Every finding on record at Inners Creek Skilled Nursing and Rehabilitation Ce

Based on review of facility policy, documentation provided by the facility, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure one of five residents reviewed was free of verbal abuse (Resident 5).Findings include: Review of facility policy, titled Abuse Prohibition, revised November 14, 2025, read, in part, the center will implement an abuse prohibition program through screening of potential hires; prevention of occurrences; identification of possible incidents or allegations which require investigation; investigation of incidents; protection of residents during investigation; and reporting incidents, investigations and facility response to the results of their investigations. Review of Resident 5's clinical record documented diagnoses that included osteoarthritis (degenerative joint disease where the protective tissue cushioning the ends of the bones wears away, causing joint pain), polyneuropathy ( peripheral nerves throughout the body or damaged or malfunctioning at the same time causing numbness, tingling and weakness in the hands and feet), depression (feelings of severe despondency and dejection), anxiety (a feeling of worry, nervousness, or unease), and muscle weakness. Review of Resident 5's care plan documented that she requires two-person assistance with transfers. Review of facility provided information revealed Employee 1 (Nursing Assistant) requested assistance from Employee 2, (Nursing Assistant) in returning Resident 5 back into bed. Employee 1's statement revealed that upon Employee 2 entering the Resident's room, Employee 2 spoke to the Resident in an aggressive and inappropriate manner; allegedly telling the Resident to shut up and referring to the Resident as a b*tch. Employee 1 reported that after the Resident was transferred into bed, Employee 2 handled the Resident roughly while repositioning her. Employee 1's statement further documented that as Resident 5 was speaking, Employee 2 placed her hand over the Resident's mouth and stated, shut the f*ck up. Employee 1 reported the incident immediately. Registered Nurse assessment was completed, no injury noted. Employee 2 was escorted from the facility, pending the investigation. During the facility's interview, Employee 1 stated that she instructed Employee 2 to leave the room and she could finish the Resident's care. Employee 2 then proceeded to tell Resident 5 that she didn't like her and instructed the Resident to shut up. Shortly thereafter, Employee 2 received a telephone call and exited the room. The facility's interview with Resident 5 revealed the same account of interactions with Employee 2. Resident 5 was her own representative and was notified of the actions being taken. Employee 2 was interviewed and denied doing anything. The attending physician, [NAME] County Office of Aging, and the [NAME] Regional Police Department were notified. The police interviewed Resident 5, who didn't wish to press charges. Employee 2 was terminated and was reported to the PA State Licensing Board. The Department of State Professional Compliance Office emailed a letter to the Director of Nursing on July 22, 2026, to inform the facility that their reported complaint was forwarded to the PA Dept of Health because the licensing board has no jurisdiction over Nursing Assistants. Abuse training in the facility's Health Stream system was initiated in January 2026; Employee 2 completed the training on January 29, 2026. Interview with Resident 5 on July 27, 2026, at 11:50 AM, revealed she had no concerns post incident. She stated that was the first and only incident with a staff member. The staff treat her well, and she receives the care she needs. She felt the facility handled the investigation timely, was satisfied with the facility investigation and response to incident. She confirmed she didn't sustain any injury, feels fine psychosocially, and feels safe in the facility. Interview with the Nursing Home Administrator on July 27, 2026, at 3:45 PM, revealed that abuse prevention is taken seriously, that is why it is reviewed multiple times throughout the year. It was also revealed that if Employee 2 needed to take a break, she should've excused herself. 28 Pa. code 201.14(a) Responsibility of Licensee28 Pa. code 201.18(b)(1) Management28 Pa. Code 201.29(c) Resident rights28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on facility policies, review of the clinical record, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs of the resident for one of five residents reviewed (Resident 1).Findings include: Review of facility policy, titled Medication Errors, revised July 1, 2024, read, in part, a medication error includes medication administered not in accordance with the prescriber's order to include the incorrect medication. Review of facility policy, titled Falls, revised March 15, 2024, read, in part, evaluate the resident for injury post-fall and provide appropriate and timely care, notify the physician of the fall report physical findings and extent of injuries. Any resident who sustains an injury to the head from a fall will be observed for neurological abnormalities by performing neurological check. The physician will be notified of an abnormal finding. The Resident Representative will be notified of the fall and any follow-up treatment. Review of facility policy, titled Change in Condition, revised July 1, 2024, read, in part, the facility must immediately inform the resident's physician and the resident representative when an accident involving the resident which results in injury and has the potential for requiring physician intervention. To provide appropriate and timely information about changes relevant to the residents' condition. Review of Resident 1's clinical record documented diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement), hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles) left non-dominant side, history of falling, and dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking). Review of the medication error report dated July 20, 2026, at 10:00 PM, documented Resident 1 took a medication cup containing apple sauce and one melatonin pill off the top of the medication cart and ingested it. He was assessed at the time of the incident, no injury noted. Review of Resident 1's clinical record revealed that no Neurological checks or alert charting were initiated. The Certified Registered Nurse Practitioner (CRNP) was notified on July 20, 2026 at 11:58 PM; however, the medication error report documented that the Resident Representative wasn't notified until July 21, 2026, at 6:35 AM. Review of the fall report dated July 20, 2026, at 11:00 PM, documented Resident 1 was found on the floor alongside his bed. He was assessed at that time and sustained an abrasion to his scalp and a hematoma to his face. Neurological checks were initiated and within normal limits. Progress note dated July 20, 2026, at 11:21 PM, documented Resident 1 had an unwitnessed fall and that the provider and Responsible Party were notified. Review of the fall report for July 21, 2026, at 2:50 AM, documented Resident 1 was found on the floor alongside his bed. He was assessed at the time, and no additional injuries were noted. Neurological checks were re-started and initially were within normal limits. However, at 8:35 AM, Resident 1 went from being alert to being drowsy, and his pupils being equal round and reactive to light to being pinpoint. The CRNP was notified at 6:46 AM (contact was made at that time), however, there was no documentation the CRNP was informed of the change in the Resident's neurologic status. The medication error report document the Resident Representative wasn't notified at that time; documented time of notification July 21, 2026, at 6:35 AM. Progress note dated July 21, 2026, at 3:40 AM, documented when completing neurological checks, the Resident was found on the floor next to his bed; will pass on to next shift to notify the provider and the Responsible Party. Progress note dated July 21, 2026, at 8:54 AM, documented the Resident was not able to take his medications at that time because he was very drowsy. Review of the fall report for July 21, 2026, at 10:00 AM, documented Resident 1 was found on the floor alongside his bed. He was assessed at that time, and pupils were pinpoint and nonreactive. It was noted that the provider and daughter were contacted, a time wasn't documented. The Resident was sent to the Emergency Room. Facility reported event to the Department of Health on July 21, 2026, also documented mental status noted to be altered as the Resident wasn't responding to verbal or tactile simulation. Review of emergency room (ER) Summary report dated July 21, 2026, documented Resident 1 was transferred to the ER due to lethargy and pinpoint pupils. The Resident wasn't on a blood thinner, however, the Resident reported he got a different Resident's medications last night. He had a bruise on his left flank and abrasions on his right forehead. Pupils are equal and reactive to light, 2 mm. Hypertensive, hypothermic, and tachypneic (rapid and shallow breathing). Computed Tomography (CT) scan of head and chest was unremarkable. Sepsis workup revealed infection, source unclear; broad spectrum antibiotics ordered. Resident admitted to the hospital for hypothermia. Interview with Nursing Home Administrator (NHA) on July 27, 2026, at 2:37 PM, revealed the facility had a meeting with one of their providers offices because it was taking a long time for the practitioners to return calls to the facility due to staff were on vacation that week. NHA assumed the time documented as notified the MD/CRNP was the actual the time they spoke with someone. Interview with Director of Nursing (DON) on July 27, 2026, at 3:25 PM, revealed a Nurse can make the judgement to send a Resident out to the hospital without a physician's order. The DON was not sure why the nurse didn't feel it was necessary to send the Resident out when there was a neurological change. Per email communication with DON on July 28, 2026, at 12:17 PM, it was revealed nursing should have notified the provider when the change in condition was noted. It had been addressed internally through the facility performance improvement process and house wide education. It was also revealed that Resident 1 was documented as a do not resuscitate with comfort as the goal, so the Registered Nurse Supervisor did not feel as though transfer was warranted at the time. The supervisor has since been educated. Interview with the NHA and don on July 28, 2026, at 1:00 PM, the surveyor revealed the concern that the Resident Representative was notified timely of the medication error and two falls. No further information was provided. The facility failed to notify the provider timely of a change in neurologic condition and failed to notify the family timely regarding the medication error and two falls; one of which Resident 1 sustained a laceration and hematoma. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.10(a)(c) Resident care policies28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on observations, policy review, and staff interviews, it was determined that the facility failed to maintain an effective pest control program so that the facility is free of pests in two of five resident areas observed (Station 3 and the Rehabilitation area) and one kitchen area observed. Findings Include: Review of the facility's policy, titled Safe and Homelike Environment, reviewed November 14, 2025, read, The resident/patient.has the right to a safe, clean, comfortable and homelike environment. Review of the facility's policy, titled Pest Control, dated February 2025, read, A program will be established for the control of insects and rodents for the Dining Services Department. Also, All preparation, service, and storage areas will be monitored regularly for any signs of pest/vermin. The center staff will be notified immediately of any concern verbally and in writing. An observation in the Station 3 nourishment room on April 20, 2026, at 9:26 AM, revealed multiple gnats, both alive and dead, on the room wall, on the floor, and equipment stored by staff for resident use. An observation on the Rehabilitation Hall on April 20, 2026, at 9:48 AM, revealed flying gnats in the hallway outside of resident rooms. An observation in the facility's kitchen on April 20, 2026, at 10:38 AM, revealed gnats, both alive and dead, flying in the kitchen and stuck on wall areas. An interview with the Food Service Director (Employee 2) at 10:40 AM, confirmed the kitchen drain produces gnats, and there are roaches in the kitchen coolers and/or refrigerator fans. An interview with the Nursing Home Administrator on April 20, 2026, at 12:19 PM, revealed that the facility is seeking out a new pest control company. The interview also revealed that kitchen staff were recently educated on pest control and were required to institute a cleaning schedule for that area. 28 Pa. Code 201.18 (b) (1) Management

