Every finding on record at Haven Place Rehabilitation and Nursing Center

Based on clinical record review and staff interview, it was determined the facility failed to timely respond to significant weight loss for three of eight residents reviewed for nutrition concerns (Residents 1, 5, and 56), implement weight monitoring and continued evaluation for a resident at nutritional risk for one of eight residents reviewed for nutrition concerns (Resident 17), and to obtain, monitor, and evaluate weights, respond to severe weight loss, notify the physician of significant/severe weight loss, and evaluate the effectiveness of nutritional interventions resulting in actual harm of further severe weight loss for one of eight residents reviewed for nutrition concerns (Resident 12). Findings include: Review of Resident 5's care plan last revised on July 29, 2026, indicated that the resident had a nutrition care plan with an established goal for the resident to not experience a significant change in weight. There were no listed interventions associated with the nutrition care plan to assist the resident in meeting the goal. There was no evidence that facility staff implemented any interventions to either monitor or treat the resident's significant weight loss. Clinical record review for Resident 5 revealed the following weight assessments: February 26, 2026, 142.4 poundsMarch 5, 2026, 140.6 poundsMarch 10, 2026, 144.1 poundsApril 27, 2026,138.8 poundsMay 2026, no weight identifiedJune 30, 2026, 136.0 poundsJuly 28, 2026, refused weightAugust 18, 2026, 126.6 pounds (15.8-pound, 11% significant weight loss for 6 months/180 days) Further clinical review revealed that the resident had no evidence of nutritional notes or assessments since May 19, 2026. There was no evidence that Resident 5's resident's weight loss indicated on August 18, 2026, had yet been addressed by the dietitian or physician as of September 2, 2026. During an interview with Employee 5, registered dietitian, on September 2, 2026, she indicated that she had not been aware of Resident 5's significant weight loss. The above information regarding Resident 5 was reviewed with the Nursing Home Administrator and the Director of Nursing on September 2, 2026, at 2:30 PM. Clinical record review for Resident 56 revealed that the facility admitted her on November 11, 2025. Further review of Resident 56's clinical record revealed the following weight assessments: January 2, 2026, 120.3 poundsFebruary 1, 2026, 111.6 pound (an 8.7-pound, 7.2 percent significant weight loss in one month)March 2, 2026, 107.2 pounds (a 13.1-pound, 10.89 percent significant weight loss in two months) Review of Resident 56's plan of care initiated on November 14, 2025, revealed Resident 56 is at nutritional risk related to her variable intake of meals, need for nutritional supplements, high risk for malnutrition due to Alzheimer's dementia (loss of memory and problem-solving skills affecting daily life activities), and failure to thrive (ability to maintain adequate nutrition needs) due to inadequate oral intake related to refusing meals. Further review of Resident 56's clinical review revealed no evidence of any nutritional notes or assessments from November 13, 2025, (admission nutritional assessment) until May 19, 2026 (two and a half months after significant weight loss), when the registered dietitian completed Resident 56's quarterly assessment. The registered dietitian indicated Resident 56 had an unintentional weight loss in the past 180 days (17 pounds/13.3 percent), noting that nutrition will continue to monitor. Interview with Employee 5 on September 2, 2026, at 11:56 AM confirmed the above findings for Resident 56. The facility failed to recognize, evaluate, and address Resident 56's significant weight loss, or notify the resident's physician of the significant weight loss in a timely manner. Clinical record review revealed the facility admitted Resident 1 on August 29, 2025. Further review of Resident 1's clinical record revealed the following weight assessments: January 1, 2026, 184. 6 poundsFebruary 1, 2026, 170.5 pounds (a 14.1-pound, 7.6% significant weight loss in one month) Resident 1's clinical record review revealed no evidence of any nutritional notes or assessments from December 15, 2025, until August 21, 2026. Employee 5 completed Resident 1's annual nutritional evaluation on August 21, 2026, noting Resident 1 had a significant weight loss in February 2026, noting it was greater than five percent in 30 days. There was no documented evidence that the facility assessed Resident 1's weight loss on February 1, 2026, until August 21, 2026 (six and a half months later). Interview with Employee 5 on September 2, 2026, at 11:56 AM confirmed the above findings for Resident 1. The facility failed to recognize, evaluate, address, and notify the physician of Resident 1's significant weight loss in a timely manner. Clinical record review for Resident 17 revealed the resident was admitted to the facility on [DATE]. Review of Resident 17's weight monitoring record revealed a weight on August 13, 2026, of 175.3 pounds. An additional weight was documented on the residents MAR/TAR (medication administration record/treatment administration record) on August 14, 2026, of 174.8 pounds. Review of a nutrition evaluation dated August 13, 2026, completed by the dietitian, revealed the resident was noted as at risk for malnutrition (body does not get the right amount of vitamins, minerals, and energy to stay healthy). The resident's weight was within normal limits, the resident was on diuretics (medications to reduce fluid buildup in the body), and weight was likely to fluctuate. It was also noted the resident had a dislike for the food and thickened liquids (modified texture of liquid to aid in swallowing difficulties), and early satiety (feeling of fullness). The dietitian noted the addition of nutrition supplements would be added at lunch and dinner, and nutrition would continue to monitor, noting weekly weight x4 (four weeks), then monthly. As of September 2, 2026, there was no evidence Resident 17 had been weighed again since August 14, 2026. Any additional weights after August 14, 2026, for Resident 17 were requested in a meeting with the Director of Nursing on September 2, 2026, at 10:35 AM. Resident 17's weight was obtained on September 2, 2026, after being requested as noted above and was 163 pounds, a 12.3-pound, seven percent significant weight loss from August 13, 2026, less than one month. Interview of Employee 5, registered dietitian, on September 2, 2026, at 12:15 PM confirmed that weekly weights are to be obtained on admission and then weekly for four weeks. There was no evidence Resident 17's weight was obtained weekly, or that any further evaluation of the resident's nutritional status, weight, or response to nutrition supplementation was completed as noted by the registered dietitian until September 2, 2026, after it was brought to the facility staff's attention and the resident experienced a significant weight loss. The above information regarding Resident 17 was reviewed with the Nursing Home Administrator and Director of Nursing on September 2, 2026, at 2:42 PM. Clinical record review for Resident 12 revealed a physician's order dated March 24, 2025, through April 30, 2026, to obtain weights twice weekly on Monday and Thursday for congestive heart failure (CHF, a condition where the heart muscle does not pump blood efficiently, causing fluid to build up in the lungs and body tissues) and to notify the physician if there was a weight gain over five pounds. There was a physician's order for Resident 12's weights dated August 6, 2025, and still active during the survey (overlapping the above order until April 30, 2026) to also obtain weekly weights on Wednesdays. Clinical record review for Resident 12 revealed the following weight assessments: October 8, 2025, 267.2 poundsOctober 27, 2026, 267.3 poundsNovember 5, 2025, 267.5 poundsDecember 1, 2025, 255.3 poundsDecember 29, 2025, 258 PoundsJanuary 4, 2026, 258.1 poundsJanuary 5, 2026, 244 pounds (re-weight, a 14.1-pound, 5.4% significant weight loss in one month)January 14, 2026, 248.8 poundsJanuary 15, 2026, 228 pounds (further decrease of 16 pounds from January 5, 2026, now 27.3 pounds since December 2025, and now a severe 10.6% weight loss in one month)January 19, 2026, 230.3 poundsJanuary 21, 2026, 230.8 poundsJanuary 28, 2026, 234.6 pounds Review of a nutrition note dated January 29, 2026, revealed the resident's weight loss was addressed noting a 23-pound, 8.9% significant weight loss in 30 days from December 29, 2025, to January 28, 2026, and a significant weight loss of 29 pounds (11%) over 180 days. It was noted the resident was on a mechanical soft diet (altered texture for easier chewing/swallowing) with average meal intakes greater than 50% in the last 30 days. It also noted that the resident had a history or poor appetite and was receiving 40 mg (milligrams) of Lasix (a medication used to treat fluid retention) daily for CHF and that fluid fluctuations may impact weight trends. It was noted that the resident's body mass index (screening tool that estimates body fat using height and weight) characterized the resident as over weight and that nutrition would follow up to trial oral nutrition supplements, discuss preferences, and portion modifications, and that the care plan (a written plan that includes a focus area, goal, and interventions for a resident detailing specific medical, physical, emotional, and daily living needs and interventions to meet them) was updated. A review of Resident 12's physician orders revealed a mighty shake (nutritional supplement) was added on January 30, 2026, two times a day to be given at lunch and dinner. A review of Resident 12's physician orders revealed an order for Lasix 40 mg by mouth one time a day related to edema (fluid retention) dated October 23, 2024. There was no evidence of changes to Resident 12's Lasix dosage, any additional fluid retention medications, or documentation to indicate resident 12 was having changes in the status of edema in the time frame of the weight loss reflected above. Review of Resident 12's care plan revealed the