Every finding on record at Greenwood Center for Rehabilitation and Nursing

Based on clinical record review and resident and staff interview, it was determined that the facility failed to implement a comprehensive person-centered care plan related to risk for falls for one of three residents reviewed (Resident 1).Findings include: Observation of Resident 1 on July 7, 2026, at 4:20 PM revealed that the resident was sitting in a common area used for dining and activities watching television. Further observation revealed that the resident was barefoot. During a concurrent interview with Resident 1's spouse, they indicated that they visit almost daily and that the resident rarely has any socks or shoes on their feet. Clinical record review revealed the resident has an active care plan (an outline of an individual's health needs, specific care requirements, and the actions necessary to achieve desired health outcomes, represented as the Focus, Goal, and Interventions) focus indicating resident is at risk for falls initiated on May 22, 2026, that includes an intervention to ensure resident is wearing appropriate footwear. Interview with Employee 2, nurse aide, on July 7, 2026, at 5:00 PM revealed that the resident usually wears nonslip socks, however, they were sent to the laundry, and they did not have any socks for him on the unit at that time. The Director of Nursing and Employee 1, assistant director of nursing, were made aware of the above findings on July 7, 2026, at 5:30 PM. 28 Pa. Code 211.10 (a)(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, comfortable, homelike environment for two of six Residents (Residents 1 and 3). Findings include: Interview with Resident 1 on June 1, 2026, at 11:00 AM, revealed that they often need to clean their own bathroom, because housekeeping does not clean it daily. Concurrent observations of Resident 1's room revealed the following; The toilet lid and seat had multiple spots of dried brown liquid located on them. The interior rim of the toilet bowl was noted to have multiple brown spots around it. A piece of tissue paper was noted to be on the floor in the bathroom. The privacy curtain had a very large, roughly round two-foot, dried brown stain on the corner of the privacy curtain During an interview with Employee 1, housekeeper, on June 1, 2026, at 11:19 AM, they indicated that resident rooms should be cleaned daily, however they often do not have enough housekeepers to clean each room daily, and this often means rooms get cleaned about every three days. Employee 1 also indicated that housekeeping does not clean the privacy curtains, those are completed by maintenance. During an Interview on June 1, 2026, at 11:28 AM, with Resident 3's daughter, she stated that the floors are often very sticky and not clean, especially in the bathroom. Concurrent observation of Resident 3's bathroom revealed the floor in front of the toilet had a large, one foot area that was roughly round and covered in black residue. The above concerns were reviewed with the Nursing Home Administrator and the Director of Nursing on June 1, 2026, at 2:00 PM. 483.10(i)(1)-(7) Safe/clean/comfortable/homelike EnvironmentPreviously cited deficiency 1/08/2026 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.18(e)(2.1) Clean Environment

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice, regarding physician ordered medications, for one of four residents reviewed (Resident 3). Findings Include: Review of Resident 3's clinical record revealed diagnoses that included Rheumatoid Arthritis (RA-a chronic autoimmune disorder causing immune system-driven inflammation, primarily leading to painful, stiff, and swollen joints) and Type 2 Diabetes Mellitus (when the body cannot use insulin correctly and sugar builds up in the blood). Review of Resident 3's current physician orders revealed an order, dated December 1, 2025, for Humira (medication used to treat RA) 40mg/0.4ml (milligrams/milliliter), inject one application every 14 days for RA. Review of Resident 3's Medication Administration Records (MAR) for February 2026, March 2026, and April 2026, revealed the Humira was scheduled on the following dates and was signed off as not being given, with corresponding eMAR notes on the following dates:February 15, 2026- not given, eMAR note stated, on route from pharmacyMarch 1, 2026- not given, eMAR note stated, not availableMarch 15, 2026- not given, eMAR note stated, none availableMarch 29, 2026- no documentation, MAR was blank on this date with no corresponding eMAR noteApril 12, 2026- not given, eMAR note stated, This medication is not available at this facility, RN [Registered Nurse] supervisor notified, per RN supervisor pharmacy was contacted and stated that this medication should be supplied from family as they do not supply, RN supervisor notified family, awaiting response at this time. Review of Resident 3's clinical record revealed no evidence that the provider, or the Resident's Representative, were made aware that Resident 3 did not receive her Humira injection on any of the aforementioned dates, with the exception of April 12, 2026. Review of Resident 3's nursing progress notes revealed a note dated April 12, 2026, stating that the nurse spoke to Resident 3's Representative, who stated they were unaware the Humira is family supplied. Pharmacy confirmed the medication is supplied by the family. The note further stated that the nurse left a message with Resident 3's Rheumatology provider for clarification. During an interview with the Director of Nursing on April 13, 2026, at 12:51 PM, she stated that around December 8, 2025, the Resident's Representative changed. She stated that the prior Representative was unreceptive and uncooperative with providing the Resident's Humira. She further stated that she could find no documented evidence, prior to April 12, 2026, that anyone was in contact with the new Representative in regard to providing Resident 3's Humira medication. She stated she also could find no documentation that Resident 3's provider was made aware that Resident 3 had not received her Humira on the aforementioned dates. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to notify a resident's representative of a new medication order for one of four residents reviewed (Resident 1). Findings Include: Review of facility policy, titled Change in a Resident's Condition or Status, revised May 2017, revealed, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. Review of Resident 1's clinical record revealed diagnoses that included hypertension (high blood pressure) and Type 2 Diabetes Mellitus (when the body cannot use insulin correctly and sugar builds up in the blood). Review of Resident 1's physician note dated March 30, 2026, revealed that Resident 1 presented with a painful rash to her right buttocks. Further review of the note revealed Resident 1 was diagnosed with shingles (a viral infection that causes a painful rash) with a new order placed for Valacyclovir (antiviral medication), 1 gram by mouth, three times a day for seven days, and initiation of contact precautions. Review of Resident 1's clinical record revealed no evidence that Resident 1's Representative was made aware of the Shingles diagnosis or the new order for Valacyclovir and the contact precautions. During an interview with the Director of Nursing on April 13, 2026, at 11:33 AM, she confirmed that Resident 1's Representative was not made aware of the Shingles diagnosis with the new medication orders. She further stated that she had a phone conversation with Resident 1's Representatives and informed them that the facility should reach out to them with any changes in condition or if there are any new treatment orders placed. 201.14(a) Responsibility of licensee211.12(d)(1)(2)(3)(5) Nursing service

Based on review of select facility policy and procedures, observation, and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner, maintain equipment in a sanitary condition, and prepare food items in accordance with professional standards in the main kitchen (Main Kitchen of Facility) and maintain equipment in a safe and sanitary condition on one of five nursing units reviewed (400 Nursing Unit).Findings include: Initial tour of the facility's main kitchen with Employee 3, Dietary Manager, on January 5, 2026, at 10:00 AM revealed the following: The parts per million (PPM) test strips used to test for appropriate dishwasher sanitizer concentration that were included in a clean, plastic sheet protector with the dishwasher temperature documentation log had expired on August 1, 2025 An appliance identified by Employee 1 as a cooler where food trays are placed during tray line had an accumulation of dust on top of it. The bottom front vents had numerous dried food stains. The commercial coffee maker located on a stainless steel table had an accumulation of dried stains and a clear liquid accumulating on the stainless steel table at the rear of the machine. A rodent glue trap was located behind the coffee machine and was noted to be wet. There were dried drip stains observed on the walls behind the coffee maker. Two ceiling vents had a black colored, dust-like substance accumulating on the vents and surrounding ceiling. A container labeled antimicrobial fruit and vegetable wash was located on a wall above a sink. The wash had expired on May 13, 2022. The black