Every finding on record at Hickory House Nursing Home

Based on review of clinical records and interview with staff, it was determined that the facility failed to notify the office of the state long term care ombudsman of emergency transfers for seven out of seven residents reviewed (Resident 2, Resident 3, Resident 6, Resident 21, Resident 101, resident 108, and Resident 106,).Findings include:Review of Resident 2's Health Status Note dated January 17, 2026, at 3:00 p.m. reveals that the resident was admitted to the hospital for the treatment of a left hip fracture. Review of Resident 2's clinical record and facility documentation failed to reveal evidence that the State Ombudsman's office was notified of Resident 2's transfer and admission to the hospital.Review of Resident 3's clinical record revealed Resident 3 was transferred to the hospital on January 3, 2026 due to right sided weakness and headache.Further review of Resident 3's clinical record revealed Resident 3 was readmitted to the facility on [DATE].Review of Resident 3's clinical record and facility documentation failed to reveal evidence that the State Ombudsman's office was notified of Resident 3's transfer and admission to the hospital.Review of Resident 6's clinical record revealed Resident 6 was transferred to the hospital on January 6, 2026 due to altered mental status and left-sided weakness.Further review of Resident 6's clinical record revealed Resident 6 was readmitted to the facility on [DATE].Review of Resident 6's clinical record and facility documentation failed to reveal evidence that the State Ombudsman's office was notified of Resident 6's transfer and admission to the hospital.A review of Resident 21's nursing progress notes dated February 1, 2026, at 9:36 a.m., revealed resident was admitted to the hospital for diagnosis of hypotension (low blood pressure).Review of Resident 21's clinical record and facility documentation failed to reveal evidence that the State Ombudsman's office was notified of Resident 21's transfer and admission to the hospital.Review of Resident 101's clinical record revealed that Resident 101 was transferred to the hospital on April 22, 2026 due to shortness of breath.Further review of Resident 101's clinical record revealed that Resident 101 was readmitted to the facility on [DATE].Review of Resident 101's clinical record and facility documentation failed to reveal evidence that the State Ombudsman's office was notified of Resident 101's transfer and admission to the hospital.Review of Resident 106's clinical record revealed that Resident 106 was transferred to the hospital on April 2, 2026 due to an unresponsive episode.Further review of Resident 106's clinical record revealed Resident 106 was readmitted to the facility on [DATE].Review of Resident 106's clinical record and facility documentation failed to reveal evidence that the State Ombudsman's office was notified of Resident 106's transfer and admission to the hospital.A review of Resident 108's nursing progress notes dated February 18, 2026, at 1:55 p.m., revealed resident was admitted to the hospital for respiratory failure.Review of Resident 108's clinical record and facility documentation failed to reveal evidence that the State Ombudsman's office was notified of Resident 108's transfer and admission to the hospital.Interview with the Nursing Home Administrator on May 14, 2026, at 1:00 p.m. confirmed that notification of Resident 2, Resident 3, Resident 6, Resident 21, Resident 101, resident 108, and Resident 106 , transfer and admission to the hospital was not sent to the State Ombudsman's office as required.

Based on review of facility policy, clinical records, facility documentation, and staff interview, it was determined that the facility failed to timely notify the resident's representative and medical provider of significant changes in physical condition resulting in hospitalization for two out of seven residents reviewed (Resident 6 and Resident 101).Findings include:A review of facility policy Changes in Resident's Condition or Status revised August 29, 2025, revealed that This facility will notify .his/her primary care provider, and resident/resident representative of changes in the resident's condition or status.A facility must immediately. consult with the resident's physician.when there is - a significant change in the resident's physical, mental or psychological status (that is a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications).Review of Resident 6's quarterly Minimum Data Set (MDS - a mandatory assessment of a resident's physical needs and condition) dated January 7, 2026, revealed that that Resident 6 was cognitively in-tact and relied on partial assistance from facility staff to complete activities of daily living. Resident 6 was independent to transfer and ambulate with a rolling walker. Resident 6 was occasionally incontinent of bladder and continent of bowel. Resident 6 was on a regular texture, therapeutic diet. Resident 6's diagnoses included hypertension, non-Alzheimer's dementia, anxiety, depression and Rheumatoid arthritis. Resident 6 received antidepressant medications, diuretic medications, and antiplatelet medications.Review of nursing progress notes dated January 9, 2026 at 4:12 p.m. revealed: Resident more confused this shift Not being able to express her self verbally when asked to tell this nurse what her roommates name was or where she had been when she just came back from the hair dresser also her vision was worse then usual for her she does have poor vision but she could not see my hand in front of her she was able to get to BR (bathroom) by herself Charge nurse notified.Further review of Resident 6's clinical record revealed there was no notification to the physician or POA or the change in mental status on January 9, 2026.Review of nursing progress notes dated January 10. 2026 at 7:19 p.m., revealed: Resident noted with alter mental status not typical of her day-to-day mentation. On call physician notified. POA (power of attorney) contacted and informed of situation, that resident is alter mental [status]. POA informed that diagnostic lab work may not be gathered until Monday and states that at this time they wish for resident to stay in house until Monday and to be observed per facility protocol.Review of nursing notes dated January 11, 2026 at 12:42 a.m. revealed, Resident is focusing on the RT (right) side of the wall w/ tremors to bilateral hands and stiffness to body and not able to voice anything, when spoken to. V/S (vital signs - temperature, heart rate, breathing rate, blood pressure, and oxygen level) read 97.7-104(tachycardia - abnormally fast heart rate)-21-147/75-92% on (RA) (room air - no supplemental oxygen) and PERRLA (pupils are equal, round and reactive to light and accommodation - a test of brain abnormality) reactive to RT eye and no reaction to LT (left) eye. This nurse asked resident to squeeze my hand and was not able to, when asked.Review of nursing progress notes dated January 11, 2026 at 6:09 a.m. revealed, Resident in bed w/ HOB (head of bed) up focusing on the RT side of wall and pt (patient) is using the RT leg up and down, but no activity on the LT side. Pupils to the RT is reactive and LT is non-reactive.Further review of Resident 6's clinical record revealed the physician and POA were not notified of the change in status on the morning of January 11, 2026.Review of nursing progress notes dated January 11, 2026 at 1:22 p.m. revealed: Resident was reported to have a change in condition yesterday with altered mental status. Family at that time had requested resident to stay in house and have testing done. RN had called on call physician. Resident was assessed this morning by this RN.Resident could not move left arm or left leg. Did not eat breakfast, but was able to drink 240ml of water.Daughter .called around 12:45pm and expressed the family and her would like the resident transferred to the ED for evaluation.Resident left the facility at 1:40pm to be transferred to Hospital.Review of admission MDS dated [DATE] revealed Resident 101 was cognitively intact and required moderate assistance from staff to complete activities of daily living; Resident 101 was continent of bladder and bowel. Resident 101's diagnoses included: coronary artery disease, hypertension, peripheral vascular disease, renal insufficiency, diabetes mellitus, and recent gall stone removal procedure. Resident 101's medications included anticoagulants and antiplatelets.Review of nursing progress notes dated April 22, 2026 at 12:45 a.m., revealed Called to residents bedside d/t (due to) fall. Resident was laying on his right side window side of his bed.Review of facility documentation dated April 22, 2026 at 1:17 a.m. revealed the following: CNA reported to this nurse that this resident did not seem himself tonight. She stated he was shaky, his blood pressure was 203/76, pulse 89, respiration 28. Oxygen saturation 89% and his temp was 99.5. When this nurse went in to recheck him at 12:35 a.m., this nurse found him on the floor window side of the bed.his initial blood pressure was 118/71, pulse 118 and irregular respirations 24 temp 99.3. He was short of breath and oxygen was started at 2L/min via nasal canula. 15 minutes later his blood pressure was 192/79 heart rate 81 and his oxygen saturation went from 89% to 94% on the 2L of oxygen.family and physician to be notified.A review of nursing progress notes dated April 22, 2026 at 5:57 a.m. revealed a call placed to the provider.A review of nursing progress notes dated April 22, 2026 at 11:18 p.m. revealed received a call from wife requesting resident be sent to ER spoke with NP (nurse practitioner) new order to send resident to ERA review of nursing progress notes dated April 23, 2026 at 4:24 a.m. revealed Spoke with (nurse) at (hospital) d/t (due to) pulmonary edema.Interview with the Nursing Home Administrator on May 14, 2026 at approximately 1:00 p.m., revealed that the residents' medical providers and representatives were not notified timely when Residents 6 and 101 experienced significant changes in physical condition.28 Pa. Code 211.10(d) Resident Care Policies28 Pa. Code: 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that resident assessments accurately reflect the residents' status for one of 22 residents reviewed. (Resident 79).Findings include:Review of Resident 79's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated February 18, 2026, revealed under section O 0110- Special Treatments, Procedures, and Programs, that Resident 79 was not receiving hospice care.Review of Resident 79's physician's orders revealed that the resident has an order for hospice.Review of Resident 79's hospice notes revealed that the resident was admitted to Holisticare hospice on November 21, 2025.Interview with the Nursing Home Administrator, on May 14, 2026, at 1:28p.m. confirmed that the resident's MDS assessment was marked incorrectly.483.20 Accuracy of Assessments28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(c) Nursing services

