Every finding on record at Lock Haven Rehabilitation and Senior Living

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure that a medication was available in a timely manner for one of three residents reviewed for medication availability concerns (Resident 1).Findings include: Review of the current facility document titled, Unavailable Medications, states that staff shall take immediate action when it is known a medication is unavailable, including determining the reason for the unavailability and notifying the physician. Clinical record review for Resident 1 revealed an active prescription for following active orders for medications used to treat seizure activity: Clobazam Oral Tablet 10 MG (milligram), give 1 tablet by mouth in the morning for seizures.Clobazam Oral Tablet 10 MG, give 2.5 tablets by mouth at bedtime for seizures. Further record review revealed nursing notes dated July 19, 2026, at 8:10AM and 9:21 PM indicating that the above-named medication was not available, and that a new script was required by the provider. Nursing note dated July 20, 2026, at 8:10 PM stated that Resident 1 had not received their clobazam medication on day shift or evening shift due to waiting for arrival from the pharmacy. There was no indication that the medical provider was made aware of the lapse in medication availability. Interview On July 24, 2026, at 5:30 PM with the Nursing Home Administrator and the Director of Nursing confirmed the above findings. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12 (d)(1)(3) Nursing services

Based on observation, and resident and staff interview, it was determined that the facility failed to provide food in accordance with resident preference for three of four residents observed (Residents 2, 5, and 9).Findings include: Observation of Resident 9 on June 2, 2026, at 11:03 AM revealed the resident eating lunch in a dining room located on the unit with several other residents. The resident was observed to have potato tots and asparagus on a main plate on the tray and a grilled cheese sandwich on a side plate. Review of Resident 9's meal tray ticket (a slip indicating the resident's diet, food items to be served for the meal, dislikes, and any special instructions) revealed the resident was to receive his food in separate bowls and was to receive double portions. Resident 9's asparagus and potato tots were on a plate and not in separate bowls. Resident 9's portions of food were observed to be the same as several other residents eating in the dining room who were not noted to require double portions. Interview with Resident 5, on June 2, 2026, at 10:40 AM revealed the resident stated food items listed on the facility menu were not always provided and that the meal portions were cut in half lately. Observation of Resident 5 on June 2, 2026, at 11:18 AM revealed the resident in his room having just been served his lunch tray. Review of the resident's meal tray ticket on the tray noted the resident was to receive four ounces of vanilla pudding, and double protein. There was no vanilla pudding on the resident's tray and the only protein item served was chicken on the chicken sandwich and the portion of chicken was the same as observed on multiple other resident's trays served on the unit who did not have a double portion listed. Observation and interview with Resident 2 on June 2, 2026, at 11:29 AM revealed the resident in her room beginning to eat a lunch meal that was on a tray in front of her, consisting of a chicken sandwich and potato tots on a main plate with a piece of cake on the side of the tray. Review of the resident's meal tray ticket on the tray revealed the resident disliked asparagus (which was on the facility lunch menu for the day), and four ounces of diced carrots were listed as food items the resident was to receive on the meal tray. There were no carrots or another alternative vegetable provided on the resident's meal tray as indicated should have been served with the meal. The above concerns with resident's receiving food items as listed on their meal tray tickets per their preference/requirement were reviewed with the Nursing Home Administrator and Director of Nursing on June 2, 2026, at 4:45 PM. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.6(a) Dietary services

Based on clinical record review, and staff and resident interview, it was determined that the facility failed to provide the highest practical care regarding physician ordered treatments for seven of eight residents reviewed (Residents 1, 3, 4, 5, 6, 7, 8). Findings include: A review of the current physician orders for Resident 1 revealed an order dated April 1, 2026, for staff to cleanse Resident 1's sacrum pressure injury with wound cleanser and normal saline (sterile solution used for wound care), apply Calcium alginate (wound treatment) to the base of the wound, secure with a dry dressing, and change daily and as needed for wound healing. A review of Resident 1's TAR (treatment administration record, a form utilized to document the administration of resident treatments) dated April 2026, revealed Resident 1's treatment was not completed per the physician order on two of the 10 days reviewed: April 2, 2026: no documentation on the TAR; blank.April 6, 2026: no documentation on the TAR; blank. A review of the current physician orders for Resident 3 revealed an order dated January 16, 2026, for staff to apply Zinc Oxide (ointment used in wound care to enhance healing, reduce infection rates, and promote skin repair) to Resident 3's buttocks and peri area topically every day and evening shift. An order dated March 11, 2026, for staff to cleanse Resident 3's sacral incontinence associated dermatitis with normal saline solution, and apply zinc to wound bed, every shift for prevention of breakdown. A review of Resident 3's TAR dated April 2026, revealed Resident 3's treatments were not completed per the physician order on one of the 10 days reviewed: April 4, 2026: no documentation on the TAR; blank. A review of the current physician orders for Resident 4 revealed an order dated March 28, 2026, for staff to clean Resident 4's left third toe skin tear with normal saline solution, apply Xeroform (medicated gauze dressing that keeps wounds moist and helps prevent infection) and a dry sterile dressing with Kling wrap (stretchy medical bandage) every day until healed. A review of Resident 4's TAR dated April 2026, revealed Resident 4's treatment was not completed per the physician order on two of the 10 days reviewed: April 7, 2026; no documentation on the TAR; blank.April 8, 2026; no documentation on the TAR; blank. A review of the current physician orders for Resident 5 revealed an order dated February 18, 2026, for staff to cleanse Resident 5's left heel arterial ulcer with normal saline, apply skin prep to the base of the wound daily and as needed for wound healing. A review of Resident 5's TAR dated April 2026, revealed Resident 5's treatment was not completed per the physician order on two of the 10 days reviewed: April 7, 2026; coded 9, other, see progress notes. There was no progress to indicate why treatment was not completed.April 8, 2026; no documentation on the TAR; blank. A review of the current physician orders for Resident 6 revealed an order dated March 3, 2026, for staff to cleanse Resident 6's frontal scalp with normal saline, apply silver alginate (dressing to enhance wound healing) to the base of the wound, secure with a dry dressing, and change the dressing two times a day, and as needed. A review of Resident 6's TAR dated April 2026, revealed Resident 6's treatment was not completed per the physician order on three of the 10 days reviewed: April 4, 2026; not documented as completed on the second shift; blank.April 8, 2026; not documented as completed on the first shift; blank.April 9, 2026; not documented as completed on the second shift; blank. A review of the current physician orders for Resident 7 revealed an order dated January 14, 2026, for staff to cleanse Resident 7's right shin abrasion with normal saline, apply Xerofoam to the base of the wound, secure with a dry dressing, and change every day and as needed for wound healing. An order dated March 19, 2026, for staff to wash the wounds on Resident 7's left great toe and inner shin with normal saline solution, cover with Xerofoam, and a dry dressing, and change daily. A review of Resident 7's TAR dated April 2026, revealed Resident 7's treatments were not completed per the physician order on three of the 10 days reviewed:April 6, 2026; no documentation on the TAR; blank.April 7, 2026; no documentation on the TAR; blank. A review of the current physician orders for Resident 8 revealed an order dated April 7, 2026, for staff to cleanse Resident 8's left dorsal ankle venous ulcer with normal saline, apply Xerofoam to the base of the wound, secure with a dry dressing and ACE wrap (bandage), and change daily and as needed for wound healing. A review of Resident 8's TAR dated April 2026, revealed Resident 8's treatments were not completed per the physician order on one of the four days reviewed: April 9, 2026; no documentation on the TAR; blank. The facility failed to provide the highest practical care regarding physician ordered treatments for Residents 1, 3, 4, 5, 6, 7, and 8. The findings were reviewed with the Nursing Home Administrator and the Director of Nursing on April 11, 2026, at 2:15 PM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of select facility policies and procedures, facility documents, clinical record review, and resident and staff interview, it was determined that the facility failed to thoroughly investigate and report an allegation of abuse for one of five residents reviewed (Resident 4).Findings include: Review of the facility's current policy entitled Abuse Prevention and Prohibition Program, revealed the purpose of the policy is to ensure the facility establishes, operationalizes, and maintains and abuse prevention and prohibition program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with the federal and state requirements. The policy indicated the facility is to promptly and thoroughly investigate reports of resident abuse, mistreatment, neglect, injuries of unknown source, and criminal acts. During an interview with Resident 4 on January 30, 2026, at 12:01 PM the resident stated, staff are great, but I had trouble with two of them quite a while ago and I had bruises on both of my arms. Resident 4 could not give a specific date of the incident occurring or staff names, but stated staff came and told her it would never happen again. Clinical record review for Resident 4 revealed a late entry nursing progress note documented on January 20, 2026, at 2:15 PM for January 19, 2026, at 2:15 PM that noted staff went to speak to the resident regarding her being mad at the night shift nurse aides. It was noted staff discussed with the resident her concern that the nurse aides grabbed her hands and she had bruising from it. The resident stated the nurse aides were changing her, she did not like how they were changing her, they grabbed her hands, and now she had bruises. The resident also stated they were laughing while doing her care. The same note indicated bruising was present on the resident's right dorsal (back) hand by her thumb measuring 1.5 cm (centimeters) by 1.8 cm and purple in color. It was also noted that a 2.0 cm by 2.0 cm purple bruise was identified on the residents left dorsal wrist area. The note indicated the nurse aides reported the resident was attempting to kick, bite, and was swinging her arms at them and felt the bruising could have come from that. They indicated that they were smiling and laughing because the roommate was making funny comments to them while they were providing care. A nursing note dated January 19, 2026, at 10:20 PM for Resident 4 noted bruising on top of both hands, stated two girls at night grabbed her hard and left bruising on both hands and the incident was reported to nursing administration. A nursing note dated January 20, 2026, at 6:57 PM for Resident 4 noted bruising to bilateral hands/wrists continues with no complaints of pain. A nursing note dated January 21, 2026, at 9:40 AM for Resident 4 noted the interdisciplinary team met to discuss bruising, and the investigation was completed and the bruising was consistent with combative behaviors. Review of a facility report dated January 19, 2026, for Resident 4 indicated an incident involving the skin for the resident was identified. The report did not indicate any incident of alleged abuse but indicated two staff members were involved in the incident. The report reviewed the bruises noted above and indicated the resident being combative with care was the likely cause of the injuries. The report included statements from the two staff members who were noted to be involved in the incident, and one additional staff member who noted the resident was heard screaming and was then observed being combative with care. There was no evidence statements were obtained from additional staff who were working at the time of the alleged incident on or near Resident 4's unit, from the resident's roommate who staff indicated was present during the incident, or any other residents who were cared for by the employees alleged to be involved in the incident to rule out potential abuse. There was no evidence that facility staff reported the allegation of abuse alleged by Resident 4 to the appropriate agencies (e.g., the local field office for the Department of Health). In an interview with Employee 2, Assistant Director of Nursing, on January 30, 2026, at 1:05 PM they indicated the facility did not identify a need to report the incident as an allegation of abuse to the local field office as they determined abuse did not occur. Interview with the Nursing Home Administrator and Director of Nursing on January 30, 2026, at 3:30 PM revealed that they did not report or more thoroughly investigate the above alleged incident of abuse reported by Resident 4. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.29(a)(c) Resident rights

