Every finding on record at Ivy Hill Post Acute Nursing & Rehabilitation LLC

Based on review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to ensure that an antianxiety medication was available for administration for 1 of 8 residents reviewed (Resident R1).Findings Include: Review of facility policy titled Medication Administration undated states, Licensed nursing professionals will administer medications according to times of administration determined by the facility. Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on [DATE] with the following diagnosis: Chronic Obstructive Pulmonary Disease (a progressive, treatable lung disease that causes obstructed airflow, making breathing difficult), Depression (common, serious mood disorder characterized by persistent sadness, loss of interest in activities), Dementia with Behavioral Disturbance (a decline in mental ability severe enough to interfere with daily life, resulting from abnormal brain changes that damage cells and non-cognitive symptoms like agitation, aggression, anxiety, depression, or psychosis), Anxiety Disorder (mental health conditions characterized by excessive, persistent, and uncontrollable fear or worry that interferes with daily life), Hypomagnesemia (an electrolyte imbalance defined by abnormally low levels of magnesium in the blood), and Dysphagia (difficulty swallowing). Review of Resident R1's MDS (Minimum Data Set- assessment of resident care needs) dated April 25, 2025, revealed that the resident was assessed with a BIMS (Brief Interview for Mental Status) score of 0 indicating severe cognitive impairment. Review of Resident R1's care plan dated February 11, 2026, revealed a care plan focus for Verbal/physical agitation/aggression related to cognitive impairment, sensory overload, unfamiliar environment/caregiver. For interventions it lists, Administer medication per physician orders. Continued review of Resident R1's care plan revealed a care plan focus for Resistive/noncompliant with treatment/care, refuses meds often. Further review of Resident R1's care plan revealed a care plan focus for At risk for behavior symptoms related to Alzheimer's Disease/Dementia, anxiety with behavior disturbances. For interventions it lists, Administer medications per physician's orders (Depakote, Lorazepam, Rexulti). Review of Resident R1's clinical record revealed the resident had an active order dated March 31, 2025 for Lorazepam gel 0.5 milligrams (mg)/ml Administer 1ml, three times a day topically for Generalized Anxiety Disorder. Observation was held of Resident R1 on March 25, 2025, at 10:00 a.m. Resident R1 was resting in (her/his) bed and upon greeting the resident continued to request a bag of potato chips from on top of the dresser. Licensed nurse Employee E5 was called to the room and provided Resident R1 with a bag of potato chips. Employee E5 asked Resident R1 if she would take her morning medication and Resident R1 agreed. After pouring one medication for Resident R1 and bringing it to the resident, Resident R1 refused to take the medication. Employee E5 stated that this was her third attempt to administer the medication to Resident R1. Employee E5 was asked to review current orders for Resident R1 for Lorazepam gel. Employee E5 did confirm that the resident had an order for Lorazepam gel but that it was currently on hold. Employee E5 was unaware of why it was on hold. Employee E5 looked in the medication cart and there was no Lorazepam gel in the medication cart. Review of Resident R1's clinical record revealed that there was a current order with a revision date of March 24, 2026, for Pharmacy NAME (Please call every 30 days for Ativan Gel) Pharmacy Address and Phone Number . Pharmacy will deliver to facility. DO NOT SIGN OUT UNLESS YOU CALL! Review of Resident R1's Treatment Administration Record from March 2026 revealed the medication was signed out as being given at 8:00 a.m. and 12:00 p.m. on March 24, 2026. Further review of Resident R1's Treatment Administration record revealed 71 possible administrations for the Ativan gel given three times a day from March 1, 2026 through March 24, 2026. Out of the 71 administrations in March 2026 there were 28 administration records that were coded as NA (Not Available). Out of the 71 administrations in March 2026 there were 4 administration records that were coded as a 5 (Hold/see nurses notes). Review of Resident R1's Treatment Administration Record from February 2026 revealed there were 84 administration opportunities for the Ativan gel. Out of the 84 administrations in February 24, 2026 were coded as NA (Not Available). Out of the 84 administrations in February 15, 2026, are coded as a 5 (Hold/see nurses notes). Interview with the Director of Nursing Employee E2 at 12:04 p.m. revealed that the resident's family had been paying out of pocket for Resident R1's Ativan gel due to it not being covered by insurance. Employee E2 confirmed that there were discrepancies with the medication not being filed timely and being signed out intermittently by nursing staff. The Director of Nursing Employee E2 stated that any of the nursing staff could call when the medication was not available to obtain a refill. The medication would be sent for refill and then Resident R1's family would have to pay for it before it gets sent out. Employee E2 confirmed that the last date the medication was obtained and administered to the resident was unknown. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observations, interviews with residents and staff, it was determined that the facility failed to provide a clean linen, safe, comfortable, and homelike environment in two of the three nursing units observed (3th and 2nd floor Nursing Units).Findings include: On 03/09/2026 at 9:00 a.m., the front door was observed to stick to the floor, preventing it from opening and closing properly. The facility's receptionist, Employee E7, confirmed the door was broken and required force to operate. On 03/09/2026 at 10:08 a.m., an interview was conducted with Resident R110. The resident reported that the facility does not have enough clean linens and towels available. During the observation, a brown spot was noted on the wall near the railing outside of room [ROOM NUMBER]. The resident stated that housekeeping staff had been notified; however, according to the resident, the area had not been cleaned for several months. On 03/09/2026 at 1:00 PM, an interview was conducted with Resident R72 who reported that his dresser drawer was missing two drawer handles. Resident R72 stated that he had never been offered a key to secure his personal belongings and valuables. Observation of Resident R72's privacy curtain revealed grey dust stripes running from top to bottom, indicating that the curtain was dirty. Resident R72 reported having three additional roommates. Observation of the roommates' furniture revealed that their dresser drawers and closet doors were also missing handles. On 03/09/2026 at 1:10 PM, during an observation conducted with the Administrator, Employee E1 the above concerns were confirmed, including the dirty privacy curtain, the bedside drawer not having a lock, and the dresser drawer missing two handles. During the observation, additional concerns related to the physical environment were identified: In room [ROOM NUMBER], the wall clock located on the dresser was observed to be broken. The dresser drawers were observed to have missing handles. The window seals had visible spider webs. The tall closet was observed to have both door handles missing. In the bathroom, the cover for the sink pipe was observed to be hanging off. In room [ROOM NUMBER], the wall near the room entrance had been patched but not painted, leaving the repair incomplete. In room [ROOM NUMBER], Bed 1 closet was observed to have two missing closet door handles. The middle drawer was completely missing from the drawer unit. The dresser for Bed 3 was missing two drawer handles. The dresser for Bed 4 was observed to have two drawer handles missing. On 03/10/2026 at 9:00 a.m., the front door was observed to still not be functioning properly. The facility had propped the first door open, which was activating the alarm. The receptionist, Employee E7, reported that the door continues to be broken and is not closing properly. On 03/10/2026 at 10:42 a.m., a Resident Council meeting was conducted with five alert and oriented residents (R46, R174, R93, R119, and R131). During the meeting, the residents reported that the facility does not have enough linens available, including washcloths, towels, fitted sheets, and flat sheets, particularly on the 2nd and 3rd floors. On 03/10/2026 at 11:15 a.m., an interview with the Administrator, Employee E1, revealed that the facility conducted an audit and identified additional concerns with missing drawer handles in rooms 300, 301, 305, 306, 307, 315, 227, 224, 218, 217, 214, 205, and 204. On 03/12/2026 at 9:00 a.m., an observation was conducted with the Administrator, Employee E1. The front door was observed sticking to the floor, which prevented it from opening and closing properly. The Administrator reported that they were not previously aware of the issue and stated that maintenance would correct it. On 03/12/2026 at 9:47 a.m., observations were conducted in the laundry area with the Housekeeping Director, Employee E8. Employee E8 reported that the facility provides in-house laundry services for approximately 148 residents. At the time of observation, the following clean linen items were available in the laundry area: 11 towels, 8 fitted sheets, 10 flat sheets, 8 blankets, 8 hospital gowns, and 42 washcloths. Additionally, a storage unit located outside the facility was observed to contain additional linen supplies that were stored in boxes and had not been opened. These supplies included one box of 72 pillowcases, approximately 600 towels (300 x 2), 200 washcloths, 48 fitted sheets, approximately 72 flat sheets (24 x 3), and approximately 36 gowns (3 dozen). On 03/12/2026 at 9:53 a.m., further observations of linen availability were conducted throughout the facility. On the 1st floor nursing unit, which had a census of 23 residents, a linen cart was observed containing 5 fitted sheets, 2 flat sheets, 1 blanket, 5 towels, 7 gowns, 7 washcloths, and 2 pillowcases. On the 2nd floor nursing unit, which had a census of 60 residents in the North Wing, no linen supplies were observed in the supply area. An additional linen cart located in the East Wing contained 2 fitted sheets, 2 flat sheets, 1 blanket, 1 towel, 1 gown, and 1 washcloth available for approximately 60 residents. On the 3rd floor nursing unit, which had a census of 59 residents, the East Wing linen cart contained 1 gown, and a second cart contained 1 gown. The linen closet contained 1 blanket and 2 gowns available for residents on the unit. Based on these observations, it was determined that the 2nd and 3rd floor nursing units did not have an adequate supply of linens available for resident care, including washcloths, towels, fitted sheets, and flat sheets. 28 Pa Code 201.18(b)(1)(3)(e)(2.1) Management

