Every finding on record at Juniper Village at Bucks County Rehab and SKD Care

Based on a review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to accurately assess and monitor weight loss for one of one resident reviewed who experienced significant weight loss. (Resident R1) Findings include:Review of facility policy titled Unintended Weight Loss revealed the purpose of the policy aims to ensure residents maintain a healthy body weight unless prevented by a medical condition. The community monitors weight closely, with a goal of minimizing unintended weight loss (less than 5% across residents). Any resident experiencing weight loss is assessed by an interdisciplinary team, which creates and adjusts care plans to prevent further loss and promote weight gain. The Director of Wellness and Dietary Manager oversee all processes related to identifying, preventing, treating, and tracking weight loss. Data on weight loss is reviewed monthly and used to guide quality improvement efforts. High rates of weight loss signal potential care issues and require corrective action. Residents are weighed regularly (monthly or more often if at risk), and those at higher risk are monitored weekly. When weight loss occurs, staff must assess causes, notify providers and family, involve dietary specialists, and implement interventions. Compliance is met when proper assessment, care planning, intervention, and ongoing evaluation are performed-even if weight loss cannot be prevented (e.g., end-of-life care or unavoidable clinical conditions). The facility must document and continuously improve its processes to maintain residents' nutritional health.Review of Resident R1's admission Minimum Data Set (MDS- assessment a resident's care needs) revealed that the resident was admitted to the facility on [DATE], with diagnoses of Gastroesophageal Reflux Disease (a digestive disorder in which stomach acid frequently flows back into the esophagus; arthritis (characterized by inflammation of the joints leading to pain, stiffness, and decreased mobility); dementia (a decline in cognitive function affecting memory, thinking, and daily functioning) traumatic brain injury (brain dysfunction caused by an external force and may result in cognitive, physical, or emotional impairments) and anxiety (a mental health condition marked by excessive worry, nervousness, or fear). Under the eating assessment, the resident was able to use suitable utensils, bring food and liquids to (her/his) mouth, and swallow safely. Resident R1 required supervision during this task. The resident had a Brief Interview for Mental Status (BIMS) score of 4, which indicated severely impaired cognition. Review of Resident R1's Mini nutrition notes dated February 21, 2026, revealed that the resident weighed 94 pounds, during the last three months the resident had no decrease in food intake and no weight. Resident R1 has scored nine on the nutrition score indicating at risk of malnutrition.Review of Resident R1's care plan revealed interventions initiated in February 2026 related to gastrointestinal alteration (diverticulitis- inflammation of abnormal pouches in the large intestine), nutritional risk factors, and significant weight loss. The care plan included recommendations for small frequent meals, monitoring intake, providing and serving nutritional supplements, documenting intake each meal, and reporting signs and symptoms of malnutrition and weight loss to the physician as needed.Review of Resident R1's clinical record revealed that the resident experienced a 7.4 % weight loss between February 6, 2026, and March 3, 2026, as follows:2/6/26- 97 (pounds) lbs.2/19/26- 94.0 lbs.2/27-93.5 lbs.3/1-86 lbs.3/3-87 lbs.Review of nursing notes dated 2/12/2026 revealed that Resident R1 needed encouragement to eat. Continued review of nursing notes revealed that on February 21-22, 2026, resident had poor appetite. On February 25, 2026, a Dietitian consult was ordered. Review of Resident R1's March 2026 physician orders revealed orders were obtained on March 4, 2026, for a nutritional supplement and March 9, 2026, for weekly weights. Review of nutritional progress notes revealed that there was not documented evidence that Registered Dietician, Employee E2 evaluated Resident R1's nutritional status and significant weight loss. Phone Interview with Registered Dietitian (RD), Employee E2 on April 22, 2026 at approximately 1:00 p.m. who is present in the facility approximately 10 hours per week, stated she was unable to recall specific details regarding this resident was unable to provide specific details regarding the resident due to lack of access to the clinical record at the time of the interview. While the resident's name was familiar, the RD could not recall when she was first notified of the resident's poor appetite or weight loss. RD, Employee E2 reported she is responsible for completing nutritional assessments and typically initiates interventions when a resident is identified as at risk for malnutrition. Interventions may include recommending nutritional supplements, monitoring weights, and collaborating with the interdisciplinary team. The RD, Employee E2 indicated that nursing staff are expected to notify her when a resident has poor intake or is not eating, and she relies on this communication to address concerns. She also stated that she communicates primarily with nursing staff regarding weight loss concerns and may recommend referrals, such as speech therapy, if swallowing issues are suspected. Additionally, RD, Employee E2 reported that typical protocol includes monitoring weights, encouraging supplements, considering diet liberalization to improve intake, and suggesting family involvement in providing preferred supplements if needed. The RD was unable to confirm whether timely interventions were implemented for this resident. 28 Pa. Code 201.18 (1) Management 28 Pa. Code 201.20 (a)(6) Staff Development 28 Pa. Code (d)(3)(d) Medical Director 28 Pa. Code 211.12 (d)(1)(5) Nursing Services

Based on observation and staff interview, the facility failed to ensure that food storage areas and kitchen environment were maintained in a clean and sanitary manner. Findings include:Observation conducted during a tour of the kitchen conducted on April 8, 2026, at 12:10 p.m., in the presence of the Director of Dietary Services, Employee E8, and the Director of Nursing, Employee E2. revealed white powder noted on the floor of the dry storage area. When asked, Employee E8 stated that an employee had spilled a tub of instant oatmeal yesterday, that's why there's oats everywhere. Observation of the walk-in freezer revealed dirt and debris under the shelving and over the open floor. Observation of the main kitchen area revealed dirt and debris over the entire floor, with a dry, dark brown, textured substance on the floor near the trash can. Employees E2 and E8 confirmed these observations, and that floor cleanliness had not been properly maintained. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.6(f) Dietary Services