Based on observation, facility document review, and resident and staff interview, it was determined that the facility failed to serve all meal ticket items for three of five residents observed (Residents 5, 6, and 7).Findings include: During an interview with Resident 5 on November 19, 2025, at 11:20 AM she stated that she often does not receive the items on her tray that she is supposed to. A review of the resident council meeting summary for October 2025, revealed that concerns regarding tray tickets and actual items on the tray are mismatched. Observation of the lunch meal service for unit 4 on November 19, 2025, at 12:15 PM revealed the following: Employee 2 NA (nurse aide), delivered meal trays to the residents and assisted Residents 6 and 7 in preparing their trays by removing the lids and placing them in front of the resident on a tray table. Review of Resident 5's lunch meal ticket (paper slip provided with tray that indicates diet, items to be received, as well as resident allergies and preferences) revealed that the resident had both bread and margarine listed on her ticket. No bread or margarine was observed on the resident's tray. Concurrent reviews and observations of Resident 6 and 7's lunch meal tickets revealed that Resident 6 should have received cottage cheese on her tray, and Resident 7 should have received a grilled cheese sandwich. These items were not present on either resident's tray. Partway through meal service at 12:30 PM, the surveyor notified Employee 2 of the residents missing lunch service items. At this time Employee 2 called down to the kitchen and requested these items be sent for these individuals. The surveyor discussed the above findings with the Nursing Home Administrator on November 20, 2025, at 3:35 PM. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

Based on observation and resident and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, safe, and orderly environment on two of four nursing units (Unit 1 and Unit 4, Residents 5 and 10).Findings included: An interview with Resident 5 on November 19, 2025, at 11:20 AM revealed that she was very unhappy with the cleanliness of her bathroom, stating she keeps her own broom and a Swiffer mop, so she can clean the area herself, but she is unable to remove the dirt. Observation of the bathroom revealed there was a lot of brown and gray debris on the floor along all of the baseboards that appeared to be stuck to the floor. The threshold was noted to have a gray strip running the width of the doorway and along this strip on both sides was a layer of dust and debris that appeared to be stuck to the floor. These findings were reviewed during an interview with the Nursing Home Administrator and the Director of Nursing on November 19, 2025, at 3:35 PM. An interview with Resident 10 on November 19, 2025, at 1:23 PM revealed concerns with the cleanliness of the bathroom floor. Concurrent observation of Resident 10's bathroom revealed a gap the resident pointed out between areas of the wall and bathroom floor. Observation revealed a small gap, most noticeably between the floor and wall located behind the commode. Some areas of this gap contained unidentified debris. The above information for Resident 10 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on November 19, 2025, at 3:30 PM. 483.10(i)(1)-(7) Safe/clean/comfortable/homelike EnvironmentPreviously cited deficiency 9/19/25 28 Pa. Code 201.18(b)(3)(e)(2.1) Management

