Every finding on record at Linwood Nursing and Rehabilitation Center

Based on a review of facility policies, clinical records, facility investigative documentation, and resident and staff interviews, it was determined the facility failed to ensure one of 10 residents reviewed (Resident 1) remained free from emotional and psychosocial abuse, exploitation, and invasion of privacy when a staff member intentionally recorded the resident on a personal cellular telephone during toileting care and while the resident was using the toilet without the resident's knowledge or consent. This deficient practice resulted in actual psychosocial harm through humiliation, loss of dignity, and violation of the resident's privacy. This deficiency is cited as past noncompliance.Findings include:A review of a facility policy titled Resident Abuse & Neglect Prevention Program last reviewed by the facility on January 21, 2026, revealed each resident has the right to be free from abuse, neglect, misappropriation, and exploitation. The policy indicated that each resident has the right to be free from mistreatment and neglect. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The policy defined mental, emotional, or psychosocial abuse as the verbal or nonverbal infliction of anguish, pain or distress that results in mental or emotional suffering, including humiliation, harassment, threats of punishment, or deprivation. A review of a facility policy titled Videotaping, Photographing, and Other Imaging of Residents last reviewed by the facility on January 21, 2026, revealed residents will be protected from invasion of privacy and or abuse that might occur from photographs, videotapes, digital images, and recordings during resident care or other facility activities. The policy defined resident image as the likeness of a resident captured through still photography, videotaping, digital imaging, scans, audio recording, etc. A review of Resident 1's clinical record revealed the resident was admitted on [DATE], with diagnoses that included dementia with psychotic disturbance (a condition in which progressive memory loss and impaired thinking are accompanied by hallucinations or false beliefs), restlessness, and agitation. A review of Resident 1's Annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 20, 2026, revealed that Resident 1 was moderately cognitively impaired with a BIMS score of 9 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8 through 12 indicates moderate cognitive impairment). The assessment revealed Resident 1 required moderate staff assistance for toilet transfers and transfers between the bed and wheelchair. A review of Resident 1's care plan dated June 20, 2025, revealed the resident exhibited behaviors including yelling out, making negative statements, paranoia, and crying. The care plan directed staff to explain care before providing assistance, maintain a consistent routine, speak in a calm and reassuring manner, and postpone care if the resident became combative until the resident regained composure. A review of facility provided investigative documentation revealed that on June 23, 2026, between 6:30 AM and 7:00 AM, Employee 2 Nurse Aide (NA) arrived for duty when Employee 1 Nurse Aide stated, Come here, you need to see this, and displayed a video on Employee 1's personal cellular telephone depicting Resident 1. During an interview on July 1, 2026, at 9:39 AM Employee 2 stated Employee 1 NA showed both Employee 2, NA, and Employee 4, NA, the recording. Employee 2 stated the recording depicted Resident 1 in bed while Employee 1 repeatedly instructed the resident to get up without providing assistance. Employee 2 stated the recording then depicted Resident 1 being taken to the bathroom where Employee 1 continued recording while Resident 1 sat on the toilet using the bathroom. Employee 2 stated the recording further depicted Resident 1 asking for assistance off the toilet while Employee 1 responded, You can get in the chair. Employee 2 stated the recording later showed Resident 1 struggling to return to bed while repeatedly requesting help and ultimately kicking the wheelchair toward Employee 1 after assistance was not provided. Employee 2 stated that throughout the recording Employee 1 did not provide the moderate assistance required for Resident 1's toileting transfers despite the resident's repeated requests for help. Employee 2 immediately reported the incident to Employee 3, Licensed Practical Nurse (LPN).During an interview on July 1, 2026, at 10:01 AM Employee 4 confirmed Employee 1 displayed the recording to Employee 2 and Employee 4. Employee 4 stated the recording depicted Resident 1 asking for assistance, using the toilet while being recorded, requesting help to get off the toilet, struggling to return to bed, and kicking the wheelchair after assistance was not provided. Employee 4 further stated Employee 1 commented while recording, See this is why I have bruising. This is what I have to deal with. Employee 4 stated she was extremely upset after viewing the recording and immediately reported the incident with Employee 2 to Employee 3. During an interview on July 1, 2026, at 10:25 AM Employee 3, LPN, stated Employees 2 and 4 immediately informed her they had viewed a video showing Resident 1 being recorded while using the toilet. Employee 3 stated she immediately notified the Director of Nursing (DON) and checked on Resident 1.An interview with Employee 3 conducted on July 1, 2026, at 10:25 AM revealed she was working in her office on the morning of June 23, 2026, when Employees 2 and 4 approached her and reported they had viewed a video on Employee 1's personal cellular telephone depicting Resident 1 while the resident was using the bathroom. Employee 3 stated she did not personally view the video. Employee 3 stated she immediately sent a text message to the Director of Nursing (DON), then went to Resident 1's room, where the resident was seated. Employee 3 stated Employee 1 had already left the facility.A review of text message communications revealed Employee 3 sent a text message to the DON on June 23, 2026, at 7:23 AM stating, Need to talk to you ASAP. A review of telephone records revealed the DON returned the call at 7:24 AM, at which time Employee 3 informed the DON about the reported video. An interview with the DON conducted on July 1, 2026, at 10:50 AM revealed that after learning of the reported video, she immediately returned to the facility and initiated an investigation. A review of an employee witness statement submitted by Employee 1 via email to the facility on June 24, 2026, at 3:30 AM revealed Employee 1 wrote that on June 22, 2026, between 6:45 AM and 7:00 AM, Resident 1 was, in Employee 1's words, acting up while Employee 1 was assisting the resident to the bathroom. Employee 1 further wrote that Resident 1 repeatedly directed racial slurs toward Employee 1 and that Employee 1 recorded Resident 1 in the resident's room as video proof to protect herself. During a telephone interview conducted by the surveyor on July 1, 2026, at 11:00 AM Employee 1 confirmed recording Resident 1 on a personal cellular telephone. Employee 1 stated she recorded the resident because she was tired of the resident's behavior and stated Resident 1 repeatedly said, Come here @#$%^&* girl, you work for me. Employee 1 stated she wanted to record the video because she was tired of being mistreated by the resident and intended to show the recording to the DON. Employee 1 further stated she deleted the video before leaving the facility because she believed the DON would not care and there would be no repercussions for Resident 1's behavior. Employee 1 stated she did not understand why she was in trouble because she believed Resident 1 was the problem. When asked, Employee 1 acknowledged she knew facility policy prohibited recording residents but stated she felt she had no other choice. When requested to retrieve the recording from the deleted files on her cellular telephone, Employee 1 stated the video had been permanently deleted and could not be recovered. During an interview on July 1, 2026, at 12:45PM, the DON and Nursing Home Administrator confirmed the facility investigation determined Employee 1 did not follow the facility's abuse and neglect policy, prohibiting unauthorized photographing or recording of residents. The DON and Nursing Home Administrator confirmed Employee 1 was immediately removed from the work schedule and employment was terminated. The facility alleged past noncompliance. Facility documentation and interviews confirmed the following corrective actions were implemented immediately following the incident. Resident 1 was assessed for any injury. Employee 1 was immediately suspended. The facility completed an audit on all residents to determine if any other residents in the facility were affected. The facility immediately conducted facility wide education on the abuse/neglect policy, videotaping policy, and dementia care policy. To sustain compliance, the facility administration initiated a plan to conduct five random audits, regarding staff care, these audits are scheduled weekly for one week, bi-weekly for two weeks, and weekly for 1 month. The results of the audits are to be reviewed by the facility's Quality Assurance and Performance Improvement (QAPI) Committee for oversight and recommendations. The facility demonstrated that substantial compliance was achieved on June 25, 2026. Therefore, this deficiency is cited as past noncompliance. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on a review of facility policies, facility investigative documentation, clinical records, and staff interviews, it was determined the facility failed to conduct a complete and thorough investigation of an allegation of abuse, neglect, and exploitation for one of 10 residents reviewed for (Resident 1).Findings include:A review of a facility policy titled Resident Abuse & Neglect Prevention Program last reviewed by the facility on January 21, 2026, revealed each resident has the right to be free from abuse, neglect, misappropriation, and exploitation. The policy indicated that each resident has the right to be free from mistreatment and neglect. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. The policy further defined mental, emotional, or psychosocial abuse as the verbal or nonverbal infliction of anguish, pain, or distress that results in mental or emotional suffering, including humiliation, harassment, threats of punishment, or deprivation. A review of a facility policy titled Videotaping, Photographing, and Other Imaging of Residents last reviewed by the facility on January 21, 2026, revealed residents will be protected from invasion of privacy and or abuse that might occur from photographs, videotapes, digital images, and recordings during resident care or other facility activities. The policy defined a resident image as the likeness of a resident captured through still photography, videotaping, digital imaging, scanning, or audio recording. The policy revealed any image or recording that may reasonably be construed as humiliating or demeaning to a resident is considered resident abuse and will be reported and investigated. A review of a facility policy titled Investigation of Allegation of Abuse, Neglect, Misappropriation, or Exploitation and Resident Protection last reviewed by the facility on January 21, 2026, revealed the investigation will include a review of the completed incident investigation, an interview of the perpetrator, witnesses, the victim, and the resident's roommate if able. The policy detailed a review of all circumstances surrounding the incident and a review of surveillance videos, and any other official documentation received regarding the incident as available. A review of Resident 1's Annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 20, 2026, revealed that Resident 1 was moderately cognitively impaired with a BIMS score of 9 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8 through 12 indicates moderate cognitive impairment). The MDS revealed Resident 1 required moderate staff assistance with toilet transfers (assistance getting on and off the toilet) and transfers between the bed and wheelchair. A review of Resident 1's care plan dated June 20, 2025, revealed the resident exhibited behaviors including yelling out, making negative statements, paranoia, and crying. The care plan directed staff to explain care before providing assistance, maintain a consistent routine, speak in a calm and reassuring manner, and postpone care if the resident became combative until the resident regained composure. A review of the facility's investigative documentation revealed that on June 23, 2026, Employee 2 Nurse Aide (NA) reported Employee 1 (Nurse Aide) NA had shown Employees 2 and 4 a video recorded on Employee 1's personal cellular telephone showing Resident 1 during resident care. The facility investigation determined Employee 1 had recorded Resident 1 in the privacy of the resident's room while providing care. The investigative documentation further revealed Employee 1 reported deleting the recording before leaving the facility. The investigation contained no documentation the facility attempted to verify Employee 1's statement that the recording had been permanently deleted. Specifically, the investigative documentation contained no evidence the facility requested Employee 1 retrieve the recording from the deleted files on the cellular telephone, examined the device to determine whether the recording remained recoverable, or otherwise attempted to verify the recording no longer existed. Because the facility did not attempt to verify whether the recording remained available, the investigation did not determine the complete content of the recording or whether the recording contained additional evidence regarding the allegation of abuse, neglect, exploitation, invasion of privacy, or failure to provide required resident care beyond the information reported by witnesses. During an interview conducted on July 1, 2026, at 12:00 PM, the Nursing Home Administrator and Director of Nursing reviewed the facility's investigative documentation. The Nursing Home Administrator and Director of Nursing acknowledged the facility did not attempt to verify whether the recording remained on Employee 1's personal cellular telephone after Employee 1 reported deleting the recording.28 Pa Code 201.18(b)(1) Management.28 Pa Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, consultant pharmacist records, clinical record review, and staff interview, it was determined the facility failed to ensure the attending physician reviewed and responded to consultant pharmacist recommendations for one resident (Resident 2) reviewed for medication regimen review. Findings include:A review of Resident 2's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included dementia (a medical condition involving loss of cognitive functioning such as memory, thinking, and reasoning severe enough to interfere with daily activities). A review of the consultant pharmacist report titled Consultant Pharmacist Communication to Physician, dated November 12, 2025, revealed the pharmacist identified that Resident 2 had physician orders for three or more central nervous system (CNS) active medications. CNS medications are drugs that affect the brain and spinal cord and may influence mood, behavior, level of alertness, or pain perception. When several CNS medications are used together, the combined effect can increase the risk of serious side effects such as excessive sedation (sleepiness), confusion, impaired balance, falls, and fractures, particularly in older adults. The pharmacist documented that Resident 2 had active orders for the following CNS medications: Venlafaxine 50 milligrams daily, an antidepressant medication used to treat depression and anxiety disorders.Quetiapine 25 milligrams daily, an antipsychotic medication used to treat conditions affecting mood or behavior. The pharmacist indicated this medication was due for a gradual dose reduction (GDR), which is a clinically supervised decrease in medication dosage intended to determine whether the medication remains necessary at the current dose.Perphenazine 4 milligrams daily, another antipsychotic medication used to treat certain psychiatric symptoms. The pharmacist also indicated this medication was due for a gradual dose reduction.Oxycodone Hydrochloride 5 milligrams three times daily, an opioid pain medication used to treat moderate to severe pain. Opioids act on the brain and nervous system to relieve pain but may also cause sedation, slowed breathing, and increased fall risk.Clonazepam 1 milligram twice daily, an anti-anxiety medication classified as a benzodiazepine that acts on the brain to produce a calming effect but may cause sedation and impaired coordination.Primidone 25 milligrams three times daily, an anticonvulsant medication used to treat seizure disorders and certain neurological conditions. The consultant pharmacist recommended the attending physician reevaluate the combination of these CNS medications due to the potential for increased adverse effects and consider performing a gradual dose reduction of Quetiapine and/or Perphenazine or provide clinical documentation explaining why reducing the medication would be medically inappropriate (a contraindication). Further review of Resident 2's clinical record did not reveal written documentation showing the attending physician reviewed, acknowledged, or responded to the pharmacist's recommendation. The record also did not contain documentation indicating the physician evaluated the medication combination, implemented a gradual dose reduction, or documented a clinical reason why a reduction could not be attempted. During an interview on March 5, 2026, at 11:00 AM, the Director of Nursing confirmed the facility could not provide documentation showing the attending physician reviewed or acted upon the consultant pharmacist's recommendation 28 Pa. Code 211.2 (d)(3)(9) Medical director 28 Pa Code 211.5 (f)(vii) Medical records 28 Pa. Code 211.9 (k) Pharmacy services

