Every finding on record at Laurel Lakes Rehabilitation and Wellness Center

Based on facility policy review, clinical record review, observations, facility provided documentation review, and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of five residents reviewed (Resident 5).Findings include: Review of facility policy, titled CPAP/BiPAP Support, with a revision date of February 2026, and a last review date of April 1, 2026, under section, titled General Guidelines for Cleaning, identified the following guidelines for routine cleaning: 4. Machine cleaning: Wipe machine with warm, soapy water, and rinse at least once a week and as needed. 5. Humidifier: b. Clean humidifier weekly and air dry; and 7. Masks, Nasal pillows, and tubing: Clean daily by placing in warm, soapy water. Rinse with warm water and allow it to air dry between uses. Place in plastic bag after drying. Review of Resident 5's clinical revealed that he was originally admitted to the facility on [DATE], with diagnoses that included obstructive sleep apnea (intermittent airflow blockage during sleep), dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), and heart failure (a chronic condition where the heart muscle can't pump enough blood to meet the body's needs). Review of Resident 5's current physician orders revealed an order for CPAP (Continuous Positive Airway Pressure- a machine that uses mild air pressure to keep breathing airways open while one sleeps) settings 18.1 pressure at bedtime on at 9:00 PM and off at 6:00 AM, dated April 28, 2026. Further review of his physician orders revealed an original order date of January 29, 2026, for the CPAP. Observation of Resident 5's room on May 17, 2026, at 11:15 AM; May 18, 2026, at 9:14 AM and 1:17 PM; and May 19, 2026, at 11:29 AM, revealed that his CPAP mask was laying on his nightstand and appeared slightly greasy on the inside. Review of Resident 5's physician orders from January 29, 2026, through May 19, 2026, failed to reveal any orders for the routine cleaning of the CPAP as indicated in the facility policy. Review of Resident 5's clinical record failed to reveal any documentation of weekly cleaning of the CPAP machine and humidifier, or daily cleaning of the mask. During a staff interview with Employee 16 (Licensed Practical Nurse) on May 19, 2026, at 11:35 AM, Employee 16 indicated that night shift manages the CPAP machines but confirmed that the mask should be in a bag when not in use. Facility provided statements dated May 20, 2026, written by Employee 2 (Registered Nurse [RN]) and Employee 3 (RN) that indicated that on room rounds on May 17, 2026, Resident 5's CPAP mask was noted to be lying on his nightstand without a bag for protection and that a new bag was obtained and the mask was placed in the bag. The statement further indicated that the same encounter happened on May 18, 2026, and that on May 19, 2026, the mask was noted to be in the bag on room rounds. The statements failed to indicate the time these rounds were completed. During a staff interview with Employee 15 (Regional Director of Clinical Operations) on May 20, 2026, at 9:11 AM, Employee 15 confirmed that the CPAP cleaning should have been ordered/implemented as per facility policy. Employee 15 indicated that the cleaning orders were not included in the facility order database to be selected and, therefore, they were not implemented. During a final staff interview with the Nursing Home Administrator and Employee 15 on May 20, 2026, at 1:02 PM, both confirmed that the CPAP should have been cleaned as per facility policy and acknowledged surveyor observations of the CPAP mask not being bagged. 28 Pa. Code 211.10(c) Resident care policies28 Pa code 211.12(d)(1)(2)(5) Nursing services.

Based on facility policy review, review of select facility temperature logs, and staff interviews, it was determined that the facility failed to utilize equipment in accordance with professional standards for food service safety in the main kitchen. Findings include: Review of facility policy, titled Freezer and Cooler Monitoring Policy & Procedure last revised December 2025, read, in part, The ensure food safety, product integrity, and regulatory compliance, all refrigeration and freezing units must be properly monitored, maintained, and documented. Temperatures must be kept within safe ranges at all times to prevent spoilage and foodborne illness. Review of facility freezer log sheets revealed freezer temperatures must be maintained below 0 degrees Fahrenheit (F - unit of measure). Review of the November 2025 kitchen equipment temperature logs revealed Freezer #1 was documented as being above 0 degrees on November 1, 16-20, 22-25, and 27-29 in the AM; and November 2, 3, 9-12, 17, 24, and 27 in the PM. No corrective action or reason was noted. Review of the December 2025 kitchen equipment temperature logs revealed:Freezer #1 was documented as being above 0 degrees on December 2, 8, 10, 14, 18, 20, 21, and 30 in the AM; and December 6, 7, 20, 22, 23, 29, and 30 in the PM. No corrective action or reason was noted.Freezer #2 was documented as being above 0 degrees on December 1, 5-8, 11, 17, 28-30 in the AM; and December 14 in the PM. The dish machine temperature log was blank for lunch and dinner on December 12, 2025. No reason was noted. Review of the January 2026 kitchen equipment temperature logs revealed:Freezer #1 was documented as being above 0 degrees on January 4, 7, 8, 10-13, 16-19, 21-23, 25 and 27 in the AM; and January 11-13, and 25 in the PM. No corrective action or reason was noted.Freezer #2 was documented as being above 0 degrees on January 16 and 19 in the AM. No corrective action or reason was noted. Review of the February 2026 kitchen equipment temperature logs revealed:Freezer #1 was documented as being above 0 degrees on February 1, 5, 6, 14, 16, 19, 24, 25, and 28 in the AM; and February 2, 6, and 7 in the PM. No corrective action or reason was noted.Freezer #2 was documented as being above 0 degrees on February 1, 2, 5, 6, 10, and 13 in the AM; and February 13 in the PM. No corrective action or reason was noted.Freezer #5 was documented as being above 0 degrees on February 7th in the AM. No corrective action or reason was noted. Review of the March 2026 kitchen equipment temperature logs revealed:Freezer #1 was documented as being above 0 degrees on March 2, 13, 15, 23, 25, and 26 in the AM. No corrective action or reason was noted.Freezer #2 was documented as being above 0 degrees on March 13, 18, 20 and 27 in the PM. No corrective action or reason was noted. Review of the April 2026 kitchen equipment temperature logs revealed:Freezer #1 was documented as being above 0 degrees on April 3, 6, 8, 9, 17, and 20 in the AM; and April 20-22 in the PM. No corrective action or reason was noted.Freezer #2 was documented as being above 0 degrees on April 1, 10, 16, 17, 21-24, 28 and 30 in the AM; and April 25 in the PM. No corrective action or reason was noted. Review of the April 2026 food temperature logs revealed temperatures failed to be logged on April 22 at dinner. During an interview with Employee 14 (Dietary Manager) on May 19, 2026, at 11:54 PM, she revealed the discrepancies and missing documentation in the aforementioned temperature logs happened prior to her employment, and she does not have any information to provide about them. She further revealed she plans to do education with the staff regarding the importance of accurate and complete kitchen equipment temperature logs. Interview with the Nursing Home Administrator on May 20, 2026, at 12:55 PM, he revealed he would expect temperature logs to be accurate and completed and kitchen equipment is utilized in accordance with professional standards. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice that meet each resident's physical, mental, and psychosocial needs for three of 33 residents reviewed (Residents 5, 13, and 135).Findings include: Review of Resident 5's clinical revealed diagnoses that included diabetes mellitus (disease that occurs when your blood glucose, also called blood sugar, is too high) and dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning). Review of Resident 5's physician orders revealed orders for Toujeo Max SoloStar Subcutaneous Solution Pen injector 300 units/milliliter (Insulin Glargine) Inject 20 unit subcutaneously one time a day, dated April 24, 2026; and Novolog FlexPen Subcutaneous Solution Pen injector 100 units/milliliter (Insulin Aspart) Inject as per sliding scale: if 0 - 100 = 0 units; 101-110 = 4units ; 111- 400 = 8 units subcutaneously with meals. Notify MD with blood sugars less than 70 or greater than 400, dated April 24, 2026. Review of Resident 5's April 2026 Medication Administration Record (MAR) revealed that his ordered Toujeo was not documented as being administered on April 27, 2026. Review of Resident 5's May 2026 MAR revealed that on May 7, 2026, his 12:00 PM blood sugar was recorded as 140 and his insulin dose administration was documented as N/A, but, per his physician orders, he should have received 8 units of insulin. Further review of Resident 5's May 2026 MAR revealed that on May 16, 2026, his 8:00 AM blood sugar was recorded as 114 and his insulin dose administration was documented as 4 (outside of parameters), but, per his physician orders, he should have received 8 units of insulin. Review of facility provided statement written by Employee 2 (Registered Nurse) on behalf of Employee 4 (Licensed Practical Nurse) dated May 20, 2026, indicated that Employee 4 did not administer Resident 5's Toujeo on April 26, 2026, because he had returned from the hospital on April 24, 2026, and the medication had not been delivered from the pharmacy. The facility was told it was enroute but it did not arrive prior to the end of her shift. Employee 4 also said that she had administered the Novolog to Resident 5 on May 16, 2026, but had coded out of parameters in error. During a staff interview with the Nursing Home Administrator (NHA) and Employee 15 (Regional Director of Clinical Operations) on May 20, 2026, at 1:27 PM, both acknowledged that Resident 5 was documented as receiving his Toujeo on April 25, 2026, even though Employee 4 said it was not available on April 26, 2026. Employee 15 indicated that they had no other information to provide. The NHA and Employee 15 both confirmed that they would expect residents to receive their medications as ordered and to be documented accordingly. Review of Resident 13's clinical record revealed diagnoses that included diabetes mellitus and moderate protein-calorie malnutrition (the state of inadequate food intake). Review of Resident 13's physician orders revealed an order for Humalog KwikPen Subcutaneous Solution Pen injector 100 units/milliliter (Insulin Lispro) Inject as per sliding scale: if 0 - 130 = 0units notify MD if BS is less than 70; 131-180 = 2 units ; 181-240 = 4units ; 241-300 = 6units; 301-350 = 8units; 351-400 = 10 units subcutaneously before meals and at bedtime. Notify Provider if BS is greater than 400, dated April 26, 2026. Review of Resident 13's April 2026 MAR revealed that on April 29, 2026, at 9:00 PM, her blood sugar was 137 and her insulin dose administration was coded as 4 (outside of parameters). Review of Resident 13's May 2026 MAR revealed that on May 11, 2026, at 11:00 AM, her blood sugar was recorded as 141 and her insulin dose was recorded as 4 (outside of parameters). In addition, her May 17, 2026, at 7:30 AM her blood sugar was recorded as 134 and her insulin dose was recorded as 4 (outside of parameters). Review of facility provided statement written by Employee 4 (Licensed Practical Nurse) dated May 20, 2026, indicated that Employee 4 remembered being on Resident 13's medication cart a couple of days in the last month and that she remembers giving Resident 13 her insulin because Resident 13 asked why she was getting the insulin if her blood sugar was not that high. Employee 4 indicated that she must have hit the wrong button after administering the insulin, resulting in incorrect documentation. During a staff interview with the NHA and Employee 15 on May 20, 2026, at 1:02 PM, they both confirmed that they would expect residents to receive their medications as ordered and to be documented accordingly. Review of Resident 135's clinical record revealed diagnoses that included type one diabetes mellitus (the body's immune system destroys insulin-producing cells in the pancreas) with hyperglycemia (high blood sugar) and major depressive disorder (mood disorder characterized by pervasive low mood and loss of interest). Review of Resident 135's physician orders revealed orders for Toujeo SoloStar Pen-injector 300 unit/milliliter (ml), inject 33 units one time a day for type one diabetes mellitus; Toujeo SoloStar Pen-injector 300 unit/ml, inject 30 units at bedtime for type one diabetes mellitus; blood sugar (BS) check one time a day related to type one diabetes mellitus update MD if less than 70 or greater than 400; Insulin Aspart FlexPen 100 units/ml inject five units before meals; Insulin Aspart FlexPen 100 units/ml inject as per sliding scale notify physician of BS greater than 401. Review of Resident 135's February 2026 MAR revealed the following documented blood sugars: February 1 - 511; February 10 - 409; and February 18 -blank no blood sugar documented. Review of Resident 135's progress notes failed to reveal any notes for the aforementioned dates indicating that the physician had been notified of Resident 135's blood sugar being greater than 401. Further review of Resident 135's February 2026 MAR revealed that on February 5 and February 17 at 8:00 AM, Resident 135's dose of Toujeo SoloStar Pen-injector was marked NA. Review of Resident 135's March 2026 MAR revealed the following documented blood sugar: March 2 - 413. Review of Resident 135's progress notes failed to reveal any notes for the aforementioned date indicating that the physician had been notified of Resident 135's blood sugar being greater than 401. Review of Resident 135's April 2026 MAR revealed the following documented blood sugar: April 3 - 500. Review of Resident 135's progress notes failed to reveal any notes for the aforementioned date indicating that the physician had been notified of Resident 135's blood sugar being greater than 401. Further review of Resident 135's April 2026 MAR revealed the following: April 4 at 8:00 PM Resident 135's dose of Toujeo SoloStar Pen-injector was marked 9. Review of the MAR chart codes revealed 9 = other/see progress notes. April 13 at 7:30 AM Resident 135's Insulin Aspart FlexPen 100 units/ml inject five units before meals was marked 4. Review of the MAR chart codes revealed 4 = vitals outside of parameters for administration. April 20 at 4:00 PM Resident 135's Insulin Aspart FlexPen 100 units/ml inject five units before meals was marked 5. Review of the MAR chart codes revealed 5 = hold/see progress notes. Review of Resident 135's progress notes failed to reveal any notes relating to Resident 135's insulin administration for the aforementioned dates. Further review of Resident 135's physician orders revealed that no parameters were indicated for Insulin Aspart FlexPen 100 units/ml inject five units before meals. An interview with Employee 15 on May 20, 2026, at 1:57 PM, revealed that the facility had no additional information to provide. Employee 15 stated that it was the expectation of the facility that physician orders be followed and insulin be administered as ordered. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of the RAI manual (Resident Assessment Instrument- A standardized guide used in nursing homes and long-term care facilities to assess residents health, functional status, and care needs), clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident's status for one of 33 residents reviewed (Residents 78).Findings include: Review of RAI Manual guidance for section K revealed A therapeutic diet is a diet intervention prescribed by a physician or other authorized nonphysician practitioner that provides food or nutrients via oral, enteral, and parenteral routes as part of treatment of disease or clinical condition, to modify, eliminate, decrease, or increase, identified micro- and macro- nutrients in the diet. Review of Resident 78's clinical record revealed diagnoses that included unspecified protein calorie malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it gets), adult failure to thrive (FTT- in adults is a significant decline in physical and emotional well-being, often characterized by weight loss, decreased appetite, and inactivity), and dysphagia (difficulty chewing and/or swallowing). Review of Resident 78's physician orders revealed an order for Regular diet, Regular texture, Thin consistency, Fortified foods at lunch and dinner, with a start date of June 28, 2025. Review of Resident 78's care plan revealed an active focus area for nutritional status with an intervention for Provide diet/supplements per orders: Regular diet, regular texture, thin liquids, fortified foods with lunch/dinner, last revised February 23, 2026. During an interview with Resident 78 on May 19, 2026, at 12:02 PM, she revealed she gets mashed potatoes as an extra item at lunch and pudding or ice cream at dinner to provide extra calories to her diet. Interview with Employee 14 (Certified Dietary Manager) on May 19, 2026, at 12:07 PM, she revealed the fortified food program includes hot cereal at breakfast, fortified mashed potatoes at lunch, and fortified pudding at dinner, but Resident 78 was very particular about her diet, and preferred fortified foods only at lunch and dinner, and swaps the pudding at dinner for ice cream at times. She further revealed Resident 78 was ordered a therapeutic diet for her complex nutritional problems. Review of Resident 78's Quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident's physical, mental or psychosocial needs) assessments with ARD (last day of the assessment period) of December 26, 2025; March 28, 2026; and March 29, 2026; revealed she was marked no for a therapeutic diet. Interview with Employee 16 (Registered Nurse Assessment Coordinator) on May 19, 2026, at approximately 12:30 PM, she revealed Resident 78 should have been coded for a therapeutic diet on her aforementioned MDS assessments. Interview with the Nursing Home Administrator on May 20, 202, at 12:55 PM, he revealed he would expect MDS assessments to be coded accurately. 28 Pa. Code 211.5 (f) Medical Records28 Pa. Code 211.5(d)(3)(5) Nursing services

Based on observations, facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure staff implement transmission-based precautions to prevent the spread of infection for two of three residents observed (Residents 72 and 164).Findings Include: Review of facility policy, titled Isolation- Categories of Transmission-Based Precautions, revised October 2018, revealed in a section labeled, Contact Precautions, staff and visitors will wear gloves (clean, non-sterile) when entering the room and staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room. Further review of this policy revealed that for residents requiring droplet precautions staff are expected to wear masks, gloves, gown, and goggles when entering the residents room. Review of Resident 72's clinical record revealed diagnoses that included shingles (a painful, blistering viral rash caused by the same virus that causes chickenpox) and Human Immunodeficiency Virus (HIV- are two species of Lentivirus that infect humans. Over time, they cause acquired immunodeficiency syndrome, a condition in which progressive failure of the immune system allows life-threatening opportunistic infections and cancers to thrive). Observation of Resident 72 on May 17, 2026, at 11:07 AM, revealed Resident 72 sitting in her wheelchair in her room. On the wall outside of her room was a sign signifying that a resident in that room was on droplet precautions and that anyone entering the room must wash their hands and then apply gloves, a protective gown, and protective face shield prior to entering, and remove them prior to exiting the room. Further observation at that time revealed Employee 8 enter the room without applying any of the required PPE (personal protective equipment) to have a conversation with Resident 72. Further observation at that time revealed Employee 6 entering Resident 72's room to provide her with drinks for the lunch meal without applying any of the required PPE. Review of Resident 72's physician orders failed to reveal any orders for transmission-based precautions. Review of Resident 72's care plan revealed a care plan focus area of: infection of shingles, initiated May 13, 2026, with an intervention of: isolation- contact precautions, with a date initiated of May 13, 2026. Review of Resident 164's clinical record revealed diagnoses that included shingles and diabetes (a condition where the body is unable to regulate blood glucose levels). Observation of Resident 164 on May 17, 2026, at 12:09 PM, revealed Resident 164 lying in bed. On the wall outside of his room was a sign signifying that a resident in that room was on droplet precautions and that anyone entering the room must wash their hands and then apply gloves, a protective gown, and protective face shield prior to entering and remove them prior to exiting the room. Further, a second sign hanging on the wall outside of Resident 164's room signified that a resident in that room was on Contact precautions and that anyone entering the room was required to wear gloves and a gown to enter, and then remove them prior to exiting the room. Further observation at this time revealed Employee 6 entering Resident 164's room, without applying PPE, to take him his lunch tray. Observation on May 17, 2026, at 12:35 PM, revealed Employee 7 entering Resident 164's room without applying any of the required PPE, collect Resident 164's lunch tray and then exit the room without performing hand hygiene. Review of Resident 164's physician's orders failed to reveal an order for any type of transmission-based precautions. Review of Resident 164's care plan revealed a care plan focus are of, Infection of shingles, initiated May 13, 2026, with an intervention of, maintain contact isolation precautions as indicated, initiated May 13, 2026. Interview with the Nursing Home Administrator on May 20, 2026, at 1:10 PM, revealed an expectation that staff would use the correct PPE when entering residents' rooms that require it. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services consistent with professional standards of practice for two of five residents reviewed for unnecessary medications (Residents 78 and 139).Findings include: Review of facility policy, titled Consultant Pharmacist Services Provider Requirement with an effective date of August 2020, read, in part, The facility will ensure regular and reliable consultant pharmacist services are provided to residents. Working with facility staff on the development, implementation, evaluation, and revision of pharmaceutical services procedures and helping ensure that the procedures address the needs of the residents and reflect current standards of practice. Assisting in the identification and evaluation of medication-related issues. Including the prevention and reporting of medication errors. Review of Resident 78's clinical record revealed diagnoses that included unspecified protein calorie malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it gets), adult failure to thrive (FTT- in adults is a significant decline in physical and emotional well-being, often characterized by weight loss, decreased appetite, and inactivity), and dysphagia (difficulty chewing and/or swallowing). Review of Resident 78's April 2026 Pharmacist Medication Regimen Review (MRR- a systematic evaluation of a patient's complete medication list to ensure safety, effectiveness, and optimal health outcomes), completed on April 8, 2026, revealed a recommendation for Currently receiving Lidoderm Patch applied once daily as needed. Per manufacturer must be removed after 12 hours to avoid tachyphylaxis (a rapid and temporary decrease in the body's response to a drug after repeated or continuous administration). Please clarify order to apply once daily for 12 hours then remove for 12 hours. The MRR was signed that the physician was in agreement on April 16, 2026. Review of Resident 78's physician orders revealed the order for the Lidocaine patch remained unchanged to reflect the above recommendations until the order was discontinued on May 13, 2026. Review of Resident 139's clinical record revealed diagnoses that included dementia (a condition characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities) and muscle weakness. Review of Resident 78's April 2026 MRR completed on April 12, 2026, revealed a recommendation for Currently receiving Neurontin (gabapentin-medication for nerve pain) 100 mg daily. Please evaluate the need and effect of low dosage. Consider trial taper to every other day for one week then discontinue if appropriate. The MRR was signed that the physician was in agreement on April 16, 2026. Review of Resident 139's physician orders revealed an order for Gabapentin Oral Capsule 100 MG, Give 1 capsule by mouth at bedtime related to chronic pain syndrome, with a start date of March 30, 2026, and discontinued on April 29, 2026. Review of Resident 139's physician orders revealed an active order for Gabapentin Oral Capsule 100 MG, Give 1 capsule by mouth at bedtime related to chronic pain syndrome, with a start date of May 1, 2026. During an interview with Employee 15 (Regional Director of Clinical Operations) on May 19, 2026, at 1:35 PM, she revealed she was unsure as to why Resident 78's April MRR was not responded to timely, and why the order in response to Resident 139's April MRR was not transcribed, as he was in agreement with the recommendation. Further he revealed that Resident 139 was hospitalized at the end of April 2026, so that was why the order was discontinued and restarted. During a follow up interview with Employee 15 and the Nursing Home Administrator on May 20, 2026, at 1:05 PM, the surveyor revealed the concern with the lack of implementation of Resident 78's and 139's pharmacy recommendations. They revealed their expectation that physician orders are transcribed as appropriate. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, review of facility documentation, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to provide pharmaceutical services to meet the needs of each resident for three of seven residents reviewed (Resident 1, 4, and 7), which resulted in actual harm as evidenced by a right elbow fracture and laceration for one of seven residents reviewed (Resident 1).Findings Include:Review of facility policy, titled Pharmscript Provider Pharmacy Requirements, last revised August 2020, read, in part, Procedures: 4. f. Providing routine and timely pharmacy service as contracted, as well as emergency pharmacy service 24 hours per day, seven days per week. New medication orders are available for administration on the next routine delivery, unless otherwise requested by facility staff. Medication will be delivered by the primary pharmacy or back-up pharmacy or are available from the emergency medication kit/back-up medication supply.Review of Resident 1's clinical record revealed diagnoses that included epilepsy (brain disorder causing reoccurring seizures), type two diabetes mellitus (body cannot use insulin correctly causing high blood sugar), and sepsis (body's extreme response to an infection causing organ damage).Review of Resident 1's nursing progress notes revealed Resident 1 was admitted to the facility from the hospital on December 24, 2025, at approximately 2:40 PM.Review of Resident 1's physician orders at the time of admission revealed the following orders:Carbamazepine extended release 200 milligrams (mg), two tablets one time a day related to epilepsy.Carbamazepine extended release 200 mg, three tablets at bedtime related to epilepsy.Doxycycline Hyclate 100 mg, one capsule two times a day related to cutaneous abscess of back.Duloxetine HCL delayed release 60 mg, one capsule one time a day for depression.Finasteride 5mg, give one tablet onetime a day for bph.Metoprolol Succinate extended release 25 mg, one tablet one time a day related to essential hypertension.Phenobarbital 100 mg, one tablet two times a day related to epilepsy.Pregabalin 100 mg, one capsule two times a day related to neuropathy.Rosuvastatin Calcium 40 mg, one tablet one time a day related to hyperlipidemia.Review of Resident 1's medication administration record (MAR) for December 2025 revealed on December 24, 2025, Resident 1's 7:00 PM doses of Carbamazepine and Doxycycline were marked 9 and on December 25, 2025; and Resident 1's 7:00 AM doses of Carbamazepine, Doxycycline, Finasteride, Metoprolol, Phenobarbital, Pregabalin, and Rosuvastatin were marked 9.Review of the MAR key code revealed 9 = other/see nursing notes.Further review of Resident 1's nursing progress notes revealed notes corresponding with the aforementioned dates, times, and medications stating that the medications were not available.Review of Resident 1's clinical record indicated he missed one dose of his antiseizure medication (Carbamazepine) on December 24, 2025, and two doses of his antiseizure medications (Carbamazepine and Phenobarbital) on December 25, 2025.Additional review of Resident 1's nursing progress notes revealed that on December 25, 2025, at 3:21 PM, Resident 1 was found lying on the floor next to his bed, unresponsive with seizure like activity and a moderate amount of blood was noted on Resident 1's forehead. The episode was noted as lasting approximately five minutes and Resident 1 was lethargic (decrease in consciousness) and postictal (recovery period following a seizure) following the episode. EMS was called and Resident 1 was transported to the hospital.Review of Resident 1's hospital summary dated December 25, 2025, at 7:49 PM, revealed that Resident 1 was initially treated in the emergency department for seizure activity and a head laceration, and was subsequently admitted to the