Every finding on record at LeTort Spring Nursing and Rehab LLC

Based on clinical record reviews, facility provided documents, and staff interviews, it was determined that the facility displayed past-non-compliance in its failure to prevent a significant medication error for one of three residents reviewed (Resident 1).Findings include: Review of Resident 1's clinical record revealed diagnoses that included chronic embolism and thrombosis of unspecified deep veins (presence of blood clots in the deep veins, typically in the legs, which can lead to serious complications if not managed properly) of the left lower extremity 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 1's physician order history revealed an order entered by Employee 4 dated February 24, 2026, to recheck PT/INR (blood test used to determine blood clotting time to assist in managing warfarin dosing) on March 11, 2026. Review of Resident 1's physician order history revealed an order entered by Employee 4 dated February 24, 2026, which indicated warfarin 2.5 milligrams give one tablet at bedtime and recheck PT/INR in two weeks (March 11, 2026), to start on February 25, 2026. Review of Resident 1's Medication Administration Record for March 2026 revealed that she received her ordered dose of warfarin from February 25, 2026, through March 10, 2026. Further review revealed that she received no warfarin on March 11 through March 17, 2026. Further review of the clinical record revealed no evidence that the PT/INR was completed as ordered on March 11, 2026. Review of Resident 1's clinical record revealed a progress note dated March 18, 2026, at 7:51 AM, by Employee 5 (Registered Nurse) that indicated she had discussed concerns regarding Resident 1's PT/INR and warfarin doses with night shift and that Resident 1's physician was present at the facility and was made aware of concern regarding medication. The note further indicated that Resident 1's physician provided a new order to obtain a stat (immediate) PT/INR that morning and then he would provide further orders on warfarin dosage. Review of Resident 1's clinical record revealed a physician's progress note dated March 18, 2026, at 4:06 PM, that indicated Resident 1 missed a few days of warfarin noted by staff and an order for PT/INR was given. The note indicated that Resident 1's physician restarted her on her previous dose of warfarin and gave an order to recheck the PT/INR in a week. Resident 1 had no adverse effects noted from the missing doses of warfarin. Review of Resident 1's Medication Administration Record for March 2026 revealed that she has been receiving her ordered dose of warfarin since March 18, 2026. Review of Resident 1's Treatment Administration Record for March 2026 revealed that she was scheduled for a PT/INR lab draw on March 24, 2026. During a staff interview with Employee 2 (Regional Director of Clinical Services) on March 23, 2026, at 2:44 PM, she confirmed that Employee 4 signed off on the order and, therefore, it did not populate on Resident 1's record to complete the lab test. Employee 2 confirmed that the medication order was also set to stop on the date the lab was ordered and, therefore, the Resident did not get lab drawn or medication. Continued interview with Employee 2 revealed that the facility initiated a plan of correction. Employee 4 was placed on the Do Not Return list. Employee 2 indicated that when Employee 5 discovered the issue with Resident 1 on March 18, 2026, Employee 5 immediately followed up with Resident 1's provider to report the concern and to obtain additional orders. In addition, Employee 5 reviewed all other residents on warfarin on March 18, 2026, to ensure that all other potentially affected residents had received their medication and lab tests as ordered and found no other concerns. On March 18, 2026, Employee 5 reinstated a warfarin log that the facility used in the past to track labs and warfarin doses for each resident receiving warfarin. Education was provided to all Registered Nurse Supervisors on March 18, 2026, as they will be the staff to manage this log. Facility provided written documentation to support all immediate action steps taken on March 18, 2026. Review of the plan of correction documents, review of clinical records and interviews with staff revealed no concerns with residents not received medications and associated labs. During a final staff interview with the Nursing Home Administrator (NHA), Director of Nursing, and Employee 2 (Regional Director of Clinical Services) on March 23, 2026, at 4:00 PM, the NHA confirmed that he would expect staff to enter orders appropriately to prevent significant medication errors. The NHA indicated that the facility was in compliance as of March 18, 2026, the same date the concern was identified. He indicated that the audits would start this week and that audits will be reviewed at the next Quality Assurance Performance Improvement Committee Meeting. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.10(c) Resident care policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy review, observations, facility documentation review, and staff interviews, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the kitchen, in two of two nourishment refrigerators, on tray service line (main dining room), and tray delivery on one of one units observed (Faith Wing).Findings include: Review of facility policy, titled General Food Preparation and Handling, dated July 2023, revealed, in part, The kitchen is kept neat and orderly. The kitchen and equipment are clean. Foods are stored properly as soon as they are delivered. Food is covered for storage. Food will be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid manual contact of prepared foods. Wash and sanitize can opener daily. Prepared food will be transported to other areas in covered containers. Leftovers must be dated, labeled, covered, cooled, and stored in a refrigerator. All food service equipment should be cleaned, sanitized, dried, and reassembled after each use. Handle utensils, cups, glasses, and dishes in such a way as to avoid touching surfaces that food or drink will come in contact with. Use tongs or other serving utensils to serve breads or other items. Never touch food directly with bare hands. Review of facility policy, titled Food from Outside Sources, dated July 2023, revealed, in part, 1. Food brought into the facility must be checked with the charge nurse to ensure it meets the resident's diet order. 2. Visitors/family members will label food and beverages with the resident's name, room number and date. All food is to be stored in a suitable container. 3. Perishable foods with a 'use by' date which is 3 days from the date that it was brought into the facility. Food or beverage items without manufacturers expiration date that have written dates should be thrown away 3 days after the date marked. Food or beverages in the original containers marked with manufacturer expiration dates and unopened do not have to be re-labeled for storage. 7. All refrigeration units will have internal thermometers to monitor for safe food storage temperatures. Units must maintain sage internal temperatures in accordance with state and federal standards for safe food storage temperatures. Review of facility policy, titled Employee Sanitary Practices, dated July 2023, revealed, in part, Hair nets or caps, covering all the hair, must be worn at all times while on duty. The cap must be one that is designated for kitchen use only and must not be used for off-duty personal dress. Use utensils to handle food. Clean equipment and work units after use. Observation of the kitchen on February 8, 2026, between 9:55 AM and 11:00 AM, with Employee 5 (Dietary Manager) revealed the following concerns:1) a pink colored residue on the edge of the white plastic guide in the ice machine- Employee 5 indicated that the maintenance cleans the ice machine monthly;2) the shelving unit under the coffee maker was soiled with coffee grounds and coffee spills, making the drawers stick when trying to open;3) the inside of the drawers of the shelving unit under the coffee machine had dried coffee spills noted to be in contact with the cup lids;4) there were caps from juice containers noted to be in the drawer with clean cup lids;5) there was food debris on the floor between the ice machine and coffee stand, to include what appeared to be an approximately inch and half hot dog wiener;6) heavy build-up of dust on the water filter and hose to the ice machine;7) the beverage reach-in refrigerator revealed a bottle of opened prune juice and honey thick apple juice with no open dates indicated, an opened gallon jug of 1% milk with no lid and no open date indicated, and a clear beverage dispenser with a red colored beverage with no label or date which had spilled onto the bottom of the refrigerator;8) the beverage reach-in refrigerator was soiled on the base and the floor in front of the beverage refrigerator was soiled with a large amount of a black-colored substance;9) there was an opened carton of nectar milk and two opened cartons of nectar thick orange juice sitting on top of a food cart with no open date indicated;10) there were two storage bins of lids in a food preparation area that had heavy dust on the actual lids and food debris noted in the bottom of the bin - Employee 5 indicated that they rarely use these lids;11) there were two blender bases sitting on a counter in a food preparation area with food debris noted on the outside and on the inside of the base; 12) there was a clear plastic bin of food thickener in a food preparation area with the scoop stored inside the bin and the lid to the bin was soiled;13) there was a yellow powdery substance along the inner edge of a drawer containing kitchen utensils in a food preparation area;14) both hoods over stove and soup area were noted to have large amount of gray colored dust and Employee 5 indicated that an outside vendor cleans the hoods quarterly;15) there was a large amount of food debris under soup pot stand and on floor under and behind;16) there were two soiled pt holders hanging on the side of the steamer unit; 17) in the dairy walk-in cooler there was an opened gallon of 1% milk, an opened carton of nectar thick milk and an opened carton cranberry juice cocktail with no open date indicated;18) also, in the dairy walk-in cooler there was a portable cart noted to have an opened gallon of milk with no open date indicated;19) there was a black substance on a power switch located outside the walk-in freezer;20) in the walk-in freezer there was a bag containing a round, white food item that had no label indicating what the item was or any dates - Employee 5 indicated that the item was perogies and took the bag out of the freezer asked someone to label and date it;21) there was an opened bag of frozen blueberries in the walk-in freezer with no open date indicated - Employee 5 indicated that he had opened them yesterday and he must have forgotten to date the bag;22) in the walk-in refrigerator there was a container of chocolate pudding dated February 7, 2026, that failed to have the lid secured; a plastic container of ham that indicated it was to be discarded on February 4, 2026; approximately 12 slices of cheese wrapped in plastic wrap that was not labeled at all; a bin of pork which indicated it was to be discarded on February 6, 2026; a container of chicken and rice soup with no dates indicated; an opened bag of celery and carrots that were not secured and no open dates indicated; a bottle of Italian salad dressing with no expiration date indicated; two rolls of ground beef with no dates indicated; a tray of meat-type patties that were not labeled or dated and the corner of the plastic wrap was not sealed exposing the meat patties;23) in the dry storage area the temperature log was not completed after January 28, 2026; there was a plastic storage rack of glass bowls and saucers stored upright and dust and a red liquid type substance was noted in one of the cups; there were clear plastic storage bins of flour, bread crumbs, and sugar that all had the scoop stored inside the bin; there was small area of brown debris on the bottom shelf of the first rack; there was a pack of hamburger rolls, hot dog rolls, and dinner rolls that were opened, unsecured, and not dated; an opened bag of glazed pecans that had no open date indicated but manufacturer expiration date was October 15, 2025; an opened bag of Craisins that had no open date indicated but manufacturer best by date was August 13, 2025; an opened box of pancake mix dated 7/9; and an opened carton of candy sprinkles with no open date indicated;24) the can opener was noted to have a heavy build-up of a black substance - Employee 5 indicated that it was cleaned weekly;25) spice rack revealed a bottle of bay leaves dated December 18, 2024; a bottle of ground mustard dated May 2, 2025; a bottle of curry dated September 30, 2024; an opened bottle of cinnamon with no open date indicated - Employee 5 indicated that spices should be discarded six months after opening;26) muffin tins and skillets stored upright;27) stove had heavy build-up of food debris - Employee 5 indicated that the stove and ovens are cleaned monthly;28) a plastic storage rack of dishes in the food preparation area was noted to have food debris on the inside the rack and dishes were stored upright with no cover noted;29) utensil drawer had a set of tongs noted to have dried white colored substance on them;30) test strips at three-compartment sanitation sink revealed three open bottles of test strips, one of which had a manufacturer expiration date of June 2024; 31) utensils were noted to be lying directly on the metal counter at the end of the three-compartment sink and the counter was noted to have a white colored substance on it - a dietary aide indicated that was the drying area32) the mixer was noted to have food debris noted;33) on the dirty side of the dish room there was food debris all over the wall and all along the front of the counter - Employee 5 indicated that the walls and cleaned at night with a deep clean twice a week;34) the entire kitchen floor was noted to have heavy food debris and black colored substance on various areas of the floor -Employee 5 indicated that the floors are mopped nightly and are deep cleaned monthly; and35) there was no thermometer or temperature log in the second dry storage area, which contained cereal and coffee creamers. During a staff interview with Employee 5 on February 8, 2026, at 11:00 AM, he indicated that I guess we have a problem with labeling food items. Observation of Faith Wing nourishment refrigerator on February 8, 2026, at 1:35 PM, revealed an opened carton of honey thick lemon water, an opened carton of Medpass 2.0 (a nutritional supplement) with no open dates indicated; an unopened 20 ounce bottle of Mountain Dew, an unopened 12 ounce can of Cherry Coke, and an unopened 8.4 ounce can of Red Bull with no names of whom the items belonged to indicated. In the freezer, there was an unopened Hershey bar with no name indicated and lime fat free sherbet with no expiration dates noted. In addition, there was a cloth covered ice pack that indicated a resident's name stored on the same shelf as the sherbet. Observation of the Love Wing nourishment refrigerator on February 8, 2026, at 1:46 PM, failed to reveal a temperature log. There was a thermometer in the refrigerator and the reading was noted to be 40 degrees Fahrenheit (F). In the refrigerator, there was a Mighty shake with no thaw date indicated (the shakes expire 14 days after the thaw date), an opened gallon of TruMoo chocolate milk with no open date or resident name indicated, and a pitcher of a red beverage with no label or date indicated. In the freezer, there was no thermometer noted, there was a frozen dinner and a frozen Hot Pocket both dated February 8, 2026, but failed to include a resident's name. During an immediate interview with Employee 6 (Licensed Practical Nurse) she confirmed that there was no thermometer in the freezer and that she could not locate a temperature log. Follow-up observation of the kitchen on February 9, 2026, at 2:00 PM, revealed that the cleanliness concerns identified remained the same. In addition, it was noted that there were two bottles of hand sanitizer that were in two separate food preparation areas; one bottle had an expiration date of March 2023 and the other had an expiration date of October 2022. Employee 5 was noted to be preparing quesadillas when the surveyor approached him to discuss the hand sanitizer concern. Employee 5 stepped away from the food preparation area, looked at the bottles, confirmed the expiration dates and proceeded to take the bottles from the surveyor and discarded them at the closest trash can. Employee 5 was then observed to go back to the food preparation area and resume making a quesadilla with the same gloves that he had touched the bottles of hand sanitizer. The surveyor immediately stopped Employee 5 and shared the observation. Employee 5 indicated yeah you're right. He then discarded the quesadilla he had prepared, removed his gloves, and washed his hands. Review of the dishwasher temperature log revealed that the minimum temperature requirements were 140 degrees F for the wash cycle and 180 degrees F for the final rinse. Review of these logs from November 1, 2025, through February 9, 2026, revealed the following:November:1st-final rinse at breakfast was 174 degrees and the final rinse at supper was 178 degrees;2nd-final rinse at breakfast was 167 degrees and the final rinse at lunch was 174 degrees;6th-the final rinse at breakfast was 154 degrees;7th-the final rinse at breakfast was 157 degrees;8th-the final rinse at breakfast was 171 degrees, the final rinse at lunch was 172 degrees, and the wash temperature at supper was 139 degrees and the final rinse was 175 degrees;9th-the final rinse at breakfast was 162 degrees and the final rinse at lunch was 170 degrees;10th-the final rinse at breakfast was 173 degrees, the final rinse at lunch was 174 degrees, and at supper the final rinse was 152 degrees;11th-the final rinse at breakfast was 170 degrees and the final rinse at lunch was 171 degrees;12th-the final rinse at breakfast was 159 degrees and the final rinse at lunch was 172 degrees;13th-the final rinse at breakfast was 160 degrees;18th-final rinse at breakfast was 172 degrees and the final rinse at supper was 174 degrees;19th-the final rinse at breakfast was 166 degrees, the final rinse at lunch was 173 degrees, and the final rinse temperature at supper was 177 degrees;20th-the final rinse at breakfast was 172 degrees;21st-the final rinse at breakfast was 170 degrees and the final rinse at supper was 172 degrees;22nd-the final rinse at breakfast was 172 degrees and the final rinse at lunch was 174 degrees;23rd-the final rinse at lunch was 173 degrees;24th-the final rinse at breakfast was 172 degrees and the final rinse at lunch was 170 degrees;25th-the final rinse at breakfast was 170 degrees;26th-the final rinse at supper was 170 degrees;27th-the final rinse at breakfast was 174 degrees, the final rinse at lunch was 178 degrees, and the final rinse temperature at supper was 172 degrees;28th-the final rinse at breakfast was 171 degrees and the final rinse at supper was 164 degrees; and29th-the final rinse at breakfast was 165 degrees. December:3rd-the final rinse at breakfast was 170 degrees;4th-the final rinse at supper was 172 degrees;5th-the final rinse at breakfast was 173 degrees, the final rinse at lunch was 171 degrees, and the final rinse temperature at supper was 170 degrees;6th-the final rinse temperature at supper was 168 degrees;7th-the final rinse temperature at supper was 170 degrees;8th-the final rinse temperature at supper was 151 degrees;9th-the final rinse at breakfast was 177 degrees, the final rinse at lunch was 174 degrees, and the final rinse temperature at supper was 167 degrees;14th-the final rinse at supper was 176 degrees;19th-the final rinse at breakfast was 171 degrees and the final rinse at lunch was 172 degrees;20th-the final rinse at supper was 177 degrees;23rd-the final rinse at breakfast was 173 degrees and the final rinse at lunch was 179 degrees;24th-the final rinse at breakfast was 172 degrees;26th-the final rinse at breakfast was 173 degrees; and29th-the final rinse at breakfast was 170 degrees. January: 2nd-the final rinse at breakfast was 171 degrees;4th-breakfast wash and final rinse temp was scribbled out;5th-the final rinse at breakfast was 177 degrees;6th-the final rinse at breakfast was 177 degrees;7th-the final rinse at breakfast was 170 degrees;9th-the final rinse at breakfast was 173 degrees;10th-the final rinse at breakfast was 163 degrees and the final rinse at lunch was 172 degrees;11th-the final rinse at breakfast was 170 degrees and the final rinse at lunch was 177 degrees;12th-the final rinse at breakfast was 177 degrees;13th-the final rinse at breakfast was 171 degrees and the final rinse at lunch was 174 degrees;14th-the final rinse at breakfast was 167 degrees and the final rinse at lunch was 170 degrees;15th-the final rinse at breakfast was 160 degrees and the final rinse at lunch was 171 degrees;16th-the final rinse at breakfast was 170 degrees and the final rinse at lunch was 171 degrees;17th-the final rinse at breakfast was 151 degrees and the final rinse at lunch was 170 degrees;18th-the final rinse at breakfast was 177 degrees;19th-the final rinse at breakfast was 170 degrees;20th-the final rinse at breakfast was 160 degrees;21st-the final rinse at breakfast was 174 degrees;22nd-the final rinse at breakfast was 155 degrees and the final rinse at lunch was 174 degrees;23rd-the final rinse at breakfast was 162 degrees and the final rinse at lunch was 170 degrees;24th-the final rinse at breakfast was 155 degrees and the final rinse at lunch was 174 degrees;25th-the final rinse at breakfast was 171 degrees;26th-the final rinse at lunch was 170 degrees;27th-the final rinse at lunch was 179 degrees; and29th-the final rinse at breakfast was 171 degrees and the final rinse at lunch was 173 degrees. February:3rd- the final rinse temp at lunch was 178 degrees and on 4th- the final rinse temp at breakfast was 175 degrees. During a staff interview with the Nursing Home Administrator (NHA) on February 9, 2026, at 3:31 PM, the kitchen observations were shared. The NHA indicated that he would expect foods to be labeled, dated, and stored properly, that cleaning would be completed routinely, and sanitary policies would be followed. He indicated that Employee 5 should not have went directly back to preparing food with the dirty gloves. Tray line observation in the Main Dining Room on February 10, 2026, at 11:54 AM, revealed that Employee 7 (Dietary Aide) was wearing a baseball cap with hair exposed. Employee 7 was observed to pick up salmon cake with a spatula and then using his left gloved hand he touched the salmon patty to guide it onto the plate. He then scooped the green beans and again used his left hand to guide the beans onto the plate while emptying the spoon onto the plate. He then followed the same process for the noodles. After plating the food, he was then noted to touch the paper meal tickets laying on the counter to begin plating the next plate of resident's food. Employee 7 was observed to complete this same process for 3 additional plates. Employee 7 then had to walk to the edge of the serving area to request a food item from the main kitchen. While he was speaking to someone in the kitchen, Employee 7 was observed to place both of his gloved hands on the lid of the hamper for soiled clothing cover-ups. Employee 7 then returned to the tray line and prepared a plate of food following the same process of touching the food with his left gloved hand. Employee 7 was stopped and an immediate interview was conducted. Employee 7 confirmed that he had been touching the meal tickets, food, and the top of the soiled linen bin and did not change gloves and was going to continue serving food. After the interview was completed, Employee 7 removed his gloves and went to wash his hands. During a staff interview with the NHA and Director of Nursing (DON) on February 10, 2026, at 12:25 PM, the NHA confirmed that Employee 7 should not have been touching the food and should have changed his gloves/washed hands after touching the laundry bin and before continuing to serve food. During tray pass observation on February 10, 2026, from 1:00 to 1:15 PM, on Faith Wing, all meal trays (approximately 20) were noted to have a small cup of pears on them that were uncovered. Nursing staff were noted to transport these trays in the hallways. Interview with Employee 5 during these observations, Employee 5 indicated that they do have lids for the small serving bowls but they don't use them. At time of exit, no additional information was provided regarding dishwasher temperatures not meeting required minimum temperatures. In addition, kitchen cleaning logs were requested for review but never provided. During a final staff interview with the NHA and DON on February 11, 2026, at 12:05 PM, the NHA acknowledged the surveyor observations. He indicated that the dietary staff were just refilling the bottles of the hand sanitizer and continuing to use them. He further indicated that he would expect the kitchen to have followed all necessary sanitary guidelines and indicated the kitchen could do better. 28 Pa code 211.6(f) Dietary services.

