Every finding on record at Heritage Ridge Senior Living at Johnstown

Based on review of the Pennsylvania Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to obtain urine culture results timely for treatment of a urinary tract infection, resulting in a delay in treatment for one of five residents reviewed (Resident 1). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated March 6, 2026, revealed that the resident was cognitively impaired, required assistance with care needs, had an indwelling catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder), was incontinent of bowel, and had diagnoses that included neuromuscular disfunction of the bladder (bladder lacks control due to nerve or muscle problems), UTI in the last 30 days and sepsis (a serious, life-threatening bodily response to infection). A nursing note for Resident 1, dated April 6, 2026, at 1:57 p.m. revealed that the nurse was alerted by the social worker that the resident stated during their visit that her pee burns. The registered nurse was notified and the resident was put on the list for the physician. A physician's order for Resident 1, dated April 8, 2026, included an order for staff to obtain a urine specimen for a urinalysis (tests urine to check for infection) to reflux (urine culture is performed if the initial urinalysis detects indicators of a potential infection). A nursing note for Resident 1, dated April 9, 2026, at 10:39 p.m. indicated that the urine results showed 2+ bacteria (moderate amount of bacteria present which often suggests a urinary tract infection) and the physician was made aware. A nursing note for Resident 1, dated April 21, 2026, at 5:19 a.m. revealed that the resident was noted to have rapid respirations, bloody stools and blood in her foley catheter tubing. Physician's orders were received for stat bloodwork. A nursing note for the resident, dated April 21, 2026, at 9:21 p.m. revealed that the Certified Registered Nurse Practitioner (CRNP) reviewed the bloodwork and ordered a urinalysis to reflux. A physician's order for Resident 1, dated April 21, 2026, included an order for staff to obtain a urine specimen for a urinalysis to reflux. A nursing note for Resident 1, dated April 22, 2026, at 5:35 p.m. revealed that the urinalysis results showed 4+ bacteria (a large amount of bacteria suggesting a urinary tract infection and nitrites (occur in urine when there is a urinary tract infection), and a culture and sensitivity (identifies the specific bacteria and determines which medications will successfully treat it) was pending. A new order was obtained for the resident to start Bactrim DS (an antibiotic) twice daily for seven days. Urine culture and sensitivity results for Resident 1 for the urinalysis performed on April 9, 2026, and obtained by the facility on May 13, 2026, at 12:52 p.m. revealed that the resident had a urinary tract infection. Review of Resident 1's clinical record revealed no documented evidence that the culture and sensitivity results were obtained for the physician to review, delaying treatment of the resident's urinary tract infection. Interview with the Director of Nursing on May 13, 2026, at 2:58 p.m. confirmed that there was no documented evidence that Resident 1's urine culture and sensitivity results from the urinalysis performed on April 9, 2026, were obtained and reviewed by the physician. 28 Pa. Code 211.12(d)(1)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policies, clinical records, observations, shower schedules, as well as staff and resident interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for two of five residents reviewed (Residents 3 and 5).Findings include: The facility policy for bathing and showering, dated August 21, 2025, indicated that residents are bathed or showered to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Document if the resident refused the shower/tub bath, the reason why and the intervention taken. Notify the supervisor if the resident refuses the shower/tub bath. An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 3, dated April 17, 2026, revealed that the resident was cognitively impaired, was able to usually understand others, was dependent on staff for showers/bathing, was incontinent of bowel and bladder, had moisture associated skin damage (inflammation of the skin caused by exposure to moisture), and had diagnoses including diabetes and obesity. Observations of Resident 3 on May 12, 2026, at 11:05 a.m. revealed that she was fully dressed and sitting in hallway in her wheelchair. Review of the activities of daily living (ADL) documentation for Resident 3 from April 2026, through May 12, 2026, revealed that she was to receive a shower twice weekly on Tuesdays and Fridays on the day shift. Showers were documented as not given on April 14, April 17, April 28, May 8 and May 12 in the ADLS documentation and in the tasks and there was no documented evidence that the resident refused her showers. An admission MDS assessment for Resident 5, dated May 6, 2026, revealed that the resident was cognitively intact, required maximum/substantial assistance from staff for showers/bathing, was occasionally incontinent of bowel and bladder, had a Stage 2 pressure ulcer and a diabetic foot ulcer and had diagnoses including diabetes and morbid obesity. Interview with Resident 5 on May 12, 2026, at 10:59 a.m. indicated that she had not had a shower since she was admitted to the facility, but did get one yesterday, finally. She stated she was supposed to get them twice a week on Thursdays and Sundays in the evening and the previous Thursday (May 7), the nurse aide said she would come back after supper to give her a shower and she did not. On Mother's day (May 10), the nurse aide never came to get her for a shower. Review of the activities of daily living (ADL) documentation for Resident 5 for May 2026, revealed that she was to receive a shower twice weekly on Sundays and Thursdays on the evening shift. Showers were documented as not given on May 3, May 7 and May 10 in the ADLS documentation and in the tasks and there was no documented evidence that the resident refused her showers. Interview with the Director of Nursing on May 12, 2026, at 2:58 p.m. confirmed that there was no documented evidence that Resident 3 and Resident 5 received and/or refused their showers on the above-mentioned dates. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on a review of facility policies, clinical records, grievances, and resident and staff interviews, it was determined that the facility failed to promptly take measures necessary to protect residents from sexual abuse after abuse was identified for four of 15 residents reviewed (Residents 1, 6, 7, 14). This failure placed the residents in immediate jeopardy due to the actual sexual abuse that already occurred, as well as the potential for further sexual abuse to occur. Findings include:Review of the facility's abuse policy, dated August 21, 2025, revealed that each resident has the right to be free from abuse.A comprehensive Medicare 5-day Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated December 16, 2025, revealed that the resident was cognitively intact, required minimal help from staff for her daily care needs, and was always continent of urine.Review of a grievance filed by Resident 14 on December 18, 2025 revealed that she reported that Nurse Aide 1 entered her room around 5:00 a.m. while she was sleeping and put his hand inside her pants to see if she was wet. She was upset because he did not tell her what he was doing, she was able to tell him that she was not wet, and she had no history of being incontinent. She felt that this was a violation of her dignity and rights.An interview with Resident 14 on April 14, 2026 at 1:47 p.m. revealed that she was upset that Nurse Aide 1 woke her up around 5:00 a.m. by putting his hand inside her pants to see if she was wet. She stated that he touched her genitalia inappropriately and she felt violated. She said she immediately asked to speak to the nurse, however, the nurse did not come in until around 7:30 a.m. She stated she told Licensed Practical Nurse 2 what happened and that she was upset about it. She stated that she felt like they dismissed her and treated her like this was not important.A quarterly MDS assessment for Resident 6, dated March 27, 2026 revealed that the resident was cognitively intact and required assistance from staff for daily care needs, including incontinence, and that she was usually incontinent of urine and bowel. Review of a grievance for Resident 6, dated January 2, 2026, revealed that the resident was upset because of her interaction with Nurse Aide 1 during incontinence care. She stated that when he answered her call bell he told her that daylight staff would change and reposition her, however it was midnight and daylight staff would not come in for another six hours. She told him that was too long to wait and he needed to change her. He told her that she was not allowed to poop and stated oh my gosh, you pooped everywhere. He proceeded to take her nightgown and her brief off, then left the room to gather supplies leaving her naked on her bed with the curtain and the door open. She was upset that she was exposed. Nurse Aide 1 returned and started providing care for her then left the room a second time to get supplies while she was naked and exposed on the bed with the curtain and door open. After providing care for the resident he asked her if she slept in the nude. She felt this was a violation of her right to privacy and dignity. She also grieved that he frequently made statements regarding disciplinary actions he has already received, such as being suspended and having the days split up so his paycheck wasn't affected; that a co-worker accused him of touching her inappropriately; and that other residents have complained about his care and the inappropriate things he says.Interview with Resident 6 on April 13, 2026 at 3:42 p.m. revealed that she felt exposed when Nurse Aide 1 left her naked on her bed with the door open and the curtain open two times while he gathered supplies. She stated that she told him she did not like being left exposed and he asked her if she slept in the nude at home. She stated this made her feel awkward and she asked him not to talk like that. He told her he liked looking at naked women, while he was looking at her, and that there was another resident that he liked to look at naked and she didn't like him doing it either. She said that he also told her that a nurse aide accused him of touching her and that he was supposed to be suspended because of it, but because staffing was so bad they needed him and could not suspend him the right way. Resident 6 said she told Nurse Aide 1 that if he was doing those things he needed to stop and get himself some help. She stated that she was not afraid for herself, but she feared for other residents who could not speak for themselves.A comprehensive MDS assessment for Resident 7, dated April 5, 2026, revealed that the resident was cognitively intact, required help from staff to get in and out of the bathroom, and that she was always incontinent of urine and bowel.An interview with Resident 7 on April 13, 2026 at 1:19 p.m. revealed that she did not want Nurse Aide 1 to provide care for her. She stated that he startled her awake by sticking his hand inside her brief to see if she was wet. She said that he did not need to do that because he should have just asked her like all of the other staff. She stated she did not like him putting his hand in her brief and that she did not want him back in her room.A quarterly MDS assessment for Resident 1, dated January 21, 2026 revealed that the resident was cognitively intact, required observation from staff for ambulation, and that she was frequently incontinent of urine and bowel.A grievance for Resident 1, dated March 27, 2026, revealed that Family Member 1 phoned the Director of Social Services on March 25, 2026 and asked her why a staff member went into Resident 1's room around 1:00 a.m. in the morning and startled her awake by turning on the light and pulling her blanket off.An interview with Resident 1 on April 13, 2026 at 9:58 a.m. revealed that she did not want to talk about the grievance or any details of the incident.An interview with Family Member 1 on April 13, 2026, at 3:53 p.m. revealed that she called the Director of Social services because she wanted to know what went on during the night. She stated that Resident 1 called her at 1:00 a.m. crying and stated that Nurse Aide 1 had put his hand inside her brief while she was sleeping and his fingers penetrated her vagina. Family Member 1 stated that Resident 1 told her that he had done this 2 or 3 other times and that she was afraid she was going to be raped by him. She said that Resident 1 was crying and afraid. She said that she phoned the Director of Social Services and told her that Resident 1 was crying and said that Nurse Aide 1 stuck his hand in her crotch while she was sleeping. She stated that Resident 1 told her later that day that Nurse Aide 1 had been fired, but he had not been. She stated that Resident 1 felt safe because she believed he was no longer working there.An interview with Nurse Aide 3 on April 13, 2026, at 10:44 a.m. revealed that when he went to provide morning care to Resident 1 following the incident she said to him that man put his hand in my pants and touched my private area. He said that she was upset while she was telling him about the incident and that he went to Licensed Practical Nurse 4 and told her immediately. An interview with Licensed Practical Nurse 4 on April 13, 2026 at 2:50 p.m. revealed that she entered Resident 1's room and Resident 1 told her that the male nurse aide on night shift put his