Based on review of the facility's planned cycle menus and menu substitution records, observation of meal service, and staff interview, it was determined the facility failed to follow the planned menu for residents who required a pureed consistency diet for 9 of 9 residents reviewed with physician-ordered pureed diets (Residents 18, 23, 28, 45, 47, 61, 81, 9, and 92).Findings include: A review of the facility's planned cycle menu revealed that the lunch meal scheduled for March 5, 2026, included a dinner roll that was to be provided in a pureed form (a food consistency in which regular foods are blended or processed into a smooth, pudding-like texture without lumps, commonly ordered for individuals who have difficulty chewing or swallowing food safely), for residents ordered on a pureed consistency diet. Observation of the lunch meal service on March 5, 2026, between 12:00 P.M. and 12:45 P.M., revealed there were no pureed dinner rolls available on the tray line where meals were prepared and distributed to residents. Continued observation of the meal service revealed Residents 18, 23, 28, 45, 47, 61, 81, 9, and 92, who all had physician orders for a pureed consistency diet, did not receive a pureed dinner roll with their lunch meal as indicated on the planned menu. During an interview on March 5, 2026, at 12:45 P.M., the Certified Dietary Manager (CDM) confirmed that pureed dinner rolls were not available on the lunch tray line during the observed meal service. The CDM confirmed that the planned menu for that meal included pureed dinner rolls for residents receiving pureed consistency diets. The CDM was unable to provide an explanation as to why the pureed dinner rolls were not prepared or available for service during the meal. 28 Pa. Code 211.6 (a) Dietary Services. 28 Pa. Code 201.18 (b)(3)(e)(3) Management.

Based on observations, test tray evaluation, review of food committee minutes, and resident and staff interviews, it was determined the facility failed to ensure foods were served at safe and palatable temperatures for residents for 1 test tray evaluated for one of 4 hallways and 2 of 2 residents (Residents 102 and 103) who voiced concerns related to food temperature and palatability.Findings include: According to the federal regulation 483.60(i)-(2) Food safety requirements, the definition of Danger Zone, found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness. A review of the facility food committee meeting minutes dated January 9,2026 revealed complaints related to food temperature, palatability (quality of food that makes it pleasant to eat including taste, smell, texture and appearance), stating that meal trays remain on the food carts in the hallway, waiting for staff to deliver to resident rooms, resulting in cold food. The meeting minutes did not identify the residents attending the food committee meeting or making the complaints. A review of the facility's posted meal service schedule for March 5, 2026 revealed that lunch for the 300 rooms hall cart was scheduled to be delivered at 12:20 PM. Observation of the kitchen tray line on March 5, 2026, at 12:22 PM, revealed that the 300 hallway cart (cart three) left the kitchen at 12:22 PM. Observation on the 300 nursing unit at approximately 12:23 PM revealed the last tray was served to residents at approximately 12:30 PM. A test tray evaluated at 12:31 PM on March 5, 2026, revealed the following food temperatures:Onion Sage Chicken entree: 134.8 FarenheitCarrots: 133.1 FAu gratin potatoes: 127.5 FCoffee: 121.5 FHot water 122.2 FPurple cold drink 57 F The chicken entree was cool and not palatable. The carrots were bland and mushy in consistency, and the au gratin potatoes were dry, hard and difficult to chew. During an interview on March 5, 2026, at 9:00 AM, Resident 102 stated that he eats his meals in the small hallway dining room and frequently receives food that is cold, unappetizing, to include coffee. He indicated that nursing staff could reheat the coffee, but he just drinks it cold. During an interview on March 5, 2026, at 9:05 AM, Resident 103 also stated that he eats his meals in the small hallway dining room and frequently receives food that is cold, unappetizing, to include coffee. He indicated that nursing staff could reheat the coffee, but he just drinks it cold. An interview conducted with the facility Certified Dietary Manager (CDM) on March 5, 2025, at approximately 1:45 PM, confirmed the facility failed to ensure that meals were served at temperatures that are palatable and in accordance with regulatory guidelines. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1) Management.

Based on review of facility policy, clinical record review, and staff interviews, it was determined the facility failed to develop a comprehensive person-centered care plan that included individualized and measurable interventions to address a resident's known behavioral needs for 1 of 19 residents reviewed (Resident 88).Findings include:A review of the facility policy titled Care Plans, Comprehensive Person Centered, last reviewed by the facility on January 21, 2026, revealed the facility will develop a comprehensive person-centered care plan that addresses each resident's identified needs. The policy indicated the care plan should include problems, needs, and individualized interventions related to the resident's social, emotional, psychosocial, physical, behavioral, rehabilitation, cultural, spiritual, nutritional, leisure, and preventative care needs based on assessment findings, resident involvement, observations, and interdisciplinary input. A review of Resident 88's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (a progressive brain disorder that slowly destroys memory and thinking skills and eventually affects the ability to perform simple daily tasks) and Bipolar Disorder (a mental health condition characterized by significant mood changes that alternate between elevated mood, known as mania, and periods of depression). A review of Resident 88's annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 9, 2026, revealed the resident was severely cognitively impaired with a BIMS score of 0 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; (a score of 0 through 7 indicates severe cognitive impairment meaning the resident has significant difficulty understanding information, remembering events, and making safe decisions independently). A review of a nursing progress note dated February 11, 2026, at 4:46 AM revealed staff observed Resident 88 defecate (pass stool) a blue rubber glove (consistent with the disposable gloves commonly worn by staff when providing resident care and performing cleaning tasks within the facility) into the toilet, The documentation indicated the glove was intact and intertwined in stool. The note indicated no blood, swelling, redness, or irritation was observed in the rectal area. Vital signs were recorded as temperature 97.8 F, pulse 53, respirations 18, blood pressure 117/72, and oxygen saturation 96 percent on room air. The resident denied pain or discomfort. The Registered Nurse notified the on-call medical provider.During an interview on March 5, 2026, at 11:00 AM, the Director of Nursing (DON) stated that family members previously informed staff that Resident 88 had a history of sexualized behaviors and inserting objects into body openings. A review of Resident 88's care plan, originally initiated on September 9, 2015, and most recently updated on January 12, 2026, revealed the care plan did not identify the resident's history of sexualized behaviors or inserting objects into body openings as a problem, nor did it include individualized goals or interventions to address or monitor this behavior, despite staff awareness of the behavior. During an interview on March 6, 2026, at 9:30 AM, the Surveyor reviewed the above findings with the Director of Nursing (DON) related to the facility's failure to develop a comprehensive person-centered care plan to address Resident 88's known behaviors involving sexualized behaviors or inserting objects into body openings, to ensure the resident's physical, psychosocial, and safety needs were addressed. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 28 Pa. Code 211.10(c)(d) Resident care policies.

Based on clinical record review and staff interview, it was determined the facility failed to ensure that nursing services met professional standards of quality as required by the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to implement appropriate nursing practices for the administration of an intravenous (IV) medication via peripheral inserted central venous catheter (PICC) for one of 19 residents reviewed (Resident 102).Findings include:According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) require the following: The LPN is prepared to function as a member of the health care team by exercising sound nursing judgement based on preparations, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. (b) The LPN administers medication and carries out the therapeutic treatment ordered for the patient in accordance with the following: (d) The Board recognizes codes of behavior as developed by appropriate practical nursing associations as the criteria for assuring safe and effective practice. Chapter 21.145 b. IV therapy curriculum requirements:(f) An LPN may perform only the IV therapy functions for which the LPN possesses the knowledge, skill and ability to perform in a safe manner, except as limited under S 21.145 a (relating to prohibited acts), and only under supervision as required under paragraph (1).(1) An LPN may initiate and maintain IV therapy only under the direction and supervision of a licensed professional nurse or health care provider authorized to issue orders for medical therapeutic or corrective measures (such as aCRNP, physician, physician assistant, podiatrist or dentist).(g) An LPN who has met the education and training requirements of S 21.145 b (relating to IV therapy curriculum requirements) may perform the following IV therapy functions, except as limited under S 21.145 and only under supervision as required under subsection (f): (1) Adjustment of the flow rate on IV infusions. (2) Observation and reporting of subjective and objective signs of adverse reactions to any IV administration and initiation of appropriate interventions. (3) Administration of IV fluids and medications. (4) Observation of the IV insertion site and performance of insertion site care. (5) Performance of maintenance. Maintenance includes dressing changes, IV tubing changes, and saline or heparin flushes. (6) Discontinuance of a medication or fluid infusion, including infusion devices. (7) Conversion of a continuous infusion to an intermittent infusion. (8) Insertion or removal of a peripheral short catheter. (9) Maintenance, monitoring and discontinuance of blood, blood components and plasma volume expanders. (10) Administration of solutions to maintain patency of an IV access device via direct push or bolus route. (11) Maintenance and discontinuance of IV medications and fluids given via a patient-controlled administration system. (12) Administration, maintenance and discontinuance of parenteral nutrition and fat emulsion solutions. (13) Collection of blood specimens from an IV access device. Clinical record review revealed that Resident 102 was admitted to the facility on [DATE], with diagnoses to include osteomyelitis (bone infection) and bacteremia (bacteria in the blood). Resident 102 was admitted to the facility with a PICC line (a peripherally inserted central catheter, a long tube introduced through a vein in the arm and passed through to the larger veins into the heart). A review of clinical orders revealed a physician's order dated February 27, 2026, directing the use of 10 milliliters (mL) intravenously (into the vein, in this instance through the PICC line in the Resident 102's left arm which leads to the larger veins into the heart) every evening and night shift for PICC line flush. The physician orders required the PICC line to be flushed with the 10 (mL) normal saline solution prior to and after daily antibiotic administration Normal saline (a sterile saltwater solution) is used to prevent the PICC line from becoming blocked. Review of the Electronic Medication Administration Record (eMAR technology that automatically documents the administration of medication into the medical record) revealed that on March 2, 2026, at 6:59 AM Employee 2 Licensed Practical Nurse (LPN) documented administration of normal saline solution to Resident 102 through the PICC line. The MAR revealed that Employee 3 LPN documented administration of the normal saline solution to Resident 102 through the PICC line on March 2, 2026, at 1:19 PM and Employee 4 LPN administered the normal saline solution through the PICC line on March 4, 2026, at 6:28 AM. The facility could not produce any documentation verifying that Employee 2, 3, and 4 completed the IV therapy education required under S21.145(b). There was no evidence of current competency validation, supervision documentation, or internal training specific to PICC line administration. During an interview conducted on March 5, 2026, at 9:50 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the facility had no documentation of required IV therapy education or competency for LPNs regarding administration of medications through PICC lines. The interview on March 5, 2026, also revealed the facility did not maintain a policy specific to PICC line medication administration and no documented competencies existed for Registered Nurses (RNs) or LPNs regarding safe administration through PICC lines. 28 Pa. Code 201.20(a) Staff Development. 28 Pa Code 211.12(c)(d)(1)(2)(3)(5) Nursing services.

