Every finding on record at Jersey Shore Skilled Nursing and Rehabilitation Ce

Based on closed clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to maintain clinical records that were complete and accurate for one of two residents reviewed (Residents CR1).Findings include:Closed clinical record review for Resident CR1 revealed the resident was admitted to the facility on [DATE], after an extensive hospital stay since [DATE], in stable condition but with a significantly poor prognosis noted by the physician. The resident was discharged from the facility on [DATE]. A review of Resident CR1's physician orders revealed the resident was ordered the following: Morphine Sulfate (an opioid pain medication used to treat severe pain) oral solution 20mg (milligrams)/5 ml (milliliters) on [DATE], to be administered 0.25 ml every one hour as needed for moderate pain, severe pain, or air hunger (not being able to get enough air, rapid shallow breathing) until her discharge. Fluoxetine HCL (an antidepressant medication) 40 mg one time day on [DATE], until discharge, and Neurontin (medication used to treat nerve pain) 300 mg every morning and at bedtime on [DATE], until discharge. Ipratropium-Albuterol Solution (an inhaled medication used to open airways) 0.5-2.5 (3) mg/3ml to be inhaled every four hours as needed for shortness of breath or wheezing with pre-treatment evaluation on supplemental documentation, in progress notes document response to instructions and education and any adverse reactions, on [DATE], until the resident's discharge. Oxygen to be administered via nasal cannula (tubing from the oxygen concentrator to the nostrils of the nose), continuously at two liters per minute on [DATE]. This order was discontinued on [DATE], with no other oxygen administration orders for Resident CR1 after that date. A review of Resident CR1's [DATE], and [DATE], medication administration record (MAR) revealed the resident had not utilized the as needed inhaled Albuterol solution at all in [DATE], and not in April until [DATE], where it was documented as administered at 11:11 PM for wheezing on the resident's [DATE] MAR. An electronic MAR note at the same date and time indicated the resident had shortness of breath and wheezing. There was no evidence of any additional progress note or supplemental documentation of a pre-treatment evaluation or any change in condition of the resident. A review of a Resident Controlled Drug Record (individual patient's narcotic record, a paper form used in conjunction with the resident's MAR to record dosages/maintain count of a narcotic drug removed from the resident's supply) for the resident's Morphine Sulfate revealed the resident had only utilized the medication once in March on [DATE], and not until [DATE]. The medication was signed (physical signature of staff) on the paper Controlled Drug Record as a dose being taken from the supply on [DATE] at 8:00 PM, [DATE], at 12:20 AM, and [DATE], at 1:20 AM. A review of Resident CR1's MAR for [DATE], revealed the MAR, which would reflect an electronic time stamp of the date and time a medication was administered, did not reflect the resident being administered the Morphine Sulfate on [DATE], or the 1:20 AM dose on [DATE]. There was also no corresponding documentation or pain assessment on [DATE], or 6, 2026, to indicate a change in condition warranting the need for the administration of the Morphine. A nursing progress note dated [DATE], at 1:31 AM noted the resident was requesting a new catheter (device inserted into the bladder to drain urine) due to burning and discomfort, although there was no assessment of the resident's pain level or breathing status and no other concerns were noted for the resident. A nursing progress note completed by a registered nurse dated [DATE], at 9:10 AM noted the nurse was called to the unit by staff and found the resident to be unresponsive, pupils fixed, with the left eye slightly larger than the right and foaming at the mouth. If was noted the resident's blood sugar level was 514, and that the resident was given two doses of Narcan (a medication used to immediately reverse opioid overdose symptoms, including respiratory depression) with no results. It was further noted the nurse was unable to obtain vital signs and fingers were cool to touch. The physician was noted as contacted and video chatted with the nurse and it was instructed to send the resident to the emergency room if the family agreed. After talking with the daughter, the resident was sent to the emergency room per her request. The same note indicated EMS (emergency medical services) notified. An additional nursing progress note for Resident CR1 dated [DATE], at 9:30 AM noted EMS here to transport to the ER (emergency room), O2 SATS (oxygen saturation) 88-95, oxygen increased to six liters vital signs and O2 SATS are still 88-95%. There was no evidence of any additional documentation leading up the noted event on [DATE], to indicate a time as to when the resident was first identified with the significant change in condition or by whom it was reported to that initiated the call to the RN. There was no evidence to indicate when oxygen was applied to the resident as the resident's oxygen administration orders were discontinued on [DATE]. Review of Resident CR1's physician orders did not reveal any order for the resident to be administered Narcan in the facility. Interview with the Director of Nursing (DON) on [DATE], at 11:30 AM revealed the DON indicated she had verbally spoke with the registered nurse responsible for documenting the Narcan was administered to the resident with no response in the facility, and it was confirmed that the nurse did not administer the Narcan as indicated in the note, but EMS personnel did when they arrived. The DON confirmed there was no evidence of any documentation of the resident's change in condition requiring the administration of inhaled solution, Morphine, at what time the resident was found unresponsive, who found the resident, or who alerted the registered nurse the morning of [DATE], in the resident's clinical record. The DON indicated a different licensed practical nurse (LPN) than who administered the Morphine would have arrived for duty on [DATE], at 7:00 AM, and a new nurse aide (NA) assigned to the resident would have also reported for duty on the same date at 7:00 AM assigned to Resident CR1. The DON indicated the NA found the resident that morning and reported it to the LPN, although there was no documentation to indicate this occurred. The DON indicated the LPN had not observed the resident prior to the NA as the LPN had not administered any medications to the resident that morning prior to the incident. Review of Resident CR1's April MAR revealed the resident was documented as receiving scheduled 8:00 AM doses of Fluoxetine and Neurontin by Employee 1 (LPN) the morning of [DATE]. Interview with Employee 1 (LPN), on [DATE], at 12:54 PM confirmed the LPN was on duty and assigned to Resident CR1 the morning of [DATE], when the incident occurred. Employee 1 indicated when she was given report that morning by the outgoing LPN she was informed Resident CR1 was having some pain through the night and was given Morphine, but that was all that was reported for the resident. Employee 1 then indicated around 7:30 AM she was notified by Employee 2 (NA) that Resident CR1 was not herself. The LPN stated she went to assess the resident and found her not responding and told the NA to page the registered nurse. The LPN stated, I documented all of that, although up until the interview with the DON as noted above at 11:30 AM no documentation existed from the LPN for the morning of [DATE], for Resident CR1. Employee 1 also confirmed she did not administer any medication to Resident CR1 after she reported for duty at 7:00 AM as she would not have gotten to the resident's room in the hall prior to the time the incident occurred with the resident. It was reviewed with Employee 1 that the resident was signed off as being administered two 8:00 AM doses of medication noted above by her. Employee 1 indicated she must have marked them in error and the medications were not administered. Further review of Resident CR1's closed clinical record during the interview with Employee 1 revealed a late entry progress note was created by Employee 1 on [DATE], at 12:31 PM after concerns with Resident CR1 were reviewed with facility staff. The late entry note indicated it was for [DATE], 7:30 AM (the incident occurred on [DATE], not [DATE]), and noted CNA's (nurse aides) to med cart reporting resident is not doing well assessed resident who was not acting herself per CNA she did have some white froth coming from mouth that was lying on lips RN was called at this time to assess mouth was cleaned also. An additional interview with the DON on [DATE], at 1:11 PM revealed the DON had a phone interview with the LPN who administered the Morphine to Resident CR1 on [DATE], who indicated the morphine was administered due to the resident having pain and shortness of breath and that the resident's daughter was in the building overnight with the resident and came to the LPN and stated the resident was still breathing hard after the first dose of Morphine and asked if another dose could be given and the daughter saw the LPN administer both doses. The LPN reported to the DON that the daughter left between 3:00 - 4:00 AM and the daughter told the LPN the resident seemed better. The LPN stated to the DON that she did not remember the exact time the resident was seen after that. Interview with Employee 2 (nurse aide) on [DATE], 1:18 PM revealed Employee 2 was the NA who found the resident the morning of [DATE]. Employee 2 stated she was passing trays on the unit at seven something and upon passing a tray to Resident CR1 she found the resident lying in bed with her eyes wide open and the resident would not respond to the NA, and she went and told Employee 1. The NA stated the resident had oxygen on her when she found the resident. Employee 2 stated she saw Employee 1 go to the resident's room and was told to page the registered nurse and the NA herself paged the registered nurse. The NA stated she was with the registered nurse when he was assessing the resident, the resident and saw him obtain vital signs (blood pressure, pulse) for the resident. The NA did not see the nurse administer any medications to the resident. The NA indicated the last date prior she worked with the resident was [DATE], and could not recall if the resident had oxygen on that day. The facility failed to ensure complete and accurate documentation for Resident CR1 prior to the resident being transferred to the hospital on [DATE], as evidenced by missing documentation of Morphine administration on the MAR, documented administration of medications that were not administered, no documented assessment for the need for Morphine or the Albuterol inhaler, nor any documentation of the resident's change in condition or events leading up to the registered nurse response from [DATE] to the morning of [DATE]. There was no evidence as to when oxygen was readministered or a new order to administer oxygen to the resident as it was observed on the resident by the NA the morning of [DATE], prior to the incident and noted to be increased with EMS onsite. A nursing progress note for Resident CR1 dated [DATE], at 2:18 PM noted the facility was notified from the hospital that Resident CR1 expired at 12:38 PM. