Every finding on record at Holland Center for Rehabilitation and Nursing

Based on review of clinical record, observations, and staff and resident interviews it was determined that the facility failed to provide appropriate equipment necessary to promote and maintain out-of-bed mobility and participation in activities of daily living (ADL) for one of one resident reviewed (Resident R1). Findings Include: Review of the facilities Facility Assessment last updated July 15, 2026, revealed that the facility identified activities of daily living including bathing and showering, and mobility and transfers as care needs of its resident population. The assessment indicated the facility would assess and provide adaptive equipment and or techniques necessary to support residents with these needs. Further review of the facility assessment under physical equipment revealed that the facilities identified wheelchairs associated positioning devices, bariatric beds, bariatric wheelchairs, lifts and lifts slings as physical resources necessary to provide care to its resident population. Review of the resident R1's clinical record revealed that the resident was admitted into the facility on July 7, 2026, with diagnoses that include hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) followed a cerebral infarction(stroke) affecting the right dominant side, generalized muscle weakness, lack of coordination and difficulty walking. Review of resident R1's care plan initiated on July 8, 2026, revealed the resident has reduced balance, strength, and activity tolerance with reducibility to perform functional mobility and activities of daily living, placing the resident at risk for falls. The established goal was for Resident R1 to demonstrate increased strength, improve balance, increased activity tolerance, and safe functional mobility and ADL (activities of daily living) performance. Interventions included Hoyer lift transfers (mechanical patient lift to safely transfer a patient who cannot independently stand, bear weight, or safely transfer between surfaces) with assistance of two to four caregivers, skilled physical and occupational therapy, therapeutic exercises and activities, neuromuscular reeducation, self-care management, activity tolerance training, and wheelchair management. Review of the physical therapy evaluation and plan of treatment, with a start of care dated of July 8, 2026, revealed resident R1 was referred to physical therapy due to decreased strength, functional mobility, transfers, range of motion, ability to safely ambulate, balance, and functional activity tolerance. The treatment plan included wheelchair management training 3 to 6 times per week. A short-term goal was established for Resident R1 to safely propel a manual wheelchair 15 to 25 feet to improve upper body strength and cardiorespiratory endurance. The baseline assessment documented that a custom wheelchair was not available for the initial assessment. Review of physical therapy note dated July 20, 2026, revealed Resident R1 was seen in a supine position in bed, Resident R1 declined to participate in therapy as resident was upset due to not getting out of bed. Appropriate wheelchair is not available at this time for Resident R1 to use or get out of bed safely. Review of Occupational Therapy treatment note dated July 27, 2026, revealed Resident R1 was very upset because he/she did not have his/her wheelchair yet. The therapist discussed the process of obtaining the wheelchair with the resident. Resident R1 became aggravated yelled and declined to participate in the full therapy session. Interview with resident R1 and his/her family member on August 13, 2026, revealed Resident R1 has not received a shower since admission and received bathing care in bed. Interview with Director of Nursing, Employee E2, on August 13, 2026, confirmed Resident R 1 has not received a shower and stated the resident was considered a bed bath because Resident R1 could not safely utilize the shower chair or shower bed. Interview with physical therapy director, Employee E3, on August 13, 2026, revealed Resident R1 was not appropriate for shower chair because of the resident's extended leg could not bend significantly to permit safe positioning. However, Physical Therapy Director, Employee E3, stated resident R1 was appropriate for the shower bed and the recommendation had been communicated to the nursing staff. Further interview with the Director of Nursing (DON), Employee E2, on August 13, 2026, revealed the shower bed was not utilized because resident R1 allegedly exceeded its allowable weight capacity. When asked to identify the showers bed weight limit, the DON was unable to do so or provide documentation demonstrating that Resident R1 exceeded the manufacturer specified capacity. The facility failed to ensure adaptive equipment was available to meet Resident R1's assessed ADL and mobility needs despite identified needs for wheelchair mobility and specialized bathing equipment. The resident remained without appropriate seating for several weeks and was not afforded bathing using a shower bed that therapy determined was appropriate. 28 Pa. Code 201.14 (a) Responsibility of licensee. 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 facility documentation, review of clinical records, and staff interviews it was determined that the facility failed to ensure a complete and thorough investigation was completed for allegations of potential abuse and neglect for 1 out of 2 residents reviewed (Resident R1). Findings include: Review of the facility policy, Abuse Prevention Program, with a review date of 11/30/22 indicated that all abuse neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported . and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.Review of Resident R1's May 2026 physician orders included the following diagnoses: atrial fibrillation (irregular heart rhythm which can cause fatigue, heart palpitations, shortness of breath, and dizziness), high blood pressure, osteoarthritis (aging and wear and tear on a joint); acute pulmonary edema (fluid accumulation in the lungs); chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe); and diabetes (the body's impaired ability to regulate blood sugars).Review of Resident R1's Comprehensive Minimum Data Set (MDS- a periodic assessment of a resident's needs) dated March 18, 2026, indicated that the resident was awake, alert and oriented.Review of Resident R1's clinical notes indicated that the resident was admitted into the facility on March 11, 2026, for rehabilitation services, and discharged to the hospital on May 2, 2026.Review of information submitted to the State Survey Agency on May 12, 2026, revealed on May 11, 2026, the facility was made aware of the following concerns regarding the care and services provided for Resident R1: missed doses of eyedrop for treatment of glaucoma (eye damage that can cause vision loss); wrong medications ordered; ineffective pain management; edema care not provided; not getting incontinence care in a timely manner; staff attitude; staff rough during care; closet door with missing hinges; and no management of Resident R1's atrial fibrillation.Review of the facility's investigation regarding the above referenced concerns did not show evidence that Resident R1 and/or the complainant were contacted for further information that may be needed for the investigation in an attempt to establish possible dates/times, names of staff and other details to ensure that a complete and thorough investigation was completed regarding the alleged allegations.In this investigation, the facility determined that Resident R1's eye drops were given and that the resident did not miss a dose, and that this allegation was unsubstantiated. However, a review of Resident R1's clinical record indicated that the medication Azopt Ophthalmic Suspension 1% (Brinzolamide), for the treatment of glaucoma, was not marked as administered in the Medication Administration Record (MAR) on March 21, 2026, at 9:00 a.m. and March 21st at 2:00 p.m., as ordered by the physician. Continued review Resident R1's MAR did not show evidence that the medication Latanoprost 0.005 % Solution, for the treatment of glaucoma, was administered on March 31, 2026, at 21:00 (9:00 p.m.), as ordered by the physician.Continued review of the facility investigation did not show evidence that the facility contacted Resident R1 and/or the complainant for an interview regarding the alleged incidents (wrong medication given, delay in pain management, not assisted with incontinence care, rude staff) to see if a date/time/medication/ description and or name of staff members could be determined to ensure and complete and thorough investigation regarding the allegations was completed.During a discussion with the Director of Nursing (DON), Employee E2, on May 29, 2026, at 2:47 p.m., it was discussed that there was no evidence that the facility contacted Resident R1 and/or the complainant to see if they can provide additional details regarding the allegations that could assist the facility in a conducting a complete and thorough investigation regarding concerns related to care and services. During the discussion the DON, Employee E2, reported that she has never contacted residents or complainants regarding any of their concerns after they have left.28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on interviews with staff, and clinical record reviews, it was determined that the facility failed to ensure that clinical records were accurately documented for 4 of four residents reviewed. (Resident R20, Resident R27, Resident R34, Resident R61) Findings include:Review of facility policy titled, Administering Medication, revised April 2020, revealed As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered; b. the dosage; c. the route of administration; d. the injection site(if applicable); e. any complaints or symptoms for which the drug is administered; F. Any results achieved and when those results were observed; and g. the signature and title of the person administering the drug.Review of Resident R20's clinical record revealed resident was admitted to the facility on [DATE], with diagnosis of need for assistance with personal care, rheumatoid arthritis.Review of Resident R20's physician orders revealed order for Oxycodone 10mg 1 tablet by mouth every 6 hours as needed for pain.Comparison of Resident R20's Individual Narcotic Record and Medication Administration Record, between the dates of April 4, 2026, through April 30, 2026, revealed according to individual Narcotic Record resident R20 received the medication four times and there is no evidence of administration in the resident's medication administration record. Dates include the following:April 2, 2026, at 10:30 p.m.April 3, 2026, at 4:30 a.m.April 4, 2026, at 9:00 p.m.April 7, 2026, at 6:00 p.m.Review of Resident R27's clinical record revealed resident was admitted to the facility on [DATE], with diagnosis of pneumonia, chronic pain syndrome.Review of Resident R27's physician orders revealed order for Oxycodone 15mg tablet by mouth every 6 hours for severe pain 7-10Comparison of Resident R27's Individual Narcotic Record and Medication Administration Record, between the dates of April 5, 2026, through April 29, 2026, revealed according to individual Narcotic Record resident R27 received the medication fourteen times and there is no evidence of administration in the resident's medication administration record. Dates include the following:April 7, 2026, at 9:00 a.m.April 9, 2026, at 9:00 p.m.April 15, 2026, at 1:50 p.m.April 15, 2026, at 10:00 p.m.April 16, 2026, at 9:00 p.m.April 19, 2026, at 10:06 a.m.April 21, 2026, at 3:00 a.m.April 21, 2026, at 8:00 p.m.April 22, 2026, at 10:00 p.m.April 23, 2026, at 11:00 p.m.April 24, 2026, at 9:00 p.m.April 25, 2026, at 4:00 a.m.April 26, 2026, at 2:00 a.m.April 29, 2026, at 2:00 p.m.Review of Resident R34's clinical record revealed resident admitted to the facility on [DATE], with diagnosis of, Lack of coordination, muscle weakness.Review of Resident R34's physician orders revealed order for Oxycodone- Acetaminophen tablet 5-325mg give 1 tablet by mouth every 6 hours as needed for pain (5-10).Comparison of Resident R34's Individual Narcotic Record and Medication Administration Record, between the dates of April 8, 2026, through April 30, 2026, revealed according to individual Narcotic Record resident R34 received the medication eighteen times and there is no evidence of administration in the resident's medication administration record. Dates include the following:April 12, 2026, at 12:10 a.m.April 12, 2026, at 06:32 a.m.April 13, 2026, at 1:10 a.m.April 13, 2026, at 2:45 a.m.April 15, 2026, at 1:00 p.m.April 16, 2026, at 10:30 a.m.April 16, 2026, at 05:00 a.m.April 22, 2026, at 12:30 a.m.April 22, 2026, at 2:30 a.m.April 23, 2026, at 6:30 a.m.April 23, 2026, at 1:30 p.m.April 25, 2026, at 4:30 p.m.April 27, 2026, at 4:45 p.m.April 28, 2026, at 5:00 p.m.April 29, 2026, at 8:00 p.m.April 30, 2026, at 4:30 a.m.Interview with Employee E2, Director of Nursing on April 30, 2026 at 12:30p.m. confirmed findings and stated Nurses are supposed to check both the Medication administration record and the individual narcotic log in case a mistake like this happens to confirm the last time the resident received the medication.Review of Resident R61's clinical record revealed resident was admitted to the facility on [DATE], with diagnosis of Chronic kidney disease.Review of Resident R61's hospital discharge records, dated October 24, 2025, revealed a current medication order for Gabapentin 100mg capsule, give 200 mg by mouth 3 times a dayReview of Resident R61's clinical record revealed that resident was ordered for Gabapentin capsule 100mg, give 2 capsule by mouth one time a day for neuropathy.Interview with Employee E2, Director of Nursing on April 28, 2026 at 12:00 p.m., confirmed the medication was transcribed incorrectly from the discharge records. 28 PA. Code 211.10 (d) Resident care policies