Based on review clinical records, facility investigation, witness statements and interviewed with staff and review of facility policy, it was determined that the facility failed to ensure that one of eight residents was free of abuse. (Resident R26). Findings include: Review of facility policy on Abuse and Neglect revealed that under section Purpose: To provide the appropriate state licensing agent both verbal and written notification of reportable occurrences. Under section Procedure: #1. This policy will be accomplished through the following: e. Investigation of all incidents and allegations by qualified and trained individuals. g. Reporting of abuse as required by law regulation. Review of the definition of abuse revealed that: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It includes verbal abuse. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. Review of documentation reported by the facility to the Pennsylvania Department of Health revealed that on September 5, 2025, Resident R26 rang her call light and the LPN (Licensed Practical Nurse) Employee E5 answered the call bell. (Resident 26) stated her tv remote was not working. Nurse's Aide Employee E4 was walking by and Employee E5 asked Employee E4 if she could help her with her remote because she was giving out medications. Employee E4 came in and stated the remote was not working and said to Resident R26 that she is a CNA (certified nurse's aide) not a TV specialist and the resident stated Employee E4 threw the remote on the overhead bed table and walked out of the room. A couple of minutes later Employee E4 walked with Resident R26 with her walker to the bathroom and (Employee E4) left the room. (Resident R26) stated she was in there for a while and no one came back. (Resident R26) did state that she did not use the bathroom call bell and stood up and was at the sink washing her hands. At this point Employee E4 returned and started yelling at Resident R26 for getting up herself and not using the call bell. Resident R26's grandson was now present in the room and heard Employee E4 yelling at Resident R26. Resident R26 stated Employee E4 threw the remote at the (overhead) table and Employee E4 was yelling at her, and that Employee E4 she was just mean. Review the investigation report submitted to the Department of Health of alleged abuse/neglect revealed that an alleged perpetrator was identified as the Nurse's Aide Employee E4. Further, the finding of facility investigation was unsubstantiated for abuse but employee was terminated from employment for gross misconduct and not following standards of behavior. Review of Social Worker Employee E6 statement dated September 5, 2025, revealed that Employee E7 informed her that Resident R26 complained that a staff member threw a remote at her and yelled at her. Both Employee E6 and Employee E7 went to Resident R26's room to talk to Resident R26. Resident R26 was crying and the grandson and the husband were sitting in the room. Employee E6 tried to investigate the incident but as soon as Employee 7 asked the question Resident R 26 started to cry again further employee six statement revealed that the grandson said that he was present during the incident and provided a statement. Review of Director of Nursing Employee E2's transcript of her interview with Resident R26 dated September 5, 2025, revealed that Resident R26 stated that she needed help with her TV remote because it was not working, and told Licensed nurse Employee E5. Employee E5 saw Nurse's aide Employee E4 walking by and ask Employee E4 to help. Further, Resident R26 stated that Employee E4 walked in and looked at the remote control and said abruptly I am a CNA (certified nurse's aide) not a TV person. Employee E4 then threw the remote at her. Resident R26 denied that the remote hit her. When employee E2 asked Resident R26 where Employee E4 threw the remote, Resident R26 said on my bed. Further, Resident R26 stated that Employee E 4 was loud, rude and was obviously annoyed to be in there (Resident R26's room). Further Resident R26 stated that she had to use the bathroom and Resident R26 called with a call bell. Employee E4 came in and Resident R26 walked with her walker to the bathroom and Employee E4 left. Further Resident R26 stated she waited there (the bathroom) for a while and Employee E4 did not come back. Further, Resident R26 revealed that it seems that she waited for over 20 minutes. Further, Resident R26 revealed that she did not ring the bell but she could not sit there any longer and got up to wash her hands and then Employee E4 came in abruptly and started yelling at her for getting up without ringing the bell. Further Resident R26 stated she felt like a child being scolded and was embarrassed. Further Resident R26 revealed that when she got back into bed, her grandson and husband were in her room and heard the whole bathroom conversation. Interview with DON Director of Nursing Employee 2 conducted on April 7, 2026, at 2:14 PM revealed that Employee E4 was terminated for gross misconduct and not for abuse. Further, Employee E2 revealed that she now agreed that what Nurse aide, Employee E4 did to Resident R26 was abuse. 28 Pa. Code 201.18(e)(1) Management28 Pa. Code 201.29(a) Resident rights

Based on observation review of facility records, review facility policy and interview with staff, it was determined that the facility failed to ensure the proper accountability of narcotics were in place in order to identify narcotic diversion in a timely manner for one of one medication carts reviewed. (Medication cart 1) Findings include:Review facility undated policy on Controlled Substance es revealed that under section Policy juniper communities have a policy regarding the handling of controlled substances in all states at all levels of care. under section Procedure: Accountability #5. An inventory count of all control substances will be performed at each change of shift then coming and outgoing nurse medication assistant on each unit responsible for handling-controlled substances will sign the inventory count this will also include a count of the number of controlled substance blister packs. Observation conducted on April 6, 2026, at 11:20AM on medication cart one revealed that there was no system in place to account for the individual narcotic sheet and there was no system in place to identify narcotic diversion in a timely manner. Further, the narcotic sheets were loose with no corresponding index inside a binder. Further, there was no accounting for individual narcotic sheet and with the narcotic blister pack. If a corresponding narcotic accountability sheet was removed from the binder, with a narcotic the incoming shift would not be able to identify the diversion. Interview with Licensed nurse Employee E5 confirmed that if an outgoing nurse takes the blister pack and the narcotic sheets, the incoming nurse will not know during narcotic count that the narcotic was missing. Interview with the Director of Nursing, Employee E2 conducted on April 7, 2026, at 11:26 AM confirmed that if an outgoing nurse takes the blister pack and the narcotic sheets, the incoming nurse will not know during narcotic count that the narcotic was missing. 28 Pa. Code 211.9(j)(3) Pharmacy services 28 Pa. Code 201.18(e)(1) Management