Based on a review of the facility's policy, clinical records review, and staff interviews, it was determined that the facility failed to appropriately assess a wound for one of four residents reviewed (Resident 1) and failed to ensure that medications ordered by physicians were available for one of 22 residents reviewed (Resident 52).Findings: A review of the facility's policy titled Documentations & Assessment of Wound, last revised on June 12, 2025, revealed the policy is designed to guide associates and nurses in the assessment of wounds to include pressure ulcer/injuries, venous, arterial, diabetic, dehisced (re-opened or pulled apart) surgical wounds, and others. Based on the comprehensive assessment of a resident, the facility must ensure that the resident receives treatment and care in accordance with professional standards pf practice, the comprehensive care person-centered care plan, and residents' choices. A review of Resident 1's hospital records titled Discharge Summary dated April 25, 2026, revealed the resident had a diagnosis of right leg ischemia (A severe reduction in blood flow to the limb caused by obstructions) and PAD (Peripheral Artery Disease- a condition which narrowed arteries reduce blood flow to the arms and legs). A review of Resident 1's admission assessment dated [DATE], revealed that the resident had an opening to the right outer ankle with a measurement of 0.5 x 0.2 cm (centimeters), red, and with drainage. The wound was identified as open area/wound. A wound treatment of an Adaptec dressing (non-adhering wound dressing) was ordered. A review of Resident 1's wound assessment dated [DATE], completed by licensed nurse Employee E2 revealed the right lateral ankle had a measurement of 0.7 x 0.6 x 0.3 cm., 100% slough (is non-viable yellow, tan, gray, green, or brown tissue; usually moist, can be soft, stringy, and mucinous in texture). A wound treatment plan to cleanse the wound with normal saline, pack with Iodoform ribbon (A sterile woven gauze strip impregnated with iodoform antiseptic), and cover with foam dressing was ordered. The wound type was identified as other, wound of unknown origin. An interview conducted with Employee E2 on May 14, 2026, at 11:00 a.m., revealed that wound assessment should include the following: wound type, measurements, presence of drainage, and wound descriptions. Employee E2 confirmed that Resident 1's right lateral wound type should have been appropriately identified during the initial assessment on April 27, 2026, and on May 8, 2025. Employee E2 reported that on May 13, 2026, wound type was identified as venous wound (a slow-healing shallow sores caused by damaged vein valves that prevent blood from returning to the heart) based on review of the resident's hospital records. Employee E2 reported that hospital records were reviewed after the surveyor asked about the resident's wound type. The above was conveyed with the Nursing Home Administrator on May 14, 2026, at 11:45 a.m. The facility failed to ensure Resident 1's right lateral ankle wound was properly and comprehensively assessed. A review of Resident 52's diagnoses included Parkinson's Disease without Dyskinesia (Parkinson's symptoms without uncontrolled movements). A review of Resident 52's physician order dated September 22, 2025, at 11:26 a.m., revealed an active order for: Nuplazid Oral Capsule 34 MG (Pimavanserin Tartrate) Give 1 capsule by mouth one time a day for Parkinson disease associated psychosis, (medication that helps reduce Parkinson's related hallucinations and delusions). A review of Resident 52's April 2026 and May 2026 electronic Medication Administration Record (eMAR) revealed Nuplazid was not administered on the following dates/times: April 23, 2026, at 8:00 p.m., April 24, 2026, at 8:00 p.m., April 26, 2026, at 8:00 p.m., April 27, 2026, at 8:00 p.m., April 28, 2026, at 8:00 p.m., April 29, 2026, at 8:00 p.m., April 30, 2026, at 8:00 p.m., May 1, 2026, at 8:00 p.m., May 2, 2026, at 8:00 p.m., May 3, 2026, at 8:00 p.m., May 4, 2026, at 8:00 p.m., May 5, 2026, at 8:00 p.m., May 6, 2026, at 8:00 p.m., May 7, 2026, at 8:00 p.m., May 8, 2026, at 8:00 p.m., May 9, 2026, at 8:00 p.m., May 10, 2026, at 8:00 p.m., May 11, 2026, at 8:00 p.m. A review of Resident 52's nursing progress notes failed to reveal any notes stating why the medication was not administered on April 23, 2026, at 8:00 p.m., April 24, 2026, at 8:00 p.m., April 26, 2026, at 8:00 p.m., and April 27, 2026, at 8:00 p.m. A review of Resident 52's nursing progress notes dated April 28, 2026, at 11:39 a.m., revealed: CRNP (CRNP name) in facility and informed resident has not had nuplazid since 4/23 as medication pending prior authorization. Suburban Geriatrics sent email to follow up on status and (CRNP name) agreed to contact them as well. A review of Resident 52's nursing progress notes dated April 29, 2026, at 1:07 p.m., revealed: CRNP (CRNP name) in facility and informed resident has not received her nuplazid. Suburban Geriatrics office attempting prior authorization. No new orders. A review of Resident 52's nursing progress notes dated April 30, 2026, at 12:52 p.m., revealed: CRNP (CRNP name) in facility and informed resident does not have her nuplazid. She informed me there is a new person doing prior authorizations at Suburban Geriatrics and I sent email for her assistance today. A review of Resident 52's nursing progress notes failed to reveal any notes stating why the medication was not administered on May 1, 2026, at 8:00 p.m., May 2, 2026, at 8:00 p.m., and May 3, 2026, at 8:00 p.m. A review of Resident 52's nursing progress notes dated May 4, 2026, at 1:13 p.m., revealed: CRNP (CRNP name) in facility and informed we are still waiting for prior authorization for Nuplazid. She agreed to follow up with office staff. A review of Resident 52's nursing progress notes dated May 5, 2026, at 10:57 a.m., revealed: CRNP (CRNP name) in facility and asked about follow up with obtaining nuplazid for resident, she states she is working with office. A review of Resident 52's nursing progress notes dated May 6, 2026, at 11:35 a.m., revealed: Resident has no nuplazid for administration. CRNP (CRNP name) asked that prior authorization form be resent to office which I did this morning. CRNP from Vital Healthcare Solutions to see resident to determine if a different medication would benefit resident. A review of Resident 52's nursing progress notes failed to reveal any notes stating why the medication was not administered on May 7, 2026, at 8:00 p.m., May 8, 2026, at 8:00 p.m., May 9, 2026, at 8:00 p.m., and May 10, 2026, 8:00 p.m. A review of Resident 52's nursing progress notes dated May 11, 2026, at 12:13 p.m., revealed: CRNP (CRNP name) in facility and informed resident does not have nuplazid. Resident to be seen by the CRNP from VHS for alternative medication. A further review of Resident 52's nursing progress notes dated May 12, 2026, at 12:46 p.m., revealed: CRNP (CRNP name) in facility and informed we still cannot obtain nuplazid for resident due to her insurance and cost of medication. CRNP from Vital Healthcare Solutions in facility today and made aware and said she will recommend alternative medication for resident. Nuplazid discontinued. An interview with the Nursing Home Administrator conducted on May 14, 2026, at 1:23 p.m., confirmed medication was not administered to the resident due to the medication being unavailable. The facility failed to ensure that Resident 52's Nuplazid medication, used to help manage Parkinson's related hallucinations and delusions by calming overactive brain signals without affecting dopamine needed for movement, was available and administered on the dates noted above. 28 Pa Code 211.5 (f) Clinical records 28 Pa. Code 211.10 (c) Resident care policies 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide appropriate care to prevent urinary tract infections for one of four residents reviewed (Resident 103) who had an indwelling urinary catheter.Findings include: Review of the facility's policy titled Indwelling Urinary Catheter (Foley) Management regarding indwelling urinary catheters (a flexible tube inserted and held in the bladder to drain urine), dated September 4, 2025, stated that Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor.Observations of Resident 103 on May 11, 2026, at 12:15p.m. revealed that the resident was in a low bed and his catheter tubing was on the floor, and on May 12, 2026, at 2:00 p.m. the resident was sitting in the wheelchair, and the catheter was touching on the floor. Interview with Employee 3 on May 11, 2026, at 12:17 p.m. confirmed that Resident 103's catheter drainage bag was on the floor and should not have been. Interview with Employee 4 on May 12, 2026, at 2:05 p.m. confirmed that Resident 103's catheter drainage bag was on the floor and should not have been.Interview with the Nursing Home Administrator on May 14, 2026, at 1:26 p.m. confirmed the above findings.28 Pa. Code 211.12(d)(5) Nursing services.