Based on clinical record review, facility documentation, and staff interview, it was determined that the facility failed to accurately update the State Survey Agency on the outcome of an investigation for one of two residents reviewed (Resident R56). Findings include: Review of Resident R56's clinical record revealed the resident was admitted to the facility on [DATE] with a diagnosis of encephalopathy (condition that affects how the brain works, causing confusion, memory problems, or changes in behavior due to illness, injury, or toxins), asthma, and muscle weakness. Review of information submitted by the Department, dated February 16, 2026, revealed on February 16, 2026 Resident R56 asked to be taken to the bathroom. CNA took the resident into the bathroom. At the time resident was in her wheelchair. During the transfer, resident stated her legs were getting weak and resident was lowered to the floor by CNA. Review of facility investigation follow up submitted revealed an x-ray was completed and revealed the resident sustained a posterior dislocation of femoral head prosthesis. Further review revealed the facility reported that the resident was provided with the appropriate level of assistance for toilet transfers, and therefore the CNA was not neglectful. Review of Resident R56's care plan, dated February 12, 2026, revealed the resident requires assist of 2 during transfers using rolling walker for safety. Interview on April 49, 2026 at 10:00 a.m. with Physical Therapist, Employee E3, confirmed Resident R57 required an assist of 2 during transfers at the time when Resident R57 had his/her fall on February 16, 2026. Interview on April 29, 2026 at 12:05 p.m. with Administrator, Employee E1, confirmed Resident R57's transfer status was not accurately reported to the state agency. 28 Pa Code 201.18(b)(3) Management 28 PA. Code 211.12(c) Nursing services

Based on review of clinical records and interview with staff, it was determined the facility failed to ensure pain medication was administered in accordance with the physician's order for two of two residents reviewed for pain management. (Resident R20 and Resident R27)Findings Include:Review of Resident R20's clinical record revealed Resident R20 was admitted to the facility on [DATE] with a diagnosis of cirrhosis of liver (condition where the liver becomes scarred and damaged over time, making it harder for the liver to work properly), lack of coordination, and rheumatoid arthritis (long-term disease where the body's immune system attacks the joints, causing pain, swelling, stiffness, and sometimes joint damage). Review of Resident R20's clinical record revealed physician's order for Oxycodone 10 mg milligrams to be given every 6 hours as needed for severe pain for 14 days, pain scale 7-10. Review of Resident R20's April 2026 Medication Administration Record (MAR) revealed that the as needed pain medication Oxycodone 10 mg was administered out of the parameter ordered by the physician as follows:April 2, 2026- Pain level 4April 3, 2026- Pain level 4April 5, 2026- Pain level 0April 7, 2026- Pain level 5Review of Resident R27's clinical record revealed Resident R27 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (long-term lung disease that makes it hard to breathe because airflow in and out of the lungs is blocked), type 2 diabetes mellitus (long-term condition where the body does not use insulin properly, causing high blood sugar levels), and chronic pain syndrome.Review of Resident R27's clinical record revealed physician's order for Roxicodone 15 mg milligrams to be given every 6 hours as needed for severe pain, pain scale 7-10. Review of Resident R27's April 2026 Medication Administration Record (MAR) revealed that the as needed pain medication Roxicodone 15 mg was administered out of the parameter ordered by the physician as follows:April 5, 2026- Pain level 0April 8, 2026- Pain level 3April 10, 2026- Pain level 3April 11, 2026- Pain level 4Interview on April 30, 2026, at 10:47 a.m. with Director of Nursing, Employee E2, confirmed Resident R20 and R27's pain medication was not administered in accordance with physician's order.28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12(d)(1) Nursing services

Based on review of clinical records, facility policy, and interview with staff , it was determined that the facility failed to provide culturally competent, trauma 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 two of two residents sampled for post-traumatic stress disorder (PTSD). (Resident R4 and R18).Findings include:Review of facility policy Trauma-Informed Care, no date, revealed the facility is committed to incorporating trauma-informed care practices into all aspects of its operations, recognizing the widespread impact of trauma and understanding pathways to recovery. Care will be provided in a manner that prevents re-traumatization and promotes healing and empowerment. Further review of facility policy revealed the facility will incorporate trauma screening into resident assessments to identify potential trauma histories and develop individualized care plans that account for trauma-related needs, preferences, and triggers.Review of Resident R4's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus (insufficient production of insulin, causing high blood sugar), post-traumatic stress disorder (PTSD) ( a mental health condition that develops after experiencing or witnessing a traumatic event, such as a natural disaster, war, violent crime, or personal loss), and emphysema (lung disease where the tiny air sacs in the lungs become damaged, making it hard to breathe and get enough oxygen . Review of Resident R4's current care plan, dated July 07, 2025 , revealed the care plan did not address possible triggers that may cause re-traumatization.Review of Resident R18's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses of anemia (condition where your body does not have enough healthy red blood cells to carry oxygen properly, which can make you feel tired, weak, or short of breath) , post-traumatic stress disorder, and depression.Review of Resident R18's current care plan, dated October 24, 2025, revealed the care plan did not address possible triggers that may cause re-traumatization.Interview with the Director of Nursing, Employee E2, on April 30, 2026, at 10:45 a.m. confirmed Resident R4 and Resident R18's care plans did not include possible triggers that may cause re-traumatization. 28 Pa. Code 211.12(c)(d)(3)(5) Nursing services

