Every finding on record at Hanover Hall for Nursing and Rehabilitation

Based on clinical record review, hospital records, staff interviews, and review of the facility incident report, it was determined that the facility displayed past non-compliance in it's failure to ensure that care and services were provided timely and consistent with professional standards of practice following a fall with fracture which resulted in harm as evidenced by fracture-related pain and delayed corrective treatment for one of three residents reviewed (Resident 1).Findings Include: Review of the facility policy, titled Falls Management System, last reviewed July 25, 2025, stated the following: Any fall that involves an actual head injury and all un-witnessed falls will include follow-up neurological checks. Neurological checks will be documented. The investigation and appropriate interventions will be evaluated at the time of the fall and reviewed by Nursing Management or the Interdisciplinary Team (IDT). When the resident sustains a fall, an evaluation for injury by a licensed nurse is completed and the results are documented in the clinical record. The attending physician and family/responsible party are notified of the fall and the resident status. Other follow-up to a resident fall will be conducted depending on the nature of any injury sustained and in keeping with accepted standards of practice. Review of the facility policy, titled Acute Condition Changes-Clinical Protocol, last reviewed July 25, 2025, stated the nurse shall assess and document/report the following baseline information:Vital signs.Neurological status.Current level of pain, and any recent changes in pain level.Level of consciousness.Cognitive and emotional status.Resident's age and sex.Onset, severity, and duration.Recent labs.History of psychiatric disturbances, mental illness, depression etc.All active diagnoses.All current medication.Phone calls to the attending or on-call physician should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident/patient's current symptoms and status. Review of Residents 1's clinical record revealed diagnoses that included osteoarthritis (a degenerative joint disease that occurs when the cartilage that cushions the joints wears down over time, leading to pain, stiffness, and loss of mobility), legal blindness as defined in USA (20/200 or worse in the better eye with correction, or a field of view less than or equal to 20 degrees), and a comminuted fracture of the distal right radius (severe wrist injury where the forearm bone is broken into multiple pieces). Review of Resident 1's Quarterly Minimum Data Set (MDS - a periodic assessment of care needs) dated November 13, 2025, indicated the diagnoses were current. Resident BIMS (brief interview of mental status) score was 14, indicating she was cognitively intact. The MDS also revealed that Resident 1 required a 1-person assist to ambulate for toileting. Review of Residents R1's care plan dated February 2026, revealed Resident 1 was high risk for falls related to vision impairment and chronic pain syndrome with muscle weakness. Interventions included responding immediately to calls, maintaining call light within reach, wear non-skid socks, physical therapy evaluation effective February 5, 2026, and occupational therapy evaluation effective February 9, 2026. Facility document review revealed Resident 1 had an unwitnessed fall on February 6, 2026, at 9:45 PM. Employee 1 (Licensed Practical Nurse [LPN]) entered a late entry progress note written on February 7, 2026, at 11:27 AM, which was based on a verbal report from Employee 2 (Registered Nurse [RN]). Employee 2 worked from 3 PM until 11 PM on February 6, 2026. The progress note stated that on February 6, 2026, at 9:45 PM, Resident 1 was found on the floor next to her bed and leaning up against the bed. Legs were extended. Resident stated that she went to take herself to the bathroom and fell. Employee 1 questioned resident if she had any pain or hit her head and resident denied. NA (Nursing Assistant) came into room and took resident to the bathroom. Review of the clinical record revealed that Employee 1 did not document the events of the fall or any assessment for Resident 1. A statement written by Employee 3 (NA) on February 8, 2026, stated that on February 6, 2026, at approximately 9:45 PM, I [Employee 3] heard what sounded like a call for help. I went to see who needed help. I walked towards the end of the hall when I heard another noise and realized it came from Resident 1's room. As I walked in, I saw Resident 1 on the floor beside her bed. Employee 2 (RN) was also in the room. I went to Resident 1 and asked her what happened. Resident 1 said she couldn't wait anymore to go to the bathroom and tried to get up herself. I asked her if anything hurt. Resident 1 stated her right wrist was hurting. I took a look at it. There was a bump on the top of her wrist. Resident 1 said she really had to go to the bathroom. I asked Employee 2 if it was OK to take her to the bathroom (I went into the hallway to ask Employee 2 at the med cart outside Resident 1's door). Employee 2 nodded yes. I went back into the room. Resident 1 stated her back was hurting. I took a look and saw a thick scrape on the mid upper part of her back on the left side. I went back out to the hallway to find an Aide to help me pick Resident 1 off the floor. We got Resident 1 off the floor, and I helped her to the bathroom. I wasn't able to hold her right hand due to her wrist, so I held my arm under her right armpit. In the bathroom Resident 1 wasn't able to use her wrist or hand to hold onto the railing to sit on the toilet. I let Resident 1 know I would give her some time to use the bathroom and that I would be back. As I went back to finish care on another resident, I let Employee 2 know of the injuries and pain Resident 1 had stated to me. I finished up with the other resident (10 minutes) and went back to get Resident 1 out of the bathroom. Resident 1 stated that her head hurt as well. I looked at her head and found a bump on the right side of her head that had a cut at the top of it and was bleeding. I also noticed another bump on her right wrist, on the left side. I cleaned her bottom and helped her back to bed, putting her brief on and making sure she was comfortable. After I left the room, I let Employee 2 know about the second bump on Resident 1's wrist and the bump on her head. A written statement by Employee 5 dated February 7, 2026, states, On February 6, 2026, during report (change of shift) it was reported to me by Employee 2 that Resident 1 had fallen to the floor because she had gotten up by herself to use the bathroom. Employee 2 stated she did not report it because the resident was already on neuro checks and she did not have time for it due to being on both carts. She said she instructed Employee 3 (Nurse Aide) to get Resident 1 off the floor. Employee 3 mentioned a resident falling with complaints of her wrist hurting. During my 11-7 shift it was reported that a resident asked for help getting a drink d/t wrist hurting which aides were not aware of or did not notice any issues with her wrist at the time. Resident 1 rang later in the shift and light was answered and Resident 1 complained of excruciating pain in right wrist, upon evaluation the writer noted visual deformity and bruising to wrist. Resident 1 stated she hurt it when she fell earlier in the night. Reported findings to Registered Nurse Supervisor and Director of Nursing. A written statement by Employee 4 (NA) on February 7, 2026, stated, Resident 1 rang her light at 2:55 AM. I answered it. Resident 1 told me she was in a lot of pain and that she wanted to go to the hospital. I told her I would tell the nurse, and I reported it to Employee 5 (Licensed Practical Nurse). A review of the progress notes dated February 7, 2026, revealed Resident 1 reported a pain score of 8/10 prior to being sent to the hospital. The physician was notified and provided an order to send Resident 1 to the hospital emergency department on February 7, 2026, at 3:15 AM. A review of the hospital record revealed the results were obtained on February 7, 2026, at 4:54 AM, revealing a comminuted fracture of the distal right radius. On February 7, 2026, at 4:07 AM, the progress notes stated, Attempt made to call emergency contact (father) voicemail full could not leave message, called second emergency contact nephew, updated on situation, was thankful. Updated that father was also in hospital. Resident 1 was discharged back to the facility on February 7, 2026, at approximately 8:30 AM, with a hard splint to be worn continuously and instructions to follow-up with orthopedics as soon as possible. On return from hospital, the Resident's pain score was 10/10. Provider notified and Resident 1 was ordered Tramadol (narcotic pain medication) every 12 hours as needed for acute pain. The Resident was seen by Orthopedics February 10, 2026, and received orders as follows: cast at all times: occupational therapy, splint right upper extremity, recommend tramadol for pain control, NWB (no weight bearing) to right upper extremity, okay for digital motion. Follow-up 2 weeks with x-rays in brace. Clinical record review revealed there was no documentation of vital signs on the neurological evaluation flow record and no progress note entered regarding the fall for Resident 1 on the 3-11 shift on February 6, 2026. There was no documentation to show any notification to the physician or responsible persons on February 6, 2026. There was no documentation regarding a pain score or assessment of the resident's wrist. A review of the Medication Administration Record (MAR) revealed Resident 1 had current orders to administer acetaminophen (pain medication aka Tylenol) 325 milligram tablets, give two tabs by mouth for a pain score of 4 to 10. The MAR was blank, indicating medication was not administered on February 6, 2026. A fall investigation was initiated by the Nursing Home Administrator (NHA) on February 7, 2026. During an interview with the NHA on February 17, 2026, the NHA said that she attempted calling Employee 2 for follow-up regarding Resident 1's fall. Employee 2 sent an email stating that she was overwhelmed by her workload with administering medications and that she asked Resident 1 twice if she hit her head or had any pain, and the Resident denied both times. Employee 2 added that Resident 1 was already on neuro checks from a previous fall on February 4, 2026, so neuro checks were not initiated. Employee 2 confirmed she did not go back in and re-assess Resident 1 after receiving concerns about her wrist, head, or back, and she did not notify the RN Supervisor. Additional emails and phone calls were attempted by the NHA with no response from Employee 2. The facility implemented a plan of correction on February 7, 2026, that included: February 7, 2026- The NHA and ADON (Assistant Director of Nursing) met with all Department Managers to review the incident and review the immediate plan of correction. February 7, 2026- A full facility audit was completed on all falls that occurred in the past 30 days. Reviewed for completion of all incident reports, documentation of assessments, and notifications to physicians and responsible persons. February 9, 2026- Education was completed to all licensed staff on the fall policy, pain clinical protocol policy, change in condition, responding to complaints of pain, incident reports, and notifications of responsible persons and physicians. February 9, 2026- weekly audits were performed on February 9, 2026, and will continue 5 x weekly for 2 weeks, 3 x weekly x 2 weeks, and 10 monthly audits x 1 month. QAPI (Quality Assessment Performance Review) is scheduled for further review. February 13, 