hours and 02 minutes. 7/21/26 was 4:37 PM for dinner, 7/22/26 was 8:28 AM for breakfast = 15 hours and 49 minutes. 7/22/26 was 4:34 PM for dinner, 7/23/26 was 8:40 AM for breakfast = 16 hours and 06 minutes. 7/23/26 was 4:32 PM for dinner, 7/24/26 was 8:26 AM for breakfast = 15 hours and 56 minutes. 7/24/26 was 4:40 PM for dinner, 7/25/26 was 8:35 AM for breakfast = 15 hours and 55 minutes. 7/25/26 was 4:28 PM for dinner, 7/26/26 was 8:43 AM for breakfast = 16 hours and 15 minutes. 7/28/26 was 4:35 PM for dinner, 7/29/26 was 8:17 AM for breakfast = 15 hours and 42 minutes. An interview with the Regional Food Service Director (RFSD) on July 30, 2026, at 11:00 a.m. confirmed that the facility was not in compliance with the 14 hour rule and was not providing substantial snack after supper, and did not have approval from the resident group for going over 14 hours. The RFSD had no answer for why the supper tray-line was starting so early. Interview on July 28, 2026, with Residents R3, R134, R131, R89 on July 28, 2026, revealed that residents reporting having to purchase their own snacks, so they have something to eat between meals. Interviews with alert and oriented residents, Resident R39, R154, R113, during resident council on July 29, 2026, at 2:00 p.m. revealed that residents are not provided with a facility snack most evenings and that they have to use their own snacks that they purchased. The facility failed to ensure that there was no more than 14 hours between substantial evening meal and breakfast the following day. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on observations, interviews with staff, and a review of facility documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.Findings include: An initial tour of the Food Service Department was conducted on July 28, 2026, at 9:30 a.m. with Employee E3, Food Service Director (FSD), which revealed the following: Observations in the receiving area revealed the trash and recycling are inside the building in uncovered dumpsters, the foul odor of garbage was intense and there was trash on the ground around the dumpsters including paper, Styrofoam and plastic. Observations in the dry storage area revealed the floor was dirty, dusty and was sticky to walk on. Observations in the walk-in refrigerator revealed the floor and walls had a buildup of dark, dirty substance and debris on the floor including packing tape. Observations in the kitchen area revealed two fans with a buildup of dust and dirt on the fan grill and blades. Observations in the dish room area revealed a buildup of dirt and a white film on the underneath the dish tables including pipes, garbage disposal and electrical box next to disposal. Interview with the FSD at 9:50 a.m. on July 28, 2026, confirmed the above findings. 28 PA Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18 (b)(3) Management

Based on observations and an interview with staff it was determined that the facility did not ensure that garbage and refuse was disposed of properly. Findings include: An initial tour of the Food Service Department was conducted on July 28, 2026, at 9:30 a.m. with Employee E3, Food Service Director (FSD), which revealed the following: Observations in the receiving area revealed the trash and recycling are inside the building in uncovered dumpsters, the foul odor of garbage was intense and there was trash on the ground around the dumpsters including paper, Styrofoam and plastic. Interview with the FSD on July 28, 2026, at 9:30 a.m., confirmed the above findings. 28 PA Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18 (b)(3) Management

Based on a review of facility policy, review of clinical records, review of facility documentation, and interviews with residents and staff, it was determined that the facility failed to protect one resident from verbal abuse for one of 10 residents reviewed (Resident R1). Findings include: Review of facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, revealed that Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Review of the clinical record for Resident R1 revealed that the resident was admitted to the facility on [DATE], and has diagnoses of quadriplegia (paralysis that affects all a person's limbs and body from the neck down), cervical spinal fusion (a surgical procedure that permanently connects two or more vertebrae in the neck to alleviate pain and stabilize the spine). Review of Resident R1's MDS (minimum data set - a comprehensive resident assessment) revealed that the resident was totally dependent for all care (helper does all of the effort. Resident does none of the effort to complete the activity). Review of facility documentation submitted to the State Survey Agency revealed that on May 22, 2026, Resident R1 reported having a verbal dispute with one of the aides in regard to washing his/her face. On May 22, 2026, at 1:00 p.m. Resident R1 reached out to administration and filed a report of verbal abuse against Nurse Aide, Employee E10. Administration and social services spoke to Resident R1 who reported nurse aide, Employee E10, made threats to him/her and also made derogatory comments regarding Resident R1's family. The eyewitness to the altercation (identified as nurse aide, Employee E9) confirmed a verbal altercation between nurse aide, Employee E10, and Resident R1. Review of facility documentation revealed a witness statement dated May 22, 2026, from nurse aide, Employee E9, who reported that he/she came into Resident R1's room to provide care for the roommate, Resident R11. When entering the room, nurse aide, Employee E10, who was taking care of Resident R1, asked nurse aide, Employee E9, to relieve him/her so nurse aide, Employee E10, could take a break. Nurse aide, Employee E9, agreed to relieve nurse aide, Employee E10, for a break. Per the witness statement, Resident R1 asked nurse aide, Employee E10, where he/she was going, and said you can't go. Subsequently, Nurse aide, Employee E10, came back into Resident R1's and went back and forth arguing with Resident R1. It turned into Employee E10 yelling, f**** you p****, that's why you laying in the f****** bed and cant move, wearing a f****** diaper and can't do s***! Call your f****** wife, she is a weirdo. Resident R1 said to get out of his room. Employee E10 said, f*** your mother!. Per the witness statement dated May 22, 2026, by nurse aide, Employee E9, Resident R1 did go back and forth with nurse aide, Employee E10. Nurse aide, Employee E9, stated that he/she attempted to remove nurse aide, Employee E10, from the room but the argument happened so quickly and ended abruptly that he/she could not intervene quickly enough. Review facility documentation revealed a statement dated May 22, 2026, by nurse aide, Employee E10, that revealed that on May 22, 2026, he/she entered Resident R1's room and the resident was sleeping. When Resident R1 woke up he/she asked to be changed and nurse aide, Employee E10, suggested he/she should wash/dress the resident, to which Resident R1 agreed. Nurse aide, Employee E10, went and got a basin, water, wash cloth and soap. Nurse aide, Employee E10, subsequently gave Resident R1 a rag to wash his/her face, to which the resident became upset that he/she couldn't do it and said nurse aide, Employee E10, wouldn't assist. Nurse aide, Employee E10, continued to change Resident R1 and cleaned him/her up after breakfast. Continued review of statement dated May 22, 2026, by nurse aide, Employee E10, revealed when attempting to leave Resident R1's room for a break, after being relieved by nurse aide, Employee E9, Resident R1 questioned where nurse aide, Employee E10, was going and became upset. Nurse aide, Employee E10, reports Resident R1 then began calling the employee vulgar names. Nurse aide, Employee E10, reported it to the unit manager and switched to a different assignment. Review of statement dated May 22, 2026, by Resident R11, confirmed that Resident R1 and Employee E10 were arguing. Resident R11 reported It was really bad on both parts. I don't want to get involved. Interview with the Nursing Home Administrator (NHA), Employee E1, and the Director of Nursing, Employee E2, on June 29, 2026, at 2:25 p.m. confirmed that the eyewitness statements from R1's roommate and Employee E9 corroborated each other that Employee E10 was arguing and using foul language toward Resident R1 in his room on May 22, 2026, and that this is verbal abuse. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services