Based on a review of clinical records, select facility policy, observation, and resident and staff interviews, it was determined the facility failed to ensure oxygen therapy was administered consistent with professional standard of practice for one resident out of 19 sampled residents (Resident 43).Findings include: A review of the facility policy titled, Oxygen Administration by Nasal Cannula (a medical device used to deliver oxygen by a small, flexible tube with two prongs that fit into the nostrils) and mask (a device worn over the nose and mouth through which oxygen is delivered) last reviewed February 19, 2026, indicated residents who require oxygen will have a physician order which includes the flow rate, how the oxygen will be administered, and the need for humidified air if necessary. The policy indicated the physician orders will also include oxygen tubing and bag will be changed monthly and dated when changed. Resident 43 was admitted to the facility on [DATE], with diagnoses which included unspecified convulsions (abnormal, electrical brain activity which leads to sudden, involuntary movements). A review of Resident 43's significant change Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 18, 2026, revealed that Resident 43 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates normal cognitive function). An observation on March 3, 2026, at 10:45 AM indicated Resident 43 was in bed and receiving oxygen by a nasal cannula attached to an oxygen concentrator (medical device that delivers oxygen through a nasal cannula). The oxygen was being delivered at 3 liters of oxygen per minute. An additional observation on March 3, 2026, at 1:15 PM included Resident 43 was sitting in a chair and continued to receive oxygen through the nasal cannula at the rate of 3 liters per minute. A review of clinical records did not include a physician order for oxygen. Interview with Employee 5 Licensed Practical Nurse (LPN) confirmed there was no physician order for oxygen. Interview with the Director of Nursing (DOH) and Nursing Home Administrator (NHA) on March 4, 2026, at 11:45 AM confirmed there was no order for Resident 43's oxygen in accordance with professional standards and facility policy. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services. 28 Pa. Code 211.10 (c)(d) Resident care policies.

Based on review of facility policy, clinical record review, and staff interview, it was determined the facility failed to follow its pain management policy and accepted standards of nursing practice by failing to attempt and document non-pharmacological interventions prior to the administration of pain medication prescribed on an as needed basis, failing to ensure the pain medication order included the specific pain indication or severity level, and failing to evaluate the effectiveness of administered pain medication using a numeric pain scale for 1 of 19 residents reviewed (Resident 102).Findings include: Clinical record review revealed that Resident 102 was admitted to the facility on [DATE], with diagnosis to include osteomyelitis (a serious infection of the bone that can cause significant pain, swelling, and damage to bone tissue) and bacteremia (presence of bacteria in the bloodstream, which may spread infection throughout the body and may also result in pain or systemic illness). A review of the facility policy titled Pain Management, last reviewed by the facility on February 19, 2026, revealed the facility will provide pain management services consistent with professional standards of practice, the resident's comprehensive person-centered care plan, and the resident's goals and preferences. The procedure indicated that once pain is identified, staff should attempt and document non-pharmacological measures prior to administering medication. Non-pharmacological measures are approaches that do not involve medication and may include repositioning the resident, providing a back rub or massage, assisting with toileting, dimming lights, or offering food or fluids in an effort to relieve discomfort. The policy revealed that pain medication orders should include the name of the medication, the strength, the frequency, the indication or location of the pain, and the pain scale category such as mild, moderate, or severe. The procedure indicated that when a medication ordered on an as needed basis and pain medication is administered the professional licensed staff will conduct a pain scale prior to administering the medication and again one hour after each method of pain relief to evaluate effectiveness. The procedure further described the use of a numeric pain rating scale. A numeric pain scale is a commonly used tool in healthcare that allows a resident to rate the severity of their pain on a scale from 0 to 10. A score of 0 indicates no pain. Scores from 1 through 3 generally represent mild pain, scores from 4 through 6 represent moderate pain, and scores from 7 through 10 represent severe pain. The scale allows staff to consistently measure pain levels and evaluate whether treatment was effective. Clinical record review revealed a nurse practitioner order dated February 27, 2026, for Oxycodone HCL 5 milligrams, one tablet every four hours as needed for pain. Oxycodone is a narcotic pain medication. Narcotic pain medications, also known as opioid medications, are a class of powerful drugs used to treat moderate to severe pain. These medications act on the brain and nervous system to reduce the perception of pain but require careful monitoring because they may cause side effects such as sedation, slowed breathing, or dependence. The physician's order was modified on February 27, 2026, to include non-pharmacological interventions consisting of repositioning, a back rub, toileting, dim lights, food, and fluids. A review of the March 2026 Medication Administration Record revealed staff administered the as needed narcotic pain medication on the following dates and times:March 1, 2026, at 3:20 AM for a documented pain level of 7March 1, 2026, at 9:22 AM for a documented pain level of 7March 1, 2026, at 3:49 PM for a documented pain level of 6March 2, 2026, at 00:58 AM for a documented pain level of 7Review of the clinical record revealed documentation did not show that non-pharmacological interventions were attempted or documented prior to any of the four administrations of the as needed narcotic pain medication, as required by the facility policy and accepted nursing practice.Clinical record review revealed the nurse practitioner order for the pain medication did not include the required pain indication or severity level, such as mild, moderate, or severe pain, as required by the facility's policy and review of the documentation also revealed staff did not document a follow-up numeric pain scale within one hour after the medication was administered to evaluate whether the medication effectively relieved the resident's pain. These findings were reviewed with the Nursing Home Administrator (NHA) and Director of Nursing (DON) during an interview conducted on March 5, 2026, at 9:50 AM. The review confirmed that the clinical record did not contain documentation that non-pharmacological interventions were attempted prior to the administration of the as needed narcotic pain medication. The review also confirmed the medication order did not include the pain indication or severity category and the documentation did not contain a follow-up numeric pain scale to evaluate the effectiveness of the medication. 28 Pa. Code 211.5(f)(iii) Medical records. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services.

Based on review of clinical records, select facility policy, and staff interview, it was determined that the facility failed to implement procedures to maintain records of controlled drugs and ensure accurate drug administration for one out of the 30 residents sampled (Resident 1).Findings include: Review of the facility policy titled Controlled Substances (medications regulated under federal law due to the potential for misuse or dependence requiring strict prescribing, storage, and record-keeping controls), last reviewed by the facility on February 19, 2026, revealed the facility will comply with all laws, regulations, and other requirements related to handling, storage, disposal and documentation of Schedule II and other controlled medications. A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that include paraplegia, (paralysis or loss of movement and sensation that affects the lower half of the body) and Chronic Obstructive Pulmonary Disease (COPD, a progressive lung disease that makes it difficult to breathe due to blocked airflow and damage to the lungs). A review of the clinical record revealed a physician's order initiated on November 16,2025 for Resident 1 to receive hydrocodone acetaminophen oral tablet 5mg/325mg (a Schedule II opiate narcotic medication; schedule II drugs have a high potential for abuse) to administer one tablet every 4 hours as needed for moderate to severe pain on a pain scale of 4-10 (commonly used scale from 0 to 10 in which 0 represents no pain and 10 represents the worst pain imaginable) related to pain in thoracic spine (middle portion of the back). The facility utilized a Controlled Medication Utilization Record to track, monitor, and reconcile each controlled medication, such as hydrocodone acetaminophen. The facility tracks medication administration for each resident by way of the Medication Administration Record (MAR). The MAR indicates the medication administered, time and date of administration, staff administering the medication, pain prior to the administration of medication, and clinical rationale for the administration of medication.A comparison of Resident 1's Controlled Medication Utilization Record with Resident 1's Medication Administration Record (MAR) from November 2025 through February 2026 revealed discrepancies in documentation related to hydrocodone-acetaminophen, a Schedule II narcotic pain medication. The review revealed 8 entries documented on the Controlled Medication Utilization Record indicating the medication was removed or utilized; however, there was no corresponding documentation on the MAR indicating the medication was administered to the resident. The dates and times of these discrepancies included: November 22, 2025, at 4:00 PMDecember 11, 2025, at 1:00 PMDecember 13, 2025, at 3:45 PMDecember 14, 2025, at 9:37 AMDecember 31 ,2025, at 1:00 PMFebruary 13 ,2026, at 10:00 AMFebruary 14, 2026, at 3:15 AMFebruary 21,2026 at 9:15 AM Continued comparison of Resident 1's Controlled Medication Utilization Record with Resident 1's Medication Administration Record from November 2025 to February 2026, revealed 5 additional entries in which hydrocodone-acetaminophen was documented on the MAR as administered to the resident; however, there was no corresponding documentation on the Controlled Medication Utilization Record indicating the medication was removed from the controlled medication inventory. The dates and times of these discrepancies included:November 22, 2025, at 9:59 AMFebruary 9, 2026, at 1:38 PMFebruary 10, 2026, at 7:44 AMFebruary 10, 2026, at 4:00 PMFebruary 11, 2026, 4:46 AM During an interview conducted on March 5, 2026, at 1:15 PM, the surveyor reviewed the above findings with the Director of Nursing (DON) related to the facility's failure to implement effective procedures to reconcile Resident 1's controlled substance medications. 28 Pa Code 211.5(f)(xi) Medical records. 28 Pa Code 211.9(a)(1)(k) Pharmacy services. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa Code 211.10 Resident care policies.

Based on review of facility policy, observation of medications, manufacturer guidance, and staff interviews, it was determined the facility failed to ensure medications were properly dated when opened and failed to discard a multi-dose medication after the manufacturer's recommended use-by period on one of four medication carts (300 hall, cart 2).Findings include: A review of the facility policy titled Storing and Expiration Dating of Medications and Biologicals, last reviewed by the facility on February 19, 2026, revealed it is the facility's expectation that staff record the date a medication container is opened and available for use on the primary medication container (for example, a vial, bottle, or inhaler). The policy revealed that when a multi-dose vial (a medication container designed to provide multiple doses for repeated use) of injectable medication is opened or accessed by needle puncture, the container must be dated and discarded within 28 days, unless the manufacturer specifies a different time frame. An observation of the medication cart located on 300 Hall, Cart 2, on [DATE], at 8:25 AM, in the presence of Employee 1 (Licensed Practical Nurse) revealed one multi-dose insulin pen of Insulin Glargine (a long-acting insulin medication used to lower blood sugar levels in individuals with diabetes). The insulin pen had been opened and was available for use; however, the pen was not dated when initially opened, preventing staff from determining when the medication should be discarded. Continued observation of the medication cart located on 300 Hall, Cart 2, on [DATE], at 8:27 AM, in the presence of Employee 1 (Licensed Practical Nurse) revealed one multi-dose insulin pen of Tresiba Insulin (U-100 a long-acting insulin medication used to control blood sugar levels). The pen was labeled as having been opened on [DATE]. Review of the manufacturer's safety information revealed that once opened, a Tresiba Insulin (U-100) multi-dose pen must be discarded 28 days after opening. Based on the labeled opening date of [DATE], the medication should have been discarded on February 11, 2026. At the time of observation on [DATE], the medication remained in the medication cart and available for use more than three weeks past the manufacturer's recommended discard date. During an interview conducted on [DATE], at 8:30 AM, Employee 1 (Licensed Practical Nurse) confirmed the Insulin Glargine multi-dose pen had been opened and was available for use but was not dated when initially opened. Employee 1 also confirmed that the Tresiba Insulin (U-100) multi-dose pen present in the medication cart was expired and should have been discarded. During an interview on [DATE], at 1:00 PM, the surveyor reviewed the above findings with the Director of Nursing (DON) regarding the facility's failure to follow facility policy and manufacturer guidance related to proper dating and discarding of multi-dose medications. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services. 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services.

