Every finding on record at Ivy Park Post Acute

Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to implement enhanced barrier precautions for one of four residents (R8), failed to maintain medication room refrigerators in a sanitary manner (Second-floor Medication Room) and failed to prevent cross contamination during a dressing change for one of three residents (Resident R128).Findings include: Review of the facility Enhanced Barrier Precautions policy last reviewed 1/9/26, indicated enhanced barrier precautions (EBP's) will be implemented for residents with a chronic wound, Staff must wear gown and gloves when performing high-contact care activities for a resident on EBP. These activities include but are not inclusive to wound care. Review of the facility policy Medication Storage in the Facility last reviewed 1/9/26, indicated medications and biologicals are stored safely, securely and properly. Review of the facility policy Wound Dressing Change last reviewed 1/9/26, indicated Residents requiring wound care will receive dressing changes according to practitioner orders, the resident's individualized plan of care, facility procedures, and accepted standards of nursing practice. Staff will follow standard infection-prevention practices during wound care, including but not inclusive to Prevention of cross-contamination. Appropriate cleaning and storage of reusable equipment and supplies. Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE]. Review of Resident R8's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/30/26, indicated diagnoses of diabetes (high sugar in the blood), anemia (low iron in the blood) and hypertension (high blood pressure). Review of Resident R8's physician orders dated 8/18/26, indicated cleanse left foot venous ulcer with wound cleanser and pat dry. Apply urgoclean (a soft adherent, poly absorbent fiber wound dressing designed to remove slough and debris, manage exudate, and support atraumatic healing in chronic or acute exuding wounds) Cover with silicon border dressing daily and as needed. The orders failed to include enhanced barrier precautions (EBP) when caring for the wound. During an observation completed on 8/24/26, a see the nurse before entering sign was observed on the doorframe to room [ROOM NUMBER] a bin with personal protective equipment was also on the door. Upon asking Licensed Practical Nurse (LPN) Employee 7 concerning the bin and signage replied, I believe she has been taken off precautions as her wound healed. During an interview completed on 8/27/26, at 10:20 a.m. upon asking Licensed Practical Nurse (LPN) Employee E16 concerning Resident R8's wound replied it was a miscommunication, I told Registered Nurse (RN) Employee E12 about the other wound that healed and the order for the EBP was discontinued. The other area was still open, it was miscommunication, the EPB should have been still on for the current wound and confirmed that the facility failed to implement enhanced barrier precautions for one of four residents (R8) During an observation completed on 8/25/26, at 11:43 a.m. the Second-floor medication room refrigerator revealed a yellow substance on the bottom shelf and around bottom drawer the back of the refrigerator contained a piece of brown cardboard inside of a large area with ice build-up. The refrigerator freezer had a large amount of ice build-up to the bottom areaDuring an interview completed on 8/25/26, at 11:51 a.m. LPN Employee E8 confirmed the above observations and that the facility failed to maintain medication room refrigerators in a sanitary manner (Second-floor Medication Room). Review of the clinical record indicated Resident R128 was admitted to the facility on [DATE], with the diagnosis of dementia, hypertension and osteomyelitis (infection of the bone). Review of Resident R128 physician orders dated 8/17/26, indicated to cleanse cossyx with wound cleanser, Sprinkle collagen powder (can help chronic or slow healing wounds by providing a scaffold for new tissue growth, absorbing excess fluid, and reducing destructive enzymes that delay healing) onto calcium alginate (highly absorbent dressing) and apply to wound bed. Cover with Absorbent dressing daily and PRN. During a dressing change observation completed on 8/26/26, at 11:23 a.m. LPN Employee E7 utilized the over bed table by preparing a clean field with a barrier for Resident R128's dressing supplies. After removing the barrier, moved the over bed table to the other side of Resident R128's bed. LPN Employee E7 failed to clean the table after removal of the dressing supplies and barrier field. During an interview completed on 8/26/26, at 11:45 a.m. LPN Employee E7 confirmed not cleaning the over bed table after using it for the dressing change and that the facility failed to prevent cross contamination during a dressing change for one of three residents (Resident R128). 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.28 (b)(1)(e)(1) Management.28 Pa Code: 211.10 (d) Resident care policies.

Based on review of facility policy, clinical records, and resident and staff interviews, it was determined that the facility failed to make certain that residents wounds were measured weekly and monitored for one of two residents reviewed (Resident R1).Findings include: Review of facility policy Review of facility policy Pressure Wound Policy dated 1/9/26, indicated the facility will make reasonable efforts to identify residents at risk for pressure injuries and implement individualized interventions intended to promote skin integrity. Resident changes in skin condition may be documented in the medical record as appropriate and consistent with facility practices. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses of quadriplegia, cardiac arrest, and cerebral infarction. Review of Resident R1's progress note 5/13/26, stated the resident has no feeling in bilateral lower extremities and is not able to move bilateral lower extremities due to a spinal cord injury. Resident had an open area on buttocks. Review of Resident R1's Braden Scale Assessment (an evidence-based, standardized assessment tool used to evaluate a patient's risk of developing pressure injuries) dated 5/13/26, revealed the resident was at a high risk for developing pressure ulcers. Review of Resident R1's physician order dated 5/14/26, indicated to cleanse right buttock with soap & water, apply Triad (barrier cream) to site every day and as needed for incontinence related to Moisture Associated Skin Dermatitis (MASD). Review of Resident R1's wound note dated 5/14/26, revealed a head to toe assessment was completed and no skin issues noted. The facility failed to timely assess and measure Resident R1's open area on buttocks. Review of Resident R1's baseline care plan failed to include the resident's wound. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/20/26, indicated diagnoses were current. Review of Resident R1's physician order dated 5/24/26, indicated to cleanse right lateral buttock with wound cleanser and pat dry. Apply Medihoney and calcium alginate to wound daily and as needed with incontinence changes, every day shift for wound care. Review of Resident R1's clinical record failed to include documentation of an assessment and measurements of Resident R1's buttocks wound from 5/13/26, to 5/27/26. Review of Resident R1's skin assessment dated [DATE], revealed the resident had an unstageable buttock wound that measured 3.2 x 3. 0 cm. During an interview on 7/8/26, at 11:39 a.m. Registered Nurse (RN) Unit Manager, Employee E1 stated resident's wounds are assessed and measure weekly by the wound care nurse and wound care nurse practitioner. During an interview on 7/8/26, at 11:59 a.m. Resident R1 confirmed he had a wound on his buttocks since his hospital stay and has had it since admission. During an interview on 7/8/26, at 12:22 p.m. the Director of Nursing (DON) stated if new wound is identified, it must be reported to the cart nurse, supervisor, then the wound care nurse is notified. Wounds are assessed weekly. During a phone interview on 7/8/26, at 1:08 p.m. Wound Care Consultant, Employee E2 stated resident's wounds are assessed weekly. Wound Care Consultant, Employee E2 confirmed Resident R1's buttock wound was not assessed weekly from admission until 5/28/26. During an interview on 7/8/26, at 1:23 p.m. Registered Nurse, Unit Manager Employee E3 indicated the day Resident R1 was admitted to the facility she was helping out. It was indicated she usually manages the third floor. RN, Unit Manager, Employee E3 confirmed Resident R1 had a buttocks wound upon admission and failed to obtain measurements. RN, Unit Manager, Employee E3 stated she believes she mistyped the open area to be the left not right. During an interview on 7/8/26, at approximately 2:00 p.m. the Director of Nursing and Nursing Home Administrator confirmed that the facility failed to make certain that residents wounds were measured weekly and monitored for one of two residents reviewed (Resident R1). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10 (c)(d) Resident care policies.28 Pa. Code: 211.12 (d)(1)(5) Nursing services.

Based on review of facility policy, closed clinical records, facility documents and staff interviews it was determined that the facility failed to provide a complete copy of a resident's medical records upon request by the resident's next of kin for one of three closed resident records (Closed Resident Record CR1).Findings include: The facility Release of information policy last reviewed on 1/9/26, indicated that the facility maintains the confidentiality of each residents' protected health information. All information contained in the resident's medical records is confidential and may only be released by the written consent of the resident or his/her legal representative. Review of Closed Resident Record CR1's admission record indicated he was admitted on [DATE]. Review of Closed Resident Record CR1's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 1/3/26, indicated he had diagnoses that included pulmonary embolism (a blockage in the arteries of the lungs that may travel to other regions of the body), B-cell lymphoma (a blood cancer that begins in the white blood cells), diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), hypertension (a condition impacting blood circulation through the heart related to poor pressure), kidney disease (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and changes in urination) and cancer. Review of Closed Resident Record CR1's nurse practitioner clinical note dated 1/9/26, indicated he was showing signs of left upper extremity being flaccid, slow to respond with speech, clinical feature of stroke. Order to send to emergency department for escalation to higher level of care. Complex medical decision making - Resident CR1 with acute, severe change upon neurological examination with clinical feature of stroke requiring labs, advanced imaging and possible surgical/medical intervention in which escalation to the hospital/Emergency department. Discussed in detail with nursing and collaborated with nursing/EMS to ensure appropriate information regarding Resident CR1. Review of Closed Resident Record CR1's clinical nurse note dated 1/9/26, indicated Resident CR1 was being transferred to hospital. He was transferred via stretcher with two attendants. Resident CR1 was sent with an acute care transfer/change of condition forms. Family made aware of transfer. No belongings sent with Resident CR1, and his cellphone was at bedside. Facility electronic communications dated 1/14/26, indicated a signed request for Closed Resident Record CR1's medical record was completed by family. Review of facility documentation dated 2/28/26, indicated that Closed Resident Record CR1's family received the mailed four-pound shipment of documents. Facility electronic communications dated 3/5/26, indicated family had a concern that not all of the medical record was released. In the communication, Administration stated that Medical Records Personnel E1 was under the impression that the whole record was sent. During an interview on 4/29/26, at 11:56 a.m. Medical Records Personnel E1 was asked if she received another medical records request for anything else? no. I gave her everything I had.When asked if she had any communications around 3/11/26? Nursing Home Administrator told me about the family. I sent records to legal and the Nursing Home Administrator. When asked if there was any evidence that the nurse notes were sent as well, she stated: I thought they were in with the other record. During an interview on 4/29/26, at 3:16 p.m. information disseminated to the Nursing Home Administrator (NHA) and the Director of Nursing (DON) that the facility failed to provide a complete copy of a Closed Resident Record CR1's record upon family initial request as required. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(2) Management