Based on observation, review of facility documents, and resident and staff interview, it was determined that the facility failed to provide sufficient staff to carry out the functions of the food and nutrition services in the main kitchen and on two of four nursing units (Unit 4, Residents 5).Findings include: An Interview with Resident 5 revealed that using plastic utensils to cut food on Styrofoam is awful, and this happens often, especially on the weekends. A review of the resident council meeting summary for October 2025, revealed that concerns regarding tray tickets and actual items on the tray are mismatched, and the Fall/Winter menus had not yet been updated or distributed, despite a launch date of October 1, 2025, as indicated on the September resident council meeting. During an interview with Employee 1, Food Services Director, on November 19, 2025, at 10:20 AM it was confirmed paper products (foam containers and plastic ware) were used to serve resident meals for dinner on Wednesday, November 12, due to not having enough food service staff to operate the dish machine to wash dishes and silverware and complete other duties. Employee 1 stated that this is done any time there is not enough staff to wash the dishes and prepare meals. Review of the food service staff schedule for November 2 to 11, 2025, with Employee 1, on November 19, 2025, at 10:20 AM revealed the following open positions for food service workers on the schedule required to meet the needs of the department: Sunday, November 2, 2025, two morning shifts Monday, November 3, 2025, three morning shifts Tuesday, November 4, 2025, one morning shift, one evening shift Wednesday, November 5, 2025, two morning shifts Thursday, November 6, 2025, three morning shifts Friday, November 7, 2025, one morning shift, one evening shift Saturday, November 8, 2025, three morning shifts and one evening shift Sunday, November 9, 2025, two morning shifts Monday, November 10, two morning shifts Tuesday, November 11, 2025, two morning shifts, and two evening shifts Wednesday, November 12, 2025, two morning shifts, and two evening shifts Thursday, November 13, 2025, two morning shifts, and one evening shift Friday, November 14, 2025, one morning shift, one evening shift Saturday, November 15, 2025, two morning shifts The above concerns regarding the timing of meals, and utilization of paper products due to staffing was reviewed with the Nursing Home Administrator on November 19, 2025, at 3:30 PM. 483.60 (a) Sufficient Dietary Support PersonnelPreviously cited 9/19/25 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

Based on observations, review of facility documents, and resident and staff interview, it was determined that the facility failed to provide sufficient staff to carry out the functions of the food and nutrition services in the main kitchen and one of four nursing units (Unit 3, Residents 37 and 38).Findings include: During an interview and observation in the facility's main kitchen on September 16, 2025, at 9:00 AM Employee 2, food service director, indicated he was working as a dietary aide because he had to fill in for the position. Employee 2 stated regular staffing for the shift would include one cook, four dietary aides, and himself as the director, but currently, they only had one cook, himself, and one additional dietary aide. Employee 12, regional food service director, was present during the observation and indicated he had recently started with the company, and it was his first time at the facility. Employee 12 stated he was now going to plan on being at the facility a few days a week to help and cover some of the directors' duties. In an interview with Resident 37 on September 16, 2025, at 11:40 AM the resident stated she was served an early lunch due to an appointment, but it was the first day in several that she got her food on real plates with real silverware. It often comes served in all disposables the resident stated, I guess they only had two workers in the kitchen. Interview with Resident 38 on September 17, 2025, at 12:10 PM in the resident's room, she stated she had not wanted to go to the main dining room because she has to wait too long to get served her meal. The resident stated, We are to go to the main dining room at 11:30 AM and don't get served any food until 12:30 PM, we should not have to go and wait an hour for our meals. An observation of the lunch meal service on September 17, 2025, on Unit 3 revealed the first meal cart for residents who eat in their rooms arrived on the unit at 12:26 PM, the second meal cart for the unit arrived at 12:51 PM, delivered by Employee 12, regional food service director. Employee 12 stated the kitchen staff was working short, and a cook had also gone home sick earlier in the morning. A review of facility meal service times revealed the first cart for Unit 3 was delivered at 12:26 PM was to start being plated in the kitchen at 11:25 PM, and the second cart for Unit 3 noted above was to start at 11:40 AM but did not arrive on the unit until 12:51 PM over an hour later. In an interview with Employee 2, and Employee 12 on September 18, 2025, at 3:20 PM, it was confirmed paper products (foam containers and plastic ware) were used to serve resident meals for lunch on Sunday, August 31, September 7, and September 14, as well as dinner on September 14, 2025, due to not having enough food service staff to operate the dish machine to wash dishes and silverware and complete other duties. Employee 2 stated only the plastic meal serving tray and any adaptive feeding equipment was utilized. Review of the food service staff schedule for the week of September 14 to 20, 2025, with Employee 2, on September 19, 2025, at 11:40 AM revealed the following open positions for food service workers on the schedule required to meet the needs of the department: Sunday, September 14, 2025, two morning shifts and one evening shiftMonday, September 14, 2025, three morning shiftsTuesday, September 16, 2025, two morning shifts, and replacement for one who left sickWednesday, September 17, 2025, two morning shiftsThursday, September 18, 2025, two morning shiftsFriday, September 19, 2025, one morning shift, one evening shiftSaturday, September 20, 2025, two morning shift and one evening shift Employee 2 indicated in the same meeting above interviews have been occurring to fill open positions. The above concerns regarding the timing of meals, and utilization of paper products due to staffing was reviewed with the Nursing Home Administrator on September 18, 2025, at 2:20 PM. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(3) ManagementCross reference F812

Based on observation and staff interview, it was determined that the facility failed to maintain food service equipment in accordance with professional standards for food service safety and store food in a sanitary manner in the facility's main kitchen and one of two nursing unit pantries (Unit 3/4).Findings include: Observation of the facility's main kitchen on September 16, 2025, at 9:00 AM with Employee 2, food service director revealed the following: Removable plastic slotted shelves holding food products in the walk-in cooler were observed with black buildup down in the slots of the shelves throughout the cooler. A large, wheeled storage bin labeled as flour in the main kitchen production area was observed with crumbs and debris on the top and sliding lid of the container. The exterior sides of the bin had dried spills and were soiled. The label indicated the product was placed in the bin on December 5, 2024, and had a use by date of March 5, 2025. The interior base of the glass two-door cooler contained dried spills and debris. Two sandwiches were observed on a shelf in the cooler with no label or date. The lower shelf of the food preparation table where cooking equipment/pans were stored was soiled with dried food, grease spots, and dust, which extended onto some of the sides of the pans. A clear plastic container with a tan colored substance in it was also observed on the lower shelf of the food preparation table. A plastic scoop was observed down in the substance. The container was not labeled with its contents or dated. Employee 2 indicated it was potato flakes. Observation of the resident food pantry located between Unit 3 and Unit 4, on September 18, 2025, at 12:03 PM revealed dried food, debris, and pieces of hair stuck in the interior of the refrigerator and freezer. A large area of dried orange/brown substance was observed under the lower drawer/rack of the refrigerator. A set of cabinets in the pantry revealed dust and debris in the drawers where coffee filters, and unwrapped plastic utensils were stored. The cabinet under the sink contained a large plastic tub under the drainpipes of the sink. A dried yellowish substance was in the tub. The interior base of the cabinet under the sink contained dirt and debris. A lower cabinet to the right of the sink where two boxes of straws were stored was dirty with dust/debris. A lower cabinet to the left of the sink contained a loose plastic cup and a plastic lid on the lower shelf among dust/dirt and a dead insect. The top shelf in the cabinet where a plastic tub of sanitizing wipes was stored contained two large spots of black substance beside the container. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on September 18, 2025, at 2:20 PM. 483.60(i)(2) Store food safe and sanitaryPreviously cited 10/18/24 28 Pa. Code 201.14 (a) Responsibility of Licensee Cross reference F802