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on [DATE], at 2:30 PM. 28 Pa. Code 211.5(i) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to store food and maintain food service equipment in accordance with professional standards for food service safety in the facility's main kitchen. Findings include:Observation of facility's main kitchen on March 24, 2026, at 10:17 AM revealed the following: Water pooled on the floor in the corners under the dish machine area with various items of debris, including papers, straws, plastic lids and pieces of food. A large bulletin board extending across the wall behind the coffee brewing station was observed with significant visible dust along the top frame edge of the board. The lower shelf of a storage shelving unit containing pans located behind the steam table area was significantly dusty, sticky to touch, and contained dried food debris. Two large clear plastic storage bins located on the lower shelf of a food preparation table next to the food serving line were observed with one labeled sugar and one labeled flour. The exterior of both containers contained dried spills and dried food debris. A large plastic scoop was observed stored inside each of the containers down in the product. A plastic bin next to the flour and sugar was observed with multiple white potholders stored in it. Several of the potholders were tattered, contained black stains, and dried food. A small storage room in which staff indicated was a storage/chemical room was observed to contain a utility sink with an empty mop bucket sitting in front of the sink. A metal shelving unit with multiple shelves directly next to the utility sink contained several carboard boxes of paper products to include paper plates, cups, bowls, and lids. A metal speed rack (cart designed to hold large sheet trays) was also observed adjacent to the shelves of paper products with multiple reusable plates and bowls stacked on trays on rack uncovered with the food contact portion of the items facing upward. Several of the bowls and plates contained dust, black specks, dried food, and debris on the food contact surfaces. Several plastic pitchers were also stored on a smaller cart next to the speed rack uncovered, standing upright, with no lids exposing the usable surface to contaminants. Observation of a Dishwasher Machine Temperature Log for March 2026, located in the kitchen revealed notes on the bottom of the form which indicated Critical limits: Wash cycle must be at least 160 degrees (Fahrenheit) Rinse cycle must be at least 180 degrees (Fahrenheit). The form also noted Corrective Action: If temperature is out of parameters, notify dietary manager. Use three-bay sink until issue is resolved. A corrective action section was also identified on the form with lines to indicate a correction action and noted to include a date. Review of the recorded temperatures for the wash cycle logged on the form for March 1 - 23, 2026, for each meal breakfast, lunch, and dinner, and breakfast March 24, 2026, revealed the wash temperature of the machine was never logged as reaching 160 degrees or higher. Temperatures ranged from 156 - 159. Several entries appeared to read 150 degrees but were written over as to make the zero in 150 read as an 8 changing it to 158. There were no documented entries of corrective action with dates for any day/meal as the wash temperature did not reach 160 degrees. Observation of the dish machine on March 24, 2026, at 11:29 AM revealed two temperature gauges on the front of the dish machine. One for the wash cycle was labeled min 160, and one was labeled for the rinse as min 180. Dietary staff were observed utilizing the machine. Five cycles of the machine were observed as staff were sending racks of items through the machine and the wash temperature reached a maximum of 152 degrees as the last rack was moving through the machine. A concurrent interview with Employee 7, food service director, revealed she was not aware of any issues with the wash temperatures of the machine, and did indicate sometimes the water does take a little time to warm up. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on March 26, 2026, at 2:30 PM. 483.60(i)(2) Store, prepare, food safe and sanitaryPreviously cited 5/16/25 28 Pa. Code 201.14 (a) Responsibility of Licensee

Based on observation, review of resident council meeting minutes, and resident and staff interview, it was determined that the facility failed to ensure resident grievances were addressed timely for three of 23 residents interviewed (Residents 13, 2, and 109).Findings include: Interview with Resident 13 on March 24, 2026, at 10:30 AM revealed she frequently must wait 30 to 40 minutes for staff to answer her call bell. Interview with Resident 2 on March 24, 2026, at 9:37 AM revealed that it can take staff 30-45 minutes for staff to answer his call bell. He stated that he was told this morning not to ring his call bell so much since Department of Health was in the building. Interview with Resident 109 on March 24, 2026, at 2:27 PM revealed she can wait an hour for her call bell to be answered, mostly on second and third shifts. Review of Resident Council Meeting minutes dated February 6, 2026, revealed the residents indicated that call bells are not being answered timely on third shift. Observation of staff response to call bells revealed Resident 13 activated her call bell on March 24, 2026, at 11:28 AM, staff responded to Resident 13's call bell at 12:12 PM (44 minutes). Further observation of staff response to Resident 13's call bell revealed on March 25, 2026, at 10:00 AM Resident 13 activated her call bell, staff responded to her call bell at 10:33 AM (33 minutes) The facility failed to resolve the residents' grievances related to call bells.The surveyor reviewed the above findings with the Nursing Home Administrator and Director of Nursing during a meeting on March 25, 2026, at 2:40 PM. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa Code: 201.18(b)(2)(3)(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(3) Nursing services

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to monitor psychotropic medication use to ensure residents' medication regime was free from potentially unnecessary psychotropic medications for three of five residents reviewed for potentially unnecessary medications (Residents 6, 79, and 12). Findings include: The facility policy entitled, Behaviors: Management of Symptoms, last reviewed without changes on January 28, 2026, revealed that non-pharmacological intervention refers to approaches to care that do not involve medications, generally directed toward stabilizing and/or improving a resident's mental, physical, and psychosocial well-being. Staff will use non-pharmacological interventions as the first line of approach to managing challenging behaviors. Behaviors and interventions will be addressed in the care plan. The purpose of the policy included that the facility would monitor outcomes of care plan interventions and minimize the use of psychotropic medications, including antipsychotics, for residents with behavioral symptoms and/or dementia. Staff will observe, monitor for, and document in the medical record, any exhibited behavioral symptoms which include physically aggressive behaviors, verbally aggressive behaviors, sexually inappropriate behaviors, and wandering that places the resident at risk. The facility will document behavioral monitoring and interventions. Clinical record review for Resident 6 revealed active physician orders for staff to administer the following psychotropic medications: Quetiapine Fumarate (Seroquel, antipsychotic medication used to treat mental disorders by balancing brain chemicals linked to mood and behavior) 25 mg (milligrams) every morning and at bedtime and 12.5 mg in the afternoon.Trazodone HCl (an antidepressant medication that increases the amount of natural chemicals in the brain) 25 mg at bedtimeSertraline HCl (medication used for depression to improve mood, reduce anxiety, and regulate emotional responses) 50 mg one time a day Resident 6's clinical record did not include evidence that the facility monitored for potential side effects from the use of the antipsychotic and antidepressant medications. Interview with the Nursing Home Administrator on March 27, 2026, at 9:58 AM confirmed that the facility had no evidence of side effect monitoring for Resident 6's antidepressant and antipsychotic medication use. Clinical record review for Resident 79 revealed active physician orders for the use of the following psychotropic medications: Amitriptyline HCl (antidepressant that works by increasing the amount of chemicals in the brain) 50 mg at bedtime Clonazepam (Klonopin, benzodiazepine medication used as an anti-anxiety, anti-seizure, sedative, hypnotic, and skeletal muscle relaxant medication) 0.5 mg at bedtimeBuspirone HCl (anti-anxiety medication) 5 mg two times a day Review of a plan of care initiated by the facility on March 22, 2026, noted that Resident 79 was at risk for complications related to the use of psychotropic medications. Resident 79's clinical record did not contain evidence that the facility identified or monitored the distressing target behaviors Resident 79 exhibited that warranted the use of the psychotropic medications. Resident 79's clinical record also did not contain evidence that the facility monitored for the ongoing potential side effects from the use of psychotropic medications. Interview with the Nursing Home Administrator on March 27, 2026, at 9:55 AM confirmed the above findings for Resident 79. Clinical record review for Resident 12 revealed a pharmacy recommendation dated November 18, 2025, noting the resident was receiving Seroquel (Quetiapine Fumarate) 100 mg in the morning and 50 mg in the evening since July 2025, and reducing the morning dose to 75 mg was recommended. Review of Resident 12's physician orders revealed an order dated December 22, 2025, for the resident to receive Quetiapine Fumarate 50 mg one tablet every morning and at bedtime for mood AM dose is 75mg NOTE DOSE. An additional order dated December 23, 2025, was also indicated for Quetiapine Fumarate 25 mg to be given one tablet one time a day for mood take with 50 mg tab to equal 75 mg dose, providing the decreased dosage as recommended. Resident 12's Quetiapine Fumarate orders were again updated on January 29, 2026, as Quetiapine Fumarate 50 mg, give one tablet by mouth every morning and at bedtime for mood, AM dose is 75 mg, NOTE DOSE. This order was discontinued on February 3, 2026, and reordered on the same date February 3, 2026, indicating the same dosage of 50 mg directing to give one tablet by mouth every morning and at bedtime for dementia with mood disturbance and anxiety AM dose is 75 mg *NOTE DOSE* Further review of Resident 12's medication orders revealed and additional active order dated January 30, 2026, for the resident to receive Seroquel 50 mg (Quetiapine Fumarate), give 50 mg by mouth at bedtime for insomnia. Review of Resident 12's February medication administration record (MAR) revealed the resident was documented as being administered Seroquel 50 mg by mouth at bedtime for insomnia at 9:00 PM every evening February 1 through February 28, 2026, and also documented as being administered Quetiapine Fumarate 50 mg one tablet by mouth every morning and at bedtime for dementia with mood disturbance and anxiety AM dose is 75 mg *NOTE DOSE* every morning scheduled at 9:00 AM and every evening scheduled at 9:00 PM from February 3 - February 28, 2026. Review of Resident 12's March 2026 MAR revealed the resident was documented as being administered Seroquel 50 mg by mouth at bedtime for insomnia scheduled at 9:00 PM every evening from March 1 - 25, 2026, and also documented as being administered Quetiapine Fumarate 50 mg one tablet by mouth every morning and at bedtime for dementia with mood disturbance and anxiety AM dose is 75 mg *NOTE DOSE* every morning scheduled at 9:00 AM and every evening scheduled at 9:00 PM from March 1 - March 25, 2026. The above information regarding Resident 12's medication orders regarding Quetiapine Fumarate (Seroquel) reflecting the resident being documented as receiving two doses of 50 mg tablets each evening was reviewed with the Director of Nursing on March 26, 2026, at 8:30 AM. Resident 12's Seroquel 50 mg tablet at bedtime order was discontinued on March 26, 2026, after it was brought to facility staff's attentions as noted above. In a follow up interview with the Director of Nursing on March 27, 2026, at 1:30 PM it was determined the Resident 12 was being documented as receiving 50 mg of the Seroquel each evening on both entry lines of the MAR, but was only actually administered 50 mg, as dispensed from pharmacy in the blister medication pack and there was no additional dose to administer. The Director of Nursing confirmed two orders for the evening dose of the medication should not have been active nor present on the resident administration record. Review of Resident 12's active plan of care revealed a focus area initiated on July 221, 2025, indicating the resident is at risk for complications related to the use of antipsychotic drugs (antipsychotic and antidepressant), with a goal the resident will have the smallest most effective dose without side effects. Review of Resident 12's physician orders revealed the resident has received Duloxetine HCL (an anti-depressant), and Quetiapine Fumarate (antipsychotic) since July 2025. Resident 12's clinical record did not include any evidence that the facility monitored for potential side effects from the use of the antidepressant and antipsychotic medications. The above information regarding Resident 12 was reviewed with the Nursing Home Administrator on March 27, 2026, at 12:30 PM. 483.10(e)(1), 483.12(a)(2), 483.45(c)(3)(i-iv)(d)(1-6)(e)(1-5) Right to be Free From Chemical RestraintsPreviously cited deficiency 5/16/25 28 Pa. Code 211.9(k) Pharmacy services 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview it was determined that the facility failed to provide written notice of the facility bed-hold policy to residents' responsible parties at the time of transfer and failed to ensure that the written notice of transfer included all the required contents for three of three residents reviewed for hospitalization concerns (Residents 8, 3, and 12). Findings include: Clinical record review for Resident 8 revealed profile information that indicated that she had a resident representative (identified as her significant other). Nursing documentation dated January 3, 2026, at 12:36 PM revealed that Resident 8 had complained of hallucinations, burning with urination, and not feeling well. Staff notified Resident 8's physician who instructed staff to send Resident 8 to the emergency room for evaluation. Nursing documentation dated January 3, 2026, at 5:31 PM revealed that the emergency room reported that Resident 8 was admitted to the hospital's critical care unit (CCU). Review of a Notice of Intended discharge date d January 5, 2026, addressed to Resident 8's representative did not include the