Every finding on record at Kittanning Health & Rehab Center

Based on review of facility policy, clinical records, staff interview, and observations, it was determined that the facility failed to provide appropriate respiratory care for three of four residents (Resident R1, R2, and R3).Findings include: Review of facility policy Oxygen Administration dated 7/17/26, indicated clinicians with demonstrated competence will administer oxygen via the specified route ordered by a provider. Change tubing, mask, cannula weekly. Change prefilled humidifier bottle when empty. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/3/26, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), depression, and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Section O Special Treatments, Procedure and Programs O0110, C1 Oxygen Therapy is marked as while a resident. During an observation on 8/31/26, at 11:01 a.m. Resident R1 was lying in bed with oxygen on. The nasal cannula (NC- a lightweight, flexible tube used to deliver oxygen to people with breathing difficulties), and humification bottle were not dated. The humidification bottle was empty. Review of Resident R1's physician order dated 5/5/26, indicated to administer oxygen via NC continuously at two liters. Check concentrator to ensure functioning and appropriate setting. Check humidifier if applicable. Review of Resident R1's physician order dated 2/18/25, indicated clean oxygen concentrator and filter, change tubing weekly on Sunday. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's MDS dated [DATE], indicated diagnoses of high blood pressure, depression, and cerebral palsy (group of disorders that affect a person's ability to move and maintain balance and posture). Section O Special Treatments, Procedure and Programs O0110, C1 Oxygen Therapy is marked as while a resident. During an observation on 8/31/26, at 11:09 a.m. Resident R2 was lying in bed with oxygen on. The NC and humification bottle were not dated. The humidification bottle was empty. Review of Resident R2's physician order dated 5/5/26, indicated to administer oxygen via NC continuously at two liters. Check concentrator to ensure functioning and appropriate setting. Check humidifier if applicable. Review of Resident R2's physician order dated 2/18/25, indicated clean oxygen concentrator and filter, change tubing weekly on Sunday. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's MDS dated [DATE], indicated diagnoses of heart failure, anxiety, and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Section O Special Treatments, Procedure and Programs O0110, C1 Oxygen Therapy is marked as while a resident. During an observation on 8/31/26, at 11:15 a.m. Resident R3 was lying in bed with oxygen on. The NC and humification bottle were not dated. The humidification bottle was empty. Review of Resident R3's physician order dated 5/5/26, indicated to administer oxygen via NC continuously at two liters. Check concentrator to ensure functioning and appropriate setting. Check humidifier if applicable. Review of Resident R3's physician order dated 7/1/25, indicated clean oxygen concentrator and filter, change tubing weekly on Sunday. During an interview on 8/31/26, at 11:25 a.m. Licensed Practical Nurse (LPN) Employee E1 stated, They should be changed every week, and confirmed the NC and humidification bottles were not dated and the humidification bottles were empty for Resident's R1, R2, and R3. LPN Employee E1 confirmed that the facility failed to provide appropriate respiratory care for three of four residents (Resident R1, R2, and R3). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services

Based on review of facility policy, clinical record review, resident interview, and interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for two of six residents reviewed (Resident R31, and R53) which resulted in actual harm (a medication overdose that caused unresponsiveness and required the administration of Narcan- a medication used to reverse overdoses of opioids [pain medication with a high risk of addiction] that is administered via a nasal spray) for Resident R31.Findings include: Review of facility policy General Dose Preparation and Medication Administration dated 6/18/25, stated prior to administration of medication, facility should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the resident. Review of the clinical record revealed that Resident R31 was admitted to the facility on [DATE]. Review of Resident 31's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 12/23/25, indicated diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and pain. Review of Resident R31's Nurse Practitioner progress note dated 4/3/25, at 11:56 a.m. indicated that Resident R31 was seen per staff request following patient requiring to have 1 mg (milligram) of Narcan due to unresponsiveness. Per staff resident asked for diazepam (medication used to treat anxiety), around midnight. He was given oxycontin (an opioid pain medication containing oxycodone that is slow released over a 12-hour period) by error which was discovered during pill count at end of shift this morning. He also received his regular two Percocet (an opioid pain medication containing oxycodone and acetaminophen) at 12:31 a.m. and one Percocet at 7:31 a.m. When going to retrieve his lunch tray staff found him lying face down on his bed. He was not waking up easily. Supervisor gave him 1 mg Narcan and, at that time resident had a pulse, and was coming around awake, and talking. Continues to feel drowsy and is complaining of a dry mouth. Vitals are stable. Patient not to receive any further narcotics today. Will reevaluate orders. Review of a written statement from Licensed Practical Nurse (LPN) Employee E28 dated 4/3/25, stated I'm trying to do everything so perfectly that I'm seeming to be making mistakes instead. If I would have only gave the resident his Valium when I moved the card to the right spot this surely wouldn't of happened. Review of Resident R31's clinical record revealed that resident was not ordered oxycontin. During an interview on 1/7/26, at 7:48 a.m. Resident R31 stated They overdosed me on pain meds. I'm on Percocet, and I asked for Valium. They gave me someone else's pain meds, and they had to Narcan me During an interview on 1/8/26, at 9:23 a.m. LPN Employee E10 stated that she worked the day that Resident R31 was overdosed and had to be administered Narcan. She stated that LPN Employee E28 Realized the count (number of drugs) was off, and she said she couldn't afford to make a mistake. The resident went unresponsive. It was terrifying. You have to read the MAR (medication administration record - a document used to track and record the administration of medications), double check the med cart, and if you're confused you need to clarify. You need to make sure you have the right resident, and the right med. The med card has a resident name on it. During an interview on 1/7/26, at 9:32 a.m. LPN Employee E25 stated that she was aware of the above incident, and that you have to double check everything when you give medications, including the resident, the medications, the dose, the route, and the time. It was a bad mistake because he already received a medication that included oxycodone and then got another dose of it that wasn't his, with an extended release. During an interview on 1/8/26, at 12:24 p.m. the Regional Nurse Consultant Employee E1 confirmed the facility failed to ensure that residents were free from any significant medication errors for Resident R31 which resulted in harm. Review of the clinical record indicated Resident R53 was admitted to the facility on [DATE]. Review of Resident R53's MDS dated [DATE], indicated diagnoses of high blood pressure, depression, and diabetes. Review of Resident R53's care plan dated 3/7/25, indicated to administer diabetic medications and insulin as per orders. Review of a physician order dated 5/9/25, indicated to administer insulin lispro 100 unit/ml (units per milliliter), 12 units with breakfast and dinner plus sliding scale, twice a day. During an observation on 1/6/25, at 9:13 a.m. of Resident R53's medication pass, Licensed Practical Nurse (LPN), Employee E27 failed to prepare or administer Resident R53's insulin. During an interview on 1/6/25. at 9:14 a.m. Resident R53 confirmed she already ate breakfast and did not receive insulin. During an interview on 1/6/25, at 9:15 a.m. LPN, Employee E27 confirmed Resident R53's insulin was not administered as ordered. During an interview on 1/6/25, at 10:38 a.m. the DON confirmed that the facility failed to ensure that residents are free of significant medication errors for one of six residents reviewed (Resident R53) as required. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.10 (c)(d) Resident Care policies.28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of facility documents, and resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of eleven of 16 residents (Group Resident (GR)1, GR2, GR3, GR4, GR5, GR6, GR7, GR8, and GR9, R51, and R88). Findings Include: Review of Payroll Based Journal (PBJ- a mandatory reporting system for nursing homes in which staffing information is reported on a quarterly basis) dated 1/1/25, through 3/31/25, indicated that the facility has a one star rating out of five stars, and that they have excessively low weekend staffing. Review of PBJ dated 7/1/25 through 9/30/25, indicated that the facility has a one star rating out of five stars, and that they have excessively low weekend staffing. During an interview on 1/6/26, at 9:52 a.m. Resident R88 stated that he is supposed to get two showers a week, and that he requires two employees for him to get a shower. I don't always get a shower as they don't always have two employes to shower me. During a resident council group interview on 1/6/26, at 1:00 p.m. nine out of nine residents voiced that the facility is short staffed. During an interview on 1/7/25, at 7:57 a.m. Resident R51 stated I'm supposed to get a shower twice a week and I'm lucky if I get one. I'm told it's because they don't have enough staff. During an interview on 1/8/26, at 9:32 a.m. Licensed Practical Nurse (LPN) Employee E25 confirmed that the facility does not have enough staff. Three to eleven shift is bad. They [residents] don't get showers then. During an interview on 1/8/25, at 10:34 a.m. Nurse Aide (NA) Employee E26 also stated that they do not have enough staff. Today I have to skip a shower because of no staff. It happens several times a week but has been worse in the past month. All shifts appear to be short. It's just hard in general, can't get people out of bed, hard to find help for Hoyer lifts (a mechanical device used to safely transfer individuals who cannot move independently and requires two employees for safe operation), and tray pass takes longer. During an interview on 1/8/26, at 10:25 a.m. the Director of Nursing confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for eleven of 16 residents. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(6) Management. 28 Pa. Code: 211.12(d)(1)(4) Nursing services.