Based on clinical record review and interview with staff, it was determined that the facility did not ensure that a pharmacy recommendation was followed up on in a timely manner related to diagnosis for a medication for one of 13 residents reviewed (Resident R11).Findings include:Review of Resident R11, clinical record revealed the resident was admitted to the facility on [DATE], with the diagnoses of acute respiratory failure, and chronic obstructive pulmonary disease (COPD- disease process that causes decreased ability of the lungs to perform).Review of physician orders for Resident R11 revealed an order for Budesonide Inhalation Suspension 0.25 MG (milligrams)/ML (milliliters) . 4 ml inhale orally two times a day for Essential (primary) hypertension, obtain on March 6, 2026. Budesonide inhalation is indicated for use in chronic lung conditions such as COPD and asthma, as it is used to dilate the airway and allow easier breathing. Review of facility documents revealed a recommendation from the consulting pharmacist, Employee E9, which stated that the diagnosis listed for Resident R11's Budesonide order was inappropriate. This recommendation was issued on March 9, 2026, and signed by the Director of Nursing, Employee E2, on the same day. Interview with Employee E2 on April 7, 2026, confirmed that it was the expectation of the facility that such changes should be made in a timely manner, and as at the time of the interview the recommended change had not yet been made, and that this did not meet expectations. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f) Medical records

Based on a review of facility documents and resident clinical records and interviews with staff and resident and family member, it was determined that the facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement for one of one resident reviewed (Resident R69). Findings include: Review of admission record indicated Resident R69 was admitted to the facility on [DATE]. Review of Resident R69's admission Minimum Data Set (MDS - a periodic assessment of care needs) dated June 12, 2025, a BIMS score of 15, which indicated that the resident was cognitively intact. Review of Resident R69's Binding Arbitration Agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) indicated that she signed the document on admission on [DATE]. The agreement was missing a name and signature who reviewed the agreement with Resident R69. An interview was conducted with the Social Worker, Employee E5, on June 17, 2025, at 10:03 a.m. Employee E5 reported that they reviewed the arbitration agreement with Resident R69 on June 9, 2025. However, it was further revealed that Employee E5 did not inform Resident R69 of their right to rescind the agreement within 30 days of signing, nor did they explain that the binding arbitration agreement does not prevent the resident from communicating with federal, state, or local officials, including federal and state surveyors, other health department employees, or representatives of the Office of the State Long-Term Care Ombudsman. Employee E5 revealed that when she reviews the biding arbitration agreement she only discusses that dispute shall be kept confidential and you can't discuss with anyone. An interview was conducted with the Nursing Home Administrator, Employee E1, on June 17, 2025, at 10:25 a.m. Employee E1 reported that when Employee E5 is on leave, she sometimes steps in to review the arbitration agreement with residents. It was further revealed that Employee E1 does not inform residents of their right to rescind the agreement within 30 days of signing, nor does she explain that the binding arbitration agreement does not prevent residents from communicating with federal, state, or local officials, including federal and state surveyors, other health department employees, or representatives of the Office of the State Long-Term Care Ombudsman. An interview was conducted with the Resident R69 and spouse, on June 17, 2025, at 12:43 p.m. which revealed that Resident R69 was not aware of that she/he able to rescind the agreement within 30 days of signing, nor that the binding arbitration agreement does not prevent residents from communicating with federal, state, or local officials, including federal and state surveyors, other health department employees, or representatives of the Office of the State Long-Term Care Ombudsman. An interview with the Administrator on June 17, 2025, at 2:45 p.m. confirmed that the facility failed to inform Resident R69-and other residents-when explaining the arbitration agreement in a language they could understand, that they have the right to rescind the agreement within 30 days of signing. Additionally, the facility did not clarify that the binding arbitration agreement does not prevent residents from communicating with federal, state, or local officials, including federal and state surveyors, other health department employees, or representatives of the Office of the State Long-Term Care Ombudsman. 28 Pa. Code: 201.14(a)(c)(d)(e) Responsibility of licensee.