Based on observations, review of clinical records, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to ensure skilled competencies were completed for three of six nursing personnel files reviewed (Employee E5, Employee E6 and Employee E7). Findings include:Review of facility contract with Nursing Agency, dated February 19, 2024, revealed under Supervision and Safety of Professionals: As between the parties, client (facility) and not Nurse Agency, shall be soley responsible for supervising and ensuring the safety of professionals while they are present at any of the Client's facilities. Without limiting the generality of the foregoing. Client shall: (i) provide all necessary and appropriate training and orientation materials to professionals, including, as applicable, client's policies and procedures regarding injury and illness prevention, fire safety, administering medications, charting and recordkeeping, and patient rights. During an interview with Employee E4 on April 30, 2026 at 8:52 a.m., revealed that Resident R34 had received Oxycodone/ acetaminophen 5mg /325mg according to the individual narcotic record on April 29, 2026 at 8:00 p.m. and on April 30, 2026 at 02:30 a.m.; No documented evidence of medication administered according to Resident R34's Medication Administration Record (MAR).Further review of Resident R34's individual narcotic record and Medication Administration Record (MAR), revealed 18 incidents between the dates of April 8, 2026 and April 30, 2026 that resident R34's medication administration record does not reflect the individual narcotic record.Interview with Employee E2, Director of Nursing on April 30, 2026 at 12:30p.m. confirmed findings and stated Nurses are supposed to check both the Medication administration record and the individual narcotic log in case a mistake like this happens to confirm the last time the resident received the medication.Review of randomly selected agency nurse personnel files revealed that Employee E5, Registered Nurse, revealed that the Annual Nurse Competency Check form, dated October 29,2025 is signed only by Employee E5. Further review revealed that there was no documentation available to indicate if Employee E5 was evaluated for competency related to medication management.Review of randomly selected agency nurse personnel files revealed that Employee E6, Registered Nurse, revealed that the Annual Nurse Competency Check form, dated July 30, 2025, is signed only by Employee E6. Further review revealed that there was no documentation available to indicate if Employee E6 was evaluated for competency related to medication management.Review of randomly selected agency nurse personnel files revealed that Employee E7, Licensed Practical Nurse, revealed that the Annual Nurse Competency Check form, dated September 10, 2025, is signed only by Employee E7. Further review revealed that there was no documentation available to indicate if Employee E7 was evaluated for competency related to medication management.Interview on with Employee E2, Director of Nursing (DON) on May 1, 2026, at 1:00 p.m., revealed when agency staff comes to facility, they review a packet with the DON and sign off that they understand the policies, I only have one copy so they don't keep it, but we review it and they sign it. Confirmed no documentation available to indicate if medication management was evaluated or demonstrated to prove competency for Employee E5, Employee E6 or Employee E7.28 Pa. Code S 201.20 (6)(b) Staff Development.

Based on review of clinical records, observations, and staff interview, it was determined that the facility failed to ensure safety interventions for falls were in place for one of three residents reviewed for falls (Resident R7).Findings include:Clinical record review revealed Resident R7 was admitted to the facility December 28, 2025 with a diagnosis of cerebral infarction (type of stroke that happens when blood flow to part of the brain is blocked, causing brain cells to be damaged or die), muscle weakness, and lack of coordination. Review of Resident R7's clinical record revealed an order, dated January 17, 2026, for floor mats to be down when the resident is in bed. Review of Resident R7's physician notes, dated April 10, 2026, revealed Resident R7 requires full assistance with ADLs. Maintain strict fall precautions and safety measures (e.g., fall mats).Observation on April 30, 2026 at approximately 09:30 a.m. revealed Resident R7 lying in bed and no floor mats in place Further observation on May 01, 2026 at approximately 8:40 a.m. revealed Resident R7 lying in bed with no floor mats in place. Interview on May 01, 2026 at 8:45 a.m. with Director of Nursing, Employee E2, confirmed no floor mats were in place while Resident R7 was lying in bed. 28 Pa. Code 211.10 (d) Resident Care Policies. 28 Pa. Code 211.12 (d)(5) Nursing Services.