2026- Review of POC revealed that the education and audits were completed and compliance date is February 13, 2026. During a telephone interview with Employee 1 on February 19, 2026, at 9:30 AM, Employee 1 confirmed that she received education based on the concerns identified with Resident 1's incident on February 6, 2026. Employee 1 added that she would have notified the RN Supervisor of the fall, completed an incident report, restart a new neurological assessment form, assess for pain, and notify the responsible person(s) while the RN Supervisor notified the physician. During a telephone interview with Employee 7 (LPN) on February 19, 2026, at 9:40 AM, Employee 7 confirmed that she received education based on the concerns identified with Resident 1's incident on February 6, 2026. Employee 7 said that she would have notified the RN Supervisor of the fall and not move the Resident until the RN Supervisor arrived, restart a new neurological assessment form, obtain vital signs, assess for pain and administer prescribed medication, and with any further change in condition would notify the RN Supervisor. During a telephone interview with Employee 8 (RN Supervisor) on February 19, 2026, at 9:50 AM Employee 8 confirmed that she received a review of the fall policy, pain clinical protocol policy, change in condition, responding to complaints of pain, incident reports, and notifications of responsible persons and physicians. Employee 8 added that she hasn't had any concerns with being notified timely when any incident occurs. Employee 8 added that when notified of a fall or change in condition, she performs the assessment on the resident, if unwitnessed fall starts neurological flow record, notifies the physician, and documents any changes and adds incident to the shift-to-shift report. During an interview with the NHA on February 17, 2026, at 1:00 PM, the NHA stated that Employee 2 was suspended pending outcome of the investigation but added that she doesn't expect Employee 2 to return to the facility. The NHA added that she would expect Employee 2 to follow the policy to assess Resident 1 initially and initiate the incident investigation form, reassess Resident 1 when the change in condition was reported, document in the progress notes, initiate a new neurological evaluation flow record, provide pain management, and contact the Registered Nurse Supervisor. The facility displayed past non-compliance in its failure to provide services consistent with professional standards, which resulted in harm as evidenced by a delay in reassessment with a change in condition, a lack of pain assessment and management that caused pain and suffering for Resident 1. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to monitor a resident's weight status in accordance with facility policy and clinical standards of practice for three of five residents reviewed (Residents 5, 8, and 85). And failed to consistently monitor a resident's weight status and implement timely interventions to maintain adequate weight resulting in actual harm as evidenced by continued weight loss for one of five residents reviewed (Resident 8).Findings include:Review of facility policy, titled Weight Assessment and Intervention, revised March 2019, read, in part, the nursing staff will measure residents' weight on admission, and then weekly for four weeks. Any weight change of 5 pounds or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will notify the Physician and Dietitian.Review of the facility's policy, titled Weight Assessment and Interventions, revised March 2019, reads, in part, The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents.The policy continued, The nursing staff will measure resident weight on admission, and then weekly for four weeks. Also, the Dietician and/or Certified Dietary Manager will review the individual weight records to follow individual weight trends over time, making recommendations as appropriate. The Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss, or increasing the risk of weight loss .for example, increased need for calories and/or protein.Weight loss is calculated using a formula to determine the percentage of weight loss. In one month, a 5 % weight loss is considered significant loss and greater and 5 % is severed loss. Over a three month period, 7.5 % is significant loss and greater than that is considered severe weight loss.Review of Resident 5's clinical record revealed diagnoses that included dysphagia (difficulty swallowing). Further clinical record review revealed Resident 5 was transferred to the hospital on December 5th, 2025, and returned to the facility on December 10, 2025.Review of Resident 5's weight history revealed that the weight on November 5, 2025, was 130.5 lb and on December 10, 2025, was 143 lb; a weight change of more than five pounds. The next weight on January 11, 2026, was 128 lb; a weight change of more than five pounds. Further review of the weight history revealed that the weight was not retaken after the five-pound change. Interview with Employee 1 (Registered Dietitian) on January 14, 2026, at 11:57 AM, it was revealed that a reweight wasn't obtained for Resident 5 and it should've been. Employee 1 stated the expectation was that a re-weight would be obtained within 48 hours.Interview with the Nursing Home Administrator (NHA) on January 13, 2026, at 1:45 PM, it was revealed that a reweight wasn't obtained for Resident 5 and it should've been.Review of Resident 8's physician orders revealed diagnoses that included hypertension (elevated blood pressure) and a history of falling.Review of Resident 8's clinical record revealed an admission date of October 13, 2025.Review of Residents 8's weights revealed the following weekly weights:October 14, 2025- (Admission) 121.9 lbOctober 21, 2025- No weight obtainedOctober 28, 2025- 120.7 lbNovember 2, 2025, 110 lbNovember 5, 2025- 110 lbNovember 11, 2025- No weight obtainedNovember 27, 2025- 111.6 lbDecember 5, 2025- 107 lbDecember 11, 2025- 98.8 lbJanuary 2, 2025- 96.6 lbJanuary 3, 2025- 96.5 lbReview of Resident 8's admission Nutritional Risk Assessment, dated October 16, 2025, revealed that the Resident was at risk for weight loss due to the healing process associated with a femur fracture. Review of the progress notes for Resident 8 revealed a WEIGHT WARNING on November 3, 2025, alerting staff to a noted weight loss. Review of Employee 1's (Registered Dietician) progress notes dated November 13, 2025, confirmed the Resident had significant weight loss of 11 lb, which equals a 9.1 % weight loss. Employee 1 recommended fortified foods, liquid protein to aid in wound healing and weigh weekly for four weeks. Nursing and the physician were made aware. Review of Resident 8's physician orders revealed that on November 13, 2025, Employee 1 also requested an order that read, Fortified Foods, diet Regular Texture, Thin consistency.Review of the facility's policy, titled Fortified Foods [Foods First] Program, read, The Fortified Foods 'Food First' program is a program for weight loss prevention and pressure ulcer prevention and treatment that helps meet the individual nutritional needs in small volumes. The policy continued, The focus on Food First aims to fortify the foods your facility already serves rather than add to the volume and cost of food by providing additional supplements.According to the policy, Fortified Foods are calorie boosters that include margarine or butter, peanut butter, fortified milk, whole milk, and fortified soup.Review of the Dietary Note from Employee 1 on December 13, 2025, noted another WEIGHT WARNING for a 10 % weight loss of 11 lb over 30 days. The notes stated, [Resident] continues on a fortified food, regular texture, thin liquids diet consuming 51-100% of meals. Will weight weekly x 4 weeks to best monitor.An additional Dietary Note on January 5, 2026, noted another WIEGHT WARNING for a 9.3 % weight loss of 10 lb over 30 days. The note stated, [Resident] continues on a fortified food, regular texture, thin liquids diet consuming 51-100% of meals. Will continue interventions as ordered and extend weekly weights x 4 weeks to best trend weight status.Review of Resident 8's meal ticket dated January 14, 2026, for her lunch meal revealed a regular diet without special instructions for the addition of fortified foods.An interview with Employee 1 on January 14, 2026, at 11:49 AM, confirmed she ordered weekly weights x 4 in November 2025 and December 2025, and was aware staff were not documenting the weights per the physician orders and Employee 1's recommendations. The interview also revealed that Employee 1 neglected to add the special instructions for Resident 8's diet and meal ticket to include fortified foods beginning November 13, 2025, per the recommendation and the physician's order.During the interview on January 14, 2026, Employee 1 made changes to Resident 8's clinical record, specifically the meal ticket, to include the special instructions for the addition of Fortified Foods.Employee 1 stated an awareness that Resident 8 weighed 121 lb at admission on [DATE], and at the most recent documented weight, dated January 3, 2026, Resident 8 weighed 96.6 lb; a total of 24.4 lb in less than three months. According to Employee 1, the ideal weight for Resident 8 would be calculated between 104 and 131 lb. Review of Resident 8's clinical record revealed that weekly weights at admission on [DATE], ordered in November 2025 and December 2025, were not obtained weekly.Clinical record review, meal ticket review, and an interview with Employee 1 revealed that the physician-ordered fortified foods were not provided to Resident 8 until January 14, 2026.According to calculations, Resident 8 experienced a non-physician-prescribed weight loss of 20.1%.An interview with the Director of Nursing on January 13, 2026, at 1:27 PM, confirmed the weekly weights ordered for Resident 8 were inconsistent. An interview with the NHA on January 14, 2026, at 12:48 PM, confirmed the fortified foods should have been added when introduced by Employee 1 and ordered by the physician on November 13, 2025.Resident 8 was identified as at risk for weight loss. The Resident had a continuous downtrend in weights. She was ordered weekly weights that were not consistently obtained and ordered fortified foods which were not put into place. Based on her nutritional assessments, her nutritional needs were based off her consumption of the fortified foods, but she was not receiving those extra nutrients, which contributed to continued weight loss totaling 24.4 lb (or 20.1%) in three months. There was no dietary assessment from Employee 1 since January 5, 2026, and no additional weight obtained since January 3, 2026.Review of Resident 85's clinical record revealed diagnoses that included dysphagia and dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking). Further review of the clinical record documented Resident 85 was admitted to the facility on [DATE].Review of Resident 85's December 2025 Physician orders failed to document weekly weights for four weeks following admission. Review of Resident 85's weight history revealed: December 5, 2025, - 167 lb; and January 5, 2026, - 168 lb.Interview with Employee 1 on January 14, 2026, at 11:57 AM, it was revealed that Resident 85's weight was obtained upon admission; however, nursing failed to enter the physician order for a weekly weight for four weeks after admission and, therefore, Resident 85's weight wasn't obtained weekly for four weeks after admission.Interview with the NHA on January 14, 2026, at 11:45 AM, it was revealed that weekly weights for four weeks after admission weren't obtained for Resident 85, and they should've been.28 Pa Code 201.18(b)(1) Management28 Pa Code 211.12(c)(d)(1)(2)(3)(5) Nursing services

