Every finding on record at Hillcrest Center

Based on review of facility documentation, observation, and interview with staff it was determined that the facility failed to ensure essential air conditioning equipment was maintained in a safe operating condition for one of three nursing units (First Floor). Findings Include: Review of facility policy titled Safe and Homelike Environment revised November 14, 2025, revealed that residents have the right to a safe, clean, comfortable, and homelike environment. The policy defines comfortable and safe temperature levels as ambient temperatures maintain within a range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia and provides a comfortable environment for residents. The policy further identified the resident environment as including resident rooms, bathrooms, hallways, dining areas and other areas frequented by residents. Review a facility policy titled Preventative Maintenance Policies and Procedures revised January 8, 2024, revealed that the preventative maintenance was to be performed on all HVAC equipment semiannually by appropriate service location staff during the spring and fall. The policy further directed that HVAC systems be inspected annually and that the maintenance of cooling towers, chillers and hydraulic heating systems be performed annually by a qualified outside source and be documented with a copy of the inspection form maintained by the facility. Interview with the Director of Nursing, Employee E1, on August 10, 2026, at approximately 9:00 a.m. revealed the central air conditioning unit that serves the first floor was not functioning properly. Director of Nursing, Employee E1, stated that alternative measures were implemented to keep temperatures at comfortable temperatures including placement of portable air conditioning units on the first-floor hallways, increase monitoring of residents, and offering additional fluids throughout the day. Interview with Maintenance Director, Employee E2, on August 10, 2026, at approximately 9:15 a.m. revealed that he was aware of the malfunctioning air condition system, and that it only affected the first-floor nursing unit. Maintenance Director, Employee E2 stated that the air conditioning system initially malfunctioned on July 10, 2026, and he was able to temporarily restore the system to operation. On approximately August 1, 2026, the system stopped functioning again and can no longer be temporarily repaired. Continued interview with Maintenance Director, Employee E2, revealed a contract HVAC (heating, ventilation, and air conditioning) company assessed the system and determined that parts were required to repair the rooftop compressor. Employee E2 stated the authorization for repair was recently obtained and the necessary parts have been ordered; however, he was unable to provide an anticipated date for completion of the repairs or restoration of the compressor. Further interview with Maintenance Director, Employee E2, revealed the facility purchased five industrial portable air condition units, which were placed in the first-floor hallways to maintain a comfortable temperature. When asked how temperatures were maintained in resident rooms, Maintenance Director, Employee E2, stated that each resident room is equipped with a PTAC unit (self contained heating and cooling system installed through an exterior wall for climate control in individual rooms) located beneath the window. Employee E2 stated the malfunctioning rooftop compressor primarily affected the first-floor hallways and that the portable air conditioner units were being used to maintain the hallway temperatures. Observation on August 10, 2026, at approximately 9:30 a.m. during a tour of the first-floor nursing unit revealed five industrial portable air-conditioner units positioned throughout the hallways. Review of the facility maintenance documentation revealed a service request dated June 17, 2026, for the rooftop unit (RTU) serving the first floor of common hallway area. The service request documented that the RTU was not cooling in the first-floor hallway was not being adequately cooled by the unit. Review of the HVAC service documentation revealed that the maintenance director, Employee E2, requested service for the rooftop unit (RTU) serving the first-floor common hallway due to the unit not cooling. Documentation from the HVAC service provided revealed that an on-site assessment identified a leak within the compressor cabinet, which was repaired. However, the service provider further identified that the compressor, compressor contactor, and filter dryer required replacement for the RTU to cool properly. Further review revealed the proposal was issued for the identified repairs. The proposal review was not signed and indicated it was valid through July 17, 2026. The identified repairs had not been completed at time of the survey on August 10th, 2026, and the RTU serving the first four hallway remained non-functional. Observations on August 10, 2026, at approximately 1:45 p.m. with Maintenance Director, Employee E2, revealed several rooms were identified to feel warmer and stagnant compared to the other resident rooms. Observation and testing of the PTAC units on August 10, 2026, at approximately 1:45 p.m. with Maintenance Director, Employee E2, in the identified rooms revealed that eight of twenty-two PTAC units were not functioning properly and were blowing warm air instead of cold air. Maintenance Director, Employee E2, accompanied the surveyor and assessed the individual PTAC units. The maintenance director confirmed that eight of twenty-two PTAC units were not functioning properly and acknowledged that he was unaware of the malfunctioning PTAC units. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 204.19 Plumbing, heating, ventilation, air conditioning and electrical.

Based on review of facility policy, review of facility documentation, review of clinical records, and staff interview it was determined that the facility failed to maintain complete and accurate documentation one of two residents reviewed (Resident R1). Findings include: Review the facility policy titled Dialysis Hemodialysis Communication and Documentation last revised November 14, 2025, revealed the facility is responsible for maintaining ongoing communication and collaboration with the certified dialysis facility regarding the resident condition before and after each hemodialysis treatment the policy requires. A licensed nurse to complete the hemodialysis communication record including the pre dialysis evaluation before the resident leaves for dialysis. The dialysis facility to complete and return the communication form with the resident following treatment. Upon the resident return, a licensed nurse to review the dialysis facilities communication, assess the resident, and complete the post dialysis treatment evaluation. If the dialysis communication form is not returned, the facility must contact the dialysis center, request the information and document that communication. Review of facility dialysis service agreement between the facility and the contracted dialysis provider revealed the agreement requires ongoing communication and coordination of care between both parties. The agreement states the dialysis center will provide the facility with information regarding the resident's dialysis treatment fully and aspects of the resident's care related to the provision of the dialysis service. The agreement also requires the facility to ensure all pertinent medical information accompanies the resident to dialysis, including the resident's medical history, current treatments, medication changes, changes in condition, diet, fluid restrictions, laboratory findings, advanced directives, and any additional information necessary to facilitate coordination of care. The dialysis provider is required to maintain reports of services rendered, and the facility has the right to obtain copies of these records for inclusion in the resident's medical records to ensure continue the of care Review of resident R1's discharge Minimum Data Set (MDS - federally mandated resident assessment and care screening) date of June 19, 2026, revealed Resident R1 was discharged to a short-term acute care hospital. Per the MDS, Resident R1 has a diagnosis of end stage renal disease (also known as kidney failure) and receives hemodialysis (machine that filters the toxins from the blood) treatment. Review of Resident R1's dialysis communication records revealed incomplete and inconsistent documentation, including missing post dialysis vital signs, post dialysis weights and post treatment assessments. In addition, discrepancies were identified between the dialysis communication record and the documentation in the resident's electronic medical record. Continued review of Resident R1 hemodialysis communication record revealed the facility failed to consistently complete the required post dialysis nursing assessment upon the resident's return to the facility on the following dates: June 5, 2026, the post hemodialysis section to be completed by the facilities licensed nurse was not completed June 8, 2026, the post hemodialysis assessment section was not completed. June 10, 2026, the post hemodialysis assessment section was not completed. June 12, 2026, the post hemodialysis assessment section was not completed. June 17, 2026, neither the section to be completed by the certified dialysis nurse allowing treatment nor the post hemodialysis section to be completed by the facility licensed nurse was completed. June 26, 2026, the post hemodialysis assessment section to be completed by the facility's licensed nurse was not completed. Further review of Resident R 1's clinical record revealed the documented vital signs in the electronic medical record did not consistently correspond with the vital signs documented in the resident dialysis communication binder. Comparison of the two records identified discrepancies in the documented vital signs, as well as missing documentation in both the electronic record and the dialysis communication binder cord. Interview with Licensed Nurse, Employee E3, on June 30th, 2026, at approximately 1:00 p.m. confirmed that the dialysis communication binder was incomplete. 28 Pa Code 211.5 (f)(ii) Medical records.28Pa. Code 211.12 (d)(3) Nursing services.