Based on facility policy review, review of medication data sheets, observations, and staff interviews, it was determined that the facility failed to label medications properly in two of two medication carts observed (Faith Short and Love 1) and in one of one medication rooms observed (Faith Wing).Findings include: Review of facility policy, titled Medication Labeling and Storage, dated February 2023, revealed, in part, Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The medication label includes, at a minimum: medication name (generic and/or brand); prescribed dose; strength; expiration date, when applicable; resident's name; route of administration; and appropriate instructions and precautions. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Review of the insulin aspart (Novolog: a fast-acting insulin used to lower blood sugar levels) medication data sheet from Drugs.com revealed that this brand of insulin should be used or discarded within 28 days of opening. Review of Medline Liquid Active Protein data sheet on Medline.com revealed that the supplement should be used or discarded within three months of opening. Review of tuberculin testing solution information at www.pa.gov revealed that tuberculin skin testing solution expires 30 days after the initial puncture into the vial. Observation of the Faith Short medication cart with Employee 3 (Licensed Practical Nurse [LPN]) on February 10, 2026, at 9:25 AM, revealed a Novolog (aspart) insulin FlexPen that was opened and had approximately 200 units remaining in the pen without any label that contained a resident's name or the date when the pen was opened. Employee 3 confirmed that approximately 100 units was missing from the pen and that she did not know which resident the insulin pen belonged to, when it would have been opened, or when it would expire. Observation of the Love 1 medication cart with Employee 4 (LPN) on February 10, 2026, at 10:41 AM, revealed an open stock bottle of liquid protein with no open date indicated on the bottle. Employee 4 confirmed that there was no open date on the bottle and, therefore, he would not know when the liquid protein would expire. Observation of the Faith Wing medication room on February 10, 2026, at 10:50 AM, with Employee 3 revealed an opened vial of Aplisol 5/0.1 milliliters (tuberculin skin testing solution) with no open date noted on the vial. Employee 3 confirmed that there was no open date on the bottle and, therefore, she would not know when the tuberculin skin testing solution would expire. During a staff interview with the Nursing Home Administrator and Director of Nursing (DON) on February 10, 2026, at 11:31 AM, the DON confirmed that she would expect medications to be labeled and properly. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.9(a)(1) Pharmacy services.28 Pa. Code 211.12(d)(1)(3) Nursing services.

Based on observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure the residents' right to a clean, comfortable, and homelike environment for one of three lounge rooms observed (Faith East lounge) and for one of 21 resident rooms reviewed (Resident 31).Findings include:Observation of the Faith East Lounge on February 8, 2026, at 9:45 AM, revealed brown substance lying on the floor in the corner of the room.Interview with the Director of Nursing (DON) on February 8, 2026, at 9:55 AM, revealed that although she would expect the room to be clean, there was a resident's family member who sometimes brings in their dog and it has accidents in the building.A request was made for documents showing the last time that the dog visited the facility and for a cleaning schedule for the Faith East lounge. No further information was provided.Observation of Resident 31's room on February 8, 2026, at 12:00 PM, revealed a streak of a brown substance on his fitted sheet on right side of the head of bed near his pillow. Follow-up observations of Resident 31 on February 9, 2026, at 10:16 AM; February 10, 2026, at 8:45 AM; and February 11, 2026, at 9:41 AM, all revealed the same observation of a streak of a brown substance on his fitted sheet on right side head of bed near his pillow.Review of Resident 31's clinical record revealed that he had received bed baths on February 8, 2026, at 10:59 PM, and February 9, 2026, at 7:14 PM and 11:07 PM. During a staff interview with the DON on February 11, 2026, at 10:20 AM, observations of Resident 31 were shared. The DON she indicated that a resident's sheets are usually changed on their shower/bath days, but if they become soiled between shower/days, they should be changed. During a final staff interview with the Nursing Home Administrator and DON on February 11, 2026, at 12:02 PM, the DON confirmed that nursing staff changed Resident 31's sheet that day and that she would have expected staff to have changed the sheet when soiling when he had his bed baths. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1)(3) Management.

Based on review of facility policy, facility documentation review, observations, and resident and staff interviews, it was determined that the facility failed to provide foods that are palatable and at a safe and appetizing temperature. Findings include: Review of facility policy, titled Serving of Food (Point of Service) dated July 2025, indicated, in part, All hot food shall be held during service at or above 135 degrees Fahrenheit; cold food shall be held at or below a temperature of 41 degrees Fahrenheit; and all food items will be served at a palatable temperature. During a resident interview with Resident 74 on February 8, 2026, at 12:37 PM, Resident 74 indicated his food is always cold. Review of facility provided food temperature logs from November 1-3, 2025, revealed the following:November 1: Breakfast fruit cup temperatures ranged from 47.9-48.1 degrees Fahrenheit [F]; Lunch three bean salad ranged from 49.7-50.2 degrees F, peaches ranged from 47.3-47.8 degrees F; Supper pudding was 47.2 degrees F.November 2: Lunch turkey sandwich was 51.3 degrees F and fresh fruit was 47.9 degrees F; Supper apple slices were 48.2 degrees F.November 3: Breakfast fruit cup was 47.7-48.1 degrees F; Lunch bean salad was 49.7-50.2 degrees F and peaches were 47.3-47.8 degrees F; Supper pudding 47.2 degrees Fahrenheit. Review of facility provided food temperature logs from December 1-3, 2025, revealed the following:December 1: Lunch tossed salad was 49.7-50.2 degrees F, mandarin oranges and apple slices were 47.6 to 48.2 degrees F; Supper pudding was 47.6 degrees F.December 2: Lunch turkey sandwich was 50.1 degrees F, egg salad sandwich was 49.2-49.6 degrees F, cucumber salad was 48.2-48.6 degrees F, and pudding was 47.6 degrees F; Supper tropical fruit ranged from 47.6-47.8 degrees F.December 3: Breakfast fruit cup ranged from 47.6-47.9 degrees F; Lunch fresh fruit was 47.6 degrees F; Supper pineapples ranged from 47.3-47.6 degrees F. Review of facility provided food temperature logs from January 1-3, 2026, revealed the following:January 1: Lunch chicken salad sandwich ranged from 48.1-49.6 degrees F, cole slaw ranged from 46.1-46.4 degrees F, tossed salad was 50.1 degrees F, and pudding was 46.9 degrees F; Supper macaroni salad ranged from 46.1-46.8 degrees F and tomato slices were 49.3 degrees F; Supper cinnamon scalloped peaches were 48.1 degrees F.January 2: Lunch pudding was 46.4 degrees F; Supper tossed salad was 49.7-50.2 degrees F and pears were 46.4-46.8 degrees F.January 3: Lunch sliced tomatoes/tomato salad was 49.9 -50.1 degrees F, mandarin oranges and apple slices were 47.6-47.7 degrees F; Supper vegetable salad ranged from 49.9-50.7 degrees F, squash rounds were 50.7 degrees F, and marinated green beans/ carrots/ peas were 50.7 degrees F. Review of facility provided food temperature logs from February 1-3, 2026, revealed the following:February 1: Lunch pudding was 46.2 degrees F; Supper apple crisp ranged from 46.8-47.2.February 2: Lunch tuna salad sandwich ranged from 47.1-48.3 degrees F, cucumber salad ranged from 49.2-49.7 degrees F, and pineapple slices ranged from 46.1-46.4 degrees F; Supper tossed salad tanged from 48.2-49.3 degrees F and pudding was 47.1 degrees F.February 3: Breakfast fruit cup ranged from 46.1-46.7 degrees F; Lunch cottage cheese was 46.3 degrees F, beet salad ranged from 47.3-47.9 degrees F, and mandarin oranges ranged from 46.4-46.8 degrees F; Supper pudding was 46.2 degrees F. A test tray completed on February 10, 2026, at 1:15 PM, with Employee 5 (Dietary Manager) on the Faith Wing cart. Test tray temperatures were taken by Employee 1 ?5 (Dietary Manager) using an infrared laser thermometer on the tray that had been prepared for Resident 103.Findings were as follows: pears 53.4 degrees F; salmon patty 125.9 degrees F; green beans 117.5 degrees F; and pasta 112.8 degrees F. During an immediate interview, Employee 5 confirmed that all the food temperatures were out of range and that the hot items were cold. During a staff interview with Nursing Home Administrator (NHA) and the Director of Nursing on February 11, 2026, at 12:05 PM, the NHA confirmed that he would expect food to be served at appropriate temperatures. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.8(b)(1)(3) Management.