Based on interviews with staff, review of grievances, and review of facility policy, it was determined that the facility did not ensure that prompt efforts were made to resolve residents' grievances related to missing items for 2 of 3 residents interviewed (Residents R7 and R8).Findings include: A Review of facility policy titled, Personal Property dated 2001, revealed under bullet 11. The facility promptly investigates any complains of misappropriation or mistreatment of resident property. A review of Resident R8's grievance dated March 18, 2026, revealed that the resident reported missing personal care items that went missing during a night shift. The facility met with the family on March 18, 2026, to take pictures of the missing items. The family requested replacement of Johnson's Baby Lotion (pink), Aveeno Skin Relief (small bottle), and Dove antiperspirant. The grievance form listed grievance as resolved on March 26, 2026. On April 13, 2026, at 11:45 a.m., an interview with the Administrator, Employee E1, confirmed that the items needed for replacement were ordered that day. An invoice was provided showing that the items were ordered on April 13, 2026. The Administrator also confirmed that the facility was not able to locate an inventory sheet for Resident R8. A review of Resident R7's grievance dated March 17, 2026, revealed that the resident's representative reported, I'm reaching out regarding an ongoing concern about my father's personal belongings. Over time, we have brought him at least eight pairs of pants and approximately fifteen shirts. Unfortunately, we have noticed that items have continually gone missing each week. The grievance form listed the grievance as resolved on March 23, 2026. A review of Resident R7's inventory sheet dated January 7, 2026, revealed that the resident had 4 shirts, 4 undershirts, 2 pajama pants, and 5 sweatpants. A second inventory sheet dated March 19, 2026, indicated 2 shirts and 3 sweatpants. An email dated April 8, 2026, from a family member of Resident R7 provided a detailed list of missing items, of which only two items were located. On April 13, 2026, at 11:45 a.m., an interview with the Administrator, Employee E1, confirmed that the grievance for Resident R7 has not yet been resolved, as the family only located a few items and still needs to speak with the night shift staff before reimbursement of items to the resident. 28 Pa. Code 201.29(a) Resident rights

Based on closed clinical record review, and staff interview, it was determined that the facility failed to ensure that enteral feeding supplies were provided and available to be obtained at the time of discharged for one of two closed records reviewed. (Resident CL1)Findings include: A review of the closed clinical record of Resident CL1 revealed admission date of March 4, 2026, and discharge date of March 20, 2026, with diagnosis of cerebral infarction due to occlusion or stenosis of small artery (stroke), adult failure to thrive, dysphagia (difficulty swallowing), and moderate protein calorie malnutrition. An interview with the facility Registered Dietitian, Employee E4, on April 13, 2026, at 11:53 a.m., confirmed that Resident CL1 was receiving enteral feeds per the physician order dated March 13, 2026, administered six times daily at a rate of 165 mL (total 990 mL every 4 hours), providing 1,485 kcal and 73 grams of protein. The Registered Dietician, Employee E4 also indicated that Resident CL1 was consuming oral intake during the day and during the night receiving eternal feedings. A discharge progress notes from the Social Worker, Employee E5, who was not available for interview, documented on March 16, 2026, that social worker made aware that resident and family requested early discharge. Family stated they had everything in place for resident to go home and would like to work on discharge for Friday 3/20/26. A subsequent progress note, dated March 21, 2026, stated, social worker made aware that supplies needed for bolus feeding and/or gravity feeding were not provided. Social worker notes resident's son was trained on both, and SW called [Home Health Agency] to make them aware of feeding and supplies. SW obtained supplies to assist . until home health arrived on Monday. Family . arrived to obtain the supplies. A review of the discharge summary indicated that the Assistant Director of Nursing, Employee E6, was the individual who discharged the resident and signed off on the discharge documentation. The discharge documentation only indicated that a walker was needed and that it was ordered per the discharge summary. An interview with the Director of Nursing, Employee E2, on April 13, 2026, at approximately 11:35 a.m., confirmed that a Hoyer lift (mechanical lift) and sling were ordered on March 20, 2026, this items were not documented in the resident's clinical record or discharge summary. An interview was conducted on April 13, 2026, at approximately 2:55 p.m. with the Director of Nursing, Employee E2, and the Regional Nurse, Employee E7, during which it was difficult to obtain complete documentation regarding the ordering of enteral feeds post-discharge. On the same date at 3:20 p.m., the Director of Nursing, Employee E2, and the Regional Nurse, Employee E7, provided an invoice in Resident CL1's name showing that a hydraulic patient lift and commode were ordered and delivered on March 20, 2026. The records further showed that on March 23, 2026, irrigation kits, bolus supplies, and enteral nutritional formula were ordered and then canceled. A third invoice dated March 31, 2026, showed that enteral nutritional formula was again ordered and subsequently canceled. The facility was unable to provide an explanation for the multiple orders or the reasons for the cancellations. On April 13, 2026, at 3:33 p.m., an interview was conducted with the Assistant Director of Nursing, Employee E6, who signed off on the discharge summary on March 20, 2026. Employee E6 revealed that Resident CL1 was receiving specialized enteral feedings. The home health agency that accepted to provide in-home services did not have the specific brand and was unable to provide the supply to Resident CL1. Employee E6 stated that when the family called the facility on March 21, 2026, reporting that they did not have supplies, the facility provided a packet to the family post-discharge. When questioned about who was responsible for ensuring that Resident CL1 had the correct enteral feeds and appropriate brand, it was reported to be the social worker, who was not available for interview. However, per the discharge summary, it was the responsibility of the nursing staff who discharged Resident CL1. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, and staff interview, it was determined that the facility failed to maintain accurate records for one of two closed records reviewed (Resident CL2).Findings include: A review of clinical closed record for Resident CL2 revealed an admission date on January 13, 2026 with diagnosis of Intestinal obstruction, unspecified as to partial versus complete obstruction (blockage of the intestines with unclear severity), colostomy (Surgical opening of the colon to the abdominal wall), malfunction, ileostomy (surgical opening of the small intestine to the abdominal wall) kidney failure. Resident CL2's clinical record review showed that the resident was hospitalized on [DATE], and March 30, 2026. A review of the SNF/NF to Hospital Transfer Form revealed that an inaccurate form was completed with conflicting dates. The form documented the Date of Transfer to the Hospital as March 4, 2026, at 9:06 a.m., and indicated that the family was notified on March 4, 2026; however, vital signs documented on the form were dated March 30, 2026, and the form was signed on March 30, 2026. An interview with the Registered Dietitian, Employee E4, on April 13, 2026, at 11:53 a.m. confirmed that Resident CL2 was on a heart-healthy, full liquid diet. The documentation of the amount consumed by Resident CL2 was tracked by nursing assistant staff under the amount eaten at meal task. The amount eaten at meal task form was missing documented percentages for breakfast and lunch on March 18, 21, 22, 23, 25, and 27, 2026. On April 13, 2026, at 2:45 p.m., an interview with the Director of Nursing, Employee E2, confirmed that the Transfer to the Hospital form did not reflect accurate information for March 30, 2026, and that the amount eaten at meal task form was not completed for breakfast and lunch on March 18, 21, 22, 23, 25, and 27, 2026. 28 Pa. Code 211.5(f)(iv) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies and documentation, clinical record review and interviews with staff, it was determined the facility failed to provide adequate supervision to one of ten residents reviewed (Resident R1), who did not have a leave of absence (LOA) order. This failure resulted in Resident R1 exiting the third floor via elevator and walking out the front entrance of the facility. Resident R1 was located two hours after the resident exited the facility approximately 1.2 miles away from the facility in a busy [NAME] area. This failure placed the resident at high risk for injury and was identified as an Immediate Jeopardy past non-compliance. (Resident R1) Findings include: Review of facility policy, Wandering and Elopements dated March 2019, revealed The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Further review revealed that If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. 