Every finding on record at Laurel Square Healthcare and Rehabilitation Center

Based on standards of professional practice, observation, and interview with staff it was determined that the facility failed to store food in accordance with standards for food service safety (main kitchen and first floor nursing unit). Findings include: Review of Leftovers and Food Safety from the U.S. Department of Agriculture, Food Safety and Inspection Service, last updated July 2020 revealed leftovers can be kept in the refrigerator for 3 to 4 days. A tour of the main kitchen conducted on May 26, 2026, at 9:50 a.m. with the Food Service Director, Employee E10, revealed the following: Observations in the walk-in refrigerator revealed pre-prepared leftover pea puree, hot dogs, and beef gravy. The prepared date for each item was May 24, and use-by date of May 30. Further observations revealed a shrimp stir fry with a prepared date of May 20 and use-by date of May 26. All items were stored in stainless steel chafing steam table pans. Observations on May 26, 2026, at 11:00 a.m. revealed the ice machine on the first-floor nursing unit had a large, white plastic tray underneath it. The ice machine was observed to be leaking water, and the white tray had a quarter inch of stagnant water in it. The white tray beneath the ice machine was also visibly dirty with black specks within it. Further observations on May 26, 2026, at 11:00 a.m. of the ice machine on the first-floor nursing unit revealed no 2-inch air gap (standard backflow prevention requirement to protect potable water and ice from contamination) between the ice machine drain and drain access point in the floor. Interview on May 26, 2026, at 2:20 p.m. with Maintenance Director, Employee E11, confirmed the stagnant water beneath the ice machine and lack of 2-inch air gap for the drain. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on review of facility documentation, observations, and staff and resident interviews it was determined that the facility failed to follow the planned menus for two of four days observed (5/26 and 5/28). Findings include: Review of the facility planned menu revealed for the week of 5/24/2026 revealed the lunch planned for Tuesday 5/26/2026 included green peas and cabbage as the main and alternate vegetable. Observations on May 26, 2026, at approximately 12:15 p.m. in the 1st floor dining room revealed the menu posted also indicated the vegetables were green peas and cabbage as the main and alternative vegetable. Interview on May 26, 2026, at 12:18 p.m. with Resident R52 revealed the facility frequently does not follow the planned menu. Interview on May 26, 2026, at 12:30 p.m. with Registered Dietitian, Employee E12, revealed he/she was unaware of any menu changes for the lunch meal on May 26, 2026. Interview on May 26, 2026, at 12:35 p.m. with Resident R63, revealed the facility does not serve what is on the planned menu. Observations on May 26, 2026, at 12:45 p.m. revealed R47 and R29 were served the alternative lunch option but was served asparagus instead of the planned cabbage. Interview on May 26, 2026, at 12:40 p.m. with Resident R47 revealed he/she does not like asparagus. The asparagus was visibly untouched on Resident R47's plate. Interview on May 26, 2026, at approximately 1:00 p.m. with the Food Service Director, Employee E10, confirmed the kitchen did not have cabbage to serve for lunch. Review of the facility menu revealed on Thursday 5/28/2026 the alternative lunch option was grilled cheese with carrots and roasted potatoes. Observations on May 28, 2026, at 12:00 p.m. in the main kitchen during lunch revealed the steam table was prepared with food items to serve for lunch. Observations revealed the dietary employee was serving mashed potatoes with the grilled cheese, instead of the planned roasted potatoes. Interview on May 28, 2026, at 12:00 p.m. with the Food Service Director, Employee E10, confirmed the facility was serving mashed potatoes instead of roasted potatoes. 28 Pa. Code 201.18(b)(3) Management

Based on review of facility documentation and staff interview it was determined that the facility failed to include active involvement from direct care staff and input from residents in the facility assessment process.Findings Include: Review of facility documentation Facility Assessment reviewed February 11, 2026, revealed individuals who were involved in completing the review included: Nursing Home Administrator (Employee E1), Director of Nursing (Employee E2), Admissions Director (Employee E3), Business Office Manager (Employee E4), House Keeping Director (Employee E5), Rehabilitation Director (Employee E6), Human Resources (Employee E7), Dietary (Employee E8), and the Medical Director (Employee E9). Review of the facility assessment and the sign-in sheet for individuals involved in completing the annual review of the facility assessment revealed no documented evidence that the facility included active involvement from direct care staff (including but not limited to Registered Nurses (RNs), Licensed Practical Nurses (LPNs), or Nurse Aides (NA)). Further review of the facility assessment revealed no documented evidence that the facility considered input from residents, their representative(s), family members, and representatives of direct care staff when formulating their assessment. Interview on May 29, 2026, at 10:50 a.m. with Nursing Home Administrator, Employee E1, confirmed no documentation was available to support evidence of active involvement from direct care staff or input from residents. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on review of clinical records, review of policy, and interview with staff, it was determined that facility did not develop and implement a baseline care plan for one out of six residents reviewed, related to bladder incontinence (Resident R2) Findings include:Review of facility policy ' Baseline Care Plans, ' revised March 2022, indicates that a baseline plan of care to meet the resident ' s immediate health and safety needs is developed for each resident within forty-eight hours of admission. Review of Resident's R2 clinical record revealed the diagnoses of acute kidney failure with acute cortical necrosis, personal history of malignant neoplasm of prostate, obstructive and reflux uropathy, acute metabolic acidosis, artificial openings of urinary tract. Review of Resident R2's ' skin and wound note completed on August 11, 2025, at 4:00 pm, stated Resident R2 was incontinent with following recommendations: use appropriate moisture barrier creams per formulary to provide thorough skin care with each episode of incontinence. Use formulary briefs when indicated to manage moisture and assess often. While the patient is out of bed using a wheelchair, the use of a chair cushion is recommended. Further review of ' skin and wound ' note stated that due to Resident R2's comorbidities, the resident had an increase risk of skin breakdown - Recommend good hygiene and skin care to prevent skin breakdown. Recommend application of emollient daily. No open wounds on today's skin assessment; please keep patient's skin clean and dry, apply barrier cream as necessary to prevent skin breakdown, and avoid pressure on any bony prominence by adhering to turning protocols and floating heels as applicable. Further review of Resident R2's ' skin and wound ' progress notes dated August 11, 2025 at 10:49 am, states new admission wound rounds conducted with in-house CRNP. The only recommendation is to have resident seen by podiatry for toes nails clipping. All other areas intact. Review of Resident R2's Braden scale for predicting pressure ulcer risk evaluation, completed on September 10, 2025, at 11:03 pm, indicated moderate risk. Further review of Resident R2 ' s clinical record revealed that the resident was hospitalized on [DATE] for surgery to sacral area due to osteomyelitis (infection of the bone). Review of R2's care plan revealed no evidence of goals or interventions related to recommended preventative measure for bladder incontinence. 28 Pa. Code 211.10( c) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policy, review of clinical records, and interview with residents and staff, it was determined that the facility failed to provide pharmaceutical services to ensure accurate receiving, dispense and administration of medication to meet the needs of a resident according to professional standards of practice relating to medication administration for 1 of 11 residents reviewed (Resident R1) Findings include:Review of the facility's policy titled Administering Medications last revised April 2019 states that medications are administered in a safe and timely manner, and as prescribed. Interview with Resident R1 on November 6, 2025, at 11:45 a.m. revealed that she had complained about her eye being red on October 22, 2025, and that the first time the eye drops were ordered they were lost by the overnight nurse, Employee E6. Then there was an issue getting the eye drops reordered due to a problem with the insurance not paying for the same prescription twice in one week. Resident R1 said that her eye got so bad that it was bright red and that she demanded to go to the emergency room (ER) to have it treated on November 2, 2025. She said that once she started using the eye drops from the hospital her eye was clearing up. Review of Resident R1's clinical record the resident was admitted on [DATE]. An October 22, 2025, progress note revealed that Resident R1 complained of allergies and left eye redness, and that the physician was notified and ordered tobramycin eye drop (an antibiotic treatment used to combat bacterial infections of the eye) four times a day for five days. Review of the electronic medication administration record (eMAR) reveals an October 22, 2025, physician order for tobramycin ophthalmic solution 0.3%, instill one drop in the left eye four times a day for left eye redness for five days starting on October 22, 2025. Further review of the eMAR revealed that each day from October 22, 2025, through November 3, 2025, has an open space, an X or a 9 (med not given see nurse note) all indicating that the resident did not receive the eye drops. Review of the nursing progress notes from October 23, 2025, through October 27, 2025, indicate when a 9 was on the eMAR, a note was written to indicate that the eye drop medication was on order and documented as not given. Interview on November 6, 2025, at 11:30 a.m. with Employee E3, floor nurse who has responsibility for Resident R1's medication administration revealed that there was a problem getting Resident R1's eye drops. That the eye drops were ordered on October 22, 2025, but did not come in until November 3, 2025, but that Resident R1 went to the ER (emergency room) on November 2, 2025, and got eye drops.Interview on November 6, 2025, at 11:35 a.m. with Employee E4, unit manager confirmed that Resident R1's eye drops never came in, and that the resident went to the ER who gave her the same antibiotic eye drops. That Resident R1 saw the eye doctor on November 5, 2025, and another eye drop without the antibiotic were ordered but were still not in yet.Interview with the Administrator on November 6, 2025, at 1:20 p.m. confirmed that there were issues getting Resident R1's eye drops and that after eleven days with no treatment the resident had to go to the ER to get the eye drops. The administrator was not satisfied with the way that the pharmacy handled this situation.28 Pa Code 211.9 (a)Pharmacy Services28 Pa. Code 211.12(d)(1) Nursing Services