hospital for observation.X-ray results revealed that Resident 1 suffered a mildly displaced fracture of the right radial head.Review of the emergency room physician's notes revealed that Resident 1 was alert and oriented at the time of the evaluation and reported he had seizures all of his life, and that he was very well controlled with medication. His last seizure was in the 1990s. He reported that the facility did not have his seizure medications in stock and were unable to administer them.During an interview on January 13, 2026, at approximately 2:00 PM, with the Nursing Home Administrator (NHA) and Director of Nursing (DON) it was revealed that the contracted pharmacy delivers to the facility twice a day and a local pharmacy can be used as a backup for emergent medications. The contracted pharmacy determines the need for the use of the backup pharmacy and sends the orders to them. The facility is not sure where a breakdown in communication occurred but stated they did identify the issue after the incident with Resident 1.Review of Resident 4's clinical record revealed diagnoses that included type two diabetes mellitus, epilepsy, and sepsis (body's extreme response to an infection causing organ damage).Review of Resident 4's nursing progress notes revealed Resident 4 was admitted to the facility from the hospital on December 23, 2025, at approximately 8:40 PM.Review of Resident 4's physician orders at the time of admission revealed the following orders:Divalproex Sodium delayed release 500 mg tablet, 1 tablet two times per day for seizures.Glipizide 5 mg tablet, 1.5 tablets one time a day for diabetes mellitus.Levetiracetam 500 mg tablet, 1 table three times a day for seizures.Memantine HCL 5 mg tablet, 1 tablet two times a day for dementia.Movantik 25 mg tablet, 1 time a day for GERD.Unisom sleep tabs 25 mg, 1 tablet at bedtime for insomnia.Review of Resident 4's MAR for December 2025 revealed that on December 23, 2025, Resident 4's 8:00 PM dose of Unisom and 9:00 PM dose of Divalproex Sodium were left blank.On December 24, 2025 Resident 4's 7:00 AM doses of Divalproex, Glipizide, Levetiracetam, Movantik, Memantine; 1:00 PM dose of Levetiracetam; 8:00 PM doses of Levetiracetam and Unisom, and 9:00 PM dose of Memantine were marked 9.On December 25, 2025 Resident 4's 7:00 AM doses of Glipizide, Movantik, and Memantine and 8:00 PM dose of Unisom were marked 9. On December 26, 2025 Resident 4's 8:00 PM dose of Unisom was marked 9.Review of the MAR key code revealed 9 = other/see nursing notes.Further review of Resident 4's nursing progress notes revealed notes corresponding with the aforementioned dates, times, and medications stating that the medications were not available.Review of Resident 7's clinical record revealed diagnoses that included epilepsy and major depressive disorder (persistently low or depressed mood).Review of Resident 7's nursing progress notes revealed Resident 7 was admitted to the facility from the hospital on December 1, 2025, at approximately 1:43 PM.Review of Resident 7's physician orders at the time of admission revealed the following orders:Imipramine HCL 10 mg tablet, 1 tablet at bedtime related to essential hypertension.Lamotrigine 100 mg tablet, 1 tablet every morning and at bedtime related to epilepsy.Topiramate 200 mg tablet, 1 tablet every morning and at bedtime related to epilepsy.Review of Resident 7's MAR for December 2025 revealed that on December 1, 2025, Resident 7's 8:00 PM doses of Imipramine HCL, Lamotrigine, and Topiramate were marked 9.On December 2, 2025 Resident 7's 8:00 AM dose of Topiramate and 8:00 PM dose of Imipramine HCL were marked 9.Review of the MAR key code revealed 9 = other/see nursing notes.Further review of Resident 7's nursing progress notes revealed notes corresponding with the aforementioned dates, times, and medications stating that the medications were not available.During an interview on January 13, 2026 at approximately 2:00 PM, the NHA stated that the facility identified the noncompliance and a plan of correction was developed and initiated. The facility has been working with the contracted pharmacy and the local hospitals. The new plan is that prior to admission to the facility the DON will coordinate with the hospital and the contracted pharmacy to initiate the resident's medications. When residents are discharged from the hospital late in the day, the hospital will either administer their medications or discharge them with one to two doses of the medication. If the hospital is unable to provide the medication, the local backup pharmacy will dispense one to two doses until the contracted pharmacy can deliver the medication. Audits were initiated and are ongoing. The DON also reviewed and updated the medications available in the facility's Omnicell (an automated secure medication dispensing system). The incident with Resident 1 and the facility's plan of correction were reviewed at a QAPI meeting on December 29, 2025.The facility's plan of correction was reviewed during an onsite survey on January 13, 2026. Audits were performed on all new admissions to ensure timely administration of medications. Audits were initiated on December 28, 2025, and are ongoing. The facility's Omnicell medication stock has been updated. Education for all licensed staff was initiated on December 26, 2025, and completed on January 2, 2026. Education was reviewed and included education on communication with pharmacy, pharmacy hours/holiday schedules, utilizing the backup pharmacy, updated medications available in the Omnicell, and the facility's updated policy titled, Pharmacy Deliveries and Medication Escalation Policy, effective December 26, 2025.Review of facility plan of correction documentation revealed that on January 2, 2026, the facility had completed audits and education for staff to ensure compliance with pharmacy services. During the abbreviated survey, audits and staff education were reviewed. Staff interviews, resident record review, and observations revealed no concerns with pharmacy services.28 Pa. Code 201.14(a) Responsibility of license28 Pa. Code 201.18(b)(1)(e)(1) Management28 Pa. Code 211.9(a)(1) Pharmacy services28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, review of facility temperature logs, and staff interviews, it was determined that the facility failed to utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen.Findings include:Observation of the dish machine in the main kitchen on July 28, 2025, at 1:22 PM, revealed kitchen staff were washing dishes from lunch, and the wash temperature of the dish machine read 138 degrees Fahrenheit (F).During an interview with Employee 3 (Certified Dietary Manager) on July 28, 2025, at 1:23 PM, he revealed the dish machine should be running at a minimum wash temperature of 150 degrees F. The surveyor questioned if he could link a sanitizing solution to the machine for safe use at a lower temperature and if he could have maintenance staff service the machine. Employee 3 revealed he could link the sanitizer to the machine as well as contact maintenance staff. Observation of the dish machine in the main kitchen on July 29, 2025, at 1:21 PM, revealed kitchen staff were washing dishes from lunch, and the wash temperature of the dish machine read 136 degrees F. Interview with Employee 3 on July 29, 2025, at 1:22 PM, revealed he had maintenance staff service the machine that morning and it had been running between 155-160 degrees F during breakfast. He further revealed he did not link the sanitizing solution to the machine. Observation of the dish machine in the main kitchen on July 30, 2025, at 1:11 PM, revealed kitchen staff were washing dishes from lunch, and the wash temperature of the dish machine read 140 degrees F. Review of the December 2024 dish machine temperature log revealed rinse temperatures were recorded below the minimum safe temperature on all days and at all meals during that month, and no corrective action was notedDuring an interview with the Director of Nursing on July 31, 2025, at 12:37 PM, she revealed her expectation that kitchen equipment is utilized in accordance with professional standards.28 Pa. Code 211.6(f) Dietary services

Based on review of facility policy, clinical record reviews, and staff interview, it was determined that the facility failed to ensure that residents who require dialysis receive such services consistent with professional standards of practice for two of two residents reviewed for dialysis (Residents 16 and 46). Findings include:Review of facility policy, titled Hemodialysis Catheters - Access and Care of, last reviewed June 20, 2025, read, in part, The nurse should document in the resident's medical record every shift as follows: 1. Location of catheter. 2. Condition of dressing (intervention if needed). 3. If dialysis was done during shift. 4. Any part of report from dialysis being given. 5. Observations post-dialysis.Review of Resident 16's clinical record revealed diagnoses that included end stage renal disease (condition in which kidneys cease functioning) and dependence on renal dialysis (treatment that removes extra fluid and waste products from the blood when the kidneys are not able to). Review of Resident 16's physician orders revealed an order to check dialysis access site dressing every shift, reinforce as needed, and notify the physician as needed. Further review of Resident 16's clinical record failed to reveal evidence that Resident 16's dialysis access site dressing checks were being completed as ordered. During an interview with the Director of Nursing (DON) on July 31, 2025 at 11:15 AM, it was revealed that a transcription error had occurred and the physician's order did not populate on Resident 16's medication or treatment administration record. The facility could not provide documentation that Resident 16's dialysis access site dressing checks were being completed. The DON stated it was the expectation of the facility that physician orders be transcribed correctly and dialysis access site dressing checks to be completed as ordered and documented. Review of Resident 46's clinical record revealed diagnoses that included end stage renal disease (condition in which kidneys cease functioning) and dependence on renal dialysis (treatment that removes extra fluid and waste products from the blood when the kidneys are not able to). Review of Resident 46's physician orders revealed an order to check dialysis access site dressing every shift, reinforce as needed, and notify the physician as needed. Further review of Resident 46's clinical record failed to reveal evidence that Resident 16's dialysis access site dressing checks were being completed as ordered. During an interview with the DON on July 31, 2025 at 11:20 AM, it was revealed that a transcription error had occurred and the physician's order did not populate on Resident 46's medication or treatment administration record. The facility could not provide documentation that Resident 46's dialysis access site dressing checks were being completed. The DON stated it was the expectation of the facility that physician orders be transcribed correctly and dialysis access site dressing checks to be completed as ordered and documented. 28 Pa Code 211.5(f) Clinical records28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to implement resident-directed care and treatment consistent with the resident's physician orders and plan of care for one of 34 residents reviewed (Resident 25).Findings include:Review of Resident 25's clinical record revealed she was readmitted to the facility from the hospital on April 21, 2025, with diagnoses that included elevation of levels of liver transaminase (indication of liver stress or injury) and need for assistance with personal care. Review of Resident 25's physician orders revealed an order for Atorvastatin Calcium Oral Tablet 10 MG (Atorvastatin Calcium) Give 1 tablet by mouth at bedtime for hyperlipidemia please stop taking when your liver enzymes are close to normal, with a start date of April 21, 2025. Further review of Resident 25's physician orders failed to reveal any active orders for laboratory work. Review of Resident 25's hospital discharge summary documentation signed on April 21, 2025, revealed She was advised at discharge to stop taking her statin therapy until liver function is rechecked in a few weeks. She was discharged to rehab in a safe and stable condition.Further review of Resident 25's hospital discharge summary documentation signed on April 21, 2025, revealed Change how you take these medications: atorvastatin 10 mg tablet, take 1 tablet (10 mg total) by mouth nightly, please stop taking until your liver numbers are close to normal. What changed: additional instructions. The document was check marked alongside that order, indicating that it had been put into the system as it read. Review of Resident 25's physician notes revealed a physician note dated April 22, 2025, that read, in part, For Transaminitis-the statin was placed on hold. CT scans and abdominal ultrasounds did not provide any causes for this. The liver enzymes were improving after the statin was held. Continue to hold the statin, recheck the liver enzymes in a few weeks with recommendations to restart atorvastatin10 mg when the labs are normal.Review of Resident 25's physician notes revealed a physician note with an effective date of July 24, 2025, that read, in part, For Hyperlipidemia continue to hold Atorvastatin until labs are checked in a few weeks.Review of Resident 25's 2025 April, May, June, and July MAR (Medication Administration Record- documentation for medication/treatment administered or monitored), revealed Resident 25 received the Atorvastatin medication on all days of those months from April 21, 2025, through July 29, 2025. During an interview with the Director of Nursing (DON) on July 30, 2025, at 1:13 PM, the surveyor questioned the order for the atorvastatin being inconsistent with the physician notes and why the liver enzyme laboratory work was never ordered.Interview with the DON on July 31, 2025, at 12:38 PM, revealed she would expect that the medication would have been held, and labs would have been obtained per the physician notes and plan of care. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on observations, facility policy review, clinical record reviews, and resident and staff interviews, it was determined that the facility failed to maintain adequate personal hygiene and grooming of residents dependent on staff for assistance with these activities of daily living for two of 34 residents reviewed (Residents 79 and 149).Findings include: Review of facility policy, titled Activities of Daily Living (ADL), Supporting, with a revised date of March 2018, and a last review date of June 20, 2025, revealed Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Review of Resident 79's clinical record revealed she was admitted to the facility on [DATE], with diagnoses that included muscle weakness, need for assistance with personal care, and legal blindness. Observations of Resident 79 on July 28, 2025, at 12:05 PM; and on July 30, 2025, at 12:15 PM, revealed the presence of a large amount of black and gray facial hair on her upper lip and chin. Review of Resident 79's care plan revealed a focus for ADL (Activities of Daily Living - washing face, brushing teeth, personal hygiene) deficit related to weakness dated July 15, 2025, with interventions that included, but were not limited to, assist with daily hygiene, grooming, dressing, oral care and eating as needed dated July 15, 2025, and shower/bath on Wednesday and Friday evening shift, dated July 14, 2025. Observation of Resident 79 on July 31, 2025, at 9:45 AM, continued to reveal the presence of a large amount of black and gray facial hair on her upper lip and chin. Immediate interview with Resident 79 revealed that she had not been offered to be shaved since residing at the facility. She further indicated that she would need help and would like to be shaved. Review of Resident 79's bath/shower task documentation revealed that she received a shower on July 16, 2025; a bed bath on July 18 and 23, 2025; was documented as non-applicable on July 25, 2025; and was documented as refused on July 30, 2025. During a staff interview with the Director of Nursing (DON) on July 31, 2025, at 11:45 AM, Resident 79's observations and interview findings were shared. During a follow-up staff interview with the DON on July 31, 2025, at 12:37 PM, she indicated that Resident 79 had been shaved and confirmed that staff should have offered to shave Resident 79's upper lip and chin on her bath/shower day. Review of Resident 149's clinical record revealed he was admitted to the facility on [DATE], with diagnoses that included type 1 diabetes mellitus (condition where pancreas makes very little or no insulin, which leads to high blood sugar levels) and radiculopathy, lumbar region (condition where a nerve root in the lower back is compressed or irritated, leading to pain, numbness, tingling, or muscle weakness that radiates down the leg). Review of Resident 149's care plan included a focus area for activities of daily living (ADLs). The care plan revealed the Resident had a self-care deficit for all ADLs that includes grooming his toenails. Review of Resident 149's annual Minimum Data Set (MDS- periodic assessment of resident needs), dated June 12, 2025, revealed that Resident 149 BIMs (brief interview of mental status) score was 15, indicating cognitive function is intact. During an interview with Resident 149 on July 28, 2025, at 12:10 PM, he stated he hasn't had his toenails trimmed for a long time. The surveyor observed his toenail on the right foot and the great toenail extended approximately an inch from the tip of his toe. The left foot had a sock on, but the Resident said it is just as long, pointing the tip of his toe and touching the end of the nail. Resident 149 added that the podiatrist (foot doctor) was in facility to trim roommate's toenails, and he asked the podiatrist if it was his turn, and the podiatrist responded, not today. Resident 149 was unable to provide the date that their roommate had podiatry care. Review of Resident 149's podiatry services since admission to the facility revealed he consented for podiatry services on May 25, 2022. On June 10, 2022, podiatry services provided the initial visit, documenting the reason was for diabetes mellitus foot care. Podiatry notes stated that all toenails were 2-3 millimeters thick, yellow in color, and crumbly. Podiatrist documented the Resident to receive follow-up care in 2-3 months. Resident 149 received podiatry care on September 8, 2022, November 10, 2022, and was scheduled to be seen on March 23, 2023, but Resident 149 was sick on March 23, 2023, and the appointment had to be cancelled. Based on clinical record review and interview with the Resident he has not received any podiatry services since November 10, 2022. On July 28, 2025, the DON was questioned about scheduled podiatry services for Resident 149 and the surveyor described Resident 149's nails. The DON also observed Resident 149's toenails. On July 29, 2025, at approximately 9:30 AM, the DON provided a form titled Ancillary Services that stated, podiatry visits to the facility are scheduled for August 8 and 23, 2025. The DON documented that the facility audited the ancillary services and residents are being tracked for all services that would include podiatry, dental, vision and audiology services. The facility is in communication with company representatives to ensure visits are completed and monitoring to ensure consultations are received timely. During an interview with the DON on July 31, 2025, at approximately 1:30 PM, the DON confirmed that podiatry care should not have been missed on Resident 149 and added that Resident 149 is scheduled for podiatry care on August 8, 2025. 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, resident and staff interviews, and facility documentation review, it was determined that the facility failed to provide comfortable temperatures on two of five nursing units (E and F) and failed to provide a clean homelike environment in one of 34 rooms observed (Resident 3). Findings include: Observation on July 28, 2025, the facility had two additional portable air conditioner (AC) units running in the main lobby and at the end of E and F nursing units. On July 29, 2025, between 10:00 AM and 11:00 AM, during the screening process with Residents 101, 141, 168, and 172, who share a room, the Residents stated that it was very warm in their room. The surveyor agreed that the temperature of the room felt very warm. Employee 10 (Director of Maintenance) was notified to obtain the temperature of the room, which was 83.6 degrees Fahrenheit (F). During an interview with Employee 10 on July 29, 2025, he stated that he would place a portable floor air conditioner in Residents' 101, 141, 168, and 172 room. Employee 10 was asked if the HVAC (Heating Ventilation Air Condition) system is working properly, and he replied “yes.” Outdoor temperature for the area was 93 degrees F at noon and 93 degrees F at 6:00 PM on July 29, 2025. A review of logged temperatures for all units obtained for July 14 through 25, 2025, revealed temperatures in the 60’s and 70’s within the facility. Additional temperature recordings on the F Hall revealed three additional rooms were recorded as 82.4, 84.4, and 82.4-degrees F. Maintenance installed portable AC units in each of these rooms. Resident 51 was the only Resident in these rooms who stated she was warm when residents were asked if they were asked about the temperature of the room. On July 29, 2025, at approximately 3:10 PM, Resident 9 approached a surveyor in the front lobby and stated that she did not feel well because of the heat. The surveyor reported immediately to Administration so that they could assess Resident 51. Resident 51's vital signs were stable, and her temporal temperature was 96.8 F. A review of the Resident 9's progress notes stated that she was on a leave from the facility on this day with family from 9:50 AM until 1:00 PM. The facility added an additional portable AC unit to Resident 9’s room. Resident 9’s room temperature was recorded to be 79 degrees F on July 29, 2025, at 2:15 PM. On July 30, 2025, at approximately 9:30 AM, the Director of Nursing (DON) informed the surveyor that during the evening of July 29,2025, temperature of the E-F dining room was 83 F and later climbed to 87 F. On July 30, 2025, the E-F dining room was closed to residents to install a split AC unit. The facility had already purchased the unit (receipt dated July 1, 2025) and it was on maintenance work plan, but with the increase in outside and inside temperatures it became a priority. During an interview with Resident 9 on July 30, 2025, at approximately 11:45 AM, Resident 9 said that she is feeling great and added that she doesn’t tolerate heat very well and was happy to have the portable AC installed in her room. The Resident was observed multiple times ambulating throughout the facility and had no complaints about the temperature. Resident 9’s room temp was 75.4 degrees F on July 30, 2025, at 9:45 AM. The facility continued to monitor temperatures of residents and resident rooms through the evening of July 29 to AM of July 30, 2025. On July 30, 2025, at 9:45 AM, the room temperatures were taken again, one room was 83.6 degrees F, that previously was 80 degrees F during the prior recording. A portable AC unit was placed in the room. No complaints by Residents in the room. On July 30, 2025, from 9:40 AM through 10:05 PM, all other room temperatures were 74.8 -79.4 F, no complaints by residents, many observed with sweaters on and covered with blankets or sheets while lying in bed. During an interview with the DON on July 31, 2025, the DON confirmed that temperatures are to remain within 71-81 degrees F for the comfort of residents. Observations in Resident 3's room on July 28, 2025, at 11:52 AM; July 29, 2025, at 2:00 PM; and on July 30, 2025, at 12:25 PM, revealed a black pedestal fan that was positioned at the head of Resident 3's bed that was running and was noted to have a moderate amount of gray fuzz on the front and back casing as well as on the blades. During a staff interview with the DON on July 31, 2025, at 1:50 PM, she confirmed that the fan should have been on a cleaning schedule. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on clinical record review, medication information review, and staff interview, it was determined that the facility failed to ensure that was free form unnecessary medications for one of five residents reviewed for unnecessary medications (Resident 4).Findings include: Review of diclofenac dosage guidelines in the Physician's Desk Reference (a comprehensive resource for drug information, providing healthcare professionals with trusted prescribing information and patient adherence resources) revealed the following: Diclofenac gel is only indicated for the relief of the pain of osteoarthritis of joints amenable to topical treatment such as the knees and hands. The gel was not evaluated for use on joints of the spine, hip, or shoulder with dosage guidelines of 4 g (4.5 inches) topically per knee, ankle, or foot joint 4 times daily (Max: 16 g/day per lower extremity joint) and/or 2 g (2.25 inches) topically per elbow, wrist, or hand joint 4 times daily (Max: 8 g/day per upper extremity joint). Do not exceed a total dose of 32 g/day over all affected joints. Do not use on more than 2 body areas at the same time. Review of Resident 4's clinical record revealed that diagnoses that included bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), depression, opioid dependence and a healing left femur (large bone located in the thigh) fracture. Review of Resident 4's clinical record revealed that she was initially admitted to the facility on [DATE], with an order for diclofenac sodium external gel 1 % apply to painful joints topically four times a day for pain. Review of Resident 4's pharmacist's admission medication regimen review dated June 9, 2025, revealed that Resident 4 had an incomplete order for the diclofenac ointment and to update the order with location of body and stop date or date for reevaluation. The review failed to identify that the diclofenac ointment did not have a specified dose to apply indicated in the order. Review of Resident 4's clinical record revealed that she was transferred and admitted to the hospital on [DATE], and was readmitted to the facility on [DATE]. Review of Resident 4's current physician orders revealed an order for diclofenac sodium external gel 1 % apply to back, hands, knees, legs topically four times a day for pain, dated June 28, 2025. Review of Resident 4's pharmacist's admission medication regimen review dated June 30, 2025, failed to identify that the diclofenac ointment did not have a specified dose to apply indicated in the order and failed to identify that applying the ointment to the back and legs may not be appropriate. Review of Resident 4's Medication Administration Records for June 2025 and July 2025 revealed that she had received the diclofenac 127 times between June 28, 2025, and July 30, 2025. During a staff interview with the Director of Nursing on July 31, 2025, at 11:16 AM, she confirmed that she would have expected the pharmacist's medication regimen review on June 9 and 30, 2025, to have identified that Resident 4's diclofenac order did not have a specified dose for nursing staff to apply. 28 Pa. Code 211.9(a)(1) Pharmacy services28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on facility policy review, clinical record review, observation, and interviews with staff and residents, it was determined that the facility failed to protect the resident's right to be free from mental abuse and neglect for two of 34 residents (Residents 21 and 54). Findings include: Review of facility policy, Abuse and Neglect- Clinical Protocol, revised March 2018, revealed, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including the caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing. Instances of abuse of all residents, irrespective or any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Review of Resident 21's clinical record revealed diagnoses of dementia (a decline in cognitive function that affects daily life) and muscle weakness (when muscles cannot exert the expected amount of force). Observation on July 28, 2025, at 10:09 AM, revealed Employee 1 entering the room of Resident 21, turn off her call bell, and ask what she needed. Resident 21 answered that she needed ice water. Employee 1 replied, I already told you that I'd take care of that, now don't ring your call bell again. Employee 1 then exited the Resident's room. Review of Resident 21's care plan revealed a care plan with a focus area that Resident 21 is at risk for falls, revised on September 28, 2020, and an intervention of keeping the call bell in reach of Resident 21 with a date initiated of April 30, 2020. Review of Resident 54's clinical record revealed diagnoses of anxiety disorder (a condition cauterized by excessive fear, worry, and anxiety that interfere with daily life) and difficulty in walking (can stem from various causes, including neurological disorders, musculoskeletal issues, and gait abnormalities). Review of Resident 54's care plan revealed a focus are of, At risk for falls, revised January 9, 2025, with interventions that include, keep call bell in reach, provide assistance to transfer as needed, and reinforce the need to call for assistance, initiated July 31, 2024. Interview with Resident 54 on July 28, 2025, at 12:09 PM, revealed that Employee 1 had told Resident 54 that she cannot use her call bell between 7:00 AM-9:00 AM; 11:00 AM-1:00 PM; and 5:00 PM- 7:00 PM because the staff is serving meals and will not answer call bells. Interview with Director of Nursing on July 31, 2025, at 11:35 AM, revealed that the facility is aware of the alleged abuse by Employee 1 and it should not have occurred. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(b)(2) Management. 28 Pa. Code 201.18(e)(1) Management.

Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of two residents reviewed for range of motion (Resident 46). Findings include: Review of facility policy, titled Restorative Nursing Services, with a last revision date of July 2017, and a last review date of June 20, 2025, indicated Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Review of Resident 46's clinical record revealed she was admitted to the facility on [DATE], with diagnoses that included muscle weakness, chronic obstructive pulmonary disorder (COPD-a type of progressive lung disease characterized by long term respiratory symptoms and airflow limitations), and chronic systolic congestive heart failure (a specific type of heart failure that occurs in the left ventricle and the ventricle cannot contract normally when the heart beats). During an interview with Resident 46 on July 29, 2025, at 11:18 AM, she indicated that she does not feel she is getting enough therapy to prepare her for her return home. Review of Resident 46's Physical Therapy Discharge summary dated [DATE], indicated in section titled RNP [Restorative Nursing Program] to facilitate patient maintaining current level of performance and in order to prevent decline, development of and instruction in the following RNP's has been completed with the IDT: bed mobility and ROM [range of motion] (Active). Review of Resident 46's care plan revealed a care plan focus for Restorative Nursing: Active Range of Motion with an intervention of Active ROM to upper/lower extremities per resident tolerance with morning and bedtime care, with an initiated date of July 20, 2025. Further review of Resident 46's care plan failed to reveal a RNP for bed mobility. Review of Resident 46's task documentation for her ROM RNP revealed that the program was not initiated until July 20, 2025, and was documented as Not Applicable on July 21, 2025, day shift and on July 22, 23, and 24, 2025, for both day and evening shifts. During a staff interview with the Director of Nursing on July 31, 2025, at 11:20 AM, she indicated that she would have expected both of Resident 46's Restorative Nursing Programs to have been initiated when she was discharged from therapy on June 27, 2025, and that she would expect staff to provide and document a resident's RNP's accordingly. She further confirmed that Not Applicable was not an appropriate documentation response to utilize. 28 Pa. Code 211.10(c)(d) Resident care policies28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on clinical record reviews and resident and staff interviews, it was determined that the facility failed to ensure that resident assessments accurately reflected the resident's status for three of 34 residents reviewed (Residents 3, 4, and 171). Findings include: Review of Resident 3's clinical record revealed diagnoses that included hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting the right side and hypertension (high blood pressure). Review of Resident 3's Medicare 5 Day MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference date (last day of the assessment period) of July 3, 2025, revealed in Section GG. Functional Abilities at Question GG0115. Functional Limitation in Range of Motion that she was coded as having no impairment in her upper extremities. During a staff interview with the Director of Nursing (DON) on July 31, 2025, at 12:27 PM, she confirmed that Resident 3's MDS was coded inaccurately and that she would MDS assessments to be coded accurately. Review of Resident 4's clinical record revealed that diagnoses that included bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), depression, opioid dependence and a healing left femur (large bone located in the thigh) fracture. Review of Resident 4's admission Medicare 5 Day MDS with the assessment reference date of June 11, 2025, revealed in Section J. Health Conditions subsection J1800. Any Falls Since Admission/Entry or Reentry or Prior Assessment that she was coded as having two or more falls with no injury. Review of Resident 4's clinical record revealed that she had experienced two falls on June 8, 2025, and had sustained a skin tear as a result of one fall. Review of Resident 4's admission Medicare 5 Day MDS with the assessment reference date of June 11, 2025, revealed in Section N. Medications subsection N0450. Antipsychotic Medication Review that she was coded as having gradual dose reduction of her antipsychotic medication on June 6, 2025. Review of Resident 4's clinical record failed to reveal any documentation that a dose reduction of her ordered antipsychotic medication was completed. Review of Resident 4's Significant Change MDS with the assessment reference date of July 3, 2025, revealed in Section J. Health Conditions subsection J1700. Fall History on Admission/Entry or Reentry that she was not coded as having had a fall with a fracture within the last 6 months prior to admission/entry or reentry. Review of Resident 4's clinical record revealed that she experienced a fall on June 26, 2025, at the facility and was identified as having a left femur fracture. Review of Resident 4's Significant Change MDS with the assessment reference date of July 3, 2025, revealed in Section N. Medications subsection N0450. Antipsychotic Medication Review that she was not coded as having physician documentation that a gradual dose reduction of her ordered antipsychotic was clinically contraindicated. Review of Resident 4's clinical record revealed a psychiatric consult note dated June 20, 2025, which indicated that a gradual dosage reduction was clinically contraindicated as it could lead to escalation of her symptoms. During a staff interview with the DON on July 31, 2025, at 11:16 AM, she confirmed that Resident 4's MDS assessments were coded inaccurately and that she would MDS assessments to be coded accurately. Review of Resident 171's clinical record revealed diagnoses that included type 2 diabetes mellitus (body doesn't produce enough insulin or use insulin properly) and cerebral palsy (movement disorder caused by damage to or disruptions in brain development). Review of Resident 171's clinical record revealed she was indicated as receiving tube feedings. An interview with Resident 171 on July 28, 2025, at 11:24 AM, revealed she had never received tube feedings. Review of Resident 171's current and discontinued physician orders failed to reveal orders for tube feedings. Review of Resident 171's quarterly MDS with the assessment reference date of May 16, 2025, revealed Resident 171 was coded as receiving feeding tube while a resident. During an interview with the DON on July 30, 2025, at 1:10 PM, it was revealed that Resident 171's MDS assessment was incorrect. The DON stated it was the facility's expectation that MDS assessments be coded correctly. 28 Pa. Code 211.5(f) Clinical records28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents were free of unnecessary psychotropic medications for one of five residents reviewed (Resident 4). Findings include: Review of facility policy, titled Psychotropic Medication Use, dated July 2022, with a last review date of June 20, 2025, revealed the following: 1. A psychotropic medication is any mediation that affects brain activity associated with mental processes and behavior. 2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: a. Anti-psychotics; b. Anti-depressants; c. Anti-anxiety medications; and d. Hypnotics. 3. Residents, families and/or the representative are involved in the medication management process. Psychotropic medication management includes: a. indications for use; b. dose (including duplicate therapy); c. duration; d. adequate monitoring for efficacy and adverse consequences; and e. preventing, identifying and responding to adverse consequences. 13. Residents receiving psychotropic medications are monitored for adverse consequences. Review of Resident 4's clinical record revealed diagnoses that included bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and depression. Review of Resident 4's physician orders revealed an order for buspirone hydrochloride (Buspar- a medication used to treat anxiety) oral tablet 5 MG (milligrams) give one tablet by mouth three times a day for anxiety, dated June 28, 2025. Review of Resident 4's clinical record and Medication Administration Records failed to reveal any side effect monitoring or behavior monitoring of resident identified behaviors with the use of the antianxiety medication buspirone. Review of Resident 4's care plan failed to include that she was receiving an antianxiety medication, any side effect monitoring to be observed for, identification of resident behaviors to monitor for, or any other interventions for the use of the antianxiety medication buspirone. During a staff interview with the Director of Nursing on July 31, 2025, at 11:16 AM, she indicated that she would expect Resident 4 to have been monitored for side effects and behaviors for the use of her antianxiety medication. She further confirmed that Resident 4's care plan should have included her antianxiety medication use as well as side effect and behavior monitoring. 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on policy review, facility documentation review, as well as resident and staff interviews, it was determined that the facility failed to ensure that a timely response was provided to a resident following submission of a grievance for one of two residents reviewed for grievances (Resident 168).Findings include: Review of facility policy, Grievance Process Procedure, dated October 2021, revealed, Upon the completion of the facility investigation, the administrator will ensure that the investigation results and resolution steps are communicated to the individual who originally submitted the grievance, complaint and/or suggestion. Resolution of the concern is desired within five (5) working days from the date the concern was filed. Routine follow up on concerns that are outstanding will be completed through the morning meeting process. During an interview with Resident 168 on July 29, 2025, at 11:05 AM, she revealed that she submitted a grievance regarding food concerns about a month ago, but never heard a thing about it. Review of a grievance form dated July 4, 2025, revealed that Resident 168 filed a grievance on that date regarding not being served her meal timely and at an appropriate temperature. Further review of the form revealed that the concern was marked as resolved, and the form was signed by the dietary manager and grievance officer. However, the portion of the form used to document the method and date for notifying the Resident of the resolution was blank. During an interview with the Director of Nursing on July 31, 2025, at 12:25 PM, she confirmed that no one followed up with Resident 168, but that someone should have. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(e)(1) Management.28 PA Code: 201.29(a) Resident rights.

Based on clinical record review and staff interviews, it was determined that the facility failed to convey resident's funds within 30 days, and a final accounting of those funds to the resident upon discharge for one of three resident closed records reviewed (Resident 179).Findings include: Clinical record review revealed Resident 179 was admitted to the facility on [DATE], discharged from the facility on February 27, 2025, and did not return. Review of Resident 179's final billing statement revealed she had a credit of $638.00 that was issued in the form of a check on May 30, 2025.Interview with Employee 4 (Business Office Manager) on July 30, 2025, at 1:40 PM, revealed the transaction history report for Resident 179 indicated that she was issued a refund check on May 30, 2025, and that a third party billing system messed up transaction so she had to reverse it, but the process for issuing resident refunds typically would occur within 30 days. During an interview with the Director of Nursing on July 31, 2025, at 12:39 PM, she revealed she had no further information to provide as to why Resident 179's refund was issued late, and she would expect refunds to be issued within 30 days. 28 Pa. Code 201.29(a) Resident rights

Based on review of facility policy, review of grievances, and interviews with staff and residents, it was determined that the facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for one of 34 residents reviewed (Resident 130). Findings include:Review of the facility policy, titled Dignity, with a last reviewed and revised date of February 2021, revealed, Each resident shall be cared for in a manner promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Review of Resident 130's clinical record revealed diagnoses of morbid obesity (a body mass greater than 40) and acute respiratory failure (when lungs cannot adequately exchange gases, leading to insufficient oxygen in the blood). Interview with Resident 130 on August 28, 2025, at 1:15 PM, revealed that Resident 130 had filed a complaint in June 2025, with the facility after Employee 1 had helped Resident 130 clean up and used disposable paper towels to dry Resident 130 because she said that she didn't have any bath towels. Review of facility provided grievance/concern form, dated June 5, 2025, revealed a complaint filed by Resident 130 that, during her daily care, she was dried off with paper towels. Further review revealed that there were bath towels available, but Employee 1 did not leave the unit to look for them. The resolution of this grievance was that Employee 1 was educated on going to other units to get supplies if they are not available where they are. Interview with Director of Nursing on April 31, 2025, at 11:35 AM, revealed that she would expect staff members to treat residents with dignity and respect. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, hospital record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided after a change in condition for one of 20 residents reviewed (Resident 1). This failure resulted in continued decline, which required hospitalization for septic shock (a widespread infection causing organ failure and dangerously low blood pressure) and death. This failure placed an additional 10 out of 20 residents reviewed who were identified as having a change in condition in an immediate jeopardy situation (Residents 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11). Findings include: The facility has a policy regarding change in condition, but does not have a specific policy or documented process for alert charting for residents that are initially assessed to have a change in condition. Review of Resident 1's clinical record revealed diagnoses that included Hypertension (above normal blood pressure), Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and Displaced Bimalleolar Fracture of right lower leg (severe injury that occurs when both the medial and lateral malleolus bones in the ankle are broken and displaced). Review of Resident 1's Admission MDS (Minimum Data Set- periodic assessment of the resident) dated [DATE], revealed a BIMS (brief interview of mental status) of 12, indicating cognitive status is moderately impaired. A score of ,d+[DATE] is moderately impaired and ,d+[DATE] is cognitively intact. Review of Resident 1's clinical record revealed a diagnosis of COVID-19 on [DATE], and on [DATE], documentation revealed Resident 1 had poor meal intake since COVID-19. Resident 1's quarterly MDS dated [DATE], now revealed a BIMS of 7, indicating severe cognitive impairment. On [DATE], Employee 1 (Registered Nurse) who was covering as the supervisor, was called to assess Resident 1 after a family member visiting stated concerns about Resident 1 having a headache and dry lips. The family member also requested that a urine sample be obtained so that a urinary tract infection could be ruled out. During a phone interview with the family member on [DATE], at 6:45 PM, she stated she had concerns for Resident 1 because she kept falling asleep and confirmed that she asked the nurse to do a urine test on Resident 1. The family member also stated that when she questioned the reason for Resident 1's dry lips, Employee 1 informed her that Resident 1 is probably dehydrated. During an interview with Employee 1 on [DATE], at 11:00 AM, Employee 1 