colored hose coming from the fruit and vegetable wash was sticky to the touch. Chemical test strips located adjacent to a red colored, wall-mounted, cleaning bucket expired on August 30, 2022. The walk-in cooler contained the following; Extensive debris on the floor. This included food debris, dust/dirt, and an unopened single-use butter packet. A container of peas and carrots labeled as an alternative vegetable had a facility use by date of January 4, 2026. There was a substantial build-up of dust on the ceiling and adjacent light that was located in front of the compressor fans of the cooler. A container of fine ground sage had a facility use by date of November 24, 2025. A container of basil leaves had a facility use by date of October 31, 2025. A container of iodized salt was open and partially used. Instructions on the box noted to use within three years. There were no dates on the container of iodized salt to determine when the box was opened. A storage shelf under a stainless steel table contained several stacked baking pans. The pans were stored upside down and the borders of multiple pans had debris in them. The front border of the storage shelf was sticky with debris and a hair stuck to it. The dry goods storage area had a wall mounted air conditioning unit. The vents located in the front of the unit had a black-colored substance accumulating in multiple areas. A vent located in the ceiling in the dry goods storage area had a black colored, dust-like substance accumulating on the vents. The walk-in freezer contained the following: Extensive debris on the floor. This included food debris, box tape, and dust/dirt. A stainless steel pan with a foil lid had a non-discernible food label. The facility use by date was December 28, 2025. A shepherd's pie had a facility past the use by date of December 2025. A container of hot dogs had a facility use by date of 12/26. A roll of corned beef being stored on a stainless steel baking rack had no labels or dates to indicate how long the item was in the freezer or when it expired. A sliced loaf of bread had no labels or dates on it. Further observation of the facility's main kitchen revealed the following: The chemical test strips to test the PPM of the sanitizer located above the three-basin sink had expired on November 15, 2023. There was a significant build-up of dust on the corner wall adjacent to the three-basin sink. A large container that contained thickener per Employee 3 had no label or dates on it. A large container that contained flour had a facility use by date of 6/25. A large ceiling vent adjacent to the kitchen office area had a significant accumulation of dust on it. Observation of the trash disposal area revealed the following: On the ground surrounding the dumpsters there was a discarded spoon, a medical glove, plastic debris, a candy wrapper, a plastic cup, cut wood pieces, cardboard pieces, and a tea wrapper. The adjacent wooden fence was broken and partially collapsed. Observation on January 5, 2026, at 1:02 PM on the 400 Nursing Unit, revealed an ice cart. The plastic of the ice cart was broken and jagged in several areas. There was scotch tape covering multiple broken areas of the cart. Review of the facility policy titled, Food Temperatures, last reviewed on January 29, 2025, revealed that foods will be maintained at proper temperature to ensure food safety. Further review of this policy revealed a section titled, Procedures, that noted (in part) that the cook is responsible to see that all food is at the proper temperature, and the temperature will be taken and recorded for all items at all meals. Observation of the lunch service tray line on January 7, 2026, at 11:35 AM revealed three staff members preparing resident trays and loading them onto delivery carts to take to the nursing units. A request for the food temperatures that should have been taken prior to plating the resident food items revealed the temperatures were not readily available. Employee 5, cook, revealed that the temperatures were not written down yet. The surveyor requested that Employee 1 provide the meal temperatures documented for the last three weeks for each meal service. Food temperature logs provided by Employee 1 reviewed from December 14, 2025, revealed the following missing temperatures: December 15, 2025: breakfast December 16, 2025: breakfast December 17, 2025: lunch and dinner December 20, 2025: breakfast and lunch December 21, 2025: breakfast and lunch December 22, 2025: lunch December 23, 2025: breakfast December 24, 2025: breakfast December 26, 2025: breakfast and lunch December 28, 2025: breakfast and lunch December 29, 2025: breakfast and lunch December 30, 2025: breakfast and lunch January 1, 2026: breakfast January 3, 2026: breakfast January 4-7, 2026: no temperature documentation provided A follow-up interview with Employee 1 on January 7, 2026, at 11:45 AM revealed that no further food temperatures could be provided. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on January 7, 2026, at 2:15 PM. 483.60(i)(1)-(2) Food safety requirementsPreviously cited deficiency 3/31/25 28 Pa. Code 201.14(a) Responsibility of licensee

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered medications for one of 27 sampled residents, and skin integrity for one of 27 sampled residents (Residents 38 and 122). Findings include: Interview with Resident 122 on November 5, 2026, at 2:10 PM revealed concerns regarding very dry skin. Resident 122 stated that her arms, hands, and feet were very dry and itchy, especially on her elbows, and that no lotions or creams were ever applied to these areas. Concurrent observations revealed that Resident 122's hands, arms, and feet had flakey white skin that seemed to be peeling and flaking off. Clinical record review revealed Resident 122 had no documented assessments related to her dry skin or any interventions. Interview with the Nursing Home Administrator and the Director of Nursing on January 7 at 2:30 PM confirmed that the resident did not have a treatment for dry skin in place at the time of the above interview. Clinical record review for Resident 38 revealed the facility admitted her on October 18, 2024, with diagnosis including Type 2 Diabetes Mellitus. A physician's order dated October 21, 2024, revealed nursing staff were to perform accuchecks (measures blood sugar levels) four times a day, and to notify Resident 38's physician if the blood sugar is less than 400 mg/dL (milligrams per deciliter). Interview with the Director of Nursing on January 7, 2026, at 2:04 PM revealed that Resident 38's accucheck physician order was wrong, and it should have read that nursing staff were to notify Resident 38's physician if her blood sugars were greater than 400 mg/dL. Review of Resident 38's Medication Administration Record (MAR, a form utilized by the facility to document the administration of medications) dated December 2025, revealed the following documentation of Resident 38's accucheck above 400 mg/dL: December 1, 2025, 467December 4, 2025, 471December 7, 2025, 478December 9, 2025, 466December 12, 2025, 487December 13, 2025, 440December 15, 2025, 444December 16, 2025, 425December 22, 2025, 467December 26, 2025, 423December 28, 2025, 420 Review of Resident 38's MAR, from January 1 to 7, 2026, revealed the following documentation of Resident 38's accuchecks above 400: January 2, 2026, 428 January 3, 2026, 440January 4, 2026, 464January 5, 2026, 426 Interview with the Director of Nursing on January 8, 2026, at 10:45 AM confirmed these findings and was unable to provide any documentation that Resident 38's physician was notified when her blood sugars were greater than 400. S483.25 Quality of CarePreviously cited 3/31/25 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to offer COVID-19 immunizations to ensure residents were up to date with the most current available immunization for five of five residents reviewed (Residents 1, 2, 3, 6, and 9), failed to maintain documentation of staff COVID-19 vaccination status, and provide evidence that staff were offered the COVID-19 vaccine or information on obtaining the COVID-19 vaccine. Findings include: Clinical record review for Resident 1 revealed that his last COVID-19 vaccine was a COVID-19 booster administered on May 31, 2024. Clinical record review for Resident 2 revealed that her last COVID-19 vaccine was a COVID-19 booster administered on November 10, 2021. Clinical record review for Resident 3 revealed that her last COVID-19 vaccine was a COVID-19 booster administered on October 21, 2022. Clinical record review for Resident 6 revealed that her last COVID -19 vaccine was a COVID-19 booster administered on May 20, 2024. Clinical record review for Resident 9 revealed that she had no documentation indicating that she received any of the COVID-19 vaccines and no evidence that she refused the vaccinations. Interview with the Director of Nursing on January 8, 2025, at 1:30 PM confirmed the above noted findings that these residents were not up to date on their COVID-19 vaccinations and there was no evidence that they were offered any further COVID-19 vaccinations. Interview with the Director of Nursing on January 8, 2025, at 1:30 PM revealed that the facility does not have evidence that they have maintained documentation related to staff COVID-19 vaccination status or that the staff were offered the COVID-19 