Based on observations, facility policy, resident interviews, and staff interview, it was determined that the facility failed to ensure comfortable air temperature levels (between 71-81 degrees Fahrenheit [ ]) were provided in the facility for three of seven days (4/13/26, 4/14/26, and 4/15/26).Findings Include: Review of the facility policy Homelike Environment dated 1/9/26, indicated the facility will provide a safe, clean, comfortable, and homelike environment. The facility staff and management maximizes, to the extent possible characteristics that include comfortable and safe temperatures (71-81 ) Review of a Resident representative concern dated 4/13/26, stated This is a nursing home that does not have a functioning air conditioning unit. We have unsafe temperatures for their residents. Review of an additional; Resident Representative concern dated 4/13/26, stated They cracked a window, but it's so hot in there. During an interview on 4/15/26, at 9:52 a.m. the Nursing Home Administrator (NHA) stated that the facility is in process for completing $1.3 million dollar installation of a new heating and cooling system, for which they have made a $350,000 down payment, and anticipate the new system to begin installation at the end of May or beginning of June. Tour of the facility with Maintenance Employee E1 conducted on 4/15/26 from 9:55 a.m. through 10:15 a.m. revealed the following temperatures: 2nd Floor Dining Room: 81.5 room [ROOM NUMBER]: 81.9 room [ROOM NUMBER]: 83.3 room [ROOM NUMBER]: 80.6 room [ROOM NUMBER]: 81.5 room [ROOM NUMBER]: 85.6 room [ROOM NUMBER]: 83.1 4th Floor Dining Room: 86.0 room [ROOM NUMBER]: 91.0 room [ROOM NUMBER]: 86.0 room [ROOM NUMBER]: 84.4 room [ROOM NUMBER]: 87.1 3rd Floor Dining Room: 84.7 room [ROOM NUMBER]: 84.0 room [ROOM NUMBER]: 84.0 room [ROOM NUMBER]: 82.2 room [ROOM NUMBER]: 81.9 room [ROOM NUMBER]: 83.8 During an interview on 4/15/26, at 9:56 a.m. Resident R2 stated It's hot in here. Like my fan? as she demonstrated how she was fanning herself with a piece of paper. During an interview on 4/15/26, at 9:57 a.m. Maintenance Employee E1 was asked if the facility had fans to utilize. Maintenance Employee E1 stated We don't have too many fans. We put them at the nurse stations and in the hallways. During an observation and interview on 4/15/26, at 10:00 a.m. Resident R3 was noted to be sitting in front of a fan. Resident R3 stated that the fan was provided by her roommates family. During an observation and interview on 4/15/26, at 10:13 a.m. Resident R4 was observed in his room with a fan, which he confirmed was his own personal fan. During an interview on 4/15/26, at 10:56 a.m. the NHA stated that a Heating Ventilation and Air Conditioning (HVAC) Vendor would be in today to address the warm temperatures. During an interview on 4/15/26, at 12:10 p.m. HVAC Vendor stated that he was in the facility to address the issue and would report back any findings as soon as information was available. During an interview on 4/15/26, at 12:32 p.m. HVAC Vendor stated that the facility must have had a power surge that shut of the cooling system, but that he was able to fix the issue and the system would now be able to work. During an interview on 4/15/26, at 1:38 p.m. Resident R2 sated that her room Is cooler now. It was hot for a few days. During an interview on 4/15/26, at 1:52 p.m. Licensed Practical Nurse Employee e23 stated It's been hot in here for a few days. It was terrible on Monday (4/13/26). During an interview on 4/15/26, at 2:56 p.m. the NHA confirmed that the facility failed to ensure comfortable air temperature levels (between 71-81 degrees Fahrenheit) were provided in the facility for three of seven days. 28 Pa. Code: 201.18(b)(3) Management

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that a dental appointment was scheduled for one of three residents reviewed (Resident R1).Findings include: Review of the facility policy Dental Services dated 1/9/26, indicated that routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Review of a Resident representative concern dated 4/13/26, stated that Resident R1's gums are so bloody. Review of the admission record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1''s Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/3/26, indicated diagnoses of high blood pressure, vitamin D deficiency, and muscle weakness. Documentation by the facility's contracted dental provider dated 10/9/25, indicated Resident R1 Was treated at bedside. Recommend resident be brought to clinic for ultrasonic scaling [a dental cleaning technique used to remove plaque, and tartar]. Deposit remains. During an interview on 4/15/26, at 2:19 p.m. the Director of Nursing stated that no appointment has been made to have Resident R1 taken to the Dental Clinic for follow up as was suggested at 10/9/25 dental visit, and confirmed that the facility failed to obtain dental services for Resident R1 as required. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services28 Pa. Code 211.15(a) Dental Services.

Based on review of facility policy, clinical closed records, resident fund account statements and staff interview it was determined that the facility failed to convey resident funds and close accounts upon discharge within 30 days for two of four closed records (Closed Resident Record CR1 and Closed Resident Record CR2).Findings include: The facility Resident fund management service policy last reviewed 5/20/25, indicated discharged resident account is closed following reconciliation. Funds are released following completion of an audit and reconciliation of the account, in accordance with applicable regulations. Review of Closed Resident Record CR1's admission record indicated he was admitted [DATE]. Review of Closed Resident Record CR1's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 11/26/25, indicated he had diagnoses that included diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts and disordered behaviors impacting daily functioning) and hypertension (a condition impacting blood circulation through the heart related to poor pressure). Review of Closed Resident Record CR1's clinical progress notes dated 1/4/26, indicated at 1:00 p.m. that Closed Resident Record CR1 was not at baseline, he was refusing all medications and screaming to kill him. Upon assessment, he was repeatedly screaming Don't come near me, don't give me any medicine. Kill me! Kill me! Kill me! Closed Resident Record CR1 a threat to himself and roommates. 302 (involuntary commitment for psychiatric evaluation and safety) was called and approved. Ambulance called for pick up. He left the facility accompanied by two EMT's and two police officers, and he was able to walk out of the facility without incident. Review of Closed Resident Record CR1's clinical record did not indicate that his monies were provided 30 days after his discharge. Review of Closed Resident Record CR2's admission record indicated she was admitted [DATE]. Review of Closed Resident Record CR2's MDS assessment dated [DATE], indicated she had diagnoses that included diabetes, hypertension and Alzheimer's dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). Review of Closed Resident Record CR2's clinical progress notes dated 1/25/26, indicated staff member was called to assess Closed Resident Record CR2. Apical pulse and respirations were absent at 11:55 p.m. She appeared to be sleeping; her skin was warm and dry. Physician's office was notified and gave physician order to release body. Nephew was also notified and will be contacting Funeral Home. Review of Closed Resident Record CR2's physician order dated 1/25/26, indicated that it was ok to release her body to funeral home. Review of Closed Resident Record CR2's clinical record did not indicate that his monies were provided 30 days after his discharge. Review of resident fund trial balance (a statement indicating current resident monies overseen by facility staff in a secured account) dated 3/18/26, indicated the following:Closed Resident Record CR1 account was open with a balance of $384.68.Closed Resident Record CR2 account was open with a balance of $7430.63 During an interview on 3/18/26, at 11:29 a.m. Business Office Manager Employee E1 confirmed that the facility failed to convey resident funds and close accounts upon discharge within 30 days for Closed Resident Record CR1 and Closed Resident Record CR2 as required. 28 Pa. Code 211.5(d) Clinical records.

