Every finding on record at Liberty Center for Rehabilitation and Nursing

Based on observations, review of facility policy and interview with staff, it was determined facility did not implement and maintain an effective infection prevention control program related to water management program and enhanced barrier precautions on one of four units observed. (Unit C)Findings include: Review of facility policy 'Enhanced Barrier Precautions (EBP) Policy and Procedure,' effective date April 1, 2024, indicates that EBP are indicated for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO (Multi Drug Resistant Organism) colonization status, infection or colonization with an MDRO when contact precautions do not otherwise apply. Further review of policy indicates that effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. eview of facility policy 'Legionella Water Management Program,' revised July 2017, indicates that the purpose of water management program is to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. Further review of policy revealed that facility's water management program includes the following:A detailed description and diagram of the water system in the facility,The identification of areas in the water system that could encourage the growth and spread of legionella or other waterborne bacteria;The identification of situation that can lead to legionella growth'Specific measures used to control the introduction and/or spread of legionella (e.g., temperature, disinfectants);The control limits or parameters that are acceptable and that are monitored;A diagram where control measures are applied'A system to monitor control limits and the effectiveness of control measures;A plan for when control limits are not met and/or control measures are not effective;Documentation of the program. Observations on second floor unit, C-wing, on May 11, 2026, at 10:00 am, revealed Residents R12, R27, R7, R16 and R34 on EBP. Further observations of C-wing unit revealed no evidence of available PPE. Interview with licensed nurse assigned to residents on C-wing, Employee E10, on Monday, May 11, 2026, at 11:00 am, confirmed no available PPE was provided on that unit. Interview with facility's Maintenance Director, Employee E4, and Administrator, Employee E1, on Wednesday, May 13, 2026, at 11:00 am, conformed facility does not have control measures implemented as per policy for water management program. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 211.10( c)(d) Resident care policies 28 Pa Code 211.12(d)(5) Nursing services

Based on staff interviews, review of facility policy, and review of facility documentation it was determined that the facility did not ensure that a complete and thorough investigation related to abuse allegation was completed for one of twenty residents reviewed. (Resident R83)Findings include: Review of facility policy titled Abuse Prevention Program, review date March 2017, revealed as the Policy Statement Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The policy continues, stating (administration will): 6. Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse within timeframes as required by federal requirement; 8. Protect residents during abuse investigations; 9. Establish and implement a QAPI review and analysis of abuse incidents; and implement changes to prevent future occurrences of abuse. Review of Resident R83's clinical record revealed that the resident was initially admitted to the facility on [DATE], with diagnoses including by not limited to Major Depressive Disorder (severe, often recurring mood disorder marked by persistent feelings of low mood and loss of interest in pleasurable activities), hypertensive heart disease without heart failure (high blood pressure causing changes in the heart without heart's losing the ability to pump blood efficiently), and Type Two Diabetes Mellitus (impaired ability of the body to regulate blood sugar, caused by lack of sensitivity to or production of insulin). Review of Resident R83's Minimum Data Set (MDS - a federally required resident assessment completed at a specific interval) completed December 18, 2025, section C0500 BIMS (Brief Interview of Mental Status) revealed that Resident R83 had a BIMS score of 9, suggesting moderate cognitive impairment. Review of documentation submitted to the State Survey Agency on December 23, 2025 revealed an allegation of sexual assault made by Resident R83 (female) involving Resident R46 (male) with BIMS score 14 (suggestive of no cognitive impairment), was reported to have occurred on December 20, 2025; the report alleged that during this incident, Resident R46 entered Resident R83's room, pulled up her shirt and started to suck on her breast. Interview with Resident R83 on May 13, 2026 at 10:49 AM revealed that during said incident, Resident R83's roommate, Resident R85, was present, but that she doesn't understand what's going on. Review of clinical records revealed that Resident R83's former roommate, Resident R85 (room D223-2) has a BIMS score of 3, indicating severe cognitive impairment. Resident R85 was not interviewed by the facility. Review of facility's Investigation Report revealed no statements from any other residents besides Resident R83 and R46 were included in the report, relating to any issues with Resident R46. Review of separate documentation submitted to the State Survey Agency on April 29, 2026, related to an incident that occurred approximately a week prior to that (estimated in report as April 21, 2026), revealed that female Resident R83 alleged that on this date, male Resident R46 entered her room and inappropriately touched her legs and breasts. Review of facility's Investigation Report revealed only two staff interviews were included in the report after the April 2026 incident: one from the DON, Employee E2, and one from Resident R83's Licensed Nurse at the time of the incident, Employee E23. Additionally, no statements from any other residents aside from the Residents involved (Residents R83 and R46) were provided. Further review of facility's Investigation Reports for both the December 2025 and April 2026 revealed no copies of police reports were included in the documentation, with no mention of a police report having been made with respect to the December 2025 incident. Review of facility documentation revealed Resident R46 was admitted to the facility on [DATE] with the following diagnosis: Type Two Diabetes (a chronic condition where your body either resists the effects of insulin or doesn't produce enough to maintain normal glucose levels), Bi-Polar Disorder (a mental health condition characterized by extreme, cyclical shifts in mood, energy, and activity levels), Hypertension (a chronic condition in which the force of blood against your artery walls is consistently too high), Kidney Disease (your kidneys are damaged and cannot filter blood properly), Acquired absences of the left and right leg above the knee, and Insomnia (a common sleep disorder characterized by difficulty falling asleep, staying asleep, or waking up too early and struggling to go back to sleep). Review of facility documentation revealed Resident R83 was admitted to the facility on [DATE] with the following diagnosis: Major Depressive Disorder (a serious mood disorder characterized by pervasive low mood and loss of interest ), Hypertensive Heart Disease (structural and functional heart damage caused by chronic, uncontrolled high blood pressure), Osteoarthritis (the most common form of arthritis), Hyperlipidemia (high levels of lipids (fats), such as cholesterol and triglycerides, in the blood), and Type Two Diabetes (a chronic condition where your body either resists the effects of insulin or doesn't produce enough to maintain normal glucose levels). Review of the facility investigation for Resident R83 revealed the resident first reported an incident of possible sexual abuse to the facility on December 20, 2025. Review of facility documentation revealed a Grievance/Concern form completed on December 20, 2025 and signed by licensed nurse Employee E5, That man Resident R46 came into my room lifted up my shirt and put his mouth on my breast. Resident R83 said the incident happened today. Review of facility documentation revealed a statement from licensed nurse Employee E5 that stated, On Saturday December 20, 2026 I was the charge nurse on 7 a.m.- 3p.m on the second floor D-Wing. I was called to room D23 by the nurse aide on that assignment in reference to resident R83. Resident stated, Resident R46 came into my room yesterday and lift up my shirt and put him mouth on my breast. Full head to toe assessment complete skin intact with no bruising, bleeding or any issues noted. I did not witness Resident R46 go into Resident R83's room. Review of facility investigation revealed a resident written interview held with the Director of Nursing and Resident R83 on April 28, 2026 states. Director of Nursing: Resident R83 is everything okay with you? Resident R83: No I can't take him. Director of Nursing: Who? Resident R83: Resident R46 I can't take him. Director of Nursing: What is he doing to you? Resident R83:He will be rubbing my legs and touching my breasts too. I am sick of him. Director of Nursing: When did this happen? The last time was last week. I didn't tell anyone but I told the nurse yesterday. I am sick of him. He asked me how am I doing and I told him to mind his business. I just want to change my room. I tell him to keep his hands off of me. He asked can he be my boyfriend and I said no I have my man that I do love. I want him off me. Director of Nursing: Can you make sure you scream for help and use your call bell when next he goes to your room? Resident R83: Yes, I will do that Further review of both facility investigations from December and April with Resident R83 revealed there were no interviews or statements taken from any residents. The above findings were confirmed on May 13, 2026 at 1:11 p.m. by the Director of Nursing Employee E2. The Director of Nursing admitted , we dropped the ball on these, I know this. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18 (b)(1)(3)(e)(1) Management28 Pa. Code 211.12 (d)(1)(2)(5) Nursing services

Based on review of facility policy, observations, and interviews with staff it was determined that the facility did not ensure a clean, comfortable, homelike environment for two of four nursing units reviewed. (C-Wing and D-Wing)Findings include: Review of facility policy titled, Quality of Life-Homelike Environment revised May 2017 states, Policy Statement- Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Further review of the policy states, 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary, and orderly environment. Review of facility policy 'Quality of Life - Homelike Environment,' revised May 2017, states that the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include:Clean, sanitary and orderly environment;Pleasant, neutral scents. Observations on Monday, May 11, 2026, at 9:30 am, on B-wing, room B16-1, revealed visibly soiled floor surface with accumulated dirt and condiments wraps, wall panel peeling and leak stains on two ceiling tiles. Further observation of C-wing unit revealed malodorous smell in room B-17. Further observations on B-wing revealed entrance doors to room B-19 to have dried food splatter, smudges, and accumulated dirt on surface. Further observations on B-wing revealed entrance doors to room B-21 to have dried food splatter, smudges, and accumulated dirt on surface. Further observations on B-wing revealed entrance doors to room B-23 to have dried food splatter, smudges, and accumulated dirt on surface as well as foul odor. Further observations of B-wing unit revealed entrance doors to room B-24 with dried food residue and food staining as well as dirt accumulation on door surface. Observations of C-wing unit on Monday, May 11, 2026, at 12:00 pm, revealed food debris in room C1-1. Further observations of C-wing unit revealed bedside table with visible dirt and accumulated dirt on floor surface. Further observation on C-wing unit revealed gnats in room C6-2 and pillowcase visibly soiled with dark discoloration. Observation was made on May 11, 2025 at 9:45 a.m. of the D-Wing unit. When walking onto the unit there were noticeable black and brown staining on the floors of the hallway. The same staining appeared in the D-wing dining room. Observation on May 11, 2026 of room [ROOM NUMBER] revealed room that smelled of urine. The resident had soiled sheets. The floor had paper trash and food particles all throughout. Interview held with the license practical nurse Employee EXX on May 11, 2026 at 12:00 p.m. revealed the resident in room [ROOM NUMBER] has behaviors and the facility does what they can with keeping the room clean. Observation on May 11, 2026 of room [ROOM NUMBER] revealed what appeared to be vomit on the floor in between the two resident beds. The dresser had colored liquid spills all over the side and front. Colored liquid spills were on the walls. One ceiling tile was stained. The Director of Housekeeping Employee E6 confirmed these findings on May 11, 2026 at 10:55 a.m. The Director of Housekeeping Employee E6 stated that he was new and still figuring out the building and what roles each housekeeping staff should have. Observation on May 11, 2026 of room [ROOM NUMBER] revealed the floor was soiled with colored stained and there was paper trash on the floor. Observation on May 11, 2026 of room [ROOM NUMBER] revealed baseboard wall falling off the wall on the left hand side when you walk into the room. There were three roaches traps in the room all had dead roaches in them. Observation on May 11, 2026 of the D-Wing unit hall bathroom revealed a toilet that was clogged and filled with feces. There was feces on the back of the toilet and on the floor surrounding the toilet. Around the heating unit by the bathtub the tile was seen peeling off. The sink was dirty and there were no paper towels located in the paper towel holder. These findings were confirmed at 12:17 p.m. with the Director of Housekeeping Employee E6. 28 Pa Code 201.14(a) Responsibility of licensee