hand inside her brief and that his fingers penetrated her vagina. Licensed Practical Nurse 4 stated that she immediately went to Registered Nurse 5 and reported the incident to her. She said that she told Registered Nurse 5 that he digitally penetrated her and she was upset.An interview with Registered Nurse 5 on April 13, 2026 at 4:50 p.m. revealed that when Licensed Practical Nurse 4 told her that Nurse Aide 1 put his finger inside Resident 1's vagina she immediately went to the Director of Social Services and told her what Resident 1 said. She said she told the Director of Social Services that Resident 1 said that Nurse Aide 1 put his hand in her brief and his finger inside her vagina. She stated that the Director of Social Services and the Assistant Director of Nursing said that they were already aware of this so Registered Nurse 5 did not do anything further regarding this issue.An interview with Registered Nurse 6 on April 13, 2026 at 10:44 a.m. revealed that she had been asked by a nurse aide if there was a hole in the schedule on the night shift since Nurse Aide 1 would not be reporting to work after the allegations that were made by Resident 1. Registered Nurse 6 said she went to the Nursing Home Administrator and asked if Nurse Aide 1 needed to be replaced on night shift. The Nursing Home Administrator asked her why he would need to be replaced and she informed him what happened with Resident 1 and Nurse Aide 1. The Nursing Home Administrator said that he was not aware of the allegation.An interview with the Director of Social Services on April 14, 2026, at 9:55 a.m. revealed that she did not believe any abuse had occurred. She stated emphatically that she knew there was no abuse, that no abuse took place, and that the resident was not sexually abused. She also stated she wished people would stop saying that. She stated that she had a very good rapport with Resident 1 and that Resident 1 would have told her if it had happened. She denied that Family Member 1, Registered Nurse 5, or the Nursing Home Administrator had told her that Nurse Aide 1 touched Resident 1's crotch, digitally penetrated her, or fingered her. She again said emphatically that she would take an allegation very seriously and that she knew there was no way this happened.An undated list of residents that Nurse Aide 1 was not permitted to work with, provided by the acting Director of Nursing, revealed that he was not to work with Residents 1, 6, or 7. Nurse Aide 1 was not to work with Resident 6 after her allegation of abuse on January 2, 2026. A review of Resident 6's task record, dated January, March, and April 2026, revealed that Nurse Aide 1 worked with her on January 26, March 14, March 15, March 16, March 28, April 2, April 6, April 11, and April 12. Nurse Aide 1was not to work with Resident 7 after she made an allegation of sexual abuse in January, 2026. A review of Resident 7's task record, dated February, and April 2026, revealed that Nurse Aide 1 worked with Resident 7 on Feburary 19, April 1, and April 2.An interview with the acting Director of Nursing on April 13, 2026 at 4:55 p.m. revealed that Nurse Aide 1 should not have worked with Resident 6 or Resident 7 on the above referenced dates.An interview with the Nursing Home Administrator and acting Director of Nursing on April 13, 2026 at 1:04 p.m. revealed that they did not feel the allegation regarding Resident 1 and Nurse Aide 1 was abuse, and just wrote the incident up as a grievance. The acting Director of Nursing stated that she was not aware of any sexual abuse allegations. The Nursing Home Administrator stated that when he was made aware of the allegation he had the Director of Social Services talk with Resident 1. He said the Director of Social Services stated that Resident 1's story had changed and therefore the incident did not happen. An Immediate Jeopardy situation was identified to the Nursing Home Administrator and the acting Director of Nursing on April 14, 2026, at 3:29 p.m. related to the facility's failure to ensure that immediate and adequate safeguards were taken to protect the residents from sexual abuse by Nurse Aide 1. On April 14, 2026, at 6:15 p.m. the facility submitted an immediate action plan that included:Nurse Aide 1 was terminated on April 14, 2026, and was no longer employed at the facility. An in-house audit was performed on residents on April 14, 2026, and assessments were completed along with interviews to confirm no other residents were identified. In-house re-education was provided to all staff on abuse and reporting of abuse on April 14, 2026. The facility will not allow an employee to work unless this education has been completed prior to returning to work. Daily random audits of care and interviews continue to ensure that no residents have been affected. The Immediate Jeopardy was lifted on April 14, 2026, at 6:46 p.m. when it was confirmed that the corrective action plans developed on April 14, 2026, were completed.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 201.29(a)(c)(d) Resident rights.

Based on review of policies, clinical records, family member interview, resident interviews, and staff interviews, it was determined that the facility failed to complete thorough investigations of incidents to rule out sexual abuse, which led to three more residents being sexually abused by a staff member for four of 15 residents reviewed (Residents 1, 6, 7, 14). Findings include:The facility's policy regarding abuse, neglect, exploitation or misappropriation - reporting and investigating, dated August 21, 2025, revealed that all allegations were thoroughly investigated and that the employee who was accused of resident abuse would be placed on leave with no resident contact until the investigation is complete.A review of Nurse Aide 1's personnel file revealed that he completed facility orientation on December 3, 2025. On December 7, 2025 Nurse Aide 7 accused Nurse Aide 1 of talking sexually to her and smacking her on her buttock. On December 18, 2025 Nurse Aide 1 received suspension for unprofessional conduct and a violation of resident rights for Resident 14. However, his suspension was scattered for one day on December 18, 2025, one day on January 5, 2026, and one day on January 8, 2026, instead of consecutive days as the facility's policy stated. On January 3, 2026 Nurse Aide 1 received a written warning for unprofessional conduct and abuse/inappropriate language regarding Resident 6. On March 27, 2026 Nurse Aide 1 received a last and final written warning for unprofessional conduct, failure to follow procedure, refusal to follow instructions after having been educated two times, and violation of resident rights regarding Resident 1. There was no indication in Nurse Aide 1's personnel file that he was disciplined for an incident involving Resident 7. A mandatory Medicare 5-day Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated December 16, 2025, revealed that the resident was cognitively intact, required minimal help from staff for her daily care needs, and was always continent of urine.A review of a grievance filed on December 18, 2025 by Resident 14 revealed that she reported that Nurse Aide 1 entered her room around 5:00 a.m. while she was sleeping and put his hand inside her pants to see if she was wet. She was upset because he did not tell her what he was doing, she was able to tell him that she was not wet, and she had no history of being incontinent. She felt that this was a violation of her dignity and rights.An interview with Resident 14 on April 14, 2026 at 1:47 p.m. revealed that she was upset that Nurse Aide 1 woke her up around 5:00 a.m. by putting his hand inside her pants to see if she was wet. She stated that he touched her inappropriately and she felt violated. She said she immediately asked to speak to the nurse, however, the nurse did not come in until around 7:30 a.m. She stated she told Licensed Practical Nurse 2 what happened and that she was upset about it. Resident 14 stated the Director of Nursing did not take her seriously and that she felt that her complaint was dismissed.A quarterly MDS assessment for Resident 6, dated March 27, 2026 revealed that the resident was cognitively intact and required assistance from staff for daily care needs, including incontinence, and that she was usually incontinent of urine and bowel. A grievance form for Resident 6, dated January 2, 2026, revealed that the resident was upset because of her interaction with Nurse Aide 1 during incontinence care. She stated that when he answered her call bell he told her that daylight staff would change and reposition her, however it was midnight and daylight staff would not come in for another six hours. She told him that was too long to wait and he needed to change her. He then told her that she was not allowed to poop and oh my gosh, you pooped everywhere. He then proceeded to take her nightgown off and her brief off. He then left the room to gather supplies leaving her naked on her bed with the curtain and the door open. She was upset that she was exposed. He then returned, proceeded to start to provide care for her and again left the room to get supplies while she was naked and exposed on the bed with the curtain and door open. After providing care for the resident he asked her if she slept in the nude. She felt this was a violation of her right to privacy and dignity. She also grieved that he often made statements regarding personal things, such as that he was suspended for being accused of touching another nurse aide and the days were split up so that they did not affect his paycheck and because the facility was so short of staff, that another co-worker accused him of touching her inappropriately and he got away with it, and that other residents have complained about his care and things he says.Interview with Resident 6 on April 13, 2026 at 3:42 p.m. revealed that she felt exposed when Nurse Aide 1 left her naked on her bed with the door open and the curtain open two times while he gathered supplies. She stated that she told him she did not like being left exposed and he asked her if she slept in the nude at home. She stated this made her feel awkward and she asked him not to talk like that. He then told her that he liked looking at naked women, while looking at her naked, and that there was another woman there that he liked to look at naked and she didn't like him doing it either. She said that he also told her that a nurse aide accused him of touching her and that he was supposed to be suspended because of that, but that staffing was so bad they needed him and could not suspend him the right way. She said she told him that if he was doing those things he needed to stop and get himself some help. She stated that she was not afraid for herself, but she feared for other residents who could not speak for themselves.A comprehensive MDS assessment for Resident 7, dated April 5, 2026, revealed that the resident was cognitively intact, required help from staff to get in and out of the bathroom, and that she was always incontinent of urine and bowel.An interview with Resident 7 on April 13, 2026 at 1:19 p.m. revealed that she did not want Nurse Aide 1 to provide care for her. She stated that he startled her awake by sticking his hand inside her brief to see if she was wet. She said that he did not need to do that because he should have just asked her like all of the other staff. She stated she did not like him putting his hand in her brief and that she did not want him back in her room.A quarterly MDS assessment for Resident 1, dated January 21, 2026 revealed that the resident was cognitively intact, required observation from staff for ambulation, and that she was frequently incontinent of urine and bowel.A grievance filed by Resident 1, dated March 27, 2026, revealed that Family Member 1, Resident 1's daughter-in-law and Power of Attorney, phoned the Director of Social Services on March 25, 2026 and asked her why a staff member went into Resident 1's room around 1:00 a.m. in the morning and startled her awake by turning on the light and pulling her blanket off.An interview with Resident 1 on April 13, 2026 at 9:58 a.m. revealed that she did not want to talk about the grievance or any details of the incident.An interview with Family Member 1 revealed that she called the Director of Social services because she wanted to know what went on during the night. She stated that Resident 1 called her at 1:00 a.m. crying and stated that Nurse Aide 1 had put his hand inside her brief while she was sleeping and his fingers penetrated her vagina. Family Member 1 stated that Resident 1 told her that he had done this 2 or 3 other times and that she was afraid she was going to be raped by him. She said that Resident 1 was crying and afraid. She said that she phoned the Director of Social Services and told him that Resident 1 was crying and said that Nurse Aide 1 stuck his hand in her crotch while she was sleeping. She stated that Resident 1 told her later that day that Nurse Aide 1 had been fired, but he had not been. She stated that Resident 1 felt safe because she believed he was no longer working there.An interview with Nurse Aide 3 on April 13, 2026 at 10:44 a.m. revealed that when he went to provide care for Resident 1 in the morning that she said to him did you hear what happened to me? That man (later identified as Nurse Aide 1), put his hand in my pants and touched my private area. He said that she was upset when she was telling him about this. He stated that he went to his nurse, Licensed Practical Nurse 4 and told her immediately. An interview with Licensed Practical Nurse 4 on April 13, 2026 at 2:50 p.m. revealed that she entered Resident 1's room and Resident 1 told her that the male nurse aide on night shift put