Based on review of the American Heart Association (AHA) Guidelines, clinical records, facility policies, and staff interviews it was determined that the facility failed to ensure consistent care by initiating Cardiopulmonary Resuscitation (CPR) to an unresponsive resident for one of 73 residents (Closed Record Resident CR1), resulting in immediate jeopardy.Findings include: The Pennsylvania Code Title 49, Professional and Vocational Standards through the Department of State indicates under Responsibilities of the Registered Nurse 21.11 General functions (a) The registered nurse assesses human responses and plans, implements, and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all the following functions: (4) Carries out nursing care actions which promote, maintain, and restore the well-being of individuals. Review of AHA Guidelines indicated: - if a person is unresponsive with no breathing and has no pulse for more than 10 seconds, start CPR.According to American Heart Association guidelines presumptive Signs of Death are as follows:The patient is unresponsive.The patient has no respirations.The patient has no pulse.The patient's pupils are fixed and dilated.The patient's body temperature indicates hypothermia: skin is cold relative to the patient's baseline skin temperature.The patient has generalized cyanosis (bluish skin color due to decreased amounts of oxygen). AHA guidelines for Conclusive (irreversible) Signs of Death are as follows: There is presence of lividity (venous pooling of blood in dependent body parts causing purple discoloration of the skin, due to the cessation of circulation). While these signs of irreversible death would not be expected to be seen in most practice settings, the American Heart Association also includes the following irreversible signs of death: decapitation (separation of the head from the body). decomposition (decay or putrefaction of the body); and rigor mortis (stiffness of the limbs and body that develops 2 - 4 hours after death and may take up to 12 hours to fully develop). Review of facility policy Emergency Procedure - Cardiopulmonary Reusuitation, dated [DATE], indicated personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. General guidelines:Sudden cardiac arrest (SCA) is a loss of heart function due to abnormal heart rhythms (arrhythmias). Cardiac arrest occurs soon after symptoms appear. It is a leading cause of death among adults.A heart attack refers to impaired blood flow to the heart which leads to damage of the heart muscle. A heart attack can cause sudden cardiac arrest. Typically heart attacks are less sudden than SCA.Victims of cardiac arrest may initially have gasping respirations or may appear to be having a seizure. Training in BLS includes recognizing presentations of SCA. The chances of surviving SCA nay be increased if CPR is initiated immediately upon collapse. Early delivery of shock with defibrillator plus CPR within 3-5 minutes of collapse can further increase chances of survival. In an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless:It is known that a do not resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; orThere are obvious signs of irreversible death (e.g. rigor mortis)If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR. Review of Resident CR1's clinical record indicated an admission date of [DATE]. Review of Resident CR1's Minimum Data Set (MDS-a periodic assessment of care needs) dated [DATE], indicated diagnoses of chronic kidney disease (long-term condition where the kidneys gradually lose their function over time), adult failure to thrive (condition where an older adult loses appetite, weight, and interest in activities), and high blood pressure. Review of Resident CR1's physician order dated [DATE], current through [DATE], indicated the resident was a full code (allows for all interventions needed to restore breathing or heart functioning). Resident CR1 ceased to breathe on [DATE], at 7:56 a.m. Review of Resident CR1's clinical record form Advance Directives dated [DATE], indicated resident had no advance directives, no living will, and no Power of Attorney. Review further noted that additional information was requested and on [DATE], PA Advance Directive Packet was provided by Social Service Employee E2 to Resident CR1. Review of Resident CR1's care plan initiated [DATE], current through [DATE], failed to identify goals, plans, and/or interventions related to resident's full code status. Review of Resident CR1's clinical progress note dated [DATE], at 7:50 a.m., entered by Licensed Practice Nurse (LPN) Employee E3, indicated that at 7:45 a.m., resident (CR1) was lying in bed on her right side. (CR1) did not respond to name being called. Eyes were open. Skin was pale and cool. Call bell was within reach. Registered Nurse (RN) Supervisor notified. Medical Doctor (MD) notified for change in condition. Further review of Resident CR1's clinical progress note dated [DATE], late entry at 10:13 a.m., entered by RN Employee E4, indicated this nurse (E4) was notified that resident (CR1) CTB (cease-to-breath) this morning at 7:56 a.m., MD was notified. Resident has no emergency contact. Funeral home was contacted for resident to be released; awaiting return call. Care has been completed on resident. Review of facility provided employee statement by LPN Employee E3, on [DATE], stated that this nurse (E3) rounded on patient (CR1) at 7:45 a.m. Patient (CR1) was lying in bed on her right side. Patient (CR1) did not respond to name being called. Eyes were open. Skin was pale and cool. CPR was not started due to irreversible death. RN supervisor notified. Physician notified of change in condition. Review of facility provided employee statement by RN Employee E4, on [DATE], stated (E4) was informed by oncoming nurse of resident's (CR1) change in condition. The MD was contacted and we were waiting for a return phone call to verify next steps. (RN E4) checked on resident when (E4) was notified of change, (CR1) was resting in bed at that time. (LPN E3) alerted (E4) about an hour later that (CR1) was checked on again and had no pulse. At that time, (LPN E4) stated (CR1)'s eyes were open, (CR1) was pale and cool. Upon assessment, aside from the obvious signs of death (no pulse, apical HR (heart rate), and respirations) it was determined that due to (LPN E4)'s assessment as well as mottling (common sign that occurs as a person approaches death, characterized by a marbled or blotchy appearance of the skin, typically indicating reduced blood circulation) in extremities, that the resident (CR1) had signs of irreversible death and CPR wound not have helped. MD was contacted and resident (CR1) was pronounced CTB at 7:56 a.m. During an interview on [DATE], at 11:20 a.m., LPN Employee E5 stated that if they walk into a room and a resident is pulseless, that they would call the RN supervisor, determine resident's code status in medical record, and if full code, initiate CPR. During an interview on [DATE], at 11:28 a.m., LPN Employee E6 stated that if a resident is found without respirations or a pulse, that a code would be called, alerting RN supervisor to room, then check code status and initiate CPR for full code status. During an interview on [DATE], at 11:35 a.m., LPN Employee E7 stated that if a resident is found pulseless, a code would be called, crash cart grabbed, and code status confirmed prior to initiating CPR. During an interview on [DATE], at 11:40 a.m., LPN Employee E8 stated once a resident is confirmed pulseless, check code status, and initiate CPR. During an interview on [DATE], at 11:45 a.m., RN Employee E9 stated that code status is checked when a resident if found pulseless, and CPR is initiated if full code. Employee E9 further stated that by the time the RN responds to a code, LPN's have initiated CPR, RN supports and supervises, calls 911, and directs paramedics on arrival. During an interview on [DATE], at 11:55 a.m., RN Employee E10 stated that CPR is initiated after checking medical chart for DNR or Full Code, call code, and then react; AED (automated external defibrillator) and crash cart are on every unit. Review of Resident CR1's clinical record failed to indicate that CPR was administered as ordered. This failure to provide CPR resulted in an immediate jeopardy situation, placing all residents at risk if they become unresponsive or pulseless. On [DATE], at 3:06 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were notified that an immediate jeopardy was identified and were provided a copy of the completed IJ template. On [DATE], at 5:15 p.m., an Immediate Action Plan was accepted with the following actions: Immediate Action: Resident R1 no longer resides in facility. All professional nursing staff (LPN/RN) will be re-educated by end-of-day (EOD) [DATE], on the CPR procedure. Agency staff will be educated prior to the start of their next shift. All professional nursing staff (LPN/RN) will be re-educated by EOD [DATE], on the definition of irreversible death and that it must be documented in the clinical record. Agency staff will be educated prior to the start of their next shift. Whole-house audit will be conducted by the DON/designee to ensure that every resident has a completed POLST (Physician Order for Life Sustaining Treatment - portable medical order form that tells all health care providers during a medical emergency what you want) order form, the code status order in EHR (electronic health record), and the care plan updated accordingly. Policies related to CPR have been reviewed by NHA and DON and updated to include signs of irreversible death. Facility will review the incident in QAPI (Quality Assurance/Process Improvement) meeting [DATE]. New admissions will be audited by DON/designee weekly times four weeks, then monthly times two months to ensure that the POLST is located in the resident chart and the DNR or Full Code status is in EHR. Findings of audits will be submitted through facility QAPI program. All new hires will be educated on CPR procedures and signs of irreversible death. On [DATE], at 9:06 a.m., it was verified that the facility's policy related to CPR was revised and updated on [DATE]. On [DATE], at 9:54 a.m., it was verified that 42 of 43 licensed nursing staff members (LPN/RN) received education and completed post-test competency prior to the start of their shift via signature sheet. Seven out of seven licensed nursing staff members (LPN/RN) on [DATE], were interviewed and confirmed training and understanding of CPR procedure. On [DATE], at 10:30 a.m., it was verified that whole-house audit was completed to ensure that every resident has a completed POLST order form, the code status order in EHR, and the care plan were updated accordingly. An Ad Hoc QAPI meeting was conducted on [DATE], at 1:30 p.m., and verified via signature sheet. The Director of Nursing (DON) or designee will conduct audits to ensure POLST is located in the resident chart, that the DNR or Full Code status in the EHR and findings will be reported in upcoming QAPI meetings. Audit tool by facility was verified for use moving forward on [DATE]. On [DATE], it was verified that all newly hired licensed staff members (LPN/RN) will be provided education and training on CPR procedures and signs of irreversible death. On [DATE], the Immediate Jeopardy was lifted at 11:20 a.m., after ensuring the Immediate Plan of Correction had been implemented. During an interview on [DATE], at 3:00 p.m., the NHA and DON confirmed that the facility failed to ensure consistent care was provided by initiating Cardiopulmonary Resuscitation (CPR) to an unresponsive resident for one of 73 residents (Closed Record Resident CR1). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 201.29(d)(j) Resident rights. 28 Pa. Code 211.10(c) Resident care policies.

Based on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to ensure consistent care was provided to initiate Cardio Pulmonary Resuscitation (CPR) to an unresponsive resident, which created an immediate jeopardy situation for one (Resident R1) of 131 residents.Findings include: The job description for the Nursing Home Administrator (NHA) dated 2/2024, stated the primary purpose is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. The job description for the Director of Nursing (DON) dated 2/2024, stated the DON is a registered nurse who oversees and supervises the care of all the residents. The DON also provides direct resident/patient care. Based on findings identified in this report, the facility failed to ensure consistent care was provided to initiate CPR to an unresponsive resident (Resident R1), which placed the residents in Immediate Jeopardy. The NHA and the DON failed to fulfill their essential job duties to ensure the federal and state guidelines and regulations were followed. During an interview on [DATE], at 3:06 p.m., the NHA and DON were notified that they failed to effectively manage the facility to ensure consistent care was provided to initiate CPR to an unresponsive resident (Resident R1), which created an immediate jeopardy situation for one of 131 residents. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on a review of the facility's documents and staff interviews it was determined that the facility failed to implement a good faith effort to correct deficiencies cited during the survey ending January 9, 2026, by failing to complete the facility's plan of correction which indicated a direct in-service (training required by the state agency that is presented by an outside vendor) would be provided to all professional nursing staff as required. (all agency professional nursing staff). Findings include: A review of the facility's plan of correction for F678 J, cited during a survey on January 9, 2026, indicated that a direct in-service would be provided to all professional nursing staff. During a review of facility documents including attendance records for a direct in - service conducted on 1/31/26, it was revealed that the documents provided no evidence of agency professional nursing staff being provided or attending the directed in-service. During an interview on 1/23/26, at 2:30 pm the Director of Nursing confirmed that the facility failed to make certain that the direct in-service was provided and attended by all agency profession nursing staff as required. 28 Pa Code: 201.14(a)(b) Responsibility of Licensee

Based on observations, facility policy, and staff interview, it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for one of three floors (3rd floor) and failed to ensure comfortable air temperature levels were provided for one of three floors (4th floor).Findings Include: Review of the facility policy Safe and Homelike Environment dated 5/20/25, indicated residents are provided a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect personalized, homelike setting. These characteristics include:Clean, sanitary and orderly environment;Comfortable and safe temperatures (71 degrees Fahrenheit - 81 degrees Fahrenheit). During an observation conducted on 1/8/26, from 10:35 a.m. to 10:50 a.m., with the Director of Nursing (DON) revealed the following:3rd floor low hallway shower room/stall - had a build-up of red grime, and black debris located where the wall meets the floor.3rd floor high hallway shower room/stall - had a build-up of red grime, and black debris located where the wall meets the floor. During an interview on 1/8/26, at 11:02 a.m., the DON confirmed the 3rd floor shower areas (low and high hall) failed to be clean and sanitary. Review of facility provided Air Temperature log, dated 1/8/25, from 11:00 a.m. to 11:45 a.m., conducted while onsite by Director of Maintenance (DOM) Employee E1, revealed the following air temperatures: 4th floor Nursing unit:room [ROOM NUMBER] - 83.0 degrees Fahrenheitroom [ROOM NUMBER] - 84.0 degrees Fahrenheitroom [ROOM NUMBER] - 86.0 degrees Fahrenheitroom [ROOM NUMBER] - 86.0 degrees Fahrenheitroom [ROOM NUMBER] - 86.0 degrees Fahrenheitroom [ROOM NUMBER] - 86.0 degrees Fahrenheitroom [ROOM NUMBER] - 85.0 degrees Fahrenheitroom [ROOM NUMBER] - 86.0 degrees Fahrenheitroom [ROOM NUMBER] - 87.0 degrees Fahrenheitroom [ROOM NUMBER] - 87.0 degrees Fahrenheitroom [ROOM NUMBER] - 87.0 degrees FahrenheitDining room area - 88.0 degrees Fahrenheit During an interview on 1/8/26, at 12:04 p.m., the DOM Employee E1 confirmed the facility failed to ensure comfortable air temperature levels were provided for the 4th floor (11 resident rooms and dining room area). During an interview on 1/9/26, at 3:00 p.m., the Nursing Home Administrator (NHA) confirmed that the facility failed to provide a clean, safe, comfortable, and homelike environment for one of three floors (3rd floor) and failed to ensure comfortable air temperature levels were provided for one of three floors (4th floor) as required. 28 Pa. Code: 201.18(b)(3) Management