Based on review of information submitted by the facility, hospital records, clinical records, policy and procedures, and interviews with residents and staff, it was determined the facility failed to ensure resident received adequate assistance and supervision with assistive devices to prevent accidents for one of eight residents reviewed for falls and functional abilities. Resident CL1 fell during an attempted improper transfer with staff causing the resident actual harm. (Resident CL1).Findings include:Review of the facility's undated policy and procedure titled Comprehensive person-centered care plans revealed it was the responsibility of the interdisciplinary care team to develop and implement a care plan for each resident with measurable objectives and time frames to meet the resident's physical, psychosocial and functional needs. The policy indicated that the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The policy also said each resident had the right to participate in the care planning process. The policy said that the care plan was to describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, psychosocial well-being of each resident.Review of the facility's policy and procedure titled Accident and incident investigation and reporting dated July 2017 revealed it was the responsibility of the administrator to investigate and report all accidents and incidents involving residents. The policy indicated that the nursing supervisor was responsible for initiation of the documentation and investigation of the incident. The director of nursing was responsible for ensuring that a complete report was submitted to the administrator. The administrative staff was responsible to review the incident with the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities.Review of Resident CL1's closed clinical record revealed an admission comprehensive assessment (MDS-an assessment of care needs) dated January 5, 2026, indicating resident CL1 was cognitively intact. The assessment indicated that Resident CL1's functional abilities for transferring from chair/bed to chair transfer (ability to and from a bed to a chair or wheelchair) was dependent (helper does all the effort or the assistance of 2 or more helpers was required to complete the activity). Review of Resident CL1's closed clinical record revealed physical therapist assessment dated [DATE], indicating Resident CL1 had abnormalities of gait and mobility and a history of recurrent falls with no osseous of the left ankle. The therapist documented Resident CL1 was at risk for falls, requiring a mechanical lift (Hoyer lift) for all transfers. The physical therapist indicated nursing was notified of the total dependence transfer status of Resident CL1. Continued review revealed as of January 7, 2026, the physical therapy department was documenting transfer for Resident CL1 continued to be total dependence on staff, with the use of a mechanical lift. Review of Resident CL1's closed clinical record for January 6, 2026, revealed a physiatrist progress note indicating Resident CL1 was cognitively intact. The physiatrist note indicated the plan was for continued physical and occupational therapy for rehabilitation for Resident CL1. Review of Resident CL1's clinical record for January 8, 2026, revealed a physician's progress note that indicated Resident CL1 was alert and oriented, follows commands without any gross focal deficits. Review of Resident CL1's clinical record revealed a comprehensive care plan that indicated Resident CL1 was at risk for accident hazards with reduced balance, strength and activity tolerance. The care plan revealed Resident CL1 had reduced ability to perform functional mobility and activities of daily living. The intervention indicated to use mechanical lift (Hoyer lift) for all transfers. The care plan indicated the care giver, nursing staff, were educated of this intervention to prevent falls.Review of information dated January 8, 2026, submitted by the facility on January 9, 2026, revealed that on January 8, 2026, at 3:00 p.m., Resident CL1 was sitting in a wheelchair in their bedroom and rang the call light/bell. The nursing staff responded to the call light/bell on January 8, 2026. The nursing assistant, Employee E5, reported that Resident CL1 was starting to slide and that Resident CL1 wanted to go back to bed. On January 8, 2026, the nursing assistant placed the walker in front of Resident CL1 and upon standing, Resident CL1 fell to the floor. Review of Resident CL1's clinical record including nursing progress notes for January 8, 2026, revealed Resident CL1 was sent to the emergency room post fall.Review of Resident CL1's hospital record for January 8, 2026, revealed Resident CL1 was diagnosed with a comminuted distal fibular shaft fracture of the right leg, transverse fracture of the medial malleolus, and dislocation of the tibiotalar joint (the joint that connects the foot to the lower leg) of the right leg. The resident required surgical repair of the fractures. Interview with the director of the therapy department, Employee E6, at 1:00 p.m., on January 29, 2026, confirmed Resident CL1 required the use of a mechanical lift (Hoyer lift) for transfers from the wheelchair to the bed. The therapist also confirmed the care plan had been discussed with the nursing staff and the care plan identified Resident CL1, was identified at risk for falls. The director of therapy also reported the nursing staff failed to implement the interventions and assistive device (Hoyer lift) as indicated on the care plan.Interview with Nursing Assistant, Employee E5, at 3:30 p.m., on January 29, 2026, revealed they were unaware Resident CL1 required a mechanical lift (Hoyer lift) and assistance of two or more staff members for safe transfers from the wheelchair to the bed. The nursing assistant confirmed that upon entering Resident Cl1's bedroom on January 8, 2026, the resident requested assistance to get back into bed. The nursing assistant, Employee E5 said that the resident was sitting in proper up right positioning in her wheelchair. The nursing assistant reported that while assisting Resident CL1 to stand from the wheelchair to then transfer the resident, alone into the bed, Resident CL1 fell to the floor. The nursing assistant reported there was blood on the floor near Resident CL1, after the fall. Review of Resident CL1's closed clinical record revealed A nursing progress notes dated January 8, 2026, which revealed that Resident CL1 was sent emergently to the hospital and was admitted for an open fracture of the right ankle. The failure by nurse aide, Employee E5 to use a mechanical lift (hoyer lift) to transfer Resident CL1 from the wheelchair into the bed by Employee E5 by herself caused physical injury to Resident CL1 who fell to the floor with blood noted near Resident CL1, after the fall. Resident CL1 was diagnosed with a comminuted distal fibular shaft fracture of the right leg, transverse fracture of the medial malleolus, and dislocation of the tibiotalar joint (the joint that connects the foot to the lower leg) of the right leg. The resident required surgical repair of the fractures. 28 PA. Code 201.18(b)(1)(3)(e)(1) Management28 PA. Code 211.10(a)(b)(c)(d) resident care policies28 PA. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations of the physical environment, interviews with staff and reviews of clinical records, hospital records and policies and procedures, it was determined that the facility failed to provide adequate supervision to prevent an unauthorized leave from the nursing unit resulting in a resident elopement from one of five residents reviewed. (Resident Cl1)Findings include:A review of the policy and procedure titled elopement and wandering dated November 2023 revealed that it was the responsibility of the facility staff to identify residents who are at risk of unsafe wandering and prevent harm from elopement and wandering. The policy said that the facility staff were responsible for clinically assessing each resident and identifying who was at risk for elopement and wandering. The policy said that for those residents identified at risk for wandering, elopement and other safety issues that strategies and interventions to maintain the safety of the resident would be implemented. The policy indicated that each resident would be assessed upon admission, re-admission, an elopement attempt, quarterly and annually.A review of the hospital record dated July 11, 2025, for Resident Cl1 revealed that this resident was diagnosed with chronic schizophrenia (mental disease characterized by loss of reality contact), bipolar disorder (condition in which a person has periods of depression and period of being extremely happy), anxiety disorder and seizure disorder. Clinical record review revealed that Resident Cl1 revealed that this resident was admitted to the facility on [DATE]. Review of Resident Cl1's physician documentation dated September 24, 2025, revealed that the resident was admitted from a behavioral health hospital after being treated for behavioral issues of aggression, and verbal expressions of suicide and homicide ideations. Resident Cl1 was alert with the ability to follow simple commands. The resident had ambulatory disfunction, wandering behaviors and required assistance with activities of daily living (transfers, ambulation, eating, grooming and bathing). The physician's care plan was to monitor Resident Cl1's behavior.Clinical record review for Resident Cl1 revealed that upon admission to the facility on September 23, 2025, the licensed nurse, Employee E3 documented that this resident was at high risk for elopement; however, there was no documentation to indicate that care planning was developed immediately and instituted for Resident Cl1's safety needs and behavioral issues of elopement/wandering risk. It was confirmed during an interview at 10:30 a.m., on October 15, 2025, with the Licensed nurse, Employee E3, who completed this assessment that a care plan to include a wander guard placement, supervision and diversional activities to prevent an unauthorized leave from the nursing unit was not implemented for Resident Cl1.Review of documentation submitted to the State Survey Agency on September 30, 2025, revealed that on September 29, 2025, at approx. 5:55pm the dietary aid came to the unit to collect dinner trays. As she was leaving the unit and getting on the elevator, Resident Cl1 got on the elevator and pushed the button for the basement. The dietary staff went back on the unit to alert the nurse and nurse aides. At approx. 6:00pm a family member saw the resident sitting on a rollator in the parking lot. Staff took resident into independent living and alerted nursing staff. Nursing staff arrived to take resident back to unit. The resident exited a door in the independent living section of the campus that was not locked, and (he/she) did not need to pass the receptionist.Clinical record review revealed that on September 29, 2025, Resident Cl1 left the nursing unit in a wheelchair at 5:40 p.m., through the locked/ code alarmed doors on the second-floor nursing unit. The resident was able to go through the doors in his wheelchair, because the dietary staff member allowed Resident Cl1 through the locked/code alarmed doors. The witness statement provided by the dietary staff member indicated that Resident Cl1 then got onto the elevator to the first floor with the dietary staff member. The nursing progress notes for September 29, 2025, indicated that the nursing staff found the wheelchair belonging to Resident Cl1 on the first floor outside the dining area. The resident took a rollator walker from outside the dining area and used it to ambulate to another elevator on the first floor to get himself to the basement area of the facility. At the basement level the resident exited the building. The resident then crossed an active roadway to a parking lot and was found seated on the rollator walker without shoes (barefoot). A dietary staff member, Employee E8 said that he took Resident Cl1 inside the building from the parking lot at about 6:00 p.m., on September 29, 2025. Employee E8 indicated that Resident Cl1 was behaving confused. Employee E8 also reported not being able to positively identify Resident Cl1 since the resident had no identification. A witness statement documented and reported on September 30, 2025, by the director of nursing, Employee E2 revealed that when asked about the wandering and elopement from the nursing unit on September 29, 2025, Resident Cl1 said that he did not know where he was going. Resident Cl1 also said that he was going to the hospital.28 PA. Code: 201.14(a) Responsibility of licensee28 PA. Code: 211.10(d) Resident care policies28 PA. Code: 211.12(d)(1)(3)(5) Nursing services

Based on a review of facility policies and procedures, employee personnel records, and staff interviews, it was determined that the facility failed to develop and implement an abuse prohibition policy that required a thorough investigation of prospective employees' employment history for three of five newly hired employees reviewed. (Employees E8, E9, E10) Findings include: A review of the Facility Policy titled Abuse Prevention Program revised November 30, 2022, revealed our residents but is not limited to freedom from corporal punishment, involuntary seclusion, verbal mental and sexual or physical abuse, physical or chemical restrains to required to treat resident's symptoms. Under Policy Implementation bullet #2 it further states Conduct employee background checks and will not knowingly employ or otherwise engage any individual who has been found guilty of abuse, neglect exploitation, misappropriation of property, or exploitations mistreatment of residents or misappropriation of their property. A review of the Activity aide, Employee E8's personnel file revealed that Employee E8 was hired on January 22, 2025, and criminal background was not done until February 3, 2025. A review of the Nurse aide, Employee E9's personnel file revealed that Employee E9 was hired on January 13, 2025, and criminal background was not done until May 14, 2025. A review of the Registered Nurse, Employee E10's personnel file revealed that Employee E10 was hired on January 13, 2025, and criminal background was not done until March 24, 2025. An interview was conducted with Human Resources staff, Employee E14 on May 15, 2025, at 1:46 p.m., confirmed Employees E8, E9 and E10 had their criminal background done after their hire date. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.19 Personnel policies and procedures

Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility did not ensure that allegations of abuse and neglect was reported immediately to the Pennsylvania Department of Health for one of four residents reviewed. (Resident R143) Findings Include: A review of the Facility Policy titled Abuse Prevention Program revised November 30, 2022, revealed our residents but is not limited to freedom from corporal punishment, involuntary seclusion, verbal mental and sexual or physical abuse, physical or chemical restrains to required to treat resident's symptoms. Under Policy Implementation bullet #2 it further states Conduct employee background checks and will not knowingly employ or otherwise engage any individual who has been found guilty of abuse, neglect exploitation, misappropriation of property, or exploitations mistreatment of residents or misappropriation of their property. Review of Resident R143's clinical record revealed that the resident was admitted to the facility on [DATE]. The resident had the following diagnoses: dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, need assistance for personal care. Review of facility's internal investigation statement dated July 16, 2024, at 6:20 p.m. revealed a nursing aide, Employee E17 stated Yesterday at 2:50 p.m. [Resident R143] started acting up in the hallway. She pulled her pants down and started to pee in the hallway. [Nurse aide, Employee E16] and [Nurse aide, Employee E18] were trying to get the resident in the room (xxx). I was walking up to help assist them. The resident door was open , [Employee E16] had a clean diaper in her hand and [the Resident R143] took the diaper out of [Employee E16] and slapped her against the face. Employee E16 grabbed it back and slapped the Resident R143 across her face. Who did you report it to? I told nurse supervisor, Employee E19 today, because when this happened the shift was over, and I went home. That's why I told E19 today. On May 14, 2025, at 2:13 p.m. an interview with the Administrator, Employee E1 and Director of Nursing, Employee E2 confirmed that nursing aid, Employee E17 failed to report an allegation of abuse immediately after the incident accrued. The incident occurred on July 15, 2024, at approximately 2:50 p.m. and nursing aide, Employee E17 reported to the nursing supervisor, Employee E19 on July 16, 2024, at 3:00 p.m. Shift Scheduled were confirmed for evening (3:00 p.m. -11:00 p.m. ) shift of July 15 going into night (11:00 p.m. -7:00 a.m.) shift of July 16, 2024, that nursing aids Employee E16, E17, E18 did not work any double shifts and were all suspended after the allegation was reported on July 16, 2024, at 3:00 p.m. The facility's staff failed to immediately report an allegation of abuse, which delayed the initiation of an internal investigation by approximately 24 hours, the immediate suspension of the alleged perpetrators, and notification to the State Licensing Agency. 28 Pa. Code: 201.14(a)(c) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management.