Based on observation, review of facility policies, and staff and resident interviews, it was determined that the facility ensure that refrigerated food items were timely discarded to ensure food safety. Findings include:Review of the facility's policy titled Food Quality and Palatability, dated February 2023, revealed that food is to be prepared using methods that conserve nutritional value, flavor, and appearance. The policy states that food must be palatable, visually appealing, and served at a safe and appetizing temperature. Additionally, food and liquids are to be prepared and served in a manner, form, and texture that meets the individual needs of residents.Further review indicated that cooks are expected to prepare food in a sanitary manner, following the principles of Hazard Analysis Critical Control Point (HACCP) and adhering to time and temperature guidelines as outlined in the federal Food Code. Recipes are to be followed, and seasoning should reflect regional and ethnic preferences as appropriate.Review of the Food Storage and Retention Guide from Health Care Service Group, incorporated into dietary operations in 2017, references the FDA Food Code 2013. It specifies that time/temperature control for safety (TCS) foods, including fruits and vegetables, may be stored for up to seven days. Day one is defined as the date of receipt into inventory, and items may be retained for one week or until visual spoilage is noted.Observation during a kitchen tour conducted at 9:50 a.m. on September 23, 2025, revealed temperature log affixed to its exterior of the produce refrigerator. The log indicated that the temperature was not recorded on the night of September 22, 2025. Inspection of the two-sided kitchen refrigerator with one side designated for dairy and the other for produce revealed the following:Shredded cabbage dated September 3, 2025, found to be spoiledTwo cases of zucchini dated September 3, 2025, were found to be visibly with green/black color around it.Case labeled August 20, 2025, containing celery and cabbage: the celery was visibly spoiled.Cantaloupe dated September 3, 2025, found to be soft to the touch and deemed spoiledAn interview with the Dietary Director Employee E3, confirmed that the produce in question was dated approximately three weeks prior and was found to be spoiled. He was unable to explain why the spoiled produce remained in the refrigerator for such an extended period.An interview with the Regional Director revealed that additional produce had been received since September 3, 2025 and stored in the walk-in refrigerator. He stated that the spoiled produce had not been used in any meal preparation and could not determine why it was still stored in the refrigerator.28 Pa Code 20114(a) Responsibility of licensee

Based on observations of the noon meal service, reviews of food committee meeting minutes, reviews of policies and procedures and interviews with residents and staff, it was determined that foods and drinks were not appetizing, palatable and served at safe temperatures that were satisfactory to the residents. Residents: (R2, R3, R4, R5, R6, R7, R8, R10, R11, R12, R15 and R16) Findings include: A review of the facility policy and procedure titled healthcare services group dated June 23, 2025 revealed that it was the responsibility of the food and nutrition department to evaluate and test the teperature of the foods being served to the residents at point of service. Interview with the director of dietary services, Employee E6, at 1:00 p.m., on July 8, 2025 confirmed that the dietitian and the director of dietary services were responsibile for conducting routine temperature test trays at point of service to the residents. The test tray evaluations were used to monitor the safety and quality of the foods along with the timeliness of the food delivery system. The director of dietary, Employee E6, reported that hot foods and fluids were expected to be served to each resident at temperatures between 120 to 135 degrees Fahrenheit and cold foods and fluids were expected to be served to each resident at temperatures between 41 and 55 degrees Fahrenheit. A review of the food committee meeting minutes dated June 13, 2025 revealed that the alert and oriented residents who attended the meeting were not satisfied with the foods and beverages being served for their meals, at the facility. The residents were complaining about the selection of foods and fluids being offered, by the food service department. The residents also voiced that they were unhappy with food temperature, taste and appearance of the foods and beverages that were being prepared and served to them by the food and nutrition services department. A review of the posted meal time scheduled revealed that the noon meal was scheduled at 11:30 a.m., until 12:15 p.m. daily. The menu posted on the unit planned for a cold meal of Tuna salad hoagie, macaroni salad, tomato basil salad and fruit salad. There were no drinks planned/listed on the menu. Observations and test tray evaluations of the noon meal service on the first floor nursing unit revealed that cold foods were not being served cold. The tuna salad inside the hoagie roll registered 75 degrees Fahrenheit. The macaroni salad measured 73 degrees Fahrenheit. The canned fruit (pears) registered 72 degrees Fahrenheit. The tomato basil salad registered 60 degrees Fahrenheit. Observations and test tray evaluations of the noon meal service on the first floor nursing unit also revealed that none of the residents were given offered or served milk on the first floor nursing unit. Although juice was not listed on the preplanned menus, four ounces of apple juice was served. The registered nurse, Employee E4, confirmed the lack of menu planning for fluids for the residents. Interviews with alert and oriented Residents: (R2, R3, R4, R5, R6, R7, R8, R10, R11, R12, R115 and R16) revealed several complaints of disappointment with the food and nutrition services department. Residents complainted that the foods and drinks were unpresentable all mixed together on a plate. The residents said the it was difficult to figure out what you were eating. Interview with Resident R6 at 10:00 a.m., on July 8, 2025 revealed that he receives foods that he does not find palatable. The resident said that he dislikes oatmeal and hard boiled eggs and was served these foods at breakfast often. Interview with Resident R7 at 10:10 a.m., on July 8, 2025 revealed that the resident was supposed to be receiving large portions at each meal, hot tea and salt as a condiment. The resident said that he does not receive hot tea it was always cold. The resident said the portion of meats that he receives was small. The resident said that he was not given a salt packet unless he asks for one. The resident said he needs a blend of herbs for his foods; it always tastes bland. Interviews with Residents R3 and R4 at 10;45 a.m., on July 8, 2025 revealed that they have been asking to have a salad platter once a day. They have already told the nursing staff several times. residents R3 and R4 expressed frustration with the palatability of their foods. The residents would be pleased to have the kitchen staff prepare and serve the salad platters (tuna, chicken ham) for them at least once a day. Interview with Resident R16 at 11:45 a.m., on July 8, 2025 revealed that this resident does not like tuna and had reported her preferences to the dietitian. Observation of Resident R16 during the noon meal service on the second floor nursing unit revealed that the resident refused the tuna hoagie that was served to her for lunch on July 8, 2025. 28 PA. Code 211.10(a)(b)(c)(d) Resident care policies 28 PA. Code 201.18(b)(1)(3) Management 28 PA. Code 201.14(a) Responsibility of licensee

