Every finding on record at Homeland Center

Based on policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for three of 22 residents reviewed (Residents 2, 3, and 8).Findings Include:Review of facility policy, titled MDS Assessment Completion and Care Planning; reviewed January 2026, revealed, Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.Review of the facility policy, titled 1:1 Observation Care with a last review date of January 2025, revealed The resident's care plan shall be reviewed and updated to reflect the need for 1:1 observation and the interventions being used. Review utilization of 1:1 observation for appropriateness and duration.Review of Resident 2's clinical record revealed diagnoses of chronic kidney disease (a condition in which your kidneys are damaged or have a problem with their structure that prevents them from filtering blood the way it should) and depression (a mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities you once enjoyed).Review of Resident 2's clinical record revealed the Resident was implemented a 1:1 observation after a fall that occurred on July 2, 2026, and has remained on one ever since.Review of Resident 2's fall care plan revealed an intervention for, 1:1 for the rest of the night, initiated on July 2, 2026. The facility failed to revise the 1:1 intervention to reflect Resident 2 was still currently on a 1:1.Review of Resident 2's care plan failed to include any focus area or intervention indicating the Resident being on an 1:1 observation.During an interview with the Director of Nursing (DON) on September 10, 2026, at 11:51 AM, revealed Resident 2 was still currently on a 1:1 observation and has been on one since their fall on July 2, 2026.Review of Resident 3's clinical record revealed diagnoses that included vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow and oxygen to the brain) and chronic atrial fibrillation (a continuous irregular heart rhythm where the upper chambers of the heart beat chaotically).Review of Resident 3's clinical record revealed they had a fall on December 24, 2025. After the fall, there was an intervention for Resident 3 to be put on a 1:1. Review of Resident 3's clinical record revealed they are still currently on a 1:1.Review of Resident 3's fall care plan failed to reveal that the 1:1 intervention was added to the care plan.During an interview with the DON on September 10, 2026, at 11:53 AM, revealed that Resident 3 was on an 1:1 observation at night, and that the 1:1 observation intervention was implemented after a fall that occurred on December 24, 2025.Review of Resident 8's clinical record revealed diagnoses that included congestive heart failure (a chronic condition where the heart muscle does not pump blood as well as it should, causing fluid to build up in the body) and diabetes (a condition where the body is unable to regulate blood glucose levels).Observation of Resident 8 on September 8, 2026, at 9:45 AM, revealed Resident 8 sitting in her wheelchair. She was using supplemental oxygen via nasal canula at 2 liters per minute.Observation of Resident 8 on September 9, 2026, at 10:55 AM, revealed Resident 8 sitting in her wheelchair. She was using supplemental oxygen via nasal canula at 2 liters per minute.Review of Resident 8's care plan failed to reveal that Resident 8 used supplemental oxygen.Review of Resident 8's physician order revealed an order for Oxygen at 2 liters per minute via nasal canula, start August 1, 2026.An interview with the Director of Nursing on September 10, 2026, at 10:45 AM, revealed that Resident 8's care plan should have been updated to include her need for supplemental oxygen. 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of the RAI manual (Resident Assessment Instrument- A standardized guide used in nursing homes and long-term care facilities to assess residents' health, functional status, and care needs), clinical record review, and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 22 residents reviewed (Residents 1, 8, and 56).Findings Include: Review of RAI Manual guidance for Section I: Active Diagnoses, revealed Code diseases that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status.or risk of death during the 7 day look back period. Review of RAI Manual guidance for section K: Nutritional Status, revealed Start with the resident's weight closest to 30 days ago and multiply it by .95. The resulting figure represents a 5% loss from the weight 30 days ago. If the resident's current weight is equal to or less than the resulting figure, the resident has lost more than 5% body weight. Review of Resident 1's clinical record revealed diagnoses that included protein-calorie malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it gets), weakness, and dysphagia (difficulty chewing and/or swallowing). Review of Resident 1's clinical record revealed she was admitted to hospice services on July 9, 2026, and had a significant change MDS assessment (Minimum Data Set is part of federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) as well as a modification significant change MDS assessment with ARD (Assessment Reference Date- last day of the assessment period) of July 15, 2025. Review of Resident 1's hospice plan of care document noted a start of care date of July 9, 2026, with a primary diagnosis of unspecified protein calorie malnutrition. Review of Resident 1's clinical record revealed she had experienced a significant weight loss of 8.9% from June 4, 2026, to July 1, 2026. Review of Resident 1's Significant Change in Status MDS, as well as her Modification of Significant Change in Status MDS, with ARDs of July 15, 2026, revealed under Section I, Resident 1 was marked no for Malnutrition; under Section K, it was marked no or unknown for Loss of 5% or more in the last month or loss of 10% or more in last 6 months; and under Section O: Special Treatments, Procedures, and Programs, it was marked no for Hospice Care. During an interview with the Director of Nursing (DON) on September 10, 2026, at 12:46 PM, she revealed both of Resident 1's aforementioned MDS assessments were coded incorrectly for malnutrition, weight loss, and hospice care, and Employee 2 (Registered Nurse Assessment Coordinator) was going to correct them. Review of Resident 8's clinical record revealed diagnoses of congestive heart failure (a chronic condition where the heart muscle does not pump blood as well as it should, causing fluid to build up in the body) and diabetes (a condition where the body is unable to regulate blood glucose levels). Review of Resident 8's Significant Change MDS assessment dated [DATE], indicated in Section O0110- Special Treatments, Procedures, and Programs, Section C1 Oxygen Therapy, indicated that Resident 6 had not received supplemental oxygen during the look-back period. Review of Resident 8's electronic medical record revealed that on July 24, 2026, at 6:07 AM, Resident 8's blood oxygen saturation level was 96% and she was receiving oxygen via nasal canula at that time. Review of Resident 8's physician's orders revealed a physician order for oxygen at 2 liters per minute via nasal canula, as needed, with a start date of April 17, 2026. Interview with the DON on September 10, 2026, at 11:45 AM, revealed that she would expect the assessment to reflect the resident's status. Review of Resident 56's clinical record revealed diagnoses that included anxiety disorder (mental health condition that involves excessive ongoing fear and worry that interferes with daily life) and depression (mood disorder that causes a persistent feeling of sadness, emptiness and loss of interest). Review of Resident 56's quarterly MDS dated [DATE], indicated no for anxiety disorder. Review of Resident 56's comprehensive plan of care revealed mode care plan: the resident has been diagnoses with anxiety. An interview on September 10, 2026, at 12:32 pm, with the Nursing Home Administrator and DON revealed that the aforementioned MDS was incorrect and it was the expectation of the facility that MDS be coded correctly. 28 Pa. Code 211.5(f) Medical records.28 Pa Code 211.12 (d)(3)(5) Nursing Services.