Based on review of select facility documentation and staff interview, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least once every 12 months for three of five nurse aides reviewed (Employee 7, 8, and 9).Findings include:Review of facility job description documentation for nurse aides revealed annual evaluations are to be completed by their supervisor. Review of select facility documentation revealed a list of nurse aides that had worked at the facility for greater than a year. Employees 7, 8, and 9 were selected from the list to review their last annual nurse aide performance evaluations.Review of Employee 7's last annual nurse aide performance evaluation provided revealed it was dated October 11, 2022. Review of Employee 8's last annual nurse aide performance evaluation provided revealed it was dated July 18, 2023. Review of select facility documentation provided revealed Employee 9 had a hire date of August 19, 2024. Employee 9 did not have an annual evaluation in 2025 for review. During an interview with the Nursing Home Administrator on January 14, 2026, at 11:19 AM, she revealed she was unable to locate annual evaluations in the past 12 months for Employees 7, 8, and 9, and she would expect them to be available and located in their employee files. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1) Management

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist, and failed to ensure any irregularities were responded to in a timely manner by the attending physician or prescriber for three of five residents reviewed for unnecessary medications (Residents 2, 11, and 56).Findings include:Review of facility policy, titled Medication Regimen Review (Monthly Report), last reviewed July 25, 2025, read, in part, The consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. Recommendations are acted upon and documented by the facility staff and or the prescriber.Review of Resident 2's clinical record revealed diagnoses that included gastro esophageal reflux disease (a chronic digestive disease where the liquid content of the stomach refluxes into the esophagus, the tube connecting the mouth and stomach), hyperlipidemia (high blood cholesterol), and dementia (a general term for severe mental function loss).Review of Resident 2's clinical record revealed failed to reveal a monthly MRR was completed during the month of April 2025. Review of Resident 2's MRR completed on June 26, 2025, revealed a recommendation to ensure Omeprazole was administered on an empty stomach, 30-60 minutes before a meal. Review of Resident 2's clinical record failed to reveal the June 2025 MRR had a response to the recommendation or that the recommendation had been implemented. Review of Resident 2's MRR completed on August 27, 2025, revealed a recommendation for routine lab values. Review of Resident 2's clinical record failed to reveal the August 2025 MRR had a response to the recommendation or that the recommendation had been implemented. Review of Resident 2's MRR completed on December 23, 2025, revealed the same recommendation to ensure Omeprazole was administered on an empty stomach, 30-60 minutes before a meal. Interview with the Director of Nursing (DON) on January 14, 2026, at 11:23 AM, revealed she would expect monthly MRRs to be completed and available for review, and she would expect a physician to review and respond to the medication regimen review in a timely manner.Review of Resident 11's clinical record revealed diagnoses that included repeated falls and dementia. Review of Resident 11's clinical record revealed failed to reveal a monthly MRR was completed during the month of April 2025. Review of Resident 11's MRR completed on September 19, 2025, revealed a recommendation to add a specific amount of grams (unit of measure) that should be applied to her diclofenac gel (topical pain relief gel) order. Review of Resident 11's clinical record failed to reveal the September 2025 MRR had a response to the recommendation or that the recommendation had been implemented. Review of Resident 11's MRR completed on December 23, 2025, revealed the same recommendation to add a specific amount of grams that should be applied to her diclofenac gel order.Interview with the DON on January 14, 2026, at 11:23 AM, revealed she would expect monthly MRRs to be completed and available for review, and she would expect a physician to review and respond to the medication regimen review in a timely manner.Review of Resident 56's clinical record revealed diagnoses that included down syndrome (a genetic condition caused by having an extra copy of chromosome 21, affecting brain and body development) and dementia.Review of Resident 56's physician's orders reveal a physician's order for Pantoprazole Sodium (a prescription proton pump inhibitor (PPI) that reduces stomach acid to treat GERD) 20 mg, once daily, with a start date of May 28, 2025.Review of Resident 56's medical record revealed a medication regimen review completed on October 28, 2025, with a recommendation to ensure the Pantoprazole Sodium is administered on an empty stomach, 30-60 minutes before a meal. Further review of the medication review revealed it was not addressed until January 13, 2026.Interview with the DON on January 14, 2026, at 10:45 AM, revealed that they would expect a physician to review and respond to the medication regimen review in a timely manner.28 Pa Code 211.9(a)(1) Pharmacy Services 28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on observations, review of facility policy, and staff interview, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the kitchen and in four of four nourishment pantries. Findings include: Review of facility policy, titled Food Storage, revised February 15, 2020, read, in part, un-served leftovers shall be labeled, dated and stored for a period not to exceed three days, bulk items should be labeled and dated clearly and appropriately. All foods should be covered, labeled and dated. When taking dietary supplements out of the freezer to defrost, they should be labelled with a use by date. Health shakes/Nutritious juice are to be used within 14 days. Review of facility policy, titled Food from Outside Sources, revised July 2023, read, in part, visitors will label food and beverages with the resident's name, room number and date. Observation in the walk-in Freezer with Employee 6 on January 11, 2026, at 10:48 AM, revealed one and a half frozen pizzas were in an open plastic bag and not date marked. At that time, Employee 6 revealed the bag should be securely closed and date marked. Observation in the walk-in refrigerator with Employee 1 on January 11, 2026, at 10:50 AM, revealed the following: 46-ounce containers of juice were open and not date marked with an open or use by date: two apple juice, and one cranberry juice. At that time, Employee 6 revealed the juice should be marked with an open date. Observation in the C1/D1 nourishment pantry on January 11, 2026, at 10:52 AM, with Employee 6, revealed the following: health shakes/juices were thawed and not date marked with a thawed or use by date: two- orange, five-vanilla. At that time, Employee 6 revealed the Styrofoam cup of chocolate pudding on the same tray was date marked January 9th, 2026, and stated that, because it was on the same tray, the health shakes/juices were pulled from the freezer on January 9th, 2026. Another tray in the same refrigerator contained the following: thawed health shakes/juices that weren't date marked: 16- chocolate, nine-orange, and eight-vanilla. At that time, Employee 6 revealed the tray was date marked January 11th, 2026, and, therefore, the nourishments were pulled from the freezer that morning. Observation in the drawer in the bottom of the refrigerator revealed the following: health shakes/juices were thawed and not date marked: five- chocolate, and seven-orange. The following items were not marked with a resident identifier: one individual serving of Greek yogurt, butter pecan ice cream, chocolate mocha creamer, and a plastic bag with blueberries and vanilla yogurt. At that time, Employee 6 revealed that the aforementioned items were not provided by the facility and are resident items, and they should be marked with a resident identifier. Observation in the A1/B1 nourishment pantry on January 11, 2026, at 10:56 AM, with Employee 6, the following items were not marked with a resident identifier: 1- pint vanilla bean ice cream, one box strawberry mochi, 3.5-ounce caramel cone ice cream, and one plastic container of coleslaw. The following items in the cabinet were not labeled and date marked: 2-quart container of thickener, one Styrofoam cup of hot chocolate mix, one bowl of rice Krispies, one bowl of corn flakes, and one 4-pound jar of peanut butter (expiration date October 29, 2024). In the refrigerator, the following nutritional shakes/juices were thawed and not date marked: 20- orange, 1- chocolate. Inside the refrigerator, there was a died yellow substance on the top shelf and a dried brown liquid on the bottom shelf. At that time, interview with Employee 6 revealed the aforementioned items should contain a resident identifier and a date, the nutritional shakes/juices should be date marked, and the refrigerator should be cleaned. Observation in the B2 nourishment pantry on January 11, 2026, at 11:05 AM, with Employee 6, the following items and thawed health shakes/juices were not date marked: one half chicken salad sandwich, six - orange, nine- chocolate, and seven-vanilla. The bottom shelf in the refrigerator contained a dried dark orange liquid. At that time, interview with Employee 6 revealed the sandwich, and health shakes/juices should be date marked, and the refrigerator should be cleaned. Observation in the C2/D2 nourishment pantry on January 11, 2026, at 11:10 AM, with Employee 6, the following items didn't contain a resident identifier and weren't date marked: two boxes ice cream sandwiches, one box creamsicles, one fudge bar, one box cheese ravioli, one chicken nugget and macaroni and cheese dinner, barbeque stake and potato dinner, three-quarters box popsicles, and one hot pocket. Observation in the refrigerator revealed one carton caramel macchiato creamer and one carton mint mocha creamer. The following items and thawed nutritional shakes/juices weren't date marked: 2 cups apple sauce, five- chocolate, seven- vanilla, and four - orange. On the bottom shelf in the refrigerator the was dried red liquid and spilled apple sauce, and on the back wall was spilled chocolate pudding. At that time, interview with Employee 6 revealed the applesauce and nutritional shakes/juices should be date marked, and the refrigerator should be cleaned. Observation of the dry storage on January 14, 2026, at 10:54 AM, revealed the following cans were not date marked: four cans of diced carrots, six cans of three bean salad, five cans of peas, three cans of crushed tomatoes, and six cans of black beans. Interview with the Nursing Home Administrator on January 13, 2026, at 1:45 PM, it was revealed the expectation was that food would be stored to meet regulatory standards. 28 Pa code 211.6(f) - Dietary Services

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure each resident the right to formulate an advance directive for one of three residents reviewed (Resident 39).Findings Include: An Advance Directive is defined as a written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated. Review of the facility's policy, titled Advance Directives, revised September 2022, reads, in part, 1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members, and/or his or her legal representative, about the existence of any written advance directives. 2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 3. Written information about the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive, is provided in a manner that is easily understood by the resident or representative. 4. Written information includes a description of the facility's policies to implement advance directives and applicable state law. Review of Resident 39's physician orders revealed diagnoses that included hypertension (elevated blood pressure) and chronic kidney disease (a disease characterized by progressive damage and loss of function in the kidneys). Review of Resident 39's most recent Brief Interview for Mental Status (BIMS) assessment, dated December 27, 2025, revealed the Resident scored a 15/15. This score denotes intact cognition. Continued review of Resident 39's clinical record revealed no documentation to support staff review of the Resident's right to formulate an Advance Directive. An interview with Employee 3 (Social Worker) on January 14, 2026, at 12:35 PM, revealed that she had no documentation of the Resident being offered the opportunity to formulate an Advance Directive. An additional interview with the Nursing Home Administrator on January 14, 2026, at 1:53 PM, revealed that the social work staff will be educated regarding the implementation of the facility's Advance Directives policy. 28 Pa. Code 211.12 (d) (5) Nursing services

Based on staff interview, clinical record review, and facility policy review, it was determined the facility failed to develop a timely hospice baseline care plan, document a hospice physician order, or have an authorized hospice agreement for one of three residents reviewed for hospice services (Resident 13).Findings include: Review of the facility policy, titled Hospice Program, last reviewed July 25, 2025, stated, the agreement with the hospital provider will be signed by the facility representative and a representative from the hospice agency before hospice services are furnished to the resident. Review of the clinical record for Resident 13 revealed clinical diagnoses that included cerebral infarction (a.k.a. stroke-brain tissue death from a blocked blood vessel), atrial fibrillation (irregular heart rhythm), and hospice status (end of life services focusing on comfort, pain management, and quality of life when a cure isn't possible). Review of Resident 13's admission Minimum Date Set (MDS-periodic assessment and care screening) dated December 3, 2025, reveals a BIMS (brief interview of mental status) score of 11, indicating moderately impaired cognitive status. Section O- Special Treatments, Procedures and Programs, of the MDS indicated the Resident was hospice status on admission to the facility November 26, 2025. Review of Resident 13's baseline care plan revealed that it was created December 4, 2025, (8 days post-admission) and not within 48 hours of admission. Review of Resident 13's physician orders for November 2025; December 2025; and January 2026 failed to reveal an order for hospice services. On January 13, 2026, the facility was requested to provide a hospice agreement for the specific hospice agency providing care to Resident 13. The facility was unable to provide an agreement until January 14, 2026, and that agreement was not signed by the hospice agency. During an interview with the Nursing Home Administrator (NHA) on January 14, 2026, the NHA confirmed the baseline care plan was not developed within 48 hours of admission, no physician order for hospice in the medical record, and the hospice agreement was never authorized by the facility and hospice agency prior to services being initiated at the facility. 28 Pa, Code 201.18(b)(1)(3) Management28 Pa Code 211.2(d)(3) Medical Director