Based on observation, review of facility documentation, facility policy, and interviews with residents and staff, it was determined that the facility failed to prepare and serve items as planned on the menu and failed to provide residents with their requested foods of preference for five of 18 residents interviewed (Residents R23, R28, R63, R70, and R289 ). Findings Include: Review of the facility posted Always Available menu posted in the first-floor dining/activities room lists beverages as Apple Juice, Cranberry Juice, Orange Juice, Hot Tea, Coffee, and Decaf Coffee. Review of facility policy titled, Therapeutic Diets revised September 2017 states, Polciy Statement- All residents have a diet order, including regular, therapuetic, and texture modification, that is prescribed by the attending physician, physician extender, or credentialed practioner in accordance with applicable guidelines. Procedures- .3.Diets are prepared in accordance with the guidelines in the approved Diet Manual and the individualized plan of care. Resident R23 was admitted to the facility on [DATE] with the following diagnoses: Dysphagia (difficulty swallowing) and Hyperkalemia (high potassium levels in the blood, which can damage your heart and muscles). Interview held with Resident R23 on June 2, 2025 at 9:54 a.m. and the resident used a electronic device to type out words and sentences to communicate. The resident stated, they approved me for regular food but I get puree. When asked who stated that he said, the dietician she say she updated it, she updated it, but it keeps happening. Review of Resident R23's quarterly Nutrition Evaluation dated May 22, 2025 states under Food Preferences, Culteral/Ethnic/Religious-On file-Updates likes mac & cheese and sweet potatoes, collard greens. Dislikes mashed potatoes. Further review of the evaluation revealed, Recommendations and Plan- Diet as ordered., textures per Speech. Large protein/veg portions. Soup with lunch daily. Observation on June 2, 2025 at 12:25 p.m. revealed the resident has a dislike of mashed potatoes and was served mashed potatoes. All portions on his plate looked like single portions. Observation on June 5, 2025 at 8:11 a.m. revbealed resident R23 was seated in bed starting to eat his breakfast. The resident made a face at the surveyor and then looked at his breakfast plate. The surveyor observed the resident with a yellow pureed food on his plate. The resident took his pen to type on his electronic device eggs puree. The resident stated the other stuff I don't know what it is so I can't eat it can I have another oatmeal. Review of Resident R23's Weight record revealed the resident had a weight of 118 pounds on May 12, 2025. On Feburary 2, 2025 the resident weighed 138.2 pounds. The resident had a weight loss of 20 pounds over three months. Resident R63 was admitted to the facility on [DATE] with the following diagnoses: gastoparesis (delayed gastric emptying, meaning the stomach takes too long to empty its contents), Hyperlipidemia ( abnormally high levels of lipids (fats) in the blood, including cholesterol and triglycerides), Gastroesophageal reflux disease (GERD) with esophagitis occurs when the stomach's acidic contents flow back into the esophagus, causing tissue erosion and unpleasant symptom, and Pancytopenia (involves having low levels of red blood cells, white blood cells and platelets), Interview was held with Resident R63 on June 2, 2025 at 10:01 a.m. and the resident stated that he still receives items that he requests not to have. He gave the example of corn and beef. Review of Resident R63's allergies from admission lists corn, green peas, beef, and pork as intolerances as of August 20, 2024. The surveyor revisited the resident during lunch on June 3, 2025 due to their being corn on the lunch menu. Observation was made of Resident R 63's lunch tray on June 5, 2025 at 12:59 p.m. the resident was eating in his room and he had corn served to him. Interview held on June 4, 2025 at 1:00 p.m. with facility registered dietician Employee E15. When asked how likes/disklikes are updated she stated there is an electronic meal tracker system and you go in and update preferences and likes/dislikes. When asked how the kitchen staff would know is a food item was a dislike from the ticket, she stated, dislikes shouldn't show up on trays. When asked about Resident R23 getting pureed eggs for breakfast on a Mechnical Soft diet she stated, When residents are on mechincal, some food can be pureed also, we follow the Diet Manual. Review of the facility menu provided by the facility listed Thursday Day 12- Scrambled Eggs- Dysphagia Mechanical Diet 1/4 cup. Further review of all the menus provided that listed scrambled eggs for breakfast list no days where Dysphagia Mechanical diet has eggs lised as pureed. Review of Resident R28's clinical record revealed that Resident R28 was admitted to the facility on [DATE] with diagnoses of but not limited to End Stage Renal Disease. Further review of Resident R28's clinical record revealed physician order for carb consistent/ renal diet. Interview with Resident R28 on June 2, 2025 at 1:05pm revealed that meal tickets don't match what the resident receives on a regular basis. Observation of dining room on June 2, 2025 at 1:15pm revealed that Resident R28 was ordered to have a ham sandwich with lettuce and tomato. Resident R28's tray did not contain lettuce or tomato. Meal ticket read peach pie for dessert, Resident R28 recieved cookie. Interview with Resident R70, an alert and oriented resident, on June 2, 2025 during the facility's lunchtime meal stated, Missing food items and food items that are different from what is listed is an everyday occurrence. Observation of Resident R70's lunch tray revealed Peach pie should have been served, instead the resident received a cookie. Interview with Resident R289's family on June 2, 2025, at approximately 1:00 p.m. indicated Resident R289, Always gets mash potatoes and most times, butterscotch pudding no matter what is being served that day. Observation of Resident R289's lunch tray revealed pureed Cheesy Rice was requested but the resident received mashed potatoes and instead of pureed peach pie with crumb topping stated on the resident's meal ticket, pudding was served. 28 Pa. Code 211.6(a) Dietary services 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