Based on review of clinical records, and staff interview it was determined that the facility failed to ensure care and services were provided in accordance with physician orders for one of one resident reviewed (Resident R1). Findings include: Review of Resident R1's discharge MDS (minimum data set - federally mandated resident assessment and care screening) dated June 19, 2026, revealed the resident was discharged to a short-term acute care hospital. Per the MDS, Resident R1 has a diagnosis of end stage renal disease (also known as kidney failure) and receives hemodialysis (a machine used to physically filter waste out of the blood). Review of Resident R1's physician orders revealed an order dated October 21st, 2025, directing staff not to obtain blood pressure measurements in resident's left arm.Review of Resident R1's clinical record revealed vital signs of documented blood pressure measurements that are repeatedly obtained in the resident's left arm on the following dates: 6/4/2026: BP (blood pressure) 137/76 left arm6/6/2026: BP 97/66 left arm6/11/2026: BP 150/68 left arm6/11/2026: BP 110/65 left arm6/14/2026: BP 138/77 left arm6/16/2026: BP 143/76 left arm6/16/2026: BP 102/66 left arm6/18 /2026: BP 117/63 left arm6/18/2026: BP 105/54 left arm6/26/2026: BP 148/72 left arm6/27/2026: BP 137/76 left arm Interview on June 30, 2026, at approximately 2:00 p.m. with Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, confirmed that staff was documenting blood pressure readings from Resident R1's left arm despite a physician order directing staff not to. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d)(5) Nursing Services.

Based on review of facility policy, review of clinical record, review of facility documentation, and staff interview, it was determined that the facility failed to notify the resident representative of a transfer to the hospital for one of one resident reviewed for notification of changes (Resident R1).Findings include: Review of facility policy titled Discharge and Transfer last revised June 11, 2026, revealed the facility is required to immediately inform the resident and residents representative when a decision is made to transfer the resident. Further, the policy states that when immediate transfers are required due to the residents' urgent medical needs, notification must be provided as soon as practicable. Review of resident R1's clinical record revealed that the resident was transported to his/her scheduled outpatient dialysis treatment on June 19, 2026, and subsequently required a transfer to the hospital, for further evaluation. Further review of Resident R1's clinical record revealed no documented evidence Resident R1's representative, Power of Attorney (POA - legal tool that grants an individual the authority to make decisions and take actions on behalf of another person), was notified of the hospital transfer. Review of Resident R1's clinical record revealed a nursing progress noted June 19, 2026, at 6:04 PM documenting the resident was transported to his/her scheduled hemodialysis treatment via medical transport. During the dialysis treatment, the dialysis center notified the facility that Resident R1 had been transferred to the hospital due to left Arteriovenous Fistula complication (An AV Fistula is a surgically created connection between an artery and an and a vein that provides vascular access for hemodialysis. Complicate complications may include clotting, bleeding, infection, poor blood flow or malfunction which can interrupt dialysis treatment and require urgent medical evaluation). The nurse's note further documented that facility staff contacted the hospital and confirmed the resident had been admitted for evaluation and treatment of the left AV fistula. Review of facility documentation revealed Resident R1's representative became aware of the transfer only after arriving at the facility approximately two days later (June 21, 2026) to visit the resident, at which time staff informed Resident R1's representative that the resident had been transferred to the hospital on June 19, 2026. Interview with Nursing Home Administrator, Employee E1, on June 30, 2026, at approximately 10:00 AM revealed he/she was covering the facilities front desk on June 21, 2026, when the Resident R1's representative arrived to visit the resident. Nursing Home Administrator, Employee E1, explained it was at that time when Resident R1's representative was notified the resident had been transferred to the hospital two days ago, on June 19, 2026. Continued interview with Nursing Home Administrator, Employee E1, on June 30, 2026, at 10:00 a.m. confirmed Resident R1's representative was not notified of the resident's hospital transfer prior to his/her arrival at the facility on June 21, 2026. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.12 (d)(3) Nursing services

Based on review of clinical records, hospital records, and staff interviews, it was determined the facility failed to appropriately monitor and notify the physician of repeated critically elevated blood pressure readings and failed to ensure an anti-hypertensive medication was administered as ordered by the physician. This failure resulted in actual harm to Resident R12 who sustained uncontrolled hypertension, transferred to the hospital with a diagnosis of hypertensive urgency requiring hospital admission for one of 30 residents reviewed. (Resident R12)Findings include:Review of Resident R12's quarterly Minimum Data Set (MDS- federal mandated assessment tool) dated December 13, 2025, revealed the resident was admitted to the facility on [DATE]. The MDS identified diagnoses including Stroke (medical condition in which blood flow to a part of the brain is interrupted, resulting in brain cell damage that can affect movement, speech, and cognitive function), Anemia (condition characterized by a reduced number of red blood cells or hemoglobin, leading to decreased oxygen delivery throughout the body and symptoms such as fatigue and weakness), Hypertension (persistently elevated blood pressure, which increases the risk of cardiovascular complications), Renal Insufficiency (decreased kidney function, affecting the body's ability to filter waste and maintain fluid and electrolyte balance), and Hemiplegia (paralysis or significant weakness on one side of the body, commonly resulting from a stroke, and often impacts mobility and the ability to perform activities of daily living). Review of Resident R12's care plan revealed; Resident exhibits or is at risk for cardiovascular symptoms or complications related to the diagnosis of Hypertension. The care plan was initiated on May 7, 2019, and revised on December 30, 2025. The goal (revised April 10, 2024) indicated the resident's blood pressure will remain within baseline parameters. Interventions including administering medications as ordered, assessing for effectiveness and potential side effects, and reporting any abnormalities to the physician, was initiated on May 7, 2019. Additional interventions included assessing and monitoring vital signs as ordered and reporting abnormalities to the physician, initiated on May 7, 2019. Review of Resident R12's physician orders revealed an order to check blood pressure every six hours related to Hypertension, initiated on September 16, 2025. Review of Resident R12's December 2025 physician orders obtained revealed an order for Clonidine HCl 0.1 milligrams (mg) obtained May 1, 2024, to be administered by mouth every six hours as needed (PRN) for systolic blood pressure greater than 150 mmHg and/or diastolic blood pressure greater than 90 mmHg, initiated on May 1, 2024. Review of Resident R12's December 2025 Medication Administration Record (MAR) revealed the following elevated blood pressures readings (normal blood pressure range 120/80) and times. December 1: 168/85 (0000), 159/82 (0600) December 2: 186/82 (0000), 174/69 (0600), 153/77 (1800) December 3: 161/79 (0000), 158/80 (0600) December 4: 165/76 (0600) December 5: 183/90 (0000), 213/87 (1800) December 6: 211/82 (0000), 208/88 (0600) December 7: 178/80 (0000) December 8: 158/76 (1200) December 9: 246/121 (0000) December 10: 152/74 (0000), 156/67 (1200), 161/90 (1800) December 11: 170/80 (0000) December 12: 163/81 (0600), 132/90 (1800) December 13: 177/78 (0000), 153/87 (0600) December 14: 188/80 (0600) December 15: 182/87 (0000) December 16: 205/79 (0000) Review of the above blood pressure readings identified multiple instances in which the resident's blood pressure exceeded the physician ordered parameters. Review of Resident R12's December 2025 MAR (medication administration record) failed to reveal the medication Clonidine HCl 0.1 mg (PRN) was administered as prescribed during those times, despite the readings meeting the criteria for administration. Review of practitioner notes dated December 16, 2025, failed to reveal evidence the practitioner evaluated the effectiveness of the PRN Clonidine HCl 0.1 mg order or made adjustments to either PRN or routine antihypertensive medications in response to the documented elevated blood pressure readings. Review of nursing notes dated December 16, 2025, revealed the resident was transferred to the hospital emergency room. A documented call (by staff) to the hospital confirmed the resident was admitted with Hypertensive Urgency (Hypertensive Urgency is defined by the American Heart Association and American College of Cardiology as a severe elevation in blood pressure, typically a systolic blood pressure of 180 mmHg and/or diastolic blood pressure of 120 mmHg, without evidence of acute target organ damage). Interview with the Director of Nursing, Employee E2 on April 16, 2026, approximately 2:30 p.m. confirmed Clonidine HCl 0.1 mg was not administered as ordered. The Director of Nursing confirmed the physician was not notified despite the resident's multiple elevated blood pressure readings. The Director of Nursing, Employee E2 revealed that although there was no specific physician order requiring notification, the nursing staff should have notified the physician of Resident's E12's elevated blood pressure readings in accordance with professional standards of nursing practice and change in condition. The facility failed to appropriately monitor and notify the physician of repeated critically elevated blood pressures readings and failed to ensure anti-hypertensive medication was administered as ordered by physician. This failure resulted in actual harm to Resident R12 who sustained uncontrolled hypertension and subsequent transfer to the emergency department with a diagnosis of hypertensive urgency requiring hospital admission. 28 Pa. Code 211.2(d)(3)(9) Medical Director 28 Pa. Code 211.9(a)(1) Pharmacy Services 28 Pa. Code 211.10 (a)(c)(d) Resident Care Policies 28 Pa. Code 211.12 (d)(1)(2)(5) Nursing Services