Based on observations, policy review, and staff interviews, it was determined that the facility failed to ensure food is stored, prepared, and distributed in accordance with professional standards for food service safety for one nourishment room observed (Station 3) and observations of two items of equipment in the kitchen (one ice machine and one three-compartment sink).Findings Include: Review of the facility's policy, titled Ice Chests, reviewed July 15, 2025, read, in part, Use an ice scoop to access ice.Grasp the handle of the scoop only and avoid touching the portion that contacts the ice. Store the ice scoop in a clean, uncovered holder. An observation in the Station 3 nourishment room on April 20, 2026, at 9:26 AM, revealed a non-working ice machine. The observation revealed the staff's use of a cooler, sitting on the counter, with melted ice inside. The observation revealed the scoop used for dispensing the ice to residents was sitting directly on top of the cooler. The observation also revealed a towel on the floor under the ice machine, as well as areas of debris and dirt surrounding the ice machine. An observation in the Station 2 nourishment room on April 20, 2026, at 10:07 AM, revealed multiple cups and lids on the floor under the ice machine as well as debris and dirt. An interview with the Nursing Home Administrator (NHA) on April 20, 2026, at 12:16 PM, revealed that the housekeeping department is responsible for cleaning the nourishment rooms. The interview also revealed the ice scoop should be contained and not exposed in order to prevent contamination. Review of the facility's policy, titled Food and Nutrition Services Policies and Procedures, dated May 1, 2023, read, in part, Food services areas are maintained in a clean and sanitary condition at all times. Observations in the facility's kitchen on April 20, 2026, at 10:49 AM, revealed an area in front of the ice machine with a significant amount of water on the floor. An immediate interview with the Dining Services Manager (Employee 3) revealed the ice machine to be out of order. The observations also revealed one large dish tub and one silver pan under the ice machine. Employee 3 revealed that those items were on the floor to catch the leaking water. An additional interview in the kitchen with Employee 3, revealed a plastic tub under the 3-compartment sink. Employee 3 revealed that the drain was leaking, and the plastic tub was placed there to catch the water from the sink to prevent spillage onto the kitchen floor. An interview with the NHA on April 23, 2026, at 9:42 AM, revealed the facility has plans in place to address the concerns observed in the kitchen. 28. Pa. Code 201.18 (b) (1) (3) Management

Based on observations, policy review, and staff interviews, it was determined that the facility failed to ensure each resident the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely, in one of three shower rooms observed (Station 3).Findings Include: Review of the facility's policy, titled Safe and Homelike Environment, reviewed November 14, 2025, read, in part, The resident/patient has the right to a safe, clean, comfortable and homelike environment. The policy continued, The Center must provide. Housekeeping and Maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. An observation in the shower room on Station 3 on April 20, 2026, at 9:30 AM, revealed one shower head wrapped with tape and a large piece of white linen. The observation also revealed non-working showers in other areas of the shower room. An interview with the Licensed Practical Nurse (Employee 6) revealed that the shower heads had been reported to be out of order and in need of repair. An interview with the Nursing Home Administrator on April 23, 2026, at 9:41 AM, revealed that the facility has ordered 15 new showerheads to replace the non-functioning ones throughout the facility. 28 Pa. Code 201.18 (b) (1) Management

Based on a clinical record, policy review, and staff interview, it was determined that the facility failed to ensure that residents received routine dental services for one of six resident records reviewed (Resident 4).Findings Include:Review of the facility's policy, titled Dental Services, revised on September 15, 2025, reads, in part, Centers [facility] will provide or obtain from an outside resource routine and emergency dental services, including 24-hour emergency dental care, to meet the needs of each patient.The policy continued, Routine dental services means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedures, e.g., taking impressions for dentures and fitting dentures.Review of Resident 4's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and chronic pain, with an admission date to the facility of November 1, 2022.Review of Resident 4's interdisciplinary plan of care revealed documentation that included an identified problem for a potential for dental or oral cavity health problem d/t [due to] aging teeth.Continued review of Resident 4's clinical record revealed no dental consultations for access to routine and/or emergent dental care since the admission date in 2022.Electronic Mail correspondence with the Administrator in Training (Employee 1) and the Director of Nursing on December 30, 2025, at 1:35 PM, confirmed Resident 4 had not been seen by a dentist for routine care, and the facility is attempting to seek means to have the Resident signed up for routine and/or emergent dental services.28 Pa. Code 201.18 (a) Management28 Pa. Code 211.12 (d) (5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to post the current daily nurse staffing information that included the facility name, current date, resident census, and the total number of direct care hours for licensed and unlicensed nursing staff, for one posted nurse staffing document observed (facility lobby). An observation of the facility's nurse staffing information, on December 29, 2025, at approximately 8:30 AM, revealed the most recent posting with information dated December 27, 2025.An interview with the Administrator in Training (Employee 1), on December 29, 2025, at 9:41 AM, confirmed that the posted information should have been updated by the night shift staff and weekend staff. The interview revealed the posted information would be updated immediately to reflect the current date and other required information.28 Pa. Code 201.14 (a) Responsibility of licensee

Based on document review, clinical review, and staff interview, it was determined that the facility failed to obtain diagnostic services to meet the needs of its residents and ensure those services are obtained promptly for one of two residents reviewed for falls (Resident 1).Findings Include:Review of Resident 1's clinical record revealed diagnoses that included Right Femur Fracture and Alzheimer's Disease (a progressive brain disease, the most common cause of dementia, that gradually destroys memory, thinking, and reasoning skills, leading to severe memory loss, confusion, and difficulty with daily tasks, behavior changes, and eventual inability to carry out even simple activities).Review of Resident 1's falls, during December 2025, revealed a fall dated December 7, 2025. According to the incident report, staff documented the following immediate action: the Certified Registered Nurse Practitioner (CRNP) notified and ordered STAT x-ray R [hip] . The time noted of the notification to the CRNP was documented as 9:20 PM.In medical terms, STAT is defined as immediately or right away. Review of the document, titled Preventive Diagnostics, dated the following day, December 8, 2025, revealed the facility's contracted mobile X-Ray provider performed the X-ray on Resident 1 at 12:09 PM.The X-ray read right subcapital hip fracture is noted. Osteopenia [reduced bone mass] noted. Fracture as noted of unknown chronicity.Electronic mail correspondence, with the Director of Nursing, on December 31, 2025, at 1:05 PM, revealed The x-ray was entered incorrectly. It was entered as one-time only instead of stat. The X-ray company states that the turnaround time for stat requests is four hours. We have notified all providers that in-house stat X-rays will not be done related to the turnaround time, and if it is necessary to obtain the X-ray stat, the resident will need to be sent to the hospital.28 Pa. Code 211.12 (d) (5) Nursing services

Based on observations, policy review, and resident and staff interviews, it was determined that the facility failed to ensure each resident is treated with respect, care, and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality, for one of eight residents observed (Resident 6). Findings Include:Review of the facility's policy, titled Resident Rights Under Federal Law, reviewed June 12, 2025, read, in part, that the purpose of the policy is To treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of their self-esteem and self-worth. The policy continued, To protect and promote the rights of the resident.Review of Resident 6's clinical record revealed diagnoses that included congestive heart failure (a chronic condition where the heart muscle weakens or stiffens, making it unable to pump enough oxygen-rich blood to meet the body's demands, leading to fluid buildup [congestion] in the lungs, legs, and other organs, causing symptoms like shortness of breath, swelling, and fatigue) and community-acquired pneumonia ( a lung infection caught outside hospitals, causing symptoms like cough [with phlegm], fever, chills, and shortness of breath, trigged by bacteria, viruses or fungi. It's a common and serious illness, especially for the elderly, and treatment often involves antibiotics, though viral causes may need supportive care.)Resident 6 was being admitted to the facility, on December 29, 2025, at 12:43 PM. Observation revealed a transportation team attempting to admit Resident 6 into a room already occupied by Resident 8.The observation prompted the Licensed Practical Nurse (Employee 3) to immediately yell, She can't go in there because she's Black. Employee 3 attempted to make telephone contact with the admissions team regarding the placement of Resident 6 in the room with Resident 8.Resident 6 was removed from the room by the transport team and presented to the nurses' station desk via stretcher. The transport person informed the staff that Resident 8 began yelling and called Resident 6 a n***** (a derogatory racial slur most often levied towards Black Americans).Resident 6 was transferred by the transport team to another area and room within the facility with the assistance and interventions of Employee 3.An interview with Employee 3, on December 29, 2025, at approximately 12:50 PM, revealed that staff have knowledge that Resident 8 is described as racist and that the staff intervene to prevent incidents or disruptions based on that knowledge. The interview also revealed that the staff are typically notified prior of admissions and would have informed staff not to admit Resident 6 to Resident 8's occupied room. An interview with Resident 6 on December 29, 2025, at 12:57 PM, revealed that Resident 8 indeed called her the racial slur, and Resident 6 stated, That was the last thing I expected. The interview revealed Resident 6 planned on participating in rehabilitation care and services, with a goal to return home with her daughter as soon as possible.An interview with the Director of Nursing and the Administrator in Training (Employee 6) on December 29, 2025, at approximately 1:40 PM, revealed that the Director of Admissions (Employee 5) was not present for work on that date. The interview revealed the facility will review its process for new admissions to determine how such an interaction could have been prevented. 28 Pa. Code 201.18 (b) (1) Management28 Pa. Code 201.29 (c) (c.3) (4) Resident rights