Based on observations, review of facility policy and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety for three of three floors reviewed. (Ground, First, and Second Floors) Findings Include: Review of facility policy titled, Food Storage: Cold Foods revised April 2018 states, Policy Statement- All Time/Temperature Control For Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines for the FDA Food Code. Further review of the policy revealed, Procedures . 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of facility policy titled, Food Storage: Dry Goods, revised September 2017 states, Procedures- . 5. All packaged and canned food items will be kept clean, dry, and properly sealed. 6. Storage areas will be neat, arranged for easy identification, and date marked as appropriate. 7. Toxic materials will not be stored with food. Initial tour held on June 2, 2025 at 9:49 a.m. with Kitchen Manager Employee E9. Observations made of the walk-in refridgerator revealed diced chicken in fridge was not labled properly and pork pieces not labled or marked. Observation of the first-floor resident care areas on June 2, 2025 at 12:00 p.m. revealed numerous unlabeled, undated and expired foods in the pantry area. Nurse aide, Employee E4 unlocked the locked resident pantry area at 12:01 p.m. outside of the first floor dining/activities room. Nurse aide Employee E4 confirmed this area was used to store resident food only. After opening the door there was dirt visible on the hand sink, on the floors, and on the refrigerator in the pantry. The refrigerator was dirty with spilled juice all over the bottom of the refrigerator and door. There were three grocery bags filled with prepared food that were unlabeled. On top of the refrigerator was a piece of corn on the cob in a paper towel and a bottle of maple syrup that had a watered-down liquid in it. All findings of unlabeled, undated, unidentifiable food were confirmed by nurse aide Employee E4. Observation of the second-floor resident care areas on June 2, 2025 at 12:10 pm in revealed numerous unlabeled, undated and expired foods in refrigerator. Pantry floors and walls visibly soiled and dirty. Multiple used and soiled trays stacked on counter next to ice machine. Interview with Kitchen Manager Employee E9 on June 2, 2025 at 12:15PM confirmed above listed findings. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policies, review of clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan for two of eighteen residents reviewed (Resident R23 and Resident R80). Findings Include: Review of facility policy titled, Care Planning- Interdisciplinary Team, with a revision date of March 2022 states, Policy Statement- The interdisciplinary team is responsible for the development of resident care plans. Policy Interpretation and Implementation- 1. Resident care plans are developed according to the timeframes and criteria established by 483.21 2. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team. Review of facility policy titled, Bath, Shower/Tub revised October 2024 states, Purpose- the purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe for condition of the resident's skin. Further review of the policy revealed, Documentation- 1. The date and time the shower/tub bath was performed. 5. If the resident refused the shower/tub bath, the reason(s). Reporting- 1. Notify the supervisor if the resident refuses the shower/tub bath. Review of Resident R23's clinical revealed the resident was admitted to the facility on [DATE] with diagnosis of: Diabetes Type Two Mellitus with Hyperglycemia (occurs when a person's blood sugar elevates to potentially dangerous levels), Dysphagia (difficulty swallowing), Hyperlipidemia, and Paralysis of Vocal Cords and Larynx. An interview was held on June 2, 2025 at 9:54 a.m. with Resident R23 who was awake, alert, and oriented. Resident R23 has a deficit in communicating therefore he utilized an electronic device and pen to use a keyboard to type out sentences. Resident R23 typed out that he has not been receiving his regular shower. When asked when Resident R23 usually receives a shower he typed, Wednesday and Saturday. When asked when the last time he got a shower was he typed, two weeks or more. Interview held with the Assistant Director of Nursing, Employee E14 on June 3, 2025 at 2:21 p.m. and Employee E14 stated, I was there when staff tried to assist him with getting out of bed the other day to get a shower and he refused. Review of Resident R23's nursing notes from the months of June 2025 and May 2025 indicate no refusals for shower. Review of Resident R23's from May 7, 2025 through the current date revealed no instances where Resident Refused was checked off. Review of Resident R23's current care plan last updated on March 13, 2025 shows no indication and no focus area for refusals for the resident. Review of Resident R80's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis of: Dysphagia (difficulty swallowing), Cognitive Communication Deficit (difficulty with communication due to impairments in cognitive functions,), and Hyperosmolality and Hypernatremia (high concentration of solutes / sodium in the blood). On June 3, 2025 at 11:05 a.m. Resident R80 was approached by the surveyor in the dining/activities room. When the surveyor asked to speak privately, Resident R80 slowly wheeled himself out of the dining/activities room towards his bedroom. Right outside of the dining/activities room the resident took a styrofoam cup he had in his hand and filled it with ice cubes from the ice machine. After obtaining the ice, Resident R80 started putting pieces of the ice in his mouth, chewing on the ice, and then swallowing it. Review of Resident R80's nursing progress notes from April 27, 2025 revealed, Resident was observed refilling his cup of water at the ice machine then returning to his room. explained to the resident that he is still nothing by mouth, and the potential complications from his non-compliance. Resident offered empathy and consoled due to his distress with wanting to eat. Residents stated I have to do what I have to do. Further review of Review R80's nursing notes from April 18, 2025 states, Writer observed resident as I was rounding on the floor with a cup of ice in his hand and a piece in his mouth. Resident is currently still NPO (nothing by mouth), education provided to the resident & I gently asked if I could have the cup, resident abided. Resident informed I will place a speech consult request for re-evaluation. Doctor in house and made aware and confirmed request. Resident also placed on observation to monitor. Review of Resident R80's clinical record revealed a physician order the resident has had a NPO (nothing by mouth) order in place since February 17, 2025. NPO (nothing by mouth) status was included in the care plan, but there was no indication that the resident has been non-compliant to his NPO (nothing by mouth) status. Review of Resident R80's current care plan last updated March 13, 2025 revealed there was no indication and no focus area for the resident being non-compliant with NPO (Nothing by mouth) status. The above findings were confirmed by licensed nurse Employee E3 on June 4, 2025 at 1:13 p.m. 28 Pa. Code 211.10 (d) Resident care policies 28 Pa. Code 211.12 (d)(5) Nursing services

Based on reviews of staff training and competency sets for nursing assistants, reviews of the facility assessment and interviews with staff, it was determined that, the facility failed to ensure that nursing assistants retained a required minimum of 12 hours of nursing training annually for two of four nurse aides personnel records reviewed. (Employees E12 and E13). Findings Include: Employee E12, nursing assistant was hired on July 25, 2025. Annual training and competencies based on the needs of the residents (dementia care of the cognitively impaired, abuse prevention, accident prevention, restorative nursing techniques, emergency preparedness, resident rights, cultural competency) were not documented and available for review for this nursing assistant. Employee E13, nursing assistant was hired on October 29, 2010. Annual training and competencies based on the needs of the residents (dementia care of the cognitively impaired, abuse prevention, accident prevention, restorative nursing techniques, emergency preparedness, resident rights, cultural competency) were not documented and available for review for this nursing assistant. Interview with the Administrator, Employee E1, at 1:00 p.m., on June 5, 2025, confirmed that the necessary trainings and competency sets for (dementia care of the cognitively impaired, abuse prevention, accident prevention, restorative nursing techniques, emergency preparedness, resident rights, cultural competency) were not documented or available for review for nursing staff (Employees E12 and E13) that were selected for review. 28 PA. Code 201.20(a)(1)(2)(5)(6) Staff development 28 PA. Code 201.14(a) Responsibility of licensee 28 PA. Code 201.19(1)(3)(7) Personnel policies and procedures