Based on facility policy review, clinical record review, review of select facility documentation, and staff interviews, it was determined that the facility failed to ensure a resident with an indwelling catheter receives appropriate treatment and services to prevent urinary tract infections for two of two residents reviewed for having an indwelling catheter (Resident 6 and 10).Findings include: Review of facility policy, titled Prevention of Catheter-Associated Urinary Tract Infections last reviewed January 2026, read, in part, Only persons (nursing home personnel, family members, or residents themselves) who have been trained in and demonstrate knowledge of the correct maintenance techniques are allowed to handle catheters or provide catheter care. Perineal Care: The peri-urethra is cleaned regularly with mild soap and water and then rinsed. Always wash from area of least contamination to area of greatest. Always wipe from front to back. Review of Resident 6's clinical record revealed diagnoses that included obstructive and reflux uropathy (when urine can't flow normally through your urinary tract due to a blockage), urinary tract infection (UTI), and retention of urine. Review of Resident 6's clinical record revealed she had an indwelling foley catheter placed at the facility on June 8, 2026, and the catheter was removed on June 24, 2026. Review of Resident 6's physician orders revealed the following: Ensure tubing is within Statlock properly and alternate left and right leg every shift, with a start date of June 8, 2026, and a discontinued date of June 24, 2026. Change leg bag for catheter alternating legs on days and evenings, every day and evening shift, with a start date of June 9, 2026, and a discontinued date of June 24, 2026. Inspect the vulval vestibule on women daily, with a start date of June 8, 2026, and a discontinued date of June 24, 2026. Review of Resident 6's care plan revealed a care plan for catheter care from June 8, 2026, until June 24, 2026, with an intervention for catheter care as per protocol.Review of Resident 6's clinical record failed to reveal an order to provide catheter care to be completed. Interview with Employee 3 (Licensed Practical Nurse) on September 10, 2026, at 1:46 PM, revealed that for an order to inspect the vulval vestibule, she would observe the resident for signs and symptoms of infection and observe to ensure that the catheter was functioning. She further revealed that if catheter care was expected to be provided, that there would be additional orders. Interview with Employee 4 (Licensed Practical Nurse) on September 10, 2026, at 1:49 PM, revealed that for an order to inspect the vulval vestibule, she would just inspect the area and provide care as needed. She further revealed if routine catheter care was expected to be provided that would be noted in the order or written as a separate order. Review of Resident 6's clinical record revealed she started to demonstrate signs and symptoms of a UTI on June 21, 2026, including increased confusion, delusion, and restlessness, and the symptoms continued on June 22, 2026. Review of Resident 6's clinical record revealed the nurse practitioner was notified of Resident 6's change of condition and ordered to replace her foley catheter and collect a urinalysis with culture and sensitivity (UA C&S- lab measure to determine the presence of a UTI) on June 22, 2026. Review of Resident 6's UA C&S collected on June 22, 2026, revealed it was positive for bacterial species (infection) and was signed by the provider on June 22, 2026, with an order for Macrobid (antibiotic) twice daily for seven days. During an interview with the Director of Nursing (DON) on September 10, 2026, at 2:00 PM, the surveyor revealed the concern with the missing documentation on Resident 6's TAR, as well as the lack of a catheter care order, including the subsequent development of a UTI. The DON revealed her expectation that physician orders are completed as ordered and residents with catheters should have physician orders for catheter care to provided by a licensed nurse. Review of Resident 10's clinical record revealed diagnoses that included personal history of urinary tract infections, other hydronephrosis (a condition where urine is prevented from flowing from the kidneys to the bladder) and muscle weakness. Review of Resident 10's physician orders revealed the following: Ensure tubing is within Statlock properly and alternate left and right leg every shift, with a start date of January 20, 2026. Change leg bag for catheter alternating legs on days and evenings, every day and evening shift, with a start date of November 21, 2025. Inspect meatus (opening at the tip of the penis) on men daily every shift, with a start date of November 20, 2025. Review of Resident 10's June 2026, July 2026, August 2026, and September 2026, TAR, failed to reveal his order for tubing is within Statlock properly and alternate was signed as completed on June 22, 2026, on day shift; June 25, 2026, on evening shift; July 12, 2026, on night shift; July 29 and 30, 2026, on evening shift; August 1 and 14, 2026, on evening shift; and September 9, 2026, on evening shift. Review of Resident 10's July 2026 and August 2026, TAR failed to reveal his order to inspect the meatus was signed as completed on July 11, 2026, on night shift; and August 14, 2026, on evening shift. Review of Resident 10's June 2026 and August 2026, TAR failed to reveal his order to change his leg bag was signed as completed on June 22, 2026, on day shift; and August 14, 2026, on evening shift. During an interview with the DON on September 10, 2026, at 12:46 PM, she revealed she was unable to provide information as to why Resident 10's physician orders were not marked as completed on the aforementioned dates. During an interview with the DON on September 10, 2026, at 1:29 PM, she revealed she would expect a resident with a catheter to have a physician order for catheter care as it is the facility process for the licensed nurses to be providing catheter care every shift. 28 Pa. Code 201.4(a) Responsibility of Licensee.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure the environment meets the individual needs of each resident by providing adaptive equipment needed to use the call bell system for one of 22 residents reviewed (Resident 46).Findings include: Review of facility policy, titled Call Light Accessibility and Timely Response, with a policy review date of January 2026, revealed, the purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Review of Resident 46's clinical record revealed diagnoses that included hemiplegia of the left non-dominant side (paralysis or significant loss of motor function on one side of the body) and muscle weakness (when your full effort doesn't produce a normal muscle contraction or movement). Review of Resident 46's care plan on May 8, 2025, revealed a care plan with a focus area of, FALL CAREPLAN; Resident at risk for falls, with a revision date of April 12, 2023, and an intervention of, be sure the Resident's call light is within reach and encourage the Resident to use it for assistance as needed. The Resident needs prompt response to all requests for assistance, with a revision date of January 14, 2025. Observation of Resident 46 on September 8, 2026, at 10:28 AM, revealed Resident 46 lying in bed and her call bell was lying on the floor under the Resident's bed. A sign hanging on the wall at the head of Resident 46's said to place the call bell in Resident 46's right hand before leaving the room. Observation of Resident 46 on September 9, 2026, at 11:25 AM, revealed Resident 46 lying in bed and her call bell was lying on the floor under the Resident's bed. Observation of Resident 46 on September 9, 2026, at 2:04 PM, revealed Resident 46 lying in bed and her call bell was lying on the floor under the Resident's bed. Interview with the Director of Nursing on September 10, 2025, at 11:35 AM, revealed that all residents should have their call bells within their reach and Resident 46 is capable of using the call bell. Pa. Code 211.12(d)(1) Nursing Services

Based on facility policy review, clinical record review, review of facility investigation documentation, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure each resident the right to be free from physical abuse for one of three residents reviewed (Resident 1).Findings Include:Review of facility policy, titled Resident Abuse, Neglect, and Exploitation, with a revised date of July 2023, revealed It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking.Review of Resident 1's clinical record revealed diagnoses that included intracranial injury (Traumatic Brain Injury [TBI] -an injury to the brain caused by an external force) and Parkinson's Disease (a progressive, neurodegenerative disorder of the central nervous system that primarily affects movement due to the death of brain cells that produce dopamine). Review of Resident 1's clinical record revealed a progress note dated January 28, 2026, at 10:47 PM, stating that a nurse aide (NA) reported that during PM care, Resident 1 became combative and the NA that was assisting with care (Employee 1) was hit in the face by Resident 1. The note further states that Employee 2 (NA) witnessed Employee 1 hit Resident 1 in the face after Resident 1 hit Employee 1. Employee 2 immediately reported what she witnessed to the nursing supervisor. Resident 1 was immediately assessed and redness was noted to the right cheek, with no bruising or skin tears noted. Resident 1 denied pain and had no change from baseline mental status. Vital signs were stable and notifications were made to the NHA (Nursing Home Administrator), DON (Director of Nursing), Compliance Officer (Employee 3), and the physician. Review of the DON witness statement revealed that on January 28, 2026, at approximately 7:30 PM, she received a phone call from the nursing supervisor who reported to her that Employee 1 hit Resident 1. The DON spoke to the reporting NA, Employee 2, who stated that Employee 1 smacked Resident 1 in the face hard. Employee 2 told the DON that Employee 1 was assisting Employee 2 with Resident 1's care. Employee 2 had a wet washcloth in her hand and Resident 1 pulled it from her hand and it hit Employee 1 in the face, and Employee 1 smacked Resident 1 