Based on observation, policy review, and staff interviews, it was determined the facility failed to develop and implement water management program for the prevention, detection, and control of water borne contaminants, such as Legionella (a bacteria that may cause lesionnaires disease, a serious type of pneumonia). Findings inlcude: Review of Centers for Disease Control and Prevention CDC guideline for Water Management in Healthcare Facilities revealed Legionella water management programs identify hazardous conditions and include taking steps to minimize the growth and spread of Legionella in the building water system. Having a water management program is now an industry standard for large buildings in the United States. Review of Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) memo Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires Disease dated July 6th, 2018, revealed Facilities must develop and adhere to policies and procedures that inhibit microbial microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water. This policy memorandum applies to Hospitals, Critical Access Hospitals (CAHs) and Long-Term Care (LTC). However, this policy memorandum is also intended to provide general awareness for all health care organizations Facilities must have water management plans and documentation that, at minimum, ensure each facility: -Conducts a facility risk assessment conducts a facility risk assessment to identify we are Legionella and other opportunistic waterborne pathogens (e.g.: Pneumonias, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi could grow and spread in the facility water system -Develops and implements a water management program that considers the ASHRAE industry standards and the CDC toolkit - specifies testing protocols and acceptable ranges for control measures, and documents the results of testing and corrective action taken when control limits are not maintained -Maintains compliance with other acceptable Federal, State and local requirements. -Conducts a facility risk assessment conducts a facility risk assessment to identify we are Legionella and other opportunistic waterborne pathogens (e.g.: Pneumonias, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi could grow and spread in the facility water system -Develops and implements a water management program that considers the ASHRAE industry standards and the CDC toolkit - specifies testing protocols and acceptable ranges for control measures, and documents the results of testing and corrective action taken when control limits are not maintained -Maintains compliance with other acceptable Federal, State and local requirements. Review of facilities water management plan which is contracted to outside company revealed the purpose of this water management plan is to establish the minimum legionella's risk management requires by illustrating the procedures for minimalizing the risk of Legionnaires disease within the building water system of this facility and practicing routine control measures Including, facility plumbing, hot water expansion tank inspection, aerator should be replaced or dismantled and cleaned on all units to be done quarterly control water systems plumed units which are to be activated weekly to flush the line and verify operation, the Expansion tank for the hot water system should be done annually check for leaks calcifications corrosions around the attachment findings stagnation is the danger and non-flow through tanks hot water heater is to be checked monthly. The aerator should be replaced or dismantled disinfected cleaned quarterly, temperature monitors and testing for legionella at least quarterly in cooling, towers, spa pools, and any fountains is recommended to demonstrate. Continued review of this water management plan revealed that the last water teste was completed February 18, 2023 Interview with Environmental Director, Employee E 4 and Nursing Home Administrator, Employee E1 on June 18, 2025, at 10:00 a.m. confirmed that the facility failed to ensure water testing and compliance of water management plan. The last testing was completed on February 18, 2023. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policy, review of clinical records, interview with staff, it was determined that the facility failed to ensure comprehensive care plans were developed to address resident care needs related to a significant weight loss for one of three residents reviewed. (Resident R169) Findings include: Review of facility policy titled Unintended Weight Loss ensures residents will maintain acceptable body weight unless a clinical condition demonstrates that this is not possible residents with unintended weight loss will be assessed by the interdisciplinary team and interventions will be implemented to prevent further weight loss and promote weight gain. The director of wellness and director dietary manager are responsible for managing the processes for prediction or prevention, treatment, monitoring and calculation of unintended weight loss. Compliance includes developing a care plan that includes measurable objectives and time frames to meet the residents needs as identified in the residence assessment, the disciplinary team assesses residents with identified weight loss, develops care plan, implements, evaluates and reevaluates to treat and prevent weight loss and maintain adequate nutritional status of the resident, and communicate of weight changes to attending provider and residents' family. The licensed nurse documents the note of vacations in the medical record. Review of facility document titled Care Plan revealed the purpose of care plan is to write activity goals and approaches for each resident based on MDS (minimum data set , a federal mandated assessment tool), triggers and current needs of the resident. The process of care planning involves identifying the problem common need and strength of each resident then determine goals that are measurable specific and have a target date lastly determine approaches or interventions which are specifically what will be done to assist the resident in meeting the goal considering physical cognitive emotional abilities monitoring approaches will be numbered and will be recorded in care plan progress notes. Review of Resident R169's clinical record revealed that this resident entered the facility on May 29, 2025, after hospital discharge. Resident R169 was discharged back to the hospital for gastrointestinal bleeding, on June 3, 2025. There resident remained NPO (no food). Resident was received back at the facility June 10, 2025. Further review of resident R169's clinical record revealed a significant weight loss of 18.8 pounds in a period of eleven days. Review of Resident R169's clinical record weight history revealed that Resident R169 was documented as being weighed June 1, 2025, at 143.8 pounds, June 10, recorded weight was 144.0 pounds upon returned to the facility, June 11, 2025, recorded weight was 125.0 pounds. Interview with dietician employee E3 on June 16, 2025, revealed that she was made aware of the weight loss on this day, she offered the resident supplemental shakes, but resident refused. Registered Dietician, Employee E3 confirmed not updating the resident's care plan to address most recent weight loss. Employee E3 stated the protocol would be conversation with nursing staff which then would be relayed to physician, then the care plan would be updated. 28 Pa. Code 211.12 (d)(3) Nursing services 28 Pa Code 211.10(b) Resident Care Plan