name, address (mailing and email), and telephone number, of the Office of the State Long-Term Care Ombudsman. Interview with the Nursing Home Administrator on March 26, 2026, at 12:18 PM confirmed that the above notice for Resident 8 did not include the required contents. The interview also confirmed that the facility had no evidence of the provision to the resident and the resident representative of a written notice which specified the duration of the facility's bed-hold policy. Nursing documentation dated February 4, 2026, at 9:25 AM revealed that staff notified Resident 8's physician of her altered mental status and jaundiced (yellow discoloration to skin and the white part of the eyes) appearance. The facility transferred Resident 8 to the emergency room. Review of a Notice of Intended discharge date d February 8, 2026 (four days after Resident 8's transfer out of the facility) revealed the notice did not include the State Long-Term Care Ombudsman information and staff noted, N/A, in the section intended to document the resident's representative's name and address. The surveyor reviewed concerns that the February 8, 2026, notice was not provided timely (within 24 hours), did not include an indication that the notice went to Resident 8's representative, and did not include the required contents (State Long-Term Care Ombudsman information) during an interview with the Nursing Home Administrator on March 26, 2026, at 12:47 PM. The interview confirmed that the facility had no evidence that Resident 8's representative received a written notice of transfer or the facility's bed-hold policy. Clinical record review revealed the facility admitted Resident 3 on March 21, 2024. Nursing documentation dated February 27, 2026, 1:11 AM noted Resident 3 had a fever of 101.6 degrees. Resident 3's physician ordered her to be sent to the emergency department for evaluation. Nursing documentation dated February 27, 2026, at 6:14 AM revealed Resident 3 was admitted to the hospital with sepsis and pneumonia.Interview with Nursing Home Administrator and Director of Nursing on March 26, 2026, at 2:19 PM, confirmed the facility had no evidence that Resident 3, or her responsible party received the facility's bed-hold policy at the time Resident 3's transfer to the hospital. Clinical record review for Resident 12 revealed the resident was transferred to the hospital and admitted on [DATE], due to a stroke (blood flow being blocked to the brain or bursting of blood vessels in the brain). Interview with the Nursing Home Administrator and Director of Nursing on March 26, 2026, at 2:36 PM confirmed the facility had no evidence that Resident 12's responsible party received the facility's bed-hold policy at the time of Resident 12's transfer to the hospital. 483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2)(i)-(iii) Discharge ProcessPreviously cited deficiency 5/16/25 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(a) Resident rights

Based on review of select facility policies and procedures, observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide a dependent resident with activities of daily living assistance for five of 10 residents reviewed (Residents 2, 1, 119, 120, and 121).Findings include: During an interview with Resident 2 on March 24, 2026, at 9:39 AM he stated that recently the staff will only give him a bed bath. Resident 2 stated that he would prefer a shower and have his hair washed. Clinical record review revealed the facility admitted Resident 2 on December 30, 2025. Review of Resident 2's admission MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated January 6, 2026, noted staff assessed Resident 2 as dependent on staff for bathing. Review of Resident 2's Kardex (documentation system used by staff to organize and reference key resident information essential for resident care) revealed he is to receive a bath every Wednesday and Saturday. Review of a Documentation Survey Report (electronic documentation completed by nurse aide staff for the completion of ADL care) from March 1 to March 27, 2026, revealed there was no documentation that staff assisted Resident 2 with a shower after March 8, 2026 (19 days). The findings were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on March 26, 2026, at 2:38 PM. Further interview with the Director of Nursing on March 27, 2026, at 10:59 AM, confirmed the above findings for Resident 2. Closed clinical record review for Resident 119 revealed an admission MDS assessment dated [DATE], that determined substantial/maximal assistance of staff was necessary for showering/bathing. Review of a Documentation Survey Report dated January 2026 revealed that Resident 119's tub/shower bathing schedule was Wednesday and Saturday evenings (3:00 PM to 11:00 PM). Staff documented that Resident 119 received tub/shower bathing assistance on Wednesday, January 21, 2026, but was not offered the care again until Friday, January 30, 2026. Staff initialed that the care was 97 (not applicable), on Sunday, January 25, 2026, and omitted any documentation on Wednesday, January 28, 2026. The surveyor reviewed the above concerns regarding the bathing omissions for Resident 119 during an interview with the Nursing Home Administrator and the Director of Nursing on March 26, 2026, at 2:00 PM. Review of the facility policy entitled, Nail Care, last reviewed without changes on January 28, 2026, revealed that assessment of resident fingernails and toenails will be conducted on admission and re-admission to determine the resident's nail condition, needs, and preferences for nail care, if possible. Resident nails should be kept short and smooth to avoid skin injury. Routine cleaning and inspection of nails will be provided during activities of daily living (ADL) care on an ongoing basis. Routine nail care, including trimming and filing, will be provided. Each resident will have their own nail care equipment (e.g., clippers, emery boards, files, etc.). Observation of Resident 1 on March 25, 2026, at 10:08 AM revealed that his fingernails were long (beyond the tips of his fingers). Interview with Resident 1 on the date and time of the interview confirmed that his fingernails were longer than he desired, however, he did not have clippers or equipment to clip his own fingernails. Clinical record review for Resident 1 revealed an admission MDS dated [DATE], that determined Resident 1 needed the partial/moderate assistance of staff for personal hygiene. A plan of care developed by the facility (initiated February 24, 2026) addressed Resident 1's risk for decreased ability to perform ADL(s) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting. The surveyor reviewed the above concerns regarding Resident 1's fingernails during an interview with the Nursing Home Administrator and the Director of Nursing on March 25, 2026, at 2:00 PM. Review of Resident 120's Care Plan (outline of an individual's health needs, specific care requirements, and the actions necessary to achieve desired health outcomes) initiated on December 19, 2025, and in place through February 10, 2026, included a focus that the resident was at risk for decreased ability to perform ADLs (ADLs, or Activities of Daily Living, refers to the basic self-care tasks that individuals perform daily to maintain personal health and independence) in bathing, grooming, and personal hygiene. Resident interventions for this focus included arranging resident environment as much as possible to facilitate ADL performance, and to stand on weaker side of resident when assisting with ADLs or other activities. Review of Resident 120's Documentation Survey Report for December 2025 to January 2026, revealed the resident's tub/shower schedule as Tuesday and Friday Evenings. There was no documentation that staff assisted Resident 120 with a shower after December 26, 2025, until January 30, 2026 (34 days). Review of Resident 121's Care Plan included a focus initiated on January 2, 2026, and in place through February 9, 2026, that the resident was at risk for decreased ability to perform ADLs in bathing, grooming, and personal hygiene. Resident interventions for this focus included providing cuing for safety and sequencing. Review of Resident 121's Documentation Survey Report for January 2026, revealed the resident's tub/shower schedule as Wednesday and Saturday Evenings. There was no documentation that staff assisted Resident 121 with a shower after January 10, 2026, until January 28, 2026 (17 days). The above findings for Residents 120 and 121 were reviewed with the Nursing Home Administrator on March 27, 2026, at 11:35 AM. 483.24(a)(2) ADL Care Provided for Dependent ResidentsPreviously cited deficiency 8/14/25 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed pharmacy recommendations for four of five residents reviewed for unnecessary medications (Residents 3, 5, 6, and 12). Findings include: The facility policy entitled, Medication Regimen Review and Reporting, last reviewed without changes on January 28, 2026, indicated that the Medication Regimen Review (MRR) or Drug Regimen Review (DRR) is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated. In accordance with state regulations, the consultant pharmacist works with the nursing care center nursing staff to gather pertinent information, and findings are communicated to the director of nursing or designee and the medical director. These findings are documented and filed with other consultant pharmacist recommendations in the resident's chart. Resident-specific MRR recommendations and findings are documented and acted upon by the nursing care center and/or physician. Recommendations should be acted upon within 30 calendar days or per facility specific protocols. For those issues that require physician intervention, the attending physician either accepts and acts upon the report and recommendations or rejects all or some of the report and should document his or her rationale of why the recommendation is rejected in the resident's medical record. Clinical record review for Resident 6 revealed the consultant pharmacist review dated July 17, 2025, resulted in a request to the physician to complete orders for Resident 6's Lexapro (antidepressant) medication to include the drug name and strength, dose, route, frequency, indication/diagnosis, and stop date if appropriate, as the Lexapro medication was missing an indication on the medication administration record (MAR). Review of Resident 6's physician orders revealed that the Lexapro medication was unchanged (did not have an indication for use) from June 26, 2025, until discontinued on December 24, 2025. Resident 6's clinical record did not have evidence that a physician responded to the consultant pharmacist's recommendation appropriately. A Note to Attending Physician/Prescriber dated August 20, 2025, requested that the physician consider treating Resident 6's depression with a single antidepressant (was taking the antidepressants Lexapro, Remeron, and Trazodone) since the use of more than one antidepressant medication has not been demonstrated to be more effective than a single agent and has the potential for increased side effects. The physician did not respond to the recommendation within 30 calendar days as per the facility policy. The physician responded on October 16, 2025, with instructions to discontinue Resident 6's Remeron. Interview with the Director of Nursing on March 27, 2026, at 10:44 AM confirmed that it is the facility's expectation that a physician responds to MRRs within 30 calendar days, however, this did not appear to occur when the physician did not discontinue Resident 6's Remeron for almost two months after the recommendation. A consultant pharmacist progress note dated September 18, 2025, at 3:11 PM indicated that a medication regimen review was performed and referred to a separate report for the comments/recommendations(s) noted. Interview with the Nursing Home Administrator on March 27, 2026, at 8:15 AM indicated that the facility could not provide the separate report referred to by the consultant pharmacist and had no indication that a physician responded to a recommendation in September 2025. A Note to Attending Physician/Prescriber dated January 19, 2026, requested that the physician consider treating Resident 6's depression with a single antidepressant (was taking the antidepressants Lexapro, Zoloft, and Trazodone) since the use of more than one antidepressant medication has not been demonstrated to be more effective than a single agent and has the potential for increased side effects. An undated and unsigned handwritten note of, (name of facility's contracted psychiatric provider) follows psyche meds, was the only response documented on the form. The attending physician did not accept or decline the recommendation. Another Note to Attending Physician/Prescriber dated January 19, 2026, requested that the physician consider a trial dose reduction of Resident 6's antipsychotic medication, Seroquel, since the dose remained at 25 milligrams three times a day since June 2025. An undated and unsigned handwritten note of, (name of facility's contracted psychiatric provider) follows psyche meds, was the only response documented on the form. The attending physician did not accept or decline the recommendation. A consultant pharmacist