2. If an employee observes a resident leaving the premises, he/she should: a. attempt to prevent the resident from leaving in a courteous manner; b. get help from other staff members in the immediate vicinity, if necessary; and c. instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises. Review of facility policy, Resident Leaves of Absence dated March 2022, revealed that Residents may safely leave the premises for a planned leave of absence (LOA). The physician will be made aware of the resident, or resident's representative's, request for the resident to go on LOA and will provide an order to allow the resident to go on LOA, if deemed safe and appropriate. The resident will notify the nurse prior to leaving the facility and will sign-out. lt is requested that an estimated time of return is provided. Review of Resident R1's clinical records revealed that the resident was admitted on [DATE], with past medical history of repeated falls, difficulty walking, fracture of pelvic bone, and cognitive communication deficit. Review of an admission MDS (Minimum Data Set- assessment of resident care needs) dated January 22, 2025 revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 10 which indicated that the resident's cognitive status was moderately impaired. Review of care plan for Resident R1 dated January 16, 2025, revealed that the resident was at risk for fall related to the history of fall with injury. Continued review of the care plan revealed that the resident required one person staff assistance for ambulation. Review of physician order for Resident R 1 from January 2025 through April 24, 2025, revealed no documented evidence that the resident had a physician order for leave of absence. Review of a psychotherapy progress note dated April 9, 2025, revealed that the resident had a diagnosis of major depressive disorder and general anxiety disorder. Resident was seen because resident reported frustration and low motivation. Review of facility investigation dated April 13, 2025, revealed that the nursing assistant assigned to the resident alerted the nurse that earlier in the shift, Resident R1 told her that the resident needed to walk, but the resident did not elaborate further. The nursing assistant at that time thought the resident was talking about walking on the unit. Later, in the shift when the nursing assistant went to the resident's room, she stated that the resident was not there. At this time the nursing assistant alerted the charge nurse, and a Code Yellow (Emergency protocol for Elopement) was announced. Further review of the investigation revealed that it was estimated that Resident R1 left the faciity on [DATE], at 3:53 p.m. through the front door. Resident R1 was appropriately dressed for the day and was ambulating with the roller walker. It was revealed that the resident arrived at a friend's apartment, the friend (who is also Resident R1 's emergency contact) was not home, however a neighbor who also knew Resident R1 contacted the friend who in turn notified the facility, The resident's friend confirmed that Resident R1 had arrived at her apartment to visit with her, but she was not home. Upon notification a nurse from the facility went to the apartment and picked up the resident and returned her to the facility at 6:30 p.m. Resident R1 stated that (she/he) was going to visit her friends in the community where (she/he) lived prior to (her/his) admission to the facility. Review of a statement from Receptionist, Employee E9, dated April 13, 2025, revealed that a group of family members came downstairs off the elevator and right behind was an individual, well dressed with a purse in hand. The receptionist indicated that she was unaware that the individual was a resident of the building due to the individual being well dressed. Employee E9 stated she was think that the individual was just visiting a resident that lived in the facility. The individual was walking slow to the door however the person stopped at the carpet because the walker got caught up in the carpet. When employee looked up the individual was able to fix (herself/himself), after the individual walked out of the building. Review of a statement from Nurse Aide, Employee E10, dated April 13, 2025, revealed that she checked on resident when she came for her shift. Employee went to Resident R1's room and said hello to the resident. Resident was sitting on the bed dressed up. Resident told the employee (she/he) needed to walk. Employee told (her/him) to sit as the dinner will be served. Later dinner was served and the resident was not in her room. Review of a statement from Registered Nurse Supervisor, Employee E9, dated April 13, 2025, revealed that at approximately 5:15 p.m., the assigned aide brought to her attention that Resident R1 was not in (her/his) room. The aide stated earlier resident mentioned that (she/he) needed to walk but she was not in (her/his) room. Employee E10 went out and bought the resident back to the facility. Review of nursing note for Resident R1 revealed a nurse's note, dated April 13, 2025, at 6 :30 p.m. which indicated that the assigned nurse aide informed the writer that [Resident R1] who is alert and oriented x 2-3 (people, place and time) mentioned earlier during her rounds that (she/he) needs to walk but (she/he) returned at a later time and noted resident was not back in (her/his) room. Resident exited the center through the front desk. The employee went out and brought resident back to the center. Interview with Resident R1 on April 24, 2025, at 10:30 a.m. revealed that the resident was not able answer the name of the facility (she/he) was in and the day of the week as well as the date. But resident stated the facility would not let (her/him) go outside so (she/he) sneaked out the facility for few hours and sneaked back in without facility staff noticed. Resident did not remember if staff bought (her/him) back. Interview with Receptionist, Employee E12 on April 24, 2025, at 10:43 a.m. revealed that when resident's go out of the facility they must sign out. There were only three residents that were allowed to go out, however Resident R1 was not one of them. Any other resident when they exit the receptionist must stop them and let the nursing know that the resident was trying to leave. A facility surveillance camera review was conducted with Employee E13, Regional Staff on April 24, 2025, at 10:43 a.m. revealed that on April 13, 2025, at 3:54 p.m. three visitors walked towards the front entrance, Resident R1 was walking approximately 6 feet behind the visitors. It was revealed that the Employee E9, who was the receptionist at the time, was doing personal shopping on the computer, she was scrolling the shopping website looking at the computer. Employee did not look at the resident when the resident first appeared in the camera. Employee opened the front door by pressing the button at the front desk. Then door closed before Resident R1 exited. Employee E9 looked up saw the resident and pressed the button to open the front door. Resident R1 was observed slowly walking out with a walker. It was also showed that the three family members did not wear a visitor badge nor sign out at the front which was the facility protocol for anyone exiting the facility. Employee E9 did not appear to ask the visitors or the resident to sign out or return the visitor badge. Outside facility security camera showed that there were numerous cars passing by the facility, which was approximately 10 to 15 feet from the front entrance. Resident R1 walked with walker through the sidewalk and later disappeared from the camera view. Interview with Registered Nurse Supervisor, Employee E11, on April 24, 2025, at 12.18 p.m. stated after the resident was missing from the facility, she called resident's personal number and one of the staff from a senior living picked up the phone. Employee stated resident walked to the place. Employee drove her car to the place and picked up the resident ad brought the resident back to the facility. Registered Nurse Supervisor, Employee E11 also stated resident did not have an order for LOA and was not allowed to leave the facility premises unaccompanied. Interview with Receptionist, Employee E9, on April 24, 2025, at 12:40 p.m. stated she was covering the front desk for another employee who called out on April 13, 2025. Employee E9 stated she saw resident walking towards the front with a walker. Resident R1's walker caught up on the carpet, resident fixed it and walked out. Employee E9 stated resident was well dressed and she did not know that it was a resident, otherwise she would have stopped the resident. Employee E9 also stated every visitor must sign in and out at the front entrance and wear a visitor badge while visiting and return the badge when leaving. Employee E9 confirmed that the visitation protocol was not followed. Review of an internet map data revealed that the resident was located 1.2 miles away from the facility in a busy [NAME] area. There were busy intersections, and multilane traffic through the route to the location. Interview with Regional [NAME] President of Operations, Employee E14, on April 24, 2025, at 12.40 p.m. confirmed that Resident R1 did not have a physician order for LOA. Employee E14 confirmed that the resident should not have been allowed to leave the facility without proper supervision or physician order. Employee E14 also confirmed that Employee E9 had a clear view of the resident and still allowed the resident to leave without intervening. Employee E14 stated Employee E9 was not familiar with the resident thought it was a visitor. Employee E14 also confirmed that the facility did not follow the visitation protocol which would have helped distinguish between residents and visitors. Interview with Employee E14, Employee E1, Nursing Home Administrator and Employee E2, Director of Nursing on April 24, 2025, at 12.40 p.m. confirmed that the facility non-compliance with LOA and visitation protocol placed Resident R1 at risk for serious injury. Based on the above findings, an Immediate Jeopardy to the safety of the resident was identified for failure to provide adequate supervision of Resident R1 who did not have a leave of absence (LOA) order. This resulted in Resident R1 exiting the third floor via elevator and walked out of the front entrance of the facility while the receptionist, who was distracted by computer use (personal shopping), opened the front entrance door. Resident R1 was located two hours later after the resident exited the facility approximately 1.2 miles away from the facility in a busy [NAME] area. This failure placed the resident at high risk for injury. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator (NHA) on April 24, 2025, at 4:36 p.m. On April 15, 2025, the facility initiated a plan of correction to address the failure of ensuring that a resident was adequately supervised to prevent elopement. The facility plan of correction included the following: 1. Resident left the Center to take a walk. The resident had walked to her previous address and was visiting (her/his) neighbors. The Center staff spoke with (her/his) friend, and (she/he) was assisted back to the Center. Upon return, RN Supervisor assessed, and no injuries were noted. Completed 4/13/2025 2. The Center completed a headcount of all residents and compared it to the midnight census to ensure all residents were accounted for and resting comfortably. Completed 4/13/2025 3. Immediate Actions/Education -The Nursing Administration held huddles on all floors with staff on duty to discuss the current residents which go on frequent LOAs as well as the signs and symptoms that may indicate the risk for leaving the Center without staff notification. No variances were noted, and no current residents were identified as an elopement risk. Completed 4/13/2025 -Shift RN Supervisor provided immediate education to receptionist on duty. Completed 4/13/2025. -RN Supervisors were educated on the completion of headcount of all residents compared to midnight census and the immediate reporting of any discrepancy to the Director of Nursing/designee. Completed 4/15/2025. Staff were educated on signs and symptoms that may indicate a risk of elopement. 91% completed 4/15/2025. The remainder was completed prior to the start of the next shift. 100% completion on 4/16/2025. Reception/security staff were educated on the process of each visitor receiving a badge that must be returned prior to door being opened and visitor leaving the premise. 91% completed 4/15/2025. The remainder was completed prior to the start of the next shift. 100% completion on 4/16/2025. Staff educated on elopement/missing person policy and procedure including code yellow announcement to notify staff in Center, search both on the premises and the surrounding areas, notification processes including local police department. 91% completed 4/15/2025. The remainder was completed prior to the start of the next shift. 100% completed on 4/16/2025. Staff educated on elopement drills including how often and expected response. 91% completed 4/15/2025. The remainder was completed prior to the start of the next shift. 100% completion on 4/16/2025. All the training above will be added to our general orientation schedule for all new future employees. Completed 4/15/2025. Residents with a current unsupervised LOA order were re-educated on the LOA policy/agreement and understood the sign out process with both the nursing staff on the unit Ongoing Compliance will be monitored by: Auditing census compared to headcount every 4 HRS (hours) for 3 days then every shift for 14 days then daily. All variances will be reported to the QAPI (Quality Assurance Improvement Program) Committee monthly. Random audit of five visitors to ensure compliance with the visitor pass system two times daily for 14 days then daily for two months. All variances will be reported to the QAPI Committee monthly. Daily audit of LOA log to ensure reception/security staff are checking for clearance to leave the Center. The audit will be completed daily for three weeks with all variances reported during the clinical meeting. The QAPI Committee will make recommendations to ensure continued compliance. Upon sustained compliance, the QAPI Committee will recommend the reduction or resolution of the audits. and the reception/security staff. Completed 4/15/2025. A review was conducted of staff education, resident elopement/wandering evaluations, facility visitation protocols, and LOA process. Interviews with facility staff were conducted on April 24, 2025, and April 25, 2025. Facility staff provided extensive feedback and understanding of the facility's Elopement policy, LOA policy and visitation process. Facility LOA and visitation process was verified through observations. Review of facility documentation revealed that the corrective action plan was immediately initiated on April 15, 2025. Following the verification of the immediate action plan the Nursing Home Administrator was notified that the Immediate Jeopardy was lifted on April 25, 2022, at 2:34 p.m. and identified as past non-compliance. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of facility policies and documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to provide adequate supervision to one of one resident reviewed (Resident R1) who was at risk for elopement. This failure resulted in Resident R1 exiting the third floor via elevator and walking out the front entrance doors. Resident R1 was unable to be located for over 24 hours. This failure placed the resident at high risk for injury and was identified as an Immediate Jeopardy of past non-compliance. (Resident R1) Findings include: Review of facility policy, Wander Management and Elopement Prevention dated March 2022, revealed that the facility will maintain the safety of residents who wander and/or at risk for elopement. Further review revealed that staff will implement routine checks for placement and functionality and that the Wander management system devices will be checked for placement each shift and will be checked for functionality daily by nursing staff. Review of Resident R1's nursing notes revealed that the resident was admitted on [DATE], with past medical history of stroke, Schizophrenia with prior psychosis (a collection of symptoms where a person has trouble distinguishing between what is real and what is not) and intermittent agitation, cognitive dysfunction. Further review of clinical records revealed a progress note by Nurse Practitioner, Employee E4, dated January 21, 2025, at 10:07 a.m. which indicated that Resident R1 was previously hospitalized and was determined not to have decisional capacity due to underlying dementia. He was granted a legal guardian, who should be used for decision making. Review of facility documentation titled, Admission/Readmission Evaluation Packet, dated January 20, 2025, revealed that the resident had no history of elopement while at home; no history of verbally expressing the desire to go home or stay near the exit door. Further review of the admission evaluation revealed that the resident wanders aimlessly or non-goal-directed (i.e. confused, moves without purpose, may enter others' rooms and explore others' belongings). Continued review of the evaluation Question 15- Is resident at risk for wander/elopement? revealed that the answer was- no. During interview with Licensed Nurse, Employee E6, on January 30, 2025, at 10:40 a.m. Question 15 of the above Admission Evaluation was reviewed. Licensed nurse, Employee E6 indicated that the resident was at risk for elopement and had no answer as to why the resident was coded not at risk. Continued interview with Employee E6 confirmed that an elopement care plan was developed/initiated January 21, 2025. Review of Resident R1's care plan revealed a care plan date-initiated January 21, 2025, which indicated that the resident was at actual / potential risk for elopement r/t (related to) adjustment reactions, cognitive impairment, New environment, non-acceptance of long-term placement. Review of nursing note for Resident R1 revealed a nurse's note, dated January 23, 2025, at 10:36 p.m. which indicated that when the Nurse Assistant entered Resident R1's room to deliver his dinner tray, she noted that Resident R1 was not present. The Nurse aide searched the unit for Resident R1 and immediately notified nursing administration; a search of all areas of the facility was performed. Further review revealed a nursing note dated, January 25, 2025, at 2:49 a.m. (over 48 hours since January 