Based on observation and staff and resident interview, it was determined that the facility failed to provide a clean, comfortable, homelike environment on four of four nursing units (Units 1, 2, 3, and 4; Residents 5, 8, 12, 14, 15, 28, 38, 71, 95, 108 115, and 129), and maintain comfortable water temperatures on two of four nursing units (Unit 1, and 4; Resident 71). Findings include: An observation of Resident 28 and Resident 38's shared room on September 16, 2025, at 2:00 PM revealed dried spills on the flooring in the room, and a significant number of crumbs and debris surrounding Resident 38's recliner. Resident 28 stated a housekeeper was just in to empty the trash can, but that was it. Resident 28 stated when staff does sweep and mop it is only in the middle of the floor or just inside the door where they can see, they don't move anything. An observation of Resident 12's room on September 16, 2025, at 2:24 PM revealed a garbage can by the sink area in the room. The garbage can did not have a liner and contained trash including medicine cups, tissues, etc. The interior of the can had dust/debris built up in the bottom of the can and contained some dried brown liquid spills on the interior sides of the can. In an interview with Resident 12 on September 17, 2025, at 11:06 AM the resident indicated that staff change his roommates brief and then dispose of it in the trash can by this sink and take the bag with them and don't put a new liner in the can, so things get thrown in the can without a liner. Resident 12 stated It gets pretty rancid (unpleasant smell) at times. An observation of Resident 15's room on September 16, 2025, at 2:49 PM revealed debris on the resident's flooring, debris beside and under the resident's bed, and black buildup on the flooring in front of the bathroom door and the transition strip between the room and bathroom. The floor was sticky to walk on. Resident 15 stated staff come into clean the room, but they don't do a very good job. An observation of Resident 95's room on September 17, 2025, at 12:20 PM revealed multiple stains on the privacy curtain between the resident and the roommate's bed. In an interview with Resident 108 on September 17, 2025, at 12:33 PM the resident stated her room hasn't been cleaned in three days. Debris, wrappers, and food crumbs were observed on the floor beside the resident's bed. A broom was observed leaning against the wall at the front of the resident's room. Resident 108 stated she brought her own broom in for when it gets too bad, she can sweep up the dirt and debris into piles in the room for housekeeping. In an interview with Resident 71 on September 16, 2025, at 11:42 AM the resident stated the water from the sink in her room doesn't get warm and she uses the sink to get cleaned up in the morning and evenings before bed. Resident 71 also stated at times the shower water temperature is cold. Observation of Resident 71's water temperature at the sink in the room was tepid (slightly warm) at 104.1 degrees Fahrenheit after allowing the water to run for four minutes. An observation of the Unit 1 shower room on September 19, 2025, at 1:45 PM revealed the water temperature from the shower head after the hot water was running at the highest setting for six minutes only reached a slightly warm temperature of 91 degrees Fahrenheit. A sink in the shower room running for three minutes on the highest hot water setting only reached 81 degrees Fahrenheit. In an interview with Employee 11, maintenance director, on September 19, 2025, at 2:07 PM Employee 11 indicated he had checked water temperatures in the Unit 1 shower room earlier that morning and had a temperature of 106 degrees Fahrenheit, and indicated the dietary staff was currently running the dishwasher and it may be drawing down the water temperature to the nursing unit. Employee 11 concurrently retested the water temperature in the Unit 1 shower room and indicated the temperature was 91 degrees initially but reached 105 degrees Fahrenheit after seven minutes. The above concerns regarding the cleanliness of Residents 12, 15, 28, 38, 95 and 108 rooms were reviewed with the Nursing Home Administrator and Director of Nursing on September 17, 2025, at 2:30 PM. Concerns regarding comfortable water temperatures and the length of time to reach comfortable warm water temperature was reviewed with the Nursing Home Administrator on September 19, 2025, at 2:07 PM. Observation of Unit 4 on September 17, 2025, at 9:49 AM revealed piles of dirt in the corners and along the edges in the hallways. An observation of Resident 14's room on September 16, 2025, at 11:42 AM revealed trash on the floor, and multiple black sticky spots. During an interview with Resident 71 on September 16, 2025, at 1:43 PM the surveyor closed Resident 71's door and there were dirty gloves and a pile of dirt behind the door. Resident 71 stated that housekeeping usually comes into her room and only cleans the main area. A follow up observation of Resident 71's room on September 17, 2025, at 9:48 AM revealed the dirt and gloves were still on the floor behind Resident 71's door. The above concerns regarding the cleanliness of Unit 4's hallway floors, and Resident 14 and 71's rooms were reviewed with the Nursing Home Administrator and Director of Nursing on September 17, 2025, at 2:10 PM Observation of Resident 5's room on September 17, 2025, at 11:16 AM revealed the nonskid adhesive that was left after the strips were removed remained on the floor as you walk towards the bathroom. The non-skid strip in front of her recliner was dirty and there were scuff marks noted by the closet. Concurrent interview of Resident 5 revealed that most of the time housekeeping only dust mops the floor and only the part that you can see. Observation of Resident 8's room on September 16, 2025, at 1:20 PM revealed the floor was dirty with crumbs and lose dirt. Behind the door to the room were crumbs, paper, and dirt particles in a small pile. There were two plastic medication cups near the head of her bed on the side near the window. The top of the air conditioner unit was dirty. The bathroom toilet seat was dirty. Behind the toilet was dirty with built up dirt around the cove base. Interview with Resident 8 revealed that they never clean too much and when they do it is just what they can see. Observation of Resident 115's room on September 16, 2005, at 1:30 PM revealed her floor was dirty and there was a clear sticky dried liquid substance in front of her recliner. Interview with Resident 115 revealed that they run the dust mop every day, but they hardly ever scrub the floor. Interview of Resident 129 on September 16, 2025, at 1:16 PM reveled that all they ever do is dust mop her room. She said they never mop the floor. Observation of her room during the interview revealed dirty nonskid strips in front of her recliner, beside her bed, and in her bathroom. There was loose dirt under the bed. There was a buildup of dirt around the cove base and behind the toilet. The toilet was dirty. The environmental concerns related to Residents 5, 8, 115, and 129 were reviewed with the Nursing Home Administrator and Director of Nursing on September 17, 2025, at 2:20 PM 483.10(i)(1)-(7) Safe/clean/comfortable/homelike EnvironmentPreviously cited deficiency 10/18/2428 Pa. Code 201.18(b)(3) (e)(2.1) Management

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to thoroughly investigate a resident's injury of unknown origin for one of 29 sampled residents (Resident 14) and failed to implement an abuse prohibition policy that required a thorough investigation of prospective employee's employment history for three of five newly hired employees reviewed (Employees 3, 4, and 5). Findings The facility policy entitled Lock Haven Rehabilitation and Senior Living Abuse Policy and Procedure, last reviewed without changes in January 2025, revealed at the time of application all prospective employees will be required to submit with the application, a report of criminal history record information. The application will not be processed without a properly processed background check. The Pennsylvania State Police must do background checks for all Pennsylvania residents. For all applicants who are not current Pennsylvania residents and have not been Pennsylvania residents for the last two years prior to their application for employment, an FBI criminal background investigation is to be performed through the Department of Aging. In accordance with Act 13 Elder Abuse Mandatory Reporting and Act 169 Criminal Background Checks, nursing facilities are required to obtain a criminal background check on all newly hired employees. Facilities are required to obtain the Pennsylvania State Police (PSP) background check within 30 days of hiring on all prospective employees. If the applicant has not been a Pennsylvania resident for the two years before application, they will need to have a PSP criminal history background check completed and a Federal Bureau of Investigation (FBI) Background Check. Review of Employee 3 (nurse aide), Employee 4 (licensed practical nurse), and Employee 5's (registered nurse) personnel records revealed no evidence that the facility determined whether these three employees resided in Pennsylvania for the last two years or completed an FBI background check on them. Interview with the Nursing Home Administrator on September 18, 2025, at 9:32 AM confirmed the above findings for Employees 3, 4, and 5. Review of facility policy entitled Lock Haven Rehabilitation and Senior Living Investigation of Injuries of Unknown Origin, last reviewed without changes in January 2025, revealed the form entitled Investigation of Injuries of Unknown Origin will be completed by the licensed staff. The investigation is conducted initially by the registered nurse supervisor and findings are given to the Director of Nursing and/or Assistant Director of Nursing and Social Services. The investigation will include an interview of the resident by social services, documentation of any medications the resident is currently taking that may be a contributing factor, any behaviors, documentation of any recent falls, and statements from caregivers in the previous 24 hours, and any other pertinent witness statements. If the investigator's conclusion is that suspected or actual mistreatment, abuse, or neglect has taken place, the Director of Nursing and/or Assistant Director of Nursing and Social Service must be notified immediately. Clinical record review revealed nursing documentation for Resident 14 dated August 20, 2025, at 4:38 AM, noting scattered bruising to the left side of Resident 14's neck. Bruising was also noted to her left forearm, right forearm, and hand. The facility was unable to provide any documentation of an investigation into Resident 14's bruising. An interview with the Director of Nursing on September 19, 2025, at 9:49 AM confirmed that the facility did not investigate Resident 14's injuries of unknown origin to rule out abuse. She stated the nurse did not report the bruising; therefore, Resident 14, nor potential staff witnesses were interviewed to rule out abuse. The facility failed to investigate Resident 14's injuries of unknown origin to rule out abuse. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1)(3)(e)(1) Management 28 Pa Code 201.19(8) Personnel policies and procedures

