Every finding on record at Kadima Rehabilitation & Nursing at Greenville

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure proper administration procedures of resident medications for one of 10 residents reviewed (Resident R1). Findings include: Review of facility policy dated 4/21/26, entitled Medication Administration indicated that Medications are to be administered at the time they are prepared.Only the licensed personnel who prepares the medication may administer it. Observation of Resident R1 in their room on 8/12/26, at 11:30 a.m. revealed a medication cup filled with multiple unknown medications sitting on the resident's bedside tray table, and the Licensed Practical Nurse (LPN) Employee E1 was down the hallway assisting other residents. During an interview on 8/12/26, at the time of the observation the Nursing Home Administrator (NHA) was made aware of the cup of medications on Resident R1's bedside tray table. The NHA confirmed that Resident R1's medications should not have been left alone in the room for the resident and that LPN Employee E1 should have ensured Resident R1 took the mediations prior to exiting their room. 28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.9(a)(1) Pharmacy services28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on review of facility policy and employee handbook, observations, and staff interviews, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in one of one main kitchens and two of two pantry refrigerators checked (Unit 1 and Unit 4), failed to served food in a safe and sanitary manner during tray line observation, and failed to monitor resident's personal refrigerators for temperatures for one of one residents reviewed with personal refrigerator (Resident R121). Findings include: Facility policy entitled Food Storage dated 4/21/26, indicated Un-served leftovers shall be labeled, dated and stored for a period not to exceed there (3) days. Facility policy entitled Storage of Perishable Foods dated 4/21/26, indicated products such as salad greens, celery, radishes, etc, should be cleaned, trimmed, rinsed, and stored in plastic bags. Facility employee handbook section entitled Meals indicated if a lunch is brought and must be refrigerated, it can be put in the refrigerator in the break room. Facility policy entitled Personal Refrigerators dated 4/21/26, indicated personal refrigerators are permitted after thorough inspection and will be subject to the same monitoring as other facility refrigerators. The policy further stated that the refrigerator must include a thermometer and will be monitored regularly for temperature compliance. Tour of the main kitchen on 6/23/26, between 10:40 a.m. and 11:30 a.m. revealed the following items labeled, dated, and stored for a period exceeding three days: Large refrigerator had four pitchers of lemonade dated 6/13/26, one pitcher of tomato juice dated 6/10/26, and one small clear sandwich bag with carrot sticks, cucumber slices and celery sticks dated 6/19/26. Tour of the main kitchen on 6/23/26, between 10:40 a.m. and 11:30 a.m. revealed the following items opened and not labeled with an open date: Large refrigerator had one pitcher of iced tea, one rotten green bell pepper (not in a bag), one package of Swiss cheese, and one container of beef base. Tour of the main kitchen on 6/23/26, between 10:40 a.m. and 11:30 a.m. revealed the following employee items in the large refrigerator with facility food: one package of pepperjack cheese, a twix candy bar, and two bottles of water. During an interview on 6/23/26, at 10:48 a.m. Dietary Manager confirmed that the lemonade, tomato juice, and bag of carrot sticks, celery sticks, and cucumber slices exceeded the three day limit and should have been discarded; the iced tea, beef base, and Swiss cheese was not dated and should have been; the green bell pepper was not in a plastic bag as it should have been and was rotten and should have been discarded, and employee items should be stored in the employee breakroom refrigerator and not in the main kitchen as it was. Tray line observation in the main kitchen on 6/23/26, at 11:45 a.m. revealed Dietary Employee E5 with gloved hands assembled five hot plates across the steam table. He/she then proceeded to place a resident meal ticket on each hot plate followed by a plate. He/she then picked up five pieces of chopped steak and placed a piece on each plate and then rubbed his/her gloved hands together followed by picking up a scoop to continue placing the remainder of the meal on each individual plate. He/she then passed the completed plate to the dietary aide to place on the individual trays. Dietary Employee E5 then proceeded to complete the same process a second time. During an interview on 6/23/26, at 11:51 a.m. Dietary Manager confirmed that Dietary Employee E5 should not have picked up the chopped steak with his/her gloved hands and there are tongs that they are to use. Observation on 6/24/26, at 1:34 p.m. of Unit 4 pantry refrigerator revealed six 473 milliliters (ml) cartons of chocolate milk with an expiration date of 6/20/26, and a build-up of ice in the freezer portion. During an interview on 6/24/26, at 1:36 p.m. Assistant Director of Nursing confirmed the six cartons of milk were expired and should have been discarded and there was a build-up of ice in the freezer. Observation on 6/24/26, at 1:46 p.m. of Unit 1 pantry refrigerator revealed one 473 ml carton of chocolate milk with an expiration date of 6/19/26, one peanut butter and jelly sandwich with an expiration date of 6/19/2026, and a build-up of ice in the back of the refrigerator. During an interview on 6/24/26, at 1:55 p.m. Licensed Practical Nurse (LPN) Employee E2 confirmed the one carton of milk and one sandwich was expired and should have been discarded and there was a build-up of ice in the refrigerator. During an interview and observation with Resident R121 on 6/23/26, at 2:08 p.m. it was observed that Resident R121 had a personal refrigerator to store food items. Resident R121 gave permission for the surveyor to open the refrigerator and observe it for safe storage of food items. Upon observation, it was noted that there were food items in the refrigerator. Upon observation there was no thermometer present to determine the temperature of the refrigerator for safe storage of food items, and no recorded temperatures noted. During an interview on 6/24/26, at 1:57 p.m. the Director of Nursing confirmed that the facility was unaware that Resident R121 had a personal refrigerator in his/her room and there was no thermometer and no temperatures recorded for Resident R121's refrigerator to ensure safe storage of items. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(2.1) Management

Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to promote cleanliness and help prevent the spread of infection regarding respirator care equipment for two of five residents reviewed (R14 and R50), and failed to obtain a physician's order for the provision of oxygen therapy for one of five residents reviewed (Resident R15). Findings include: Facility policy entitled Medication and Treatment Orders dated 4/21/26, indicated each medication administration will have a corresponding and complete physician's order and oxygen orders will contain: The rate of flow, route, and rationale (i.e., Oxygen 2-3 L/min [liters per minute] per nasal cannula prn [as needed] for SOB [shortness of breath]). Resident R14's clinical record revealed an admission date of 6/20/25, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), Atrial Fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications),and anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone). Resident R14's clinical record revealed a physician's order dated 6/2/26, for oxygen via Nasal Cannula (a thin tube with two prongs that fit in a residents nostrils to deliver oxygen) every shift for shortness of breath. Titrate oxygen to maintain saturation greater than or equal to 92%. Further review revealed a physician's order dated 6/18/26, that identified to change oxygen tubing, change humidification bottle, cleanse oxygen filter, inspect easy foam wraps (replace if soiled or missing) every night shift every Monday for maintenance of oxygen equipment. Observation on 6/24/26, at 10:00 a.m. revealed Resident R14 sitting in his/her wheelchair with supplemental oxygen in place and the oxygen concentrator liter flow set at 2 lpm via Nasal Cannula. Further observation of the concentrator filter on the back of the oxygen concentrator revealed a large amount of gray fluffy substance covering the entire filter. During an interview on 6/25/26, at 2:30 p.m. the Director of Nursing confirmed that Resident R14's oxygen concentrator filter contained a large amount of gray dusty substance and should be cleaned. Resident R50's clinical record revealed an admission date of 12/24/25, with diagnoses that included COPD, Respiratory Failure (a condition where you don't get enough oxygen or you get too much carbon dioxide in your body), and Diabetes (a health condition caused by the body's inability to produce enough insulin). Resident R50's clinical record contained a physician's order dated 4/21/26, to administer Albuterol Sulfate Inhalation Nebulization Solution via nebulizer (medical device that coverts liquid medication into a fine mist that can be inhaled directly into the lungs) every eight hours as needed for wheezing. Observation on 6/23/26, at 2:13 p.m. revealed Resident R50's nebulizer mask lying in the bedside drawer and not stored in a plastic bag. Observation on 6/25/26, at 12:15 p.m. revealed Resident R50's nebulizer mask lying on top of the bedside stand not stored in a plastic bag. During interview on 6/25/26, at 12:15 p.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that Resident R50's nebulizer mask was lying on top of the bedside stand and was not stored in a plastic bag when not in use and should have been. Resident R15's clinical record revealed an admission date of 11/13/25, with diagnoses that included Respiratory Failure, Diabetes, and High Blood Pressure. Observation on 6/23/26, at 2:38 p.m. and 6/25/26, at 1:30 p.m. revealed Resident R15 lying in bed wearing oxygen nasal cannula connected to an oxygen concentrator delivering 2 liters of oxygen per minute. Resident R15's clinical record lacked evidence of a physician's order for the use of oxygen therapy. During an interview on 6/25/26, at 1:35 p.m. LPN Employee E3 confirmed that Resident R15 was administered oxygen therapy and his/her clinical record lacked physician's order for the oxygen therapy as required. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records, 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 as documented on the resident's Pennsylvania Order for Life Sustaining Treatment (POLST - a legal document specifying the resident/responsible party choices regarding life-sustaining treatments) for three of 27 residents reviewed (Residents R14, R38, and R50).Findings include: Facility policy entitled Advanced Directives dated [DATE], indicated that All residents shall be presumed as having consented to CPR (Cardiopulmonary Resuscitation - emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest) unless there is documentation in the medical record that the resident has specified that a DNR (Do not attempt resuscitation and allow natural death) order is present on the clinical record. Further review revealed that All DNR orders must be rewritten by the attending physician for each admission / readmission. Resident R14's clinical record revealed an admission date of [DATE], with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), Atrial Fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications), and Anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone). Resident R14's clinical record revealed a POLST dated [DATE], indicating DNR. Review of current physician orders lacked evidence of his/her code status. Resident R38's clinical record revealed an admission date of [DATE], with diagnoses that included Dementia (loss of memory, language, problem-solving, and other thinking abilities), Hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones), and high blood pressure. Resident R38's clinical record revealed a POLST dated [DATE], indicating DNR. Further review revealed a physician's order dated [DATE] for CPR. During an interview on [DATE], at 1:30 p.m. the Director of Nursing (DON) confirmed Resident R14's clinical record lacked active physician orders reflecting his/her code status, and Resident R38's physician orders and POLST were not consistent with one another. The DON further confirmed that regardless of Resident having a POLST, his/her physician orders are to reflect their code status and that resident's physician's orders and POLST should match. Resident R50's clinical record revealed an admission date of [DATE], with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), Respiratory Failure (a condition where you don't get enough oxygen or you get too much carbon dioxide in your body), and Diabetes (a health condition caused by the body's inability to produce enough insulin). Resident R50's clinical record revealed a POLST dated [DATE], indicating DNR. Review of current physician orders lacked evidence of his/her code status. During an interview on [DATE], at 1:55 p.m. the DON confirmed Resident R50's clinical record lacked active physician orders reflecting his/her code status. The DON further confirmed that regardless of Resident having a POLST, his/her physician orders are to reflect their code status. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.5(f)(i) Medical records 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing service