Based on clinical record review, review of facility policy, and staff interview, it was determined that the facility failed to ensure that residents were free from sexual abuse, which resulted in actual harm as evidenced by emotional distress and a vaginal wound for one of four residents reviewed for abuse (Resident 1). Findings include:Review of facility policy, Abuse Prohibition, revised October 24, 2022, revealed, Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/patient property, and exploitation for all patients .Sexual abuse is a non-consensual sexual contact of any type with a patient. It includes but is not limited to sexual harassment, sexual coercion, or sexual assault.Review of Resident 1's clinical record revealed diagnoses that included Alzheimer's disease (gradual loss of memory, thinking skills, and self-care abilities) and heart failure (occurs when the heart doesn't pump blood as well as it should).Review of Resident 1's most recent BIMS score (Brief Interview for Mental Status) dated August 26, 2025, revealed a score of 3 out of 15, indicating severe cognitive impairment.Review of Resident 2's clinical record revealed diagnoses that included Parkinson's Disease (movement disorder that affects the nervous system and worsens over time) and dementia (decline in cognitive functioning that affects memory, thinking, and social abilities).Review of Resident 2's most recent BIMS score, dated July 7, 2025, revealed a score of 11 out of 15, indicating moderate cognitive impairment.Review of facility incident report dated September 13, 2025, at 6:15 AM, revealed that two nurse aides were in Resident 1's room giving care to Resident 1's roommate when they heard crying from behind the curtain. When the curtain was drawn, they found Resident 2 laying naked beside Resident 1 in her bed. Resident 1's brief had been removed. Staff observed that Resident 2 had one arm around Resident 1, and his fingers were inserted into Resident 1's vagina.Staff immediately addressed Resident 2 who removed himself and returned to his room across the hallway.Review of Employee 1's (Nurse Aide) witness statement, undated, revealed, I and another aide went to get [Resident 1's roommate] out of bed. I went to look behind the curtain because [Resident 1] was crying. We then saw [Resident 2's] clothes all the way off and him play with her private parts.Review of Employee 2's (Nurse Aide) witness statement, dated September 13, 2025, revealed, Me and another CNA [Certified Nurse Aide] went to get [Resident 1's roommate] out a bed. She went to look behind the curtain because [Resident 1] was crying. We then saw [Resident 2's] clothes all the way off and [Resident 1's] diaper off and him play with her private parts.Review of Employee 3's (Licensed Practical Nurse) witness statement, dated September 13, 2025, revealed, Around 0615 I was using the bathroom and heard someone yelling 'Nurse!' When I came down the hallway to assess the situation, 3 CNA's told me that [Resident 2] was found in [Resident 1's room] with his clothes off laying in bed with [Resident 1], [Resident 1's] clothes and brief were off of her and CNA stated [Resident 2] had his hand in [Resident 1's] genital area. CNA stated that [Resident 1] was crying while [Resident 2] was touching her. CNAs removed [Resident 2] from [Resident 1's room] and notified me when they saw me in the hallway. I immediately notified RN [Registered Nurse] supervisor.Resident 1 was transported to the emergency department following the incident and a forensic exam was performed. Review of hospital visit documentation dated September 13, 2025, revealed that, upon exam, a small tear on the outside of Resident 1's labia (part of the external female genitalia) was discovered.At the time of the incident, both Resident 1 and Resident 2 resided on the locked memory care unit.Resident 1 was moved to another nursing unit on September 13, 2025, and Resident 2 was placed on 1:1 supervision following the incident.During an interview with the Nursing Home Administrator on September 16, 2025, at 1:47 PM, he revealed that it's the facility's goal that residents are free from abuse.28 Pa. Code 201.18(b)(1)(e)(1) Management28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 211.12(d)(1) Nursing services

Based on facility document review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide physician ordered enriched diet and nutritional supplements for four of five residents reviewed (Resident 1, 3, 4, and 5).Findings include: Review of Resident 1's clinical record documented diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important [NAME] functions), dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking), muscle weakness, psychosis (a health condition characterized by a loss of contact with reality), dysphagia (difficulty swallowing), and protein calorie malnutrition (a condition where a person's body doesn't get enough protein and calories to meet its needs). Review of Resident 1's physician orders included Regular/Liberalized diet, Dysphagia Advanced texture, thick liquids-Nectar consistency, initiated July 22, 2025, and nutritional treat 4 times a day, initiated July 31, 2025. Review of Resident 1's care plan included a focus area for nutritional risk related to dementia, high blood pressure, chronic kidney disease (kidneys don't function as they should), congestive heart failure (the heart doesn't pump blood as it should), and a history of stroke' diuretic therapy, chronic malnutrition related to ongoing non-significant weight loss, low body mass index (BMI - estimated body fat percentage based on height and weight) for age, initiated October 3, 2023, and revised on August 31, 2024. Interventions included the following: Provide and serve diet as ordered: Enhanced, dysphagia advanced texture, thin liquids, initiated October 3, 2023, and revised on May 13, 2024; provide extras on trays as ordered for additional nourishment, initiated October 13, 2023, and revised March 14, 2024; provide supplement as ordered: nutritional treat twice a day, initiated October 13, 2023, and revised on March 14, 2024. Resident 1's care plan did not include the nutritional treat four times a day per physician orders. Observations on August 7, 2025, at 12:15 PM, Resident 1 was feeding himself in the dining room, being observed by the Speech Therapist. Observation revealed he did not receive applesauce (his dessert for that meal) or a nutritional treat. Review of Resident 3's clinical record revealed diagnoses that included paraplegia (loss or impairment of motor and sensory functions in the lower half of the body), history of traumatic brain injury, and protein calorie malnutrition. Review of Resident 3's physician orders included regular/liberalized diet, regular texture, standard thin liquids consistency, initiated January 8, 2025, and house supplement three times a day, initiated February 13, 2025. Review of Resident 3's weight history (2025) documented 129.4 lb on May 6th; 130 lb on April 4th; 135.6 lb February 4th; and 145 lb January 3rd; significant loss noted in February. Review of Resident 3's care plan included a focus area related to history of traumatic brain injury, edema, schizoaffective disorder, dementia, moderate malnutrition, decreased nutrient needs due to paraplegia, likes to order delivery food; significant/ongoing weight loss requiring therapeutic supplementation, initiated December 12, 2018, revised March 29, 2025. Interventions included built up fork and spoon, scoop plate, initiated April 22, 2019, revised on April 26, 2021; enhanced, regular texture, thin liquids diet, initiated April 17, 2019, revised May 16, 2024. Observation on August 7, 2025, at 1:09 PM, revealed Resident 3 failed to receive the enhanced chocolate milk and house shake. Surveyor had asked for the guidelines for the Enriched food diet on August 7, 2025, at 3:00 PM. Per the Nursing Home Administrator (NHA), there wasn't written guidelines. When a resident is ordered enriched food diet, additional items are added to the resident's tray such as cookies, enhanced chocolate milk, or pudding. Review of Resident 4's clinical record documented diagnoses that included hemiplegia left nondominant side (paralysis or severe weakness on one side of the body) and vascular dementia. Review of Resident 4's physician orders included regular/liberalized diet, dysphagia advanced texture, standard thin liquids consistency, enhanced, may have breads, initiated October 29, 2024; fluid restriction-1920 cc daily: nursing provides day shift-240 ml, evening shift-240 ml, night shift-120 ml, and dietary provides breakfast-540 ml, lunch-480 ml, dinner-300 ml, initiated December 4, 2023. Review of Resident 4's care plan included a focus area for nutritional risk related to congestive heart failure (heart doesn't pump blood the way it should), diuretic use and frequent fluid shifts causing weight fluctuations; therapeutic diet was liberalized due to history of poor intake and texture modified diet; need for fluid restriction; significant weight loss x 1 year related to combination of declined intake/diuretic therapy, initiated November 4, 2022, and revised February 6, 2025. Interventions included nutritional treat at bedtime, initiated January 17, 2024, and revised March 1, 2024. Observations on August 7, 2025, at 1:15 PM, revealed Resident failed to receive the following items per the residents tray ticket: 8 ounces of Lactaid milk, cold cereal, and oatmeal cream cookie. Per physician order, the Resident should've received 480 ml fluid on her meal tray and she only received 240 ml (juice and Jello). Review of Resident 5's clinical record documented she was admitted to the facility on [DATE], and diagnoses that included multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves, disrupts the communication between the brain and the body), pressure ulcer sacral region and left heel, and protein calorie malnutrition. Review of Resident 5's physician orders included regular/liberalized diet, regular texture, standard thin liquids consistency for admission protocol, initiated August 2, 2025; Ensure plus with meals initiated August 6, 2025. Review of Resident 5's weight history documented 65 lb on August 2nd, 2025, and 73 lb on August 6th, 2025. Review of Resident 5's care plan included a focus area for nutritional risk related to severe malnutrition, anorexia, nutritional marasmus (a form of severe malnutrition caused by a lack of calories and protein- muscle wasting, fat depletion), initiated August 4, 2025, and created by Employee 4 (Registered Nurse). Interventions included honor food preferences within meal plan, monitor intake at all meals, offer alternate choices as needed, alert dietitian and physician to any decline in intake, initiated August 4, 2025. Progress note dated August 1, 2025, documented a change in appetite, Difficulty chewing, decreased fluid intake. Meal supplements ordered. Resident reported loss of appetite and difficulty chewing food, prefers soft food. Review of history and physical dated August 4, 2025, read, in part, malnutrition and multiple wounds, care plan regarding malnutrition included dietitian consult, vegetarian, nursing to encourage intake and start supplemental shakes with meals. Review of Psychiatry progress note dated August 4, 2025, read, in part, the Resident reports not wanting to eat much in the facility due to food choices and asked to speak with dietary and requested protein shakes. Resident decreased protein levels when in hospital, cachectic with severe muscle wasting, discussed dietary needs with dietitian and nurse, recommended protein supplements to dietitian. Review of note dated August 4th, 2025, documented the Resident, Resident Representative and Social Services were in attendance for the post-admission care plan, a copy of the medication list, and dietary instruction was provided. The care plan was reviewed and updated. Further review of the clinical record failed to document a progress note or an initial assessment by the Registered Dietitian as of August 7th, 2025; 7 days post admission. Observation on August 6, 2025, at 12:45 PM, revealed Resident 5 failed to receive the following items per the residents tray ticket: Stuffed shells, dessert of the day (diced pears), and diet fruit cup. The Resident received orzo with tomato sauce and cheese (the cheese was not visible and the orzo appeared dry), a side salad, hot tea and 4 ounces of apple juice, and 4-ounce mighty shake. Interview with the Resident 5 on August 6, 2025, at 12:45 PM, revealed that she is vegetarian, and had provided her preferences to staff but doesn't receive what she has requested, which included Greek yogurt vanilla or plain, and cottage cheese. She also noted that was the first time she had received