Based on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure staff implement infection control policies to prevent the spread of infection for two of 23 residents observed on enhanced barrier precautions (Residents 11 and 35), and failed to ensure that staff implement appropriate infection control policies to prevent the spread of infection during two of two medication administration observations (Faith Short and Love 1). Findings include: Review of facility policy, titled Enhanced Barrier Precautions, revised December 2024, revealed, Enhanced barrier precautions apply when: A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained; and contact precautions do not otherwise apply. Review of facility policy titled Specific Medication Administration Procedures IIB6: Eye Drop Administration, undated, failed to reveal any information regarding glove usage. Review of Resident 11's clinical record revealed diagnoses that included artificial opening of the urinary tract and open wound of abdominal wall. Review of Resident 11's clinical record revealed that she had a nephrostomy (a tube placed through the skin and into the kidney to drain urine) and urostomy (artificial opening of the urinary tract on the abdomen). Observation of Resident 11's room door on February 8, 2025, at 10:20 AM, failed to reveal any signage that it was necessary to use personal protective equipment when caring for Resident 11. Review of Resident 11's physician orders failed to reveal a physician's order for Resident 11 to be on enhanced barrier precautions. Review of Resident 11's care plan failed to reveal any care plan dealing with Resident 11's need to be on enhanced barrier precautions. During a staff interview with the Director of Nursing (DON) on February 11, 2026, at 12:21 PM, the DON indicated that Resident 11 should have been on enhanced barrier precautions and the facility policy should have been followed. Review of Resident 35's clinical record revealed diagnoses that included unstageable pressure ulcer (a severe, full-thickness wound where the true depth [Stage III or IV] is hidden by slough [yellow, tan, gray, green, or brown] or eschar [tan, brown, or black]) and venous ulcers (a wound that takes longer to heal because of poor of blood flow issues). Observation of Resident 35's room door on February 8, 2025, at 9:30 AM, failed to reveal any signage that it was necessary to use personal protective equipment when caring for Resident 35. Review of Resident 35's wound team consult dated February 3, 2026, revealed that Resident 35 had an unstageable pressure on her right plantar foot with a moderate amount of serosanguinous (a thin, watery, pink-to-light-red fluid consisting of serum and blood) drainage. Review of Resident 35's physician orders failed to reveal a physician's order for Resident 35 to be on enhanced barrier precautions. Review of Resident 35's care plan failed to reveal any care plan dealing with Resident 35's need to be on enhanced barrier precautions. Interview with the DON on February 11, 2026, at 12:15 PM, revealed that Resident 35 should have been on enhanced barrier precautions and the facility policy should have been followed. Observation of Faith Short medication cart on February 10, 2026, at 9:19 AM, revealed that the spoons being utilized for medication administration were lying in a plastic bin on top of the cart, completely exposed. Observation of Love 1 medication cart on February 10, 2026, at 10:40 AM, revealed that the spoons used for medication pass were in a box on the side of the cart, completely exposed. Observation of medication administration pass with Employee 4 (Licensed Practical Nurse) on February 10, 2026, between 9:45 AM and 10:45 AM, revealed the following concerns:a) Employee 4 did not cleanse or sanitize hands between Resident 49 and Resident 74.b) Employee 4 applied gloves prior to entering Resident 74's room because he indicated that he needed to wear gloves to administer eye drops to Resident 74, and that he was also going to clean Resident 74's eyes before administering the eye drops. After applying gloves, Employee 4 was noted to touch the lid of the trash can on the medication cart as well as the handles of the medication cart.c) Employee 4 then entered Resident 74's room and used his gloved hands to adjust Resident 74's bed using the control panel on the footboard of the bed. Employee 4 then proceeded to administer Resident 74's oral medications.d) After administering the oral medications, Employee 4 used his right gloved hand to open Resident 74's bathroom door, he wet the washcloth, then came out and cleansed and dried resident's eyes and proceeded to administer the eye drops. e) Employee 4 then exited Resident 74's room, taking the washcloth with him. At the medication cart, Employee 4 removed his gloves and then carried the washcloth up the hall to the soiled utility room and washed his hands. During a staff interview with the Nursing Home Administrator and DON on February 10, 2026, at 11:31 AM, the DON confirmed that she would expect nursing staff to follow appropriate infection control guidelines when administering medications. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to implement the licensed pharmacist's recommendations for one of five residents reviewed for unnecessary medications (Resident 7).Findings Include:Review of facility policy, titled Medication Regimen Review (Monthly Report), last revised April 22, 2025, revealed G. Recommendations are acted upon and documented by the facility staff and or the prescriber.Review of Resident 7's clinical record revealed diagnoses that included bipolar II disorder (mental health disorder with depressive episodes alternating with hypomanic episodes) and major depressive disorder (persistent feelings of intense sadness, worthlessness, and loss of interest in activities).Review of Resident 7's physician orders revealed the following orders: olanzapine (Zyprexa) antipsychotic medication) at bedtime for behaviors/mood and pantoprazole sodium (protonix one time a day).Review of Resident 7's monthly December medication review revealed that on December 28, 2025 a pharmacy recommendation was made to administer protonix on an empty stomach 30 - 60 minutes before a meal.Further review of the December 2025 pharmacy review revealed that the physician signed the recommendation on January 6, 2026.Additional review of Resident 7's physician's orders revealed that the scheduled administration time for Resident 7's protonix was 9:00 AM, which is after the facility breakfast meal service.Review of Resident 7's January 2026 monthly medication review revealed that on January 29, 2026 a pharmacy recommendation was made to include an appropriate diagnosis for Zyprexa.Further review of the January pharmacy review revealed that the physician signed the recommendation on February 9, 2026, and indicated bipolar II disorder as the diagnosis.Additional review of Resident 7's physician's orders revealed that no changes had been made to Resident 7's Zyprexa order indicating Zyprexa was prescribed for bipolar II disorder.During an interview on February 11, 2026, at 12:32 PM, with the Nursing Home Administrator (NHA) and Director of Nursing (DON), it was revealed that the facility had no additional information regarding why the pharmacy recommendations were not implemented. The NHA and DON stated it was the facility's expectation that pharmacy recommendations be implemented.28 Pa. code 211.9 (a)(1) Pharmacy services28 Pa. Code 211.12(c)(d)(3)(5) Nursing services

Based on policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to provide necessary services to carry out activities of daily living to maintain good nutrition and personal hygiene for residents' dependent on staff for assistance for two of 21 residents reviewed (Residents 5 and 12).Findings include:Review of the facility policy, titled Activities of Daily Living (ADLs), Supporting with a last revised and review date of April 24, 2025, revealed, 5. Appropriate care and services are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care); b. mobility (transfer and ambulation, including walking); c. elimination (toileting); d. dining (eating, including meals and snacks).Review of Resident 5's clinical record revealed diagnoses that included hypertension (high blood pressure) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).Review of Resident 5's comprehensive care plan revealed an ADL focus area related to self-care performance deficit related to dementia, initiated on October 14, 2025, and revised on December 18, 2025, with an eating intervention that Resident 5 required feeding assistance with all meals and that staff are to attempt to queue; encourage and let them know what she is eating and then assist with all meals if she is not eating, initiated and revised on January 9, 2026.Review of Resident 5's current physician's orders revealed the following order: Assistance with all meals (Staff to attempt to queue; encourage and let them know what she is eating and then assist with all meals if she is not eating), with an active date of January 9, 2026.Observation of Resident 5 on February 9, 2026, at 1:12 PM, revealed that she was lying asleep in her bed. Further observation on February 9, 2026, at 1:14 PM, revealed Employee 6 took Resident 5's tray into her room and set it on her bedside table. At 1:14 PM, Employee 6 exited Resident 5's room. At 1:30 PM, Resident 5 was lying asleep in bed, with their lunch tray on their bedside table with the lid on the plate. There were no observations of staff going into Resident 5's room to encourage or assist her with eating.Review of Resident 5's task for amount eaten revealed on February 9, 2026, it was documented on 12:42 PM that the Resident refused to eat. The refusal was documented prior to Resident 5 receiving their lunch tray.Review of a nursing progress note on January 15, 2026, at 6:04 PM, revealed Resident 5 was assisted with their evening meal for 30 minutes, and that she gets easily distracted and needs assistance and cueing for eating. She was able to eat 95% of evening meal.During an interview with the Director of Nursing (DON) on February 10, 2026, at 12:24 PM, she revealed that she would have expected staff to try to encourage and assist Resident 5 with eating.Review of Resident 12's clinical record revealed diagnoses that included hypertension and major depressive disorder.Observation of Resident 12 on February 9, 2026, at 12:33 PM, revealed his call bell light was on.Observation on February 9, 2026, at 12:41 PM, revealed a staff member going into Resident 12's room, telling Resident 12 to give them a minute, turned the call light off, and exited the room.Interview with Resident 12 on February 9, 2026, at 1:06 PM, he revealed that he needed assistance with continence care as his skin was burning. Resident 12 revealed that he was not able to get to the restroom on his own and required staff assistance.Observation of Resident 12 on February 9, 2026, at 1:06 PM, revealed that he put his call light back on. Observation revealed Resident 12 was wearing a brief.Further observation of Resident 12 on February 9, 2026, at 1:07 PM, revealed a different staff member came into Resident 12's room and told him to let her finish passing the rest of the meal trays out and then she will come back and assist him with continent care.On February 9, 2026, at 1:16 PM, a staff member went into Resident 12's room and provided continent care to him.Review of Resident 12's comprehensive care plan revealed an ADL focus area for self-care performance deficit related to humerus fracture, last initiated and revised on October 13, 2025; and a transfer status intervention that they transfer and ambulate with one assist using rollator.Review of Resident 12's clinical record revealed the Resident was seen by wound care on February 10, 2026, for a reconsult for wound to sacrum and bilateral buttocks. On assessment, Resident 12 was determined to have a fungal rash with excoriation noted to sacrum and bilateral buttocks and was recommended to receive treatment of medication and probiotics for it.During an interview conducted with the DON on February 10, 2026, at 12:23 PM, she revealed that she would expect staff to provide continent care to residents in a timely manner.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to address weight loss in a timely manner for one of four residents reviewed (Resident 1).Findings include: Review of facility policy, titled Weight Assessment and Intervention, dated March 2022, revealed, in part, 3. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. a. If the weight is verified, nursing will immediately notify the dietitian in writing. 4. Unless notified of significant weight change, the dietitian will review the unit weight record monthly to follow individual weight trends over time. 5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight - actual weight)/(usual weight) x 100]: a. 1 month - 5% weight loss is significant; greater than 5% is severe. b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months - 10% weight loss is significant; greater than 10% is severe. Review of Resident 1's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning) and pressure ulcers to bilateral heels. Review of Resident 1's nutritional assessment completed by the facility dietician on December 3, 2025, indicated that Resident 1 was not at risk for unintended weight loss. Review of Resident 1's weight documentation revealed that on January 7, 2025, he weighed 131 pounds and on February 4, 2025, he weighed 116.2 pounds, which was an 11.3% (14.8 pounds) weight loss. Review of Resident 1's clinical record on February 11, 2026, at 9:17 AM, failed to reveal any documentation between February 4 and 11, 2026, that Resident 1 had been reweighed, or that the dietician or physician had been made aware of Resident 1's weight loss. Follow-up review of Resident 1's clinical record revealed a dietary note dated February 11, 2026, at 10:43 AM, written by the facility dietician, which indicated that Resident 1 had a confirmed weight loss of 11.5% (15 pounds) in 30 days. The note further indicated that there was no known cause for the weight loss, a nutritional supplement was added twice a day at lunch and supper, weekly weights would be monitored for four weeks, and that Resident 1's physician was made aware of the weight loss. During a staff interview with the Nursing Home Administrator and Director of Nursing (DON) on February 11, 2026, at 12:52 PM, the DON indicated that Resident 1 had been reweighed that morning. She indicated that typically the dietician would direct staff to get a reweight at the time of the original weight if a discrepancy was noted. The DON confirmed that nursing staff nor the dietician had addressed Resident 1's weight loss until this morning after the surveyor questioned the weight loss. The DON also confirmed that Resident 1's weight on February 11, 2026, was 115.6 pounds, which would be an additional loss of 0.6 pounds. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide appropriate care and services to residents receiving tube feedings for one of one residents reviewed for tube feeding (Resident 75). Findings include:Review of the facility policy, titled Enteral Tube Feeding via Continuous Pump with a last revised date of November 2018, and a last review date of April 24, 2025, revealed, Initiate Feeding; 5. On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order.Review of Resident 75's clinical record revealed diagnoses that included diabetes (a condition that happens when your blood sugar is too high) and hemiplegia (the severe or complete paralysis of one side of the body, caused by brain or spinal cord damage).Observation of Resident 75 on February 9, 2026, at 9:39 AM, revealed that the Resident's feeding pump had been idle for 10 minutes and the pump had been inactive. Further review revealed that the bottle of Glucerna 1.2 and tubing were not labeled with a time or date that they were opened and hung at the Resident's bedside.Observation of Resident 75 on February 11, 2026, at 10:20 AM, revealed that the Resident's feeding pump has been idle for 10 minutes and the pump has been inactive. Further review revealed that the bottle of Glucerna 1.2 and tubing were not labeled with a time or date that they were opened and hung at the resident's bedside.Review of Resident 75's February 2026 MAR (Medication Administration Record) revealed an enteral feed order, every 4 hours feeding-gravity/bolus: Glucerna 1.5 to be given until pump supplies available: 4:00 PM = 300 ml (milliliters); 8:00 PM = 300 ml; 12:00 AM = 300 ml; 4:00 AM 300 ml; 8:00 AM 225 ml; total = 1425 ml; with a start date of February 3, 2026, and a discontinue date of February 7, 2026. Further review of the February 2026 MAR revealed that Resident 75 received 0 ml of Glucerna 1.5 at 12:00 PM on February 4 and 6, 2026.During an interview with the Director of Nursing (DON) on February 10, 2026, at 12:25 PM, she revealed there was an equipment issue and they did not have to correct pumps to administer the Glucerna 1.5 to Resident 75.Further interview with the DON on February 11, 2026, at 12:32 PM, revealed she would expect Resident 75's tube feed to be labeled and dated per facility policy.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observations, facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that respiratory care and services provided were consistent with professional standards of care for two of two residents reviewed for respiratory care (Residents 8 and 89). Findings Include:Review of facility policy, titled Oxygen Therapy revised April 24, 2025, revealed, Policy: A physician must order the oxygen therapy. 1. Verify that there is a physician's order for this procedure.Review of Resident 8's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (lung and airway disease that restricts breathing) and protein-calorie malnutrition (inadequate intake of protein and calories).During an interview with Resident 8 on February 8, 2026, at 10:38 AM, an observation was made of Resident 8 receiving supplemental oxygen via nasal cannula at 2 liters (of oxygen) per minute.An additional observation was made on February 9, 2026, at 11:20 AM, of Resident 8 receiving supplemental oxygen via nasal cannula at 2 liters (of oxygen) per minute.Review of Resident 8's physician orders failed to revealed a physician order for supplemental oxygen use.During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on February 11, 2026, at 12:25 PM, the DON confirmed Resident 8 did not have a physician order for supplemental oxygen. The NHA and DON stated it was the facility's expectation that physician orders be obtained and entered for supplemental oxygen use.Review of Resident 89's clinical record revealed diagnoses that included hypertension (high blood pressure) and anxiety (excessive and persistent worry and fear about everyday situations).Review of Resident 89's comprehensive care plan revealed a focus area that the Resident had morbid obesity, obstructive sleep apnea and uses a CPAP (Continuous Positive Airway Pressure - a therapy device that helps keep your airways open while you sleep), initiated and revised on March 5, 2025.Review of Resident 89's clinical record revealed a physician's order that their CPAP mask is to be placed in a storage bag when not in use, every day and evening shift, with an active date of August 30, 2024.Review of Resident 89's comprehensive care plan revealed a focus area that the Resident had morbid obesity, obstructive sleep apnea and uses a CPAP, initiated and revised on March 5, 2025.During an interview conducted with Resident 89's guardian on February 8, 2026, at 10:27 AM, she revealed that she comes to visit the Resident almost daily and his CPAP mask is often not clean and never bagged when she is there.Observation of Resident 89's room on February 8, 2026, at 10:27 AM, revealed his CPAP and mask were on his nightstand beside his bed, not bagged.Observation of Resident 89's room on February 9, 2026, at 10:52 AM, revealed his CPAP and mask were on his nightstand beside his bed, not bagged.Observation of Resident 89's room on February 11, 2026, at 10:05 AM, revealed his CPAP and mask were on his nightstand beside his bed, not bagged.During an interview with the DON on February 11, 2026, at 12:38 PM, she revealed she would expect physician's orders to be followed and Resident 89's CPAP mask to have been bagged per order.28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that the residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of one residents reviewed (Resident 10). Findings Include:Review of facility policy, titled Trauma Informed Care and Culturally Competent Care, revised April 22, 2025, revealed, Purpose to address the needs of trauma survivors by minimizing and/or re-traumatization. Resident Assessment 1. Assessment involves an in-depth process of evaluation the presence of symptoms, their relationship to trauma, as well as identification of triggers.Review of Resident 10's clinical record revealed diagnoses that included post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event. The condition may last months or years, with triggers that can bring back memories of the trauma, accompanied by intense emotional and physical reactions) and major depressive disorder (ongoing feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life).During an interview with Resident 10 on February 9, 2026 at 8:47 AM, it was revealed that Resident 10 had suffered sexual abuse as a young child.Review of Resident 10's admission social service evaluation dated December 23, 2025, revealed section D titled psychosocial evaluation, question 8b. was marked no, indicating Resident 10 did not have a diagnosis of PTSD.Review of Resident 10's comprehensive care plan failed to reveal a focus area or interventions for PTSD or trauma.Further review of Resident 10's clinical record failed to reveal that any additional trauma screening had been completed.The facility was unable to provide additional information indicating Resident 10 had received trauma informed care.During an interview on February 11, 2026, at approximately 3:30 PM, with the Nursing Home Administrator and Director of Nursing, it was revealed that it was the expectation of the facility that residents receive trauma informed care.28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1) Management28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on facility policy, staff interviews, and clinical record reviews, it was determined that the facility failed to provide an explanation of the risks and benefits of psychotropic medications use and obtain consent prior to administering psychotropic medications for one of five residents reviewed for psychotropic medication use (Resident 9). Findings included: Review of facility provided policy, titled Psychotropic Medication Use, revised February 2025, revealed, Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record. Review of Resident 9's clinical record revealed diagnoses that included major depressive disorder (a serious, common mood disorder characterized by persistent sadness, loss of interest, and fatigue, lasting at least two weeks and impairing daily life) and dementia (a general term for severe mental function loss). Review of Resident 9's physician orders revealed an order for Depakote (medication used to treat seizures and bipolar disorder) 250 mg, given by mouth at bedtime for mood, starting on September 12, 2025. Review of Resident 9's Care plan revealed a focus of: Resident 9 uses antidepressant and mood stabilizer medication related to depression, lasted revised on September 21, 2025. Interview with the Director of Nursing on February 11, 2026, at 11:45 AM, revealed that Resident 9 did not have an appropriate diagnosis for Depakote documented in the medical record. 