Based on review of clinical records, staff interview, and pharmacy review recommendations, it was determined that the facility failed to act on the pharmacy recommendations in a timely way for three of four residents reviewed (Resident R10, R14 and R70). Findings include: Clinical record review revealed Resident R10 was admitted to the facility on [DATE], with a diagnosis that included but not limited to Major Depressive Disorder. The physician ordered Mirtazapine (used to treat to depression) and Citalopram (used to treat depression). Further review of Resident R10's clinical record revealed the physician ordered Mirtazapine and Citalopram on February 2024. During a drug regiment review on August 15, 2024, the pharmacist recommended that Mirtazapine and Citalopram be considered for a gradual dose reduction. The pharmacy recommendation was not addressed by the attending physician until September 17, 2024, a delay of 33 days. During an interview on September 18, 2024 at 12:00 p.m. Director of Nursing E2 confirmed that the facility failed to implement the pharmacy recommendations for Resident R10 in a timely manner. Review of pharmacy consultation report for Resident R14 for August 1 to 31, 2024, revealed a pharmacy recommendation to: evaluate if atorvastatin 40 MG is indicated at this time, monitor symptoms, follow-up serum CK concentration in 14 days and to evaluate Eliquis dose for a dose increase twice a day. Further review revealed that that DON, Employee E2, signed off on the pharmacy review. Interview with the DON, Employee E2, conducted on September 19, 2023, at 1:20pm confirmed that the physician reviewed the pharmacy recommendation late. Further Employee E 2 revealed that the facility will improve their process so that the pharmacy reviews will be reviewed by the physician in a timely manner. Review of Resident R70's pharmacy consultation report for August 1 to 31, 2024 revealed a comment from the pharmacist as follow: During the review of Resident R14's medical record, the following irregularities were noted on the Electronic Medication Administration record. Directions for use was incomplete. Ascorbic acid order is missing strength. Further, the pharmacy consultation report revealed a recommendation to Please clarify or correct these items. Further review of the pharmacy consultation report revealed that the form did not have the signature of the physician attesting that physician has reviewed the pharmacy report, comments and recommendations. Interview with the DON Employee E2 conducted on September 19, 2024, at 1:20 pm confirmed that the form did not have a physician's signature on it attesting that the physician has reviewed the pharmacy recommendations Further Employee E2 revealed that the facility will improve their process so that the pharmacy reviews will be reviewed by the physician in a timely manner. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that advanced directives were accurately reflected in residence records for one of 8 residents reviewed (Resident R70). Findings: Review of facility undated policy on Advance directives, revealed that under section Policy: Residents are afforded the opportunity to create advanced directives for their medical care should they be unable to communicate them for themselves at the time needed. Under section Purpose To provide instruction and offering residents the opportunity to create advanced directives. Under section Procedure: #1 If the resident already has an advanced directive, such directive is copied. If the resident has a MDPOA or other legal responsible party, a copy of this paperwork is put in the Advanced Directives Legal section of the chart. They should also be scanned to the Miscellaneous tab of the residence chart in Point Click Care. #2. The DNR(do not resuscitate) form and other advanced directive information is filed in Advanced Directive section of the chart. They should also be scanned to the Miscellaneous tab of the residence chart in Point Click Care. #4. The associate completing the admission process or the social service representative assisting the resident, and/or responsible party in creating advance directives alert the admitting nurse to the advanced directive such that the appropriate physician order is obtained. Review of Resident R70's clinical record revealed that Resident R 70 was admitted to the facility on [DATE], with diagnosis of but not limited to Chronic Respiratory Failure, Sepsis due to Streptococcus Infection, Cognitive Communication Deficit. Review Further review of resident R70 clinical record revealed that Residence DNR status and advanced directives was not reflected on Resident R 70s electronic medical record. Further, Resident R70s there was no physician's order for advanced directives and there was no care plan for Resident R70's advance directives. Review of resident R 70s. Pennsylvania orders for life sustaining treatment. (POLST) Section A. Cardiopulmonary Resuscitation (CPR): DNR Do not attempt resuscitation (allow natural death) was checked. Section B. Medical Interventions: Person has paused and or breathing. Limited Additional Interventions was checked. Section C. Antibiotics: Determine use or limitation of antibiotics when infection occurs with comfort as goal was checked. Section D. Artificially Administered Hydration/Nutrition. No hydration and artificial nutrition by tube was checked. Section E. Discuss with patient. Was checked. Further review of Resident R70's POLST form revealed that the form was signed by the physician and signed by Resident R70. Further the form was dated [DATE]. Interview with Employee E4 conducted on [DATE], at 10: 36 am confirmed that Resident R70 signed a POLST Form and that resident R70 wanted to be on DNR, use medical treatment, IV fluids and cardiac monitor as indicated, no hydration/ no artificial nutrition by tube. Further Employee E4 confirmed that Resident R70's advance directives were not reflected on Resident R70's electronic medical record. Interview with Facility Administrator Employee E1, on [DATE], at 10:40 AM confirmed that there was no advance directive for Resident R70 in his electronic medical record. 28 Pa Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of facility policies, clinical record reviews, and interviews with staff, it was determined that the facility failed to develop a baseline care plan within 48 hours of residence admission that includes the minimum healthcare information necessary to properly care for a resident for four of 16 residents reviewed (Resident R14, Resident R70, Resident R9, and Resident R120). Findings include: Review of facility policy on care planning provided by Employee E2 Revealed that the policy did not address baseline care plan. Review of Resident R14's clinical record revealed that resident R14 was admitted to the facility on [DATE], with diagnoses of but not limited to reduced mobility, Muscle weakness, Cognitive communication deficit, Altered mental status, Dysarthria, and Anarthria. Review resident R14's Admission MDS (minimum data set- a federally required resident assessment to be completed at a specific interval) dated August 5, 2024, revealed that under section L0200. Oral dental status B. (No natural teeth or tooth fragments. Edentulous) was coded No Interview with facility Regional MDS coordinator, revealed that the admission MDS dated August.5, 2024, Section L, B was coded in error, and that Section L 0200 B should have been quoted as. Yes. (No natural teeth) Observation of resident R14 conducted on September 16, 2024, at 09:21 AM reveal that Resident R14 was in his room, with breakfast tray- breakfast was approximately 90% consumed- further observation revealed that resident was edentulous. Further observation revealed that resident R14 was not wearing dentures. Interview with Resident R14 at the time of the observation revealed that he has dentures but did not like wearing them. Further review of Resident R14's clinical record revealed that there was no baseline care plan in place within 48 hours of Resident R14's admission to the facility. Review of Resident R70's clinical record revealed that Resident R 70 was admitted to the facility on [DATE], with diagnosis of but not limited to chronic venous hypertension with ulcer on right lower extremity, Non pressure chronic ulcer of other part of left lower leg with fat layer exposed, Non pressure chronic ulcer of buttocks with unspecified severity, Non pressure chronic ulcer of right calf with necrosis of muscles, Chronic venous hypertension with ulcers of left lower extremity, Muscle weakness, Morbid obesity. Observation conducted during tour of facility on September 16, 2024, at 11:52 AM revealed that Resident R17 had bilateral lower extremity dressing. Further observation revealed that Resident R70s lower extremities were dark in color. Further review of Resident R70's clinical record reveal that there was no baseline care plan for alteration in skin integrity or wound care in place within 48 hours of Resident R70's admission to the facility. Review of Resident 9's clinical record revealed Resident R9 was admitted to the facility on [DATE] with a diagnosis that included but not limited to Sepsis (serious condition in which the body responds improperly to an infection), abnormalities of gait and mobility, and absolute glaucoma (eye that has lost all vision and has uncontrolled pressure). Review of Resident R9's clinical record revealed Resident R9 had a care plan dated August 15, 2024 for impaired vision, potential for pressure ulcer development, and risk for infection. Further review of Resident R9's care plan revealed no interventions in place to provide the necessary care to properly care for Resident R9. Review of Resident 120's clinical records revealed Resident 120 was admitted to the facility on [DATE] with a diagnosis that included but not limited to Thoracic Spine fracture (occurs when a bone in the middle section of the spine collapses), Bipolar Disorder (episodes of mood swing ranging from depressive lows to manic highs), and muscle weakness. Review of Resident R120's clinical record revealed Resident 120 had a care plan dated September 13, 2024 for high risk of falls, impaired cognitive function, behavior problem, limited physical mobility, activies of daily living self-care deficit. Further review of Resident 120's care plan revealed no interventions in place to provide the necessary care to properly care for Resident 120. Interview on September 18, 2024 at 11:40 a.m with Employee E2, Director of Nursing, confirmed Resident R9 and Resident R120 did not have a completed baseline care plan completed within 48 hours of admission. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c)Resident care policies 28 Pa. Code 211.12(d)(2) Nursing services