a supplement of any kind, which was a mighty shake (contains 220 calories and 6 grams of protein). The Resident revealed she was to be on a high protein diet, and the facility had not provided high protein foods. While at home, she consumed a nutritional drink that contained 42 grams of protein for 12 ounces, which her husband has been providing, as well as Greek yogurt and cottage cheese. It was also revealed that the yogurt the facility has provided, nonfat plain yogurt, contained only 4 grams of protein. Interview with Employee 1 (Food Service Director) on August 6, 2025, at 1:10 PM, revealed she was on vacation the previous week when Resident 5 was admitted and obtained her preferences on August 4th, 2025. The Resident didn't receive the stuffed shells due to not being available. The stuffed shells were ordered and will be delivered that week. Employee 1 formulated a vegetarian meal plan based on Resident 5's preferences to enable dietary staff a guide on what to provide if the main and alternate menu items would not suffice. Items included: plain yogurt, toast with peanut butter, grilled cheese, tomato soup, peanut butter and jelly sandwich, chef salad with extra cheese (no meat or eggs), cottage cheese and fruit plate, macaroni and cheese, stuffed shells. Employee 3 (Registered Nurse) documented to Employee 1 that she reached out to the Dietitian regarding Resident 5, and the Dietitian thought the resident required extra calories and nutritional supplements and would submit a request for an order. Review of Resident 5's Medication Administration Record (MAR- documentation of administration of physician orders) documented ensure plus with meals was administered 12:00 PM on August 6th, 2025. Observation and interview on August 7, 2025 at 12:55 PM revealed Resident 5 did not receive the Ensure plus. Interview with The Director of Nursing on August 7, 2025, at 11:30 AM, it was revealed that there are two Registered Dietitians who work remotely to provide services to the facility. It was also revealed that they don't attend care plan meetings remotely. Nutrition recommendations are communicated to the Unit Managers and they will complete a request form and place it in the physician book to be reviewed. During an interview with the NHA on August 7, 2025, at 3:30 PM, the concern regarding items missing from four resident's trays to include enhanced meal items and nutritional supplements, and lack of a timely nutrition assessment and direct communication with Resident 5 by a Registered Dietitian were communicated. No further information was provided. The facility failed to ensure physician orders and care plan interventions were followed to maintain nutritional status of four residents. The facility failed to provide timely nutritional assessment, participation in a care conference, and have direct communication with Resident 5 to provide resident-centered care for a nutritionally compromised resident. 28 Pa, Code 201.18(b)(1) Management28 Pa. Code 211.12(d)(3) Nursing services

Based on facility policy review, facility documentation reviews, clinical record reviews, and staff interviews, it was determined the facility to ensure that each resident is free from abuse for two of six of residents reviewed (Residents 2 and 3).Review of facility policy titled OPS300 Abuse Prohibition with a last revision date of October 24, 2022, revealed [in part] the following:Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish.Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Injuries of unknown source are defined as an injury with both of the following conditions: The source of the injury was not observed by any person or the source of the injury could not be explained by the patient; and the injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time.5. Actions to prevent abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of patient property, will include: 5.2 identifying, correcting, and intervening in situations in which abuse, neglect, and/or misappropriation of patient property is more likely to occur.6. Staff will identify events - such as suspicious bruising of patients, occurrences, patterns, and trends that may constitute abuse - and determine the direction of the investigation. This also includes patient-to-patient abuse.6.3 If the suspected abuse is patient-to-patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation and an investigation will be completed.6.3.1 The Center will provide adequate supervision when the risk of patient-to-patient altercation is suspected.6.3.2 The Center is responsible for identifying patients who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation.6.3.3 The patient representative and physician will be notified and any follow-up recommended will be completed (e.g., psychiatric evaluation).6.3.4 Options for room changes will be provided based on the situation.6.3.5 The Center should seek alternative placement for the patient exhibiting the abusive behavior, if warranted.6.4 Injuries of unknown origin will be investigated to determine if abuse or neglect is suspected;8. The Center will protect patients from further harm during an investigation.8.1 Provide the patient with a safe environment by identifying persons with whom he/she feels safe and conditions that would feel safe.8.2 Assign a representative from Social Services or a designee to monitor the patient's feelings concerning the incident, as well as the patient's involvement in the investigation;9. The Administrator or designee will:9.4 Take steps to resolve patient and family issues, concerns and allegations and clearly recording the same; and9.5 Take appropriate corrective actions. Review of Resident 2's clinical record revealed diagnoses that included heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs) and adjustment disorder with mixed disturbance of emotions and conduct (a mental health condition characterized by emotional and behavioral symptoms in response to a significant stressor, impacting daily functioning). Review of Resident 2's clinical record progress notes revealed a noted dated April 21, 2025, at 9:38 PM, which indicated that he stated he wanted to be moved because his roommate (Resident 3) had hit him on his arm with a reacher. Resident 2 indicated that this had not been the first time this had occurred. The note further indicated that there were no other beds available at the time of the incident and that administration and social services will discuss situation the next morning. Review of Resident 2's facility provided incident report for the resident-to-resident altercation with Resident 3 dated April 21, 2025, at 9:00 PM, revealed a note dated April 22, 2025, by the Director of Nursing which indicated Resident 2 would be evaluated for moving/changing rooms. Review of Resident 2's clinical record failed to include any documentation regarding his request to change rooms or an evaluation of such between April 15, 2025, and June 15, 2025. Review of Resident 2's clinical record progress notes revealed a note dated June 15, 2025, at 6:06 PM, which indicated he had got into a verbal/physical altercation with his roommate-Resident 3 and that he had hit his roommate-Resident 3 with his walker which also caused Resident 2 to experience a fall. Review of Resident 2's facility provided incident report dated June 15, 2025, at 4:00 PM, revealed a note dated June 16, 2025, by the Director of Nursing which indicated Resident 2 would be evaluated for a room change due to residents not getting along. Review of Resident 2's clinical record failed to include any follow-up documentation regarding his request to change rooms, evaluation of a room change, offers of a room change, or why his request could not be accommodated between April 15, 2025, and July 17, 2025. Review of Resident 3's clinical record revealed diagnoses that included heart failure, vascular dementia with other behavioral disturbances (brain damage caused by multiple strokes which causes memory loss in older adults), and post-traumatic stress disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event with triggers that can bring back memories of the trauma accompanied by intense emotional and physical reactions). Review of Resident 3's clinical record progress notes revealed a note dated April 21, 2025, at 9:53 PM, which indicated Resident 3 admitted he had struck Resident 2 with his reacher because he was bothering the staff by always putting on his call bell. Review of Resident 3's facility provided incident report for the resident-to-resident altercation with Resident 2 dated April 21, 2025, at 9:00 PM, revealed a note dated April 22, 2025, by the Director of Nursing which indicated Resident 3 verbally argued with his roommate and hit his roommate and he would be evaluated for moving/changing rooms. Review of Resident 3's clinical record failed to include any documentation regarding a room change evaluation between April 15, 2025, and June 15, 2025. Review of Resident 3's clinical record progress notes revealed a note dated June 15, 2025, at 4:54 PM, which indicated he had been struck in his right arm with a walker by his roommate-Resident 2 and that he had sustained a skin tear measuring 2 centimeters by 1 centimeter. Review of Resident 3's facility provided incident report dated June 15, 2025, at 4:00 PM, revealed a note dated June 16, 2025, by the Director of Nursing which indicated a room change evaluation would be completed for one of the residents. Review of Resident 3's clinical record failed to include any follow-up documentation regarding an evaluation of a room change between June 15, 2025, and July 17, 2025. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on July 18, 2025, at 3:33 PM, the NHA indicated that there were and continue to be no appropriate male beds to move Resident 2 or 3 into. The NHA said that for the first altercation they removed the reacher from Resident 2 as it was determined he did not need one and all items were to be placed in easy reach of resident. The NHA said that the facility cannot prevent all resident-to-resident altercations, and that the facility cannot force a resident to change rooms or just medicate them for their behavioral issues. The NHA further indicated that he had multiple email communications with Resident 2's responsible party regarding a room change. The NHA indicated that he would send the email communications for surveyor review. The NHA confirmed that he nor any other staff had documented any evaluations or discussions about a room change for Resident 2 or Resident 3. He further indicated that he was not aware of any other measures the facility could have implemented to prevent the resident-to-resident altercations between these 2 residents. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 201.29(a) Resident rights28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on facility policy review, facility documentation reviews, clinical record reviews, and staff interviews, it was determined the facility failed to ensure that an injury of unknown origin was investigated for one of two residents (Resident 4).Review of facility policy titled OPS300 Abuse Prohibition with a last revision date of October 24, 2022, revealed [in part] the following: 6.4 Injuries of unknown origin will be investigated to determine if abuse or neglect is suspected;8. The Center will protect patients from further harm during an investigation.8.1 Provide the patient with a safe environment by identifying persons with whom he/she feels safe and conditions that would feel safe.8.2 Assign a representative from Social Services or a designee to monitor the patient ' s feelings concerning the incident, as well as the patient ' s involvement in the investigation;9. The Administrator or designee will:9.4 Take steps to resolve patient and family issues, concerns and allegations and clearly recording the same; and9.5 Take appropriate corrective actions. Review of Resident 4'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), Vitamin D deficiency, muscle weakness, and gait (walking) and mobility (the ability to move or be moved freely and easily) abnormalities. Review of Resident 4's clinical record revealed a progress note dated July 7, 2025, at 12:30 PM, which indicated that Resident 4 was observed by Physical Therapy (PT) staff with a shortened right lower leg turned outward prior to their session. The PT staff promptly contacted the Registered Nurse (RN) who then assessed the resident along with a provider. The resident complained of pain in the right lower extremity and pain upon touch. The note further indicated that Resident 4 was transferred to the hospital. Review of Resident 4's hospital records provided by facility revealed that she was found to have a fracture through the surgical neck (the portion of the bone that connects the head of the femur to the shaft of the femur and is a common site for fractures) of her right femur (large bone located in upper leg) with superior migration of the distal fracture fragment with surgical intervention planned. During an interview with the NHA and DON on July 15, 2025, at 2:20 PM, the DON indicated no investigation had been completed into Resident 4's injury of unknown origin. The DON confirmed that this injury could not be considered a result from Resident 4's initial fall on June 10, 2025, because of the time lapse and nursing staff had not noted any abnormal physical assessment findings post-fall as well as the original x-rays completed right after Resident 4's fall on June 10, 2025, were negative for any fractures. In addition, the DON indicated that Resident 4 was evaluated by physical therapy on July 5, 2025, and that there were no abnormal physical assessment findings at that time. She confirmed that she was aware that Resident 4 was diagnosed with a confirmed fracture at the hospital on July 7, 2025. The DON indicated that she had talked with a family member of Resident 4 a day or two after Resident 4 was transferred to the hospital to discuss the event at which time Resident 4's family member shared that other family members of Resident 4 had transferred her to the bathroom on July 4 and 5, 2025, however, the DON confirmed that there was no documentation of any abnormal physical assessment findings of Resident 4 between July 5, and July 7, 2025, at 12:30 PM, when the Physical Therapist found Resident 4 with a shortened right lower leg turned outward prior to their session. During a follow-up staff interview with the NHA and DON on July 17, 2025, at 3:22 PM, both confirmed that the facility should have completed an investigation into Resident 4's injury of unknown origin, a fracture, should have been investigated. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 201.29(a) Resident rights28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on clinical record review, facility provided documentation review, and staff interviews it was determined that the facility failed to provide adequate supervision and assistance to prevent accidents for one of three residents reviewed (Resident 4). Review of facility policy titled NSG215 Falls Management with a last revision date of March 15, 2024, revealed 2. Implement and document patient-centered interventions according to individual risk factors in the patient's plan of care. 2.1 Adjust and document individualized intervention strategies as patient condition changes. 4.Educate staff, patient, and/or patient representative(s) as appropriate to increase awareness of 'at risk' patients and to provide possible strategies to minimize risk for falls. Review of Resident 4'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), Vitamin D deficiency, muscle weakness, and gait (walking) and mobility (the ability to move or be moved freely and easily) abnormalities. Review of Resident 4's clinical record revealed a progress note dated June 10, 2025, at 10:48 AM, that indicated she had an unwitnessed fall. The note further indicated that the nurse was sitting at the nurse's station, heard a thud, and when the nurse stood up Resident 4 was observed sitting on the floor. Review of Resident 4's care plan revealed a care plan focus for at risk for decreased ability to perform bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to limited mobility dated May 7, 2025. Interventions included, but were not limited to, be aware: poor safety awareness dated May 7, 2025; and PT [Physical Therapy] mobility recommendations: one-person assist with transfers and ambulation for safety dated May 11, 2025. Further review of Resident 4's care plan revealed a care plan focus for at risk for falls related to cognitive loss, lack of safety awareness, impaired mobility, and possible side effects of medication dated May 7, 2025. Interventions failed to include her ambulation status or level of assistance needed for safe ambulation. Review of Resident 4's Physical Therapy Discharge summary dated [DATE], revealed resident needed supervision with stand-by assistance with ambulation and no assistive device. Review of Resident 4's facility provided incident report revealed the following: Nursing Description: Resident observed walking on the unit this evening. The nurse was at the nursing station and heard a hard thump and realized that this resident had fallen on her butt. Staff did not witness her fall. The resident was unable to give a description. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on July 17, 2025, at 3:30 PM, the DON confirmed that Resident 4's fall care plan did not indicate her ambulation assistance status. The DON indicated she was not aware that Resident 4 was to be one assist and said that she thought there were occasions where Resident 4 had utilized a walker for ambulation. The NHA and DON both confirmed that her care plan was not followed and should have been to prevent accidents. 201.4(a) Responsibility of licensee.201.18(b)(1) Management.211.10(d) Resident care policies.211.12(d)(1)(3)(5) Nursing services.

Based on policy review, staff interview, and other documents review, it was determined that the facility failed to ensure food is served at a safe and appetizing temperature for one meal test tray completed (lunch meal). Findings Include: Review of the facility's policy, titled Food Handling, revised January 26, 2024, read, Foods are stored, prepared, and served in a safe and sanitary manner. The purpose of the policy read To prevent bacterial contamination and the possible spread of infection. The policy continued, food must remain at 135 [degrees] or above. Review of the facility's document titled Resident Council Minutes, dated May 1, 2025, revealed that residents reported concerns about the temperatures of food, and residents reported trays are cold. An interview with Employee 3 (Dietary Manager) on June 9, 2025, at 9:30 AM, revealed an awareness of the resident concerns regarding food temperatures. The interview revealed the facility has requested the replacement of a food/plate warmer to keep food at a safe and palatable temperature at delivery. An observation of a lunch meal test tray completed on June 9, 2025, at 12:16 PM, revealed the ham slices' temperature registered at 124 degrees Fahrenheit. An immediate interview with Employee 3 revealed the temperature of the ham was out of range per the facility's policy and expectation for safety and palatability. An interview with the Nursing Home Administrator on June 9, 2025, at 1:29 PM, revealed the facility is aware of resident complaints of cold food and the need to replace the food/plate warmer in the dining services department. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on policy review, resident and staff interviews, and clinical record review, it was determined that the facility failed to ensure its residents the right to exercise his or her rights as a resident of the facility and as a citizen of the United States for voting in one election (local election) for three of four residents interested in voting (Residents 2, 5, and 6). Findings Include: Review of the facility's policy, titled Resident Rights Under Federal Law, revised February 1, 2023, revealed a purpose to Treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her self-esteem and self-worth. To incorporate the resident's goals, preferences, and choices into care. To recognize each resident's individuality as well as honor and value his/her input. To protect and promote the rights of the resident. Review of Resident 2's interdisciplinary plan of care revealed an activity preference that read It is important for me to vote, and I prefer to vote by absentee ballot while in the facility. An interview with Resident 2 on June 9, 2025, at 12:46 PM, revealed she was informed that her option to vote absentee/by mail was not pursued or honored by the facility during the most recent election. Review of Resident 5's interdisciplinary plan of care revealed an activity preference that read It is important for me to vote, and I prefer to vote by absentee ballot while in the facility. An interview with Resident 5 on June 9, 2025, at 12:26 PM, revealed she wanted to vote in the most recent local election and was informed by staff that the deadline to vote absentee/by mail had been missed. Review of Resident 6's interdisciplinary plan of care revealed an activity preference that read It is important for me to vote, and I prefer to vote by absentee ballot while in the facility. An interview with Resident 6 on June 9, 2025, at 11:15 AM, revealed she is an active voter. Resident 6 stated she did not have the option to vote in the most recent election and was informed that her application for an absentee/mail-in ballot had been shredded by the facility. The interview also revealed Resident 6 requested to be transported to her polling place and was unable due to the facility not having a means to transport her on the day of the election. An interview with Employee 5 (Director of Therapeutic Recreation) on June 9, 2025, at 11:10 AM, revealed all resident applications for an absentee/mail in ballot were received in February 2025, placed in a basket and found by staff in May 2025, after the deadline for residents to apply for and/or vote absentee/mail in ballot. Employee 5 stated that when the applications were found, it was too late to return the applications for the residents interested in voting. The interview also revealed the facility does not have access to a van to transport residents to a polling place if requested. An interview with the Nursing Home Administrator (NHA) on June 9, 2025, at 1:29 PM, revealed an acknowledgement of the information provided by Employee 5 and confirmed that transportation to a polling place is not readily accessible. The NHA also stated that going forward, the facility would make arrangements for residents to exercise their right to vote either by mail or in person. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on facility policy review, job description review, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of four residents reviewed (Resident 1). Findings Include: Review of facility policy, titled NSG122 Change in Condition: Notification of, revised July 1, 2024, revealed A center must immediately inform the patient, consult with the patient's physician, and notify, consistent with their authority, the patient's representative, where there is: .A significant change in the patient's physical mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications); . or A decision to transfer or discharge the patient from the Center. Review of facility job description for the Licensed Vocational Nurse (LVN), also known as the Licensed Practical Nurse (LPN), revealed Under the direction of a Registered Nurse (RN), the Licensed Vocational Nurse delivers efficient and effective nursing care while achieving positive clinical outcomes and patient/family satisfaction. He/she operates within the scope of practice defined by the State Nurse Practice Act. The LVN contributes to nursing assessments and care planning, provides direct patient care, and supervises patient care provided by unlicensed staff. The job description further states that the LPN Observes conditions and reports changes in condition to RN; . Communicates pertinent data to RN and/or physician; .Consults and seeks guidance from the RN as necessary; .Participates in shift-to-shift communication between incoming and outgoing nursing staff. Review of Resident 1's clinical record revealed diagnoses that included depression, anxiety, and hypertension (elevated blood pressure). Review of Resident 1's nursing progress notes revealed a note written by Employee 1 (Licensed Practical Nurse [LPN]), dated April 22, 2025, at 6:29 AM, stating that the Resident told the nurse aide she was having chest pain and that when the nurse arrived, the Resident's vital signs were within normal limits. The note further stated that the Resident said it wasn't really a pain. [Patient] said she was AFib [atrial fibrillation-an irregular, often rapid heart rate] at hospital and thought she was again. There was no indicator of