resident did have a focus area for nutritional problems/potential nutritional problems initiated prior to the January 2026, weight loss, and the resident's goal was updated on January 29, 2026, reflecting that the resident would not develop complications related to obesity, but it did not reflect the resident's significant weight loss. There was no evidence that any interventions were updated at that time on the care plan to address the significant weight loss. There was no evidence identified or provided during the survey that Resident 12's physician was made aware of the significant weight loss identified in January 2026. Review of Resident 12's medication administration record (MAR) for February, March, and April 2026, after the significant weight loss revealed the following regarding obtaining/monitoring Resident 12's weight as ordered: February 4, 5, 9, 12, 16, 19, 25; March 5, 9, 12, 19, 23, 30; and April 2, 8, 9, 13, 20, 23, no documentation at all that the task was completed or evidence of a weight. March 11, and April 22, 2026, checked off as completed, although there was no evidence of the weight in the resident's documentation or provided during the survey. February 11, 2026, cannot get Hoyer (mechanical transfer device) weight due to the lift being broken.February 23, 2026, Hoyer with weight broken. Unable to obtain weight.February 26, 2026, Hoyer lift awaiting to be fixed.March 4, 2026, unable to obtain weight due to Hoyer lift with scale being broken.March 16, 2026, Hoyer lift scale is still broken. Unable to obtain weight.March 18, 2026, weight lift broken. Unable to obtain weight.March 25, 2026, do not have Hoyer that weighs.March 26, 2026, unable to obtain weight, no Hoyer weight scale.April 1, 2026, no Hoyer available to obtain weight.April 6, 2026, weight Hoyer lift unavailable weight not obtained.April 16, 2026, weight scale display screen not working. There was no evidence of any reassessment/evaluation of Resident 12's weight change, the effectiveness of the added nutritional supplementation added in January or other measures to assess the resident's weight since the resident's significant weight loss was addressed by the dietitian in January 2026, until March 2026. A nutrition note dated March 12, 2026, for Resident 12 noted there was no updated weight due to missing part for Hoyer lift scale, that the medical team was treating edema, and that the resident was noted with no edema on March 6. The note reflected a significant weight change of greater than 10% since August 6, 2025, and that the last weight was recorded in January. The note further indicated the resident was on a mechanical soft diet, meal intake average greater than 50% of food served in the past 30 days, resident consumes 50-100% of house shake twice daily added on January 30, 2026, and will continue to trend weights and nutritional status. There was no evidence of any changes to the resident's nutritional care plan, or any evidence the resident had any medication or treatment changes due to the management of fluid retention. There was no documentation to indicate any other measures were to be utilized to obtain the resident's weight. There was no evidence of any weight assessments for Resident 12 from January 28, 2026, until April 27, 2026 (three months later). Resident 12's weight documented on April 27, 2026, was 199 pounds, a 35 pound (15%) severe weight loss since the resident's last weight on January 28, 2026, and a 68.3 pound (25%) severe weight loss since October 27, 2025 (6 months/180 days). An additional weight documented on April 29, 2026, was 197.2 pounds. There was no evidence that Resident 12's physician was made aware of the severe weight loss in April 2026, or that the severe weight loss in April 2026, was addressed by the physician or nutrition professional, or that any interventions were implemented at the time related to another severe weight change for the resident. A review of Resident 12's weights since the severe weight loss in April 2026, revealed the following weight assessments: June 26, 2026, 183.2 pounds, (a further 14-pound weight loss since the last weight on April 29, 2026). June 29, 2026, 183 poundsAugust 20, 2026, 183.4 poundsAugust 26, 2026, 184 pounds There was no evidence of any documented weights for Resident 12 in May 2026, (as the resident had remained on a weekly weight order since August 2025), or in June 2026, until the weight on June 26, 2026. There was no evidence of any documented weights in July 2026, or in August until August 20, 2026. There was no evidence of any reassessment by a nutrition professional since the nutrition note in March 2026, until it was brought to the facility staff's attention on September 2, 2026. Clinical record review for Resident 12 revealed no documentation by the physician or nurse practitioner of changes in edema in 2026 or any documentation about the resident's weights. Interview with Employee 5, registered dietitian, on September 2, 2026, at 12:10 PM confirmed that the facility had one Hoyer lift scale and Resident 12 was unable to be weighed due to that scale being broken. She also confirmed that she did not change any nutritional interventions on this resident since January 30, 2026, or that there was any documentation by a nutrition professional since March 2026. Employee 5 indicated Resident 12 refuses to be weighed at times although there is no documentation of the resident refusing to be weighed in the time frame reviewed above. Interview with the Nursing Home Administrator and the Director of Nursing on September 2, 2026, at 2:42 PM confirmed the above information on Resident 12, that the Hoyer lift scale was not functioning, and the facility ordered a new scale. The Nursing Home Administrator added that the staff could have borrowed a Hoyer lift scale from their sister facility. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Cross refer 656, 908

Based on observations and staff interviews, it was determined that the facility failed to ensure an environment free of the potential spread of infection on one of two nursing units (First floor; Resident 17).Findings include: Clinical record review for Resident 17 revealed he was admitted to the facility on [DATE]. A physician order dated August 12, 2026, revealed resident was in isolation for active methicillin-resistant staphylococcus aureus (MRSA) (a type of staph bacteria that does not respond to many common antibiotics) infection and during treatment all meals and services were to be provided in his room. Clinical record review for Resident 17 revealed a physician order dated August 14, 2026, for vancomycin (a powerful antibiotic used to treat severe, resistant bacterial infections) 1 gram intravenously daily and treatment to end on September 30, 2026. Observation of Resident 17 on September 1, 2026, at 9:27 AM and September 2, 2026, at 9:17 AM revealed the resident in a chair in the common dining room on the first floor with other residents. Interview with Employee 4, licensed practical nurse, on September 2, 2026, at 9:20 AM confirmed that resident was in the common dining room with other residents and she was unaware of the physician order for meals and services to be provided in his room. Observation of Resident 17's room on August 31, 2026, at 10:48 AM revealed a sign outside the resident's door instructing those who enter to implement contact precautions (infection control measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or resident's environment). The sign included instructions to don (put on) a gown and gloves before entering room and doffing (take off) the gown and gloves before exiting the room. Observation of Resident 17 on August 31, 2026, at 12:26 PM revealed Employee 8, nursing assistant, entered the resident's room with a meal tray. Employee 8 did not don a gown or gloves prior to entering the room and did not perform hand hygiene prior to exiting his room. Concurrent interview with Employee 8 revealed she had asked other staff if she needed to wear a gown and gloves to deliver a meal tray and she was told no. Observation of the first floor on August 31, 2026, at 10:35 AM revealed Employee 8 walking down the hallway carrying an uncovered soiled brief to the trash receptacle. Interview with Employee 8 revealed she was unaware that practice would potentially contaminate the environment. Observation of the first floor on September 1, 2026, at 8:28 AM revealed a large clean linen cart located in the hallway near the beauty shop with the front uncovered. The facility failed to reduce the risk of accidental contamination of the clean linen. The surveyor reviewed the above infection control concerns during an interview with the Director of Nursing on September 2, 2026, at 10:35 AM. 483.80 (a)(1)(2)(4)(e)(f) Infection Prevention and ControlPreviously cited 9/5/25 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 that the resident's representative received written notice of the facility bed-hold policy as soon as practicable for four of five residents reviewed for hospitalizations (Residents 4, 87, 5 and 9). Findings include: Clinical record review for Resident 4 revealed he was transferred to the emergency department for further evaluation after a fall on July 13, 2026. There was no evidence Resident 4's responsible party received a written notice of the bed hold policy as soon as practicable for Resident 4's transfer. Clinical record review for Resident 5 revealed they were transferred to the emergency department for further evaluation of a change in mental status on May 29, 2026. There was no evidence Resident 5's responsible party received a written notice of the bed hold policy as soon as practicable for Resident 5's transfer. Clinical record review for Resident 9 revealed they were transferred to the emergency department for further evaluation of respiratory distress on May 27, 2026, and for further evaluation of increased somnolence (drowsiness) on July 20, 2026. There was no evidence Resident 9's responsible party received a written notice of the bed hold policy as soon as practicable for Resident 9's transfers. Clinical record review for Resident 87 revealed she was transferred to the emergency department for further evaluation of a change in her mental and physical status on August 3, 2026. There was no evidence Resident 87's responsible party received a written notice of the bed hold policy as soon as practicable for Resident 87's transfer. Interview with Employee 9 (business office manager) on September 2, 2026, at 10:05 AM, confirmed that the facility did not provide Residents 4, 5, 9 and 87's responsible party written bed-hold notices for the above-mentioned hospitalizations. The findings were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on September 2, 2026, at 1:35 PM. 28 Pa. Code 201.14(a) Responsibility of license