Based on observation and review of facility policy, it was determined that the facility failed to ensure that medications were properly stored and disposed on two of three nursing units. (1st and 3rd floors) Findings include: Review all facility policy titled Medication Storage storage of medication the the January of twenty 6 revealed medication biologicals are stored properly following manufacturers or provider pharmacy recommendations to keep their integrity and to support safe, effective drug administration the medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications.Medications requiring storage at room temperature or captive temperatures ranging from 59 degrees Fahrenheit to 77 degrees Fahrenheit. Controlled room temperature is defined as 68 degrees Fahrenheit 77 degrees Fahrenheit excursions between 59 degrees Fahrenheit to 86 degrees Fahrenheit are layout with transit spikes to 104 degrees Fahrenheit as long as they don't exceed 24 hoursMedications requiring refrigeration or temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit are kept in any refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place may be refrigerated unless otherwise directed on the label as cool temperatures are those between 46 degrees Fahrenheit and 59 degrees Fahrenheit a temperature log or tracking mechanism is maintained to verify the temperature has remained within acceptable limits. The temperature of any refrigerator that stores vaccine should be monitored and recorded twice daily.Insulin products should be stored in the refrigerator until open. Note the date on the label for insulin vials and pens when first used. The open insulin vial may be stored in the refrigerator or at room temperature. Open insulin pen should be stored at room temperature.Refrigerator medications should be kept enclosed and labeled containers, with internal medications separated from external medications and all medications segregated from fruit juices applesauce and other foods used in administering medications. Any other food such as employee lunches and activity department refreshments should not be stored in this refrigerator. The refrigerator should be kept clean and frost free to protect refrigerated medications from freezing stir them away from the freezer section A review of the facility's January 2026 'Medication Storage' policy indicates that medications and biologicals must be stored according to manufacturer or pharmacy guidelines to maintain integrity and ensure safe administration. Access to medications is restricted to authorized personnel. Room-temperature medications are maintained within defined ranges, and refrigerated medications are stored between 36 F and 46 F with continuous temperature monitoring and documentation. Vaccine storage temperatures are recorded twice daily. Insulin is refrigerated until opened, with specific storage guidelines thereafter. All refrigerated medications must be properly labeled, separated by type, and kept apart from food items, with refrigerators maintained in a clean, frost-free condition to prevent contamination or temperature compromise. Observation of 3rd floor medication room accompanied with Licensed nurse, Employee E7 on April 13, 2026, at 9:30 am revealed, the temperature log that records daily temperatures of the refrigerator revealed that the log was dated July of 2025. Inside the medication refrigerator was observed an employee lunch bag, and the following medications: -Novolin insulin dated January 2026 -Lanzapizole dated February 2026-Multi use insulin bottle without no date Observation of the medication storage room on the 1st Floor on April 13, 2026, at 10:40a.m. with Licensed staff, Employee E4, revealed two bottles of Vitamin B12 500 microgram (mcg) with an expiration date of January 2026. Observation of the medication refrigerator on the 1st floor revealed no record of temperature of the refrigerator. The temperature recorded inside the refrigerator at the time of the observation was 39-degree Fahrenheit. Interview with Licensed staff, Employee E4 at the time of the observation confirmed the above findings. 28 Pa Code 211.12(d)(1) Nursing services