Based on a review of the observations, and an interview with residents and staff, it was determined that the facility failed to ensure that the most recent Department of Health Survey results were readily accessible to residents and visitors in three of three nursing floors.Findings include: On 03/10/2026 at 10:42 a.m., a Resident Council meeting was conducted with five alert and oriented residents (R46, R174, R93, R119, and R131). During the meeting, residents reported that the facility does have a sign at the front desk stating, Survey results are available upon request, but the survey binder itself is not readily accessible and must be requested. On 05/13/2025 at 11:52 a.m., a facility tour was conducted with the Administrator, Employee E1, to observe the placement of the Department of Health Survey binder. Employee E1 reported that the survey binder is located only on the first floor and is available upon request. During observation, a sleeve displaying the sign Survey results are available upon request was noted; however, it was not positioned at a wheelchair-accessible level. The binder containing the survey results was located in the Administrator's office. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility assessment and staff interview, it was determined that the facility failed to ensure the direct care staff and input from residents, resident representatives, and/or family members was included when conducting the facility assessment. Findings include: Review of the facility's facility assessment, dated July 28, 2025, revealed there was no indication that the facility involved direct care staff, input from residents, resident representatives, and/or family members. Interview with Employee E2, Director of Nursing, on March 12, 2026, at 10:20 a.m., confirmed there was no direct care staff, resident representatives, and/ or family members included in the facility assessment. 28 Pa. Code 201.18(b)(3) Management28 Pa. Code 211.12(c)(d)(1) Nursing services

Based on staff interviews and a review of employee credentials, it was determined that the facility failed to employ a qualified director of food and nutrition services.Findings include: An interview on March 9, 2026, at 9:20 a.m. with Employee E3, Food Service Director (FSD), revealed that her responsibilities included oversight of ordering, receiving, storing, preparation and service of food. Further interview with the FSD confirmed that she was not a certified dietary manager (CDM); or a certified food manager (CFM); or had a national certification for food service management and safety from a national certifying body; or had an associate's or higher degree in food service management or hospitality from an accredited institution; and that she had not received frequently scheduled consultations from a qualified dietitian. A review of Employee E12's credentials revealed that Employee E12 did not meet the statutory qualifications of a director of food and nutrition services. During an interview on March 10, 2026, at 12:15 p.m. with Employee E1, the Nursing Home Administrator, acknowledged that the FSD did not possess the regulatory required qualifications to provide operational oversight of the dietary department. 28 Pa Code 201.18(e)(6) Management 28 Pa Code 201.14(a) Responsibility of licensee

Based on review of clinical records, review of facility policy, interview with staff and residents, it was determined that the facility failed to ensure that a resident's advance directives were accurately documented in resident's clinical record for one of 28 residents reviewed. (Resident R110)Findings include: Review of facility policy ADVANCED MEDICAL DIRECTIVES revealed that section POLICY: Ivy Hill Post Acute and Rehabilitation Center conforms to all applicable laws and regulations. Although no resident will be compelled to designate a surrogate for purposes of establishing an advanced medical directive, all residents will be informed of these options and given the opportunity to make these arrangements at the time of admission to the facility. All professional staff at the facility will be instructed on the recording of advanced directives in resident records. This process will be incorporated into a system of ongoing psychosocial support for residents around issues of illnesses, incapacity, and death and dying. Under section PROCEDURE: #2. As a routine part of resident care, the Social Worker will, at reasonable intervals, ascertain whether initial choice and decisions expressed by the resident at the time of admission continue to reflect his/her wishes. When this is not the case, the Social Worker will document the changes in the resident's wishes. # 4. All medical electronic charts have an advanced section in which there should be either: a. Do Not Resuscitate/Do Not Intubate (DNR/DNI) b. Health Proxy (HCP) c. Durable Power of Attorney d. Living Will ([NAME]) Review Resident R110's clinical record revealed that Resident R110 was admitted to the facility on [DATE], with diagnosis of but not limited to Cerebral Palsy and Acute Respiratory Failure. Review of Resident R110's physicians orders dated December 29, 2025, revealed an order for Full Code (a medical directive indicating that a patient wishes to receive all possible life-saving interventions in the event of cardiac or respiratory arrest). Review of Resident R110's Pennsylvania Orders for Life Sustaining Treatment (POLST) for resident R110 revealed that cardio DNR (do not resuscitate)/ do not attempt resuscitation (allow natural death) was marked X and signed by Resident R110. Interview with Resident R110 conducted on March 10, 2026, at 12:22PM revealed that Resident R110 wanted DNR (do not resuscitate if his/her heart stops beating). Interview with Licensed nurse, Employee E9 revealed that resident was a Full Code. Further, Employee E9 revealed that in the event of a code, she would use the full code indicated on the facility's electronic medical record. Employee E9 was shown by the surveyor Resident R110's POLST. Employee E9 confirmed that the resident was DNR per POLST. Interview with Director of Nursing Employee E2 conducted on March 11, 2026, at 2:55PM confirmed that Resident R110 should have been a DNR and that the facility had corrected the error. 28 PA Code 211.10(c) Resident care policies 28 PA Code 211.12(d)(1) Nursing services