Based on review of facility policy. Review of clinical records and staff interviews, it was determined that the facility failed to develop and implement an individualized comprehensive care plan for two of eight residents observed (Resident 14 and Resident R70) Findings include: Review of facility's Care Planning Assessment Policy revealed that under section Policy, residents will receive initial, quarterly, annual and significant change assessments according to the federal and state regulations. In addition, the residents will have a care plan created that addresses the individualized needs the residents present. This process will be accomplished through observation, assessment, interviews which cover all three shifts and obtain the necessary information from all appropriate disciplines, the resident, and any other responsible party necessary. Under section Procedure 1. Utilizing information from the Wellness, Activity, Dietary and Psychosocial Assessments, the MDS is coded per the MDS 3.0 manual, 2. When a comprehensive MDS assessment is done, the RAPS CAA's will be completed for each triggered area. From the CAA, it is determined which areas need to be care planned to provide the necessary care for the resident, 3. The Care Plan Team creates these long-term care plans. Areas outside of the triggered items can also be care planned to provide guidance to staff for care of the resident. (i.e. pain management or discharge planning), 4. Acute care plans are created by staff for injuries, illnesses, or changes in condition that may only last 30 days. Once 30 days is over, if the problem remains, a long-term care plan is created. The Acute Care Plans are kept in the wellness notes section of the chart, 10. In addition, quarterly reviews and updates are completed by the Care Plan Team to clarify problems, goals and evaluate effectiveness of the interventions, 13. The MDS Coordinator monitors compliance with assessment, care planning and filing of assessments and care plans in the appropriate areas. Review of Resident R14's clinical record revealed that resident R14 was admitted to the facility on [DATE], with diagnoses of but not limited to reduced mobility, Muscle weakness, Cognitive communication deficit, Altered mental status, Dysarthria and Anarthria. Review resident R14's Admission MDS (minimum data set- a federally required resident assessment to be completed at a specific interval) dated August 5, 2024, revealed that under section L0200. Oral dental status B. (No natural teeth or tooth fragments. Edentulous) was coded No Interview with facility Regional MDS coordinator, revealed that the admission MDS dated August.5, 2024, Section L, B was coded in error, and that Section L 0200 B should have been quoted as. Yes. (No natural teeth) Observation of resident R14 conducted on September 16, 2024, at 09:21 AM reveal that Resident R14 was in his room, with breakfast tray- breakfast was approximately 90% consumed- further observation revealed that resident was edentulous. Further observation revealed that resident R14 was not wearing dentures. Interview with Resident R14 at the time of the observation revealed that he has dentures but did not like wearing them. Further review of Resident R14's clinical record revealed that there was no individualized comprehensive care plan in place to address Resident R14's dental issues. Review of Resident R70's clinical record revealed that Resident R 70 was admitted to the facility on [DATE], with diagnosis of but not limited to chronic venous hypertension with ulcer on right lower extremity, Non pressure chronic ulcer of other part of left lower leg with fat layer exposed, Non pressure chronic ulcer of buttocks with unspecified severity, Non pressure chronic ulcer of right calf with necrosis of muscles, Chronic venous hypertension with ulcers of left lower extremity, Muscle weakness, Morbid obesity. Observation conducted during tour of facility on September 16, 2024, at 11:52 AM revealed that resident R17 had bilateral lower extremity dressing. Further observation revealed that resident R 70s lower extremities were dark and color. Further review of Resident R70's clinical record reveal that the care plan for Venous stasis ulcer to bilateral lower legs r/t Diabetes Date Initiated: 08/28/2024 with goals of: Pressure ulcer will show signs of healing and remain free from infection by/through review date. Date Initiated: 08/30/2024. Further, there were no interventions listed in the care plan. Further review of Resident R70's care plan revealed that the following care plan did not have any interventions: Falls care plan (no interventions), impaired vision (no intervention) and Potential for pressure ulcer (no intervention) 28 Pa. Code 211.10(d) Resident care plan policies 28 Pa. Code 211.12(d)(5) Nursing services