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to properly store medications, and failed to properly date two [NAME]-dose vial of Aplisol (an injectable diagnostic solution test to determine if a person has been infected with tuberculosis) in one of three medication storage rooms reviewed (Unit One medication storage room). Findings include: A facility policy entitled Storage of Medications with a policy review date of 4/21/26, revealed Medications are stored in a safe, secure, and orderly manner in accordance with federal and state regulations and facility policies. No discontinued, outdated, or deteriorated medications are available for use in the facility. All such medications are destroyed. Review of the manufacturer's instructions for Aplisol revealed, Aplisol vials should be inspected visually for both particulate matter and discoloration prior to administration and discarded if either is seen. Vials in use for more than 30 days should be discarded. An observation on 6/24/26, at approximately 9:49 a.m., of the Unit One medication storage room revealed two multi-use vials of Aplisol opened and in the refrigerator for use not dated with an opened or use by date. Licensed Practical Nurse (LPN) Employee E6 confirmed that the vials should be dated after opened for use with open and use by date and was unable to determine if they were opened within 30 days. Another observation in the same medication storage room revealed two resident medications sitting on top of the refrigerator and not stored properly. Employee E6 confirmed that the medications should be in the medication cart and not sitting on top of the refrigerator. During an interview with the Director of Nursing (DON) on 6/24/26, at approximately 10:30 a.m., it was confirmed that multi-use vials should be dated with open and use by dates to confirm that they are still safe for use, and resident medications should not be stored on top of refrigerators in the medication room. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to ensure a safe environment related to smoking for one of six residents who smoke at the facility reviewed (Resident R48). Findings include: Facility policy entitled, Smoking Policy, dated 4/21/26, revealed Designated smoking areas have been established outside the building for these residents, staff or visitors who choose to smoke; Smoking restrictions apply to all smoking methods including cigarettes, pipes, cigars and electronic cigarettes; To ensure the safety of all residents, smoking supplies for all residents will be kept locked in the medication cart and provided to the resident upon request. Review of Resident R48's clinical record revealed an admission date of 2/12/26, with diagnoses that included gastro-esophageal reflux disease (GERD-a condition where stomach acid flows back into the esophagus [tube that passes food from the mouth into the stomach]), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and high blood pressure. Review of Resident R48's Quarterly Minimum Data Set (MDS-a periodic assessment of resident care needs), dated 5/15/26, revealed under Section C: cognitive patterns, questions from C0500 BIMS Summary Score: Resident R48 scored an 8, indicating cognitive impairment. Review of Resident 48's clinical record revealed a Smoking Assessment completed 2/12/26 indicating safe to smoke with apron and supervision. The assessment indicated that Resident is aware that the facility needs to store lighter and cigarettes. Observation on 6/24/26, at 1:00 p.m. and 1:30 p.m. revealed Resident R48 sitting in his/her wheelchair in his/her room with one pack of cigarettes and disposable lighter sitting on his/her bedside table. During an interview on 6/24/26, at 1:30 p.m. Registered Nurse Employee E4 confirmed that Resident R48's cigarettes and lighter were on his/her bedside table. He/she further confirmed that resident's cigarettes and lighters are to be kept locked in the medication cart in the smoking area. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services 28 Pa. Code 201.18(b)(1)(3) Management

Based on observations, review of facility policies, clinical records, and staff and resident interviews, it was determined that the facility failed to obtain a physician's order for the management of a colostomy for one of 27 residents reviewed (Resident R26), and failed to ensure physician's orders were followed for medication administration for one of 27 residents reviewed (Resident R4).Findings include: Review of facility policy dated 4/21/26, entitled Medication Administration revealed Medications are administered in accordance with written orders of attending physicians; The Resident's E-MAR (Electronic Medication Administration Record) is initialed by the person administering a medication in the space provided under the date and on the line for that specific medication dose administration. Documentation is done immediately after the administration and/or refusal of the medication or attempt; The employee who administers medications to residents shall record and sign on the individual medication record of each resident the medication, dosage and time it was given. This shall be done as soon as possible after the medications have been given. Resident R26's clinical record revealed an admission date of 4/14/25, with diagnosis that include Colostomy Status( an opening in the colon, allowing feces to be diverted through an opening on the abdomen), schizophrenia (mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), and high blood pressure. Review of Resident R26's current physician orders lacked evidence of an active order for colostomy care. Further review of physician orders revealed an order dated 6/2/25 and discontinued on 12/25/25 for change colostomy appliance, wafer, and barrier ring every day shift every Thursday. Interview with Resident R26 on 6/24/26, at 2:46 p.m. revealed Resident R26 has a colostomy. He/she stated the facility used to care for it, but that he/she has been changing it for months now. Resident R4's clinical record revealed an admission date of 4/13/26, with diagnoses that included Sepsis due to Methicillin Resistant Staphylococcus Aureus (systemic bacterial infection), fracture of the left femur (a break in the thigh bone), and anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone). Review of Resident R4's clinical record revealed a Physician's order dated 5/14/26, for Cathflo Activase Injection Solution Reconstituted (a medication used to clear out blood clots that are blocking a medical catheter such as a Peripherally Inserted Central Catheter [PICC-a thin, soft flexible tube placed in the vein of the upper arm also called an IV to deliver fluids and medications]) Use 2mg (milligrams) IV one time only for clogged PICC for one day. Review of Resident R4's clinical record under E-MAR and progress notes lacked evidence that Cathflo was administered as ordered; Physician's order dated 5/3/26, for Saline Flush Solution 0.9% (Sodium Chloride Flush) Use 10ml (milliliters) IV (Intravenous) every shift for health monitoring. Administer before and after every IV medication and once every shift while not in use. Out of 86 opportunities to document completion, 71 were documented as completed and 15 were blank. Interview with Resident R4 on 6/25/26, at 10:45 a.m. revealed that he/she had a PICC in May, and the facility often would not flush the PICC at night with Saline as ordered and then it would get clogged. During an interview on 6/25/26, at 11:50 a.m. the Director of Nursing (DON) confirmed that Resident R4's clinical records lacked evidence that Cathflo and Saline Flushes was administered in accordance with physician's orders. The DON also confirmed that Resident R26's did not have an active order for Colostomy care. The DON further confirmed that Resident R26 should have an order for colostomy care and that he/she transferred to the hospital on [DATE] and the order for colostomy care was not reordered when he/she returned to the facility as required. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f)(i)(x) Medical records 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies, clinical record, and staff interviews, it was determined that the facility failed to provide resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) and failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for two of three residents reviewed for hospitalization (Residents R12 and R50). Findings include: Facility policy entitled Bed Hold Policy and Procedure dated 4/21/26, indicated that upon discharge from the facility and admission to a hospital, the Social Service Department or the Administrator's designee will contact, by telephone and in writing, the resident/responsible part to inform them that the resident was discharged to the hospital and of the 15-day bed hold, under Medicaid. Resident R12's clinical record revealed an admission date of 7/8/25, with diagnoses that included Breast Cancer, Dementia (loss of cognitive functioning affecting a person's memory and behaviors), and Atrial Fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications). Resident R12's clinical record revealed a progress note dated 2/21/26, indicating a transfer to the hospital. The clinical record lacked evidence that the resident's necessary clinical information was communicated to the receiving health care provider. Resident R12's clinical record also lacked evidence indicating that Resident R12 and/or his/her representative were provided with a copy of the facility bed-hold policy upon transfer or within twenty-four hours of transfer. Resident R50's clinical record revealed an admission date of 12/24/25, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), Respiratory Failure (a condition where you don't get enough oxygen or you get too much carbon dioxide in your body), and Diabetes (a health condition caused by the body's inability to produce enough insulin). Resident R50's clinical record revealed a progress note dated 3/13/26, and again 4/16/26, indicating transfers to the hospital. The clinical record lacked evidence that the resident's necessary clinical information was communicated to the receiving health care provider. Resident R50's clinical record also lacked evidence indicating Resident R50 and/or his/her representative were provided with a copy of the facility bed-hold policy upon transfer or within twenty-four hours of transfer. During an interview on 6/26/26, at 9:43 a.m. the Director of Nursing confirmed that Resident R12 and R50's clinical records lacked evidence that necessary clinical information was communicated to the receiving health care provider and lacked evidence that the resident and/or their representative were provided with a copy of the facility bed-hold policy upon transfer or within twenty-four hours of transfer. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c.3)(2) Resident rights