Based on clinical record review, review of employee personnel records, review of facility policies and procedures, and staff interviews, it was determined the facility failed to develop, implement, and maintain an effective training program to ensure licensed nursing staff possessed the knowledge and competencies necessary to safely manage a peripherally inserted central catheter (PICC line) for 1 resident (Resident 102) of 16 residents reviewed who required care involving a PICC line.Findings include:Federal regulation requires that a facility develop, implement, and maintain an effective training program for all new and existing staff. The facility must use the facility assessment, which is an evaluation the facility conducts to identify the resident population served to determine the amount and types of training necessary to ensure staff competencies meet the needs of the residents as identified in their care plans and the facility assessment. Clinical record review revealed Resident 102 was admitted to the facility on [DATE], with diagnosis to include osteomyelitis (a serious infection of the bone) and bacteremia (the presence of bacteria in the bloodstream). Resident 102 was admitted with a PICC line (a long, flexible tube inserted through a vein in the arm and advanced into the larger veins near the heart. It allows medications, such as intravenous antibiotics, to be delivered directly into the bloodstream for extended periods).Orders dated February 27, 2026, required the administration of the antibiotic Daptomycin (an intravenous antibiotic used to treat serious bacterial infections), daily through the PICC line. Review of the nurse practitioner orders required the PICC line to be flushed with a 10 milliliter (mL) normal saline solution prior to and after the antibiotic administration and every evening and night shift. Flushing the catheter with normal saline (a sterile saltwater solution) helps maintain catheter function and prevents the line from becoming blocked.A review of Resident 102's February 2026 electronic Medication Administration Record (eMAR, serves as the legal record used to document medications administered to residents) revealed the following:During February 2026, the antibiotic was documented as administered one time, and normal saline flushes were documented four times through the PICC line by licensed nursing staff. During March 2026, the antibiotic was documented as administered two times, and normal saline flushes were documented eleven times through the PICC line by licensed nursing staff. Further review of the eMAR revealed the following licensed nurses documented accessing the PICC line to administer normal saline flushes: On March 2, 2026, at 6:59 AM, Employee 2, Licensed Practical Nurse (LPN), documented administering a normal saline flush through the PICC line.On March 2, 2026, at 1:19 PM, Employee 3, LPN, documented administering a normal saline flush through the PICC line.On March 5, 2026, at 6:28 AM, Employee 4, LPN, documented administering a normal saline flush through the PICC line. Review of Employee 2 LPN personnel file revealed a hire date and orientation completion date of January 15, 2026. The personnel file did not contain documentation demonstrating that Employee 2 received education, training, or competency validation related to PICC line management prior to performing care involving a PICC line. Review of Employee 3 LPN personnel file revealed a hire date of November 12, 2024, orientation completion date of November 16, 2024, and documentation of annual licensed nursing education completed on November 16, 2024. The personnel file did not contain documentation demonstrating that Employee 3 received education, training, or competency validation related to PICC line management prior to performing PICC line care. Review of Employee 4 LPN personnel file revealed a hire date and orientation completion date of April 11, 2025. The personnel file did not contain documentation demonstrating that Employee 4 received education, training, or competency validation related to PICC line management prior to providing care involving a PICC line. During an interview on March 5, 2026, at 9:50 AM, the surveyor requested documentation from the Nursing Home Administrator (NHA) and Director of Nursing (DON) demonstrating education and competency validation for licensed nursing staff providing care to residents with PICC lines. The requested documentation was not provided through the conclusion of the survey on March 6, 2026. During a follow-up interview on March 5, 2026, at 11:30 AM, the Director of Nursing stated the facility had not developed or implemented a training program specific to PICC line care for licensed nursing staff and had not included PICC line management in annual licensed nursing competency or skills reviews. The Nursing Home Administrator and Director of Nursing indicated the facility should have developed and implemented training related to PICC line care based on the resident population and the facility assessment prior to licensed nursing staff providing care involving PICC lines and reviewed this training on an annual basis. Pennsylvania State Board of Nursing regulations (Title 49, Chapter 21) require Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) performing intravenous therapy, which includes administration of medications and care involving PICC lines, to complete a board-approved education program, receive supervised clinical instruction, and undergo ongoing competency assessments. LPNs may perform only those intravenous therapy functions for which they have documented knowledge, skills, and abilities under appropriate supervision The facility did not provide documentation demonstrating licensed nursing staff completed education or competency validation related to PICC line care prior to accessing the PICC line and administering intravenous medications. Therefore, the facility failed to develop, implement, and maintain an effective training program based on the facility assessment to ensure licensed nursing staff possessed the knowledge and competencies necessary to safely provide care to residents requiring PICC line management. 28 Pa. Code 201.20(a) Staff Development. 28 Pa Code 211.12(c)(d)(1)(2)(3)(5) Nursing services.