Based on review of the manufacturer's recommendations, observations, and staff interview, it was determined that the facility failed to ensure the medications were properly dated when opened for one of two medication rooms (Unit 2). Findings include: Review of manufacturer's recommendations for Tubersol (medication used for tuberculosis testing) revealed when a vial of Tubersol is opened it should be discarded after 30 days. Observation of the refrigerator on Unit 2 medication room on March 09, 2026 at approximately 10:25 a.m. revealed an open vial of Tubersol that did not have an open date, therefore staff was unable to determine the discard date. During an interview at the time of the observation, Licensed Practical Nurse, Employee E12, confirmed that the Tubersol did not have an open date and that it should have been dated upon opening to ensure it could be properly discarded after 30 days. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on direct observation, clinical record review, and interviews with staff, it was determined that the facility failed to ensure enteral feedings were administered and monitored according to professional standards of practice, specifically related to labeling, for one of one resident reviewed for tube feeding (Resident R135).Findings include: A review of the clinical record for Resident R135 indicated that the resident was admitted to the facility on [DATE], with diagnoses including cerebral infarction (stroke), muscle wasting, dysphagia (difficulty swallowing), and hypertension (high blood pressure). A review of the physician's order for Resident R135, dated February 3, 2026, indicated an enteral feeding order as follows: Glucerna 1.5 at a rate of 60 mL/hour via PEG tube, up at 5:00 p.m., down at 3:00 p.m., for a total volume of 1300 mL, total calories 1980 kcal. On March 9, 2026, at 10:17 a.m., an observation was conducted with Licensed Nurse, Employee E9. revealed that Resident R135 was in bed receiving enteral feeding. The feeding bag was not labeled with the time of initiation, the rate of the feed, or the initials of the nurse administering the feed. 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(3)(5) Nursing services

Based on observation, clinical record review and staff interview, it was determined that the facility failed to obtain treatment orders for one of four residents reviewed with skin impairment. (Resident R145)Findings include: Review of Resident R145's clinical record revealed that Resident R145 was admitted to the facility on [DATE], with diagnosis of but not limited to Cerebral Infarction and Nontraumatic Intracerebral Hemorrhage (brain bleed). Review of Resident R145's Wound Evaluation and Management Summary dated March 4, 2026, revealed a Focused Wound Exam (Site 4), STAGE 3 PRESSURE WOUND OF THE LEFT, DORSAL FOOT PARTIAL THICKNESS Wound Size (L x W x D): 1.5 x 0.5 x 0.1 cm, Care goal(s) this month: Decrease Wound Area, Maintain Skin Integrity, Prevent Infection, DRESSING TREATMENT PLAN Primary Dressing(s): Skin prep apply once daily and as needed: if saturated, soiled, or dislodged. For 9 days. Review of resident R145's physician orders revealed no treatment order for Resident R145's wound on the dorsal area (top side) of the left foot was obtained. Review of Resident R145's TAR (treatment administration record) for March 2026 revealed no treatment for on Resident R145's wound on the dorsal area (top side) of the left foot. Observation of Resident R145, conducted on March 18, 2026, at 10:24AM during wound care observation with unit manager Employee E13 and licensed nurse Employee E12 revealed that wound care and treatment was performed for Resident R145's sacral wound, right shin wound, left heel wound. There was no treatment performed on Resident R145's wound on the dorsal area (top side) of the left foot. Interview with Employee E12 and Employee E13 conducted at the time of the observation, confirmed that treatment to Resident R145's wound on the dorsal area (top side) of the left foot was not done. Further Employee E13 confirmed that there was no order for treatment on Resident R145's wound on the dorsal area (top side) of the left foot. 28 PA. Code 211.12(c) Resident care policies 28 PA Code 211.12(d)(1)(5) Nursing services

Based on observation, staff interview, and clinical record review, it was determined that the facility failed to ensure that a communication board was available or one of one resident reviewed who spoke a language other than English (Resident R3). Findings Include: A review of Resident R3's clinical record revealed an admission date of February 29, 2012. Review of the resident's comprehensive care plan, dated August 30, 2023, indicated: Communication device: [NAME] communication board at the bedside at all times. A review of Resident R3's clinical record did not indicate the language the resident spoke. Observation conducted on March 9, 2026, at 10:36 a.m., revealed that Resident R3 was unable to speak English. When asked what language the resident spoke, the resident stated Mandarin, Cambodian. When asked if (he/she) had any concerns, Resident R3 began speaking in another language. There was no evidence that an interpreter line or the communication board available in resident's room. Interview with Licensed Nurse, Employee E9, conducted on March 11, 2026, at 12:55 p.m. revealed that when asked what language Resident R3 spoke, Employee E9 stated it was unknown. When asked if the resident had a communication board, Employee E9 stated, I have seen it. Interview conducted on March 11, 2026, at 12:58 p.m., with the Rehabilitation Director confirmed that per resident's care plan, the resident benefit from the communication board. With the resident's permission, the Rehabilitation Director looked for the communication board at the bedside table, closet, and dresser, and there was no evidence of the communication board being present. When asked if Resident R3 had a communication board, the resident was unable to comprehend the question. On March 11, 2026, at 1:31 p.m., an interview was conducted with the Unit Manager, Employee E11. During the interview, Employee E11 brought a communication board to Resident R2. The resident was observed holding the board and reviewing the pictures. A review of the progress note dated March 3, 2026, indicated that Resident R3 refused to attend a cardiology appointment. Employee E11 asked Resident R2, without using the communication board, if he would agree to reschedule the appointment, and Resident R3 shook his head no. Resident R3 was then seated in a wheelchair, and a surveyor used the communication board to ask if he would agree to reschedule and attend the cardiology appointment. Using the board, Resident R3 agreed to attend the appointment. 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(5)(7) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to incorporate the recommendations from the Pre-admission Screening and Resident Review (PASARR) level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for one of 10 residents reviewed (Resident 27) Findings include:Review of Resident 27's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses including schizophrenia, (mental health disorder that changes how you think, feel and act) legal blindness (severe vision loss meeting legal criteria, and atrophy (wasting or shrinkage of body tissue, organs or body parts). Review of the PASARR screening dated July 16, 2024, revealed that the resident required a Level II evaluation. Documentation indicated the resident and/or representative was to be notified of the need for further evaluation. Review of a determination letter dated July 18, 2023, revealed Resident 27 qualified for additional services. Review of Resident R27 clinical record revealed no documented evidence that the facility coordinated with the Office of Long-Term Living to ensure delivery of PASARR Level II recommended services and that the services were obtained, coordinated, or provided. Interview with the mental health counselor, Employee E14 on March 11, 2026, at 9:34 a.m. revealed she was unable to complete full sessions with Resident 27. The counselor stated sessions were limited to redirection, with minimal communication, and the longest session lasting approximately 17 minutes with interruptions. The counselor stated she was unaware of any specialized services associated with the resident's PASARR Level II status. Interview with the Director of Nursing on March 11, 2026, at 1:00 p.m. confirmed that Resident 27 was identified through PASARR Level II; however, the facility was unable to provide evidence of coordination of services or care plan implementation related to PASARR recommendations. 28 Pa. Code 201.29(a) Resident rights

Based on clinical record reviews, and interviews with staff, it was determined that the facility failed to complete a discharge MDS assessment for 2 of 28 residents reviewed (Resident R65, R76).Findings include: Review for Resident R65 MDS (Minimum Data Set) quarterly assessments revealed that the MDS assessment was initiated on November 1, 2025, and completed on November 14, 2025. A clinical record review for Resident R76 revealed that the resident resident's MDS (Minimum Data Set) quarterly assessments revealed that a quarterly MDS assessment was initiated on, October 31, 2025, and completed on November 14, 2025. On March 11, 2026, at 10:25 a.m., an interview was conducted with the Registered Nurse in Extended Care (RNEC), Employee E6 who is responsible for initiating, reviewing, and validating MDS assessments. The RNEC confirmed that the quarterly MDS assessments for Resident R65 and Resident R76 was not completed within the required 7-day timeframe due to a high turnover rate of staff. 28 Pa. Code 211.12(d)(1) Nursing services