his hand inside her brief and that his fingers penetrated her vagina. Licensed Practical Nurse 4 stated that she immediately went to Registered Nurse 5 and reported that Nurse Aide 1 and reported this to her. She said that she told Registered Nurse 5 that he digitally penetrated her and she was upset.An interview with Registered Nurse 5 on April 13, 2026 at 4:50 p.m. revealed that when Licensed Practical Nurse 4told her that Nurse Aide 1 put his finger inside Resident 1's vagina she immediately went to the Director of Social Services and told her what the Resident 1 said. She said she told the Director of Social Services that Resident 1 said that Nurse Aide 1 put his hand in her brief and his finger inside her vagina. She stated that the Director of Social Services and the Assistant Director of Nursing said that they were already aware of this so Registered Nurse 5 did not do anything further regarding this issue.An interview with Registered Nurse 6 on April 13, 2026 at 10:44 a.m. revealed that a nurse aide asked her if there was a hole for the night shift since they thought that Nurse Aide 1 would not be reporting to work that night after the allegations that were made by Resident 1. Registered Nurse 6 stated she went to the Nursing Home Administrator and asked if Nurse Aide 1 needed replaced on the night shift and the Nursing Home Administration asked her why he would. She stated that she said because a resident says that he fingered her two nights ago and that the Nursing Home Administrator was not aware of the allegation.An interview with the Nursing Home Administrator and acting Director of Nursing on April 13, 2026 at 1:04 p.m. revealed that they did not feel the allegation regarding Resident 1 and Nurse Aide 1 was abuse and they just wrote the incident up as a grievance. The acting Director of Nursing stated that she was not aware of any sexual abuse allegations. The Nursing Home Administrator stated that when he was made aware of the allegation related to Resident 1 he had the Director of Social Services talk with her. He said that Director of Social Services stated that Resident 1's story had changed and therefore the incident did not happen. An interview with the Director of Social Services on April 14, 2026 at 9:55 a.m. revealed that she did not believe any abuse occurred. She stated emphatically that she knew there was no abuse, that no abuse took place, and that the resident was not sexually abused. She stated she wished people would stop saying that. She stated that she had a very good rapport with Resident 1 and that Resident 1 would have told her if that happened. She denied that Family Member 1, Registered Nurse 5, and the Nursing Home Administrator told her that Nurse Aide 1 touched Resident 1's crotch, or that he digitally penetrated her, or that he fingered her, as they all said they told her. She again said emphatically that she would take an allegation very seriously and she knew there was no way this happened.Interview with Nurse Aide 1 on April 14, 2026 at 5:15 p.m. revealed that he denied touching any of the residents in appropriately. He said why would I do something like that? He further stated that he could tell when a resident was wet by looking at their brief because there is a line on the brief that indicates if it is wet or not. He denied that he put his hand inside any of the resident's briefs. He could not recall who Resident 14 was. He stated that Resident 1 was simply mad at him for waking her up the way he did, which was by turning the light on and yelling her name. He denied that he put his hand inside Resident 1's brief.There was no documented evidence that statements were obtained from the residents who made accusations of sexual abuse, the staff who were told about the incidents by the residents, or any staff that interviewed the residents. There was no documented evidence that a thorough investigation was completed for Residents 1, 6, 7, and 14's allegations of sexual abuse, including interviews with all pertinent staff to rule out that the abuse may have occurred. Interview with the Nursing Home Administrator and acting Director of Nursing on April 13, 2026 at 1:04 p.m. revealed that they did not conduct an investigation into Residents 1, 6, 7, or 14's allegations because they did not feel that the abuse occurred. The Nursing Home Administrator stated that he had a grievance filled out instead of doing an investigation.28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 211.10(d) Resident care policies.28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policies, personnel files, clinical records, and grievances filed by residents, as well as resident, family and staff interviews, it was determined that the facility failed to implement its abuse policy by not immediately protecting residents who were at risk of sexual abuse, which led to three more residents being sexually abused by a staff member for four of 15 residents reviewed (Residents 1, 6, 7, 14). Findings include:The facility's policy regarding abuse, dated August 21, 2025, indicated that any employee whose conduct gives rise to a reasonable suspicion of resident abuse may be immediately removed from the floor, and where appropriate suspended without pay pending an investigation and that facility staff were to investigate all possible incidents of abuse.A review of Nurse Aide 1's disciplinary file revealed that on December 7, 2025, Nurse Aide 7 reported that Nurse Aide 1 asked her personal questions, told her to get on her knees while she was helping provide care for a resident, and then shortly after that, slapped her on her buttock. She said that he told her she was not the first co-worker.A mandatory Medicare 5-day Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated December 16, 2025, revealed that the resident was cognitively intact, required minimal help from staff for her daily care needs, and was always continent of urine.A review of a grievance filed on December 18, 2025 by Resident 14 revealed that she reported that Nurse Aide 1 entered her room around 5:00 a.m. while she was sleeping and put his hand inside her pants to see if she was wet. She was upset because he did not tell her what he was doing, she was able to tell him that she was not wet, and she had no history of being incontinent. She felt that this was a violation of her dignity and rights.An interview with Resident 14 on April 14, 2026 at 1:47 p.m. revealed that she was upset thatNurse Aide 1woke her up around 5:00 a.m. by putting his hand inside her pants to see if she was wet. She stated that he touched her inappropriately and she felt violated. She said she immediately asked to speak to the nurse, however, the nurse did not come in until around 7:30 a.m. She stated she told Licensed Practical Nurse 2 what happened and that she was upset about it.An interview with Licensed Practical Nurse 2 on April 13, 2026 at 2:30 p.m. revealed that Resident 14 told her that Nurse Aide 1 put his hand in her pants while she was sleeping and the he touched her inappropriately. She stated that she immediately reported this to the Director of Nursing. She stated that she was aware that Nurse Aide 1 had sexually assaulted a nurse aide and that the nurse aide quit because nothing was done about it the week prior to this happening to Resident 14. She stated she was very concerned for her other residents, especially Resident 2 who was a [AGE] year old female and in a comatose state. She said she told the Director of Nursing that she did not want him working on her hall, or at all for that matter and that she was surprised that he was permitted to return to work that evening.A quarterly MDS assessment for Resident 6, dated March 27, 2026 revealed that the resident was cognitively intact and required assistance from staff for daily care needs, including incontinence, and that she was usually incontinent of urine and bowel.A grievance form for Resident 6, dated January 2, 2026, revealed that the resident was upset because of her interaction with Nurse Aide 1 during incontinence care. She stated that when he answered her call bell he told her that daylight staff would change and reposition her, however it was midnight and daylight staff would not come in for another six hours. She told him that was too long to wait and he needed to change her. He then told her that she was not allowed to poop and oh my gosh, you pooped everywhere. He then proceeded to take her nightgown off and her brief off. He then left the room to gather supplies leaving her naked on her bed with the curtain and the door open. She was upset that she was exposed. He then returned, proceeded to start to provide care for her and again left the room to get supplies while she was naked and exposed on the bed with the curtain and door open. After providing care for the resident he asked her if she slept in the nude. She felt this was a violation of her right to privacy and dignity. She also grieved that he often made statements regarding personal things, such as that he was suspended and the days were split up so that they did not affect his paycheck; that a co-worker accused him of touching her inappropriately; and that other residents have complained about his care and things he says.Interview with Resident 6 on April 13, 2026 at 3:42 p.m. revealed that she felt exposed when Nurse Aide 1 left her naked on her bed with the door open and the curtain open two times while he gathered supplies. She stated that she told him she did not like being left exposed and he asked her if she slept in the nude at home. She stated this made her feel awkward and she asked him not to talk like that. He then told her that he liked looking at naked women, while looking at her naked, and that there was another woman there that he liked to look at naked and she didn't like him doing it either. She said that he also told her that a nurse aide accused him of touching her and that he was supposed to be suspended because of that, but that staffing was so bad they needed him and could not suspend him the right way. She said she told him that if he was doing those things he needed to stop and get himself some help. She stated that she was not afraid for herself, but she feared for other residents who could not speak for themselves.A comprehensive MDS assessment for Resident 7, dated April 5, 2026, revealed that the resident was cognitively intact, required help from staff to get in and out of the bathroom, and that she was always incontinent of urine and bowel.An interview with Resident 7 on April 13, 2026 at 1:19 p.m. revealed that she did not want Nurse Aide 1 to provide care for her. She stated that he startled her awake by sticking his hand inside her brief to see if she was wet. She said that he did not need to do that because he should have just asked her like all of the other staff. She stated she did not like him putting his hand in her brief and that she did not want him back in her room.A quarterly MDS assessment for Resident 1, dated January 21, 2026 revealed that the resident was cognitively intact, required observation from staff for ambulation, and that she was frequently incontinent of urine and bowel.A grievance filed by Resident 1, dated March 27, 2026, revealed that Family Member 1, (Resident 1's daughter in law and power of attorney), phoned the Director of Social Services on March 25, 2026 and asked her why a staff member went into Resident 1's room around 1:00 a.m. in the morning and startled her awake by turning on the light and pulling her blanket off.An interview with Resident 1 on April 13, 2026 at 9:58 a.m. revealed that she did not want to talk about the grievance or any details of the incident.An interview with Family Member 1 revealed that she called the Director of Social services because she wanted to know what went on during the night. She stated that Resident 1 called her at 1:00 a.m. crying and stated that Nurse Aide 1 had put his hand inside her brief while she was sleeping and his fingers penetrated her vagina. Family Member 1 stated that Resident 1 told her that he had done this 2 or 3 other times and that she was afraid she was going to be raped by him. She said that Resident 1 was crying and afraid. She said that she phoned the Director of Social Services and told her that Resident 1 was crying and said that Nurse Aide 1 stuck his hand in her crotch while she was sleeping. An interview with Nurse Aide 3 on April 13, 2026 at 10:44 a.m. revealed that when he went to provide care for Resident 1 in the morning that she said to him did you hear what happened to me? That man put his hand in my pants and touched my private area. He said that she was upset when she was telling him about this. He stated that he went to his nurse, Licensed Practical Nurse 4 and told her immediately. An interview with Licensed Practical Nurse 4 on April 13, 2026 at 2:50 p.m. revealed that she spoke to Resident 1 and Resident 1 told her that the male nurse aide on night shift put his hand inside her brief and that his fingers penetrated her vagina. Licensed Practical Nurse 4 stated that she immediately went to Registered Nurse 5 and reported this to her. She said that she told Registered Nurse 5 that he digitally penetrated her and she was upset.An interview with Registered Nurse 5 on April 13, 2026 at 4:50 p.m. revealed that when Licensed Practical Nurse 4 told her that Nurse Aide 1 put his finger inside Resident 1's vagina she immediately went to the Director of Social Services and told her what Resident 1 said. She said she told the Director of Social Services that Resident 1 said that Nurse Aide 1 put his hand in her brief and his finger inside her vagina. She stated that the Director of Social Services and the Assistant Director of Nursing said that they were already aware of