vaccine or information on obtaining the COVID-19 vaccine. The facility failed to offer COVID-19 immunizations to ensure residents were up to date with the most current available immunization and failed to maintain documentation of staff COVID-19 vaccination status and provide evidence that staff were offered the COVID-19 vaccine or information on obtaining the COVID-19 vaccine. The surveyor reviewed the above findings during an interview with the Director of Nursing on January 8, 2026, at 1:32 PM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations and staff interview, it was determined that the facility failed to ensure residents' rights to secure and confidential personal and medical information in the lobby area of the facility and for one of one resident reviewed for privacy concerns (Facility Main Lobby Area; Resident 12). Findings include: Observation of the main lobby area of the facility on January 5, 2026, at 12:30 PM revealed a binder titled Department of Health Survey Results, For Public Review. The binder contained the results of recent surveys of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. Review of the contents of the binder revealed that the facility placed the full health survey and complaint survey results in the binder. Further review of the binder contents revealed a survey deficiency letter and associated Statement of Deficiencies (Form CMS-2567) for a survey completed on March 31, 2025. The letter noted the full resident's name and associated specific resident identifier for Resident 12 and 15 additional residents associated with the survey. The facility failed to ensure a resident's right to privacy of their personal and medical information. The above information was reviewed in a meeting with the Director of Nursing on January 5, 2026, at 12:40 PM. 28 Pa. Code: 201.18(e)(1) Management

Based on observation and staff interview, it was determined that the facility failed to provide adequate housekeeping services to ensure a clean, safe, and orderly environment on one of five nursing units (Medication and Medical Supply Area located on the 400 Nursing Unit).Findings include: Observation of the house stock medication and medical supply storage room located at the end of the 400 Nursing Unit on [DATE], at 9:25 AM revealed dust and debris accumulated on the floor and under the storage shelving. There were also pieces of various paper products discarded on the floor. Further observation of the area revealed various packaged medical items discarded on the floor that included: a shower cap, toothbrush, a nutritional drink that expired in [DATE], a catheter protector cap, and rolled gauze. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on [DATE], at 2:15 PM. 483.10(i)(1)-(7) Safe/clean/comfortable/homelike EnvironmentPreviously cited deficiency [DATE] 28 Pa. Code 201.18(b)(3)(e)(2.1) Management

Based on clinical record review, and resident and staff interview, it was determined that the facility failed to ensure that a resident received proper treatment for vision services for one of two residents reviewed for vision concerns (Resident 9).Findings include: Interview with Resident 9 on January 5, 2026, at 1:43 PM revealed that she had concerns with receiving timely vision services. Resident 9 stated they keep cancelling my cataract surgery and now they do not know when I can have it done. Clinical record review revealed the facility admitted Resident 9 on December 20, 2022. Review of Resident 9's clinical record revealed an ophthalmology consult dated November 27, 2024, noting Resident 9 had cataracts and needed surgery in both eyes. Review of the ophthalmology consult dated June 3, 2025, revealed the procedure was not performed due to Resident 9 eating breakfast. Further review of Resident 9's clinical record revealed no documentation that Resident 9's cataract procedure was rescheduled. The surveyor reviewed the above concerns with Resident 9's vision services during an interview with the Director of Nursing on January 8, 2026, at 10:04 AM. She confirmed Resident 9's cataract procedure has not been rescheduled. The Director of Nursing verified the facility was aware Resident 9 was to receive the cataract surgery on June 9, 2025, and did not obtain an order from her physician to be NPO (nothing by mouth) prior to the procedure. The facility failed to provide timely vision services for Resident 9. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to arrange for the necessary foot care for one of 27 residents reviewed (Resident 122).Findings include: Interview with Resident 122 on January 5, 2026, at 2:10 PM revealed that she had not seen the podiatrist in a very long time, and she thought her toenails were very long and in need of clipping. Resident 122 indicated that the left foot was worse than the right foot. Concurrent observation of Resident 122's toenails revealed that her right foot had multiple elongated toenails including the large toe and the middle toe, with toenails grown over the tip of the toe by 1 cm (centimeter). The left foot toenails were all noted to be overgrown with 1 cm of growth noted over the tips of the toes. All toenails appeared to have jagged edges. Review of Resident 122's clinical record revealed that the resident was last seen by podiatry on May 23, 2025. The progress note located on the podiatry consult stated, Non-professional treatment is hazardous to the patient. Interviews with the Nursing Home Administrator and the Director of Nursing on January 7, 2026, at 2:30 PM, and with the Director of Nursing on January 9, 2026, at 12:37 PM, confirmed that the facility had no evidence of any further podiatry services provided for Resident 122. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for one of six residents reviewed for mood/behavior (Resident 4). Findings include: Clinical record review for Resident 4 revealed the facility admitted him on June 2, 2025. A diagnosis of Post Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event) was added to his diagnosis list on July 11, 2025. A review of Resident 4's quarterly Minimum Data Set (MDS, an assessment completed by the facility at specific intervals to determine care needs) assessment dated [DATE], indicated a diagnosis of PTSD for Resident 4. Review of Resident 4's care plan identified that he had a diagnosis of PTSD. There were no identified triggers (everyday situations that cause a person to re-experience the traumatic event as if it was reoccurring). Review of Resident 4's psych visit notes dated September 3, 2025, and November 11, 2025, revealed no mention of his diagnosis of PTSD. An interview with the Director of Nursing on January 8, 2026, at 11:39 AM confirmed the above noted findings related to Resident 4's diagnosis of PTSD. The facility failed to identify and care plan triggers that may retraumatize Residents 4 related to his diagnosis of PTSD. 28 Pa Code 211.12 (d)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by one of three residents reviewed (Residents 4). Findings include: Clinical record review for Resident 4 revealed the facility admitted him on June 2, 2025. A diagnosis of Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life) was added to his diagnosis list on June 26,2025. A review of Resident 4's quarterly Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated, October 18, 2025, indicated that Resident 4 had a diagnosis dementia. A review of Resident 4's care plan revealed that the facility failed to develop a person center care plan with individualized interventions related to his diagnosis of dementia. An Interview with the Director of Nursing on January 8, 2026, at 11:39 AM confirmed that the facility failed to develop a person-centered care plan related to dementia for Resident 4. The facility failed to develop a person-centered care plan for Resident 4 related to his diagnosis of dementia. 483.40(b)(3) Dementia Treatment and ServicesPreviously cited 3/31/2025 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (100 Nursing Unit; Residents 21 and 46).Findings include: The facility's medication error rate was eight percent based on 25 medication opportunities with two medication errors. Review of Resident 46's current physician orders dated [DATE], indicated staff were to administer Centrum Silver Oral Tablet (multiple vitamin with minerals); give one tablet by mouth daily. Observation of Resident 46's medication administration pass on [DATE], at 9:12 AM revealed that Employee 1, licensed practical nurse, prepared the medications prior to administration. This preparation included a Senior Tab Multivitamin (house stock substituted for the Centrum Silver oral tablet per Employee 1). Employee 1 proceeded to administer the medication to Resident 46. Upon review, it was determined that the Senior Tab Multivitamin had expired in [DATE]. Review of Resident 21's current physician orders revealed an order dated February 17, 2024, for Biotin Oral Tablet (a part of the B-complex vitamins) give 10,000 micrograms (mcg) one tablet by mouth one time a day. Observation of Resident 21's medication administration pass on [DATE], at 9:39 AM revealed that Employee 1 prepared the medications prior to administration. This preparation included Biotin 1000 mcg. Employee 1 proceeded to administer the medication to Resident 21. A follow-up interview with Employee 1 on [DATE], at 10:37 AM regarding Resident 21's medication pass confirmed that Employee 1 administered the 1000 mcg dose of Biotin; however, the physician's order was for 10,000 mcg. Employee 1 stated she would have to check with the registered nurse to confirm the dose and proceeded to contact the registered nurse via cell phone. Clinical record review for Resident 21 revealed that the Biotin order was later changed after surveyor questioning to the following: Biotin Oral Capsule 1 milligram (mg; 1000 mcg) give one capsule by mouth in the morning to start [DATE], at 8:00 AM. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on [DATE], at 2:15 PM. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, and resident and staff interview, it was determined that the facility failed to obtain dental services for one of nine residents reviewed for dental concerns (Resident 122).Findings include: Interview with Resident 122 on November 5, 2026, at 2:10 PM revealed that she was concerned about her teeth chipping and breaking. Concurrent observations of the resident's teeth revealed multiple teeth that appeared chipped and broken. Clinical record review revealed that Resident 122 had last received dental services on May 13, 2025. The exam indicated five teeth that were fractured and not restorable. The consultant requested a referral to an oral surgeon for radiographic imaging (images on a sensitive plate or film by X-rays, gamma rays, or similar radiation examination) and extractions of any teeth with a less than favorable prognosis. Interview with the Nursing Home Administrator and the Director of Nursing on January 8, 2026, at 2:30 PM confirmed that there no evidence that a referral to an oral surgeon had been attempted. 28 Pa. Code 211.15 Dental services. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to obtain professional dental services for three of nine residents reviewed for dental concerns (Residents 9, 28, and 125). Findings include: Interview with Resident 28 on January 6, 2026, at 11:47 AM revealed that she has decayed and broken teeth that cause her pain. She said the facility dentist has seen her and he is waiting for her to get her teeth pulled so he can start making her dentures. She said she has to see an oral surgeon that will accept her insurance. Observation of Resident 28 during the interview confirmed her statement that she has decayed and broken teeth. Interview with the Director of Nursing on January 7, 2026, at 2:21 PM revealed that Resident 28 has been seen by the dentist and by the oral surgeon and she would provide all the dental consultation notes. The facility provided the following documents related to Resident 28's dental visits: Review of dental consult documentation dated March 14, 2025, revealed that Resident 28 was seen by the dentist in facility. His documentation indicated that Resident 28 did not have her tooth extractions done yet. He then indicated that the action required by the nursing home staff was for the facility to refer Resident 28 to an oral surgeon for extraction of all remaining dentition. Review of dental consult documentation dated May 13, 2025, revealed that Resident 28 was seen by the dentist in the facility. The dentist again noted that Resident 28 has not been seen by the oral surgeon yet and that he cannot proceed with dentures until the extractions are completed. He again asked that the facility refer her to an oral surgeon. Review of the dental consult documentation dated July 11, 2025, revealed that Resident 28 was seen by the dentist in the facility. The dentist again noted that Resident 28 was not yet seen by the oral surgeon but noted that she has an appointment on July 29, 2025, and he will follow up after that. Review of the oral surgeon's documentation dated July 29, 2025, revealed that he was unable to treat Resident 28 in his office due to her complex medical problems He indicated for the facility to refer Resident 28 to a hospital based oral surgery practice. Review of dental documentation dated November 20, 2025, revealed that Resident 28 was seen by a new contracted in-house dentist and he indicated that she needs x-rays, cleaning, extraction of all remaining teeth, and then she will need dentures. He recommended she be referred to an oral surgeon. Review of dental documentation dated December 8, 2025, revealed that Resident 28 was seen by the in-house dentist for a cleaning and that Resident 28 indicated that it was hard for her to eat related to tooth or mouth problems. He also noted that the resident is waiting for oral surgery to extract her teeth so she can get dentures. Interview with the Director of Nursing on January 7, 2026, at 2:33 PM revealed that the resident is not currently scheduled for oral surgery. She also indicated that there is no evidence that the facility attempted to schedule Resident 28 for dental services at a hospital based oral surgery practice. The facility failed to provide Resident 28 with dental services as noted above. Observation of Resident 9 on January 5, 2026, at 1:41 PM revealed that she had several broken and missing teeth. Interview with Resident 9 at this time revealed that she is not happy with the facility dental services. Resident 9 stated she has several broken teeth and cavities, but that the dentist only looks at her teeth and never fixes them. Clinical record review revealed the facility admitted Resident 9 on December 20, 2022, with payment sources that included the state Medicaid benefit. Review of Resident 9's dental documentation provided by the facility, revealed Resident 9 had an initial exam on June 12, 2023. A review of this progress notes revealed the recommended treatment for Resident 9 included prophylactic dental cleaning every six months and a fluoride varnish. Resident 9's clinical record revealed that there were no further dental visits until December 8, 2025. The facility provided a dental visit note dated May 13, 2025, indicating that Resident 9 was not treated on this date due to her not being brought to the treatment room. Observation of Resident 125 on January 6, 2026, at 10:04 AM revealed that she appeared to have her own teeth. Resident 125 was unable to be interviewed pertaining to her dental services due to her current cognitive status. Clinical record review revealed the facility admitted Resident 125 on February 25, 2016, with payment sources that included the Medicaid benefit. Further review of Resident 125's clinical record revealed an initial exam by a dentist on November 20, 2025, and a prophylactic cleaning by a dental hygienist on December 8, 2025. Resident 125's clinical record revealed the facility was unable to provide documentation of dental care prior to November 20, 2025. Interview with the Director of Nursing on January 8, 2026, at 10:24 AM confirmed these findings and had no further information to indicate that Residents 9 and 125 received routine dental services every six months as the State plan allows. 483.55(b)(1)-(5) Routine/emergency Dental Services in NFsPreviously cited deficiency 3/31/2025 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.15 Dental services

Based on a review of facility procedures, observation, and resident and staff interview, the facility failed to follow proper infection prevention practices for foot care equipment for two of 27 residents reviewed (Residents 29 and 48). Findings include: Observation of the 500 Hall on January 7, 2026, at 11:08 AM revealed Employee 1, nurse aide (NA), retrieved nail clippers from a staff member standing near a med cart and began trimming Resident 48's fingernails. At 11:12 AM, Employee 1 walked over to Resident 29 and began to trim his fingernails. Review of the facility policy and procedure entitled Care of Fingernails/Toenails under the section titled Steps in the Procedure revealed that step 20 instructs staff to clean reusable equipment and supplies, and step 25 instructs staff to wash and dry hands thoroughly. Employee 1 did not clean the fingernail clippers or wash and dry her hands between each resident's nail care. Interview with Resident 29 on January 7, 2026, at 12:35 PM revealed that he does have his own personal nail clippers in his room, but he stated that they must have used the nurses' clippers today. Resident 48 was not interviewable. The above findings were reviewed with the Nursing Home Administrator and the Director of Nursing on January 7, 2026, at 2:30 PM. 483.80 Infection ControlPreviously cited deficiency 3/31/25 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 201.18(b)(1)(3) Management