Based on observation and resident and staff interviews, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, comfortable, and homelike environment for three of three nursing units observed (first floor, second floor, third floor). Findings include: On March 24, 2025, at 12:57 p.m., Unit Manager Employee E19 confirmed that Resident R37 in room [ROOM NUMBER]-2 did not have access to a locked drawer at his bedside to store his personal belongings. Resident R37 had filed a grievance on January 3, 2025, regarding the missing $80, which was not reimbursed, and had been promised a locked drawer to secure his personal items. Observation on March 25, 2025 at 11:44 a.m. in room [ROOM NUMBER] revealed Resident R15 lying in bed in a fetal position. Interview with Resident R15 on March 25, 2025 at 11:45 a.m. revealed room [ROOM NUMBER] did not have a working heating unit. Resident R16 further stated the middle part of her bed was broken and she is unable to lay comfortably. Interview with Certified Nursing Assistance, Employee E13, confirmed Resident R15's bed and heating unit were broken. Observation of Resident R6 and R89's room [ROOM NUMBER] on March 24, 2025 at 11:30am, revealed unmaintained, leaking windowsill. Windowsill appeared dirty with thick dust and large dried clumps of patching plaster dripped along sill with no evidence of an attempt to clean up. Further observation revealed multiple soiled ceiling tiles. Observation of resident room [ROOM NUMBER] was confirmed by Maintenance Director, Employee E20, on March 24, 2025 at 11:44 AM. Observation of Resident R52 and R66's room [ROOM NUMBER] on March 24, 2025 at 11:15 AM revealed multiple soiled ceiling tiles. Observation of resident room [ROOM NUMBER], was confirmed by Maintenance director, Employee E20, on March 24, 2025 at 11:45 AM. On March 25, 2025, at 10:30 a.m. a resident council meeting was held with 8 alert and oriented residents ( R31, R70, R89, R71, R34, R34, R127, R94) who reported that they do not have locks on their drawers to keep their personal belonging. On March 25, 2025, at 12:48 p.m., an observation was made with Maintenance Director, Employee E20, who confirmed that the residents in the rooms 318-2, 303-2, 215-2, 300-1, 107-2, 308-1, 112-2, 231-1did not have access to locked drawers for storing their personal belongings. Observation of first floor dining room on March 25, 2025 at 11:32 AM revealed multiple soiled ceiling tile dispersed throughout dining area. 28 Pa Code 201.18(b)(1)(3) Management.

Based on observations of care and services, interviews with residents and staff and reviews of policies and procedures, it was determined that the facility failed to ensure that three of 38 residents were protected from inappropriate sexual behaviors from one resident. (Residents R63, R44, R82) Findings include: A review of the undated facility policy titled resident rights, abuse, neglect, mistreatment or misappropriation of resident property revealed that it was the responsibility of the facility to prevent abuse, neglect, mistreatment or misappropriation of resident property. All staff were responsible for reporting and investigating abuse including resident to resident abuse. All employees would be screened for convictions of abuse. Residents would be screened by the social worker for personal or family history of abuse. All employees, including management staff and volunteers would receive training upon orientation and annually about recognizing, reporting and prevention of abuse. The training was to include how staff was to report their knowledgement of allegations of abuse without fear of reprisal. The policy indicated that all residents and families and staff were encouraged to report concerns of abuse without fear of retribution. The facility administration was responsible to provide feedback regarding the concern that was expressed. That all staff and volunteers would be trained to immediately report an observed/suspected incident of abuse. The facility had a zero tolerance for resident abuse, neglect, mistreatment or misappropriation of resident property by anyone including staff members, other residents, consultants, volunteers, and staff of other agencies serving the residents. Any witness to abuse must submit a report immediately to the employee's supervisor. The witness must report to the nursing supervisor the following information: name of the resident involved, date and time of the incident, location of the incident, the perpetrator, names of other witnesses to the incident, type of abuse. The nursing supervisor was then responsible for examining the resident. The nursing supervisor was responsible for recording the incident of abuse or alleged abuse in the residents' clinical record. The nursing supervisor was to notify the abuse coordinator (the Nursing Home Administrator and Director of Nursing). During the investigation the perpetrator will be supervised or suspended, pending the results of the investigation. The policy indicated that an incident report (documentation) would be completed for the abuse event and the physician would examine the resident as indicated. The abuse coordinator would be responsible for complete a comprehensive investigation of the alleged abuse. The investigation would be recorded and reported to State Agencies as required with corrective actions taken. The abuse coordinator would contact the resident or responsible party with the results of the abuse investigation report and corrective actions taken. Review of Resident R44's quarterly Minimum Data Set (MDS- a federal mandated assessment for all residents) dated December 25, 2024, revealed Resident R44 was admitted into the facility June 2, 2023, with diagnoses of bipolar disorder (condition in which a person has periods of depression and periods of being extremely happy), human immunodeficiency virus and dysphasia (problem swallowing). Resident R44's cognition was evaluated as a BIMS (brief interview mental status) score of 10 indicating resident R44 has moderate cognitive impairment and independent with mobility. Review of Resident R44's November 2024 physician orders revealed an order for resident to be checked every hour initiated November 6, 2024. Continued review of the physician orders also revealed an order obtained on January 13, 2025 for one to one supervision at all times. Review of nursing notes date November 6, 2024, revealed that Resident R44 ordered for one hour checks. The resident was observed several times throughout the shift coming in and out of resident's rooms, and community rooms showing inappropriate sexual behaviors. Continued review of Resident R 44's clinical record revealed multiple room changes from November 2024 through January 2025 as follows: November 11, 2024 room [ROOM NUMBER], December 3, 2024 room [ROOM NUMBER], December 23, 2024, room [ROOM NUMBER], January 8, 2025 room [ROOM NUMBER], January 9, 2025 room [ROOM NUMBER], January 11, room [ROOM NUMBER]. There was no documented evidence in the resident's clinical record of the rationale for the room changes. Review of psychology note dated February 21, 2024, noted that the resident displayed hypersexual thoughts and behaviors. The clinician informed unit nurse manager and voiced the concerns that he is fixated on having sex and has made comments about wanting to act when his urges. Review of resident's care plan dated December 19, 2025, revealed cognitive loss related to traumatic brain injury resident has a BIMS score of 10 with interventions to include, speaking in a calm positive manner, do not rush or supply words, and identify self when speaking to resident. Continued review of Resident R44's care plan revealed that Resident R44 has sexual inappropriate behavior and sexual abuse allegations dated December 24, 2025, with interventions to continue 1:1 supervision. Resident R44 has been observed displaying sexual inappropriate behaviors, touching of genitals, grabbing at staff in appropriate areas, inappropriate sexual comments toward staff dated December 19, 2024. Interview with nursing aide, Employee E8 on March 24, 2025, at 10:15 a.m. revealed that this employee had witnessed Resident R44 taking off Resident R63's underwear. Resident R63 does not have the cognition to consent. Employee 8 stated that she went directly to the nurse unit manager and reported it last January. Employee E8 stated that Assistant Director of Nursing and Director of Nursing and Nursing Home Administrator were all made aware of the incident. Employee E8 stated that she is aware of two other occasions that Resident R44 was caught having inappropriate sexual behavior. Continued interview with nurse aide, Employee E8 stated that on another occasion the visiting volunteer pastor had caught Resident R44 touching a resident's breast during the service. The volunteer pastor immediately reported the incident to staff. Interview with volunteer pastor, Employee E10 on March 26, 2025, at 3:00 p.m. revealed that Employee E10 stated that he remembered an incident that when he saw Resident R44 with his hand on Resident R82's breast, over her sweater. Employee E10 stated that resident R44 is no longer allowed to attend services, he is very uncomfortable with resident R44's gestures towards the pastor's wife. Review of Resident R78's MDS (Minims Date Set) dated January 7, 2025, in Section C- cognitive patterns, revealed that resident has a BIMS (brief interview for mental status) of 12 (moderately impaired). Review of Resident R78's progress note dated December 15, 2025 at 1:18PM, revealed resident is cognitively intact. Interview with Resident R78 on March 27, 2025 at 9:11 a.m., revealed that he had witnessed multiple occasions of sexually inappropriate behaviors of Resident R44 towards Resident R82 in common areas. These behaviors included Resident R44 touching the leg of Resident R82. Resident R44 acting sexually toward Resident R82. Resident R44 grabbing Resident R82 from behind and wrapping his arms around her. Resident R44 giving little gifts to Resident R82. Staff would tell Resident R44 to leave the common area when inappropriate behaviors observed, sometimes other residents would intervene as well. Interview with nursing aide, Employee E30 on March 25 at 3:45 p.m. when question why Resident R44 was on one to one supervision she stated that he is touchy with other residents Interview with nurse aide, Employee E31 on March 25 , 2024 at 3:55p.m. he touches residents inappropriately Review of Resident R63's quarterly MDS dated [DATE] indicated that this resident had diagnoses of adjustment disorder with anxiety and dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking) with agitation. The assessment indicated a BIMS of 3 which indicated severe cognitive impairment. The assessment indicated that this resident used a wheelchair, required staff supervision and contact guard (minimal physical support) with chair to bed/bed to chair transfers. The resident was assessed with bowel and bladder incontinence. Interview with a nurse aide, Employee E8 on March 24 and March 26, 2025 during the seven to three nursing tour of duty revealed that this employee witnessed Resident R44 in the bed room of Resident R63 in January, 2024. Employee E8 reported seeing Resident R44 was in the process of removing Resident R63 underwear (brief), while the resident was supine in bed. Further interview with Employee E8 revealed that Resident R44 was escorted to the dining room on the third floor nursing unit away from Resident R63. Employee E8 also reported that Resident R44 was fully clothed upon entering the bed room. Interview with nurse aide, Employee 8, at 10:30 a.m., on March 26, 2025 revealed that this employee reported the incident of nonconsensual touching to a licensed nurse on the unit and to the unit manager. Review of Resident R63 and Resident R44's January 2025 nursing documentation revealed no documented evidence of the above observation reported by nurse aide, Employee E8. Interview with administrative staff Employees E1 and E2 at 11:00 a.m., on March 26, 2025 confirmed that there was no documentation at the facility of any report related the Resident R44 being observed removing Resident R63's brief. Interview with nursing aide, Employee E9 at 9:30 a.m., on March 26, 2025 revealed that this employee was familiar with the care of Resident R44. The nursing aide, Employee E9 described Resident R44 as being independently ambulatory throughout the facility and that it was common knowledge of Resident R44 to ambulate away from the third floor nursing unit, unsupervised and down to the vending machine for snack foods. Interview with registered nurse, Employee E25 at 2:30 p.m., on March 26, 2025 confirmed that this nurse was responsible for supervising Resident R44 during the 3-11 tour of duty on the third floor nursing unit. The registered nurse reported that Resident R44 likes to verbally curse profanity toward the male residents. The registered nurse said that Resident R44 was independently ambulatory and would walk into other residents (male and female) rooms unsupervised taking their clothing. The registered nurse also reported that Resident R44 would expose himself and urinate in the hallway or lounge area during the 7-11 nursing shift. A review of the clinical record and care plan for Resident R44 revealed that there was incomplete and unavailable documentation to indicate that staff were monitoring this resident's whereabouts, since January, 2024. There was no documentation to indicate that 15 minute, 30 minutes, or hourly checks were complete and accurately documented by staff for this resident since January, 2024. The facility documentation of monitoring of Resident R44's whereabouts was confirmed with the Director of Nursing at 10:15 a.m., on March 26, 2025. A review of the nursing staff assignment sheets for March 24 and March 25, 2025 revealed that nursing staff were not explicitly assigned duties to supervise the care of Resident R44. The nursing assignments for March 24, 2025 and March 25, 2025 were confirmed with Licensed nurse, Employee E24, on March 26, 2025 at 9:00 a.m. 28 Pa. Code 201.14(b) Responsibility of licensee 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1) Nursing services 28 Pa. Code 211.5(f)(ii)(iii)(ix) Medical records