Based on review of facility policy and review of clinical records, it was determined that the facility failed to develop and implement a baseline care plan for one of two clinical records reviewed (Resident R140). Findings Include: Review of facility policy, Care Plan, Comprehensive Person-Centered revised March 2022, revealed, A comprehensive, personal -centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of Resident 140's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of severe protein-calorie malnutrition, anorexia (eating disorder that involves severe calorie restriction), depression (loss of interest in pleasurable activities), muscle weakness. On May 13, 2025, at 12:13 p.m. an interview was held with Resident 140 who reported I lost a lot of weight. Review of Resident R140's clinical record revealed no documented evidence a baseline care plan was developed and implemented related to the resident's nutrition diagnosis. On May 14, 2025, at 1:35 p.m. an interview with the Director of Nursing, Employee E2 confirmed that Resident R140 did not have a baseline care plan developed related to nutrition. 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 records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan for three of twelve residents reviewed (Residents R29, R4 and R188 ). Findings include: Review of facility policy, Care Plan, Comprehensive Person-Centered revised March 2022, revealed, a comprehensive, personal -centered care plan that includes measurable objectives and timetables to [NAME] the resident's physical, psychosocial and functional needs is developed and implemented for each resident and services not provided due to the resident exercising their right to refuse treatment. A review of the clinical record for Resident R4 revealed an admitted [DATE], with diagnoses including chronic pulmonary disease (disease process that causes decreased ability of the lungs toperform), respiratory failure with hypoxia (low levels of oxygen). Review of Resident R4's physician orders dated May 11, 2025, for change nebulizer mask and tubing weekly; date and place in dated plastic bag. Place in date bag when not in use. On May 13, 2025, at 11:11 a.m., an observation and interview were conducted with Resident R4 who reported that his nebulizer is at bedside; however, as of today it stopped nursing staff were aware. A review of the comprehensive care plan dated, April 2, 2025, did not have a care plan related to nebulizer treatments. On May 13, 2025, at 11:42 a.m. a assistant director of nursing, Employee E3 confirmed that Resident R4 did not have a care plan related to nebulizer treatments. Review of Resident R29's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included Parkinson's Disease (Parkinson's disease is a progressive neurological disorder characterized by the degeneration of brain cells that produce dopamine, a neurotransmitter essential for motor control. This leads to a variety of motor symptoms, including tremors, stiffness, slowness of movement, and balance problems. Additionally, non-motor symptoms like depression, anxiety, and sleep disturbances can also occur), and Syncope and Collapse (Syncope, commonly known as fainting, is a brief loss of consciousness accompanied by a loss of postural tone due to reduced blood flow to the brain). Review of physician order for Resident R29, dated April 14, 2025, indicated an order to administer Oxygen Continuous at 2 Liters. Another order of the same date indicated an order to administer Oxygen as needed. Review of the care plan for Resident R29, on May 15, 2025, at 11:16 a.m., revealed that there were no focus, interventions, and outcomes (goals) care- planned for oxygen administration. On May 15, 2025, at 11:19 a.m., interview with Employee E13, a Registered Nurse confirmed the above findings. Review of Resident R188's admission MDS (minimum Data Set, an assessment of residents' needs) dated December 31, 2024, indicated the resident was admitted with pressure ulcers and was at risk for further injury. Review of Resident R188's physician order, ordered PR boots (to elevate heels) be worn while the resident was in bed Interview with Resident R188 on May 13, 2025, at 2:00 p.m. observed the resident not wearing the boots while in bed and the resident stated the resident does not wear them. Review of documentation from the wound team documented Resident R188 was noncompliant with the boots. Review of the treatment administration record revealed the resident was documented compliant and marked as wearing the boots. Review of Resident R188's care plan failed to develop a care plan for boots worn to reduce pressure injury and/or resident's noncompliant with care. 28 Pa Code 211.10 (c)(d) Resident care policies 28 Pa Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, clinical record review, review of facility policy and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for two of 12 residents reviewed (Residents R4, R29). Findings include: Review of the Facility Policy and Guidelines for implementation of Oxygen administration indicated that the nurse should review and follow the physician's orders while administering Oxygen via nasal canula. Review of Resident R29's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included Parkinson's Disease (Parkinson's disease is a progressive neurological disorder characterized by the degeneration of brain cells that produce dopamine, a neurotransmitter essential for motor control. This leads to a variety of motor symptoms, including tremors, stiffness, slowness of movement, and balance problems. Additionally, non-motor symptoms like depression, anxiety, and sleep disturbances can also occur), and Syncope and Collapse (Syncope, commonly known as fainting, is a brief loss of consciousness accompanied by a loss of postural tone due to reduced blood flow to the brain). Review of physician order for Resident R29, dated April 14, 2025, indicated an order to administer Oxygen Continuous at 2 Liters. Another order of the same date indicated an order to administer Oxygen as needed. In May 2025, at 11:09 a.m., observed Resident R29, and that no oxygen administered as ordered. Registered Nurse, E13 confirmed the finding at the time of the observation. A review of the clinical record for Resident R4 revealed an admitted [DATE], with diagnoses including chronic pulmonary disease (disease process that causes decreased ability of the lungs to perform), and respiratory failure with hypoxia (low levels of oxygen in the body tissue) . Review of Resident R4's physician orders dated July 18, 2024, for O2 at 3 liter/minute via nasal cannula continuously for chronic obstructive pulmonary disease. On May 13, 2025, at 11:11 a.m., an observation and interview were conducted with Resident R4, revealed 2 liter of oxygen flow rate. The oxygen consecrator had a dirty filter and oxygen tubing was labeled with a bandage only readable label 11-7 shift. On May 13, 2025, at 11:24 a.m., the above observations were confirmed by Licensed Nurse, Employee E6. The labeling on the tubing was unreadable; therefore, Employee E6 decided to replace the entire tubing, increased the resident's oxygen flow to 3 liters, and confirmed that the filter on the back of the oxygen concentrator was dirty. 28 Pa Code 211.12(d)(5) Nursing services

Based on a review of employee personnel records and staff interviews, it was determined that the facility failed to complete performance reviews for nurse aides in one out of the two employee personnel records reviewed. (Employee E12) Findings include: Record review of personnel file for Employee E12 revealed that employee was hired by the facility on March 23, 2024 as a nurse aide. There was no further documentation available in the record to demonstrate that a skills evaluation or post orientation performance evaluation had been completed. Interview on May 16, 2025 at 10:44 a.m. with the Director of Nursing revealed that the facility does not complete competencies or performance reviews on staff and confirmed that Employee E12 does not have a completed performance review on file. Continued interview with the Director of Nursing revealed that the facility does not have a policy or procedure related to staff competencies or performance reviews and stated that none of the nurse aides have annual performance reviews completed. 28 Pa. Code 201.19 Personnel policies and procedures