Based on observation, clinical record review and staff interview, it was determined that the facility failed to ensure that supervision was provided to one of 30 residents reviewed (Resident R4) and the safe temperature of hot beverages in one of three nursing floors (Third Floor)Findings include: Review of Resident R4's clinical records revealed that the resident was admitted to the facility on [DATE], the diagnoses of Impulse Disorder, Dementia (Progressive cognitive decline), Abnormal Gait/Mobility (Unsteady walking pattern). Review of Resident R4's April 2026 physician orders revealed an order obtained March 1, 2026, for one-to-one supervision, at all times, every shift. Review of the resident's care plan dated March 3, 2026, revealed 1:1 supervision initiated at time of escalation -February 27, 2026. Observation conducted on April 13, 2026, at 10:45 a.m. revealed Resident R4 was alone in the room without any nursing staff present providing 1:1 supervision. Observation conducted on April 14, 2026, at 9:23 a.m. revealed a staff member (Nurse Aide E23) providing 1:1 supervision to Resident R4. Nurse aide, Employee E23 was asked by the surveyor regarding no 1:1 supervision observed on April 13, 2026, at 10:45 am. Nurse Aide, E23 stated there was no staff coverage available at that time. Observation conducted on April 16, 2026, at 9:46 a.m., revealed Resident R4 in the (his/her) room attempting to get out of bed with both legs dangling off the left side of the bed. An individual (Employee E22) was observed attempting to assist the resident by moving the resident's legs from the left side of the bed back to the middle of the bed. On April 16, 2026, at 9:50 a.m., interview conducted with a individual (Employee E22) revealed that she was not assigned as the 1:1 staff for the resident. Employee E22 identified herself as an occupational therapist for the resident's roommate, stated she is employed by an outside company, and stated she attempted to assist the resident because she did not want the resident to fall. Interview on April 16, 2026, 9:52 am, with the Unit Manager (Nurse E4) confirmed the resident required continuous 1:1 supervision and confirmed there was no staff present in the resident's room providing 1:1 supervision at the time of observation on April 13, 2026, at 10:45 a.m. Review of facility hot beverage temperature logs revealed instructions that after preparing a hot beverage, measure and record the initial temperature immediately after preparation. Per the distribution process instructions, hot beverages should be held until the temperature is in range of 120 to 150 degrees Fahrenheit before delivering to the nursing station. Once temperature is within temperature range of 120 to 150 degrees Fahrenheit, the dietary employee will document the delivery temperature, time of delivery, and their signature on the log. Observation in the third-floor dining room on April 15, 2026, at approximately 12:15 p.m. revealed 14 residents were present at the time in the dining room. An activities assistant was observed distributing coffee and cautioned one resident by stating, Careful, it's hot. Visual observation of the coffee showed steam rising from the top of the cup. Interview with the Activity assistant, Employee E20 at the time of the observation revealed that when asked about the coffee temperature, she stated, We don't take the temperature of the coffee. Observations on April 15, 2026, at 12:35 p.m. the Regional Dietary Manager, Employee E16, poured a cup of coffee from the third-floor dining room beverage dispenser and obtained a temperature of 165 degrees. Review of the hot beverage log for April 15, 2026, revealed the lunch coffee delivery temperature was documented as 145 degrees at 11:30 a.m. The log did not specify which floor this was for. Interview on April 15, 2026, at 12:40 p.m. with Dietary Aide, Employee E17, revealed he/she did not check the temperature of the coffee delivered to the third-floor dining room before delivery. Dietary aide, Employee E17, reported the third-floor insulated coffee beverage dispenser was prepared pretty fresh before delivery. Interview on April 15, 2026, at 12:54 p.m. with the Regional Dietary Manager, Employee E16, reported that the coffee brews at 200 degrees Fahrenheit. 28 Pa Code 201.18(b)(3) Management 28 Pa. Code 211,10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, clinical record review, staff interview and review of professional medical information, it was determined that the facility failed to ensure that four of four licensed nursing staff were knowledgeable in stoma/colostomy care. (Employees E5, E6, E7, and E10)Findings include: Review of the National library of Medicine article titled Intestinal Stoma last updated June3, 2023, revealed an intestinal stoma (colostomy or ileostomy) is a surgically created opening of the bowel through the abdominal wall and is a common, often life-saving procedure used to treat conditions such as colorectal cancer, bowel obstruction, and inflammatory bowel disease. Although stomas are common, they are associated with a high rate of complications (10-70%), including infection, retraction, prolapse, ischemia, fistula formation, and fluid/electrolyte imbalances. These complications can significantly impact the resident's health and require ongoing assessment, clinical judgment, and intervention. Care of a stoma is not limited to basic hygiene or appliance changes. Management often requires: Recognition of abnormal stoma appearance and complicationsUse of specialized supplies (barrier systems, rings, powders, advanced dressings)Understanding of bowel function, output changes, and risk of dehydrationTimely clinical decision-making and provider notificationThe literature emphasizes that stoma care requires an interdisciplinary approach, including trained nursing staff and, when needed, wound/ostomy specialists. Both preoperative and postoperative education are critical to ensure safe and effective care and to reduce complications. Review of facility assessment for Resident Population Profile April 10, 2025, through April 9, 2026, revealed 4.4% of admissions/stays include residents with an ostomy (urostomy, ileostomy, colostomy). Interview on April 16, 2026, at 11:40 a.m. with Nurse Practice Educator, Employee E7, revealed a skills fair was held in October 2025 which included a review of ostomy care. Continued interview on April 16, 2026, at 11:40 a.m., Nurse Practice Educator, Employee E7, confirmed Resident R106 had a colostomy. Nurse Practice Educator, Employee E7, was unaware of any special care needs for Resident R106's colostomy. Further interview on April 16, 2026, at 11:40 a.m. with Nurse Practice Educator, Employee E7, revealed there was no process for confirming hands-on skills evaluations for agency nursing staff. Review of facility documentation and staff interview revealed Licensed Nurse, Employee E5, and E10 were agency nurse staff. Licensed Nurse, Employee E6, was hired by the facility in February 2026. Review of facility education documentation revealed no evidence that Licensed Nurse Employee E5, E6, and E10 received any skills competency evaluations to ensure competency of hands-on skills and techniques necessary for colostomy care. Interview on April 16, 2026, at 11:40 a.m. the Nurse Practice Educator, Employee E7, confirmed that no hands-on skills evaluations for Employees E5, E6 and E10 related to colostomy care were available for review at the time of the survey. Review of the Resident R106's Minimum Data Set (MDS- a federal mandated assessment tool for all residents), dated March 16, 2026, revealed the resident was admitted to the facility on [DATE], with a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required supervision or touching assistance with activities of daily living (ADLs) and had diagnoses including colostomy status (a surgically created opening (stoma) in the abdominal wall that allows stool to exit the body into an external pouching system) and polyneuropathy (a condition involving damage to multiple peripheral nerves, which can result in weakness, numbness or decreased sensation, and impaired coordination and fine motor skills). Review of Resident R106 April 2026 physician's orders revealed orders for colostomy care every shift and as needed, monitor stoma for changes and notify physician, and peri-stomal wound care, including cleansing, application of ointment, dressing changes and the antibiotic treatment Clindamycin 300 milligrams. Interview with Resident R106 on April 13, 2026, at 11:20 am, revealed this resident reported having a complex colostomy that (she/he) described as herniated and prolapsed, measuring approximately 6-8 inches, which made management difficult, particularly due to limited hand function. The resident stated that colostomy care typically required assistance from at least one staff member. Resident R106 further reported that staff were inconsistent in both their ability to provide colostomy care. While a few staff members were identified as helpful, the resident stated that only certain staff were knowledgeable in performing colostomy care, and those staff were not consistently available. During interview Resident R106 described that some staff assigned to provide care lacked knowledge of colostomy management, including proper handling of the appliance and overall care needs. Additionally, the resident stated that although she was informed that all nursing staff were trained in colostomy care, this was not reflected in actual care delivery, resulting in difficulty managing the colostomy and reliance on a limited number of available staff. Observation of Resident R106 at time of interview on April 13, 2026, confirmed that the resident had a prolapsed colostomy stoma characterized by a beefy red segment of bowel extending approximately 8 inches beyond the abdominal wall and positioned within a colostomy appliance. Interview with Licensed nurse, Employee E6 on April 14, 2026, at 1:00 p.m., who was the assigned nurse for Resident R106, stated she is competent in changing a colostomy bag but unsure of the technique and additional care required for this resident. Interview with Licensed Nurse Educator, Employee E7 on April 16, 2026, at 2:00 p.m. confirmed that she is responsible for staff education, including colostomy care. She stated that the resident did not require specialty care and that all nursing assistants and licensed nurses have been educated and are competent to provide colostomy care in accordance with professional standards, including care for this resident. Licensed nurse educator, Employee E7 further stated that she is knowledgeable and capable of performing colostomy care. Licensed Nurse Educator, Employee E7 was asked to demonstrate colostomy care for Resident 106. Licensed Nurse Educator, Employee E7 stated that she could provide complete and appropriate care for the resident. However, upon observation on April 14, 2026, at 1:00 p.m. of the resident's stoma, which presented with an unusual appearance, Licensed nurse educator, Employee E7 was unable to proceed with the colostomy care at that time. She stated that she needed to review the resident's medical record and consult additional resources prior to providing care. Licensed nurse educator, Employee E7 subsequently stated that this specific type of colostomy would require additional staff education to ensure proper care and assessment. 28 Pa. Code 201.19(2)(3)(7) Personnel Records28 Pa. Code 201.20(a)(6)(b)(d) Staff Development 28 Pa. Code 201.29(4) Resident Rights28 Pa. Code 211.10(b)(c)(d) Resident Care Policies 28 Pa. Code 211.12(d)(1)(4)(5) Nursing Services

Based on observation and resident interview, the facility failed to ensure that the environment remains free of pest for one on three dining rooms. (3rd floor) Findings include:Interview with Resident 1 on April 13, 2026, revealed concerns regarding the presence of pests in the facility. The resident reported repeatedly observing mice in her room and provided photographic documentation supporting the presence of rodents within the living environment. Interview with Resident 154 on April 15, 2026, at approximately 12:00 p.m. in the third-floor dining room revealed concerns regarding pest activity within the facility. The resident stated that mice are frequently observed throughout the unit and reported that the issue has been ongoing for several months without resolution. The resident further stated that he observed a mouse earlier that day in the dining room under the PTAC (packaged terminal air conditioner) unit. 28 Pa Code 201.18(b)(3)(e)(1)(2.1) Management

Based on review of facility policy, review of facility documentation, review of grievances, and interviews with residents and staff, it was determined that the facility failed to ensure a sanitary, and homelike environment for one of three nursing units (2nd floor) Findings include:During an initial tour of the 2nd floor on April 13, 2026, at 11:15 a.m. there was a strong feces odor in the back hallway. Observations on April 13, 2026, at 11:50 a.m. revealed Resident R93's toilet was covered in feces. Resident R93 reported accidentally making a mess on the toilet overnight. Interview on April 13, 2026, at 11:56 a.m. with nurse aide, Employee E18, confirmed Resident R93's toilet was observed to be covered in feces at the start of his/her shift at 7:00 a.m. Observations on April 16, 2026, at 10:15 a.m. on the 2nd floor revealed meal trays from breakfast (consisting of eggs, and pudding) were left on the counter in the nourishment room. Further observations revealed a hole in the wall behind the sink. 28 Pa. Code 201.18(2.1) Management