Based on personnel record review, and staff interview, it was determined that the facility failed to provide abuse, neglect and exploitation training for two of two volunteer staff reviewed (Employee E10, and E11). Findings: A review of the Facility Policy titled Residents/Patient Right-Abuse, Neglect, Mistreatment or Misappropriation of Resident/Patient's Property undated, revelated All employees, including management staff and volunteers, will receive training upon orientation and annually. In-services regarding abuse, neglect, mistreatment or misappropriation of resident's/patient's property. Training will include how staff should report their knowledge of allegations without fear of reprisal; How to recognize signs of burnout, frustration and stress that may lead to abuse On March 26, 2025, at 2:04 p.m. an interview with Volunteer Pastor, Employee 10 revealed that he and his wife, Employee E11 had been coming to the facility for [AGE] years to conduct religious activities. On March 28, 2025, at 1:15 p.m. an interview with the Human Services Director, Employee E12 revealed that she is not responsible for conducting training for any volunteers. An interview was conducted with the Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2 on March 28, 2025, at 1:30 p.m. confirmed that abuse training for volunteer Pastor, Employee 10 and Employee E11 ere not conducted or available for review. 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 201.19(8) Personnel policies and procedures

Based on review of clinical records and interview with staff, it was revealed that the facility did not ensure revisions were made to the PASRR (Pre-Admission Screening and Resident Review) application to include mental health diagnoses for 3 out of 3 residents reviewed. (Resident R108, R10, R90). Findings include: Review of Resident R108's PASRR completed on January 31, 2024, indicated that Resident R108 had no mental health diagnosis. Review of R108's clinical record revealed on May 2, 2024, obtained a mental disorder and on April 4, 2024, obtained an anxiety disorder. A review of Resident R10's PASRR completed on February 24, 2023, indicated that Resident R10 had a mental health condition of Schizophrenia (serious mental health condition that affects how people think, feel, and behave) , altered mental status. A review of the resident diagnosis revealed that Resident R10 also had mood disorder due to known physiological condition as of July 24, 2023. Clinical record review revealed Resident R90 had a mental diagnosis of Bipolar Disorder (mental health condition that causes extreme mood swings), obtained October 11, 2024, and Schizophrenia obtained October 28, 2024. Review of Resident R90's PASRR completed on October 11, 2024 revealed Resident R90 had a mental diagnosis of Bipolar Disorder. Further review of Resident R90's clinical record revealed no updated PASRR to include Resident R90's diagnosis of Schizophrenia. Interview with the facility Social Worker, Employee E3 on March 26, 2025, at 02:05 p.m., confirmed that facility did not update any PASSAR forms for any residents if they were not a target for level 2. It was further confirmed that the PASSR forms for Residents R108, R10 and R90, should have been updated with the additional updated mental health diagnosis. 28 PA Code 211.10 (c) Resident Care Policies 28 PA Code 211.5(f)(viii) Medical records