Based on review of facility policy, observations, and staff interviews it was determined that the facility failed to ensure that fit testing of NIOSH-approved N-95 masks (a respirator mask used to care for residents with suspected or confirmed Covid-19) was completed to care for residents with suspected or confirmed Covid-19 (an infectious disease caused by a virus) during an outbreak in order to prevent the transmission of communicable diseases and infections during a COVID-19 outbreak from 12/29/25 through 1/9/26, and failed to properly monitor residents refrigerator temperatures for one of two residents (Resident R88). Findings include: A review of facility policy Respiratory Protection dated 6/18/25, indicated that it is designed to protect employees by establishing accepted practices for respirator use. The infection preventionist or designee is responsible for the implementation with training, oversight, medical evaluation procedures, annual review, and enforcement of the policy. Employees have responsibilities to wear their respirator when required to. Fit Testing: The Infection Preventionist and at least one backup will be the designated fit test administrators at the facility. Fit testing administrators will complete applicable training before administering fit testing to employees. Fit testing: A procedure to ensure a tight- fitting respirator forms a proper seal on a person's face. Review of the Pennsylvania Department of Health Bureau of Epidemiology, Respiratory Virus Outbreak Toolkit dated 9/25/25, revealed the following: Masking The long-term care facility should encourage masking of health care providers, residents, and visitors during any respiratory virus outbreak. This provides protection for the wearer and protection for others. When masking, the masks: Should be well-fitting with minimal gaps Should cover both nose and mouth Should be changed if they become soiled, damaged, or had to breathe through Health Care Providers working with suspected of confirmed COVID residents should use fit-tested, NIOSH-approved N95's. Review of the facility policy Food Brought in From Outside the Facility dated 6/18/25, indicated that the refrigerator where the food will be stored will have an internal thermometer. Units will maintain safe internal temperatures in accordance with state and federal standards for safe food storage temperatures. Temperatures will be monitored daily. Residents with personal refrigerators will be assisted by staff in ensuring their personal unit is in compliance with all of the above storage guidelines. During entrance into the facility on 1/5/26, at 9:00 a.m. a notification of facility having a COVID outbreak was observed hanging on the front door. During an interview on 1/5/26, at 9:15 a.m. the Regional Nurse Consultant/Infection Preventionist Employee E1 confirmed that the facility had positive cases of COVID and were in an outbreak. During a review of documentation provided by facility on 1/5/26, at 9:30 a.m. 11 out of 29 residents were in isolation precaution for positive COVID tests results or being exposed to someone with COVID. During a tour of the facility on 1/5/26, at 9:30 a.m. Isolation signs and Personal Protective Equipment (PPE) were hanging on exposed or confirmed COVID resident's door. During a tour of unit one from 1/5/26, through 1/9/26, N95's were observed being worn by staff to provide care for exposed or confirmed COVID residents. During an interview on 1/6/26, at 10:20 a.m. Regional Nurse Consultant/Infection Preventionist Employee E1 stated that the facility has not fit tested any staff for N-95 respirators since working at the facility, which has been since March 2025. We do not have anyone trained to fit test staff for N-95's at the facility and that staff are not wearing fit tested N-95's to provide care and treatment to residents who are exposed or are confirmed with COVID. During an interview on 1/9/26, at 10:00 a.m. Registered Nurse Employee E13 stated, Not here, No I haven't been fit tested, and I take care of residents who are COVID positive. During an interview on 1/9/26, at 10:03 a.m. Licensed Practical Nurse Employee E14 stated, I have not been fit tested for a N-95 at the facility. I take care of positive COVID residents. During an interview on 1/9/26, at 10:06 a.m. Nurse Aide Employee E7 stated, No, I have not been fit tested for a N-95. I go into all the COVID rooms to care for the residents. We have to wear a gown, googles, gloves, and N-95's to enter the room. During an interview on 1/9/26, at 1:00 p.m. Regional Nurse Consultant/Infection Preventionist Employee E1 confirmed that the facility failed to ensure that fit testing of NIOSH-approved N-95 masks was completed in order to care for residents with suspected or confirmed Covid-19 during an outbreak in order to prevent the transmission of communicable diseases and infections during a COVID-19 outbreak from 12/29/25 through 1/9/26. Review of the clinical record revealed that Resident R88 was admitted to the facility on [DATE]. Review of Resident 88's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 11/12/25, indicated diagnoses of high blood pressure, thyroid disorder, and chronic pain. During an observation on 1/6/26, a Refrigerator Temperature Log was posted on Resident R88's wall above his personal refrigerator. Review of the Refrigerator Temperature Log had dates for September 2025, and October 2025. September 2025 did not have temperatures recorded on 9/6/25, 9/7/25, 9/8/25, 9/9/25, 9/12/25, 9/13/25, 9/14/25, 9/20/25, 9/21/25, 9/22/25, 9/24/25, 9/26/25, 9/29/25, 9/30/25 (missing 14 out of 30 days) October 2025 had no data recorded for the whole month (missing 31 out of 31 days). During an interview on 1/8/26, at 12:25 p.m. the Director of Nursing confirmed that there were no Refrigerator Temperature logs kept for November 2025, and December 2025, which indicated that there was missing data for 30 out of 30 days for November 2025, and missing data for 31 days out of 31 days for December 2025, and that the facility failed to monitor refrigerator temperatures as required. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(d)(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for two of two of the facilities crash carts (a cart that contains supplies in the event of an emergency), (Common Room and Memory Impaired Unit) and two of two Automated External Defibrillator (AED-a portable, electronic device designed to diagnose and treat life-threatening cardiac arrhythmias), (Common Room and Main Dining Room).Findings include:Review of facility Emergency Equipment Check policy dated [DATE], indicated the emergency equipment will be checked daily and items which are outdated or opened will be replaced. The cart will be re-stocked promptly after any use.During a review of facility provided document labeled Emergency Cart Daily Checklist of the facilities crash cart (common room) on [DATE], at 10:30 a.m. revealed missing signatures for [DATE], and [DATE].The Emergency Cart Daily Checklist indicated that if AED on site, check battery life and presence of pads daily.During an observation of the facilities crash cart, located in the common room, on [DATE], at 10:35 a.m. revealed the following supplies to be expired:(3) suctioning tubing - expired [DATE](1) Ambu bag (a handheld manual resuscitator used to provide positive pressure ventilation) was opened and had a date of 07/2015 on the package.During an interview on [DATE], at 10:40 a.m. Registered Nurse Employee E13 confirmed the above missing signatures, expired supplies, and that AED battery checks were missing.During an observation of the facilities crash cart, located in Memory Impaired Unit, on [DATE], at 10:40 a.m. revealed the following supplies to be expired:(1) Continu-Flo Solution IV tubing - expired [DATE](2) IV start kits - expired [DATE](3) suction tubing - expired [DATE]During an interview on [DATE], at 10:48 a.m. Licensed Practical Nurse Employee E12 confirmed the expired supplies on Memory Impaired Unit crash cart.During an interview on [DATE], at 1:00 p.m. the Director of Nursing confirmed that the facility failed to make certain that equipment was in safe operating condition for two of two of the facilities crash carts (Common Room and Memory Impaired Unit) and two of two Automated External Defibrillator (Common Room and Main Dining Room).28 Pa Code: 201.14(a) Responsibility of licensee.

Based on review of facility policy, closed clinical records, resident fund account statements and staff interview it was determined that the facility failed to convey resident funds and close accounts upon discharge within 30 days for three out of three closed resident records (Closed Resident records CR110, CR111, and CR112). Findings include: The facility Resident fund management policy dated [DATE], indicated that trust accounts for discharged or expired residents are to be closed and funds disbursed timely. Review of Closed Resident Record CR110's admission record indicated he was admitted on [DATE] and re-admitted to the facility on [DATE]. Review of Closed Resident Record CR110's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated [DATE], indicated he was admitted with diagnoses that included dementia (a condition characterized by memory loss and progressive or persistent loss of intellectual functioning), depression (a state of consistent sadness and loss of interest interfering in daily life activities), anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry) and restlessness. Review of Closed Resident Record CR110's physician orders dated [DATE], indicated to release CR110's body to the funeral home. Review of Closed Resident Record CR110's clinical progress documentation dated [DATE], indicated CR110 ceased to breathe. Hospice notified resident expired. Review of Closed Resident Record CR111's admission record indicated she was admitted on [DATE]. Review of Closed Resident Record CR111's MDS assessment dated [DATE], indicated she had diagnoses that included dementia, hypertension (a condition impacting blood circulation through the heart related to poor pressure), and Takotsubo syndrome (sudden temporary weakening in the heart muscle). Review of Closed Resident Record CR111's clinical nurse notes dated [DATE], staff called to CR111's room and she was observed for two minutes with no audible pulse. Review of Closed Resident Record CR111's physician note dated [DATE], indicated to release CR111 body to morgue or funeral home. Review of Closed Resident Record CR112's admission record indicated she was admitted on [DATE]. Review of Closed Resident Record CR112's MDS assessment dated [DATE], indicated she had diagnoses that included lumbar fracture, hypertension and chronic pain. Review of Closed Resident Record CR112's clinical nurse notes dated [DATE], indicated staff heard a noise and went into CR112's room at 8:39 a.m. CR112 was observed sitting by her roommate bed and bleeding from back of head. Other staff called and applied compressing dressing. CR112 stated she was trying to [NAME] the bathroom. CR112 was sent to the hospital. Review of Closed Resident Record CR112's physician order dated [DATE], indicated CR112 may discharge to other nursing facility. Review of the facility trust fund account (resident funds account with current accounts open and holding resident monies) dated [DATE], indicated the following: Closed Resident Record CR110 had a balance of $108.60Closed Resident Record CR111 had a balance of $79.50Closed Resident Record CR112 had a balance of $20.03 During an interview on [DATE], at 11:13 a.m. the Business office manager Employee E15 confirmed that the facility failed to convey resident funds and closed resident accounts within 30 days upon discharge for Closed Resident Record CR110, CR111, and CR112 as required. 28 Pa. Code 211.5(d) Clinical records.