Based on clinical record review, staff interview and review of facility policy, it was determined that the facility failed to to ensure that nursing staff was informed of a resident with a diagnosis of PTSD (Post traumatic Stress Disorder) to ensure treatment and services for one of one resident review with PTSD. (Resident R4) Findings include: A review of the facility policy titled, Trauma-Informed Care undated, reveals This policy establishes guidelines for implementing trauma-informed care (TIC) in the long-term care facility to support residents and staff who may have experienced trauma. The goal is to provide care that is safe, respectful, and responsive to the effects of trauma while fostering a supportive environment. Rreview of Resident R4's clinical record revealed that the resident was admitted to the facility on [DATE]. Continued review of the resident's clinical record revealed a psychological notes completed by Nurse Practitioner , Employee E7 on March 27, 2025, and May 1, 2025, which documented that [Resident R4] has PTSD symptoms, including nightmares several times per month. Resident states he tolerates the nightmares and is not seeking any treatment for them. The PTSD diagnosis was listed under the Other Diagnoses category in the progress notes on both dates. On May 15, 2025, at 11:57 a.m., an interview was conducted with Registered Nurse, Employee E15, who stated he was unaware that Resident R4 had a PTSD diagnosis. Employee E15 explained that he is typically responsible for assessing residents by reviewing hospital records, identifying active diagnoses, and developing comprehensive care plans. In this instance, the psychological progress notes indicating PTSD were not communicated to him. On May 16, 2025, at approximately 9:30 a.m., an interview was conducted with the Director of Nursing, Employee E2 and the Administrator, Employee E2, who confirmed that Resident R4 is a veteran. They further stated that they were not aware of the PTSD diagnosis or related symptoms. It was also acknowledged that there was no established communication system in place for the psychologist to report new resident diagnoses to the facility's staff. 28 Pa Code 211.12 (d)(1) Nursing services

Based on review of clinical records and interviews with staff, it was determined the facility failed to acquire, receive and administer medications to a newly admitted resident for one of 12 resident records reviewed (Resident 190). Findings include: Review of Resident R190's nursing note revealed that the resident was admitted to the facility on [DATE], at 11:52 a.m. from the hospital, with a diagnosis of traumatic subdural hematoma due to a fall prior to admission. Resident R190 was alert and oriented, capable of making their own decisions. Continued review of nursing notes indicated Writer reviewed and provided a copy of all of physician orders including medication administration and treatment administration records to resident. Resident reviewed and is agreeable with and received a copy of baseline and discharge plan of care. On March 1, 2025 the electronic medication administration record (EMAR) noted Heparin Sodium (Porcine) Injection Solution 5000 UNIT/ML instructed to inject 50000 unit subcutaneously two times a day for deep vein thrombosis, (blood clot) prophylaxis, Dronabinol Oral Capsule 2.5 milligrams (mg) taken two times a day for nausea, Modafinil Oral Tablet 200 mg, given one tablet by mouth two times a day for Sleep apnea (a serious sleep disorder where breathing repeatedly stops and starts during sleep), was not administered. The nurse noted the reason why the medication was not administered was due to the resident being a new admit (admission) and that the medication on order from pharmacy. On March 2, 2025, at approximately 10:00 a.m., the EMAR noted Dronabinol Oral Capsule 2.5 mg , Modafinil 200 mg, and Mekinist Oral 2 mg given one tablet a day for cancer was not administered with the morning medications due to the medication not being available. On March 3, 2025 at 4:00 p.m. nursing note indicated the script for modafinil and dronabinol were faxed to the pharmacy. At approximately 11:00 p.m. EMAR note indicated both medications were not available and were still waiting on the pharmacy to deliver them. March 4, 2025 at approximately 1:00 p.m. indicated dronabinol and modafinil were still not available. That same day the physician progress note noted Resident R190's poor intake and nausea and stated to continue taking dronabinol. At 11:00 p.m. EMAR progress note noted dronabinol and Modafinil had still not been received from pharmacy and again on March 5, 2025 at approximately 10:00 a.m. and 9:00 p.m. Further review of the clinical record revealed no evidence the physician was aware medications were still not available from the pharmacy. Physician progress not dated March 6, 2025 noted to continue modafinil for neuro stimulation and due to Resident R190 poor intake, continue taking dronabinol. Interview on May 16, 2025, at 11:00 a.m. with the Director of Nursing indicated the facility does not have a policy or a procedure that is followed that ensures residents receive their prescribed medication nor a protocol that is followed when medications are not available from the pharmacy nor if the medication is not administered. 28 Pa Code 211.9(a)(1) Pharmacy services 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(5) Nursing services

Based on observations, review of clinical records, and interviews with facility staff, and facility policy it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for one of four residents observed during medication administration (Residents R29), and failed to administer medications in a timely manner, and as ordered by the physician for one of 12 resident records reviewed (Resident R188). Findings include: Review of the facility's policy titled, Administering Medications revised on April 2020 states medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit not staff convenience. Medications are administered within one hour of prescribed time, if a dosage is believed to be inappropriate or excessive for a resident the person preparing or administering the medication will contact the prescriber. Resident R188 was initially admitted to the facility December 28, 2024, with diagnoses that included fibromyalgia, chronic pain, heart disease, obstructive pulmonary disease (Lung disease) , and Type 2 Diabetes mellitus (body cannot produce insulin). Interview with Resident R188 on May 13, 2025, at 2:00 p.m. stated the nurse was late administering the resident's medication January 1, 2025. I didn't get any of my morning meds until noon. I started getting shooting pain in my feet because I didn't have my gabapentin. Review of Resident R188 physician orders for January 1, 2025, revealed an order for Gabapentin oral tablets 600 mg 1 tablet given four times a day for neuropathy (nerve pain), scheduled to be given at., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m. Review of the facility's medication audit report received from the Director of Nursing, revealed 8:00 a.m. dose was not given until 12:31 p.m., (4 1/2 hours late), 12:00 p.m. dose was not given until 2:36 p.m., (over 2 1/2 hours late), , 4:00 p.m. dose was not given until 5:18 p.m. and the 8:00 p.m. dose was not given until 10:32 p.m. Lidocaine external patch 4% lidocaine for the resident's low back pain was to be applied at 9:00 a.m. but documented it was applied at 12:33 p.m Metformin HCI oral tablets 1000 mg was to give 1 tablet two times a day at 9:00 a.m., and 5:00 p.m. given with meals for the resident's diagnosis of Diabetes. The audit revealed the 9:00 a.m. dose was not administered until 12:34 p.m., and the 5:00 p.m. dose was administered at 5:18 p.m., almost 5 hours since last dose not 8 hours as ordered. It was confirmed by the Director of Nursing there was no evidence the physician was notified, nor orders allowing the medications to be given sooner than the expected time frame Review of physician orders for Resident R29, indicated orders dated January 9, 2025, for Metoprolol Succinate Extended-Release (ER) Oral Tablet 24 Hour 25 MG (milligrams), give 0.5 tablet by mouth one time a day for Hypertension ( high blood pressure); Finasteride Oral Tablet 5 MG, give 1 tablet by mouth one time a day for BPH (condition where the prostate gland, located below the bladder in men, enlarges); Clopidogrel Bisulfate Oral Tablet 75 MG, give 1 tablet by mouth one time a day for AFib. (condition where the upper chambers of the heart (atria) beat irregularly and rapidly) Observations conducted on May 15, 2025, at 9:01 a.m., revealed Employee E13, a Registered Nurse, decanted Metoprolol Succinate ER Oral Tablet Extended Release 12.5 MG, Finasteride Oral Tablet 5 MG, and Clopidogrel Bisulfate Oral Tablet 75 MG, with other medications as ordered, into a Tablet Crusher Pouch, and was initiating to crush the medications, before administering it to Resident R29; but Employee E13 was prevented from crushing those three medications, as those medications should be administered whole. Review of literature revealed as follows: Metoprolol Succinate ER (Extended-Release) oral tablets should not be crushed, broken, or chewed because it can disrupt the extended-release mechanism, potentially leading to a rapid release of the medication and an increased risk of side effects. Metoprolol Succinate ER tablets are designed to release the medication slowly over a prolonged period, usually 24 hours, to provide a consistent therapeutic effect. A rapid release of metoprolol can result in higher than intended blood levels, potentially leading to an overdose and increasing the risk of side effects, such as dizziness, fatigue, and low blood pressure. Finasteride Oral Tablets are coated and will prevent contact with the active ingredient during normal handling, provided that the tablets are not broken or crushed. Clopidogrel Bisulfate oral tablets, should not be crushed because this can lead to a rapid and higher concentration of the drug in the body, potentially increasing the risk of bleeding. At the time of the observation, interview with Employee E13, confirmed the above findings. The facility incurred a medication error rate of 12.00%. . 28 Pa Code 211.9(a)(1) Pharmacy services 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(5) Nursing services