this so Registered Nurse 5 did not do anything further regarding this issue.An interview with Registered Nurse 6 on April 13, 2026 at 10:44 a.m. revealed that a nurse aide asked her if there was a hole in the schedule for the night shift since they thought that Nurse Aide 1 would not be reporting to work that night after the allegations that were made by Resident 1. Registered Nurse 6 stated she went to the Nursing Home Administrator and asked if Nurse Aide 1 needed replaced on the night shift and the Nursing Home Administration asked her why he would. She stated that she said because a resident says that he fingered her two nights ago but the Nursing Home Administrator was not aware of the allegation. Registered Nurse 6 stated that Nurse Aide 1 did come to work that night.An interview with the Nursing Home Administrator and acting Director of Nursing on April 13, 2026 at 1:04 p.m. revealed that they did not feel the allegation regarding Resident 1 and Nurse Aide 1 was abuse and they just wrote the incident up as a grievance. The acting Director of Nursing stated that she was not aware of any sexual abuse allegations. The Nursing Home Administrator stated that when he was made aware of the allegation he had the Director of Social Services talk with Resident 1. He said that the Director of Social Services stated that Resident 1's story had changed and therefore the incident did not happen. An interview with the Director of Social Services on April 14, 2026 at 9:55 a.m. revealed that she did not believe any abuse occurred. She stated emphatically that she knew there was no abuse, that no abuse took place, and that the resident was not sexually abused. She stated she wished people would stop saying that. She stated that she had a very good rapport with Resident 1 and that Resident 1 would have told her if that happened. She denied that Family Member 1, Registered Nurse 5, and the Nursing Home Administrator told her that Nurse Aide 1 touched Resident 1's crotch; or that he digitally penetrated her; or that he fingered her, as they all said they told her. She again said emphatically that she would take an allegation very seriously and she knew there was no way this happened.An interview with the Nursing Home Administrator and acting Director of Nursing on April 13, 2026, at 1:04 p.m. revealed that the facility did not investigate the allegations of abuse made by Residents 1, 6, 7, or 14 because they did not believe that it happened and therefore did not need to do an investigation. The Nursing Home Administrator stated that he filled out a grievance form instead of conducting an investigation.28 Pa. Code 201.14(c) Responsibility of licensee.28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of job descriptions and the deficiencies cited during the current survey, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to assume responsibility for effective management of the facility to ensure that the residents' environment remained free of abuse.Based on review of job descriptions and the deficiencies cited during the current survey, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to assume responsibility for effective management of the facility to ensure that the residents' environment remained free of abuse.Findings include:The current job description for the NHA indicated that the primary purpose of this position was to direct the day to day functions of the facility in accordance with current federal, state, and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care be provided to our residents at all times. The administrative functions included planning, developing, organizing, implementing, evaluating, and directing the facility's programs and activities in accordance with guidelines issued by the Regional Manager, and review incident and accident reports (falls, injuries of unknown origin, abuse, etc.) and monitor to determine the effectiveness of the facility's risk management program.The current job description for the DON indicated that the primary purpose of this position was to plan, organize, develop, and direct the overall operation of the nursing department in accordance with current, federal, state, and local standards, guidelines, and regulations that govern the facility and as may be directed by the Administrator of the Medical Director to ensure that the highest degree of quality care was maintained at all times. The administrative functions included ensuring that all nursing staff follow established departmental policies and procedures.The deficiencies cited under the Code of Federal Regulatory Groups for Long-Term Care, 483.12 Freedom from Abuse, Neglect, and Exploitation (F600), revealed that the NHA and DON failed to fulfill their essential job duties for ensuring that the residents' environment remained free from abuse.Refer to F600. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a review of facility policies, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide care in a manner that maintained dignity for one of 15 residents reviewed (Resident 6). Findings include:The facility's policy regarding Resident Rights, dated August 21, 2025, indicated that a resident has the right to a dignified existence and will be treated with dignity. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated March 27, 2026, indicated that the resident was cognitively intact and required extensive assistance from staff for activities of daily living, including incontinence care.Review of a facility grievance for Resident 6, dated January 2, 2026 revealed that the resident was receiving incontinence care from Nurse Aide 1 during the night on January 1, 2026. She stated that he undressed her completely, told her that she was not allowed to poop, and then left the room to get supplies leaving her fully exposed with the curtain open and the door open. He then returned and again left the room during care while she was still naked and fully exposed with the curtain open and the door open. When he returned she asked him why he left her naked and he asked her if she slept in the nude at home. She told him that she did not think that was appropriate.Interview with Resident 6 on April 13, 2026 at 3:42 p.m. revealed that she did not like the way that Nurse Aide 1 provided care for. She stated that he left her naked and exposed while providing care for her and that he spoke inappropriately to her. She stated that he asked her if she slept in the nude when she was at home and then proceeded to tell her that he likes to look at naked women. She said that he told her that he was staring at a naked woman there and that she did not like it, but it didn't matter to him because he can get away with it. She said that Nurse Aide 1 also bragged to her about stuff that he was doing and getting away with. She said that Nurse Aide 1 told her that he was suspended because of something he did, but that the facility needed him to work so bad that they had to stagger his suspension over two weeks, instead of consecutive nights. Resident 6 stated that she was told that he would not work with her again after she informed staff of what he had done and said. She said that she felt exposed and undignified being left naked with the curtain and the door open.Interview with the acting Director of Nursing on April 13, 2026 at 4:08 p.m. confirmed that this was an undignified experience for Resident 6.28 Pa. Code 201.29(j) Resident rights.

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications for one of 15 residents reviewed (Resident 1). Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications for one of 15 residents reviewed (Resident 1).Findings include:The facility's policy regarding discarding and destroying medication, dated August 21, 2025, indicated that Schedule IV controlled substances will be disposed of in accordance with state regulations and federal guidelines.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated January 21, 2026, indicated that the resident was cognitively intact and required assistance from staff for all daily care needs.Physician's orders for Resident 1, dated October 28, 2025 , included an order for the resident to receive one 0.5 milligram (mg) tablet of Lorazepam (an anti-anxiety medication) three times daily.A review of Resident 1's Medication Administration Record, dated February and March 2026, revealed that on March 21, 2026 the Director of Nursing destroyed five tablets of Resident 1's Ativan, however, she did not have a witness for the destruction of the Scheduled IV controlled substance (Ativan). Interview with the Acting Director of Nursing on April 13, 2026 at 2:38 p.m. confirmed that there were not two nurses signatures on the controlled drug log for Resident 1 when destroying her Ativan and there should have been.28 Pa. Code 211.9(h) Pharmacy Services.28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of policies, clinical records, observations, resident interviews, and staff interviews, it was determined that the facility failed to report multiple incidents of alleged sexual abuse for four of 15 residents reviewed (Residents 1, 6, 7, 14). Findings include:The facility's policy regarding abuse, neglect, exploitation or misappropriation - reporting and investigation, dated August 21, 2025, indicated that the administrator or the individual making the allegation immediately reports his or her suspicion to the state licensing agency; the local/state ombudsman; the resident's representative; adult protective services; law enforcement officials; the resident's attending physician; and the facility medical director.A mandatory Medicare 5-day Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated December 16, 2025, revealed that the resident was cognitively intact, required minimal help from staff for her daily care needs, and was always continent of urine.A review of a grievance filed on December 18, 2025 by Resident 14 revealed that she reported that Nurse Aide 1 entered her room around 5:00 a.m. while she was sleeping and put his hand inside her pants to see if she was wet. She was upset because he did not tell her what he was doing, she was able to tell him that she was not wet, and she had no history of being incontinent. She felt that this was a violation of her dignity and rights.An interview with Resident 14 on April 14, 2026 at 1:47 p.m. revealed that she was upset that Nurse Aide 1 woke her up around 5:00 a.m. by putting his hand inside her pants to see if she was wet. She stated that he touched her genitalia inappropriately in doing so and she felt violated. She said she immediately asked to speak to the nurse, however, the nurse did not come in until around 7:30 a.m. She stated she told Licensed Practical Nurse 2 what happened and that she was upset about it. An interview with Licensed Practical Nurse 2 on April 14, 2026 at 2:16 p.m. revealed that Resident 14 did tell her about what happened to her with Nurse Aide 1 as soon as she got on shift the morning of December 18, 2026. She stated that she immediately went to the Director of Nursing and reported this to her. She stated that the Director of Nursing did not take the allegation seriously and that Nurse Aide 1 was back to work that night.A quarterly MDS assessment for Resident 6, dated March 27, 2026 revealed that the resident was cognitively intact and required assistance from staff for daily care needs, including incontinence, and that she was usually incontinent of urine and bowel. A grievance form for Resident 6, dated January 2, 2026, revealed that the resident was upset because of her interaction with Nurse Aide 1 during incontinence care. She stated that when he answered her call bell he told her that daylight staff would change and reposition her, however it was midnight and daylight staff would not come in for another six hours. She told him that was too long to wait and he needed to change her. He then told her that she was not allowed to poop and oh my gosh, you pooped everywhere. He then proceeded to take her nightgown off and her brief off. He then left the room to gather supplies leaving her naked on her bed with the curtain and the door open. She was upset that she was exposed. He then returned, proceeded to start to provide care for her and again left the room to get supplies while she was naked and exposed on the bed with the curtain and door open. After providing care for the resident he asked her if she slept in the nude. She felt this was a violation of her right to privacy and dignity. She also grieved that he often made statements regarding personal things, such as that he was suspended and the days were split up so that they did not affect his paycheck, that a co-worker accused him of touching her inappropriately, and that other resident's have complained about his care and things he says.Interview with Resident 6 on April 13, 2026 at 3:42 p.m. revealed that she felt exposed when Nurse Aide 1 left her naked on her bed with the door open and the curtain open two times while he gathered supplies. She stated that she told him she did not like being left exposed and he asked her if she slept in the nude at home. She stated this made her feel awkward and she asked him not to talk like that. He then told her that he liked looking at naked women, while looking at her naked, and that there was another woman there that he liked to look at naked and she didn't like him doing it either. She said that he also told her that a nurse aide accused him of touching her and that he was supposed to be suspended because of that, but that staffing was so bad they needed him and could not suspend him the right way. She said she told him that if he was doing those things he needed to stop and get himself some help. She stated that she was not afraid for herself, but she feared for other