Based on a review of resident clinical records, select facility policies, and staff interview, it was revealed the facility failed to ensure that one of the five residents sampled was free of a significant medication error (Resident 1).Findings include:Review of facility policy titled Administration of Medications, last reviewed on September 9, 2025, stated medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms .Staff who are responsible for medication administration will adhere to the 10 Rights of Medication Administration . including the Right Drug .Right resident .and Right dose. Review of facility policy titled Opioid-Induced Respiratory Depression, last reviewed on September 3, 2025, stated that the facility will be prepared and able to address emergencies related to substance use by providing increased monitoring, maintaining, and having knowledge of administering opioid reversal agents like naloxone (a medication that reverses narcotic effects).Review of Resident 1's admission Minimum Data Set (MDS - a mandatory assessment of a resident's abilities and care needs) dated December 9, 2025, revealed that Resident 1 was cognitively intact and dependent upon staff for completion of activities of daily living. The overall goal for Resident 1 was to remain in the facility for long term care.Review of Resident 1's admission profile revealed that he had not appointed a power of attorney and that he was his own representative.Review of Resident 1's nursing progress note dated March 6, 2026, at 1:00 p.m. revealed that Resident 1 had been admitted to hospice on March 6, 2026.Review of Resident 1's March 2026 Medication Administration Record (MAR) revealed a physician's order dated March 6, 2026, for Morphine Sulfate (Concentrate) Solution 20MG (milligram) per ML (milliliter). Give 5 milligram by mouth every 2 hours as needed for Pain/SOB (shortness of breath) please attempt and document 3 non-pharmacological interventions for pain prior to giving this medication for pain.Review of the Controlled Medication Utilization Record dated March 7, 2026, at 9:15 p.m. revealed that Resident 1 received 1ML of morphine concentrate instead of 0.25MLReview of nursing progress note dated March 7, 2026, at 9:50 p.m. state that Resident 1 received dose of morphine concentrate above prescribed amount. Residents VS (Vital signs - blood pressure, pulse, respirations, temperature, and oxygen levels), NEURO (neurological evaluation - an assessment of consciousness and upper/lower extremity strength), mentation (mental status) WNL (within normal limits). On call physician notified order for Q15 min (every 15 minutes) VS checks x8 hrs ordered. Resident informed of situation states understanding, POA contacted and informed of situation states understanding. Resident stable at this time.Review of an employee statement dated March 7, 2026, stated the nurse on the unit administered an excess amount of morphine concentrate over the prescribed dosage.Review of a nursing progress note dated March 7, 2026, at 10:15 p.m. stated Resident noted with increased lethargy and decreased bp (blood pressure) at this time. 1 dose of IM (intramuscular) Narcan (a medication to reverse the effects of narcotics) administered for possible side effects from morphine increased morphine dose, after 3 minutes of remaining lethargy 2nd dose of IM Narcan administered with improved BP and increased mentation. Resident is stable at this time.Review of a nursing progress note dated March 8, 2026, at 6:59 a.m. stated Resident was monitored for signs of respiratory distress & change of mental status during the night Q15m. All vitals continued to be wnl for resident. Resident continues to answer questions appropriately responding to verbal and external stimuli (questions asked of the resident and changes in the resident's environment).A physician's progress note dated March 9, 2026, at 1:00 a.m. stated nursing reports that on 3/7/26 [Resident 1] received Morphine dose above prescribed amount, became lethargic and with decreased BP, and was given x2 doses of Narcan, then returned to baseline. Today found laying in bed, sleeping but easily arousable,. says he is comfortable, denies pain.The above findings were reviewed and confirmed with the Director of Nursing and the Nursing Home Administrator on April 14, 2026 at approximately 2:00 p.m.28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3)(e)(1) Management28 Pa. Code 211.5(f) Clinical records28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review, observations, and resident interview, it was determined the facility failed to follow a physician's order for oxygen therapy for one of four residents reviewed (Resident 50). Findings include: Review of facility policy, titled Oxygen Administration (Infection Control, Safety, & Storage) last revised 04/08/2025 revealed Change oxygen supplies (e.g., cannula, tubing, humidifier) weekly and when visibly soiled. Equipment should be labeled with resident name and dated when setup or changed out. Review of Resident #50's clinical record revealed there was a current physician's order for the resident to be receiving oxygen therapy via a nasal cannula. The cannula was to be changed every night shift every Wednesday. Observation of Resident #50 on June 3, 2025, at 01:56 p.m. Revealed the nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help). Was dated 05/15/2025. It was soiled with red tinged nasal prongs, 2 brownish red dots also appeared on the side of the cannula on wrapping. Further observation on June 4, 2025, at 09:03 a.m. revealed the same soiled cannula, dated 05/15/2025. Interview with Resident #50 on June 3, 2025, at 01:59 p.m. revealed the resident wears the oxygen often and while in the facility and has it hooked up to an oxygen concentrator. The facility failed to follow a physician's order for oxygen therapy for Resident #50. PA Code 211.10(c) Resident Care Policies

Based upon review of facility policy and procedure and review of facility documentation, it was determined the facility failed to report an allegation of abuse for one of one resident reviewed (Resident 101). Findings include: Review of facility policy and procedure titled Abuse - Conducting an Investigation, reviewed May 7, 2025 revealed Complaints and grievances will be investigated as outlined in the Concern and Comment (Grievance) Program Policy and will be reported immediately if the investigation reveals any alleged violations involving neglect, abuse (including injuries of unknown source), and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider, and as required by State law. Review of a grievance filed by Resident 101 on May 8, 2025, revealed Resident 101 felt he was not spoken to nicely and the CNA threw the shirt at him and told him to put it on. [Resident] said [CNA] would not help [Resident] put socks on then left the room and didn't come back. Interview with the Director of Nursing on June 6, 2025, at 10:30 a.m. confirmed that the above abuse allegation was not reported to the State agency as required. 28 Pa. Code 201.14(a) Responsibility of Licensee Previously cited 5/31/2024 28 Pa. Code 201.18(v)(1)(2) Management Previously cited 5/31/2024 28 Pa. Code 201.29(c) Resident Rights Previously cited 5/31/2024

Based upon review of facility policy and procedure and review of facility documentation, it was determined the facility failed to investigate an allegation of abuse for one of one resident reviewed (Resident 101). Findings include: Review of facility policy and procedure titled Abuse - Conducting an Investigation, reviewed May 7, 2025 revealed When an incident or suspected incident of resident abuse and/or neglect, injury of unknown source, exploitation, or misappropriation of resident property is reported, the administrator/designee will investigate the occurrence. Protection will be provided to the alleged victim and other residents, such as room or staffing changes as needed to protect the resident(s) from the alleged perpetrator. Review of a grievance filed by Resident 101 on May 8, 2025, revealed Resident 101 felt he was not spoken to nicely and the CNA threw the shirt at him and told him to put it on. [Resident] said [CNA] would not help [resident] put socks on then left the room and didn't come back. Interview with the Director of Nursing on June 6, 2025, at 10:30 a.m. confirmed that the above abuse allegation was not fully investigated. 28 Pa. Code 201.14(a) Responsibility of Licensee Previously cited 5/31/2024 28 Pa. Code 201.18(v)(1)(2) Management Previously cited 5/31/2024 28 Pa. Code 201.29(c) Resident Rights Previously cited 5/31/2024

Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure physician's orders were followed for three of three residents reviewed. (Resident 40, Resident 42 and Resident 50). Findings include: Review of Resident 40's clinical record revealed a physician's order for Midodrine (medication used to treat hypotension) 2.5 milligrams (mg) to be administered three times per day and to hold the medication for systolic blood pressure greater than 125 mm/Hg (millimeters of mercury). Review of Resident 40's May 2025 Medication Administration Record (MAR) revealed Resident 40 received Midrodrine 2.5 mg on May 26, 2025 for a blood pressure of 134/43; May 30, 2025 for a blood pressure of 126/46 and May 31, 2025 for a blood pressure of 131/45. Review of Resident 40's June 2025 MAR revealed Resident 40 received Midrodrine 2.5 mg three times on June 2, 2025 for blood pressure readings of 145/50, 135/52 and 135/52 and June 3, 2025 for blood pressure of 131/55. The above information was conveyed to the Nursing Home Administrator and Director of Nursing on June 6, 2025 at 10:00 a.m. Review of Resident 42's clinical record revealed diagnoses including acute congestive heart failure, unspecified protein-calorie malnutrition (critical condition resulting from adequate intake of protein and calories) and dementia (general loss of cognitive abilities, including memory). Review of Resident 42's physician's orders dated May 30, 2025 revealed an order for fluid restriction of 1800 milliliters (ml) in 24 hours- 360 ml on each meal tray, shift 1 -360 ml, shift 2- 360 ml and shift 3 -120 ml every shift for CHF. Review of Resident 42's physician orders dated February 6, 2025 revealed Nursing bedside hydration three times a day. This order was discontinued on June 3, 2025. Review of Resident 42's Fluid Task sheet and Medication Administration Record revealed Resident 42 exceeded the daily fluid allotment as follows: May 31 2025; June 1 2025, June 2 2025 and June 3 2025. Interview with Director of Nursing on June 6, 2025, at 10:15 a.m. confirmed the physician orders were not followed for fluid restriction. Review of Resident 50's clinical record revealed diagnoses including hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease. (A medical condition referring to damage to the kidney due to chronic high blood pressure.) Review of Resident 50's physician's orders revealed Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MG. Give 1 tablet by mouth two times a day for HTN Hold if SBP <110 or HR <60 Review of Resident 50s medication administration record (MAR) for the month of March 2025, and April 2025, revealed the facility administered the above medication four times outside of parameters. The facility failed to ensure Resident 50's medication order Metoprolol Succinate ER was administered as ordered. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 5/31/2024

Based on facility policy and procedure review, clinical record review, and staff interviews, it was determined the facility failed to thoroughly investigate incidents for three of 32 residents reviewed. (Residents 2, 95, and 155) Findings include: Review of facility policy and procedure titled Protection of Residents: Reducing the Threat of Abuse & Neglect, reviewed May 15, 2020, revealed when an incident of or suspected incident of resident abuse and/or neglect of unknown source, exploitation or misappropriation of resident property is reported the administrator/designee will investigate the occurrence. The administrator/designee will complete an Incident Report and will utilize the Incident Investigation Questionnaire Form to document the investigation. The written summary of the investigation should include, but is not limited to: a review of the incident report, an interview with the person reporting the incident, interviews of any witnesses to the incident, an interview with the resident if appropriate, a review of the residents medical record, an interview with employees as needed, a review of the employees file as needed, Interviews with staff members on all shifts having contact with the resident at the time of the incident. Interview with the resident's roommate, family, and or visitors which may have information regarding the incident, interview other resident who received care and services from the alleged perpetrator, a review of all circumstances surrounding the incident. Review of Resident 2's clinical record revealed the following diagnosis: Unspecified Dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), Cognitive communication deficit (difficulty with communication that is caused by a problem with thinking), Anxiety disorder (intense, excessive and persistent worry and fear about everyday situations.), Major Depressive disorder (a persistent feeling of sadness and loss of interest). Additional review of Resident 2's clinical record revealed Resident 2 was actively prescribed Eliquis (blood thinner, blocks the activity of certain clotting substances in the blood). Review of Resident 2's progress notes revealed a progress note dated April 23, 2024, which states the following On this night the CAN (Certified nursing assistant) informed me that this resident had blood on his hand, wrist and on many tissues in the trash can. When assessing the situation, there was a band aide soaked with blood on his left wrist. When the band aide was removed the area was still bleeding. There was approximately a straight line cut approximately 1 centimeter long with no depth nor width on his left wrist. The area kept bleeding. The edges were approximated with 2 steri strips (strong adhesive bandages. They're often used to hold together the edges of a cut or wound, providing support for healing) after cleansing with NSS (normal saline solution). A pressure dressing of 4x4's was applied and wrapped with cling. Interview conducted with Resident 2 on May 29, 2024, at 1:18 p.m. reported that he/she does not remember how he/she sustained a laceration but remembers a male nurse placing a band aid on his wrist. Review of incident report, provided by the Director of Nursing (DON) on May 30, 2024, failed to contain any documentation identifying the nurse that treated Resident 2's wound and failed to provide any evidence of the nurse notifying the supervisor. Additional review of the incident report revealed the DON failed to attain any witness statements. Interview conducted with the Nursing Home Administrator on May 31, 2024, at 11:47 a.m. confirmed the incident was not thoroughly investigated. Review of Resident 95's diagnosis list includes Dementia (term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life), and Metabolic Encephalopathy (A group of neurological disorders that affects the brain due to a chemical imbalance in the blood). Review of Resident 95's Admission Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) revealed resident had a severe cognitive impairment. Review of Resident 95's nursing progress notes dated April 26, 2024, at 7:57 p.m., revealed that at around 9:30 p.m., the nursing supervisor received a call from a state trooper stating that the resident had called 911 due to feeling of not being safe in the facility. The resident informed the nursing supervisor that he/she did not feel safe and would like his/her sleeping pill. The state trooper came to the facility and spoke to the resident who reported that he/she was beaten and tossed into bed by two men. Documentation revealed that as per the trooper, the resident's description of the men who tossed him/her in bed was that of an EMT staff. Review of the facility documentation, Incident Report revealed that on April 26, 2024, at 7:30 p.m., the RN supervisor received a call from the state trooper stating that the resident had called 911 due to not feeling safe in the facility. The report revealed that as per the resident description, he/she was beaten and tossed in bed by two men. The resident was assessed, and the physician and POA were notified. Review of Resident 95's clinical records and facility documentation failed to reveal that a statement was taken from staff that had or possibly was in contact with the resident. Interview with the Director of Nursing conducted on May 31, 2024, confirmed that there was no documented evidence that staff who had or possibly had contact with the resident was interviewed. The facility failed to ensure Resident 95's allegation of physical abuse was comprehensively investigated. Review of Resident 155's census tab of the clinical record revealed the resident was admitted to the facility on [DATE] from the hospital after a surgical repair of a fractured hip. Review of Resident 155's Progress Notes revealed a Nursing Entry dated April 23, 2024 at 12:03 a.m. stating, This RN (Registered Nurse) was alerted by CNA (Certified Nursing Assistant) that while providing incont (incontinent) care she saw a gold point sticking out of resident's anus; while attempting to wipe resident's buttocks a fully intact writing pen came out of resident's rectum. Resident Alert with confusion and unable to explain how the pen became lodged in his rectum and denied pain. Resident was assessed for trauma none noted. Facility was asked to provide all documentation related to the investigation of this incident upon admission for Resident 155. An incident report was provided but there was no documented evidence any staff, or residents had been interviewed or that the company that had transported the resident to the facility from the hospital, or the hospital itself was contacted by the facility for investigation into this incident. Interview with the Nursing Home Administrator and the Director of Nursing on May 31, 2024 at 11:30 a.m. confirmed there was not a thorough investigation into the incident to Resident 155 upon admission on April 22, 2023. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.29(a)(d) Resident Rights 28 Pa. Code 211.5(f) Clinical Records