Based on clinical record review and staff interview, it was determined the facility failed to ensure that a resident with a limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for two of 29 residents reviewed (Residents 9 and 17).Findings Clinical record review revealed the facility readmitted Resident 9 on June 2, 2025. Review of Resident 9's most recent MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated September 7, 2025, noted staff assessed Resident 9 as having impairment to his range of motion (ROM, movement of the body to maintain a resident's ability) of his bilateral lower extremities. Review of Resident 9's plan of care-initiated June 23, 2023, revealed Resident 9 has a potential for decreased function in functional abilities due to dementia, immobility, poor attention span, weakness, and deconditioning. An intervention the facility noted was may participate with restorative nursing programs. Further review of Resident 9's clinical record revealed no services to treat his bilateral lower extremity limitations or prevent further decline in his range of motion. The facility submitted a therapy screening form on September 18, 2025, following the surveyor questioning. Therapy noted Resident 9 would benefit from implementation of a restorative nursing program to bilateral upper and lower extremities to maintain his current level of function. These findings were reviewed during an interview with the Director of Nursing on September 19, 2025, at 9:45 AM. Clinical record review revealed the facility admitted Resident 17 on August 30, 2022. Review of Resident 17's recent MDS assessment dated [DATE], noted staff assessed Resident 17 as having impairment to her range of motion of her bilateral lower extremities. Review of Resident 17's plan of care-initiated May 16, 2023, revealed Resident 17 has a potential for decreased functional abilities due to anxiety, debility, and dementia. An intervention the facility implemented was Resident 17 may participate with restorative nursing programs. Review of Resident 17's occupational therapy's Discharge summary dated [DATE], noted therapy recommended staff complete passive range of motion to Resident 17's bilateral upper and lower extremities. Further review of Resident 17's clinical record revealed no services to treat her bilateral lower extremity limitations or prevent further decline in her range of motion. Interview with the Director of Nursing on September 18, 2025, at 1:40 PM confirmed these findings for Resident 17. There was no documentation the facility attempted the recommended range of motion program for Resident 17. 28 Pa. Code 211.12 (d)(1)(5) Nursing services

Based on review of facility documentation and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of residents dressing changes for four of four employees reviewed for competencies (Employees 7, 8, 9, and 10). Findings The Centers for Medicare and Medicaid Services (CMS) QSO-24-13-NH memo dated June 18, 2024, noted that requirements specify that the facility assessment must include an evaluation of diseases, conditions, physical or cognitive limitations of the resident population, acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and any other pertinent information about the resident population as a whole that may affect the services the facility must provide. The assessment of the resident population should drive staffing decisions and inform the facility about what skills and competencies staff must possess to deliver the necessary care required by the residents being served. The facility assessment reviewed during the onsite survey on September 18, 2025, revealed that LPN (licensed practical nurse) competency and training would include blood glucose monitoring, finger sticks, hand hygiene, donning and doffing PPE (personal protective equipment), cleaning/disinfection/sterilization, Heimlich maneuver, urine specimen collection, foley catheter insertion, and medication administration. The facility assessment did not include competencies for RNs (registered nurses). Further review of the facility assessment revealed wound care is a service provided by facility staff. Interview with the Director of Nursing on September 19, 2025, at 9:52 AM revealed the facility currently had 12 residents with pressure ulcers, and 54 residents with dressing changes. A request for nursing staff competencies of dressing change-wound care for Employees 7 and 8 (licensed practical nurses) and Employees 9 and 10 (registered nurses) revealed the facility was unable to provide any competencies addressing these areas. These findings were reviewed during an interview with the Director of Nursing and Nursing Home Administrator on September 19, 2025, at 10:14 AM. 28 Pa Code 201.20(a) Staff development