Based on a review of clinical records, select facility policy, observations, and staff interviews, it was determined the facility failed to ensure the resident environment was free from potential accident hazards for one out of four nursing units observed (300 Hall), including observations made of one out of 14 residents' rooms (Resident 1).Findings included: A review of facility policy titled Medication Administration Practice Recommendations, last reviewed by the facility on August 14, 2025, revealed it is facility policy that a nurse or qualified staff should stay with the resident until medication has been taken. A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease (gradual loss of kidney function). A physician's order for Tylenol tablet 325 mg (acetaminophen-a pain-relieving medication) with directions to give two tablets by mouth every four hours as needed for mild pain was initiated on April 2, 2025. A physician's order for cranberry oral tablet 300 mg, with directions to give one tablet by mouth two times a day for frequent urinary tract infections, initiated on April 16, 2025. A physician's order for oxycodone HCI (hydrochloride) oral tablet 5.0 mg (oxycodone is a schedule II opiate narcotic medication; the United States Drug Enforcement Administration indicates schedule II drugs are defined as drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence; these drugs are also considered dangerous) with directions to administer 5.0 mg by mouth one time a day for chronic pain initiated on May 26, 2025. A clinical record review revealed an evaluation titled Medication Self-Administration Safety Evaluation-CHR (11-2012), dated July 27, 2025. The evaluation indicated Resident 1 was not determined to be safe to self-administer medications. The evaluation documented that Resident 1 required nursing assistance with medication administration and could not state the purpose of each medication, the proper dosage, or the time the medication was to be taken. The evaluation also directed that medications were to be maintained by the nursing department and administered per facility staff.An observation conducted on September 23, 2025, at 9:23 AM, in Resident 1's room revealed five small clear plastic cups on the bedside table, containing a total of seven tablets and two capsules. The medications were unsecured and accessible in an open resident room, allowing potential access by other residents. The presence of multiple medications at the bedside created the risk of accidental consumption by other residents and the risk of Resident 1 consuming medications outside of prescribed parameters. During an interview on September 23, 2025, at 10:30 AM, the Director of Nursing (DON) confirmed the medications observed included six Tylenol 325 mg tablets, one cranberry 300 mg tablet, and two oxycodone HCl 5.0 mg capsules. The DON also confirmed the oxycodone medication had been distributed from the pharmacy in a capsule form rather than the ordered tablet form. The DON acknowledged it was facility policy that licensed staff remain with residents until medications are ingested 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, the facility failed to ensure adequate monitoring of behaviors and potential adverse consequences prior to administering psychoactive medications for one of 10 residents reviewed (Resident 2). Findings include: Review of Resident 2's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included anxiety disorder (a group of symptoms, such as stress, anxiety, feeling sad or hopeless, and physical symptoms that can occur after you go through a stressful life event), encephalopathy ( a medical condition characterized by a general dysfunction of the brain that affects cognitive function, consciousness, and behavior), and chronic pain. Review of a quarterly Minimum Data Set Assessment (MDS-a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated April 14, 2025, indicated the resident had a BIMS (brief interview mental screener that aids in detecting cognitive impairment) score of 15(a score of 13-15 indicates a cognitively intact resident). A review of the clinical record revealed multiple physician orders for Lorazepam 0.5mg (psychotropic medication used to treat anxiety) The following orders were documented:April 22, 2025- 0.5 mg every 12 hours for anxiety.May 19, 2025-0.5 mg every 12 hours as needed (PRN) for anxiety.August 12, 2025-0.5 mg every 12 hours as needed (PRN)for anxiety.August 14, 2025-0.5 mg every 8 hours as needed (PRN)for anxiety. A review of Resident 2's June 2025 Medication Administration Record (MAR) revealed the resident was administered one dose of as needed (PRN) Lorazepam 0.5mg on June 4, 2025, at 1:35PM. The facility failed to document the specific behaviors the resident was exhibiting for the Lorazepam to be administered, and the Documentation Survey Report for June 2025 noted that the resident was exhibiting no behaviors related to anxiety on that date. A review of Resident 2's August 2025 MAR revealed the resident received Lorazepam on 13 occasions (August 12-27, 2025) without documented evidence of anxiety-related behaviors or symptoms to justify administration. Examples include:August 12, 2025, at 10:50 PMAugust 14, 2025, at 9:26 AM and 9:03 PMAugust 15, 2025, at 9:13 PMAugust 16, 2025, at 9:18 PMAugust 17, 2025, at 6:40 AM and 8:34 PMAugust 18, 2025, at 4:49 AM and 9:02 PMAugust 25, 2025, at 10:06 PMAugust 26, 2025, at 12:21 PM and 11:24 PMAugust 27, 2025, at 9:53 PM An interview with Resident 2 conducted on September 23, 2025, at 12:35 PM revealed the resident reported frequent pain but denied experiencing anxiety symptoms on the above dates. The resident stated she did not request Lorazepam and that staff administered it in addition to her pain medication to help me sleep. Review of Resident 2's MAR confirmed on the following dates the resident was administered the lorazepam in addition to the prescribed controlled substance (drug which has been declared by federal or state law to be illegal for sale or use but may be dispensed under a physician's prescription. The basis for control and regulation is the danger of addiction, abuse, physical and mental harm including death), pain medication Hydrocodone/Acetaminophen 5/325mg (an opioid pain medication) without documented indication. Examples include:June 2, 2025 -Hydrocodone/Acetaminophen at 2:00 PM, 25 minutes after Lorazepam was given.August 14, 2025 -Both medications administered at 9:03 PM.August 17, 2025 -Hydrocodone/Acetaminophen at 8:40 PM, 6 minutes after Lorazepam was given.August 25, 2025 -Hydrocodone/Acetaminophen at 10:05 PM, 1 minute before Lorazepam was given.August 26, 2025 -Hydrocodone/Acetaminophen at 11:26 PM, 2 minutes after Lorazepam was given. The above information documented in the clinical record confirmed Resident 2 was administered a controlled substance pain medication with the as needed (PRN) lorazepam without proper indication for use, as stated in the resident interview.Interview with the Director of Nursing on September 23, 2025, at 1:20 PM confirmed the facility was unable to provide documentation supporting the need for Lorazepam when administered. The DON acknowledged that monitoring of behaviors and clinical indications was not consistently documented. The facility failed to record adequate monitoring for behaviors and the use of psychoactive medication in combination with opioid medication, with no documented evidence supporting the need for administration of the lorazepam. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on observation, review of clinical records and select facility documentation, and staff and resident interviews, it was determined that the facility failed to ensure that staff implemented a physician-ordered adaptive device (lidded cup) to mitigate the risk of injury from hot liquids for one of 21 sampled residents (Resident 60) resulting in actual harm, a burn injury to the upper thigh area and failed to ensure nurse aides demonstrated the necessary skills and competencies to safely perform mechanical lift transfers for one of 21 residents reviewed (Resident 195). These failures resulted in actual harm to both residents. Findings include: A review of Resident 60's clinical record revealed the resident was admitted to the facility February 1, 2024, with diagnoses to include dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated May 2, 2025, revealed that the resident was severely cognitively impaired with no BIMS score recorded (Brief Interview for Mental Status, a tool to assess the resident's attention, orientation, and ability to register and recall new information). The assessment noted that during eating, the resident had the ability to use suitable utensils to bring food and /or liquid to the mouth and required set up and clean up assistance Review of physician orders revealed that as of November 5, 2024, and active through May 20, 2025, the resident was to be provided with lidded cups for all liquids. An Occupational Therapy treatment encounter note dated May 13, 2025, identified the resident required set up/clean up assistance for all meals. A nurse's note dated May 19, 2025, at 2:16 PM, indicated that at approximately 11:45 AM that day, Resident 60 spilled hot coffee into her lap. The nurse noted pink, non-blanchable skin and four clear, fluid-filled blisters, each approximately 0.5 cm x 0.5 cm, located on the left anterior thigh. Silvadene was applied per protocol, and the practitioner and resident's family were notified. Resident denied pain and discomfort at that time. A Skin Evaluation completed by Employee 1 the RN Supervisor on May 20, 2025, at 9:15 AM, described six intact, clear fluid-filled blisters across multiple areas of the upper thigh. Left proximal 2 cm x1. 5 cm Left lateral 2 cm x1 cm Left lateral 1cm x 0.5cm Left distal 3. 5cm x 1. 5cm Left distal/ lateral 0.5cm x 0.5cm Left medial 3.5 cm x 1cm Silvadene was applied per physician order during the assessment. The resident denied having pain and was resting comfortably in bed with the call bell within reach. A Wound Care Physician evaluation dated May 20, 2025, at 1:53 PM, identified the burn as measuring 8 cm x 25 cm x 0 depth, with no exudate (discharge of moisture) or odor. The wound area was warm to the touch and the skin remained closed. The resident reported no pain. A review of facility's investigative report completed by the Director of Nursing (DON) dated May 19, 2025, at 11:45 AM, indicated the resident had been provided coffee without a lid, in violation of the physician's order, and subsequently spilled the beverage into her lap. A witness statement from Employee 5, Nurse Aide, dated May 19, 2025, revealed during the lunch meal, she placed the coffee in front of the resident without a lid and turned her back toward this resident to prepare another resident's beverage. When she turned back toward the resident she noticed Resident 60 had spilled the coffee into her lap. She reported to the Nursing Home Administrator (NHA) and Director of Nursing (DON) being unaware of the resident's requirement for a lidded cup. Employee 5 was suspended pending investigation and was unavailable to be reached by phone for an interview. On May 21, 2025, at approximately 10:00 AM, with the resident's permission, an observation of the resident's burn was conducted in the presence of the DON. The resident's burn was visible on her upper left thigh. The burn appeared pink, with scattered areas of white. Four blister like clusters remained, with no open areas seen, and no evidence of drainage or odor. Review of Resident 60's Kardex, which is used by staff to determine whether a resident required adaptive equipment for meals, prior to May 19, 2025, revealed the order for a lidded cup was not on the Resident's Kardex. However, the resident did have a physician's order dated originally November 5, 2024, for lidded cups for all fluids. An interview with the NHA on May 21, 2025, at approximately 9:00 AM revealed there was an error in linking the active physician's order for lidded cups to the resident's Kardex. Review of the food and beverage temperature logs maintained by the facility at resident meal service for May 19, 2025. The food/beverage temperatures for May 19, 2025, showed the coffee temperature for lunch tested at 139 degrees Fahrenheit. Interview with the NHA on May 21, 2025, at approximately 10:00 AM confirmed, the resident was not provided the ordered adaptive device (cup with lid). The administrator acknowledged the omission directly contributed to the hot liquid spill and subsequent injury. Following the incident on May 19, 2025, corrective actions were implemented by May 20, 2025, and included: Immediate clinical intervention following the incident, including removal of soiled clothing, application of cool compresses, wound treatment, and notification of the practitioner and family. Resident was evaluated by the Occupational Therapist for safety in consuming hot liquids. Occupational Therapist updated orders to include [NAME] Cup (spill proof cup that can be turned upside down without spilling) to further reduce spill risk. Residents with current adaptive equipment orders were prescreened by the Occupational Therapist to verify current orders and interventions are appropriate. Director of Nursing will review each order to verify the order is care planned and visible on the Kardex. Regional Dietician re-educated the facility Dietician on appropriate steps to document orders, so they flow to the care plan and the Kardex. The DON/designee provided in-service to facility staff on hot beverage policy. Staff not present during initial training were reeducated before their next shift. The DON/designee will review new resident orders for adaptive equipment to verify that they are documented correctly including link to Kardex. Implementation of an audit system to review adaptive equipment use, ensure consistency between physician orders, care plans, and Kardex, and present findings to the facility's QAPI committee. A review of the clinical record revealed that Resident 195 was admitted to the facility on [DATE], with diagnoses to include, transient ischemic attach (TIA-a short period of symptoms similar to those of a stroke, caused by a brief blockage of blood flow to the brain), cerebral infarction (occurs when the blood supply to part of the brain is blocked or reduced and prevents brain tissue from getting oxygen and nutrients that results in brain cells beginning to die) without residual deficits (recovered without any effect), age related osteoporosis (a condition in which the bones become thinner, weaker, and more likely to break), and aphasia (a result of a stroke or brain injury that affects a person's ability to communicate). A Significant Change Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan a resident's care) dated January 14, 2025, revealed that Resident 195 had severe cognitive impairment with a BIMS score of 3 (Brief Interview for Mental Status - a tool to assess cognitive function - a score of 0 -7 indicates severe cognitive impairment), dependent (helper does all of the effort to complete the activity or the assistance of two or more helpers required to complete the activity) for bed mobility, transfers, toileting, and bathing. The resident was assessed to require a mechanical lift (a mechanical device used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone) for all transfers. A review of Resident 195's physician's orders dated December 3, 2024, at 2:02 AM, specified mechanical lift use for all transfers. A review of a facility policy entitled Mechanical Lifting last reviewed February 18, 2025, indicated the facility utilizes floor-based full body sling lifts and overhead full body sling lifts with universal slings (intended as a general transfer sling, designed to be interchangeable between all manufacture's lifts and provides trunk and leg support for patients with limited upper body tone) and refer to the manufacturer's instructions for use of the universal slings. A review of facility provided investigative documentation completed by Employee 1, Registered Nurse (RN) Supervisor, dated January 30, 2025, revealed that at 8:00 AM, Resident 195 had a witnessed fall by Employee 2, an agency Nurse Aide (NA), and Employee 3, an agency Licensed Practical Nurse (LPN), the resident slid from the sling during a Hoyer lift transfer performed by Employee 2 (agency nurse aide) and Employee 3 (agency LPN), and struck her head on the floor. Employee 1 assessed Resident 195 and noted that the resident was moaning and not answering questions and 911 was called. The Resident's RP (Responsible Party), her son, was made aware and agreeable to send resident to the emergency department and the MD was made aware. A review of a witness statement completed by Employee 2, agency NA, dated January 30, 2025, no time indicated, Employee 2 reported: I was getting her {Resident 195} dressed and washed. I put the sling under her and strapped her up real good. The LPN was in with me when I lifted her up with the Hoyer. She slipped right out, landed on the bed and then on the floor. Wasn't a fall, she slipped onto the floor and hit her head. The LPN went to get the supervisor, and I tried to get her vitals, but she wouldn't let me. She was halfway on the bed when it happened. Employee 3's, agency LPN, witness statement dated January 30, 2025, no time indicated, noted I was called in by the nursing assistant to transfer the resident via Hoyer lift, with safety harness intact. The NA pulled the lift back and the resident slid out of the pad and bounced off the bed to the floor. Resident hit head on the floor. Supervisor was called and safety protocols initiated. A witness statement completed by Employee 4, former Director of Nursing (DON), dated January 30, 2025, documented the reenactment of the event that occurred at approximately 8:20 AM. The DON noted: Employee 2 stated she had retrieved a sling from the laundry, hooked the resident up appropriately, and sought assistance with the transfer. Unable to locate another aide, she was assisted by Employee 3. During the lift, the resident slid out from the bottom of the pad (sling) onto the bed and then onto the floor. When asked whether she crossed the leg straps of the sling, Employee 2 replied, no. Employee 3 described the lift transfer as follows: She was asked to come in and spot the resident transfer. She entered the room and stood by the bed while the lift was being performed. Upon elevation of the resident on the lift, the resident slid out of the bottom onto the bed and then the floor. A review of the emergency department after visit summary dated January 30, 2025, at 11:03 AM, revealed that she was being seen due after a fall off the Hoyer lift. Imaging results completed and CAT scan (computerized axial tomography - uses x-rays to take pictures of your blood vessels, tissues, bones, or organs) of the chest/abdomen/pelvis and CAT scan of her head, brain, and spine and determine that imaging was negative for intercranial bleed and fractures but positive for left posterior scalp hematoma (a condition characterized by the accumulation of blood beneath the scalp and occurs as a result of various factors, including trauma, head injuries, or medical conditions that affect blood clotting) with a planned discharge back to the facility for 11:30 AM. A review of Resident 195's clinical record revealed a nurses' progress notes dated February 4, 2025, at 10:28 PM, that indicated that the resident was complaining of increased pain to the left thigh area. Resident offered PRN (as needed) Tylenol and declined; resident was agitated and yelling at staff. Refusing all PRN medication but allowed the NA to reposition her in bed. Orders were obtained from the CRNP (Certified Nurse Practitioner) for left hip and femur x-rays and to increase Tramadol (opioid pain medication used to manage moderate to severe pain) to 25 mg po BID (twice per day) to TID (three times per day) and hold for sedation. Further review of the resident's clinical record revealed final x-ray results that indicated a left hip fracture, not present on prior study; clinical correlation and follow up radiographs suggested. CRNP made aware new orders received and noted to send the resident to the hospital emergency room (ER). A review of Resident 195's hospital discharge summary for admission February 5, 2025, through February 10, 2025, revealed the resident was admitted due to a left periprosthetic fracture (are considered fractures associated with an orthopedic implant, whether a replacement or internal fixation device) and multiple closed fractures of ribs (is a common injury that occurs when one of the bones in the rib cage breaks or cracks caused by hard impacts from falls, car accidents or contact sports) of the left side. A review of the manufacturer's instructions for the universal lift sling use during transfers from bed to chair indicated that for maximum security, gently raise the individual's legs, and pull the leg loops forward and under the thigh, cross the loops over the thighs, pull one strap through the other, and bring the lift over to the bed and roll the base as far underneath the bed as possible while positioning the cradle over the individual. When both sides of the sling are attached to their respective sides of the cradle, raise the individual slowly. Place the specific loop or chain the individual requires to ensure the proper fit to prevent from sliding out of the sling. The instructions for the universal sling confirmed that sling leg loops were to be crossed under the thighs and properly secured to prevent the resident from sliding. A review of a facility provided document entitled New Employee Orientation handbook provided by the Nurse Staffing Agency, reviewed and signed by Employee 2, Agency Nurse Aide (NA) on May 11, 2022 (date of hire with the nursing agency), acknowledged that Hoyer lift safety was completed on that date. Additionally, Employee 2 completed the facility's Nursing Agency Orientation on January 17, 2025, which included resident transfer safety. A review of the nursing agency's new hire documentation for Employee 3, Agency LPN, revealed that she was hired by the agency on August 17, 2023, however, no documentation was provided by the facility or staffing agency to demonstrate that Employee 3 had ever received training or competency validation on mechanical lift use. During on-site survey, telephone calls were placed to both Employee 2 and Employee 3, but the employees did not return the calls. During an interview with the Nursing Home Administrator (NHA) on May 20, 2025, at 10:45 AM, he acknowledged that Employee 2 failed to properly apply the universal sling and failed to cross the leg straps, resulting in the resident sliding from the sling onto the bed and then the floor. He further confirmed the facility was unable to produce documented evidence that Employee 3 had ever received mechanical lift training prior to assisting with the transfer. Further interview with the NHA confirmed that Employee 2 failed to ensure Resident 195's safety when applying the universal sling when performing a Hoyer/mechanical lift transfer that resulted in Resident 195 sliding out of the bottom of the sling onto the bed and then onto the floor hitting her head. Subsequently, Resident 195 sustained a left posterior scalp hematoma, left periprosthetic fracture, and multiple closed fractures of ribs on the left side. The facility failed to ensure that all nursing staff had the necessary clinical competency validation skills when operating mechanical lifts with universal slings for resident transfers to prevent injuries sustained from unsafe transfer practices by staff. Following the incident with Resident 195 on January 30, 2025, the facility provided evidence that corrective actions were completed by January 31, 2025. Resident was assessed for injury (no injury apparent) and was sent to the hospital for an evaluation. The current residents who utilize a Hoyer lift for care were audited to determine the following a-proper sling fitment b-care plan updated The maintenance director/designee re-audited all lifts to ensure proper functioning. Lifts are on a monthly preventative maintenance schedule. The DON/designee will in-service the nursing staff on proper sling use, colors, sizes and location. The ESD audited all slings in the building to ensure they are functional. The NHA/designee will randomly audit nursing staff 2x/week for 4 weeks to ensure the slings/lifts are being used in accordance with manufacturer recommendation and facility policy. 28 Pa Code 201.18(b)(1) Management. 28 Pa Code 211.10 (d) Resident care policies. 28 Pa Code 211.12 (d)(3)(5) Nursing services.