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to maintain a clean homelike environment and ensure resident's wheelchairs were in working order for one of four units (Unit 1). Findings include: Facility policy entitled Resident Environment dated 4/21/26, indicated the facility will provide an environment that is safe, clean, comfortable, and homelike. Observation on Unit One on 6/23/26, at 2:01 p.m. revealed Resident R116 sitting in his/her wheelchair with dried dirty substance down the right side of the wheelchair and crumbs / debris on the frame of the wheelchair. Observations on Unit One on 6/23/26, at 2:25 p.m. revealed Resident R59 sitting in his/her wheelchair. The left wheelchair brake was not working, left armrest plastic covering was cracked and pealing exposing the foam underneath it, and the right armrest was missing the foam and plastic covering. During an interview on 6/23/26, at 3:34 p.m. the Director of Nursing confirmed that Resident R116's wheelchair was unclean with dried debris noted, and Resident R59's wheelchair bilateral armrest were in disrepair and his/her left wheelchair brake was broken and needed repaired. 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policies and clinical records and staff interviews, it was determined that the facility failed to maintain accurate and complete documentation for one of 27 residents reviewed (Resident R4). Findings include: Review of facility policy dated 4/21/26, entitled Medication Administration revealed Medications are administered in accordance with written orders of attending physicians; The Resident's E-MAR (Electronic Medication Administration Record) is initialed by the person administering a medication in the space provided under the date and on the line for that specific medication dose administration. Documentation is done immediately after the administration and/or refusal of the medication or attempt; The employee who administers medications to residents shall record and sign on the individual medication record of each resident the medication, dosage and time it was given. This shall be done as soon as possible after the medications have been given. Review of facility policy dated 4/21/26, entitled Documentation revealed Nursing documentation will follow the guidelines of good communication and be concise, clear, pertinent, and accurate; Documentation for subsequent and/or routine care and procedures may be completed by exception, or the use of a checklist, flowcharts or other documentation tools; Nursing documentation will provide accurate reflection of resident condition and will meet federal and state requirements. Resident R4's clinical record revealed an admission date of 4/13/26, with diagnoses that included Sepsis due to Methicillin Resistant Staphylococcus Aureus (systemic bacterial infection), fracture of the left femur (a break in the thigh bone), and anxiety(a condition that causes a person to be nervous, uneasy, or worried about something or someone). Review of Resident R4's May 2026 E-MAR revealed the following orders: Physician's order dated 5/3/26, for Saline Flush Solution 0.9% (Sodium Chloride Flush) Use 10ml (milliliters) IV (Intravenous) every shift for health monitoring. Administer before and after every IV medication and once every shift while not in use. Out of 86 opportunities to document completion, 71 were documented as completed and 15 were blank. Physician's order dated 5/14/26, for Cathflo Activase Injection Solution Reconstituted(a medication used to clear out blood clots that are blocking a medical catheter such as a Peripherally Inserted Central Catheter [PICC-a thin soft flexible tube placed in the vein of the upper arm also called an IV to deliver fluids and medications]) Use 2mg (milligrams) IV one time only for clogged PICC for one day. Review of Resident R4's clinical record under E-MAR and progress notes lacked documentation that Cathflo was administered. During an interview on 6/25/26, at 11:50 a.m. the Director of Nursing confirmed that Resident R4's clinical records were incomplete regarding medication administration documentation. 28 Pa. Code 211.5(f)(ii)(viii) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to monitor oxygen saturation (a measurement to determine the amount of hemoglobin carrying oxygen in the red blood cells) according to physician orders for one of eight residents reviewed (Resident R1).Findings include: Facility policy entitled Oxygen Administration dated 4/21/26, indicated oxygen therapy will be provided when a resident needs oxygen at a concentration greater than room air.to administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues. Resident R1's clinical record revealed an admission date of 1/28/26, with diagnoses that included congestive heart failure (heart does not pump blood efficiently leading to fluid retention), respiratory failure with hypoxia (respiratory system fails to adequately oxygenate the blood), and chronic obstructive pulmonary disease (a progressive group of lung diseases that cause damage and inflammation in the lungs making it difficult to breath). Residents R1's clinical record revealed he/she had a physician's order dated 4/29/26, for supplemental oxygen via nasal canula every shift for shortness of breath, titrate (adjusting the amount of oxygen provided) to maintain saturation greater than or equal to 92 percent. Resident R1's clinical record lacked evidence after 5/9/26, that his/her oxygen saturation levels were being monitored. Therefore staff were unable to determine whether Resident R1's supplemental oxygen needed to be titrated to maintain a saturation greater than or equal to 92 percent per physician's orders. During an interview on 6/8/26, at 10:17 a.m. the Director of Nursing confirmed that Resident R1's clinical record lacked evidence that his/her oxygen saturation levels were being monitored after 5/9/26 and therefore staff were unable to determine whether Resident R1's oxygen needed to be titrated to maintain a saturation greater than or equal to 92 percent per physician's orders. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, guidance from the Pennsylvania Department of Health (PADOH), clinical record review, and staff interview, it was determined that the facility failed to implement infection control practices by incorporating transmission-based precautions (infection control measures used in healthcare settings to prevent the spread of highly transmissible pathogens) for the required duration related to a positive Respiratory Syncytial Virus (RSV-a highly contagious respiratory virus that infects the lungs and breathing passages) test for one of eight residents reviewed (Resident R1).Findings include: Review of the facility policy entitled Infection Control Plan, Program, and Committee dated 4/21/26, indicated transmission-based precautions are the second tier of basic infection control and are used in addition to standard precautions (the minimum set of infection control practices used for all patient care in a healthcare setting) for patients who may be infected or colonized with certain infectious pathogens for which additional precautions are needed to prevent infection transmission. Review of the guidance provided by the PADOH, entitled, Respiratory Virus Outbreak Toolkit last updated 11/24/25, revealed that for positive RSV contact isolation precautions (a type of transmission-based precaution that requires certain personal protective equipment to be worn) should be in place until symptoms resolve or seven days, whichever is longer. Resident R1's clinical record revealed an admission date of 1/28/26, with diagnoses that included congestive heart failure (heart does not pump blood efficiently leading to fluid retention), respiratory failure with hypoxia (respiratory system fails to adequately oxygenate the blood), and chronic obstructive pulmonary disease (a progressive group of lung diseases that cause damage and inflammation in the lungs making it difficult to breath). Residents R1's clinical record revealed he/she tested positive at the hospital for RSV on 3/15/26. During an interview on 6/4/26, at 10:52 a.m. the Nursing Home Administrator (NHA) provided information that Resident R1 was positive for RSV at the hospital on 3/15/26, isolation was put in place on 3/15/26, when he/she returned from the hospital. On 3/18/26, the isolation was removed due to Resident R1 no longer having a fever and no longer having symptoms. During an interview on 6/5/26, at 3:25 p.m. the NHA confirmed that the facility did not isolate Resident R1 for the required duration related to his/her positive RSV test. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, facility documents, clinical records, and staff interviews, it was determined that the facility failed to implement sufficient safety precautions to prevent a resident with a history of suicide ideations from inflicting self-harm for one of seven residents reviewed with a history of suicide ideation and resulted in an Immediate Jeopardy situation (Resident R1).Findings include: A facility policy entitled, Suicide Threats dated 4/01/26, indicated that:A staff member must remain with the resident until the nurse supervisor/change nurse arrives to examine the resident.Place the resident on one-on-one observation until the acute episode has been resolved if the resident is physically capable of self-injury.The resident shall remain one-on-one until transfer from the facility or nursing assessment has identified that the resident is no longer a safety risk.The charge nurse or designee shall immediately notify the resident's attending physician, and responsible party of record of such threats.The nurse supervisor will notify the resident's attending physician of the assessment findings and seek further medical instructions from the physician.The resident shall be assessed by the nursing supervisor to determine if acute interventions are required.If the resident remains in facility, an assessment of the resident's behavior will be made by the interdisciplinary care plan team to determine interventions that may be necessary to prevent the recurrence of such threats.Revised care plans will be developed to reflect such interventions.Following the assessment nursing staff will remove any items with which the resident could use to harm self.A behavioral health professional consult is indicated whenever the resident makes a suggestion of suicide. Information submitted by the facility on 4/27/26, at 5:20 p.m. revealed that at approximately 8:00 a.m. on 4/27/26, Resident R1 attempted suicide by cutting his/her wrists with a box cutter and was discovered in his/her room with several horizontal cuts across his/her left arm when staff entered the room to pass his/her breakfast tray. Statements made to staff at that time by Resident R1 indicated that he/she cut himself/herself so they could go to heaven. Resident R1's clinical record revealed an admission date of 11/19/25, with diagnoses that included stroke, suicidal ideations, and post-traumatic stress disorder (mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety). A care plan entitled history of suicidal ideations dated 11/21/25, included the following interventions: one-on-one as indicated; consult psych as needed; document behaviors; notify the doctor as indicated; and redirect from negative thoughts and feelings. On 4/14/26, at 9:19 p.m. a departmental progress note written by the Social Services Director (SSD) revealed: Resident R1's friend called in to request that someone talk to Resident R1 due to his/her being scared regarding his/her health. The SSD indicated that he/she spoke with Resident R1 and that Resident R1 feared he/she would not live through the night due to cancer spreading throughout his/her body, and the level of pain he/she was experiencing. The SSD noted that he/she spoke with the nursing supervisor to see if they could clear up any concerns Resident R1 had regarding medications. The SSD returned to Resident R1 and shared the nursing supervisor's response. At that time Resident R1 stated I might as well kill myself. Resident R1 did not mention a suicide plan and requested to speak with the supervisor. The SSD informed the nursing supervisor of Resident R1's request. There was no evidence on 4/14/26, in Resident R1's clinical record that the nursing supervisor spoke with Resident R1, conducted an assessment, placed Resident R1 on one-on-one observation, staff members remained with Resident R1 