stated that she didn't remember Resident 1. Employee 1 was asked about alert charting; Employee 1 was aware that residents are placed on alert charting for a change in condition. Employee 1 stated that the alert charting process keeps changing, sometimes resident's names are entered in a logbook and sometimes entered in the clinical record under the forms tab. Employee 1 was unaware that alert charting must be entered into the electronic medical record by administrative staff so that it automatically populated to an area in the treatment administration record. A review of the clinical record for Resident 1 revealed that an alert charting note was documented by Employee 1 dated [DATE], at 10:47 AM. The logbook was reviewed and the entry for Resident 1 was not in the logbook. The Nursing Home Administrator (NHA) informed the surveyor that the forms are discarded after each page is completed. The alert charting note on [DATE], stated, daughter concerned, resident has a headache, lips dry, VS (vital signs) stable, alert charting, MD (Medical Director) aware. There was no documentation that the MD was informed of the Resident's lower-than-normal blood pressure of ,d+[DATE], decreased oral intakes, or a decline in cognition. There was no documentation regarding the family member requesting a urine sample be tested to rule out a urinary tract infection. Further review of Resident 1's clinical record revealed there was no alert charting or any progress notes by nursing staff on [DATE], 5, 6, or 7, 2024, prior to 11:30 AM. On [DATE], at approximately 11:30 AM, Resident 1 was found unresponsive in her wheelchair. Staff attempted calling her name and doing a sternal rub with no response. A review of Resident 1's clinical record revealed the only nursing staff documentation after being found unresponsive was, [DATE], at 11:56 AM, RN Called to assess resident that was unresponsive sitting in the wheelchair at the nurse's station. Resident was not responding to name or sternal rub. Resident was assisted to the bed, vital signs monitored. Pulse was weak and thready. Defibrillator indicated to start chest compressions. EMS called. MD notified, and order obtained to send resident to the hospital for further evaluation. RP [responsible party] notified. [DATE], at 12:03 PM, Resident was sent out to the hospital today this nurse called the family and spoke with them about residents' condition and that resident was taken to hospital by EMS. [DATE], 7:48 PM admitted to hospital with septic shock. There was no blood pressure recorded in the medical record during the code event or prior to transport. There was no documentation of the details of the life sustaining measures that were done. There was no documentation of what, if anything, was performed by EMS or their arrival and leave time. During an interview with Employee 2 (Registered Nurse) on [DATE], at 9:45 AM, Employee 2 said that she was called to Resident 1's unit and found her unresponsive. She and other staff placed the Resident into her bed. Employee 2 said that Resident 1 had a weak, thready pulse (typically considered an emergency and could be an indication of low blood pressure). Chest compressions were initiated while a code was called, and the AED (automated external defibrillator) was applied that informed the staff to continue CPR. The MD was notified and gave orders for transport to the emergency room and Emergency Medical Services (EMS) was notified. During a review of the hospital records dated [DATE], Resident 1 was diagnosed in the emergency room with septic shock due to a complicated urinary tract infection. Prior to being sent to the ICU (intensive care unit) on [DATE], at 2:36 PM, documented vital signs in the emergency room were blood pressure ,d+[DATE], temperature 97.9, heart rate 108, respirations 40, and blood sugar 76. Resident was transferred to the ICU, however, the hospital team was unable to reverse the organ failure. With family agreement, medications were discontinued and the Resident was placed on comfort measures. The Resident passed away [DATE], at 2:54 AM. During an interview with the NHA on [DATE], at 10:08 AM, he was not in agreement that the absence of the alert charting and further monitoring of Resident 1 rose to the level of immediate jeopardy. On [DATE], at 10:08 AM, the NHA was provided the Immediate Jeopardy template, and an immediate action plan was requested to ensure that residents were being assessed for and receiving adequate monitoring for changes in condition. On [DATE], the facility performed an audit of residents who were on alert charting for a change in condition and identified that at least one shift of monitoring/vital signs were not performed. Audits revealed Residents ,d+[DATE] had a change in condition that included: Resident 2 - vomiting; Resident 3 - shortness of breath; Resident 4 -conjunctivitis (inflammation of the eye); Resident 5 - pneumonia (lung infection); Resident 6 - ill feeling and dizzy; Resident 7 - urinary tract infection with antibiotic therapy; Resident 8 - urine with blood; Resident 9 - urinary tract infection with antibiotic therapy; Resident 10 - scrotum pain; and Resident 11 - diarrhea. The facility was notified on [DATE], at 2:05 PM, that the action plan was accepted. The plan of action included: 1) An audit will be completed on all residents with reported change of conditions in the past 30 days to ensure monitoring (alert charting) was completed, after a change in condition was identified. If monitoring was not completed, a RN assessment will be completed to ensure resident is at baseline; 2) Director of Nursing (DON) or designee will provide re-education to facility licensed staff that after a resident has a change in condition, monitoring a resident with a change in condition needs to be completed. Licensed Nursing staff will be educated on how to enter alert charting process, what to monitor for, how often, how to document interventions, document detailed code interventions i.e. EMS arrival and leave times, ongoing status, and document the physician response when notified. Education is to be completed by [DATE], and any nursing licensed staff member that did not receive education will not be able to work their next scheduled shift until education is provided. During daily clinical meeting process, progress notes will be reviewed, and alert charting will be monitored for compliance, the alert charting log binders will be brought to daily clinical meeting for review of the log to ensure residents with a change in condition are added to the log for monitoring; 3) DON or designee will complete random audits of any change of condition daily for 4 weeks and then monthly for 2 months to ensure the monitoring is completed and documented. Audit findings will be reported to the monthly QAA (Quality Assessment and Assurance) meeting for review and recommendation. On [DATE], at 1:45 PM, the audit of Residents ,d+[DATE] with a change in condition was reviewed. Staff interviews revealed the facility had re-educated staff to the revised alert charting process and utilization of the logbook for change in condition. Interviews were conducted with one RN and two Licensed Practical Nurses; all were able to verbalize their role in obtaining vital signs, the facility Change in Condition policy, the new process to follow for alert charting, proper order entry for alert charting, and documentation of all clinical information in the resident's clinical record. An interview was conducted with one nurse aide who was able to verbalize their role in obtaining vital signs and reporting vital signs to the Licensed Practical Nurse for review and data entry every shift when residents are on alert charting. On [DATE], at 2:05 PM, the Immediate Jeopardy was lifted. The facility failed to ensure care and services were provided to Resident 1 after a change in condition, failed to report all changes to the MD, and failed to continue monitoring Resident 1's status that would include vital signs every shift, resulting in continued decline, hospitalization for septic shock, and death. At the time of the survey, this failure identified 10 additional residents with at least one missed alert charting in an immediate jeopardy situation. 201.14(a) Responsibility of licensee 201.18(b)(1) Management 211.12(d)(1)(2)(3)(5) Nursing services

Based on review of the clinical record, facility documentation review, review of policy and procedure, and staff interviews, it was determined that the facility displayed past non-compliance by failure to implement appropriate monitoring, supervision, and safety measures to prevent unsafe wandering of a resident (Resident 1) to an unsupervised area of the facility. This failure resulted in harm to the resident who was found unresponsive, had an external body temperature of 106 degrees Fahrenheit (F) and transfer to the hospital where she was intubated (tube inserted into the airway) and placed on a ventilator (a machine that helps someone breathe when they are unable to do so on their own). This failure placed Resident 1 in an Immediate Jeopardy situation. Findings include: Review of facility policy, titled Wandering and Elopements last revised June 2023, indicated that the facility will identify residents who are at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for the resident. An elopement is defined as when a resident leaves the premises or a safe area without authorization. The policy also states, If a resident is missing, initiate the elopement/missing resident emergency procedure. Review of Resident 1's clinical record on July 14, 2023, revealed diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - disease process that causes decreased ability of the lungs to perform), Bipolar disorder (A disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and history of Traumatic Brain Injury (TBI - injury to the brain caused by a motor vehicle accident in 1987) Review of Resident 1's Quarterly Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated May 18, 2023, revealed the Resident had moderate cognitive impairment. Review of Resident 1's elopement/wandering risk assessment dated [DATE], revealed the Resident was not at risk for elopement, but was coded yes for being cognitively impaired with poor decision-making skills. Review of Resident 1's current care plan revealed a focus area that was initiated February 14, 2023, for cognitive/communication loss related to effects of TBI. Review of information dated July 7, 2023, at 3:30 PM, and submitted by the facility, revealed that Resident 1 was found in her wheelchair in the outdoor courtyard at approximately 3:30 PM by Employee 1 (Dietary Staff Member). Employee 1 found Resident 1 unresponsive and slumped over in her wheelchair. The dietary staff member immediately went for help. Resident 1 was immediately pushed in her wheelchair back to her room while cold compresses were being applied. Resident 1's body temperature was 106 degrees F with a non-contact thermometer to the temporal/forehead area. Resident 1 was placed in bed with cold compresses and ice applied to the entire body. Resident 1's vital signs included: blood pressure 95/87 right arm; pulse 160; respirations 24; pulse ox reading was 85% and then increased to 98% when placed on a non-rebreather oxygen mask at 15 Liters per minute of oxygen. The first temperature taken was 106.0 degrees F, the temperature obtained prior to transfer to the hospital was 99.8 degrees. Resident remained unresponsive. The physician was notified about the incident and gave orders to transfer Resident 1 to the hospital for evaluation and treatment. The Resident's Responsible Party was called and a voice message was left several times. Resident 1 was transferred to hospital by EMS on July 7, 2023, at 3:58 PM. Review of hospital records revealed that Resident 1 was admitted with altered mental status and respiratory distress. The Resident was noted to have respiratory acidosis (failure of ventilation resulting in an accumulation of carbon dioxide). The Resident was intubated and placed on a ventilator and transferred to the critical care unit. On July 8, 2023, Resident 1 was extubated (tube and ventilation removed), and on July 9, 2023, the Resident was transferred out of the critical care unit. The outside temperatures on July 7, 2023, for the facility's location, per online historical data, was 87 degrees at 1:53 PM; 89 degrees at 2:53 PM; and 90 degrees at 3:53 PM. During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON), regarding Resident 1's incident on July 7, 2023, both agreed Resident 1 had the ability to go outside to the courtyard by pushing a handicap button that opens the doors to the courtyard. The door did not alarm if the handicap button was used. The NHA stated that the doors to the courtyards were always locked at night, but open through the day for residents. If exiting the door without using the handicap button, the door would alarm and a code would have to be reset to turn the alarm off. The NHA stated that Resident 1 was observed by a dietary staff person in the courtyard on July 7, 2023, at 1:50 PM, and appeared her usual self. Observation with the NHA on July 14, 2023, of the courtyard where Resident 1 was found on July 7, 2023, revealed that Resident 1 was located at the most distant area from the door, and the area was blocked by overgrown lavender plants. It was obvious that a person would have to physically walk the path in the courtyard to visualize Resident 1. A written statement by day shift Employee 2 (Nurse Aide) dated July 8, 2023, regarding the Resident 1 incident on July 7, 2023, stated, She [Resident 1] ate lunch in the little dining room. Lunch is usually over by 12:30 PM. I did not see her after that. I started rounds at 1:00 PM. I don't normally go look for her because she comes back, or another unit will call. She takes off, all day, every day. She will get nasty if you go after her and tell her she is wet. She normally returns when she is wet. She knows where her room is. I've never seen her go outside before ever. Employee 2 stated she never checked on Resident 1 after seeing her at 12:30 PM, and Employee 2 said she ended her shift at 2:00 PM. A written statement by evening shift Employee 3 (Nurse Aide) dated July 10, 2023, regarding the Resident 1 incident on July 7, 2023, stated, I've never seen her [Resident 1] outside before, she visits F wing and A wing. Employee 3 also documented that when she initiated rounds that day (2:00 PM), she knew she would have to go and look for her, but decided to do her charting first. Employee 3 never initiated the search for Resident 1 because staff brought Resident 1 onto the unit unresponsive in her wheelchair, after finding her in the courtyard. The NHA and DON were notified of the Immediate Jeopardy on July 14, 2023, at 1:00 PM. An Immediate Action Plan was requested. The facility initiated immediate interventions on July 7, 2023, after the incident. Documents and actions provided by the facility to address the Immediate Jeopardy included: The courtyard doors were switched to lock the automatic door opening function. Residents wanting to go out to the courtyard will need to sign out on the unit, and any cognitively impaired residents will need to be accompanied by a staff or family member. A head count was completed, and current residents were accounted for at that time of the incident. Temperatures were taken on current residents. The Nurse Aide (Employee 2) responsible for this Resident (Resident 1) on the 6:00 AM to 2:00 PM shift was suspended pending the outcome of the investigation. The Nurse Aide (Employee 3) that was assigned to this Resident (Resident 1) on the 2:00 PM to 10:00 PM shift was suspended pending the outcome of the investigation. An investigation was initiated to interview employees in the facility on July 7, 2023; Administrator/Designee continue to obtain staff statements. A risk management report was completed on July 7, 2023; the Medical Director was updated on the incident and the Resident's condition; on the Resident's return, the care plan will be reviewed and updated as needed. Additionally, an ad hoc QAA committee meeting was held to review the investigation process and develop additional recommendations on July 7, 2023. An audit was completed of current residents that are triggered for locomotion off unit to ensure care plan intervention for observation. The facility will continue to audit current residents that trigger for locomotion off unit to ensure care plan intervention for observations weekly for two months, then monthly for two months. Will review outcomes at QAPI (Quality Assurance Performance Improvement) meetings with interdisciplinary teams. The facility's Immediate Action Plan was reviewed on July 14, 2023, during the onsite survey. Facility staff were interviewed during the onsite survey regarding the facility's Immediate Action Plan and demonstrated knowledge that the following steps were taken: 1) Residents with cognitive impairment that wander throughout the facility had their care plans reviewed and updated, if needed, to ensure adequate supervision 2) Education was initiated on July 7, 2023, with the facility staff on the Federal Regulation citation F 689 Free of Accident Hazards/Supervision/Devices 3) Education was initiated on July 7, 2023, with the facility staff on courtyard guidelines 4) Education was initiated on July 7, 2023, with the staff on the facility policy for Wandering and Elopements 5) Newly admitted residents that wander throughout the facility continue to be evaluated for safety and elopement risks during the admission observation and with a change in condition 6) Courtyard doors addressed so they are immediately alarming when opened until responded to by staff The facility's Immediate Action Plan was reviewed on July 14, 2023, which included audits and education. Observations were made of the courtyard and the exit door to ensure safety measures were in place and facility staff were interviewed to confirm understanding of education. Prior to the onsite investigation, the facility failed to implement appropriate monitoring, supervision, and safety measures to prevent unsafe wandering of Resident 1 to an unsupervised area of the facility. This failure resulted in harm to Resident 1, who was found unresponsive in the courtyard on a 90 degree day, had an external body temperature of 106 degrees Fahrenheit (F) and transfer to the hospital for a five day stay which included mechanical ventilation. The Immediate Jeopardy was lifted on July 14, 2023, at 3:03 PM, and the deficient practice was found to be past non-compliance. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a)(b)(1)(3)(e)(1) Management 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on facility policy review, review of clinical records and incident reports, as well as staff interviews, it was determined that the facility failed to ensure that residents were not served foods they were allergic to, which resulted in harm with an allergic reaction, requiring Benadryl (allergy medication), epinephrine (an injection used to treat life-threatening allergic reactions), and transfer to the hospital for difficulty breathing and a swollen external throat and tongue, for one of six residents reviewed (Resident 6). Findings Include: Review of facility policy titled Food Allergies and Intolerances, revised August 2017, revealed Residents with food allergies and/or intolerances are identified upon admission and offered food substitutions of similar appeal and nutritional value. Steps are taken to prevent resident exposure to the allergen(s). Severe food allergies are noted on the face of the chart (in the form of a sticker or permanent marking indicating 'Severe Food Allergy: (name of food)' and communicated in writing directly to the dietician and the director of food and nutrition services. Review of Resident 6's clinical record revealed that Resident 6 was admitted to the facility on [DATE], with diagnoses that included Type 2 Diabetes Mellitus (an impairment in the way the body regulates and uses sugar as a fuel), Bipolar Disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows), Gastro-Esophageal Reflux Disease (GERD- occurs when stomach acid frequently flows back into the tube connecting your mouth and stomach), and 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). Further review of Resident 6's clinical record listed allergies including, but not limited to, egg, seafood and shellfish. Review of Resident 6's current physician orders revealed an order dated May 20, 2022, for consistent carbohydrate diet, mechanical soft texture, regular/thin consistency, and no fish, eggs, seafood or shellfish. Review of Resident 6's current care plan revealed Allergy to egg and shellfish, fish, seafood, with a revision date of May 20, 2022. Further review of Resident 6's current care plan revealed that for eating, Resident 6 requires supervision/set-up and assist as needed, with a revision date of February 22, 2021. Review of Resident 6's nursing progress note, dated July 10, 2022, revealed that at approximately 5:20 PM, the Nurse was made aware by the Nurse Aide that Resident 6 is allergic to fish and received tuna on her dinner tray. Resident 6 reported she has an anaphylactic reaction to fish. Resident 6 complaining of a tingling tongue. Assessment revealed Resident 6 with a swollen tongue, and Resident 6 was complaining of difficulty breathing. Resident 6 was given 50 mg of Benadryl by mouth. Resident 6 continued to talk to the staff, but then started to become hoarse. Resident 6 stated her tongue felt bigger and she was struggling to breathe. Epinephrine was given at 5:35 PM. Assessment revealed Resident 6 had swollen external throat and tongue was also noted to have swollen raised edges on outer portion. Resident 6 continued talking to staff with hoarse voice. Resident 6 was transferred to the hospital at approximately 5:46 PM. Review of Resident 6's hospital records revealed Resident 6 required no further treatment in the Emergency Department and was discharged from the hospital at approximately 8:45 PM to return back to the facility. Review of facility incident report for Resident 6 revealed that Resident 6 stated I could not smell what I was eating due to chronic decrease smells. I only realized it was tuna after a couple of bites. Review of Employee 1's witness statement revealed Employee 1 gave Resident 6 her dinner. Resident 6 took a bite of the sandwich thinking it was chicken salad, but it was actually a tuna sandwich. Resident 6 stated her tongue was starting to swell due to eating the tuna. Review of Employee 2's witness statement revealed that Employee 2 was passing drinks to Resident 6 and her roommates. Employee 2 stated Resident 6 took a bite of her sandwich and then called Employee 2 over. Further review of Employee 2's witness statement revealed Resident 6 asked me if her sandwich was chicken or tuna? I smelled it and told her tuna. She then told me she thought so because her tongue felt funny and that she is allergic to tuna. Employee 2 stated she immediately went and reported this to the Charge Nurse. Review of Resident 6's tray ticket for the evening meal on July 10, 2022, revealed Resident 6 was to get vegetable soup and salisbury steak with gravy. Further review of Resident 6's tray ticket revealed allergies listed as fish, shellfish and eggs, and dislikes were listed as eggs and seafood. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on July 13, 2022, at 2:25 PM, it was stated that the primary evening meal on July 10, 2022, was a tuna salad sandwich and vegetable soup. They revealed that salisbury steak was the alternate, which Resident 6 was supposed to receive. They stated that they think there was a mix-up in the kitchen with the trays and tickets, and the wrong ticket was placed on the wrong tray. They also stated that nursing staff should be looking at the tray ticket when a meal is served, but that they thought she was being served chicken salad. During a follow up interview with the NHA and DON on July 14, 2022, at 10:17 AM, it was stated that during their investigation, they are unable to confirm Resident 6's allergies, except to shellfish, iodine and eggs. They feel that the incident was more of a panic attack/anxiety attack, and not a true anaphylactic reaction. The NHA stated she believes seafood is a dislike, and that is why it was put on Resident 6's tray card as a dislike. At this time, the NHA did confirm that Resident 6's allergy list in her electronic health record lists seafood as an allergy, dated June 19, 2020, and also confirmed that Resident 6's care plan lists allergies to egg, shellfish, fish and seafood, and the physician order specifies no fish. The NHA stated their investigation into this incident is ongoing. The facility failed to ensure that residents were not served foods they were allergic to for one of six residents reviewed (Resident 6), which resulted in harm with an allergic reaction, requiring epinephrine, Benadryl and transfer to the hospital for difficulty breathing and a swollen external throat and tongue. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of facility policies, manufacturer's instructions, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of 30 residents reviewed (Resident R2), resulting in harm to the resident due to a fall from a mechanical lift that resulted in the resident sustaining three fractured ribs. Findings include: The facility's policy regarding abuse and neglect, dated January 18, 2017, indicated that neglect was defined as the failure of the facility, its employees or service providers, to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility's policy regarding the use of mechanical lifts (devices that use hydraulic power to transfer a resident from one surface to another), dated January 18, 2017, indicated that two staff were to be present for all mechanical lift transfers. The manufacturer's instructions for the Invacare Electric Mobile Patient Lift, dated November 2013, indicated that two assistants were recommended for all lifting preparation and transferring procedures. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R2, dated February 9, 2017, revealed that the resident was confused, was totally dependent for transfers, and required the extensive assistance of two for transfers. The resident's care plan regarding fall and injury prevention, dated January 23, 2017, indicated that the resident required a mechanical lift and the assistance of two for transfers. An incident report for Resident R2, dated March 2, 2017, at 6:30 a.m. revealed that the resident was being transferred with the mechanical lift when one of the sling straps popped off the lift bar, which caused the resident to fall and hit her left upper back on the lift. The resident complained of pain in the area. An X-ray report, dated March 2, 2017, at 10:24 a.m. revealed that Resident R2 had fractures of the left third, fourth, and fifth ribs. Information submitted by the facility, dated March 8, 2017, revealed that Nurse Aide 16 was tranferring Resident R2 using an Invacare Reliant 450 mechanical lift when the incident occurred. Although Nurse Aide 16 initially stated that Nurse Aide 17 was assisting during the transfer, the facility concluded that this testimony was false as Nurse Aide 17 denied that she assisted Nurse Aide 16 with Resident R2's transfer. Information submitted by the facility, dated March 8, 2017, revealed that Nurse Aide 16 confirmed that she received training on using the Invacare Reliant 450 mechanical lift when it was purchased in 2016, and she confirmed her understanding of the requirement to have two staff members involved in a mechanical lift transfer. Interview with Nurse Aide 16 on March 7, 2017, at 3:10 p.m. revealed that she was the operator of the mechanical lift for Resident R2 when the accident occurred on March 2, 2017. She indicated that she did not have the assistance of any other staff member during the transfer in which the loop of the lift sling popped off of the lift suspension bar. She also indicated that she placed the resident back in bed using the lift without assistance before Licensed Practical Nurse 18 or Registered Nurse 19 came to the resident's room to assess her for injuries. Interview with Nurse Aide 17 on March 8, 2017, at 9:20 a.m. revealed that she was working in the same hall as Nurse Aide 16 on March 2, 2017, but was not present in Resident R2's room when the fall occurred. Interview with the Nursing Home Administrator on March 7, 2017, at 9:30 a.m. and with the Director of Nursing on March 8, 2017, at 3:15 p.m. revealed that they determined that Nurse Aide 16 performed Resident R2's transfer herself, and that Nurse Aide 17 was not in the resident's room when the resident fell from the lift or when the resident was placed back in bed. 28 Pa. Code 201.18(e)(1) Management. Previously cited 12/7/16, 10/14/16, 5/28/16, 4/2/15. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 10/14/16, 11/9/15, 9/13/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 2/8/17, 1/19/17, 12/7/16, 11/9/16, 10/14/16, 9/15/16, 8/17/16, 5/28/16, 3/10/16, 2/13/16, 11/9/15, 9/13/15, 8/26/15, 4/2/15.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that interventions to prevent falls were in place as planned for one of 30 residents reviewed (Resident R2), resulting in harm to Resident R2 due to a fall from a mechanical lift that resulted in three rib fractures. Findings include: The facility's policy regarding the use of mechanical lifts (devices that use hydraulic power to transfer a resident from one surface to another), dated January 18, 2017, indicated that two staff were to be present for all mechanical lift transfers. The manufacturer's instructions for the Invacare Electric Mobile Patient Lift, dated November 2013, indicated that two assistants were recommended for all lifting preparation and transferring procedures. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R2, dated February 9, 2017, revealed that the resident was confused, was totally dependent for transfers, and required the extensive assistance of two for transfers. The resident's care plan regarding fall and injury prevention, dated January 23, 2017, indicated that the resident required a mechanical lift and the assistance of two for transfers. An incident report for Resident R2, dated March 2, 2017, at 6:30 a.m. revealed that the resident was being transferred with the mechanical lift when one of the sling straps popped off the lift bar, which caused the resident to fall and hit her left upper back on the lift. The resident complained of pain in the area. An x-ray report, dated March 2, 2017, at 10:24 a.m. revealed that Resident R2 had fractures of the left third, fourth, and fifth ribs. Interview with Nurse Aide 16 on March 7, 2017, at 3:10 p.m. revealed that she was the operator of the mechanical lift for Resident R2 when the accident occurred on March 2, 2017. She indicated that she did not have the assistance of any other staff member during the transfer in which the loop of the lift sling popped off of the lift suspension bar. She also indicated that she placed the resident back in bed using the lift without assistance before Licensed Practical Nurse 18 or Registered Nurse 19 came to the resident's room to assess her for injuries. Interview with Nurse Aide 17 on March 8, 2017, at 9:20 a.m. revealed that she was working in the same hall as Nurse Aide 16 on March 2, 2017, but was not present in Resident R2's room when the fall occurred or when the resident was placed back into bed. Interview with the Nursing Home Administrator on March 7, 2017, at 9:30 a.m. and with the Director of Nursing on March 8, 2017, at 3:15 p.m. revealed that they determined that Nurse Aide 16 performed Resident R2's transfer herself, and that Nurse Aide 17 was not in the resident's room when the resident fell from the lift. 42 CFR 483.25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/Supervision/Devices. Previously cited 11/9/15. 28 Pa. Code 207.2(a) Administrator's responsibility. Previously cited 7/15/16, 2/13/16, 4/2/15. 28 Pa. Code 201.18(b)(1) Management. Previously cited 7/15/16. 28 Pa. Code 201.18(e)(1) Management. Previously cited 12/7/16, 10/14/16, 5/28/16, 4/2/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 2/8/17, 1/19/17, 12/7/16, 11/9/16, 10/14/16, 9/15/16, 8/17/16, 5/28/16, 3/10/16, 2/13/16, 11/9/15, 9/13/15, 8/26/15, 4/2/15.