progress note dated February 16, 2026, at 3:52 PM indicated that a medication regimen review was performed and referred to a separate report for the comments/recommendations(s) noted. Interview with the Nursing Home Administrator on March 27, 2026, at 8:15 AM indicated that the facility could not provide the separate report referred to by the consultant pharmacist and had no indication that a physician responded to a recommendation in February 2026. Clinical record review for Resident 3 revealed consultant pharmacist progress notes dated August 15, 2025, September 18, 2025, September 22, 2025, October 1, 2025, and February 16, 2026, that indicated that a medication regimen review was performed; and referred to a separate report for the comments/recommendations noted. Interview with the Director of Nursing on March 27, 2026, at 9:45 AM indicated that the facility could not provide the separate reports referred to by the consultant pharmacist for Resident 3 and had no indication that a physician responded to the recommendations, from August 2025, September 2025, October 2025, and February 2026. Clinical record review for Resident 12 revealed the consultant pharmacist completed medication regimen reviews for the resident on July 22, 2025, August 19, 2025, September 19, 2025, and February 17, 2026, which noted further comments/recommendations were provided in a separate report. The Nursing Home Administrator indicated in an interview on March 27, 2026, at 8:16 AM that the facility could not provide the separate reports referred to by the consultant pharmacist as noted above for Resident 12, nor indicate what was recommended or if medication changes were made as a result of any recommendations. Clinical record review for Resident 5 revealed consultant pharmacist progress notes dated September 19, 2025, November 18, 2025, January 16, 2026, and February 17, 2026, that indicated that a medication regimen review was performed and referred to a separate report for the comments/recommendations noted. Interview with the Nursing Home Administrator on March 27, 2026, at 11:35 AM indicated that the facility could not provide any of the reports referred to by the consultant pharmacist and had no evidence that a physician responded to the recommendations made for Resident 5. 28 Pa. Code 211.9 (k) Pharmacy services 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to properly secure and store resident medications and treatments on two of three nursing units (Second and Third Floor Nursing Unit; Residents 2, 5, 13 and 73). Findings include: Observation on the third-floor nursing unit on March 24, 2026, at 10:49 AM revealed the E Hall medication cart was unlocked in the hallway, immediately visible when entering the unit from the stairwell. The computer was noted to have resident information visible on the screen for Resident 73, including the resident's birthday, room number, and medication list. In addition, an insulin pen with Resident 73's name was located on top of the cart. Employee 1, licensed practical nurse, returned to the cart at 10:51 AM and indicated he had been called away to assist with another resident. Observation on the third-floor nursing unit on March 25, 2026, at 10:43 AM, revealed the D Hall medication cart was unlocked in the hallway outside Resident 5's room, with the computer unlocked and Resident 5's information visible on the screen, including the resident's birthday, room number, and medication list. Employee 2, licensed practical nurse, returned to the cart at 10:45 AM. The above information regarding the third-floor medication carts was reviewed with the Nursing Home Administrator and the Director of Nursing on March 26, 2026, at 2:45 PM. Observation of Resident's 2 room on March 24, 2026, at 10:17 AM revealed a tube of Voltaren gel (topical pain reliever for arthritic joint pain) in a clear plastic bin beside his bed. Interview with Resident 2 at this time revealed staff are supposed to apply the Voltaren gel to his knees but indicated that staff do not administer. Review of Resident 2's clinical record revealed no physician order for Resident 2's Voltaren gel. The findings were reviewed with the Nursing Home Administrator and Director of Nursing on March 26, 2026, at 2:39 PM. The Director of Nursing stated they removed the Voltaren gel from Resident 2's room. Observation of Resident 13 on March 24, 2026, at 10:38 AM, revealed she was seated on the side of her bed. On Resident 13's overbed table were eight medications spread out, and a medicine cup with one medication in it. Interview with Resident 13 revealed that staff gave her medications, and she indicated that she would take them when she was more awake. Review of Resident 13's clinical record revealed the facility admitted her on January 15, 2019, with diagnosis including paranoid schizophrenia. Further review of Resident 13's clinical record revealed there was no assessment, or physician order indicating Resident 13 was able to self-administer her medications. These findings were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on March 26, 2026, at 2:45 PM. They confirmed the above findings for Resident 13 and indicated that she was never assessed to self-administer her medications. 28 Pa. Code 211.9 (a)(1)(k) Pharmacy services 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on a review of employee personnel and education records and staff interview, it was determined that the facility failed to ensure that each nurse aide received 12 hours of in-service training annually for three of three nurse aides reviewed (Employees 3, 4, and 5).Findings include: Review of Employee 3's (nurse aide) personnel record revealed that the facility hired her on December 10, 2022. Review of training records provided by the facility for Employee 3 dated December 10, 2024, to December 10, 2025, revealed that Employee 3 completed only nine hours and 47 minutes of in-service education. Review of Employee 4's (nurse aide) personnel record revealed that the facility hired her on December 10, 2022. Review of training records provided by the facility for Employee 4 dated December 10, 2024, to December 10, 2025, revealed that Employee 4 completed only seven hours and 37 minutes of in-service education. Review of Employee 5's (nurse aide) personnel record revealed that the facility hired her on July 5, 2023. Review of training records provided by the facility for Employee 5 dated July 5, 2024, to July 5, 2025, revealed that Employee 5 completed only nine hours and 43 minutes of in-service education. Interview with the Director of Nursing and the Nursing Home Administrator on March 27, 2026, at 10:20 AM confirmed the above findings for Employee 3, 4, and 5. 28 Pa. Code 201.19(7) Personnel policies and procedures 28 Pa. Code 201.20(a)(6)(d) Staff development

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure that active physician orders incorporated resident wishes related to end-of-life care for two of three residents reviewed for advanced directives concerns (Residents 79 and 81). Findings include: The facility policy entitled, Health Care Decision Making, last reviewed without changes on [DATE], revealed that it is the right of all residents to participate in their own health care decision-making, including the right to decide whether they wish to request, accept, refuse, or discontinue treatment, and to formulate or not formulate an advance directive. The facility must approach a capable resident who does not have an advance directive upon admission, quarterly, and with a change in condition to discuss whether they wish to consider developing an advance directive. Inquire with the resident's patient representative if the resident is incapacitated. The facility must establish a mechanism for documenting and communicating the resident's choices to the interprofessional team and staff responsible for the resident's care. A POLST (Physician Orders for Life Sustaining Treatment) form is a portable medical order form that records treatment wishes so that emergency personnel know what treatments the resident wants in the event of a medical emergency. Upon admission, determine whether the resident has an advance directive and/or portable medical orders such as POLST. If the resident has a copy with them, make copies, place it in the medical record, and notify the interprofessional team. If the resident has not brought the document to the facility, the facility designee will advise the resident that wishes cannot be honored without a copy in the medical record. Clinical record review for Resident 79 revealed an active physician order dated [DATE], that instructed staff to not provide life-sustaining treatment should Resident 79 have no pulse or stop breathing (DNR, Do Not Resuscitate, do not provide chest compressions or assist with breathing). Resident 79's clinical record did not include evidence that facility staff obtained Resident 79's preference to accept or refuse medical treatment in the event of a medical emergency. Resident 79's medical record contained no POLST form either in her electronic medical record or in a binder maintained at the nurses' station that included all active residents' POLST forms. Interview with Employee 1 (licensed practical nurse) and Employee 2 (licensed practical nurse) on [DATE], at 11:59 AM confirmed that there was no POLST document on the nursing unit, in Resident 79's medical record, or in the POLST binder to confirm Resident 79's DNR wishes. The surveyor reviewed the above concerns regarding Resident 79's active physician orders to not provide life-sustaining treatment without evidence of her participation in the decision during an interview with the Nursing Home Administrator and the Director of Nursing on [DATE], at 2:00 PM. The facility provided a POLST form signed by staff on [DATE], that Resident 79's physician provided a verbal order to implement DNR care decisions in the event Resident 79 did not have a pulse or was not breathing. Interview with the Director of Nursing and the Nursing Home Administrator on [DATE], at 2:00 PM indicated that the POLST form for Resident 79 was in a folder in an office on another floor of the facility and would not be available to staff or emergency personnel. The interview confirmed that the facility had no evidence that the form was completed prior to the surveyor's questioning. Review of Resident 81's advances directives revealed a POLST signed by the resident upon admission to the facility in February 2026, indicated the resident wished to be a DNR. Clinical record review for Resident 81 revealed an active physician's order dated February 27, 2026, that the resident was to be a full code (life sustaining measures including cardiopulmonary resuscitation (CPR - chest compressions and breathing assistance) would be implemented if the individual's heart or breathing stops). During an interview with Resident 81 on [DATE], at 11:01 AM the resident confirmed that if their heart stopped beating, they did not want CPR to be performed and wished to be listed as a DNR. The above findings regarding Resident 81's wishes indicted on the resident's POLST conflicting with the resident's physician ordered code status were reviewed with the Nursing Home Administrator and the Director of Nursing on [DATE], at 2:45 PM. 483.10(c)(6)(8)(g)(12)(i)-(v) Request/Refuse/Discontinue Treatment; Formulate Adv DirPreviously cited deficiency [DATE] 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation and staff and resident interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to maintain a clean and odor free environment on two of three nursing units (First and Second Floor Nursing Units, Residents 13, 31, and 92). Findings include: Observation of Resident 13's room on March 24, 2026, at 10:46 AM revealed Resident 13 was seated on the side of her bed. The bed sheets were visibly soiled with a large yellow and light brown stain. There was a strong urine odor in the room and adjacent hallway. A subsequent observation at 12:24 PM revealed Resident 13's sheets were changed but the urine odor remained. Observation of Resident 13's room on March 25, 2026, at 10:02 AM revealed Resident 13 was seated on the side of her bed. The bed sheets were visibly soiled with a large dark yellow stain. A subsequent observation at 11:41 AM revealed Resident 13 was standing beside her bed, changing her soiled bed sheets. There was a strong urine odor in the room and adjacent hallway. The above concerns for Resident 13 were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on March 25, 2026, at 2:05 PM. An observation of Resident 31's bathroom on March 24, 2026, at 1:30 PM revealed the toilet seat was significantly stained yellow/brown. The white caulking around the base of the toilet was worn and covered in black spots. An observation of Resident 92's room on March 26, 2026, at 11:57 AM revealed the flooring upon entrance to the room was significantly sticky to walk on. The resident's bathroom floor near the entrance to the room was significantly sticky to walk on throughout the bathroom. The bathroom had a strong urine odor with no visible urine in the toilet. A white bracket attaching the toilet seat to the bowl area of the toilet was worn, cracked, and covered in a black/rusty substance. A large area of the flooring behind and to the corner wall of the toilet was discolored/stained yellow. A black buildup was present along the back wall of the bathroom behind the sink and toilet where the cove base meets the flooring. The above findings regarding Resident 31 and 92's room were reviewed with the Nursing Home Administrator and Director of Nursing on March 26, 2026, at 2:30 PM. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3)(e)(1)(2.1) Management 28 Pa. Code 211.12(d)(3) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to implement a comprehensive, person-centered care plan for resisting care one of 23 residents reviewed (Resident 82). Findings include: Clinical record review revealed the facility admitted Resident 82 on May 1, 2025. Nursing documentation dated January 22, 2026, at 3:47 AM revealed there was a strong smell of ammonia emanating from the room, out into the hallway. Resident 82's entire bed was visibly wet from urine. Resident appeared not to have been changed for several hours with saturated brief and bed linens. Licensed practical nurse noted Resident 82's sacrum was red from her incontinence of bowel and bladder. Nursing documentation dated January 23, 2026, at 2:00 AM revealed the nurse was called to assist the nurse aides with care. Resident 82 was observed hitting and threatening staff. The nurse explained to Resident 82 that her bed and brief was soiled, and Resident 82 continued yelling at staff. The licensed practical nurse notified the registered nurse supervisor of Resident 82's refusal of care and combative behavior. Registered nurse also spoke to Resident 82, and she continued to be verbally and physically aggressive and uncooperative with staff, refusing care. Nursing documentation dated January 28, 2026, at 11:02 AM revealed Resident 82 refused care, the licensed practical nurse and registered nurse were made aware. Nursing documentation dated January 30, 2026, at 06:52 AM and 12:06 PM, noted Resident 82 refused all care, stating it was dirty to get washed up. The registered nurse was made aware, and staff were to continue to offer every shift. Nursing documentation dated February 4, 2026, at 7:09 AM revealed Resident 82 refused care, stating it was dirty to get washed up. The registered nurse was made aware and staff will offer again. Nursing documentation dated February 9, 2026, at 2:00 PM, noted Resident 82 refused all care with the nurse present, again stating it is a dirty thing. The registered nurse was made aware, and staff were to continue to offer every shift. Nursing documentation dated March 17, 2026, at 10:31 AM, noted Resident 82 refused all care this morning, again stating it was a dirty thing to get washed up. Documentation revealed this is Resident 82's norm, and staff are continuing to offer and encourage care. Nursing documentation dated March 18, 2026, at 1:33 PM noted Resident 82 refused care, with the nurse present in the room. Documentation revealed staff are to continue to offer care each time they are in the room. Review of Resident 82's care plan on March 24, 2026, revealed no comprehensive, person-centered care plan that addressed Resident 82's refusal of care. The above findings for Resident 82 were reviewed with the Nursing Home Administrator and Director of Nursing on March 25, 2026. The facility added some individualized interventions for Resident 82 on March 25, 2026, after talking with the surveyor. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview it was determined that the facility failed to implement care and services to maintain activities of daily living (ambulation) for one of three residents reviewed for declines in activities of daily living (Resident 6). Findings include: Clinical record review for Resident 6 revealed an active physician order dated March 16, 2025, that instructed that Resident 6 was to transfer with the assistance of one staff, then was to walk with a front-wheeled walker from her room to the E hallway window with chair to follow behind. An annual MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated May 8, 2025, indicated Resident 6 required partial to moderate assistance of staff to walk 10 feet and to transfer to and from a bed to a chair (or wheelchair). A physical therapy Discharge summary dated [DATE], included the instructions for a restorative nursing program (RNP) that included range-of-motion treatment for Resident 6's bilateral lower extremities and the assistance of one staff for transfers with a walker, short distance ambulation, with fww (front wheeled walker), assist 1 doorway to bed (assistance of one staff from the doorway to the bed). Quarterly MDS assessments dated August 8, 2025, November 8, 2025, and February 8, 2026 noted that Resident 6 declined from needing partial to moderate assistance of staff to transfer to and from a bed to a chair to now totally dependent or needing substantial or maximal assistance of staff to transfer to and from a bed to a chair. The assessment also noted that instead of Resident 6 needing partial to moderate assistance of staff to walk at least 10 feet in her room staff now noted that the activity was, not applicable (the activity was not attempted and the resident did not perform this activity prior to the current illness), although staff assessed this activity on the May 2025 MDS assessment as noted above. Interview with the Nursing Home administrator on March 27, 2026, at 9:55 AM indicated that the facility had no documented evidence that staff performed an RNP program for ambulation with Resident 6 (despite the active physician order instructing staff to do so).28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide appropriate care and services for supplemental oxygen use for one of two residents reviewed for oxygen administration concerns (Resident 16).Findings include: Observation of Resident 16 on March 24, 2026, at 2:12 PM revealed him to have supplemental oxygen in use via a room concentrator (machine that draws in room air and condenses the oxygen saturation of the room air to administer supplemental oxygen to a resident at 90 percent or higher through a mask or nasal cannula (NC, flexible tubing with prongs at one end that insert into the nares) set at four liters per minute (4 l/m). Clinical record review for Resident 16 revealed an active physician order dated February 20, 2026, for staff to administer supplemental oxygen as needed (PRN) at two liters per minute (2 l/m) via nasal cannula (NC) when short of breath (SOB) for comfort. Observation of Resident 16 with Employee 1 (licensed practical nurse) on March 27, 2026, at 8:38 AM confirmed that Resident 16 continued to have supplemental oxygen in place via the room concentrator set at 4 l/m. Employee 1 confirmed that active physician orders for Resident 16 instruct staff to use supplemental oxygen PRN at 2 l/m. Review of Resident 16's medical record indicated that the facility failed to develop a care plan that included Resident 16's use of supplemental oxygen. Interview with the Nursing Home Administrator on March 27, 2026, at 8:15 AM reviewed the above concerns related to Resident 16's use of supplemental oxygen in excess of the physician ordered liter flow and the lack of a care plan related to the use of supplemental oxygen. 483.25(i) Respiratory/tracheostomy Care and SuctioningPreviously cited deficiency 5/16/25 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on employee personnel record review and staff interview, it was determined that the facility failed to complete a performance evaluation of each nurse aide at least once every 12 months for one of one nurse aides reviewed (Employee 5).Findings include: Review of Employee 5's (nurse aide) personnel file revealed a hire date of July 5, 2023. There was no evidence the facility completed an annual performance evaluation for Employee 5 at least once every 12 months. Upon request to facility administration the facility could not provide any completed performance evaluations for Employee 5. Interview with the Nursing Home Administrator and Director of Nursing on March 27, 2026, at 11:45 AM confirmed that a performance evaluation was not completed annually for Employee 5. 28 Pa. Code 201.19 (2) Personnel policies and procedures

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide routine dental care for one of three residents reviewed for dental concerns (Resident 13).Findings include: Interview and observation of Resident 13 on March 24, 2026, at 10:53 AM revealed Resident 13 had several broken and missing teeth. Resident 13 could not recall the last time she had seen a dentist. Clinical record review revealed the facility admitted Resident 13 on January 15, 2019, the State Medicaid plan was her primary payer source. Further review of Resident 13's clinical record revealed a dental progress note dated October 2, 2024, indicating Resident 13 was not seen on this date due to refusing dental services. Review of Resident 13 care plan-initiated January 15, 2019, revealed Resident 13 is at risk for dental or oral cavity health problems related to abnormal mouth tissue, natural broken teeth with obvious cavities. An intervention added on this date revealed the facility would refer Resident 13 to a dentist for evaluation or recommendations related to pulling or repairing Resident 13 carious teeth. Review of Resident 13's most recent annual MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated August 8, 2025, noted staff incorrectly assessed Resident 13 as having no obvious or likely cavity or broken natural teeth. Interview with the Nursing Home Administrator on March 27, 2026, at 12:21 PM confirmed these findings for Resident 13 and had no further information to indicate that Resident 13 was offered routine dental services every six months as the State plan allows. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.15. Dental services

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide recommended pneumococcal immunizations for two of five residents reviewed for immunizations (Residents 6 and 9).Findings include: Clinical record review revealed the facility admitted Resident 9 on April 16, 2024. Documentation in Resident 9's clinical record revealed he received two pneumococcal vaccines prior to his admission (PCV13 and Pneumovax Dose 1). Review of Resident 9's clinical record revealed no evidence that the facility obtained a consent from Resident 9 or his responsible party to administer the updated pneumococcal vaccine. According to the CDC guidance entitled Pneumococcal Vaccine Timing for Adults dated October 2024, Resident 9's pneumococcal vaccinations would not be completed until he received a PCV20 or PCV21 at least one year after PCV13. There was no documented evidence to indicate that the facility offered Resident 9 an updated pneumococcal vaccination. Clinical record review revealed the facility admitted Resident 6 on May 15, 2024. Documentation in Resident 6's clinical record revealed she received two pneumococcal vaccines prior to her admission (PCV13 and Pneumovax Dose 1). Review of Resident 6's clinical record revealed no evidence that the facility obtained a consent from Resident 6 or her responsible party to administer the updated pneumococcal vaccine. According to the CDC guidance entitled Pneumococcal Vaccine Timing for Adults dated October 2024, Resident 6's pneumococcal vaccinations would not be completed until she received a PCV20 or PCV21 at least one year after PCV13. There was no documented evidence to indicate that the facility offered Resident 6 an updated pneumococcal vaccination. Interview with the Nursing Home Administrator on March 27, 2026, at 8:30 AM confirmed the above findings for Residents 9 and 6. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on clinical record review and staff interview, it was determined that the facility failed to provide physician ordered treatment for wounds for four of five residents reviewed (Residents CR1, 1, 2, and 4). Findings include: Clinical record review for Resident 1 revealed a physician's order dated July 26, 2025, for the resident to have treatment to a Stage 3 (full thickness skin loss that extends to the fat layer) of the right heel daily cleansing with a normal saline solution (NSS), pat dry, apply skin prep to the wound and leave open to air. There was no evidence this treatment was completed on September 11, and 17, 2025. Closed clinical record review for Resident CR1 revealed a physician's order dated August 25, 2025, for the resident to have a left lateral foot wound cleaned with NSS and have a betadine (antiseptic) soaked cover, pads, and gauze applied and covered with a bandage wrap every three days. The resident also had an order dated August 25, 2025, to receive treatment to venous ulcers (due to poor circulation) on his right foot first toe, left foot third toe, and the left heel to cleanse with NSS, paint with betadine, leave open to air, and to be done daily. Review of Resident CR1's treatment record for August 2025, revealed the resident was not documented as receiving the treatment on August 31, 2025, as ordered/scheduled. Clinical record review for Resident 2 revealed a physician's order dated September 19, 2025, for the resident to have treatment with negative pressure wound therapy (a vacuum to remove fluid and debris from wounds to promote healing) continuously, with a treatment to include the wound cleansed with wound cleanser, gauze placed into the wound, apply skin prep to intact skin around the wound, apply a dressing and secure the vacuum tubing per the manufacturer's guidelines every Monday, Wednesday, and Friday. Review of Resident 2's treatment record for September 2025, revealed the resident was not documented as receiving the treatment as ordered on Friday, September 26, 2025. Clinical record review for Resident 4 revealed a physician's order dated September 10, 2025, for the resident to have treatment completed to a pressure ulcer (wound of the skin due to prolonged pressure to an area) on the resident's coccyx to be cleansed with normal saline and apply calcium alginate (cream used for wound treatment), and cover with foam dressing every day. Review of Resident 4's treatment record for September 2025, revealed no evidence that the resident received the treatment as ordered on September 15, 19, 22, 29, 30, 2025. Further review for Resident 4 revealed a physician's order dated September 8, 2025, for negative pressure wound therapy continuously to the resident's left hip with a treatment to the wound itself including cleansing the wound with cleanser, placing foam into the wound, covering the wound with a dressing, and securing the wound vacuum tube every Monday, Wednesday, and Friday. Review of the resident's treatment record for September 2025, revealed no evidence the treatment was completed as ordered on September 15, 19, 22, or 29, 2025. A nursing note dated September 30, 2025, at 5:17 PM noted the resident's wound vacuum had been alerting full canister from the start of shift and the resident indicated the wound nurse came to his room that morning to change it but didn't have the supplies and was told the wound nurse had to order the supplies. The information regarding no evidence of the above noted treatments was reviewed with the Director of Nursing and Nursing Home Administrator on October 1, 2025, at 3:30 PM. There was no additional information to indicate whether the treatments were completed as ordered or that the resident had refused or was not available for the treatment to be completed. The Director of Nursing indicated Resident 4 utilized a different negative pressure machine for his wound than others in the facility and supply delivery was delayed, which may have impacted Resident 4's treatments. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of select facility policies, clinical record review, and resident and staff interview, it was determined that the facility failed to provide timely medications to one of five residents reviewed (Resident 3) and failed to obtain and provide medications for one of five residents reviewed (Resident CR1). Findings include: Review of the facility's current policy entitled Medication Administration General Guidelines, revealed it is the facility's policy that medications are administered within 60 minutes of scheduled times, except before or after meal orders, which are administered based on mealtimes. In an interview with Resident 3 on October 1, 2025, at 3:14 PM the resident indicated she sometimes needs to tell staff she needs her medications because they are late. Resident 3 stated she used to get her morning medication closer to 8:00 AM but it has been closer to 10:30 AM at times, and that she believes her medication times were going to change because staff were working on two floors. Review of Resident 3's medication administration record for September 2025, revealed the following medications administered outside the 60-minute window of the scheduled administration time. Breo Ellipta Inhalation Aerosol Powder (a maintenance medication to assist with breathing conditions) scheduled for 8:00 AM was administered late between 10:00 and 11:00 AM on September 26, 27, 28, and 29, 2025. Diltiazem HCL Extended Release (used to treat blood pressure) scheduled for 8:00 AM was administered late between 10:00 and 11:00 AM on September 26, 27, 28, and 29, 2025. This medication was also ordered to be held for the resident for a systolic blood pressure (top/upper number, pressure when your heart beats) less that 90, and a heart rate less than 50. There was no evidence that Resident 3's blood pressure or heart rate was checked prior to the administration of this medication on September 27, 28, 29 or 30, 2025. Eliquis (blood thinner) scheduled for administration two times a day at 8:00 AM and 8:00 PM was administered late between 10:00 and 11:00 AM on September 26, 27, 28, and 29, 2025, and too early for the second dose between 5:00 PM and 6:00 PM on the same days the morning dose was administered late on September 26, 27, and 28, 2025. The resident was not documented as being administered, the evening dose on September 29, or the morning or evening dose on September 30, 2025. There was no evidence to indicate the resident refused or was not available for staff to administer the medication. Metoprolol Succinate Extended Release (blood pressure and heart medication) scheduled to be given one time a day at 8:00 AM was administered late between 10:00 and 11:00 AM on September 26, 27, 28, 29, 2025. The medication was also ordered to be held for a systolic blood pressure less than 90 and a heart rate less than 50. There was no evidence that Resident 3's blood pressure or heart rate was checked prior to the administration of this medication on September 27, 28, 29 or 30, 2025. Potassium Chloride Extended Release (mineral supplement to maintain fluid balance and heart and kidney function) scheduled to me administered three times a day at 6:00 AM, 2:00 PM, and 8:00 PM was not documented as administered for the 6:00 AM dose on September 16, and 24, and late between 9:00 AM and 10:00 AM on September 30th, 10:00 and 11:00 AM on September 26, 27, 28, 29, 2025. Resident 3 was then documented as receiving the next dose of the extended-release medication within the scheduled time of 1:00 PM - 3:00 PM (one hour before/after scheduled 2:00 PM) potentially leaving only 4 hours between doses. Tylenol (mild pain reliever) scheduled to be administered two times a day at 8:00 AM and 8:00 PM was administered late between 10:00 and 11:00 AM on September 26, 27, 28, 29, 2025, and the evening dose was documented as being administered early between 5:00 and 6:00 PM on September 26, 27, and 28, 2025, three of the same days the morning dose was administered late. The resident was not documented as being administered, the evening dose on September 29, or the morning or evening dose on September 30, 2025. There was no evidence to indicate the resident refused or was not available for staff to administer the medication. In an interview with the Director of Nursing on October 1, 2025, at 2:30 PM she indicated Resident 3 is permitted to self-administer medications, but the time documented on the Medication Administration Record would be the time staff provided the resident with the medication. Closed clinical record review for Resident CR1 revealed the resident was re-admitted to the facility on [DATE], from the hospital where the resident was being treated for a wound of the left foot and returned to the facility with a PICC line (flexible tube inserted into a vein used for long-term intravenous medication administration). A facility physician history and physical note dated August 22, 2025, at 8:02 PM indicated that Resident CR1 was admitted and treated at the hospital for a left foot abscess, and was discharged from the hospital with Levofloxacin (potent, broad-spectrum antibiotic used to treat bacterial infections), 750 milligrams to be given orally every 48 hours, and Vancomycin (powerful antibiotic used for systemic infections throughout the body), to be given intravenously (IV) every 24 hours until September 27, 2025. The physician's plan indicated to continue the Vancomycin and Levofloxacin as directed. There was no evidence Resident CR1 was ordered Levofloxacin or Vancomycin upon admission to the facility on August 22, 2025. Review of Resident CR1's physician orders revealed Vancomycin as noted above was not ordered and administered until August 25, 2025, three days later, and Levofloxacin was not ordered until August 27, 2025, and administered on August 28, 2025, six days later. A follow up physician's note dated August 27, 2025, at 10:10 PM indicated that staff did not transcribe the Vancomycin order because it was not clearly documented on the hospital discharge instructions from the hospital and noted facility nursing staff contacted the provider on August 22, 2025, indicating the resident had a PICC line and needed IV medication and was advised to talk to the hospital discharging physician about which IV antibiotic, and noted the IV antibiotic was never transcribed and was not given noting the resident missed two doses (August 23, and 24, 2025). The note did not address the Levofloxacin not being ordered or administered. Results of a Vancomycin trough (lab measure obtained to assess the concentration of the antibiotic in the bloodstream to ensure the drug is at a level high enough to be effective and not too high to be toxic) ordered and obtained on August 25, 2025, revealed a level of 9 ug/ml (microgram/milliliter) below the desired minimum level of 10. Review of Resident CR1's hospital discharge instructions revealed one page of the resident's medications and discharge instructions was missing (page 9 of a 23-page document), of which facility staff indicated would have contained the IV medication and the Levofloxacin. It could not be determined if the page was available upon the resident's admission. Resident CR1 did not receive the antibiotics as noted above and noted by the physician on August 22, 2025, upon admission to the facility to continue as part of the resident's plan of care. The above findings regarding Resident 3's timing of medication administration, and Resident CR1's missed doses of antibiotics were reviewed with the Nursing Home Administrator and Director of Nursing on October 1, 2025, at 3:30 PM. 28 Pa. Code 211.9 (a)(1)(d) Pharmacy services 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on a review of select facility policies and procedures, observation, clinical record review, and staff interview, it was determined that the facility failed to implement appropriate enhanced barrier precautions for three of four residents reviewed for infection control concerns (Residents 1, 2, and 3).Findings include: Review of the Center for Medicaid and Medicare Services (CMS) memo entitled, Enhanced Barrier Precautions (EBP, gown and glove use) in Nursing Homes to Prevent the Spread of Multi-drug Resistant Organisms, released by CMS on March 20, 2024, with an implementation date of April 1, 2024, revealed that nursing care facilities are to use EBP for residents with chronic wounds or indwelling medical devices (e.g., indwelling urinary catheters) during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care. Review of the facility's current policy entitled Enhanced Barrier Precautions, last revised December 16, 2024, revealed that EBP is defined as an infection control intervention designed to reduce the transmission of novel or multi-drug-resistant organisms (MDROs, bacteria and other microorganisms that have developed resistance to one or more classes of antimicrobial medications). It employs targeted personal protective equipment (PPE) use during high-contact resident activities. Use EBP for a resident with a wound or indwelling medical device. The policy referred to an Enhanced Barrier Precautions procedure. Review of the facility's, Procedure: Enhanced Barrier Precautions, revealed that the first step is for staff to post the appropriate EBP sign on the resident's room door. For all residents with a chronic wound and/or an indwelling medical device (e.g., urinary catheter) staff are required to use a gown and gloves prior to high-contact care activities which include: dressing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, and device care. Clinical record review for Resident 3 revealed her diagnoses list included: Urinary tract infection (infection of any part of the urinary system such as the urethra, bladder, ureters, or kidneys)Neuromuscular Dysfunction of Bladder (neurogenic bladder, communication between the brain and bladder malfunctions and can cause retention of urine)Bacteremia (presence of bacteria in the blood)Pressure ulcer of the sacrum, Stage IV (wound with full-thickness skin and tissue loss over the area at the base of the spine) Active physician orders for Resident 3 included: Change Indwelling catheter when occluded or leaking as needed (dated August 8, 2025) Indwelling catheter 16FR (diameter size of tubing, size 16 French) with 10 ml (milliliters) balloon to bedside straight drainage for diagnosis of neuromuscular dysfunction of bladder (dated August 8, 2025) Wound: Negative Pressure Wound Therapy (wound vac, gentle suction applied to the wound bed to improve the wound environment and promote healing of complicated wounds) to buttocks. Cleanse with wound cleanser, place gauze/black into wound, apply skin prep (liquid protective skin barrier) to intact skin around the wound, and window tape the peri-wound (area around the wound) with a transparent dressing. Cover with