The facility failed to store and prepare food in accordance with professional standards for food safety in the main kitchen and on one of three nursing units (,d+[DATE] solarium pantry). Findings include: The United States Food and Drug Administration (FDA) Cooling Cooked Time/Temperature Control for Safety Foods and the FDA Food Code: for Food Employees stipulates that the FDA Food Code requires a two-step cooling process for cooked food: a two-hour rapid cool from 135 degrees Fahrenheit to 70 degrees Fahrenheit followed by a four-hour window where foods must be cooled to 41 degrees Fahrenheit or less. This means that within two hours, the food must be cooled from cooking temperature (135 degrees Fahrenheit) to 70 degrees Fahrenheit to eliminate risk of pathogen growth. Over the next four hours the food must be cooled from 70 degrees Fahrenheit to 41 degrees Fahrenheit or less. If 70 degrees Fahrenheit is reached before two hours, you have the remaining time to reach 41 degrees Fahrenheit or less. Observation of a walk-in freezer in the facility's main kitchen on [DATE], at 10:11 AM with Employee 9, dietary manager, revealed the following foods identified as leftovers available for additional resident food service: Vegetable soup, two six-quart containers labeled [DATE] Bar-B-Cue pork labeled February 27, 2025 Ham and bean soup labeled [DATE] Loose fish portions labeled [DATE] Turkey labeled [DATE] A review of the Cooling Log provided by Employee 9 revealed that 11 food items recorded from [DATE] through 23, 2025 had no temperature assessments after 1.5 hours of cooling. The last temperature taken for 10 of the 11 food items ranged from 58 to 69 degrees Fahrenheit 1.5 hours after placed in cooling equipment. The corrective active grid included on the form instructed that if food was not below 41 degrees at six hours, discard. The cooling log did not indicate that the five leftover items observed in the freezer reached 41 degrees within six hours or less. Observation of the dry storage area of the facility's main kitchen on [DATE], at 10:13 AM with Employee 9 revealed approximately one-half of a one-gallon container of vegetable oil that was labeled with a used by date of [DATE]. Employee 9 confirmed that this product was still accessible for food preparation use. An opened container labeled pure lemon extract (labeled as arrived [DATE]) with less than one-quarter left in the container had no label when staff opened the food product or when staff should use the product by (discard date). Observation of the facility's main kitchen shelving on [DATE], at 10:26 AM with Employee 9 revealed a container marked as thickener with the scoop used by staff to dispense the product stored inside the container, in direct contact with the food product. CMS State Operations Manual Appendix PP, Guidance to Surveyors for Long Term Care Facilities, 483.60(i)(1)-(2) Food safety requirements, stipulates that a potential cause of foodborne outbreaks is improper cleaning (washing and sanitizing) of equipment and protecting equipment from contamination via splash, dust, grease, etc. Dishwashing machines use either heat or chemical sanitization methods. Manufacturer's instructions must always be followed. The general recommendations according to the U.S. Department of Health and Human Services, Public Health Services, and the Food and Drug Administration Food Code for each method note that for low temperature dishwashing (chemical sanitization) the water temperature during the wash cycle is to be 120 degrees Fahrenheit. The chemical solution must be maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. Observation of the main kitchen dishwasher on [DATE], at 10:45 AM with Employee 9 revealed that the first cycle observed revealed a water temperature of 100 degrees Fahrenheit during the wash cycle and 110 degrees Fahrenheit during the rinse cycle. A second cycle observed with Employee 9 revealed a water temperature of 118 degrees during the wash cycle and 128 degrees during the rinse cycle. Observation of labeling on the dishwasher machine stipulated that water temperatures should be a minimum of 120 degrees Fahrenheit for both the wash and rinse temperatures. Observation of the main kitchen dishwasher on [DATE], at 9:32 AM with Employee 9 revealed that the first cycle observed revealed a water temperature of 110 degrees Fahrenheit during the wash cycle. A second cycle observed with Employee 9 revealed that the water temperature again reached a plateau at 110 degrees Fahrenheit. Interview with Employee 10, dietitian, and Employee 9 on [DATE], at 11:23 AM indicated that the facility's dishwasher maintenance contractor was contacted regarding the water temperatures recorded from the machine. The facility did not have a resolution to the findings during the onsite survey. Chapter 8 of the 2018 International Plumbing Code, 802.3.1 Air gap, stipulates that the air gap between the indirect waste pipe and the flood level rim of the waste receptor shall not be less than twice the effective opening of the indirect waste pipe. Chapter 8 of the 2018 International Plumbing Code, 802.3.2 Air break, stipulates that an air break shall be provided between the indirect waste pipe and the trap seal of the waste receptor. Observation of the facility's main kitchen ice machine on [DATE], at 10:58 AM revealed no visible air gap between the indirect waste pipe and the floor drain. Interview with Employee 7, environment director, on the date and time of the observation revealed that she did not believe that there was another air gap between the ice machine's indirect waste pipe and the facility's waste line. Interview with Employee 7 on [DATE], at 12:05 PM revealed that the facility's equipment maintenance contractor would be onsite the following day to repair the omitted air gap for the main kitchen and two other ice machines in the facility. Observation of the facility's main kitchen ice machine on [DATE], at 11:12 AM revealed an air gap between the machine's indirect waste pipe and the floor drain. Observation of the ,d+[DATE] hallway solarium pantry on [DATE], at 11:10 AM revealed a three-compartment divider on the counter that contained numerous individual packages of jellies, tea bags, sugar packets, and various condiments. Interview with Employee 11 (speech therapist) on the date and time of the observation confirmed that there was no decipherable date on the products to ensure safe consumption. Employee 11 stated that she believed that the container was communal condiments that anyone could use. Interview with Employee 12, assistant dietary manager, on [DATE], at 11:20 AM, revealed that, .they (nursing staff) take stuff off the cart provided by dietary and store them themselves in the solarium, which are then items available for resident use. Employee 12 confirmed that there is no monitoring of the expiration dates for those items and those individual items are not marked with a date received, opened, or expired. Observation of the main kitchen with Employee 10, dietitian, on [DATE], at 11:23 AM revealed a male dietary worker on the food service line with a mustache and facial beard hair not contained under a covering. Employee 10 directed the male employee to don a face covering over his facial hair. The surveyor reviewed the above concerns regarding the facility's main kitchen and ,d+[DATE] solarium pantry during an interview with the Nursing Home Administrator on [DATE], at 2:00 PM. 483.60(i)(1)-(2) Food safety requirements Previously cited deficiency [DATE] 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(2.1) Management 28 Pa. Code 211.6(f) Dietary services

Based on observation and resident and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, safe, and orderly environment on three of five nursing halls (100, 200, and 400 Nursing Halls, Residents 16, 42, 91, and 101). Findings include: Clinical record review for Resident 91 revealed that the facility admitted him on March 5, 2025. On March 25, 2025, at 12:10 PM the drywall to the right of Resident 91's wall heater was marred and gouged. Concurrent interview with Resident 91 revealed that this occurred before their admission. On March 26, 2025, at 1:59 PM the drywall was marred behind Resident 42's head of the bed. Concurrent interview with the Director of Nursing acknowledged the drywall concerns for both Resident 91 and 42. Observation of Resident 16's room on March 25, 2025, at 11:27 AM revealed marring and uneven drywall on the wall outside the bathroom and between the closets. The bathroom walls were also marred. A cobweb was observed hanging from the wall to the center ceiling light in the bathroom. Dirt and debris was observed on the floor along the edge and corners of the bathtub. A light bulb was not working in the light fixture above the resident's sink. A follow up observation of Resident 16's room and bathroom on March 27, 2025, at 9:41 AM revealed the above observations remained unchanged. Observation of Resident 101's room on March 25, 2025, at 10:57 AM revealed loose dirt in a corner behind the door along with a candy wrapper. The wall behind the door was all marred. The bathroom door frame and the bathroom door were all marred, and the wood was visible at the bottom of the bathroom door. The bathroom wall near the wall register was patched but not painted. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on March 27, 2025, at 2:40 PM. 28 Pa. Code 201.18(b)(3) Management

Based on staff interview it was determined the facility failed to employ qualified activity personnel to oversee the facility's activity program (Employee 6) Findings included: Interview with Employee 6, Activity Director, on March 28, 2025, at 12:17 PM revealed that she was promoted from her nurse aide position to the activity director on February 17, 2025. Interview with the Director of Nursing on March 28, 2025, at 1:00 PM confirmed that Employee 6's qualifications were a certified nurse aide and that she did not possess the regulatory qualifications required to oversee the facility's activity programs. The facility failed to employee a qualified activity professional. 28 Pa Code: 201.3 (i)(ii) Resident activities coordinator. 28 Pa. Code: 201.18(b)(3) Management.