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, staff interview, and observations, it was determined that the facility failed to ensure that it was free from a medication error rate of five percent or greater based on two medication errors out of 29 opportunities.Findings include: Review of facility policy, titled Specific Medication Administration Procedures IIB6: Eye Drop Administration, undated, revealed, in part, Wait at least five (5) minutes before applying additional medication to the eye. Observation of medication administration on February 10, 2025, at 9:19 AM, Employee 3 (Licensed Practical Nurse [LPN]) was observed administering Resident 10 sucralfate 1000 MG (1 gram) oral tablet. Medication packaging indicated that the medication was to be administered before meals and at bedtime. During an immediate staff interview with Employee 3, she confirmed that Resident 10 had already completed her breakfast. Employee 3 indicated that she was running behind and that Resident 10's medication was not given as ordered. Observation of medication administration on February 10, 2025, at 10:40 AM, Employee 4 (LPN) was observed administering Resident 74 Cipro HC ophthalmic solution 0.3% (antibiotic eye drop) one drop to each eye followed immediately by Refresh eye drops (lubricating eye drops) one drop to each eye. During an immediate interview with Employee 4, he confirmed that he had administered the eye drops consecutively without waiting between medication administrations. During medication administration observations, there were two errors and 29 opportunities, resulting in a medication error rate of 6.9%. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing on February 11, 2026, at 11:51 AM, the NHA confirmed that he would expect nursing staff to administer medications as ordered and within standard practice guidelines. 28 Pa. Code 211.9(a)(1) Pharmacy services.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to document a physician order for hospice services for one of one resident reviewed for hospice services (Resident 8).Findings Include:Review of the facility policy, titled Hospice Program, last reviewed April 22, 2025, failed to reveal that a physician order must be obtained for hospice services.Review of the clinical record for Resident 8 revealed clinical diagnoses that included chronic obstructive pulmonary disease (progressive irreversible lung disease causing chronic coughing, wheezing, and severe shortness of breath) and protein-calorie malnutrition (severe nutritional deficiency from inadequate intake of protein, calories, or both).Review of Resident 8's Significant change Minimum Date Set (MDS-periodic assessment and care screening) dated December 19, 2025, Section O- Special Treatments, Procedures and Programs, of the MDS indicated that Resident 8 was receiving hospice services.Review of Resident 8's physician orders failed to reveal an order for hospice services.During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on February 11, 2026, the DON confirmed that Resident 8 did not have a physician's order for hospice services. The NHA and DON stated it was the facility's expectation that physician orders be in place for care and services.28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 211.12(d)(3)(5) Nursing services28 Pa. Code 201.18(b)(1)(3) Management

Based on observations, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for three of 21 residents reviewed (Residents 16, 49, and 74).Findings include: Review of Resident 16's clinical record revealed diagnoses that included cognitive communication deficit (a group of disorders that affect a person's ability to communicate, which can cause difficulty with understanding or producing language and nonverbal communication skills, such as gestures and facial expressions) and metabolic encephalopathy (a change in how your brain works due to an underlying condition that can cause confusion, memory loss, and loss of consciousness). Review of Resident 16's physician orders revealed an order for a wanderguard bracelet to left lower extremity, night shift to check every shift for function and every shift to check proper placement, dated February 3, 2026. Observations of Resident 16 on February 8, 2026, at 12:35 PM, and February 9, at 9:14 AM, revealed that his wanderguard bracelet was lying on his overbed table. Observation of Resident 16 on February 9, 2026, at 2:15 PM, revealed that he was ambulating in his room, he was barefoot, and his wanderguard bracelet was lying on his overbed table. During a resident interview with Resident 16, he indicated that he only had to wear the bracelet for seven days. As the surveyor was leaving Resident 16's room, a nurse was entering the room. Observation of Resident 16 on February 10, 2026, at 9:47 AM, again Resident 16 was noted to be barefoot, ambulating in his room, and his wanderguard bracelet was lying on his overbed table. Review of Resident 16's February Treatment Administration Record revealed that he was documented as having his wanderguard bracelet in place every shift and that function was checked every night. During an observation of Resident 16 on February 10, 2026, at 1:43 PM, with the Nursing Home Administrator (NHA) and Director of Nursing (DON), Resident 16 was noted to have his wanderguard bracelet on his right ankle. Prior surveyor observations were shared with the NHA and DON, as well as staff documentation on the Treatment Administration Record. The DON confirmed that Resident 16's wanderguard bracelet should have been on the Resident as ordered. Review of Resident 74's clinical record revealed diagnoses that included need for assistance with personal care and legal blindness. Observations of Resident 74 on February 8, 2026, at 12:40 PM, and February 9, 2026, at 11:12 AM, revealed a tube of Voltaren gel (a topical nonsteroidal anti-inflammatory drug [NSAID] used for the temporary relief of joint pain associated with osteoarthritis) and a tube of wound treatment cream laying on his bedside stand. There was also a handwritten note that indicated Resident 74 was legally blind. During a medication pass observation of Resident 74 on February 10, 2026, at 9:57 AM, with Employee 4 (Licensed Practical Nurse), the tube of Voltaren gel and the tube of wound treatment cream remained on his bedside stand, within the Resident's reach. Review of Resident 49's clinical record (Resident 74's Roommate) revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning) and delusional disorder (serious mental illness where a person cannot tell what is real from what is imaginary). Review of Resident 49's care plan revealed that he was independent with ambulation. Observation of Resident 49 on February 8, 2026, at 12:50 PM, revealed he was ambulating independently around the room. During a follow-up observation and interview with the NHA and DON on February 10, 2026, at 1:20 PM, the DON confirmed that the medication and cream should not have been left on Resident 74's bedside stand. She removed the items from the room. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, observations, clinical record review, and staff interview, it was determined that the facility failed to ensure the care plan was reviewed and revised timely for one of 21 residents reviewed (Resident 1).Findings include: Review of facility policy, titled Care Plan, Comprehensive Person-Centered, with a last revision date of September 2022, revealed, in part, Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change; and The Interdisciplinary Team must review and update the care plan: d. At least quarterly, in conjunction with the required quarterly MDS assessment. Review of Resident 1's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning) and pressure ulcers to bilateral heels. Observations of Resident 1's room on February 8, 2026, at 12:29 PM, and February 9, 2026, at 8:36 AM, revealed he had a sign on his door indicating that he was on Contact Precautions (precautions intended to prevent the transmission or spread of infectious agents, which are spread through direct or in-direct contact with the patient or patient's environment). Review of Resident 1's care plan revealed a care plan focus for wound infection and Contact Precautions, dated October 28, 2025. Review of Resident 1's physician order history revealed that his Contact Precautions were discontinued on November 1, 2025. Review of Resident 1's clinical record revealed that he had a Significant Change Comprehensive 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) completed on November 17, 2025, and had a Quarterly MDS completed on December 3, 2025. During a staff interview with the Nursing Home Administrator and Director of Nursing (DON) on February 11, 2026, at 12:17 PM, the DON confirmed that Resident 1's Contact Precautions were discontinued on November 1, 2025, and that staff had revised his care plan as February 9, 2026. She further indicated that she would have expected Resident 1's care plan to have been revised when his orders changed or at least at the time of his MDS assessments. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure that a baseline care plan, to included the minimum healthcare information necessary to properly care for a resident, was developed and implemented within 48 hours of admission for one of 23 residents reviewed (Resident 2).Findings Include: Facility policy, titled Care Plans - Baseline, revised on April 24, 2025, read, in part, Policy Interpretation and Implementation 1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality of care and must include the minimum healthcare information necessary to properly care for the resident including but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b. Physician orders. Review of Resident 2's clinical record revealed diagnoses that included fracture of the neck of the left femur (break occurring at the upper part of the thigh bone) and after care following joint replacement surgery (comprehensive post-op care focused on preventing complications like blood clots and infections). Further review of Resident 2's clinical record revealed that Resident 2 was admitted to the facility on [DATE], from the hospital after being treated for a hip fracture with surgical repair. Review of Resident 2's physician orders revealed an order for enoxaparin sodium (anticoagulant medication) twice daily. Review of Resident 2's baseline care plan failed to reveal a care area for anticoagulation medication use or monitoring for side effects. An interview with the Nursing Home Administrator and Director of Nursing (DON) on February 11, 2026, at 12:29 PM, revealed that the DON confirmed Resident 2's care plan did not include a care area for anticoagulation medication use or side effect monitoring and that Resident 2's care plan had been updated. The DON stated it was the facility's expectation that resident care plans be accurate. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 21 residents reviewed (Resident 9, 11, and 68). Findings include: Review of Resident 9's clinical record revealed diagnoses that included major depressive disorder (a serious, common mood disorder characterized by persistent sadness, loss of interest, and fatigue, lasting at least two weeks and impairing daily life) and dementia (a general term for severe mental function loss). Review of Resident 9's Annual MDS (Minimum Data Set is part of federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated November 24, 2025, indicated in Section N0415 High-Risk Drug Classes: Use and Indication, A. Antipsychotic, indicated that Resident 9 had taken antipsychotic medications during the 7-day look-back period. Review of Resident 9's clinical record failed to reveal any evidence that Resident 9 had had taken antipsychotic medications during the 7-day look-back period. Interview with the Nursing Home Administrator (NHA) on February 11, 2026, at 11:45 AM, revealed that it was marked in error and a correction was being completed.Review of Resident 11's clinical record revealed diagnoses that included major depressive disorder and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of Resident 11's admission Comprehensive MDS dated [DATE], indicated in Section B. Hearing, Speech, and Vision at question B0100 Comatose that Resident 11 was coded Yes for being in a persistive vegetative state/ no discernible consciousness. Review of Resident 11's admission nursing assessment dated [DATE], revealed in Section 9. Neurological that she was alert and oriented to person, place and time. During a staff interview with Employee 1 (MDS Coordinator) on February 10, 2026, at 10:50 AM, Employee 1 indicated that Resident 11's MDS was coded incorrectly and that an assessment modification would be completed. During a staff interview with the NHA and Director of Nursing (DON) on February 10, 2026, at 11:31, the NHA confirmed that he would expect MDS assessments to be completed accurately. Review of Resident 68's clinical record revealed diagnoses that included dementia (cognitive decline accompanied by significant changes in behavior) and anxiety disorder (excessive fear of or apprehension about real or perceived threats). Review of Resident 68's physician orders revealed the following orders: Buspirone HCL (antianxiety medication) every eight hours for anxiety and Xanax (antianxiety medication) every 12 hours for anxiety/behaviors. Review of Resident 68's quarterly MDS dated [DATE], revealed Resident 68 was coded no for antianxiety medication use during the seven-day look back period, indicating that Resident 68 had not received antianxiety medication. Review of Resident 68's December 2025 medication administration record revealed Resident 68 was documented as receiving the aforementioned antianxiety medications during the December look back period. An interview with Employee 1 on February 11, 2026, at 11:04 AM, revealed that Resident 68's quarterly MDS date December 17, 2025, had been coded incorrectly. An interview with the NHA and DON on February 11, 2026, at 12:23 PM, revealed it was the facility's expectation that MDS reports be coded correctly. 28 Pa Code 211.12 (d)(3)(5) Nursing services.

Based on facility policy review, clinical record review, facility documentation 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 will meet each resident's physical, mental, and psychosocial needs for three of three residents reviewed (Residents 1, 2, and 3) which resulted in actual harm as evidenced by two hospital transfers for seizure activity for one of three residents reviewed (Resident 1).Findings include: Review of facility policy, titled IIA2. Medication Administration-General Guidelines, undated, revealed, in part, Medications are administered in accordance with written orders of the attending physician. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR (Medication Administration Record) to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off duty without first recording the administration of any medications. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (e.g. the resident is not in the facility at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the MAR for that dosage administration is initialed and coded appropriately. An explanatory note is entered in the record. If two consecutive doses of a vital medication are withheld or refused, the physician is notified. Review of facility policy, titled IC4: Ordering and Receiving Controlled Medications, undated, revealed, in part, Schedule II controlled medications prescribed for a specific resident are delivered to the facility only if a faxed or original written prescription has been received by the pharmacy. Schedule III, IV and V may also be dispensed pursuant to a verbal order from the physician. In addition, if medication is needed prior to the next delivery, the pharmacist may authorize a nurse at the facility to remove a supply of the medication from the emergency supply in the facility according to policy IC5. In an emergency situation, the provider pharmacy can accept a telephone order for a schedule II medication. The DEA defines emergency to mean that the immediate administration of the drug is necessary for the proper treatment of the intended individual, that no alternative is available and that it is not possible for the prescriber to provide a prescription for the drug at that time. In no situations will an emergency dispensing exceed a 7-day supply. An individual resident's controlled substance record is prepared by the pharmacy or the facility for each controlled substance medication prescribed for a resident. The following information is completed: 1) Name of resident 2) Prescription number 3) Drug name, strength (if designated), and dosage form of medication 4) Date received 5) Quantity received and 6) Name of person receiving the medication supply. Schedule II controlled substance medications are reordered when a seven-day supply remains to allow for transmittal of the prescription to the pharmacist. Review of Resident 1's clinical record revealed diagnoses that included epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures) 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 1's physician orders revealed orders for lacosamide (a medication used to manage seizure activity) 100 milligrams give one tablet by mouth every 12 hours. Review of Resident 1's past Controlled Substance Record's for her ordered lacosamide revealed that 30 tablets were received at the facility on December 29, 2025, and nursing staff began administering the medication from this package on January 1, 2026, at 9:10 AM. Further review of this record revealed that the last dose was administered to Resident 1 on January 15, 2026, at 8:00 PM. Review of Resident 1's January 2026 MAR revealed that she was administered a dose of lacosamide on January 16, 2026, at 8:00 AM, by Employee 1 (Licensed Practical Nurse [LPN]), despite that all available doses of Resident 1's lacosamide had been administered as of January 15, 2026, at 8:00 PM. Review of a written statement from Employee 1 on January 28, 2026, revealed that Employee 1 called the pharmacy on January 16, 2026, to inform them that Resident 1 was out of her lacosamide and it was needed. The statement indicated that the medication had already been ordered days prior and that the pharmacy indicated that the medication would be on the next pharmacy delivery. Employee 1 further indicated that she had erroneously charted administering Resident 1 her January 16, 2026, 8:00 AM dose of lacosamide and was going to correct the documentation. Further review of Resident 1's January 2026 MAR revealed that her lacosamide was documented as 16 Hold/See Nurses Note for her January 16, 2026, 8:00 PM dose administration, and her January 17, 2026, 8:00 AM and 8:00 PM dose administrations. Review of Resident 1's clinical record revealed a Medication Administration Note dated January 16, 2026, at 8:12 PM, that indicated Resident 1's lacosamide was on order from the pharmacy. Review of Resident 1's clinical record revealed a Medication Administration Note dated January 17, 2026, at 1:26 PM, that indicated Resident 1's lacosamide was on back order and pharmacy was notified. Review of Resident 1's clinical record revealed a Medication Administration Note dated January 17, 2026, at 10:26 PM, that indicated Resident 1's lacosamide was not available, pharmacy was called, and that the medication was on order. Review of Resident 1's clinical record progress notes revealed a nurse's note written by Employee 2 (LPN) dated January 17, 2026, at 10:40 PM, which indicated that Resident 1 was noted to be having a seizure which lasted from 10:20 PM to 10:26 PM. The note further indicated a call had been placed to the pharmacy earlier in the day regarding Resident 1's lacosamide and that the pharmacy indicated that the drug would be sent. The note also indicated that when Employee 2 called the pharmacy again to confirm that the lacosamide would be in the next pharmacy delivery run (night of January 17, 2026), the pharmacy indicated a script would be needed to dispense Resident 1's lacosamide. The note indicated that Employee 3 (Registered Nurse [RN]) reached out to the physician and requested that Resident 1 be sent out to the ER for further evaluation. Review of Resident 1's clinical record progress notes revealed a nurse's note written by Employee 3 (RN) dated January 17, 2026, at 11:20 PM, which indicated that Resident 1 had a seizure that lasted approximately 20-25 minutes. The note further indicated that Resident 1's physician was made aware of Resident 1's seizure, that her ordered lacosamide was not available, and that Resident 1's physician provided a new order to send Resident 1 to the hospital for evaluation and treatment. Based on review of Resident 1's progress notes for January 17, 2026, at 10:40 PM and 11:20 PM, it was unclear how long her seizure lasted.Review of Resident 1's clinical record progress notes failed to reveal any documentation that Resident 1's physician was made aware that the facility did not have Resident 1's ordered lacosamide to administer on January 16 or 17, 2026, (a total of four doses missed) until after Resident 1 suffered a seizure on January 17, 2026, at 10:00 PM, requiring a transfer to the hospital for evaluation and treatment. Review of Resident 1's hospital records for her transfer on January 17, 2026, revealed no seizure medications were administered while she was at the hospital. Review of Resident 1's clinical record revealed that she returned to the facility on January 18, 2026, at 3:16 AM. At that time, the facility still did not have the required lacosamide medication. Resident 1's lacosamide was ordered to be administered on January 18, 2026, at 8:00 AM. Review of Resident 1's clinical record progress notes revealed a physician's progress note dated January 18, 2026, at 8:41 AM, which indicated that he was