Based on observations, review of facility policy and interview with staff, it was determined that facility did not ensure to develop and implement a resident centered care plan for one of 20 residents reviewed related to psychosocial health. (Resident R21)Findings include: Review of facility policy 'Comprehensive Person - Centered Care Plans,' revised December 2016, indicates that the comprehensive, person -centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable , physical mental, and psychosocial well-being and describe any specialized services to be provided as a result of Preadmission Screening and Resident review (PASARR) recommendations. Review of Resident R21's clinical record revealed medical history of schizophrenia (mental disease characterized by loss of reality contact), and cerebral infarction (stroke). Review of Resident R21's 'psychotropic medications review,' completed on March 10, 2026, revealed Resident R21 received the following medications for Schizophrenia: Risperdal 0.5 milligrams (mg), Depakote delayed release 500 mg and Depakote delayed release 250 mg, and Ziprasidone 8 mg. Review of Resident R21's Minimum Data Set (MDS), completed on March 23, 2026, revealed Brief Interview for Mental Status (BIMS) score of 9 which indicated that the resident had moderate cognitive impairment. Review of 'Senior Care Therapy,' evaluation, completed on March 27, 2026, by licensed marriage and family therapist, Employee E20, revealed that resident was assessed for display of symptoms of anxiety and depression related to adjustment to current life phase. Further review of 'Senior Care Therapy' evaluation prognosis and rationale revealed that Resident R21 presents with moderate depressive symptoms . (She/He) demonstrates insight and benefits from strong protective factors, including supportive adult children, engagement in activities, and daily spiritual practices. Further review of 'Senior Care Therapy' evaluation revealed treatment goals related to adjustment to change in life phase, sadness, difficulty coping with medical issues. Observations during day shift on Monday, May 11, 2026, on B-wing unit, revealed Resident R21 anxiously moving around the day room in wheelchair. Interview with nurse aide, Employee E12, on Monday, May 11, 2026, at 11:00 am, who was assigned to supervise residents in day room on B-wing, revealed that Resident R21 has a type of dementia and anxious behavior is typical - specifically, requesting to be out of bed and placed back in bed continuously throughout shift. Review of Resident R21's nursing notes dated May 13, 2026, at 4:27 pm, revealed she was observed to be crying, restless and confused, distressed when placed in wheelchair and consistently requesting to be placed back in bed. Once resident was in bed (she/he) wants to get out of bed once in bed. Further review of nursing notes dated May 13, 2026, at 9:56 pm, revealed that Resident R21 was observed crying to go to bed, and after a while was observed attempting to get out of bed. Review of Resident R21's care plan revealed no goals or interventions developed related to psychosocial behaviors. 28 Pa Code 211.10 (c) (d) Resident care policies28 Pa Code 211.12 (d)(1)(3)(5) nursing services

Based on interview with resident, review of clinical records, review of facility policy and facility provided documentation, it was determined that facility did not ensure to provide adequate supervision to prevent an accident for two residents and one employee (Resident R7, R46, and Employee E19)Findings include: Review of facility policy 'Abuse Prevention Program,' revised December 2016, indicates that as part of the resident abuse prevention, the administration will develop and implement policies and procedures to aid our facility in preventing abuse, neglect or mistreatment of our residents. Review of facility policy 'Behavioral Assessment, Intervention and Monitoring,' revised December 2016, indicates that the interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Further review of policy indicated that safety strategies will be implemented immediately if necessary to protect the resident and others from harm. Review of Resident R7's clinical record revealed medical history of psychoactive substance abuse, bipolar disorder (mental health condition characterized by extreme mood swings), depression (major loss of interest in pleasurable activities), and paraplegia (paralysis of the legs and lower body). Review of Resident R7's Minimum Data Set completed on March 16, 2026, revealed Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident was cognitively intact. Review of Resident R46 clinical record revealed medical history of acquired absence of bilateral legs above knees, bipolar disorder, syphilis (sexually tramsmitted infection). Review of Resident R46's Minimum Data Set completed on March 23, 2026, revealed Brief Interview for Mental Status (BIMS) score of 15. Further review of Resident R7 clinical record revealed that on June 9, 2025, there was an altercation between Resident R7 and Resident R46. Altercation between both residents was related to stolen money and broken phone. The altercation occurred in Resident R7's room and both residents had to be separated. Resident R46 became verbally threatening towards Resident R7 and towards staff. Further review of nursing progress notes revealed that Resident R46 became increasingly agitated, continued to yell, cursing staff who was attempting to calm (him/her) down. Further review of nursing progress notes, dated June 19, 2025, at 2:27 pm, revealed that Resident R7 expressed verbal aggression towards staff. Further review of nursing progress notes, dated June 21, 2025, at 12:53 pm, revealed another altercation between Resident R7 and Resident R46; two staff members witnessed Resident R46 leaving Resident R7's room after allegedly pulling (her/his) cover off and throwing (her/his) personal belongings on the floor. Resident R7 called the police and was informed on instruction for how to apply for a protection/restraining order against Resident R46. Further review of nursing progress notes, dated June 27, 2027, at 11:01 pm, revealed that R7 reported again R46 entered her room and started hitting her in back section. Staff member who witnessed the incident separated them, took resident aggressor to the nurse's station. As he was angry, he was trying to go back on C-wing to physically aggress R7, he held on the rail, his chair tilted back, he fell on his back. Interview with Resident R7 on May 13, 2026, at 11:00 am, indicated that she does not feel safe at the facility due to continuous harassment by Resident R46. Review of facility provided 'investigation of alleged abuse, neglect, misappropriation of property,' revealed that another altercation occurred between Resident R7 and Resident R46 on March 31, 2026, at 10:15 pm. Assigned nurse aide, Employee E19, heard commotion coming from room C3 and observed Resident R7 lying in (her/his) bed and R46 sitting in wheelchair hitting Resident R7 with a grabber. Further review of investigation report revealed that both residents were separated and Resident R46 started attacking the staff and in the process of trying to hit staff, Resident R46 fell out of the wheelchair face down to the floor. Resident R46 sustained an open area under 9his/her) left eye, a bump to the forehead. Resident R7 also sustained skin tear to the right knee. Interview with facility's Director of Nursing, Employee E2, on Thursday, May 14, 2026, at 1:00 pm, revealed that Nurse aide (Employee E19) is currently on leave of absence due to injured finger resulting from incident on March 31, 2026. 28 Pa Code 201.18 (b)(1) Management 28 Pa Code 211.10 (d) Resident care policies 28 Pa. Code 211.12(d)(10(5) Nursing services

Based on review of facility policy, review of resident clinical records, observations, and staff interviews, it was determined that the facility did not ensure a resident received appropriate behavioral health management to maintain the highest practicable well-being for one of twenty residents reviewed (Resident R46).Findings Include: Review of facility policy titled, Behavioral Assessment, Interventions and Monitoring last revised December 2016 states, Policy Interpretation and Implementation- General Guidelines 1. Behavior is the response of an individual to a wide variety of factors. These factors may include medical, physical, functional, psychosocial, emotional, psychiatric, or environmental causes. Further review of the policy states, Assessment.3. The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition, including: a. Onset, duration, intensity and frequency of behavioral symptoms. 4. New onset or changes in behavior will be documented regardless of the degree of risk to the resident or others. Review of facility documentation revealed Resident R46 was admitted to the facility on [DATE], with the following diagnosis: Bi-Polar Disorder, (condition in which the person has periods of depression and periods of being extremely happy) acquired absences of the left and right leg above the knee, and insomnia (unable to fall asleep). According to the two facility reported incidents, the resident was accused of sexual abuse in December 2025 and again in April 2026. An interview was held with the Nursing Home Administrator Employee E1 and the Director of Nursing Employee E2 on May 13, 2026 at 2:00 p.m. to discuss the facility reported incidents. The Director of Nursing Employee E2 explained that Resident R46 refused to change rooms/floor after a sexual assault allegation in April 2026. Therefore, Resident R46 was instructed not to go on C-Wing unit past room C3. During an observation on May 12, 2026 at 11:45 a.m. Resident R46 was seen ambulating in (his/her) wheelchair down the hall past resident room C3. When Resident R46 was re-directed by staff (he/she) became verbally aggressive stating, I pay here, I don't care what they say, If they tell me what to do, put me out, I pay for this, put me out. I pay for this I don't care, put me out The resident was re-directed to in front of (his/her) room. An interview was held on May 12, 2026 at 11:47 a.m. with Licensed Nurse Employee E5. who stated that he/she was aware of Resident R46 not being allowed past resident room C3 due to the previous incident with two female residents. Interview held with Employee E5 revealed, Resident R46, you can't tell him/her anything, he/she does that all the time. Resident R46 will spit, throw things, curse you out, throw things at you, and will physically attack staff. When asked if the Resident was easily re-directed, the licensed nurse Employee E5 confirmed that the resident becomes easily agitated and is not easily re-directed with staff. The licensed nurse Employee E5 was asked what else the staff does besides re-direction and Employee E5 stated that was it. Review of Resident R46's nursing progress notes revealed no documentation of behaviors or causes for behaviors. There was not enough evidence to show that nursing staff was identifying, documenting, and informing the physician about specific details regarding changes in Resident R46's mental status and behavior including; onset, duration, intensity, and frequency of behavioral symptoms. Further review of the psychological progress notes revealed a note from April 9. 2026 that stated: Follow up recent altercation of this patient with another patient. Patient stated, I am not allowed to talk about incident. Mood and behavior at baseline, Denies depression or anxiety. No reported changes to sleep, energy, or appetite. Nursing staff offered no concern at this time Review of Resident R46's psych progress notes from 2025 all revealed, Nursing staff offered no concerns at this time for every visit. The above findings were confirmed with the Director of Nursing on May 14, 2026 at 1:00 p.m. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management28 Pa. Code 211.12(c)(d)(3) Nursing services