until the nurse supervisor/change nurse arrived to examine him/her, notification to Resident R1's attending physician, and responsible party of record of such threats, interdisciplinary care plan team (IDT) to determination of interventions that may be necessary to prevent the recurrence of such threats, care plan revision, removal of any items with which the Resident R1 could use to harm him/her self, and a behavioral health professional consult. On 4/16/26, at 4:31 p.m. a departmental progress note indicated that the behavior committee evaluated Resident R1's psychotropic medications, noted that Resident R1 was seen by psych on 3/23/26, and that Resident R1 was having increased episodes of anxiety/paranoia/delusional thoughts. No documentation of review of suicidal threats. Further review of Resident R1's clinical record revealed that on 4/20/26, and 4/24/26, Resident R1 was assessed by contracted psychiatric professional and there was no indication that Resident R1's suicidal threats were addressed and/or reviewed. Resident R1's clinical record included a departmental progress note written by the Registered Nurse Supervisor dated 4/27/26, at 8:50 a.m. revealed: At approximately 8:00 a.m. he/she was notified that a significant amount of bright red blood was observed on bed resident's bed sheets, floor, trash can, and clothing. When asked what happened Resident R1 reported I cut myself so I can go to heaven. Assessment revealed several horizontal lacerations on Resident R1 left forearm. Area cleansed and pressure immediately applied, 911 notified. Pressure maintained to area until Emergency Medical (EMS) arrived and took over. Resident R1 left with EMS via stretcher at 8:25 a.m. Report called to hospital. Review of a witness statement submitted by Registered Nurse (RN) Employee E6 dated 4/27/26, revealed that shortly after 6:15 a.m. he/she passed Resident R1 in the hallway standing outside of the door to his/her room. And then when RN Employee E6 passed Resident R1's room around 6:30 a.m. the door was shut. Review of a witness statement submitted by Nurse Aide Employee E1 dated 4/27/26, revealed that he/she went to drop off Resident R1's breakfast tray and noticed a lot of blood on the floor and bed, went out the room quick and told a nurse and he/she went into see about it. Review of a witness statement submitted by Licensed Practical Nurse Employee E5 dated 4/27/26, revealed that he/she was called to Resident R1's room by Nurse Aide due to blood being seen upon entering room, blood could be seen on bed, floor, and tray table. Upon further assessment, cuts were seen to Resident R1's right forearm. During an interview on 4/30/26, at 9:50 a.m. the Nursing Home Administrator confirmed that the facility hasn't been able to determine how Resident R1 got the box cutter, and all they could determine was that he had it for a while. During an interview on 4/30/26, at approximately 10:05 a.m. Maintenance Employee E2 confirmed that the instrument used by Resident R1 was known as a break-away utility knife and that the facility does not use them due to the thinness of the blade. Maintenance Employee E2 also confirmed that 'they' couldn't figure out how Resident R1 got the knife. Observation on 4/30/26, at 10:15 a.m. in the Director of Nursing (DON) office revealed a thin utility knife with break-away blades and a yellow handle. The knife and glove were noted to have a moderate amount of dried blood. The DON confirmed that the knife was located in Resident R1's room at the time of the incident and that the facility hadn't figured out how he/she got it. During an interview on 4/30/26, at 11:45 a.m. the Assistant Director of Nursing confirmed that there was no evidence of the following: that the facility implemented increased monitoring, documented an assessment, notified the attending physician and representative, that the IDT reviewed the care plan and revised the care plan, removed of any items that may be used by Resident R1 to self-harm, and requested a behavioral health consult for Resident R1 between his/her suicidal threats on 4/14/26, and his/her self-harm on 4/27/26. In an interview on 4/30/26, at 1:05 p.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility should have taken more safety measures to prevent Resident R1 self-harm. The facility failed to implement sufficient safety measures to prevent residents with a history of suicidal ideations from attempting self-harm, putting a resident with a history of suicide ideations at risk and causing an Immediate Jeopardy. The NHA and DON were notified of the Immediate Jeopardy (IJ) situation on 4/30/26, at 4:05 p.m. An Immediate Action Plan was requested and the IJ template was provided to the NHA. The Immediate Action Plan was provided by the NHA and DON on 4/30/26, at 5:58 p.m., which was accepted at 6:03 p.m.The plan included:Inspection of Resident R1's room for items that may be used for self-harm on 4/30/26.4/30/26, audit current residents for suicidal ideations and update care plans to reflect resident's current condition and include safety interventions as appropriate.4/30/26, NHA, DON, and Regional Clinical consultant will review and update the facility policy and procedures for suicidal threatsStaff will be re-educated on the facility policy and procedures for suicidal threats, care plans, and supervision of residents identified with suicidal ideations prior to their next shift.Education started on 4/27/26 and will be completed by 5/05/26.As needed, casual staff and frequent agency staff will be called and educated by 5/12/26.All incidents and accidents will be reviewed daily and results reported to the Quality Assurance and Process Improvement Committee for review and frequency of audits. After reviewing facility documentation, observations, and staff interviews, the implementation of the above stated action plan was confirmed on 5/01/26, at 3:27 p.m. and the NHA was informed that the Immediate Jeopardy situation was removed. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of clinical records, facility documentation, facility policies, and staff interview, it was determined that the facility failed to maintain complete and accurate records for six of seven residents reviewed (Residents R1, R2, R3, R4, R5, and R6).Findings include:A facility policy entitled, Admission date 4/01/26, indicated that an inventory of all resident valuables will be completed, staff will record the quantity and description of each item, staff and resident/representative will sign the form.Resident R1's clinical record revealed an admission date of 11/19/25, with diagnoses that included stroke, suicidal ideations, and post-traumatic stress disorder [PTSD-mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety].Resident R1's admission checklist lacked documentation that his/her inventory was completed and signed.Resident R1's Inventory of Personal Effects indicated he/she had clothing items, a wheelchair, shaving kit, and phone and charger upon admission to the facility and further review of Resident R1's Inventory of Personal Effects lacked the resident/representative signature. Resident R2's clinical record revealed an admission date of 12/01/23, with diagnoses including suicidal ideations, dementia, stroke, and recurrent depression.Resident R2's clinical record lacked evidence of a completed admission checklist and/or a completed Inventory of Personal Effects. Resident R3's clinical record revealed an admission date of 11/10/25, with diagnoses including suicidal ideations, dementia, anxiety disorder, and recurrent depression.Resident R3's clinical record lacked evidence of a completed admission checklist.Resident R3's Inventory of Personal Effects indicated he/she had clothing items upon admission and was not signed by the resident and/or representative. Resident R4's clinical record revealed an admission date of 5/18/25, with diagnoses including PTSD, bipolar disorder [also known as manic depressive illness or manic depression, is a mental health condition characterized by significant mood swings, including manic (or hypomanic) episodes and depressive episodes], recurrent depression, and anxiety disorder.Resident R4's clinical record lacked evidence of a completed admission checklist.Resident R4's Inventory of Personal Effects indicated he/she had clothing items, shaving kit, hearing aids and glasses, a laptop computer, and a purse upon admission. There was no evidence that the contents of his/her purse were inspected and the Inventory of Personal Effects sheet was not signed by facility staff. Resident R5's clinical record revealed an admission date of 7/26/24, with diagnoses including PTSD, below the right knee amputation, phantom limb syndrome with pain (occurs when a person perceives sensations, including pain, in a limb that no longer exists), broken back, ribs, hip, and facial bones.Resident R5's clinical record lacked evidence of a completed admission checklist.Resident R5's Inventory of Personal Effects indicated he/she had clothing items, multiple orthopedic braces, a cell phone and charger, and personal papers. The Inventory of Personal Effects was not signed by facility staff. Resident R6's clinical record revealed an admission date of 10/28/17, with diagnoses including intentional self-harm by jumping from a high place, Schizophrenia [severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking] mood disorder, and anxiety disorder.Resident R6's clinical record lacked evidence of a completed admission checklist.Resident R6's Inventory of Personal Effects on admission included clothing items, stuffed animals and a yellow ring, and was not signed by the resident/representative or facility staff.Resident R6's Inventory of Personal Effects dated 4/30/26, indicated that Resident R6 refused to allow facility staff to inspect his/her belongings and that Resident R6 possessed two plastic bags of clothes, and the form was not signed by the resident or facility staff. During an interview on 4/30/26, 11:45 a.m. the Assistant Director of Nursing and Licensed Practical Nurse Employee E4 confirmed the above lack of documentation for Residents R1, R2, R3, R4, R5, and R6. 28 Pa. Code 211.5(f)(v) Medical records28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility records and job descriptions, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to make certain that proper supervision and self-harm prevention interventions were effectively implemented in the facility. Findings include: The NHA's job description revealed that the NHA's primary purpose is to manage the facility in accordance with current applicable federal, state, and local standards, guidelines and regulations that govern long-term care facilities. To follow all facility policies and apply them uniformly to all employees. To ensure the highest degree of quality care is provided to our residents at all times. The DON's job description revealed that the DON's primary purpose is to plan, organize, develop, and direct the overall operations of the Nursing Service Department in accordance with current federal, state and local standards, guidelines and regulations that govern the facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality of care is maintained at all times. The findings in this report identified that the facility failed to consistently supervise and maintain all safety interventions to prevent self-harm for their residents, and the NHA and the DON failed to fulfill their essential job duties to ensure that the federal and state guidelines and regulations were followed. Refer to F689 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing Services 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of facility policy, manufacturer's guidelines, and clinical records and staff and resident interviews, it was determined that the facility failed to ensure insulin was administered in accordance with good nursing principles and practices for three of 35 residents reviewed (Residents R7, R1, and R2)Findings include: A facility policy, Medication Administration dated 1/20/26, revealed medications are administered, as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so to comply with Federal Laws governing Medication Administration and in order to ensure the safe, accurate and timely administration of medications. Manufacturer's guidelines for Humalog (Insulin Lispro) revealed