Based on clinical record reviews and interviews with staff, it was determined that the facility failed to notify the office of the State Long Term Care Ombudsman of facility initiated emergency transfers and facility initiated discharges for four or four facility-initiated discharges reviewed for three residents (Resident R73, Resident R74 and Resident R75) Findings include: Review of facility document (list of all facility-initiated discharges) revealed that Resident R73 was discharged from the facility to the hospital on July 26, 2024. Review of the facility notice of transfer or discharge form for resident R73 revealed that on July 27, 2024, Resident R73's responsible party was informed of his transfer to the hospital. Review of resident R73 clinical record revealed no documented evidence that the State Long Term Care Ombudsman was notified of Resident R 73s facility-initiated discharge (hospital admission). Further review of the facility document (list of all facility-initiated discharges) revealed that Resident R74 was discharged from the facility to the hospital on May 19, 2024, and on June 23, 2024. Review the facility notice of transfer or discharge form for Resident R74 revealed that resident R74's responsible party was informed of his May 19, 2024, hospital transfer and of his June 23, 2024, hospital transfer. Review of resident R74's clinical record revealed no documented evidence that the State Long Term Care Ombudsman was notified of Resident R 74's facility-initiated discharge (hospital admission). Further review of the facility document (list of all facility-initiated discharges) reveal that Resident R75 was discharged from the facility to the hospital on July 25, 2024. Review the facility notice of transfer or discharge form for Resident R75 revealed that resident R75's responsible party was informed of his July 25, 2024, hospital transfer. Review of resident R75's clinical record revealed no documented evidence that the State Long Term Care Ombudsman was notified of Resident R 75's facility-initiated discharge (hospital admission). Interview with Employee E1, Facility Administrator, conducted on September 18, 2024 at 2:05 PM, revealed that the facility did not have a process of providing the ombudsman a copy of the discharge notices. Further, employee E1 confirmed that the ombudsman was not notified of Resident R73, Resident R74 and Resident R75' discharges to the hospital. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(2) Management

Based on observations, review of facility policies, review of facility documentation, review of clinical records, and staff interviews, it was determined that the facility failed to establish an effective infection control program related to infection surveillance and periodic review of antibiotic use. Findings include: Review of facility policy and antibiotic stewardship reveal that. Under section policy, Juniper Village has a policy regarding antibiotic stewardship program. Under a section purpose to implement an antibiotic stewardship program which will promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use. Under section Procedure #1 Accountability, a. The Antibiotic Stewardship Program team will be established to be accountable for stewardship activities. As a team, they will: i. Review infections and monitor antibiotic usage pattern on a regular basis, ii. Obtain and review antibiograms or similar information for institutional trends of resistance, iii. Monitor antibiotic resistance pattern, iv, Report on number of antibiotics prescribed and the number of residents treated each month, v. Include a separate report for the number of residents and antibiotic that did not meet criteria for active infection. #5 Tracking a. The Director of Wellness will be responsible for infection surveillance and MDRO (multi-drug resident organisms) tracking. B. The director of Wellness will collect and review data. Review of facility infection control documents revealed no documented evidence that the facility was tracking the infections in the facility. Further review of facility infection control documents revealed no documented evidence that the facility conducted a periodic review of antibiotic use. Interview with Employee E2 conducted on September 17, 2024 at 1:04 PM revealed that the facility did not have a system in place to track infections and the use of antibiotics. Further Employee E2 also confirmed that there was no periodic review of antibiotic use in the facility. Further interview with Employee E2 revealed that the facility will improve their infection control and antibiotic stewardship program to ensure that infections are monitored and tracked and antibiotic use are reviewed regularly. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(d) Management

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet care needs for one of nine residents reviewed. (Resident R116) Findings include: Review of an undated facility policy titled, Care Planning indicated that residents Care Plan ae based on Quarterly Minimum Data Set (MDS - federally mandated assessment of a resident's abilities and care needs) triggers and current needs of the resident. Review of Resident R116's admission MDS dated , October 23, 2023, revealed Resident R116 was admitted to the facility on [DATE], and had a BIMS (Brief Interview for Mental Status) score of two, indicating that the resident had severely impaired cognition. Review of Resident R116's admission elopement risk evaluation dated, October 20, 2023, revealed that Resident R116 was a potential elopement risk. Further review of Resident R116's clinical record revealed no documented evidence a comprehensive care plan was developed regarding elopement risk. Interview with the Director of Nursing, Employee E2, was conducted on November 2, 2023, at approximately 3:34 p.m. where the above-mentioned findings were brought to her attention. Employee E2 confirmed that a care plan regarding Resident R116's elopement risk should have been developed upon assessment. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record reviews and interviews with staff, it was determined that the facility failed to accurately complete a resident assessment related to discharge status for one of 27 residents reviewed (Resident R9). Findings include: Review of undated facility policy titled, Electronic Transmission of the MDS, indicated that all MDS (Minimum Data Set - a mandatory periodic resident assessment tool) assessments, including significant change, will be transmitted in accordance with OBRA regulations (schedule of assessments that will be performed for a nursing facility resident at admission, quarterly, and annually, whenever the resident experiences a significant change in status, and whenever the facility identifies a significant error in a prior assessment). Review of Resident R9's clinical records revealed a physician order dated, April 12, 2023, which stated Resident R9 was admitted on Hospice on April 11, 2023. Further review revealed Resident R9 was discharged from hospice on October 12, 2023. Review of Resident R9's MDS titled, Significant Change in Status, dated April 18, 2023, was coded No for Hospice. Further review of Resident R9's MDS dated [DATE], revealed that Hospice Care was still coded, No. Interview with the Registered Nurse Assessment Coordinator, Employee E5, conducted on November 3, 2023, at 11:07 a.m. confirmed that the Significant Change in Status MDS, dated [DATE] and July 17, 2023, for Resident R9 was coded inaccurately. 28 Pa Code 201.14(a) Responsibility of licensee 2 Pa Code 211.5(f) Medical records