Based on observation and staff interview, facility did not ensure proper storage of controlled substance medications for 1 of 2 medication rooms. (1st Floor)Findings Include: Observation on May 13, 2026 at 10:15 AM of the 1st floor medication room revealed only medication cart nurses and the Director of Nursing (DON), Employee E2, have keys to the medication room and to the medication room's refrigerator, with controlled substances stored inside a separate box within the refrigerator. Further observation revealed drawer containing controlled substances inside the refrigerator lacked permanent affixing to the refrigerator and was able to be removed from the refrigerator. Interview with the Director of Nursing (DON), Employee E2, at the time of observation revealed her statement that only the nurses and I (DON) have access to the controlled substances and it was due to the fact that the inside shelf was made of glass. Further interview with the DON, Employee E2, at this time revealed her confirmation that this would not prevent staff diversion. 28 Pa. Code 211.9 Pharmaceutical services 28 Pa. Code 211.12 Nursing services

Based on a review of the facility assessment and staff interviews, it was determined that the facility did not ensure active involvement of direct care staff and input from residents, resident representatives, and family members in the development and revision of the facility assessment. Additionally, the facility failed to identify within the facility assessment an accurate resident population with mental health and substance abuse diagnosis. Findings include:Review of facility policy 'Facility Assessment,' updated July 14, 2025, states that the purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. The assessment is used to make decisions about direct care of staff needs, as well as capabilities to provide services to the residents in facility. The facility assessment is used to ensure that each resident is provided with care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being. Further review of the facility assessment dated [DATE] included only three members completing the assessment. The three members included were the Nursing Home Administrator, Director of Nursing Employee, and one other staff. The resident assessment did not include involvement of direct care staff, or input from residents or resident representatives. This was confirmed on May 14, 2026 at 10:15 a.m. with the Director of Nursing Employee E2.Further review of the resident assessment included Special Treatments and Conditions- Mental Health- Behavioral Health Needs- 0-1 was listed as the number/average or range or residents. For Active or Current Substance Use Disorders- 1-3 was listed as the number/average or range residents. The facility assessment revealed that facilities must review and update assessments yearly or whenever resident care needs change significantly (e.g., admitting residents needing ventilators or dialysis), ensuring staffing, resources, environment, training, and supplies can meet those needs. Further review of facility assessment, under 'special treatments and conditions, revealed that facility has 0-1 residents with behavioral health needs and 1-3 residents with active or current substance use disorder.Review of clinical record for Resident R3 revealed medical diagnosis of schizophrenia, and depression. Review of clinical record for Resident R62 revealed medical diagnosis of severe intellectual disabilities, mood disorder, restlessness and agitation, psychotic disorder with delusions, autistic disorder. Review of clinical record for Resident R60 revealed medical diagnosis of bipolar disorder, diffuse traumatic brain injury, intellectual disabilities, alcohol abuse, cannabis use. Review of clinical record for Resident R21 revealed medical diagnosis of schizophrenia. Review of clinical record for Resident R4 revealed medical diagnosis of post traumatic stress disorder, schizophrenia, anxiety disorder. Review of clinical record for Resident R71 revealed medical diagnosis of Huntingdon's disease, schizophrenia, major depressive disorder. Review of clinical record for Resident R68 revealed medical diagnosis of paranoid schizophrenia, major depressive disorder. Review of clinical record for Resident R7 revealed medical diagnosis of bipolar disorder, depression, psychoactive substance abuse, opioid dependance with opioid-induced mood disorder. Review of clinical record for Resident R9 revealed medical diagnosis of schizophrenia, anxiety disorder. Review of clinical record for Resident R47 revealed medical diagnosis of schizophrenia, major depressive disorder. Review of clinical record for Resident R73 revealed medical diagnosis of schizophrenia. Review of clinical record for Resident R29 revealed medical diagnosis of schizoaffective disorder, depression. Review of clinical record for Resident R6 revealed medical diagnosis of schizophrenia. Review of clinical record for Resident R61 revealed medical diagnosis of alcohol abuse, alcohol dependance with alcohol-induced persisting dementia. Review of Resident R1 clinical record revealed a diagnosis of Psychoactive Substance Abuse ( (is a medical condition characterized by an impaired ability to stop or control cocaine use despite adverse social, occupational, or health consequences) and Depression (a common, treatable mood disorder characterized by persistent sadness, loss of interest, and physical symptoms like fatigue or sleep changes). Review of Resident R23 clinical record revealed a diagnosis of Cocaine Abuse (is a medical condition characterized by an impaired ability to stop or control cocaine use despite adverse social, occupational, or health consequences) and Alcohol Abuse (is a medical condition characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences). Review of Resident R25 clinical record revealed a diagnosis of Alcohol Abuse (is a medical condition characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences). Review of Resident R32 clinical record revealed a diagnosis of Schizoaffective Disorder (a chronic mental health condition characterized by a combination of schizophrenia symptoms like hallucinations or delusions and mood disorder symptoms like depression or mania). Review of Resident R44 clinical record revealed a diagnosis of Anxiety (a group of mental health conditions that cause persistent, excessive, and uncontrollable fear or worry that interferes with daily activities) and Schizophrenia (a chronic brain disorder characterized by disruptions in thought processes, perceptions, and emotional responsiveness). Review of Resident R46 clinical record revealed a diagnosis of Bipolar Disorder (a mental health condition characterized by extreme, cyclical shifts in mood, energy, and activity levels). Review of Resident R53 clinical record revealed a diagnosis of Bipolar Disorder (a mental health condition characterized by extreme, cyclical shifts in mood, energy, and activity levels). 28 Pa. Code S 201.18(b)(3) Management.

Based on a review of clinical records, facility documentation, and interviews with staff and residents, it was determined that the facility to implement its abuse policy related to investigation and protection of residents, and to immediately protect a resident involved in resident to resident sexual abuse for one of three residents reviewed (Resident R83).Findings include:Review of facility policy titled Abuse Prevention Program, review date March 2017, revealed as the Policy Statement Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Review of Resident R83's clinical record revealed that the resident was initially admitted to the facility on [DATE], with diagnoses of Major Depressive Disorder (severe, often recurring mood disorder marked by persistent feelings of low mood and loss of interest in pleasurable activities), hypertensive heart disease without heart failure (high blood pressure causing changes in the heart without heart's losing the ability to pump blood efficiently), and Type Two Diabetes Mellitus (impaired ability of the body to regulate blood sugar, caused by lack of sensitivity to or production of insulin). Review of Resident R83's Minimum Data Set (MDS - a federally required resident assessment completed at a specific interval) completed December 18, 2025, section C0500 BIMS (Brief Interview of Mental Status) revealed that Resident R83 had a BIMS score of 9, suggesting that Resident R83 has moderate cognitive impairment. Review of documentation submitted to the State Survey Agency on December 23, 2025 revealed an allegation of sexual assault made by Resident R83 (female) involving Resident R46 (male), BIMS score 14, suggesting no cognitive impairment, was reported to have occurred on December 20. 2025. Further review of documentation submitted to the State Survey Agency revealed that within this allegation, Resident R46 had entered Resident R83's room, lifted up her shirt, and started to suck on her breast. Continued review of documentation submitted to the State Survey Agency revealed a head to toe skin assessment was performed on Resident R83 following the incident, with no abnormal findings. Hourly safety checks were initiated, Representative Party and Attending Physician were notified, and Residents R83 and R46 were interviewed. Review of facility Investigation report of this incident revealed alleged victim Resident R83 told Nurse Aide, Employee E18, who told resident's Licensed Nurse, Employee E5, the latter who then filed a Grievance/Concern form with Social Services. Further review of facility's Investigation Report revealed written statements from Nurse Aide and Licensed Nurse for Resident R83 (Employees E18 and E5) that neither had seen Resident R46 enter Resident R83's room. The incident/grievance was deemed resolved by Social Services Director, Employee E3 on December 22, 2025, due to lack of witnesses, denial of accusations by Resident R46, and stated Resident R46 was re-educated to avoid all contact with Resident R83. Continued review of facility's Investigation Report revealed no statements from any other residents besides Resident R83 and R46 were included in the report. Statements from staff included Director of Nursing ( DON) (Employee E2), who interviewed both involved residents, Resident R83's Nurse Aide (Employee E18), Resident R83's Licensed Nurse (Employee E5) and Social Services Director/Grievance Officer (Employee E3). Review of separate documentation submitted to the State Survey Agency on April 29, 2026, related to an incident that occurred approximately a week prior to that (estimated in report as April 21, 2026), revealed that female Resident R83 alleged that on this date, male Resident R46 entered her room and inappropriately touched her legs and breasts. The report continued by stating no injuries or abnormalities were found upon skin assessment. The report included that residents R83 and R46 were interviewed, the latter who denied the allegation. No other witnesses were identified, according to the report. The incident was reported to police and attending physician. Residents were separated and Resident R46 was instructed to have no contact with Resident R83, and Resident R83's room was changed from D wing (room D223-1) to C wing at her request. The report further states that staff were advised to uphold increased supervision and no-contact interventions between the two residents, including frequent staff rounding. Additionally, residents' Care Plans were updated accordingly, and alleged victim, Resident R83, was to continue to be monitored daily with hourly safety checks. Review of Resident R83's clinical records reveal no order (even discontinued or completed) for hourly safety checks. Review of Facility Investigation Report revealed written statement by Resident R83's nurse at the time of second incident, Employee E23, revealed Resident R83 told Resident R46 to stop and to leave her room, and he has not touched her again since this instance, however stated Resident R46, sits outside her [Resident R83's] room looking in, which makes her uncomfortable. Further review of facility Investigation Report revealed the DON, Employee E2, had interviewed Resident R83; Employee E2's written statement revealed Resident R83 told her the incident with male Resident R46 happened about a week ago but she had not reported it to anyone. Employee E2, in her statement, had responded to Resident R83 to scream for help and use your call bell if Resident R46 came to her room. Interview with DON, Employee E2 on May 13, 2026 at 1:11 PM confirmed this suggested intervention made to the alleged victim, Resident R83. Furthermore, she admitted that it would be difficult to confirm sexual abuse allegation from a skin check in both of these incidents, as there had been no alleged penetration/rape. Continued review of facility Investigation Report revealed only two staff interviews were included after the April 27, 2026 incident: from the DON, Employee E2, and from Resident R83's Licensed Nurse at the time of the incident, Employee E23. Employee E2 wrote in a separate statement within the Investigation Report, dated April 28, 2026, that the matter was considered resolved following an Interdisciplinary Team meeting held with Resident R46 and his brother post-incident, Resident R46's denial of having touched Resident R83 inappropriately but had admitted to going to her room, and Resident R83's room having been changed from the D wing to the C wing at her request. Interview with Resident R83 on May 13, 2026 at 10:49 AM revealed she and Resident R46 were friends before he started acting like that (in a sexual nature toward her) and that Resident R46 told her he wanted to touch her breasts and asked her if he could kiss her, she replied no and reiterated that she has a boyfriend to whom she is committed outside the facility. However, it was unclear if these statements were made by Resident R46 before the first or the second incident. Further interview with Resident R83 confirmed the incident involving sexual abuse by Resident R46 happened on or slightly before April 27, 2026. Resident R83 revealed she immediately slapped him and told him to leave and that she did not want to talk to him anymore (effectively ending their friendship), and he left. She stated she asked for a room change to a different wing, and that Resident R46 does not know where her room is now but she observes him passing by and looking into rooms, and other residents have told her he is looking for her. She said he saw her getting onto the elevator one day to go to an activity and that he said Where are you going? but she did not respond. Continued interview with Resident R83 revealed that during the first incident (December 2025), Resident R83's roommate was present, but that the roommate doesn't understand what's going on. Furthermore, per Resident R83's account, there were no witnesses during the second, most recent incident in April 2026. Review of clinical records revealed that Resident R83's former roommate, Resident R85 (room D223-2) has a BIMS score of 3, indicating severe cognitive impairment. Resident R85 was not interviewed by the facility. Further review of facility's Investigation Report revealed the facility unsubstantiated the event of April 27, 2026 based upon no witnesses to the incident, Resident R46's denial of accusation, no anomalies noted upon skin inspection, and lack of corroborating evidence. Interview with DON, Employee E2, on May 13, 2026 at 1:11 PM confirmed both of these instances of alleged sexual abuse made by Resident R83 against R46, and confirmed that both investigation reports had no documented interviews with residents other than the alleged perpetrator and victim. 28 Pa. Code 201.18(b)(3)(e)(1) Management28 Pa. Code 202.29(a) Resident rights28 Pa. Code 211.10(d) Resident care policies28 PA. Code 211.12(c) Nursing services