23, 2025, when the resident was noted missing) which indicated that the resident arrived to the unit with the Director of Nursing. Upon arrival, Resident R1 was escorted to their room and assessed. Due to respiratory concerns, Resident R1 was sent to the emergency room for further evaluation. Resident R1 returned to the facility shortly after and was placed under one-to-one supervision. Review of nursing note dated January 25, 2025, at 7:35 a.m. indicated that the resident returned from hospital emergency room 1:1 protocol was instituted. Resident continues 1:1 care for elopement risk. Review of facility documentation reported to the State Survey Agency on January 23, 2025, at 6:30 a.m. revealed that Resident R1 was last seen by staff at 3:00 p.m. It was determined that Resident R1 took the elevator from the third-floor nursing unit and exiting through the doors of the main entrance of the facility. On January 25, 2025, at 12:21 a.m. the Director of Nursing, Employee E2 received a call from a nearby center stating that the resident came to their facility. Resident R1 returned to the nursing facility on January 25, 2025, at 2:49 p.m. Review of internet maps revealed that the center in which the resident was located was 2.2 miles, approximately a fifty-minute walk, from the nursing facility, in a busy [NAME] area. Interview with the Activities Director, Employee E7, conducted on January 29, 2025, at 11:45 a.m., revealed that she was filling in for the receptionist on January 23, 2025, from 2:00 p.m. to 10:00 p.m. and that she had not seen the resident in the foyer at all prior to Resident R1's elopement. Interview with Central Supply Staff, Employee E3, on January 30, 2025, at 1:14 p.m. revealed that she had put the wander guard on Resident R1 upon admission, on January 20, 2025, at approximately 4:00 p.m. Employee E3 stated, I got into the elevator from ground; the elevator wouldn't move so I reset the alarm and walked up the 3rd floor and put it on him. Further interview revealed, the elevator wouldn't move so that was my way of knowing because the alarm is inside the elevator. Follow-up interview with the facility Nursing Home Administrator and Director of Nursing conducted on January 31, 2025, at 10:19 a.m. revealed that the wander guard must be checked by a tester box which is not available at the facility and is on order. Review of Resident R1's entire clinical record failed to reveal an order for a wander guard. Further review of Resident R1's clinical record failed to reveal documented evidence confirming that the wander guard was tested before application and upon residents return; and that the device was checked for placement each shift and checked for functionality daily by nursing staff. Interview with the Nursing Home Administrator and Director of nursing confirmed this finding on January 31, 2025, at 11:13 a.m. Based on the above findings, an Immediate Jeopardy to the safety of the resident was identified for failure to provide adequate supervision of Resident R1 who was identified as an elopement risk by the facility. This resulted in Resident R1 exiting the third floor via elevator and walked out of the front entrance of the facility. The resident was not able to be located for over 24 hours. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator (NHA) on January 30, 2025, at 11:07 a.m. On January 24, 2025, the facility initiated a plan of correction to address the failure of ensuring that a resident was adequately supervised to prevent elopement. The facility plan of correction included the following: 1. Resident left the Center. The Philadelphia Police Department and guardian were notified. The resident returned to the Center on January 25th from, an all-male boarding home, where he resided previously. 2. The Center completed a headcount of all residents and compared it to the midnight census to ensure all residents were accounted for and resting comfortably. Completed 1/23/2025. 3.Immediate Actions/Education a. The Nursing Administration reviewed all resident EHR (Electronic Health Record) for accurate elopement/wandering evaluations, orders for every shift placement checks, daily function tests and care plans. The elopement book found at reception desk was reviewed to ensure that all residents identified as elopement risks were current, and resident identifiers were available. Completed 1/23/2025 b. Staff were educated on the implementation of resident specific interventions to prevent elopement. 92% completed 1/24/2025. The remainder was completed prior to the start of the next shift. c. Staff were educated on the procedure for elopement monthly drills and the announcement of code YELLOW to notify all staff. 92% completed 1/24/2025. The remainder was completed prior to the start of the next shift. d. RN Supervisors were educated on the completion of headcount of all residents compared to midnight census and the immediate reporting of any discrepancy to the Director of Nursing/designee. 92% completed 1/24/2025. The remainder was completed prior to the start of the next shift. e. Staff were educated on signs and symptoms that may indicate a risk of elopement. 92% completed 1/24/2025. The remainder was completed prior to the start of the next shift. f. Reception/off shift staff were educated on the process of each visitor receiving a badge that must be returned prior to door being opened and visitor leaving the premise. 92% completed 1/24/2025. The remainder was completed prior to the start of the next shift. Staff educated on elopement/missing person policy and procedure including code yellow announcement to notify staff in Center, search both on the premises and the surrounding areas, notification processes including local police department. 92% completed 1/24/2025. The remainder was completed prior to the start of the next shift. g. Staff educated that elopement devices are checked daily for functionality and every shift for placement by the professional nursing staff. 92% completed 1/24/2025. The remainder was completed prior to the start of their next shift. h. Staff educated on elopement drills including how often and expected response. 92% completed 1/24/2025. The remainder completed prior to the start of the next shift. i. All the training above will be added to our general orientation schedule for all new future employees. 92% completed 1/24/2025. The remainder was completed prior to the start of the next shift. The low voltage contractor responded to the Center immediately and changed the settings on front door requiring guest services staff to allow all visitors entrance and exit by hitting a button under the desk. Completed 1/23/2025 j. Testing box ordered. Completed 1/27/2025 k. Nursing Administration was educated on their responsibility to apply all new elopement devices and obtain and input orders for functionality and placement into the EHR. 4. Ongoing Compliance will be monitored by: a. Auditing census compared to headcount every 4HRS for 3 days then every shift for 14 days then daily. All variances will be reported to the QAPI Committee monthly. b. Random audit of five visitors to ensure compliance with the visitor pass system two times daily for 14 days then daily for two months. All variances will be reported to the QAPI Committee monthly. c. Random audit of 10 new admissions weekly to ensure thorough evaluation and care planning. All variances will be reported to the QAPI Committee monthly. d. The QAPI Committee will make recommendations to ensure continued compliance. Upon sustained compliance, the QAPI Committee will recommend the reduction or resolution of the audits. A review was conducted of staff education, resident elopement/wandering evaluations, function of front door, and test box order slip related to Resident R1's elopement. Interviews with facility staff were conducted on January 31, 2025. Facility staff provided extensive feedback and understanding of the facility's Elopement policy and process. Facility staff stated that wander management system devices will be checked for placement each shift, and for functionality daily by nursing staff. Review of facility documentation revealed that the corrective action plan was immediately initiated on January 24, 2025. The facility's action plan was accepted on January 31, 2025, at 1:24 p.m. and identified as past non-compliance. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of clinical records, facility policies and procedures, and interviews with residents and staff, it was determined that the facility failed to monitor a resident's weight and nutritional status resulting in harm to Resident R5 who sustained an unplanned 21.8 pounds weight loss (23.7 %) in 2 months, for one of seven residents reviewed. (Resident R5) Findings include: Review of facility policy, Weight Measurement dated March 2018, revealed that after weight is obtained it is to be compared to the previous weight. If there is a discrepancy, review with the nurse and weigh the patient again. Discrepancies are considered to be 5 lbs. (pounds) if patient is over 100 lbs., 2.5 lbs. if patient is 99 lbs. or under. Identifying/calculating significant weight change is done by the registered dietitian. Significant weight loss is defined as 5% in 30 days, 7.5% in 90 days and 10% in 180 days. Review of the clinical record for Resident R5 revealed resident was admitted on [DATE], with diagnoses of pulmonary embolism (condition in which one of the pulmonary arteries in the lungs gets blocked by a blood clot. This causes chest pain, breathlessness and cough.) protein-calorie malnutrition (nutritional deficiency resulting from either inadequate energy (caloric) or protein intake manifested by wasting of body tissues, particularly muscles and subcutaneous fat) and dysphagia (condition with difficulty in swallowing food or liquid. This may interfere in a person's ability to eat and drink.) A review of code status revealed that Resident R5 was a Full Code (means that if you have cardiopulmonary arrest, that is if you stop breathing or your heart stops beating, the medical team will do everything in their power to bring you back such as defibrillation (shocking with paddles) giving drugs to start your heart, putting you on a ventilator). Review of the resident's Annual MDS Assessment (Minimum Data Set - a mandatory periodic resident assessment tool), dated May 18, 2022, Section G Functional Status for section H. Eating - how the resident eats and drinks revealed the resident was coded as Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance, and the resident was coded as a one person physical assist. Review of Resident R5's physician orders revealed an order for supervision with all meals every day shift and night shift for monitoring. The Resident's Care plans included: The resident is at nutritional risk related to dysphagia with need for mechanically altered diet, weight fluctuations with a goal that the Resident will consume 75% or more of majority of meals and will maintain weight within 5% of 89 pounds. An intervention included to provide mechanically altered diet as ordered. Diet is puree. House Supplement three times a day and for the Registered Dietician to evaluate and make diet change recommendations PRN (As needed). The Resident is at nutritional risk 2nd to weight loss trend/to very low BMI/Increased needs of healing with a goal that the Resident will meet 100% calories/protein/fluid needs, via diet + supps + snack, to promote weight gain/improved nutritional status. The interventions included to monitor intake tolerance, weight trend, skin integrity, labs, alert Registered Dietician/MD, as needed and to offer alternate food choices if < 50% consumed at mealtime. The resident has nausea and vomiting related to Disease process with a goal that the resident will not have significant weight loss through the review period. An intervention included a Diet consult as needed. Further review of Resident R5's clinical record revealed weights taken on the following dates: 5/11/2022 - 90.0 lbs., 6/8/2022 - 91.0 lbs., 7/6/2022 - 92.0 lbs. and the next available weight was 9/8/2022 - 69.0 pounds with a re-weight completed on the same day of 70.2 pounds. There was no documented weights in the month of August 2022. Weight loss from the 7/6/2022 weight of 92.0 lbs. to the 9/8/2022 weight of 70.2 lbs. was a loss of 21.8 lbs. or 23.7 % of her body weight during a 2 month period. Review of Resident R5's physician orders revealed an order for evening snack on May 20, 2022 house supplement three times a day initiated on May 22, 2022, and a diet order dated August 15, 2022, for a regular/liberalized dysphagia diet with a puree texture. Review of documented meal consumption from August 11, 2022 through September 8, 2022, revealed a 50-100% meal consumption. Further review of documented acceptance of three times a day house supplement was 100%. Review of Resident R5's nutrition notes completed by Registered Dietician, Employee E7 dated May 12, 2022, revealed the resident's weight on March 30, 2022, was 99.3 pounds and on May 11, 2022 the resident's weight decreased to 90 pounds. The resident meal intake was recorded between 50%-75% on a puree diet with house shakes twice a day. Further review of nutritional notes dated May 16, 2022, revealed that Resident R5 had a 9.4% weight loss from March 30, 2022 to May 11, 2022. The resident was now on house shakes three times a day. On May 31, 2022, the Registered Dietician noted that the resident expressed that she had been trying to eat as much as she could and sometimes called the kitchen for a special request. The Registered Dietician indicated that the resident was going to be followed for weight trends and further recommendation. Continued review of nutritional notes revealed that the next available nutritional note was August 18, 2022, which noted the resident's last weight to be July 6, 2022, of 92 pounds with no significant weight changes. Interview with Resident R5 on September 8, 2022, at approximately 10:30 a.m., revealed that the resident stated that she was weighed today and was only 69 pounds. She pulled up her gown to reveal her legs and abdomen which were very thin with the bones protruding. Resident R5 said she felt like she was just skin and bones. When Resident R5 was asked about her appetite she said that she loves chocolate and would accept chocolate milk, chocolate shakes or chocolate pudding. Interview with Licensed nurse, Employee E3, on September 8, 2022, at approximately 11:00 a.m., revealed that the weight was just taken that morning and she was not aware of the weight loss. When surveyor inquired about Resident 5's weight loss and assessment by a Registered Dietician, Employee E3 stated that the facility has not had a consistent dietitian for a while. Interview with the Director of Nursing, on September 8, 2022, at approximately 11:30 a.m., revealed that they have a Registered Dietitian who comes every Wednesday. Telephone interview with Employee E6, Clinical Dietitian, on September 8, 2022, at approximately 11:45 a.m., regarding Resident R5's 21 pound weight loss confirmed that she was not aware of the weight loss. When asked about her schedule to cover the 150-bed facility she said that she worked on Wednesdays and that there was another dietitian (Employee E9) who come in on weekends to help. When asked about the resident's intake or if she was receiving a supplement, she said that she would have to check, but thought that she was receiving a supplement. Interview with the Nursing Home Administrator, revealed that previous Registered Dietitian, Employee E7, last day was July 15, 2022, and that a contracted company has been providing coverage with two part time dietitian's (Employee E6 & Employee E9) until a permanent full-time person could be hired. The facility failed to monitor Resident R5's weight and nutritional status which resulted in harm to Resident R5 who sustained an unplanned 21.8 pounds weight loss in a 2 months. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, clinical record review, interviews with residents and staff and review of facility documentation, it was determined that the facility failed to maintain a safe environment for three of 4 nursing units and failed to provide adequate supervision and monitoring for two of 24 residents reviewed resulting in actual harm to both residents, one sustained a fractured ankle and the other a burn (Resident R82 and CL1). Findings include: Review of Resident R82's clinical record revealed a History and Physical form dated April 23, 2017, that noted that the resident had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. (difficulty lifting the front part of the foot) and respiratory failure with intubation (the placement of a flexible plastic tube into the windpipe to maintain an open airway). In addition, it stated that the resident's spouse would bring in a brace for the right foot drop. The resident was seen in consultation by the rehabilitation physician on April 24, 2017, who documented that the resident had lower back pain, difficulty walking, chronic morbid obesity, a permanent right hip spacer, right foot drop, edema (swelling) in both legs and had previously walked short distances, spent most of the time in a wheelchair and recommended physical and occupational therapies. An initial comprehensive Minimum Data Set assessment (MDS- an assessment of resident care needs) dated April 27, 2017 indicated the resident's Brief Interview for Mental Status (BIMS - a tool used to assess a residents cognitive status) was a 15 out of 15 indicating that the resident was cognitively intact. The resident required extensive assistance of two staff for transfers and ambulation, needed extensive assistance of one staff for dressing and personal hygiene and bathing, and the resident was 5 feet 2 inches tall and weighed 213 pounds. Employee E13, a Registered Nurse, stated in an interview on May 21, 2017, at approximately 9:00 a.m. that Resident R82 used orthotic (specialty made for support of the feet) shoes for walking, that she had them before she was admitted to the facility, that the resident had lost a lot of weight and that the shoes were too big on her. Observation at that time revealed a very large ankle boot with metal braces attached