Based on clinical record review and family and staff interview, it was determined that the facility failed to provide quarterly resident trust fund statements for four of four sampled residents (Residents R11, R31, R80, and Residents R88). Findings include: The facility Resident fund management policy dated 6/10/25, indicated that quarterly statements are to be sent by corporate office and addresses are to be maintained in the resident fund management system. During a resident council group interview on 1/6/26, at 1:00 p.m. three out of nine residents voiced that the facility has not provided them with quarterly statements. Review of the facility trust fund account (resident funds account with current accounts open and holding resident monies) dated 1/6/25, indicated the following residents had active resident fund accounts: Residents R11, R31, R80, and Residents R88. Further review of facility business records and resident records for did not include evidence that the residents were provided quarterly statements. During an interview on 1/7/26, at 12:55 p.m. Business office manager Employee E15 confirmed that the facility could not provide evidence of sending quarterly statements and the facility failed to provide a quarterly resident fund statements for Residents R11, R31, R80, and Residents R88 as required. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(a) Resident rights

Based on review of facility in-service documentation, personnel files, and staff interviews it was determined that the facility failed to implement and maintain an effective training program for three out of five personnel files reviewed (Licensed Practical Nurse (LPN) Employee E10, Nurse Aide (NA) Employee E11, and LPN Employee E12).Findings include: Review of LPN Employee E10's personnel file indicated a date of hire on 10/2/23. Review of LPN Employee E10's personnel file did not include annual in-service training on Effective Communication, Resident Rights, Abuse, QAPI (Quality Assurance and Performance Improvement), Infection Control, Compliance and Ethics, and Behavioral Health from 1/1/25 through 12/31/25. Review of NA Employee E11's personnel file indicated a date of hire on 7/1/23. Review of NA Employee E11's personnel file did not include annual in-service training on Effective Communication, Resident Rights, Abuse, Infection Control, Compliance and Ethics, and Behavioral Health from 1/1/25 through 12/31/25. Review of LPN Employee E12's personnel file indicated a date of hire on 7/1/23. Review of LPN Employee E12's personnel file did not include annual in-service training on QAPI and Behavioral Health from 1/1/25 through 12/31/25. During an interview on 1/7/26, at 11:31 a.m. Regional Nurse Consultant Employee E1 confirmed that the facility failed to implement and maintain an effective training program for three out of five personnel files reviewed (LPN Employee E10, NA Employee E11, and LPN Employee E12). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.20(a)(d) Staff development.

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to ensure a physician response for medication regimen reviews (MRR) for four of six sampled resident records (Resident R2, R5, R9, and R71). Findings include: The facility Medication Regimen Review policy last reviewed 6/18/25, indicated that the drug regimen review of each resident is completed at least monthly by the consultant pharmacist and any irregularities are reported. Facility should encourage physician/prescriber or other responsible parties receiving the MRR and the Director of Nursing to act upon recommendation contained in MRR. For those issues that require physician/prescriber intervention, facility should encourage physician/prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations and provide and explanations as to why recommendation was rejected. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/14/25, indicated diagnoses of high blood pressure, bipolar disorder (a mental condition marked by alternating periods of elation and depression), and wound infection. Review of Resident R2's MRR in the clinical record on 1/8/26, at 9:00 a.m. indicated the following: November 2025 - facility failed to provide the completed MRR by attending physician December 2025 - facility failed to provide the completed MRR by attending physician Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's MDS dated [DATE], indicated diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Resident R5's MRR in the clinical record on 1/8/26, at 9:10 a.m. indicated the following: June 2025 – facility failed to provide the completed MRR by attending physician July 2025 – facility failed to provide the completed MRR by attending physician August 2025 - facility failed to provide the completed MRR by attending physician September 2025- facility failed to provide the completed MRR by attending physician October 2025 - facility failed to provide the completed MRR by attending physician Review of the clinical record indicated Resident R9 was admitted to the facility on [DATE]. Review of Resident R9's MDS dated [DATE], indicated diagnoses of heart failure, diabetes, and anxiety. Review of Resident R9's MRR in the clinical record on 1/8/26, at 9:20 a.m. indicated the following: February 2025 – facility failed to provide the completed MRR by attending physician March 2025 – facility failed to provide the completed MRR by attending physician September 2025 - facility failed to provide the completed MRR by attending physician October 2025- facility failed to provide the completed MRR by attending physician November 2025 - facility failed to provide the completed MRR by attending physician December 2025 - facility failed to provide the completed MRR by attending physician Review of the clinical record indicated Resident R71 was admitted to the facility on [DATE]. Review of Resident R71's MDS dated [DATE], indicated diagnoses of dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), Parkinson's Disease (a degenerative brain disease that affects muscle control, among other symptoms), and depression. Review of Resident R71's medication regimen reviews (MRR) dated 12/18/25, revealed the resident has received Phenazopyridine (a medication used to treat symptoms of a urinary tract infection) for symptomatic relief of dysuria (painful or uncomfortable urination) greater than two days. Prolonged use may mask the symptoms of unresolved cystitis and increase the risk of complications. Recommendations indicated to please discontinue Phenazopyridine. A further review of Resident R71'ss MRR dated 12/18/25, failed to include a physician's response as required. During an interview on 1/7/26, at 12:59 p.m. the Director of Nursing and the Regional Nurse Consultant, Employee E1 confirmed that the facility failed to provide documentation of medication regimen reviews (MRR) were signed by physician for Resident R71. During an interview on 1/8/26, at 9:30 a.m. the Director of Nursing confirmed that the facility failed to ensure MRR's were completed by the facility for four of six residents (Resident R2, R5, R9, and R71). 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.5(f) Medical records. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for three of five residents (Resident R13, R36, and R100).Findings include:Review of facility policy Oxygen Administration dated 6/18/25, indicated licensed clinicians with demonstrated competence will administer oxygen via specified route as ordered by physician.Review of the clinical record indicated Resident R13 was admitted to the facility on [DATE].Review of Resident R13's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/3/25, indicated diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), asthma (condition where the airways narrow and swell), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Section O Special Treatments, Procedure and Programs O0110, C1 Oxygen Therapy is marked as while a resident.Review of a physician's orders dated 10/29/25, indicated to administer oxygen via nasal cannula (a thin tubing that delivers oxygen from the oxygen concentrator to the nose) two liters per minute as needed for shortness of breath. During an observation on 1/5/26, at 10:45 a.m. Resident R13 was lying in bed with oxygen in use. The oxygen concentrator was located beside the bed. Oxygen tubing was dated 12/15/25.Review of the clinical record indicated Resident R36 was admitted to the facility on [DATE].Review of Resident R36's MDS dated [DATE], indicated diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and asthma. Section O Special Treatments, Procedure and Programs O0110, C1 Oxygen Therapy is marked as while a resident.Review of physician's orders dated 4/21/25, indicated to administer oxygen via nasal cannula at two liters per minute at bedtime as needed for comfort.During an observation on 1/5/26, at 10: 50 a.m. Resident R36 was lying in bed with oxygen in use. The oxygen concentrator was located beside the bed. The oxygen tubing failed to have a date when it was changed. The humidification was connected to the concentrator and failed to have a date which it was put on for use.Review of the clinical record indicated Resident R100 was admitted to the facility on [DATE].Review of Resident R100's MDS dated [DATE], indicated diagnoses of COPD, asthma, and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Section O Special Treatments, Procedure and Programs O0110, C1 Oxygen Therapy is marked as while a resident.Review of a physician's orders dated 1/31/25, indicated to administer oxygen via nasal cannula three liters per minute continuously. Add humidification for comfort, if needed.Review of physician's orders dated 11/24/25, indicated to administer ipratropium-albuterol (a medication used to open air ways in the lung) via nebulizer (a machine used to deliver inhaled medication using tubing and handheld device) every four hours as needed. During an observation on 1/5/26, at 10:55 a.m. Resident R100 was lying in bed with oxygen in use. The oxygen concentrator was located beside the bed. The oxygen tubing was dated 12/15/25, and the humidification bottle was empty and failed to have a date on which it was put on for use. The nebulizer machine was observed on the bedside stand. The nebulizer tubing was dated 11/11/25, and was not stored in a bag when not in use.During an interview on 1/5/26, at 11:21 a.m. Licensed Practical Nurse (LPN) Employee E3 stated that the oxygen and nebulizer tubing should be changed weekly and stored in a bag when not in use. I was taught to date everything. How would you know when it was changed? and confirmed the above findings.During an interview on 1/5/26, at 2:00 p.m. the Director of Nursing confirmed that the facility failed to provide appropriate respiratory care for three of five residents (Resident R13, R36, and R100).28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services

Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to develop and implement a comprehensive resident-specific plan of care for a resident with limited mobility requiring equipment and assistance to maintain or improve mobility for one of two residents (Resident R10). Review of facility policy Splint Issuance Policy dated 6/18/25, indicated that the patient splint schedule will be communicated to the multidisciplinary team and documented in the care plan. Review of the clinical record revealed that Resident R10 was admitted to the facility on [DATE]. Review of Resident 10's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 11/12/25, indicated diagnoses of hemiplegia (paralysis on one side of the body), cerebral vascular accident (a loss of blood flow to the brain, which damages brain tissue). Review of Resident R10's clinical record revealed a physician's order dated 9/5/25, to wear resting hand splint to left upper extremity nightly as tolerated at bedtime. Review of Resident R10's care plan failed to include the development of goals and interventions related to Resident R10's resting hand splint usage. During an interview on 1/7/26, at 1:35 p.m. the Director of Nursing confirmed that facility failed to develop and implement a comprehensive resident-specific care plan for Resident R10's resting hand splint. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, review of personnel files, and staff interview, it was determined that the facility failed to properly screen an employee by failing to conduct a criminal background check prior to the start of employment for one of five personnel files reviewed (Licensed Practical Nurse (LPN) Employee E9).Findings include: Review of facility policy Abuse, Neglect and Exploitation dated 6/18/25, indicated it is the policy of the Facility to undertake background checks of all employees and to retain on file applicable records or current employees regarding such checks. Review of the facility Payroll/Human Resources Coordinator job description indicated an essential function of the position is to ensure that pre-screening of employees is completed (license verification, exclusion checks, background checks, drug screen/physical as required). Maintain complete employee files with accurate and up-to-date information. Review of LPN Employee E9's personnel file revealed a hire date of 9/25/25. Review of the personnel file did not include a completed state criminal background check prior to their date of hire. During an interview on 1/7/26, at 10:31 a.m. Human Resources Employee E2 confirmed that the facility failed to properly screen an employee by failing to conduct a criminal background check prior to the start of employment for one of five personnel files reviewed (LPN Employee E9). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.19(8) Personnel records.