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the dietary department. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Review of a facility policies titled Refrigerator and Frozen Food Storage last reviewed by the facility on February 18, 2025, indicated that all TCS (time, temperature, control foods) and ready to eat foods prepared on site and held for longer than 24-hours, must be properly labeled and dated with the date by which it should be consumed or discarded (use by date). The initial tour of the dietary department was conducted with the facility's weekend dietary supervisor on May 18, 2025, at 8:45 AM, revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness, were identified: Observations of inside the reach-in tray line refrigerators revealed that the following foods failed to include use by date or thaw date as follows, two opened half gallons of chocolate milk, one prepared plated tossed salad with chicken, one opened gallon of milk, and one opened can 8-ounce cola. Further observations of the reach-in tray line refrigerators revealed that the following nutritional supplements were thawed but failed to include a thaw date or discard date as follows, four thawed 6-ounce nutritional juice drinks (high calorie/high protein supplement) and twelve thawed Magic Cup (high calorie/high protein supplement) supplements. The manufacture's safe food handling instructions indicate that once defrosted, supplements should be used within 14-days. However, the actual discard date was not able to be determined due to items lacking a noted thaw date or discard date on each item. The dietary supervisor confirmed the above observations and indicated that all food items that were opened and/or thawed inside the refrigerator should have a use by date or thaw date listed on the items to prevent the potential for food contamination and foodborne illness. 28 Pa. Code 201.18 (e) (2.1) Management 28 Pa. Code 211.6 (f) Dietary Services

Based on document review, clinical record review, and staff interviews, it was determined that the facility failed to timely provide the required Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) to notify one of three residents reviewed (Resident 95) that Medicare Part A coverage for skilled nursing services was ending. Findings Include: A review of Resident 95's clinical record revealed admission to the facility on [DATE], with diagnoses to include fusion of the spine (a surgical procedure that connects two or more vertebrae in the spine to eliminate movement between them, providing stability and pain relief). Review of the resident's Medicare coverage documentation revealed the last day of covered Medicare Part A services was February 24, 2025. Further review revealed the facility did not issue the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) form to Resident 95 until February 25, 2025, after Medicare Part A coverage had ended. An interview conducted with the Director of Social Services on May 19, 2025, at 11:00 a.m., confirmed the resident had exhausted Medicare Part A benefits as of February 24, 2025, and acknowledged that the SNF-ABN form had not been provided until the following day. An interview with the Nursing Home Administrator on May 20, 2025, at 1:45 p.m., confirmed the facility's failure to issue the required notice prior to the end of coverage. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on a review of clinical records, the Resident Assessment Instrument (RAI), and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessments accurately reflected the status of one resident out of 21 sampled (Resident 72). Findings include: According to the Resident Assessment Instrument (RAI) User's Manual (an assessment tool utilized to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan, and the RAI also assists staff to evaluate goal achievement and revise care plans accordingly by enabling the facility to track changes in the resident's status) dated October 2024, Section N Medications Subsection N0350A: Insulin, indicate the number of days during the 7-day look-back period that the resident received insulin (a hormone medication used to treat diabetes) injections. A clinical record review revealed Resident 72 was admitted to the facility on [DATE]. A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 11, 2025, Section N Medication Subsection N0250. Insulin revealed that Resident 72 received one injection of insulin during the 7-day look-back period. A review of Resident 72's medication administration record dated April 2025 revealed no documented evidence Resident 72 received an insulin injection during the seven-day look-back period. During an interview on May 21, 2025, at approximately 11:00 AM, the Director of Nursing (DON) confirmed Resident 72 did not receive an insulin injection during the seven-day look-back period, as indicated in the resident MDS assessment dated [DATE]. After inquiries made during the survey, the facility corrected the error and submitted a modification to the April 11, 2025, MDS assessment for Resident 72. 28 Pa. Code 211.12(d)(3) Nursing services.

Based on a review of clinical records and interviews with staff, it was determined the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight, unless the resident's clinical condition demonstrates that is not possible, for one out of 21 residents sampled (Resident 51). Findings include: A facility policy titled Weighing of Residents, last reviewed by the facility on February 18, 2025, revealed it is the facility's policy to monitor residents' weight to detect significant weight loss or gain in order to ensure that the resident maintains acceptable parameters of nutritional status. The policy indicates if the resident exhibits a weight change of 5 lbs from the previous weight, the resident shall be re-weighed within 24 hours and the re-weighing shall be recorded. If the re-weight is validated as a 5% change, the registered dietician completes an assessment to investigate the cause of the weight change. The policy states the charge nurse will notify the registered dietician, doctor, family, and registered nurse assessment coordinator of significant weight changes. A clinical record review revealed Resident 51 was admitted to the facility on [DATE], with diagnoses that include dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of an annual Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 14, 2025, revealed that Resident 51 was severely cognitively impaired with a BIMS score of 03 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 00-07 indicates cognition is severely impaired). A care plan focus indicating Resident 51 has an enteral feeding tube (a method of delivering nutrition directly into the gastrointestinal (GI) tract through a feeding tube) to meet nutrition and hydration needs related to dysphagia (a condition that creates blockages or causes your throat or esophagus to be too narrow can make it hard to swallow) was initiated on May 17, 2022. Interventions developed to assist Resident 51 with her goal for maintaining weight over the next 90 days included treatment as ordered for gastronomy tube (a thin, flexible tube inserted into the stomach through a small incision in the abdominal wall) and weighing the resident as ordered. An additional care plan focus indicated Resident 51 was at nutritional risk related to an inability to meet nutritional needs with oral intake and required a gastronomy tube initiated on May 25, 2022. Interventions developed to assist Resident 51 with her goal of consuming oral intake as able and continuing to tolerate enteral feedings to meet estimated nutritional needs include weighing per orders and alerting the dietitian and physician to any significant weight loss or gain and monitoring for changes in nutritional status (unplanned weight loss or gain) and reporting to the physician as indicated. Further clinical record review revealed Resident 51 weighed 144.2 lbs on April 11, 2025, and weighed 134.4 lbs on May 5, 2025, a 9.8 lb weight loss (-6.8 %) in 24 days. Resident 51 was reweighed 4 days later on May 9, 2025, and weighed 135.2 lbs, a 9.0 lb weight loss (-6.24%) in 28 days. An unplanned weight loss greater than 5.0% in 30 days is considered a significant weight loss. A clinical record review revealed there was no documented evidence Resident 51 was reweighed within 24 hours as indicated in the facility policy following the identification of significant weight loss on May 5, 2025. There was no documented evidence Resident 51 was reweighed within 24 hours as indicated in the facility policy following the identification of significant weight loss on May 9, 2025. A clinical record review of Resident 1's assessments tab on the electronic health record revealed no documented evidence that a nutritional assessment was completed following the identification of significant weight loss on May 5, 2025, or May 9, 2025. A nutrition progress note dated May 15, 2025, at 3:01 PM revealed Resident 51's significant weight loss of -6.6% over the last 30 days. The note included a recommendation for weekly weight monitoring. Further clinical record review revealed no documented evidence the physician or resident representatives were notified regarding the identification of significant weight loss. During an interview on May 20, 2025, the Registered Dietician (RD), confirmed there was no documented evidence that Resident 51's significant weight loss was reviewed until 10 days after it was identified. The RD confirmed there was no documented evidence the physician or Resident 51's representative was notified following the identification of a significant weight loss on May 5, 2025, or May 9, 2025. 28 Pa Code 211.5 (f)(ii)(iii)(x) Medical records. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services.