Based on reviews of personnel files and the Department of State documents, staff interviews and reviews of policies and procedures, it was determined that the facility failed to perform criminal history background checks for two of two volunteer files (Employees E10, and E11) reviewed and the facility failed to ensure residents were protected from abuse by implementing the established abuse policy (Residents R63 and R44). Findings include: A review of the undated facility policy titled resident rights, abuse, neglect, mistreatment or misappropriation of resident property revealed that it was the responsibility of the facility to prevent abuse, neglect, mistreatment or misappropriation of resident property. The policy indicated that all staff were responsible for reporting and investigating abuse including resident to resident abuse. The policy indicated that all employees would be screened for convictions of abuse. The nurse aide registry, licensing authorities and references would be referenced for each employee prior to hire. Residents would be screened by the social worker for personal or family history of abuse. The policy indicated that all employees, including management staff and volunteers would receive training upon orientation and annually about recognizing, reporting and prevention of abuse. The training was to include how staff was to report their knowledgement of allegations of abuse without fear of reprisal. All residents and families and staff were encouraged to report concerns of abuse without fear of retribution. The facility administration was responsible to provide feedback regarding the concern that was expressed. All staff and volunteers would be trained to immediately report an observed/suspected incident of abuse. The facility had a zero tolerance for resident abuse, neglect, mistreatment or misappropriation of resident property by anyone including staff members, other residents, consultants, volunteers, and staff of other agencies serving the residents. Any witness to abuse must submit a report immediately to the employee's supervisor. The witness must report to the nursing supervisor the following information: name of the resident involved, date and time of the incident, location of the incident, the perpetrator, names of other witnesses to the incident, type of abuse. The nursing supervisor was then responsible for examining the resident. The nursing supervisor was responsible for recording the incident of abuse or alleged abuse in the residents' clinical record. The policy indicated that the nursing supervisor was to notify the abuse coordinator (the nursing home administrator and Director of nursing). During the investigation the perpetrator will be supervised or suspended, pending the results of the investigation. An incident report (documentation) would be completed for the abuse event and the physician would examine the resident as indicated. The abuse coordinator would be responsible for complete a comprehensive investigation of the alleged abuse. The investigation would be recorded and reported to State Agencies as required with corrective actions taken. The abuse coordinator would contact the resident or responsible party with the results of the abuse investigation report and corrective actions taken. On March 26, 2025, at 2:04 p.m. an interview with Volunteer Pastor, Employee 10 revealed that he and his wife, Employee E11 had been coming to the facility for [AGE] years to conduct religious activities. On March 28, 2025, at 1:15 p.m. an interview with the Human Services Director, Employee E12 revealed that she was not responsible for conducting the State Police background checks. An interview was conducted with the Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2 on March 28, 2025, at 1:30 p.m. confirmed that criminal record for Volunteer Pastor, Employee 10 and his wife, Employee E11 were not conducted or available for review. Review of Resident R44's Minimum Data Set (MDS- a federal mandated assessment for all residents) dated December 25, 2024, revealed Resident R44 was admitted into the facility June 2, 2023, with diagnoses of bipolar disorder (condition in which a person has periods of depression and periods of being extremely happy), human immunodeficiency virus and dysphasia (problem swallowing). Resident R44's cognition was evaluated as a BIMS (brief interview mental status) score of 10 indicating resident R44 has moderate cognitive impairment. This resident functional abilities are mainly independent with ADLs (activities of daily living). Review of psychology note dated February 21, 2024, revealed summary of session, which noted that Resident R44 admitted to physically assaulting a staff member. He displayed hypersexual thoughts and behaviors. The clinician informed unit nurse manager and voiced the concerns that he is fixated on having sex and has made comments about wanting to act when his urges. Interview with nursing aide, Employee E8 on March 24, 2025, at 10:15 a.m. revealed that this employee had witnessed Resident R44 taking off Resident R63's underwear. Resident R63 does not have the cognition to consent. Employee 8 stated that she went directly to the nurse unit manager and reported it last January. Employee E8 stated that Assistant Director of Nursing and Director of Nursing and Nursing Home Administrator were all made aware of the incident. Employee E8 stated that she is aware of two other occasions that Resident R44 was caught having inappropriate sexual behavior. Interview with the Nursing Home Administrator, Employee E1 and Director of Nursing, Employee E2 at 12:00 p.m., on March 26, 2025 revealed that both administrative staff members who were the facility's abuse coordinators, said that they were unaware of any reports of possible sexual abuse, for Resident R44. Continued interviews with the director of nursing and the administrator confirmed that they were unaware of any reports of inappropriate sexual conduct by Resident R44. 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 201.19(8) Personnel policies and procedures

Based on a review of clinical records, observations, and staff interviews, it was determined that the facility failed to identify the placement of beds against the wall as a restraint, the use of a seatbelt on a wheelchair as a restraint, and did not assess the functional status of an individual resident to determine the appropriateness of using a restraint for two of the 26 residents reviewed (Resident R108 and Resident R26) Findings Include: Review of Resident R108's clinical record revealed that the resident was admitted to the facility February 1, 2024, with a diagnosis of difficulty in walking, and encephalopathy (disease that affects the brain's structure or function). On March 24, 2025, at 12:52 p.m., Resident R108 was observed sitting in a wheelchair in the dining room with a seatbelt fastened across his waist. The seatbelt was locked, preventing the resident from being able to release it. This observation was confirmed by the unit manager, Employee 19, who reported that Resident R108 does not have an order for the use of a seatbelt restraint and expressed uncertainty as to why the seatbelt was locked across his knees. Clinical record review revealed Resident R26 was admitted to the facility November 06, 2020 with a diagnosis of diabetes mellitus (condition of high blood sugar caused by insulin problems), morbid obesity, and difficulty walking. Observation on March 24, 2025 at 10:05 a.m. revealed Resident R26's left side of bed was against the wall. Interview with Resident R26 on March 24, 2025 at 10:06 a.m. revealed Resident R26's bed against the wall is not preference based and the bed was against the wall when resident was moved into the room. Further interview with Resident R26 revealed his bed against the wall prevents him from getting out of bed on the left side. Review of Resident R26's clinical record revealed no physician assessment for Resident R26's bed against the wall and no care plan related to the purpose of Resident R26's bed against the wall. Interview on March 18, 2025 at 9:30 a.m. with Unit Manager, Employee E24, revealed Resident R26 has a larger bed due to residents size and Resident R26's bed may be against the wall due to limited space. 28 Pa. Code 211.8(e)(f) Use of Restraints. 28 Pa. Code:211.12(d)(1)(5) Nursing services.