Based on observations, review of clinical records and review of facility policy, it was determined that facility did not ensure to provide activities of daily living (ADL's) assistance for two of 20 residents reviewed (Residents R34, R41)Findings include: Review of facility policy 'Activities of Daily Living Support,' revised March 2018, indicates that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.Further review of policy revealed that appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with plan of care, including appropriate support and assistance with:Hygiene (bathing, dressing, grooming, and oral care)Elimination (toileting) Review of Resident R34's clinical record revealed medical history of need for assistance with personal care, schizophrenia (mental disease characterized by loss of reality contact), lack of coordination, muscle weakness, gait and mobility abnormalities, leukemia (a type of cancer that affects the blood and bone marrow). Review of Minimum Data Set (MDS) completed on May 7, 2026 revealed Resident R34's brief interview for mental status (BIMS) score of 3, which indicated that the resident was cognitively impaired. Further review of Resident R34's MDS revealed he requires partial/moderate assistance with toileting and hygiene care. Further review of Resident R34's MDS revealed he is frequently incontinent of bowel and bladder. Review of Resident R34's care plan revealed interventions to check Resident R34 as needed and as required for incontinence care, change clothing as needed after incontinence episode. Review of Resident R41's clinical record revealed medical history of need for assistance with personal care, bell's palsy, cerebral infarction, gait and mobility abnormalities, muscle weakness, aphasia, fall. Review of Minimum Data Set completed on February 12, 2026 revealed Resident R41's brief interview for mental status (BIMS) score of 12, which indicated that the resident was cognitively intact. Further review of Resident R41's MDS revealed he requires supervision or touching assistance with toileting and hygiene care. Review of Resident R41's care plan revealed interventions to check R41 as needed and as required for incontinence care, change clothing as needed after incontinence episode. Observations on Monday, May 11, 2026, at 11:05 am, on C-wing unit, revealed Resident R34 wearing a hospital gown, ambulating alone from room C-12 to emergency eye wash station room with brief observed to be heavily saturated with urine and overflowing on to the floor. Further observation on C-wing unit, at 11:35 am, revealed Resident R41 sitting in wheelchair on hallway with soiled from urine clothing. 28 Pa Code 211.10(d) Resident care policies28 Pa Code 211.12(d)(1)(5) Nursing services

Based on observations, interviews with staff, and review of facility documentation it was determined that the facility did not ensure to update and implement a comprehensive centered care plan related to behaviors for one of twenty residents reviewed. (Resident R46)Findings Include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered last revised December 2016 states, Policy Statement- A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Further review of the facility policy states, g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems. Review of facility documentation revealed Resident R46 was admitted to the facility on [DATE] with the following diagnosis: Type Two Diabetes (a chronic condition where your body either resists the effects of insulin or doesn't produce enough to maintain normal glucose levels), Bi-Polar Disorder (a mental health condition characterized by extreme, cyclical shifts in mood, energy, and activity levels), Hypertension (a chronic condition in which the force of blood against your artery walls is consistently too high), Kidney Disease (your kidneys are damaged and cannot filter blood properly), Acquired absences of the left and right leg above the knee, and Insomnia (a common sleep disorder characterized by difficulty falling asleep, staying asleep, or waking up too early and struggling to go back to sleep). Review of facility documentation revealed Resident R83 was admitted to the facility on [DATE] with the following diagnosis: Major Depressive Disorder (a serious mood disorder characterized by pervasive low mood and loss of interest ), Hypertensive Heart Disease (structural and functional heart damage caused by chronic, uncontrolled high blood pressure), Osteoarthritis (the most common form of arthritis), Hyperlipidemia (high levels of lipids (fats), such as cholesterol and triglycerides, in the blood), and Type Two Diabetes (a chronic condition where your body either resists the effects of insulin or doesn't produce enough to maintain normal glucose levels). Review of facility documentation revealed a Grievance/Concern form completed on December 20, 2025 and signed by licensed nurse Employee E5, That man Resident R46 came into my room lifted up my shirt and put his mouth on my breast. Resident R83 said the incident happened today. Review of facility documentation revealed a statement from licensed nurse Employee E5 that stated, On Saturday December 20, 2026 I was the charge nurse on 7 a.m.- 3p.m on the second floor D-Wing. I was called to room D23 by the nurse aide on that assignment in reference to resident R83. Resident stated, Resident R46 came into my room yesterday and lift up my shirt and put his mouth on my breast. Full head to toe assessment complete skin intact with no bruising, bleeding or any issues noted. I did not witness Resident R46 go into Resident R83's room. Review of Resident R46's care plan revealed a care plan update on December 24, 2025 with one intervention Re-educated to stay away from resident (Resident R83) Resident R46's care plan included no mention of inappropriate behavior. Review of Resident R46's clinical record revealed a Behavioral Assessment completed on March 20, 2026 that lists Identified Behavioral Symptoms as, yelling/repetitive verbalizations, agitation/irritability or hyperactivity, and verbal aggression. Further review of the assessment revealed Seriousness of the Behavioral Symptom- Patient is immediate threat to others -immediate intervention required is checked of as YES. Further review of the assessment reads Additional comments- just angry for no reason will not listen to re-direction. Review of the resident's care plan revealed no goals or interventions added on March 20, 2026. According to the two facility reported incidents. The resident was accused of sexual abuse against another resident in December 2025 and again in April 2026. An interview was held with the Nursing Home Administrator Employee E1 and the Director of Nursing Employee E2 on May 13, 2026 at 2:00 p.m. to discuss the facility reported incidents. The Director of Nursing Employee E2 explained that Resident R46 refused to change rooms/floor after the sexual assault allegation in April 2026. Therefore, the other resident was moved and Resident R46 was instructed not to go on C-Wing unit past room C3. During an observation on May 12, 2026 at 11:45 a.m. resident R46 was seen ambulating in his/her wheelchair down the hall past resident room C3. When Resident R46 was re-directed by staff he/she became verbally aggressive stating, I pay here, I don't care what they say, If they tell me what to do, put me out, I pay for this, put me out. I pay for this I don't care, put me out The resident was re-directed to in front of his/her room. An interview was held with licensed Nurse Employee E5. Employee E5 did state that he/she was aware of Resident R46 not being allowed past resident room C3 due to the previous incident with two female residents. Interview held with Employee E5 revealed, Resident R46, you can't tell him/her anything, he/she does that all the time. Resident R46 will spit, throw things, curse you out, throw things at you, and will physically attack staff. When asked if the Resident was easily re-directed, the licensed nurse Employee E5 confirmed that the resident becomes easily agitated and is not easily re-directed with staff. The licensed nurse Employee E5 was asked what else the staff does besides re-direction and Employee E5 stated that was it. Interview was held with the Director of Nursing Employee E2 on May 12, 2026 at 2:10 p.m., who confirmed there could have been more goals and interventions added after the first incident investigations. 28 Pa. Code 201.18 (b)(1)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12 (d)(1)(2)(5) Nursing services