a subcutaneous injection (medication is injected into the fatty tissue beneath the skin) should be administered within 15-minutes before a meal or immediately after a meal. Manufacturer's guidelines for Novolin Regular (Insulin) revealed a subcutaneous injection should be administered within 30-minutes before a meal or immediately after a meal. Resident R7's clinical record revealed an admission to the facility on 6/20/25, with diagnoses that included Diabetes (a health condition caused by the body's inability to produce enough insulin), Congestive Heart Failure (CHF - a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply causing blood and fluids collect in your lungs and legs over time), and Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing). Resident R7's physician's orders revealed Insulin Lispro Sliding Scale with coverage before meals. The February 2026 Medication Administration Record (MAR) revealed a blood sugar at 5:00 p.m. on 2/26/26, was 336. The clinical record revealed that Licensed Practical Nurse (LPN) Employee E5 administered 10 units of insulin per physician's orders. On 2/26/26, at approximately 5:45 p.m. Resident R7 had not yet received his/her meal tray and experienced a hypoglycemic episode (blood sugar becomes low often times resulting in symptoms such as paleness, shakiness, sweating, slurred speech, confusion, etc.) requiring the administration of Glucagon (medication given to increase your blood sugar) at 5:50 p.m. and again at 6:10 p.m. Resident R1's clinical record revealed an admission to the facility on [DATE], with diagnoses that included Diabetes, Altered mental status (a quick change in brain function ranging from confusion to coma), High Blood Pressure, and Coronary Artery Disease (a heart condition caused by plaque buildup that narrows/blocks arteries in the heart). Resident R1's physician's orders revealed Novolin R Flexpen Injection (Insulin Regular Sliding Scale with coverage with meals. The March 2026 MAR revealed a blood sugar at 11:30 a.m. on 3/05/26, was 315. The clinical record revealed that LPN Employee E3 administered 5 units of insulin per physician's orders. On 3/05/26, at 1:25 p.m. Resident R1's meal for lunch was delivered; confirmed by Certified Nursing Assistant (CNA) Employee E2. Evening insulin administration on 3/05/26, at 4:00 p.m. for Resident R1 revealed LPN Employee E4 administered Novolin R 4 units for a blood sugar of 276. During an interview on 3/05/26, at approximately 5:15 p.m., LPN Employee E4 indicated he/she typically administers insulin one hour before the resident's meal. The dinner meal was then observed being served to Resident R1 at 6:50 p.m. Resident R2's clinical record revealed an admission to the facility on 1/01/26, with diagnoses that included Diabetes, COPD, Gastrointestinal Hemorrhage (blood loss from the digestive tract), and Hypovolemic Shock (a life-threatening emergency caused by a large amount of blood loss from the body). Resident R2's physician's orders revealed Insulin Lispro Sliding Scale with coverage with meals. The March 2026 MAR revealed a blood sugar at 4:00 p.m. on 3/05/26, was 236. LPN Employee E4 administered 3 units of insulin per physician's orders. During an interview on 3/05/26, at approximately 5:15 p.m., LPN Employee E4 indicated he/she typically administers insulin one hour before the resident's meal. The dinner meal was then observed being served to Resident R2 at 6:49 p.m. During an interview on 3/05/26, at 7:30 p.m. the Nursing Home Administrator (NHA) confirmed that insulin should be administered timely before/after a resident's meal such as a 15-minute time span to prevent adverse effects such as hypoglycemia. The NHA further confirmed the manufacturer's guidelines for insulin administration is timely before/after meals. 28 Pa. Code 211.5(f)(i)(x) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, job descriptions, clinical records, resident council minutes, and grievances, observations, and resident and staff interviews, it was determined that the facility failed to provide sufficient nursing staff and services to promote the physical and mental well-being and meet the needs for eight of 15 residents reviewed (Residents R1, R3, R4, R5, R8, R9, R10, and R11).Findings include: A facility policy entitled Call Light Response dated 1/20/26, indicated that staff will respond to the call light and the resident's needs in a timely manner. A facility job description for a Certified Nursing Assistant and RN Charge Nurse revealed part of their Specific job function is to Answer resident calls promptly and Ensure that residents who are unable to call for help are checked frequently. Part of their Customer Service and Resident Rights is to Ensure that call lights are answered by all employees of the facility regardless of department. If you are not trained to assist with request / need then inform resident that you will seek appropriate personnel immediately, then do so. Review of Resident Council minutes over three months from December 2025, and January and February 2026, revealed the following: 12/29/25 Resident Council minutes revealed eight residents in attendance and there are times when the call bells are not answered as timely as they prefer. 2/23/26 Resident Council minutes revealed 20 residents in attendance and staff are not answering call bells on afternoon and midnight shift. Review of grievance logs from December 2025, and January and February 2026, revealed the following related to call bell response: 1/5/26 Resident reported there are times on afternoon shift he/she has to wait longer than preferred for bell to be answered. 1/12/26 Resident reported it takes staff two to three hours to come and help them. 1/13/26 Resident reported staff taking thirty minutes to help him/her. 1/16/26 Resident reported one of the aides makes his/her roommate wait a long time when he/she is using the restroom and they would like their call bell answered timelier. Interviews on 3/05/26, and 3/06/26, with Resident R1 and R1's resident representative, and Residents R3, R4, R5, R8, R9, R10, and R11 all revealed they must wait longer than 30 minutes for their call bell to be answered. Interviews with these residents in addition to a response of 30 minutes or greater revealed the following: Resident R4 indicated during an interview on 3/05/26, at 10:45 a.m. that he/she no longer utilizes his/her call bell since nobody responds to it timely. Resident R4 indicated that he/she just does things himself/herself. Resident R2 indicated during an interview on 3/05/26, at 10:55 a.m. that he/she waited two hours for staff to assist him/her the evening of 3/04/26. Resident R1 indicated during an interview on 3/05/26, at 11:05 a.m. that he/she stopped using the call bell and tap bell provided. Resident R1 stated, I would pound on that bell and nobody would come, so I just holler out. Resident R1's resident representative nodded his/her head in agreement. Observation and interview on 3/05/26, at 12:15 p.m. revealed Resident R8 resting in bed, upset and calling out for a nurse. Resident R8 indicated at this time he/she called 911 due to bleeding related to a foley catheter. Resident R8 further indicated that he/she placed his/her call bell on at 10:30 a.m. and had been waiting for staff to assist him/her. The Director of Nursing (DON) confirmed while at Resident R8's bedside on 3/05/26, at 12:30 p.m. that Resident R8 was bleeding with large blood clots observed. Emergency medical service with a stretcher did arrive at Resident R8's room at 12:30 p.m. and he/she was transferred to the hospital. Resident R8 returned to the facility evening of 3/05/26 without additional medical interventions. Resident R5 indicated during an interview on 3/05/26, at 3:15 p.m. that he/she must propel his/her wheelchair to the nurses' station to get staff to assist him/her. During an interview on 3/05/26, at 6:20 p.m. the DON confirmed that all residents should have their call bells responded to in a timely manner, and waiting 30 minutes or greater is an unacceptable response to have their needs met by staff. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(4)(5) Nursing services

Based on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to ensure that the call bell system was adequately working for one of six halls (500 hall)Findings include: A facility policy entitled Call Light Response dated 1/20/26, revealed that a call bell or alternative device will be placed within the reach of each resident while in their room, toilet, or bathing area. The policy further revealed that staff will be alerted to signals that the call bell is on by the following: Flashing light on intercomBeeping of intercomLighted call signal over the resident's doorSounding of a tap bell During an interview on 3/05/26, at 9:15 a.m. the Nursing Home Administrator (NHA) revealed that the call bell system on Unit 1 had stopped working and a new system was installed and functioning effective 12/10/25. NHA revealed that some residents still utilized a tap bell per their preference. Observations on 3/5/2026, at 1:22 p.m. revealed each resident room had two assigned numbers outside their room. One number was for the room call bell and the second number was for the bathroom call bell. Observations also revealed an oblong digital unit sitting on the nurse's desk that displayed a two-digit number when a call bell was activated. If the digital unit was cleared of any call bell alerts and a call bell was activated the digital unit beeped three times and displayed a two-digit number. The number remained on the digital unit at the nurse's station until the call bell was acknowledged in the resident's room and/or bathroom but did not continue to beep to notify staff and there was no visible overhead light that illuminated down the hall or outside the resident's room. It was observed that if another resident activated their call bell before the first call bell was acknowledged, the two-digit number was displaced on the digital unit, but there was no audible sound or light that illuminated to alert staff. The digital unit that displayed the two-digit number could only display up to eight numbers at a time. If more than eight call bells are activated, they would not be displayed on the digital unit until previously activated call bells were acknowledged. Testing and observation of all call bells on 500 hall revealed that call bell number 47 associated with room [ROOM NUMBER] did not display on the digital unit when activated. Interview on 3/5/26, at approximately 1:00 p.m. with Resident R7 and his/her family revealed the call bells have not been working adequately for probably a few months now. Resident R7 revealed the facility provided him/her with a tap bell, but his/her daughter purchased him/her a cow bell to use instead to ensure staff heard it. Interviews with facility staff working Unit 1 on 3/5/26, at 1:22 p.m. revealed that even if they hear the three beeps for the first call bell that is activated the only way they know which room it is, is to go to the nurse's station and look at the box sitting on the desk to see which number is displayed. Since the unit only displays two-digit numbers, they then must refer to a list that has all resident room numbers and what their correlating call bell number is to know which resident is calling for something. The staff further revealed they have no way to know if more than one call bell was activated unless they go to the nurse's station to look at the box. During interview on 3/5/26, at 1:33 p.m. Certified Nursing Assistant (CNA) Employee E2 confirmed that the call bell for room [ROOM NUMBER] did not display on the digital unit at the nurse's station when activated. During interview on 3/05/26, at 3:30 p.m. Resident R6's resident representative indicated that the call bell is not working for Resident R6. Observation on 3/6/26, at 1:26 p.m. on Unit 1 revealed the digital unit audible alert was changed from three beeps to a siren that went off four times. Testing and observation of all call bells on 500 hall revealed for a second day that call bell number 47 associated with room [ROOM NUMBER] did not display on the digital unit when activated. During interview on 3/6/35 at 1:40 p.m. Director of Nursing confirmed that the call bell for room [ROOM NUMBER] did not display on the digital unit at the nurse's station when activated. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1) Management