Based on review of select Resident Council meeting minutes, resident and staff interviews, observations, and completion of one meal test tray, it was determined that the facility failed to provide foods that are palatable, attractive, and at appetizing temperatures. Findings include: Review of the Resident Council Meeting minutes for October 29th, 2025, and December 26, 2025, revealed residents voiced concerns with cold food and dry meat. During the initial pool process, Residents 75, 97, and 107 voiced concerns about the meals to include food temperature, texture, taste, and portion size. Review of the Culinary and Nutrition Test [NAME] form, not dated, documented point of service temperatures as follows: hot entree and starch greater than 135 degrees Fahrenheit (F), cold entree and dessert less than 41 degrees F. A test tray completed on January 12, 2026, revealed adequate portions size for all meal items; however, the chicken tenders, mixed vegetables, and potato salad weren't palatable for temperature, and the potato salad wasn't palatable for texture or taste (potatoes were hard and the dressing was thin consistency, bland and stark white in color). The test tray was placed on a meal cart and delivered to D2 unit with other trays being delivered at that time; 14 minutes had elapsed between the time the test tray was delivered to the unit and presented for evaluation. Employee 6 (Food Service Director) took temperatures of the food items at the time the test tray was served for evaluation. The following were the recorded highest temperatures: Chicken tenders - 115 degrees Fpotato salad - 44 degrees Fmixed vegetables - 123 degrees Fchocolate pudding 42 - degrees Fmilk- 44 degrees F Interview with Employee 6 during the test tray evaluation on January 12, 2026, at 11:59 AM, it was revealed that the facility made the potato salad in house. Review of the recipe for the potato salad included potatoes, vegetable oil, cider vinegar, lemon juice, yellow mustard, salt, black pepper, and mayonnaise. Interview with Employee 6 on January 12, 2026, at 12:40 PM, it was revealed that the menu, extension sheets, and recipes utilized are from the contracted Foodservice Distributer. It was revealed that mustard should've been used in the potato salad and noted there wasn't a significant amount of mustard in the recipe. 28 Pa. Code 201.14. Responsibility of licensee28 Pa code 211.6 - Dietary Services

Based on facility policy review, observation, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one resident reviewed (Resident 94). Findings include: Review of facility policy, titled Administering Medications, last reviewed July 25, 2025, read, in part, Medications are administered in a safe and timely manner, and as prescribed. Review of Resident 94's clinical record revealed diagnoses that included gastro esophageal reflux disease (a chronic digestive disease where the liquid content of the stomach refluxes into the esophagus, the tube connecting the mouth and stomach), muscle weakness, and hypertension (high blood pressure). Observation in Resident 94's room January 11, 2026, at 11:10 AM, revealed a cup containing 11 medications on her bedside table.During an interview with Employee 4 (Licensed Practical Nurse) on January 11, 2026, at 11:11 AM, the surveyor inquired about the medications being left at Resident 94's bedside. Employee 4 stated when she went to pass Resident 94's medications, the Resident was eating breakfast, so she left them on her bedside table. She further revealed she signed them off as administered at 8:51 AM, and Resident 94 should have taken her medications by then. Interview with the Director of Nursing on January 14, 2026, at 11:21 AM, revealed she would expect Resident 1's medications not to be left at the bedside, and she would expect medications to not be signed off as administered until after they are taken by a resident.28 Pa. Code 201.18(b)(1) Management28 Pa Code 211.12(c)(d)(1)(5) Nursing Services

Based on facility policy review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to develop and implement a person-centered care plan for two of 23 residents reviewed (Residents 39 and 75).Findings Include:Review of the facility's policy, titled Care Plans, Comprehensive Person-Centered, revised March 2022, read, in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physician, psychosocial, and functional needs is developed and implemented for each resident.Review of Resident 39's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and hemiparesis (weakness on one side of the body, affecting the arm, leg, and sometimes face, making it difficult to perform daily tasks like walking or grasping objects, often due to brain damage from conditions like stroke, tumors, or injury).An observation of Resident 39 in his bed on January 11, 2026, at 11:05 AM, revealed bilateral enabler bars attached to his bed. An immediate interview with Resident 39 revealed that he uses them to help position himself in his bed.Review of Resident 39's interdisciplinary plan of care revealed none developed to address Resident 39's use of the enabler bars based on his diagnoses and bed mobility status. An interview with the Nursing Home Administrator (NHA) on January 13, 2026, at 1:26 PM, confirmed no care plan was developed for Resident 39's use of enabler bars.Review of Resident 75's clinical record revealed diagnoses that included gastro esophageal reflux disease (a chronic digestive disease where the liquid content of the stomach refluxes into the esophagus, the tube connecting the mouth and stomach), hyperlipidemia (high blood cholesterol), and dementia (a general term for severe mental function loss).Observation of Resident 75 in his bed on January 11, 2026, at 10:58 AM, revealed bilateral enabler bars attached to his bed.Review of Resident 75's clinical record revealed a bed rail evaluation and a consent form were completed on October 23, 2025. Review of Resident 75's care plan failed to reveal a plan of care developed to address Resident 75's use of the enabler bars based on his diagnoses and bed mobility status.During an interview with the NHA on January 14, 2026, at 11:24 AM, revealed she would expect Resident 75 to have a care plan developed for his use of bed rails. 28 Pa. Code 211.10(d) Resident care policies.28 Pa. Code 211.11(d)(3)(5) Nursing services

Based on review of facility policy, record review, and staff interview, it was determined that the facility failed to provide side effect monitoring for one of five residents reviewed (Residents 56). Findings include:Review of facility provided policy, titled Policy for Psychotropic Medication Use, revised February 2025, revealed, Residents receiving psychotropic medication are monitored and the response to treatment is documented.Review of Resident 56's clinical record revealed diagnoses that included down syndrome (a genetic condition caused by having an extra copy of chromosome 21, affecting brain and body development) and dementia (a general term for severe mental function loss).Review of Resident 56's physician orders revealed an order for Risperidone (antipsychotic medication) 0.25 mg, given by mouth, twice daily, starting on December 2, 2025.Review of Resident 56's Care plan revealed a focus are of, the Resident uses psychotropic medications, with a date initiated of November 3, 2025, an intervention to monitor/record/report to MD, as needed, side effects of antipsychotic medications, which may include, but are not limited to: Dystonia, Tremors, Confusion, Restlessness, pacing, anxiety, Tardive Dyskinesia, Dry mouth, Blurred Vision, Constipation, Hypotension, Sedation/Drowsiness, Increased falls, Appetite/Weight change, Headache, Insomnia, Sore throat, Seizures, Sweating/Rash, Urinary Retention, with a date Initiated of November 3, 2025.Review of Resident 56's medical record failed to reveal any documented side effect monitoring for antipsychotic medication.Interview with the Director of Nursing on January 14, 2026, at 11:45 AM, revealed that Resident 56 did not have any side effect monitoring documented.211.12(d)(1)(3)(5) Nursing services

Based on observations and staff interviews, it was determined that the facility failed to post the nurse staffing data on a daily basis at the beginning of each shift, including an accurate resident census, on January 11 and 12, 2026. Findings include:During entrance to the facility on January 11, 2026, at 9:26 AM, the posted staffing was reviewed and observed to be dated January 9, 2025. Employee 2 (Director of Rehabilitation) came over and removed the two sheets of January 9 and 10, 2026, that were overtop of the staffing data sheet from January 11, 2026.Further observation of the posted staffing information for January 11, 2026, revealed a census number of 120 residents. During an interview with the Nursing Home Administrator (NHA) on January 11, 2026, at 10:13 AM, she revealed the facility census was 114 residents. Observation on January 12, 2026, at 1:28 PM, the posted staffing was reviewed and observed to be dated January 11, 2026; there was no sheet available for January 12, 2026.During an interview with the NHA on January 13, 2026, at 1:27 PM, she revealed she would expect daily staffing to be posted per the federal regulation. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on clinical record review and staff interviews, it was determined that the facility failed to maintain adequate personal hygiene and grooming of residents who are dependent on staff for assistance with these activities of daily living for two of four residents reviewed (Residents 2 and 3).Findings include: Review of Resident 2's clinical record documented diagnoses that included anxiety (a feeling of worry, nervousness, or unease), depression (feelings of severe despondency and dejection), Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills, eventually affecting the ability to carry out daily tasks), vascular dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking), bipolar (a mental health condition alternating periods of elation and depression), and hallucinations (a false perception of sight, sound, smell [NAME] or touch that seems real but has no externa stimulus). Further clinical record review revealed that Resident 2 was dependent, one-person physical assistance, for bathing/showering and was scheduled for showers on Tuesdays and Fridays on day shift.Review of task documentation revealed she received a bed bath, not a shower, on October 20th, 22nd, 23rd, and 24th, 2025, and was washed up at the sink on the 21st. The clinical record failed to include documentation for bathing on October 28th and 31st, 2025, and November 4th, 7th, and 11, 2025.During an interview with the Director of Nursing (DON) on November 19, 2025, at 3:15 PM, it was revealed that the family voiced concerns that included Resident 2 was not receiving showers. In response to the concern, the facility obtained statements from staff. Statements revealed Resident 2 would refuse to get out of bed, refused showers, and at times morning care was provided by night shift. Resident 2 was on Occupational Therapy (OT) and the DON witnessed OT providing a shower on one instance: November 14th, 2025. Review of Resident 3's clinical record documented diagnoses that included dementia with behavioral disturbances, vascular parkinsonism (cause by brain damage and symptoms may include gait disturbance, slowness, stiffness and cognitive issues), and adjustment disorder with mixed anxiety and depressed mood with disturbance of emotions and conduct. Further clinical record review revealed that Resident 3 was dependent, two-person physical assistance due to combativeness, for bathing/showering and was scheduled for showers on Tuesdays and Fridays on evening shift. Review of task documentation revealed she received a shower on October 31st, 2025, and was washed up at the sink on October 28th, 2025, and November 7th, 2025.The clinical record failed to include documentation for bathing on October 21st and 24th, 2025, and November 4th, 11th, and 14th, 2025.During an interview with the Nursing Home Administrator and DON on November 19, 2025, at 3:15 PM, it was revealed she felt that Resident 3 has had bathing completed but staff hadn't documented it. It was also revealed that Resident 3 had verbal and physical behaviors, as well as being up for several days. If the Resident is sleeping after long periods of being awake, the staff will let her sleep. 28 Pa code 211.12.(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a urinalysis and urine culture and sensitivity were completed timely for one of two resident records reviewed (Resident 4).Findings include:Review of Resident 4 clinical record revealed diagnoses that included history of urinary tract infection.Review of Resident 4's physician orders included: obtain UA (urinalysis) C&S (culture and sensitivity) one time only for 2 Days, started October 7, 2025, at 5:30 PM.Review of the Medication Administration Record documented 15 (resident refused and requested the urine be collected on day shift) on December 7th, 2025.Further review of the physician orders included obtain UA/ C&S discontinue once completed, started October 13th, 2025, at 3:00 PM, and discontinued October 13th, 2025, at 4:39 PM.Review of the urinalysis report dated October 13, 2025, at 6:20 PM, revealed the specimen was taken October 13th, 2025, at 10:19 AM, was received at 3:57 PM, and the result was available at 4:22 PM. The results revealed urine appeared turbid, trace protein, and 2+ glucose and protein; however, there was no bacteria present. Due to no bacteria, a C & S was not preformed.During an interview with the Nursing Home Administrator and Director of Nursing on November 19, 2025, at 3:30 PM, it was confirmed that Resident 4's urine sample should've been collected prior to October 13th, 2025, per physician order. It was also revealed that the Resident had requested the urine be collected on day shift. The Nurse completed the Medication Administration Record and didn't extend the order to include the following day; therefore, the order appeared like it was completed in the electronic record.28 Pa code 211.12 (d)(1)(5) Nursing Services