Based on a review of Resident Council meeting minutes, resident grievances, and resident and staff interview, it was determined that the facility failed to resolve resident complaints regarding laundry services on three of four nursing units (Units 2, 3, and 4; Residents 5, 6, 12, 38, 93, 95, 108, and 115). Findings include: A review of Resident Council meeting minutes dated July 16, 2025, revealed residents voiced concerns at the meeting regarding resident laundry being backed up and residents were missing their clothing, blankets, and other personal items. A review of the Resident Council meeting minutes dated August 13, 2025, revealed environmental services was going to introduce a new laundry system bag and tag, (place all resident laundry in mesh bag in the room and wash to keep it together), and a lost and found display was to be set up for residents to claim items. Review of facility resident/family grievance/concern forms for July 2025, revealed concerns regarding laundry being wrinkled, missing/lost clothes, and not getting clothing returned when sent to laundry to be labeled. In an interview with Resident 12 on September 17, 2025, at 11:06 AM he indicated laundry is a real problem at the facility. The resident stated he sent a shirt to get labeled and did not get it back for two months, and that it takes two weeks to get your laundry back. Resident 12 stated he was fortunate he has a lot of extra shirts, but some residents on his unit don't have extra clothing and he knows some residents on his unit have had to wear the same clothes for a week and a half. In an interview with Resident 93 on September 17, 2025, at 11:47 AM he stated facility staff did his laundry, but he doesn't get his clothes back for weeks and he is currently missing a bunch of clothing that is down in laundry somewhere. Resident 93 stated staff brought him some clothing they said would fit him, but they were not his own clothes. Resident 93 stated he started washing some items himself and hangs them up to dry in his room. A plastic basin full of water with articles of clothing in it was observed on a chair in the front of the resident's room. Resident 93 stated it is quicker to wash his clothes that way than to send any more clothing to laundry. Resident 93 stated someone gave him a special bag to put his dirty clothes in to keep them together, but he still hasn't received any clothing. An interview with Resident 38 on September 17, 2025, at 12:10 PM she stated she received three outfits for her birthday in the middle of August and sent them to laundry to get labeled and washed, and she has not yet received them back as of the time of the interview. Resident 38 also stated she is missing a blanket that was sent to get washed, and laundry staff told her it was in the laundry room, but that was weeks ago, and no one has brought it to her. An interview with Resident 95 on September 17, 2025, at 12:20 PM she stated she has been wearing the same black pants for two weeks due to her other three pairs being down in the laundry. The resident stated she only has a clean shirt to wear because a friend brought her in some shirts. Observation of the resident's closet and clothing drawers with the resident's permission revealed two shirts in the closet and only one pair of black dress pants in the drawer. The resident indicated that the dress pants are only worn when she leaves the facility to go to church, she did not have any of the pants she wears in the facility. Directly before the interview with Resident 95 as noted above Employee 2, environmental services, was overheard and observed speaking to Resident 95, looking in her dresser drawers and asking the resident what size pants she wore so she could find her a pair to wear. Resident 95 replied to Employee 2 that she wanted her own pants back. In an interview with Resident 108 on September 17, 2025, at 12:33 PM she stated she is missing a new pair of shorts, a pair of jeans and a pair of cut offs she sent to laundry weeks ago. Resident 108 stated the clothing was labeled. Resident 108 stated they brought her a pair of cut offs but they were not hers. Resident 108 stated she was going out of the facility the next day with family and is taking her laundry with her to wash it there, so she has her clothing. During an interview with Resident 6 on September 16, 2025, at 2:17 PM Resident 6 revealed he's had an issue for months with laundry not returning his clothes timely, and he indicated the facility is aware of the issue. Resident 6 stated that he frequently runs out of laundry. Observation of Resident 6's closet revealed no pants, two pairs of shorts, and one shirt in his closet and drawers. Follow up interview and observation with Resident 6 on September 17, 2025, at 9:52 AM revealed that Resident 6 still had no pants, and now had no shirts left in his closet or drawers. Resident 6 was wearing pajama pants with the last shirt that was hanging in his closet. Resident 6 stated I guess I am wearing my pajama pants downstairs to the activity. Further observation of Resident 6's room revealed piles of clothes on the floor under the sink in his room, visible from the hallway. Resident 6 stated that is where staff told him and his roommate to put their dirty laundry. An observation of the facility laundry room area on September 17, 2025, at 12:53 PM with Employee 2 revealed multiple carts and racks filled with resident clothing. One large, 5 feet wide and four feet deep wheeled hopper bin was observed filled and overflowing with resident clothing, which was piled three feet above the top of the bin. Two additional wheeled metal carts and another hopper bin were observed by the large cart filled and overflowing with resident clothing. Two wheeled hanging racks used to sort resident clothing by room were also observed with some resident clothing on them. Employee 2 stated one of the laundry employees had sorted some of the clothing from the piles onto the racks and delivered it to residents that day but was continuing to sort through the piles that were there for labeled clothing to make another delivery. A large six-foot-wide linen rack with several shelves packed with clothing and blankets was also observed in the area. Employee 2 indicated the rack had items that were not labeled and/or they did not know who they belonged to. Some mesh laundry bags full of articles of clothing were observed on top of some of the stacks of clothing. Employee 2 stated they were trialing the bags on some of the resident units to keep clothing together, so items do not get lost. Employee 2 stated the clothing gets washed in the bag and dried in the bag to keep the resident items together. Employee 2 stated the laundry department has been working short staffed without any applicants for open positions since at least March 2025. Employee 2 stated there was some help from company regional staff prior to the Labor Day holiday a few weeks prior and all the laundry was caught up, to get the department back on a three-day turnaround for resident laundry, but then the holiday weekend came, and laundry has not been caught up since. Employee 2 stated nursing staff has come down to laundry at times to find some clothes for the residents. Two washers and two dryers were observed in the laundry room, all in operation during the above observation. They were all filled with wash cloths, towels, and gowns. Two large gray trash bins were also observed on the washer side filled with towels/wash cloths (facility owned linens), of which Employee 2 indicated had been washed once, but needed treated, and were waiting to be washed again. Interview with Resident 5 on September 18, 2025, at 11:56 AM revealed that the laundry people are not picking up laundry timely. She said that they have blue bags now to put their dirty laundry in, but the laundry staff are not picking it up. She said they had not picked up her laundry since last week. She also indicated that they are bringing her laundry back in the blue bag after it is washed and dried and all her clothes are wrinkled. Observation in Resident 5's bathroom revealed a blue laundry bag hanging on the door with dirty laundry in it. The bag was noted to be half full. There were clothes hanging on a metal laundry stand belonging in her bathroom. Resident 5 indicated that she put them there. She then proceeded to show the surveyor the wrinkled green dress that was returned to her from laundry. The surveyor observed a green silk dress with wrinkled lines throughout it. Interview with Resident 115 on September 16, 2025, at 1:30 PM revealed that about two weeks ago she was completely out of shirts to wear. She stated that the laundry was not being done and when it was it was not coming back timely. She said her daughter is now doing her laundry because of issues with the laundry at the facility. Concerns regarding laundry services were reviewed with the Nursing Home Administrator and Director of Nursing on September 17, 2025, at 2:40 PM. 28 Pa. Code 201.18 (e)(1)(4) Management28 Pa. Code 201.29(a) Resident rights

Based on clinical record review and staff interview, it was determined that the facility failed to ensure assessments accurately reflected a resident's status for two of 29 residents reviewed (13 and 30). Findings include:Clinical record review for Resident 30 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated July 3, 2025, that facility staff assessed Resident 30 as receiving an anticoagulant medication during the last seven days in the assessment period. Further clinical record review revealed no evidence that Resident 30 received an anticoagulant medication during the assessment period for the MDS noted above. Interview with the Director of Nursing on September 19, 2025, at 9:49 AM confirmed that Resident 30's July 3, 2025, MDS was coded in error regarding receiving an anticoagulant medication. Clinical record review for Resident 13 revealed an annual MDS assessment dated [DATE]. Review of the assessment revealed that Resident 13's diagnosis of cataracts was not documented under the diagnosis section of the MDS. Interview with Employee 15 (Registered Nurse Assessment Coordinator) on September 19, 2025, at 10:00 AM confirmed the above noted findings related to Resident 13. 28 Pa. Code 211.5(f)(ix) Medical records28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, and resident and staff interview, it was determined that the facility failed to provide appropriate treatment and services regarding incontinence care for one of one resident reviewed (Residents 5). Findings include: Interview with Resident 5 on September 17, 2025, at 11:42 AM revealed that she has repeated issues with getting a urinary tract infection (UTI) and that she is scheduled to see a urologist but not until after the first of the year. She also indicated that she does not get help and that she feels as though she is not always able to get herself clean. Clinical record review for Resident 5 revealed a diagnosis of stress incontinence (when movement or activity puts pressure on the bladder causing urine to leak) and urge incontinence (an uncontrollable urge to pee). She also has chronic cystitis with hematuria (inflammation of the bladder accompanied by blood in the urine). Further clinical record review for Resident 5 revealed that she had a UTI on April 8, 2025, that revealed greater than 100,000 Escherichia (E. coli, a type of bacteria) present in the urine. On May 19, 2025, that revealed greater than 100,000 E. coli present in the urine, and July 28, 2025, that revealed again E. coli present in the urine. Review of Resident 5's last occupational therapy plan of treatment and discharge summary revealed that Resident 5 was independent with toileting hygiene. There was no evidence to indicate that Resident 5 was educated on proper toileting hygiene in order to prevent urinary tract infections to include proper peri care and handwashing. Further clinical record review revealed no documentation indicating that Resident 5 was educated on UTI prevention related to her recurrent infections related to E. coli in her urine. The above noted concerns related to Resident 5's recurrent urinary tract infections were discussed with the Director of Nursing on September 19, 2025, at 12:30 PM. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on employee personnel record review and staff interview, it was determined that the facility failed to complete a performance evaluation of each nurse aide at least once every 12 months for one of two nurse aides reviewed (Employees 6).Findings include: The facility noted Employee 6, nurse aide, was hired on September 5, 2023. A request to review the annual performance evaluations (EPR, employee performance review) revealed no documented evidence that the facility completed performance evaluations for Employee 6 at least once every 12 months. Interview with the Director of Nursing on September 18, 2025, at 10:14 AM confirmed that Employee 6's performance evaluation was not completed annually. 28 Pa. Code 201.19 (2) Personnel policies and procedures