occlusive transparent dressing and secure tubing per manufacturer guide every day shift every three day(s) for sacral wound and as needed for soilage or dislodgement (dated August 8, 2025) If wound vac malfunctions, stop the wound vac, remove the dressing, cleanse the area with wound cleanser, and apply a dry dressing. Notify the provider (dated August 8, 2025) Nursing documentation dated August 12, 2025, at 2:50 PM revealed that staff noted Resident 3 had a urinary catheter intact, and she had a pressure ulcer on her sacrum and coccyx (tailbone, triangular shaped bone at the end of the spine). Observation of Resident 3's room door on August 14, 2025, at 9:45 AM revealed an EBP sign that Bed C (Resident 3's bed assignment in the three-bed room) required EBP. Observation of the room revealed four individuals (three facility staff and one staff from the facility's contracted transport company) transferring Resident 3 from her bed to a wheelchair. None of the four individuals observed were wearing an isolation gown. The contracted transport company staff propelled Resident 3's wheelchair out of the room and the tubing and collection container of an indwelling urinary catheter was observed near Resident 3's lower legs and feet. Observation of Resident 3's room on August 14, 2025, at 2:04 PM revealed Employee 2 (nurse aide) with the facility's contracted transport company staff returned Resident 3 to her room. Employee 2, Employee 3 (nurse aide), and Employee 6 (nurse aide), donned gloves to begin transferring Resident 3 from the wheelchair to her bed. Resident 3's indwelling urinary catheter collection bag and tubing was visible. The staff requested additional assistance from Employee 1 (licensed practical nurse) to complete the transfer. Employee 1 donned gloves. None of the four individuals donned an isolation gown before transferring Resident 3 from her wheelchair to her bed. Employees 3 and 6 changed Resident 3's incontinence brief during the observation without donning an isolation gown. The surveyor reviewed the above concerns regarding EBP for Resident 3 during an interview with the Nursing Home Administrator and the Director of Nursing on August 14, 2025, at 3:30 PM. Clinical record review for Resident 2 revealed active physician orders for staff to complete a treatment to Resident 2's left lower leg daily in the evening and as needed for dislodgement. Observation of Resident 2's room door on August 14, 2025, at 9:51 AM revealed a sign for EBP; however, the sign indicated that only Bed C in the room (the resident closest to the window) required EBP. Resident 2 was assigned the first bed, Bed A, the bed closest to the door. Observation of Resident 2's left lower leg with Employee 1 on August 14, 2025, at 9:54 AM revealed that she had a dressing covering the middle of her left lower leg. Employee 1 confirmed that evening shift staff complete a dressing change to Resident 2's left lower leg daily. Observation of Resident 2 on August 14, 2025, at 1:38 PM revealed that she was yelling, and she wanted to get out of bed. Observation of Employees 1 and 3 on August 14, 2025, at 1:48 PM revealed they donned gloves (but did not don an isolation gown) before changing Resident 2's incontinence brief and transferring Resident 2 from her bed to her wheelchair via a full-body mechanical lift. Once Resident 2 was in her wheelchair, Employee 1 completed a full linen change of her bed. Employee 1 was not wearing an isolation gown. Interview with Employee 1 on August 14, 2025, at 2:19 PM confirmed that the EBP sign on Resident 2's door did not indicate that EBP were necessary for Resident 2 although Resident 2 had a wound that required daily treatment. Employee 1 confirmed that the PPE used for Resident 2's care was limited to glove use, and staff did not utilize an isolation gown for her high-contact care (that included dressing, transferring, changing her incontinence brief, and changing her linens). The surveyor reviewed the above concerns regarding the implementation of EBP for Resident 2 during an interview with the Director of Nursing and the Nursing Home Administrator on August 14, 2025, at 3:30 PM. Clinical record review for Resident 1 revealed active physician orders for staff to provide care to: A right flank and left flank nephrostomy tube (thin, flexible tubing surgically inserted through the side and directly into the kidney for the purpose of draining urine) daily and as neededA left inner thigh wound every shift and as neededA sacral wound every shift and as needed Nursing documentation dated August 13, 2025, at 6:38 PM revealed that staff admitted Resident 1 to the facility, and she had nephrostomy tubes draining urine into bags at her bedside. Observation of Resident 1's room door on August 14, 2025, at 2:32 PM revealed an EBP sign that indicated the residents in the B and D beds required EBP. Resident 1 resided in the C bed (bed closest to the window on the right side of the room). Observation of the second-floor nursing unit on August 14, 2025, at 2:35 PM revealed that Employee 5 (nurse aide) attempted to assist Resident 1 to transfer from her wheelchair to her bed; however, Employee 5 did not don an isolation gown to assist Resident 1 to transfer. Interview with Employee 4 (licensed practical nurse) on August 14, 2025, at 2:39 PM confirmed that the sign on Resident 1's door did not indicate that she required EBP; however, she did due to the presence of nephrostomy tubes. Employee 4 obtained a marker and added, Bed C, to the sign on Resident 1's room door. During continued observation of Resident 1's room on August 14, 2025, at 2:42 PM Employee 5 requested additional assistance from Employee 4 to transfer Resident 1 to her bed. Employee 4 entered the room, did not don an isolation gown, and with the extensive physical assistance of Employees 4 and 5 (neither wearing an isolation gown), Resident 1 transferred from her wheelchair to her bed. Interview with Employee 7 (registered nurse) on August 14, 2025, at 2:42 PM while observing the staff transfer Resident 1, confirmed that the staff did not don an isolation gown to perform the high-contact activity. Employee 7 indicated that she was not familiar with Resident 1 due to her recent admission; however, the facility's infection preventionist would want a resident with indwelling nephrostomy tubes to have EBP in place. The surveyor reviewed the above concerns regarding the implementation of EBP for Resident 1 during an interview with the Nursing Home Administrator and the Director of Nursing on August 14, 2025, at 3:30 PM. 483.80 Infection ControlPreviously cited deficiency 5/16/25 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to ensure that a resident was free from abuse regarding the use of a physical restraint not required to treat a resident's medical symptoms for one of one resident reviewed for restraints resulting in actual harm (Resident 1). Findings include: Review of the policy entitled Abuse Prohibition, last reviewed on September 27, 2024, indicates that the facility prohibits abuse, mistreatment, neglect, misappropriation of resident/patient property, and exploitation for all patients. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptoms. Anyone who witnesses an incident of suspected abuse is to report the incident to his or her supervisor immediately. Review of the policy entitled Use of Restraints, last reviewed on September 27, 2024, indicates the patients have the right to be free from any physician or chemical restraints imposed for purpose of discipline or convenience, and not required to treat the patient's medical symptoms. Convenience is defined as the result of any action that has the effect of altering a patient's behavior such that the patient requires a lesser amount of effort or care and is not in the patient's best interest. A physical restraint is defined as any manual method, physical or mechanical device, equipment or material that is attached or adjacent to the body, cannot be easily removed by the patient, and restricts the patient's freedom of movement or normal access to their body. When the use of a restraint is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. There must be documentation identifying the medical symptom being treated and an order for the use of the specific type of restraint. Consent must be obtained prior to the application of the restraint. Emergency restraint use may be used for as a last resort to protect the safety of the patient and others if the patient's unanticipated violent or aggressive behavior places self or others in imminent danger. The order for the restraint must be obtained from the physician either during the application or immediately after the restraint has been applied. Supporting documentation must reflect what the patient was doing and what happened that presented the imminent danger. Review of a facility submitted information to the Department of Health dated January 11, 2025, indicated that employees used a sheet across Resident 1's chest and tied her to her chair on January 8, 2025, and again on January 11, 2025. Review of the facility's investigation into Resident 1's use of a sheet as a restraint revealed a statement by Employee 1, licensed practical nurse (LPN), that indicated on January 8, 2025, around 5:00 AM, Resident 1 would not stay in her chair. Employee 1 indicated she put a sheet across her chest and tied it around the chair. There was no evidence in Employee 1's statement nor in Resident 1's clinical record to indicate a medical or emergent need to use a restraint. Review of Employee 2's, LPN, statement dated January 11, 2025, indicated that on January 8, 2025, she observed Resident 1 restrained to a reclining chair with a folded sheet across her chest and abdomen area and tied underneath the back of the chair. Interview with Employee 2 on January 21, 2025, at 1:30 PM confirmed this information. Employee 2 also indicated during the interview that she arrived on the unit around 7:00 AM when she observed this and that she did not report the use of the restraint to her supervisor at that time. Resident 1 was in a restraint for almost two hours. Review of a statement from Employee 3, nurse aide, dated January 11, 2025, indicated that on January 11, 2025, at 6:00 AM she observed Employee 4, LPN, holding Resident 1's arms down while Employee 5, nurse aide, placed a sheet across Resident 1's chest and tied it underneath her chair. Review of Employee 4's statement dated January 11, 2025, indicated that Resident 1 was trying to get up on her own and there was no medication ordered for agitation. Employee 4 stated she notified her supervisor and was told someone had to stay with Resident 1, but we all had work to do. Review of Employee 5's, nurse aide, statement dated January 11, 2025, at 1:15 PM indicated that Resident 1 was trying to hop out of her chair. Employee 5 indicated that she stretched a sheet long like a seat belt over Resident 1's hips and tied it behind the back of her chair. Employee 5's statement indicated that Employee 4 held onto her shoulders. Employee 5 indicated in her statement that other staff had been doing it, even last week. There was no evidence in Employee 5's statement nor in Resident 1's clinical record to indicate a medical or emergent need to use a restraint. Review of a statement from Resident 5, undated, indicated that he saw nursing staff restraining Resident 1's arms. Review of a statement from Resident 6, dated January 14, 2025, indicated that she saw nursing staff tie Resident 1 to her chair, and that Resident 1 was kicking and screaming. Resident 6 also indicated in a separate statement that Resident 1 was screaming and crying as staff were applying the sheet. Review of Resident 1's clinical record revealed no documented evidence to indicate that the facility obtained a physician's order for the use of the restraint, obtained consent before using the restraint, or attempted a least restrictive device. There was no documented evidence in Resident 1's clinical record to indicate that there was an identified medical reason for the use of the restraint, or that an emergency use was appropriate or approved, either on January 8, 2025, or January 11, 2025, when the restraint was used. Interview with Employee 6, physical therapist, on January 21, 2025, at 9:45 AM revealed that no one in the therapy department had received updated restraint and/or abuse training after Resident 1's incident on January 8, 2025, and January 11, 2025. Review of a list of therapy employees revealed that there are currently nine employees that work with residents. Interview with the Administrator on January 21, 2025, at 1:45 PM acknowledged the above findings, confirmed that the therapy department did not receive additional training until after the surveyors questioning, and confirmed that Employee 2 did not report inappropriate restraint use on January 8, 2025. The facility failed to ensure that a resident was free from abuse regarding using a sheet as a restraint for non-medical and/or non-emergent reasons. 28. Pa Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.8 (c.1) Use of Restraints 28 Pa. Code 211.12(d)(5) Nursing Services