Based on facility policy, clinical record review, facility document review, hospital record review, and resident and staff interviews, it was determined the facility displayed past non-compliance by failing to ensure that residents were free from any significant medication errors, which resulted in actual harm, as evidenced by low blood pressure, low heart rate, sweating, lightheadedness, and hospital transfer, for one of two residents (Resident 1). Findings Include:Review of facility policy, titled Administering Medications, last revised April 2019, indicated medications are administered by licensed nurses or other staff who are legally authorized to do so in this state.The policy states:Medications are administered in accordance with prescriber orders, including any required time frame.The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include:a. Checking identification bandb. Checking photograph attached to medical record, andc. If necessary, verifying resident identification with other facility personnelThe policy also included, The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Review of the admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included congestive heart failure (condition in which the heart doesn't pump blood as well as it should) and discitis (a rare and serious medical condition that involves inflammation and infection of the intervertebral discs in the spine).Review of Resident 1's quarterly MDS (minimum data set- standardized assessment tool to gather comprehensive information about residents' functional capabilities, health status, and care needs) dated June 2, 2025, revealed a BIMS (brief interview of mental status) of 14, indicating intact cognition.In a statement by Resident 1 on July 4, 2025, Resident 1 verbalized that he was given his roommate's medications in error after swallowing more than his normal number of tablets, and that the same nurse approached him with an inhaler and nasal spray that belonged to his roommate.During an interview with Resident 1 on July 21, 2025, at approximately 9:30 AM, Resident 1 was asked to share the medication event that occurred on July 4, 2025. Resident 1 stated it was approximately 9:00 AM on July 4, 2025, that the nurse brought a cup of pills and glass of water and sat them on my bedside table, then told me she had to go to the cart for additional medications. I usually take 6-7 pills but there were many more once I placed them in my mouth. I swallowed them and then the nurse returned with an inhaler and Flonase (nasal spray) and that's when I realized the nurse was giving me my roommates medications. I looked right at her and said, you gave me my roommates medications, and Employee 1 responded, no I didn't. Resident 1 replied back to the nurse, I'm telling you, you did, and Resident 1 said he refused the nasal spray and inhaler, knowing it was his roommates. Employee 1 replied, I have other pills to give, I will be back. Resident 1 stated that he wasn't sure Employee 1 would report the error. Resident 1 said he requested his Nurse Aide to dress him so that he could go to the 1st floor and speak with the Supervisor. Resident 1 said he sat in the lounge for a while on the first floor thinking about how to handle the situation. At approximately 11:00 AM Employee 2 approached him and ask him if he was feeling OK, and also told him he didn't look well, you look white as a sheet. Resident 1 said he was feeling OK at that point but explained to Employee 2 that he was sure he received his roommate's medications. Resident added, the nurse began to monitor me, I remember feeling very tired, and later they sent me to the hospital. Review of the clinical record revealed Employee 2 notified Employee 3 (Registered Nurse) to assess Resident 1. Employee 3 initiated monitoring of Resident 1, which included taking his blood pressure every 15 minutes. A review of Resident 1's clinical record revealed that Resident 1's normal blood pressures were Systolic range 108-135 and diastolic range 52-70. Resident 1's normal heart rate range per his clinical record was 64-71. The physician was notified on July 4, 2025, at 10:45 AM and informed that Resident 1 stated he was given the wrong medication. The physician advised to monitor the Resident and notify him with any changes.On July 4, 2025, at 11:58 AM, Resident 1's BP [blood pressure] was 86/50; at 12:07 PM BP was 77/40; and at 12:07 PM, BP was 77/32. Resident 1's heart rate at 10:56 AM was 57; at 11:58 AM was 57; at 12:07 PM was 44, and at 12:17 was 34. The physician was notified of the drop in blood pressure and low heart rate. The physician ordered Resident 1 to be sent to the hospital. EMS arrived at 12:30 PM. Resident 1 arrived in the ED on July 4, 2025, at 12:44 PM. The facility sent the roommate, Resident 2's medication list with EMS so that the hospital was aware that medications included two AM blood pressure medications (one being a beta blocker that lowers heart rate, reduces blood pressure, and relaxes blood vessels). Review of the hospital discharge summary revealed Resident 1 presented with a medication error resulting in hypotension (low blood pressure). One liter of fluids was administered intravenously (IV) with improvement observed in blood pressure. Resident 1 remained bradycardic (low heart rate) but gradually improved over the course of ED observation. An ECG (electrocardiogram) revealed sinus bradycardia. Resident 1 was maintained on telemetry (remote collection and transmission of data i.e. vital signs) throughout the 5- and 1/2-hour hospital stay. The hospital clinical impression was documented to be accidental overdose. Resident 1 was instructed by hospital staff not to take any meds the rest of the day and to confirm his medications every morning with the nurse as he is being given them.A written statement by Employee 1 stated that Resident 1 believed he was given the wrong medication, but Employee 1 did not admit to a medication error. Employee 1 was questioned by the Nursing Home Administrator (NHA) about identification of the Resident prior to administering medications. Employee 1 stated she recognized the Resident because he used to be on the first floor. A review of Resident 1's record and Resident 2's record revealed both residents were previously on the 1st floor and were moved to the 2nd floor, in the same room, within 24 hours of each other. The facility implemented a plan of correction that included the following: Resident 1 was assessed immediately by RN. Vitals stable at the time. When change in condition was noted, he was transferred to hospital. Resident 2 (Resident 1's Roommate) was also interviewed and assessed at the time of the concern. Every shift vital sign and alert charting being completed on both Residents for three days. Residents were reviewed on that floor to ensure no others received the wrong medication. No complaints noted. Facility completed education with the licensed nurse on medication administration policy at the time of the incident. Resident 1 also received education to ensure his meds are correct prior to taking them. Facility initiated education on medication administration to all licensed staff to ensure appropriate 6 rights of administration are followed, and medication administration policy is followed. Director of Nursing/designee completed observation of medication pass on 2 staff daily x 2 days, then 3 observations per week for 4 weeks to ensure medication administration policy is followed; completed 7/5/2025 and 7/6/2025, respectively. Then initiated 3 x week for 4 weeks to ensure medication administration policy is followed. Results were reviewed at QAPI (Quality Assurance Performance Improvement) Committee meeting to ensure compliance and quality of care on July 7, 2025. During a phone interview on July 2, 2025, at 10:25 AM, Employee 4 (Licensed Practical Nurse) verified that she had received education on Administering Medications and was able to verbalize understanding, and stated the 6 rights of medication administration, adding the use of 2 forms to identify to ensure she has the right resident.During a phone interview on July 2, 2025, at 10:20 AM, Employee 2 (Licensed Practical Nurse) verified that she had received education on Administering Medications and was able to verbalize understanding, and stated the 6 rights of medication administration, adding the use of 2 forms to identify to ensure she has the right resident.During a phone interview on July 2, 2025, at 10:30 AM Employee 5 (Licensed Practical Nurse) verified that she had received education on Administering Medications and was able to verbalize understanding, and stated the 6 rights of medication administration, adding the use of 2 forms to identify to ensure she has the right resident. The facility demonstrated compliance with the above since July 7, 2025. Information was verified via review of Plan of Correction documentation and staff interviews. During an interview on July 21, 2025, at 1:15 PM, with the NHA and review of the facility's immediate actions, education, and review of the QAPI monitoring process, it was verified that the facility had implemented a plan of correction and achieved compliance ensuring residents are provided adequate safety during medication administration.During an interview on July 22, 2025, at 1:30 PM, the NHA confirmed the facility failed to ensure that residents were free from any significant medication errors for one of two residents, which resulted in harm for Resident 1. 28 Pa Code: 201.18 (b)(1)(3) Management28 Pa Code: 211.10 (d) Resident care policies

Based on observations, policy review, and staff and resident interviews, it was determined that the facility failed to ensure residents unable to carry out activities of daily living receive the necessary services to maintain good grooming and personal hygiene for four of 28 residents reviewed (Residents 3, 15, 17, and 93). Findings Include: Activities of Daily Living (ADLs) refer to basic self-care tasks that people typically perform daily. A review of the facility's policy, titled Activities of Daily Living (ADL's), revised March 2018, read, in part, Appropriate care and services will be provided for residents who are unable to carry out ADLs, including appropriate support and assistance with hygiene [bathing, dressing, grooming and oral care]. A review of Resident 3's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and quadriplegia (a condition characterized by the complete or partial loss of motor and sensory function in all four limbs [arms and legs]). An observation of Resident 3, on February 24, 2025, at 1:10 PM, revealed facial hair including hair on her upper lip and chin areas. An immediate interview with Resident 3 revealed she does not like having hair on her face and would prefer to be assisted with shaving by staff. A review of Resident 3's interdisciplinary plan of care revealed the need for staff assistance with personal hygiene, including ADLs. An interview with the Social Services Director (Employee 4) and the Nursing Home Administrator (NHA) on February 26, 2025, at 11:00 AM, revealed Resident 3's family had been contacted regarding supplying an electric razor, and the facility has no documentation of such requests made to the family. Review of Resident 15's clinical record revealed diagnoses that included muscle weakness (decreased ability of muscles to generate force) and chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty or discomfort in breathing). During an interview with Resident 15 on February 24, 2025 at 11:25 AM, Resident 15 stated that she is scheduled for showers twice a week, but staff only give her a bed bath and sometimes she goes weeks without having her hair washed. She stated that she is told that there are not enough staff to assist her with her showers. Review of Resident 15's clinical record revealed she is scheduled for showers on the 7 AM - 3 PM shift on Wednesdays and Saturdays. Review of Resident 15's shower documentation for August 2024 - February 2025 revealed Resident 15 is documented as receiving four showers since her admission in August 2024: September 9, 2024; October 5, 2024; December 28, 2024; and February 22, 2025. During an interview with the NHA and Director of Nursing (DON), on February 26, 2025 at 1:50 PM, the DON revealed she had no additional information as to why Resident 15 was not getting showers. A review of Resident 17's clinical record revealed diagnoses that included muscle weakness and dementia (a group of neurological disorders characterized by a progressive decline in cognitive abilities, such as memory, thinking, reasoning, and problem-solving). An observation of Resident 17, on February 24, 2025, at 1:23 PM, revealed a significant amount of facial hair covering her upper lip and chin areas. An immediate interview with Resident 17 revealed she does not like having facial hair and stated, It's like they can't do nothing about it. A continued review of Resident 17's clinical record revealed she requires, at times, limited, extensive, or total dependence with her hygiene care. An interview with the DON on February 25, 2025, at 1:03 PM, revealed the facility staff have been going back and forth with the family regarding supplying an electric razor. However, the facility could not produce documentation of such discussions with Resident 17's family. An additional observation of Resident 17 on February 27, 2025, at 10:39 AM, revealed no change in her facial hair. An interview with the Nurse Aide (Employee 7) on February 27, 2025, at approximately 10:45 AM, revealed she would assist Resident 17 today with shaving her facial hair. Review of Resident 93's clinical record revealed diagnoses that included peripheral vascular disease (narrowing of the arteries causing reduced blood flow to the limbs) and acquired absence of left foot (surgical removal of the foot). During an interview with Resident 93 on February 24, 2025, at 11:11 AM, Resident 11 stated that she is scheduled for showers twice a week but, usually only receives one shower a week. She stated she required staff assistance in the shower, and she is told that there are not enough staff to assist her with her showers. Review of Resident 93's clinical record revealed she is scheduled for showers on the 7 AM - 3 PM shift on Tuesdays and Fridays. Review of Resident 93's shower documentation for December 2024 - February 2025 revealed Resident 93 is documented as receiving a bed bath instead of a shower on the following dates: December 3 and 27, 2024; January 7, 10, 17, 21, 24, and 31, 2025; and February 7 and 25, 2025. Resident 93's shower is documented as not applicable on December 17, 2024, and January 28, 2025; and there is no documentation Resident 93 received a shower on December 6, 13, and 20, 2025; and February 14 and 18, 2025. During an interview with the NHA and DON on February 26, 2025, at 1:50 PM, the DON revealed she had no additional information as to why Resident 93 was not getting showers. 28 Pa. Code 211.12 (d) (1) (5) Nursing services