Based on review of facility policies, observations and staff interview, it was determined that the facility failed to maintain a clean and homelike environment for two of two nursing units observed (First Floor and Second Floor Units). Findings Include: Review of facility policy titled, Homelike Environment revised February 21, 2025, states Policy Statement- Residents are provided with safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary, and orderly environment; f. pleasant, neutral scents. Review of the facility policy titled, Resident Dining Room Meal Service dated December 2023 states, Policy Statement- The purpose of this policy is to facilitate a safe, comfortable, and resident centered dining experience. Procedure- 1. Dining room staff will perform hand hygiene. 2. Nurse Aides, will offer residents clothing protectors. 3. Once meals are prepared and delivered by dietary, the nurse aides will begin passing to each table. 4. Deliver all ordered good to every resident at the first table. 5. Provide any food prep assistance to the residents at table one prior to moving to the next table. Observations on June 2, 2025 at 10:01 a.m. of Resident R63's room revealed two brown water-stained ceiling tiles. Observations on June 2, 2025 at 12:20 p.m. of the lunch service on the first floor revealed the residents gathering to the dining/activities room for lunch. The lunch menu posted for the day listed Truck arrived at 12:26 p.m. The nurse aides started serving the lunch trays at 12:27 p.m. Nurse Aide, Employee E4, came into the room with the first lunch tray and stated, They ain't got no juice today for lunch so I just want to let you all know so you do not ask. There was one table where five people were seated together at the time they started serving lunch. The first resident was served their lunch at 12:28 p.m. The second person at the table was served their lunch tray at 12:33 p.m. The third person at the table was served their lunch tray 12:43 p.m. The fourth person at the table was served their lunch tray 12:44 p.m. The fifth person at the table was served their lunch tray 12:48 p.m. Nurse aide Employee E4 served all five of the residents at the table on their lunch trays. All lunch trays at the table contained no drink or fluids. Further observations on June 3, 2025 at 12:20 p.m. of the lunch service on the first floor revealed the residents. At no time were clothing protectors offered to residents. Observations on June 3, 2025 at 11:05 a.m. of Resident R80's room revealed five brown water-stained ceiling tiles. Further observation on June 5, 2025 of the first floor unit at 8:18 a.m. revealed paper trash and plastic trash on the floors in the hallways. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based upon interviews with resident and staff, review of clinical records and facility policies, it was determined the facility failed to ensure the rights of a resident were exercised to refuse a room change in accordance with professional standards of practice for one of 18 resident records reviewed (Resident R70). Findings Include: Review of the facility's policy titled, Resident Rights states, basic rights to all residents of the facility include exercising his or her rights and be supported by the facility in exercising those rights. Residents have the right to perform services for the facility if chooses or the right to refuse and the right to refuse a transfer from a distinct part within the institution. Review of the facility's policy titled, Transfer, Room to Room revised December 2016 states under Documentation The following information should be recorded in the resident's medical record: 1. The date and time the room transfer was made. 2. the name and title of the individual(s) who assisted in the move 3. If the resident refused the move, the reason(s) why and the intervention taken. Under the heading Reporting it states to notify the supervisor if the resident refuses the move, and 2. Report other information in accordance with facility policy and professional standards of practice. Review of Resident R70's clinical record revealed that the resident was admitted to the facility on [DATE]. The resident was alert and oriented and diagnosed with high blood pressure and a history of bladder cancer. Review of Resident R70's social service progress notes indicated on April 9, 2025, the resident was moved to another room due to Roommate Incompatibility. Review of Resident R70's psychiatric note dated, April 24, 2025, stated the resident Is not happy that they move out of her room into another room for her roommate. She feels that she was being punished by administration just to pacify her former roommate. NP (nurse practioner) notified and pacified patient to hold on while she discusses with administration. Interview with Resident R70 on June 3, 2025, at approximately 11:00 a.m. explained, They (the facility) told me my roommate was difficult. It was easier to move me than (roommate's name) even though she was the one that requested the move. I was very close to another resident in that room. The roommate had a hard time opening up to people but wasn't like that with me. I cried when I had to leave. Interview with the Nursing Home Administrator and Director of Nursing on June 3, 2025, stated Resident R70 wanted to move, and she likes her new room but failed to reveal documentation that a written notice and the reason for the room change was given to Resident R70 before the resident's room, in the facility, was changed. 28 Pa. Code 201.14(a) Responsibility of licensee 29 Pa. Code 201.29(d) Resident rights 29 Pa. Code 201.29(j) Resident rights

Based on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan for one of eighteen residents reviewed (Residents R50). Findings Include: Review of facility policy titled, Care Planning- Interdisciplinary Team, with a revision date of March 2022 states, Policy Statement- The interdisciplinary team is responsible for the development of resident care plans. Policy Interpretation and Implementation- 1. Resident care plans are developed according to the timeframes and criteria established by 483.21 2. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team. A review of the clinical record for Resident R4 revealed an admission date of September 13, 2022, with diagnoses including Dementia (a progressive decline in cognitive abilities, including memory, language, and reasoning, that significantly impairs daily life and activities) with agitation. Review of Resident R4's current care plan last updated October 4, 2024 revealed the resident's care plan did not address interventions related to the resident's diagnosis of Dementia. 28 Pa Code 211.10 (c)(d) Resident care policies 28 Pa Code 211.12(d)(1)(3)(5) Nursing services

Based on observations and an interview with staff, it was determined that the facility did not ensure that garbage and refuse was disposed of properly. Finding Include: Observations were made on the day of arrival to the facility, June 2, 2025 at 9:03 a.m. of the parking lot grass area where there were multiple trash items. Trash items in the grass and in the parking lot included; used paper towels, latex gloves, empty plastic bottles, plastic disposable utensils, and food particles. A tour of the Food Service Department was conducted on June 2, 2025, at 10:23 a.m., with the Food Director, Employee E9. In the area of the loading dock, refuse area one of two dumpsters was so full boxes were preventing the dumpster from completely closing. A toilet was near the dumpster area along with PVC piping that was once used at the facility. The Director could not say how long these items where there because he was not aware of the trash schedule. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 207.2(a) Administrator's responsibility

The facility must ensure that residents who require colostomy services, received such care consistent with professional standards of practice and the comprehensive person-centered care plan, and the resident's goals and preferences for one of five residents reviewed. (Resident R1) Findings Include: According to guidelines from American Cancer Society for Caring for colostomy (A colostomy is an opening in the belly abdominal wall that's made during surgery. It's usually needed because a problem is causing the colon to not work properly, or a disease is affecting a part of the colon and it needs to be removed) , The skin around your stoma should always look the same as skin anywhere else on your abdomen. Use the right size pouch and skin barrier opening. An opening that's too small can cut or injure the stoma and may cause it to swell. If the opening is too large, output could get to and irritate the skin. In both cases, change the pouch or skin barrier and replace it with one that fits well. Change the pouching system regularly to avoid leaks and skin irritation. It's important to have a regular schedule for changing your pouch. Don't wait for leaks or other signs of problems, such as itching and burning. Interview with Resident R1 on March 13, 2025, revealed that her colostomy appliance was loose and not fitting properly, as a result it was leaking. She stated she had to change the appliance several times which lead to shortage of supply. Resident stated she cared for the colostomy and was using a special tape to seal the leak. Resident stated she was out of the tape, and she used a paper tape to seal the surrounding. Resident stated her colostomy leakage and use of additional supplies and frequent changes were happening for at least past four months. Resident stated she spoke to staff including the unit manager, but she was only seen by a nurse two days ago but did not receive any recommendations. Resident stated she had her brother deliver additional supplies like tape because she used it a lot to prevent leakage. Observation of Resident R1's stoma site and colostomy appliance revealed that the appliance was lose on right and left side of the stoma, resident used paper tape to secure the appliance however it appears that the paper tape was adhering Review of progress note for Resident R1 dated January 7, 2025, reveaed that resident requested for her colostomy bag to be changed two times this morning before leaving at 8am and after returned from appointment with request to get changed again. Resident was informed that the bag could get emptied however that bag could not keep getting discarded due to limited supplies. Further review of the clinical record did not reveal any evidence that the staff assessed the stoma site or the colostomy appliance to ensure proper seal or any issues. Review of progress note for Resident R1 dated January 29, 2025, revealed that resident was reportedly sent colostomy supplies by her brother at resident's request. Package was delivered to facility, and items were given to resident. Review of a progress note by wound care nurse practitioner dated March 10, 2025, revealed that the resident was seen by the request of the resident and staff for stomal leakage with new recommendations for larger size colostomy appliance and dressing. Review of progress note for Resident R1 dated February 25, 2025, revealed Received call from resident's brother stating that resident is calling and requesting for colostomy supplies, wafers, bags, and tape- resident's brother had provided supplies in addition to what is provided from the facility- resident is removing wafers and colostomy bags multiple times during the day- had used 60 colostomy bags within 2 weeks- resident was educated on recommended changes and to allow nursing to apply items- resident is very anxious regarding colostomy care and had asked brother for additional supplies. Nursing will continue to supply colostomy care . and resident's brother was notified that supplies are given and that it's resident's preference to request supplies from brother. Further review of the clinical record did not reveal any evidence that the staff assessed the stoma site or the colostomy appliance to ensure proper seal or any issues. Review of Resident R1's active care plan on March 13, 2025, revealed no evidence that a comprehensive resident centered care plan for resident R1 for colostomy care was developed. Interview with the Director of Nursing (DON) on March 13, 2025, stated facility was aware of resident using additional supplies for colostomy due to issues from her past concerns. DON stated facility had a wound care nurse practitioner who was specialized in ostomy care visit the facility every week. DON stated she requested the nurse practitioner to see the resident a while ago but was only seen on March 10, 2025. The nurse practitioner recommended larger supplies, but it was on order and resident did not receive the supplies yet. Observation of the resident's stoma site with the DON on March 13, 2025, revealed that the skin surrounding the stoma was red and irritated consistent with tape usage. Resident stated she had to use the tape to prevent leakage. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing Services 28 Pa. Code 211.10(a)(c) Resident care policies