Based on clinical records review and staff interview, it was determined that the facility failed to follow the physician's orders and notify the physician of missed medications for three of the 24 residents reviewed (Residents 9, 51, and 95). Findings include: Review of Resident 9's physician order dated May 18, 2024, revealed an order for Vancomycin HCL (antibiotic) Oral Capsule 125 mg given one capsule by mouth every 12 hours for C-diff (An inflammation of the colon caused by the bacteria Clostridium difficile) until May 18, 2024. Review of Resident 9's clinical record including May 2024 Medication Administration Record revealed Vancomycin was not administered to the resident until the morning of May 18, 2024, missing three doses due to unavailability of the medication. Review of the physician's progress notes dated May 20, 2024, revealed the assessment and plan: Diarrhea (loose stool), history of recent C-diff, and Vancomycin completed. Review of Resident 9's clinical records failed to reveal that the physician was notified that the resident was only administered one out of four doses of Vancomycin ordered on May 16, 2024, due to the unavailability of the medication from the pharmacy. Interview with Director of Nursing conducted on May 31, 2024, confirmed the physician was not notified of the missed Vancomycin doses ordered on May 16, 2024, until May 21, 2024. Review of Resident 51's physician's orders revealed an physician's order dated February 26, 2024, for Coreg Oral Tablet (beta blocker used to treat high blood pressure and heart failure) 25 milligrams (mg) two times a day at 8 a.m. and 4 p.m., hold for systolic blood pressure (SBP) less than 100 or heart rate (HR) less than 60. Review of Resident 51's May 2024 Medication Administration Report (MAR) revealed the resident received Coreg 25 mg on May 8, 2024, with a documented HR of 59, May 12, 2024, with a documented HR of 56, May 18, 2024, with a documented HR of 59, May 22, 2024, with a documented HR of 54, May 23, 2024, with a documented HR of 55, and May 24, 2024, with a documented HR of 53. Review of Resident 51's April 2024 MAR revealed the resident received Coreg 25mg on April 3, 2024, for a documented HR of 57, April 6, 2024, for a documented HR of 57, April 7, 2024, for a documented HR of 58, April 21, 2024, for a documented HR of 57, April 23, 2024, for a documented HR of 56, April 26, 2024, for a documented HR of 55, and April 29, 2024, for a documented HR of 58. Review of Resident 51's March 2024 MAR revealed the resident received Coreg 25mg on March 22, 2024, for a documented HR of 54, and March 23, 2024, for a documented HR of 55. Review of Resident 51's clinical records revealed a physician note dated April 30, 2024, documenting medication was administered to resident with a documented heart rate of less than 60 for three days in April. Interview conducted on June 3, 2024, at 10:46 a.m. with the Nursing Home Administrator occurred and during which the above information was conveyed. Review of the Resident 95's nursing progress notes dated May 22, 2024, at 2:12 p.m., revealed Nurse Practitioner was in to see the resident due to having loose stools. A new order to continue the current Vancomycin until May 28, 2024, was made. Review of Resident 95's physician's order dated April 24, 2024, revealed an order for Midodrine (medication used to treat low blood pressure) 5 mg give one tablet by mouth three times a day for Hypotension (low blood pressure). Hold for Systolic Blood Pressure (SBP) over 130 Review of the May 2024, Medication Administration Record (MAR) revealed that from May 1, 2024, until May 22, 2024, Resident 95 was administered Midodrine 13 times with a systolic blood pressure above 130 ranging from 132/55 mmHg to 169/51 mmHg. Interview with the Director of Nursing on May 31, 2024, confirmed the Midodrine medication was administered to Resident 95 outside of ordered parameters. The facility failed to ensure physician's order for the Midodrine medication administration parameter order was followed. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical records review, facility documentation review, and staff interviews, it was determined that the facility failed to provide appropriate assessment and supervision to prevent a fall for one of the 24 residents reviewed (Resident 35). Findings include: Review of resident 35's diagnosis list includes Dementia (term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life), and Cerebral Vascular Accident (CVA- interruption in the flow of blood to cells in the brain). Review of Resident 35's AdmissionMinimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated November 22, 2023, revealed Resident 35 had a severe cognitive impairment and was dependent on transfers. The same MDS revealed car transfer assessment was not attempted due to medical conditions or safety concerns. Review of the active care plan initiated on November 22, 2023, revealed a care plan for ADLs (activities of daily living) which indicated that Resident 35 was an extensive assistance with two (persons) with transfers using the hemi walker (A kind of walker used for patient with full or partial paralysis on one side of the body). Review of the facility documentation and incident Report revealed that on January 1, 2024, at 11:45 a.m., the resident was found on the floor in the driveway outside of the facility by the main entrance on the passenger side of the family van. The family (grandson) signed the resident out for an outing. As per the resident, her/his knees got weak, and was unable to stand to get into the van causing the fall. Interview conducted with the Director of Nursing on May 31, 2024, revealed that for a resident going out on pass and requiring a two-person assist with transfers, rehab will be notified to assess the resident's safety with car transfers. Interview conducted with licensed Physical Therapist Employee E3 conducted on May 31, 2024, revealed that the rehab department was not notified that Resident 35 was going out on pass with a family. Employee E3 reported that a car transfer assessment would have been done if they had been informed. Review of the facility documentation revealed that on January 1, 2024, at 10:22 p.m., Resident 35 was assisted by an aide from a wheelchair to the bed but slipped from the chair, the aide lowered the resident to the floor and called for help. Review of the unlicensed employee E5 statement dated January 1, 2024, revealed: I attempted to pivot transfer patient from a chair to bed. The same statement revealed resident was lowered to the floor when she/he slipped. Interview conducted with the Diretor of Nursing on May 31, 2024, confirmed Resident 35 was provided with one person to assist with transfers on the night of January 1, 2024, despite needing a two-person assist with the use of hemi-walker as documented on the resident's plan of care. The facility failed to ensure Resident 35 was provided with appropriate assessment and supervision to prevent two falls in a day. 28 Pa. Code 211.10 (c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of the facility's policy, observation, clinical records review, and resident and staff interview, it was determined that the facility failed to ensure a physician order for Oxygen use was in place for one of the residents reviewed (Resident 205). Findings include: Review of the facility's policy titled Oxygen Administration, revised on February 27, 2024, revealed that an oxygen order should be written for specific liter flow required by the resident. Review of Resident 205's diagnosis list includes Chronic Obstructive Pulmonary Disease (COPD-A type of lung disease characterized by long-term respiratory symptoms and airflow limitations), Bronchiectasis with an acute lower respiratory infection, and Pleural Effusion (A buildup of fluid between the tissues that line the lungs and the chest). Observation conducted May 28, 2024, at 9:49 a.m., revealed Resident 205 sited in a wheelchair receiving supplemental oxygen per nasal cannula (A device that delivers extra oxygen through a tube and into your nose). An observation of the oxygen concentrator machine gauge revealed resident was receiving supplemental oxygen at two liters per minute (LPM). Interview conducted with Resident 205 on May 28, 2024, at 10:00 a.m., revealed that she/he was on as-needed supplemental oxygen at home but had been using continuous supplemental oxygen since being admitted to the facility four days ago. Observation conducted on May 30, 2024, at 11:35 a.m., revealed Resident 205 in the rehab room receiving supplemental oxygen per nasal cannula at two LPM while doing therapy. An interview with Resident 205 revealed she/he needed supplemental oxygen because she/he got short of breath during exertion. Review of Resident 205's clinical records failed to reveal an active physician's order for supplemental oxygen use and the liter per minute required. Interview with the Director of Nursing conducted on May 31, 2024, at 11:00 a.m., confirmed that there was no physician's order for Resident 205's supplemental oxygen from admission. The DON confirmed that the order was made on May 31, 2024. Review of the physician's order dated May 31, 2024, revealed an order for oxygen at two to four LPM per nasal cannula, which may be titrated to keep saturation above 90%. Notify the physician if saturation needs cannot be met at four liters. The facility failed to ensure that there was a physician's order for the supplemental oxygen use for Resident 205. 28 Pa. Code 211.10 (c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on facility policy and procedure review, clinical record review and staff interview it was determined the facility failed to ensure residents did not receive unnecessary medications for one of six residents reviewed. (Resident 79) Findings Include: Review of facility policy and procedure titled Definition of Infections for Surveillance Activities, last reviewed May 16, 2024 revealed Identification of infection should not be based on a single piece of evidence but should always consider the clinical presentation and any microbiologic (lab studies) or radiologic (X-rays, CT scan etc.) information that is available. Microbiologic and radiologic findings should not be the sole criteria for defining an event as an infection. Similarly, diagnosis by a physician alone is not sufficient for a surveillance definition of infection and must be accompanied by documentation of complete signs and symptoms. Review of Resident 79's progress notes revealed a nursing entry dated May 10, 2024 at 2:17 p.m. stating CNA (Certified Nursing Assistant) to desk stating resident complaining of dysuria (pain during urination) and was noted to have drops of blood on his penis and in brief. Doctor's office called, await call back. Review of the entire clinical record revealed there was no documented evidence of an assessment of the resident completed by a nurse on Resident 79 related to his complaint of dysuria and the blood noted by the CNA. Further review of Resident 79's progress notes revealed a nursing entry dated May 10, 2024 at 2:30 p.m. stating Doctor's office returned phone call and was updated on resident. He said because it is Friday afternoon and resident is symptomatic with noted blood, he ordered antibiotic. Review of the entire clinical record revealed there was no evidence Resident 79's urine was tested to confirm a urinary infection. Review of Resident 79's Medication Administration Record (MAR) revealed the resident received Amoxicillin-Pot Clavulanate (antibiotic) Tablet 500-125 MG (milligrams) twice a day for five days from May 11-15 2024 for a diagnosis of probable UTI (Urinary Tract Infection). Interview with the Director of Nursing and the Nursing Home Administrator on May 31, 2024 at 11:30 a.m. confirmed Resident 79 did not have a nursing assessment to confirm the signs and symptoms reported to the RN by the CNA or a laboratory study to confirm a UTI and the sensitivity of the organism causing the infection prior to the administration of antibiotics. 28 Pa Code 211.5 (f) Clinical records 28 Pa code 211.10 (c) Resident care policies 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician orders were followed and insulin administration was given timely for three of four residents reviewed (Residents R2 R3, and Resident R4). Findings Include: Review of Resident R2's clinical record revealed diagnoses including but not limited to Diabetes Mellitus (impaired ability of the body to produce or respond to insulin and thereby maintain proper levels of sugar (glucose) in the blood). Review of Resident R2's clinical record revealed a physician's order for Lantus (long acting insulin) SoloStar Solution Pen-Injector 100 UNIT/ML (mililiter) with instruction to Inject 10 unit subcutaneously (under the skin) one time a day for diabetic, give 8 am. Review of Resident R2's clinical record including the September 2023 MAR (Medication Administration Record) revealed the Lantus insulin was not administered within acceptable time parameter ten times from September 1, 2023 through September 15, 2023. Review of clinical record of Resident R3 revealed a diagnosis of Diabetes Mellitus. Further review of Resident R3's clinical record revealed a physician's order initiated on April 21, 2023 for NovoLOG FlexPen Solution Pen-injector 100 UNIT/ML (Insulin Aspart) with instructions to Inject 8 unit subcutaneously four times a day for diabetic give 6a/12p/4p/8p. Additional review of Resident R3's clinical record including September 2023 MARs revealed the following: September 1, 2023 NovoLOG was to be administered at 4 p.m. but was not administered until 8:48 p.m. with the next administration scheduled for 8 p.m. which was administered at 8:50 p.m. On September 2, 2023, Novolog was to be administered at 4 p.m. but was not administered until 7:41 pm. with the next administration dose scheduled for 8 p.m. which was administered at 7:42 p.m. On september 3, 2023 the 4 p.m. scheduled dose was administered at 6:34 p.m. and the 8 p.m. NovoLOG dose was administered at 8:39 p.m. September 6, 2023 the NovoLOG 4 p.m. dose was administered at 6:35 p.m. and the 8 p.m. dose was administered at 7:09 p.m. Further review of Resident R3's September 2023 MARs revealed on September 12, 2023 the NovoLOG 6 a.m dose was not administered until 9:59 a.m. On September 13, 2023 the 4 p.m. Novolog dose was not administered until 8:46 p.m. and the 8 p.m. dose was adminstered at 9:01 p.m. Review of Resident R4's clinical record revealed a diagnosis of Diabetes Mellitus. Further review of Resident R4's clinical record revealed a physician's order for HumaLOG (short acting insulin) KwikPen Subcutaneous Solution 100 UNIT/ML with instructions Inject as per sliding scale: if 0 - 200 = 0 units Call doctor if BGT (Blood Glucose Test) less than 70 and initiate hypoglycemia protocol; 201 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units call doctor if BGT over 400, subcutaneously four times a day for diabetes give 7:30 am, 12p, 5p, 8p. Review of Resident R4's clinical record including the September 2023 MAR revealed the HumaLOG insulin was not administered within acceptable time parameters seven times from September 1, 2023 through September 15, 2023. Interview conducted on Sepember 15, 2023 at approximately 6:56 p.m. with the Nursing Home Administrator when the above information was conveyed. 28 Pa Code 211.12(d)(1)(5) Nursing Services