AFib again all vitals are [within normal limits]. The note continued on, stating that the Resident told the nurse aide that the nurse is doing nothing to help her and that the nurse is concerned about possible increase in Resident's confusion. Review of Resident 1's clinical record revealed no evidence that Employee 1 notified the RN or the Resident's provider about Resident 1's complaint of chest pain. Further, there is no evidence of any diagnostic testing being done to determine if the Resident was or was not in AFib. The next progress note in Resident 1's clinical record was on April 22, 2025, at 8:52 AM, written by Employee 2 (RN). The note stated At about 0800 [8:00 AM] a CNA [nurse aide] stated the resident had called 911 and was sending herself to the hospital. The resident's friend was behind the CNA and stated she would explain what was happening while she had 911 on the phone with the operator stating to give the resident an aspirin. While this writer was attempting to find out what was happening, the friend stated the resident was having chest pain since 0530 [5:30 AM] and no one has done anything about it. This writer went into the resident's room and she was laying in the bed in no apparent distress .This writer began talking to the resident who stated she told the nurse this morning that she was having chest pain and she pointed to the left side of her chest. She stated it was more of a pressure at this time. The resident stated she was also having some SOB [shortness of breath]. The resident stated nothing was done when she first complained of the pain so she called her family who called 911. The note further stated that the Resident was transferred to the hospital and the physician was notified. Review of Resident 1's hospital records dated April 22, 2025, revealed that Resident 1 was admitted to the hospital with a pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest) and lower extremity edema (swelling). During an interview with the Director of Nursing (DON) on May 7, 2025, at 12:45 PM, she was asked if the LPN notified the RN or the Resident's provider of Resident 1's complaint of chest pain, or if she passed the information along to the next nurse during change of shift. The DON stated she would look into it but stated that she looked at the change of shift report for that day and did not see anything about Resident 1's chest pain on the report. In a follow up interview with the Nursing Home Administrator (NHA) and DON on May 7, 2025, at 1:15 PM, the DON stated that if a Resident is complaining of chest pain, the provider should be notified for any new orders or guidance. In an email correspondence from the DON on May 8, 2025, at 2:20 PM, the DON stated that she spoke to the night shift RN supervisor from April 22, 2025, who stated she was not made aware from Employee 1 about Resident 1's complaints. The DON stated she also spoke to the day shift RN, who wrote the note at 8:52 AM. That RN also stated she was unaware of Resident 1's complaints until she was told by other staff that the Resident was complaining of not feeling well, which is when the day shift RN went to assess Resident 1. No additional information was provided. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure each resident recieves adequate supervision and assistance to prevent accidents and hazards for one of three residents reviewed (Resident 1). Findings Include: Review of the facililty's policy, titled Elopement of Patient, recently revised October 24, 2022, defined elopement as .any situation in which the patient leaves the premises without the facility's knowledge and supervison . Review of Resident 1's clinical record revealed diagnoses that inlcuded Post Traumatic Stress Disorder (PTSD - A disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event. The condition may last months or years, with triggers that can bring back memories of the trauma accompanied by intense emotional and physical reactions) and bipolar disorder (a mental illness characterized by extreme and unusual shifts in mood, energy, and activity levels). Review of Resident 1's clinical record revealed a progress note dated March 25, 2025, that read Resident continues with confusion. OOB [ out of bed] in his power wheelchair this shift. Continues to state he is leaving and waiting for his family to arrive to pick him up. Going though [through] things in bags. Offered to assist him to lay down and rest, he declined at this time . The progress notes continued, Resident remained in his room this shift- would not get into bed. Continued with packing his belongings stated he needed to be ready for when his ride arrived. Pleasant with writer but very difficult to redirect. Continued review of the interdisciplinary progress notes dated March 27, 2025, at 14:28 [2:28 PM], revealed Resident [Resident 1] exited the building in manual wheelchair. Receptionist was able to keep sight of resident at all times and staff was summoned to assist. Resident was hesitant to return inside facility, believes he is moving to Washington DC. Wander Guard was present on the left ankle, but did not alarm per staff report. Wander Guard was replaced on resident's wheelchair . A Wander Guard is defined as a system that relies on three components: bracelets that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time. When a resident with a bracelet approaches a monitored door, the system alerts your caregivers. Additional review of Resident 1's progress notes revealed documentation on March 27, 2025, at 20:37 [8:37 PM], Resident 1 was found in the parking lot near the main entrance by an activities staff member (Employee 9). She was unable to coax him back into the building and had other staff get help from the supervisors present this evening . The administrator, was called and updated about this evenings events. An interview with the Director of Nursing (DON) on April 24, 2025, at 10:32 AM, revealed Resident 1 recently had a change in condition and caused physical damage to the building, including hallways. The interview revealed Resident 1 was difficult to redirect and was not exhibiting behaviors known to his personality. The interview also revealed that although Resident 1 was fitted with a Wander Guard, Resident 1 knew the code to exit the building. An additional interview with the Registered Nurse (Employee 1) on April 24, 2025, at approximately 11:00 AM, confirmed Resident 1 was found in parking lot, without staff knowledge, and had known the code to exit the building. A final interview with the Nursing Home Administrator and DON on May 2, 2025, at 1:41 PM, revealed no additional information or explanation regarding Resident 1 being found outside of the building without staff knowledge on March 27, 2025, by Employee 9 according to the facility's interdisciplinary progress notes. 28 Pa. Code 201.18 (b) (1) Management 28 Pa. Code 211. 12 (d) (1) (2) (5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the physician reviews the resident's total program of care, including medications, for one of three residents reviewed (Resident 1). Findings Include: A review of Resident 1's clinical record revealed diagnoses that included bilateral knee osteoarthritis (a degenerative joint disease that causes the cartilage and bone in your joints to break down over time. It's the most common type of arthritis and can affect the hands, hips, knees, back, and other joints) and muscle weakness. A review of Resident 1's consultation form dated November 13, 2024, with an Orthopaedic Surgery Specialist ([NAME]), revealed recommendations that included a new order for Tylenol 1000 mg (milligrams) Q (every) 8 hours. A review of Resident 1's physician's orders revealed the Resident was already receiving Tylenol with an order that read Tylenol 8-hour oral tablet extended release three times a day for pain. Do not exceed [more than] 3 grams /24 hour. The order was dated October 15, 2024, and was 650 mg per day. An interview with Employee 1 (Registered Nurse) on December 23, 2024, at 9:59 AM, revealed she entered the new order for the 1000 mg of Tylenol for Resident 1 as the facility's Certified Nurse Practitioner (CRNP-Employee 2) signed off on the [NAME] consult and did not realize Resident 1 already had an order for the Tylenol 8 hour three times per day. Employee 2 is the provider working on behalf and in coordination with the Resident's attending physician. According to Employee 1, the Resident received over 15000 mg of Tylenol over three days, October 15-18, 2024. An interview with Employee 2 on December 23, 2024, at 10:51 AM, revealed the Resident should not have received more than 3000 mg per day due to concerns with liver damage. An interview with the Nursing Home Administrator on December 23, 2024, at 10:11 AM, revealed Resident 1 was placed on alert charting for five days, vital signs were monitored for five days, and blood testing was performed once for two weeks. An additional interview with Employee 2, at approximately 11:00 AM, revealed no concerns with a review of Resident 1's laboratory testing and no concerns with a change in the Resident's condition based on the excessive amount of Tylenol administered by the Nursing Staff. 28 Pa. Code 201. 18 (b) (1) Management 28 Pa. Code 211.12 (c) (d) (1) (2) (5) Nursing services

Based on clinical record review, policy review, and staff interviews, it was determined that the facility failed to ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing services to assure resident safety or maintain the highest practicable physical well-being of each resident for one of three residents reviewed (Resident 1). Findings Include: A review of the facility's Registered Nurse Job Description, revised June 16, 2017, read, in part, The Registered Nurse [RN] delivers efficient and effective nursing care while achieving positive clinical outcomes and patient/family satisfaction. He/she operates within the scope of practice defined by the State Nurse Practice Act . The RN manages patient care by performing nursing assessments and collaborating with the nursing team and other disciplines .to develop effective plans of care. A review of the facility's policy, titled Medication Administration, dated January 2024, read, in part, Medications are administered in accordance with written orders of the prescriber. If a dose seems excessive considering the resident's age and condition, or the medication order seems unrelated to the resident's current diagnosis or condition, the nurse calls the provider pharmacy for clarification prior to administration of the medication. A review of Resident 1's clinical record revealed diagnoses that included bilateral knee osteoarthritis (a degenerative joint disease that causes the cartilage and bone in your joints to break down over time. It's the most common type of arthritis and can affect the hands, hips, knees, back, and other joints) and muscle weakness. A review of Resident 1's consultation form dated November 13, 2024, with an Orthopaedic Surgery Specialist ([NAME]), revealed recommendations that included a new order for Tylenol 1000 mg (milligrams) Q (every) 8 hours. A review of Resident 1's physician's orders revealed the Resident was already receiving Tylenol with an order that read Tylenol 8-hour oral tablet extended release three times a day for pain. Do not exceed [more than] 3 grams /24 hour. The order was dated October 15, 2024, and was 650 mg per day. An interview with Employee 1 (Registered Nurse) on December 23, 2024, at 9:59 AM, revealed she entered the new order for the 1000 mg of Tylenol for Resident 1 as the facility's Certified Nurse Practitioner (CRNP-Employee 2) signed off on the [NAME] consult and did not realize Resident 1 already had an order for the Tylenol 8 hour three times per day. Review of the MAR (Medication Administration Record) revealed on November 15, 2024 Resident 1 received 650 mg of Tylenol at 8:00 AM, 12:00 PM and 4:00 PM. Resident 1 also received 1000 mg of Tylenol at 4:00 PM. On November 16, 2024 Resident 1 received 650 mg at 8:00 AM, 12:00 PM and 4:00 PM. Resident 1 also received 1000 mg of Tylenol at 12:00 AM, 8:00 AM and 4:00 PM. On November 17, 2024 Resident 1 received 650 mg at 8:00 AM, 12:00 PM and 4:00 PM. Resident 1 also received 1000 mg of Tylenol at 12:00 AM, 8:00 AM and 4:00 PM. On November 18, 2024 Resident 1 received 650 mg at 8:00 AM, 12:00 PM and 4:00 PM. Resident 1 also received 1000 mg of Tylenol at 12:00 AM and 8:00 AM. Further review of the MAR revealed a note under the Tylenol order that read .do not exceed >3gm/24hr. The nurses adminstered the Tylenol and did not question or clarify that the total dose of Tylenol was greater than 3 gm (3000 mg) in 24 hours. According to Employee 1, the Resident 1 received over 15000 mg of Tylenol over three days, November 15-18, 2024. An interview with Employee 2 on December 23, 2024, at 10:51 AM, revealed the Resident should not have received more than 3000 mg per day due to concerns with liver damage. An interview with the Nursing Home Administrator (NHA) on December 23, 2024, at 10:11 AM, revealed Resident 1 was placed on alert charting for five days, vital signs were monitored for five days, and blood testing was performed once for two weeks. An additional interview with Employee 2, at approximately 11:00 AM, revealed no concerns with a review of Resident 1's laboratory testing and no concerns with a change in the Resident's condition based on the excessive amount of Tylenol administered by the Nursing Staff. A final interview with the NHA confirmed Employee 1 should have consulted the physician or Employee 2 to clarify the additional 1000 mg of Tylenol ordered by the consultant physician visit and signed off by Employee 2 on October 15, 2024. 28 Pa. Code 201. 18 (b) (1) Management 28 Pa. Code 211.12 (c) (d) (1) (2) (5) Nursing services