Based on review of facility policy, observations, and staff interviews it was determined that the facility failed to maintain infection control practices related to collection and transport of biohazards on one of three nursing units (2nd floor).Findings Include: Review of facility policy Collection and Transport of Specimens revised March 20, 2026, revealed that specimen collection items are kept in a separate area away from food, medications, and other items. Observations on April 13, 2026, at 10:20 a.m. revealed consultant lab tech, Employee E19, was holding a biohazard specimen transport pouch with a vial of blood enclosed in the bag. Lab tech, Employee E19, proceeded to hold the biohazard specimen pouch inside a cooler filled with ice [located at the 2nd floor nurses station] and used the ice scoop to pour ice into the biohazard specimen pouch enclosed with a vial of blood. Interview on April 13, 2026, at 10:20 a.m. surveyor asked lab tech, Employee E19, if this is how he/she should be preparing the vial of blood for transport to which the lab tech, Employee E19, replied it was normal practice. Interview on April 13, 2026, at 10:25 a.m. with Registered Nurse, Employee E7, revealed the cooler of ice was intended to be used for resident drinking water, and subsequently should not be used for blood specimen samples. Registered Nurse, Employee E7, promptly removed the ice chest from the nursing unit. 28 Pa. Code 201.14 (a) Responsibility of licensee.28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of facility policy, review facility documentation, review of clinical records, observations, and staff interviews, it was determined that the facility failed to ensure residents with limited range of motion received treatment and services to maintain or improve range of motion/mobility for one of three residents reviewed with limited range of motion (Resident R93).Findings Include: Review of facility policy Restorative Nursing revised August 7, 2023, revealed restorative programs are coordinated by nursing or in collaboration with rehabilitation and are patient specific based on individual patient needs. Review of Resident R93's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated March 4, 2026, revealed the resident was assessed with a BIMS of 12 and had diagnoses of hemiplegia or hemiparesis (weakness to one side of the body) and malnutrition. Review of Resident R93's comprehensive care plan dated April 10, 2025, revealed the resident was at risk for alterations in comfort related to left side flaccidity and immobility. Interventions dated April 10, 2025, included assist resident to a position of comfort utilizing positioning devices. Review of Resident R93's occupational therapy Discharge summary dated [DATE], revealed Resident R93 was able to wear a resting hand splint on the left hand for up to 4 hours. Review of Resident R93's Restorative Nursing Program Goals dated December 3, 2025, revealed occupational therapy recommended Resident R93 wear a left-hand splint daily for 4-6 hours with skin checks pre and post wearing. Recommendations also included that Resident R93 perform daily upper and lower extremity active range of motion. Further review of Resident R93's Restorative Nursing Program Goals dated December 3, 2025, revealed Registered Nurse, Employee E13, was trained in the procedures for the restorative nursing program and signed and acknowledged the recommendations. Observations on April 13, 2026, at 11:53 a.m. revealed Resident R93 had a contracture to the left hand. On the wall next to Resident R93's bed was a picture of a splint with instructions to apply the splint to the left hand daily and perform skin checks before / after applying the splint. Resident R93 did not have the splint on and reported staff do not apply it. Follow-up observations on April 16, 2026, at 10:15 a.m. revealed Resident R93 was not wearing the splint. Interview on April 16, 2026, at 10:20 a.m. with Director of Rehabilitation, Employee E14, confirmed Resident R93's splint should be applied daily. Interview on April 16, 2026, at 10:25 a.m. with Resident R93's assigned Licensed nurse, Employee E15, confirmed Resident R93 was not wearing the splint. Licensed nurse, Employee E15, reported no physician order was in Resident R93's clinical record for a splint. Continued interview on April 16, 2026, at 10:25 a.m. with Licensed nurse, Employee E15, revealed Resident R93 was going to be referred to therapy to evaluate use and splint and obtain a physician order. Interview on April 16, 2026, at 10:50 a.m. with Director of Rehabilitation, Employee E14, revealed therapy recommended use of a left-hand splint for Resident R93 in December 2025. Per the Director of Rehab, Employee E14, the hand splint was never discontinued by therapy and should have been used daily since December 2025 recommendation. Review of Resident R93's entire clinical record revealed no documented evidence the restorative nursing program recommendations were implemented. There was no documented evidence that Resident R93's splint was applied daily with subsequent skin checks from December 3, 2025, through April 16, 2026. 28 Pa. Code 211.12 (d)(3) Nursing services.28 Pa. Code 211.12 (d)(5) Nursing services.