to it. A physical therapy progress note dated May 1, 2017, reported donning and doffing (putting on and taking off) the AFO (ankle foot orthosis- device to control ankle/foot movement). A nursing progress note dated May 1, 2017, at 11:40 a.m. noted right foot drop and that the right ankle had swelling. Physical therapy progress notes dated May 3, 2017, stated that they had called the orthotist (healthcare professional responsible for prescription, manufacture and management of orthotic devices) to discuss Resident R82's right shoe and brace and had sent a face sheet (resident information) to him. The orthotist was to look at the brace and see if he could fix it or make a new brace and that he was to come in to the facility to see the brace. On May 3, 2017, at 10:54 a.m. nursing documentation noted right foot drop and that the right ankle had swelling and bruising to the right foot. Physical therapy progress notes dated May 4, 2017, noted that Resident R82 ambulated up to 5 feet with a rolling walker, and when attempted further, the resident reported increased lower back pain and right lower extremity pain, and during the second attempt the patient was unable to advance secondary to lower extremity pain. The Certified Registered Nurse Practitioner (CRNP) progress note dated May 4, 2017, stated that the resident had requested to be seen due to a new complaint of right ankle pain. The resident had reported that the right ankle brace had fallen off in therapy the previous day but that she continued therapy without the brace and twisted her right ankle. A mobile X-ray was obtained on May 5, 2017, that indicated no fracture. The resident was seen in consultation by the rehabilitation physician on May 8, 2017, who documented that the resident's leg brace had come loose during gait training causing the resident to turn her ankle inward and she had ankle pain and the right ankle was tender. It was noted that the resident had a right ankle sprain and the resident would be evaluated with the leg brace the next day to see if adjustments could be made, that the shoe may need revision with the orthotist versus a new shoe since there was major weight loss. On May 9, 2017, the resident was seen again by the rehabilitation physician who stated that the AFO shoe was ill fitting, that it was too large, that it could not be tightened appropriately, that it likely contributed to the resident's ankle sprain the previous week, and to contact orthotist for fabrication of new AFO shoe, to trial an aircast (an ankle brace) underneath for now. On May 15, 2017, the resident was seen again by the rehabilitation physician who stated, at that time, the resident had chronic distal right lower limb weakness and foot drop and developed a recent ankle sprain and that the AFO shoe was ill fitting due to weight loss. An aircast had been recommended but that the facility did not have one and the resident had been ambulating in therapy without it. It stated further that the resident reported pain in the right ankle and it was worse over the previous several days and the Percocet (a narcotic medication for severe pain) had been increased to two tablets due to pain complaints because the pain was severe. On May 16, 2017, the rehabilitation physcian reported that the resident had been sent to the emergency room and an X-ray dated May 15, 2017, noted (compared with May 5, 2017 X-ray) a fractured distal (away from the center of the body) tibia (lower leg bone) with disruption of the tibiatolar joint and a non-displaced lateral malleolus fracture (fractured ankle). Employee E16, a Physical Therapy Aide, in a written statement dated May 18, 2017, noted that on May 4, 2017, the resident first reported increased ankle pain after ambulation with the orthopedic shoes and she continued to report pain. On May 11, 2017, the physician had discussed that the shoes and brace were too big and the physcian had recommended an aircast but the therapist was unable to find one and the resident had no other shoes to use. The resident had reported constant pain. The physcian stated in an interview on May 22, 2017, at 1:15 p.m. that Resident R82 had distal weakness in the leg, that the foot orthrosis (brace) did not fit well and the resident had complained of ankle pain. Resident R82 stated in an interview on May 23, 2017, at 9:00 a.m. that she was in therapy when her ankle first started hurting. She stated that the AFO shoe was too big and she was not using it any more. Employee E16, stated in an interview on May 18, 2017, at 11:10 a.m. that the resident had an orthotic shoe with double uprights (metal braces and an AFO shoe) for foot drop. Employee E16 indicated that the shoes fit poorly and that Resident R82's foot slid around. Employee E16 stated that the resident had reported pain, that the staff were trying to tighten the laces as much as possible and that the resident did not like it tight. There was no evidence available for review at the time of the survey to indicate that the physician had been notified that the resident had been in constant pain, that the aircast had not been available or that the resident was still participating in physical therapy without the aircast. In addition, there was no evidence that physcian's orders had been obtained for the use of an orthotic shoe or the type of shoe to use prior to beginning therapy. The facility failed to provide adequate monitoring and supervision for a resident with multiple orthopedic disorders receiving physical therapy causing a fractured ankle and actual harm. Review of the clinical record for Resident CL1 revealed an admission MDS dated [DATE], indicating a BIMS (Brief Interview for Mental Status, a brief screening tool that aids in detecting cognitive impairment) score of 15 out of 15, indicating the resident was cognitively intact. Review of an occupational therapy discharge summary, dated July 11, 2016, revealed that Resident CL1 was currently utilizing a wheelchair and required the wheelchair for item retrieval. Review of a quarterly MDS assessment dated [DATE], revealed another BIMS score of 15, and that the resident utilized a wheelchair for mobility. Review of a care plan evaluation progress note, dated September 15, 2016, revealed that Resident CL1 had a past medical history with [DIAGNOSES REDACTED]. Further review of the care plan evaluation progress note indicated that Resident CL1 was able to self-propel in the wheelchair. Review of a Change in Condition-Skin nursing progress note, dated October 2, 2016, at 11:32 p.m. revealed that Resident CL1 was noted with a, blister received from a burn on the left thigh, measuring 11 centimeters (cm) wide by 9 cm long, that the blister, is opened up, that the injury was a stage 2, and that new physician's orders [REDACTED]. Review of a physician's progress note, dated October 3, 2016, revealed that Resident CL1 spilled a hot drink on his left thigh, sustained a burn to the area, he then picked at the blister, and an Optifoam dressing had been applied by the staff. Further review of the physician's progress note indicated that Resident CL1 would not allow the physician to examine the area, that the physician's [DIAGNOSES REDACTED]. Review of a care plan evaluation nursing progress note, dated October 7, 2016, at 11:46 a.m. revealed the nurse asked Resident CL1 how the burn to the resident's left thigh occurred with the resident stating that he made hot chocolate in the microwave in the kitchen. Review of a Certified Registered Nurse Practioner (CRNP) wound consultant report, dated October 7, 2017, revealed Resident CL1's [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of another physician's orders [REDACTED]. Review of the facility's documentation into the incident revealed that on October 2, 2016, Resident CL1 stated he went into the pantry on the nursing unit sometime in the morning around 9:30 a.m. had his own hot chocolate packet, and used the facility's microwave to heat up the water. After heating up the water and attempting to exit the pantry, the resident stated that he bumped into the door to the pantry causing the spill. The facility's documentation included a statement from a Licensed Practical Nurse (LPN) indicating that Resident CL1 did not realize he had burned himself when the injury originally occurred, and when the resident was preparing for bed that evening saw a wet spot on his pants, and felt irritation and pain to the area. The statement from the LPN additionally revealed, When he removed his pants there was a fluid filled blister on his thigh. After (sic) being assessed by me (the nurse) I went to grab supplies to measure and address the wound. When I returned the resident had opened up the blister and removed the skin. The area measure (sic) width 11 cm and length 9 cm . The area was cleansed and dried and an Optifoam dressing applied. An interview with the Director of Nursing (DON) on May 24, 2017, at approximately 2:35 p.m. revealed that at the time of Resident CL1's burn that occurred on October 2, 2016, the pantry on the facility's Third Floor Nursing Unit was made available to the short term residents who were alert and