Based on review of clinical records and staff interview, it was determined that the facility failed to notify the physician of a change in condition for one of five residents (Resident R1).Review of the clinical face sheet indicated that Resident R1 was admitted to the facility 4/4/24, with diagnoses that included seizures, moyamoya disease (rare blood vessel condition in which the carotid artery in the skull becomes blocked or narrowed) and cerebral infarction. A review of Resident R1's quarterly MDS assessment(minimum data assessment)- periodic assessment of resident care needs) dated 6/18/25, indicated the diagnosis remained current. Review of physician orders dated 8/5/25 indicated an order for valproic acid, cbc w/diff, cmp. Facility provided documentation indicated resident refused bloodwork. Review of clinical progress notes dated 8/5/25-8/25/25 indicated no notification to physician. During an interview on 9/3/25, at 1:35 p.m. Director of Nursing confirmed that the staff failed to notify the physician of Resident R1's lab work refusal. 28 Pa. Code: 211. 12(d)(1) Nursing services.

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to properly store food products in the walk in cooler and reach in cooler which created the potential for cross contamination (Main Kitchen). Findings include: Review of facility policy Food Receiving and Storage dated 5/20/25 indicates foods shall be received and stored in a manner that complies with safe food handling practices. During an observation of the main designated kitchen on 6/23/25, at 9:15 a.m. the following was observed: Walk in cooler: -cinnamon bread(3)-no date -bagels(2)-no date -deli ham (3)-no date or label Reach in cooler -salads(3)- no label or date -sandwiches(5)-no label or date During an interview on 6/23/25, at 10:00 a.m. Dietary Manager Employee E20 confirmed that the facility failed to properly store food products and maintain sanitary conditions which created the potential for food borne illness and cross contamination in the Main Kitchen. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(3) Management.

Based on review of facility policy, clinical record and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained for two of three residents (Residents R2 and R21) and failed to maintain a current dialysis contract with dialysis vendor for two of three (Resident R2, and R61). Findings include: Review of the facility policy End-Stage Renal Disease (ESRD), Care of a Resident with dated 5/20/25, indicated agreements between this facility and the contracted ESRD facility include all aspects of how the resident ' s care will be managed, including: a. how the care plan will be developed and implemented; b. how information will be exchanged between the facilities; and c. responsibility for waste handling, sterilization and disinfection of equipment. Review of the admission record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/12/25, indicated diagnoses of high blood pressure, anemia (too little iron in the blood), and renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids). Review of Resident R2's physician orders dated 6/18/25, indicated dialysis: Monday, Wednesday, and Friday at dialysis vendor. Pick up time at 5:30 a.m. and chair time at 6:30 a.m. Review of Resident R2's current care plan indicated dialysis: Monday, Wednesday, and Friday at dialysis vendor. Pick up time at 5:30 a.m. and chair time at 6:30 a.m. Review of Resident R2's dialysis communication forms indicated the following: -June 2025, failed to be present. -May 2025, had one incomplete form dated 5/28/25. No other forms were present. -April 2025, had one incomplete form with the starting date of 4/2/25, and the ending date of 4/12/25. No other forms were present. -March 2025, had one incomplete form dated 3/19/25. No other forms were present. -February 2025, had one incomplete form dated 2/14/25. No other forms were present. Interview on 6/23/25, at 1:00 p.m. Licensed Practical Nurse (LPN) Employee E22 confirmed the sheets failed to be present and complete as listed. Review of the admission record indicated Resident R21 was admitted to the facility on [DATE]. Review of Resident R21's MDS dated [DATE], indicated the diagnosis of high blood pressure, diabetes (high sugar in the blood) and end stage renal disease (final stage of chronic kidney disease, kidneys can Review of Resident R21's physician orders dated 6/18/25, indicated dialysis: Tuesday, Thursday, and Saturday at dialysis vendor. Pick up 10:00 a.m. and chair time 12:00 p.m. Review of Resident R21's current care plan indicated dialysis Tuesday, Thursday, and Saturday at dialysis vendor. Pick up 10:00 a.m. Review of Resident R2's dialysis communication forms indicated the following: -June 2025, had two complete forms 6/3/25, and 6/17/24. One incomplete form dated 6/19/25. No other forms were present. -May 2025, had three complete forms dated 5/6/25, 5/15/25 and 5/27/25. One incomplete form dated 5/24/25. No other forms were present. -April 2025, had three complete forms dated of 4/1/25, 4/3/25, and 4/22/25. One incomplete form dated 4/22/25. No other forms were present. During an interview completed on 6/26/25, at 10:48 a.m. Licensed Practical Nurse Employee E12 confirmed the sheets failed to be present and complete as listed and stated, we just started the books a few weeks ago. Review of the admission record indicated Resident R61 was admitted to the facility on [DATE]. Review of Resident R61's MDS dated [DATE], indicated diagnoses of high blood pressure, anemia, and renal insufficiency. Review of Resident R61's physician orders dated 6/18/25, indicated dialysis: Monday, Wednesday, and Friday at dialysis vendor. Pick up time at 9:00 a.m. and chair time at 10:00 a.m. Review of Resident R61's current care plan indicated dialysis: Monday, Wednesday, and Friday at dialysis vendor. Review of the facility provided dialysis agreements failed to include an agreement for dialysis vendor for Resident R2 and Resident R61 as required. Interview with the Nursing Home Administrator confirmed the facility did not have a current contract with Resident R2's and Resident R61's dialysis vendor as required. Interview on 6/27/25, at 12:15 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to make certain consistent dialysis communication was maintained for two of three residents (Residents R2 and ) and failed to maintain a current dialysis contract with dialysis vendor for two of three (Resident R2, and R61) as required. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(d)(2)(3) Nursing services

Based on review of facility policy, clinical records, facility documents, resident interviews, and staff interviews, it was determined that the facility failed to make certain residents with behaviors triggering elopement risk were identified timely, failed to assess on an ongoing basis, and failed to provide care plan and physician orders for interventions regarding exit seeking behaviors for three of five residents (Resident R70, R104, and R120). Findings include: Review of facility policy Elopement Risk Assessment Policy dated 5/20/25, indicated all residents will have an elopement risk assessment completed upon admission, quarterly, and with a significant change in condition, such as increased confusion, agitation, or mobility changes. If a resident is identified as an elopement risk, the care plan will include individualized interventions to address safety and monitoring. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2024, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment. Review of the admission record indicated Resident R70 was admitted to the facility on [DATE]. Review of Resident R70's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/18/25, indicated diagnoses of high blood pressure, anemia (too little iron in the blood),and dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life). Section C0500 indicated a BIMS score of 12 - moderately impaired. Section GG indicated resident able to wheel self independently in manual wheelchair. Review of Resident R70's current care plan indicated Resident exhibits fluctuating mood symptoms related to adjustment disorder with anxiety, dementia, sleeplessness, pain and frustration over residing in a facility. Review of Resident R70's progress note dated 5/27/25, indicated nursing states patient still often fixated on going home. Resident becomes angry when talking about it. Resident denied any pain, chest pain, shortness of breath, or abdominal pain. Resident indicated they can take care of themselves. Resident is a limited historian due to dementia. Review of Resident R70's Elopement Risk Screen dated 8/20/24, was the only Elopement Risk Screen noted in the clinical record. It indicated Resident was not at risk and did not trigger a care plan for wandering. Interview on 6/24/25, at 10:43 a.m. Resident R70 indicated awaiting Social Services assistance to get to the next place. Interview on 6/24/25, at 11:00 a.m. Licensed Practical Nurse (LPN) Employee E13 indicated Resident R70 gets out of bed and into the wheelchair, wanders about the unit, and always talks about going home. Interview on 6/26/25, at 2:00 p.m. the Director of Nursing confirmed Resident R70's elopement risk screen was not completed quarterly as required, or when increased behaviors of wanting to go home and having the ability to wander about the unit in a manual wheelchair were not identified as triggers for elopement risk. Review of the admission record indicated Resident R104 was admitted to the facility on [DATE]. Review of Resident R104's MDS dated [DATE], indicated diagnoses of anemia (low iron on the blood), high blood pressure, and Alzheimer's disease (affects memory, thinking and behavior). Review of Resident R104's current care plan indicated Resident is at risk for elopement/exit seeking/wandering related to dementia or other cognitive behavior. Review of Resident R104's admission elopement and wandering risk observation dated 11/26/24, indicated if the total score is 10 or greater, the resident would be considered At Risk for Wandering or Elopement. Resident R104 scored a 16. Further review of Resident R104's clinical record revealed no further elopement assessments completed. During an interview completed on 6/25/25, at 1:32 p.m. the Assistant Director of Nursing (ADON) Employee E1 confirmed Resident R104's elopement risk assessment was not completed quarterly as required. Review of Resident R120's clinical record indicated resident was admitted to the facility on [DATE]. Review of Resident R120's MDS dated [DATE], indicated diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and dementia. During a review of Resident R120's physician orders dated 1/5/25, failed to include to check function of resident's wanderguard. During an observation on 6/24/25, at 2:15 p.m. Resident R120 was sitting in the common room and failed to have a wanderguard applied to person. During an interview on 6/24/25, LPN Employee E2 stated I checked it this morning, I don't know where its at and I don't have time to look for it right now, and confirmed that Resident R120 did not have a wanderguard on per physician order. Interview on 6/27/25, at 12:15 p.m. the Director of Nursing confirmed the facility failed to make certain residents with behaviors triggering elopement risk were identified timely, failed to assess on an ongoing basis, and failed to provide care plan and physician orders for interventions regarding exit seeking behaviors for three of five residents (Resident R70, R104, and R120). 28 Pa. Code 211.10(c)(d) Resident Care Policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services 28 Pa. Code: 201.18(b)(1) Management.