Based on the review of clinical records, facility documentation, facility policies, and interviews with resident and staff, it was determined that the facility failed to demonstrate evidence that a grivance was promptly documented and resolved for one of 26 resident records reviewed. (Resident R95) Findings Include: The facility will fully investigate and respond to all concerns or complaints regarding patient/resident care and/or treatment. The patient/resident/ resident representative has the right to file a grievance orally, in writing, or anonymously. All grievances will be responded to within 48-72 hours, and in writing if requested. On March 24, 2025, at 12:55 p.m., an interview was conducted with Resident R37, who reported that $80 had gone missing in January 2025. The facility investigated the concern but did not issue a refund, stating that the amount was not documented on the resident's inventory sheet. Resident R37 also mentioned that the facility had promised to provide a locked drawer for storing his personal belongings. At 12:57 p.m. on the same day, Unit Manager Employee E19 confirmed that no locked drawer was available at Resident R37's bedside for the storage of personal items. Grievance was not resolved. On March 25, 2025, at 10:30 a.m. a resident council meeting was held with 8 alert and oriented residents ( R31, R70, R89, R71, R34, R34, R127, R94) who reported that resolution of the grievances are not communicated to the residents. Resident R94 reported that he requested for the resolution of his grievance would be given to him in writing and facility declined. On March 26, 2025, at 2:15 p.m., an interview was conducted with the family representative of Resident R108, who expressed concern that the resident's clothing was missing. The representative explained that they personally bring new clothing, label it, and place it in the resident's closet. However, they were unaware that the facility is supposed to complete an inventory sheet for every item brought to Resident R108. The representative also reported that, during a visit two days ago, the resident was seen wearing someone else's clothing for two consecutive days. A review of the grievance which was filed by a resident's R95 family representative on January 22, 2025, listed missing clothing items such as black & gray skinny jeans, black hoodie, 1 black long sleeve thermal, plain black short sleeve t-shirt, burgundy pants with pink paw prints, fresh empire black t-shirt with lime green, gray long sleeve with pink stirp around collar, burgundy pants stretchy. Grievance noted that items were found, and grievance resolved. A review of the inventory sheet dated November 27, 2024, none of the above missing items were listed on the inventory sheet. On March 28, 2025, at 10:05 a.m., an observation was conducted with the Housekeeping Supervisor, Employee E16, regarding Resident R95's clothing. It was noted that the resident had additional items in her closet, none of which were listed on the inventory sheet. E16 is responsible for labeling the clothing and managing its location when items go missing as part of the grievance process. However, R16 does not complete the inventory sheet. It was also confirmed that some of Resident R95's clothing, such as a black winter jacket, had been labeled by the family using tape, which can easily come off. The clothing should have been labeled by the facility instead with facility's ironing labeling process. On March 28, 2025, at 10:28 a.m., an interview was conducted with Social Worker Director, Employee E3, who confirmed that she does not educate residents or their representatives about the clothing inventory process, nor does she complete the inventory sheet. E3 handles grievances and reported that families are notified about the clothing inventory process upon admission, based on the facility's signage at the receptionist desk. E3 further confirmed that in the case of Resident R95's grievance, dated January 22, 2025, the missing clothing had not been originally documented on the resident's inventory sheet. On March 28, 2025, at 10:36 a.m. an admission director, Employee E18 was interviewed who reported that she does not educate families about the inventory sheet and personal belongings upon admission. On March 28, 2025, at 10:43 a.m., an interview was conducted with the receptionist, Employee E17, who reported that when families bring in bags of clothing, she asks if the items are for the resident. If the family confirms, she provides them with an Inventory of Personal Possessions form to complete and checks the clothing against the form. E17 then hands the clothing bag, along with the form, to the nursing assistant or unit manager for the resident, who is responsible for completing the inventory sheet and placing it in the resident's hard chart. However, if the family handles the resident's laundry, the receptionist does not check the clothing or provide the Inventory of Personal Possessions form. In this case, the family simply drops off the clothing directly in the resident's room, and the clothing is neither labeled nor added to the inventory list. On March 28, 2025, at 10:50 a.m., a follow-up interview was conducted with the Social Work Director, Employee E3, who acknowledged that there is a broken process with the inventory sheet. There is no documentation for clothing when families handle the laundry for the resident, nor is there a clear process to track and locate the clothing, as was the case with Resident R95. 28 Pa. Code 201.18 (b)(1)(3)(2.1)(4) Management 28 Pa. Code 201.29 (a) Resident Rights

Based on clinical record review, interviews with residents and staff and reviews of policies and procedures, it was determined that for one of two residents reviewed that the interdiciplinary care planning team failed to assess each resident for self adminitration of medications and determine if the practice was clinically appropriate and safe in accordance with their residents rights. (Resident R94) Findings include: A review of the undated facility policy titled self-medication administration revealed that it was each resident's right to manage their medications independently within the nursing home. The policy indicated that the facility was responsible for assessing each resident to deem if the resident was capable of safely managing their own medications. Clinical record review for Resident R94 revealed a quarterly comprehensive assessment dated [DATE] that indicated this resident was cognitively intact, had no swallowing problems with foods or fluids. The assessment also indicated that the resident had adequate vision, was able to follow directs and had no functional limitations of upper extremities. Interview with Resident R94 at 2:30 p.m., on March 24, 2025 revealed that the resident does order medications (airbone gummies, centrum silver, finasteride, folic acid, glipizide, glycolax powder, docusate sodium, ascorbic acid, ferrous sulfate) to be delivered to the facility or that the facility pharmacy delivers to the facility for him. Resident R94 reported that he was a retired pharmacist and he was interested in administering medications to himself. The resident was understanding that he would have to be provided with a locked bed side cabinet to secure the medications from staff and other residents. Inreview with the licensed practical nurse, Employee E24 at 2:40 p.m., on March 24, 2025 confirmed that Resident R94 had been given the opportunity of assessment by the interdisiplinary care team, to the determine his ability to self administer medications. The licensed nurse, Employee E24 reported being aware that the resident had been requesting to self administer medications, since admission to the facility on [DATE]. The licensed practical nurse, Employee E24 verified that there was no care plan developed for Resident R94 to self administer medications as he desired. 28 PA. Code 211.10(a)(b)(c)(d) Resident care policies 28 PA. Code 211.12(d)(1)(3)(5) Nursing services 28 PA. Code 201.29(a) Resident rights