Based on review of facility policies and clinical record and staff interview, it was determined that the facility failed to develop a comprehensive plan of care for one of five residents reviewed (Resident R12).Findings include: A facility policy entitled MDS[Minimum Data Set-a periodic assessment of resident care needs]/RAI/Care Planning dated 1/20/26, indicated the facility will develop a written plan of care individualized for each resident. A facility policy entitled Resident Elopement dated 1/20/26, indicated that any resident with a successful elopement will be reassessed and additional interventions will be identified and included with the Plan of Care. A facility policy entitled Resident Elopement Follow-Up Procedure dated 1/20/26, indicated the plan of care will be modified to incorporate an increased elopement risk and increased monitoring as needed based on behaviors. Resident R12's clinical record revealed an admission date of 11/7/14, with diagnoses that included Paranoid Schizophrenia (a severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations [seeing things or hearing voices that other don't], delusions [believing things that are not real or true], and disorganized thinking), Diabetes (a health condition caused by the body's inability to produce enough insulin), and High Blood Pressure. Review of information submitted by the facility revealed that on 2/26/26, Resident R12 eloped from the facility. Clinical record review revealed an Elopement Risk Assessment completed 2/26/26, that identified Resident R12 was at risk for elopement. Review of Resident R12's comprehensive plan of care failed to reveal a care plan for Resident R12's risk for and/or actual elopement. During an interview on 3/6/26, at 10:41 a.m. Registered Nurse Assessment Coordinator Employee E1 confirmed that Resident R12's comprehensive plan of care did not include a care plan for his/her risk for or actual elopement. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on review of facility policies and clinical record, and staff interview, it was determined that the facility failed to maintain accurate and complete documentation related to an incident for one of five residents reviewed (Resident R12).Findings include: A facility policy entitled Documentation dated 1/20/26, indicated nursing documentation will follow the guidelines of good communication and be concise, clear, pertinent, and accurate and that it will communicate resident's status and provided accurate accounting of care and monitoring provided. A facility policy entitled Resident Elopement dated 1/20/26, indicated that residents shall be reassessed at least quarterly related to elopement risk. Resident R12's clinical record revealed an admission date of 11/7/14, with diagnoses that included Paranoid Schizophrenia (a severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations [seeing things or hearing voices that other don't], delusions [believing things that are not real or true], and disorganized thinking), Diabetes (a health condition caused by the body's inability to produce enough insulin), and High Blood Pressure. Review of facility reported incident revealed that on 2/26/26, Resident R12 eloped from the facility. Clinical record progress notes lacked any evidence of Resident R12 eloping from the facility, his/her safe return, and/or physician and/or resident representative notifications. Review of Elopement Risk Assessment's completed on Resident R12's revealed they were completed on 1/14/25, 4/17/25, and 2/26/26. The clinical record lacked evidence that they were completed quarterly. During an interview on 3/6/26, at 10:35 a.m. the Director of Nursing (DON) confirmed that Resident R12's clinical record lacked evidence of Resident R12 eloping from the facility, his/her safe return, and/or physician and/or resident representative notification. The DON further stated that Risk Management and/or a progress note should have been completed for Resident R12. During an interview on 3/06/26, at 10:30 a.m. the DON and Registered Nurse Assessment Coordinator (RNAC) Employee E1 stated they were not sure how often Elopement Risk Assessments were completed on each resident. During an interview on 3/6/26, at 11:44 a.m. Nursing Home Administrator (NHA) was unable to verify how often Elopement Risk Assessments were done and would check with the RNAC. The NHA confirmed that Resident R12's clinical record lacked evidence of Elopement Risk Assessments being completed on a quarterly basis. 28 Pa. Code 211.5(f)(ii)(iii) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, facility policy and staff interview, it was determined that the facility failed to notify the physician in a timely manner of changes in a resident's condition after sustaining an injury from a fall for one of four residents (Resident CR1) that resulted in actual harm of emotional distress related to increasing pain to the resident. Findings include: Resident CR1's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. The clinical record also indicated that Resident CR1 was at high risk for falls and experienced pain frequently, rating the pain on the current Minimum Data Set (MDS - periodic assessment of resident care needs), dated 8/15/19, as three out of 10 on a pain scale, with ten being the most severe rating. The facility policy entitled Notification of Condition Change: Physician, dated 9/04/19, indicated that licensed professional nurses are responsible to provide timely and complete communication to physicians when there is a change in a resident's condition, that if a nurse feels uncomfortable with a situation, contacting the physician should not be delayed, and indicated examples of conditions that may require notification included falls, [MEDICAL CONDITION] (swelling), and pain. The policy further indicated physician notification should be documented in the 24-hour report and in the clinical record. Resident CR1's clinical record revealed that on 10/20/19, at 5:11 p.m. he/she was discovered sitting on the floor of his/her room after sliding out of the wheelchair. The record indicated that upon assessment, Resident CR1 had no complaints of injuries, pain or discomfort and that the on-call Certified Registered Nurse Practitioner (CRNP), family and Director of Nursing were notified of the fall. On 10/20/19, at 7:44 p.m. documentation indicated that Resident CR1 began to complain of left lower leg pain and that [MEDICAL CONDITION] (swelling) was present in the left knee and ankle. The note further indicated that it was painful for Resident CR1 to move his/her toes and after notifying the CRNP, an order for [REDACTED]. On 10/20/19, at 10:47 p.m. a progress note indicated that Resident CR1 continued to complain of pain in the left knee and ankle, and that noticed a hematoma (a collection of blood with swelling) that was swelling, went and had RN (Registered Nurse) look at the knee and she did . when putting resident to bed and put legs on bed resident yelled out in pain and more swelling and left ankle swollen and complaining in ankle also. On 10/21/19 at 1:05 a.m. a progress note revealed that Resident CR1 had continued pain and swelling of the left knee and that [MEDICATION NAME] (an over-the-counter medication for pain and inflammation), 400 milligrams (mg) was administered at 1:35 a.m. for complaints of leg pain rated as a ten on the pain scale. A re-assessment of Resident CR1's pain at 3:56 a.m. evaluated the pain medication as ineffective with Resident CR1 rating the pain as a nine out of ten. At 6:32 a.m. on 10/21/19, progress notes indicated that Resident CR1 was repositioned and that ice packs were applied to the left leg with ineffective results. Documentation indicated that the left leg remained swollen, was curved inward and that Resident CR1 was crying and wanting relief. The note indicated the supervisor assessed the resident for positioning and swelling of the leg. The note indicated family aware of discomfort and will continue to monitor. On 10/21/19, at 2:22 p.m. a progress note indicated that x-ray results of the left lower leg, revealed that Resident CR1 had a [MEDICAL CONDITION] proximal (nearest to the body) tibia and fibula (lower leg bones) with mild displacement (bones out of alignment) and that Resident CR1 was transferred to the hospital at at 3:31 p.m. Resident CR1's clinical record lacked evidence that the physician or CRNP was notified of Resident CR1's ongoing increasing pain with emotional distress and unrelieved by pain medication, the development of a hematoma, or the documented deformity of the lower left leg. During an interview on 11/14/19, at 2:45 p.m. the RN Supervisor Employee E2 confirmed that there was no evidence in the clinical record that the physician or CRNP was notified of the declining condition resulting in increasing pain with emotional distress for Resident CR1 occurring after the second call placed on 10/20/19, at 7:44 p.m. until x-ray results were received on 10/21/19 identifying a fracture, a period of approximately 18 1/2 hours. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 1/24/18, 1/26/18, 6/11/18 28 Pa. Code 201.18(a)(b)(1) Management Previously cited 4/25/19, 6/11/18, 1/24/18 28 Pa. Code 211.5(f)(g) Clinical records Previously cited 12/21/18, 1/26/18 28 Pa. Code 211.10(a)(d) Resident care policies Previously cited 12/21/18 28 Pa. Code 211.12(c) Nursing services Previously cited 6/11/18, 1/24/18 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 12/21/18, 6/11/18, 1/26/18

Based on review of clinical records, facility documentation and policy and staff interviews, it was determined that the facility failed to provide timely, appropriate, and effective interventions for a resident involved in an accident with an injury of leg fractures resulting in actual harm of increased pain and emotional distress for one of four residents sustaining a fall with injury (Resident CR1). Findings include: Resident CR1's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. The clinical record also indicated that Resident CR1 was at high risk for falls and experienced pain frequently, rating the pain on the current Minimum Data Set (MDS - periodic assessment of resident care needs), dated 8/15/19, as three out of ten on a pain scale, with ten being the most severe rating. Resident CR1's care plan related to pain, indicated that pain was to be assessed for pain relief measures, that staff were to respond immediately to any complaints of pain, to medicate with ordered medications and provide non-pharmacological interventions such as distraction and repositioning, and that the physician was to be notified if interventions were unsuccessful or if the current complaint was a significant change from the resident's past experience of pain. The facility policy entitled Notification of Condition Change: Physician, dated 9/04/19, indicated that licensed professional nurses are responsible to provide timely and complete communication to physicians when there is a change in a resident's condition, that if a nurse feels uncomfortable with a situation, contacting the physician should not be delayed, and indicated falls, [MEDICAL CONDITION] (swelling) and pain as examples of conditions that may require physician notification. The policy further indicated physician notification should be documented in the 24-hour report and in the clinical record. Resident CR1's clinical record revealed that on 10/20/19, at 5:11 p.m. Resident CR1 was discovered sitting on the floor of his/her room after sliding out of the wheelchair. Upon assessment, Resident CR1 had no complaints of injuries, pain or discomfort. On 10/20/19, at 7:44 p.m. documentation indicated that Resident CR1 began to complain of left knee and ankle pain, and that 2 + [MEDICAL CONDITION] (swelling marked by the tissue/skin leaving a slight indentation when pressed) of the left knee and 1 + [MEDICAL CONDITION] of the left ankle (swelling marked by the tissue/skin leaving a barely imperceptible indentation when pressed) was present on assessment. The note further indicated that it was painful for Resident CR1 to move his/her toes and after notifying the Certified Registered Nurse Practitioner (CRNP), an order for [REDACTED]. Resident CR1's Medication Administration Record [REDACTED]. A clinical progress note, dated 