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to follow physician orders for Blood Glucose levels for one of eight residents (Resident R50), failed to provide parameters of when to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels or notifying physician of results outside parameters ordered for five of eight residents (Residents R25, R34, R53, R75, and R120), failed to document appropriate interventions for a resident with hypoglycemia (low blood glucose) for one of eight residents (Resident R53), failed to provide therapeutic lab monitoring for one of three residents (Resident R58) and failed to ensure timely follow up physician appointments were scheduled for one out of three residents (Residents R111). Findings include: The facilities Nursing Care of the Older Adult with Diabetes Mellitus policy dated 5/20/25, indicated to provide overview of diabetes in the older adult, its symptoms and complications, and the principles of glucose monitoring. The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called blood glucose (BG) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it's untreated for long periods of time, you can damage your nerves, blood vessels, tissues, and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds. The facilities Change in a Resident's Condition or Status policy dated 5/20/25, indicated the facility will promptly notify the attending physician and the resident representative of changes in the resident ' s medical change. The facilities Specimen Collection policy dated 5/2/25, indicated our facility will collect specimens in accordance with nursing service procedures. Review of Resident R50's admission record indicated resident was admitted on [DATE]. Review of Resident R50's Minimum Data Set (MDS - periodic assessment of resident care needs) assessment dated [DATE], indicated diagnoses of high blood pressure, diabetes (a metabolic disorder impacting organ function related to glucose levels in the human body), and depression. MDS Section N Medications N0300 coded as resident receives insulin injections. Review of Resident R50's physician orders dated 6/26/24, indicated to check blood glucose levels two times a day. Order failed to include parameters as to when to call the physician. Review of Resident R50's physician orders dated 7/22/24, indicated to administer Lantus (a long-acting medication used to treat diabetes) 12 units at bedtime. Review of Resident R50's blood glucose monitoring revealed the facility failed to obtain blood glucose levels from 10/24/24 through 6/24/25. During an interview on 6/25/25, at 12:15 p.m. Director of Nursing confirmed that the order was incorrectly taken off by nursing, failed to include parameters as to when to notify the physician, and failed to obtain blood glucose levels from 10/24/24 through 6/24/25 for Resident R50. Review of the clinical record revealed that Resident R25 was admitted to the facility on [DATE] . Review of Resident R25's MDS dated [DATE], indicated the diagnosis of anemia (low iron in the blood), diabetes (high sugar in the blood) and right leg above the knee amputation. Review of Resident R25's physician orders dated 9/9/24, indicated HumaLOG KwikPen Solution Pen-injector 100 UNIT/ML (Insulin Lispro- fast acting insulin that lowers blood sugar) Inject as per sliding scale: 0 - 70 = 0 units implement diabetic protocol and call physician: 71 - 140 = 2 units; 141 - 180 = 4 units; 181 - 220 = 6 units; 221 - 260 = 8 units; 261 - 300 = 10 units; 301 - 340 = 12 units; 341 - 500 = 14 units over 341, give 14 units and call MD, subcutaneously before meals and at bedtime. Review of resident R25's glucometer readings indicated that on 6/9/25, at 4:30 p.m. the level was 375.0 mg/ml. Review of resident R25's progress notes failed to include notification to the physician for glucometer reading over 341. During an interview completed on 6/26/25 at 10:55 a.m. Licensed Practical Nurse (LPN) Employee E12 confirmed that the physician was not notified of increased glucometer check on 6/9/25, and stated I only see notes for 6/8/25, and 6/20/25, there are no other notes in between that time. Review of Resident R34's admission record indicated resident was admitted on [DATE]. Review of Resident R34's MDS dated [DATE], indicated diagnoses of high blood pressure, diabetes, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). MDS Section N Medications N0300 coded as resident receives insulin injections. Review of Resident R34's physician orders dated 2/4/25, indicated to administer Humalog (a short acting medication used to treat diabetes) according to a sliding scale and notify physician if BG is less than 70 or greater than 350. Review of Resident R34's physician orders dated 6/24/25, indicated to administer Lantus five units at bedtime. Review of Resident R34's clinical records for April 2025, though May 2025, indicated the following blood glucose measurements: 4/18/25 - 377 mg/dL 5/11/25 - 400 mg/dL 5/16/25 - 400 mg/dL 5/26/25 - 369 mg/dL Review of Resident R34's progress notes from 4/18/25, through 5/26/25, failed to include documentation that a physician was notified of Resident R34's abnormal blood glucose levels on the dates listed above. During an interview on 6/25/25, at 12:20 p.m. Director of Nursing confirmed that the physician was not notified of the blood glucose readings per physician order for Resident R34. Review of Resident R53's admission record indicated resident was admitted on [DATE]. Review of Resident R53's MDS dated [DATE], indicated diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels), diabetes, depression. MDS Section N Medications N0300 coded as resident receives insulin injections. Review of Resident R53's physician orders dated 4/30/25, indicated to administer Lantus 20 units at bedtime. Review of Resident R53's physician orders dated 6/11/25, indicated to check blood glucose levels three times a week. The order failed to indicate parameters as to when to notify the physician. Review of Resident R53's clinical records for May 2025, indicated the following blood glucose measurements: 5/2/25 - 62 mg/dL 5/7/25 - 58 mg/dL 5/14/25 - 60 mg/dL 5/16/25 - 67 mg/dL Review of Resident R53's progress notes from 5/1/25, through 5/31/25, failed to include documentation that a physician was notified of Resident R53's abnormal blood glucose levels on the dates listed above and failed to document interventions used to treat hypoglycemia. During an interview on 6/25/25, at 12:25 p.m. Director of Nursing confirmed that the physician was not notified of the abnormal blood glucose readings per physician order and failed to document interventions used to treat hypoglycemia for Resident R53. Review of Resident R75's admission record indicated resident was admitted on [DATE]. Review of Resident R75's MDS dated [DATE], indicated diagnoses of high blood pressure, diabetes, and dementia. MDS Section N Medications N0300 coded as resident receives insulin injections. Review of Resident R75's physician orders dated 1/30/25, indicated to check blood glucose levels three times a day. The order failed to indicate parameters as to when to notify the physician. Review of Resident R75's physician orders dated 3/12/25, indicated to administer Lantus 8 units at bedtime. Review of Resident R75's clinical records from 4/24/25 through 6/5/25, indicated the following blood glucose measurements: 4/24/25 - 300 mg/dL 4/25/25 - 340 mg/dL 5/5/25 - 350 mg/dL 5/22/25 - 340 mg/dL 6/5/25 - 335 mg/dL Review of Resident R75's progress notes from 4/24/25, through 6/5/25, failed to include documentation that a physician was notified of Resident R75's abnormal blood glucose levels on the dates above. During an interview on 6/25/25, at 12:30 p.m. Director of Nursing confirmed that the physician was not notified of the abnormal blood glucose readings per physician order and failed to include parameters as to when to notify the physician for Resident R75. Review of Resident R120's admission record indicated resident was admitted on [DATE]. Review of Resident R120's MDS dated [DATE], indicated diagnoses of high blood pressure, diabetes, and dementia. MDS Section N Medications N0300 coded as resident receives insulin injections. Review of Resident R120's physician orders failed to indicate how often to check blood glucose readings, and parameters as to when to notify the physician. Review of Resident R120's physician orders dated 4/30/25, indicated to administer Lantus 30 units at bedtime. Review of Resident R120's clinical records from 5/16/25 through 6/17/25, indicated the following blood glucose measurements: 5/16/25 - 416 mg/dL 5/26/26 - 530 mg/dL 5/30/25 - 400 mg/dL 6/6/25 - 400 mg/dL 6/15/25 - 385 mg/dL 6/17/25 - 400 mg/dL Review of Resident R120's progress notes from 5/16/25, through 6/17/25, failed to include documentation that a physician was notified of Resident R120's abnormal blood glucose levels on the dates above. During an interview on 6/25/25, at 12:35 p.m. Director of Nursing confirmed that the physician was not notified of the abnormal blood glucose readings per physician order and failed to include parameters as to when to notify the physician for Resident R120. Review of Resident R58's admission record indicated resident was admitted on [DATE]. Review of Resident R58's MDS dated [DATE], indicated diagnoses of diabetes, bipolar disorder (a mental condition marked by alternating periods of elation and depression), and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of Resident R58's physician orders dated 11/24/24, indicated to administer Lithium Carbonate 150 mg by mouth two times a day. The physician orders failed to include therapeutic lab monitoring for Resident R58's Lithium. During an interview on 6/25/25, at 12:37 p.m. Director of Nursing stated resident should have been getting routine Lithium lab work and confirmed that Resident R58 did not have any orders for lab draws to monitor Lithium levels. Review of the clinical record indicated that Resident R111 was admitted to the facility on [DATE]. Review of Resident R111's MDS dated [DATE], indicated diagnosis of anxiety disorder, hypothyroidism (thyroid gland doesn ' t produce enough hormones), gastro-esophageal reflux disorder (GERD- stomach acid flows back up through the esophagus). Section C0500 Brief interview for mental status (BIMS-tool used to screen and identify the cognitive condition of a resident the score of 0-7 severely impaired cognition, 8-12 moderately impaired cognition 13-15 intact cognition) coded as 14 indicating resident has intact cognition. During an interview completed on 6/23/25, at 11:10 a.m. Resident R111 stated we have trouble with our appointments, I missed one on Friday because it was not put on the calendar, now I have to wait longer for it to be rescheduled. During an interview completed on 6/24/25 at 12:32 p.m. upon asking LPN Employee E12 concerning Resident R111's missed appointment stated, it might have been one of the days the transportation company messed up they never showed to pick her up. During an interview completed on 6/24/24 at 1:14 p.m. upon asking Medical Records (MR) Employee E24 about Resident R111's missed appointment stated Resident R111 makes her own appointments and gives it to different staff members there are too many people involved in making appointments. A lot is broken there is no communication, the staff will sometimes text me the information to schedule the transportation. The transport company needs 24-hour notice for a wheelchair transfer and 48 hours for a stretcher transport. There is no process for scheduling. Resident R111 has been rescheduled for 7/22/25. During an interview completed on 6/24/25, at 2:02 p.m. upon asking the Assistant Director of Nursing (ADON) Registered Nurse (RN) Employee E1 concerning the scheduling of resident appointments stated the process on the floor varies from person to person. If the resident has a BIMS score of 13 or above, they can arrange their own transportation and appointments. There have been a few times when an appointment is missed, we try to reschedule as soon as we can. We are working on our own transportation and confirmed that the facility failed to ensure timely physician follow up appointments were scheduled for one out of three residents (Residents R111). 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29(a) Resident Rights 28 Pa. Code 211.10 (c)(d) Resident Care policies 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