Based on clinical record review and family and staff interviews, it was determined that the facility failed to obtain a urinary study in a timely manner for a resident with an indwelling urinary catheter and experiencing bleeding from the urinary catheter for one of five residents reviewed. (Resident R1). This failure resulted in actual harm to Resident R1 who was transferred to the hospital, diagnosed with a urinary track infection, anemia and required two units of PRBC (packed red blood cells). Findings include: Review of Resident R1's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated February 6, 2023, revealed that the resident was admitted to the facility, November 12, 2022, with diagnoses of middle cerebral artery stroke (MCA stroke may cause language deficits, as well as weakness, sensory deficits and visual defects on the opposite side of the body) and urinary tract infection (UTI is an infection in any part of the urinary system including the kidneys, ureters, bladder and urethra). Continued review of the MDS revealed that the resident had short and long term care memory impairment, required extensive assistance with bed mobility and transfer and had an indwelling urinary catheter. Review of Resident R1's care plan initiated November 13, 2022, revealed that the resident had the potential for complications related to the use of foley catheter with a supporting diagnosis for the use of a foley catheter due to a sacral pressure ulcer. Interventions included to observe foley catheter for signs and symptoms of a UTI. Review of Resident R1's nursing notes dated April 8, 2023, at 7:29 p.m. by licensed nurse, Employee E11, Nurse received resident in bed with foley catheter draining bright red blood, and during incont (incontinent) care the resident's diaper was saturated with bright red blood along with bright red blood clots small to largest the size of a quarter. Resident appeared to be in no pain no distress. A review of Resident R1's hospice documentation revealed that the resident was admitted to hospice services on November 12, 2022. Continued review of R1's hospice record revealed a note dated April 8, 2023, stating that there was a change in condition with the bleeding from the foley catheter. Review of Resident R1's nursing note dated April 9, 2023, at 3:29 a.m. by Licensed nurse, Employee E11, revealed that the hospice nurse was in to assess resident, and during the exam the resident presented with several extra-large bright red blood clots (larger then previously) inside her incontinence brief, which was also saturated with blood, and the foley catheter was also draining bright red blood. The resident appeared to be very lethargic, even more than usual, as the resident was falling asleep during care. The hospice nurse indicated that she would have another nurse out in morning to follow-up. Review of nursing note date April 10, 2023, at 3:10 p.m. by Licensed nurse, Employee E9, revealed that hospice had made a recommendation for obtaining UA C&S (urine analysis with culture and sensitivity test used in diagnosing urinary tract infections, especially in patients who have a catheter inserted for an extended period of time) to rule out a UTI (urinary tract infection) related to a change in condition and hematuria (blood in the urine). The MD's (physician) office and daughter were made aware. Nursing to monitor. Continued review of nursing documentation dated April 10, 2023, at 9:18 p.m. by Licensed nurse, Employee E12, noted that urine specimen was obtained and placed in the refrigerator for the UA C&S test to diagnose a UTI. Further review of Resident R1's clinical record revealed no nursing note written on April 11, 2023, indicating that nursing was monitoring the change in condition with blood in the foley catheter and bright red blood and blood clots in the resident's incontinent brief. Review of nursing note dated April 12, 2023, at 1:54 p.m. revealed that Resident R1's daughter was present at the nurse's station with concerns about her mother related to her hematuria and increased trach secretions. Call was placed to MD office to approve recommendation by hospice for a UA C&S. Awaiting call back from office. Nursing note dated April 12, 2023, at 5:40 p.m. noted that the physician's office contacted the facility with verbal orders for a UA C&S collection. Continued review of nursing documentation dated April 13, 2023 at 2:57 p.m., revealed that Resident R1's daughter requested that the resident be sent out to the hospital related to increased secretions and hematuria. An interview with Resident R1's daughter, who is the resident's responsible party, at the facility on April 25, 2023, at 12:50 p.m. revealed that the daughter was frustrated that it took the facility too long to diagnose and treat her mother for a UTI which she, and everyone she spoke with was sure was causing her mother's bleeding in her Foley catheter, and her lethargy and sleeping through her visits which was not her norm. She stated that she pointed out the purple red urine in her mother's catheter bag every time she visited and how her mother's condition had continued to decline from when she first was aware of the bleeding on April 8, 2023, until she demanded that she be sent out to the hospital on April 13, 2023, because they still did not have any lab results and were not treating her mother's UTI. Resident R1's daughter was upset and said that her mother had to receive a transfusion of two units of blood once she got to the hospital. Review of Resident R1's hospital records dated April 21, 2023, revealed a urinalysis laboratory test completed 4/13/23 which indicated that the resident urine color was red and large content of blood. Continued review of hospital records revealed a CBC (complete blood count) which revealed a Hemoglobin level of 5.2 grams (gm)/per deciliter (dl) normal 12g/dl-16g/dl) and a Hematocrit level of 16.6% (normal levels 35.5 to 44.9%). Review of the iron panel revealed results which were consistent with iron deficient anemia, likely from bleeding. Resident R1's daughter consented for blood transfusion, and that 2 units PRBC (packed red blood cells are a type of blood replacement product used for blood transfusions. PRBC transfusion is typically given in situations where the patient has either lost a large amount of blood or has anemia that is causing notable symptoms) were transfused. Interview with Licensed nurse, Employee E9, Unit Manager on April 25, 2023, at 1:20 p.m. revealed that the facility became aware of the bleeding on April 8, 2023, which she pointed out was a Saturday. Hospice recommendation for a UA C&S was on April 10, 2023, and that the facility collected a sample that day. That it can take a day or two for results and when the daughter visited on April 12, 2023, asking about the results she called that lab who said that they never received the sample. Licensed nurse, Employee E9 got an order to collect another urine sample to send out for a UA C&S. That a sample was collected on April 12, 2023, but that it had not been picked up by the lab yet when the daughter arrived on April 13, 2023, demanding that her mother be sent out to the hospital. Interview with the Director of Nursing (DON) on April 25, 2023, at 2:15 p.m. confirmed that Resident R1's change in condition related to bleeding in her catheter and blood clots in her brief started on April 8, 2023, and that a urine sample was collected on April 10, 2023, at 10:30 p.m. and that it was picked up the next morning (April 11, 2023) and that when the Licensed nurse, Employee E9 called on April 12, 2023, she was told that it was not received by the lab, and that another order was initiated but it was not processed before the daughter insisted her mother be sent out. The DON confirmed that the change in condition was noted on Saturday, April 8, 2023, and that Resident R1 was sent out to the hospital six days later on Thursday, April 13, 2023, and that the resident never had UA C&S results or treatment with antibiotics during this time. The facility failed to ensure that laboratory testing was completed timely for a Resident R1 with urinary catheter who experience bleeding from the catheter and presented with blood clots. This failure resulted in actual harm to Resident R1 who was transferred to the hospital, diagnosed with a urinary tract infection and anemia and required two units of PRBC. 28 Pa. Code:201.18(a)(b)(1)(3) Management 28 Pa Code 211.119c) Resident care policies 28 Pa. Code:211.12(d)(1)(5) Nursing services

Based on clinical record review, review of facility documentation and interviews with staff, it was determined that the facility failed to implement established interventions related to staff assistance during care, resulting in harm to one resident (Resident CL1). Findings include: Review of Resident CL1's clinical record revealed a Minimum Data Set (MDS-periodic assessment of needs), dated [DATE], indicating [DIAGNOSES REDACTED]. The MDS also indicated that the resident was moderately impaired in cognitive skills for decision making, was incontinent of bowel and bladder, and required the physical assistance of two staff members for bed mobility, transfers, and personal hygiene. Review of nursing documentation revealed on [DATE], the resident was diagnosed with [REDACTED]. Further review of nursing documentation revealed the resident developed a fever on [DATE], and was admitted to an acute care hospital for the fever from [DATE]-22, 2010. physician's orders [REDACTED]. Review of Resident CL1's care plan, dated last updated [DATE], revealed that the resident was a risk for falls and indicated that the resident must receive an assist of two staff members during care, specifying one staff member on each side of the bed. A reportable event dated [DATE], received via the Pennsylvania Department of Health's Event Reporting System, indicated that the resident had fallen during the administration of care at 5:30 a.m., and sustained injuries as a result of the fall. Review of Resident CL1's nurse's notes, dated [DATE], at 6:30 a.m., revealed that the licensed nurse was called to the room by a certified nursing assistant (CNA) at 5:30 a.m., where the resident was observed lying on the floor, face down, near the resident's bed. Review of a witness statement dated [DATE], by Employee E1, CNA, related to Resident CL1's fall, revealed that while performing perineal (from the genitals to the rectum) care, the CNA pulled the resident toward her and Resident CL1 fell to the floor with the resident's head hitting the floor, followed by the rest of the resident's body. The CNA did not have another staff member present while performing perineal care to the resident. Review of nursing documentation revealed that after Resident CL1's fall at 5:30 a.m., staff put the resident back to bed and at 7:10 a.m., the resident was unresponsive to verbal and tactile stimuli, remained unresponsive to sternal (breast bone) rub, and was sent to the emergency room for evaluation via 911 emergency services. Review of facility documentation indicated that at the hospital, the resident was diagnosed with [REDACTED]. Further review of nursing documentation revealed the resident returned to the facility from the emergency roiagnom on [DATE], at 10:44 a.m., was placed on palliative (comfort) care, and was pronounced dead on [DATE], at 11:15 a.m. Review of the certificate of death, dated [DATE], at 11:15 a.m., revealed cause of death was acute intra-cerebral (brain) bleed. Interview with the Administrator and Director of Nursing on [DATE], at 9:00 a.m., confirmed that during the administration of personal care, Resident CL1 had fallen off the bed, onto the floor, face down, and was later transported to the hospital where it was determined that the resident had sustained multiple brain injuries, and subsequently expired as a result of the injuries sustained from the fall. Further interview confirmed that Employee E1 did not follow the resident's care plan which indicated an assist of two staff members was required for Resident CL1's care. The facility failed to ensure that the resident received safe care in accordance with established interventions, resulting in actual harm to the resident. Refer to F282. 483.25(h) Accidents and Supervision. Previously cited state deficiency [DATE]. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. Previously cited [DATE] and [DATE]. 28 Pa. Code 211.11(a) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited [DATE], [DATE] and [DATE].