10/20/19, at 10:45 p.m. indicated that Resident CR1 continued to complain of left knee pain, had swelling of the left ankle, yelled out in pain when placed in bed and that a hematoma (a swollen area filled with blood, usually from a broken blood vessel) of the left knee was now present and evaluated by a Registered Nurse (RN). The clinical record lacked evidence of an assessment of the knee by the RN or documentation to support that the physician ordered [MEDICATION NAME] or non-pharmacological interventions were implemented or offered. At 1:05 a.m. on 10/21/19, documentation revealed Resident CR1 continued to complain of pain in the left knee and was medicated with [MEDICATION NAME] 400 mgs at 1:35 a.m. (over five hours after initial complaints of pain) for pain in the knee, rated now by Resident CR1 as ten out of ten. A re-assessment of Resident CR1's pain at 3:56 a.m. indicated that the pain medication administered at 1:05 a.m. was ineffective and that Resident CR1 rated the leg pain as a nine out of ten. At 6:32 a.m. on 10/21/19, progress notes indicated that Resident CR1 was repositioned and that ice packs were applied with ineffective results. Documentation indicated that the left leg remained swollen, was curved inward and that Resident CR1 was crying and wanting relief. The note indicated the supervisor assessed the resident for positioning and swelling of the leg. The record lacked an assessment by the supervisor or any intervention to address the unrelieved pain. The note stated scheduled for an x-ray, family aware of residents discomfort. Will continue to monitor. On 10/21/19, at 2:22 p.m. a nursing progress note indicated that x-ray findings, faxed to the facility at 12:47 p.m. revealed Resident CR1 had a [MEDICAL CONDITION] proximal tibia and fibula with mild displacement (bones out of alignment). A progress note dated 10/21/19, at 3:31 p.m. indicated that Resident CR1 was transferred to the hospital (22 hours after the initial injury.) A progress note, written by Certified Nurse Practitioner Employee E3, based on an exam prior to Resident CR1's transfer to the hospital, indicated that Resident CR1 sustained a mildly displaced [MEDICAL CONDITION] (nearer to the body) tibia and fibula on the evening of 10/20/19, when he/she slid from the wheelchair and fell on the left knee. The note indicated that the resident rated his/her current pain as ten out of ten, that [MEDICATION NAME] had been somewhat effective but that two tablets of [MEDICATION NAME] (a narcotic pain medication) 5/325 mg, was ordered for pain prior to transport to the hospital. The left lower leg was described in the note as slightly deformed at the knee, with bruising to the knee and upper shin. A statement signed by the RN Supervisor Employee E1, who worked from 7:00 p.m. to 7:00 a.m. on 10/20/19, through 10/21/19, indicated that he/she was advised that Resident CR1 had fallen and sustained an injury to the left knee and ankle on the prior shift and was having a lot of pain since the fall. The statement further indicated the leg was [MEDICAL CONDITION] (swollen) just below the knee and his/her foot was rotated in. The statement further indicated that Resident CR1's pain was worse with movement and that the on-call x-ray service had been contacted immediately, order received for stat (urgent/rushed) x-ray. Stated would be in through the night but by 6 a.m. x-ray still had not come by the end of my shift in the a.m. During an interview on 11/14/19, 10:30 a.m. RN Employee E2, who was on duty the morning of 10/21/19, indicated that the x-ray service did not arrive to perform Resident CR1's x-ray until late morning and didn't call to report that Resident CR1 had sustained a fracture. RN Employee E2 indicated that the report was found on a printer, at which time the CRNP was notified, and an order obtained for [MEDICATION NAME] (a narcotic pain medication) 5/325 mg, two tablets to be given by mouth now prior to transfer to the hospital. During an interview on 11/14/19, at 2:45 p.m., the Nursing Home Administrator and Director of Nursing confirmed that Resident CR1 was not provided timely care and services to address the change in condition following a fall that resulted in actual harm of increased associated pain with emotional distress. 28 Pa. Code 201.18(a)(b)(1) Management Previously cited 4/25/19, 10/24/18, 6/11/18, 1/24/18 28 Pa. Code 211.5(f)(g) Clinical records Previously cited 12/21/18, 1/26/18 28 Pa. Code 211.10(a)(d) Resident care policies Previously cited 12/21/18 28 Pa. Code 211.12(c) Nursing services Previously cited 6/11/18, 1/24/18 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 12/21/18, 6/11/18, 1/26/18

Based on observation, review of clinical records and facility documentation, and staff interviews, it was determined that the facility failed to adequately supervise and maintain a safe environment for residents with [MEDICAL CONDITION] (SI) for one of two residents (Resident R1) who accessed the roof through an unsecured second floor window resulting in the potential for serious harm. This failure placed the resident at a high risk for injury and resulted in an Immediate Jeopardy situation. Findings include: Review of the information dated 6/3/18, submitted by the facility revealed Resident R1 was observed by an employee on 6/2/18 to be on the facility's roof from 3:15 p.m. until 3:20 p.m. and the resident then voluntarily reentered the building through their bathroom window. Resident R1's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED].), obsessive-compulsive disorder (an anxiety disorder in which people have unwanted and repeated thoughts, feelings, images, and sensations), impulsiveness (a tendency to act on a whim), recurrent [MEDICAL CONDITION] (a severely depressed mood that persists for at least two weeks), and unspecified intellectual disabilities (causes a person with a low IQ (below 70) to have behavioural as well as social problems). Review of Resident R1's History and Physical dated 4/3/18, revealed 1) the resident had [DIAGNOSES REDACTED]. to act on this; 5) resident consents to safety and to not act on impulses today, monitor closely. A psychiatric progress note for Resident R1 dated 4/24/18, revealed [DIAGNOSES REDACTED]. Resident R1's Certified Registered Nurse Practitioner (CRNP) progress note, dated 5/23/18, revealed the resident to be very agitated with a desire to harm himself, and was requesting voluntary psych admission for safety. The resident indicated he/she wanted to hit people, was upset with the social worker and is going to go off, cannot promise not to harm him/herself or others if he/she does not get away. Further review revealed the resident was admitted to an acute care facility from 5/23/18 to 5/31/18, and had returned to the facility on [DATE]. Resident R1's nursing progress notes dated 6/1/18, at 1:28 p.m. revealed the resident had increased anxiety and was pacing the halls with fist doubled up, expressing a desire to be out of the facility. Nursing progress notes dated 6/2/18, at 11:37 a.m. noted increased agitation and behaviors, using the roommate's computer without permission, banging doors, and being verbally abusive to staff. Resident R1's nursing progress note dated 6/2/18, at 4:11 p.m. revealed the resident was seen on the kitchen roof by the staff and that the window in the bathroom was unlocked and able to be opened. After returning into the building from the roof, Resident R1 was threatening harm to staff and then gained access to the dining room and called his/her mother on the phone. Resident R1's nursing progress note dated 6/2/18, at 4:02 p.m. revealed Resident R1 broke into the dining room after being on the roof, had called his/her mother and stated to her he/she was going to jump off the roof. A facility tour on 6/7/18, at 9:00 a.m. of the second floor locked unit where Resident R1 resided revealed one side of the hallway with rooms that had a window with a secured window air conditioning unit in place that looked out onto an adjacent attached first floor kitchen roof. Some of the second floor rooms also had a bathroom with a window overlooking the roof. The window was located beside the bathroom sink. Resident R1, had a bathroom window located beside the bathroom sink, which at the time of the tour was secured to permit the window to open no more than four inches. During an interview on 6/7/18, at 4:40 p.m. the Director of Nursing (DON) stated the facility was unaware of the documentation in the History and Physical stating the resident had a suicide plan to jump out a window, but should have been aware of this information. During an interview on 6/7/18, at 10:06 a.m. the Maintenance Director stated that at the time of the incident, maintenance had been notified to check the windows. Resident R1's room window was not secured and was able to be opened. An audit of all the windows was completed and revealed two additional windows on the unit that were able to be opened, which were then secured. The Maintenance Director stated that the windows were not routinely checked to prevent roof access and were not checked when Resident R1 was admitted . Immediate Jeopardy of the health and safety of the residents was identified to the Nursing Home Administrator at 5:55 p.m. on 6/7/18, and an immediate corrective action plan was requested. The facility's immediate corrective action plan submitted on 6/7/18, included: 1) Resident came in off roof on (their) own and went to (their) room on 6/2/18. 2) Nurse found him/her lying in his/her bed and visually observed him/her walk out of room and go into dining room. 1:1 was immediately implemented when resident came in off roof. 3) Nursing Supervisor placed call to (facility) due to resident expressing desire to be admitted there. (facility) informed this facility could not direct admit. 4) Call was placed to (ambulance company) by DON to transport resident to (acute care facility) for a psych evaluation. DON called (acute care facility) to inform resident was in route. 5) (acute care facility) would not admit and resident returned to facility. 6) 1:1 was maintained with resident from return from (acute care facility) on 6/2/18 and was maintained until 6/4/18, when resident was transferred to (another acute care facility) and then to (psychiatric facility). 7) Maintenance immediately secured resident's bathroom window on 6/2/18. An audit was completed to ensure all windows were secured to prevent residents from elopement on 6/2/18. 8) RCA (root cause analysis) was completed to determine why facility did not have physician note from 4/3/18. RCA revealed physician note was not either given to facility by physician or failed to be scanned into chart. Either way facility was not aware of note. 9) Nursing Administration will exit or round with Physician/CRNP for critical alerts. 10) DON/Assistant DON will review Physician/CRNP notes prior to be filed in medical record. 11) Education will be provided to medical records, nursing, and physician/CRNP on new procedure for rounding and exiting to communicate critical alerts. 12) Maintenance was educated on securing windows on 6/2/18. Education/Training regarding rounding with the physician/CRNP to review any critical alerts from visits and ensuring History and Physical's and progress notes from physicians/CRNP are reviewed and transferred into the medical record was not completed until 6/8/18. Following verification of the implementation of the immediate corrective action plan and review of the assessment of roof access, the Immediate Jeopardy was subsequently lifted at 11:58 a.m. on 6/8/18. The facility failed to ensure each resident received adequate supervision to prevent accidents, and failed to ensure the resident environment remained free of accident hazards related to roof access through unsecured windows with a resident who had [MEDICAL CONDITION] that caused the potential for more than serious harm to one resident, and placed other residents at risk for potential harm, identifying an Immediate Jeopardy situation. Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) - Previously cited 12/01/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 01/26/18, 01/24/18, 12/01/16 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(1) Management Previously cited 01/26/18, 01/24/18, 12/01/16 28 Pa. Code 201.18(b)(3)(e)(1) Management Previously cited 01/24/18 28 Pa. Code 207.2(a) Administrator's responsibility Previously cited 01/24/18, 12/01/16 28 Pa. Code 211.12(c) Nursing services Previously cited 01/24/18 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 01/26/18, 12/01/16