residents who could not speak for themselves.A comprehensive MDS assessment for Resident 7, dated April 5, 2026, revealed that the resident was cognitively intact, required help from staff to get in and out of the bathroom, and that she was always incontinent of urine and bowel.An interview with Resident 7 on April 13, 2026 at 1:19 p.m. revealed that she did not want Nurse Aide 1 to provide care for her. She stated that he startled her awake by sticking his hand inside her brief to see if she was wet. She said that he did not need to do that because he should have just asked her like all of the other staff. She stated she did not like him putting his hand in her brief and that she did not want him back in her room.A quarterly MDS assessment for Resident 1, dated January 21, 2026 revealed that the resident was cognitively intact, required observation from staff for ambulation, and that she was frequently incontinent of urine and bowel.A grievance filed by Resident 1, dated March 27, 2026, revealed that Family Member 1, Resident 1's daughter-in-law and Power of Attorney, phoned the Director of Social Services on March 25, 2026 and asked her why a staff member went into Resident 1's room around 1:00 a.m. in the morning and startled her awake by turning on the light and pulling her blanket off.An interview with Resident 1 on April 13, 2026 at 9:58 a.m. revealed that she did not want to talk about the grievance or any details of the incident.An interview with Family Member 1 revealed that she called the Director of Social services because she wanted to know what went on during the night. She stated that Resident 1 called her at 1:00 a.m. crying and stated that Nurse Aide 1 had put his hand inside her brief while she was sleeping and his fingers penetrated her vagina. Family Member 1 stated that Resident 1 told her that he had done this 2 or 3 other times and that she was afraid she was going to be raped by him. She said that Resident 1 was crying and afraid. She said that she phoned the Director of Social Services and told him that Resident 1 was crying and said that Nurse Aide 1 stuck his hand in her crotch while she was sleeping. She stated that Resident 1 told her later that day that Nurse Aide 1 had been fired, but he had not been. She stated that Resident 1 felt safe because she believed he was no longer working there.An interview with Nurse Aide 3 on April 13, 2026 at 10:44 a.m. revealed that when he went to provide care for Resident 1 in the morning that she said to him did you hear what happened to me? That man (later identified as Nurse Aide 1) put his hand in my pants and touched my private area. He said that she was upset when she was telling him about this. He stated that he went to his nurse, Licensed Practical Nurse 4 and told her immediately. An interview with Licensed Practical Nurse 4on April 13, 2026 at 2:50 p.m. revealed that she entered Resident 1's room and Resident 1 told her that the male nurse aide on night shift put his hand inside her brief and that his fingers penetrated her vagina. Licensed Practical Nurse 4 stated that she immediately went to Registered Nurse 5 and reported that Nurse Aide 1 and reported this to her. She said that she told Registered Nurse 5 that he digitally penetrated her and she was upset.An interview with Registered Nurse 5 on April 13, 2026 at 4:50 p.m. revealed that when Licensed Practical Nurse 4 told her that Nurse Aide 1 put his finger inside Resident 1's vagina she immediately went to the Director of Social Services and told her what the Resident 1 said. She said she told the Director of Social Services that Resident 1 said that Nurse Aide 1 put his hand in her brief and his finger inside her vagina. She stated that the Director of Social Services and the Assistant Director of Nursing said that they were already aware of this so Registered Nurse 1 did not do anything further regarding this issue.An interview with Registered Nurse 6 on April 13, 2026 at 10:44 a.m. revealed that a nurse aide asked her if there was a hole for the night shift since they thought that Nurse Aide 1 would not be reporting to work that night after the allegations that were made by Resident 1. Registered Nurse 6 stated she went to the Nursing Home Administrator and asked if Nurse Aide 1 needed replaced on the night shift and the Nursing Home Administration asked her why he would. She stated that she said because a resident says that he fingered her two nights ago and that he was not aware of the allegation.An interview with the Nursing Home Administrator and acting Director of Nursing on April 13, 2026 at 1:04 p.m. revealed that they did not feel the allegation regarding Resident 1 and Nurse Aide 1 was abuse and they just wrote the incident up as a grievance. The acting Director of Nursing stated that she was not aware of any sexual abuse allegations. The Nursing Home Administrator stated that when he was made aware of the allegation he had the Director of Social Services talk with Resident 1. He said that Director of Social Services stated that Resident 1's story had changed and therefore the incident did not happen. An interview with the Director of Social Services on April 14, 2026 at 9:55 a.m. revealed that she did not believe any abuse occurred. She stated emphatically that she knew there was no abuse, that no abuse took place, and that the resident was not sexually abused. She stated she wished people would stop saying that. She stated that she had a very good rapport with Resident 1 and that Resident 1 would have told her if that happened. She denied that Family Member 1, Registered Nurse 5, and the Nursing Home Administrator told her that Nurse Aide 1 touched Resident 1's crotch, or that he digitally penetrated her, or that he fingered her, as they all said they told her. She again said emphatically that she would take an allegation very seriously and she knew there was no way this happened.There was no documented evidence that the allegations of sexual abuse by Nurse Aide 1 were reported to the Department of Health, the local/state ombudsman, the resident's representatives, adult protective services, law enforcement officials, the resident's attending physician, or the medical director. Interview with the Nursing Home Administrator and the acting Director of Nursing (was the Assistant Director of Nursing when the incidents occurred) on April 13, 2026 at 1:04 p.m. revealed that they did not report these incidents to the necessary entities because they did not think that abuse occurred and that it would not need reported.28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the Pulmonologist wrote, signed, and dated progress notes with each visit for one of 15 residents reviewed (Resident 2).Findings include:An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated February 18, 2026, revealed that the resident was cognitively impaired, was dependent on staff for her daily care needs, and received tracheostomy (open airway directly into the trachea) care. A physician's order, dated February 4, 2026, included an order for the resident to see a Pulmonologist.A nursing note, dated February 4, 2026, at 1:35 p.m. indicated that the Pulmonologist was just in and evaluated the resident.As of April 14, 2026, there was no documented evidence in Resident 2's clinical record that the Pulmonologist had completed a progress note for the visit on the above date.Interview with the Acting Director of Nursing on April 14, 2026, at 6:45 p.m. confirmed that she could not find any documented evidence of a progress note from the Pulmonologist visit on February 4, 2025.28 Pa. Code 211.5(f) Clinical Records.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that medications were provided as ordered by the physician for three of 33 residents reviewed (Resident 6, 9, 28). Findings include:A facility policy for administering medications dated August 25, 2025, indicated that medications are given in a safe and timely manner, and as prescribed. The following information is checked/verified for each resident prior to administering medications: allergies to medications and vital signs if necessary. A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated December 8, 2025, revealed that the resident was cognitively intact, required assistance for care needs, and had a diagnosis that included diabetes.Physician's orders for Resident 6, dated October 23, 2025, included an order for the resident to receive 12 units of Humalog lispro insulin subcutaneously before meals, and to hold for blood glucose less than 90mg/dL.A review of Resident 6's Medication Administration Record (MAR) for November 2025, revealed that the resident's blood glucose was 76mg/dL on November 10, 2025, at 5:00 p.m. and was 83mg/dL on November 20, 2025, at 5:00 p.m., and that the resident received 12 units of Humalog lispro insulin on the above dates and times.Physician orders for Resident 6, dated December 2, 2025, included an order for the resident to receive 12 units of Humalog lispro insulin subcutaneously before meals, and to hold for blood glucose less than 90mg/dL.A review of Resident 6's MAR for January 2026, revealed that on January 1, 2025, at 5:00 p.m. the resident's blood sugar was 80 mg/dl, and that the resident received 12 units of Humalog lispro insulin on the above date and time.An interview with the Director of Nursing on January 14, 2026, at 3:56 p.m. confirmed that the 12 units of Humalog lispro insulin was administered on the above dates and times and should not have been. An admission MDS for Resident 9, dated November 25, 2025, revealed that the resident was cognitively intact, required assistance with daily care needs, and had diagnoses that included Orthostatic hypotension (a sudden drop in blood pressure when standing up from sitting or lying down).Physician's orders for Resident 9, dated November 19, 2025, included an order for the resident to receive 2.5 milligrams (mg) of midodrine (medication used to treat low blood pressure) three times a day; hold for a systolic blood pressure (SBP-top number on a blood pressure reading) greater than 120. Review of the MAR for Resident 9 dated November and December 2025, revealed that 2.5 mg of midodrine was administered to the resident on November 27 when his SBP was 144, on November 28 when his SBP was 145, on December 2 when his SBP was 144, on December 9 when his SBP was 124, on December 11 when his SBP was 136, and on December 14 when his SBP was 140. Interview with the Director of Nursing on January 14, 2025, at 2:39 p.m. confirmed that midodrine was administered to Resident 9 on the above-mentioned dates and times when his SBP was outside the physician ordered parameters. An admission MDS assessment for Resident 28, dated December 9, 2025, revealed that the resident was cognitively impaired, required assistance with personal care needs, and had diagnoses that included hypotension (low blood pressure). Physician's orders for Resident 28, dated December 23, 2025, included an order for the resident to receive 10 milligrams (mg) of Midodrine (used to treat low blood pressure) three times a day and to hold the medication if the resident's systolic blood pressure (SBP-the top number in a blood pressure reading) is greater than 120.Review of the Medication Administration Record (MAR) for Resident 28, dated January 2026, revealed that 10 mg of Midodrine was administered on January 5 at 8:00 a.m. when the resident's SBP was 124, on January 5 at 1:00 p.m. when the resident's SBP was 124, on January 9 at 5:00 p.m. when the resident's SBP was 140, and on January 10, 2026 at 5:00 p.m. when the residents SBP was 134. Interview with the Director of Nursing on January 13, 2026, at 12:33 p.m. confirmed that Midodrine was administered to Resident 28 on the above-mentioned dates and times when it should have been held per physician's orders when the resident's SBP was greater than 120.28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on a review of facility policies and clinical records as well as staff interviews, it was determined that the facility failed to ensure that residents medication regimen was free from unnecessary psychotropic medication (drugs that affect a person's mental state, emotions, and behavior) for two of 33 residents reviewed (Residents 20 and 39).Findings include: The facility's policy regarding psychotropic medication use, dated August 25, 2025, included that non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medication when possible. As needed orders for psychotropic medications are limited to 14 days. A quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of the resident's abilities and care needs) for Resident 20 dated November 21, 2025, indicated that the resident had cognitive impairment, required assistance from staff for daily care needs, and had diagnosis that included dementia, anxiety and depression. Physician's orders for Resident 20 dated December 31, 2025, included an order for the resident to receive 0.25 milligrams (mg) of Xanax (an antianxiety medication) every four hours as needed for restlessness/anxiety. Review of the Medication Administration Record (MAR) for Resident 20 dated January 2026 revealed that 0.25 mg of Xanax was administered to the resident on January 4 at 2:46 a.m.; on January 7 at 6:54 p.m.; on January 8 at 1:15 p.m.; on January 10 at 2:43 p.m.; on January 11 at 10:06 a.m.; on January 11 at 8:27 p.m.; and on January 14 at 12:46 a.m. There was no documented evidence that non-pharmacological interventions were attempted prior to administering the as needed doses of Xanax on these dates and times. A quarterly MDS assessment for Resident 39 dated October 19, 2025, indicated the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included Alzheimer's dementia. Physician's orders for Resident 39 dated October 6, 2025, included an order for the resident to receive 0.5 mg of lorazepam (a psychotropic medication used to treat anxiety) every eight hours as needed for anxiety for 90 days. Review of the MAR for Resident 39 dated October and November 2025 revealed that the resident was administered 0.5 mg of lorazepam on October 29 at 8:29 p.m., October 30 at 8:48 p.m., October 31 at 8:37 p.m., November 1 at 11:50 p.m., November 11 at 8:24 p.m., November 13 at 8:00 p.m., November 14 at 4:05 a.m., and November 19 at 3:46 p.m. There was no documented evidence that non-pharmacological interventions were attempted prior to administering the as needed doses of lorazepam on these dates and times. Interview with the Director of Nursing on January 14, 2026, at 3:34 p.m. confirmed that there was no documented evidence that non-pharmacological interventions were attempted before administering Xanax to Resident 20 and lorazepam to Resident 39 on the above-mentioned dates and times and there should have been. She also confirmed that there was no duration included in the physician's order on December 31, 2025, and no documented evidence from a physician or prescriber to indicate the rationale to extend the as needed Xanax for Resident 20 beyond 14 days. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to serve palatable food that was at appropriate temperatures. Findings include: The facility's policy regarding food temperatures and point of service, dated August 25, 2025, indicated that hot foods would be held at temperatures of 135 degrees or above. Best efforts would be made to present hot food hot and cold foods cold at point of service by using thermal lids and bases and heated or chilled plates. Interview with Resident 3 on January 12, 2026, at 11:01 a.m. revealed that the food is always cold, the bread is stale, and it doesn't taste good. Interview with Resident 6 on January 12, 2026, at 11:32 a.m. revealed that the food is like cold dog food. Observations of the kitchen's lunch meal tray line on January 14, 2025, revealed that it began at 12:01 p.m. and included spaghetti, mixed vegetables, garlic bread, side salad, coffee and juice. The last tray was placed on the cart at 12:12 p.m. The cart left the kitchen and arrived on the unit at 12:17 p.m., and the last tray was removed from the cart and served at 12:27 p.m. The test tray was removed from the cart at 12:30 p.m. The spaghetti was 122 degrees Fahrenheit (F), the pureed mixed vegetables were 144 degrees F, the garlic bread was 72 degrees F, the side salad was 51 degrees F, the coffee was 153 degrees F, and the juice was 47 degrees F. The spaghetti was cold and not palatable. Interview with Director of Dietary on January 14, 2025, at 12:40 p.m. confirmed that the spaghetti was not at a proper temperature. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to obtain laboratory studies as ordered by the physician for one of 33 residents reviewed (Resident 13).Findings include: The facility's policy regarding laboratory services and reporting, dated August 25, 2025, revealed that the physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The staff will process the test requisitions and arrange for tests, the laboratory, diagnostic radiology provider, or other testing source will report test results to the facility.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated November 3, 2025, revealed that the resident was cognitively impaired, was dependent on staff for daily care needs and was always incontinent of bladder.Physician's orders for Resident 13, dated November 28, 2025, included an order for staff to obtain a urine culture and sensitivity (a diagnostic test for urinary tract infection).Review of the clinical records for Resident 13 revealed no documented evidence that the urine culture and sensitivity was completed as of January 14, 2026.Interview with Director of Nursing on January 14, 2025, at 11:09 a.m. confirmed that there was no documented evidence that Resident 13's urinary culture and sensitivity was completed as ordered. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a peripherally inserted central catheter (PICC- a thin, flexible tube that is inserted into a vein in the upper arm) was flushed according to facility policy for one of 33 residents reviewed (Resident 9). Findings include:The facility's policy regarding flushing and locking peripheral and midline catheters dated August 25, 2025, indicated that the purpose of the procedure was to maintain catheter patency, to prevent mixing of incompatible medications and solutions, and to ensure the entire dose of a solution or medication is administered into the venous system. For short and long peripheral and midline catheters used for intermittent infusions, flush (procedure involving the injection of saline into a catheter using a small syringe to clear or maintain patency) the catheter and aspirate for blood return prior to each infusion and at least every 24 hours to assess catheter function. Lock (a peripheral intravenous catheter is capped off and filled with a saline (saltwater) solution instead of being connected to a continuous drip) following each use. When flushing before and after medication administration of fluid administration, document the procedure in the treatment administration record. An admission Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) for Resident 9, dated, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, had diagnosis that included Methicillin-resistant Staphylococcus aureus infection (infection caused by Staphylococcus aureus bacteria that has become resistant to common antibiotics like methicillin) and was receiving intravenous medications. Physician's orders for Resident 9, dated November 19, 2025, included an order for the resident to receive 2 grams of Oxacillin Sodium intravenous solution (an antibiotic used to fight serious bacterial infections) intravenously every four hours for osteomyelitis (an infection and inflammation of bone tissue). Review of Medication Administration Records (MARs) for Resident 9, dated November and December 2025 revealed that 2 grams of Oxacillin Sodium intravenous solution was administered intravenously every four hours from November 19, 2025, at 8:00 p.m. through December 9, 2025, at 6:00 p.m. However, there was no documented evidence that staff flushed Resident 9's PICC before and after the administration of Oxacillin Sodium intravenous solution. Interview with the Director of Nursing on January 14, 2026, at 3:38 p.m. confirmed there was no documented evidence that Resident 9's PICC was flushed before and after medication administration per facility policy on the dates listed above.28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents received proper care for nephrostomy tubes (a small, flexible catheter inserted through the skin in the back directly into the kidney to drain urine when there's a blockage in the urinary system) for one of 33 residents reviewed who had nephrostomy tubes (Resident 4).Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated November 12, 2025, revealed that the resident had moderate cognitive impairment, required assistance from staff for daily care needs, had an indwelling urinary catheter (includes nephrostomy tubes), and had diagnosis that included obstructive uropathy (a condition in which the flow of urine is blocked).Review of Resident 4's post procedure note for a nephrostomy tube change, dated December 17, 2025, revealed that current outpatient medications included to flush with 10 milliliters (ml) sodium chloride 0.9% (salt water) daily, flush left and right nephrotomy tubes as directed. A nurse's note for Resident 4 dated January 5, 2026, at 2:31 p.m. revealed that the registered nurse was notified by the Licensed Practical Nurse that upon flushing (gently injecting sterile liquid into the tube to keep it clear of clots) the resident's bilateral nephrostomy tubes as prescribed, the left nephrostomy tube was meeting resistance, was very difficult to flush, and the tubing was milked (process to dislodge clots that may be attached to the sides of the tubes) by the registered nurse with the flush remaining very difficult to push through.Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for Resident 4 dated December and January 2025 revealed no documented evidence that the residents left and right nephrostomy tubes were flushed daily per interventional radiology orders.Interview with the Director of Nursing on January 13, 2026, at 2:10 p.m. confirmed that orders to flush Resident 4's left and right nephrostomy tubes should have been added to the resident's MAR or TAR, however they were not and there was no documented evidence that the residents left and right nephrostomy tubes were flushed daily or as needed. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to discard a multi-use vial of Tubersol (solution used to detect tuberculosis infection) and an expired multidose medication for one resident (Resident 10) in one of one medication rooms reviewed. Findings include: The facility's policy regarding medication administration, dated [DATE], indicated medications are administered in a safe and timely manner and as prescribed. The expiration date on the medication label is checked prior to administration. When opening a multidose medication the opened date is recorded on the container. Manufacturer's instructions for Tubersol, dated [DATE], indicated that a multi-dose vial of Tubersol solution should be discarded 30 days after it is opened. Physician's orders for Resident 10, dated [DATE], included an order for the resident to receive 20 ml (milliliters) for a total of 40 mg(milligrams) of Omeprazole Oral Solution (used to treat gastroesophageal reflux disease) 2 mg/ml daily. Observations in the facility's medication room refrigerator in the medication room on [DATE], at 11:20 a.m. revealed one multi-use vial of Tubersol that was open and dated [DATE], and a multidose bottle of Omeprazole Oral Solution (used to treat gastroesophageal reflux disease) 2 mg/ml for Resident 10 with an expiration date of [DATE]. An interview with the Director of Nursing on [DATE], at 1:00 p.m. confirmed that the multi-use vial of Tubersol and the multidose bottle of Omeprazole Oral Solution 2 mg/ml for Resident 10 should have been discarded when expired. 28 Pa. Code 211.9(a)(1) Pharmacy Services. 28 Pa. Code 211.12(d)(1) Nursing Services.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending February 12, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending January 14, 2026, identified repeated deficiencies related to accuracy of assessment, failure to provide quality of care, failure to provide proper catheter care, failure to store and label residents medications properly, and failure to ensure food was palatable and served at the proper temperature. The facility's plan of correction for a deficiency regarding the accuracy of assessment, cited during the survey ending February 12, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F641, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding accuracy of assessment. The facility's plan of correction for a deficiency regarding quality care, cited during the surveys ending February 12, 2025, July 12, 2025, and October 1, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding quality of care. The facility's plan of correction for a deficiency regarding failures to provide proper catheter care, cited during the survey ending February 12, 2025, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F690, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding catheter care. The facility's plan of correction for a deficiency regarding labeling and storing medications, cited during the survey ending February 12, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding labeling and storage of medications. The facility's plans of correction for deficiencies regarding ensuring that food was palatable and at proper serving temperatures, cited during the survey ending on February 12, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F804, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding food being served was palatable and at the proper temperature. Refer to F641, F684, F690, F761, F804 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for two of 33 residents reviewed (Residents 4 and 41). Findings include:The RAI User's Manual, dated October 2025, indicated that Section O0110K1B Hospice care (a specialized form of end-of-life care that provides comfort, support, and medical assistance to terminally ill patients and their families) was to be checked to indicate if the resident was receiving hospice services while a resident. Physician's orders for Resident 4 dated May 14, 2025, include for the resident to be admitted to Hospice care. A quarterly MDS assessment for Resident 4, dated November 12, 2025, revealed that Section O0110K1B was not checked, indicating that the resident did not receive hospice service during the seven-day look-back assessment period. Interview with the Director of Nursing on January 13, 2026, at 11:12 p.m. confirmed that Resident 4 was receiving hospice services and her MDS assessment dated [DATE], was coded inaccurately.Physician's orders for Resident 41 dated April 4, 2025, include for the resident to be admitted to Hospice care. A quarterly MDS assessment for Resident 41, dated October 20, 2024, revealed that Section O0110K1B was not checked, indicating that the resident did not receive hospice service during the seven-day look-back assessment period. Interview with the Director of Nursing on January 14, 2025, at 11:11 a.m. confirmed that Resident 41 was receiving hospice services and his MDS assessment dated [DATE], was coded inaccurately.28 Pa. Code 211.5(f) Clinical Records.

Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 33 residents reviewed (Resident 42).Findings include: The facility's policy regarding medication administration, dated August 25, 2025, indicated that after medication administration, the facility staff should take all measures required by facility policy and applicable law, including but not limited to documenting necessary medication administration/treatment information (when the medication was given, prn/as needed medications) on appropriate forms. Document the administration of controlled substances in accordance with applicable law. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated November 14, 2025, indicated the resident was cognitively impaired, required assistance for daily care needs, took opioid medications, and had diagnoses that included heart failure. Physician's orders for Resident 42, dated June 3, 2025, included an order for the resident to receive 25 milligrams (mg) of Tramadol (a narcotic pain medication) every twelve hours for pain. A review of the Medication Administration Record (MAR) for Resident 42, dated October and November 2025, revealed that 25 mg of Tramadol was administered to the resident on October 30 at 9:00 p.m.; October 31 at 8:00 a.m.; October 31 at 9:00 p.m.; November 1 at 8:00 a.m.; November 1 at 9:00 p.m.; November 2 at 8:00 a.m.; November 2 at 9:00 p.m.; November 3 at 8:00 a.m.; November 3 at 9:00 p.m.; November 4 at 8:00 a.m.; November 4 at 9:00 p.m.; November 5 at 8:00 a.m.; November 5 at 9:00 p.m.; November 6 at 8:00 a.m.; November 6 at 9:00 p.m.; November 7 at 8:00 a.m.; November 7 at 9:00 p.m.; November 8 at 8:00 a.m.; November 8 at 9:00 p.m.; November 9 at 8:00 a.m.; November 9 at 9:00 p.m.; November 10 at 8:00 a.m.; November 10 at 9:00 p.m.; November 11 at 8:00 a.m.; November 11 at 9:00 p.m.; November 12 at 8:00 a.m.; November 12 at 9:00 p.m.; November 13 at 8:00 a.m.; November 13, 2025 at 9:00 p.m. However, a review of the resident's-controlled medication record (a form that accounts for each tablet/pill/dose of a controlled drug), dated October and November 2025 revealed no documented evidence that 25 mg of Tramadol was signed out for administration on the above-mentioned dates and times. Interview with the Interim Director of Nursing on January 14, 2026, at 11:10 a.m. confirmed that she was unable to locate the controlled medication record for Resident 42 therefore there was no documented evidence that 25 mg of Tramadol was signed out for administration on the above-mentioned dates and times. 28 Pa Code 211.5(f) Clinical Records. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies, investigation reports, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of three residents reviewed (Resident 3), resulting in a large laceration that required surgical intervention and repair. Findings include: The facility's policy regarding abuse and neglect, dated February 23, 2024, indicated that the facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated May 8, 2024, revealed that she was cognitively impaired, dependent on staff for transfers, had diagnoses that included dementia and heart failure, and was receiving an anticoagulant (blood thinning) medication. Physician's orders for Resident 3, dated May 3, 2024, included an order for the resident to be transferred with a full mechanical lift. The July, 2024 nurse aide task sheet for Resident 3, indicated that she was a full body mechanical lift for transfers. A nursing/incident note for Resident 3, dated July 18, 2024, at 6:50 p.m., revealed that the nurse was called to the resident's room. Staff reported that the resident was sitting at the bedside after a transfer from the wheelchair to her bed and was noted to have a large laceration to the right lower extremity with a significant amount of bleeding. Pressure was applied to the area. The physician was notified and an order was received for Resident 3 to be transported to the emergency department by ambulance. A witness statement by Nurse Aide 1, dated July 18, 2024, at 6:50 p.m., regarding Resident 3's right lower leg laceration revealed that she had transferred the resident from her wheelchair to the bed with a two-person physical assist. Resident 3 sat on the edge of the bed and it was noted that the skin was open. Nurse Aide 1 immediately applied pressure while Nurse Aide 2 left to inform the registered nurse. A witness statement by Nurse Aide 2, dated July 18, 2024, at 6:50 p.m., regarding Resident 3's right lower leg laceration revealed that she assisted Nurse Aide 1 to physically stand Resident 3 from her chair and turn her toward the bed. That is when Nurse Aide 1 noticed that Resident 3's leg was cut and bleeding. The cut was covered and Nurse Aide 2 left the room to get help. A witness statement by Licensed Practical Nurse 3, dated July 18, 2024, at 6:50 p.m., regarding Resident 3's right lower leg laceration revealed that he received a report that Resident 3 had split her leg open and he went to her room. The resident was lying in bed with towels wrapped around her right lower extremity. Licensed Practical Nurse 3 applied pressure to the area until emergency services arrived. Hospital emergency room documents, dated July 19, 2024, at 12:32 a.m., indicated that Resident 3 presented to the emergency department with a significant right leg laceration. She was reportedly at the facility being moved into bed by facility staff when staff inadvertently bumped her right leg against one of the iron bedposts. The hospital trauma surgery service has admitted the resident, because she required operative intervention to repair the laceration. There was significant hemorrhaging noted during her work up with episodes of hypotension (low blood pressure) consistent with hemorrhagic shock (insufficient blood flow can cause damage to organs). Resident 3 was given one unit of uncrossmatched blood at this time. An interview with the Therapy Director on August 5, 2024, at 2:30 p.m. revealed that the therapy department worked with Resident 3 trialing her with a two-person physical assist with pivot. Resident 3 had cognitive issues, and at times therapy staff were unable to transfer the resident with a physical assist. The physician's order for Resident 3 to be a mechanical lift transfer remained in place and was not changed to a two-person physical assist with pivot. An interview with the Director of Nursing on August 5, 2024, at 3:33 p.m. confirmed that Nurse Aides 1 and 2 transferred Resident 3 incorrectly causing an injury to her leg. Resident 3 was sent to the hospital and did not return. 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 201.24(e)(4) Admission Policy. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care-planned interventions to prevent falls and/or injury were followed for two of 22 residents reviewed (Residents 5, 108), resulting in a fall with a fracture for Resident 5. Findings include: The facility's policy regarding safety and assistive devices, updated (MONTH) 22, (YEAR), indicated that safety devices were to be utilized to promote safety and minimize trauma from unavoidable injury, and a fall risk assessment was to determine the safety devices available for use by each resident. A comprehensive admission Minimum Data Set (MDS) assessment (a mandated assessment to determine a resident's abilities and care needs) for Resident 5, dated (MONTH) 11, (YEAR), revealed that the resident was confused and required extensive assistance from staff for bed mobility and transfers. A fall risk assessment, dated (MONTH) 4, (YEAR), indicated that the resident was at significant risk of falls. A nursing note for Resident 5, dated (MONTH) 2, (YEAR), revealed that the resident was found lying on the floor on the right side of his bed, and physician's orders [REDACTED]. A nursing note for Resident 5, dated (MONTH) 7, (YEAR), revealed that the resident attempted to get out of bed, went down on the floor, and was found lying on his right side between the bed and the wall. The fall mats were propped against the wall heater. The resident had a small hematoma (a localized swelling filled with blood) to the right forehead, his right cheek was reddened, and he had skin tears on the back of the right wrist, the right inner wrist, and the right upper arm. The physician gave an order, dated (MONTH) 7, (YEAR), for the resident to be transferred to the hospital. A hospital discharge summary for Resident 5, dated (MONTH) 13, (YEAR), revealed that following a fall, the resident had a navicular fracture (bone on the thumb side of the wrist) of his right hand and a cast was applied. Interview with the Nursing Home Administrator on (MONTH) 4, (YEAR), at 10:22 a.m. confirmed that fall mats should have been in place at the time of Resident 5's fall on (MONTH) 7, (YEAR), and they were not in place in accordance with physician's orders [REDACTED]. A quarterly MDS assessment for Resident 108, dated (MONTH) 22, (YEAR), indicated that the resident was confused and required extensive assistance from staff with transfers. physician's orders [REDACTED].-skid footwear. A nursing note for Resident 108, dated (MONTH) 12, (YEAR), indicated that the resident was found siting on the floor against the toilet, that he was left alone in the bathroom, and that the alarm was on the wheelchair. The note also indicated that the resident did not have non-skid socks or shoes on, and that he had regular socks on, which were slippery. Upon interview with the Director of Nursing on (MONTH) 4, (YEAR), at 5:37 p.m., she indicated that it was the facility's unwritten policy that any resident who used a chair alarm was at high risk for falls and should not be left alone in the bathroom. She also confirmed that Resident 108 did not have the proper footwear on at the time of the fall, and in accordance with his care plan. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 10/12/16, 6/6/16. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 4/11/17. 28 Pa. Code 201.18(b)(1) Management. Previously cited 10/12/16. 28 Pa. Code 201.18(e)(1) Management. Previously cited 4/11/17, 10/12/16, 6/6/16. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 4/11/17, 11/2/16. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 7/17/17, 6/16/17, 4/11/17, 6/6/16. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 10/6/17, 7/17/17, 6/16/17, 4/11/17, 11/2/16, 6/6/16, 3/23/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 10/6/17, 7/17/17, 6/16/17, 4/11/17, 11/2/16, 10/12/16, 6/6/16, 3/23/16.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the physician about a significant change in condition in a timely manner and failed to follow their hypoglycemic protocol for one of six residents reviewed (Resident CR3), resulting in continued [DIAGNOSES REDACTED] with hospitalization for the resident, and failed to notify the physician about a change in condition resulting in a delay in treatment for one of six residents reviewed (Resident CR6). Findings include: The facility's policy regarding physician notification, dated March 16, 2017, indicated that staff were to immediately notify the physician when there was a change in the resident's physical, mental, or psychosocial status. The physician was also to be notified about life threatening conditions. The facility's protocol regarding [DIAGNOSES REDACTED] (low blood sugar), dated March 16, 2017, indicated that if the resident's blood sugar levels were less than 50 milligrams per deciliter (mg/dL) (normal range is between 70 and 120), staff were to give oral glucose (sugar) gel and recheck the blood sugar level in one half hour. Admission records for Resident CR3 revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Physician's admission orders [REDACTED]. A nursing note for Resident CR3, dated May 24, 2017, indicated that at 8:00 a.m. on May 21, 2017, the resident's blood sugar level was 47 mg/dL and the resident was given 8 ounces of orange juice instead of oral glucose gel per the facility's protocol. At 8:30 a.m. the resident's blood sugar level was rechecked and was 82 mg/dL; the note indicated that as the resident's blood sugar level was in the normal range, the licensed practical nurse passing medications at that time administered [MEDICATION NAME] and [MEDICATION NAME] to the resident. There was no documented evidence that the resident was assessed by a registered nurse due to the hypoglycemic event, and no documented evidence that the physician was contacted to determine if [MEDICATION NAME] and [MEDICATION