Based on clinical record review, and interviews with staff and residents, it was determined that the facility failed to provide care and services as ordered by the physician for two of 28 residents reviewed (Residents 6 and 99). Findings Include: Review of the clinical record for Resident 6 revealed diagnoses that included lymphedema (swelling in the legs caused by lymphatic system blockage) and peripheral vascular disease (circulatory condition which narrowed blood vessels reduce blood flow to the limbs). During an interview with Resident 6 on February 24, 2024, at 11:14 AM, the Resident was asked about his lymphedema pumps (pumps that use compressed air to apply pressure to the affected limb to force excess fluid out of the limb) that were lying in his room. Resident 6 stated that the pumps are to be applied twice a day but they are never done twice a day and sometimes goes a week without it being done. Review of Resident 6's physician orders dated February 2025, stated, lymphedema pumps to bilateral lower extremities: cover legs with pillowcases before putting boots on. To perform for 1 hour twice a day- can do three times a day. Pressure setting at 35 mmHg (millimeters of mercury-unit of measure for pressure) due to open wounds. Use foam wedge under legs. Further review of Resident 6's physician orders dated February 2025, required staff to cleanse both lower legs with soap and water, apply A&D ointment or Vaseline (per availability) twice a day and leave open to air every dayshift and evening shift. Review of Resident 6's TAR (Treatment Administration Record) for February 2024, revealed that the order for lymphedema pumps was not signed as administered on February 1, 5, 7, 10, 13, 14, 18, 19, and 22, 2025, on dayshift. Further review of the TAR for February 2025 revealed the order for cleansing the lower legs and applying A&D or Vaseline was not signed off as completed on dayshift February 1, 5, 6, 7, 10, 13, 14, and 19, 2025; and not signed off as completed February 24, 2025, evening shift. During an interview with the Director of Nursing (DON) on February 27, 2025, at 11:20 AM, the DON informed the surveyor that staff assigned to apply the lymphedema pumps and perform treatment to the lower legs, on the above dates, were unable to provide the treatment because they were too busy covering as house supervisor. Review of Resident 99's clinical record revealed diagnoses that included end stage renal disease (condition where one's kidneys are functioning below 10 percent of their normal function) and type II diabetes mellitus (impairment in the way the body regulates and uses sugar [glucose] as a fuel resulting in too much sugar circulating in the bloodstream). Review of Resident 99's physician orders revealed an order for Novolin (insulin - hormone produced by the body which allows the body to use sugar), inject per sliding scale before each meal and at bedtime related to diabetes mellitus, effective December 2, 2024. Further review of the order revealed instructions to notify the physician if Resident 99's blood sugar reading was greater than 351. Review of Resident 99's February 2025 MAR (Medication Administration Record - form used to document physician orders as well as when and how medications are administered to a resident) revealed that a blood sugar reading of 365 was recorded on February 17, 2025. Review of Resident 99's clinical record revealed no evidence that the physician was notified of this blood sugar reading on that date. During an interview with the DON on February 27, 2025, at 9:30 AM, she revealed that she was unable to locate evidence that the practitioner was notified of Resident 99's blood sugar reading on February 17, 2025. 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents who required dialysis services received such services consistent with professional standards of practice for two of two residents reviewed for dialysis (Residents 80 and 99). Findings include: A review of facility policy, End-Stage Renal Disease, Care of a Resident with, revised September 2010, revealed, Agreements between this facility and the contracted ESRD [End Stage Renal Disease] facility include all aspects of how the resident's care will be managed and may include: how information will be exchanged between the facilities. A review of Resident 80's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and chronic end-stage or end-stage kidney (a severe and irreversible condition where the kidneys lose their ability to function). A review of Resident 80's physician orders revealed an order for dialysis treatments every Monday, Wednesday, and Friday. A review of Resident 80's dialysis communication forms (documents pre-dialysis, dialysis center, and post-dialysis information and vitals) for February 2025 revealed either incomplete or non-existent communication forms with the dialysis center on February 3, 7, 19, 21, and 24, 2025. Continued review of Resident 80's physician orders revealed an order for daily weights for Health Monitoring Notify MD [Medical Doctor] if 4 lb. [pound] or greater weight gain. A review of Resident 80's Medication Administration Record for the month of February 2025 revealed missing weights on February 1, 3, 7, 9, 12, 17, 19, 25, and 26, 2025. Interviews with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on February 27, 2025, at 9:35 AM, confirmed the lack of completion of Resident 80's dialysis communication forms and confirmed staff had not documented the daily weights as ordered by the physician. A review of Resident 99's clinical record revealed diagnoses that included end-stage renal disease (a condition where one's kidneys are functioning below 10 percent of their normal function) and dependence on renal dialysis (treatment that removes extra fluid and waste products from the blood when the kidneys are not able to function properly). A review of Resident 99's physician orders revealed an order for dialysis every Monday, Wednesday, and Friday effective November 5, 2024. A review of dialysis communication forms revealed that forms were only present for the following dates: February 10, 12, 14, and 17, 2025; and that the forms were not completed in their entirety on February 12, 14, and 17, 2025. During an interview with the DON and NHA on February 27, 2025, at 9:39 AM, they confirmed that they could not locate any additional dialysis communication forms for Resident 99. They also revealed the expectation that the forms should have been fully completed each time Resident 99 received dialysis services. A review of Resident 99's physician orders also revealed an order for daily weights for health monitoring, effective October 19, 2024. A review of Resident 99's January 2025 and February 2025 MARs (Medication Administration Records - a form used to document physician orders as well as when and how medications are administered to a resident) revealed that daily weights (or refusal of) were not recorded on four dates in January 2025 and on six dates in February 2025. During an interview with the DON and NHA on February 26, 2025, at 1:20 PM, they revealed they were unable to locate any additional information about the missing weights. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on resident and staff interviews, clinical record review, and policy review, it was determined that the facility failed to provide sufficient nursing staff to provide nursing and related services for two of 26 residents reviewed (Residents 15 and 93). Review of the facility assessment and documentation determined that the facility failed to meet the staffing needs of their residents. Findings Include: Review of the facility's document, titled Facility Assessment, approved August 9, 2024, revealed its purpose is to determine what resources are necessary to care for our residents competently during both day-to-day operations (including nights and weekends) and emergencies. The document continued, This assessment addresses . The care required by the resident population using evidence-based, data driven methods that consider the types of diseases, conditions, physical and behavioral health needs, cognitive disabilities, overall acuity, and other pertinent facts that are present within that population, consistend with and informed by individual resident assessments. Also, The facility assessment will be used to inform staffing decisions to ensure there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs and consider specific staff needs for each resident unit in the facility and adjust as necessary based on any changes to its resident population. According to the section, titled Skilled Acuity .October-December 2024, the facility assessed its population to include 20 residents as Special Care High; 15 Clinically Complex residents; 13 Orthopedic residents; 4 Major Joint Replacement or Spinal Surgery residents; 51 Medical Management residents; 46 residents with a Function score between 10-23; and 13 Other Orthopedic residents. Resident acuity affecting the Nurse Aide staff revealed 97 residents Assistance Provided with Dressing and Bathing; 83 residents Assistance Provided with Transfers; 88 residents Assistance Provided with Toileting; and 72 residents Assistance with Mobility, to name a few. Review of the documented staffing needs per shift for Nurse Aide staff revealed 12 Nurse Aide staff required for the day shift. Review of day shift staffing information dated February 22, 2025, revealed there were 8.57 Nurse Aide staff working that day shift; 7.80 on February 23, 2025; and 7.37 on February 24, 2025. Therefore, based on the Facility Assessment, the facility was not meeting its assessed staffing needs of its residents. Review of facility policy, titled Activities of Daily Living (ADLs), Supporting, reviewed July 2024, revealed, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care). Review of Resident 15's clinical record revealed diagnoses that included muscle weakness (decreased ability of muscles to generate force) and chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty or discomfort in breathing). During an interview with Resident 15 on February 24, 2025, at 11:25 AM, Resident 15 stated that she is scheduled for showers twice a week, but staff only give her a bed bath and sometimes she goes weeks without having her hair washed. She stated that she is told that there are not enough staff to assist her with her showers. Review of Resident 15's clinical record revealed she is scheduled for showers on the 7 AM - 3 PM shift on Wednesdays and Saturdays. Review of Resident 15's shower documentation for August 2024 - February 2025 revealed Resident 15 is documented as receiving four showers since her admission in August 2024: September 9, 2024; October 5, 2024; December 28, 2024; and February 22, 2025. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON), on February 26, 2025, at 1:50 PM, the DON revealed she had no additional information as to why Resident 15 was not getting showers. The NHA acknowledged that there have been staffing issues. Review of Resident 93's clinical record revealed diagnoses that included peripheral vascular disease (narrowing of the arteries causing reduced blood flow to the limbs) and acquired absence of left foot (surgical removal of the foot). During an interview with Resident 93 on February 24, 2025, at 11:11 AM, Resident 11 stated that she is scheduled for showers twice a week but, usually only receives one shower a week. She stated she requires staff assistance in the shower, and she is told that there are not enough staff to assist her with her showers. Review of Resident 93's clinical record revealed she is scheduled for showers on the 7 AM - 3 PM shift on Tuesdays and Fridays. Review of Resident 93's shower documentation for December 2024 - February 2025 revealed Resident 93 was documented as receiving a bed bath instead of a shower on the following dates: December 3 and 27, 2024; January 7,10, 17, 21, 24, and 31, 2025; and February 7 and 25, 2025. Resident 93's shower was documented as not applicable on December 17, 2024, and January 28, 2025; and there was no documentation Resident 93 received a shower on December 6, 13, and 20, 2025; and February 14 and 18, 2025. During an interview with the NHA and DON on February 26, 2025, at 1:50 PM, the DON revealed she had no additional information as to why Resident 93 was not getting showers. The NHA acknowledged that there have been staffing issues. During interviews with Employees 5, 6, and 7, on February 27, 2025, at approximately 12:30 PM, they stated that there are not enough staff to assist residents with care, especially showers and that typically there are only two nurse aides to cover the entire unit. 28 Pa code 211.12(d)(1)(5) Nursing services