Based on clinical record review and staff interview it was determined that the facility failed to provide the highest practicable care regarding physician ordered diagnostic testing for one of three residents reviewed (Resident CR1) and physician ordered medications that resulted in hospitalization for one of three residents reviewed resulting in harm (renal failure and digoxin toxicity) (Resident 1). Findings include: Closed clinical record review for Resident CR1 revealed physician documentation by Employee 2 (physician) dated January 20, 2025, at 12:35 PM that indicated Resident CR1 presented with a cough. The assessment indicated that Resident CR1 had a viral upper respiratory infection (URI, affecting the sinuses and throat). Physician orders included to obtain a chest x-ray. A telephone physician's order from Employee 3 (certified registered nurse practitioner) dated January 20, 2025, at 10:57 AM instructed staff to obtain an oropharyngeal specimen (a type of sample collection method used in medical testing; it involves taking a sample from the middle part of the throat (pharynx) just beyond the mouth) for influenza (viral infection of the nose, throat and lungs) and COVID-19 testing. A verbal physician's order from Employee 4 (physician) dated January 21, 2025, at 10:30 AM repeated an instruction for staff to obtain an oropharyngeal specimen for influenza testing. A verbal physician's order from Employee 3 dated January 21, 2025, at 3:36 PM repeated an instruction for staff to obtain an oropharyngeal specimen for influenza testing. Physician documentation by Employee 3 dated January 21, 2025, at 8:41 PM indicated that the chest x-ray dated January 20, 2025, for Resident CR1, showed mild CHF (congestive heart failure, inability of the heart to pump effectively, which results in the accumulation of fluid in the body), and Employee 3 ordered the administration of Lasix (a diuretic medication used to remove excess fluid from the body). Resident CR1's closed clinical record contained no evidence that staff obtained an oropharyngeal specimen for influenza or COVID-19 testing. Nursing documentation dated January 27, 2025, at 9:08 PM revealed that Resident CR1's daughter called the facility with concerns that Resident CR1 was declining (lethargic, decreased mental acuity, decrease in consciousness; not eating, grabbing for things that were not present in the room) and requested that the facility send Resident CR1 to the emergency room . Nursing documentation dated January 27, 2025, at 9:18 PM indicated that the facility sent Resident CR1 to the emergency room . Hospital Discharge Summary documentation dated February 5, 2025, revealed that Resident CR1 was admitted to the hospital on January 27, 2025, with diagnoses that included bilateral pulmonary embolus (blood clots in both lungs that block blood vessels within the lungs) with influenza A. Interview with Employee 1 (registered nurse) and Employee 2 on February 27, 2025, at 1:45 PM, and Employee 1 on February 27, 2025, at 2:24 PM, confirmed the above findings for Resident CR1. Clinical record review for Resident 1 revealed documentation by Employee 3 dated December 22, 2024, at 12:47 PM that Resident 1 had an overall decline, increased generalized weakness, poor appetite, and low blood sugars. Employee 3 informed the family that Resident 1 had not been eating or drinking well for the past couple of weeks. The decision was made to send Resident 1 to the emergency room . Nursing documentation dated December 22, 2024, at 8:16 PM indicated that the emergency room staff admitted Resident 1 to the hospital. A hospital History and Physical dated December 22, 2024, indicated that Resident 1's presenting problems were hyperkalemia (high blood potassium levels), AKI (acute kidney injury, a sudden decline in the ability of your kidneys to work and perform their normal functions), UTI (urinary tract infection), and pneumonia (lung infection). Hospital Discharge Instructions dated December 29, 2024, instructed, Your medications have changed. Start taking Amlodipine (Norvasc, medication that lowers blood pressure by relaxing the blood vessels) on December 30, 2024. Stop taking Digoxin (medication used to help make the heart beat stronger and with a more regular rhythm) 125 mcg (micrograms), Lisinopril (medication used to lower blood pressure) 5 mg (milligrams), Metformin ER (medication used to lower blood sugar) 500 mg, and potassium chloride (mineral supplement used to prevent or to treat low blood levels of potassium) ER 10 mEq (milliequivalents). Physician progress note documentation by Employee 2 dated December 30, 2024, at 9:58 AM stipulated that the facility readmitted Resident 1 on December 29, 2024, and that a Medicine reconciliation and management was also done. I obtained and reviewed the discharge information. I reviewed the need for diagnostic tests/treatments and/or follow up on pending diagnostic tests/treatment. The same documentation indicated a continuation of the medications Metformin, Digoxin, and Lisinopril. Interview with Employee 2 on February 27, 2025, at 1:45 PM revealed that the December 29, 2024, discharge instructions for Resident 1 did not include a dated initial from him, which is his customary practice after reviewing hospital discharge orders. Employee 2 stated that he may not have had this document at the time of his review of Resident 1 when she returned to the facility after her hospitalization . Review of Resident 1's medication administration record (MAR, electronic documentation of the administration of medications) dated December 2024, revealed that staff continued to administer the following medications upon Resident 1's readmission from the hospital: Digoxin 125 mcg in the morning every other day Lisinopril 5 mg daily Metformin ER 500 mg daily Potassium chloride ER 20 mEq daily The MAR did not indicate the start of the medication, Amlodipine. Nursing documentation dated February 13, 2025, at 4:47 PM indicated that Resident 1 was in her room yelling for help. Resident 1 was lethargic with confusion and stated that she did not feel well but could not explain why. Her skin was dusky in color, she could not hold her head up, and she was incontinent of a very large liquid stool. Nursing documentation dated February 14, 2025, at 12:11 AM revealed that Resident 1's blood pressure was low at 86/48 mm Hg (millimeters of mercury, the American Heart Association outlines a normal blood pressure reading of 130/80 mm Hg for adults.), her heart rate was low at 28 (The American Heart Association outlines a target heart rate for someone [AGE] years old or older as 75 to 128 beats per minute, bpm), she was pale in color, with increased respiratory effort, oxygen saturation was low on room air at 89 percent (normal oxygen saturation is greater than 90 percent). The writer contacted a provider on call who instructed staff to send Resident 1 to the hospital for evaluation. EMS (emergency medical service) personnel arrived at Resident 1's room and Resident 1's heart rate on a monitor varied from 24 to 32 bpm, and her blood pressure was 70/50 mm Hg. Resident 1 was transported out of the facility by EMS staff at 11:45 PM, .in guarded condition. Nursing documentation dated February 14, 2025, at 1:55 AM revealed that the hospital emergency department admitted Resident 1 for hyperkalemia (high blood potassium; potassium level was 8.8), and AKI with BUN of 96 mg/dL (blood urea nitrogen, test to measure the amount of urea nitrogen in your blood to see how well the kidneys are working, normal 6 to 20 milligrams per deciliter); creatinine 3.8 mg/dL (waste product of muscle breakdown, normal 0.5 to 1.0 milligrams per deciliter); and GFR of 12 (glomerular filtration rate, measure of how well your kidneys are removing waste from your blood, normal greater than 60). Review of hospital cardiology consult documentation dated February 14, 2025, at 10:42 AM revealed that Resident 1 was seen regarding hypotension (low blood pressure) and bradycardia (slow heart rate). Pt (patient) was discharged from (the hospital) to (the nursing home) back in Dec (December) where her digoxin, lisinopril and potassium were to be stopped but in review of the (nursing home) MR (medical record) and medication administration these medications were still being given, which then resulted pt to become (sic) back to (the hospital) in CHB (complete heart block) with AKI and digoxin toxicity. Her digoxin level was not drawn until later in admission after getting IVF (intravenous fluids) and her HR (heart rate) and electrolytes and kidney function starting to improve. And her digoxin level was elevated still at 1.9 ng/mL (nanograms per milliliter), which makes me assume it was even higher on admission. Recent admission in December with severe AKI (acute kidney injury) on CKD (chronic kidney disease) and at that time digoxin and lisinopril were discontinued given hyperkalemia and bradycardia .review of her med list from the nursing home indicates that despite discontinuation request in December has still been receiving metformin, lisinopril, potassium and digoxin, which have contributed to her current level of renal failure .digoxin should be discontinued, given her renal failure should not ever be resumed. The hospital discharge summary dated February 17, 2025, at 3:27 PM, noted that Resident 1 was found severely bradycardic with HR in the twenties. Resident 1 was also found to have severe hyperkalemia of 8.8 mm/L (normal 3.5 to 5.1 millimoles per liter). Resident 1's AKI on CKD with metabolic acidosis (condition where blood becomes too acidic) and digoxin toxicity had since resolved. Of note, patient was discharged from (the hospital) to nursing home in December and it was recommended to stop digoxin, lisinopril and oral potassium but per nursing MR and medication administrations this (sic) were still being given. Which may have contributed to patient's current presentation. Interview with Employees 1 and 2 on February 27, 2025, at 1:45 PM confirmed that the facility did not implement Resident 1's hospital discharge physician orders for medication changes on December 29, 2024, and that staff continued to administer the medications until Resident 1's rehospitalization on [DATE]. 