NAME] were to be administered or held (not given) due to the hypoglycemic episode that occurred half an hour prior. A nursing note, dated May 21, 2017, at 5:14 p.m. and amended on May 22, 2017, at 12:13 p.m. indicated that Resident CR3's blood sugar level was 51 mg/dL, the resident was assessed by a registered nurse, and was given 8 ounces of chocolate milk and 2 graham crackers. The resident's blood sugar level was then 48 mg/dL, the resident was given 4 ounces of orange juice with 2 sugar packets, and the physician's answering service was contacted. A recheck of the resident's blood sugar level showed a reading of 47 mg/dL. The note indicated that the resident was able to eat from her evening meal tray, and a recheck of the blood sugar level after the meal revealed that it was 50 mg/dL. There was no documented evidence that the facility's hypoglycemic protocol was followed, and no documented evidence that the physician returned the facility's call to his answering service. A nursing note, dated May 21, 2017, at 5:48 p.m. revealed that Resident CR3 complained of nausea, had a blood sugar level of 50 mg/dL, and the resident agreed to be transported to the emergency room for evaluation. There was no documented evidence that the resident's physician was notified about the resident's hypoglycemic episodes until a nursing note, dated May 22, 2017, at 7:56 a.m. indicated that the physician was notified that the resident was admitted to the hospital. A hospital history and physical for Resident CR3, dated May 22, 2017, indicated that the resident was admitted to the Intensive Care Unit with multiple [DIAGNOSES REDACTED]. cells) secondary to a urinary tract infection, [DIAGNOSES REDACTED] (low blood sugar levels) most likely secondary to decreased oral intake and [MEDICATION NAME], and diabetes. A hospital discharge summary for Resident CR3, dated June 6, 2017, included [DIAGNOSES REDACTED]. Interview with Physician 2, Resident CR3's attending physician, on June 15, 2017, at 2:10 p.m. confirmed that he expected the facility's nursing staff to contact him prior to giving medication to a resident with a hypoglycemic episode. He stated that had he been contacted, he would have given an order for [REDACTED]. Interview with the Director of Nursing on June 15, 2017, at 2:45 p.m. confirmed that Resident CR3's physician should have been notified about the hypoglycemic episode prior to staff administering [MEDICATION NAME] and [MEDICATION NAME]. She also confirmed that the facility's hypoglycemic protocol was not followed during Resident CR3's episodes, and she would have expected the physician to be notified that evening after the second blood sugar level remained low. A nursing note for Resident CR6, dated June 4, 2017, at 2:16 p.m. revealed that the resident had increased shortness of breath, lung sounds were decreased, he had [MEDICAL CONDITION] (swelling in which an indentation remains when the area is pressed with a finger) in both lower extremities (legs), and a call was made to the physician. However, there was no documented evidence that the physician returned the facility's telephone call. physician's orders [REDACTED]. The sliding scale included that the resident was to receive 6 units of [MEDICATION NAME] for a blood sugar reading that was greater than 340 mg/dL, and that the physician to be notified about blood sugar readings that were greater than 340 mg/dL. A nursing note for Resident CR6, dated June 4, 2017, at 6:32 p.m. indicated that the resident's blood sugar level was 369 mg/dL, the resident was given insulin as ordered, and a message was left with the physician's answering service. There was no documented evidence that the physician contacted the facility. A nursing note, dated June 5, 2017, at 9:53 p.m. revealed that Resident CR6 reported that he had some shortness of breath in the morning, and that the swelling remained in both legs. The note indicated that a telephone call was placed to the physician and that the physician was paged two times. There was no documented evidence that the physician contacted the facility in reply. A nursing note for Resident CR6, dated June 6, 2017, at 9:56 a.m. indicated that the resident reported that he had some shortness of breath earlier and that his lung sounds continued to be diminished. The physician was contacted and ordered a chest X-ray. A nursing note for Resident CR6, dated June 6, 2017, at 1:34 p.m. revealed that the chest X-ray showed bilateral (both sides) lower lobe pneumonia or effusion accumulation of fluid, and the physician ordered 250 milligrams (mg) of [MEDICATION NAME] (an antibiotic) daily for ten days. A nursing note, dated June 6, 2017, at 5:25 p.m. indicated that Resident CR6 reported that he was having a hard time breathing, his oxygen saturation (percentage of oxygen in the blood) was 86 percent (normal is over 90 percent), and he was receiving oxygen at 4 liters per minute. A call was placed to the physician's answering service, and the facility was awaiting a return call. A nursing note for Resident CR6, dated June 6, 2017, at 7:06 p.m. (approximately one hour and forty-one minutes after the call was placed to the physician's answering service) indicated that the physician was contacted and an order was received to transport the resident to the emergency room for evaluation. A nursing note, dated June 7, 2017, at 1:51 a.m. revealed that Resident CR6 was admitted to the hospital with [REDACTED]. There was no documented evidence that nursing staff took any action when Resident CR6's physician did not respond to their telephone calls in a timely manner. Interview with the Director of Nursing on June 15, 2017, at 3:10 p.m. confirmed that there was no documented evidence of any follow-up actions taken by the nursing staff when Resident CR6's physician did not respond in a timely manner. 42 CFR 483.24, 483.25(k)(1) Provide Care/Services for Highest Well Being. Previously cited 4/11/17, 6/6/16. 28 Pa. Code 211.2(a)(c) Physician services. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 4/11/17, 11/2/16, 6/6/16, 3/23/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 4/11/17, 11/2/16, 10/12/16, 6/6/16, 3/23/16.

Based on review of facility policies, clinical records and investigative information, as well as staff interviews, it was determined that the facility failed to ensure that staff followed residents' care planned transfer procedures, in order to prevent neglect for one of one residents reviewed (Resident R1), which resulted in harm for the resident. Findings include: The facility's policy and procedure regarding mechanical lifts (device that uses hydraulic power to lift and transfer a person who cannot bear weight), dated August 2014, indicated that the mechanical lift required the assistance of two persons at all times. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R1, dated September 21, 2016, indicated that the resident was cognitively impaired and required the extensive assistance of two staff for transfers. A physical therapy screen, dated April 22, 2015, indicated that the resident could not stand, pivot her feet, or take a step, and the recommendation was made to continue to use a mechanical lift for transfers for safety. The resident's care plan, dated October 4, 2014, indicated that the resident was to be transferred using a mechanical lift. The facility's investigation information, submitted on September 12, 2016, indicated that on September 11, 2016, Nurse Aide 1 transferred Resident R1 manually and by herself from the wheelchair to the bed, and the resident sustained [REDACTED]. The facility's investigation found that a metal part on the wheelchair aligned with the top of the resident's laceration. A nursing note, dated September 12, 2016, revealed that Resident R1 was transferred to the hospital emergency room for a laceration to the right lower extremity, and the hospital's emergency room report, dated September 11, 2016, indicated that there was a 12 centimeter curved laceration to the resident's right lower extremity, and it was sutured together using four sets of running stitches. A nursing note, dated September 12, 2016, indicated that the suture line was in a reversed C with a total of 29 sutures split into four segments and that the trauma happened with transferring. An interview with Nurse Aide 1 on September 30, 2016, at 12:00 p.m. revealed that she knew she was supposed to use the mechanical lift to transfer Resident R1, and that she knew that the facility required two people to perform a mechanical lift transfer. She indicated that she stood Resident R1 up and manually pivoted her into bed by herself, and when she took the resident's pants down in bed, the resident screamed and started to cry. She looked and saw a big rip in the resident's leg. An interview with the Nursing Home Administrator on October 4, 2016, at 1:30 p.m. confirmed that Nurse Aide 1 did not use a mechanical lift at the time of Resident R1's leg injury. She confirmed that Nurse Aide 1 knew to use the mechanical lift with the assistance of two staff but failed to do so. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(e)(1) Management. Previously cited 6/6/16, 10/10/15, 4/30/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 6/6/16, 3/23/16, 1/22/16, 1/6/16, 12/21/15, 11/3/15, 4/30/15.

Based on review of facility policies, clinical records and investigative information, as well as staff interviews, it was determined that the facility failed to ensure that residents were transferred using safe techniques and as care planned, for one of one residents reviewed (Resident R1), which resulted in harm for the resident. Findings include: The facility's policy and procedure regarding mechanical lifts (device that uses hydraulic power to lift and transfer a person who cannot bear weight), dated August 2014, indicated that the mechanical lift required the assistance of two persons at all times. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R1, dated September 21, 2016, indicated that the resident was cognitively impaired and required the extensive assistance of two staff for transfers. A physical therapy screen, dated April 22, 2015, indicated that the resident could not stand, pivot her feet, or take a step, and the recommendation was made to continue to use a mechanical lift for transfers for safety. The resident's care plan, dated October 4, 2014, indicated that the resident was to be transferred using a mechanical lift. The facility's investigation information, submitted on September 12, 2016, indicated that on September 11, 2016, Nurse Aide 1 transferred Resident R1 manually and by herself from the wheelchair to the bed, and the resident sustained [REDACTED]. The facility's investigation found that a metal part on the wheelchair aligned with the top of the resident's laceration. A nursing note, dated September 9, 2016, revealed that Resident R1 was transferred to the hospital emergency room for a laceration to the right lower extremity, and the hospital's emergency room report, dated September 11, 2016, indicated that there was a 12 centimeter curved laceration to the resident's right lower extremity, and it was sutured together using four sets of running stitches. A nurse's note, dated September 12, 2016, indicated that the suture line was in a reversed C with a total of 29 sutures split into four segments and that the trauma happened with transferring. An interview with Nurse Aide 1 on September 30, 2016, at 12:00 p.m. revealed that she knew she was supposed to use the mechanical lift to transfer Resident R1, and that she knew that the facility required two people to perform a mechanical lift transfer. She indicated that she stood Resident R1 up and manually pivoted her into bed by herself, and when she took the resident's pants down in bed, the resident screamed and started to cry. She looked and saw a big rip in the resident's leg. An interview with the Nursing Home Administrator on October 4, 2016, at 1:30 p.m. confirmed that Nurse Aide 1 did not use a mechanical lift at the time of Resident R1's leg injury. She confirmed that Nurse Aide 1 knew to use the mechanical lift with the assistance of two staff but failed to do so. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices Previously cited 6/6/16, 1/22/16. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(e)(1) Management. Previously cited 6/6/16, 10/10/15, 4/30/15. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 6/6/16, 3/23/16, 1/22/16, 1/6/16, 12/21/15, 11/3/15, 4/30/15.