Based on observations, clinical record review, as well as resident and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for each resident for two of 28 residents reviewed (Residents 63 and 99). Findings include: Review of Resident 63's clinical record revealed diagnoses that included quadriplegia (partial or total loss of use of all four limbs) and muscle weakness. Observation of Resident 63 on February 24, 2025, at 12:20 PM, revealed that contractures (permanent shortening and tightening of muscle fibers that reduces flexibility and makes movement difficult) were present in both of his hands. Resident 63 was observed wearing a splinting device on his right hand. During an immediate interview with Resident 63, he confirmed he had contractures and utilized splinting devices to prevent further functional loss. Review of Resident 63's physician orders revealed an order to cleanse both hands and check placement of cushion pad/brace that is worn at all times for contractures each shift, effective June 1, 2023. Review of Resident 63's occupational therapy discharge summary (focuses on helping individuals perform everyday activities), dated December 18, 2024, revealed that the therapist educated and communicated with nursing staff on Resident 63's splint wearing schedule and the need to assess his skin. Review of Resident 63's care plan revealed that his use of splints for hand contractures and related interventions/precautions was not included in his plan of care until February 25, 2025. During an interview with the Nursing Home Administrator on February 27, 2025, at 12:09 PM, she revealed the expectation that this information should have been included in Resident 63's care plan prior to that date. Review of Resident 99's clinical record revealed diagnoses that included end stage renal disease (condition where one's kidneys are functioning below 10 percent of their normal function) and type II diabetes mellitus (impairment in the way the body regulates and uses sugar [glucose] as a fuel, resulting in too much sugar circulating in the bloodstream). Review of Resident 99's physician orders revealed an order for Novolin (insulin - hormone produced by the body which allows the body to use sugar) before each meal at at bed time for diabetes mellitus, effective December 2, 2024. Review of Resident 99's care plan failed to reveal any information related to his diagnosis of diabetes mellitus or his use of insulin. In an email received from the Director of Nursing on February 27, 2025, at 12:23 PM, she confirmed that there was no present or past care plan for Resident 99's diagnosis of diabetes or his use of insulin, but that his care plan would be updated with this information. 28 Pa. Code 211. 12(d)(1)(3)(5) Nursing services

Based on observations, clinical record review, facility policy review, and resident and staff interviews, it was determined the facility failed to comprehensively assess and provide treatment to a wound resulting in harm, as evidenced by deterioration of the wound, pain, and a positive wound culture which required antibiotic administration for 10 days for one of five residents reviewed (Resident 1); failed to date a wound dressing for one of five residents reviewed (Resident 2); and failed to off-load heels per treatment order for one of five residents reviewed (Resident 3). Findings include: A review of the facility policy, titled Skin and Wound Management System, last revised April 2017, states, facility to identify and assess residents with wounds and/or pressure ulcers .provide appropriate treatment .ongoing monitoring and evaluation are then provided to ensure optimal resident outcomes. A review of the clinical record for Resident 1, revealed clinical diagnoses that included Dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and Dysphagia (difficulty swallowing). Review of Resident 1's Quarterly Minimum Data Set (MDS-periodic assessment of resident needs) dated February 2, 2023, revealed a BIMS (brief interview of mental status) score of 4, indicating severe cognitive impairment. During an attempted interview with Resident 1 on May 6, 2023, at approximately 8:45 AM, a wound bandage was observed near the left clavicle region (between shoulder blade and the sternum) that continued down onto the left scapula area. Due to being unable to visualize the entire bandage, Employee 1 (Licensed Practical Nurse) was requested to reveal the bandage for surveyor observation. Employee 1 stated immediately the dressing is dated April 22, 2023, and that is unacceptable. Employee 1 initiated removing the dressing and a moderate amount of purulent drainage (yellowish/greenish/grayish thick drainage- a sign of infection) and a foul odor was noted. Employee 1 stopped removing the bandage because Resident 1 was yelling out with pain. Resident 1 requested pain medication and it was administered. Employee 1 immediately notified Employee 2 (Registered Nurse Supervisor), who then notified the Director of Nursing (DON) regarding the dressing and drainage. The DON also notified the physician for orders. Employee 2 and the DON removed the dressing completely. The wound was measured by Employee 2 and measured 5.0 centimeters by 4.0 centimeters by 0.1 centimeters. A wound culture was obtained at 9:55 AM from the bed of the wound per physician orders, followed by an ordered treatment to the area; which consisted of cleansing the wound with normal saline solution, applying calcium alginate, and a border dressing. After identifying the wound and lack of a dressing change, Resident 1's progress notes were reviewed. The progress notes dated April 21, 2023, at 5:19 PM, stated, late entry for 4/20/2023, resident has a known lesion on her left shoulder that prior to today has been closed. However, Nurse Aide found blood on her sheet and ask RN to look at it. There was a small open area measuring 0.2 centimeters x 0.2 centimeters that opened, most likely friction with fragile skin, cleansed with normal saline solution and covered with Optifoam [non-adhesive foam dressing]. Further review of the progress notes dated April 22, 2023, at 1:58 PM, stated, there is a small open area on residents left [no location noted] measuring 0.2 centimeters x 0.2 centimeters that has been cleansed with normal saline solution and covered with Optifoam. No complaints of pain. Will continue to monitor throughout shift. There were no additional progress notes for Resident 1 regarding the left shoulder area, and no notification to the physician or Resident Representative. A review of the clinical record for Resident 2, revealed diagnoses that included a stage 3 pressure ulcer (ulcer involving full thickness of skin loss, exposing tissue) on the right gluteus (buttock) and type 2 diabetes mellitus (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin). A review of the current physician orders for Resident 2, effective April 24, 2023, indicated a treatment as follows: cleanse area with normal saline solution, apply medi-honey patch, and cover with foam dressing daily and prn (as needed). Observation of Resident 2's dressing on May 6, 2023, at 10:55 AM, revealed the foam dressing was not dated. Employee 1 confirmed that the dressing was not initialed and dated and stated that the wound doctor was in to assess the wound. Review of the clinical record did reveal the Resident's wound was evaluated on May 5, 2023, by the wound care physician. A review of the clinical record for Resident 3 on May 6, 2023, at 10:46 PM, revealed diagnoses that included deep tissue injury (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure or shear) of the right heel and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). A review of the current treatment orders for Resident 3 is to off-load heels while in bed. Observation on May 6, 2023, at 10:40 AM, revealed Resident 3's heels were touching the mattress. The mattress of the bed had slid down several inches and was propped on top of the bottom bed board that was applying additional pressure to the heels. Employee 3 was present and advised the Nurse Aide to immediately pull mattress into place and off-load pressure on Resident 3's heels. During an interview with the DON and Nursing Home Administrator (NHA) on May 6, 2023, at approximately 1:00 PM, the DON and NHA confirmed Resident 1's wound dressing should have been reported, the dressing should have been dated, and routine treatments should have been initiated on April 20, 2023, when the wound was identified. On May 6, 2023, all residents were evaluated for any unknown wounds. Residents with current dressings were assessed to make sure they were changed per physician order. The NHA and DON also agreed that Resident 2's dressing should have been dated, and Resident 3's heels should have been off-loaded. Resident 1's wound was identified and then the wound dressing was left in place for 14 days with no further assessment or treatment; which resulted in harm to the Resident who suffered with pain, had deterioration of the wound, a positive wound culture that revealed the wound was infected with two types of bacteria, and required antibiotic administration for 10 days. 28 Pa, Code 201.18(b)(2) Management 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.12(c)(d)((1)(2)(5)(e)Nursing services