Based on review of policies and clinical records, observations and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions and/or goals to address the care needs of residents for three of five residents reviewed (Resident R4, R25, and R120). Findings include: Review of the facility policy Care Plans Comprehensive Person-centered last reviewed 5/20/25, indicated that a comprehensive, person-centered care plan that includes measurable objectives and time frames, to meet a resident's, physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan includes measurable objectives and timeframes, describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including but not inclusive to: Services that would otherwise be provided for the above but are not provided due to the resident exercising his or her rights, including but not inclusive to: - The right to refuse treatment. - Which professional services are responsible for each element of care. - Includes the resident's stated goals upon admission and desired outcome. - Builds on the resident's strength. - Reflects currently recognized standards of practice for problem areas and conditions. - Services provided for or arranged by the facility and outlined in the comprehensive care plan are: provided by qualified persons, culturally competent and trauma informed. Review of the clinical record revealed that Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/28/25, indicated the diagnoses of coronary artery disease (reduced blood flow to the heart), hypertension (high blood pressure) and acute osteomyelitis (infection in the bone) right foot and ankle. During an observation completed on 06/23/25, at 10:07 a.m. Resident R4 was in bed a wound vac (a vacuum-assisted device that uses negative pressure to pull a wound together) was on her right foot. Review of Resident R4's physician orders dated 5/27/25, indicated wound vac to be applied Monday, Wednesday and Friday to right distal amputation site. Site to be cleansed with wound cleanser and pat dry after removal. Wound vac to be changed as needed every day shift and as needed. Review of Resident R4's current care plan dated 5/27/25, indicated resident has right foot infection related to right foot amputation and failed to reflect that Resident R4 had a wound vac. During an interview completed on 6/26/25, at 8:28 a.m. the Director of Nursing confirmed the comprehensive care plan did not include interventions for Resident R4's wound vac. Review of the clinical record revealed that Resident R25 was admitted to the facility on [DATE]. Review of Resident R25's MDS dated [DATE], indicated the diagnosis of anemia (low iron in the blood), diabetes (high sugar in the blood) and right leg above the knee amputation. During an observation completed on 6/23/25, at 9:58 a.m. Resident R25 was in his bed a trapeze bar (mobility aid) was noted above his head. Review of Resident R25's current care plan on 6/26/25, failed to include interventions for the over the bed trapeze. During an interview completed 6/26/25, at 12:52 p.m. Licensed Practical Nurse (LPN) Employee E12 confirmed the trapeze above residents bed and stated he uses it to get in and out and confirmed the care plan did not include interventions for the over the bed trapeze. Review of Resident R120's clinical record indicated resident was admitted to the facility on [DATE]. Review of Resident R120's MDS dated [DATE], indicated diagnoses of high blood pressure, diabetes, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Residents R120's physician orders dated 1/5/25, indicated resident to wear wander guard/wander elopement device (a device that alarms) due to poor safety awareness, check placement every shift. Review of Resident R120's current care plan on 6/26/25, at 1:04 p.m. failed to include a care plan with interventions, and goals for Wanderguard or elopement. During an interview on 6/26/25, at 1:43 p.m. Registered Nurse Employee E1 confirmed that Resident R120's wanderguard/elopement risk was not care planned. During an interview on 6/25/25, at 2:35 p.m. Director of Nursing confirmed that the facility failed to develop comprehensive care plans that included specific and individualized interventions and/or goals to address the care needs of residents for three of five residents reviewed (Resident R4, R25, and R120). 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12 (d)(5) Nursing Services.

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of six residents sampled with facility-initiated transfers (Residents R2, R13) and failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for one of six resident hospital transfers (Resident R13), and failed to obtain a physician order for discharge for one of three residents ( Closed Record Residents R127). Findings include: Review of facility policy Transfer or Discharge last reviewed 5/20/25, indicated transfer and discharges must meet specific criteria and require resident/representative notification, orientation, and documentation in the medical record. Review of the clinical record indicated Resident R13 was admitted to the facility on [DATE]. Review of Resident 13's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/27/25, indicated diagnoses of dementia(group of brain disorders that cause a progressive decline in cognitive functions, such as memory, thinking, reasoning, and problem-solving), major depressive disorder(mental health condition characterized by persistent feelings of sadness, loss of interest, and changes in mood and behavior that significantly impact daily life) and urinary tract infection. Review of the clinical record indicated Resident R13 was transferred to the hospital on 4/11/25, and returned to the facility on 4/16/25. Review of Resident R13's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected return, which included the resident's care plan goals and all information necessary to meet the resident's specific needs at the receiving facility, the clinical record also failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 4/11/25. Review of the admission record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's MDS dated [DATE], indicated diagnoses of high blood pressure, anemia (too little iron in the blood), and renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids). Review of the clinical record indicated Resident R2 was transferred to the hospital on 4/28/25. Review of Resident R2's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected return, which included the resident's care plan goals and all information necessary to meet the resident's specific needs at the receiving facility. Interview with the Director of Nursing on 6/24/25, at 12:43 p.m. confirmed Resident R2 and Resident R13's clinical record did not contain all of the required information prior to transferring to the hospital. Interview with the Director of Nursing on 6/27/25, at 12:15 p.m. confirmed the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for four of six residents sampled with facility-initiated transfers (Residents R2 and R13). During an interview on 6/25/25, at 2:15 p.m. Director of Nursing confirmed that the facility failed to notify the resident or resident's representative of the facility bed-hold policy for of six resident hospital transfers (Residents R13). Review of the clinical record on 6/25/25, indicated Closed Record (CR) Resident R127 was admitted to the faciltiy on 4/24/25, and was discharged home on 5/29/25. Review of the clinical record revealed that CR Resident R127 failed to have a physician discharge order in the clinical record. During an interview on 6/25/25, at 1:27 p.m. Assistant Director of Nursing Employee E1 confirmed that the facility failed to obtain a physician order for discharge for one of three residents ( CR Resident R127) 28 Pa. Code: 201.29 (a)(c)(3)(2) Resident rights.

Based on a review of facility documents, observations, and staff interviews, it was determined that the facility failed to maintain a homelike environment for seven of eight residents (Resident R12, R38, R40, R41, R46, R81, and R120). Findings include: A review of facility policy Linen Management dated 5/20/25, indicated to ensure a consistent, sanitary, and efficient process for handling, distribution, and storage of linens used throughout the facility to support resident care. A review of facility policy Homelike Environment dated 5/20/25, indicated residents are provided with a safe, clean, comfortable, and homelike environment. During a tour of the unit on 6/24/25, at 1:00 p.m. the following were observed: - Resident R12's bed had stains on the fitted sheet and pillow case - Resident R38's bed had holes in the fitted sheets - Resident R40's bed had a thin, stretched, see through fitted sheet - Resident R41's bed had holes in the fitted sheets - Resident R46's bed had a dirty, stained blanket - Resident R81's bed had stains on the fitted sheet - Resident R120's bed had a thin, stretched, see through fitted sheet During an interview on 6/24/25, at 1:17 p.m. Licensed Practical Nurse (LPN) Employee E2 confirmed the above findings. During an interview on 6/24/25, at 2:30 p.m. Nursing Home Administrator confirmed that the facility failed to maintain a homelike environment on seven of eight residents. 28 Pa. Code: 201.18(b)(3) Management

Based on review of personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for three of five nurse aides (NA Employee E17, E18 and E19). Findings include: Review of personnel files revealed that Nurse Aide Employee E17 last hire date was 9/27/17, last performance evaluation was completed 12/28/18-12/29/19. Review of personnel files revealed that Nurse Aide Employee E19 last hire date was 4/20/05 , last performance evaluation was completed 7/20/20-7/19/21 . Review of personnel files revealed that Nurse Aide Employee E18 last hire date was 3/27/23, there was no performance evaluations was completed in file. During an interview on 6/27/25, at 8:15 a.m. Human Resource Employee E16 confirmed that the facility does not have up to date performance appraisals completed on NA Employee E17, E18 and E19 as required. 28 Pa Code: 201.20 (a)(b)(c)(d) Staff development. 28 Pa Code: 201.14 (a) Responsibility of licensee.

Based on review of facility policy, observation and staff interview it was determined that the facility failed to properly contain and dispose of garbage in two of three outside dumpsters to prevent the potential for rodent and insect infestation (dumpster one and two). Findings include: Review of facility policy Dumpster Area dated 5/20/25 indicates area will be a clean, safe, and complaint waste disposal area that minimizes infection risks, deters pests, and adheres to Department of Health, Department of Environmental Protection, and local sanitation regulations. During an observation of the facility's outdoor trash receptacles on 6/23/25, at 10:30 a.m. Dietary Manager Employee E20 confirmed that the lid/cover was not closed on dumpster one and two and that there was liquid from the dumpster area collecting in the disposal area. 28 Pa. Code 201.18(b)(3) Management.