Based on a review of the observations, and an interview with residents and staff, it was determined that the facility failed to ensure that the most recent Department of Health Survey results were readily accessible to residents and visitors in two of two nursing floors. (First Floor and Second Floor. Findings include: On May 13, 2025, at 11:52 a.m., a facility tour was conducted with the Director of Social Services, Employee E4 to observe the placement of the Department of Health Survey binder within the facility. During the tour of the first and second-floor nursing units, it was noted that the Department of Health Survey results binder was not readily accessible to residents or visitors, as it was placed behind the nursing station, requiring individuals to request access. Additionally, the binder on the second floor was outdated, with the most recent survey results dated January 22, 2019. During a resident council meeting held on March 14, 2025, at 10:30 a.m., with 4 residents (R27, R9, R140, R14), who were identified as alert and oriented, it was revealed that the residents were unaware of the recent Department of Health Survey results. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of clinical record, review of facility policies, review of documentation, and interview with staff, it was determined that the facility failed to timely assess a resident for respiratory distress and failed to ensure that emergency transportation services were provided in a timely manner for one of 13 residents reviewed (Resident R158). This failure resulted in an Immediate Jeopardy situation for Resident R158 who experienced a change in condition related to respiratory distress and did not receive a timely nursing assessment and was not transferred in a timely manner to emergency room and subsequently died . (Resident R158) Findings include: Review of facility policy Change in Condition, revised [DATE], revealed that The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): significant change in the resident's physical/emotional/mental condition; need to transfer the resident to a hospital/treatment center. The nurse will confirm with the physician to clarify the mode of emergency transport requested by the physician according to the level of emergency indicated (911 emergency transport vs. non-emergency transport. Review of facility policy Oxygen Administration, revised [DATE], indicates to verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. Review of Resident R158's clinical record revealed that he was admitted to facility on [DATE]. Resident R158 resided in a memory care unit and was admitted to emergency room for respiratory issues prior to admission to the facility. Continued review of Resident R158's clinical record revealed that the resident was admitted with the diagnoses of status post abscess incision and drainage of right posterior shoulder. He was started on antibiotics and admitted to facility for rehabilitative services. The resident had a past medical history of Alzheimer's disease (progressive degenerative disease of the brain), type 2 diabetes (failure of the body to produce insulin), and high blood pressure. Review of facility provide investigation report, completed [DATE], revealed that on [DATE], at approximately 3:00 p.m. Resident R158's spouse expressed concern to nursing staff about R158's breathing status. Review of statement from day shift licensed nurse, who was assigned to care for Resident R158 on [DATE], Employee E13, stated On Thursday [DATE] at approximately 1537 (3:37 p.m.) as I was on my way out of unit I overheard pt's (patient) spouse telling charge nurse that her husband was not breathing well, I turned around and asked charge nurse to go and assess pt's lungs, obtain VS (vital signs) and call MD (physician), and I left unit. Interview with licensed nurse, Employee E4, who was assigned to care for Resident R158 on evening shift (,d+[DATE] shift) on [DATE], revealed that Resident R158's spouse approached her during shift report and she continued to focus on taking report because she did not know who that woman was. Further during interview with Employee E4 revealed that at approximately 7:00 p.m., she went to assess the resident whose pulse oximeter (SpO2) reading was between 60% and 70%. At that point, Employee E4 administered 2L (litters) of oxygen and then increased it to 5L of oxygen which resulted in between 80% and 85% SpO2. Employee E4 stated that she contacted physician on call and called non-emergency transport for transfer to medical center. Further interview with Employee E4 revealed that at approximately 8:10 p.m., the resident was picked up by non-emergent transportation and coded (cardiac arrest) on the facility's parking lot at which point, the non-emergent transportation staff called 911 (Medical Emergency Services). The Resident expired at 9:47 p.m., and was taken back to facility. Interview with Nursing Supervisor, Employee E5, who was assigned to work on the medication cart on the evening shift of [DATE], revealed that at approximately 6:40 p.m., she was approached by Employee E4 who reported that a resident on her unit was having respiratory distress in a non-emergent manner. Employee E5 went to see Resident R158 and stated she could hear the resident's heavy breathing upon approaching resident's room and observed Resident R158 using accessory muscles. Nursing Supervisor, Employee E5 instructed Licensed nurse, Employee E4 to administer oxygen and call the physician. Nursing Supervisor, Employee E5 also confirmed that non-emergency staff called 911 when Resident R158 coded on the parking lot. Further interview with Employee E5 revealed that she spoke with resident's spouse the following day who reported that during day shift on [DATE] she expressed concern about her husband's breathing issues to four nurses and that no one went to see him. Nursing Supervisor, Employee E5 stated that Licensed nurse, Employee E4 worked as a supervisor at times and she expected this nurse to know when to call 911. Interview with facility's Director of Nursing, Employee E2, on [DATE], at approximately 11:45 a.m. revealed that the physician who was on call on [DATE] evening shift returned call at 7:38 p.m In the meantime the resident remained at facility, emergency services were not contacted until physician called back, at which point, Licensed nurse, Employee E4 contacted non-emergency transportation. Review of Resident R158's nursing notes, completed by Licensed nurse, Employee E4, dated [DATE], at 6:21 p.m. noted that Resident R158 is very tense and shaking Review of nursing note dated [DATE], at 8:10 p.m. completed by Nursing Supervisor, Employee E5, revealed that Resident R158's charge nurse report a change of condition. This nurse went to assess resident and noted resident was labor breathing on auscultation scattered crackles heard. HOB (head of the bed) elevated, POX 91% on room air. 2L of O2 (oxygen) administered via nasal cannula. MD was called upon returning the call MD give order to send resident to ED for eval. This nurse prints necessary paperwork and give it to charge nurse. Continued review of nursing notes dated [DATE], at 10:12 p.m. completed by Nursing Supervisor, Employee E5, revealed that charge nurse (Employee E4) called this nurse to inform her transport return to the building with resident's body. This nurse went up to the unit and observed resident on the stretcher body totally covered and was told resident coded in the (non-emergency transportation) ambulance, (emergency transportation) rescue assisted with CPR (cardio pulmonary resuscitation) and doctor from (medical center) pronounced him deceased at 9:47 p.m. Review of employee discipline report, completed on [DATE], regarding incident on [DATE] revealed that Licensed nurse, Employee E4 was disciplined for violating facility's Group 4 violations #1 - any deviations from a resident's course or treatment that creates the risk of, or results in serious or substantial harm to the resident. Based on above findings, an Immediate Jeopardy to the safety of Resident 158 was identified for the facility's failure to ensure that a resident with a change in condition received timely nursing assessment and timely transportation to the emergency room . An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator on [DATE], at 1:16 p.m. The facility initiated a plan of correction to address the failure of ensuring that a resident received timely emergency services. Facility plan of correction included the following: 1. Current residing resident's at facility were assessed for change in condition and physician notified in timely manner with appropriate interventions initiated if indicated. 2. Facility initiated a comprehensive Quality Assurance/Performance Improvement Plan to ensure that residents in the facility who experience change in condition are immediately assessed with appropriate and timely physician notification, and to ensure that physician ordered interventions are immediately initiated with appropriate use of emergency transport services in accordance with professional standards of practice. 3. Facility conducted audits of emergency transfers starting on [DATE], which remain ongoing to ensure that the change in condition was appropriately identified and assessed with physician notification and the appropriate emergency transfer services were utilized in a timely manner with continuous monitoring of the resident until such time. 4. Facility policy regarding a resident's change in condition was revised on [DATE], to include when emergency services (911) vs private ambulance services for emergencies should be utilized, ensuring that physician orders for transfers are clarified with the preferred method of transportation for transfer, and that the resident is continuously monitored for nay additional changes in condition until emergency transport has arrived with appropriate updates on changes to the physician as necessary. 5. Facility licensed nurse received education on [DATE], with 100% completion to be done by [DATE], from director of nursing/designee on ensuring timely identification of a resident's change in condition, timely and appropriate physician notification , timely implementation of physician ordered interventions, identifying when it is appropriate to utilize 911 emergency services vs private emergency services, ensuring that physician orders for transfers are clarified with the preferred method of transportation for transfer, and that the resident is continuously monitored for any additional changes in condition until emergency transport has arrived with appropriate updates on changes to the physician as necessary. 6. The nurses involved in this incident were immediately educated and disciplined. 7. The QAPI committee will continue to meet to identify root causes, and to initiate improvements to the facility's process and procedures relate to timely identification of a resident's change in condition, timely and appropriate physician notification, timely implementation of physician ordered interventions and identifying when it is appropriate to utilize 911 emergency services vs private emergency services, ensuring that physician orders for transfers are clarified with the preferred method of transportation for transfers, and that the resident is continuously monitored for any additional changes in condition until emergency transport has arrived with appropriate updates on changes to the physician as necessary. Audits will occur weekly x 4 weeks, bi-weekly x 2 months, then monthly x 2 months to ensure the facility remains in compliance. Review of facility documentation revealed that the corrective action plan was immediately developed and initiated on [DATE]. Audits were initiated to assess residents and facility updated their policy. In-service training provided for nursing staff. Interviews were conducted with nursing staff from First floor and Second floor nursing units and nursing staff reported that they received in-service training on protocol for residents change in status. It was confirmed during interview that they were able to recognize importance of timely assessments, signs of respiratory distress which requires emergency services and timely notification of 911 services. The immediate jeopardy was lifted on [DATE], at 4:36 p.m 28 Pa Code 211.12(c ) Nursing Services 28 Pa Code 211.12( d)(1)(2)(3)(5)Nursing services