483.25 Quality of Care Previously cited deficiency 5/29/24 28 Pa. Code 211.2(d)(3) Medical director 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on closed clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to thoroughly investigate an incident regarding the use of interventions and appropriately implemented interventions resulting in harm (multiple fractures of her pelvis, a fracture of her upper arm, a possible right hip fracture, and compression fractures of her thoracic spine) for one of seven residents reviewed (Resident CR1). Findings include: The policy entitled Falls-Clinical Policy, provided by the Director of Nursing as the facility's current policy, indicates that staff will document risk factors for falling in the resident's medical record and discuss the resident's fall risk. For an individual that has fallen, staff will attempt to define possible causes within 24 hours. Based on the resident assessment, the staff and physician will identify pertinent interventions to try and prevent falls and to address the serious consequences of falling. Review of Resident CR1's closed clinical record revealed that the facility admitted her on November 8, 2021. Resident CR1's admission Minimum Data Set Assessment (MDS, an assessment completed at specific time intervals to determine care needs) dated November 15, 2021, indicated that the facility assessed Resident CR1 as having a fall history resulting in major injury prior to admission. Despite the November 15, 2021, MDS triggering a fall problem, the facility did not proceed with a care plan to address the fall risk at that time. The admission MDS also indicated that the facility assessed her as having a Brief Interview for Mental Status (BIMS, an assessment done to determine cognition level) score of 3, which means Resident CR1 had severely impaired cognition. The facility continued to assess Resident CR1's cognitive status as severely impaired for her February 15, 2022 and April 25, 2022 MDS assessments. A physician's order dated April 20, 2022, indicated that nursing staff were to use a chair alarm to her wheelchair, and to check placement and function every shift. Nursing documentation dated June 1, 2022, at 8:43 AM indicated that Resident CR1 was found on the floor in her bedroom, kneeling beside her bed. Resident CR1's fall care plan was initiated on June 1, 2022, and indicated to use bed and chair alarms. An assessment completed by nursing staff on June 1, 2022, now indicated that the facility assessed Resident CR1 as being at high risk for falls. Nursing documentation dated July 4, 2022, at 3:48 PM indicated that Resident CR1 fell to the floor. Resident CR1 was unable to move her right arm due to extreme pain. Additional nursing documentation dated July 4, 2022, at 3:51 PM indicated that nursing staff heard a smack and saw Resident CR1 lying face down on the floor. Nursing documentation dated July 4, 2022, at 9:17 PM indicated that Resident CR1 was transferred to the emergency room , over 5 hours later and suffered multiple fractures. Nursing documentation dated July 4, 2022, at 9:20 PM indicated that when Resident CR1 fell earlier in the shift, her chair alarm did not sound. Review of the facility's investigation of Resident CR1's July 4, 2022, fall revealed that she was using her wheelchair, and that the alarm was in place and functioning. In the same investigation, staff indicated the alarm did not sound. There was no documented evidence to clarify the use of the chair alarm. Review of the facility's Fall Scene-Investigation Report dated July 4, 2022, indicated that Resident CR1 was alone and unattended with alarm. Resident CR1 was last seen sleeping in the blue chair. A section of the report asks the question Alarm being used at the time of fall? with the documented answer of No, did not sound. The investigation indicated that Resident CR1's fall occurred 10 feet from her transfer surface, or the blue chair. There was no documented evidence in the facility's investigation of Resident CR1's fall to indicate why the alarm did not sound, or how Resident CR1 was able to ambulate 10 feet from her chair without staff being alerted and sustaining a fall. Interview with Employee 1, licensed practical nurse, on August 4, 2022, at 11:10 AM indicated that Resident CR1 was placed in a recliner type seating prior to her falling on July 4, 2022. This is referenced by the blue chair in the facility's investigation. Interview with Employee 2, regional Director of Nursing on August 4, 2022, at 12:55 PM indicated that the physician's order for Resident CR1's chair alarm was just for her wheelchair, not the recliner. Employee 2 could not provide documented evidence that the facility assessed the blue chair or recliner seating as a safe alternative to the use of Resident CR1's wheelchair and could not provide documented evidence as to what interventions were implemented for use while Resident CR1 was seated in the blue chair. Review of Resident CR1's hospital admission records dated July 4, 2022, indicated that she sustained multiple fractures of her pelvis (Left superior pubic ramus and Right inferior pubic ramus), a fracture of her right upper arm (right humerus), a possible right hip fracture (the correlation was never done), and compression fractures of her thoracic spine (T7 and T9). Resident CR1 returned to the facility on [DATE], on comfort measures and required the use of a urinary catheter due to severe pain with turning and movement. Resident CR1 was admitted to Hospice services on July 7, 2022, and passed away on July 9, 2022. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 211.10(d) Resident care policies

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate resident accidents and implement appropriate interventions to prevent accidents for three of six residents (Residents 3, 71, and 81); and failed to implement interventions to prevent an accident with serious injury for one of six residents who sustained multiple rib fractures and a [MEDICAL CONDITION] (Resident 123). Findings include: The facility policy entitled, Falls and Fall Risk, Managing, last reviewed without changes on (MONTH) 13, (YEAR), indicated that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input of the attending physician, will identify appropriate interventions to reduce the risk of falls. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. In conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. Clinical record review for Resident 71 revealed nursing documentation dated (MONTH) 9, (YEAR), at 12:58 PM indicating that the writer was called to Resident 71's room at 8:15 AM to see him lying on the floor, next to his bed, on his stomach. Resident 71 stated that he slid out of bed but did not know why. Staff assessed a bruise on Resident 71's left forearm and an abrasion on his right knee. Review of the facility's investigation of Resident 71's fall dated (MONTH) 9, (YEAR), revealed that Resident 71's right knee abrasion measured 6.5 cm (centimeters) by 3 cm. Resident 71's left forearm bruise measured 5 cm by 5 cm. The section of the form that the facility documents the additional corrective action(s) implemented to prevent potential fall recurrence was blank. Interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 25, (YEAR), at 7:00 PM revealed that the facility had no evidence of obtaining statements as part of the fall investigation. The interview also confirmed that the facility made no changes to Resident 71's plan of care, or implemented any new corrective actions, after the fall. Clinical record review for Resident 81 revealed nursing documentation completed by a registered nurse dated (MONTH) 15, (YEAR), at 11:22 AM indicating that staff called the writer to the nursing unit living room at 9:45 AM. The writer noted Resident 81 lying on her back on the floor. Resident 81 stated that she stood up from her wheelchair to walk and fell to the floor backwards. Resident 81 stated that she hit the back of her head. Review of the facility's investigation of Resident 81's fall dated (MONTH) 15, (YEAR), revealed that staff obtained a new physician's orders [REDACTED]. Nursing documentation dated (MONTH) 16, (YEAR), at 6:33 PM revealed that licensed practical nursing staff called the writer to the secure dementia unit. The writer found Resident 81 lying in the middle of the hall, on her right side, with her wheelchair behind her. The documentation indicated that Resident 81's chair alarm had been sounding at the time of the fall. Review of the facility's investigation of Resident 81's fall (completed by the licensed practical nurse on Resident 81's unit at the