Based upon clinical record review, it was determined the facility failed to follow physician orders for medication administration for two of 18 residents reviewed (Resident 22 and Resident 63). Findings include: Review of Resident 22's physician orders dated June 2, 2023, revealed an order for Ampicillin-Sulbactam (antibiotic medication) Sodium Intravenous Solution 3 grams to be administered intravenously every 6 hours for a right foot infection. Review of Resident 22's June Medication Administration Record (MAR) failed to reveal evidence that Resident 22 received the antibiotic medication as ordered by the physician on June 28, 2023, at 6:00 a.m. Interview with the Assistant Director of Nursing on June 30, 2023, at 10:00 a.m. confirmed Resident 22 did not receive the antibiotic medication as ordered by the physician. Review of Resident 63's physician orders dated May 31, 2023, revealed an order for Lorazepam (anti-anxiety medication) 0.5 milligrams (mg) to be administered daily at 8:00 a.m. Review of Resident 63's clinical progress notes revealed Resident 63 was administered Lorazepam 0.5 mg on June 14, 2023, at 2:15 a.m. Resident 63 was then unable to receive the scheduled dose at 8:00 a.m. Interview with the Assistant Director of Nursing on June 30, 2023, at 10:05 a.m. confirmed Resident 63 received Lorazepam 0.5 mg at 2:15 a.m. on June 14, 2023, instead of receiving it at 8:00 a.m. as ordered by the physician. The facility failed to ensure medications were administered according to physician orders. 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on observation, clinical record review and staff interview, it was determined the facility failed to provide respiratory care consistent with professional standards of practice, for one of 32 residents reviewed (Resident 92). Findings include: Observation conducted on June 27, 2023, at approximately 11:24 a.m. revealed Resident 92 was receiving oxygen therapy via nasal cannula (device that delivers extra oxygen to your nose through soft prongs). Review of Resident 92's clinical record on June 27, 2023, failed to reveal any active orders for oxygen therapy. Further review of Resident 92's clinical record revealed a care plan intervention for 2-3 L continues oxygen via nasal cannula. Interview conducted with the Director of Nursing (DON) and Nursing Home Administrator on June 30, 2023, at approximately 12:15 p.m. confirmed that Resident 92 did not have an order for oxygen therapy. 28 Pa. Code 211.10 (c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, it was determined that the facility failed to ensure the physician provided a clinical rationale for declining a consultant pharmacist recommendation for one of five residents reviewed for unnecessary medications (Resident 26). Findings include: Review of Resident 26's physician's orders revealed an order dated May 12, 2023 for hydroxyzine pamoate (medication used to treat allergies and can also be used to treat anxiety) 25 milligrams (mg) - give 1 capsule by mouth three times a day for anxiety and picking at skin. Review of Resident 26's pharmacy reviews revealed a Note to Attending Physician/Prescriber dated May 18, 2023, which stated that hydroxyzine was a potentially inappropriate medication for residents over the age of 65 due to increased risk for confusion, dry mouth, constipation, and other side effects. Further review of Resident 26's pharmacy review from May 18, 2023, revealed the physician signed the recommendation on May 26, 2023, and checked off the box for disagree but did not provide a clinical rationale for declining the pharmacist's recommendation. The physician's failure to provide a clinical rationale for declining the consultant pharmacist's recommendation for Resident 26 was discussed and confirmed with the Assistant Director of Nursing on June 30, 2023, at 10:10 a.m. 28 Pa. Code 201.18(b)(1)(2) Management

Based on review of facility policy and clinical records and resident and staff interviews, it was determined that the facility failed to report an allegation of abuse to the State Agency for one of 30 residents reviewed (Resident 43). Findings include: Review of facility policy entitled Protection of Residents: Reducing the Threat of Abuse and Neglect, revised May 15, 2020, revealed Facilities must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Failure to do so will mean that the facility is not in compliance with the federal regulations. Review of Resident 43's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 43's Admission Minimum Data Set assessment (MDS - periodic assessment of resident needs) dated December 22, 2020 revealed resident had a Brief Interview for Mental Status score of 15 indicating Resident 43 was cognitively intact. Review of Resident 43's clinical progress notes dated December 31, 2020 revealed documentation identifying that the resident had an issue for two nights with a Nurse Aide (NA) and that the NA made the resident walk to the restroom instead of allowing them to use their wheelchair (w/c). The notes revealed that the resident had stated that his/her feet hurt and that the NA stated you're a liar. The notes further indicated that the resident also stated the NA then left the resident in the restroom alone, never came back, that he/she placed the resident's w/c in the restroom. The resident then stated he/she had to get him/herself off the commode, wipe, maneuver back to bedside then transferred him/herself to bed. The resident had stated this NA was verbally aggressive with him/her. The note also identified that Social Services was notified. On Friday June 25, 2021, at approximately 1:00 p.m. documentation regarding an investigation into the allegation of abuse and evidence that the allegation was reported to the State Agency was requested from the Nursing Home Administrator (NHA). On Monday June 28, 2021, at 9:00 a.m. documentation regarding an investigation into the allegation of abuse was again requested from the NHA since no documentation was provided from the June 25, 2021 request. On Monday June 28, 2021 at 11:00 a.m. a third request was made to the NHA to provide documentation regarding an investigation into the allegation of abuse and evidence that the allegation was reported to the State Agency. At that time, a statement from the Social Worker (SW) Employee E3 was provided. Review of the statement from SW Employee E3 dated December 31, 2020, revealed documentation that described a reported incident. The resident reported that the NA working last night treated the resident badly. The resident had stated that at approximately 12 midnight he/she rang the bell to use the bathroom and the NA came in, grabbed their walker, and slammed it down next to their bed and told him/her to walk to the bathroom. The resident explained that his/her feet were very sore but the NA told the resident he/she was lying and therapy told her that he/she could walk. Documentation also identified that the resident did walk to the bathroom and did everything for him/herself in the bathroom and then the resident walked back to bed. The resident admitted that he/she was able to do all of this him/herself but was mad that the NA didn't help. Documentation continued that when the he/she rang the bell again a few hours later to use the bathroom, the resident said it was the same routine. When the resident finished in the bathroom he/she got him/herself cleaned up and then sat back down on the toilet because he/she did not feel he/she was able to walk back to bed. The resident stated that the NA said to him/her is that where you are going to stay all night? The resident stated he/she stayed in the bathroom until the NA threw the wheel chair into the bathroom where the resident got him/herself into the wheel chair, out of the bathroom and back to bed. The resident was able to give a detailed description about the nurse aide. Interview with SW Employee E3 on June 28, 2021, at 11:40 a.m. revealed that he/she had no further documentation regarding the investigation into this incident and further stated that he/she had no knowledge if the allegation was reported to the State Agency. SW Employee E3 further stated that normally he/she would receive a completed file from the Director of Nursing which would include statements from employees, a copy of the incident report submitted to the State agency and a copy of the investigation report submitted to the State agency. SW Employee E3 stated he/she received no such file regarding this allegation and further stated he/she did not follow up with the resident. Interview with Resident 43 on June 28, 2021, at approximately 12:00 p.m. revealed that the resident recalled the evening that the alleged abuse occurred. Resident 43 stated during the interview that the NA treated him/her very, very, very, badly on the evening of December 30, 2020. Interview with the NHA on June 28, 2021, at 12:15 p.m. confirmed that he/she could not locate any documentation indicating that the facility reported the allegation of abuse to the State Agency as required. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14 Responsibility of Licensee 28 Pa. Code 201.18(a)(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(d) Resident Rights