Based on observations, clinical record reviews, staff interviews and resident interviews, it was determined that the facility failed to provide an environment that ensured the air temperature in the residents' rooms remained between 71 degrees Fahrenheit (unit of measuring temperature) and 81 degrees Fahrenheit, causing the residents unnecessary discomfort and placing the health and safety of the residents in Immediate Jeopardy for one of 5 nursing units reviewed (E Wing Hall). Findings include: Observation on July 14, 2014, at 5:50 p.m. of the E Wing Hall revealed the following temperatures: 80.3 degrees Fahrenheit (F) in the room of Resident 5, 81.3 degrees F in the room of Resident 3, and 81.9 degrees F in the room of Resident 1. During an interview with Resident 1 on July 14, 2016, at 5:50 p.m. who resides on the E Wing Hall, the resident revealed that the temperature was, cool enough now because of my fan. My son brought a fan in for me last week. Review of Resident 1's admission Minimum Data Set assessment (MDS-a periodic assessment of resident needs), dated July 6, 2016, revealed that she had a BIMS score (Brief interview of Mental Status - a structured evaluation used to determine a residents level of cognitive functioning) of 12 indicating her mental status is cognitively intact. An interview with Licensed Practical Nurse (LPN) 2 on July 14, 2016, at 5:50 p.m. revealed that the temperatures were monitored with the digital thermostat (a device used to regulate the temperatures which provides a numeric read out) located on the E Wing Hall wall and that the temperatures were recorded from that reading and not from the resident rooms. Observations on July 14, 2014, at 5:50 p.m. revealed that the staff did not have access to a thermometer and relied on the wall thermostat on the E Wing Hall to monitor the temperature. An interview with LPN 2 on July 14, 2016, at 5:55 p.m. revealed, we are passing fresh ice water twice a shift instead of once, because it is melting so fast. We are trying to keep both the staff and residents hydrated. Observations of temperatures taken in the room of Resident 2 on the E Wing Hall, on July 14, 2016, at 5:55 p.m. revealed a temperature of 82.6 degrees F and Resident 2 stated she is too hot. Resident 2 was observed to have her night gown pulled up to expose her abdomen. Review of Resident 2's admission MDS dated [DATE], revealed she has a BIMS of 13 indicating her mental status is cognitively intact. Observations of Resident 3's room, on the E Wing Hall, on July 14, 2016, at 6:00 p.m. revealed a temperature of 81.2 degrees F. Resident 3 stated, I was so warm last night that I couldn't sleep. I got my fan out today. Resident 3 had the fan running in her room at the time of the observation. Review of Resident 3's admission MDS dated [DATE], revealed a BIMS of 15 indicating her mental status is cognitively intact. The Maintenance Department, Maintenance Staff 1, arrived at the facility on July 14, 2016, at 6:30 p.m. and informed the surveyor that an exhaust motor for the E Wing Hall air conditioning unit had a, squeaky bearing (a part of the motor that turns) and had to be removed for repairs between the hours of 1:00 p.m. and 2:00 p.m. on this day. He stated that this affected the temperatures on the E Wing Hall of the facility. Maintenance Staff 1 indicated that the HVAC (heating ventilation air conditioning) company had been contacted and would evaluate the air conditioning unit for E Wing Hall. Maintenance Staff 1 further indicated that the staff on the E Wing Hall had been requested to monitor the temperatures on the E Wing Hall during the afternoon and evening shifts. A review of the temperature log revealed that temperature checks had been performed on July 14, 2016, at 2:08 p.m., 3:30 p.m., and 5:30 p.m. on the E Wing Hall and that the temperatures were recorded as 79.8 degrees F, 78.9 degrees F and 79.8 degrees F respectively. Further review of the temperature log revealed no temperatures were recorded for resident rooms during this time. Maintenance Staff 1 rechecked the temperatures on July 14, 2016 on the E Wing Hall and obtained the following temperatures: 6:45 p.m. Resident 1's room was 82 degrees F. 6:47 p.m. Resident 3's room was 82 degrees F. LPN 1 rechecked the temperature in Resident 2's room, and obtained a temperature of 83.3 degrees F. An interview with Maintenance Staff 1 revealed that at approximately 7:00 p.m., the HVAC technician arrived to the facility. He was informed by the HVAC technician that the temperatures should improve on the E Wing Hall in approximately an hour and to call if they do not improve. An interview with LPN 1 on July 14, 2016, at 7:10 p.m. revealed that a thermometer (a device used to measure temperature) was not available for staff to monitor environmental temperatures. She indicated that there was a thermometer in the shower room to monitor the temperature of that room. At the request of the surveyor, LPN 1 checked the temperature of Resident 2's room, using the thermometer from the shower room, and obtained a temperature of 83.3 degrees F. An interview with the Nursing Home Administrator (NHA), on July 14, 2016, at 7:31 p.m. revealed that the staff were currently asking all of the residents on the E Wing Hall if they would like to be moved off of the unit and/or if they would like to have a fan. Further interview with the NHA revealed that she was unable to find a policy that directed the facility on how to respond to temperatures above 81 degrees F, and that she wasn't sure if one existed. On July 14, 2016, at 8:00 p.m. the NHA and the Director of Nursing were notified that Immediate Jeopardy had been identified related to air temperature in the resident rooms being at greater than 81 degrees Fahrenheit causing the residents unnecessary discomfort and placing the health and safety of the residents in Immediate Jeopardy. The Nursing Home Administrator and the Director of Nursing were then asked to provide a corrective action plan. On July 14, 2016, at 8:15 p.m. the NHA informed the surveyor that all of the residents had chosen to stay in their rooms but that Resident 2 and Resident 5 had requested a fan. The facility provided fans to these residents immediately. An interview with the NHA, on July 14, 2016, at 8:30 p.m. revealed that the, Corporate Office for the facility approved to have 8 (eight) 14,000 BTU (British thermal unit, is a basic measure of thermal (heat) energy) air conditioning units brought into the facility to decrease the temperatures on the E Wing Hall. The air conditioning units would arrive as soon as possible. During an interview with the NHA on July 14, 2016, at 8:48 p.m. she revealed a plan of correction as follows: All residents on E Wing Hall were offered hydration immediately. All Residents on E Wing Hall were offered to move if they wished to move. All resident on E Wing Hall were offered fans. Called HVAC contractor to come an assess the units. (8) 14,000 BTU portable air conditioners were being delivered and installed tonight (7/14/2016). Monitor room temperatures every hour and make adjustments as need be. Maintain portable air conditioning units until repairs or upgrades to HVAC system can be completed. During an interview with the NHA on July 14, 2016, at approximately 9:15 p.m. she was informed that the surveyor would return on July 15, 2016 to check the status of the temperatures taken on the E Wing Hall during the night shift and that the Immediate Jeopardy status would continue. On July 15, 2016, at 9:00 a.m. an interview with the NHA revealed that the 8 air conditioning units arrived at 2:00 a.m. on July 15, 2016, and were all installed by 4:00 a.m. The NHA informed the surveyor that all of the temperatures on the E Wing Hall were in compliance by 4:30 a.m. The NHA stated that there are 3 rooms on the E Wing Hall that do not have air conditioning units and they continue to trend (go) upward in temperature but remain in compliance (between 71 and 81 degrees). On July 15, 2016, temperature logs were provided by Maintenance Staff 1 that revealed the E Wing Hall temperatures, taken by maintenance staff during the 10:00 p.m. check on July 14, 2016, indicated: room [ROOM NUMBER] 83.8 degrees F room [ROOM NUMBER] 85.1 degrees F room [ROOM NUMBER] 83.8 degrees F room [ROOM NUMBER] 82.2 degrees F room [ROOM NUMBER] 77.9 degrees F room [ROOM NUMBER] 83.0 degrees F room [ROOM NUMBER] 82.1 degrees F room [ROOM NUMBER] 78.2 degrees F room [ROOM NUMBER] 81.5 degrees F room [ROOM NUMBER] 78.6 degrees F room [ROOM NUMBER] 79.1 degrees F room [ROOM NUMBER] 79.1 degrees F room [ROOM NUMBER] 81.5 degrees F All temperatures that were recorded after 10:00 p.m., were within the 71 to 81 degree F requirement. The NHA also stated that since the start of the dayshift, the staff have been rounding frequently (fresh ice water was passed twice a shift) to assess the residents on the E Wing Hall. The staff have encouraged the residents to wear cool clothing and therapy is screening residents that are high risk for falls to determine that they are able to mobilize (walk or use a wheel chair)around the portable air conditioning units. The NHA confirmed that no policy existed to direct the facility on how to respond to temperatures above 81 degrees Review of the report from the HVAC technician for July 14, 2016, revealed that the air conditioning unit for E Wing Hall was not cooling to its full efficiency and he indicated that the fan was overheating. Maintenance was instructed to check the temperatures every three hours and the technician would be back tomorrow (July 15, 2016) to fix the fan. Review of the HVAC technician's report for the July 15, 2016, visit to the facility indicated that the repairs were made and the HVAC system was functioning well at the time of the visit. Observation of room [ROOM NUMBER] and room [ROOM NUMBER] on the E Wing Hall on July 15, 2016, at 10:50 a.m. revealed that two air conditioning units were unable to be run at the same time because it overloaded the system and the power goes out in both rooms. The NHA informed the surveyor and provided documentation that another generator was being delivered. The NHA also revealed that a 25 ton large capacity air conditioning unit was being rented and was to be delivered on July 15, 2016. The Immediate Jeopardy for the temperatures was lifted on July 15, 2016, at 11:16 a.m. On July 15, 2016, at 12:00 p.m. the NHA provided a revised plan of correction to include the July 15, 2016 plan of correction additions. 42 CFR 483.15(h)(6) Comfortable and Safe Temperature Levels. Previously cited 2/13/16. 28 Pa. Code 207.2(a) Administrator's responsibility. Previously cited 2/13/16, 4/2/15. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 4/2/15. 28 Pa. Code 201.18(b)(1) Managment.

Based on review of Department of Health files and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that protective devices to prevent injuries from falls were applied as ordered by the physician for one of two residents reviewed (Resident R1) who fell and suffered a fracture. Findings include: Department of Health files revealed that the facility reported that on 6/17/14 Resident R1 fell from bed and received a fractured hip. The facility's report indicated that their investigation revealed that at the time of the fall, a staff member failed to have a fall mat in place in accordance with the resident's plan of care. A quarterly assessment, dated 5/23/14, for Resident R1 revealed that the resident was confused, had a [DIAGNOSES REDACTED]. A fall risk assessment, dated 5/12/14, and care plan, dated 5/27/14, revealed that the resident was at high risk for falls and staff were to offer the resident hipsters (padded under garment to protect the hip area) and have fall mats next to his bed. Observations on 6/24/14, at 1:05 p.m., revealed that Nurse Aides 1 and 2 transferred the resident from a geriatric chair into bed with a mechanical lift and the resident did not have hipsters on. Interviews with Nurse Aides 1 and 2 on 6/24/14, at 1:08 p.m., revealed that they never applied hipsters on the resident. Interview with Licensed Practical Nurse 3 on 6/24/14, at 1:10 p.m., revealed that the resident was to wear hipsters and the information indicating that he was to wear them was located on the "Nurse Aide Kardex" (care plan). Interview with the Care Plan Coordinator on 6/24/14, at 1:38 p.m., revealed that the care plan was current and the resident was to wear hipsters due to being a fall risk. Interview with Nurse Aide 4 on 6/24/14, at 2:25 p.m., revealed that the resident never wore hipsters and was not wearing hipsters at the time of the fall on 6/17/14. Interview with the Director of Nursing on 6/24/14, at 1:40 p.m., confirmed that the resident was to wear hipsters and should have had them on at the time of the fall. 28 Pa. Code 211.12 (d)(5) Nursing services. Previously cited 3/13/14.

Based on clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to ensure that fall prevention devices were applied for one of 17 residents reviewed (Resident R5) who had a history of [REDACTED]. Findings include: A quarterly assessment, dated 5/30/14, for Resident R5 revealed that the resident required assistance to dress and transfer. Nursing notes, dated 6/14/14, revealed that the resident fell out of bed; and a nursing note, dated 6/15/14, indicated that the resident continued to attempt to transfer himself without assistance. A care plan, dated 6/16/14, indicated that the resident was at risk for falls and was to wear non-skid socks when in bed. Observations on 8/5/14 at 1:00 p.m. revealed that Nurse Aide 1 transferred the resident from his wheelchair to his bed. The resident was wearing regular socks during the transfer; and after he was transferred to bed, the nurse aide did not apply non-skid socks. At that time, non-skid socks were observed lying on the resident's bedside stand. Interview with Nurse Aide 1 on 8/5/14 at 1:30 p.m. confirmed that she did not put non-skid socks on the resident, and she was not aware that he was to have non-skid socks on. Interview with the Director of Nursing on 8/5/14 at 2:10 p.m. confirmed that the nurse aide should have put non-skid socks on the resident. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited 6/24/14. 28 Pa. Code 211.12 (d)(5) Nursing services. Previously cited 6/24/14, 3/13/14.