Based on review of facility policy, resident clinical record, incident reports, reports submitted to the State, and staff interview it was determined that the facility failed to make certain each resident received adequate supervision which resulted in a resident ingesting a skin cleanser for one of four residents (Resident R71).Findings include: Review of the facility Resident Incident and Accident Report policy dated 6/18/25, indicated an incident is any occurrence that is not consistent with routine care of a particular resident. Review of the clinical record indicated Resident R71 was admitted to the facility on [DATE]. Review of Resident R71's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/8/25, indicated diagnoses of dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), Parkinson's Disease (a degenerative brain disease that affects muscle control, among other symptoms), and depression. Review of Resident R71's care plan dated 8/6/24, indicated to monitor the resident frequently within the unit. Review of Resident R71's care plan dated 9/26/24, indicated to observe frequently and place in supervised area when out of bed. Review of Resident R17's progress note dated 12/4/25, at 8:34 p.m. stated Resident was found in the MIU (Memory Impaired Unit) hall sitting in a chair with a bottle of [NAME] Perineal and Skin Cleanser open and appeared that she had drank some of the soap. Poison Control called and verified product is non-toxic and to just monitor. Called and spoke with the on-call provider who advised to just continue to monitor. The resident's family was notified and advised of the incident and explained the providers recommendation along with Poison Control. During an interview on 1/7/25, at 11:02 a.m. the Director of Nursing and Regional Nurse Consultant, Employee E1 confirmed that the facility failed to make certain each resident received adequate supervision to prevent a resident from ingesting a skin cleanser for one of four residents (Resident R71). 28 Pa Code: 201.14 (a)(c) Responsibility of licensee.28 Pa Code: 201.18 (b)(1)(e)(1) Management.

Based on review of clinical records and staff interview, it was determined that the facility failed to provide care and treatment as ordered by physician for one of three residents (Residents R71).Findings include: Review of the clinical record indicated Resident R71 was admitted to the facility on [DATE], with diagnoses of dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), Parkinson's Disease (a degenerative brain disease that affects muscle control, among other symptoms), and depression. Review of Resident R71's care plan dated 4/22/25, indicated the resident has Parkinson's disease and to provide drug therapy per order. Review of Resident R71's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/8/25, indicated diagnoses were current. Review of Resident R71's Neurology after visit summary dated 11/19/25, revealed the resident was ordered to increase 20 mg (milligrams) entacapone (medication used primarily to treat symptoms of Parkinson's disease by enhancing effects of Sinemet), 1 tablet, four times a day, take with each of the first four doses of Sinemet (medication used to treat Parkinson's symptoms) in order to extend the benefit of Sinemet and shorten the wearing off dose. Review of Resident R71's progress note dated 11/22/25, revealed the resident was seen by Certified Registered Nurse Practitioner (CRNP), Employee E21 after follow up with neurology appointment. Recommendations to add entacapone 200mg with first four doses of Sinemet. Review of Resident R71's physician order dated 12/1/25, indicated to administer entacapone tablet, 200mg, one tablet, four times a day with first four daily doses of Sinemet. A total of 12 days after it was ordered. During an interview on 1/7/26, at 12:59 p.m. Director of Nursing and Regional Nurse Consultant, Employee E1 confirmed the facility failed to timely administer Resident R71's entacapone to provide care and treatment as ordered by physician for one of three residents (Residents R71). 28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.10 (c)(d) Resident Care policies.28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider, including bed hold policy for two of four residents sampled with facility-initiated transfers (Residents R1 and R5). Findings include:Review of facility policy Discharge Planning dated 6/18/25, indicated transfers and discharges will meet requirements. The facility will take steps to ensure that the transfer or discharge is documented in the resident's medical record and necessary information is communicated to the receiving health care institution or provider.Review of facility policy Bed Hold Letter dated 6/18/25, indicated it is the policy of the facility to track bed hold days and notify appropriate parties via bed hold letter.Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 11/12/25, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), arthritis, and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain).Review of the clinical record indicated Resident R1 was transferred to the hospital on [DATE], and returned to the facility on [DATE].Review of Resident R1's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the bed hold policy, to meet the resident's specific needs at the receiving facility.Review of the clinical record revealed that Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's MDS dated [DATE], indicated diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), heart failure, and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time).Review of the clinical record indicated Resident R5 was transferred to the hospital on [DATE], and returned to the facility on [DATE].Review of Resident R5's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the bed hold policy, to meet the resident's specific needs at the receiving facility.During an interview on 1/9/26, at 9:11 a.m. Director of Nursing confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of four residents sampled with facility-initiated transfers (Residents R1 and R5).28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights.

Based on review of facility policy, resident clinical record, incident reports, reports submitted to the State, and staff interview it was determined that the facility failed to report an incident of neglect for two of five residents (Resident R71, and R88). Findings include: Review of facility Pennsylvania Resident Abuse policy dated 6/18/25, indicated all reports of resident abuse, neglect, misappropriation of resident property are reported immediately to the administrator, Director of nursing, and to the applicable state agency. Review of the clinical record indicated Resident R71 was admitted to the facility on [DATE]. Review of Resident R71's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/8/25, indicated diagnoses of dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), Parkinson's Disease (a degenerative brain disease that affects muscle control, among other symptoms), and depression. Review of Resident R71's care plan dated 8/6/24, indicated to monitor the resident frequently within the unit. Review of Resident R71's care plan dated 9/26/24, indicated to observe frequently and place in supervised area when out of bed. Review of Resident R71's progress note dated 12/4/25, at 8:34 p.m. stated Resident was found in the MIU (Memory Impaired Unit) hall sitting in a chair with a bottle of [NAME] Perineal and Skin Cleanser open and appeared that she had drank some of the soap. Poison Control called and verified product is non-toxic and to just monitor. Called and spoke with the on-call provider who advised to just continue to monitor. The resident's family was notified and advised of the incident and explained the providers recommendation along with Poison Control. Review of Nurse Aide (NA), Employee E20's witness statement dated 12/4/25, revealed NA, Employee E20 was exiting another resident's room when Resident R71 was observed running up the hallway with a bottle in hand. The resident then sat on a chair and tipped the bottle back in her mouth. The item was in the resident's closet on the top shelf in a closed container. Resident has previously demonstrated that she is capable of retrieving items. Review of information submitted to the State Agency on 12/4/25, and 12/5/25, failed to include Resident R71's incident of neglect. During an interview on 1/8/25, at 12:37 p.m. the Regional Nurse Consultant, Employee E1 confirmed that the facility failed to report an allegation of neglect for one of five residents (Resident R71). Review of the clinical record revealed that Resident R88 was admitted to the facility on [DATE]. Review of Resident 88's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 11/12/25, indicated diagnoses of high blood pressure, thyroid disorder, and chronic pain. Review of a written statement dated 12/24/25, revealed that Business Office Manager (BOM) Employee E15 stated the following: As I was reviewing the RFMS (Resident Fund Management Service- banking account information) account for Resident R88 on 12/24/25, I noticed a check issued to Nurse Aide Employee E29 in the amount of $750 on April 22, 2025. I asked the resident who this person was and why he asked for the check to be issued as it was over the $500 Medicaid gifting limit. The resident stated, 'That is a nurse aide from here (the facility) who was having a rough time, and I felt bad and wanted to help.' I then informed the resident that he was a very generous person; however, employees are not permitted to receive gifts of any kind from residents. Review of the RFMS report for Resident R88 that was ran on 12/30/25, and included transactions from 1/1/25, through 12/30/25, indicated that two checks were written on 4/22/25, for the amount of $750. One was for NA Employee E29, and NA Employee E30. The RFMS report also stated that the checks were cashed and cleared on 4/25/25. During an interview on 1/6/25, at 9:54 a.m. Resident R88 stated that he Gave two employees $750, and they got fired. I feel so bad. During an interview on 1/7/25, at 2:54 p.m. BOM Employee E15 was asked if the resident is able to write his own checks from the RFMS account. BOM Employee E15 stated No. He would have had to get the former BOM to write a check from that account. He (Resident R88) called me and asked me to write him a check for his credit union for $750. I told him that anything over $500 gets questioned by Medicaid and advised him to keep it under 500. That's when I checked his account and saw that he had written other checks for $750 (to NA Employee E29, and E30). BOM Employee E15 was asked if the former BOM should have advised him not to write a check out to employees, to which she responded: Yes. Review of information submitted to the State Agency from 11/24/25 through 1/8/26, failed to include Resident R88's misappropriation of money. During an interview on 1/8/26, at 12:20 p.m. the Regional Nurse Consultant (RNC) Employee E1 confirmed that the facility failed to report misappropriation of money for Resident R88. 28 Pa Code: 201.14 (a)(c) Responsibility of licensee.28 Pa Code: 201.18 (b)(1)(e)(1) Management.

Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents' medication regime was free from unnecessary psychotropic (a mind-altering medication) medication for two of five residents (Resident R2 and R9).Findings include:Review of facility Psychotropic Medication Use policy dated 6/18/25, indicated all medications used to treat behaviors must have a clinical indication to be used. As needed, medications shall be limited to 14 days and cannot be renewed unless the attending physician evaluates the resident for the appropriateness of that medication. The physician must document rationale for medication for more than 14 days.Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE].Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/14/25, indicated diagnoses of high blood pressure, bipolar disorder (a mental condition marked by alternating periods of elation and depression), and wound infection.Review of Resident R2's clinical record revealed physician orders for the following psychotropic medications and failed to have a diagnosis for use of the medication:Sertraline (used to treat depression) 100 mg (milligrams) daily - no diagnosis indicatedSeroquel (used to treat mental health disorders) 200 mg daily - no diagnosis indicatedDuring an interview on 1/8/26, at 9:08 a.m. the Director of Nursing (DON) stated, I've seen medications don't have diagnosis and I've been working on it.During an interview on 1/8/26, at 11:54 a.m. Registered Nurse Employee E13 stated, When we put orders in, we put the diagnosis of the medication in the order. It's been beaten in my head over the years to do that.Review of the clinical record indicated Resident R9 was admitted to the facility on [DATE].Review of Resident R9's MDS dated [DATE], indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and anxiety.Review of Resident R9's physician orders dated 10/16/25, indicated to administer Ativan (used to treat anxiety) one milligram every two hours as needed (PRN) for anxiety/restlessness.Review of Resident R9's physician order failed to include a 14 day stop date and there was no documented rationale by the physician for the medication to extend past 14 days for Resident R9's Ativan.During an interview on 1/8/26, at 2:00 p.m. the DON confirmed Resident R2's medications did not include a diagnosis for use and the facility failed to make certain that medical records on each resident are complete and accurately documented for one of five residents (Resident R2), and confirmed that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic medication for one of five residents (Resident R9). 28 Pa. Code 211.2(d)(3) Medical Director.28 Pa. Code 211.10(a) Resident care policies.

Based on a review of facility policy, facility documents, clinical records, incident investigations, and staff interviews, it was determined that the facility failed to ensure that residents are free from misappropriation of property for one of two residents (Resident R88).Findings include: Review of the facility policy Pennsylvania Resident Abuse dated 6/18/25, indicated that the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. Exploitation was defined as the unfair treatment or use of a resident or the taking of a selfish or unfair advantage of a resident for personal gain, through manipulation, intimidation, threats or coercion. Review of the clinical record revealed that Resident R88 was admitted to the facility on [DATE]. Review of Resident 88's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 11/12/25, indicated diagnoses of high blood pressure, thyroid disorder, and chronic pain. Review of a written statement dated 12/24/25, revealed that Business Office Manager (BOM) Employee E15 stated the following: As I was reviewing the RFMS (Resident Fund Management Service- banking account information) account for Resident R88 on 12/24/25, I noticed a check issued to Nurse Aide Employee E29 in the amount of $750 on April 22, 2025. I asked the resident who this person was and why he asked for the check to be issued as it was over the $500 Medicaid gifting limit. The resident stated, 'That is a nurse aide from here (the facility) who was having a rough time, and I felt bad and wanted to help.' I then informed the resident that he was a very generous person however; employees are not permitted to receive gifts of any kind from residents. Review of the RFMS report for Resident R88 that was ran on 12/30/25, and included transactions from 1/1/25, through 12/30/25, indicated that two checks were written on 4/22/25, for the amount of $750. One was for NA Employee E29, and NA Employee E30. The RFMS report also stated that the checks were cashed and cleared on 4/25/25. During an interview on 1/6/25, at 9:54 a.m. Resident R88 stated that he Gave two employees $750, and they got fired. I feel so bad. During an interview on 1/7/25, at 2:54 p.m. BOM Employee E15 was asked if the resident is able to write his own checks from the RFMS account. BOM Employee E15 stated No. He would have had to gotten the former BOM to write a check from that account. He (Resident R88) called me and asked me to write him a check for his credit union for $750. I told him that anything over $500 gets questioned by Medicaid and advised him to keep it under 500. That's when I checked his account and saw that he had written other checks for $750 (to NA Employee E29, and E30). BOM Employee E15 was asked if the former BOM should have advised him not to write a check out to employees, to which she responded: Yes. During an interview on 1/8/26, at 12:20 p.m. the Regional Nurse Consultant (RNC) Employee E1 confirmed that employees should not accept gifts from residents, but that it was not felt to be misappropriation as Resident R88 is alert and oriented. State Agency reminded RNC Employee E1 that the regulation specifically gives an example of misappropriation of a resident who provides monetary assistance to staff, after staff had made resident believe that staff was in a financial crisis. RNC Employee E1 then confirmed that the facility failed to ensure that residents are free from misappropriation of money for one of two residents. 28 Pa. Code: 201.29(a) Resident rights.

Based on review of clinical record review, and staff interviews, it was determined that the facility failed to ensure the physician was appropriately notified of change in condition for one of four residents reviewed (Resident R99).Findings include: Review of the facility Resident Change in Condition policy dated 6/18/25, stated for physician and family will be notified as soon as the nurse had identified the change in condition and the resident is stable. Review of the clinical record indicated Resident R99 was admitted to the facility on [DATE]. Review of resident R99's care plan dated 8/19/25, indicated to notify physician of any changes. Review of Resident R99's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/22/25, indicated diagnoses of dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), anxiety, and depression. Review of Resident R99's progress note dated 9/4/25, at 10:18 p.m. stated During evening care resident began swinging at the staff and then started to punch himself on his head. No injuries noted at this time and resident has been redirected and placed at the nursing station for monitoring. Review of Resident R99's clinical record failed to reveal evidence the resident's physician was notified of the change in condition on 9/4/25. Review of Resident R99's progress note dated 10/13/25, at 10:18 p.m. stated Multiple times throughout the evening resident stating he wants to die, asking staff to kill him, hitting self on his head. Review of Resident R99's clinical record failed to reveal evidence the resident's physician was notified of the change in condition on 10/13/25. During an interview on 1/8/26, at 10:52 a.m. information was disseminated to the Regional [NAME] President of Operations, Employee E17, that the facility failed to ensure the physician was appropriately notified of change in condition for one of four residents reviewed (Resident R99). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.10 (c)(d) Resident Care policies.28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, review of clinical records, observations and staff interviews, it was determined that the facility failed to determine whether it was safe to self-administer medications for one of four residents (Resident R77).Findings include:Review of the facility policy Self-Administration of Medications dated 6/18/25, indicated facility should comply with policy with respect to resident self-administration of medications. The facility should assess and determine whether self-administration of medications is safe and clinically appropriate, based on the resident's functionality and health condition. Facility should ensure that orders for self-administration list the specific medications the resident may self-administer.Review of the clinical record indicated Resident R77 was admitted to the facility on [DATE].Review of resident R77's Minimum Data Set (MDS-a periodic assessment of care needs) dated 10/17/25, indicated the diagnoses of high blood pressure, Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life).During an observation on 1/5/26, at 10:17 a.m. Resident R77 was sitting on the edge of the bed with a bedside table. On the bedside table included a paper towel with 10 medication pills laying on top. Medications included: four white pills, two yellow pills, two red pills, one peach pill, and one pink pill. No nurse was observed in the room at this time.Review of Resident R77's physician orders failed to include an order for self-administration of medications.Review of Resident R77's care plan failed to address self-administration of medications.During a review of facility provided documentation labeled Self-Administration of Medications dated 11/30/25, indicated that resident did not want to self-administer medications.During an interview on 1/5/26, at 10:21 a.m. Licensed Practical Nurse (LPN) Employee E3 stated We should not leave medications in a resident's room. We are supposed to watch them take them. and confirmed the unsecured medications at bedside for Resident R77.During an interview on 1/9/26, at 10:09 a.m. LPN Employee E14 stated, I watch residents take medication. I would not leave medications in room for them to take. There is too much liability against my license. It's not safe for residents. Other residents could take the medication. The resident may not take the medication.During an interview on 1/5/26, at 2:00 p.m. the Director of Nursing confirmed the facility failed to determine whether it was safe to self-administer medications for one of four residents (Resident R77).28 Pa. Code 201.18(b)(1)(3) Management28 Pa. Code: 211.12(d)(1)(5) Nursing services