Based on review of facility policies, clinical records, incident reports, and staff interview, it was determined that the facility failed to provide adequate assistance during a transfer, resulting in actual harm (fracture of the right humerus [upper arm bone]) for one of three residents (Resident R1). Findings include: A review of the facility policy Mechanical Lift reviewed 8/12/21, indicated the purpose is to move immobile or obese residents for whom manual transfer poses potential for staff or resident injury and to verify transfer assist needed per Kardex. Obtain additional assistance and needed equipment as indicated. A review of the facility policy Bed Positioning reviewed 8/12/21, indicated for staff to verify the transfer assistance needed for the resident in the medical chart Kardex. The facility Falls Practice Guide reviewed 8/12/21, indicated the facility, through resident assessment, fall risk assessment and implementation of appropriate intervention, will provide a medical and environmentally safe home for the resident thus ensuring his/her optimum physical, mental, and psychosocial well-being. Review of the medical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included abnormal posture, high blood pressure, and depression. Review of the Quarterly Minimum Data Set assessment (MDS- periodic assessment of care needs) dated 5/6/22, Section G, Question G0110: Activities of Daily Living (ADL) Assistance indicated Resident R1 required two plus persons for physical assistance for transfers. Review of the Kardex dated 6/10/22, indicated Resident R1 was to be a transfer with mechanical lift (to lift and transfer patients from one place to another) and assist of 2 staff. Review of the care plan dated 11/11/19, indicated Resident R1's assistance level was as follows; ADL Assist: Transfer with mechanical lift with yellow size sling and assist of two. A review of the facility investigative witness statement dated 6/8/22, revealed that on 6/6/22, at 3:45 p.m. Licensed Practical Nurse (LPN) Employee E1 transferred Resident R1 from his wheelchair to the bed using the stand and pivot method (lifted him under his arms, stood the Resident on his feet, and turned him to position him on the bed). During the transfer LPN Employee E1 stated he heard a noise, like a pop. LPN Employee E1 asked Resident R1 if the noise came from his back, to which the resident answered No, LPN Employee E1 then left the room. Further Review of the facility investigative witness statement dated 6/9/22, revealed that on 6/6/22, Nurse Aide (NA) Employee E2 was preparing to put Resident R1 into bed with the Hoyer lift (mechanical lift) when LPN Employee E1 asked if she needed help. NA Employee E2 did not try to stop LPN Employee E1 from transferring Resident R1 by himself. A review of a progress note dated 6/7/22, at 10:39 a.m. indicated Resident R1 was seen by the Nurse Practitioner for right shoulder pain, and Resident R1 requested to be sent to the Emergency Department. A review of the x-ray report dated 6/7/22, indicated a concern for a non-displaced fracture of the right humerus. Review of a physician order dated 6/7/22, revealed Resident R1 was ordered a sling for comfort and non-weight bearing to right upper extremity, and to follow up with the orthopedic clinic in three weeks. Further review of a physician's order dated 4/18/22, indicated to give [MEDICATION(S)] (pain medication) 2.5 milligrams (ml) every four hours as needed for back pain, and on 6/7/22, [MEDICATION(S)] 5 ml every eight hours as needed for pain. During a telephone interview on 7/21/22, at 1:45 p.m. regarding the incident on 6/6/22, LPN Employee E1 stated he arrived at work about 3:30 to 4:00 p.m. and Resident R1 wanted to get back in bed, he asked NA Employee E2 if she needed help. He stated he put his arms under Resident R1's arms, lifted him up and pivoted him to sit on the bed. He heard a noise, like a pop and was unsure where the sound came from. LPN Employee E1 stated he was unsure if the noise happened when he lifted Resident R1's legs onto the bed, but he thought it might have been the Resident's back that made the noise. He inquired if the resident was ok, when Resident R1 said yes, he left the room. Resident R1 complained of pain around 9:00 p.m. and received his prescribed pain medication. LPN Employee E1 stated he has transferred Resident R1 before using the same inappropriate technique and that it was my fault for doing it. During a telephone interview on 7/21/22, at 4:15 p.m. regarding the incident on 6/6/22, NA Employee E2 stated that she was about to put Resident R1 back to bed with the Hoyer lift. The lift was in the resident's room and the lift sling was under him in his wheelchair. NA Employee E2 stated that LPN Employee E1 did not use the mechanical lift to transfer Resident R1. She did not hear any noise during the transfer, and once in bed Resident R1 seemed uncomfortable, and grimaced. Resident R1 did not cry out but looked uncomfortable. She did not try to stop LPN Employee E1 from the inappropriate transfer stating He [LPN Employee E1] was my supervisor that night, I wasn't going to tell him what to do. During an interview on 7/21/22, at 8:20 a.m. LPN Employee E3 stated she would check the Kardex to find the transfer status of a resident. During an interview on 7/21/22, at 8:25 a.m. LPN Employee E4 stated she would look at the Kardex to check the transfer status of a resident. During an interview on 7/21/22, at 8:27 a.m. NA Employee E5 stated she checks the Kardex for resident transfer status. During an interview on 7/21/22, at 8:29 a.m. NA Employee E6 stated she checks the Kardex for resident transfer status or will ask the nurse. During an interview on 7/21/22, at 8:33 a.m. LPN Employee E7 stated he checks the Kardex for resident transfer status. During an interview on 7/21/22, at 8:38 a.m. LPN Employee E8 stated she checks the Kardex for resident transfer status. During an interview on 7/21/22, at 8:42 a.m. NA Employee E9 stated she checks the Kardex for resident transfer status or would ask her nurse. During an interview on 7/21/22, at 9:30 a.m. the Director of Nursing confirmed the facility failed to provide adequate staff assistance during a transfer resulting in actual harm to Resident R1. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (e)(1) Management. 28 Pa Code: 211.10 (c)(d) Resident care policies. 28 Pa Code: 211.11 Resident care plan.

Based on review of facility policy, clinical records and incident reports, and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect by not performing a safe bed positioning for one of four residents reviewed (Resident R2), which resulted in actual harm of a laceration to the head requiring 14 sutures and transfer to the hospital for treatment. Findings include: A review of the facility's policy, Patient Protection - Abuse, Neglect, Mistreatment, and Misappropriation Prevention, dated 4/18/22, indicated that the resident has the right to be free from neglect. A review of the facility's policy, Bed positioning, dated 4/18/22, indicated to verify the transfer assist needed. Obtain additional assistance as needed and indicated. A review of the clinical record revealed that Resident R2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Data Set (resident assessment) dated 6/2/22, indicated that Resident R2 required extensive assist of two persons for bed mobility and transfers. A review of the care plan dated 5/27/22, indicated that Resident R2 required extensive assist of two persons for bed mobility. A review of a nurse progress note dated 6/6/22, indicated that while care was being provided, Resident R2 rolled out of the bed onto the floor. A pressure dressing was applied to the resident's head to control bleeding. The resident was sent to the hospital for evaluation. A review of a hospital discharge report dated 6/6/22, indicated that Resident R2 sustained a scalp laceration. A review of a nurse progress note dated 6/6/22, indicated Resident R2 returned from the Emergency Department with 14 staples to the back of the head. A review of a facility incident report and investigation information dated 6/6/22, submitted by the facility indicated that facility staff neglected to follow proper procedure for bed mobility for Resident R2. Nursing Assistant (NA) Employee E1 failed to assist Resident R2 using two persons for bed mobility. A review of NA Employee E1's employee transcript dated 7/30/21, indicated they had received education on proper body mechanics, and was educated on abuse/neglect on 3/8/22. During an interview on 6/22/22, at 3:00 p.m., NA Employee E1 confirmed the resident required extensive assist of two persons for bed mobility on 6/6/22. NA Employee E1 further revealed, they did not look at the clinical record to check mobility and transfer status prior to providing care to Resident R2, and another person there would have prevented the fall. During an interview on 6/22/22, at 3:30 p.m. the Director of Nursing and the Nursing Home Administrator confirmed that the facility neglected to provide proper bed positioning for Resident R2, resulting in a fall with serious injury. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical records and facility documentation, and resident and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate assistive devices, for activities of daily living resulting in actual harm for one of three residents when the resident was burned with coffee (Resident R277). Findings include: The Admission Record Report indicated that Resident R277 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Certified Nurse Practioner (CRNP) progress notes dated 3/14/19, and 3/16/19, indicated Resident R277 had a [DIAGNOSES REDACTED]. Review of clinical record Occupational Therapy OT Evaluation & Plan of Treatment dated 3/14/19, revealed the current level of function was; decline in ability to perform functional activities without physical assistance. Decreased activities of daily living (ADL - which includes eating, daily hygiene, grooming and dressing) and significant weakness, fatigue, decreased cognition with ADL and functional mobility deficits. The plan of treatment revealed short and long term goals use of 2 handled mug. The care plan dated 3/14/19, indicated that Resident R277 required the assistance of one staff for all ADL's due to muscle weakness. The care plan updated 3/18/19, indicated that resident R277 required adaptive equipment that included (devices used to assist with completing ADL's such as eating, bath chairs, etc) a sippy cup, divided plate and built - up utensils with meals. The Minimum Data Set assessment (MDS - periodic assessment of care needs) dated 3/20/19, indicated that Resident R277 required extensive assistance of one person for eating. A general progress note dated 3/22/19, indicated Resident R277's wife was upset over blister on his legs. A CRNP note dated 3/22/19, indicated Resident R277 was seen due to painful thigh area. There was no documentation prior to this date regarding Resident R277's burns. Review of facility incident investigation included a Statement dated 3/22/19, completed by Nurse Aide (NA) Employee E1. NA Employee E1 indicated: I went to the break room to get the coffee. I didn't review the kardex and was not aware the Resident R277 used a sippy cup. I brought the coffee up (in a styrofoam cup) . I went out the room . The nurse came down and told me Resident R277 spilled the coffee. A hospital note dated 3/28/19, indicated Burn Thigh Right posterior (back) superficial partial deep partial thickness (2nd degree) pink center (type of burn affects both the top and second layer of skin, may cause swelling and discolored skin, blisters may develop and pain can be severe), darker outer edges, Burn thigh left superficial partial, deep partial thickness (2nd degree) pink center, dark outer edges and Burn groin medial left superficial partial, deep partial thickness (2nd degree) pink center, darker outer edges. The note also indicated Resident R277 was having pain in the affected area. During an observation of the right posterior thigh wound on 4/24/19, at 9:05 a.m. revealed the burn to be horizontal across the posterior thigh, three inches above the knee and measured 10 centimeters (cm) in length and was scabbed. During an observation of the left posterior/inner thigh area on 4/24/19, at 9:10 a.m. the burn wound extended from five inches above Resident R277's left knee to the left buttocks and measured 22cm in length x 2.5 cm wide. During an interview on 4/24/19, at 9:15 a.m. Resident R277 spoke of the night the he got burned and said I couldn't pick up the cup. I told them I spilled it (coffee) and it was hot. During an interview on 4/26/19, at 12:12 p.m. the Nursing Home Administrator confirmed that NA Employee E1 brought coffee from the employee breakroom in a styrofoam cup (instead of the physician ordered sippy cup) which Resident R277 spilled and resulted [MEDICAL CONDITION] the thighs. The facility failed to make certain that Resident R277 was provided with the appropriate assistive devices when hot coffee was provided in a styrofoam cup that caused a burn resulting in actual harm. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. 28 Pa. Code 201.14(a)Responsibility of licensee. Previously cited 4/18/17 and 5/11/18 28 Pa. Code 201.18(b)(1)(b)(3)(e)(1)Management. Previously cited 4/18/17 28 Pa. Code 201.29(j) Resident rights. Previously cited 4/18/17 and 5/11/18 28 Pa. Code 201.29(a)(c)(d)Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited 4/18/17 and 5/11/18 28 Pa. Code 211.12(d)(3)(5) Nursing services. Previously cited 4/18/17 and 5/11/18 28 Pa. Code 211.12(d)(1)Nursing services.