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and resident representative receive written notice of the facility bed-hold policy at the time of a facility-initiated transfer to a hospital for one of nine residents reviewed. (Resident R2) Findings include: Review of MDS (Minimum Data Set-Assessment of resident care needs) for Resident R2 dated August 29, 2023, revealed that the resident was admitted to the facility on [DATE]. Further clinical record review revealed Resident R2's responsible party was her daughter. Review of nursing note for Resident R1 dated July 29, 2023, revealed that the resident was discharged to the hospital related to a fall. Further review of Resident R2's clinical record revealed that there was no documented evidence that Resident R1's representative was provided with a written notice of the facility bed-hold policy at the time of Resident R1's facility-initiated transfer to the hospital. Interview with the Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, on November 3, 2023, at 9:42 a.m. confirmed that the Residents R2's representative was not provided with the bed hold policy upon transfer. 28 Pa Code 201.14(a) Responsibility of licensee

Based on the review of clinical records and interview with staff, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer to the hospital and the reasons for the transfer in a timely manner, after a selected resident was transferred to the hospital for one of nine residents reviewed. (Resident R2) Findings Include: Review of MDS (Minimum Data Set-Assessment of resident care needs) for Resident R2 dated August 29, 2023, revealed that the resident was admitted to the facility on [DATE]. Further clinical record review revealed Resident R2's responsible party was her daughter. Review of nursing note for Resident R1 dated July 29, 2023, revealed that the resident was discharged to the hospital related to a fall. Review of clinical record revealed no evidence that Resident R2's representative was notified of the transfer to the hospital and the reasons for the transfer in writing, and in a language and manner they understood. Interview with the Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, on November 3, 2023, at 9:42 a.m. confirmed that the Residents R2's representative was not notified in writing of the reasons for the transfer, and in a language and manner they understood. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights

Based on interview with staff and review of facility provided documentation, it was determined that the facility did not ensure that an allegation regarding nursing aide practicing administering medication was thoroughly investigated (Employee E12) Findings include: Review of nurse aide, Employee E12's personnel file, revealed that Employee E12 was hired on July 20, 2023, for a full time nurse aide position. Review of witness statement provided by Nursing Home Administrator, dated August 23, 2023, stated the following: while sitting at the nurses station I observed that [Employee E12] was passing medications, to my knowledge she was only a CAN (nurse aide). This happened on multiple occasions but when asking it was stated she took her test and she was just waiting for her license. Notified director of nursing and then informed of the nepotism. (Employee E12 was director of nursing's daughter in-law). Director of nursing did not want to reprimand her daughter in law and both resigned that day. Review of Employee E12's 'exit interview form' dated August 24, 2023, reason for termination was 'involuntary' due to other: falsely documenting. Review of facility reported incident dated August 24, 2023, noted medication administration records were reviewed and it is noted 08/15/2023 - 08/24/2023, [Employee E12] signed as the person administering the medications on the unit. Review of facility provided investigation report failed to include witness statements from residents and facility staff. Further the investigation report did not included list of medications which were administered by Employee E12 as well as list of residents which were assessed after incident. 28 Pa Code 211.12(c )(d)(1)(5) Nursing Services 28 Pa Code 201.14(a)Responsibility of licensee

Based on review of clinical record, facility documentation, and interview with staff it was determined that the facility failed to issue the resident/responsible party a Notice of Medicare Non-Coverage (NOMNC) prior to termination of Medicare A services, as required for one of three resident records reviewed (Resident CL118). Findings include: Interview with the Nursing Home Administrator, Employee E1, conducted on November 3, 2023, at approximately 12:00 p.m. revealed the facility did not have a policy regarding notice of Medicare non-coverage. Review of Resident CL118 revealed that the resident was admitted to the facility on [DATE], with Medicare Insurance Coverage for skilled nursing care. Further review of clinical record revealed that the resident was discharged from the facility on July 8, 2023. There was no documented evidence that a Notice of Medicare Non -Coverage (NOMNC-written notice to the resident, beneficiary, or resident representative, of the right to an expedited review of a Medicare service termination of Medicare A Services prior to the discharge from the facility) was provided to the Resident CL118 or the resident's responsible party. Interview on November 3, 2023, at 12:30 p.m. with Nursing Home Administrator, confirmed that the facility had no documented evidence that a Notice of Medicare Non-Coverage (NOMNC) had been issued to Resident CL118 prior to the termination of the Medicare A service. 28 Pa. Code 201.29 (f) Resident Rights