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to assist residents to obtain routine dental care for one of three residents reviewed (Resident 1). Findings include: Observation of Resident 1 on September 16, 2025, at 9:55 AM revealed that she had natural teeth, with several teeth that appeared to be broken. Clinical record review revealed the facility admitted Resident 1 on December 10, 2024, with payment sources that included the state Medicaid benefit. Further review of Resident 1's clinical record revealed that she has not been offered dental care. Review of Resident 1's admission MDS (Minimum Data Set, an assessment completed at specific intervals to determine resident care needs) dated December 13, 2025, revealed staff assessed Resident 1 as having obvious or likely cavities or broken natural teeth. Further review of Resident 1's clinical record revealed a plan of care initiated December 17, 2024, noting Resident 1 has impaired dentition related to carious teeth. There was no documentation that indicated Resident 1 was offered routine dental services every six months as the State Plan allows. Interview with the Director of Nursing on September 18, 2025, at 12:02 PM confirmed these findings for Resident 1. The facility did not provide any evidence that Resident 1 received or refused professional dental services since his admission to the facility. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.15. Dental services

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to implement appropriate Transmission Based Precautions (TBP) for one of four residents reviewed on TBP (Resident 135).Findings included: Review of the facility's current policy entitled Categories of Transmission Based-Based Precautions revealed Transmission-Based Precautions will be used whenever measures more stringent than standard based precautions (gloves and hand hygiene), are needed to prevent or control the spread of infection. The policy also indicated that Contact Precautions would be implemented for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Examples of infections requiring Contact Precautions included diarrhea associated with Clostridium difficile (C diff - bacteria that causes an infection of the colon). Steps for administering the contact precautions indicated in the policy to wear gloves when entering the room and remove the gloves before leaving the room and wash hands or use a waterless antiseptic agent. In addition to the gloves, wearing a gown for all interaction that may involve contact with the resident or potentially contaminated items in the resident's environment. The gown should be removed before leaving the resident's environment. Review of the facility's current policy entitled Infection Control Education, revealed it is the facility's policy that all new personnel will attend an orientation program that addresses infection control including the basic principles and the infection control policies and procedures of the facility. An observation of Resident 135's room on September 17, 2025, at 11:25 AM revealed a sign outside the door to the room indicating Contact Precautions were in place for the room. The sign indicated that everyone must clean their hands before room entry and when leaving in addition to staff and providers must put gloves and a gown on before room entry and discard them before room exit. A concurrent observation revealed Employee 14, social services, knocked on Resident 135's door and proceeded to enter the room and go to the resident's bedside and ask questions about the resident's stay at the facility. Employee 14, then walked out of the room. Employee 14 did not put gloves or a gown on to enter the room and did not perform any hand hygiene when entering or exiting the room. In an interview with Employee 14 at the time of the observation the employee indicated she was not aware of any special precautions needed to enter Resident 135's room. After reading the sign, Employee 14 stated, maybe she was supposed to put on gloves and a gown, but she did not see the sign. Employee 14 stated she was newly hired and would have to ask her boss what she needed to do for the precautions as she was not aware. Continued observation of Resident 135's room on September 17, 2025, at 11:38 AM revealed Employee 1, director of environmental services, knocked on the resident's door and entered the room walking past the resident to speak to the resident's roommate. Employee 2 then began looking in the roommate's closet and dresser drawers. Employee 1 then exited the room. Employee 1 did not put on a gown or gloves to enter the room or perform hand hygiene upon exit. A concurrent interview with Employee 1 after exiting the room noted above, Employee 1 indicated she only needed to put a gown and gloves on if she was going to do care to the resident and she wasn't providing care. Employee 1 stated she keeps track of the resident on special precautions so she can relay it to her housekeeping/laundry staff and thought there was only one resident on precautions in the building currently. Clinical record review for Resident 135 revealed the resident had a current order for contact precautions for C-diff, ordered on September 5, 2025. The above concerns regarding the proper usage of personal protective equipment (gown/gloves) were reviewed with the Nursing Home Administrator and Director of Nursing on September 18, 2025, at 2:20 PM. 483.80(a)(1)(2)(4) Infection Prevention & ControlPreviously cited deficiency 10/18/2428 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of employee personnel and education records and staff interview, it was determined that the facility failed to ensure that each nurse aide received 12 hours of in-service training annually for one of one nurse aide reviewed (Employee 6). Findings include: Review of Employee 6's personnel record revealed that the facility hired her on September 5, 2023. The surveyor requested training records for Employee 6 during an interview with the Nursing Home Administrator and the Director of Nursing on September 17, 2025, at 2:15 PM. Review of training records provided by the facility for Employee 6 dated September 5, 2024, to September 5, 2025, revealed that Employee 6 completed only 8.6 hours of in-service education. Interview with the Director of Nursing on September 19, 2025, at 9:48 AM confirmed the above findings for Employee 6. 28 Pa. Code 201.19(7) Personnel policies and procedures 28 Pa. Code 201.20(a)(6)(d) Staff development