Based on observations and interviews with residents and staff, it was determined that the facility failed to ensure that essential equipment related to bathroom sink and ice and water dispenser on the first floor were in a safe and working condition for use by residents and nursing staff on one of two nursing units (Second Floor nursing unit). Findings include: Observation on December 3, 2024, at 10:45 a.m. in room [ROOM NUMBER] on the second-floor nursing unit revealed a sink with no fixtures (hot and cold water faucets and spout) were on the sink so that no water could be run to wash your hands. Interview with Resident R5, who lives in room [ROOM NUMBER], Bed A, revealed that the water in the sink has not been working for at least the past five days. She stated that she has to walk to the other end of the hall to go to the bathroom and wash her hands and to wash up in the morning. Interview with Resident R8, who lives in room [ROOM NUMBER], Bed C, revealed that she also has to walk to the other end of the hall to the central bath go to the bathroom and wash her hands and to wash up. Interview with the Maintenance Director on December 3, 2024, at 12:40 p.m. revealed that the sink in room [ROOM NUMBER] has been out of service since Thursday, November 28, 2024, and that they had to patch the wall which took longer. Interview with the Director of Nursing on December 3, 2024, at 12:50 p.m. revealed that it was not appropriate for these two residents and staff giving care in room [ROOM NUMBER] to have to walk to the central bath to wash their hands. Observation on December 3, 2024, at 10:55 a.m. on the second floor nursing unit revealed an ice and water dispenser in the hall outside the dining room that was not working, it would not dispense ice or water. Interview with Employee E9, nurse aide, on December 3, 2024, at 10:55 a.m. revealed that the ice and water dispenser has not been working for at least a week, and before it was turned off it was dispensing water that was very cloudy and disgusting. She further indicated that they get the ice from the first floor and the water from Dietary. Interview with the Administrator on December 3, 2024, at 12:40 p.m. confirmed that the water and ice dispenser has been out of service for the past few days, that they are waiting for a new filter. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(5) Nursing services

Based on observations and interviews with resident and staff, it was determined that the facility failed to make a process available to allow residents to file a grievance anonymously on two of two nursing units. (First and Second Floor) Findings include: During a group interview conducted on September 10, 2024, at 1:30 p.m. with seven alert and oriented residents (R42, R7, R19, R63, R17, R73 and R11), the residents stated that they were not aware of how to file a grievance with the facility anonymously. All seven residents in attendance stated that they thought there should be a box with a lock so they could file a grievance anonymously if they wanted to. Observations of the nursing unit on the Frist and Second Floor and bulletin boards throughout the facility, conducted on the first two days of survey from September 9, 2024, through September 10, 2024, revealed no place to file an anonymous grievance. During an interview during a tour of the facility on September 11, 2024, at 9:15 a.m., the Social Services Director confirmed that there were no locked boxes on the nursing units to file a grievance anonymously. An interview on September 11, 2024, at 9:15 a.m. the Administrator acknowledged that the facility failed to provide the residents with a way to file a grievance anonymously. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 201.29(c)(d)(e) Resident rights

Based on review of facility policy, review of facility documentation, and review of clinical records, it was determined that the facility did not ensure to develop a person-centered, comprehensive care plan related to bowel obstruction and constipation for one of 19 residents reviewed (Resident R72) Findings include: Review of facility provided policy 'care plans, comprehensive person - centered,' revised March 2022, states that the comprehensive, person-centered care plan: e. reflects currently recognized standards of practice for problem areas and conditions. Review of Resident R72's clinical record revealed medical diagnosis of intestinal obstruction, retention of urine, ulcerative colitis, acute abdomen, nausea and vomiting, hemiplegia and hemiparesis following cerebral infarction (paralysis/weakness post stroke) on right side of body. Review of R72's hospital discharge documentation dated April 30, 2024 revealed Resident R72 presented to emergency room with 4 days of suprapubic abdominal pain and constipation for 4 days. Evaluation revealed high grade small bowel obstruction in the right lower quadrant and visible transition point. Further review of Resident R72's hospital discharge summary, dated May 10, 2024, indicated Resident R72 was hospitalized for hematochezia (presence of blood in stool) and small bowel obstruction. Review of Resident R72's medication administration record revealed an active physician order, started May 10, 2024, for Senna, 2 tablets to be administered at bedtime for constipation, polyethylene glycol powder, 17 gram to be administered twice a day for constipation, Bisacodyl rectal suppository 10 mg every 24 hours as needed for constipation, bisacodyl suppository , 10 mg, every 24 hours as needed for bowel protocol if no bowel movement after milk of magnesia, enema every 24 hours as needed for bowel protocol if no result from suppository, and milk of magnesia suspension 1200 mg/15 ml's to be given 30 ml's every 24 hours as needed for constipation if no bowel movement in 3 days. Review of R72's care plan revealed no evidence of goals, measurable interventions or timeframes related to constipation and bowel obstruction. 28 Pa Code 211.10(d) Resident care policies

Based on review of facility policy, review of facility documentation, review of clinical records and interview with residents, it was determined that facility did not ensure to assist dependent residents with activities of daily living related to hearing aids, nail care and hygiene care (Residents R2, R9) Findings include: Review of facility policy 'Care of Hearing Aid,' revised February 2018, indicates that nursing staff are to review resident's care plan to assess for any special needs of the resident, and if hearing aid is not functioning properly, check the battery. Review of Resident R89's care plan, revised on May 7, 2024, revealed Resident R9 has a communication problem related to hearing deficit, with intervention to ensure availability and functioning of adaptive communication equipment message board, hearing aids, telephone amplifier, computer, pocket talker, etc. Review of Resident R9's clinical record revealed an active physician order to assist resident with hearing aides at 6:00 AM. Observations of Resident R9 on September 9, 2024 at 11:42 AM revealed Resident R9 watching television with hearing aids on bedside table in front of him. Upon greeting Resident R9, he stated they're not working, I can't hear. Observations of R9 on September 10, 2024 at 10:21 AM without hearing aids. Review of facility policy 'Care of Fingernails/Toenails,' revised February 2018, indicates to review resident's care plan to assess for nay special needs of the resident, and nail care includes daily cleaning and regular trimming. Review of Resident R2's care plan, revised March 26, 2024, indicates that Resident R2 has ADL self care performance deficit and requires two staff assistance for ADL. Observed Resident R2 on September 9, 2024 at 11:39 AM with untrimmed and dirty nails. Upon interview, Resident R2 stated he would like to have nail care and it gets in the way, and staff get frustrated when I ask for things. Interviewed nurse aide, Employee E13, regarding Resident R2's nail care, on September 9, 2024 at 11:45 AM, assigned to care for Resident R2, who stated that we are short staffed Further observations of Resident R2 on day shift of September 9th, 2024 and September 8, 2024 revealed resident in bed, leaning to the right side, with used urinal attached to right bed side rail, near Resident R2's face. Further observations revealed unkempt facial hair. 28 Pa Code 211.12(d)(5) Nursing Services