Based on observations and interviews with residents and staff, it was determined that the facility failed to provide a safe, clean and homelike environment for three of four nursing units observed (B, C and D units).Findings include: Interview on April 28, 2026, at 9:29 a.m. Resident R1 stated that the room was in disrepair, including broken furniture, soiled and broken privacy curtains, soiled walls and broken baseboards. Observation, at the time of the interview, of room B16, revealed the following: The dresser for bed 1 was tattered and worn; the dresser for bed 3 was also tattered and had broken drawer handles; the air conditioning unit in the room had insulation that was falling out, creating an opening that would allow pests and debris to enter the room; the air conditioning unit's filter was caked with dirt and debris; the baseboard behind bed 1 was peeling away from the wall and exposing a hole that would allow pests and debris to enter the room; the wall behind bed 3 was soiled with a brown substance; the privacy curtain for bed 3 was soiled, torn and unable to close completely; the privacy curtain for bed 1 was soiled and unable to close properly; there was no callbell for bed 3; the bathroom faucet was covered in corrosion and the bathroom had soiled tiles and missing baseboards behind the toilet. Observation of the resident shower room on the B unit revealed that the tub was soiled with dirt and debris and that there were missing tiles around the faucet for the tub. Interview on April 28, 2026, at 10:23 a.m. Resident R3 stated that the grab bar next to the toilet was loose. Observation, at the time of the interview, confirmed that the grab bar between the toilet and sink in the bathroom for room C2 was loose and unstable. Continued observation revealed that the handrail in the corridor by room C2 was loose and falling away from the wall with exposed screws. Continued observation revealed that the bathroom in room C7 had broken floor tiles. The bedside tray table for the resident in room C7 bed 2 had a section of the tray that was peeled away. Further observation revealed that in room D17 the dresser was missing a drawer, with the resident's personal items falling from the cavity; the closet was missing a handle knob, the bathroom sink was covered in corrosion, the bathroom also had a broken towel rack and broken tiles below the sink. A tour was conducted with the Nursing Home Administrator and Director of Nursing on April 28, 2026, at 10:40 a.m. and the above areas were reviewed. 28 Pa Code 201.14(a) Responsibility of licensee28 Pa Code 204.12 Toilet room equipment28 Pa Code 205.9(a) Corridors28 Pa Code 205.67(j) Electrical requirements for existing construction

Based on review of facility documentation, observations, and staff interview it was determined that the facility failed to ensure food was stored and prepared in accordance with standards for food service safety. Findings Include: Review of facility policy Food Storage revealed temperatures for the freezer should be 0 degrees or below and must be recorded daily. A tour of the main kitchen was conducted on June 2, 2025, at 10:00 a.m. with the Food Service Director, Employee E27, which revealed the following: Observations in the outbuilding containing the walk-in freezer revealed a steel entry door that was not closed properly, and the bottom of the door was rusted through and did not seal. There was significant dirt and debris built-up within the outbuilding containing the walk-in freezer. Observations inside the walk-in freezer revealed it had a significant build up of ice on the outside of the fan and ceiling. The hot dogs and bread were not frozen solid to touch which indicated that these food items had began to defrost. The thermometer on the outside of the freezer was reading 32 degrees Fahrenheit (F), and the thermometer on the inside of the freezer was reading 28 degrees F. Per an interview with the Food Service Director, Employee E27, the morning cook had reported that the freezer temporarily turned off. The facility had no log or documentation to show the ongoing monitoring of the freezer temperature and its components. Following a tour of the walk-in freezer located in the outbuilding, we continued into the main kitchen located within the facility: Observations of the juice machine revealed it was sticky to touch. Observations inside the reach-in produce refrigerator revealed a large bag of cabbage was sitting in a stagnant puddle of water. Observations of the dish machine revealed when in use water began to pour out from the food trap and all over the floor. Observations were confirmed by the Food Service Director, Employee E27, along the duration of the tour. Observations on June 2, 2025, at 12:30 p.m. revealed the ice machine was in the hallway that leads into Social Services office. Observations revealed there was no 1-inch air gap between the end of the ice machine drain and floor drain. The ice machine drain was observed to be sitting in a stagnant pool of water collected in the floor drain. Interview with Maintenance, Employee E5, confirmed the drain set-up and reported it would be fixed.

Based on review of facility documentation, observations, and resident interviews it was determined that the facility failed to serve meals timely for one of three dining observations (June 3, 2025, breakfast meal). Findings Include: Review of facility documentation Mealtimes revealed breakfast is scheduled to be served at 8:00 a.m. Observations on June 3, 2025, at 9:26 a.m. revealed seven residents were still waiting for breakfast to be served. Resident R20 and R36 complained of being hungry. Observations on June 3, 2025, at 9:30 a.m. revealed dietary staff just began to plate meal trays from the steam table in the 1st floor dining room. Interview with the Registered Dietitian, Employee E8, confirmed breakfast was late due to dietary employees not showing up for work. Interview on June 3, 2025, at 11:30 a.m. during the group meeting with alert and oriented Resident R20, R29, R40, and R22 revealed meals are not served in accordance with posted meal times which reportedly interferes with being able to develop a consistent routine for residents. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on observations and interview with staff and residents as well as review of facility provided documentation, it was determined facility did not ensure to maintain effective pest control program on two out of four units observed (Units, A, C, and D). Findings include: Review of facility policy 'Pest control,' revised May 2008, indicates that facility shall maintain an effective pest control program, and garbage and trash are not permitted to accumulate and are removed from facility daily. Maintenance services assist, when appropriate and necessary, in providing pest control services. Observations on Monday, June 2nd,2025, at 10:00 am, C-unit, revealed excess trash, gnats, food crumbs in room C-12; used cups, used apple sauce cups, dirty bed side tables, used utensils. Further observations on C-unit revealed a large bin near room D-19, with used breakfast utensils, cups and plates with gnats flying around. Further observations revealed excess trash on floor in room D-26. Further observations on D-unit, revealed two urine filled portable urinals on floor in room D-21as well as dirty bed linens. Interview with nurse aide, employee E19, on Monday, June 2nd, 2025, at 10:38 am, revealed that this is the cleanest this unit has been in a while, and it's due to surveyors being here . Further observations on C-unit dining room, revealed pillow case, food crumbs, and wheel chair foot rests stored under table. Additional observations during week of full health survey revealed excess amount of flies during medication administration observation, on Tuesday, June 3rd, 2025, with licensed nurse, employee E1 and on June 4th, 2025 at 9:23 am with licensed nurse, employee E18. Interview on June 3, 2025, at 11:00 a.m. Resident R79 (room A-9) complained of gnats in the room. Review of facility provided pest log revealed gnats and flying insects reported on dates January 31, 2025, on second floor units, and on March 13, 2025 on first floor units; no further elaboration on pest control measures or exact location of staff observations. Review of facility provided service inspection report, completed on May 22, 2025 at 3:06 pm, revealed the following: A3 - gnats 5/21 confirmed via phone. Inspected and treated room A3 for gnats. Treated walls, window sills and frames, floor, bed frames and bathroom drain. Excessive activity observed during service. Poor sanitation and room [NAME] of urine. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1)(3)( e)(1)(2)(2.1) Management

Based on observations, interview with staff and residents, it was determined facility did not ensure the facility was maintained in a clean, safe, and homelike environment on two out of four nursing units observed (A-wing, C-Wing, D-Wing, and Dining Room). Findings include: Review of facility policy 'Quality of Life - Homelike Environment,' revised May 2017, indicates that the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, home-like setting. The characteristics include: a.Clean, sanitary and orderly environment; e. clean bed and bath linens that are in good condition Observations on Monday, June 2, 2025 at 10:00 am, on wing C, revealed gnats in room C-12, as well as used cups, excess food crumbs on floor, dirty bedside tables, used utensils and used apple sauce cups on bed side tables. Room C-12 was noted to have foul urine odor. Further observations on wing-D, near room D-19, revealed a large bin with used breakfast cups/plates, gnats. Further observations in room D-21 revealed used portable urinals hanging on trash bin, used napkins and plastic wraps on floor, as well dirty bed linen. Further observations in room D26 revealed excess trash on floor consisting of food crumbs as well as gnats. Further observations on Monday, June 2, 2025 at 11:09 AM, on second floor units (wing C and D revealed a collection of used breakfast cups/plates/utensils in a large bin near day room as well as gnats. Further observations during lunch meal service, in dining room on second floor units, revealed used linen under a table as well as foot rests stored under a table. Observations on June 2, 2025, at 12:58 p.m. revealed a steam table was set up in the 1st floor dining room to arrange and deliver meal trays to residents in their rooms. Observations on June 2, 2025, at 1:00 p.m. revealed the 1st floor dining room was only equipped with two tables. The back half of the dining room was also being used to store bed frames. Further observations revealed three resident meal trays were left on one of the tables from breakfast. Interview on June 2, 2025, at 1:00 p.m. with Registered Dietitian, Employee E8, revealed not many residents utilize the dining room for mealtimes. Registered Dietitian, Employee E8, confirmed observations of the 1st floor dining room. Observations on June 3, 2025, at 10:58 a.m. revealed the sink in room A-9 was hanging off of the wall. Observations on June 3, 2025, at 11:00 a.m. revealed the window shades in room A-11 were stained with a brown substance. 28 Pa Code 201.14(a) Responsibility of licensee.