Based on closed clinical record review and staff interview, it was determined that the facility failed to timely identify and treat a pressure ulcer for one of two residents reviewed, which resulted in actual harm (Residents CR1). Findings include: Closed clinical record review for Resident CR1 revealed the resident was admitted to the facility on [DATE], after a hospital stay with a list of complex medical diagnosis that included a new right leg below knee amputation, and surgery for repair of a left hip fracture. An admission evaluation started September 1, 2023, and completed September 2, 2023, revealed facility staff assessed Resident CR1 as having multiple skin alterations in addition to the left hip and right leg surgical site due to the procedures noted above, including a deep tissue injury to the resident's left heel with a protective boot in place. A skin and wound evaluation dated September 2, 2023, noted the area on Resident CR1's left heel to be a deep tissue injury measuring 2.9 centimeters (cm) in length, by 1.5 cm in width, it was noted a boot was in place and the heel was covered with purple eschar. Resident CR1 was transferred to the hospital three days after admission on September 4, 2023, for medical reasons and returned to the facility on [DATE], at which time another admission/re-admission evaluation was completed on September 7, 2023. The admission/re-admission evaluation dated September 7, 2023, revealed facility staff assessed Resident CR1 as having a skin alteration of the left heel measuring1.5 centimeter red area with a black center (length and width was not provided). There was no other skin/wound evaluation assessment identified upon the residents return to the facility. A physician's order was identified dated September 7, 2023, to apply skin prep to the resident's left heel two times a day. There was no evidence of any further assessments or weekly monitoring to include measurements of the area, decline or improvement of the area, or effectiveness of treatment on Resident CR1's left heel, until a skin/wound evaluation was completed on October 30, 2023, eight weeks later. Review of Resident CR1's skin and wound evaluation dated October 30, 2023, revealed a deep tissue injury to the resident's left heel measuring 2.1 cm by 1.6 cm and although the measurement was noted as smaller than the assessment on September 1, 2023, the evaluation noted the area as deteriorating. There was no change in treatment identified. A physician's order dated November 3, 2023, was identified to schedule an appointment with the resident's podiatrist and request treatment for the left lower extremity. A skin wound evaluation completed on November 4, 2023, for the left heel deep tissue area now assessed the area as measuring 4.5 cm by 1.5 cm but noting the area as stable. A physician's order the same day, November 4, 2023, was identified with a new treatment to the left heel to wash with normal saline, pat dry, paint with betadine, allow to dry, apply a 4x4, then kling wrap to the foot pad area with heel foam then kling wrap to hold it in place daily. A nursing note dated November 8, 2023, at 10:23 PM noted the wound on Resident CR1's left heel appears to be improving with less yellow slough. A skin wound evaluation completed on November 11, 2023, assessed the area as measuring 5.4 cm by 3.1 cm. No changes in treatment were identified. A nursing note dated November 13, 2023, at 5:56 PM noted Resident CR1's left heel was showing little improvement with a black area still on the upper portion of the wound. Resident CR1 did not see his podiatrist until November 14, 2023, and returned with new orders for treatment to the left heel, which started on November 16, 2023, to apply Exufiber (material used for treatment of wounds) to the wound with a change every other day and apply a football dressing consisting of three layers of padding. A skin wound evaluation completed on November 18, 2023, assessed the left heel area as 6.0 cm by 3.8 cm and deteriorating. An electronic medication administration note dated November 19, 2023, at 6:41 PM noted while changing Resident CR1's dressing it was noted there was a lot of yellow and green slough (slough is essentially the by-product of the inflammatory phase of wound healing), and the registered nurse was asked to evaluate it. The note indicated a dressing was changed back to paint the heel with betadine and cover with gauze and cotton wrap as ordered and call the wound care doctor in the morning for further instruction. Review of Resident CR1's closed record did not reveal any evidence the wound care doctor or any doctor was contacted regarding the condition of the resident's heel after the November 19, 2023, note above. Nursing documentation dated November 22, 2023, at 6:47 PM revealed that Resident CR1 was observed to be lethargic and shaking with a temperature of 104 degrees Fahrenheit, after blankets were removed the temperature was retaken at 102.2 degrees Fahrenheit. The family had arrived at the facility and requested the resident be transferred to the hospital at that time. Documentation at 10:44 PM on November 22, 2023, noted the dressing change was completed with a foul odor noted. The resident was transferred to the hospital on November 22, 2023, and did not return to the facility. In an interview with the Nursing Home Administrator on December 4, 2023, at 3:55 PM it was confirmed that Resident CR1 did not receive weekly assessments of the deep tissue injury on the left heel from September 7 to October 30, 2023, see a physician for the resident's left heel wound until November 14, 2023, after being admitted to the facility, or receive follow up after a decline in the heel was noted on November 19, 2023. 483.25(b)(1)(i)(ii) Treatment/svcs to Prevent/heal Pressure Ulcer Previously cited deficiency 5/11/23 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing care services

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to provide a resident with the appropriate supervision to prevent an accident with serious injury for one of 10 residents reviewed who sustained an acute tibial fracture of her left leg (Resident 85). Findings include: Review of Resident 85's clinical record revealed that the facility admitted her on (MONTH) 28, (YEAR). Resident 85's [DIAGNOSES REDACTED]. Review of Resident 85's care plan revealed that she had an activity of daily living (ADL) self-care deficit related to a history of a right humerus fracture (a long bone in the upper arm), weakness, and chronic left rotator cuff (a capsule with tendons that supports the arm at the shoulder joint) damage. Her interventions included to transfer with a stand-up lift with assist of two and a yellow sling. Review of Resident 85's nurse aide care Kardex (a computerized list of the resident's care needs) revealed that she was to transfer with a stand-up lift with a yellow sling and assistance of two. The date of the printed care Kardex was (MONTH) 3, (YEAR). Clinical record review of Resident 85's physical therapy discharge summary dated (MONTH) 4, (YEAR), revealed that Resident 85 had poor ability to stand and they encouraged the use of a stand-up lift with an assist of two. Observation of Resident 85 on (MONTH) 27, (YEAR), at 9:16 AM revealed that she had a cast on her left foot and leg. Review of the facility's investigation into Resident 85's injury dated (MONTH) 3, (YEAR), at 8:30 PM revealed that Employee 3, nurse aide, was transferring Resident 85 into bed and heard a cracking noise when she was sitting the resident down. She stated that Resident 85 complained of pain after the transfer. The investigation into the injury revealed that Employee 3's statement indicated that she did not look at Resident 85's Kardex to see what her transfer status was and that she transferred her by herself with a gait belt. Employee 3 had Resident 85 put her arms around her and then she turned her and sat her on the bed. That is when she heard the noise. Employee 3 then started to take Resident 85's pants off and she yelled so she cut her sock off the left foot and went to get the nurse. The facility investigation revealed a statement from Employee 4, Licensed Practical Nurse, that indicated that she observed Resident 85's left ankle and it was [MEDICAL CONDITION] with no discoloration and there was a 5 centimeter (cm) by 4 cm raised area noted on the left front of her leg that was firm to touch. Employee 4 then notified the RN (Registered Nurse) supervisor and the physician. The physician ordered an x-ray on (MONTH) 3, (YEAR), at 8:39 PM. The x-ray was completed on (MONTH) 3, (YEAR), at 11:45 PM. The results of the x-ray revealed an acute tibial (a bone in the lower leg) fracture. During an interview with the Nursing Home Administrator and the Director of Nursing on (MONTH) 29, (YEAR), at 11:00 AM they acknowledged that Employee 3 did not follow Resident 85's plan of care related to transfer status, resulting in a fracture to Resident 85's left tibia. The facility failed to provide the appropriate supervision to prevent an accident resulting in harm to the Resident 85. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 1/20/17 28 Pa. Code 201.18(e)(1) Management Previously cited 1/20/17 28 Pa. Code 211.10(d) Resident care policies Previously cited 12/8/2017, 1/20/17 28 Pa. Code 211.11(d) Resident care plan Previously cited 1/20/17 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 12/8/17, 1/20/17

Based on facility guidelines, clinical record review, and staff interview, it was determined that the facility failed to provide interventions to prevent an accident for one of 20 sampled residents (Resident 54). Findings include: The facility guideline entitled "Falls Practice Guide" last reviewed on January 4, 2010, revealed that the facility completes a Nursing Admission Evaluation to determine the resident's risk for falls. The guideline defines fall risk factors as a history of falls, depression, visual impairments, unsteady gait, and cognitive impairment. When the facility determines that the resident is a fall risk, based on the assessment, the facility contacts the resident's physician for orders and develops an individualized plan of care to address resident falls. The facility evaluates the resident following a fall. The post-fall evaluation includes an evaluation of the resident's room, a review of the care plan, the resident's response to interventions, and a revision of the care plan to address the resident's current risk factors and needs. Clinical record review for Resident 54 revealed that the facility admitted her on May 6, 2010, with a [DIAGNOSES REDACTED]. The Minimum Data Set assessment (MDS, an assessment tool completed at specific intervals to determine care needs) dated May 13, 2010 revealed a Resident Assessment Protocol (RAP, the evaluation of a triggered area on the MDS assessment) indicating that Resident 54 is at risk for falls. The Nursing Admission Evaluation dated May 6, 2010 revealed that Resident 54 has a history of falls, an unsteady gait, and uses psychotropic medication. A review of Resident 54's plan of care revealed that the facility developed a Fall Risk care plan on May 6, 2010. The care plan indicates that Resident 54 is a fall risk with poor safety awareness. The care plan indicates that the facility determined that Resident 54 required non-skid footwear to prevent falls. The facility did not implement any other safety interventions for Resident 54 to prevent falls. Resident 54's clinical record contained nursing documentation dated July 7, 2010, indicating that Resident 54 fell from her bed and hit her head on the bed side table. The documentation indicates that Resident 54 was not wearing non-skid footwear at the time as she refuses to wear non-skid slippers. The facility investigation into the fall revealed that the facility determined that the necessary intervention to prevent falls for Resident 54 was to contact Resident 54's responsible party (an outside guardian agency) to obtain slippers with non-skid soles. The facility investigation determined that no changes were necessary to Resident 54's plan of care to prevent falls. A review of the social service documentation for Resident 54 revealed an entry dated August 11, 2010, indicating that Resident 54's guardian is to bring in personal items for the resident. Nursing documentation dated August 15, 2010, revealed that nursing staff found Resident 54 on the floor in her bathroom. The facility investigation into the incident revealed that Resident 54 was not wearing non-skid footwear because she refuses to wear it. Resident 54 sustained a fracture to her left hip as a result of the fall. The facility transferred Resident 54 to the hospital for a total hip repair. An interview with the Nursing Home Administrator and the Director of Nursing on November 3, 2010 at 2:30 PM revealed that the facility failed to obtain proper footwear for Resident 54 following her July 7, 2010 fall. The interview confirmed that the facility failed to review the effectiveness of the facility's planned interventions for Resident 54 following the July 7, 2010 fall and determine the need to implement further interventions to prevent Resident 54 from falling. 8 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 211.10 (d) Resident care policies. Previously cited 11/13/2009. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services. Previously cited 11/13/2009.