Based on observation, review of facility documentation, review of facility's policy and residents and staff interviews, it was determined that the facility failed to maintain an effective pest control program to ensure that the building was free of rodents.Findings include: Review of the facility policy titled PM 105 Infection Control Practices indicated that the facility is responsible for maintaining a pest-free environment through the use of a contracted pest control vendor, providing services on a periodic basis (weekly, monthly, or as needed). Review of pest control service reports revealed ongoing and repeated interventions for rodent activity throughout the facility. On April 3, 2026, at 8:00 PM, pest control documentation indicated the placement of two snap traps in the staff bathroom, identification of rodent feces in the corner near vending machines, and capture of a mouse in the maintenance office. Additionally, a mouse was reported in resident room [ROOM NUMBER], prompting placement of rodenticide (Nectus) within the heater area and the setting of two traps along the wall near the heater and television stand. Further review showed that on March 27, 2026, pest control services were performed in the kitchen, resident rooms [ROOM NUMBERS], and the third-floor therapy area due to mouse activity. On March 13, 2026, services were provided across multiple resident rooms (324, 113, 216, and 222) and common areas, including replacement of glue boards and snap traps, indicating widespread and persistent rodent concerns. During interviews conducted on April 7, 2026, at approximately 6:15 PM, two of eight alert and oriented residents (R2 and R4) reported observing mice in their rooms. During an interview with family members of Resident R1 on April 7, 2026, at 6:20 p.m. reported observing mice within the resident's room and provided photographic evidence to support their concerns. They identified structural deficiencies, including holes in the baseboards and near the heating/air conditioning unit, which could allow rodent entry. The family further reported that traps had been placed and subsequently removed along with a deceased mouse, and that the baseboard was later filled. Observations conducted during a facility tour on April 7, 2026, at approximately 6:30 PM revealed evidence of rodent activity on the first floor. In room [ROOM NUMBER], mouse droppings were observed on the floor near the window and on top of the heating/air conditioning unit. In room [ROOM NUMBER], mouse droppings were observed on the floor near bed A, behind the headboard, as well as a hole in the baseboard along the bathroom wall. Interview with first-floor Staff member, Employee E5 on April 7, 2026, at 6:30 p.m. confirmed having witnessed mice on the unit, although the staff member indicated there had been some recent improvement. Observation of the kitchen and dry food storage areas on April 7, 2026, at approximately 7:45 p.m. revealed no visible evidence of rodent droppings, and all food items appeared intact and properly stored. Interview with kitchen staff member, Employee E11 at the of the observation confirmed sightings of mice in the hallway adjacent to the kitchen. Interview with Nurse aides Employee E6, Employee 7, Employee E8 and Licensed staff Employee E9 and Employee E10 on April 7, 2026, at 8:00 p.m. confirmed rodent sightings on those floors, indicating the issue was not isolated to a single area of the facility. 28 Pa. Code 201.18(a)(b)(1) Management 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of clinical records, facility policy, dietary guidelines, and interview with staff, it was determined the facility failed to ensure Resident R369 was provided food items congruent with his/her dysphagia diet. This failure resulted in actual harm to Resident R369 who was able to obtain food items incongruent with his/her dietary restrictions, experienced a choking episode, requiring Cardio Pulmonary Resuscitation (CPR), and transfer to the hospital for one of 33 reviewed (Resident R369). Findings include: Review of the facility provided guidelines, Diet and Nutritional Care Manual Dysphagia Advanced (Level 3) or Mechanical (Dental) Soft Diet revealed This diet is used for individuals with mild oral and/or pharyngeal phase dysphagia. Foods that are difficult to chew are chopped, ground, shredded, cooked, or altered to make them easier to chew and swallow. Food should be prepared according to individual tolerance to the food. Any food that are very hard, sticky, chewy, or crunchy should be avoided . Food allowed Grains (Low-fat as appropriate) well moistened biscuits, breads, muffins, pancakes, waffles, etc. (moistened with syrup , jelly, margarine or butter as appropriate for the diet) . Review of facility policy titled Person-Centered Care Plan, revised on [DATE], indicated the purpose is to attain or maintain the patient's highest practicable physical, mental and psychosocial wellbeing, and to promote positive communication between patient, patient representative, and team to obtain the patient's and resident representative input into the plan of care, ensure effective communication, and optimize clinical outcomes. Review of R369's clinical record revealed the resident was admitted to facility on [DATE], with medical history of Vascular Dementia (progressive degenerative disease of the brain), Schizophrenia (mental disease characterized by loss of reality contact), Dysphagia (difficulty swallowing), Anxiety, contracture of left upper extremity, Stroke, and behavioral disturbances. Review of Resident R369's annual Minimum Data Set (MDS- assessment of resident's needs), dated February 6, 2025, indicated the resident was assessed with short and long term cognitive impairment, the resident had poor appetite or overeating and required set up with eating. Review of Resident R369's care plan initiated [DATE] revealed I am at risk for impaired swallowing related to CVA (cardio vascular accident-stroke). Interventions included a dysphagia puree, nectar thick liquids set up supervision all meals. Encourage resident to be seated with other residents who have a similar diet consistency when food is being served. Provide assistance during all meals. Resident will be at 90 degrees upright position/out of bed when swallowing food or drink. Encourage small sips/bites and cue as needed (inititiated [DATE]). Monitor for sign/symptoms of aspiration i.e. coughing,watery eyes, choking, moist sounding voice, daily lung checks (inititiated [DATE]) and if coughing occurs no food or liquids until coughing resolves. Continued review of Resident R369's care plan revealed a care plan inititiated [DATE] for restorative swallowing. [Resident R369] demonstrates difficulty with swallowing CVA with interventions developed as the resident to consume meals safely without signs and symptoms of aspiration. Continued review of the resident's care plan revealed care plan developed on [DATE], for the resident exhibiting or had the potential to exhibit physical behaviors related to cognitive loss/dementia. Interventions updated on February 18, 2019, included for the resident to maintain a safe distance from other residents during group activities and resident was not to eat meals within arms length of other residents. Review of Resident R369's speech therapy discharge recommendations, completed by speech therapist, Employee E8, on [DATE], at 10:34 a.m., revealed under strategies slow rate of intake, small bites/sips, alternate solids/liquids. Review of Resident R369's [DATE] physician orders revealed an order for advanced dysphagia and nectar thick liquid diet. Review of Resident R369's clinical record revealed that on [DATE], at 3:15 p.m., in dining room on first floor unit, Resident R369 showed signs and symptoms of choking. The Heimlich maneuver (first aide method for choking) was initiated and expelling bolus of undigested and unidentified food. Upon further assessment, resident became pulseless, and CPR (Cardio Pulmonary Resuscitation) was initiated. Review of Resident R369's investigation report dated [DATE], confirmed the resident was in the dining room for an Easter event, received a snack per the resident dysphagia advanced diet, with resident then impulsively grabbed a snack from a tray which was being passed to other residents. Resident began to choke, staff present in the dining room responded. The nurse aide called for nurses and nurses started Heimlich, a code was called and the nursing staff continued CPR and Heimlich. Pulse was 68 BPM (beats per minute - normal pulse 60 to 100 beats per minute) to no pulse and 78% SPO2 (saturation oxygen rate- normal 95%-100%). EMS (Emergency Medical services) was called and responded and were able to get a pulse and obtained blood presure. The EMS took the resident to the ER (emergency room ). Review of written statement of nurse aide, Employee E11 revealed I came into the dining room around 3:15PM. We had special snacks for the resident for the holiday. I had a tray of hot dogs, about ,d+[DATE] inch long, that I was passing around for the resident. I knew [Resident R369] was not able to get them so I gave [resident] an Oatmeal Cream Pie. [Resident] ate it. As I passed (his/her) seat, (he/she) grabbed a small hot dog from the tray and shoved it down (his/her) mouth. I did not leave the tray unsupervised and I did not take my eyes off it. He started making a noise like (he/she) was choking. I immediately tried to open (his/her) mouth and take it out but (he/she) fought me and refused to open (his/her) mouth but I got it open and I placed my finger inside (his/her) mouth and removed about ,d+[DATE] inch piece of the hot dog. I yelled to the nurse who was also in the DR (dining room) with me. Review of Resident R369's hospital documentation dated [DATE], revealed patient was intubated on the scene by EMS (Emergency Medical Services), and they noted copious amount of food in patient's airway. Patient underwent ,d+[DATE] minutes of ACLS (cardiovascular life support), received epinephrine x 2, and return of spontaneous circulation (ROSC) was achieved. Further review of hospital documentation revealed resident presented with status post out of hospital cardiac arrest secondary to aspiration of food, acute respiratory failure on vent secondary to above, bilateral pneumonia (an infection of the airsacs in one or both lungs) secondary to above, rib fractures on the left secondary to CPR . Review of hospital dietitian/nutrition documentation, dated [DATE], indicated Resident R369 presented to hospital after choking, cardiac arrest at nursing home. Pt (patient) was intubated at scene, large food bolus removed during intubation. Interview with Licensed nurse, Employee E10, on [DATE], at 10:40 a.m., revealed that she was one of the nursing employees who responded to the code on [DATE], during Resident R369's choking incident. Per Employee E10's statement - during intubation process, a mushy white creamy and brownish substance was expelled. Employee E10 further stated the food substance did not have consistency of hot dog and that she was not made aware of this resident choking on a hot dog. Further interview with Licensed nurse, Employee E10 revealed Resident R369 has a history of eating too fast and impulsively grabbing food from other residents' meal trays. The facility failed to ensure Resident R369 was provided food items consistent with his/her dysphagia diet. This failure resulted in actual harm to Resident R369 who was able to obtain foods inconsistent with dietary restrictions, and care plan interventions who then experienced a choking episode requiring CPR, and transferred to the hospital for evaluation and treatment (Resident R369). 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(c)(d)(1)(3) Nursing services

Based on observations, interview with staff and review of facility provided documentation, it was determined that facility did not ensure to maintain infection control and prevention practices on one of three units observed (1st floor unit) Findings include: Review of facility policy 'Standard Precautions,' revised on May 1, 2024, instructs employees to handle, transport, and process soiled, used linen in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and avoids transfer of microorganisms to other individuals and the environment. Review of facility policy 'Enhanced Barrier Precautions, (EBP's) revised on December 16, 2024, indicates that EBP's are an infection control intervention designed to reduce transmission of novel or multi-drug-resistant organisms. It employs targeted personal protective equipment (PPE) use during high- contact patient/resident activities. Observations on 1st floor unit, on Wednesday, April 30, 2025, at 9:30 a.m., revealed nurse aide, Employee E6, collected soiled personal laundry from residents' in room [ROOM NUMBER], and transferred soiled personal belongings in three mesh bags by dragging the bags on floor of the unit's hallway to soiled utility room. Review of Resident R8's clinical record on Wednesday, April 30, 2025, revealed a [AGE] year old resident with history of colonized methicillin - resistant staphylococcus aureus (MRSA) and is at risk for sepsis. Review of R8's care plan, revised on February 12, 2025, further revealed interventions for EBP's; Use gown and gloves when performing high-contact activities: dressing, bathing and showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of a device (e.g.central line, urinary catheter, feeding tube, tracheostomy, or ventilator), wound care (any skin opening requiring a dressing) Observations on 1st floor unit, on Wednesday, April 30, 2025 at 9:15 am, revealed EBP sign in place in Resident R8 without PPE available to staff. Findings confirmed with units charge nurse, Employee E4 at thet time of the observation. 28 Pa Code 211.10(d) resident care policies 28 Pa Code 211.12(d)(5) nursing services

Based on interview with staff and review of facility provided documentation, it was determined facility did not notify Long Term Care State Ombudsman of facility-initiated discharges for two of six months reviewed. (November 2024 and December 2024) Findings include: Review of facility policy 'Discharge and Transfer,' revised on March 24, 2025, indicates that copies of notices for emergency transfers must also be sent to the ombudsman, but they may be sent when practicable, such as in a list of patients on a monthly basis or per state requirements. Review of facility provided documentation revealed that facility's Social Services, Employee, E9, e-mailed long term care ombudsman on February 3, 2025 at 12:15 pm - forwarding monthly discharges from November 2024 - January 2025 stating I have been sending the discharges to another e-mail address which kept bouncing back. Review of e-mail response from Long Term Care Ombudsman on February 3, 2025, at 12:24 pm, revealed that only January 2025 and February 2025 notices are acceptable at this point and anything earlier, there's not much we can do for the resident. Please forward notices on monthly basis. 28 Pa Code 201.14(a)Responsibility of licensee 28 Pa Code 201.18(b)(2)Management