Based on observations and review of clinical records, it was determined facility did not maintain proper grooming and personal hygiene for two of 19 residents reviewed (Resident R26, R52) Findings include: Review of facility's policy 'Activities of Daily Living (ADL's) , Supporting,' revised March 2018, indicates that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Further review of policy indicates that if residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate. Review of R26's clinical record revealed an [AGE] year old male resident with medical diagnosis of need for assistance with personal care, difficulty walking, schizophrenia, anxiety, gait and mobility abnormalities, vision impairment. Further review of R2'6s minimum data set (MDS) , completed on May 6, 2025, indicates that he requires substantial/maximal assistance with toileting/hygiene. Review of R26's care plan revealed resident is to be checked for incontinence as required, wash, rinse and dry perineum. Change clothing as needed after incontinence episodes. Observations on Monday, June 2nd, 2025 at 10:00 am, in room C-12, revealed R26 in bed with soiled brief exposed and gnats flying around. Review of R52's clinical record revealed a [AGE] year old male resident, with medical diagnosis of attention and concentration deficit, cognitive communication deficit, dementia with behavioral disturbance, major depressive disorder, psychotic disorder with delusions. Review of R52's MDS, completed on May 19, 2025, indicates he is substantial/maximal assistance for shower/bathing. Review of R52's care plan revealed he is to receive bath/shower twice weekly. Observations of R52 on Monday, June 2nd, 2025 at 10:00 am, in room C-12, revealed him in bed with only briefs on and heavily soiled lower extremities. Used breakfast meal tray was on resident's bed with gnats flying around. 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.12(d)(1) nursing services

Based on interview with residents and staff as well as review of clinical records, it was determined facility did not develop and implement a comprehensive resident centered care plan related to maintaining resident's hearing and nutrition for one of 19 residents reviewed (Resident R25) Findings include: Review of facility's policy Care Plans, Comprehensive Person-Centered, revised March 2022, indicates that the comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and c. reflects currently recognized standards of practice for problem areas and conditions. Review of resident R25's clinical record revealed an [AGE] year old male resident, awake, alert and oriented to self only, with medical diagnosis of psychomotor deficit (impaired motor function accompanied by cognitive or mental slowing), and cognitive communication deficit (difficulty with communication due to impairments in cognitive functions, rather than speech or language problems). During interview with Resident R25, on Monday, June 2, 2025, at 10:30 am , R25 stated he is hard of hearing and that staff at times become frustrated with him when he can not hear them. R25 further asked if he can receive assistance regarding hearing aides. Interview with licensed nurse, employee E1, on Tuesday, June 3, 2025 at 9:50 am, indicated that R25 currently does not have any hearing aides. Review of R25's clinical record revealed admission screening completed on January 2, 2025 at 8:27 pm, indicating resident has hearing aides in both ears. Review of R25's progress notes, dated January 29, 2025 at 12:13 p.m., indicates resident was assessed to be hard of hearing. Further review of progress notes, dated January 3, 2025 at 1217, indicates resident is hard of hearing. Further review of progress notes, dated January 22, 2025 at 1530, indicates resident is hard of hearing. Further review of progress notes, dated April 2, 2025 at 1557, indicates resident is hard of hearing. Further review of progress notes, dated March 26, 2025 at 1358, indicates resident is hard of hearing. Further review of progress notes, dated March 19, 2025 at 1449, indicates resident is hard of hearing. Further review of progress notes, dated February 26, 2025 at 1543, indicates resident is hard of hearing. Further review of progress notes, dated February 19, 2025, at 1527, indicates resident is hard of hearing. Review of R25's care plan revealed no evidence of goals or interventions related to maintaining his hearing. Review of facility policy titled Weight Assessment and Intervention dated September 2008 revealed the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the physician, nursing staff, the dietitian, the consultant pharmacist, and the resident or the resident's legal surrogate. The care plan Interventions for undesirable weight loss shall be based on careful consideration of resident choice or preferences comment nutrition and hydration needs of the resident, functional factors, environmental factors, chewing and swallowing abnormalities, medications, use of supplementation and advanced directives. Review of the resident's three months of weights revealed : 3/6/2025 153lbs. 4/7/2025 149.5 lbs. 4/14/2025 146.9 lbs. 5/5/2025 144.4 lbs. 5/8/2025 142.5 lbs. 5/21/2025 139.7 lbs. 6/2/2025 139.8 lbs. Total decline of weight over three-month period equaling 8.63 % / 13.2 pounds. Review of resident R28 care plan dated December 23, 2024, revealed that the resident was at a nutritional risk due to mechanically altered diet, with interventions including encourage adequate through the fluid intakes at meals all for alternate choices as needed, provide diet is ordered by medical doctor and respite care. Further review of resident R28's care plan revealed no indication that the residents weight loss had been addressed or any interventions were created to communicate the plan of care. Review of residents clinical record revealed a dietary note of a weigh warning, weight change warning dated June 3, 2025, weight is down 10.3% since December 23, 2024 resident receives a mechanically soft diet, meal intake is 70 to 100 percent, the resident's weight has been trending downward since admission. Recommended supplemental protein and caloric drink. Interview with dietician employee E8 on June 4, 2025, at 2:38 p.m. revealed that the resident did not trigger for significant weight loss until June 3, 2025, she did confirm that the resident has been trending downward and had implemented 60 cc med pass (supplemental drink). Employee E8 stated that typically after the resident has triggered for a weight loss, it is the protocol to address the loss, discuss with interdisciplinary team, including physician(email), offer alternate choices, determine resident's meal intake, and care plan. Continued interview with dietician employee E8 on June 5, 2025, at 10:00 a.m. revealed that she also has a weight meeting with departments and confirmed that there is no indication in this resident chart of any weight meeting and no current updated care plan to address the resident weight loss. 28 Pa Code 211.10 (c )(d) Resident Care Policies 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of clinical record, observations, and staff interview it was determined that the facility failed to maintain dignity for one of eight residents during dining (Resident R70). Findings Include: Review of Resident R70's physician order summary revealed a diet order dated April 7, 2025, that the resident was NPO (nothing by mouth for food or drinks). Review of Resident R70's comprehensive care plan dated April 16, 2025, revealed the resident was allowed pudding or applesauce at lunch time only with specific feeding instructions. Continued review of Resident R70's comprehensive care plan dated December 16, 2024, revealed the resident was dependent on staff for eating, dressing, and mobility. Observations on June 4, 2025, at 12:45 p.m. revealed Resident R70 was in the 1st floor activity room sitting in a geri chair (specialized medical recliner) surrounded by about 5 other residents who were consuming lunch. Resident R70 did not have any pudding or applesauce provided during dining. Interview on June 4, 2025, at 12:45 p.m. with Nurse Aide, Employee E20, confirmed Resident R70 was put in the dining room while other residents ate lunch. Further interview with Nurse Aide, Employee E20, revealed Resident R70 was allowed pudding and applesauce but was not offered any during dining with the other residents. 28 Pa. Code 201.29 (a) Resident Rights

Based on review of facility policy, review of clinical records, observation, and staff interviews it was determined the facility failed to ensure that residents were free from neglect for one of 8 residents reviewed relating to one employee not providing supervision and care for one resident over a period of two scheduled shifts.(resident R16) Findings include: Review of policy titled Abuse Prevention program dated January 1st, 2022, revealed residents have the right to be free from abuse common neglect, misappropriation of resident property and exploitation. This includes neglect which is defined as a failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. The following are some examples of neglect and signs and symptoms of neglect that should be promptly recorded reported some signs of neglect are dehydration, poor hygiene, inappropriate clothing, inadequate provision of care, caregiver indifference to resident's personal care and needs, leaving someone unattended who needs supervision. Review of facility documentation certified nursing assistant job description revealed the description is to ensure resident care is provided according to the care and manner that meets the residents physical, mental and psychosocial needs and enables the individual to attain or maintain the highest practical level of functioning, complete assignments timely, conduct resident rounds, and identify resident problems and concerns. Review of resident R16's quarterly minimum data set (MDS-federal mandated assessment tool for all residents) dated May 5, 2025, revealed that resident R16 entered the facility on July 23, 2021 with diagnosis' including cerebral vascular accident )CVA-stroke-blockage of blood flow to the brain), seizure disorder(uncontrolled electrically activity between brain cells which cause temporary abnormalities in movements), Schizophrenia(mental disorder that affects a person's ability to think, feel, and behave clearly) with a cognitive brief mental interview (BMI- cognition assessment) score of 3 indicating the resident has severe cognitive impairment . Resident R16 was assessed with behaviors of wandering (pacing, trying to leave a care facility or home, and or becoming lost in a familiar place). Most of resident R16, functional abilities such as eating, toileting, showering, dressing required partial or moderate assistance (helper does more than half the effort), with supervision required for walking. This resident is having been determined occasional incontinence of bowel and bladder. Review of resident R16's care plan dated September 13, 2021, revealed that this resident has been identified as having the following health status and conditions that are individually planned with goals and interventions to meet the resident specific needs: Bowel and bladder incontinence with interventions to encourage fluids, assist to the bathroom and check as needed as required for incontinent care, use of anti-psychotropic drugs dated April 11 2024 for interventions to monitor behaviors and moods to monitor their side effects, impaired cognitive function dated with interventions to monitor document and report changes of cognitive function. Further review of resident R 16's care plan revealed that resident R 16 is risk of elopement dated September 13th, 2021, with interventions to ensure that all ancillary staff is aware of elopement potential and provide supervision while outside. Continued review of this document revealed that resident R16 is care plans for seizure activity dated April 11 2024 with interventions to take vitals and perform neuro checks if any signs and symptoms of a seizure to turn the resident on his side, to remain with the resident and maintain his airway, and monitor signs and symptoms of seizure activity, and this resident requires assistance with activities of daily living (ADLs)dated June 1, 2019 with interventions including supervised transfers one assist while dressing one assist with grooming resident requires setup for eating and occasional supervision for mobility. Review floor assignment schedules on the days on May 31, 2025, and June 2, 2025, for the second floor nursing unit 7a.m.-3p.m. shift revealed that employee E 14 was assigned to room C1-C7 (resident R16 occupied room C5). Observation on the second-floor nursing unit on June 2, 2025, at 11:00 a.m. revealed resident R16, room shared with resident R1. Bed A was observed to have no sheets, a plastic mattress torn with foam emerging and infested with bugs. Interview with nurse assistant Employee E 14 at time of the above observation, employee E 14 stated there is no one in that bed This employee is new to the floor but has had this assigned room before and confirmed there was never any resident in bed A. Review of resident R16's clinicla record revealed the resident was assigned to that room bed A. Further review revealed facility midnight census indicated that R16 was also assigned to the room and Bed A. Employee E 14 believed that the resident must have been moved to another room, again, confirming she had no knowledge of that bed occupied for the last week. Interview with Licensed nurse Employee E10 on June 2, 2025, at 12:10 p.m. on the second-floor nursing unit, revealed that resident R 16 and Resident R 1 occupy room C 5. Employee E 10 stated that she had seen resident R 16 earlier that morning and had administered his medications in the hall. This employee claimed that resident R 16 is always walking around. When asked why employee E 14 was unaware that she had this resident to care for, employee E10 stated that she is new to the floor. Interview with employee E 1 on June 5, 2025, at 10:55 a.m. revealed that all shifts have staff reports. The staff are informed of the resident and their specific needs. Interview with certified nurse Employee E 21 on June 5, 2025 at 11:50 a.m. revealed that this employee usually rotates assignments and has confirmed being assigned to room C5 . This employee states that at the beginning of each shift there is a report given and employee E 21 then checks on all residents. Employee E 21 revealed that there is no conceivable way that an employee assigned to a resident would not know the resident is their responsibility. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.29(d) Resident Rights