time of the fall) on (MONTH) 16, (YEAR), indicated that although an alarm device was used at the time of the fall, it did not sound. The investigation included no witness statements that attested to the presence and/or correct functioning of the alarm. Interview with Employee 2, Registered Nurse Clinical Consultant, on (MONTH) 26, (YEAR), at 10:22 AM confirmed that the facility's investigation noted that Resident 81's (MONTH) 16, (YEAR), fall was witnessed; however, the licensed practical nurse and the registered nurse documented that they found Resident 81 on the floor. No documentation indicated a witness to the fall. Although the registered nurse documentation in the clinical record noted that an alarm sounded, the investigation completed by the licensed practical nurse on the unit at the time noted that an alarm did not sound. The investigation contained no witness statements or clarification regarding the discrepancy regarding the alarm. Clinical record review for Resident 123 revealed nursing documentation dated (MONTH) 2, (YEAR), at 7:18 AM indicating that Resident 123's alarm sounded at 6:20 AM. Staff assessed Resident 123's head on the floor between the night stand and the bed, the lower half of her body on the bed, and a 1.8 cm by 0.2 cm by 0.4 cm deep gash (laceration) on her left eyebrow. Nursing documentation dated (MONTH) 2, (YEAR), at 7:24 AM revealed that the writer assessed Resident 123 post fall. Review of the facility's investigation of Resident 123's fall on (MONTH) 2, (YEAR), recommended speaking to the physician regarding a personal alarm (although a staff statement indicated that an alarm was sounding when staff found Resident 123 on the floor). Nursing documentation dated (MONTH) 12, (YEAR), at 8:11 PM revealed that staff called the writer to the nursing unit's dining room to note Resident 123 lying on the floor after sliding out of her wheelchair. Review of the facility's investigation of Resident 123's fall on (MONTH) 12, (YEAR), revealed that the section of the form that the facility documents the additional corrective action(s) implemented to prevent potential fall recurrence was blank. Interview with the Director of Nursing and Employee 2 on (MONTH) 26, (YEAR), at 9:15 AM confirmed that the facility had no evidence of any corrective actions to prevent recurrence were implemented following Resident 123's fall on (MONTH) 12, (YEAR). Nursing documentation dated (MONTH) 11, (YEAR), at 7:48 AM revealed that staff responded to a sensor alarm and call bell in Resident 123's room. Staff noted Resident 123 sitting on the floor, complaining of pain while pointing to her sternum (bone in the center of the chest), and calling out, I'm dying. Over-the-counter [MEDICATION NAME], Tylenol, and narcotic [MEDICATION NAME], was ineffective for Resident 123's pain. Nursing documentation dated (MONTH) 11, (YEAR), at 9:03 AM reiterated an assessment of Resident 123 clutching her mid-sternal chest area with both hands, yelling out with pain, and a reddened mid-sternal area. Staff notified the physician and obtained an order to send Resident 123 to the emergency room for evaluation. Resident 123 exited the facility via an ambulance litter. Nursing documentation dated (MONTH) 11, (YEAR), at 1:16 PM revealed that Resident 123 returned from the hospital with the [DIAGNOSES REDACTED]. An addendum nursing documentation entry on (MONTH) 11, (YEAR), at 2:44 PM revealed that the emergency room provider diagnosed acute fractures of Resident 123's right seventh, eighth, and ninth ribs. Review of the facility's investigation of Resident 123's fall on (MONTH) 11, (YEAR), reiterated that Resident 123's roommate rang her call bell for help. The investigation included no statements obtained from staff. The investigation stipulated that Resident 123 has a history of non-compliant behavior and is non-compliant with her plan of care. Review of the plan of care developed by the facility to address Resident 123's fall risk revealed the implementation of a sensor alarm to her bed and chair at all times starting (MONTH) 11, (YEAR). Interview with the Director of Nursing and Employee 2 on (MONTH) 26, (YEAR), at 9:15 AM confirmed that Resident 123 was to have an alarm in place at the time of her fall on (MONTH) 11, (YEAR) (despite the fact that the intervention did not start on her fall risk plan of care until (MONTH) 11, (YEAR)). The interview confirmed that the incident investigation indicated that Resident 123's roommate activated her call bell, and that a nurse aide initially found Resident 123 on the floor; however, the facility could provide no evidence of a witness statement from the nurse aide to attest that the personal alarm was activating at the time of the fall (versus responding to Resident 123's room secondary to the roommate activating the call bell). The interview confirmed that the licensed practical nurse (who was not the first to respond to Resident 123) completed the incident report to reflect that an alarm sounded; however, there was no written statement from the licensed practical nurse regarding the presence/absence of the alarm. Nursing documentation dated (MONTH) 19, (YEAR), at 3:41 AM and 6:20 AM revealed that Resident 123 was repeatedly setting off her sensor alarms in her bed and chair while attempting to transfer independently. Nursing documentation dated (MONTH) 19, (YEAR), at 1:34 PM revealed discussion with Resident 123's daughter regarding the usage of the chair alarm. The writer indicated that Resident 123's daughter would like to have her chair alarm removed; but agrees with keeping the bed alarm. Interview with the Director of Nursing and Employee 2 on (MONTH) 26, (YEAR), at 9:15 AM indicated that the facility agreed to discontinue Resident 123's chair alarm in response to Resident 123's daughter's request; however, failed to implement any other assistive device that would alert staff of, or deter, Resident 123's attempts to self-transfer (e.g. increased staff supervision, silent alarms, altering chair positioning to deter rising, etc.). The interview confirmed that upon review of the plan of care developed by the facility to address Resident 123's fall risk, staff did not discontinue the alarm intervention following the discussion with her daughter. This intervention remained on her fall risk care plan since (MONTH) 11, (YEAR). Nursing documentation dated (MONTH) 22, (YEAR), at 7:03 AM (three days after the facility's discussion with the daughter), indicated that Resident 123 had a witnessed fall, in the nursing unit dining room, at 6:40 AM. Nursing documentation dated (MONTH) 22, (YEAR), at 4:40 PM revealed Resident 123 was difficult to transfer and was holding her right leg while refusing to bear weight. The writer noted that at 12:00 PM, the writer entered the unit to assess Resident 123's right leg; however, she grabbed at her upper thigh and yelled, don't touch it. The writer called the physician who ordered an x-ray of the right hip and femur (upper leg bone) to rule out a fracture. An x-ray obtained at 4:15 PM diagnosed a possible femoral neck fracture. The technician had to cancel the femur x-ray as Resident 123 was too uncomfortable. Review of the facility's investigation of Resident 123's fall on (MONTH) 22, (YEAR), indicated that Resident 123's alarms were previously discontinued and were not in place at the time of the fall. The summary of findings indicated that staff would reapply the alarms and consult therapy to assess Resident 123's positioning in her chair to potentially recline more. Nursing notes dated (MONTH) 22, (YEAR), at 5:03 PM revealed that the Radiology report results were returned. The radiologist concluded Resident 123 had a recent intertrochanteric fracture right femur with varus deformity ([MEDICAL CONDITION] with inward angulation). Resident 123 was sent to the emergency room for evaluation and treatment. Nursing notes dated (MONTH) 22, (YEAR), at 11:47 PM revealed that Resident 123 was admitted to the hospital for surgery of her [MEDICAL CONDITION]. The facility failed to maintain assistive devices or supervision to alert staff of Resident 123's attempts to transfer without staff assistance secondary to her known history of non-compliance and repeated falls. Clinical record review for Resident 3 revealed nursing documentation dated (MONTH) 10, (YEAR), at 7:52 AM indicating that at 4:30 AM staff found Resident 3 sitting on the floor beside her bed. At 2:10 PM the same day, staff implemented a fall mat as a new intervention. Review of the facility's investigation dated (MONTH) 10, (YEAR), revealed that staff were outside Resident 3's room and heard her calling for help. The staff member entered Resident 3's room and found her sitting by her bed. Staff indicated that Resident 3's fall interventions that were in place as previously ordered were a low bed, fall mat, and alarms; however, staff documented that there were no alarms being used. There was no documentation that staff heard an alarm when Resident 3 was observed on the floor or indicated that Resident 3's fall mat was in place at the time of the event, nor were there any staff statements available regarding this incident. Interview on (MONTH) 26, (YEAR), at 11:38 AM with Employee 2, director of clinical services/staff development, confirmed the above findings. 28 Pa. Code 211.11(d) Resident care plan Previously cited 10/28/16 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 11/9/17, 10/28/16