Based on facility policy review, observations, clinical record review, review of facility master menu diet guide sheets, and staff and resident caregiver interviews, it was determined that the facility failed to provide an altered texture diet, as prescribed by the physician, for nine residents (Resident's 37, 41, 57, 59, 78, 112, 155, 162, and 167) observed. This failure placed 31 residents that had similar diet needs at a high risk for death, and resulted in an Immediate Jeopardy (IJ) situation for Residents 1, 3, 4, 5, 6, 7, 9, 10, 13, 15, 16, 17, 18, 19, 21, 22, 23, 24, 26, 27, 30, 31, 32, 33, 34, 36, 38, 39, 58, and 92. Findings include: Review of facility policy, titled Consistency Alterations and Therapeutic Menus, dated May 1, 2023, read, in part, Purpose: To provide diets as ordered by the physician/advanced practice provider, chopped or ground meat modifications may be used in conjunction with any diet for individuals having difficulty chewing meat. Review of physician's orders revealed that Residents 37, 41, 57, 59, 78, 112, 155, 162, and 167 were ordered the dysphagia advanced texture diet or the dysphagia mechanically altered texture diet (special diets for people who have difficulty chewing and/or swallowing- dysphagia). According to the National Dysphagia Diet, for a dysphagia advanced texture diet, food needs to be moist and pieces need to be smaller than 1 inch (bite size). For the dysphagia mechanically altered texture diet, food should be moist and soft-textured. Meats should be ground or minced and be no larger than 1/4 inch pieces. Review of the lunch menu on October 23, 2024, revealed residents were to be served meatloaf as their entree and the alternate entree item was baked fish. Review of facility master menu diet guide sheets revealed the dysphagia advanced and dysphagia mechanically altered diets should have been served ground meatloaf or fish. Observations during tray line meal service on October 23, 2024, between 11:58 AM and 12:30 PM, revealed Residents 37, 41, 57, 59, 78, 112, 155, 162, and 167 had notation on their meal tickets that they should be served ground meatloaf or fish, but they were served a regular piece of meatloaf or fish. Observations throughout the facility on October 23, 2024, between 12:10 PM and 12:46 PM, revealed Residents 37, 41, 57, 59, 78, 112, 155, 162, and 167, had been served the regular piece of meatloaf or fish. Observation of Resident 155 on October 23, 2024, at 12:32 PM, revealed he was served a whole piece of meatloaf and was receiving feeding assistance from his private caregiver. Interview with Resident 155's private caregiver on October 23, 2024, at 1:01 PM, revealed she provides feeding assistance to Resident 155 and whatever is served from dietary is what she believes he is allowed to have. Interview with Employee 3 (Speech Language Pathologist) on October 23, 2024, at 1:13 PM, revealed she would expect diets to be served from the kitchen staff at the appropriate textures, per the facility master menu diet guide sheets. Interview with Employee 1 (Dietary Manager) on October 23, 2024, at 1:18 PM, revealed they serve whole pieces of meatloaf to the dysphagia advanced and dysphagia mechanically altered texture diets as the meat is ground prior to being baked, and that has been the case since she has been employed at the facility and she never questioned it. Employee 1 also stated, since the fish is soft, they just serve it whole to those diets. She further revealed she had overlooked that the meatloaf and fish should have been ground for those texture diets. Review of physician's orders revealed Residents 1, 3, 4, 5, 6, 7, 9, 10, 13, 15, 16, 17, 18, 19, 21, 22, 23, 24, 26, 27, 30, 31, 32, 33, 34, 36, 38, 39, 58, and 92, were also ordered the dysphagia advanced texture diet or the dysphagia mechanically altered texture diet. Interview with the Nursing Home Administrator (NHA) on October 24, 2024, at 9:34 AM, revealed his expectation that the facility master menu diet guide sheets for mechanically altered diets should be followed. The NHA was notified of the IJ situation on October 23, 2024, at 2:28 PM, and was provided the IJ template. An Immediate Action Plan was requested. The Immediate Action Plan was provided by the NHA on October 23, 2024, at 4:24 PM, and approved at 4:35 PM. The approved plan included: 1. The facility cannot retroactively go back and fix the diet textures for the residents that were served. 2. Food Service Director will immediately re-educate the dietary and nursing team members that are currently working on following the master menu diet guide sheet in regards to altered texture diets. Remaining team members will be educated prior to the start of their next shift. Speech Language Pathologist will re-evaluate current residents on an altered texture diet to determine appropriateness. 3. Meal service will be audited for 7 days to assure the appropriate diet textures are being followed. 4. Results will be reported to QAPI (Quality Assurance and Performance Improvement) to further follow-up and recommendations. 5. Date of compliance: October 24, 2024. On October 24, 2024, between 7:56 AM and 9:12 AM, breakfast tray line meal service was observed to ensure all residents received the appropriate texture diet per their physician order. The audit of dinner service on October 23, 2024, as well as the audit of breakfast service on October 24, 2024, were reviewed without concern. Staff interviews revealed the facility had re-educated staff on mechanically altered diets and the master menu diet guide sheet. Interviews were conducted with three registered nurses, six licensed practical nurses, eight nursing assistants, three dietary employees, and the dietary manager; all were able to verbalize their role in providing appropriate diet textures. Interview with Employee 3 on October 24, 2024, at 9:18 AM, revealed she had evaluated Resident 59, 112, and 167, a call went out to Resident 155's hospice provider to get an order for an evaluation; and she plans to see Resident 41, 57, and 78 that day, as well as evaluate all other residents as per the action plan. On October 24, 2024, at 10:59 AM, the Immediate Jeopardy was lifted when the action plan implementation was verified. Observations on October 23, 2024, revealed that the facility failed to provide food in a form ordered by the physician to meet the individual needs of nine residents (Resident's 37, 41, 57, 59, 78, 112, 155, 162, 167). This failure placed 31 additional residents that had similar diet needs at a high risk for death and resulted in an Immediate Jeopardy situation for Residents 1, 3, 4, 5, 6, 7, 9, 10, 13, 15, 16, 17, 18, 19, 21, 22, 23, 24, 26, 27, 30, 31, 32, 33, 34, 36, 38, 39, 58, and 92. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing services

Based on facility policy review, clinical record review, review of facility investigation documentation, and staff interview, it was determined that the facility displayed past non-compliance in its failure to ensure that interventions were put into place to prevent accident hazards, resulting in arm and leg fractures requiring surgical intervention following a fall, for one of three residents reviewed (Resident 1). Findings include: Review of facility poilicy, Bed Positioning, updated February 2019, revealed, Verify transfer assist needed per Kardex [Resident care guide]. Obtain additional assistance and needed equipment as indicated. Review of Resident 1's clinical record revealed diagnoses that included morbid obesity, muscle weakness, congestive heart failure (weakness of the heart that leads to build-up of fluid in the lungs and surrounding body tissues), and unspecified abnormalities of gait and mobility. Review of a nursing progress note entered by Employee 1 (Registered Nurse) dated July 10, 2022, revealed, Employee 1 was called to Resident 1's room due to the Resident being rolled out of bed during care. Staff was providing care, rolled Resident 1, and was unable to stop Resident from rolling to the floor. Assessment of Resident 1 revealed skin tear above left knee measuring 1.0 x 0.5 x 0.1 centimeters (cm). Area cleansed with normal saline (cleansing solution) and a dry dressing was applied. A discoloration was noted to left mid back measuring 5.0 x 0.1 cm. Range of motion to bilateral lower extremities without pain, some soreness noted to left knee. Resident 1 complained of pain to bilateral shoulders, which increased with movement. X-ray was requested. Review of nursing progress note entered by Employee 3 (Registered Nurse), dated July 10, 2022, revealed that Employee 3 was called to Resident 1's room to assess the knee after the fall. The dressing applied to the knee was saturated in red blood. When Employee 3 removed the dressing from the knee, a quarter size blood clot came out and a steady stream of blood poured down Resident 1's leg. Employee 3 continued to apply pressure to knee. On-call physician notified and stated to hold pressure for 20 minutes; and if knee continues to bleed, send Resident to emergency room . Resident 1's knee continued to bleed after the 20 minutes and emergency medical services (EMS) was contacted. EMS arrived and transported Resident 1 to the hospital. Review of witness statement written by Employee 2 (Nurse Aide) (undated), revealed, At 6:30 I started care on [Resident 1]. Around 6:40 I was finishing up and was putting a new draw sheet under her. As I was rolling her towards me her momentum kept going and I couldn't keep her on the bed from falling. Review of Resident 1's care plan that was in place at the time of the fall on July 10, 2022, revealed a care plan related to the Resident's self care deficit with an intervention of maximum assist of 2 for bed mobility. Review of hospital orthopaedic surgical consult notes dated July 10, 2022, revealed it was discovered that Resident sustained a left distal femur fracture (leg) and bilateral proximal humerus fractures (shoulders). Further review revealed Resident 1 underwent surgery on July 11, 2022, for repair of the left femur fracture During an interview with the Nursing Home Administrator (NHA) on July 25, 2022, at approximately 1:45 PM, he revealed the expectation that Employee 2 should have provided care per Resident 1's care plan. After the investigation, the facility determined that Employee 2 failed to ensure that assistance of two individuals per Resident's care plan was used to move Resident 1 in bed, resulting in a fall with injury. Employee 2 was suspended during the course of the investigation, and was given a final written notice. The facility's education and audits were reviewed during the onsite survey. Review of Employee 2's warning notice dated July 11, 2022, revealed that Employee 2 was educated on reviewing the Kardex (Resident's care guide) prior to completing resident care, abuse and neglect, and bed positioning. At that time, Employee 2 was also made aware that further incidents would result in termination. Review of education dated July 25, 2022, provided by the facility on July 11, 2022, and July 12, 2022, revealed that nursing staff were educated on abuse and neglect, bed positioning, and the need to review a resident's Kardex prior to providing care. Review of education dated July 25, 2022, provided by the facility on July 11, 2022, revealed that RN supervisors and unit managers were educated on identifying neglect and conducting fall investigations. Review of facility documentation and an interview with the NHA on July 26, 2022, at 1:35 PM, revealed that the facility printed and distributed copies of all resident Kardex guides to the nurse aides on July 11, 2022. An audit of all Resident Kardex guides was completed. All resident Kardex guides were reviewed by RNs and the physical therapy department, and updated as necessary throughout the period of July 11, 2022, through July 19, 2022. All falls are investigated and reviewed for compliance with the Kardex and to rule out neglect. Observation of facility Eagle Room fall tracking tool during onsite investigation on July 25, 2022, as well as an interview with the NHA on July 26, 2022, at 1:35 PM, revealed that all falls are reviewed the following day by the interdisciplinary team, unless neglect is identified or the resident requires transfer to the hospital. Those falls are reviewed immediately. The following information is evaluated during the fall review: date and time of event, name of resident, whether a medication review was needed, notification of doctor and responsible party, completion of incident report, whether incident was reportable, whether investigation was completed, pain, whether new interventions were needed, calcium/vitamin D protocol, root cause analysis, and whether the care plan and resident task lists were updated. The NHA also revealed that all falls from the week are reviewed each Friday for tracking and trending. Review of resident falls since July 10, 2022 revealed no evidence that staff not following the Residents' care plan contributed to the falls. An interview with the NHA on July 25, 2022, at 1:35 PM, confirmed the same. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, facility incident reports, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure that residents were free of neglect which resulted in actual harm, evidenced by arm and leg fractures requiring surgical intervention, for one of three residents reviewed (Resident 1). Findings include: Review of facility policy, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Patient Property Prevention reviewed February 1, 2021, revealed, The most critical step toward detecting and preventing abuse is acknowledging that no one should be subjected to violent, abusive, humiliating or neglectful behavior. Facility policy, Patient Protection dated October 2021, defined neglect as .failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of Resident 1's clinical record revealed diagnoses that included morbid obesity, muscle weakness, congestive heart failure (weakness of the heart that leads to buildup of fluid in the lungs and surrounding body tissues) and unspecified abnormalities of gait and mobility. Review of the nursing progress note entered by Employee 1 (Registered Nurse) on July 10, 2022, revealed that Employee 1 was called to Resident 1's room due to the Resident being rolled out of bed during care. Staff Member was providing care, rolled Resident 1, and was unable to stop Resident from rolling to the floor. Assessment of Resident 1 revealed skin tear above left knee, measuring 1.0 x 0.5 x 0.1 centimeters (cm). Area cleansed with normal saline (cleansing solution) and a dry dressing was applied. A discoloration was noted to left mid-back, measuring 5.0 x 0.1 cm. Range of motion to bilateral lower extremities was without pain, some soreness noted to left knee. Resident 1 complained of pain to bilateral shoulders, which increased with movement. X-rays were requested. Review of the nursing progress note entered by Employee 3 (Registered Nurse), on July 10, 2022, revealed that Employee 3 was called to Resident 1's room to assess the knee after the fall. The dressing applied to the knee was saturated in red blood. When Employee 3 removed the dressing from the knee, a quarter size blood clot came out and a steady stream of blood poured down Resident 1's leg. Employee 3 continued to apply pressure to knee. On-call physician notified and stated to hold pressure for 20 minutes and, if knee continues to bleed, send to emergency room . Resident 1's knee continued to bleed after the 20 minutes and emergency medical services (EMS) was contacted. EMS arrived and transported Resident 1 to the hospital. Review of witness statement written by Employee 2 (Nurse Aide) (undated), revealed, At 6:30 I started care on [Resident 1]. Around 6:40 I was finishing up and was putting a new draw sheet under her. As I was rolling her towards me her momentum kept going and I couldn't keep her on the bed from falling. Review of Resident 1's care plan that was in place at the time of the fall on July 10, 2022, revealed a care plan related to the Resident's self care deficit, with an intervention of maximum assist of 2 for bed mobility. Review of hospital orthopaedic surgical consult notes dated July 10, 2022, revealed that Resident 1 sustained a left distal femur fracture (leg) and bilateral proximal humerus fractures (shoulders). Further review revealed Resident 1 underwent surgery on July 11, 2022, for repair of the left femur fracture. During an interview on July 28, 2022, at 3:08 PM, Employee 2 confirmed that she did not look at the Kardex prior to starting care on the resident. She stated that Resident 1 used to be a one assist and didn't realize anything changed with the resident's care, but acknowledged that she should have checked the Kardex and did not. During an interview with the Nursing Home Administrator (NHA) on July 25, 2022, at approximately 1:45 PM, he revealed the expectation that Employee 2 should have provided care per Resident 1's care plan. After the fall investigation, the facility determined that Employee 2 failed to follow Resident 1's care guide for a two person assist for bed mobility, resulting in a fall from bed with injury. Employee 2 was suspended during the course of the investigation and was given a final written notice. The facility's education and audits were reviewed during the onsite survey. Review of Employee 2's warning notice dated July 11, 2022, revealed that Employee 2 was educated on reviewing the Kardex (Resident's care guide) prior to completing resident care, abuse and neglect, and bed positioning. At that time, Employee 2 was also made aware that further incidents would result in termination. Review of education dated July 25, 2022, provided by the facility on July 11, 2022, and 12, 2022, revealed that nursing staff were educated on abuse and neglect, bed positioning, and the need to review a resident's Kardex prior to providing care. Review of education dated July 25, 2022, provided by the facility on July 11, 2022, revealed that RN supervisors and unit managers were educated on identifying neglect and conducting fall investigations. Review of facility documentation and an interview with the NHA on July 26, 2022, at 1:35 PM, revealed that the facility printed and distributed copies of all resident Kardex guides to the nurse aides on July 11, 2022. An audit of all Resident Kardex guides was completed. All resident Kardex guides were reviewed by RNs and the physical therapy department, and updated as necessary throughout the period of July 11, 2022, through July 19, 2022. All falls are investigated and reviewed for compliance with the Kardex and to rule out neglect. Observation of facility Eagle Room fall tracking tool during onsite investigation on July 25, 2022, as well as an interview with the NHA on July 26, 2022, at 1:35 PM, revealed that all falls are reviewed the following day by the interdisciplinary team, unless neglect is identified or the resident requires transfer to the hospital. Those falls are reviewed immediately. The following information is evaluated during the fall review: date and time of event, name of resident, whether a medication review was needed, notification of doctor and responsible party, completion of incident report, whether incident was reportable, whether investigation was completed, pain, whether new interventions were needed, calcium/vitamin D protocol, root cause analysis, and whether the care plan and resident task lists were updated. The NHA also revealed that all falls from the week are reviewed each Friday for tracking and trending. Review of resident falls since July 10, 2022 revealed no evidence that staff not following the Residents' care plan contributed to the falls. An interview with the NHA on July 25, 2022, at 1:35 PM, confirmed the same. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of clinical records and facility documentation and interviews with staff, it was determined that the facility failed to provide timely care and services for one of three residents (Resident R1) who had a change in condition. Findings include: Review of Resident R1's Physician Transfer Orders from the hospital dated January 11, 2011, identified that his discharge [DIAGNOSES REDACTED]. His admission nursing assessment written on January 11, 2011, at 4:59 p.m., identified that he required assistance with all his activities of daily living, that he was continent of bowel and bladder and his temperature was recorded as 95.3 degrees Fahrenheit (F) (resident's norm while in hospital was 98 degrees F.). Interdisciplinary progress notes from January 11-24, 2011, reported multiple occasions when the resident's temperature was recorded below 98.0 degrees F. as follows: 1/11/11 4:00 p.m. 95.3 degrees F. 1/11/11 9:00 p.m. 95.0 degrees F. 1/13/11 5:15 a.m. 93.0 degrees F. 1/14/11 3:15 a.m. 97.4 degrees F. 1/15/11 10:00 p.m. 96 degrees F. 1/16/11 10:30 p.m. 95.0 degrees F. 1/19/11 5:30 a.m. 97.2 degrees F. Additionally, his Neurological Evaluation Flow Sheet dated January 13-16, 2011, reported temperature readings from 93.0- 97.4 degrees F. (majority at 96.0 degrees F.) His Weights and Vitals Summary identified that of the eight temperature readings recorded from January 11-22, 2011, the low point of 97.0 degrees F. was exceeded five times. There was no evidence that the physician was made aware of his subnormal temperatures. Physician's history and physical evaluation competed on January 13, 2011, reported that Resident R1 was admitted following treatment for [REDACTED]. Subsequent interdisciplinary progress notes from January 11-24, 2010, report the resident's confusion, he was incontinent of bowel and bladder and had poor oral intake and to encourage fluids. On January 24, 2011, at 1:30 a.m., Registered Nurse 1 was called to assess Resident R1 secondary to low blood pressure (62/48). His heart rate was also low at 46 beats/minute. The resident was pale but responded appropriately to simple questions. The physician was not notified until 5:45 a.m. (over 4 hours later) and ordered the resident to be transferred to the hospital. Hospital records revealed that he was lethargic, his extremities were cool to touch, his heart rate was in the 40's, he had low blood pressures and his rectal temperature was 87.7 degrees F. , and a bear hugger (warming blanket) was applied and he was given 4 liters of warm intravenous fluids. Resident R1 was admitted to the hospital for [MEDICAL CONDITION] (blood infection) which was unresponsive to intravenous fluids, likely leading towards septic shock (medical emergency that occurs when infection spreads to the bloodstream abd leads to low blood pressure and blood flow). There was no evidence that Resident R1 was consistently and comprehensively monitored for complications related to his admission [DIAGNOSES REDACTED]. Additionally, there was no evidence that RN 1 continued to monitor Resident R1's condition after 1:30 a.m. The facility's Patient Transfer to the hospital form dated January 24, 2011, at 6:00 a.m., reported the resident's vital sign results from 1:30 a.m. and indicated that his "blood pressure was 61/41 earlier this shift." Interview with the Administrator and Director of Nursing on February 17, 2011, at 9:11 a.m. and 10:47 a.m., revealed that RN 1 had no explanation as to her lack of reassessment or delay in calling the physician when Resident R1 had a significant change in condition as this was a standard of practice. They were also unaware that the resident had multiple episodes of subnormal temperature with no follow-up. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. 28 Pa. Code: 211.10 (d) Resident care policies. 28 Pa. Code: 211.11 (a) Resident care plan. 28 Pa. Code: 211.12 (d)(1)(5) Nursing services.