Based on review of facility policies, documentation, observations, resident and staff interviews and state and federal guidance it was determined that the facility failed to implement COVID and Influenza monitoring, tracking, and testing in accordance with state and federal guidance for 95-101 residents from 11/29/24, through 1/15/25. The facility failed to adhere to state return to work guidance for staff. These failures placed all residents in the facility in an Immediate Jeopardy situation. Review of the facility Infection Prevention and Control Program Policy dated 4/16/18, last revised 9/11/23, indicated it is the facility's policy to maintain an organized, effective facility-wide program designed to systemically prevent, identify, control and reduce the risk of acquiring and transmitting infections among employees, volunteers, visitors, and contract healthcare workers, to conduct surveillance of communicable disease and infectious outbreaks, and to monitor employee health. It was indicated employees must follow return to work guidance. Review of the Pennsylvania Department of Health Influenza Outbreaks in Long-Term Care Facilities: Toolkit for Facilities dated 2023-2024, and expanded from infection prevention and control guidance from the Centers for Disease Control and Prevention (CDC) for nursing homes and Long-Term Care Facilities revealed the following: -As soon as a respiratory outbreak is suspected, the response should include laboratory testing (i.e., rapid antigen testing, PCR, and/or viral isolation) to evaluate residents and staff and determining the etiology of the outbreak. Specimens should be collected within the first 24-72 hours after symptoms onset and no later than 5 days after symptom onset. -Upon identification of an outbreak, a line listing (designed to collect information about all ill cases for residents and staff during an outbreak of influenza in a long-term care facility) should be utilized to collect and organize information. Information should be updated periodically during the outbreak for all cases. -During an outbreak, conduct daily active surveillance for ILI (influenza-like illness-fever greater than 100F plus cough or sore throat) among residents, staff and visitors to the facility until at least one week after the last confirmed influenza case occurred. -All residents and staff with ILI should receive antiviral treatment immediately; treatment should NOT be delayed while waiting for laboratory confirmation. Review of the Pennsylvania Department of Health COVID-19 Infection Control and Outbreak Response Toolkit for Long-Term Care Version 1.1 dated February 2024, and expanded from infection prevention and control guidance from the Centers for Disease Control and Prevention (CDC) for nursing homes and Long-Term Care Facilities revealed the following: During the Outbreak: COVID-19 Outbreak Management and Control Measures included: -Identify and Isolate First Case. -Identify Additional Cases and Exposures. -Exposed asymptomatic residents and HCP (health care professional) should be tested with a series of up to three viral tests. -Determine approach (contact-tracing, unit-based, facility-based). -Identify exposures because of close contact. -Test exposures immediately (but not within 24 hours of exposure) and if negative, another test at 48 hours, and if negative another test 48 hours later. -Returning to Routine Operations -The facility can return to routine operations when the outbreak has been deemed as complete, which occurs after 14 days without new cases. -Evaluation and Monitoring of Residents -It is important to assess for the following symptoms and implement prompt isolation and further evaluation for COVID Fever or chills Cough Shortness of breathe Fatigue Muscle or body aches Headache New loss of taste or smell Sore throat Congestion or runny nose Nausea or vomiting Diarrhea -Return to Work Criteria for Healthcare Personnel (HCP) who are NOT moderately to severely immunocompromised At least seven days have passed since symptoms first appeared; AND a negative antigen (test used to determine current or recent infection) or Nucleic Acid Amplification Test (NAAT-detects one or more RNA sequences of SARS-CoV-2 and is considered the gold standard for clinical testing. If someone with prior COVID infection within 90 days, antigen testing is recommended) ) is obtained within 48 hours prior to returning to work OR 10 days have passed if testing is not performed or the HCP tests positive at day 5-7; At least 24 hours have passed since last fever without the use of fever-reducing medications; AND Symptoms (e.g., cough, shortness of breath) have improved. Review of resident clinical records and facility documents revealed: Review of Resident R11's clinical record indicated an admitted [DATE], and readmitted [DATE], with diagnoses of heart failure (occurs when the heart muscle doesn't pump blood as well as it should), myopathy (disorders of the muscles that cause them to function less effectively), and chronic kidney disease (disease that involves a gradual loss of kidney function). Review of a report submitted to the Department of Health dated 11/30/24, indicated Resident R11 tested positive for COVID on 11/29/24, while at the hospital. It was indicated as a follow-up action, the facility tested staff prior to the start of their shifts. The COVID Tool Kit will be followed, and a line listing will be developed for tracking purpose. We will also assess any resident, staff, visitors that would be symptomatic during our COVID testing. Review of the facility's COVID tracking log indicated Resident R11 tested positive at the hospital on 12/3/24. The facility failed to accurately track when the COVID outbreak started. Review of Resident R9's clinical record indicated an admitted [DATE], and readmitted [DATE], with diagnoses of Chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs), high blood pressure, and bipolar disorder (a mental health condition that causes extreme mood swings). Review of the facility's COVID tracking log revealed Resident R9 tested positive at the hospital on 12/9/24. Review of the facility documents and resident's clinical records revealed residents tested negative on Day 1, Day 3, and Day 5. The facility failed to provide evidence that all residents were monitored for signs and symptoms of COVID after Day 5 (12/15/24) of testing. Review of the facility documents revealed Nurse Aide, Employee E8 tested positive for COVID on 12/25/24. Review of the facility document titled COVID Dec/[DATE] Contact Tracing indicated contact tracing was completed for Nurse Aide, Employee E8 and Residents (R5, R6, R8, R9, R12, R13, R21, R26, R27, R33, R38,R43, R44, R47, R52, R53, R57, R62, R68, R70, R73, R87, R92, R94 R199, R201, R248, R249) were tested on Days 0, 3, and 5 and they were all negative. Review of the facility testing log revealed the facility failed to test residents on Day 1, 12/26/24. Review of the facility documents revealed Infection Preventionist, Employee E1 tested positive for COVID on 1/8/25. During an observation on 1/14/25, at 11:30 a.m. the signage posted at the facility's entrance stated if staff test positive for a respiratory illness (COVID, Flu, RSV) in the last 10 days, do not enter resident care areas. It was indicated to wait 10 days after the date of the positive test, symptom onset, or exposure to return work. During an interview on 1/14/25, at 12:52 p.m. Infection Preventionist, Employee E1 stated during a COVID outbreak residents are tested on Day 0, 1, 3, and 5. IP, Employee E1 stated if staff members are positive for COVID, they can return to work on the 5th day if they test negative. IP, Employee E1 confirmed she tested positive for COVID on 1/8/25, and returned to work on 1/13/25. IP, Employee E1 confirmed she failed to wait at least seven days since symptoms first appeared and test negative 48 hours prior to returning to work or wait at least 10 days since she tested positive to return to work. During an interview on 1/14/25, at 1:26 p.m. the NHA and Regional Director of Clinical Services, Employee E5 confirmed Infection Preventionist, Employee E1 failed adhere to return to work guidelines. During an interview on 1/15/25, at 10:54 a.m. IP, Employee E1, NHA, and RDCS, Employee E5 confirmed the facility failed to accurately track, test, and monitor resident's during the COVID outbreak. Review of Resident R9's clinical record indicated on 1/3/25, Resident R9 was ordered Guaifenesin (medication used for cough) for a cough. Review of clinical record failed to indicate he was monitored for ILI symptoms or tested for Influenza. Review of Resident R9's progress note dated 1/5/25, indicated Resident R9 requested Robitussin (medication used for cough) for his cough. Review of Resident R9's progress note dated 1/10/25, at 5:15 p.m. indicated Resident R9 was demanding to have an ambulance called to be taken to the emergency room for cold symptoms. The facility staff informed him that the ER is for life-threatening emergencies and that his cold could be treated in house. Resident R9 then requested a breathing treatment. Review of Resident R9's progress note dated 1/11/25, indicated he was sent out to the hospital for behaviors. The resident tested positive for Influenza A at the hospital. Review of Resident R27's clinical record indicated an admitted [DATE], with diagnoses of heart failure, intellectual disabilities (a condition that limits intelligence and disrupts abilities necessary for living independently), and pneumonia (infection that affects the lungs). Review of Resident R27's progress note dated 1/6/25, indicated the resident complained of stomach pain and hyperemesis (severe nausea and vomiting) that was dark green in color. Resident R27 was sent to the hospital for further evaluation. The facility failed to assess the resident for ILI symptoms and test for Influenza. Review of Resident R27's progress note dated 1/7/25, indicated on 1/6/25, the resident returned to the facility and was diagnosed with Influenza A. Review of Resident R52's clinical record indicated an admitted [DATE], and readmitted [DATE], with diagnoses of depression, anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), and dorsalgia (back pain). Review of Resident R52's progress note dated 1/7/25, indicated the resident went to the hospital for a CT scan. RN, Employee E3 received a call from the emergency room that indicated while the resident was at her appointment she became short of breath and had a cough. She was taken to emergency room and tested positive for Influenza A. During an interview on 1/15/25, at 10:48 a.m. Resident R52 stated I was sick for a couple of days before the hospital with nausea and coughing, I don't think they gave me anything for it. I told the nurses I didn't feel well, I had an appointment out of the building and the doctor sent me to ER and that's when they tested me for flu. Review of Resident R52's clinical record failed to indicate the facility assessed the resident for ILI symptoms and test for influenza. Review of Resident R42's clinical record indicated an admitted [DATE], and readmitted [DATE], with diagnoses of heart failure, hypoxemia (low levels of oxygen in your blood, and anemia. Review of Resident R42's progress note dated 1/11/25, at 9:45 a.m. indicated the resident had fever of 102.5 Fahrenheit, audible wheezing, and oxygen saturation was 78% on room air. The facility failed to conduct Influenza testing. Review of Resident R42's progress note dated 1/11/25, at 2:15 p.m. indicated the resident was transferred to the hospital and tested positive for Influenza. Review of facility's Flu [DATE] line listing report for Influenza, revealed Resident R27 tested positive for Influenza A on 1/6/25. Resident R52 tested positive on 1/7/25. The last reported positive cases were on 1/11/25 (Resident R9, R42, and Housekeeper, Employee E9.) The facility was in an Influenza outbreak as of 1/11/25. During an observation on 1/14/25, at 11:30 a.m. the signage posted at the facility's entrance failed to indicate the facility was in an Influenza outbreak. During an interview on 1/14/25, at 11:32 a.m. the Nursing Home