Based on a review of clinical records, facility-initiated transfer notices, and staff interview, it was determined the facility failed to notify the resident and the resident's representative(s) of the transfer in writing and in a language and manner they understand and to provide copies of written notice of facility-initiated hospital transfers of residents to a representative of the Office of the State Ombudsman for one out of 21 residents reviewed (Resident 72). Findings include: A clinical record review revealed Resident 72 was admitted to the facility on [DATE]. Further clinical record review revealed Resident 72 was transferred to a community hospital on December 29, 2024, and was readmitted to the facility on [DATE]. The facility was unable to provide documented evidence the resident and resident representative were notified of the reasons for the transfer in writing or provide documented evidence the facility sent copies of written notices of these transfers to the representative of the Office of the State Long-Term Care Ombudsman. An interview with the nursing home administrator on May 21, 2025, at approximately 10:00 AM confirmed there was no documented evidence that copies of transfer notices for Resident 72 were sent to a representative of the Office of the State Long-Term Care Ombudsman. The nursing home administrator was unable to provide documented evidence that Resident 72 or his representative was notified of the reasons for the transfer on December 29, 2024. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on observations, a review of facility documentation, clinical record review, and resident and staff interviews, it was determined the facility failed to ensure the call bell system was adequately equipped to allow residents to call for staff assistance, by failing to ensure the call bell system was fully functional in three (100, 200 and 300) out of the four areas of the facility. The facility failed to identify the risks and safety of the residents who need to utilize their call bell for staff assistance placing the residents in an Immediate Jeopardy situation. Findings include: A review of a facility documentation dated September 3, 2024, revealed on August 31, 2024, at approximately 7:00 PM the facility experienced a possible lightning strike causing the call bell alert system to malfunction. Upon the building assessment, it was noted the call bell system was not functioning in the 100, 200, and 300 Halls of the resident units. Further it was indicated the residents were provided tap call bells (non computerized device that when tapped by a resident a bell sounds, this sound cannot be heard throughout the facility or over long distances) which were placed in their rooms and facility staff would complete safety checks. This was the plan upon identification of the non functioning call bell system. An interview with Employee E4, maintenance director, on September 5, 2024, at approximately 10:40 AM revealed he was called into the facility on [DATE], due to the call bell system not working. The employee stated at around 8:00 PM the contracted company for the call bell system came to the facility to assess the call bell system. The employee stated the contracted company went through the system and identified the server was down and the 100, 200, 300, and 400 halls with the exception of rooms 408, 409, 411, and 412, call bells were nonfunctional. The Employee E4 was informed that technicians would be back out to the facility during the week. At that time the employee indicated he retrieved tap bells and gave them to the nursing supervisor who was on duty. The employee stated he did not know if there was enough call bells for all the residents who did not have a functioning call bell. Furthermore, Employee E4 stated on Tuesday September 3, 2024, two technicians were in the building to diagnose the call bell system. At that time the technicians identified system devices were shorted and the server and hard drives were bad. They suggested at that time the whole system will need to be replaced. Employee 4 stated he had not heard anything further about when the system will be replaced. Observations of the 100 Hall on September 5, 2024, at approximately 11:00 AM revealed the call bells system in the hall were not functioning. The call bells were not lighting up or sounding when the call bells were activated (button pressed by a resident to alert staff of the need for assistance) in the resident bedrooms and bathrooms. Further observations on the 100 Hall revealed Resident A4 did not have a tap bell in her room to ring for staff assistance. Observations of the 200 Hall on September 5, 2024, at approximately 11:05 AM revealed the call bell system in the hall were not functioning The call bells were not lighting up or sounding when the call bells were activated in the resident bedrooms and bathrooms. An interview with Employee E1 Agency NA (nurse aide) on September 5, 2024, at 11:08 AM indicated the employee stated she was never educated on how often frequent rounding (intentionally checking and visualizing residents at regular intervals) and safety checks were to be completed, but she rounds (observes) the residents every two hours. When asked if all residents had tap bells the employee indicated that not all residents had tap bells to use. Furthermore, the employee was asked how they would know if a resident needed assistance in the bathroom since there were nonfunctioning call bells in the bathroom, the employee stated she would just go check on the resident but doesn't know how the residents could alert the staff. An interview with Employee E2 RN (registered nurse) on September 5, 2024, at 11:12 AM revealed the call bell system has not been functioning and the residents were to use tap bells. The employee stated they do resident rounding every two hours but have not been told to increase the rounding due to the nonfunctioning call bell system. When asked how they would know if a resident needed help in the bathroom, she stated the staff should be bringing them into the bathroom and staying with them, but if resident's go to the bathroom by themselves, they should bring their tap bell in with them. When asked if residents were educated to do so, the employee stated she didn't know. An interview with Employee E3 NA on September 5, 2024, at approximately 11:15 AM indicated she does resident rounding every 2 hours. The employee stated she was not told she had to do more frequent rounding since the call bell system was not functioning. The employee indicated that everyone should have a tap bell but not all residents know how to use them. When asked how she would know if someone needed help, that was unable to use the bell, or if a resident was in the bathroom where no bells were accessible, the employee stated I guess I would just hear them yell out. Observations of the 300 Hall on September 5, 2024, at approximately 11:20 AM revealed the call bells in the hall were not functioning. The call bells were not lighting up or sounding when the call bells were activated in the resident bedrooms and bathrooms. Further observations revealed Resident A5, Resident A6, and Resident A7 did not have tap bells in their rooms to ring for staff assistance. An interview with Resident A8 on September 5, 2024, at the time of the observations on the 300 Hall indicated the resident stated when you hit the tap bell the staff do not know where it is coming from. The resident indicated he would just have to wait for staff's assistance until they figured out who was ringing the tap bell. Furthermore the resident indicated, since the call bell was not working in the bathroom, he would just have to yell out for help until someone hopefully heard him to arrive to assist him. An observation of Resident A9 on September 5, 2024, at approximately 11:30 AM revealed the resident was in her room in the bathroom. The resident was retching and spitting up mucus in the toilet. The resident appeared upset and moaning at times while coughing and retching. The resident indicated she wheeled herself to the bathroom because her stomach was bothering her, and she was coughing up mucus. The resident stated she needs help but doesn't know how to get the staff's attention to help her since the call bell system doesn't work. The resident pointed to the call bell on the wall in the bathroom and stated it was broken. A review of Resident A10's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) affecting the left side and seizure disorder. A review of quarterly MDS (minimum data set- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated August 3, 2024. The resident is cognitively intact with a BIMS of 15 (13 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact). The resident was able to ring her call bell for assistance if needed. A review of the resident's plan of care initially dated April 19, 2023, indicated the resident is non compliant with safety interventions and has poor safety awareness. The resident's care plan dated April 22, 2023 indicated to place the call light within her reach and educate on the importance of using the call bell for assistance. A review of a progress note dated September 3, 2024, at 7:22 PM revealed staff had to be alerted by another resident that Resident A10 was lying on the floor in her bedroom. The resident was found lying on her back with her head towards the bedroom door. The resident's call bell was not functional and resident could not ring bell for assistance to transfer or to be helped off the floor. The resident was noted to have a lump and abrasion above her right eyebrow. The resident was complaining of a headache at that time. The resident was sent out to the hospital for further evaluation. An interview with the Nursing Home Administrator (NHA) on September 5, 2024, 2024, at approximately 12:24 PM revealed when the call bells system became inoperable, the staff were alerted to do frequent rounding or make frequent observations of residents to anticipate their need for care. When asked what frequent rounding meant, the NHA stated the standard every two hours. When asked how the facility was tracking that frequent rounds were being completed, the NHA indicated the supervisor would sign a paper that the rounding was completed every shift. The NHA was asked how the supervisors would know if the observations were completed in order to sign off indicating the observations were completed, if they were not the ones doing the rounding. The NHA stated they would ask the staff if it was completed. The facility could not provide documentation completed by the staff that were actually doing the frequent rounding to assure rounding was completed. When asked how residents would alert staff if they needed assistance while in the bathroom, the NHA stated the staff would take them into the bathroom. The NHA was questioned regarding independent residents who are able to take themselves to the bathroom, if they required assistance how would stff be alerted? The NHA could not answer the question and stated there are no working call bells in the bathrooms and no residents should be going to the bathroom independently. Immediate Jeopardy was called on September 5, 2024, due to the facility's failure to timely identify the health and safety of the residents due to the facility not having a functioning call bell system to alert staff when the residents needed assistance beginning on August 31, 2024 at 7:00 PM when the facility's call bell system became inoperable. The facility was notified of the Immediate Jeopardy on September 5, 2024, at 1:15 PM and the IJ template was provided to the facility. An immediate plan of correction was requested and received on September 5, 2024. The plan included: 1. Clip alarms will be placed in all bathrooms, shower rooms, and lobby visitor bathrooms with signs that say please pull string for assistance. All cognitively aware residents will be educated on the temporary call bell system and its purpose. 2. The call bell system quote and proposal will be signed by the NHA for repair of the call bell system 3. A full house facility audit will be completed to ensure all residents have tap bells in their rooms. 4. The facility will educate all staff on the 7am to 3pm, 3pm to 11pm, and 11pm to 7am shifts on the temporary call bell system and hall monitoring system. All staff on shift will be educated by September 5, 2024. All other nonscheduled staff and as needed staff will be educated on the temporary call bell system and hall monitoring system prior to the beginning of their next scheduled shift. Following verification of the implementation of the corrective action plan, a tour of the facility and inspection of the supervision, the Immediate Jeopardy was lifted at on September 5, 2024, at 4:55 PM. 28 Pa. Code 201.18 (b)(1) Management 205.67(j) Electric requirements for existing construction. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on a review of clinical records, select facility reports and the facility's abuse prohibition policy, and resident and staff interviews, it was determined that the facility failed to ensure that one resident was free from sexual abuse (Resident 48) and the facility neglected to provide the necessary care and services to prevent psychosocial and/or physical harm and physical discomfort for two residents out of 21 sampled (Residents 21 and 80). Findings include: A review of the current facility policy titled Abuse Policy, last reviewed by the facility on May 10, 2024, indicated that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in the regulation. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. Each resident has the right to be free from mistreatment, neglect, and misappropriation of property. This includes the facility's identification of residents whose personal histories render them at risk for abusing residents, the development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Sexual abuse is non-consensual sexual contact of any type with a resident, including sexual harassment, sexual coercion, or sexual assault. Sexual contact or assault that results from threats, force, or the inability of the person to give consent and involving a range of activities. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. A review of Resident 48's clinical record revealed admission to the facility on [DATE], with diagnoses that included Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking, and behavior and is a gradually progressive condition), cognitive communication deficit (occurs when someone has trouble with one or more cognitive processes involved in communication), and anxiety disorder (a group of mental illnesses that cause constant fear and worry and are characterized by sudden feelings of worry, fear, and restlessness). Resident 48's care plan, initiated on May 17, 2022, and revised on November 24, 2023, identified that the resident had impaired/declined cognitive function or impaired thought processes related to diagnosis of Alzheimer's dementia without behavioral disturbance diagnosis. A review of the resident's annual Minimum Data Set (MDS), a federally mandated standardized assessment conducted at specific intervals to plan resident care] assessment dated [DATE], indicated that the resident had severe cognitive impairment with a BIMS (brief interview for mental status - a tool to assess cognitive status) of 3. A review of Resident 8's clinical record revealed admission to the facility on [DATE], with diagnoses that included unspecified dementia and adjustment disorder (difficulty in managing stressful life changes such as coping with work-related problems, loss of loved ones, or relationship issues that leads to significant impairment in functioning) with mixed disturbance of emotions and conduct. The resident had severe cognitive impairment. A review of Resident 8's plan of care initiated June 25, 2023, and revised on March 26, 2024, indicated that the resident had the potential to demonstrate verbally abusive and sexually inappropriate behaviors related to dementia and poor impulse control, with the noted goal that the resident would verbalize understanding of the need to control verbally abusive behavior. Planned interventions were to conduct every fifteen-minute checks related to behaviors, analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document, monitor and document observed behavior and attempted interventions in behavior log, and intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. Additionally, encourage seating next to males and/or leader during activities and meals or otherwise provide arm's length space or supervision and reminders of expected behavior. A progress note in Resident 8's clinical record completed by Employee 4, Social Services, dated October 16, 2023, at 5:13 p.m., indicated that it was called to this social workers attention that Resident 8 may become a little too handsy with some female residents and likes to hold and sometimes kiss female residents hands and was known as a ladies' man. According to the entry, it was explained to him the best way possible by myself {Employee 4} and his daughter. However, his BIMS score was 9 (moderate cognitive impairment) with his short-term memory impaired and resident needs reminders. The Activity Department was also made aware and will intentionally seat Resident 8 closer to men and all staff will continue to provide reminders. The progress note written by Employee 4 did not document details regarding the resident's behavior towards female residents and if the resident becoming too handsy was sexual abuse, sexual harassment, sexual coercion, or sexual