Based on observation, facility policy review, clinical record review and staff interview, it was determined that the facility failed to timely identify and address declines in skin integrity under a palm protector to the left hand which resulted in harm with the development of a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure or friction on the skin) to the left hand for one of three residents reviewed for pressure ulcers (Resident 96); and failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer for two of two dressing change observations (Residents 96 and 102). Findings Include: Review of Resident 96's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 96's Occupational Therapy discharge summary, for dates of service March 2, 2021-March 19, 2021, revealed that therapy was working with Resident 96 to trial wearing a palm protector to her left hand. Review of the discharge summary dated March 19, 2021, revealed that therapy staff educated Resident 96's caregivers on positioning, safety precautions, splinting schedule and skin checks. Review of therapy's discharge recommendations revealed a recommendation for the palm protector to be worn at all times and taken off for hygiene. Review of Resident 96's physician orders, revealed an order with a start date of March 19, 2021, and a discontinued date of April 5, 2021, to wear white palm protector to left hand at all times except during bathing and dressing in order to complete hand hygiene. Further review of Resident 96's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 96's care plan revealed an intervention initiated on March 19, 2021, and resolved on April 6, 2021, to wear white palm protector to left hand at all times except during bathing and dressing in order to complete hand hygiene. Review of Resident 96's nursing progress note, dated April 5, 2021, at 3:28 PM revealed that during weekly wound rounds with the wound nurse and wound physician to assess Resident 96's existing pressure ulcers, Resident 96 was noted to have a stage 4 pressure injury (full thickness tissue loss with exposed bone, tendon or muscle) to the left hand. Further review of the nursing note revealed, Wound related to pressure from a medical device. Resident utilizes palm protector to left hand, wound is related to placement and tightness of palm protector. Review of Resident 96's wound physician consult, dated April 5, 2021, revealed that the wound physician documented Resident 96 as having a stage 4 medical device associated pressure injury to the left hand, measuring 2.0 cm (centimeters) in length, 1.0 cm in width, unable to determine the depth and a wound area of 2.0 cm2 (square centimeters). Review of Resident 96's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was dated April 6, 2021 and stated to cleanse the wound, apply skin prep around the wound, apply [MEDICATION(S)] ointment (prescription medication used to treat skin infections) to the wound bed and cover with foam adhesive dressing every day and as needed. Review of Resident 96's clinical record revealed no evidence of any skin breakdown being identified to Resident 96's left hand prior to April 5, 2021. Review of nurse aide documentation titled, skin review on April 5, 2021, at 12:18 AM revealed no skin issues were documented or identified. During an interview with Licensed Practical Nurse (LPN) 4 on April 7, 2021, at 10:01 AM LPN 4 stated that both nurses and nurse aides were responsible for Resident 96's splint and that it would be removed with care in the morning and evening. In a follow up interview with LPN 4 on April 7, 2021, at 10:55 AM, LPN 4 stated she was not trained with the splint but she knew how to use it. LPN 4 stated that when a resident is ordered a splint/brace from therapy, therapy shows the staff how to use it. During an interview with Nurse Aide (NA) 2 on April 7, 2021, at 10:53 AM, NA 2 stated Resident 96's palm protector would be removed with care twice a day- once in the morning and once in the evening. NA 2 stated occupational therapy took her into the room and trained her how to correctly apply and remove the palm protector. During an interview with NA 3 on April 7, 2021, at 11:39 AM, NA 3 stated she did not care for Resident 96 during the time Resident 96 was ordered the palm protector. NA 3 stated that when a device is recommended by therapy, therapy will show staff how to correctly apply and remove the splint. During an interview with NA 4 on April 7, 2021, at 12:11 PM, NA 4 stated she did not care for Resident 96 during the time Resident 96 was ordered the palm protector. NA 4 stated that when a device is recommended by therapy, therapy will teach staff how to use it correctly. NA 4 stated if staff work an off shift, such as nightshift when therapy is not there, nursing staff will train her how to correctly use the device. The facility failed to timely identify and address declines in skin integrity to prevent the development and/or worsening of a pressure ulcer which resulted in harm in the development of a pressure ulcer to the left hand of Resident 96. Review of facility policy titled, Handwashing/Hand Hygiene, initiated October 2017, and reviewed most recently in December 2020, revealed use of alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before performing any non-surgical invasive procedures; before handling clean or soiled dressings, gauze pads, etc.; before moving from a contaminated body site to a clean body site during resident care; after handling used dressings, contaminated equipment, etc. Also revealed, the use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Also revealed, Applying and Removing Gloves, 1. Perform hand hygiene before applying non-sterile gloves. Observation of Resident 96's pressure ulcer dressing change to Resident 96's left lateral foot, on April 7, 2021, at 10:02 AM revealed Licensed Practical Nurse (LPN) 4 gathering supplies and washing her hands. LPN 4 then applied gloves and removed the old dressing using scissors to cut the gauze wrap. Wearing the same pair of gloves, LPN 4 then cleansed the wound with normal saline, applied skin prep around the wound, removed her gloves and applied new gloves. LPN 4 did not perform hand hygiene after removing her old gloves and prior to applying new gloves. LPN 4 applied Santyl (ointment used to remove dead tissue from wounds to help them heal) to the wound bed and then used the same scissors as used prior to cut the old dressing, to cut the calcium alginate (used to promote healing of a wound) that was then placed on the wound. LPN 4 was not observed cleaning the scissors after using them to remove the old dressing and prior to using them to cut the calcium alginate. Review of Resident 96's active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident 96's dressing change on April 7, 2021, at approximately 10:15 AM revealed LPN 4 first looking in Resident 96's clinical record to confirm the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN 4 was not observed performing hand hygiene prior to applying gloves. LPN 4 then removed her gloves, exited the room to gather skin prep that was needed for the dressing change, and then performed hand hygiene upon entering Resident 96's room. LPN 4 then applied gloves, placed skin prep around the wound, applied the [MEDICATION(S)] ointment, removed her gloves and applied new gloves. No hand hygiene was performed after removing the old gloves and prior to donning new gloves. LPN 4 then wrapped Resident 96's wound with Kling wrap (stretch gauze). LPN 4 was not observed cleansing the wound nor applying an adhesive foam dressing, per the current physician order. Review of nursing progress note dated April 6, 2021, revealed that the adhesive foam dressing was not sticking to the intact skin around the wound and a new treatment order was recommended to cleanse the wound, apply skin prep around the wound, apply [MEDICATION(S)] to wound bed, cover with 4x4 gauze and secure with Kling wrap. On April 8, 2021, at 9:45 AM the Director of Nursing (DON) stated that the wound nurse reassessed Resident 96's left hand treatment on April 6, 2021, and recommended the new treatment. The DON stated the provider was aware, but the order was never changed in the system. The DON also stated that LPN 4 knew about the new dressing recommendation. LPN 4 did not follow the current physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 102's clinical record revealed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 102's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident 102's dressing change procedure on April 7, 2021, at 10:26 AM revealed LPN 2 performed the entire ordered dressing change on Resident 102's sacral region and did not sanitize her hands with alcohol based hand sanitizer or soap and water prior to starting the dressing, after removing the soiled dressing, after cleansing the wound, after applying the [MEDICATION(S)] cream, the [MEDICATION(S)] gel, the [MEDICATION(S)] ointment, and the Santyl; or before covering the wound with the [MEDICATION(S)] and the [MEDICATION(S)]. LPN2 did not perform hand hygiene from the time she entered Resident 102's room until she cleaned up her supplies and was preparing to leave Resident 102's bedroom. Interview with the DON on April 7, 2021, at 1:45 PM revealed that the nurse who applied the dressing should have followed facility policies. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.12(a)(c)(d)(3) Nursing services. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation and interviews with staff, it was determined that the facility failed to ensure the environment remained free of accident hazards for one out of 2 floors toured (first floor), thereby placing the health and safety of the residents in Immediate Jeopardy. Findings include: Observation of the C-1 Lounge (first floor lounge) during a facility tour, accompanied by the Housekeeping Supervisor 1 (HKSP 1) on September 17, 2014, at 9:40 a.m., revealed a water cooler with dispensers for both hot and cold water. The temperature, as gauged by HKSP 1's thermometer, registered at 154 degrees Fahrenheit. An interview with HKSP 1 on September 17, 2014, at 9:55 a.m., revealed that the lounge is accessible to residents and families. According to the Director of Nursing, at the time of the survey there were 138 residents living in the facility, of those 45 were able to ambulate independently and 67 were diagnosed has having intellectual disabilities and/or dementia. The dispensers located in the C-1 Lounge were accessible to all of the residents. On September 17, 2014, at 10:40 a.m., the Nursing Home Administrator was notified that Immediate Jeopardy (IJ) had been identified, related to the hot water dispenser. An action plan was requested on September 17, 2014, at 10:45 a.m., to immediately put systems in place to ensure the safety of the residents and prevent third degree (full thickness) burns from high water temperatures. The IJ was removed on September 18, 2014, at 9:10 a.m., when the plan of action was fully implemented. The water cooler with hot water had been replaced with a water cooler which only dispensed cold water. An interview with the Nursing Home Administrator on September 18, 2014, at 9:10 a.m., revealed that the original water cooler was installed in July of 2014, and he was unaware that it would dispense hot water. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. Previously cited 8/8/13, 9/21/12.

Based on review of clinical records and staff interview, it was determined that the facility failed to ensure the necessary care and services to maintain resident well-being related to the administration of medication and following advanced directives for one of three sampled residents (Resident 2). Findings include: Review of Resident 2's Initial MDS (minimum data set assessment - an assessment tool used to document resident care needs) revealed admission to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the nursing notes revealed that Resident 2 experienced a change in condition and was transferred and admitted to the hospital on [DATE]. Upon readmission to the facility on [DATE], the physician ordered [MEDICATION NAME] (a medication that treats nerve pain) 300mg at noon and bedtime and 600mg in the morning and midafternoon with instructions to hold for sedation (increased sleepiness or drowsiness caused by a medication). Review of Resident 2's nursing documentation revealed: On [DATE], at 10:06 p.m., a nurse's note stated, "Alert but drowsy and confused"; On [DATE], at 7:11 a.m., a nurse's note stated, "Resident also drowsy this shift"; On [DATE], at 11:29 a.m., a nurse's note stated, "Confusion and lethargy noted. Unable to hold things in hand without dropping." The staff continued to administer the [MEDICATION NAME] and did not hold for sedation as per the physician's orders [REDACTED]. On [DATE], the staff notified the physician regarding the resident's drowsiness and need for increased assistance. The physician responded to the fax on [DATE], with an order to discontinue Resident 2's [MEDICATION NAME] (a narcotic pain medication). The staff continued to document in the nurse's notes about the resident's increased confusion, drowsiness and lethargy until the physician was made aware on [DATE], that Resident 2's, "condition continues to decline". From [DATE] until [DATE], the staff continued to document in the nurse's notes about Resident 2's increased confusion, drowsiness and lethargy. On [DATE], at 10:14 p.m., the Licensed Practical Nurse (LPN) administering medications held Resident 2's bedtime dose of [MEDICATION NAME], "due to resident being drowsy and not safe to swallow". From [DATE] until [DATE], the staff continued to document in the nurse's notes about the resident's increased confusion, drowsiness and lethargy six more times. On [DATE], Resident 2 was transferred to the hospital for evaluation for a decline in condition. Review of Resident 2's [DATE], Medication Administration Record [REDACTED]. During an interview on [DATE], at 1:30 p.m., the Director of Nursing was unable to explain why the physician's orders [REDACTED]. Review of Resident 2's [DATE], physician's orders [REDACTED]. She was designated a "full code" in accordance with those desires. A physician's note dated [DATE], confirmed that the resident was a "full code". Review of a nurse's note, written by the Registered Nurse (RN) 1 dated February 16, 2014, at 10:00 p.m., revealed that, "LPN called me to come check on resident at which time she was not breathing, no pulse". The RN 1's nurse's note further indicated Resident 2 was bathed at 9:00 p.m. and was pronounced dead at 9:35 p.m. and that the LPN had, "also tried to arouse her, to no avail, while waiting for me (the RN) to get to the floor". There is no evidence that the staff attempted Cardiopulmonary Resuscitation (CPR) or called 911 in accordance with Resident 2's wishes and directives. During an interview on [DATE], at 1:15 p.m., the Nursing Home Administrator stated that CPR should have been initiated and 911 called in accordance with the resident's wishes. 28 Pa. Code: 211.12 (d)(1)(5) Nursing services. Previously cited [DATE].