Administrator confirmed the signage posted at the entrance of the facility failed to indicate the facility was in an Influenza outbreak. During an interview on 1/14/25, at 12:58 p.m. IP, Employee E1 stated Resident R27 was sent to the hospital and tested positive for Influenza on 1/6/24. IP, Employee E1 confirmed Resident R52 was sent out for routine visit and was transferred to hospital for a change in condition and tested positive for Influenza. IP, Employee E1 stated we didn't know she had flu until we sent her and stated she was aware she had respiratory symptoms the whole week prior to sending her out to her appointment. IP, Employee E1 stated she would only test for Influenza if the physician was notified, and it was ordered. IP, Employee E1 confirmed the facility failed to monitor residents for ILI symptoms during an Influenza outbreak and test 4 of 4 Residents who had signs and symptoms of Influenza (Resident R9, R27, R42, and R52). During an interview on 1/15/25, at 11:07 a.m. the NHA and RDCS, Employee E5 confirmed the facility failed to test four of four residents for Influenza who had symptoms (Resident R9, R27, R42, and R52). The NHA confirmed no residents were tested for Influenza in the facility. During an interview on 1/15/25, at 2:49 p.m. the Nursing Home Administrator (NHA), Director of Nursing (DON), and RCDS Employee E5 were made aware that an Immediate Jeopardy (IJ) existed. The NHA was provided the IJ Template and at that time a corrective action plan was requested. On 1/15/25, at 5:47 p.m. an acceptable Corrective Action Plan was received, which included the following interventions: Issue #1 -Facility immediately initiated monitoring signs and symptoms for residents with COVID. IP/Designee will conduct house audit of residents with signs and symptoms of COVID by EOD 1/16/25. -Regional Director of Clinical Services will conduct in-service regarding Infection Control and Outbreak Response to facility Infection Preventionist and Director of Nursing by 1/16/25. -IP/Designee will conduct education to all staff regarding infection control measures and monitoring at their start of shift beginning 1/15/25 and before next shift by EOD 1/16/25. -To prevent reoccurrence, DON/Designee will conduct audits to monitor for resident's signs and symptoms for COVID, daily x5 days for 14 days , then weekly for 4 weeks then monthly x2. -Negative findings will be addressed. Policies and Procedures to be reviewed and updated as needed. Ad hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. Issue #2 -Effective 1/15/25, facility will ensure that COVID testing occurs on Day 1 following a positive result in accordance with PA DOH COVID 19 Infection Control Outbreak Response Toolkit for Long Term Care. -IP/Designees will conduct house audit of all COVID testing to ensure Day 1 testing complete upon positive result by EOD 1/16/25. -Regional Director of Clinical Services will conduct in-service regarding Infection Control and Outbreak Response testing procedures to facility Infection Preventionist and Director of Nursing by 1/16/25. -IP/Designee will conduct education to all staff regarding Infection Control and Outbreak Response testing procedures at their start of beginning 1/15/2025 and before next shift by EOD 1/16/25. -To prevent reoccurrence, DON/Designee will conduct audits to monitor for completion of Day 1 testing for positive COVID results, daily x5 days for 14 days , then weekly for 4 weeks then monthly x2. -Negative findings will be addressed. Policies and Procedures to be reviewed and updated as needed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. Issue #3 -Effective 1/15/25, facility will ensure that return to work guidance for a staff member who tested Outbreak Response Toolkit for Long Term Care. -IP/Designee will monitor for any COVID positive staff weekly x4 weeks, monthly x2 months, and ongoing with occurrence, to ensure that return to work guidance for a staff member who tested positive for COVID is followed. -IP/Designee will conduct education regarding return to work guidance for a staff member who tested positive for COVID is followed in accordance with PA DOH COVID 19 Infection Control and Outbreak Response Toolkit for Long Term Care beginning 1/15/2025 and before next shift by EOD 1/16/25. -To prevent reoccurrence, DON/Designee will conduct ongoing monitoring for COVID positive staff and monitor return to work status, weekly with outbreak occurrence in accordance with PA DOH COVID 19 Infection Control and Outbreak Response Toolkit for Long Term Care by 1/16/25. -Negative findings will be addressed. Policies and Procedures to be reviewed and updated as needed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. Issue #4 -Effective 1/15/2025, IP/Designee to ensure that residents exhibiting signs and symptoms of Influenza are monitored in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care. -IP/Designee will monitor all residents weekly x 4 weeks, monthly x 2 months and ongoing with occurrence for any sign and symptoms of Influenza in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care. -Regional Director of Clinical Services will conduct Inservice regarding identification of Influenza signs and symptoms and testing in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care by 1/16/25. -IP/Designee will conduct education to all staff regarding identification of Influenza signs and symptoms and testing in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care beginning 1/15/2025 and before next shift by EOD 1/16/25. -To prevent reoccurrence, DON/Designee will conduct ongoing monitoring for Influenza signs and symptoms and testing, weekly with occurrence in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care by 1/16/25. -Negative findings will be addressed. Policies and Procedures to be reviewed and updated as needed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. Issue #5 -Effective 1/15/2025, IP/Designee will conduct an initial audit of all residents ' temperatures to ensure that residents exhibiting signs and symptoms of Influenza are monitored in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care. -IP/Designee will monitor all residents ' temperatures weekly x 4 weeks, monthly x 2 months and ongoing with occurrence for any sign and symptoms of Influenza in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care. -Regional Director of Clinical Services will conduct Inservice regarding identification of Influenza signs and symptoms and monitoring in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care by 1/16/25. -IP/Designee will conduct education to all staff regarding identification of Influenza signs and symptoms and monitoring in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care beginning 1/15/25 and before next shift by EOD 1/16/25. -To prevent reoccurrence, DON/Designee will conduct ongoing monitoring for Influenza signs and symptoms, weekly with occurrence in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care by 1/16/2025. -Negative findings will be addressed. Policies and Procedures to be reviewed and updated as needed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. Review of medical records and facility documents on 1/16/25, revealed 98 of 98 residents were assessed for signs and symptoms of Influenza and COVID. No residents exhibited IFI symptoms and required Influenza testing. The facility obtained Influenza tests from hospital and were available for staff to use if needed. Facility wide testing was conducted on all residents and staff prior to the start of their shift for COVID. The DON completed an audit of tests and no positive COVID results were identified. The facility will conduct COVID testing until Day 5, then monitor residents and staff for signs and symptoms of COVID, and test as needed, until Day 14. Review of facility documents revealed the policy for Managing respiratory Illnesses and Outbreaks and Investigating Communicable Outbreaks was created 1/16/25. During an observation on 1/16/25, at 9:02 a.m. the signage posted at the entrance of the facility indicated the facility was currently in an influenza and COVID outbreak. Review of facility documents on 1/16/25, revealed the Regional Director of Clinical Services, Employee E5 conducted an in-service with the Infection Preventionist, Employee E1, and the Director of Nursing on 1/15/25. Review of facility documents on 1/16/25, revealed that the facility had 104 employees and 100% had received education on the facility's COVID-19 and Influenza infection control practices and outbreak response. 48 of these employees received formal education on the facility's COVID-19 infection control practices. 56 of these employees had received this education via telephone as they had not been working in the building. Staff are to sign that they received this education when they are in the building before the start of their next shift. During staff interviews conducted on 1/16/25, between 2:45 p.m. and 3:02 p.m. 28 employees confirmed that they received education on the facility's COVID-19 and Influenza infection control practices and outbreak response. 21 of these employees had received education in person and seven of these employees had received education over the telephone and signed the training sheet prior to the start of their shift. The Immediate Jeopardy was lifted on 1/16/25, at 5:49 p.m. when the action plan implementation was verified. During an interview on 1/16/25, at 6:39 p.m. the Nursing Home Administrator confirmed that the facility failed to implement COVID and Influenza monitoring, tracking, and testing in accordance with state and federal guidance for 95-101 residents from 11/29/24, through 1/15/25. The facility failed to adhere to state return to work guidance for staff. These failures placed all residents in the facility in an Immediate Jeopardy situation. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(d)(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policies and documentation, observations, and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program by failing to follow infection control guidelines from the Centers for Disease Control (CDC) and the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections and prevent cross-contamination during a COVID-19 outbreak. The facility failed to perform contact tracing and testing per PA DOH guidelines and cohorted (an infection prevention and control strategy of grouping residents together who are identified with the same organism to confine their care to one area and prevent contact and spread to other residents) residents who were positive for COVID-19 with residents who were not tested and did not have symptoms of COVID-19. This failure placed the facility in an Immediate Jeopardy situation for 35 of 47 residents reviewed (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, and R35). Review of the Pennsylvania Department of Health COVID-19 Infection Control and Outbreak Response Toolkit for Long-Term Care Version 1.1 dated February 2024, and expanded from infection prevention and control guidance from the Centers for Disease Control and Prevention (CDC) for nursing homes and Long-Term Care Facilities revealed the following: During the Outbreak: COVID-19 Outbreak Management and Control Measures included: 1. Identify and Isolate First Case. a. Isolate with transmission-based precautions (TBP) on COVID-19 Care Unit in accordance with most up-to-date isolation guidance or provide source control to positive resident and isolate in room (ideally residents should be placed in a single-person room). b. Place TBP signs on the door to indicate to those entering the COVID-19 Care Unit/room of the personal protective equipment (PPE) requirements when providing care to residents with COVID-19. c. Ensure all required PPE is available including N95 or higher-level respirator, gowns, gloves, and eye protection and is worn. d. Reinforce core infection prevention practices among residents, visitors, and healthcare personnel (HCP) including hand hygiene, appropriate use of PPE, environmental cleaning, and disinfection. 