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by three of five residents reviewed (Residents 4, 11, and 2). Findings include: Clinical record review for Resident 4 revealed the facility admitted him on September 16, 2024, with diagnoses including dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 4's annual Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated May 4, 2026, indicated that the facility assessed Resident 4 as having a diagnosis of dementia, or cognitive loss. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 4's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. Clinical record review revealed the facility admitted Resident 11 on May 5, 2026, with diagnoses including dementia. A review of Resident 11's admission MDS dated [DATE], indicated that the facility assessed Resident 11 as having a diagnosis of dementia, or cognitive loss. The facility determined that a care plan for dementia and cognitive loss would be developed. The facility developed a care plan for Resident 11 noting he had verbal and physical agitation related to his dementia on June 5, 2026. The only interventions listed were for staff to administer Resident 11's medications per his physician orders, if Resident 11's behavioral intervention strategies are not working then leave and reapproach Resident 11 later, and a psych consult as needed. There were no individualized behavioral intervention strategies noted for the resident. A review of Resident 11's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. Clinical record review for Resident 2, admitted [DATE], revealed they an active diagnosis of dementia since December 12, 2023. A review of Resident 2's annual MDS dated [DATE], indicated that the facility assessed Resident 2 as having a diagnosis of dementia, or cognitive loss. The facility determined that a care plan for dementia and cognitive loss would be developed. The facility developed a care plan for Resident 2 noting he had impaired cognitive function/dementia, impulse control disorder, anxiety, schizophrenia, and a history of suicidal ideation on May 25, 2023. Interventions listed included for staff to administer Resident 2's medications per his physician orders, maintain environmental and routine consistency, cue, reorient and supervise as needed, and ask yes/no questions. There were no individualized behavioral intervention strategies noted. A review of Resident 2's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. The above findings for Residents 4, 11 and 2 were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on September 2, 2026, at 2:36 PM. They confirmed the facility had no further documentation that the facility developed and implemented an individualized person-centered care plan to address managing the resident's dementia. 483.40(b)(3) Dementia Treatment and ServicesPreviously cited 9/5/25 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services

Based on clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a medication error rate of less than five percent (Residents 13, 38, and 40).Findings include: The facility's medication error rate was 15.38% based on 26 medication opportunities with four errors. Observation of Resident 13's medication administration on September 1, 2026, at 8:27 AM revealed Employee 3, licensed practical nurse, administered tamsulosin (medication that relaxes the muscles in the opening of the bladder) 0.4 milligrams (mg). Further observation revealed that the blister pack (a pre-formed plastic packaging used to store pharmaceuticals) had a yellow sticker that indicated taking the medication a half hour after the same meal every day. Concurrent interview with Employee 3 revealed that the resident had just received her breakfast tray and had not started eating. The medication reference Drugs.com instructions regarding the administration of tamsulosin noted, Tamsulosin is taken once daily, about half an hour after the same meal every day. Resident 13 did not receive the medication within the above defined parameters. Resident 13's current physician orders contained the following medication order: sensipar (a medication used to lower high levels of parathyroid hormone and calcium in the blood) 30mg give one tablet my mouth with meals. Further observation of Resident 13's same medication administration pass on September 1, 2026, revealed that Employee 3 prepared the resident's medication prior to administration. Employee 3 proceeded to crush most of the tablets with a pill crusher device which included the sensipar tablet. Employee then proceeded to place the medication in pudding and administer them to Resident 72. Observation of the blister pack for the sensipar medication included a yellow sticker that indicated do not crush the medication. Concurrent interview with Employee 3 revealed that she had crushed the sensipar tablet prior to administering it in pudding. The medication reference Drugs.com instructions regarding the administration of sensipar noted, Do not crush or break a tablet. Observation of Resident 38's medication administration on September 2, 2026, at 8:40 AM revealed that Employee 4, licensed practical nurse, administered Colestid Oral Tablet 1 gram (a cholesterol lowering medication) while the resident was actively eating their breakfast. Observation of the blister pack had a yellow sticker indicating that the medication should be administered one hour after meals. Clinical record review of Resident 38 revealed that the Medication Administration Record (MAR, document that includes all medications ordered for a resident by the physician and used to record administration data) also indicated that the medication should be taken one hour after meals. Observation of Resident 40's medication administration on September 2, 2026, at 8:55 AM revealed Employee 4, licensed practical nurse, administered trazodone HCl (a type of antidepressant) Oral Tablet 25 milligrams. Clinical record review for Resident 40 revealed that the physician order for Resident 40's trazadone medication instructed it should be administered at bedtime, indicating the medication was administered at the incorrect time. The surveyors reviewed the above concerns with Resident 13, 38, and 40 during an interview with the Nursing Home Administrator and the Director of Nursing on September 3, 2026, at 10:25 AM. 483.45(f) Medication ErrorsPreviously cited 5/1/26 28 Pa Code 211.9 (a)(1) Pharmacy Services 28 Pa Code 211.10 (c) Resident Care Policies 28 Pa Code 211.12 (d)(1)(5) Nursing Services

Based on clinical record review and staff and resident interviews, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for one of two residents reviewed for mood and behaviors (Resident 11).Findings include: Clinical record review for Resident 11 revealed the facility admitted him on June 5, 2026, with a diagnosis of Post Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event). Review of Resident 11's history and physical dated May 8, 2026, revealed Resident 11's active problems included PTSD. Review of a Trauma Screening Tool completed by Employee 11 (social worker) on June 5, 2026, revealed Employee 11 and psych nurse practitioner resolved Resident 11's PTSD. Review of a social service social history completed with Resident 11's daughter dated August 31, 2026, revealed Resident 11 was exhibiting symptoms of PTSD, noting loud noises as a trigger, and to keep Resident 11 in a quiet area. Interview with Resident 11 on September 3, 2026, at 10:58 AM revealed Resident 11 became emotional when discussing his PTSD. Resident 11 stated his PTSD was related to his son passing away. Interview with Employee 11 (social worker) on September 3, 2026, at 10:41 AM revealed that she was aware of Resident 11's son passing away. Employee 11 confirmed the facility failed to develop a comprehensive, person-centered care plan for Resident 11 related to his PTSD. 28 Pa Code 211.12 (d)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to provide services to maintain a resident's range of motion of one of two residents reviewed (Resident 12).Findings Include: Clinical record review for Resident 12 revealed he was admitted on [DATE], and he currently has diagnosis including dementia (a group of symptoms affecting memory, thinking, and social abilities) and schizophrenia (a mental illness that affects how people think, feel, and behave). Review of Resident 12's quarterly Minimum Data Set (MDS, an assessment completed at periodic intervals of time to determine resident care needs) dated May 19, 2026, revealed facility staff assessed the resident as having no functional limitation in upper and lower extremity range of motion, and that the resident was dependent (required staff to perform the activity) for upper body dressing, lower body dressing, roll left and right, chair/bed to chair transfers, as well as not being able to ambulate. Clinical record review for Resident 12 revealed an occupational therapy Discharge summary dated [DATE], which included discharge recommendations for a restorative range of motion program to be performed during activity of daily living (ADL) tasks. Resident 12's clinical record revealed no evidence of a restorative range of motion program initiated after discharge from occupational therapy. Interview with the Nursing Home Administrator and the Director of Nursing on September 3, 2026, at 10:09 AM confirmed no restorative range of motion program was initiated for Resident 12. 483.25(c) MobilityPreviously cited 9/5/25 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 provide treatment in accordance with professional standards of practice for a resident with an indwelling urinary catheter one of two residents reviewed (Resident 8).Findings include: Clinical record review for Resident 8 revealed the resident returned from the hospital on July 1, 2026, with an order for a foley catheter (a flexible tube placed through the urethra into the bladder to drain urine continuously). The diagnosis provided by the physician for his foley catheter was urinary retention (inability to completely empty the bladder) due to obstructive uropathy (blockage in the urinary tract). There was no evidence of any orders related the care of Resident 8's catheter. Review of Resident 8's treatment administration record (electronic document completed by licensed nurses to document administration of treatments) for July and August 2026, revealed no documentation for catheter care provided. Review of Resident 8's nurse aide documentation for July and August 2026, revealed no documentation for catheter care provided. Interview with the Director of Nursing on September 3, 2026, at 11:38AM confirmed the facility was unable to provide documentation that catheter care was provided to Resident 8. 483.25 Quality of CarePreviously cited 9/5/25 28 Pa Code 211.12(d)(1)(3)(5)