Based on review of clinical records, staff and resident interviews, it was determined that the facility failed to provide culturally competent, trauma informed care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for one of 33 residents sampled (Resident R 73) Findings include: A review of the clinical record revealed that Resident R73 was admitted to the facility on [DATE], with diagnoses panic disorder (episodic paroxysmal anxiety), anxiety disorder, major depressive disorder (loss in pleasurable activities), post-traumatic stress disorder (PTSD), dementia (progressive defenerative disease of the brain), psychotic disturbance, mood disturbance and anxiety. Interviewed with Social Worker, Employee E12 on May 2, 2025, at 11:47 a.m., revealed that the Resident R73's PTSD triggers is unknown by facility. Resident R73's current care plan on February 3, 2025, revealed a care plan for PTSD. Further review of the care plan did not address resident's actual diagnoses/condition of PTSD, identifying the resident's past experiences and possible triggers that may cause re-traumatization. Interview with the Social Worker, Employee E12, on May 2, 2025, at 11:50 a.m. confirmed that Resident R73 care plan for PTSD did not include resident's actual diagnoses/condition of PTSD, identifying the resident's past experiences and possible triggers that may cause re-traumatization. 28 Pa. Code 211.12(c)(d)(3)(5) Nursing services

Based on observations of care and services, clinical record reviews, and interviews with staff, it was determined that the facility failed to ensure that a physician's order was obtained, for the use of resident care adapted equipment for one of two residents reviewed. (Resident R151) Findings iclude: Review of Resident R151's quarterly Minimum Data Set (MDS- assessment of resident's needs) dated April 22, 2025 revealed that the resident only sometimes responded adequately to simple directions and had severe cognitive impaired. Continued review of the MDS revealed that the resident was functionally impaired on one side with the upper body extremity (shoulder, elbow, wrist and hand) and totally dependent on staff assistance for eating, personal hygiene and putting on and taking off foot wear. Clinical record review indicated that Resident R151 had diagnoses that included: left hemicraniectomy (brain surgery that removes part of the brain to reduce swelling), left sided hemiplegia (weakness to one side of the body) and aphasia (difficulty speaking and trouble understanding). Observations of Resident R151 throughout the days of the survey April 29, 30 and May 1, 2025 revealed that this resident was resting in bed. Observations with Employee E4, licensed practical nurse at 10:30 a.m., on May 2, 2025 of Resident R151's wardrobe and personal belongings confirmed resident care equipment of a (helmet with a buckle chin strap). Review of Resident R151's clinical record revealed that there was no documentation to indicate that the nursing staff obtained a physician's order for the use of adaptive resident care equipment (helmet with [NAME] chin strap) for Resident R151, when she was out of bed to the wheel chair. Interviews with licensed practical nurse, Employee E13 at 10:00 a.m., on April 30, 2025 revealed that Resident R151 wears a helmet when out of bed sitting in the wheel chair. This nurse reported that nursing staff will apply the helmet to the resident's head and secure the chin strap. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)Nursing services

Based on clinical record reviews, interviews with staff and reviews of policies and procedures, it was determined that the interdisciplinary care team failed to update or revised the care plan for activities of daily living for one of two residents reviewed. ( Resident R90) Findings include: Review of the policy titled Center Policies and Operations revealed that it was the interdisciplinary care teams' responsibility to revise and implement a care plan for each resident. The care plan was developed for each resident to attain their highest practicable physical, mental and psychosocial well being. The care plan for each resident was to indicate any services and treatments to be administered for the resident to achieve measurable goals of care. Clinical record review for Resident R90 revealed a quarterly assessment dated [DATE] that indicated this resident was cognitively impaired, and had bilateral upper and lower extremity impairments. The assessment indicated that this resident used a wheel chair for mobility and required maxium assistance provided by staff, for transfers from the chair to the bed and bed to the chair. Interview with the licensed practical nurse, Employee E4 at 11:00 a.m., on May 1, 2025 revealed that Resident R90 had been refusing to get out of bed for a shower or to participate in activities over the last three months. The licensed practical nurse, Employee E4 also mentioned during the interview that Resident R90 has a sister who lives in the facility on the third floor. The licensed practical nurse was planning to invite his sister to a group activity where both resident would be out of bed and socializing with each other as they did in the past. A review of Resident R90's activities of daily living care plan revealed that it was dated February 24, 2025. through March 3, 2025. Resident R90 had no current care plan revision and implementation to reflect a care plan for resident participation in activities and for refusal of showers. Interview with the Director of Nursing, Employee E2, at 10:00 a.m., on May 2, 2025 confirmed the lack of care planning for Resident R90. 28 Pa. Code 211.10(d) Resident care polices 28 Pa. Code 211.12 (c)(d)(1) Nursing services

Based on interview with resident and staff, review of facility provided documentation, and review of clinical record, it was determined that facility did not provide reasonable accommodations related to phone services for one of 33 residents reviewed. (Resident R149) Findings include: Review of facility policy 'Resident Right's: Role of Social Services,' revised on February 16, 2024, indicates that purpose of policy is to assure that patient's personal dignity, psychosocial well-being, and self-determination are maintained. Review of Resident R149's Minimum Data Set, completed on February 6, 2025, indicates that resident's BIMS (Brief Interview for Mental Status) is score 8. Review of R149's clinical record, on Wednesday, April 30, 2025, revealed medical history of Alzheimer's disease (progressive degenerative disease of the brain), fluency disorder (trouble speaking in a fluid or flowing way), depression (major loss of itnerest in pleasurable activities), and cognitive communication deficit. Interview with Resident R149 on Tuesday, April 29, 2025, at 11:30 am, revealed that she was not able to make or receive calls from phone in her room provided by facility. Observations of Resident R149's room environment revealed no evidence of instructions or reminders on how to accurately dial a phone number. Interview with Resident R149's nurse aide, Employee E5, on April 29, 2025, at 11:50 am, revealed that #9 is to be dialed prior to dialing phone number and that her reminder post was most likely taken off by resident. Interview with Resident R149 on Wednesday, April 30, 2025, indicated continuous concern that resident was unable to receive phone calls. Per interview with Resident R149's charge nurse, Employee E4, on Wednesday, April 30, 2025, as well as review of facility provided documentation - it was revealed that inaccurate phone number was assigned to Resident's R149 room phone. 28 Pa Code 201.29(a)Resident Rights 28 Pa Code 211.10(d)Resident care policies