assault and if abuse reporting and investigation was required, including identifying Resident 8's female resident victims. A progress note written by Employee 5, a licensed practical nurse (LPN), dated January 7, 2024, at 12:09 p.m., revealed that Resident 8 was observed multiple times the shift being sexually inappropriate with the female residents, rubbing their thighs up to their crotch. This was witnessed by this nurse {Employee 5} and by one of the CNAs. Resident 8 was placed in his room and told that he needs to be appropriate and to keep his hands to himself. This nurse {Employee 5} also called resident's daughter and explained the situation to her. Daughter seemed to be embarrassed and apologized. Daughter also stated that if it happened again, to give her a call and put him on the phone with her. A nurse progress note completed by Employee 6, RN Supervisor, dated January 7, 2024, at 12:31 p.m., revealed that related to inappropriate sexual behavior, Resident 8 was redirected and placed on every 15-minute checks for behavioral observation. Resident made aware behaviors was inappropriate. Resident stated, I don't remember doing it. Daughter was in to visit and made aware of behavior and behavioral monitoring checks and was okay with same. Employee 6 failed to initiate an investigation into the sexual abuse perpetrated by Resident 8 and failed to identify the female resident victims. At the time of the survey ending June 28, 2024, the facility was unable to provide documented evidence that they attempted to identify and protect the female resident victims from sexual abuse perpetrated by Resident 8. The facility failed to prevent, report, investigate and protect female residents from sexual abuse by Resident 8 as indicated in the facility's abuse prohibition policy. Resident 8's clinical record revealed a progress note completed by Employee 7, RN/former DON, dated February 29, 2024, at 5:55 p.m., revealed that the resident's representative was made aware on February 28, 2024, that a female resident reported that on February 27, 2024, Resident 8 approached her in the lobby and rubbed her leg over her clothes and stated oh you like this, and when she responded that she did not like this, he proceeded to grab her left breast over her clothes. The female resident removed herself from the lobby. Resident's RP, daughter, was very apologetic and has spoken with her father regarding these behaviors. RP reported that Resident 8 had no recollection of these behaviors when they happened, and he was remorseful and tearful when they discuss his actions. The facility failed to report this sexual abuse of the female resident perpetrated by Resident 8 and failed to promptly implement their abuse prohibition policy. An interview with the DON on June 26, 2024, at 11:25 a.m., confirmed that the facility was unable to provide documented evidence that the facility had implemented their abuse prohibition policy for identifying, reporting, investigating and protecting residents from sexual abuse perpetrated by Resident 8. The facility failed to identify the female resident victim. A review of Resident 48's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking, and behavior and is a gradually progressive condition), cognitive communication deficit (occurs when someone has trouble with one or more cognitive processes involved in communication), and anxiety disorder (a group of mental illnesses that cause constant fear and worry and are characterized by sudden feelings of worry, fear, and restlessness). Resident 48's care plan, initiated on May 17, 2022, and revised on November 24, 2023, identified that the resident had impaired/declined in cognitive function or impaired thought processes related to diagnosis of Alzheimer's dementia without behavioral disturbance diagnosis. A review of the resident's annual Minimum Data Set assessment dated [DATE], indicated that the resident had severe cognitive impairment with a BIMS of 3. An incident report, completed by Employee 1, a Registered Nurse (RN), dated June 6, 2024, at approximately 5:30 p.m., revealed that Employee 2, a nurse aide (NA), reported that while by nurses' station talking with the scheduler, she looked down the hall (300's hallway) and saw another resident {Resident 8} close to Resident 48. Employee 2 went to Resident 48 and observed that her right breast was exposed and a male resident {Resident 8} had his hand on the resident's bare breast. Residents were separated immediately and taken to their rooms. Resident 48 was assessed by this writer {Employee 1} and no signs or symptoms of distress and offered no complaints and was acting per usual, pleasantly confused. Vital signs were obtained, and skin check completed with no abnormalities or injuries noted. Voice message left for Resident 48's attending physician and responsible party (RP), son, were informed of incident. A review of a witness statement written by Employee 2, no date or time noted, described that at approximately 3:30 p.m., I was at the nurses' station talking to [scheduler] about staying tonight. I happened to look down the hall and saw Resident 8 feeling Resident 48's right exposed breast. I ran down the hall, separated them and I put her {Resident 48} in her room and Resident 8 in his room. Further review of the incident report indicated that Resident 8's attending physician and RP were notified of the incident and the facility immediately initiated one-to-one direct observation of Resident 8. A review of a physician's order dated June 6, 2024, at 8:28 p.m., revealed an order for one-to-one direct observation by staff at all times. There was no documented evidence that the facility consistently provided sufficient supervision of Resident 8 and monitored the resident every fifteen-minute checks as care planned as of March 26, 2024, to ensure the safety of other residents due to Resident 8's sexual behaviors towards female residents. A review of Resident 8's clinical record revealed a nurses' progress note Health Status Note completed by Employee 3, a licensed practical nurse (LPN), dated June 6, 2024, at 10:26 p.m., revealed this writer last saw resident at approximately 5:00 p.m., seated in his wheelchair by nurses' station sleeping intermittently. One-to-one supervision and one-to-one supervision followed post incident and continued with no further incident this shift. An interview with the Director of Nursing (DON) on June 26, 2024, at 2:05 p.m., revealed that that Resident 8 was known to have sexually inappropriate encounters/behaviors with female residents as noted in his clinical record by staff. The DON was unable to provide documented evidence that the incidents noted on October 16, 2023, January 7, 2024, and on February 29, 2024, were thoroughly investigated. The facility did not report these incidents to the State Survey Agency, there were no incident reports or PB-22s (state agency standardized format for completion of abuse investigations) completed. The DON was unable to state why the facility did not implement their abuse policy for reporting, investigating and protecting residents because this DON was not employed at the facility during the times of the noted incidents. The only incident reported and investigated was the abuse of Resident 48 on June 6, 2024. The DON confirmed that the facility could not provide documented evidence that every fifteen-minute checks were conducted to provide supervision of Resident 8 with known sexually inappropriate behaviors to prevent him from further sexually abusing other female residents. The facility failed to protect and ensure that Resident 48 {victim} was free from sexual abuse perpetrated by Resident 8 who had a known documented history of sexual inappropriate behaviors. According to the Centers for Medicare and Medicaid Services psychosocial outcome guide, application of reasonable person concept, Resident 48 would have the expectation that she was safe in her home and treated with respect and dignity. When applying the reasonable person concept, Resident 48 would have suffered psychosocial harm and humiliation due to being sexually abused by Resident 8. An interview with the Nursing Home Administrator (NHA) on June 27, 2024, at 2:30 p.m., confirmed that the facility failed to protect Resident 48 from a resident {Resident 8} with known sexually inappropriate behaviors from sexual abuse. The NHA confirmed that the facility failed to ensure that each incident of sexual abuse towards other female residents was identified, by implementing their abuse policy in response and timely initiate an investigation to identify resident victims of sexual abuse perpetrated by Resident 8 and the protection of other female residents. A review of the facility's policy titled Bladder and Bowel Screening and Assessment, dated reviewed by the facility on May 10, 2024, revealed that incontinent management (check and change) is a technique for use with residents who are mostly incontinent, and staff will perform incontinent care on a check and change schedule. A clinical record review revealed that Resident 80 was admitted to the facility on [DATE], with diagnoses that included transient ischemic attack (a temporary blockage of blood flow to the brain) and cerebral infarction (brain damage that results from a lack of blood). The resident's care plan indicated that Resident 80 was at risk for decreased ability to perform activities of daily living in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting, initiated on May 16, 2024. An MDS assessment dated [DATE] revealed that Resident 80 was cognitively intact with a BIMS score of 14 (a score of 13-15 indicates cognition is intact), dependent on staff for toileting hygiene (the ability to maintain perineal hygiene and adjust clothes before and after voiding having a bowel movement) and required substantial or maximal assistance for lower body dressing, showering, bathing, and moving from a sitting position to a standing position or transferring to the toilet. Resident 80 was always incontinent of bowel and bladder according to this assessment. A facility investigation dated June 6, 2024, revealed that Employee 12, Nurse Aide (NA), checked Resident 80 for incontinence and changed her at 11:20 AM on June 5, 2024 . Employee 12, NA, indicated that the resident is incontinent of urine, every two hours, and {communicates to staff when she} needs to be changed. Employee 12, NA, explained that she recalls seeing Resident 80 at 1:30 PM or 2:00 PM {on that date}but stated that she did not check if Resident 80 was incontinent because she was multi-tasking and helping two other residents with moving rooms. A facility investigation, dated June 6, 2024, revealed that Employee 13, NA, indicated that she changed Resident 80 before therapy {on June 5, 2024} and responded to her call bell later in the day. Employee 13, NA, indicated that Resident 80 is normally incontinent, and it is frequent. Employee 13, NA, indicated that she last checked and changed Resident 80 prior to the resident's therapy session {at 11:30 AM} A witness statement, undated, revealed that Employee 14, Certified Occupational Therapy Aide, indicated that Resident 80 received therapy services and was returned to her room at approximately 12:00 PM {on June 5, 2024}. A facility investigation, dated June 6, 2024, revealed that Employee 15, NA, checked Resident 80 during her first set of rounds on the 3:00 PM to 11:00 PM shift on June 5, 2024. Employee 15, NA, explained that the resident was soiled through her clothes and had dried bowel movement on her at the time. Employee 15, NA, indicated that Resident 80 was upset because she asked to be changed after lunch, but no one changed her when requested. A witness statement provided by Resident 80 dated June 6, 2024, revealed that on June 5, 2024, Resident 80 indicated she rang her call bell between 1:00 PM and 2:00 PM on June 5, 2024, to be changed. Resident 80 explained that the nurse aide told her she would change her, then told her the next shift staff would provide her care and left without providing her care. A witness statement provided by Employee 11, Registered Nurse, dated June 6, 2024, revealed that she entered Resident 80 ' s room {on June 5, 2024,} at 5:20 PM and saw urine dripping to the floor from the resident's lift pad. Employee 11, RN, explained that Resident 80 looked at her with tear-filled eyes and said they {staff} said they would be back, but they didn't come. Employee 11, RN, promised the resident that she would take care of this, changed the resident's clothes and hoyer pad, then assisted the resident to bed. A progress note dated June 5, 2024, at 11:34 PM indicated that a skin check assessment was performed and no new skin injuries or wounds were identified. During an interview on June 27, 2024, at 10:30 AM, Resident 80 stated that she sometimes waits over 30 minutes or more for care from staff when she needs to be changed. The resident explained that she needs staff assistance because she is not able to care for herself. Resident 80 recalled that on June 5, 2024, staff came into her room and told her that they couldn't change her because they were assisting others and too busy to provide her care. She explained that they told her the next shift would have to take care of her. She stated that she waited in a soiled brief for hours that day. Resident 80 stated that she is upset, frustrated, and cries when she needs to wait for care after soiling her brief. Resident 80 stated that staff continue to check on her, turn her call bell light off, but leave her without providing care. During an interview on June 28, 2024, at approximately 10:30 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that that facility neglected to provide the care and services necessary to avoid psychosocial upset and physical discomfort for Resident 80 failing to assure the resident's physical, mental, and psychosocial well-being. The NHA and DON confirmed that the facility investigation identified that Resident 80 was left in a soiled brief from approximately 1:30 PM on June 5, 2024, until 5:20 PM. The NHA and DON stated that Employee 12, NA, was terminated for neglecting Resident 80's needs. A clinical record review revealed that Resident 21 was admitted to the facility on [DATE], with diagnoses that include cerebral infarction (brain damage that results from a lack of blood) and hemiplegia (paralysis on one side of the body). A review of a quarterly MDS assessment dated [DATE] revealed that Resident 21 is cognitively intact with a BIMS score of 15 (a score of 13-15 indicates cognition is intact), and required substantial or maximal assistance for lower body dressing, showering, bathing, and moving from a sitting position to a standing position or transferring to the toilet. Resident 21's care plan indicated that the resident was at risk for urinary incontinence related to impaired mobility, physical limitations, and a history of hemiplegia initiated January 14, 2024, with a planned intervention to check the resident every two hours and as needed for incontinence also implemented on January 14, 2024. A facility investigation, dated May 23, 2024, revealed that Resident 21 reported that at night sometimes the {staff} comes in and tells me I'm not wet and leave my room. Resident 21 explained that in the middle of the night last {May 22, 2024}, she rang her call bell because she was wet. Resident 21 relayed that staff came in and told her she wasn't wet and would be back later but did not return to provide her care for about two hours. A statement dated May 24, 2024, at 11:00 AM, revealed that Employee 16, NA, stated that she changed Resident 21 at 3:00 AM on May 22, 2024. Employee 16 indicated that she responded to Resident 21's call bell for assistance at 4:30 AM. Employee 16, NA, stated that she did not check to see if Resident 21 was wet or provide Resident 21 with incontinence care because she assumed she was dry, despite the resident indicating she needed to be changed. Employee 16, NA, stated that she was trying to get caught up on documentation that night and went back to change the resident at 4:55 AM. Employee 16, NA, stated that her action in making the resident wait to be changed was wrong. A progress note dated May 24, 2024, at 9:01 PM indicated that Resident 21's skin was assessed and no new skin injuries or wounds were identified. During an interview on June 27, 2024, at 10:00 AM, Resident 21 stated that sometimes she waits a long time for care. She stated that she waits 20 minutes for staff to provide her care and longer when the facility is short on staff. Resident 21 stated that a few weeks ago, there was an incident where she rang her call bell for assistance to be changed, but staff told her she had to wait to be changed. Resident 21 stated that she felt disappointed because she was treated in that manner by staff. During an interview on June 28, 2024, at approximately 10:30 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that that facility neglected to provide the care and services necessary to avoid harm and to attain or maintain Resident 21's physical, mental, and psychosocial well-being. The NHA and DON confirmed that the facility investigation identified that Resident 21 rang her call bell because she soiled her brief but was not provided care timely because Employee 16, NA, was completing documentation. The NHA and DON stated that Employee 16, NA, was suspended, received a final level of discipline, and returned to work after completing abuse, neglect, and resident rights training. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a) Resident Rights 28 Pa. Code 211.12 (d)(5) Nursing Services