Based on clinical record review and staff interview, it was determined that the facility failed to implement measures to assess a pressure ulcer and failed to timely identify and treat a pressure ulcer for two of six residents reviewed (Resident 27 and Resident 85) which resulted in actual harm to Resident 27 who experienced a 5 day delay in treating redness to the sacrum which deteriorated to a stage 3 pressure ulcer. The facility also failed to put interventions into place to prevent the development of a pressure ulcer for one of six residents reviewed (Resident 85). Findings include: Review of Resident 27's (MONTH) 9, (YEAR) Braden Scale for Predicting Pressure Sore Risk revealed the resident had a score of 13, placing the resident at moderate risk for developing pressure ulcers. Review of Resident 27's care plan initiated on (MONTH) 19, (YEAR) identified the resident as at risk for impaired skin integrity related to incontinence, decreased mobility, Braden score, and deep skin folds. Interventions in place included skin assessments weekly and as needed if condition changes, report any reddened areas that do not blanch when pressed to wing nurse for further assessment and documentation, and notify the physician and family of any change in skin condition. Review of Resident 27's weekly skin integrity data collection revealed that on (MONTH) 7, (YEAR) an open area was identified on the resident's sacrum. Review of Resident 27's progress notes revealed a nurse's note dated (MONTH) 7, (YEAR) that was a late entry for the evening shift on (MONTH) 6, (YEAR) stating Husband and daughter informed nurse that a few days ago someone reported a red area on residents buttocks, this nurse had not been informed of this Nurse and CNA assisted resident into bed, skin assessment done, open area at sacrum area cleansed with NSS (normal saline), hydrogel (wound treatment to provide moisture) applied with ([MEDICATION NAME]) (absorbent dressing). Further review of Resident 27's progress notes revealed that the area to Resident 27's sacrum resolved on (MONTH) 12, (YEAR). The Director of Nursing was asked for Resident 27's wound tracking or assessments for the wound identified on (MONTH) 7, (YEAR) on (MONTH) 5, 2019 at 12:00 p.m. The Director of Nursing was again asked for documentation on (MONTH) 6, 2019 at 9:00 a.m. and 10:30 a.m. The surveyor then asked licensed nurse Employee E4 for the above requested documentation on (MONTH) 6, 2019 at 1:40 p.m. Interview with licensed nurse Employee E4 on (MONTH) 6, 2019 at 2:00 p.m. confirmed that there were no assessments of Resident 27's (MONTH) 7, (YEAR) pressure ulcer. Further review of Resident 27's weekly skin integrity data collection revealed an assessment on (MONTH) 28, (YEAR) which identified redness to the resident's sacral area. Review of Resident 27's clinical record failed to reveal evidence that the physician was notified of the reddened area to the resident's sacrum. Further review of Resident 27's progress notes revealed a nurse's note on (MONTH) 2, 2019 which stated area of injury on the sacrum measuring 0.5 x 0.5 x 0.1 cm wound base is 25% yellow center. There is no drainage and no pain. It is classified as a stage 3 (full thickness loss of skin; slough (non-viable yellow or white tissue that adheres to the ulcer bed in strings or thick clumps) and/or eschar (dead tissue that sheds or falls off from healthy skin) may be visible) injury. Review of the facility's weekly wound report revealed Resident 27's stage 3 pressure ulcer to the sacrum healed on (MONTH) 17, 2019. Review of Resident 27's (MONTH) (YEAR) physician's orders [REDACTED].) Interview with licensed nurse, Employee E4 on (MONTH) 6, 2019 at 2:00 p.m. revealed that it was unknown why Resident 27's pressure ulcer was not identified until it was at a stage 3, why the physician was not notified when the redness to the sacrum was identified on (MONTH) 28, (YEAR), and why there were no treatments implemented on (MONTH) 28, (YEAR) to prevent further breakdown to the reddened sacrum. The facility failed to notify Resident 27's physician about the redness to the sacrum on (MONTH) 28, (YEAR), resulting in a delay in treatment to the sacrum and the sacral redness worsening to a stage 3 pressure ulcer on (MONTH) 2, 2019. Review of Resident 85's Significant Change Minimum Data Set (MDS - periodic assessment of resident needs) dated (MONTH) 28, 2019 revealed Resident 85 required the extensive assistance of two staff persons for turning side to side in bed and repositioning body while in bed, was at risk for pressure ulcers and did not have any unhealed pressure ulcers. Review of Resident 85's Braden Scale for Predicting Pressure Sore Risk evaluation revealed Resident 85 was at moderate risk for developing pressure ulcers and review of Resident 85's Braden Scale dated (MONTH) 9, 2019 revealed Resident 85 was at high risk for developing pressure ulcers. Review of Resident 85's care plan revealed Resident 85 had potential impairment to skin integrity related to deep skin folds, decreased mobility, incontinence and Braden score with interventions including heel trough (long knee-to-ankle cushion used to elevate heels off of bed). Review of Resident 85's progress notes dated (MONTH) 13, 2019 revealed on 8/12/19 it was noted that there is a wound on the left medial (middle) planter (bottom) heel. The wound is irregular in shape and has a deep purple color on the ridge of the area and partially fluid filled, painful to touch. Surrounding area normal and intact. Heels are elevated off the bed surface with a heel trough and are not touching. Staff made aware of the area and education provided for the importance of elevation. Review of Resident 85's Weekly Wound Report dated (MONTH) 14, 2019 revealed the left medial plantar heel wound measured 2.4 cm (centimeters) x 2.3 cm and was a mixture of purple and yellow coloring, soft to touch with fluid palpable. Review of Resident 85's progress notes dated (MONTH) 28, 2019 revealed assess deroofed (open) blister on back of left calf, area is moist pink, bleeds easily with cleaning. Noted to have intact fluid blister next to deroofed blister on lateral post calf measuring 2.0 cm L (length) x 1.5 cm W (width). Clear fluid with purple tissue surrounding. Review of resident 85's updated care plan dated (MONTH) 5, 2019 revealed has break in skin integrity - L (left) medial plantar heel injury, 8/20/19 L calf deroofed blister 8/28/19 L post (posterior - back) calf intact blister 9/1/19 wound L post calf 9/4/19 blisters L post calf, with interventions including educate resident and/or family regarding skin problem and treatment; treatment as ordered. Review of Resident 85's clinical record failed to reveal evidence of any wound documentation for Resident 85's calf blisters. Interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 5, 2019 at approximately 1:00 p.m. confirmed that the facility did not have any documented evidence related to prevention or assessment of Resident 85's calf blisters as requested. The facility failed to provide evidence of wound reports related to Resident 85's calf blisters as requested and failed to provide evidence as requested of any interventions in place to prevent Resident 85's calf blisters. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services