Based clinical record review, review of facility policy and staff interview, it was determined that the facility failed to timely identify, assess, and provide pressure ulcer treatments to one of three residents (Resident R22), which resulted in actual harm to Resident R22, who developed a facility acquired Stage 4 pressure ulcer on the left gluteal fold/thigh. Findings include: Review of facility Policy entitled Skin Integrity and Wound Management with effective date: July 1, 2001, and review and revision date of September 1, 20212, revealed the following: The facility staff will continually observe and monitor patients for changes and implement revisions to the plan of care as needed. The purpose of the policy is to provide safe and effective care to promote optimal skin health, prevent pressure injuries, and promote healing to the context of what matters most to all patients. Practice Standards included: Complete risk evaluation on admission/re-admission, weekly for the first month, quarterly, and with significant change in condition Identify patient's skin integrity status and need for prevention or treatment interventions through review of all appropriate assessment information. The Nursing Assistant will observe the skin daily and report any changes or concerns to the nurse. The licensed nurse will: Evaluate any reported or suspected skin changes or wounds; perform and document skin inspection on all newly admitted /readmitted patients weekly thereafter and with any significant change in condition Review of Resident R22's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of Pressure Ulcer of the Sacral Region Stage 4 (ulcer involving loss of skin layers, exposing muscle and bone), Complete Paraplegia (paralysis of the legs and lower body), Neural/Neuritis Unspecified, Unspecified Osteo arthritis/unspecified site, Obesity and Generalized Muscle Weakness. Review of Resident R22's Admission MDS (MDS-Minimum Data Set (a federally required resident assessment completed at a specific interval), dated October 17, 2022, revealed that the resident was assessed with a BIMS (Brief Interview of Mental Status) Score of 15 which indicated that Resident R22 was cognitively intact. Further review of the MDS revealed that the resident required extensive assistant of two person with bed mobility and transfer. The resident was identified with impairment of range of motion on both left and right lower extremities. Review of Resident R22's admission orders revealed that treatment order dated October 15, 2022, was in place for the Stage 4 sacral pressure ulcer present on admission as follows: Negative Pressure Wound Therapy (NPWT) to sacral, set unit to 125 mmHg continuously, cleanse with wound cleanser, place gauze/black foam/ into wound, apply skin prep to intact skin around the wound, cover with occlusive dressing and secure tubing per manufacturer guide every 72 hours and as needed. If NPWT needs to be turned off for any care, tests/procedures (Bathing, MRI, etc), or for transport; remove dressing entirely, cleanse wound (Normal Saline Solution/Skin Integrity) and apply hydrogel gauze and secure with ABD. Change Negative Pressure Canister every day shift every 7 day(s) and as needed. Review of Resident R22's care plan dated October 15, 2022, revealed that Resident R22 was at risk for skin break down related to actual skin breakdown (sacral pressure ulcer). The interventions included to observe skin for signs and symptoms of skin breakdown example: redness, cracking, blistering, decrease sensation, skin that does not blanche easily. Review of Resident R22's nursing note dated November 2, 2022, revealed a nursing assessment indicating a stable pressure wound Stage 4 present on admission Location: Sacrum was assessed today (November 2, 2022). Prognosis: Slow to Heal: wound healing is slow or stalled but stable, little/no deterioration. Nurse's notes date November 4, 2022, revealed that wound dressing was re-enforced, wound vac container was changed, brownish drainage was draining. Nurse will continue monitor. Nurse's note dated November 5, 2022, at 10:40 p.m. revealed at a skin check was performed with no other open skin areas documented. Nurse's note dated November 7, 2022, at 2:32 p.m., revealed a new pressure wound Stage 4 in-house acquired on the Left Thigh (Rear) was assessed and the resident's physician was notified. Nurse's note dated November 7, 2022, at 2:43 p.m. revealed that the resident's right Thigh (Medial) was assessed and the physician was notified. Review of Wound Evaluation dated November 7, 2022, revealed the following information: Stage 4 pressure ulcer, Body location-Left thigh (rear), New-(minutes old), in-house acquired, Dimensions: length- 5.17 cm, width-3.17 cm, area-12.41 square cm. No depth of the wound was documented. Further, the wound evaluation revealed that the wound bed had one hundred percent epithelial tissues, no infection and bleeding was noted, there was moderate sanguineous (bloody) exudate, peri-wound edges were attached with no induration or edema was noted. Further review of Resident R22's November 2022, physician order revealed that there was no treatment order specific to the facility acquired pressure ulcer on the left gluteal fold/thigh at the time that the pressure ulcer was identified on November 7, 2022. Physician order dated November 8, 2022, at 6:05 p.m. revealed a treatment order to clean with Vashe apply Maxorb cover with border dry dressing, in the evening to clean with Vashe apply Maxorb cover with border dry dressing. This order did not indicate the site and type of wound the treatment was for. Continue review of physician orders revealed that it was not until November 14, 2022, that a treatment order was obtained for the Stage 4 left gluteal fold/thigh. The order was to cleanse left gluteal fold/thigh with Vashe, pat dry, apply Maxorb, cover with border dry dressing in the evening and as needed for soilage. Review of Resident R22's November 2022 Treatment Administration Record (TAR) revealed a treatment to clean with Vashe and apply Maxsorb cover with border dry dressing was completed on November 8, 2022, and was discontinued on November 10, 2022. The treatment order did not specify the type of wound and site but was initialed by nursing staff as completed on November 8, 2022, and November 9, 2022. Continued review of resident R22's TAR revealed that there was no treatment specific to the facility acquired left gluteal fold Stage 4 pressure ulcer from November 7 through November 14, 2022, a period of 8 days. Surveyor attempted to observe the resident's wounds but observations were unsuccessful as the resident refused to be observed. Interview with Licensed nurse, Employee E20 revealed that she discovered Resident R22's left gluteal area Stage 4 pressure ulcer on November 7, 2022. Licensed nurse, Employee E20 described the left gluteal pressure ulcer when it was first discovered on November 4, 2022, as being covered by a hard dark brownish material. Interview with Director of Nursing, Employee E2 conducted on November 14, 2022, at 4:08 p.m. revealed that the facility did not have a policy specific to wound assessment, staging and measurement. The facility failed to timely identify, assess and provide pressure ulcer treatment to Resident R22 who was assessed at high risk for pressure ulcer development, which resulted in Resident R22 developing a Stage 4 left gluteal fold/thigh. 28 Pa. Code 211.18(b)(1) Management 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on observation, resident interview, review of facility policy, clinical record review, review of facility documentation and staff interviews, it was determined that the facility failed to ensure an environment free of accident hazards and failed to provide adequate monitoring and supervision for two of 28 residents reviewed causing actual harm to one resident (Residents R21 and R20). Findings include; Review of Resident R21's history and physical dated September 21, 2015, revealed [DIAGNOSES REDACTED]. Review of Resident R21's annual Minimum Data Set assessment (MDS- an assessment of resident care needs) dated March 22, 2016, revealed that the resident was cognitively intact, used a wheelchair for mobility, required extensive assisstance of one staff for transfers, dressing, hygiene, and bathing and had impaired mobility to both upper extremities (shoulder, elbow, wrist, hand). Review of information dated April 3, 3016, submitted by the facility revealed that Resident R21 was noted with an intact blister (unbroken skin over a blister). The facility documentation indicated that the resident had used a microwave to heat a personal supply of soup and Resident R21 had spilled some of it on the forearm causing the blister. Following Resident R21's injury all of the pantries in the building were issued a pad lock on the doors to limit access and signs were placed to advise families and visitors to alert staff if a microwave was needed. The facility Medical Director stated in a physcian's progress note dated April 4, 2016, that Resident R21's left forearm was examined for first degree (burn affecting the outer layer of skin) and second degree burns (burn that extends into some of the underlying tissue) that measured 10 centimeters by 4 centimeters (4 inches by 1 1/2 inches). Employee E16 reported in a statement (undated) obtained by the facility regarding the event that Resident R21 was observed opening the pantry door, that the resident had water in a bowl with packaged noodles in it, that Resident R21 wanted to cook it, that Employee E16 microwaved the bowl then set the resident up in the dining room with it. Review of a, Root Cause and Conclusion regarding the incident dated April 3, 2016, revealed that, All staff were to receive in-servicing on not heating food for residents and going through dietary services for proper heating. In addition, it stated that, All pantries pad locked for microwave use, residents will need to request assistance and the dietary department will heat all of the facility food. Observation of the first floor nursing unit pantry during the initial tour and on all days of the survey revealed that the door was unlocked with no padlock or other device to secure it, that a microwave was on the counter and within reach for residents to use. The Director of Nursing (DON) stated in an interview on September 23, 2016, that the padlock had been broken by a resident who wanted to use the microwave, that it was not replaced and that the residents have the right to use the microwave. The DON stated that the staff are not allowed to heat or reheat food for residents in the microwave and that dietary staff are not allowed to reheat food not prepared in the facility kitchen. Review of facility policy titled, Smoking revised on April 1, 2015, stated that, smoking supplies (tobacco, matches, lighters, lighter fluid, ect) will be labled with the patient name, room number, bed number, maintained by staff and stored in a suitable cabinet kept at the nursing station, patients will not be allowed to maintain their own lighter fluid or matches. Review of Resident R20's clinical record revealed physcian's progress notes for September 22, 2016, that indicated Resident R20 was [AGE] years old, had [DIAGNOSES REDACTED]. Observation of the resident on September 22, 2016, at 2:15 p.m. revealed the resident seated in a wheelchair next to the bed. Two opened packages of cigarettes were observed on the bed. In an interview at that time the Resident stated that, I am [AGE] years old and I can smoke if I want the resident was then observed to remove a cigarette lighter from a purse. The Nursing Home Administrator stated in an interview on September 22, 2016, at approximately 4:30 p.m. that the staff are supposed to collect the cigarettes and lighters from the residents as they come back into the building from smoking outside. The facility failed to ensure an environment free of accident hazards and failed to provide adequate monitoring and supervision to prevent injury and to ensure the safety for two of 30 residents resulting in actual harm to one resident (Resident R21). 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 09/23/14, 08/04/15 28 Pa. Code 201.18(a)(b)(3)(e)(1)Management 28 Pa. Code 201.18(b)(1) Management Previously cited 09/23/14, 08/04/15 28 Pa. Code 211.10(d) Resident care policies