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for identified care needs for four of 19 residents reviewed (Resident 2, 5, 51 and 60).Findings Include: Clinical record review for Resident 5 revealed they were admitted on [DATE]. An admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) completed on the same date indicated nutritional status triggered on the Care Area Assessment (CAA- section of the MDS that identifies what risks or complications exist, and whether a care plan intervention is needed and if it is going to proceed to a care plan) for the resident and that it was to proceed to the resident's care plan (an outline of an individual's health needs, specific care requirements, and the actions necessary to achieve desired health outcomes, represented as the Focus, Goal, and Interventions/Tasks) . Further review revealed that Resident 5 had active physician orders for nutritional supplements including 4oz of Boost VHC (a very high calorie nutritional drink) two times a day and ice cream one time a day. Review of Resident 5's care plan revealed the resident's care plan listed a focus on the resident's nutrition with goals including maintaining nutritional status, and no significant change in weight, although, no interventions at all were listed for the resident's nutrition focus area. During an interview on September 2, 2026, at 11:45 AM with Employee 5, registered dietitian, they confirmed that there were no interventions present for Resident 5 because they had not been aware it was their responsibility to ensure these were updated. The Nursing Home Administrator and the Director of Nursing made aware of the above findings for Resident 5 on September 2, 2026, at 2:30 PM. Clinical record review for Resident 2 revealed a nursing progress note dated August 30, 2026, that indicated the resident was exit seeking that afternoon and attempting to get on the elevators. Further review revealed additional progress notes dated August 9, 2026, indicating the resident was exit seeking, and again on May 8, 2026, stating that the resident was intercepted exiting before elevator doors closed. Additionally, a progress note inputted by social services on August 21, 2026, for Resident 2 indicated the resident was positive for wandering behavior. Practitioner notes dated August 21, 2026, also discussed recent nocturnal wandering, and episodic exit-seeking behavior. There was no evidence that the facility developed a care plan that described the resident's needs and preferences, and how the facility will assist in meeting these needs and preferences related to wandering and exit seeking behavior. Documentation available related to Resident 2's wandering behavior was requested on September 2, 2026, at 2:30 PM from the Nursing Home Administrator and the Director of Nursing. A progress note written by the Director of Nursing on September 2, 2026, at 5:21 PM after the above request, described the exit seeking behavior that occurred with Resident 2 on August 30, 2026, as an isolated event, and that the resident was not an elopement risk. Interview with the Director of Nursing on September 3, 2026, at 9:30 AM, revealed that she was unaware of the additional documented exit seeking episodes, and she confirmed that Resident 2 had not had a care plan in place related to their wandering behaviors. Clinical record review for Resident 51 revealed resident had been admitted on [DATE]. Review of the resident's admission MDS dated [DATE], revealed dental care triggered as an area on the resident's CAA summary as an area that was to proceed to the resident's plan of care. Review of Resident 51's care plan revealed no evidence the resident's dental care was addressed. Clinical record review for Resident 60 revealed resident was admitted on [DATE]. Review of an admission MDS completed on June 30, 2026, revealed dental care triggered as an area on the CAA summary as an area that was to proceed to the resident's plan of care. Review of Resident 60's care plan revealed no evidence the resident's dental care was addressed. Additional record review of Resident 60's admission MDS dated [DATE], revealed that nutritional status triggered on the CAA summary and was to be added to resident's plan of care. Review of Resident 60's care plan revealed a nutrition focus area and goal were added to the resident's care plan although, no interventions at all were listed for the nutrition focus area. During an interview on September 2, 2026, at 11:45 AM with Employee 5, registered dietitian, they confirmed that there were no interventions present for Resident 60 because they had not been aware it was their responsibility to ensure these were updated. The above information was reviewed with the Nursing Home Administrator and Director of Nursing, on September 3, 2026, at 9:30 AM. 483.21(b)(1)(3) Develop/Implement Comprehensive Care PlanPreviously cited 06/05/2026 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure residents' medication regime was free from potentially unnecessary medications for two of five residents reviewed for medication regimen review (Residents 4 and 11).Findings include: The facility policy titled Behavior Assessment, Intervention and Monitoring last reviewed without changes on July 23, 2026, indicates that the facility will identify residents with impaired cognition, altered behavior, or mental illness, and will then identify, document and inform the physician regarding any changes in a resident's mental status, behavior, and cognition. The facility will then monitor residents who are being treated for altered mood or behavior for any improvements or worsening in the resident's behavior, mood, and function, and document this in the clinical record. The facility nursing staff and physician will monitor for side effects and complications related to psychoactive medication (such as lethargy, anorexia, involuntary movements, recurrent falling). Clinical record review revealed the facility admitted Resident 11 on June 5, 2026. Review of Resident 11's medication regime included the use of the following psychotropic medications: Seroquel (antipsychotic medication) 50 milligrams (mg), one tablet three times a day, related to a brief psychotic disorder.Seroquel 25 mg, one table three times a day. Olanzapine (antipsychotic medication) 2.5 mg, one tablet in the morning, related to his brief psychotic disorder.Trazodone (antidepressant medication)100 mg, one tablet at bedtime, related to his major depressive disorder. The facility initiated a care plan on June 5, 2026, noting Resident 11 was at risk for adverse effects related to his psychotropic medication use, with a goal to show no side effects of his medication use. Review of Resident 11's Medication Administration Record and Treatment Administration Records dated June, July, and August 2026, revealed no ongoing monitoring of Resident 11's potential adverse side effects from the use of his antipsychotic and antidepressant medications. Clinical record review revealed the facility admitted Resident 4 on September 16, 2024. Review of Resident 4's medication regime included the use of the following psychotropic medications: Rexulti (Antipsychotic medication) 1 mg, one tablet every day, related to his brief psychotic disorderTrazodone 50 mg, one tablet at bedtime related to his major depressive disorderTrazodone 100 mg, one tablet at bedtime related to his major depressive disorder Review of Resident 4's clinical record did not include evidence that the facility monitored Resident 4's individualized targeted behavior symptoms related to his use of psychotropic medications. Interview with the Nursing Home Administrator and Director of Nursing on September 3, 2026, confirmed the above findings for Residents 11 and 4. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to maintain adequate housekeeping and maintenance services to ensure a clean, comfortable, orderly, and homelike environment on two of two nursing units, (first floor and second floor) and for four of 24 residents reviewed (Residents 9, 24, 90, and 91). Findings: Observation of Resident 24's room on August 31, 2026, at 12:00 PM revealed four areas on the wall beside the bathroom door, each measuring four inches and roughly round, that appeared to have been treated with drywall mud. Concurrent interview with the resident revealed that the areas had always been like that and that her whole room was a mess, as Resident 24 alerted to chairs that were in their room that were piled with personal items including clothing, blankets, washcloths, and assorted boxes and containers. Observation on September 1, 2026, at 10:00 on the first floor in Hallway C revealed a clean linen cart with assorted items piled on top, including washcloths, a pillow, unopened boxes of gloves, wipes, tissues, an umbrella, a personal fan, and a reusable ice pack holder. Concurrent interview with Employee 7, licensed practical nurse, revealed she was unsure why those items were being stored up there. Continued observation of the C Hallway revealed that the white tile floor at the threshold to the hallway near the first-floor nursing unit appeared to be gray and dirty. A metal dividing strip in the C Hallway across the floor was filled with crumbs and black debris. Observation of Resident 9's room revealed a plastic chair rail running along the wall behind the resident's bed was broken and cracked. An eight-inch piece of plastic had separated and was noted to have jagged edges and pointed, sharp looking corners. Observation of the second-floor environment on August 31, 2026, at 11:03 AM revealed the wall behind Residents 90 and 91's bed was marred. The floor in Resident 90's room was dirty with black sticky spots throughout the room. Observation of the dining room at this time revealed the floor was still dirty with food from breakfast and there were large sticky spots all over the floor. When walking across the dining room the surveyor's shoe stuck to the floor. Observation of Resident 90's floor on September 1, 2026, at 10:52 AM revealed the floor remained dirty with sticky spots throughout. Concurrent observation of Resident 48's floor revealed there was smashed food on the floor in front of her bed. The food appeared to be from the day prior. Further observation of Resident 48's floor on September 1, 2026, at 1:28 PM revealed the smashed food remained on the floor. The above environmental concerns were reviewed with the Nursing Home Administrator and the Director of Nursing on September 1, 2026, at 1:30 PM. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management

Based on review of clinical records, and staff interview, it was determined that the facility failed to provide documentation that residents or resident representatives were given the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for one of 11 residents reviewed (Resident 7). Findings include: Clinical record review for Resident 7 revealed an admission date of July 7, 2026. Resident 7 had no active physician's order indicating their code status (whether or not the patient wishes to receive all possible life-saving interventions if their heart stops or they stop breathing). During an interview with Resident 7 on September 1, 2026, at 11:00 AM, they stated nobody had spoken with them regarding advanced directives, and that they did not have a living will and would like assistance in getting one. Subsequent interview with Employee 6, registered nurse, at 11:15 AM confirmed the resident had no documented advanced directive available at the nursing station, and nothing in the resident's electronic health records indicated she had an advanced directive. Information regarding Resident 7's advanced directive was requested from the Nursing Home Administrator and the Director of Nursing on September 1, 2026, at 1:30 PM. The Nursing Home Administrator confirmed that no information related to Resident 7's advanced directives was available on September 3, 2026, at 9:30 AM. 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed pharmacy recommendations for one of five residents reviewed for unnecessary medications (Resident 11).Findings include: The facility policy entitled Pharmacy Consultant Policy and Procedures, last reviewed without changes July 23, 2026, revealed the pharmacy consultant will conduct a monthly review of the medication administration record to assure the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals to meet the needs of each individual resident. The pharmacy consultant will review the medication record for new admissions, re-admissions, and as requested by the Director of Nursing or Physician. The pharmacist will report any irregularities to the attending physician and the Director of Nursing, and these reports must be acted upon in a timely manner. The pharmacist will provide the Director of Nursing with pharmacy recommendation reports on an ongoing basis each month. The Director of Nursing will act upon these recommendations by bringing them to the attention of the attending physician and ensuring any changes are implemented in a timely manner. Clinical record review for Resident for Resident 11 revealed a consultant pharmacist recommendation dated June 9, 2026, noting Advair (a prescription inhaler) contains an inhaled steroid and recommended rinsing mouth after each use to help avoid developing thrush, be added to the physician order, and medication administration record. The pharmacist also noted the Lidocaine Patch (pain relieving patch) order does not appear to have a prompt to remove the patch, noting the patches would be worn 12 hours on, 12 hours off, requesting a prompt be added to remove Lidocaine patch 12 hours after applying. Further review of Resident 11's clinical record revealed there was no evidence that the physician or Director of Nursing acted upon the pharmacist recommendation. A consultant pharmacy recommendation dated July 21, 2026, revealed the pharmacist repeated the June 9, 2026, recommendations for the Advair and Lidocaine patch. There was no evidence that the physician or Director of Nursing acted upon the pharmacist's July 21, 2026, recommendation. Interview with the Nursing Home Administrator and Director of Nursing on September 3, 2026, at 9:42 AM confirmed the facility failed to act upon Resident 11's June 9, and July 21, 2026, pharmacy recommendations until after the surveyor's questioning. The facility failed to ensure that Resident 11's attending physician addressed the pharmacy recommendations in a timely manner. 28 Pa. Code 211.9 (k) Pharmacy services 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on clinical record review and staff interviews it was determined that the facility failed to ensure essential equipment for obtaining weights is maintained in a safe, operating condition for one of 10 residents reviewed (Resident 12).Findings include: Clinical record review for Resident 12 revealed thirteen nursing progress notes between the dates of February 1, 2026, and April 16, 2026, that reported his weight was unable to be obtained due to the Hoyer lift scale (medical transfer device used to safely lift and move patients with limited mobility and obtain weights) not functioning. Interview with Employee 5, registered dietitian, on September 2, 2026, at 12:10 PM confirmed that the facility had one Hoyer lift scale and Resident 12 was unable to be weighed due to that scale not in operational condition at that time. Interview with the Nursing Home Administrator and the Director of Nursing on September 2, 2026, at 2:42 PM confirmed that the Hoyer lift scale was not functioning at that time and the facility ordered a new scale which they have received. The Nursing Home Administrator added that the staff could have borrowed a Hoyer lift scale from their sister facility. Cross refer 692 28 Pa Code 201.14 (a) Responsibility of licensee

Based on clinical record review and staff interview, it was determined that the facility failed to ensure assessments accurately reflected a resident's status for one of 19 residents reviewed (Resident 1).Findings include: Clinical record review for Resident 1 revealed a MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated June 1, 2026, that the facility assessed Resident 1 as having an active diagnosis of pneumonia. Interview with the Director of Nursing and Nursing Home Administrator on September 2, 2026, at 2:36 PM confirmed Resident 1's MDS was coded in error regarding his pneumonia diagnosis. The Director of Nursing confirmed Resident 1 was never diagnosed with pneumonia. The facility failed to accurately assess Residents 1's MDS assessments as noted above. 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to implement a comprehensive person-centered care plan regarding seizures and an implanted device to control seizures for one of one resident reviewed (Resident 1).Findings Include: Clinical record review for Resident 1 revealed the resident was admitted to the facility on [DATE]. Review of Resident 1's diagnoses list revealed the resident was listed with a conversion disorder (neurological symptom disorder) with seizures (sudden surge of abnormal electrical activity in the brain that causes temporary changes in behavior, awareness) or convulsions (rapid, involuntary muscle contractions causing uncontrollable shaking and body spasms), since admission to the facility. Review of documentation from the resident's hospital admission prior to admission to the facility revealed an Epilepsy Monitory Unit Discharge summary dated [DATE], which noted the resident had a long-standing history of seizure/seizure like activity first noted back in the year 2012. It noted the resident had a VNS device (Vagus Nerve Stimulation - an implanted device used to send mild electrical impulses to the brain via the vagus nerve in your neck at programmed intervals which can also be activated manual if a patient senses a seizure starting by swiping a magnet over the chest device to deliver an extra burst of stimulation to help stop or shorten the seizure), placed June 18, 2012, and changed in March 31, 2021. A progress note dated January 22, 2026, at 9:50 AM for Resident 1 noted facility staff were called to the resident's room for the resident experiencing back-to-back seizures with a time length of 45 seconds to five minutes. A follow up note 10:27 AM noted the resident was sent to the emergency room for an evaluation. There was no evidence of any documentation as to whether the resident's VNS device was utilized during the incident. Review of a neurology consult for Resident 1 dated February 24, 2026, noted the resident's magnet output increased, and autostim threshold decreased, in reference to the resident's VNS device. The consult also noted the residents battery is at 25-50% - next range is 12.5-25% - would then need to get established with neurosurgery for battery replacement. Further review of Resident 1's clinical record revealed the resident was ordered routine and as needed medication for seizures on January 22, and January 24, 2026, and that the resident continues to receive routine and as needed medication for seizures. Review of Resident 1's May medication administration record revealed the resident received as needed doses of seizure medication on