Based on review of facility policies, review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to adequately supervise one of three residents reviewed who exhibited elopement behaviors, resulting in Resident R1 eloping from the facility and found by medical personnel at a park the next day and taken to the local hospital. This failure placed Resident R1 at high risk for injury and resulted in an Immediate Jeopardy situation. (Resident R1) Findings include: Review of the facility policy, Wandering and Elopements, with a revision date of March 2019 indicated that the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Continued review of the facility policy indicated that if a resident is identified as a risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Review of Resident R1's July 2023, physician orders indicated that the resident was admitted into the facility on [DATE], with the diagnoses of kidney failure (loss of kidney function); encephalopathy (a disease that affects brain structure or function. It causes altered mental state and confusion); anxiety (the mind and body's reaction to stressful, dangerous, or unfamiliar situations) and dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities). Review of Resident R1's quarterly Minimum Data Set Assessment (MDS- periodic assessment of a resident's needs) dated July 19, 2023, indicated that the resident was severely cognitively impaired. Review of a nursing note dated April 20, 2023, at 7:09 p.m. indicated that around 6:30 p.m. on the referenced date, Resident R1 was found downstairs in the facility lobby. Continued review of the note revealed that the resident stated to the licensed nursing staff member, I want to go outside to the store. The note indicated that Resident R1 was placed on 30 minute checks. Continued review of nursing note revealed that the resident was monitored for elopement attempts from April 20, 2023, through April 23, 2023. Review of the Elopement Risk Evaluation dated April 21, 2023, completed by licensed nursing staff did not reflect the resident's elopement behavior that occurred on April 20, 2023. The questions, Does the resident have a history of elopement or an attempted elopement while at home was marked, No despite the resident's exiting the nursing unit on April 20, 2023. The question, Does the resident wander? was marked No. Continued review of the assessment also indicated that the question, Is the wandering behavior a pattern, goal-directed (i.e. specific destination in mind, going home, etc.)? was marked by licensed nursing staff as No. The question, Is the resident's wandering behavior likely to affect the safety or well-being of self/others? was also marked, No by the licensed nursing staff member despite the documented incident on April 20, 2023. During a discussion with the facility's Regional Nurse Representative, Employee E5, on August 3, 2023, at 5:15 p.m. it was reported that the facility had no policy/instructions for nursing staff related to the assessment criteria needed when deciding which residents need a wander guard, and no policy/written instructions on completing the Elopement Risk Evaluation on resident to ensure that staff is conducting complete and accurate assessments of the residents who may exhibit wandering/elopement behaviors. Review of the resident's current person-centered plan of care initiated September 3, 2021, revealed that the resident was care planned for alteration in cognition related to Alzheimer's, dementia with expected decline and progression of the disease. Interventions included to monitor resident's where about. Continued review of the resident's plan of care did not show evidence that the resident's plan of care was updated after the April 20, 2023, incident to ensure appropriate interventions were put in place to ensure safety for Resident R1 who exhibited the elopement behaviors. During a discussion with the Nursing Home Administrator (NHA) and the Assistant Director of Nursing (ADON) on August 3, 2023, at 12:00 p.m. regarding Resident R1, it was discussed that the resident's person-centered plan of care was not updated after the April 20, 2023 incident to reflect the resident's elopement behavior. Review of information provided to the State Survey Agency on July 30, 2023, indicated that on the referenced date, Resident R1 eloped from the facility after following a dietary worker, Employee E3 out of the front door at approximately 7:10 p.m. after his shift was over. This observation was determined by the NHA after reviewing the security footage. Documentation from the facility indicated that dietary worker, Employee E3, was interviewed, Employee E3 did not know that the resident was behind him once he used his employee badge to open the door and leave after his shift. Review of facility documentation regarding the incident indicated that the resident's assigned nurse, Employee E4 noticed that the resident was missing from the unit at approximately 7:45 p.m. on July 30, 2023 and that he was last seen on the unit at approximately 6:45 p.m. During an interview with Licensed nurse, Employee E4 on August 4, 2023, at 2:09 p.m. Employee E4 reported that he noticed that he did not see the resident, so he started looking on the unit for him. When he could not locate him, he contacted the Nursing Supervisor, Employee E5 to let her know that he could not locate the resident on the unit. Review of the facility information indicated that the facility was notified by the Social Worker at a local hospital on July 31, 2023, at approximately 10:00 a.m. that the resident was at that hospital. Review of hospital records indicated that Resident R1 was found outside on a bench and brought to the hospital by emergency medical staff on July 31, 2023 where he became responsive to chest rubs, was a poor historian, did not remember his name, was not able to finish two words, did not understand that he was in the hospital, and did not recall why was in the hospital. Based on the above findings, an Immediate Jeopardy to the safety of the resident was identified to the Nursing Home Administrator on August 3, 2023 at 5:19 p.m. for failure to provide proper monitoring and adequate supervision to Resident R1 who went missing on July 30, 2023. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator (NHA) and Director of Nursing (DON) on August 3, 2023 at 5:19 p.m. On August 3, 2023 at 8:49 p.m., the facility provided the following corrective action plan: 1. Facility wide education with all staff, including agency regarding residents at risk for elopement. 2. Education with licensed nursing staff members regarding the recognition of residents and behaviors that put them at risk for elopement and measures to put in place to avoid elopement and the importance of completing an accurate elopement assessment. 3. Audits completed by the ADON/designee of current resident's electronic medical records to evaluate if elopement assessments were current and accurate. Such assessments were updated and revised as needed. 4. Audits of the last two months of progress notes, completed by the ADON/designee to evaluate for behaviors, exit seeking and behaviors indicating that the resident wants to leave the facility. 5. Any new admissions will have progress notes reviewed and elopement assessments checked by the ADON/designee. Interviews were conducted with facility staff on July 9, 2022 between 10:00 a.m.- 4:30 p.m. to verify the implementation of the action plan. Facility staff was able to verbalize what they would do if they found a resident with exit seeking behaviors and Resident R1 was observed in his room with a wander guard on his right ankle (device that is place adjacent to the body which activates an alarm when the resident is near an exit door) A review was conducted of the education provided to facility staff related to resident elopement. Following verification of the implementation of the immediate action, the Immediate Jeopardy was lifted on August 4, 2023, at 4:59 p.m. 28 Pa. Code 201.18(b)(1)Management 28 Pa. Code 201.18 (b)(3)Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on observations, clinical record review, interviews with residents and staff, reviews of policy and procedures and facility documentation, it was determined that the facility failed to protect the residents from possible accident hazards by not ensuring that the hot water temperatures were maintained at a safe level. This environmental hazard was widespread resulting in a determination of immediate jeopardy to resident safety. The facility also failed to provide a safe environment that was free of accident hazards related to a lack of supervision of residents on both nursing units during the medication administration pass and a lack of assessment of two resident ambulation/transfers of 24 residents reviewed (Residents R67 and R54). Findings include: Water temperatures were observed with Licensed Nurse, Employee E9, on December 1, 2014, at 9:30 a.m., on the first floor at water outlets (sinks) in the resident rooms of the first floor. Room 102 and room 105 were registering 138 and 138.3 degrees Fahrenheit, respectively. Employee E9 observed the temperature reading and reported that the water was too hot to place their hands into. On December 1, 2014, at 9:34 a.m., the Director of Maintenance, Employee E3, was called to come to the first floor nursing unit to evaluate the water temperatures. At 9:30 a.m., in the second floor central bathing area at the hot water outlet (sink) a temperature of 125 degrees Fahrenheit was observed in the presence of Licensed Nurse, Employee E4, who reported, "oh that feels hot." The water at the sink in the central bath was rechecked 15 minutes later at 9:45 a.m. and was found to register 118 degrees Fahrenheit and was checked again 15 minutes later and