in the face after she got hit. The DON's statement further stated that during the interview process with Employee 1, when asked if Employee 1 slapped Resident 1 she said yes, but it was a reaction. Review of Employee 3's witness statement dated January 28, 2026, revealed she received a call from the nursing supervisor about an allegation of physical abuse. The nursing supervisor was instructed to remove the alleged perpetrator, Employee 1, from the unit and to place the alleged perpetrator and the witness, Employee 2, in separate rooms. Employee 3 arrived at the facility at approximately 7:45 PM to conduct an immediate investigation. Employee 3 stated she asked Employee 1 if she knew why she was removed from the nursing unit. Employee 1 stated she did not and Employee 3 informed her it was due to an allegation that she slapped Resident 1. Employee 1 said Yes, I responded. It was just a reaction. I know I was wrong but it was just a reaction and I feel bad but he hit me first. Employee 3 reminded Employee 1 of her NA training and that she can never respond. Employee 3's statement further stated that she informed Employee 1 that regardless of whether she is kicked, hit, punched, slapped, etc., you are trained to never respond. It is not permissible and is considered abuse. Employee 1 said she was wrong but it was just a reaction. Further review of Employee 3's witness statement revealed that English is not Employee 1's first language, so Employee 1 agreed to dictate her statement to Employee 3 to type and then Employee 3 would read it back to her. Employee 3 stated that Employee 1 began to change her story and said she did not slap him in the face, she pushed his hand away so he could not hit her again and that maybe that is how his face got hit. When asked if he hit her with the washcloth, she said he did not, it was with his hand.Employee 3's statement further revealed that she notified the police who then arrived at the facility for investigation. Employee 3 stated she requested that Employee 1 be charged with assault. Review of Employee 1's witness statement dated January 28, 2026, revealed Employee 2 asked her for assistance. She stated that they went to Resident 1's room and transferred him into bed. Employee 1 stated that it was hard to wash Resident 1 because he always fights people. He was trying to slap [Employee 2] and I saw it so I told [Employee 2] to move her face back so she would not get hit. Employee 1 stated that Resident 1 was in front of her, because she was holding him over for Employee 2 to put a brief on him. Employee 1's statement revealed He then just slapped me near my right eye. I was surprised and grabbed my face. He then used his foot to try and push me and then I reacted by pushing his arm away because he was about to slap me again. I then left the room.Review of Employee 2's witness statement dated January 28, 2026, revealed that she asked Employee 1 for help with Resident 1's nighttime routine. She stated that they put Resident 1 into bed and then he became combative, hitting both Employee 1 and 2. Employee 2 stated that she had a wet rag in her hand doing incontinence care and Resident 1 smacked the rag and it hit Employee 1. Employee 2 stated that As soon as it hit [Employee 1], she smacked him in the face with an open hand. After smacking him in the face she says, 'You think you're just going to keep hitting me!' Employee 2 stated she quickly finished Resident 1's care, Employee 1 left the room, Employee 2 ensured Resident 1 was okay and then Employee 2 went to report what she witnessed. Resident 1 was unable to be interviewed due to his diagnosis. Review of facility's investigation revealed The facility concluded the accused [nurse aide] was physically abusive to resident when she chose to hit him in return for his actions toward her. Resident's actions did not warrant her inappropriate reaction, and as such, they are considered Resident Abuse and will not be tolerated by Homeland Center. Further review revealed that Employee 1 was terminated on January 30, 2026. During an interview with Employee 3 and the DON on February 4, 2026, at 11:57 AM, they stated that the police have been to the facility to investigate but it will be up to the District Attorney on whether or not charges will be filed against Employee 1. Facility began refresher education on January 30, 2026, for aggressive behaviors and inappropriate responses to them, as well as abuse and abuse reporting. As of February 2, 2026, facility staff were educated on Dealing with Aggressive Behavior in the Elderly.Prior to the abbreviated survey, the facility failed to ensure residents were free from physical abuse, as evidenced by Employee 1 slapping Resident 1. The facility reported the incident timely, investigated the incident thoroughly, and initiated interventions in an effort to prevent a future incident. During the abbreviated survey, plan of correction documentation was reviewed. Staff interviews, resident interviews, resident record review, and observations revealed no abuse concerns.28 Pa. Code 201.14 (a) Responsibility of licensee28 Pa. Code 201.18 (b)(1) Management28 Pa. Code 201.29 (a) Resident rights

Based on facility policy review, clinical record review, review of facility investigation documentation, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure that a comprehensive, person-centered care plan was implemented, which resulted in actual harm as evidenced by a fracture of the left hip and laceration for one of three residents reviewed (Resident 1).Findings Include:Review of facility policy, titled MDS Assessment Completion and Care Planning, last revised October 2024, read in part, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially when changes are made.Review of Resident 1's clinical record revealed diagnoses that included dementia (a decline in mental ability that interferes with daily life) and osteoporosis (bone disease causing bones to become weak, porous, and brittle).Review of Resident 1's fall care plan revealed the interventions for, tab alarm at all times in bed and chair, bilateral floor mattresses/alarming floor mats, low bed, can roll onto mattress beside bed at times which was last revised on August 15, 2025.Review of Resident 1's Kardex (quick reference tool utilized to identify a resident's care needs/preferences and assistance needed) revealed section titled, Safety, which stated, tab alarm at all times in bed and chair, bilateral floor mattresses/alarming floor mats, low bed, can roll onto mattress beside bed at times.Review of facility incident report dated December 15, 2025, revealed Resident 1 sustained an unwitnessed fall from bed at 4:15 PM. Review of the incident description revealed, resident rolled out of bed to floor. Bed was not in low position and mats were not on floor. Resident sustained a 4-5 cm laceration to left forehead.Review of Resident 1's interdisciplinary progress notes revealed that an assessment conducted by the Registered Nurse revealed Resident 1 sustained a 4.5-5 cm laceration to left forehead, bleeding noted from the laceration. The physician was notified and an order to send Resident 1 to the emergency room for evaluation and treatment was obtained.Review of Resident 1's hospital summary dated December 15, 2025, at 5:41 PM, revealed that the Resident was initially treated in the emergency department and was subsequently admitted to the hospital for an orthopedic consult and monitoring.Review of the emergency room physician's notes revealed Resident 1's 2 cm facial laceration was repaired with staples. X-ray results revealed Resident 1 suffered a mildly displaced fracture of the proximal left femoral metaphysis (hip fracture). Resident 1 was deemed not appropriate for surgical intervention due to multiple health factors.Review of a witness statement by Employee 1 (Certified Nurse Assistant assigned to Resident 1 at the time of the fall), dated December 15, 2025, revealed Employee 1 stated, in part, .I did put her to bed. I did place floor alarms on both sides. I also put the bed as low as it would go. I put her in bed at about 2 PM.Review of a second witness statement by Employee 1, dated December 16, 2025, revealed Employee 1 stated, On 12/15/25 at 2pm I put the resident to bed. I kept her body alarm that was on her chair on the lift pad as she was transferred so that it remained on her. Both floor alarms were down, I did fail to put the second fall mat down on the side her closet is on. Once in bed, I lowered her bed down as low as it would go. I left around 3:30 to get my food and saw her in bed. I returned maybe 5-10 minutes later and continued to my set assigned for 2nd shift.Review of witness statements from Employee 4 (CNA), Employee 5 (Licensed Practical Nurse [LPN]), and Employee 6 (Registered Nurse [RN]) revealed that when they responded to Resident 1's room after the fall, Resident 1's bed was observed in an elevated position, the fall mattresses were propped against the wall, and fall mat alarms were in place but not connected.During an interview with the Nursing Home Administrator (NHA) on December 29, 2025 at approximately 1:00 PM, he revealed that Employee 1 was an agency CNA and had completed orientation to the facility and training on November 25, 2025. Following the facility's investigation, it was determined that Employee 1 failed to follow Resident 1's plan of care, which resulted in Resident 1 falling from her bed and sustaining a left hip fracture and facial laceration. The facility notified Employee 1's agency and placed Employee 1 on the do not return list. The NHA revealed that he expected staff to follow residents' plans of care and that an all staff in-service was completed to review the importance of following care plans.Review of education documentation dated December 17 - 23, 2025, revealed that nurse aides and licensed staff were educated on the importance of alarms functioning, mat placement, and following care plans.During an interview with Employee 2 (Assistant Director of Nursing [ADON]) on December 29, 2025 at approximately 1:05 PM, Employee 2 confirmed she had received training on the importance of alarms functioning, mat placement, and following care plans.During an interview with Employee 3 (RN) on December 29, 2025 at approximately 1:15 PM, Employee 3 confirmed she had received training on the importance of alarms functioning, mat placement, and following care plans.The facility initiated weekly care plan compliance audits on December 15, 2025. Audits continue and results are reviewed at the weekly Quality Assurance and Performance Improvement Committee meetings.Review of facility documentation revealed that on December 23, 2025, the facility had completed audits and education for staff to ensure compliance with following the care plan. During the abbreviated survey, audits and staff education were reviewed. Staff interviews, resident interviews, resident record review, and observations revealed no concerns with following resident care plans. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(e)(1) Management28 Pa. Code 211.10(c)(d) Resident care policies28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to provide the highest practical well-being by not following physician orders for three of 22 residents reviewed (Residents 3, 8, and 84).Findings include: Review of Resident 3's clinical record revealed diagnoses that included dependence on renal dialysis (an artificial process for removing waste products and excess fluids from the body that is needed when the kidneys are not functioning properly), hypertension (high blood pressure), and weakness. Review of Resident 3's physician orders revealed an order for Midodrine HCl Oral Tablet 5 mg, Give 2 tablets by mouth every 8 hours as needed for hypotension (low blood pressure), give for SBP (systolic blood pressure) less than 120, with a start date May 5, 2025. Review of Resident 3's clinical record revealed a document titled Physician Orders with an order dated May 5, 2025, that read, Change Midodrine to 10 mg PRN (as needed) for SBP <120. Further review of Resident 3's clinical record revealed her SBP measure was below 120 on May 27; June 6, 25, 29; July 8; and August 13, 2025. Review of Resident 3's May-August 2025 MAR (Medication Administration Record- documentation for treatments/medication administered or monitored), revealed she did not receive any doses of the PRN midodrine order on May 27; June 6, 25, 29; July 8; and August 13, 2025. Interview with Employee 2 (Registered Nurse) on August 21, 2025, at 11:04 AM, she revealed the midodrine should have been given on the aforementioned dates and those were medication errors. During an interview with the Director of Nursing (DON) on August 21, 2025, at 11:39 AM, she revealed she would expect medications to be given per physician orders. Review of Resident 8's clinical record revealed diagnoses that included hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting left non-dominant side, enterocolitis (inflammation of the digestive tract) due to clostridium difficile (a bacteria that causes an infection of the colon, the longest part of the large intestine), and dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning). Review of Resident 8's clinical record revealed that her medication regimen was reviewed by the facility pharmacist on April 28, 2025. Review of the facility provided Consultant Pharmacist's Medication Regimen Review form revealed that the pharmacist noted that according to the MAR [Medication Administration Record] in PCC [Point Click Care-the facility's electronic health record] no vancomycin doses are scheduled to be administered on 5/9/2025, 5/17/25-5/24/25 or 6/1/2025-6/7/2025. There was a written notation in the Follow-Through section on this report that indicated transcribed correctly in PCC with no signature or date noted. Review of Resident 8's physician order history revealed the following orders dated April 14 2025: vancomycin 50mg/ml give 2.5 ml via PEG every 6 hours for 10 days (start on April 15, 2025 and stop on April 25, 2025); then give 2.5 ml every 8 hours for 7 days (start on April 25, 2025, and stop on May 2, 2025); then give 2.5 ml every 12 hours for 7 days (start on May 2, 2025, and stop on May 9, 2025); then give 2.5 ml daily for 7 days (start on May 10, 2025, and stop on May 17, 2025); then give 2.5 ml every 48 hours (start on May 25, 2025, and stop on June 1 , 2025); then give 2.5ml every 72 hours (start on June 8, 2025, and stop on June 15, 2025). There was no order entered for the week of May 17-24, 2025. Review of Resident 8's May 2025 MAR revealed that she received no doses of vancomycin on May 9, 2025. In addition, there was no entry for vancomycin to be delivered between May 17-May 24, 2025. During a staff interview with Employee 3 and Employee 4 on August 21, 2025, at 10:20 AM, Employee 3 confirmed that she had transcribed the order incorrectly and therefore Resident 8 did not receive all ordered doses of the vancomycin. She confirmed that Resident 8 did not receive any vancomycin on May 9, 2025, a total of 2 missed doses. She further indicated that during the week of May 18-24, 2025, Resident 8 should have started the every 48 hour dose and that the week of June 1-8, 2025, Resident 8 should have started the every 72 hour dose. She confirmed that Resident 8 missed a dose on May 19 and 21, 2025, a total of 2 missed doses as Resident 8 was transferred to the hospital for an acute illness on May 22, 2025, and did not return to the facility until June 3, 2025, at which time Resident 8's medication orders changed. During a staff interview with the Nursing Home Administrator, the Assistant Nursing Home Administrator, and the DON on August 21, 2025, at 11:36 AM, the DON confirmed that she would have expected Resident 8's medication order to have been transcribed correctly so that Resident 8 would have received her ordered doses of medications. Review of Resident 84's clinical record revealed diagnoses that included chronic kidney disease (when damaged kidneys cannot filter blood properly) and diabetes (a disease causing high blood sugar due to insufficient insulin production or ineffective insulin use). Review of the facility policy, titled Insulin Administration with a last revised and reviewed date of January 2025, revealed 1. All insulins will be administered in accordance with physician's orders. Review of Resident 84's clinical record revealed a physician's order for Basaglar KwikPen Subcutaneous Solution Pen injector, 100 unit per milliliter (ml) (insulin glargine), inject 36 unit subcutaneously in the morning related to type 2 diabetes mellitus, give half dose if not eating or blood sugar is less than 100; with a start date of May, 19, 2024. Review of Resident 84's July 2025 Medication Administration Record (MAR) revealed that on July 1, 2025, at 9:00 AM, Resident 84 had a blood sugar level of 98, and it was documented that 36 units of insulin was administered. On July 23, 2025, at 9:00 AM, Resident 84 had a blood sugar level of 108, and 18 units of insulin was administered. On July 25, 2025, at 9:00 AM, Resident 84 had a blood sugar level of 114, and 18 units of insulin was administered. Further review of Resident 84's clinical record revealed a physician's order for Novolog solution 100 unit per ml (insulin aspart), inject 8 unit subcutaneously with meals related to type 2 diabetes mellitus, give 4 units if blood sugar is less than 110; hold if less than 90; with a start date of January 4, 2024. Review of Resident 84's July 2025 MAR, revealed that on July 26, 2025, at 8:00 AM, Resident 84 had a blood sugar level of 103, and 8 units of insulin was administered. On July 26, 2025, at 5:00 PM, Resident 84 had a blood sugar level of 131, and it was documented that they were administered 0 units of insulin. On July 30, 2025, Resident 84 had a blood sugar level of 96, and 6 units of insulin was administered. During an interview with the DON and Nursing Home Administrator on August 21, 2025, at 11:35 AM, they revealed they would have expected Resident 84 to have been administered the correct dosage of insulin as per physician's order. 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to maintain adequate personal hygiene and grooming of residents dependent on staff for assistance with these activities of daily living for two of two residents reviewed (Residents 6 and 64).Findings include: Review of facility policy, titled Activities of Daily Living (ADLs), with a last review date of January 2025, revealed Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care; and 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of Resident 6's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), Parkinson's disease (long term degenerative disorder of the central nervous system that mainly affects the motor system), and lack of coordination. Review of Resident 6's care plan revealed a focus for ADL Care Plan: Alteration in self-care related to Parkinson's, limited mobility, cognitive deficit with a last revised date of March 3, 2023. Interventions included, but were not limited to, Grooming: Dependent with shampoo, shave, nail care with a last revision date of November 30, 2024. Observation of Resident 6 on August 18, 2025, at 12:25 PM, revealed that she was up in her chair in the unit common area. She had visual facial hair noted on her upper lip. Follow-up observations of Resident 6 on August 19, 2025, at 9:53 AM, in the unit common area; August 20, 2025, at 12:12 PM, in the unit dining room; and August 21, 2025, at 9:37 AM, in the unit common area, all revealed that she was well-groomed with visual facial hair noted on her upper lip. During a staff interview with Employee 7 (Nurse Aide assigned to Resident 6) on August 21, 2025, at 9:42 AM, Employee 7 indicated that residents are usually shaved on shower days and that residents and/or their families can ask between showers if needed. Review of facility provided documentation revealed that Resident 6's bath/shower schedule was Monday and Thursday on day shift. Review of Resident 6's August care task documentation revealed that she had received personal hygiene every shift and failed to reveal any documentation of refusals of care. Review of Resident 64's clinical record revealed diagnoses that included hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (CVA-a stroke-damage to the brain from interruption of its blood supply) affecting right dominant side, dementia, and generalized muscle weakness. Review of Resident 64's care plan revealed a focus for ADL Care Plan: Alteration in self-care related to weakness, dementia, CVA with hemiplegia with a last revision date of August 8, 2024. Interventions included, but were not limited to, Grooming: Assistance required with shampoo, shave, nail care with an initiated date of November 27, 2024. Observation of Resident 64 on August 19, 2025, at 10:50 AM, revealed that she was up in her chair in the unit common area. She had visual facial hair noted on her chin. Follow-up observations of Resident 64 on August 20, 2025, at 9:15 AM, in the unit common area; and August 21, 2025, at 9:38 AM, in the unit common area, revealed that she was well-groomed with visual facial hair noted on her chin. Review of facility provided documentation revealed that Resident 64's bath/shower schedule was Wednesday and Saturday on evening shift. Review of Resident 64's August care task documentation revealed that she had received personal hygiene every shift and failed to reveal any documentation of refusals of care. During a staff interview with the Nursing Home Administrator, the Assistant Nursing Home Administrator (ANHA), and the Director of Nursing (DON) on August 21, 2025, at 11:36 AM, the DON confirmed that Residents 6 and 64 should have been shaved on their shower days, or at least offered and documented if they refused. The ANHA indicated that Residents 6 and 64 had now been shaved. 