Based on observations, review of select facility policies, and staff interview, it was determined that the facility failed to maintain a sanitary kitchen for all residents creating an Immediate Jeopardy (IJ) situation for one of one kitchens. Findings include: The Sanitation policy, dated 9/28/17, indicated that all kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies, and other insects. On initial tour of the kitchen on 1/10/18, between 7:50 a.m. and 8:25 a.m., there were 14 live cockroaches and two dead stink bugs observed in the dish area and one dead stink bug by the steam table. This was confirmed by Registered Dietitian (RD) Employee E1 on 1/10/18 at 8:20 a.m. At 8:50 a.m., there was one small live bug on the steam table; confirmed by Dietary Employee E2 at the time of the observation. The facility contracted with a Pest Control company and recommendations on the 11/14/17 invoice included to clean food debris under and behind equipment, on stainless steel counters, in corners, and advise that all cracks and crevices be eliminated. Observation of the kitchen on 1/10/18, between 7:50 a.m. and 8:40 a.m. revealed that the floors under and behind the equipment and in corners were dirty with food items, leaves, and dirt. This was confirmed by Dietary Manager Employee E3 on 1/10/18 at 8:30 a.m. There were two leaking pipes in the dish area creating wet conditions under/on top of equipment; confirmed by RD Employee E1 on 1/10/18 at 10:15 a.m. The red buckets used for sanitizing the counters were on the floor containing brownish water and used towels. This was confirmed by Dietary Manager Employee E3 on 1/10/18 at 8:25 a.m. The kitchen's walls and containers on the walls had a brown/black substance on them. There was an unknown/offensive odor in the dish area confirmed by RD Employee E1 on 1/10/18 at 8:17 a.m. The ventilation hood had a brown/black substance on it. The opening of the outside plastic packages for two loaves of bread were lying on a rug with brown/black areas. This was confirmed by the Regional Assistant Director of Dining Employee E4 on 1/10/18 at 9:00 a.m. Cracks and crevices were observed in the corners and in the flooring underneath the equipment, which was confirmed by RD Employee E1 on 1/10/18 at 8:18 a.m. The facility contracted with a different Pest Management company on 12/29/17 for cockroach control in the kitchen areas. However, as stated above, on 1/10/18, there were 14 live cockroaches and two dead stink bugs observed in the dish area and one dead stink bug by the steam table. In addition, there was one small live bug on the steam table. The kitchen area had a weekly cleaning schedule with a spreadsheet that was to be initialed when each daily cleaning task was completed. When reviewing the (MONTH) (YEAR) through (MONTH) 9, (YEAR) spreadsheets, it was determined that each monthly spreadsheet was missing a significant number of initials of the staff members completing the cleaning tasks. During an interview on 1/10/18 at 1:15 p.m., Dietary Manager Employee E3 confirmed that the weekly cleaning schedule was not being followed and cleaning tasks were not getting done. On 1/10/18, at 9:30 a.m. the Nursing Home Administrator (NHA) was informed that Immediate Jeopardy (IJ) was identified in the kitchen because of 14 live cockroaches in the dish area and one small live bug on the steam table. The first immediate action plan for kitchen sanitation was received on 1/10/18, at 2:55 p.m.; the second revision was received on 1/10/18, at 4:30 p.m.; the third revision was received on 1/10/18, at 5:36 p.m. The immediate action plan was accepted on 1/10/18, at 5:55 p.m. The plan included continued treatment with the Pest Management company, audit of areas in the kitchen that needed cleaned, education to dietary staff on kitchen sanitation, immediate intense cleaning of the dish room, drawers, floors, under salad sink, carts, fans, shelf below the mixer, cobwebs, and storage room floor, implemented sanitation audit, updated cleaning protocol including pest control recommendations, audits of kitchen sanitation twice a week, and daily audits of kitchen by NHA/designee. The dietary manager/designee will conduct opening and closing rounds of the kitchen, and the dietary manager/designee will report issues and corrections during daily meetings. The IJ was subsequently lifted on 1/11/18, at 1:25 p.m. when the plan was confirmed to be fully implemented and all kitchen areas were deemed safe to store and serve food. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 12/01/16, 11/01/16 28 Pa. Code 201.18(b)(1) Management Previously cited 12/01/16 28 Pa. Code 201.18(b)(3)(e)(1)(3) Management 28 Pa. Code 207.2(a) Administrator's responsibility Previously cited 12/01/16, 01/28/16 28 Pa. Code 211.6(d) Dietary services 28 Pa. Code 211.6(f) Dietary services Previously cited 09/09/17, 12/01/16

Based on review of facility documentation, review of select facility policies, and staff interview, it was determined that the facility failed to ensure nursing services provided met professional standards of quality regarding medication administration as set forth in the Pennsylvania code Title 49. Professional and Vocational Standards, Section 21.145 (b) Functions of the Licensed Practical Nurse for 17of 38 residents on Unit Four. Findings include: The facility Agency Orientation policy, dated 9/28/17, indicated that the Agency staff must meet Pennsylvania requirements for working in Long Term Care. As defined in the 28 Pa. Code Long Term Care Facilities Licensure Guidelines 201.3(i), a Nurse Aide (NA) is an individual providing nursing or nursing-related services to residents in a facility who does not have a license to practice professional or practical nursing in the Commonwealth. The Pennsylvania code Title 49. Professional and Vocational Standards, Section 21.145 (b) Functions of the Licensed Practical Nurse notes that the LPN (licensed practical nurse) administers medications and carries out therapeutic treatment prescribed as ordered for the patient. Review of information dated 12/29/17, submitted by the facility, to the PA Department of Health revealed that Agency Employee E5 was a NA and passed medications on 12/27/17 to residents on Unit Four. The (MONTH) (YEAR) Medication Administration records revealed that Agency NA Employee E5 administered medications to 17 of 38 residents on 12/27/17, from 6:00 p.m. until 11:00 p.m. on Unit Four as follows: Resident R1 was administered [MEDICATION NAME] (medication to treat elevated cholesterol level) 10 milligrams (mg) and 20 mg dose; [MEDICATION NAME] (medication to treat inability to sleep) 3 mg; Artificial tears 2 drops both eyes, [MEDICATION NAME]([MEDICATION NAME] sulfate ER to treat pain) 15 mg; and PRN (as needed) [MEDICATION NAME] (pain medication) 325 mg. Resident R2 was administered Atorvastatin (medication to treat elevated cholesterol) 80 mg; [MEDICATION NAME] mg; Klor Con M20 (potassium supplement); [MEDICATION NAME] (medication to nerve disorder) 300 mg; [MEDICATION NAME] (medication to treat nausea) 4 mg Resident R3 was administered Donepezil (medication to treat senile dementia) 10 mg; [MEDICATION NAME] 20 mg; [MEDICATION NAME] (medication to treat [MEDICAL CONDITION]) 0.5 mg; [MEDICATION NAME] (medication to treat elevated blood pressure) 0.1 mg; [MEDICATION NAME] (medication to treat anxiety) 0.5 mg; [MEDICATION NAME] (medication to treat elevated blood pressure) 25 mg; [MEDICATION NAME] ER (medication to treat pain) 10 mg; Nudexta (medication to treat uncontrollable crying or laughing); [MEDICATION NAME] (medication to treat dementia and behavior disturbances) 500 mg. Resident R4 was administered Senna (medication to treat constipation) 8.6 mg; Artificial tears on drope both eyes; Tylenol Extra Strength (medication to treat pain) 500 mg. Resident R5 was administered [MEDICATION NAME] 3 mg. Resident R6 was administered Tamsulosin (medication to treat [MEDICAL CONDITION]) 0.4 mg; [MEDICATION NAME] (medication to treat diarrhea) AD-Tablet 2 mg; Sodium [MEDICATION NAME] (medication to treat stomach acidity) 1950 mg. Resident R7 was administered [MEDICATION NAME] 5 mg; Carvediol (medication to treat elevated blood pressure) 12.5 mg; [MEDICATION NAME] (form of vitamin D) 2000 units; [MEDICATION NAME] (medication to treat constipation) 100 mg; Tylenol Extra Strength 500 mg. Resident R8 was administered Atorvastatin 40 mg; [MEDICATION NAME] (medication to treat pain) 5-325 mg; Eliquis (medication to treat improper beating of the heart) 2.5 mg; [MEDICATION NAME] 37.5 mg. Resident R9 was administered Atorvastatin 20 mg; [MEDICATION NAME] (allergy relief medication) one spray each nostril; [MEDICATION NAME] 250 mg. Resident R10 was administered Simvistatin (medication to treat elevated cholesterol) 40 mg; [MEDICATION NAME] (medication to treat pneumonia) 500 mg; [MEDICATION NAME] 25 mg; [MEDICATION NAME] (medication to increase tear production in the eyes) one drop both eyes. Resident R11 was administered [MEDICATION NAME] (powder applied to abdominal folds); [MEDICATION NAME] Sodium (medication to treat elevated cholesterol) 40 mg; Trazadone (medication to treat depression) 75 mg; [MEDICATION NAME] Diskus Aerosol Powder (medication to treat lung disorder) one puff inhaled orally; Carvediol 25 mg; Insulin (medication to help stabilize blood sugar level) 43 units; [MEDICATION NAME] Solution (medication to treat [MEDICAL CONDITION]) one drop both eyes. Resident R12 was administered Simvistatin 40 mg; [MEDICATION NAME] (medication to treat acid reflux) 150 mg; Eliquis 2.5 mg; [MEDICATION NAME] 36 units; ProAir HFA Aerosol Solution (medication to treat wheezing) two puffs inhaled; Tylenol Arthritis Pain 650 mg. Resident R13 was administered Atorvastatin 10 mg; Senna 8.6 mg; Carvediol 3.125 mg; [MEDICATION NAME] (medication to help bowel movements) 17 grams; [MEDICATION NAME] one vial inhaled orally; [MEDICATION NAME] Acetate (steroid to treat a variety of conditions) one drop both eyes. Resident R14 was administered [MEDICATION NAME] Cream (cream to treat pain); [MEDICATION NAME] 5 mg; [MEDICATION NAME] 100 mg; [MEDICATION NAME] 650 mg. Resident R15 was administered [MEDICATION NAME] (blood thinner medication) 3 mg; [MEDICATION NAME] 24 units; [MEDICATION NAME] (blood thinner medication) 75 mg; [MEDICATION NAME] Sodium 80 mg; Senna 8.6 mg; [MEDICATION NAME] 100 mg; [MEDICATION NAME] 50 mg; [MEDICATION NAME] 500 mg; Prosource (nutritonal supplement) 30 milliliters; [MEDICATION NAME] (medication to treat pain) 5 mg. Resident R16 was administered [MEDICATION NAME] 3 mg. Resident R17 was administered Atorvastatin 10 mg; [MEDICATION NAME] (medication to treat elevated blood pressure) 10 mg; [MEDICATION NAME] 1 mg; Trazadone 50 mg; Saline Nasal Spray four sprays each nostril; [MEDICATION NAME] (medication to treat pain) 50 mg. The facility investigation revealed that Agency NA Employee E5 did not identify themselves as a NA and did not inform anyone that they were not a Licensed Practical Nurse (LPN). Investigation revealed that it was unknown if NA Employee E5 wore a name badge. The investigation also revealed that Agency NA Employee E5 passed medications on Unit Four. During an interview on 1/10/18, at 10:15 a.m., LPN Employee E6 confirmed that Agency NA Employee E5 did not identify themselves as a NA on 12/27/17. During an interview on 1/10/18, at 11:50 a.m., Scheduler Employee E7 confirmed that Agency NA Employee E5's credentials were not verified prior to working on 12/27/17. During an interview on 1/10/18, at 10:40 a.m., the Director of Nursing confirmed that Agency NA Employee E5 was not qualified to have passed medications to those 17 residents and that their credentials were not verified prior to working on 12/27/17. 28 Pa. Code 201.3 Definitions 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 12/01/16, 11/01/16 28 Pa. Code 201.18(b)(1) Management Previously cited 12/01/16 28 Pa. Code 201.18(b)(3)(e)(1) Management 28 Pa. Code 201.19 Personnel policies and procedures 28 Pa. Code 201.21(a) Use of outside resources 28 Pa. Code 211.12(c)(d)(2) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 12/01/16, 01/28/16