observed to be 123 degrees Fahrenheit. An observation with Licensed Nurse, Employee E9, on December 1, 2014, at 9:55 a.m., revealed the water at the hot water outlet (sink) in the central bathing area on the second floor was 65 degrees Fahrenheit. An interview with Employee E3 on December 1, 2014, at 10:15 a.m., revealed that the facility's policy for monitoring hot water temperatures at the resident outlets (sink) was to obtain daily temperatures. The policy indicated that logs of the temperatures at the hot water outlets (sink)in the various resident rooms and bathing areas were to be kept to ensure the safe operating condition of the facility water system. A review of the hot water temperature logs for September, October, November, through December 1, 2014, revealed that the facility was not following their established policy in order to ensure resident safety. The facility was not monitoring and recording water temperatures daily. This was confirmed during an interview with the Nursing Home Administrator (NHA) at 10:20 a.m., on December 1, 2014. Further review of the facility, "Hot Water Temperature Policy," revealed that the nursing staff were responsible for checking the hot water temperatures before placing a resident in a shower or bath by "feeling" the water temperature. The policy did not direct nursing staff to verify the hot water temperature by use of a bath thermometer. An interview with Employee E3 on December 1, 2014, at 11:05 a.m., revealed that the temperature of the hot water at the boiler/mixing valve was 112 degrees Fahrenheit this morning and that it was turned down. There was no documentation of this or that other water temperatures were recorded on November 29 or 30, 2014, in the facility's temperature log. On December 1, 2014, at 11:40 a.m., Employee E3 reported that the hot water temperature that he had obtained on the first floor nursing unit in the central shower/tub was 125 degrees Fahrenheit. The water temperatures were again tested on the first floor central bath area on December 1, 2014, at 12:21 p.m., with Nurse Aide, Employee E5, and the water at the sink was 135 degrees Fahrenheit and Employee E5 stated that the water was too hot to touch. The water at the same outlet was tested again at 12:55 p.m., with Nurse Aide, Employee E6, using the central bath thermometer at the same time as the surveyor's thermometer and both registered 120 degrees Fahrenheit. An interview with Licensed Nurse, Employee E9, identified Resident R11 in room 105 and Resident R7 in room 103 as being interviewable and able to use the bathroom sink independently. An interview with both Resident R11 and Resident R7, on December 1, 2014, at 1:05 p.m., revealed that both residents felt the water was too hot and that they had to mix the water with cold water to wash at the sink. Resident R7 and Resident R11 were identified as alert and oriented by interview with the Director of Nursing (DON) at 3:10 p.m., on December 1, 2014. During a resident group interview of seven alert and oriented residents (Residents R1, R2, R38, R44, R47, R67 and R84), as identified by the Director of Activities, Employee E12, at 11:00 a.m., on December 1, 2014, all seven residents stated that the hot water was too hot in the bathrooms and needed to be adjusted for safe usage. On December 1, 2014, at 2:45 p.m., Employee E3 reported that he obtained another hot water temperature that registered 120 degrees Fahrenheit at the shower/tub in the central bathing area on the first floor nursing unit. On December 1, 2014, at 3:00 p.m., Employee E3 reported that he obtained a hot water temperature of 118 degrees Fahrenheit at the shower/tub in the central bathing area on the second floor nursing unit. An interview with the DON on December 1, 2014, at 3:10 p.m., revealed that of the eighty-three residents in the facility, twenty-three of them (R16, R1, R26, R19, R23, R11, R9, R31, R7, R22, R15, R10, R28, R52, R41, R60, R46, R45, R49, R71, R68, R83 and R67) were ambulatory and physically capable of using the hot water outlets, giving the residents access to uncontrolled hot water outlets and causing them to be at risk for a burn. Of the twenty-three residents identified as being at risk for burns, there were ten (R16, R9, R22, R15, R60, R45, R71, R68, R83 and R67) that were moderately or severely cognitively impaired, according to an interview with the DON, on December 1, 2014, at 3:10 p.m. On December 1, 2014 at 4:00 p.m. , the NHA was notified that Immediate Jeopardy (IJ) had been identified, related to hot water temperatures at the water outlets which were accessible to the residents. An action plan was requested at this time and received on December 1, 2014, at 5:20 p.m., to immediately put systems in place to ensure the safety of the residents from burns related to high water temperatures. An interview with the NHA, on December 2, 2014, at 9:00 a.m., revealed that a certified plumber was called into the facility on [DATE]. The plumber reported that the hot water at the outlets that were accessible to the residents was "too hot". The plumber noted that there were fluctuating hot water temperatures, which may be a sign of a defective mixing valve, defective cold water pressure reducing valve or inoperative re-circulating pump. The plumber recommended, "rebuilding or replacing the valve." The IJ was removed on December 3, 2014, at 10:30 a.m., when the plan of action was fully implemented. This included the replacement of a faulty mixing valve and consistent hot water temperatures which were observed and validated by the survey team for greater than 12 hours. Observation of the medication administration pass on December 2, 2014, at 8:50 a.m., with Licensed Nurse, Employee E8, revealed that Employee E8, left the medication cart to answer a call bell leaving medications on top of the cart without supervision. These medications included: Vitamin B 12, Aspirin, Protonix (medication that decreases gastric stomach upset), Lopressor (medication used in the treatment of [REDACTED]. Employee E8 left the medications on the cart unsupervised for approximately three minutes and further left the Colace on top of the cart for 15 total minutes, unsupervised. Observation of the medication administration pass on December 2, 2014, at approximately 1:00 p.m., with Licensed Nurse, Employee E4, revealed that Employee E4 prepared the medications, Apresoline (medication to control blood pressure) and Baclofen (a muscle relaxer), while at the medication cart and then proceeded into the resident's room leaving the packet of medications on the top of the cart with the Medication Administration Record (MAR) open and the medications easily accessible to other residents and visitors in the area. Employee E4 did not return to the cart until the medications had been administered to the resident per a gastric tube, which was approximately 15 minutes later. This nursing unit cares for those residents with dementia requiring a safe environment and close observation. The comprehensive MDS (Minimum Data Set-a periodic assessment of needs) assessment, dated November 4, 2014, indicated that Resident R67's cognition was moderately impaired and that this resident required staff assistance with transfers and ambulation with a mobility device (wheelchair). On August 4, 2014, the nursing progress notes indicated that Resident R67 was being pushed in the wheelchair by an activity aide and fell out of the wheelchair onto the floor. The facility's incident investigation form dated August 4, 2014, indicated that Resident R67 tends to use her legs to stop the wheelchair while in motion. An interview with the Licensed Physical Therapist, Employee E10, at 1:00 p.m., on December 2, 2014, revealed that Resident R67 was discharged from the therapy department with leg rests to promote safe staff assisted transportation in the wheelchair. There was no documentation to indicate that the activity aide provided/assisted Resident R67 with leg rests on August 4, 2014, as care planned for fall prevention. Observations of Resident R67 on December 2, 2014, revealed that the resident did not have leg supports for wheelchair use. The comprehensive MDS assessment dated [DATE], for Resident R54 indicated that the resident's cognition was moderately impaired and that Resident R54 was totally dependent on staff for transfer/ambulation with a mobility device (wheelchair). The nursing progress notes on August 26, 2014, indicated that while this resident was being transferred by the nursing staff in the wheelchair, the resident slid out of the chair onto the floor. The facility's incident investigation dated August 26, 2014, indicated that the resident put herself on the floor. An interview with Employee E10 on December 2, 2014, at 2:10 p.m., revealed that this resident has foot rests and was discharged from the therapy department with foot rests for the wheelchair for safe transfers/ambulation. There was no documentation to indicate that foot rests were utilized on August 26, 2014, as care planned for safety to prevent falls. The facility failed to have a thorough knowledge of their hot water distribution system, the controls needed to maintain the temperatures, the knowledge of the various resident accessible areas supplied by the water, and adequate monitoring of these systems, which posed a safety risk and the widespread potential for harm to the residents. The facility also failed to provide a safe environment to ensure that the wandering residents did not have access to medications and to keep residents safe during ambulation and transfers with assistive devices. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(d)(1) Management. 28 Pa. Code 205.64(c) Plumbing and piping systems required for existing and new construction. 28 Pa. Code 211.10(d) Resident care policies.