28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to maintain an effective infection control program related to the preparation and administration of medications for two Residents observed (Residents 3 and 55).Findings include: Review of facility policy, titled IIB2: Oral Medication Administration, with a last review date of January 2025, revealed C. For solid medications: 1) Pour or push the correct number of tablets or capsules into the souffle cup, taking care to avoid touching the tablet or capsule, unless wearing gloves. During a medication pass observation on August 20, 2025, between 9:22 AM and 9:30 AM, Employee 6 was observed preparing and administering medications to Residents 3 and 55. When preparing medications, Employee 6 was observed using an ink pen to poke a hole in the back of the pill pouch on each blister pack, and then used the ink pen to poke the pill through from the front of the blister pack into the medication cup. She prepared and administered six medications to Resident 3, and 10 medications to Resident 55. During a staff interview with Employee 6 on August 20, 2025, at 9:40 AM, Employee 6 confirmed that she had used the pen to poke the back of the blister pack and could not be sure that the pen did not touch the pills. She said that the pills are hard to push through the blister pouches sometimes, and sometimes the back of the blister pack falls into the medication cup. During a staff interview with the Nursing Home Administrator, the Assistant Nursing Home Administrator, and the Director of Nursing (DON) on August 20, 2025, at 2:00 PM, the DON confirmed that Employee 6 should not have been using her ink pen to poke holes into the back of the medication blister packs to remove medications. 28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for two of nine residents reviewed for limited range of motion (Residents 30 and 40). Findings include: Review of facility policy, titled Restorative Nursing Programs, dated April 16, 2022, read, in part, It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Restorative aides will implement the plan for a designated length of time, performing the activities, and documenting on the Restorative Aide Documentation Form. Review of Resident 30's clinical record revealed diagnoses that included cerebrovascular accident (CVA- poor blood flow to the brain that causes cell death), hemiplegia (one-sided paralysis or weakness caused by brain or spinal cord problems), and muscle weakness. Interview with Resident 30 on September 9, 2024, at 10:03 AM, revealed he had been in therapy before, but he was not sure if he is on a restorative nursing program (RNP). Review of Resident 30's care plan revealed a focus area ADL Care Plan: Alteration in self-care r/t [related to] CVA with left hemiplegia and ambulatory dysfunction, last revised January 9, 2024, with an intervention for Restorative - Passive ROM Program- [Resident 30] is at risk for decline in functional mobility, joint flexibility and contracture development. Goal: To help maintain participation in functional mobility, maintain flexibility and prevent contractures. Maintain comfort level and quality of life, initiated on October 30, 2023. Review of Resident 30's PROM nurse aid task documentation from January 2024 to September 10, 2024, failed to reveal documentation to indicate the RNP program was implemented 25 times on day shift and 11 times on evening shift. Review of Resident 40's clinical record revealed diagnoses that included muscle weakness, chronic pain, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). Review of Resident 40's nurse aide task documentation on September 10, 2024, revealed the following tasks: Restorative - Transfer Program- [Resident 40] is at risk for decline in functional mobility skills and tasks and at risk for contracture development. GOAL: To help prevent decline in functional mobility skills and tasks. Maintain flexibility as much as possible. Restorative - Splint Assistance Program - [Resident 40] is to wear palm protector to left hand. Goal: [Resident 40] will not develop a contracture of left hand or limited range of motion. Review of Resident 40's nurse aid task documentation from January 2024 to September 10, 2024, failed to reveal documentation to indicate the Transfer RNP program was implemented 51 times on day shift and 73 times on evening shift. Review of Resident 40's nurse aid task documentation from January 2024 to September 10, 2024, failed to reveal documentation to indicate the Splint RNP program was implemented 44 times on day shift and 81 times on evening shift. Review of Resident 40's care plan on September 10, 2024, failed to reveal the current splint RNP program on her care plan. During an interview with the Director of Nursing (DON) on September 11, 2024, at 1:46 PM, the surveyor questioned the missing RNP documentation for Residents 30 and 40. Email correspondence with the DON on September 11, 2024, at 5:36 PM, revealed The RNP programs on [Resident 30] and [Resident 40] were documentation errors that should have stated refused. During an interview with the DON on September 12, 2024, at 10:40 AM, the surveyor revealed the concern with the inaccurate and lack of documentation for Resident 30's and 40's RNP programs, and that Resident 40's care plan was not updated with her current RNP program. The DON revealed her expectation for documentation in the clinical record to be accurate. 28 Pa. Code 211.10(d)(a) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 19 residents reviewed (Residents 28 and 66). Findings Include: Review of Resident 28's clinical record revealed diagnoses that included chronic kidney disease (CKD - when a disease or condition impairs kidney function, causing kidney damage to worsen over several months or years) and heart failure (when the heart muscle doesn't pump blood as well as it should). Observation of Resident 28 on September 9, 2024, at 10:09 AM, revealed Resident 28 sitting in her room with a CPAP (continuous positive airway pressure - a machine that uses mild air pressure to keep breathing airways open while you sleep) on her bedside table. Resident 28 revealed she uses it daily. Review of Resident 28's clinical record revealed a progress note dated July 27, 2024, at 7:23 AM, indicating Resident 28 slept with her CPAP on throughout the night. Review of Resident 28's clinical record revealed a progress note dated July 28, 2024, at 6:44 AM, indicating Resident 28's CPAP functioning and in place. Review of Resident 28's MDS (Minimum Data Set is part of the federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated August 2, 2024, revealed that Section O0110. G1. Non-invasive Mechanical Ventilator was marked No. During an interview with the Director of Nursing (DON) on September 12, 2024, at 9:30 AM, revealed that the facility was unaware of Resident 28 having a CPAP, and that a modification MDS has been initiated to reflect that Resident 28 was using a non-invasive mechanical ventilator during the look back period on the MDS, dated [DATE]. Review of Resident 66's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), pressure ulcer of sacral region (a wound that occurs from prolonged pressure on your skin), and hypertension (high blood pressure). Review of Resident 66's physician orders revealed an order for Diabetic Supplement three times a day for skin support, with a start date of June 19, 2024, and discontinued on August 15, 2024. Review of Resident 66's Quarterly MDS with ARD (assessment reference date- last day of assessment period) of July 5, 2024; Modification of Quarterly MDS with ARD of July 5, 2024; and Significant Change MDS with ARD of August 7, 2024; revealed Resident 66 was marked no for nutrition or hydration intervention to manage skin problems on all three assessments. Interview with Employee 3 (Registered Nurse Assessment Coordinator) on September 11, 2024, at 1:06 PM, revealed the aforementioned MDS assessments were coded inaccurately and they have now been modified. Interview with the DON on September 11, 2024, at 1:48 PM, revealed she would expect resident MDS assessments to be coded accurately. 28 Pa. Code 211.5(f) Medical Records 28 Pa Code 211.12 (d)(3)(5) Nursing Services