May 1, 3, 4, 5, 6, 15, 2026. There was no evidence to indicate if the resident's VNS device was utilized during any of these instances. Observation and interview of Resident 1 on May 20, 2026, at 1:29 PM indicated the resident stated a long history of seizure activity and that she had a device implanted in her chest that she indicated is going to need a battery replacement. Resident 1 pointed out a watch like band (magnet) on her right wrist which she indicated was to be used for the device when she was having a seizure. Review of Resident 1's active plan of care revealed the resident's seizure disorder was not addressed on the plan of care until May 20, 2026, (date of survey), despite the resident being admitted to the facility in June 2025 with the disorder and the presence of an implanted VNS device, or after having seizure like activity in January 2026, with the addition of seizure medication. The plan of care initiated on May 20, 2026, also did not include any information regarding the resident's VNS device (location of magnet, when to utilize it, or how staff are to utilize the device). The above findings were reviewed with the NHA and DON on May 20, 2026, at 3:43 PM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, clinical record review, review of facility documents, applicable state professional nursing standards, and staff interview, it was determined the facility failed to ensure a licensed nurse correctly administered the correct dosage of medication to two of two residents reviewed (Residents 3, and 7). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards State Board of Nursing 21.145 (a) indicates the LPN (licensed practical nurse) is prepared to function as a member of the health-care team by exercising sound nursing judgement based on preparation, knowledge, experience in nursing and competency. A nursing note dated April 18, 2026, at 7:29 PM noted Resident 3's provider was notified of medication error for the resident and staff were to monitor the resident for nausea/vomiting, sedation, and increased confusion. A nursing note for Resident 3 dated April 18, 2026, at 8:03 PM by Employee 2 (licensed practical nurse) noted Resident 3 was administered the wrong dose of medication and at the wrong time, noting a family member for the resident was in the room when the medication was administered and questioned the writer. Review of facility documentation dated April 18, 2026, at 6:40 PM regarding an investigation into the incident noted above for Resident 3, noted Resident 3 had no injury but was given the incorrect dose of Depakote (a medication used to treat mood disorders, migraine headaches or epilepsy) by Employee 2 and the resident was monitored by nursing. Root cause analysis to be completed by admin. It was then noted on the report April 20, 2026, that the medication error was reviewed by the interdisciplinary committee and education provided and med pass competency completed. A statement from Employee 2, dated April 23, 2026, regarding the incident indicated Employee 2 read the medication order of 250 mg (milligrams) as 650 mg, and that the pills were taken out of Resident 3's medication card and after administration the resident's responsible party and physician was made aware. A review of Resident 3's medication ordered revealed the resident was ordered Depakote oral tablet delayed release 250 mg to be given two tablets by mouth every day and evening shift for mood disorder. A provider note dated April 18, 2026, at 1:00 AM for Resident 3 noted the provider was notified by facility staff that Resident 3 was intended to receive Depakote 500 mg in the evening (two 250 mg tablets) but was administered 1500 mg instead (six 250 mg tablets). Earlier the same day, the resident had already received 500 mg, for a total of Depakote 2000 mg given that day. It was noted as an accidental overdose of the medication due to administration with no reported acute change at the time, noting a risk of sedation, gait instability, or GI symptoms. Review of facility documentation revealed Employee 2 received a Medication Administration Competency by the Director of Nursing on April 23, 2026. The form also noted Education provided on rights of administration There was no evidence that any additional licensed facility staff received education on the rights of administration after the incident with Employee 2 and Resident 3 noted above. Observation on May 1, 2026, at 9:36 AM of Resident 7's medication administration revealed that Employee 1, licensed practical nurse, administered one 81 mg (milligram) tablet of Aspirin (a medication used to relieve mild to moderate pain, fever, inflammation, or in low doses to prevent heart attacks and strokes) from the facility stock medication located in the medication cart. Clinical record review for Resident 7 revealed a physician order dated March 13, 2025, for the resident to be administered Aspirin tablet 325 mg, give one tablet by mouth one time a day related to peripheral vascular disease (a circulation disorder that causes narrowing, blockage, or spasms in blood vessels outside the heart and brain). Interview with Employee 1 on May 1, 2026, at 2:42 PM confirmed Resident 7 was to receive 325 mg of Aspirin as ordered and not the 81 mg administered. Concurrent observation of Employee 1's medication cart revealed a bottle of Aspirin 325 mg tablets was available in the medication cart. Employee 1 confirmed the dosage of Resident 7's Aspirin was not confirmed prior to administering the medication. In an interview with the Nursing Home Administrator and Director of Nursing on May 1, 2026, at 3:26 PM it was indicated that Employee 2, was recently hired at the facility in February 2026, and there was no evidence of any medication administration competency available prior to the one completed after the error with Resident 3. It was also indicated that Employee 1 was agency staff who had worked several other shifts in the building, and there was no evidence of any medication administration competency completion for Employee 1, nor any education to the licensed staff regarding medication administration after the error occurred for Resident 3. Employee 2 failed to follow the Five Rights of Medication Administration (right resident, right medication, right dose, right route, right time), a safety process used to ensure medications are administered accurately and safely, by administering the incorrect dosage to Resident 3. Employee 1 also failed to administer the correct dose of Aspirin to Resident 7 less than one month after the incident occurred with Resident 3. Interview with the Nursing Home Administrator and Director of Nursing on May 1, 2026, at 4:40 PM confirmed facility staff failed to verify the correct dosage of medication prior to medication administration and that nursing services were not provided with accepted standards of nursing practice, including verifying the correct dosage prior to administration of medications. 28 Pa. Code 211.12 (b)(1) Management 28 Pa. Code 211.9 (a)(1)(d) Pharmacy services 28 Pa. Code 211.10 (c)(d) Resident care policies 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing Services

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure a medication error rate of less than five percent (Resident 7).Findings include: The facility's medication error rate was 33 percent based on 3 medication opportunities with one medication error. Observation on May 1, 2026, at 9:36 AM of Resident 7's medication administration revealed that Employee 1, licensed practical nurse, administered one 81 mg (milligram) tablet of Aspirin (a medication used to relieve mild to moderate pain, fever, inflammation, or in low doses to prevent heart attacks and strokes) from the facility stock medication located in the medication cart. Clinical record review for Resident 7 revealed a physician order dated March 13, 2025, for the resident to be administered Aspirin tablet 325 mg, give one tablet by mouth one time a day related to peripheral vascular disease (a circulation disorder that causes narrowing, blockage, or spasms in blood vessels outside the heart and brain). Interview with Employee 1 on May 1, 2026, at 2:42 PM confirmed Resident 7 was to receive 325 mg of Aspirin as ordered and not the 81 mg administered. Concurrent observation of Employee 1's medication cart revealed a bottle of Aspirin 325 mg tablets was available in the medication cart. The above information for Resident 7 was reviewed with the Nursing Home Administrator and Director of Nursing on May 1, 2026, at 4:40 PM. 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure preventative fall interventions were implemented for one of three residents reviewed for falls (Resident 1).Findings include: Review of Resident 1's plan of care revealed a focus area indicating the resident was at risk for falls related to impaired mobility and incontinence (involuntary leakage of urine/stool), was initiated for the resident on August 4, 2025. An intervention to the falls care plan dated August 4, 2025, indicated the resident was to have antiskid (non-slip) strips applied to the floor in front of her recliner chair. Review of Resident 1's clinical record and facility documents revealed Resident 1 had recent falls as noted below: February 26, 2026, the resident was found on the floor in her room and sustained a hematoma (collection of clotted blood outside blood vessels, often caused by trauma) to her left forehead and a skin tear to her elbow. March 20, 2026, the resident was found on the floor in her room by her bed, with no injuries noted. April 17, 2026, the resident was found on the floor in her room and sustained a slightly red left shoulder, left knee skin abrasion, and a front head abrasion. Observation of Resident 1's room on May 1, 2026, at 2:36 PM revealed the resident in her room seated in her wheelchair beside the bed. Her recliner was also located to the right of the bed. There were no antiskid strips observed on the resident's floor The above information regarding Resident 1's antiskid strips not in the resident's room as indicated on the resident's fall prevention plan of care was reviewed with the Nursing Home Administrator on May 1, 2026, at 3:26 PM. In a follow up interview with the Nursing Home Administrator and Director of Nursing on May 1, 2026, at 4:40 PM, the Administrator indicated Resident 1 was recently moved to her current room on April 28, 2026, so the resident would be closer to the nursing station due to her fall risk, and the antiskid strips were not placed in the resident's new room. The facility failed to implement care planned fall preventative measures for Resident 1. 