made aware last evening about Resident 1's lacosamide concern and seizure activity. The note further indicated that there was a concern that Resident 1 may have not gotten the lacosamide since January 11, 2026, and that the physician had issues getting a new script faxed to the pharmacy on the evening of January 17, 2026, that the facility had no acute medications to administer for seizure and he gave an order to transfer Resident 1 to the hospital for evaluation and treatment. Further review of Resident 1's clinical record progress notes revealed a physician's progress note dated January 18, 2026, at 8:43 AM, which indicated that he was called again because Resident 1 had another seizure lasting approximately 20 minutes, that there were no acute medications available at the facility to stop seizure activity, that it was still unclear if Resident 1 had been receiving her lacosamide or if the pharmacy had delivered it on January 11, 2026, and that he ordered for Resident 1 to be sent to the emergency room again for evaluation and treatment. Review of Resident 1's clinical record progress notes revealed a nurses note written by Employee 4 (RN) dated January 18, 2026, at 9:00 AM, which indicated that Resident 1 experienced another seizure from approximately 7:06 AM to 7:23 AM, and that Resident 1's physician was made aware of her seizure activity, that concerns regarding the Resident's medications were reviewed with Resident 1's physician, and that Resident 1's physician provided a new order for Ativan 1 milligram intramuscular every 12 hours as needed for seizure activity and was in agreement to send Resident 1 to emergency room again for evaluation and treatment. The note further indicated that concerns regarding Resident 1's lacosamide were discussed with emergency medical services staff at time of transfer to the hospital at approximately 7:40 AM. The note indicated that the pharmacy was contacted at approximately 8:40 AM regarding Resident 1's medication concern and a voicemail indicated the pharmacy was closed, but that an urgent message was left for the on-call pharmacist at 8:44 AM. Review of Resident 1's clinical record revealed that she returned to the facility on January 18, 2026, at 10:48 AM, and that she received her morning doses of lacosamide while in the emergency room. Review of facility provided documentation revealed that Resident 1's January 18, 2026, 8:00 PM dose of lacosamide was retrieved from the facility's emergency medication supply. Review of Resident 1's current Controlled Substance Record for her lacosamide revealed that 60 tablets were received at the facility on January 19, 2026, and the first dose was administered on January 19, 2026, at 8:00 AM. Further review of Resident 1's clinical record revealed that she had no seizure activity between August 3, 2025, and January 17, 2026, while receiving her medications and suffered two seizures, resulting in two hospital transfers when the lacosamide was not administered as ordered. During a staff interview with Employee 9 (Regional Director of Clinical Services) on January 28, 2026, at 1:25 PM, she confirmed that Employee 1 had erroneously documented administering Resident 1's lacosamide. She further indicated she had spoken to the pharmacy to get some clarification as to what occurred. Employee 9 indicated that the pharmacy said that the facility had ordered Resident 1's lacosamide on January 12, 2026, and that the pharmacy did have an active script for the medication, but it must have been overlooked by pharmacy staff and was not filled. Employee 9 also confirmed that there was no documentation in Resident 1's chart that her physician was notified about the Resident not being able to receive her lacosamide until after Resident 1 experienced her first seizure on January 17, 2026. During a staff interview with the Nursing Home Administrator (NHA), Director of Nursing (DON), and Employee 9 on January 29, 2026, at 3:50 PM, the DON indicated that she would expect nursing staff to administer a resident's medications as ordered by their physicians or to notify a resident's physician promptly for further guidance when a medication was not available to administer. The DON confirmed that facility nursing staff reordered Resident 1's lacosamide on January 12, 2026, (three days before Resident 1's supply exhausted), and that she would have expected nursing staff to follow-up with the pharmacy when the medication was not delivered when ordered. She confirmed that there was no documentation of any notifications to or from pharmacy between January 12 and 17, 2026, regarding Resident 1's lacosamide supply. The DON indicated that the facility does have lacosamide in their locked electronic emergency medication supply but nursing staff were unable to utilize this for Resident 1 between January 16 and 18, 2026, because the pharmacy said that they did not have a current script for the lacosamide and, therefore, would not supply an authorization code to retrieve the medication from the locked emergency supply. The DON further confirmed that the pharmacy indicated on January 18, 2026, after a new prescription was provided by Resident 1's physician, that the pharmacy already had a current prescription for Resident 1's lacosamide and that it was overlooked and, therefore, the mediation was not refilled when initially ordered on January 12, 2026. The DON indicated that she would expect nursing staff to reorder a medication when they are down to a five-day supply. The DON confirmed that she would expect the pharmacy to dispense and deliver medications timely or to notify the facility immediately if there was an issue with filling a medication order. Review of Resident 2's clinical record revealed diagnoses that included dementia and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of Resident 2's physician orders revealed orders for buspirone (medication to treat anxiety) 10 milligrams give one tablet every 8 hours, dated January 7, 2026; Tylenol Extra Strength 500 milligrams give two tablets three times a day, dated May 18, 2025; and Xanax (medication used to treat anxiety) 0.5 milligrams give one tablet every 8 hours, dated December 22, 2025. Review of Resident 2's January 2026 MAR revealed that on January 11, 2026, her 2:00 PM doses of her buspirone, Tylenol Extra Strength, and her Xanax were blank. Review of Resident 2's Controlled Substance Record revealed that on January 11, 2026, her 2:00 PM dose of Xanax was signed out as being administered by Employee 10 (RN). Review of Resident 2's January 2026 MAR revealed that on January 17, 2026, her 2:00 PM dose of Xanax was documented as 16 Hold/See Nurses Note. Review of Resident 2's Controlled Substance Record revealed that on January 17, 2026, her 2:00 PM dose of Xanax was signed out as being administered by Employee 6 (RN). Review Resident 2's clinical record progress notes revealed a Medication Administration Note written by Employee 6 dated January 17, 2026, at 2:52 PM, that indicated her ordered Xanax was not needed. Review of Resident 2's clinical record progress notes revealed a nurses note written by Employee 7 (LPN) dated January 17, 2026, at 8:27 PM, which indicated Resident had calling out behaviors and agitation. Resident listening to other staff and resident conversations and responding to them with agitation and yelling. Resident assisted to her room with snacks, fluids and calming music playing. Resident assisted herself with her snacks and was able to stop yelling. Resident approached by this nurse sitting in her room awake drinking her water. Resident in a pleasant mood. Resident continued to sit inside her room as this was effective for her behaviors. Review of Resident 2's January 2026 MAR revealed that on January 21, 2026, her 2:00 PM doses of her buspirone, Tylenol Extra Strength, and her Xanax were blank. Review of Resident 2's Controlled Substance Record revealed that on January 21, 2026, her 2:00 PM dose of Xanax was signed out as being administered by Employee 1. Review of Resident 2's clinical record progress notes failed to reveal any documentation as to why her ordered doses of buspirone, Tylenol Extra Strength, and her Xanax were not administered as ordered on January 11 and 21, 2026. Review of Resident 2's January 2026 MAR revealed that on January 26, 2026, her 6:00 AM and 2:00 PM doses of Xanax were documented as 16 Hold/See Nurses Note. Review of Resident 2's clinical record progress notes revealed a Medication Administration Note written by Employee 8 (LPN) dated January 26, 2026, at 8:45 AM, that indicated Resident 2's Xanax was not administered and awaiting pharmacy delivery. Review of Resident 2's clinical record progress notes revealed a nurses note written by Employee 4 dated January 26, 2026, at 3:34 PM, that indicated Employee 4 contacted the pharmacy about retrieving Resident 2's Xanax from the emergency medication supply. Employee 4 questioned why they could not administer Xanax 0.25 milligrams two tablets to equal Resident 4's ordered dose of 5 milligrams, but that the pharmacy indicated that medications must be dispensed as written. The note further indicated that Employee 4 contacted Resident 2's physician for further orders and that the pharmacy indicated that the medication would be on the next pharmacy delivery to the facility. Review of Resident 2's clinical record progress notes revealed a nurses note written by Employee 4 dated January 26, 2026, at 4:27 PM, that indicated Resident 2's physician gave a one-time order for Xanax 0.25 milligrams give two tablets now. Review of Resident 2's current Controlled Substance Record revealed that the pharmacy filled the Xanax prescription on January 25, 2026, but the Receipt Verification section of the form was blank. According to the record, the first dose was administered from the package on January 26, 2026, at 6:30 PM. During a staff interview with the NHA, DON, and Employee 9 on January 29, 2026, between 3:48 PM and 4:00 PM, the DON indicated that she would expect nursing staff to administer a resident's medications as ordered by their physicians and complete documentation appropriately. The NHA indicated that Resident 2's medication packets were audited and that there were no pill pouches still in the cart dated for January 11 and 21, 2026, and, therefore, the Tylenol and buspirone medications must have been administered and that the nurses must have failed to complete all the administration documentation of Resident 2's medications on those dates. The DON indicated that she would expect nursing staff to reorder a medication when they are down to a five-day supply. The DON confirmed that she would expect the pharmacy to dispense and deliver medications timely or to notify the facility immediately if there was an issue with filling a medication order. The DON confirmed that she would expect staff to complete the Receipt Verification on a resident's Controlled Substance Record. At the interview, no additional information was provided regarding the conflicting documentation of Resident 2's January 17, 2026, 2:00 PM, dose of Xanax or information as to when nursing staff reordered Resident 2's Xanax from the pharmacy. Review of Resident 3's clinical record revealed diagnoses that included dementia, hypertension (high blood pressure), and unspecified cough. Review of Resident 3' s physician orders revealed orders for albuterol sulfate nebulization solution 2.5 milligrams/ 3 milliliters 0.083% administer 3 milliliters orally via nebulizer every four hours, dated October 31, 2025; geri-tussin oral syrup 100 milligrams/5 milliliters give 10 milliliters every four hours, dated October 31, 2025; and Protonix delayed release 40 milligrams in the morning, dated October 30, 2025. Review of Resident 3's November 2025 MAR revealed that on November 1, 2025, his 4:00 AM doses of albuterol and geri-tussin as well as his 6:00 AM dose of Protonix were blank. Review of Resident 3's clinical record progress notes failed to reveal any documentation as to why these medications were not administered as ordered. During a staff interview with the NHA, DON, and Employee 9 on January 29, 2026, between 3:48 PM and 4:00 PM, the DON indicated that she would expect nursing staff to administer a resident's medications as ordered by their physicians and to complete all documentation appropriately. She indicated that she had a call out to the nurse to determine if Resident 3 received his medications. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.9(a)(1) Pharmacy services28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to provide pharmaceutical services to accurately acquire, receive, dispense, and administer drugs to meet the needs of each resident for two of three residents reviewed (Residents 1 and 2), which resulted in actual harm as evidenced by two hospital transfers for seizure activity for one of three residents reviewed (Resident 1).Findings include:Review of facility policy, titled IC4: Ordering and Receiving Controlled Medications, undated, revealed, in part, Schedule II controlled medications prescribed for a specific resident are delivered to the facility only if a faxed or original written prescription has been received by the pharmacy. Schedule III, IV and V may also be dispensed pursuant to a verbal order from the physician. In addition, if medication is needed prior to the next delivery, the pharmacist may authorize a nurse at the facility to remove a supply of the medication from the emergency supply in the facility according to policy IC5. In an emergency situation, the provider pharmacy can accept a telephone order for a schedule II medication. The DEA defines emergency to mean that the immediate administration of the drug is necessary for the proper treatment of the intended individual, that no alternative is available and that it is not possible for the prescriber to provide a prescription for the drug at that time. In no situations will an emergency dispensing exceed a 7-day supply. An individual resident's controlled substance record is prepared by the pharmacy or the facility for each controlled substance medication prescribed for a resident. The following information is completed: 1) Name of resident 2) Prescription number 3) Drug name, strength (if designated), and dosage form of medication 4) Date received 5) Quantity received and 6) Name of person receiving the medication supply. Schedule II controlled substance medications are reordered when a seven-day supply remains to allow for transmittal of the prescription to the pharmacist. Review of Resident 1's clinical record revealed diagnoses that included epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures) 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 1's physician orders revealed orders for lacosamide (a medication used to manage seizure activity) 100 milligrams give one tablet by mouth every 12 hours. Review of Resident 1's Controlled Substance Record (document for signing out and tracking medications) for her ordered lacosamide revealed that 30 tablets were received at the facility on December 29, 2025, and nursing staff began administering the medication from this package on January 1, 2026, at 9:10 AM. Further review of this record revealed that the last dose was administered to Resident 1 on January 15, 2026, at 8:00 PM. Further review of Resident 1's January 2026 Medication Administration Record (MAR) revealed that her lacosamide was documented as 16 Hold/See Nurses Note for her January 16, 2026, 8:00 PM dose administration and her January 17, 2026, 8:00 AM and 8:00 PM dose administrations. Review of Resident 1's clinical record revealed a Medication Administration Note dated January 16, 2026, at 8:12 PM, that indicated Resident 1's lacosamide was on order from the pharmacy. Review of Resident 1's clinical record revealed a Medication Administration Note dated January 17, 2026, at 1:26 PM, that indicated Resident 1's lacosamide was on back order and pharmacy was notified. Review of Resident 1's clinical record revealed a Medication Administration Note dated January 17, 2026, at 10:26 PM, that indicated Resident 1's lacosamide was not available, pharmacy was called, and that the medication was on order. Review of Resident 1's clinical record progress notes revealed a nurse's note written by Employee 2 (Licensed Practical Nurse [LPN]) dated January 17, 2026, at 10:40 PM, which indicated that Resident 1 was noted to be having a seizure which lasted from 10:20 PM to 10:26 PM. The note further indicated a call had been placed to the pharmacy earlier in the day regarding Resident 1's lacosamide and that the pharmacy indicated that the drug would be sent. The note also indicated that when Employee 2 called the pharmacy again to confirm that the lacosamide would be in the next pharmacy delivery run (night of January 17, 2026), the pharmacy indicated a script would be needed to dispense Resident 1's lacosamide. The note indicated that Employee 3 (Registered Nurse [RN]) reached out to the physician and requested that Resident 1 be sent out for further evaluation. Review of Resident 1's clinical record progress notes revealed a nurse's note written by Employee 3 (RN) dated January 17, 2026, at 11:20 PM, which indicated that Resident 1 had a seizure that lasted approximately 20-25 minutes. The note further indicated that Resident 1's physician was made aware of Resident 1's seizure, that her ordered lacosamide was not available, and that Resident 1's physician provided a new order to send Resident 1 to the hospital for evaluation and treatment. Based on review of Resident 1's progress notes for January 17, 2026, at 10:40 PM and 11:20 PM, it was unclear how long her seizure lasted. Review of the written statement from Employee 1 (LPN) on January 28, 2026, revealed that Employee 1 called the pharmacy on January 16, 2026, to inform them that Resident 1 was out of her lacosamide and it was needed. The statement indicated that the medication had already been ordered days prior and that the pharmacy indicated that the medication would be on the next pharmacy delivery. Review of Resident 1's clinical record progress notes revealed a nurses note written by Employee 4 (RN) dated January 18, 2026, at 9:00 AM, which indicated that Resident 1 experienced another seizure from approximately 7:06 AM to 7:23 AM, and that Resident 1's physician was made aware of her seizure activity, that concerns regarding the Resident's medications were reviewed with Resident 1's physician, and that Resident 1's physician provided a new order for Ativan (an antianxiety medication that can be used to treat seizures) 1 milligram intramuscular every 12 hours as needed for seizure activity and was in agreement to send Resident 1 to emergency room again for evaluation and treatment. The note further indicated that concerns regarding Resident 1's lacosamide were discussed with emergency medical services staff at time of transfer to the hospital at approximately 7:40 AM. The note indicated that the pharmacy was contacted at approximately 8:40 AM regarding Resident 1's medication concern and a voicemail indicated the pharmacy was closed, but that an urgent message was left for the on-call pharmacist at 8:44 AM. Review of Resident 1's clinical record progress notes revealed a nurse's note written by Employee 3 dated January 18, 2026, at 9:42 AM, which indicated that prescriptions for Resident 1's lacosamide and Ativan were signed by Resident 1's physician and faxed to the pharmacy at 8:51 AM. Review of Resident 1's clinical record progress notes revealed a nurses note written by Employee 3 dated January 18, 2026, at 9:43 AM, which indicated that the pharmacy had called the facility and discussed concerns with Resident 1's lacosamide. The note further indicated that the pharmacist determined that the last delivery date of Resident 1's lacosamide was on December 28, 2025, with a 15-day supply. The pharmacist indicated that the pharmacy already had a script for the lacosamide and confirmed that Resident 1's lacosamide and Ativan would be included in the next pharmacy delivery to the facility (night of January 18, 2026). Review of Resident 1's January 2026 MAR revealed that she was administered a dose of lacosamide on January 18, 2026, at 8:00 PM, by Employee 5 (LPN). The dose of lacosamide was retrieved from the facility's emergency medication supply. Review of Resident 1's current Controlled Substance Record for her lacosamide revealed that 60 tablets were received at the facility on January 19, 2026, and the first dose was administered on January 19, 2026, at 8:00 AM. Further review of Resident 1's clinical record revealed that she had no seizure activity between August 3, 2025, and January 17, 2026, while receiving her medications and suffered two seizures resulting in two hospital transfers when her lacosamide was not administered as ordered as a result of the pharmacy failing to provide Resident 1's ordered medication or communication to the facility in a timely manner as to why medication could not be supplied when initially ordered. During a staff interview with Employee 9 (Regional Director of Clinical Services) on January 28, 2026, at 1:25 PM, she confirmed that Employee 1 had erroneously documented administering Resident 1's lacosamide. She further indicated she had spoken to the pharmacy to get some clarification as to what occurred. Employee 9 indicated that the pharmacy said that the facility had ordered Resident 1's lacosamide on January 12, 2026, and that the pharmacy did have an active script for the medication, but the pharmacy indicated that it must have been overlooked by pharmacy staff and was not filled as requested. During a staff interview with the Nursing Home Administrator (NHA), Director of Nursing (DON), and Employee 9 on January 29, 2026, between 3:48 PM and 4:00 PM, the DON confirmed that facility nursing staff reordered Resident 1's lacosamide on January 12, 2026, (three days before Resident 1's supply exhausted), and that she would have expected nursing staff to follow-up with the pharmacy when the medication was not delivered when ordered. She confirmed that there was no documentation of any notifications to or from pharmacy between January 12 and 17, 2026, at 1:26 PM regarding Resident 1's lacosamide supply. The DON indicated that she would expect nursing staff to reorder a medication when they are down to a five-day supply. The DON further indicated that the facility does have lacosamide in their locked electronic emergency medication supply, but nursing staff were unable to utilize this for Resident 1 between January 16 and 18, 2026, because the pharmacy said that they did not have a current script for the lacosamide and, therefore, would not supply an authorization code to retrieve the medication from the locked emergency supply. The DON further confirmed that the pharmacy indicated on January 18, 2026, after a new prescription was provided by Resident 1's physician, that the pharmacy already had a current prescription for Resident 1's lacosamide and that it was overlooked by pharmacy staff and, therefore, the medication was not refilled when initially ordered on January 12, 2026. The DON confirmed that she would expect the pharmacy to dispense and deliver medications timely or to notify the facility immediately if there was an issue with filling a medication order. Review of Resident 2's clinical record revealed diagnoses that included dementia and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of Resident 2's physician orders revealed an order for Xanax (medication used to treat anxiety) 0.5 milligrams give one tablet every 8 hours, dated December 22, 2025. Review of Resident 2's clinical record progress notes revealed a Medication Administration Note written by Employee 8 (LPN) dated January 26, 2026, at 8:45 AM, that indicated Resident 2's Xanax was not administered and awaiting pharmacy delivery. Review of Resident 2's clinical record progress notes revealed a nurses note written by Employee 4 (RN) dated January 26, 2026, at 3:34 PM, that indicated Employee 4 contacted the pharmacy about retrieving Resident 2's Xanax from the emergency medication supply. Employee 4 questioned why they could not administer Xanax 0.25 milligrams two tablets to equal Resident 4's ordered dose of 5 milligrams, but that the pharmacy indicated that medications must be dispensed as written. The note further indicated that Employee 4 contacted Resident 2's physician for further orders and that the pharmacy indicated that the medication would be on the next pharmacy delivery to the facility. Review of Resident 2's clinical record progress notes revealed a nurses note written by Employee 4 dated January 26, 2026, at 4:27 PM, that indicated Resident 2's physician gave a one-time order for Xanax 0.25 milligrams give two tablets now. Review of Resident 2's current Controlled Substance Record revealed that the pharmacy filled the Xanax prescription on January 25, 2026, but the Receipt Verification section of the form was blank. According to the record, the first dose was administered from the package on January 26, 2026, at 6:30 PM. During a staff interview with the NHA, DON, and Employee 9 on January 29, 2026, between 3:48 PM and 4:00 PM, the DON indicated that she would expect nursing staff to reorder a medication when they are down to a five-day supply. The DON confirmed that she would expect the pharmacy to dispense and deliver medications timely or to notify the facility immediately if there was an issue with filling a medication order. The DON confirmed that she would expect staff to complete the Receipt Verification on a resident's Controlled Substance Record. At time of interview, no additional information was provided regarding when nursing staff reordered Resident 2's Xanax from the pharmacy or why there was a delay in delivery from the pharmacy. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.9(a)(1) Pharmacy services28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on clinical record review, observations, facility document review, staff interviews, and facility policy review, it was determined that the facility displayed past non-compliance by failing to implement interventions, supervision, and effective safety measures to prevent elopement of a resident identified as being at risk for elopement and exhibiting exit seeking behaviors (Resident 1). Resident 1 was found approximately one half mile from the facility approximately 17.5 hours following his elopement with injury to his forehead. This failure placed an additional 16 residents, who were identified as being at risk on their elopement risk evaluations, in an immediate jeopardy situation (Residents 2, 4, 5, 6, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, and 20). Findings include: Review of facility policy, titled Elopement, revised June 2023, read, in part; It is the policy of this facility to provide a safe and secure environment for our residents and to be proactive in preventing resident elopement. Residents at risk for elopement will be appropriately monitored to reduce the potential for injury . Residents that are identified at moderate or high risk for elopement will have an intervention implemented for their safety. Those residents identified as low risk will have an Interdisciplinary review to determine if intervention/s are necessary . Elopement risk will be care planned with individualized approaches to reduce the potential for elopement and/or to redirect the resident in the event that an elopement attempt is made .Electronic monitoring systems may be implemented as possible interventions as appropriate. Review of Resident 1's clinical record revealed diagnoses that included alcohol dependence with alcohol-induced persisting dementia (caused by long-term, excessive consumption of alcohol, resulting in neurological damage and impaired cognitive function) and Alzheimer's disease (progressive neurological disorder characterized by a gradual decline in memory, thinking, and behavior due to the build-up of proteins in the brain, leading to death of brain cells). Further review of Resident 1's clinical record revealed that he was admitted to the facility from the hospital on April 9, 2025. Review of hospital treatment notes dated March 31, 2025, through April 4, 2025, indicated that Resident 1 required a sitter as an elopement precaution while hospitalized . Review of Resident 1's elopement/wander risk evaluation completed on April 9, 2025, revealed a score of 11 (high risk) with suggested care plan intervention to provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Review of Resident 1's nursing progress notes revealed the following: April 9, 2025 15:20 - Resident pushing on exit doors, increasingly agitated, asking how the hell do I get out of here. Resident began banging on doorway to steps. Staff attempting to redirect with little effect. April 10, 2025 12:43 - Resident sitting in his winter coat, saying he needs to go get in his truck. Resident pushing on exit doors. April 16, 2025 09:47 - Actively exit seeking all morning. Staff provided redirecting, provided snack/drinks, 1:1 conversation, activity with no effect. Resident banging on doors. Resident asking how to leave to get to his truck. Resident increasingly agitated and becoming tired. April 16, 2025 11:26 - Stated he wanted to get out of here, cont.[continuing] to exit seek. Attempting redirection, taken to TV room for monitoring. April 19, 2025 12:48 - Pacing the unit all day. Frequently states he is looking for a way to get out so he can 'get to his truck.' April 20, 2025 11:33 - Resident Eloped on 4/19/25 - Search party continues at this time. Resident is not in facility. Review of facility incident report revealed that on April 19, 2025, at 9:25 PM, staff identified that Resident 1 was missing. A facility search was conducted and a resident count was completed at that time. After Resident 1 was not able to be located, 911 was called at 9:50 PM. Police arrived at 10:00 PM and began their investigation. At 10:15 PM, additional police personnel, [NAME], and K9 support arrived and continued the search. IT personnel arrived and pulled video from the facility lobby, which showed Resident 1 left the facility via the front doors at 6:33 PM. Around noon on April 20, 2025, fire police entered the building and informed staff that Resident 1 was located approximately one half mile from the facility attempting to get into a truck, and was being sent to the emergency department for evaluation and treatment of scratches on his head. Resident 1 returned to the facility from the emergency department at 5:47 PM. Further review of the incident report revealed that, upon investigation, it was determined that no alarms sounded nor did anything else bring Resident 1's exit to staff's attention. It was determined that Resident 1 likely exited the locked unit where he resided by following a visitor or staff person who had entered the exit code to the doors. Review of emergency department treatment notes dated April 20, 2025, revealed that Resident 1 was brought to the emergency department by Emergency Medical Services (EMS) and that he had superficial lacerations and abrasions to his forehead. It was noted that Resident 1 did not recall if or how he fell. Resident 1 was able to tell his name, but did not know where he was or the date. Resident 1 believed he lived at home with his wife. Additional review revealed that Resident 1 was treated for a 2 cm (centimeter) U-shaped laceration to the right forehead. During an interview with the Director of Nursing (DON) on April 23, 2025, at 11:35 AM, she revealed that after investigation they were not able to conclusively state how Resident 1 was able to exit the locked unit, but it's assumed that he followed, or was let out by, a visitor since he could have been easily mistaken for a visitor himself. The DON also revealed that until the incident, it had been the practice that family members and visitors knew and could independently enter the codes needed to exit the locked unit doors. Additionally, the DON revealed that the use of wanderguard monitors for residents residing on the locked unit was discontinued by the prior administration. During a later interview with the DON on April 23, 2025, at 11:55 AM, she confirmed that the front lobby doors were not locked from the inside. She also revealed that the lobby was not routinely monitored since the receptionist position is vacant, and administrative staff with offices in that area are not typically present after normal work hours. During an additional interview with the DON on April 24, 2025, at 9:15 AM, she confirmed that no staff were present in the offices nearest to the lobby when Resident 1 exited the building on April 19, 2025. She also revealed the expectation that Resident 1 would not have left the building unaccompanied. The facility is located on a main road. There are parking lots on each side of the front entrance, and a portico located at the main front entrance outside of the door that vehicles can drive through. Clinical record review for Residents 1, 2, 4, 5, 6, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, and 20 revealed that they resided on the locked unit and scored greater than zero on their elopement risk evaluations. Per the aforementioned interview with the DON, wanderguards were not in use for residents residing on the locked unit. The facility failed to implement interventions, supervision, and effective safety measures to prevent elopement. The Nursing Home Administrator was provided the immediate jeopardy template on April 23, 2025, at 1:16 PM, and an immediate action plan was requested. On April 23, 2025, at 3:32 PM, the facility's immediate action plan was accepted, which included: 1) The facility completed a new resident elopement evaluation and updated Resident 1's care plan . Resident 1 was issued an electronic monitoring device. 2) The facility completed new elopement evaluations on all current residents in house. Care plans were updated based on the risk score. Other residents identified at risk for elopement were issued an electronic monitoring device. 3) The egress time on the locked unit doors was reduced from 20 to 10 seconds. 4) The egress code was changed for the locked unit doors. 5) Additional signage was posted near the locked unit exits to remind visitors and staff not to allow residents to exit the unit unassisted. 6) Staff were educated on the current elopement policy, including the code changes and escorting all non-employees off the locked unit. 7) The DON or designee will audit new admission elopement scores to determine if appropriate interventions are in place. The audits will be reviewed at QAPI (Quality and Process Improvement) meetings. The Immediate Jeopardy was lifted on April 23, 2025, at 3:32 PM, after ensuring that the immediate action plan had been implemented. The facility demonstrated past non-compliance by initiating immediate interventions starting April 20, 2025, following the incident. Documents and actions provided by the facility to address the Immediate Jeopardy were reviewed on April 23, 2025, during the onsite survey and included: - A new elopement risk assessment was completed for Resident 1 on April 20, 2025. His care plan was updated and an electronic monitoring device was issued. Resident 1 was placed on 1:1 supervision during waking hours and 15 minute checks when sleeping. - An audit of all residents was completed on April 20, 2025 to identify those at risk for elopement. Electronic monitoring devices were issued to those residents determined to be at risk for elopement. Care plans were updated accordingly. - The code to the locked unit door was changed on April 21, 2025, and the escort time was shortened from 20 seconds to 10 seconds. - Staff were educated not to share the new codes with visitors and to assist them off of the unit. - Additional signage was placed at the locked unit doors to notify visitors and staff not to allow residents to exit the unit unassisted. - Staff were educated on the facility elopement policy. - An elopement drill was conducted on April 22, 2025. - Audits were initiated on April 21, 2025, and will be done daily on new admissions to determine if elopement risk is present and appropriate interventions are in place. During the onsite survey on April 23, 2025, no additonal concerns related to elopement were identified based on observations, clinical record review, interviews with staff, review of audits, and review of education provided to staff. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, and staff and resident representative interviews, it was determined that the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status for three of six residents reviewed for nutrition or hydration (Residents 17, 28, and 58). This failure resulted in harm for Resident 17, as evidenced by significant weight loss. Findings include: Review of facility policy, titled Weight Monitoring, last reviewed January 17, 2025, read, in part, The facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the residents clinical condition demonstrates this is not possible or residents preferences indicate otherwise .the facility will utilize a systematic approach to optimize a residents nutritional status. This process includes .Monitoring the effectiveness of interventions and revising them as necessary .Residents with weight loss-monitor weight weekly .the physician should be informed of a significant change in weight and may order nutritional interventions .The Registered Dietitian or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes .the interdisciplinary plan of care communicates care instructions to staff. Review of Resident 17's clinical record revealed diagnoses that included vascular dementia (a type of dementia caused by brain damage from impaired blood flow marked by memory disorders, personality changes, and impaired reasoning), dysphagia (difficulty swallowing), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). Review of Resident 17's clinical record revealed he had oral surgery on May 20, 2024, with recommendation to follow a soft diet for a week after surgery. Review of Resident 17's physician orders revealed a diet order, Regular diet, Mechanical Soft texture, Regular/Thin consistency, Soft diet is recommended for first week post extractions, with a start date of May 20, 2024, and discontinued May 27, 2024. Review of Resident 17's physician orders revealed a diet order, Regular diet, Regular texture, Regular/Thin consistency, mechanical soft meats; add gravy to meats, with a start date of May 28, 2024, and discontinued on June 16, 2024. Review of Resident 17's physician orders revealed a change to the diet order on June 16, 2024, Regular diet, Puree texture, Regular/Thin consistency. Review of Resident 17's clinical record revealed a progress note on June 16, 2024, that stated Resident was in dining room at lunch and resident was observed coughing on corn. Resident was able to clear the corn. Resident also noted to be coughing on mechanical soft ground ham. Spoke with resident and resident is ok with puree foods. Spoke with POA (power of attorney- legal representative) who was unaware that resident went back to Regular diet mechanical soft meats. POA is ok with resident being pureed. Dietary made aware. Review of Resident 17's clinical record revealed a significant weight loss of 28 pounds (-10.4%) from April 23, 2024, to October 18, 2024. Review of Resident 17's clinical record revealed a dietitian note on October 25, 2024, that read, in part, Review of monthly weight. Current weight of 241.8 pounds (October 18, 2024) triggers as a significant loss in 6 months. Weight fluctuations anticipated related to diuretic therapy. Recommending weekly weights to monitor trend. Resident continues to tolerate a regular diet, puree, thin liquids. Weight loss and intake reviewed with POA; POA is not interested in supplementation at this time. POA sees weight loss as beneficial. Care plan reviewed/updated. A follow up dietitian note was linked to the aforementioned note on October 29, 2024, that read, Per nursing, resident with decreased snacking between meals; may contribute to weight loss. Review of Resident 17's physician orders on February 5, 2025, revealed that the diuretic was not a new medication for him, and he had been on it since March 1, 2023. Review of Resident 17's physician orders revealed an order to Weigh weekly every day shift every Monday, with a start date of October 28, 2024. Review of Resident 17's clinical record failed to reveal weekly weights were obtained on the week of November 11 and 18, 2024. During an email correspondence with the Nursing Home Administrator (NHA) on February 5, 2025, at 11:49 AM, the surveyor inquired if the aforementioned weekly weights were obtained, she revealed, These weights were not obtained. On November 11, 2024, the PRN [as needed] nurse who was working didn't sign off with no explanation. On November 18, 2024, the agency nurse signed off saying it would be obtained on 3-11 shift, but the weight was then missed by 3-11. Additionally, during the email correspondence with the NHA on February 5, 2025, at 11:49 AM, she revealed [Physician notification of] weight loss missing on [Resident 17] due to communication between dietitian and POA stating she felt the weight loss was ok due to his current weight. Therefore, no notification was made to the physician. We had lots of conversation at interdisciplinary meetings around this as [Resident 17] had recently had oral surgery and was not snacking as prior. He also had been downgraded to puree diet and he was not happy with his meal options. All weight loss (anticipated and not) is discussed at QAPI (quality assurance meeting) monthly. [Resident 17's] weight loss situation did not follow normal protocol due to circumstances explained. In an additional interview with the NHA on February 5, 2025, at 1:39 PM, she stated that residents with weight loss are discussed in QAPI, and the physician signs the QAPI sign in sheet. No physician notification or response to the weight loss was noted in Resident 17's medical record. Review of Resident 17's weight measures revealed his weight loss continued 8.8 pounds (-3.6%) from October 18, 2024, to December 2, 2024. Review of Resident 17's clinical record revealed a dietitian note on December 4, 2024, that read, in part, Weight and intake reviewed with [POA]; she maintains wish for no supplementation at this time. Further review of Resident 17's weight measures revealed his weight loss continued 8.2 pounds (-3.5%) from December 2, 2024, to January 20, 2025. Review of Resident 17's clinical record revealed a physician note written by Employee 6 (Medical Director) on January 30, 2025, that read, Resident weight noted down some, intake good, on Lasix [diuretic medication] monitor [electro]lytes, NAD, today eating lunch. Interview with Employee 2 (Registered Dietitian) on February 5, 2025, at 1:35 PM, revealed she was concerned about Resident 17's weight loss, but the Resident's POA did not want him on supplements. During an interview with the NHA and the Director of Nursing (DON) on February 5, 2025, at 1:39 PM, revealed the weekly weights that were missed should have been obtained per physician order, and that Resident 17 has remained on a puree diet because his POA refused speech therapy services for a potential diet upgrade. The surveyor requested documentation in the medical record to indicate the refusal of speech therapy services and any physician involvement in response to weight loss prior to January 30, 2025. Interview with Resident 17's POA on February 6, 2025, at 2:58 PM, revealed she did not refuse speech therapy services and that, when supplements were discussed with her, she was concerned that Resident 17 needs more food rather than supplements, and he would eat more food if he wasn't on a puree diet. Follow-up interview with the NHA and DON on February 6, 2025, at 3:38 PM, the surveyor revealed the concern with lack of documentation to indicate speech therapy services were refused and lack of physician response to the significant weight loss, no further information was provided. The Resident was noted to have significant weight loss. The Resident was not reassessed by speech therapy after his diet was downgraded in June 2024. There was no evidence that a speech therapy consult or supplements were discussed with the physician. There were no physician progress notes that addressed Resident 17's weight loss from when his weight loss became significant in September 2024, until January 30, 2025. Review of Resident 28's clinical record revealed diagnoses that included heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), 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 28's physician orders revealed an order for Daily weight - Notify MD if increase of 3 pounds in 24 hr or gain/loss of 5 pounds in 1 week every night shift for fluid balance management, with an original order date of October 26, 2024. Review of Resident 28's Treatment Administration Record for October revealed that on October 28, 2024, the weight and signature box were both blank; October 30, 2024, was signed as completed on night shift but the box where the weight was to be entered was marked with an X and the entries for the weight and signature boxes on day shift were blank; and October 31, 2024, was signed as completed on night shift with an X marked in the box where the weight was to be entered. Review of additional information provided by the facility revealed that Resident 28 weighed 144 pounds on October 30, 2024, and weighed 152.3 pounds on October 31, 2024, indicating an 8.3-pound weight gain in 24 hours. Review of Resident 28's progress notes failed to reveal any documentation