Based on review of facility policy, resident and staff interviews, and observations, it was determined that the facility failed to post the required grievance information, provide residents access to grievance forms, and failed to post the required information of the Grievance Official for three of three areas identified ([NAME] Wing, First floor, Second floor). Findings include: Review of facility policy, titled Resident and Family Grievances, last reviewed January 2024, revealed, .Notices of resident's rights regarding grievances will be posted in prominent locations throughout the facility (i.e. Resident Handbook, Main Lobby, and throughout the Units) and Information on how to file a grievance or complaint will be available to the resident Information may include, but is not limited to: The contact information of the grievance official with whom a grievance can be filed, including his or her name, business address (mailing and email) and business phone number . Further review of facility policy, titled Resident and Family Grievances, failed to include the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email), and business phone number. During an interview with Resident 1 on September 10, 2024, at 10:21 AM, revealed the Resident normally attends the monthly Resident Council meetings. Resident 1 further revealed the Resident does not know how to file a grievance or where the grievance forms or information are located. During an interview with Resident 2 on September 11, 2024, at 9:37 AM, revealed the Resident normally attends the monthly Resident Council meetings. Resident 2 further revealed the Resident does not know how to file a grievance or where the grievance forms or information are located. During an interview with Resident 35 on September 11, 2024, at 9:28 AM, revealed the Resident normally attends the monthly Resident Council meetings. Resident 35 further revealed the Resident does not know how to file a grievance or where the grievance forms or information are located. Observations of all resident areas on September 9, 10, 11, and 12, 2024, revealed the facility failed to post written information on the grievance policy, and failed to post information that identified the facility's Grievance Official, the Grievance Official's business mailing and email address, and phone number. Review of the facility's grievance log on September 11, 2024, for the past six months, revealed there was one grievance filed during that time, on January 17, 2024. During an interview with Employee 1 on September 11, 2024, at 2:00 PM, revealed that every resident is provided with a handbook upon admission with information on grievances. Employee 1 revealed if a resident would like to file anonymously, they would have to tell a staff member and the staff would keep it anonymous. Review of the facility's Skilled Nursing Resident Handbook, dated September 2023, failed to provide information on how to file a grievance anonymously, and fails to provide the business address (mailing and email) contact information of the grievance official with whom a grievance can be filed. During an interview with the Nursing Home Administrator and Director of Nursing on September 12, 2024, at approximately 10:30 AM, revealed that they do not have a grievance form for residents to fill out and that if the residents have an issue, they tell a staff member and it gets resolved right away. 28 Pa code 201.18(b)(2)(3) Management 28 Pa code 201.29(a) Resident rights

Based on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections for three of 21 residents reviewed (Residents 13, 16, and 61). Findings include: Review of facility provided policy, titled Homeland Center Infection Prevention and Control Manual, Transmission-Based Precaution, dated 2021, revealed, It is essential both to communicate transmission-based precautions to all health care personnel and for personnel to comply with requirements. Pertinent signage (i.e., isolation precautions) and verbal reporting between staff can enhance compliance with transmission-based precautions to help minimize the transmission of infections within the facility. Review of Resident 13's medical record revealed diagnoses that included urinary tract infection (UTI - an infection in any part of the urinary system) and Chronic obstructive pulmonary disease (COPD - a common, preventable, and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough). Review of Resident 13's medical record revealed a urine culture and sensitivity result that was positive for Escherichia coli (E. coli- a bacterial infection) that was reported on October 29, 2023, at 10:48 AM. Observation of Resident 13's room on October 30, 2023, at 1:27 PM, revealed a PPE (personal protective equipment) caddie being hung on the Resident's door. Further observation revealed that no signage was hung with instructions on what type of precautions needed to be followed or what PPE should be used. Further observation of Resident 13's room on October 31, 2023, at 8:15 AM, revealed that no signage was hung with instructions on what type of precautions needed to be followed or what PPE should be used at that time. Review of Resident 13's physician's orders on November 1, 2023, revealed a current physician order for contact isolation for seven days to start on October 30, 2023, at 4:00 PM. Interview with the Director of Nursing (DON) on November 2, 2023, at 1:31 PM, revealed that the facility should have had signage hanging outside of Resident 13's room indicating what type of PPE needed to be used. Review of Resident 16's clinical record revealed diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning) and stage 4 pressure ulcer of the sacrum (localized damage to the skin and/or underlying soft tissue usually over a bony prominence; stage 4 is full-thickness skin and tissue loss). Observation of Resident 16's wound care on November 1, 2023, at 8:12 AM, revealed Employee 2 (Registered Nurse) removing Resident 16's old, soiled dressing and placing it in the trashcan. Observation of the old dressing revealed wound drainage present. At the conclusion of the dressing change, Employee 2 left the room, but did not remove the trash, with the soiled dressing in it, from Resident 16's room. During an interview with Employee 3 (Registered Nurse, Infection Preventionist) on November 2, 2023, at 9:33 AM, Employee 3 stated that, at the conclusion of wound care, the nurse should tie the trash bag shut, remove it from the room, and take it to the soiled utility room. During an interview with the Nursing Home Administrator (NHA) and DON on November 2, 2023, at 1:28 PM, the DON stated that the trash bag with the soiled dressing should have been removed from Resident 16's room at the conclusion of the dressing change. Review of Resident 61's clinical record revealed diagnoses that included UTI and hypertension (elevated blood pressure). Review of Resident 61's nursing progress notes revealed a note on October 27, 2023, stating that the Resident's urine culture returned positive for UTI and VRE (vancomycin-resistant Enterococcus; an infection with bacteria that are resistant to the antibiotic called vancomycin), and that Resident 61 was placed on contact isolation. Review of Resident 61's physician orders revealed an order dated October 27, 2023, to write a progress note every shift related to antibiotic usage for UTI VRE and contact isolation. Observation of Resident 61's room on October 30, 2023, at 11:29 AM and again at 1:56 PM, revealed a PPE caddy hanging just inside Resident 61's room. Further observations failed to reveal any signage on the outside of Resident 61's room stating that Resident 61 was on contact precautions. Observation of Resident 61's room on October 31, 2023, at 9:03 AM, revealed the PPE caddy present, but no signage present. Observation on October 31, 2023, at 9:46 AM, revealed a contact precautions sign had been placed on the outside of Resident 61's room. During an interview with the NHA and DON on November 1, 2023, at approximately 1:15 PM, they were made aware of Resident 61 not having contact precaution signage outside of his room until October 31, 2023, at 9:46 AM. During an interview with Employee 3 on November 2, 2023, at 9:31 AM, Employee 3 stated that signage should be placed at the same time the PPE caddy is placed. During a follow up interview with the NHA and DON on November 2, 2023, at 12:06 PM, they were again made aware of the surveyor's concern with the lack of contact precautions signage for Resident 61's room. The NHA stated he had a concern with that as well. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer for one of two residents reviewed for pressure ulcers (Resident 16). Findings Include: Review of facility policy, titled Wound Care and Dressing Change, revised January 2020, revealed Clean portion of surface before placing supplies on table. Wash hands and don gloves .Undress wound, assess area and cleanse and appropriately dispose of soiled dressing. Remove gloves and sanitize hands. Don new gloves. Apply new treatment as ordered. Review of Resident 16's clinical record revealed diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning) and stage 4 pressure ulcer of the sacrum (localized damage to the skin and/or underlying soft tissue usually over a bony prominence; stage 4 is full-thickness skin and tissue loss). Review of Resident 16's current physician orders revealed a treatment order dated October 21, 2023, to cleanse the sacral pressure ulcer with sea cleanse (a saline-based solution for cleansing and irrigating acute and chronic wounds), apply Mesalt to wound (a type of dressing used for wound healing), and cover with foam. Observation of Resident 16's wound care on November 1, 2023, at 8:12 AM, revealed Employee 2 (Registered Nurse) cleansed Resident 16's bedside table. Employee 2 then applied gloves. Employee 2 did not perform hand hygiene prior to applying the gloves. Employee 2 then removed Resident 16's old dressing and discarded it. Next, Employee 2 removed her gloves and applied new gloves. Employee 2 did not perform hand hygiene after removing her old gloves and prior to applying new gloves. Employee 2 then cleansed Resident 16's wound with sea cleanse, removed her gloves, and applied new gloves. Employee 2 did not perform hand hygiene after removing her old gloves and prior to applying new gloves. Employee 2 then applied Mesalt to Resident 16's wound bed and applied the foam dressing. At the conclusion of the wound care, Employee 2 removed her gloves and performed hand hygiene. During an interview with the Nursing Home Administrator and Director of Nursing (DON) on November 2, 2023, at 1:28 PM, the DON stated that hand hygiene should have been performed between glove changes. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 21 residents reviewed (Residents 70 and 85). Findings include: Review of Resident 70's clinical record revealed diagnoses that included Alzheimer's with early onset (gradually progressive brain disorder that causes problems with memory, thinking, and behavior) and anxiety disorder (mental disorder characterized by feelings of worry about future events and/or fear in reaction to current events). Observation of Resident 70 on October 30, 2023, at 9:39 AM, revealed her wandering throughout the nursing unit. Review of Resident 70's current plan of care revealed that she had a care plan for elopement, where it was noted that she is a wanderer and wanders aimlessly. This information was updated to Resident 70's care plan on October 2, 2023. Review of Resident 70's behavior tracking documentation revealed that she exhibited wandering behavior on October 4, 2023. Review of Resident 70's October 6, 2023, quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs) revealed that this assessment was not coded to indicate that Resident 70 exhibited wandering behavior during the look back period (seven day period prior to the assessment date). During an interview with the Nursing Home Administrator (NHA) on November 2, 2023, at 1:28 PM, he agreed that the MDS assessment should have been coded to indicate that Resident 70 exhibited wandering behavior. Review of Resident 85's clinical record revealed diagnoses that included Parkinson's disease (long-term movement disorder where the brain cells that control movement start to die and cause changes in how one moves, feels, and acts) and dementia (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life). Review of nursing progress note dated July 28, 2023, revealed Resident 85 experienced a fall on that date, where she obtained a laceration to her right pointer finger and a hematoma (localized collection of blood outside the blood vessels, due to either disease or trauma including injury or surgery, and may involve blood continuing to seep from broken capillaries) to her left forehead. Review of Resident 85's August 23, 2023 quarterly MDS revealed that it was not coded to indicate that Resident 85 experienced any fall with injury since the prior assessment was completed. Review of Resident 85's assessment submissions revealed that the prior applicable assessment was completed on May 26, 2023. During an interview with the NHA on November 2, 2023, at 11:58 AM, he confirmed that Resident 85's August 23, 2023, MDS was coded incorrectly. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility investigation, clinical record review, observations, and staff interviews it was determined that the facility displayed past noncompliance, in that they had failed to provide food for a resident in a form to meet the resident's individual need which resulted in harm for one of 18 residents reviewed (Resident 50). Findings include: Review of facility's investigation regarding an incident that took place on July 11, 2021; revealed that Resident 50's diet order was not followed. Resident 50 was served regular texture meat instead of ground meat. During the meal Resident 50 was noted to be off and did not respond when asked if she was ok. Further assessment identified Resident 50 had no clear air flow. The [MEDICATION(S)] maneuver was preformed and dislodged a solid piece of food. Resident 50 was sent to the Emergency Department for evaluation, where a chest x-ray was performed, and revealed aspiration pneumonia of the right lung. Resident 50 returned the facility the same day and two antibiotics were initiated. Review of Resident 50's clinical record documented diagnosis that included: [CONDITION(S)] (a chronic progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, symptoms include numbness, impaired speech, muscle coordination, blurred vision, and severe fatigue), non-[CONDITION(S)] (a form of malignant cancer where the body produces too many abnormal lymphocytes, a type of white blood cell), anxiety (a feeling of worry, nervousness, or unease) , depression (feelings of severe despondency and dejection) , ataxia (the loss of full control of bodily movements), dysphagia (difficulty swallowing), expressive language disorder (a condition that impacts the ability to use language, the person with the disorder understand what others are saying, but have difficulty expressing their ow ideas when they speak). Review of Resident 50's Physician orders July 2021 through November 2021 documented: mechanical soft diet (made up of foods that require less chewing and may include chopped or ground foods, fork tender foods) with a start date of February 17, 2021, and a discontinued date of July 15, 2021; puree diet (foods you don't need to chew, blended foods that are spoon thick) with a start date of July 15, 2021, and a discontinued date of July 23, 2021; mechanical soft diet with ground meat with a start date of July 23, 2021, and a discontinued date of September 29, 2021; mechanical soft diet with a start date of September 29, 2021; and [MEDICATION(S)] (an antibiotic used to treat bacterial infections) 500 milligram (mg - unit of measure) twice a day with a start date of July 12, 2021 and a discontinue date of July 16, 2021; and [MEDICATION(S)] ( an antibiotic used to treat bacterial infections) 500mg twice a day with a start date of July 12, 2021 and a discontinue date of July 16, 2021. Review of Resident 50's hospital discharge summary dated July 11, 2021 documented: an Emergency Department visit; completion of a chest x-ray which revealed aspiration pneumonia to the right lung; and a recommendation to start [MEDICATION(S)] and [MEDICATION(S)]. Review of Resident 50's plan of care included problem areas for alteration in nutrition related to chewing and swallowing difficulty, with an initiated date January 19, 2021, and most recently reviewed October 11, 2021. And interventions that included provide diet as ordered, provide eating assistance, and adaptive equipment as indicated, and observe for need to change diet texture. Resident 50 was on a restorative nursing program that included an eating and swallowing program that was initiated March 26, 2021; that documented Resident 50 was at risk for aspiration and decreased oral intake. The restorative nursing program included: to position Resident 50 upright at a 90 degree angle for all meals; use maroon spoons and oyster forks for feeding small bites; allow her time to chew and swallow; check for pocketing in both sides of her mouth but primarily the left; alternate bites of food with a drink or pureed item to clear her mouth. Interventions also included that Resident 50 requires an extended amount of time to complete meals, her intake is normally good, reduce environmental distraction, and you may need to pause or turn off her movies. Staff review of Resident 50's restorative nursing program on June 15, 2021 documented that Resident 50 utilizes adaptive equipment for feeding, had limited use of her upper extremities, requires staff to assist with meals, and that staff monitors so that mouth is cleared after each amount taken. Resident 50 is tolerating diet without signs or symptoms of aspiration. Staff review of Resident 50's restorative nursing program on September 13, 2021 documented that Resident 50 utilizes adaptive equipment, is limited due to upper extremity limitations, she is tolerating diet without signs and symptoms of aspiration. Further review of Resident 50's clinical record revealed documentation of Speech Language Pathology summary for services provided July 11, 2021 through August 9, 2021 which included evaluation for swallow function and oral function therapy, and recommendation for nursing restorative program for eating. After the investigation, the facility determined that one dietary staff member and one nursing staff member failed to ensure that the food served to the resident was the appropriate texture; the two aforementioned staff members were immediately suspended and were eventually terminated. The facility initiated a new system to alert staff when a resident is on an altered texture diet by placing a color coded sticker on all tray tickets for resident who are to receive an altered texture diet. All dietary and Nursing Assistant staff were re-educated on altered textured diets, and their roll during meal service to ensure all residents receive the appropriate texture food and fluids. Audits were initiated to ensure accuracy of all trays that included mechanically altered items, for each meal. Review of Resident 50's meal ticket on November 10, 2021, documented a mechanical soft diet, yellow colored mechanical soft diet sticker, meat documented as ground with extra gravy or sauce, and a maroon spoon and oyster fork (small size utensils to control the amount of food fed at each bite). Review of dietary staff education on November 10, 2021, completed July 13, 2021, and July 15, 2021, included diet accuracy for mechanically altered diets. Review of nursing staff education on November 10, 2021, performed on July 16, 2021, included signs and symptoms of a person with swallowing difficulties and how to recognize if a resident is having trouble with the swallowing process, safety facts, diet types and modifications for meal textures. Review of audits on November 10, 2021, revealed that tray accuracy audits were completed for each meal July 14, 2021 through [DATE]. 2021. Observation on November 10, 2021, revealed that on the wall outside of the dining room on the first floor there was a posting: Dining Protocol, revised date April 11, 2017, pantry aide to uncover the plate to review meal for accuracy, and the staff serving the resident should review the menu with the resident and ensure meal accuracy. Meal observations on November 8, 2021, revealed residents on the [NAME] unit received the appropriate diet textures and adaptive ware at the noon meal. Meal observations on November 9, 2021, revealed residents on the 1st floor and the [NAME] unit received the appropriate diet textures and adaptive ware at the noon meal. Interviews with the following Nursing Assistants on November 10, 2021, between 9:40 AM and 10:00 AM revealed that they were provided education regarding the different diet textures, where the information is located regarding each residents diet, and what their tasks are during meal service (NA 1, 2, 4, and DA/NA 3). Interview with Dietary Aide 1 on November 10, 202, at approximately 10:05 AM revealed that education was provided regarding the different diet textures, and the duties of the tray line checker/pantry aide. Prior to the full health survey the facility failed to provide the appropriate diet texture to one resident, which resulted in harm to that resident. The facility reported the incident timely, investigated the incident thoroughly, and initiated interventions in an effort to prevent a future incident. During the full health survey; a review of audits, staff education, and initiated procedures during meal service were observed. Staff interviews revealed that staff were educated, and knowledgeable regarding altered texture diets and their roll during meal service. Observations on several units fail to revealed continued or additional concerns regarding residents not receiving the appropriate diet texture. 28 Pa code 211.6(a)(b)(e) - Dietary Services