Based on review of clinical records, facility documentation, and interviews with staff, it was determined the facility failed to provide adequate supervision consistent with the resident's needs, and professional standards of practice for an ambulatory resident diagnosed with dementia, with a history of wandering, and at risk for elopement. When not properly supervised, the resident eloped from the facility, and was found wandering the streets, for one of nine residents reviewed at risk for elopement (Resident R1). The deficiency was identified as Immediate Jeopardy past non-compliance. Findings include: Review of the facility's policy titled, Standard and Guidelines: Elopement and Wandering revised on, November 2023, stated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Care plans will include strategies and interventions to maintain the resident's safety. Review of Resident R1's clinical record revealed an admitted [DATE], diagnosed with Congestive heart failure (heart cannot pump sufficiently). Dementia (progressive degenerative disease of the brain), with agitation, and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of Resident R1's quarterly Minimum Data Set (MDS- assessment of residents' needs), dated November 15, 2023, revealed the resident was cognitively impaired, and needed partial/moderate assistance (helper does less than half the effort) for activities of daily living and required supervision or touching assistance (verbal cues ) when walking. Review of Resident R1's clinical record revealed the resident was a high risk for elopement, physician orders dated March 16, 2023, instructed the resident to wear a Wanderguard bracelet (device designed with a sounding alarm when attempts are made to leave a unit and/or facility) and nursing to check the placement and function of the alarm every shift. Review of Resident R1's care plan initiated on March 16, 2023, for the risk of elopement was developed due to the resident's diagnosis of dementia, impaired safety awareness, a history of attempting to leave the facility unattended and a prior history of wandering in the community before admission. Interventions included redirecting and/or distracting the resident from wandering with diversions, and structured activities. Review of facility documentation submitted to the Department of Health on September 9, 2023, indicated multiple staff members were redirecting Resident R1 back to the resident's nursing unit. The resident went through a backdoor during the same time the Maintenance Director saw the resident and intervened. Resident R1 care plan was updated to place the resident on close supervision. From September 9, 2023, nursing staff documented the whereabouts of Resident R1 every 15 minutes that slowly graduated to 90-minute checks starting January 2024. Review of the logbook revealed an entry indicating the resident was last observed on January 6, 2024, at 4:00 p.m. Review of facility documentation submitted to the Department of Health indicated on January 6, 2024, the facility was notified by Resident R1's past caregiver, around 5:24 p.m. that the resident was currently being treated at the hospital after exiting Liberty Center. The caregiver stated that at 4:58 p.m. she was made aware by a police officer that the resident was found walking down the avenue, about a quarter of a mile away from the facility and was taken to the hospital for treatment. The facility's security cameras revealed the resident exiting through the front lobby of the facility at 4:20 p.m. Prior to the elopement, nursing progress note documented at 2:45 p.m. the resident Continued with wandering behavior and exit seeking; redirection was in progress noting the wanderguard alarm was functioning. Review of hospital records dated, January 6, 2024, confirmed Resident R1 was evaluated after being found wandering the streets, in cold rainy weather, wearing only a light sweater, noting a bystander that provided a warmer coat. The hospital records further noted the resident was 'without complaints, able to stand and ambulate with a steady gait and initially hypoglycemic, with a low blood glucose level of 60 (normal fasting blood sugar levels are between 70 -100 mg/dl (milligrams per deciliter). The resident was given a sugar packet improving to the low 90's. This deficiency was identified as Immediate Jeopardy past non-compliance. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator on January 18, 2024 at 11:19 a.m. On January 6, 2024, the facility initiated a plan of correction to address the failure of providing adequate supervision for an ambulatory resident diagnosed with dementia, displaying signs of wandering, and elopement. The facility's plan of correction included the following: 1. On January 6, 2024, the facility initiated a comprehensive Quality Assurance/Performance Improvement Plan to ensure the continued safety of resident currently residing in the facility to include: 2.The resident was readmitted to the facility on [DATE], and was immediately placed on 1:1 supervision and will continue to be on 1:1 until discharged . 3. An elopement risk quality review of current residents conducted by the Director of Nursing. Residents that were identified as being an elopement risk were checked to ensure that wanderguard was in place and functioning as ordered, care plan updated, and elopement binder placed by both nursing stations, Front desk, and in the activities department. 4.100% of facility staff received education starting on January 6, 2024 and completed on January 7, 2024 from the Director of Nursing and Executive Director regarding the procedures for monitoring resident that are identified as a high risk for elopement as well as the policy and procedure for missing residents, identifying elopement risks, who to immediately report to, location of our elopement binder and properly checking for the wanderguard bracelet. 5. Mock elopement drills were held across all shifts. 6. Mock elopement drills will continue to be held weekly on all shifts to include weekends. 7. An Ad Hoc Safety Meeting was held to discuss the events surrounding the resident's elopement to identify the root cause, and to initiate improvements to the facility's processes and procedures regarding elopements. 8. Any staff member that did not receive education related to the above mentioned was notified by the staff coordinator verbally via phone indicating they may not return to work until the education is received. 9. New hired staff will receive education in orientation. 10. Actions to prevent further deficient practice related to the facility's alleged deficient practice regarding the elopement on January 6, 2024 as follows: Education for current licensed nurses as stated above, mock code drills conducted on various shifts/various days to include the weekends, implementation of the advanced directives discussion form, quality review of current residents who are at risk for elopement to ensure the appropriate safety measures are in place, orders reflecting the residents elopement status are present in the HER/PCC, and care plans are active and reflect appropriate interventions to reduce the risk of elopement. 11. Actions were completed on January 6, 2024. 12. The Quality Improvement Performance Committee will continue to hold weekly meetings to review and discuss the results of the ongoing quality monitoring. The findings of these quality reviews to be reported to the Quality Assurance/Performance Committee weekly. Quality Review schedule modified based on findings. Review of facility documentation revealed that the corrective plan was immediately developed and initiated on January 6, 2024 and completed on January 7, 2024. Interviews were conducted with facility staff and were able to verbally demonstrate their knowledge of the trainings they received and the facility's policies and procedures to ensure residents' safety. 28 Pa. Code 211.10(c) Resident Care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on clinical record review, observations of resident care and services, and interviews with staff, it was determined that the facility failed to ensure that one of three residents reviewed for pressure ulcers was monitored, assessed and received the necessary services to prevent new ulcers from developing, resulting in actual harm of pressure ulcer development for Resident R28. Findings include: Review of Resident R28's clinical record revealed an admitted [DATE] diagnosed with cerebral palsy, severe intellectual disabilities, epilepsy, encephalopathy (A broad term for any brain disease that alters brain function or structure), acute respiratory failure with hypoxia, retention of urine with use of a Foley catheter, a tracheostomy used to assist in breathing, and a gastrostomy (feeding tube) for nutritional needs. Review of Resident R28's Admission Minimum Data Set (MDS is an assessment of resident's care needs) dated November 28, 2022 revealed severe cognitive impairment, totally dependent on staff with the need of two staff members assisting him for bed mobility, transfers, dressing, toileting, hygiene, and bathing, Further review of Resident R28's clinical record revealed a care plan dated November 23, 2022, At risk for skin breakdown related to his immobility, and medical condition. Interventions on admission included keeping his skin clean and dry, providing a pressure reducing mattress and a well-balanced diet via feeding tube. Review of Resident R28's nursing progress notes dated December 10, 2022, revealed, Treatment to BLLE (bilateral lower extremity) maintained, dressing is intact at 5:21 p.m., Wound care provided and at 10:29 p.m. indicated, Treatment to sacrum is ongoing. Review of Resident R28's clinical record did not include further wound assessments and/or documentation related to the wound. Review of the facility's policy titled Prevention of Pressure Ulcer/Injuries dated March 2022 stated the purpose of the procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. The policy states to assess the resident on admission and to repeat the risk assessment weekly. Review of a Wound Care note dated December 14, 2022, revealed: wound on the area is deemed unavoidable due to history of PEG tube requiring Head of Bed elevated to at least 30 degrees at all times, Cerebral Palsy, unable to reposition self, incontinence, weakness. Preventative measures currently in place: Low Air Loss Mattress. Review of Resident R28's nursing assessment on admission, dated November 22, 2022 and Weekly Skin assessment dated [DATE] indicated no pressure areas and/or skin conditions. Further review of the resident's record revealed no further skin assessments since November 29, 2022 and/or documented evidence the facility completed weekly skin assessments when the sacral wound was discovered on December 10, 2022. The same policy stated to Repositioning resident as indicated on the care plan. Review of Resident R28's care plan did not have interventions to turn and reposition the resident. Review of the tasks completed by the nursing assistants revealed no documented evidence the resident was being turned and repositioned. The task was documented as being completed once the sacral wound was discovered. Review of the facility's policy titled, Shower/Tub Bath dated March 2022 revealed one purpose was to observe the condition of the resident's skin for any redness, broken skin, reddish or blue-gray area of skin over a pressure point. The policy further states to document the date and time the shower was performed in the resident's medical record, including assessment data (e.g., reddened areas, sores), notify the physician of any skin areas that may need to be treated and report other information in accordance with facility policy and procedures. Review of the tasks completed by the nursing assistants prompts the nursing assistant to document whether a shower, bath or bed bath were given to the resident. Review of Resident R28's clinical record revealed no documented evidence the resident was given a shower, bath or bed bath since admission and the nursing assistants responses were non-applicable. An order for bi-weekly showers was not ordered until December 15, 2022, after the sacral wound was discovered. Review of the facility's policy Pressure Ulcers/Skin Breakdown dated March 2022 stated when an assessment and recognition of a pressure ulcer occurs nursing shall describe and document/report the full assessment of the pressure ulcer including the location, stage, length, width and depth, presence of exudate's or necrotic tissue. Further review of Resident R28's clinical record revealed the facility failed to assess and document the sacral wound in the resident's clinical record. Request of this documentation was not available for review Per the Director of Nursing on December 12, 2022 at 3:00 p.m. stated, The incident report, (which is not part of the resident's clinical record) was still under investigation. On December 15, 2022 at 1:30PM. an interview with Charge Nurse, Employee E9, who initially assessed the wound and completed the facility's incident report could not describe the wound when it was initially found and could not provide further documentation revealing the description of the wound, only what was documented in the incident report stating the wound Was about 4 cm x 5 cm. Further review of the incident report stated a pressure reducing mattress was in place when the sacral wound was found. Documentation and further review of the care plan indicated a pressure reducing mattress was used since admission and a new order for a low air loss mattress was not obtained until after the sacral wound was found. On December 14, 2022 Resident R28's sacral wound was clinically assessed by a certified wound specialist, four days after the initial observation. The wound was assessed and measured with full-thickness ulceration of the Sacrum that measures 8.0 x 5.0 x 0. 2cm, wound base is 90% adherent yellow slough and 10% intact, scant non-odorous serous drainage, edges adherent to the wound base. The specialist further stated, The sacral wound is assessed as unstageable pressure ulcer/injury of the sacrum secondary to slough and stated that it would be expected that with the resolution of slough and necrotic tissue, wound depth and undermining is likely to be observed. The wound specialist noted that the staff reports the Resident R28's with fecal incontinent, poor bed mobility, and unable to self-reposition. Instructs the staff to off-load pressure to affected areas, continue with Low-air loss support surface mattress, and turn and reposition. The facility failed to implement wound prevention measures for a resident who was at increased risk of pressure ulcer development related to the resident's head of bed needing to be elevated to at least 30 degrees at all times for feeding, Cerebral Palsy, the resident being unable to reposition self, incontinence and weakness, which resulted in actual harm to the resident for not turning and repositioning the dependant resident, not properly assessing the resident leading to an unstageable wound being discovered, and not having a Low-air loss support surface mattress in place until after the wound was discovered. 28 Pa. Code 211.5 (f) Clinical Records 28 Pa. Code 211.12 (d) (1) Nursing Services 28 Pa. Code 211.12 (d) (3) Nursing Services