Based on review of facility policy, clinical records and facility documentation and resident and staff interviews, it was determined that the facilty failed to make certain that residents were free from neglect resulting in actual harm for one of three residents when the resident was burned with coffee (Resident R277). Findings include: Review of facility policy Patient Protection Abuse, Neglect, Exploitation, Mistreatment & Misappropriation Prevention dated 1/31/19, indicated for the purpose of this guide: abuse includes all types of abuse, neglect, exploitation, mistreatment and misappropriation of patient property. The most critical step toward detecting and preventing abuse is acknowledging that no one should be subjected to violent, abusive, humiliating, exploitive or neglectful behavior. The Admission Record Report indicated that Resident R277 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Certified Nurse Practioner (CRNP) progress notes dated 3/14/19, and 3/16/19, indicated Resident R277 had a [DIAGNOSES REDACTED]. Review of clinical record Occupational Therapy OT Evaluation & Plan of Treatment dated 3/14/19, revealed the current level of function was; a decline in ability to perform functional activities without physical assistance. Decreased activities of daily living (ADL - which includes eating, daily hygiene, grooming and dressing) and significant weakness, fatigue, decreased cognition with ADL's and functional mobility deficits. The plan of treatment revealed short and long term goals use of 2 handled mug. The care plan dated 3/14/19, indicated that Resident R277 required the assistance of one staff for all ADL's due to muscle weakness. The care plan updated 3/18/19, indicated that Resident R277 required adaptive equipment (devices used to assist with completing ADL's such as eating, bath chairs, etc) that included a sippy cup, divided plate and built - up utensils with meals. The Minimum Data Set assessment (MDS-periodic assessment of care needs) dated 3/20/19, indicated that Resident R277 required the extensive assistance of one staff for eating. A general progress note dated 3/22/19, indicated Resident R277's wife was upset over blister on his legs. A CRNP note dated 3/22/19, indicated Resident R277 was seen due to painful thigh area. There was no documentation prior to this date regarding Resident R277's burns. Review of facility incident investigation included a Statement form dated 3/22/19, completed by Nurse Aide (NA) Employee E1. NA Employee E1 indicated: I went to the break room to get the coffee. I didn't review the kardex and was not aware Resident R277 used a sippy cup. I brought the coffee up (in a styrofoam cup) . I went out the room .The nurse came down and told me Resident R277 spilled the coffee. A hospital note dated 3/28/19, indicated Burn Thigh Right posterior (back) superficial partial deep partial thickness (2nd degree) pink center (type of burn that affects both the top and second layer of skin, may cause swelling and discolored skin, blisters may develop and pain can be severe), darker outer edges, Burn thigh left superficial partial, deep partial thickness (2nd degree) pink center, dark outer edges and Burn groin medial left superficial partial, deep partial thickness (2nd degree) pink center, darker outer edges. The note also indicated Resident R277 was having pain in the affected area. During an observation of the right posterior thigh wound on 4/24/19, at 9:05 a.m. revealed the burn to be horizontal across the posterior thigh, three inches above the knee, and measured 10 centimeters (cm) in length and was scabbed. During an observation of the left posterior/inner thigh area on 4/24/19, at 9:10 a.m. the burn wound extended five inches above Resident R277's left knee to the left buttocks and measured 22 cm in length x 2.5 cm wide. During an interview on 4/24/19, at 9:15 a.m. Resident R277 spoke of the night he got burned and said I couldn't pick up the cup. I told them I spilled it (coffee) and it was hot. During an interview on 4/26/19, at 12:10 p.m. the Nursing Home Administrator confirmed that NA Employee E1 brought coffee from the employee breakroom in a styrofoam cup (instead of the physician ordered sippy cup) which Resident R277 spilled and resulted [MEDICAL CONDITION] his thighs. The facility failed to make certain that Resident R277 was protected from neglect when provided hot coffee that caused a burn resulting in actual harm. 42 CFR 483.12(a)(1) Free From Abuse and Neglect. 28 Pa. Code 201.14(a)Responsibility of licensee. Previously cited 4/18/17, 5/11/18. 28 Pa. Code 201.18(b)(1)(b)(2)(b)(3)(e)(1)Management. Previously cited 4/18/17. 28. Pa. Code 201.29(j)Resident rights. Previously cited 4/18/17 and 5/11/18. 28 Pa. Code 201.29(a)(c)(d)Resident rights. 28 Pa. Code 211.10(c)(d)Resident care policies. Previously cited 4/18/17 and 5/11/18. 28 Pa. Code 211.2(d)(3)(5) Nursing services. Previously cited 4/18/17 and 5/11/18. 28 Pa. Code 211.2(d)(1) Nursing services.

Based on review of facility documentation, clinical records, and resident family and staff interviews, it was determined that the facility failed to maintain skin integrity with the use of assistive devices resulting in the development of pressure ulcers for two of 7 residents reviewed (Resident R7 and Resident CR22) which resulted in actual harm. Findings include: Review of the, Face Sheet, (a form that identifies resident's personal and medical information to health care providers) indicated that Resident R7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set assessment (MDS-a periodic assessment of care needs) dated 7/1/16, revealed an additional [DIAGNOSES REDACTED]., [DIAGNOSES REDACTED], and other disorders). Review of the Treatment Administration Record (TAR - a clinical record documenting treatments) indicated a treatment of [REDACTED]. The Wound Care Specialist's initial evaluation note dated 8/12/16, stated, wound duration > (greater than) 35 days etiology pressure, wound size 4.9.x 2.8x .0.2cm (centimeters). The note indicated the area was on the left medial ankle and indicated the pressure ulcer was from the ankle bracelet (Wanderguard - a tracking application designed to prevent persons at risk from leaving a facility unless they are accompanied, usually in the form of a bracelet worn by the resident. The device sounds an alarm to notify the staff when a resident is in an alarmed area, such as the elevator. The resident ' s bracelet was applied to the right ankle.) Review of the TAR dated 7/1/16, revealed daily documentation that the Wanderguard was in place and functioning. During an interview on 4/13/17, at 10:30 a.m. with Resident R7's family member, who reported that he had visited his mother almost every day since she was admitted to the facility, the family member remembered that his mother had the Wanderguard on the right ankle in July of 2016, and that he noticed some 'seepage' on her left ankle sock, which he reported to the staff. He remembered that the staff removed the Wanderguard from the right ankle, and did not replace it at the time. Review of the General Progress Notes dated 7/9/16, at 18:11 (6:11 p.m.) completed by Licensed Practical Nurse (LPN), Employee 19, indicated that, family present states pt. (patient) has history of stasis ulcers (a breakdown of the skin caused by fluid build-up in the skin from poor vein function) LLE (left lower extremity) ankle and request wound team evaluation of left ankle. RN (Registered Nurse) supervisor notified and assessed, protective dressing applied for safety, will monitor for changes. Review of the Social Service notes dated 7/20/16, at 2:21 p.m. revealed a care conference note where the wound care treatment was discussed with Resident R7's son. Review of the Skin notes dated 7/22/16, at 3:11 p.m. completed by Registered Nurse (RN), Employee R2, revealed that the wound area to be 2 x 1 x 0.1 with scant clear drainage. Review of the, Pressure Ulcer Healing Chart (PUSH - measures length and width, drainage and tissue type and converts them into a score, as scores decreases to '0' the ulcer is healed), for 7/22/17, revealed a PUSH total score of 7 for the left medial ankle ulcer. Review of the Skin notes dated 7/29/16, at 11:47 a.m. completed by Employee R2 revealed the left ankle wound area to be 3.5 L x 2.5 W x 0.1 D and was noted as PUSH 12 on the Pressure Ulcer Healing Chart with scant serous (clear watery) drainage. Review of the Nutrition/Weight notes dated 7/31/16, at 2:41 p.m. documented that the L medial ankle wound to be stage II (a Stage II Pressure Ulcer - partial thickness loss of dermis presenting as a shallow ulcer). Review of the Wound Care Specialist Initial Evaluation dated 8/12/16, completed by the Wound Care Physician, it was documented, a Stage III pressure wound (a full thickness tissue loss that may extend into the subcutaneous tissue layer) of the left medial ankle. Pressure ulcer from ankle brace (Wanderguard). Review of the PUSH chart data for 4/10/17, reveals that the left medial ulcer was scored at 7 after 275 days of treatment. During an interview on 4/13/17, at 1:30 p.m. with the DON and Registered Nurse (RN) Unit Manager, Employee E6, confirmed that the physician wound care specialist identified the Wanderguard as the cause of the left medial pressure ulcer. Resident CR22 was admitted to the facility on [DATE], and re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident CR22 was readmitted with a knee brace/immobilizer. Review of Resident CR22 clinical record progress notes revealed on 12/31/16, Wound care was not seeing patient. Neither patient nor staff were aware of wound. Patient states that PT (physical therapy) put a long 'sock' on his leg because the brace was turning his leg dark. Patient stated that the sock had been on for a few days. Wound is located to the inner left knee, slightly below healing incision site. Area measures 1 1/2 x 1 x 0.6 cm and is draining a small amount of yellow drainage. Review of Resident CR22's Wound Care Specialist Initial Evaluation dated 1/6/17, revealed he presents with a stage 3 pressure wound of the left medial knee, of at least 5 days duration . and etiology (source) pressure. During an interview on 4/18/17, at 9:52 a.m. the Director of Nursing confirmed the progress notes dated 12/31/16, that stated wound care not seeing patient, neither patient nor staff aware of wound. The facility failed to maintain skin integrity with the use of assistive devices. As a result, there was actual harm for two residents who suffered wounds. 28 Pa. Code 211.5(f) Clinical records Previously cited 5/5/16, 4/2/15. 28 Pa. Code 211.10(a) Resident care policies. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 6/8/16, 4/2/15. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 6/8/16, 4/18/16, 4/2/15. 28 Pa. Code 211.12(c) Nursing services. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 1/24/17, 6/8/16, 4/18/16, 9/28/15, 4/2/15. 28 Pa. Code 211.12(d)(2) Nursing services. Previously cited 6/8/16. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 1/24/17, 6/8/16, 9/28/15, 4/2/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 6/8/16, 4/18/16, 9/28/15, 4/2/15.