483.25 (d)(1) AccidentsPreviously cited 9/5/25 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of select facility policies and procedures, employee personnel records, and staff interview, it was determined that the facility failed to implement an abuse prohibition policy that required a thorough investigation of prospective employee's employment history for five of five newly hired employees reviewed (Employees 1, 2, 3, 4, and 5).Findings include: The facility policy entitled Staff Screening, last reviewed without changes August 7, 2025, revealed the facility will utilize reasonable and prudent criminal background screening and reference checks for prospective staff. Prior to employment or commencement of a contract, the facility will verify and document or obtain a copy of the following information that may include but not limited to previous and/or current employer regarding work history, criminal background checks, national sex offender public website, Office of Inspector General Exclusion Screening, State Exclusion screening, current licenses and certifications, and references. Review of Employee 1's (housekeeper) personnel record revealed a hire date of July 2, 2025. Employee 1's personnel record contained no evidence that the facility attempted to obtain personal and/or professional reference information (whether favorable or unfavorable). In accordance with Act 13 Elder Abuse Mandatory Reporting and Act 169 Criminal Background Checks, nursing facilities are required to obtain a criminal background check on all newly hired employees. Facilities are required to obtain the Pennsylvania State Police (PSP) background check within 30 days of hire on all prospective employees. If the applicant has not been a Pennsylvania resident for the two years before application, they will need to have a PSP criminal history background check completed and a Federal Bureau of Investigation (FBI) Background Check. Review of Employee 4's (registered nurse) personnel record revealed the facility hired her on May 18, 2025, and her criminal background check was not completed until September 2, 2025. Review of Employee 1 (housekeeper), Employee 2 (registered nurse), Employee 3 (nurse aide), Employee 4 (registered nurse), and Employee 5's (recreation aide) personnel records revealed no evidence that the facility determined whether these five employees resided in Pennsylvania for the last two years or completed an FBI background check on them. Interview with Employee 13 (human resources) on September 4, 2025, at 9:45 AM, she confirmed the above findings for Employees 1, 2, 3, 4, and 5. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1)(3)(e)(1) Management 28 Pa Code 201.19(8) Personnel policies and procedures

Based on review of select facility policies, facility documentation, clinical record review, and resident and staff interviews, it was determined that the facility failed to protect a resident's right to be free from mental abuse by a staff member for two of three residents reviewed causing actual harm (Residents 1 and 2). Findings include: Review of a Centers for Medicare and Medicaid Services (CMS) Memo S&C: 16-33-NH entitled, Protecting Resident Privacy and Prohibiting Mental Abuse Related to Photographs and Audio/Video Recording by Nursing Home Staff, dated August 5, 2016, revealed that each resident has the right to be free from all types of abuse, including mental abuse. Mental abuse includes, but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or in a manner that would demean or humiliate a resident. There may be situations in which the resident is unable to express him/herself due to a medical condition and/or cognitive impairment, cannot relate what has occurred, or may not express outward signs of physical harm, pain, or mental anguish. A lack of response by resident does not mean that mental abuse did not occur. Mental abuse may occur through either verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Examples of verbal or nonverbal conduct that may cause mental abuse, include but are not limited to nursing home staff taking photographs or recordings of residents that are demeaning or humiliating using any type of equipment and keeping or distributing them through multimedia messages or on social media networks. Review of the Social Security Act, Sections 1819(c)(1)(A)(ii) and 1919(c)(1)(A)(ii) revealed that every resident has the right to be free from mental and physical abuse. A reasonable person would not expect that they would be harmed in his/her own home or a health care facility and would experience a negative psychosocial outcome. Review of the Personal Electronic Device Usage (PED) policy last reviewed without changes on October 29, 2024, revealed that the facility will eliminate unnecessary risk created using PED's when conducting facility business by eliminating personal distractions and maintaining patient rights to privacy. The facility defined PEDs to include cell phones, smart phones, and smart devices. The policy indicated that while in the clinical environment, conducting facility business, and for staff members that are within listening distance or view of a patient, resident, and/or guest, all PEDs should be turned off .and only permitted during designated breaks and during assigned meal periods. Staff are only permitted to use their PED in designated area (such as a break room), and in a manner intended to prevent disruption and prevent patient privacy. A staff's failure to abide by this policy and/or applicable state, local, and federal law, may result in corrective action in accordance with facility policy. Review of the Social Networking policy last reviewed without changes on October 29, 2024, revealed that knowledge sharing through social networking (including all social media sites) is recognized as critical for the facility. Facility staff must protect patient information and follow the facility's code of conduct. Without prior consent, staff should not independently establish (or otherwise participate in) websites, social networks, electronic bulletin boards or other web-based application or tools that reference facility, patients and/or patient information, share information regarding medical records, make misleading statements, display photos of patients on work premises engaged in patient care, and/or display facility photos that violate facility policy. Facility staff will not transmit any material (by upload, send, email, or otherwise) that violates any local, state, federal laws, and regulations and/or is threatening, slanderous, libelous, or a violation of facility policy. Staff may not use facility systems to engage in solicitation during work time and/or off-duty. Staff who chose to participate in online community or other forms of social media understand that they are accountable for anything they send/post. Staff must be aware that their actions can be recorded, written about, or videotaped and quickly posted or sent. Should a staff member's comments/photographs/videos/posts violate facility policy, mission statement, or values, staff will be subject to corrective action, up to and including discharge. Clinical record review for Resident 1 revealed that the facility completed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) on November 13, 2024, which indicated that she was severely cognitively impaired. Clinical record review for Resident 2 revealed that the facility completed an initial MDS on August 28, 2024, which indicated that she was moderately cognitively impaired. Review of facility documentation and recording of a live TikTok video posted the night of November 17, 2024, into the early morning of November 18, 2024, by Employee 1, nurse aide, going by the username of Pxxxxx or Pxxx94 (not the real usernames) revealed the following: The recording of the live TikTok post started as Employee 1 entered Resident 1's room after placing her PED on the heater ledge in Resident 1's room prior to leaving the resident room. Employee 1 walked past the PED, then looked back and directly into the phone screen, and stated Did I miss anything chico? Employee 1 read a comment posted to the live video and responded to the comment. Employee 1 then moved out of view of the live TikTok and returned past the PED with a resident brief, unfolding it as she passed. She then proceeded to Resident 1's bathroom area, out of view of the PED, but within listening distance, and stated, Alright hun .you ready to get up, you ready to go back to bed? to which Resident 1 responded yeah along with another indiscernible mumbling statement, and audibly sighed. Employee 1 completed what was perceived to be incontinence care to Resident 1 based on the actions heard off camera. Off camera, Employee 1 asked Resident 1 Can you hold it? Resident 1 mumbled indiscernibly then stated yeah giggled, and said Oh, I see. Employee 1 requested that Resident 1 Put your hand right here. Resident made unintelligible statements, sighs, and mumbling as Employee 1 stated, Alright honey, flushed the toilet, and assisted Resident 1, clothed in a hospital gown that was tied once in the back, to ambulate with a walker from the bathroom area that was offscreen, and into full view of the live TikTok recording via Employee 1's PED. Employee 1 prepped Resident 1's bed while Resident 1 stood beside the bed holding onto her walker, then stated Alright sweety, and assisted Resident 1 to back up to the side of her bed, pull her hospital gown up enough to side down on the side of the bed, stating Go ahead honey, and helped Resident 1 sit down. When Resident 1 sat down on the side of the bed, she was just off to the right side of the live TikTok viewing area. Employee 1 then assisted Resident 1 with getting into bed by swinging Resident 1's bare legs up and onto