Based on a review of clinical records, facility policies and procedures and interviews with staff, it was determined that the facility failed to implement interventions for one resident during an emergent medical condition, involving the administration of CPR (cardiopulmonary resuscitation) according to the wishes of one of 4 residents reviewed (Resident CL1). Findings include: Review of the facility policy, Cardiopulmonary Resuscitation (CPR) Guideline, effective [DATE], revealed: Guideline: If a resident is found unresponsive, begin evaluation to determine presence or absence of pulse and/or respirations. In the absence of pulse and/or respirations do the following: 1. Remain calm. 2. Call out for help. Direct another staff member to announce the emergency per Living Center protocol and call Emergency Medical Services (EMS-dial 911). Direct another staff member to bring the emergency supplies and AED (Automated External Defibrillator) to the scene. 3. A charge nurse will assume command of the scene and will direct other personnel in the effort. CPR certified personnel, when present in the facility, shall manage the physical efforts involved in resuscitation. 4. A staff member other than the one who is providing the resuscitative effort must promptly identify/validate current code status. While that step is undertaken, AED should be prepared and [MEDICATION NAME] placed. 5. If DNR (do-not-resuscitate) status is validated, do not initiate CPR. If CPR/Code Status is undetermined, CPR will be initiated and will continue until the arrival of EMS, 6. Depending on time of event and staff available: (a) Direct available staff to meet EMS personnel at arrival point and (b) Direct available staff to reassure other residents. Review of Resident CL1's clinical record revealed that the resident had been readmitted to the facility from the hospital on [DATE], with [DIAGNOSES REDACTED]. The resident was maintained on continuous oxygen at four liters per minute. Further review of Resident CL1's clinical record revealed that the resident was a Full Code (to intercede if a patient's heart stops beating or if the patient stops breathing) with a Do Not Hospitalize (resident's advance directive indicated that resident did not wish to be hospitalized .) During morning rounds on [DATE] at approximately 5:20 AM, Employee E3, a Night Charge Nurse, noted that Resident CL1 had no signs of life, including no blood pressure, respirations or pulse. Registered Nurse Employee E3 made a determination not to initiate CPR and implement the facility policy. Registered Nurse Employee E3 contacted the resident's physician. As per Employee E3's written statement, The physician provided a telephone order to pronounce resident CL1's death and release remains to funeral home. There was no CPR initiated and the facility policy was not implemented. During an interview on [DATE] at 9:00 AM, with the Nursing Home Administrator and the Interim Director of Nursing, it was confirmed that Registered Nurse Employee E3, upon finding a resident unresponsive, failed to activate the emergency medical services and initiate CPR for one resident. It was also indicated that there were other staff members in the building at the time who could have initiated the CPR. There was no evidence that the facility initiated CPR or attempted resuscitation in the absence of a pulse or breath sounds or blood pressure as was Resident CL1's wishes. The facility failed to implement interventions for Resident CL1 in an emergent situation and did not adhere to the resident's wishes for CPR or attempt resuscitation. The Nursing Home Administrator and the Interim Director of Nursing conducted an investigation which revealed that Employee E3, failed to implement the facility policy, Cardiopulmonary Resuscitation (CPR) Guideline. A request was made to review Registered Nurse, Employee E3's CPR certification. Further interview revealed that Employee E3 did not have a current CPR certification and that the CPR certificate on file had expired. 42 CFR 483.25 Provide Care/Services for Highest Well Being Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(c) Resident care policies Previously cited [DATE] 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 211.12(d)(3) Nursing services Previously cited [DATE], [DATE]

Based on observation, review of clinical records and facility documentation and interviews with staff, it was determined that the facility failed to ensure timely care for an injury and failed to follow the physician's orders [REDACTED]. Findings included: Review of Resident R1's nurses' notes dated August 14, 2015, revealed that the resident was observed with a wound to the right lower leg which was assessed as measuring 2.2 cm. (centimeters) by 2.5 cm. with purulent drainage (containing pus) coming from a small opening at the distal (bottom) end of the wound. The note indicated that the rest of the wound was scabbed (necrotic- dead skin). The note continued that the resident reported receiving a burn from E-stim (electrical stimulation treatments that are used to strengthen muscles and promotes healing), that the resident had last received in physical therapy in June 2015. Review of the facility documentation of their investigation into this burn, revealed a statement from Employee E4, a Restorative Aide. This statement indicated that Employee E4 had first observed the resident with a blister to the lower leg in, late June or July (2015) but had not reported this because the employee assumed that the nursing staff was aware. Review of the physician's orders [REDACTED]. The physician ordered this area to be cleansed with normal saline solution and that Santyl (a [MEDICATION NAME] agent) be applied to the wound bed and the wound covered with a gauze dressing daily and whenever necessary. A review of the wound evaluation flow sheets, dated September 4, 2015, revealed that the resident's burn now measured 1.5 cm. by 1 cm. by .1 cm. and had slough (dead tissue) and had a moderate amount of thin, watery discharge. Observation of the wound care on September 11, 2015 at 10:00 a.m., confirmed that the resident continued with the wound being treated. Interview with Employee E3, the Registered Nurse, on September 10, 2015 at 2:55 p.m., confirmed that Employee E4 should have reported the observation of the blister and that there was a delay in treatment. The facility failed to monitor and provide timely care to the resident that resulted in harm for over two months to the resident. The resident stated that the injury occurred in June and the staff did not obtain a physician's orders [REDACTED]. Review of Resident R49's physician's orders [REDACTED]. Review of the resident's clinical records on September 9, 2015, revealed no evidence that the psychiatric consultation had been completed as ordered. Interview with Employee E3 on September 10, 2015, confirmed that the psychiatric consultation had not been completed. Review of Resident R56's clinical record revealed that the resident received [MEDICAL TREATMENT] treatment (procedure by which impurities and waste are removed from the blood) three times per week. The plan of care indicated that the access site was to be checked daily and that the resident was to be weighed before and after each treatment and that the weights were to be recorded on the designated communication form. Review of the [MEDICAL TREATMENT] communication forms for the months of August and September, revealed that the resident's weights were not being recorded before and after each [MEDICAL TREATMENT] treatment as indicated in the care plan. An interview conducted with the Nursing Home Administrator on September 11, 2015 at 10:30 a.m., confirmed that the documentation of weights before and after each [MEDICAL TREATMENT] treatment were not available. Resident R42 has [DIAGNOSES REDACTED]. The antipsychotic medicine, [MEDICATION NAME], was prescribed for the resident. She had an Abnormal Involuntary Movement test (an AIMS test aids in the early detection of drug induced movements) on her chart dated July 17, 2014, which was done on admission. On March 26, 2015, the physician ordered an AIMs test every 6 months and ordered that the results be placed on the chart to evaluate for extrapyramidal symptoms (drug induced movements) related to the unspecified [MEDICAL CONDITION]. A review of the resident's clinical record revealed there was no current AIMS test on her chart. The pharmacist wrote a recommendation on April 24, 2015, stating, Aims ordered but not done. The pharmacist again noted on the consultation dated August 31, 2015, and recommended, AIMS. 42 CFR 483.25 Provide Care/Services for Highest Well Being. Previously cited 10/02/14, 07/15/15 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 10/02/14, 07/15/15 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 07/15/15