oriented, including free access to a microwave located in the pantry. Further interview with the DON confirmed that Resident CL1, a resident with a [DIAGNOSES REDACTED]. The facility failed to provide adequate monitoring and supervision to prevent accidental burns, for residents who had free access to the facility pantry areas with microwave ovens, causing actual harm to Resident CL1. An observation of the Second Floor Nursing Station on May 21, 2017, at 12:30 p.m. revealed eight medications; Chlorthalidone (treats high blood pressure), three dispensing cards, Bactrim (antibiotic) two dispensing cards, Hydrochlorothiazide (diuretic/water pill) one dispensing card, Prednisone (cortisone/antinflammatory) one dispensing card, Gabapentin (treats seizure and nerve pain) one dispensing card, Spironoaldactone (treats heart failure and fluid excess) four dispensing cards, Remeron (antidepressant) one dispensing card and Klor-Con (potassium supplement) one dispensing card, were left at the nursing station unattended and at risk of being picked up and ingested (swallowed) by residents. An interview with Employee E20 during the observation confirmed this finding. Observation of the Fifth Floor Nursing Unit on May 21, 2017, at 9:40 a.m. revealed the presence of an unattended treatment cart located in the hallway adjacent to resident room 503. Further observation of the treatment cart revealed that the third drawer of the cart was unlocked and easily opened. Present in the drawer, at the time of the observation, were five bottles of Skin Integrity Wound Cleanser, one five ounce container of Caldesene powder (a medicated powder used to treat minor skin irritation), one four ounce tube of Hydrogel (a gel used for wound care), one spray can of Simply Saline (salt solution) and one tube of Nystatin Cream (used to treat fungal infections) 100,000 units per gram (gm). Observation of the Fourth Floor Nurses' Station on May 23, 2017, at 12:00 p.m. revealed the presence of a prepackaged syringe sitting on the counter of the nurses' station. The nurses' station was unattended at the time of the observation and the syringe was clearly visible to any individuals standing by the nurses' station. The facility failed to maintain an environment free of accident hazards on three of four nursing units and failed to provide adequate supervision and monitoring to two residents resulting in actual harm to two residents, when one sustained a fractured ankle and the other a burn. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 04/09/15 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 04/19/15 28 Pa. Code 201.18(a)(b)(3) Management 28 Pa. Code 201.18(b)(1) Management Previously cited 04/09/15 28 Pa. Code 201.18(e)(1) Management Previously cited 07/01/15 28 Pa. Code 211.5(f) Clinical records Previously cited 04/09/15 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 04/09/15 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 04/09/15, 07/10/15, 12/07/15, 03/25/16

Based on review of clinical records and facility documentation, and interviews with staff, it was determined that the facility failed to provide adequate supervision and assistive devices to ensure the safety of a resident, identified as a fall risk, resulting in actual harm for one of 24 residents reviewed (Resident CL3). Findings include: Review of the clinical record for Resident CL3 revealed a physician's history and physical, dated October 11, 2013, indicating the resident was admitted to the facility from an acute care hospital with [DIAGNOSES REDACTED]. Review of nursing documentation dated October 11, 2013, clarified that Resident CL3 had a left long leg cast. Review of nursing documentation dated October 15, 2013, revealed Resident CL3 had a follow-up appointment at the orthopedic surgeon who removed the resident's left long leg cast due to resident's complaints of ill fit, and was unable to recast due to discovery of a left heel pressure ulcer. The note further indicated that a brace-locked in extension was applied to the resident's left leg, to be worn for five weeks, and only to be removed for wound care while in bed "(can be undone but not entirely removed ever)." Review of the orthopedic consult report, dated October 15, 2013, recommended that Resident CL3, "must remain in full extension" of left knee, no range of motion of left knee, and to "wear brace at all times." Review of physician's orders [REDACTED]. Review of physical therapy documentation dated October 15, 16, 17, 18, 20, 21, 22, 23, 24, 26, 27 and 29, 2013, revealed precaution of straight leg brace to left lower extremity at all times. Review of nursing documentation, dated October 17, 2013, revealed that Resident CL3 attempted to transfer self (without staff assistance) from recliner chair to go to the bathroom, lost balance and fell backwards, with complaint of increased pain in the left knee. Review of updated care plan for risk of falls, dated revised October 17, 2013, included monitor for and assist with the resident's toileting needs. Review of a physician's assistant progress note, dated October 24, 2013, revealed that during a physical therapy session, Resident CL3 complained of legs feeling shaky, causing the resident to fall to the ground, striking the left knee. Review of another physician's assistant progress note, dated October 25, 2013, indicated a left knee X-ray was performed showing possible avulsion of the left patellar tendon (reinjury to the left knee). Review of a follow-up orthopedic consult, dated October 25, 2013, revealed Resident CL3 had a questionable re-partial rupture of the left patella tendon, and recommended to continue the constant knee immobilizer to the left leg. Review of physician's orders [REDACTED]. Review of a physician's assistant progress note dated October 29, 2013, revealed that Resident CL3 sustained an unwitnessed fall in the bathroom, stating that the resident's knees began shaking and then gave out, causing a fall to the floor, landing on both knees in a kneeling position. The note further stated that Resident CL3 endorsed that a "pop" was felt in the left knee, was not wearing the left leg brace at the time of the fall, and that the brace was to be in locked extension at all times. Review of the facility's investigation report revealed on October 29, 2013, a certified nursing assistant (CNA-Employee E1) placed Resident CL3 on the toilet and informed the resident to ring the call bell when ready to transfer. The report further indicated the resident attempted to self-transfer without assistance, and fell off the toilet. Review of an employee witness statement (Employee E1), dated October 29, 2013, revealed that Employee E1 removed the resident's left knee brace to get the brace, "out of (the resident's) way for transferring," and to remove the resident's pants. Another physician's assistant progress note, dated October 30, 2013, stated the resident's left knee X-ray showed changes from prior imaging with anterior displacement (change in alignment) of femoral component in relation to tibial portion of total knee replacement, and was sent to the hospital for evaluation. Review of the Mobilex Radiology Report, dated October 29, 2013, of Resident CL3's left knee confirmed there was a change from a left knee X-ray that was performed on October 24, 2013. Review of a nursing progress note, dated October 30, 2013, at 15:42 (3:42 p.m.), revealed that the facility nurse received a call from a nurse at the hospital stating that Resident CL3 was returning to the facility with [DIAGNOSES REDACTED]. The resident was to be on total bedrest until surgery the following week. Review of a physician assistant discharge note, dated November 4, 2013, revealed Resident CL3 was transferred to the hospital for planned admission for surgery of the left leg. Review of nursing assistant documentation related to Resident CL3's assistive devices revealed, "Knee immobilizer to remain in place at all times," was not implemented until October 31, 2013, 16 days after the original recommendation by the orthopedic surgeon, and order by the facility's physician, on October 15, 2013. Interview with Employee E3, nurse educator, on March 7, 2014, at 12:00 p.m., confirmed the first entry by nursing assistants for knee immobilizer at all times was on October 31, 2013. Interview with Employee E2, nurse manager, on March 7, 2014, at 12:15 p.m., revealed that during internal investigation of the incident, Employee E1 was unaware that Resident CL3's brace was to remain in place at all times. Interview with the Director of Nursing, on March 7, 2014, at 12:30 p.m., confirmed that Employee E1 removed Resident CL3's left knee brace/immobilizer contrary to physician's orders [REDACTED]. This failure to follow physician's orders [REDACTED]. 28 PA Code: 201.18(b)(1) Management. 28 PA Code: 211.10(a) Resident care plan. 28 PA Code: 211.10(c) Resident care plan. Previously cited 5/02/13. 28 PA Code: 211.12(d)(1) Nursing services. Previously cited 12/04/13 and 8/02/13. 28 PA Code: 211.12(d)(3) Nursing services. 28 PA Code: 211.12(d)(5) Nursing services. Previously cited 12/04/13, 8/02/13 and 5/02/13.