2. Identify Additional Cases and Exposures. a. Exposed asymptomatic residents and HCP (health care professional) should be tested with a series of up to three viral tests. b. Determine approach (contact-tracing, unit-based, facility-based). c. Identify exposures because of close contact. d. Test exposures immediately (but not within 24 hours of exposure) and if negative, another test at 48 hours, and if negative another test 48 hours later. 5. Returning to Routine Operations a. The facility can return to routine operations when the outbreak has been deemed as complete, which occurs after 14 days without new cases. Evaluation and Monitoring of Residents included: Early detection of signs and symptoms of COVID-19 is key to minimize transmission throughout the facility, as It enables HCP to implement mitigation strategies early. Older adults with COVID-19 may not show common symptoms such as fever or respiratory symptoms, and it is important to assess for other symptoms such as: 1. Fever or chills 2. Cough 3. Shortness of breath 4. Fatigue 5. Muscle or body aches 6. Headache 7. New loss of taste or smell 8. Sore throat 9. Congestion or runny nose 10. Nausea or vomiting 11. Diarrhea With identification of any COVID-19 symptoms, implement prompt isolation and further evaluation for COVID-19 infection. Identify a COVID-19 Care Unit Dedicated to Monitor and Care for Residents with Confirmed COVID-10 included: Dedicating an area within the facility to cohort residents on isolation for confirmed COVID-19 during their infectious period is best practice for decreasing the likelihood of transmission. Components of a COVID-19 Care Unit ideally include the following: 1. Physical separation from other rooms and spaces where residents are not confirmed with COVID-19 2. Single-person room(s) with designated bathroom(s); a. Place a resident with suspected COVID-19 in a single-person room. The door should be kept closed, if safe to do so. The resident should have a dedicated bathroom. b. If limited single rooms are available, or if numerous residents are simultaneously identified to have symptoms concerning for COVID-19, residents may remain in their current location until cause of symptoms is determined. c. If cohorting, only residents with the same pathogens should be housed in the same room. Resident Cohorting Guide included: 1. Resident positive for COVID-19 should not be cohorted with a resident with no respiratory symptoms and not in isolation. 2. Resident positive for COVID-19 should only be cohorted with another resident positive for COVID-19. Review of facility policy Guidelines in Managing Respiratory Illness & Outbreaks dated 1/2/24, indicated one case of COVID-19 is considered an outbreak. The facility is to isolate symptomatic residents as appropriate. Only cohort symptomatic residents with same pathogen confirmed via testing. Conduct contact tracing to determine high risk exposures, perform testing and symptom monitoring as required. Conduct daily symptom surveillance until all cases resolved. The facility must follow mandated testing requirements for COVID, test ALL residents with respiratory symptoms and identified high risk exposures for COVID-19 on days 1, 3, and 5. During an interview on 9/11/24, at 12:38 p.m. when asked how she determines how to handle a communicable disease outbreak, Infection Preventionist Employee E1 stated, I go by what the CDC guidelines are, that's pretty much how I handled the situation, whatever the CDC guidelines say. I do reference the PA HAN as well. When asked if roommates of confirmed positive COVID-19 residents were tested , Infection Preventionist Employee E1 stated, The roommate stayed in the room with the positive resident, we treated them as if they were exposed, but all the residents still had the right to come out of their room, we just encouraged masking. I did not perform contact tracing or testing. I think they did before, but the regulations have changed since the beginning of COVID. We only tested residents if they showed symptoms of COVID or if they requested to be tested . During an interview on 9/11/24, at 12:42 p.m. when asked if the facility cohorted COVID-19 positive residents with residents who had not been tested or displaying symptoms, Infection Preventionist Employee E1 stated, No, we did not split the residents, in the past we did. What I observed is that it [COVID-19] would spread when we would move residents room to room. Review of resident clinical records and facility documents revealed: Resident R1 had symptoms of a sore throat and decreased appetite on 8/5/24, and tested positive for COVID-19 on 8/6/24. Resident R1 remained in the same room with Resident R2, who was not tested . Resident R3 tested positive on 8/7/24, and had symptoms of not feeling well, sweating, and congestion, and remained with roommate Resident R4, who was not tested . Resident R5 tested positive on 8/8/24, and had symptoms of dry cough, and remained with roommate Resident R6, who was not tested . Resident R7 tested positive on 8/10/24, and had symptoms of cough and congestion, and remained with roommate Resident R8, who was not tested . Resident R9 tested positive on 8/13/24, and had symptoms of a fever, sore throat, congestion, and sweating, and remained with roommate Resident R10, who was not tested . Review of a nursing progress note dated 8/13/24, stated, Resident R10 was notified that his roommate has COVID-19. Resident R10 denied having any symptoms. It was explained to Resident R10 that because he has already been exposed to the virus he would need to wash his hands and wear a mask when outside his room. Resident R10 states he understands this but is refusing to re-enter the room. Resident R10 states he hasn't been exposed and spent the night on the dayroom couch. Review of Resident R10's clinical record indicated he was moved to a different room on 8/13/24, upon his request. Resident R11 tested positive on 8/17/24, and had symptoms of congestion and a head cold, and remained with roommate Resident R12, who was not tested . Resident R13 tested positive on 8/17/24, and had no symptoms documented, and remained with roommate Resident R14, who was not tested . Resident R15 tested positive on 8/21/24, and had symptoms of an elevated temperature, and remained with roommate Resident R16, who tested positive on 8/28/24, and had symptoms of a low-grade temperature and feeling flushed. Resident R17 tested positive on 8/24/24, and had symptoms of not feeling well and a low grade temperature, and remained with roommate Resident R18, who was not tested . Resident R19 tested positive on 8/24/24, and had no documented symptoms, and remained with roommate Resident R20, who tested positive on 8/25/24, and had no documented symptoms. Resident R21 tested positive on 8/25/24, and had symptoms of hypoxia (not enough oxygen in the blood). Resident R21 ceased to breathe on 8/26/24. Resident R21 remained with roommate Resident R22, who tested positive on 8/26/24, and had symptoms of hypoxia, altered mental status, and hypoxia. Resident R23 tested positive on 8/27/24, and had flu-like symptoms, and remained with roommate Resident R24, who was not tested . Resident R25 tested positive on 8/27/24, and had symptoms of being flushed, sweaty, emesis, and liquid stools, and remained with roommate Resident R26, who was not tested . Resident R27 tested positive on 8/28/24, and had symptoms of coughing, congestion, sneezing, and malaise (feeling tired), and remained with roommate Resident R28, who was not tested . Resident R29 tested positive on 8/28/24, and had symptoms of coughing, congestion, sneezing, and malaise, and remained with roommate Resident R10, who was not tested . Resident R30 tested positive on 8/29/24, and had symptoms of wheezing and rhonchi (coarse lung sounds caused by constricted airways), and remained with roommate Resident R31, who was not tested . Resident R32 tested positive on 8/30/24, and had symptoms of a fever, and remained with roommate Resident R33, who tested positive on 8/31/24, and had no documented symptoms. Resident R34 tested positive on 9/1/24, and had symptoms of not feeling well, and a low-grade temperature, and remained with roommate Resident R35, who was not tested . During an interview on 9/11/24, at 3:32 p.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) were made aware that an Immediate Jeopardy (IJ) existed. The NHA was provided the IJ Template and at that time a corrective action plan was requested. On 9/11/24, at 6:11 p.m. an acceptable Corrective Action Plan was received, which included the following interventions: - Per PA Department of Health COVID Response Tool Kit, the facility will perform COVID testing for all residents and healthcare providers identified as exposed regardless of vaccination status. - If negative, the facility will test again in 48 hours, after the second negative test (typically day 1, 3, and 5) if additional cases are identified testing should continue on affected units or facility-wide every 3 - 7 days until there are no new cases for 14 days. - The facility is with limited rooms available, residents will remain in their current location until cause of symptoms are determined. - The Medical Director was notified and resident care plans were updated. - All staff will be in-serviced on COVID-19 infection control practices. If any identified COVID infections are noted, the responsible party will be notified. - Education will be completed in person, if staff are not working, phone calls will be made. - To monitor and ongoing compliance, the DON/designee will complete COVID testing. - If COVID positive resident is confirmed, we will shelter in place and pull privacy curtains between both residents, masks will be worn by both residents. - To monitor ongoing compliance, the DON/designee will complete COVID testing according to the PA DOH COVID infection control outbreak response weekly x 4 weeks, then monthly x 2 months. - Results of the audits will be forwarded to the facility Quality Assurance Performance Improvement Committee for review upon completion and recommendations. Review of medical records on 9/12/24, indicated that 101 residents that were not previously tested for COVID-19 were tested on [DATE], all with negative results. 84 staff members who had not previously tested positive for COVID-19 were tested , all with negative results. Review of facility documents on 9/12/24 and 9/13/24, revealed that the facility had 105 employees and 100% had received education on the facility's COVID-19 infection control practices. 57 of these employees received formal education on the facility's COVID-19 infection control practices. 48 of these employees had received this education via telephone as they had not been working in the building. Staff are to sign that they received this education when they are in the building before the start of their next shift. During staff interviews conducted on 9/12/24, between 10:15 a.m. and 2:00 p.m. 22 employees confirmed that they received education on the facility's COVID-19 infection control practices. 13 of these employees had received education in person and nine of these employees had received education over the telephone and signed the training sheet prior to the start of their shift. During an interview on 9/12/24, at 10:07 p.m. Nurse Aide Employee E3 stated, I was told we were cited for not doing the right thing. I figured that was coming. They [administration] don't put too much thought and effort into things. We have been telling them they need to do something. The Immediate Jeopardy was lifted on 9/13/24, at 10:54 a.m. when the action plan implementation was verified. During an interview on 9/13/24, at 11:00 a.m. the DON confirmed that the facility failed to maintain an infection prevention and control program by failing to follow infection control guidelines from the Centers for Disease Control (CDC) and the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections and prevent cross-contamination during a COVID-19 outbreak. This failure placed the facility in an Immediate Jeopardy situation for 35 of 47 residents reviewed. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(d)(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.