that their physician was notified of the greater than 3-pound weight gain in 24 hours on October 31, 2024. Review of Resident 28's Treatment Administration Record for November 2024 revealed that the Resident refused their weight on November 15 and 24, 2024. All other entries for the month were signed that the weight was obtained, but the box where the weight was to be entered was marked with an X. Review of Resident 28's Treatment Administration Record for December 2024 revealed that on December 10 and 11, 2024, the weight and signature box were both blank; December 1-9, and 12-20, 2024, were signed that the weight was obtained, but the box where the weight was to be entered was marked with an X. Further review of Resident 28's Treatment Administration Record for December 2024 revealed that on December 24, 2024, the Resident weighed 146.8 pounds and on December 25, 2024, weighed 150 pounds; indicating a 3.2-pound weight gain in 24 hours. In addition, on December 28, 2024, the Resident weighed 153.5 pounds and on December 29, 2024, weighed 156.8 pounds; indicating a 3.3-pound weight gain in 24 hours. Review of Resident 28's progress notes failed to reveal any documentation that their physician was notified of the greater than 3-pound weight gain in 24 hours on December 25 or 29, 2024. Review of Resident 28's Treatment Administration Record for January 2025 revealed that the Resident refused their weight on January 11, 13, 16, 17, and 24, 2025; and on January 1 and 19, 2025, the weight and signature boxes were both blank. Further review of Resident 28's Treatment Administration Record for January 2025 revealed that on January 29, 2025, the Resident weighed 150.8 pounds and on January 30, 2025, weighed 157 pounds; indicating a 6.2-pound weight gain in 24 hours. Review of Resident 28's progress notes failed to reveal any documentation that their physician was notified of the greater than 3-pound weight gain in 24 hours on January 30, 2025. Review of Resident 28's Treatment Administration Record for February revealed that on February 1 and 4, 2025, the weight and signature boxes were both blank. Further review of Resident 28's clinical record revealed a nutrition/dietary note dated October 28, 2024, at 12:04 PM, that indicated a comprehensive nutrition assessment had been completed when Resident 28 returned from a hospital stay. The note indicated that Resident 28 had experienced a significant weight gain over 30 days, 3 months, and 6 months. There was a late entry nutrition/dietary note dated October 28, 2024, at 3:28 PM, that indicated Resident 28 had experienced a significant weight loss following hospitalization , not a significant gain as previously documented. Review of Resident 28's progress notes revealed a physician's progress note dated October 29, 2024, at 4:27 PM, which indicated that Resident 28 was seen post hospital stay and the vital signs and appetite were ok and that the Resident had minimal edema (swelling) to their bilateral legs. There was no documentation of an assessment of Resident 28's significant weight loss. Email communication received from the NHA on February 5, 2025, at 8:33 PM, indicated that she acknowledged Resident 28 had missing weights. During an interview with the NHA, DON, and Employee 2 (Dietician) on February 6, 2025, at 11:53 AM, Employee 2 confirmed that Resident 28 had a significant weight loss upon return to the facility from a hospital stay. Employee 2 indicated that the weight loss was reviewed with Resident 28's physician during the Quality Assurance Performance Improvement (QAPI) Meeting on November 15, 2024. The DON confirmed that she would expect staff to obtain and document resident weights as ordered and that staff should have notified Resident 28's physician of the greater than 3-pound weight gains as per physician order. Email communication received from the NHA on February 6, 2025, at 1:29 PM, confirmed that Resident 28's October 28, 2024, weight loss was reviewed in the facility's QAPI Meeting on November 15, 2024, at which Resident 28's physician was in attendance. She confirmed that she had no information to provide that the physician assessed Resident 28 for their weight loss. In addition, the NHA confirmed that she would expect that Resident 28's daily weights to be obtained, documented, and physician follow-up completed as indicated in the order. During a staff interview with the NHA and the DON on February 6, 2025, at 2:10 PM, the NHA acknowledged that the Resident 28's physician was not made aware of their weight loss identified on October 28, 2024, until November 15, 2024. During a final staff interview with the NHA, DON, and Employee 2 on February 6, 2025, 2:25 PM, the DON indicated that she could not give a direct expectation of physician notification of a weight loss because it is on a case-by-case basis. She said that she felt Resident 28's physician was aware that she had been hospitalized in October and that he would have been aware of treatment received at the hospital regarding her fluid status and the continued monitoring at the facility. Review of Resident 58's clinical record revealed diagnoses that included dementia, heart failure, and dysphagia (difficulty swallowing). Review of Resident 58's progress notes revealed a weight change note dated August 1, 2024, at 3:56 PM, that indicated Resident 58's weekly weights were reviewed and that Resident 58 current weight triggered as a significant loss (7.1%) over 30 days. The note also indicated that the weight fluctuations would be anticipated related to diuretic therapy. Review of Resident 58's progress notes revealed a nutrition/dietary note dated August 16, 2024, at 10:06 AM, that indicated that Resident 58's weekly weights were reviewed and that Resident 58's weight was fairly stable over approximately a 3-week span, but the Resident continued to trigger for a significant loss over 30 days. Review of Resident 58's physician progress notes that were dated August 7, 11, 15, 16, 22, and 28, 2024, all of which failed to reveal any documentation of them being aware of or evaluating Resident 58's significant weight loss. Review of Resident 58's clinical record revealed a nutrition/dietary note dated October 24, 2024, at 3:00 PM, that indicated a comprehensive nutrition assessment was completed upon the Resident's return to the facility from a hospital stay, and Resident 58 was noted to have a significant loss over 30 and 180 days following hospitalization . The note further indicated that weekly weight monitoring was in place per admission protocol, that Resident 58's oral intake was not adequate to meet needs, and supplements were added. Review of Resident 58's physician progress notes revealed notes that were dated October 25, 28, 29, and 30, 2024, all of which failed to reveal any documentation of them being aware of or evaluating Resident 58's significant weight loss. Review of Resident 58's Treatment Administration Record for November 2024 revealed that on November 18, 2024, it was signed that the weight was obtained, but the box where the weight was to be entered was marked with an X. Email communication from the NHA on February 5, 2025, at 8:33 PM, regarding Resident 58's identified weight losses on August 1 and 16, 2024, the dietician documented that weight was stable and that weight loss was anticipated due to diuretic therapy and this would not be considered emergent and would be discussed at QAPI. The NHA further indicated that in November 2024 and December 2024 Resident 58's weight loss remained on the dietician's report and that there was still monitoring of the weight loss. She also indicated that Resident 58's weight loss was first discussed in August QAPI meeting reports, in which Resident 58's physician participated. During a staff interview with the NHA, DON, and Employee 2 on February 6, 2025, at 12:20 PM, the NHA confirmed that they could not provide any information for Resident 58's weight being signed as completed with no weight recorded on November 18, 2024. She said that she would expect weights to have been obtained as ordered by the physician. She again indicated that weight losses were reviewed with the physician during the facility's monthly QAPI meeting. She confirmed that there was no physician documentation regarding Resident 58's weight loss. During a final staff interview with the NHA, DON, and Employee 2 on February 6, 2025, at 2:25 PM, the DON indicated that she could not give a direct expectation of physician notification of weight loss because it is on a case-by-case basis. 28 Pa Code 201.18(b)(1) Management 28 Pa Code 211.2(d)(3) Medical director 28 Pa Code 211.12(c)(d)(1)(2)(3)(5) Nursing services

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure proper monitoring and timely implementation of interventions to maintain acceptable parameters of nutritional status for four of 17 residents reviewed (Residents 22, 23, 45, and 57), resulting in actual harm as evidenced by continued weight loss after a significant weight loss was documented for two of 17 residents reviewed (Residents 22 and 45). Findings include: Review of facility policy, titled Weight Monitoring, dated October 2022, read, in part, The facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the residents clinical condition demonstrates this is not possible or residents preferences indicate otherwise .the facility will utilize a systematic approach to optimize a residents nutritional status. This process includes .Monitoring the effectiveness of interventions and revising them as necessary .Residents with weight loss-monitor weight weekly .the physician should be informed of a significant change in weight and may order nutritional interventions .The Registered Dietitian or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes .the interdisciplinary plan of care communicates care instructions to staff. Review of Resident 22's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), dysphagia (difficulty swallowing), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). Review of Resident 22's weights revealed she weighed 127.5 pounds (lbs) on January 22, 2024; 109.8 lbs on February 2, 2024; 109.7 lbs on February 7, 2024; and 107.4 lbs on February 13, 2024. This equated to a weight loss of 17.7 pounds (-13.8%) from January 22, 2024, to February 2, 2024, and a continued weight loss of 2.4 pounds (-2%) from February 2, 2024, to February 13, 2024. Review of Resident 22's clinical record failed to reveal that a nutritional assessment was completed for Resident 22 between the dates of August 14, 2023, and March 20, 2024; and failed to reveal that any interventions were put into place for a significant weight loss between February 2, 2024 (the date a significant weight loss was noted), and February 16, 2024 (the date the physician was notified of Resident 22's weight loss). Review of Resident 22's progress notes revealed a note dated February 16, 2024, that stated, [Employee 11 (Physician)] notified of resident's 20 lb weight loss over past 3 weeks. Resident is consuming 0-25% of meals consistently, has Med Pass 2.0 ordered twice daily and receives snacks between meals three times daily. Antibiotic treatment for UTI (urinary tract infection) was completed on 2/10/24. New order received for Remeron 15 mg by mouth in the evenings. POA (power of attorney) notified of new order. Review of Resident 22's progress notes revealed a note dated February 19, 2024, that stated, Fax placed to MD in regards to obtaining weekly weights. Review of Resident 22's progress notes revealed a note dated February 20, 2024, that stated, New order for weekly weights due to weight loss. POA aware. Review of Resident 22's physician orders revealed an order for Weekly weights x 4 every day shift every Mon for 4 Administrations, with a start date of February 26, 2024. Review of Resident 22's MAR (Medication Administration Record - documentation for treatments/medication administered or monitored) and her clinical record failed to reveal a weekly weight was obtained on March 11, 2024, as per physician order. Review of Resident 22's progress notes revealed a note dated February 22, 2024, that stated, Notified by Social worker that resident's family was updated at care plan meeting about resident's weight loss and declining condition. Family will discuss hospice. During an interview with the Nursing Home Administrator (NHA) on March 20, 2024, at 2:34 PM, the surveyor revealed the concern with Resident 22's weight loss not being assessed timely, interventions not being put into place timely and implemented per order, and continued weight loss without interventions. The NHA confirmed she would have expected nutrition assessments and interventions to be put into place timely and implemented following a significant weight change. The NHA further revealed nursing was responsible for notifying the physician of significant weight changes at that time, since the facility did not have dietitian coverage during the period of Resident 22's weight loss. She also revealed that there was a corporate Certified Dietary Manager that they should have consulted during that time, but that they failed to consult them. The facility failed to ensure timely evaluation and implementation of new interventions to prevent further weight loss for Resident 17 following a significant weight loss of 17.7 lbs (13.8%) in less than 14 days, resulting in harm as evidenced by an additional weight loss of 2.3 lbs (2%) before interventions were put into place. Review of Resident 23's clinical record revealed diagnoses that included dementia, hypertensive heart disease (heart condition caused by high blood pressure), and depression. Review of Resident 23's weight records revealed that they weighed 194.8 lbs on July 18, 2023; 187 lbs on September 3, 2023; and 164.2 lbs on March 1, 2024 (a loss of 12.19%). Review of Resident 23's Physician Services notes revealed a note dated February 27, 2024, which indicated the following: Resident 23 was being seen for a routine visit and review of their weight loss; the Resident had an 11.98% weight loss over the past six months; their weight had consistently declined month-to-month in that time; their nutritional supplement was increased in January 2024; the resident was on a regular diet with double portions and increased dessert portions; and their cause of weight loss was unknown as their caloric intake and meal consumption was high, but was likely unavoidable secondary to advanced dementia. The note further indicated that the practitioner's plan was to increase the nutritional supplement again, to have Resident 23 weighed weekly, and follow further recommendations of the dietician. Review of Resident 23's clinical record on March 19, 2023, at 10:31 AM, revealed that they had one nutritional assessment completed by the facility dietician on July 25, 2023, at the time of their admission to the facility. Review of Resident 23's clinical record progress notes on March 19, 2023, at 10:31 AM, revealed that the last documentation completed by a dietician was dated August 3, 2023, at which time the note indicated that they were questioning a weight that had been obtained and had requested that the resident be reweighed. During an interview with the NHA and Employee 1 (Registered Nurse Assessment Coordinator - RNAC) on March 20, 2024, at 2:24 PM, the aforementioned information from the practitioner's note was shared, as well as concern regarding the lack of nutritional assessments or any documented follow-up by a dietician. The NHA confirmed that there were no additional nutritional assessments completed on Resident 23 since they were admitted to the facility on [DATE]. She indicated that the facility was without a dietician from September 15, 2023, until March 5, 2024. She indicated that during the time the facility was without a dietician, the Director of Nursing (DON) was to be reviewing resident weights and addressing weight concerns in the interim, and that there was a corporate Certified Dietary Manager that the facility could have reached out to when needed. The NHA shared that this DON was no longer an employee at the facility, and that the facility had failed to contact the corporate Certified Dietary Manager for assistance. A follow-up review of Resident 23's clinical record on March 21, 2024, at 8:59 AM, revealed a progress note by the dietician which indicated that there was an order clarification for the weekly weight monitoring due to significant weight loss over six months. At the time of this review, there was still no documented nutritional assessment by the facility dietician. During a final interview with the NHA on March 21, 2024, at 10:29 AM, she confirmed that she would expect a resident to have a nutritional assessment completed quarterly by a dietician, at minimum, and with any nutritional change, such as weight loss. Review of Resident 45's clinical record revealed diagnoses that included dementia, dysphagia, and breast cancer. Review of Resident 45's weight records revealed the following weights: December 1, 2023, 111 lbs; January 22, 2024, 101.5 lbs; January 30, 2024, 101.6 lbs; February 20, 2024, 97.5 lbs February 21, 2024, 95.4 lbs February 22, 2024, 96.2 lbs February 26, 2024, 85.6 lbs February 27, 2024, 88.7 lbs March 1, 2024, 93.6 lbs March 5, 2024, 93.5 lbs This equated to a significant weight loss of 13.5 lbs (12.2%) between December 1, 2023, and February 20, 2024; an additional 11.9 lb weight loss between and February 20, 2024 and February 26, 2024; and a total weight loss of 17.5 lbs (15.7%) between December 1, 2023 and March 5, 2024. Review of Resident 45's clinical record revealed that their last nutritional assessment was completed by a dietician on September 20, 2023, at the time of their admission to the facility. Review of Resident 45's clinical record progress notes revealed a note by the facility dietician dated March 6, 2024, at 1:09 PM, which indicated that their weekly weights were reviewed and that their current weight on March 5, 2024, triggers as a significant loss of 6.9% x 30 days. Resident continues to tolerate a Regular diet, regular texture, thin liqs [liquids] PO [oral] intake is not adequate to meet estimated needs at ~ [approximately] 30 % ave[rage] w[ith]/ 9 meal refusals. Resident continues to receive and accept Medpass [a nutritional supplement] 240 mL [milliliters] BID [twice a day], ~[approximately] 100% ave[rage]. Recommending to increase Medpass to 240 mL TID [three times a day] to provide additional calories and protein. Order added on (2/17) to encourage fluids. Weekly wt [weight] monitoring to continue. Care plan updated. In addition, there was a progress note dated March 6, 2024, at 1:37 PM, which indicated that Resident 45's responsible party was notified of their weight change and new recommendations. The documentation did not indicate if Resident 45's physician was made aware of the weight loss. Further review of Resident 45's clinical record progress notes failed to reveal any documentation regarding Resident 45's weight loss, including physician notification and responsible party notification between February 20, 2024, when the resident started triggering for weight loss, and March 6, 2024. The last documentation of Resident 45's physician being made aware of any weight loss was on December 19, 2023, during which time the resident was experiencing a COVID-19 infection and additional orders were given for nutritional supplementation. During an interview with the NHA on March 20, 2024, at 10:24 AM, the aforementioned concerns were shared regarding Resident 45's weight loss identification, lack of dietician involvement, and lack of documentation that the physician or responsible party were notified of the weight loss that triggered on February 20, 2024, and of ongoing weight loss triggered with each weight obtained thereafter. The NHA confirmed that there were no other nutritional assessments completed for Resident 45 since they were admitted to the facility on [DATE]. She indicated that the facility did not have a dietician during this timeframe, and that nursing was attempting to identify and address weight concerns. During another interview with the NHA and Employee 1 on March 20, 2024, at 2:24 PM, the aforementioned concerns were all shared again. The NHA indicated that the facility was without a dietician from September 15, 2023, until March 5, 2024. She indicated that during the time the facility was without a dietician, the DON was to be reviewing resident weights and addressing weight concerns in the interim, and that there was a corporate Certified Dietary Manager that the facility could have reached out to when needed. The NHA shared that this DON was no longer an employee at the facility and that the facility had failed to contact the corporate Certified Dietary Manager for assistance. During an interview with the NHA on March 21, 2024, at 10:29 AM, she confirmed that she would expect a resident to have a nutritional assessment completed quarterly by a dietician, at minimum, and with any nutritional change, such as weight loss. During a final interview with the NHA on March 21, 2024, at 1:24 PM, the NHA confirmed that Resident 45's physician and responsible party should have been notified when they began triggering for weight loss at the end of February 2024. The facility failed to ensure timely evaluation and implementation of new interventions to prevent further weight loss for Resident 45 following a significant weight loss of 13.5 lbs. (12.2%), resulting in harm as evidenced by an additional weight loss which totaled 17.5 net pounds (15.7%) before interventions were put into place. Review of Resident 57's clinical record revealed diagnoses that included dementia, major depressive disorder, and vitamin D deficiency. Review of Resident 57's weight measures revealed she had a significant weight gain of 9.4 lbs. (+10.6%) from October 17, 2023, to November 3, 2023. Review of Resident 57's clinical record on March 20, 2024, failed to reveal that a nutritional assessment was completed for Resident 57 between the dates of September 15, 2023, and present. During an interview with the NHA on March 20, 2024, at 2:34 PM, the surveyor revealed the concern that Resident 57 did not have a nutritional assessment completed following a significant weight change. The NHA confirmed she would expect nutrition assessments to be conducted timely following a significant weight change. The NHA further revealed nursing was responsible for notifying the physician of significant weight changes at that time, as the facility did not have dietitian coverage during the period of Resident 57's weight gain. She also revealed there was a corporate Certified Dietary Manager that they should have consulted during that time, but failed to do. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(6) Management. 28 Pa Code 211.12(d)(1)(3)(5) Nursing Services.