her bed and into view of the live TikTok video. Employee 1 covered Resident 1 up with a sheet and comforter. Employee 1 stated, There you go, to which Resident 1 indicated thank you. Employee 1 responded your welcome turned off Resident 1's overbed light, placed her overbed table beside Resident 1's bed, picked up dirty linens off Resident 1's floor, pulled a mesh bag off a hook on Resident 1's closet door, removed her right glove, moved out of view of the live TikTok, and then immediately returned into view. Employee 1 picked up her PED, stated Alright, that room is done while leaving Resident 1's room. Employee 1 looked directly into her PED screen and read the live TikTok comments and badges, stating Chico again with the team bracelet. Let's go [NAME]. Alright, alright, I'm about to go into the next room y'all hold on. Thank you for the follow [NAME]. Employee 1 then exited Resident 1's room into the facility hallway and stated, So I take this stuff out (holding up Resident 1's dirty linens), bring it to this bin, like that in here, put that in there, and continued walking down the hallway. While walking, Employee 1 stated, I have two more people to do showed two gloved fingers to the live TikTok screen, looked away from the PED screen and up the hallway, then back to the screen, and continued walking up the hallway and into Resident 2's darkened room. Employee 1 placed her PED on the sink counter, turned on Resident 2's light above the sink, picked up her PED, moved to the heater ledge, and placed the PED on the ledge, using a stuffed animal to prop the PED to show Resident 2's elevated legs and feet while she sat in a chair beside her bed. Resident 2's TV could be heard playing in the background and out of sight. Employee 1 moved out of the view of the live TikTok, returned with resident care supplies, including Resident 2's blue night gown, and placed them on Resident 2's bed. Employee 1 moved around Resident 2 and closer to the live TikTok on her PED, briefly glanced at the screen, and stated, Hi [NAME]. We're gonna change you, ok? Employee 1 paused beside Resident 2, turned, and looked at her PED to read the live TikTok screen comments. Employee 1 stated, [NAME], thank you for liking the live, I appreciate you, turned back towards Resident 2, brushed her hair back from her face, immediately turned back to her PED screen and stated, [NAME], I'm gonna go ahead and add you on snap in a sec. Employee 1 returned to Resident 2 and put her legs down and moved her walker in front of her, locking the walker brakes. Employee 1 moved out of view of the live TikTok screen, then returned and donned a pair of gloves, moved to the far side of Resident 2, between her bed and chair and stated, Remember, hold onto this (pointing to Resident 2's walker), turned to Resident 2's bed, opened a disposable pad and brief and placed them on Resident 2's chair. Employee 1 asked Resident 2 Ready? Resident 2 stood on her own, holding onto her walker with her left hand and pushing up off the chair with her right hand. Employee 1 indicated Now, put your hand here, and pointed to Resident 2's right handle on her walker. Resident 2 moved her right hand from the chair to the walker handle and continued to stand on very shaky legs. Employee 1 then stated, Yep, good job. As Resident 2 stood and continued standing, her face and front half of her body was in full view of the live TikTok screen. Resident 2's nightgown that she had on was pulled up to her mid- thigh/upper hip area, which exposed the front part of an incontinence brief that she was wearing. Employee 1 released Resident 2's brief tabs, moved from behind Resident 2 to the front side, looked towards her PED screen, and reached down, pulled Resident 2's night gown up to her belly area, fully exposed the front part of Resident 2's incontinence brief, glanced again at her PED screen, pulled the incontinence brief down, pushed it in between Resident 2 legs, briefly exposing Resident 2's groin area, and let Resident 2's nightgown fall back down to Resident 2's mid-thigh/upper hip area. Employee 1 stated, You're doing really great. A person with the user name xxx0327 (not the real username) was watching the live TikTok and immediately commented Hippa. Employee 1 continued the incontinence brief change and told Resident 2 to Keep up the good work, you're almost done. You're almost done. Honey, you're doing good. I told you you'll get strong every time. As Resident 2 grunted and her leg wobbles increased, Resident 2 requested Hurry, hurry, can you hurry? Employee 1 stated, You can't sit down yet ok. You're about to be done just bear with me. Almost done. Resident 2 continued to grunt with the exertion of standing and stated, I want to sit down, I want to sit down, I want to sit down. Can I sit down? Employee 1 stated, Alright, hold on, but Resident 2, unable to stand any longer, sat down with a grunt. Resident 2 stated, I gotta sit, as she sat back down in her chair with a [NAME]. When Resident 2 sat back down in her chair, only her upper legs and knees were visible in the live TikTok screen. Employee 1 immediately removed Resident 2's current gown, placed it on the bed, then returned in front of Resident 2 (out of view of the live Tik Tok screen), picked up Resident 2's gown that Employee 1 had placed on the bed prior to the incontinence change, placed it over Resident 2's head, assisted to put Resident 2's arms into the nightgown, and moved the gown covering Resident 2's chest area. Employee 1 moved the gown out of sight of the live TikTok screen, returned to Resident 2, moved her walker out of the way, and stated, Alright honey-girl, now let's recline you. Employee 1 picked up the chair's controls and elevated Resident 2's legs while looking into the PED screen and not paying attention to Resident 2. Employee 1 read the comments and stated, Hippa. Hippa is when you show them, when you're showing the client. I'm not showing the client and walked/turned away from the PED screen. Employee 1 immediately returned to the PED screen, pointed at the screen, and stated, We'll you can show the client, you just can't show the private stuff and turned back to Resident 2. Employee 1 repositioned Resident 2's legs, walked to the sink out of view of the live TikTok video, washed her hands, and returned to the PED screen. In between the time Employee 1 made the Hippa statement, and when she returned to the live TikTok video, a person with the username Cxxxxstick (not the real username) typed, Want me to mute him? Employee 1 read and verbalized Cxxxxstick's comment of Want me to mute him? and stated, Yeah, who ever said that yeah, you can mute them and turned back towards Resident 2. A person by the username Bxxxx (not the real username) immediately commented I don't think she's showing more than just herself idk (I don't know) why u (you) be bitching. Cxxxxstick (not the real username) commented @Bxxxx (not the real username) fr (for real) tho. During these comments, Employee 1 was providing care to Resident 2, which was out of view of the live TikTok. She then put Resident 2's legs down via the electronic controls, continued care out of the view of the live TikTok and stated, Now lean over there, honey, lean on over. There you go [NAME], now all good. Now let's stand up so I can pull your gown down. Employee 1 moved Resident 2's walker back in front of her and stated, Alright honey, and assisted Resident 2 in attempting to stand; however, Resident 2 was unable to stand fully and fell back into the chair. Employee 1 moved in front of Resident 2 and stated, There you go, you're all done, and put Resident 2's feet back up. As Employee 1 was leaving she stated, Alright honey, get some sleep. Resident 2 stated, thank you and Employee 1 responded, you're welcome, picked up her phone with a gloved hand and began reading the live TikTok screen comments verbally. Employee 1 stated, Always, I think I missed what was going on. Some people to .seriously .for real. Hold on guys, I gotta go (undiscernible comment), hold on. Employee 1 carried her PED into the facility's hallway and the live TikTok video ended. Both Resident 1 and Resident 2 were easily identifiable based on their facility identification photo as their faces were visible during these interactions with Employee 1. Employee 1 provided incontinence care to Resident 2 during the live TikTok screen. At no time during the video recording of the live TikTok did Employee 1 inform either Resident 1 or 2 that they were being recorded nor did Employee 1 gain Resident 1 or 2's consent to record them. The video recording of Employee 1's live TikTok was a total of 17 minutes. The Nursing Home Administrator (NHA) received an anonymous phone call on November 18 2024, at 1:30 PM. The caller referenced this live TikTok, described Employee 1, and provided a video recording of the live TikTok to the NHA for review. Facility administration reviewed the video, initiated a facility investigation, and immediately suspended Employee 1. Review of the facility's investigation revealed that the NHA spoke with Employee 1 on November 18, 2024, at 5:15 PM. Employee 1 revealed to the NHA that she didn't know she did anything wrong and that you couldn't see residents faces. Employee 1 also validated she received a violation by TikTok, and her account was temporarily suspended. Employee 1 also admitted to doing a daily day in the life of a CNA TikTok. The facility's human resources office spoke with Employee 1 on November 19, 2024. Employee 1 confirmed that she did not inform the Residents that she was live on TikTok, that the Residents could not say yes or not if she were to ask them if she could record them, and that she thought she was doing her best to protect their privacy. Employee 1 acknowledged now that it was wrong what she did but noted that she sees videos like that all the time on TikTok. Employee 1 confirmed that someone on her live (TikTok) reported her, she doesn't know why she was reported, and doesn't receive compensation for her TikTok. Interview on December 19, 2024, at 10:15 AM and 3:30 PM with the Nursing Home Administrator and the Director of Nursing confirmed the above findings. 28 Pa. Code 201.29 (c.3)(4) Resident rights