Based on review of clinical records and staff interview, it was determined that the facility failed to provide adequate assistance and supervision to ensure the safety for one of five residents resulting in actual harm to Resident H8. Findings include: Review of Resident H8 ' s clinical record revealed an admitted [DATE] with the following (but not limited to) Diagnoses: [REDACTED]. Review of Resident H8 ' s fall risk assessment dated [DATE] revealed the resident as being a high risk for falls with a score of 24 out of 30 due to a past history of falls and recent hip surgery. Review of Resident H8 ' s care plan dated December 31, 2015 revealed fall precautions were to be put into place with the use of a bed alarm (signals the staff when the resident is attempting to get out of bed with an alarm and light that shines in the hallway) and a low bed. Review of the Admission Minimum Data Set (MDS-assessment of resident's care needs) date December 20, 2015 identified the resident as requiring extensive assist of one person for ambulation on and off the unit. Review of nursing notes dated December 27, 2015 at 10:55 p.m. revealed that the resident was ambulating down hall with walker, before staff reached the resident witnessed he lost balance leaning towards left and falling onto left side. A review of the facility investigation into the fall incident dated December 27, 2015 indicated that the bed was not in the lowest position, the call light was on and the alarms were sounding. Review of report filed with the state agency on December 27, 2015 at 11:55 p.m. stated During change of shift two nurses at the nursing station saw resident down the hallway walking with his walker. They immediately got up to assist him and as they did he fell backwards and landed on the floor. At the same time a CNA came out of another residents room and saw him and she also saw that his outside call bell light had been activated by the bed alarm. Call bell was lit and alarms were sounding. Review of nursing documentation dated December 27, 2015 at 12:08 a.m. revealed that 911 emergency services were called and the resident was transferred to the local hospital. Further review of nursing documentation dated December 27, 2015 at 6:40 a.m. revealed that the resident was admitted to the hospital with [REDACTED]. An interview was conducted with the Director of Nursing and the Nursing Home Administrator on January 28, 2016 at 3:15 p.m. revealed that at the time of the fall it was change of shift and the one nursing assistant that was working tried to respond as quickly as she could. There was no explanation of why the nursing staff at the nurses station was not able to respond when the resident bed alarm was activated. The facility failed to provide supervision and required assistance to Resident H8, which resulted in actual harm to Resident H8 sustaining a fall with fracture of the left femur. 28 Pa. Code 211.5(f) Clinical records. 28 Pa Code 211.11(a)(d) Resident Care Plan 28 Pa. code 211.12(d)(5) Nursing services.

Based on review of clinical records, event report, manufacturer's manual and staff interviews, it was determined that the facility failed to ensure resident safety during transfer with a mechanical lift for one of 19 residents (Resident R63) which resulted in actual harm to the resident. Findings include: Review of Resident R63's clinical chart revealed that the resident was admitted to the facility on [DATE], with the following [DIAGNOSES REDACTED]. (pressure sore) on the hip. Review of the information dated August 3, 2015, submitted to the Department of Health, revealed that when an occupational therapist and two nursing assistants were trialing a Sebena lift staff did not attach two loops on the top bar. When the staff began to turn the lift the resident let go of the bar (that the resident was instructed to hold onto) and fell to the floor. Resident R63 sustained a cut to her head and complained of her left hip or leg hurting. Review of the nursing note dated August 3, 2015, confirmed that the staff was called to the resident's room and the resident was observed laying on her left side on the floor with the knee bent and right leg out straight. The resident immediately complained of pain in the left hip area and had a small amount of bleeding from the head and a small cut/laceration was noted on the left side of the head. The staff reported during a trial use of a stand assist lift, the resident slipped to the floor. Further investigation revealed a clinical note dated August 3, 2015, that Resident R63 was being admitted to the hospital with [REDACTED]. A review of the manufacturer's operation instruction manual warning stated the following: before the patient is lifted from the underlying surface, but after the straps have been fully extended, make sure the straps are properly connected to the sling bar. An interview with the Director of Nursing conducted on August 27, 2015, at approximately 2:30 p.m., revealed statements gathered from the three individuals involved, acknowledging they forgot to attach the support straps properly to the sling bar. The facility failed to provide Resident R63 a safe transfer, failed to use the transfer equipment properly and failed to ensure that the straps were properly connected to the sling bar while assisting the resident with standing as it was indicated by the manufacturer's instructions. This resulted in actual harm to Resident R63, sustaining a fall with a fracture to the left hip. 28 Pa. Code 201.18(b)(1) Management. Previously cited 09/29/2014 28 Pa. Code 201.20(a) Staff development. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 09/29/2014

Based on a review of clinical records, staff interview and review of facility's policy, it was determined that the facility failed to accurately assess, identify and prevent the development of pressure ulcers for one of 19 sampled residents (Resident R7), resulting in actual harm to the resident. Findings include: Review of the facility's policy entitled Pressure Ulcer Program Manual revised October 7, 2010, for pressure ulcers: prevention and treatment, assessing tissue damage and monitoring outcomes indicated that A Category/Stage II: Partial-Thickness Skin Loss pressure ulcer was a wound in which partial thickness loss of dermis (dense inner layer of skin) presenting as a shallow open ulcer with a red or pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture). May also present as an intact or open/ruptured blister. A Category/Stage III: Full-Thickness Skin Loss pressure ulcer was a wound in which full thickness tissue loss. Subcutaneous fat (under the skin) may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining (erosion of the wound) or tunneling (narrow passageway). Review of Resident R7's admission record revealed that the resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Review of the Braden scale (a tool used to evaluate the risk for developing skin breakdown) dated August 4, 2015, revealed a score of 15 which placed the resident at a mild risk for developing pressure ulcers. Review of the nursing documentation dated August 4, 2015, indicated that the resident was alert and oriented to person, place and time and a soft cast was in place to the right lower leg. Review of the interim care plan dated August 4, 2015, revealed the resident was at risk for breakdown in skin integrity with a goal to maintain intact skin. The weekly skin assessment completed on August 6, 2015, which was two days after the resident's admission, revealed that the resident had a bruise to the left shin. Review of the resident's plan of care developed August 11, 2015, revealed that the resident was identified to be at risk for skin breakdown in relation to a decrease in mobility, and had a full ACE wrapped cast (stretchable bandage used to hold a soft cast in place) on the right leg. The application of skin prep (a topical medication use for the prevention of skin breakdown) to be applied to bilateral (both the right and left side) heels every shift was indicated as one of the interventions listed on the plan of care. Review of the wound assessment documentation dated August 15, 2015, (eleven days after admission to the facility) revealed that the resident had developed a left heel, unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed). There was no documented evidence that the left heel pressure ulcer was timely identified and assessed prior to being an unstageable pressure ulcer. Further review of the nursing documentation dated August 18, 2015, revealed that a hard cast was applied to Resident R7's right leg fracture. Review of the wound assessment documentation dated August 24, 2015, (twenty days after admission to the facility revealed that the resident had developed an inner left side of the knee Stage II pressure ulcer measuring 5.0 centimeters x 4.0 centimeters x 0.0 centimeters in depth (could not determine). Wound care observation on August 26, 2015, at 10:15 a.m., completed by the wound team regarding the dressing change to the left inner knee revealed measurements of 4.9 centimeters x 5.4 centimeters x depth could not determine due to slough. There was a moderate amount of serosanguinous drainage on the soiled dressing and in the wound. There was a suspected deep tissue injury at three o'clock (at the right angle of the wound) which was deep purple in color. After the dressing change, review of the wound assessment documentation dated August 26, 2015, indicated that the inner left side of the knee pressure ulcer was a Stage II, measuring 4.9 centimeters x 5.4 centimeters x depth could not be determined with a small amount of serosanguinous drainage described as 5% yellow slough and 95% deep red and purple (suspected deep tissue injury at three o'clock). During the wound care observation, the wound team recommended that moleskin (soft material utilized to prevent friction) be ordered and placed around the top of the cast to prevent further skin breakdown. Interview with Licensed Nurse, Employee E5, on August 27, 2015, at 12:15 p.m., confirmed that the wound assessment and documentation was inaccurate related to the description of stages. Employee E5 also confirmed that the inner left side of the knee should have been staged at a Stage III and the description of the wound was 95% yellow slough and 5% deep red and purple (suspected as a deep tissue injury at three o'clock). There was no evidence that the facility put in place interventions to prevent the development of pressure ulcers after a hard cast was applied to the resident's right leg to prevent skin breakdown resulting in actual harm to Resident R7 with development of a Stage III pressure ulcer to the inner left side of the knee caused by pressure from the hard cast. 42 CFR 483.25(c) Treatment/Services to Prevent/Heal pressure Sores. Previously cited 09/29/2014 28 Pa. Code 201.18(b)(1)Management. Previously cited 09/29/2014 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.5(f) Clinical records. Previously cited 09/29/2014 28 Pa. Code 211.10(d) Resident care policies. Previously cited 09/29/2014 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 09/29/2014