Based on clinical record review, facility documentation review and staff interview, it was determined that the facility failed to promptly implement necessary interventions to prevent accidents or injuries, resulting in self-inflicted harm to one of three residents reviewed (Resident 1). Findings Include: A review of the facility's policy titled, Accidental Hazards, last reviewed in (MONTH) (YEAR), stated that the facility must ensure that the resident's environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Record review during the onsite visit on (MONTH) 20, (YEAR), revealed that Resident 1 was admitted to the facility, from an assisted living residence, on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. In (MONTH) (YEAR), while at the assisted living residence, Resident 1 had voiced suicidal thoughts and was sent to the ER (emergency room ) at a hospital where an assessment was done and he was noted to have active suicidal ideation and a plan to cut his wrists. On (MONTH) 23, (YEAR), as part of the nursing home admission paperwork/assessment, a Pennsylvania Preadmission Screening Resident Review Identification form (PASRR-ID - an assessment form required for nursing home admission) was completed by facility Social Worker 2. Section IIIB of the PASRR-ID-Significant Life disruption due to Mental Illness-was answered yes with the following explanation, 7/2/17-ER visit related to suicidal thoughts-stated he would never hurt himself, then stated he needed to be locked in a padded room because he will hurt himself. Section VIII of the PASRR-ID stated that the individual has a positive screen for Serious Mental Illness; requires further evaluation. He was deemed nursing home eligible via the Medical Assistance (MA)-51 (a medical evaluation completed for nursing home care) on (MONTH) 1, (YEAR). Review of Resident 1's facility developed care plan dated (MONTH) 3, (YEAR), revealed it included concern areas for Mood State and Behavior Problem. The mood state care plan stated that Resident 1 will have no problematic concerns related to mood state through next review and interventions included, 1:1 discussion with resident to assist in unhappiness and offer opportunities to discuss concerns and feelings as needed. The behavior problem care plan stated that Resident 1 has made suicidal ideations in the past and may be prone to this type of thinking; interventions included, to intervene as needed to ensure safety of residents and others. A nursing progress note dated (MONTH) 3, (YEAR), at 1:27 p.m. stated that, PT (physical therapy) staff found a pair of scissors and a single edge razor blade in resident's room. Items removed from room and given to Social Services. Resident refused PT x 3 this shift. On (MONTH) 20, (YEAR), at 9:45 a.m. in an interview with the Certified Occupational Therapist Assistant (COTA), who removed the scissors and razor blade, stated she had visited Resident 1's room 3 times on (MONTH) 3, (YEAR), and on the third time she saw the items and recalled reading his history and thus removed the items without either she or Resident 1 acknowledging them. The COTA gave the items to a nurse who then gave them to Social Worker 1. In an interview with Social Worker 1 on (MONTH) 20, (YEAR), at 11:45 a.m. she acknowledged receiving the items and putting them in her office and said that at the time she was glad that the items were out of Resident 1's room, but she did not have a discussion with him. Social Worker 1 stated that she had one interaction with Resident 1, on (MONTH) 4, (YEAR), at which time he asked for a TV guide and she gave it to him and he appeared very pleasant. Review of an incident/witness statement dated (MONTH) 7, (YEAR) at 4:00 a.m. by Nurse Aide 1, revealed she went into the room of Resident 1 with the Licensed Practical Nurse 1 and there was blood on the floor and we found the Resident 1 self-harmed himself. Licensed Practical Nurse 1 got the Registered Nurse. We started to apply pressure and Resident 1 placed pliers and a broken piece of glass on the book shelf. The Registered nurse asked what happened and Resident 1 stated he tried to kill himself. He stated he is to old and it is time to die. A review of a facility incident report dated (MONTH) 7, (YEAR), revealed at 4:00 a.m. it was reported by a Nurse Aide to Registered Nurse 1, that Resident 1 was losing a copious amount of blood from a laceration on his left wrist. Resident 1 stated, I was trying to kill myself. I am too old to still be living. The facility's investigation section of the incident report stated that a broken mirror and a pair of pliers were noted in the room at the time of the occurrence. 911 was called and Resident 1 was transported to the hospital where he was admitted . The facility failed to provide adequate supervision and interventions to prevent an accident which resulted in a suicide attempt with injuries and hospitalization . During an interview with the Nursing Home Administrator on (MONTH) 20, (YEAR), at 2:15 p.m. she confirmed that her expectation was that the facility's accident prevention policy and a resident's care plan be followed. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 7/29/16. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 7/13/17. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 7/29/16. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 7/13/17, 7/29/16. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 7/13/17. 28 Pa. Code 211.16(a) Social services.

Based on clinical record review, incident report review, observation and interview, it was determined that the facility failed to ensure that staff transferred a resident according to physician's orders [REDACTED]. (Resident 1) Findings include: Review of Resident 1's clinical record revealed a [DIAGNOSES REDACTED]. In addition, Resident 1 also has a [DIAGNOSES REDACTED]. Review of Resident 1's Minimum Data Set Assessment (periodic assessment of resident needs), Section G, Functional Assessment, dated April 22, 2015, revealed that Resident 1 required extensive assistance of two plus persons for physical assist for bed mobility, transfers, dressing, toileting and bathing. Review of Resident 1's physician orders [REDACTED]. Additionally, on May 19, 2015, the order included may use stand-lift (mechanical device used with a vest to assist the resident from a sitting to standing position) for toileting and pericare. In an interview on June 18, 2015 at 11:15 a.m., Resident 1 stated that the following events occurred on June 12, 2015. Resident 1 stated that a nurse aide (NA1) that she had never seen before, provided care. Resident 1 stated after lunch she had to go to the bathroom and two staff brought in a stand lift. Resident 1 said it was a much shorter stand-lift than anyone had used prior during a transfer. Resident 1 stated she was left alone in the bathroom and when she was finished she called for staff and only one person (NA1) responded. There were not 2 people to assist her off of the commode. The resident stated she was assisted to the stand lift but her right leg kept slipping out of the lift so NA1 stood her up to readjust her position and when she sat her back down her left arm fell under her hip. Resident 1 said she yelled out ouch, my arm and NA1 then yanked my arm out from under me. Resident 1 also stated the facility does not allow NA1 to provide care to her anymore, at the resident's request. In an interview on June 18, 2015 at approximately 1:00 p.m. via telephone with the physician (Physician 1) he stated that Resident 1 is a bright individual and is able to recall what happened when her arm was fractured. Physician 1 stated that Resident 1 should be transferred in the safest manner and that Resident 1 required more assistance than usual due to he left leg amputation and left arm hemiparesis. Review of the physician progress notes [REDACTED]. Review of incident report, revealed that on June 12, 2015 staff responded to Resident 1 ' s call bell at 4:20 p.m. and the resident stated she needed to go to the bathroom. Resident 1 informed the staff they had to be careful with her left arm and upon assessment, staff were unable to lift the left arm due to the resident's pain. The pain was reported to the charge nurse and the documentation dated June 12, 2015 at 4:44 p.m., revealed left shoulder was noted to be severely swollen and when attempting to pick up the LUE (left upper arm) resident began to yell out. Call placed to MD (Medical Director) to request an X-ray and MD gave new orders to send to ER (Emergency Department) for evaluation and treatment. In an interview on June 18, 2015 at 12:19 p.m. NA1 stated that she was a fairly new employee (date of hire, May 25, 2015). When asked how many staff are required when using the stand-lift, she stated generally, all facilities use two persons for these types of transfers, at least those that I worked at before. NA1 stated that she should have asked another staff to assist with Resident 1 but she just wanted to hurry up and get the resident back to her recliner to make her more comfortable. NA1 included a comment that the resident's arm never fell under her hip and that the only time she saw the resident's arm stuck under the resident was in the recliner chair, when she sat her down and at that point she took her arm and placed it on Resident 1's lap. NA1 documented a witness statement on June 12, 2015, that reflected, Resident 1 put her light on to go to the bathroom. Another CNA and I placed on toilet with lift, when she was done she complained of her behind hurting, I lifted her up and cleaned her and then sat her back down and repositioned the lift pad, continued the transfer. All the resident stated was wow that was a trip. A second witness statement was written on June 15, 2015, and in this statement NA1 documented I did not have an assistant getting Resident 1 out of toilet. When I placed the sling correct and comfortable I cleaned her and put her in her recliner. At that time I ask if she was in pain, Resident 1 stated no just sore as always. I did my best to ensure resident safety but I do believe waiting for assistance was the better choice. In an interview on June 18, 2015, at approximately 12:30 p.m., RN1 stated as a rule we use two persons for all lifts. RN1 stated that since the incident, the facility reviewed the policy and determined that the policy for the stand lift did not stipulate the number of staff to use for the stand lift, until yesterday. In an interview on June 18, 2015 the Nursing Home Administrator (NHA) stated that the policy for the Stand Lift did not include a requirement that two persons be used for the stand-lift but the policy has been changed. In addition, the NHA stated that the facility has an expectation that physician orders [REDACTED]. 28Pa Code: 211.12 (d)(1)(5) Nursing services

Based on review of facility policy, clinical records, and interviews with staff, it was determined that the facility failed to provide timely, necessary care and services, to attain or maintain the highest practicable, physical well-being, for one resident (Resident R1) reviewed. Findings include: Review of the facility's Change of Resident Condition policy, reviewed September 2010, indicated that any change in condition of the resident, the attending physician and the power of attorney (POA) will be notified. The physician will be notified via telephone for clinical and/or emergent changes to the resident's physical condition. Review of facility's Medical Emergency Response policy, reviewed September 2010, indicated the following categories would constitute a medical emergency: acute respiratory distress or arrest as characterized by decreasing oxygen saturation rates (blood oxygen levels) unchanged by supplemental oxygen, increasing respiratory rate, and use of intercostal muscles (accessory muscles). Review of Resident R1's nurses notes dated November 26, 2010, at 3:00 p.m., revealed that she had a coughing episode with thin liquids. Nurses notes dated November 27, 2010, at 9:40 a.m., reported that she had crackles in lung bases (rattling or bubbling sounds in the lungs). Physician (P1) was made aware and a chest X-ray was done that day, which revealed that she had a mild pneumonic infiltrate in the lateral right, middle lung (infiltrate is a substance that has entered the lung causing infection). P1 ordered [MEDICATION NAME] (antibiotic used to treat infections) 400 milligrams (mg) daily, for 10 days, and [MEDICATION NAME] (helps reduce diarrhea from antibiotics) 250 mg daily, for 10 days. A physician's orders [REDACTED]. Nurses notes dated November 30, 2010, at 6:00 p.m., written by Licensed Practical Nurse (LPN) 1, reported that Resident R1 had a temperature of 99.7 degrees Farenheit (F) and Tylenol 650 mg was given. Her blood oxygen level was 90% on 3.5 liters per minute (Lpm). Nurses notes dated November 30, 2010, at 9:10 p.m., written by Registered Nurse (RN) 1, reported vital signs from 4:00 p.m., (five hours earlier) of a temperature of 100.3 degrees Farenheit and respirations of 32 breaths per minute (resident's norm was 18-20) and Tylenol was given (but recorded as given by LPN 1 at 6:00 p.m., on the Medication Administration Record, [REDACTED]. There was no evidence that a comprehensive respiratory assessment was done at this time or that LPN 1 was aware of the resident's elevated temperature or increased respiratory rate. The nurses notes dated November 30, 2010, at 9:10 p.m. , written by RN 1 also reported that at 8:50 p.m., Resident R1's blood oxygen level was 86-87%, while the resident received O2 at 5 Lpm. Resident R1's respirations were 28 breaths per minute and labored, with use of accessory muscles. There was no evidence that a comprehensive respiratory assessment was done at this time. The nurse's note also indicated, "will continue to monitor." At 10:12 p.m., (one hour and twenty-two minutes later) RN 1 placed a call to the physician. Physician (P2) returned a call to the facility at 11:45 p.m., (one and 1/2 hours later) and ordered the resident to be sent to the hospital. The resident left the facility via ambulance at 11:07 p.m., seven hours after the onset of respiratory distress. Nurses notes dated December 1, 2010, at 5:30 a.m., reported that Resident R1 was admitted to the intensive care unit because of [MEDICAL CONDITION] (inadequate oxygen levels). Review of the interview between the Assistant Director of Nursing (ADON) and RN 1, dated December 1, 2010, where RN 1 indicated that Resident R1's blood oxygen levels were only in the 80's during her shift, but she was in and out of the resident's room every 45 minutes to check on her. RN 1 failed to identify the resident's increased respiratory rate and low oxygen levels as an emergent change requiring an emergency medical response. Interview with the Director of Nursing on January 4, 2011, at 11:30 a.m., revealed that nurse aides were responsible for taking the resident's vital signs and are to report anything unusual to the LPN. She confirmed that a respiratory rate of 32 breaths per minute should be reported to the LPN. Interview on January 5, 2011, at 11:15 a.m., with RN 2, revealed RN 1 informed her at 9:50 p.m., on November 30, 2010, of Resident R1's condition and that she would fax the information to the physician. RN 2 told her to call the physician immediately because he wouldn't receive the fax until December 1, 2010. Interview with the Administrator and Director of Nursing on January 4, 2011, at 11:50 a.m., confirmed that the actions of RN 1 were negligent in providing the attention and care that the resident required. 28 Pa. Code: 201.14 (a) Responsibility of licensee. Previously cited 10/08/09. 28 Pa. Code: 211.10 (c) Resident care policies. Previously cited 11/18/10. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services. Previously cited 10/8/09, 11/18/10. 28 Pa. Code: 211.12 (d)(2) Nursing services.