Based on personnel record review and staff interview it was determined that the facility did not perform Pennsylvania Nurse Aide Registry verification for three of three Temporary Nurse Aide (TNA) personnel records reviewed (TNA 2, 5, and 6). Findings include: Review of TNA 2's personnel record on November 10, 2021, at approximately 10:00 AM, revealed TNA 2's date of hire was August 27, 2021. Review of TNA 2's personnel record revealed that the facility did not perform a screening search on the Pennsylvania's Nurse Aide Registry to rule out previous disciplinary action(s) towards TNA 2. Review of TNA 5's personnel record on November 10, 2021, at approximately 10:05 AM, revealed TNA 5's date of hire was September 21, 2021. Review of TNA 5's personnel record revealed that the facility did not perform a screening search on the Pennsylvania's Nurse Aide Registry to rule out previous disciplinary action(s) towards TNA 5. Review of TNA 6's personnel record on November 10, 2021, at approximately 10:10 AM, revealed TNA 6's date of hire was July 19, 2021. Review of TNA 6's personnel record revealed that the facility did not perform a screening search on the Pennsylvania's Nurse Aide Registry to rule out previous disciplinary action(s) towards TNA 6. During a staff interview on November 10, 2021, at approximately 1:30 PM, Human Resources Director 1 confirmed that the facility did not perform verification of TNA 2, 5 and 6 via the Pennsylvania Nurse Aide Registry. 28 Pa code 201.19 Personnel policies and procedures

Based on observation, clinical record review, select facility document review, and staff interview, it was determined that the facility failed to ensure that one of 30 residents reviewed was assessed and determined clinically appropriate for self-administration of medications (Resident 13). Findings include: Review of Resident 13's clinical record revealed [DIAGNOSES REDACTED]. During interview with Resident 13 in his room on March 9, 2020, at 10:58 AM it was observed that there was a bottle of [MEDICATION NAME] mouth wash on his bedside table. When Resident 13 was asked about the mouth wash, he stated This is the only thing they will let me do myself. Review of Resident 13's current active physician orders [REDACTED].{May keep at bedside) PRN (as needed) also, Refresh Eye Drops Instill 1 drop to both eyes 4 times a day as needed May keep in room and self-administer (PRN) and Metronidazol Gel 1% ( a synthetic drug that is effective against certain bacteria and parasites; the topical forms (gels, creams, and lotions) are used for treating skin conditions) apply topically to face daily***May keep in room and self-administer (PRN). Review of facility policy titled IIA101: Self Administration of Medications with noted Effective Date: February 2019, revealed Policy In order to maintain the residents' highest level of independence residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents the facility and there is a prescriber's order to self-administer. Review of Procedures line A. revealed If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive (including orientation to times), physical, and visual ability to carry out this responsibility during the care planning process. Review of line C. revealed For those residents who self-administer , the interdisciplinary team verifies the residents' ability to self-administer medications by means of a skill assessment conducted on a periodic basis as determined by the facililty state regulations basis or when there is a significant change in condition. Review of line E. revealed If the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted. On March 11, 2020, facility was requested to provide documentation of Resident 13 being assessed for appropriateness to self-administer medications. On March 11, 2020, at approximately 2:30 PM interview with Director of Nursing (DON) revealed that Resident 13 had been living in the facility's Personal Care Center and following fracturing a femur had been admitted to hospital from which he was discharged and admitted to Skilled Nursing services of the facility on September 14, 2019. DON provided copy of a Care Plan Conference Summary which was held on September 14, 2019. Review of the summary revealed (Resident) does self-administer some things other than pills and (Resident) does show poor safety awareness at times related to his h/x (history) of falls but he can make decisions about his care, and self administer items requested. On March 12, 2020, during an interview with DON at 11:51 AM, , the DON revealed that they were unable to provide information that an assessment process had been put into place for Resident 13 to ensure that he was appropriate to self-administer medications. 28 PA code 211.12(D)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a significant change MDS assessment was completed timely after election of hospice care for one of 20 residents reviewed (Resident 64). Findings include: Review of the clinical record for Resident 64 revealed [DIAGNOSES REDACTED]. Further review of the clinical record revealed that Resident 64 started receiving hospice services on February 21, 2020. Review of the Significant Change MDS (Minimum Data Set) (a periodic assessment tool) revealed that it was not completed until March 9, 2020, sixteen days after hospice services began. During an interview with the Registered Nurse Assessment Coordinator (RN 1) on March 12, 2020 at 10:06 AM she confirmed that the significant change MDS was not done in 14 days. During an interview with the Nursing Home Administrator and Director of Nursing on March 12, 2020 at 11:56 AM they acknowledged that the significant change MDS was not done timely. 28 Pa. Code 211.5 (f) Clinical records

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 23 residents reviewed (Residents 20, 31 and 35). Findings include: Review of Resident 20's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 20's quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs), dated December 20, 2019, revealed that in Section H under appliances, none of the above was checked, meaning Resident 20 did not have an indwelling catheter, external catheter, ostomy, or received intermittent catheterization for the past seven days. Further review of section H revealed that under Urinary Continence, it was coded as not rated meaning resident had a catheter, urinary ostomy or had no urine output for the entire seven day look back period. Review of Resident 20's clinical record revealed that during the lookback period for the MDS, Resident 20 had an indwelling catheter. During a staff interview on March 12, 2020, at 10:09 AM the Registered Nurse Assessment Coordinator (RNAC) stated that there was an error on the MDS and indwelling catheter should have been checked. During a staff interview on March 12, 2020, at 11:47 AM the Director of Nursing (DON) confirmed that the MDS was coded incorrectly. Review of Resident 31's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 31's annual MDS assessment, dated January 6, 2020, revealed that in Section D, Mood, it was coded that Resident 31 said yes to the question of having thoughts that you would be better off dead, or of hurting yourself in some way and Resident 31 had these thoughts over the past 7-11 days. On March 12, 2020, at approximately 8:30 AM the facility provided a statement from the director of social services stating that a documentation error occurred and self harm/worthless thoughts were not reported during Resident 31's interview. Review of Resident 31's facility form titled Periodic Social Work Assessment for the MDS period of December 31, 2019-January 6, 2020, revealed that Resident 31 did not have self harm/worthless thoughts. Further review of Resident 31's annual MDS, dated [DATE], revealed that in section N, Medications Received, it was coded that Resident 31 received an antipsychotic medication on seven out of the past seven days. In section N0450, Antipsychotic Medication Review it was coded that Resident 31 did not receive an antipsychotic medication since admission/entry or reentry or the prior assessment. During a staff interview on March 12, 2020, at 10:09 AM the RNAC stated that Section N0450 was coded incorrectly on Resident 31's MDS assessment. During a staff interview on March 12, 2020, at 11:47 AM the DON confirmed the MDS errors. Review of Resident 35's clinical record revealed [DIAGNOSES REDACTED]. Review of nursing progress notes dated December 11, 2019, revealed that as a result of Resident 35 complaining of burning with urination, the physician was notified and new orders were received for a urinalysis and culture and sensitivity (urine test used to determine if infection is present and the exact organism responsible for the infection). Review of urine culture laboratory report dated December 15, 2019, revealed that the urine sample tested on [DATE], tested positive for infection. Review of nursing progress notes dated December 16, 2019, revealed new orders were received for [MEDICATION NAME] (antibiotic) for a urinary tract infection. Review of physician progress notes [REDACTED]. Review of Resident 35's comprehensive significant change MDS dated [DATE], revealed that the assessment was not coded to indicate that he had a urinary tract infection within 30 days of the assessment date. During an interview with the RNAC on March 12, 2020, at 10:07 AM, she confirmed that this assessment should have been coded to indicate that Resident 35 had a urinary tract infection within 30 days from the assessment date. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.12(d)(1)(5) Nursing services.