Based on observation, clinical record review, review of facility documentation and staff interview, it was determined that the facility failed to provide adequate monitoring and supervision for one of 12 residents reviewed which resulted in actual harm to one resident who sustained a laceration that required 20 sutures(Resident R5). Findings include: Review of Resident R5's quarterly Minimum Data Set assessment (MDS-an assessment of resident care needs) completed on May 24, 2017, indicated that Resident R5 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The resident's plan of care for impaired skin integrity included interventions such as geri sleeves to both arms and geri legs to both legs, that they should be worn for all transfers and to transfer the resident with two staff members. Review of information submitted by the facility, dated for July 4, 2017, at 7:15 p.m. stated that Resident R5 had sustained a laceration to the right lateral (side) calf during a transfer from the wheelchair to the bed, that the resident was transferred by one staff member and required two persons for the transfer. Review of the facility documentation regarding the event for July 4, 2017, revealed that the resident was transferred to the emergency room (ER), the laceration measured 10 centimeters (approximately 3 3/4 inch) x 7 centimeters (approximately 2 3/4 inch) x 4 centimeters (approximately 1 3/4 inch) and the resident received 20 sutures and was started on antibiotics. A nursing note dated July 5, 2017, at 2:56 a.m. noted that the resident had returned from the ER, sutures had been placed, the resident was to receive Keflex (an antibiotic) 250 milligrams by mouth for 10 days and that the resident had received Tylenol 650 milligrams for pain. The sutures were removed on July 17, 2017. Review of nursing assistant Employee E5's written statement, dated July 4, 2017, noted that as the resident was being assisted to stand up from the wheelchair, Employee E5 saw the wheelchair moving and realized the lock had not engaged. There was no evidence available at the time of the survey to indicate that the Resident R5 had geri legs in place on the lower legs. The Director of Nursing stated in an interview on October 13, 2017, at 10:50 a.m. that the transfer should have been done by two staff members and that she was not sure what exactly caused the laceration, and that it might have been caused by the leg rests. The facility failed to follow physician's orders [REDACTED]. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 10/01/15 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(1) Management Previously cited 04/07/17, 11/17/16, 10/01/15 28 Pa. Code 201.18(b)(3) Management Previously cited 04/07/17 28 Pa. Code 211.10(d) Resident care policies 28 Pa. code 211.11(d) Resident care plan 28 Pa. Code 211.12(c) Nursing services Previously cited 04/07/17 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 11/17/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 11/17/16, 10/01/15

Based on observation, review of clinical record, facility documentation, and interviews with staff, it was determined that the facility failed to adequately and thoroughly assess and monitor a resident who swallowed their dentures, developed respiratory distress and suffered harm (Resident R1). Findings include: Review of Resident R1's clinical record revealed an admission physician order, dated January 25, 2013, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set Assessment (MDS, an assessment of needs) dated February 1, 2013, revealed that Resident R1 needed extensive assistance for dressing, eating, and personal hygiene. Further review of the Admission Comprehensive Nursing Data Collection Tool dated January 25, 2013, noted that Resident R1 had full upper and lower dentures. Review of the plan of care, dated January 25 and 26, 2013, for nursing, revealed no plan of care for oral hygiene. Review of the Care Plan Kardex for the nurse aide (a check list for the nurse aide, used to inform the staff regarding what the resident needs help with, and if the resident has special needs), dated January 25, 2013, revealed a blank section (not completed from admission to transfer to the hospital, a total of 17 days, from January 25, 2013 to February 11, 2013) for oral care, oral care products, the presence of dentures, and what kind (if present). During an interview on February 20, 2013, at 2:00 p.m., Employee E4, a Nurse Aide, revealed that a nurse aide must go to the Care Plan Kardex (kept at the nurse's station) to see what kind of oral care needs to be done, and to see if the resident has dentures. Review of all nursing care documentation for the 17 days that Resident R1 resided in the facility, revealed no evidence of oral care. A review of the nursing progress note dated February 9, 2013, at 2:00 p.m., revealed that both of Resident R1's lungs had rhonchi (a whistling or snoring sound heard on auscultation (listening with a stethoscope) indicating the air channels are partly obstructed) and that the lung sounds in both lungs were diminished at the bases (lower portion of the lungs), indicating minimal air flow. Further review of the nursing progress notes dated February 9, 2013, at 2:00 p.m. revealed that a request was made to the physician for a chest X-ray. Five hours later, at 7:00 p.m., on February 9, 2013, the nursing progress notes revealed that Resident R1 still had rhonchi throughout both lungs and now had a temperature of 99 degrees Fahrenheit. Further review of the nursing progress notes dated February 9, 2013, at 7:00 p.m., revealed a telephone order given by the physician for a chest X-ray to be done immediately. Further review of the nursing progress notes dated February 9, 2013, at 7:00 p.m., revealed that Resident R1's family notified nursing that the resident's dentures were missing. A review of facility documentation (Employee Witness Statement) dated February 9, 2013, revealed that the physician was notified that the family was concerned that Resident R1 had swallowed the dentures. During the onsite visit on February 20, 2013, a review of the nursing progress notes and the Care Tracker (computerized nurse aide documentation) from January 25, 2013 to February 11, 2013, revealed no evidence of nursing documentation as to when the dentures were cleaned or seen last. A review of the nursing progress notes dated February 9, 2013, at 11:50 p.m., revealed that the chest X-ray showed slight lower lobe infiltrate (a shadow seen on a chest X-ray and assumed to represent other body fluids in the lung) which was reported to the physician. Review of the written report of the chest X-ray, dated February 9, 2013, at same time, stated, "Examination of the chest demonstrates a slight infiltrate versus atelectasis (collapse) in the right lower lobe". Review of the nursing progress notes dated February 10, 2013, at 12:00 p.m., revealed that the resident's condition was unstable with a temperature of 100.2 degrees Fahrenheit, both lungs still with rhonchi, and the resident still sounds congested. Review of the nursing progress notes dated February 10, 2013, at 9:00 p.m., revealed that the resident was coughing off and on, and both lungs had wheezing sounds and congestion. Review of the nursing progress notes dated February 11, 2013, at 12:00 p.m., revealed that Resident R1's temperature was 100.6 degrees Fahrenheit, with a pulse of 140 beats per minute (normal is 60-80), and respirations of 26 breaths per minute (normal is 12-18). Further review of the nursing progress notes dated February 11, 2013, at 12:00 p.m. revealed that breathing treatments were given with no effect. Review of physician orders [REDACTED]. Resident R1's pulse oximetry (oxygen content in the blood) was 74% (normal is 96%-100%). Oxygen was started and Resident R1's pulse oximetry was still only 76% to 78%. Further review revealed that the resident had flushed skin, was pale and sweaty, and had labored (difficult) breathing. The physician was notified and gave an order to transfer the resident to the hospital. Resident R1 was emergently transferred to the hospital by ambulance at 10:00 a.m. An observation during the onsite visit on February 20, 2013, of the chest X-ray film done on February 9, 2013, revealed Resident R1's denture (a U-shaped denture of approximately 10-12 teeth, with no roof) in the throat /neck area, above the two lungs. An interview with Employee E3, Resident R1's physician and the Medical Director of the facility on February 20, 2013, at 11:00 a.m., confirmed the presence of the denture on the X-ray. Further interview with Employee E3, the resident's physician and the Medical Director of the facility, directly stated that he was told by the lung physician (in the intensive care unit at the hospital) that when the lung physician intubated the resident (inserted a breathing tube into the lungs to connect the resident to a breathing machine) the resident's dentures were found laying on the vocal cords. Further interview with Employee E3 revealed that Resident R1's [DIAGNOSES REDACTED]. The facility did not adequately or thoroughly assess and monitor a resident who had respiratory problems. The resident exhibited lung sounds of rhonchi for two and one half days. The family questioned the possibility of the resident swallowing their dentures, the resident had a portable chest X-ray done which showed the dentures at the entrance of the lungs, but the dentures were not identified. The Resident R1 was transferred emergently to the hospital, two and one-half days after respiratory problems were identified by the facility, and placed in the intensive care unit, on a breathing machine. 28 Pa. Code 211.12(d)(1) Nursing services. 28 Pa. Code 211.12(d)(3)(5) Nursing services. Previously cited 11/08/2012.