Based on clinical record review and staff interview, it was determined that the facility failed to establish clear and consistent resident wishes regarding advance directives for one of six residents reviewed resulting in actual harm (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed Durable Health Care Power of Attorney and Health Care Treatment Instructions (Living Will) for the resident dated [DATE], in which the resident appointed a sister as his health care agent to make decisions on his behalf per terms and conditions described in the document. Further review of the document revealed the terms included the sister was authorized to obtain health information for the resident regardless whether the resident was competent or not, but only at such time the resident was determined incompetent should the agent (sister) be authorized to make health care decisions on the resident's behalf regarding health care treatment which included giving directions to initiate, continue, withhold, or withdraw any or all forms of life-sustaining treatment, or request that a physician responsible for his care issue a do-not-resuscitate (DNR) order, including an out -of -hospital DNR order or a POLST (Physician Orders for Life-Sustaining Treatment, a document for specific medical orders to be honored by health care workers during a medical crisis). In an interview with the Director of Nursing on [DATE], at 11:30 AM it was revealed Resident CR1's sister who was appointed as the agent in the document above was deceased (no date provided), and there was no evidence the resident ever appointed another individual to act on his behalf should he be deemed incapable, or developed a new living will. Review of Resident CR1s closed record revealed the resident was listed with a diagnosis that included intellectual disabilities as an admitting diagnosis (admitted [DATE]), although there was no evidence in the record to indicate the resident was not capable of making decisions affecting his care or had ever been deemed incapable during his stay at the facility. A quarterly MDS assessment (Minimum Data Set - an assessment completed at periodic intervals of time to assesses resident care needs) completed on [DATE], revealed facility staff assessed the resident as having a BIMS (brief interview for mental status) score of 15, indicating the resident was cognitively intact. A POLST was identified as part of the resident's closed clinical record dated [DATE], in which the resident indicated it was his wish to receive CPR (cardio-pulmonary resuscitation, an emergency treatment that is done when someone's breathing or heartbeat has stopped). The POLST was signed by Resident CR1 and a nurse practitioner. Review of Resident CR1's physician orders revealed the resident was ordered a DNR on [DATE], which was discontinued on [DATE], and reordered on [DATE], after a hospital leave of absence. A review of a physician's readmission note for Resident CR1 dated [DATE], upon return from a hospital stay listed the resident as having a code status of No Code (no CPR), and that advance directives were discussed. The document does not indicate who the advance directives were discussed with, i.e., if it was the resident himself or family. A Code Status document with the same date of [DATE], was identified for the resident with DNR, and DNI (do not intubate), checked off and the sheet was signed by the physician and the nurse receiving the order. There was no resident or family signature on the form or who determined the DNR/DNI for the resident. The facility was not able to provide evidence to show Resident CR1 was ordered to have CPR administered after the resident completed the POLST indicating desired CPR on [DATE], or if the order was changed from wishing to have CPR between the [DATE], date and the order dated [DATE], as the Director of Nursing indicated in an interview on [DATE], that the facility changed electronic records in [DATE], and any current orders at the time were carried over to the new system, which is why the DNR order for the resident was dated [DATE]. A physician's readmission note dated [DATE], after the resident had another hospital leave noted the resident's code status was No Code, and per record review his code status remains DNR/DNI. The note indicated advance directives were discussed, the patient is a DNR. Again, there was no evidence as to who advance directives were discussed with and if the resident was involved or made the decision. Another Code Status sheet dated [DATE], was completed for Resident CR1, which checked off DNR and DNI for the resident and was signed by the physician and nurse receiving the order, but the form did not indicate any discussion with the resident. Resident CR1 was noted to have a change in condition beginning [DATE], with nausea, progressing to emesis from [DATE] - 7, 2025. A nursing note dated [DATE], at 2:30 PM noted the nurse was called to the resident's room to assess the resident as he was vomiting and cool to touch but alert and speaking. It was noted the nurse was unable to get a blood pressure and the provider was consulted and the decision was made to send the resident to the emergency department. Emergency services were noted as contacted. The note then indicated the resident expired at 2:20 PM as there were no respirations or apical heartrate for one full minute and emergency personnel were updated upon arrival. A physician's death pronouncement note dated [DATE], at 12:11 PM noted the resident expired at the facility on [DATE], noting the resident had worsening status in the afternoon of [DATE], and emergency services were called due to transfer to the emergency department for further evaluation, but the patient was noted by nursing to have agonal breathing, respiratory distress, and became pulseless. It was noted no code blue was called as the patient is known DNR/DNI. There was no evidence to indicate it was Resident CR1's decision to change from his desire to have CPR as the resident signed a POLST in October of 2021, indicated to become a DNR (no CPR) as orders reflected after that date, as there is no evidence to indicate a discussion actually occurred with the resident himself, or that the resident signed a new document indicating a desire to change his wishes. There was no evidence the resident became incapable to not make that decision during his stay at the facility. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on [DATE], at 3:45 PM. Cross Refer F684 483.10(c)(6)(8)(g)(12)(i)-(v) Request/Refuse/Discontinue Trmnt; Formulate Adv Dir Previously cited deficiency [DATE] 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on closed clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care for a resident's change in condition that resulted in death for one of six residents reviewed causing actual harm (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed that the resident had been a long-term resident of the facility with an admitted [DATE]. Review of Resident CR1's closed clinical record revealed a nursing note dated [DATE], at 8:25 PM noting the resident had complaints of nausea and not feeling well. A nursing note followed dated [DATE], at 2:38 AM noting no further emesis, and a clear liquid tray was ordered for breakfast. There was no further documentation identified between the notes identified above between the evening of [DATE], through the night to [DATE], regarding the number of times emesis occurred or any other details. A review of meal intakes for Resident CR1 for [DATE], revealed the resident was documented as only consuming ,d+[DATE] percent of breakfast and lunch and had refused dinner on that day. Review of meal intakes for the resident prior to [DATE], back to [DATE], revealed the resident had normally consumed at least 51% of meals and mostly ,d+[DATE] percent of meals. Resident CR1's meal intakes for [DATE], breakfast continued to be low for the resident at ,d+[DATE] percent, with lunch slightly better at ,d+[DATE] percent and dinner ,d+[DATE] percent. Resident CR1 was also documented on his bowel record of having a loose/diarrhea bowel movement on the evening of [DATE]. The resident was documented as having normal stools almost daily for several days leading up to [DATE]. There were no further nursing notes for Resident CR1 for [DATE], reflecting the decrease in meal intakes, whether his nausea had subsided, if there was any further emesis during the day of [DATE], or that the resident had a loose/diarrhea bowel movement since nausea and vomiting has been recently documented. The next nursing note for the resident was dated [DATE], at 2:13 PM, which noted the resident had emesis twice during the shift with coffee ground appearance, very foul odor, and the resident complaining overall of not feeling well. It was noted the registered nurse supervisor was notified and observed the emesis, and the resident would be monitored for increased emesis and vital sign changes. A late entry note documented by the registered nurse on [DATE], at 9:54 AM for [DATE], at 2:51 PM noted the resident was having multiple emesis during the shift, it was liquid brown in color, there was no concern for gastrointestinal (GI) bleeding, and the emesis had no coffee brown texture noted upon assessment. The note indicated GI illness was circulating around the building and the resident's provider was aware with Zofran (an anti-nausea medication) ordered and fluids encouraged. A review of Resident CR1's orders revealed Zofran was ordered on [DATE], at 10:00 PM to be administered every eight hours for nausea/vomiting for three days. An order for the resident to have vital sign checks each shift was also identified as ordered on [DATE], at 11:00 PM. Further review of Resident CR1's bowel records for [DATE], also revealed loose stools/diarrhea were documented for that day. Nursing documentation dated [DATE], at 8:05 PM noted the resident refused an evening snack due to nausea and vomiting. A nursing note dated [DATE], at 10:22 PM noted the resident had two extra-large emesis during the shift of dark brown liquid noting the resident consumes a chocolate nutritional supplement, and the Zofran was given. Resident CR1's bowel records also indicated the resident had a loose/diarrhea stool documented the early morning hours of [DATE]. A review of resident CR1's vital signs on [DATE], revealed the resident's blood pressure obtained at 8:49 AM as ,d+[DATE] mmHg (millimeters of mercury) with a warning indicating the Diastolic (bottom number) was low below 60, and the Systolic (top number) was low below 90. Review of Resident CR1's [DATE], medication administration record revealed a medication Lisinopril (medication used to treat high blood pressure) was ordered for the resident daily in the morning and is to be held for a Systolic blood pressure less than 110 mmHg. The Lisinopril was documented as not administered due to vitals outside parameters for administration. A correlated administration note for [DATE], at 10:38 AM noted the medication order as it appears on the medication administration record to hold for a Systolic blood pressure of less than 110 mmHg. An administration note also followed for Resident CR1 at 10:39 AM on [DATE], noting the resident's sliding scale insulin was not administered as the resident is vomiting and refusing meals. The resident's routine insulin was also noted in an administration note that followed at 10:41 AM that it was not administered as the resident was refusing meals, and an administration note at 12:03 PM that the resident's nutritional supplement was refused as the resident was vomiting. A nursing note dated [DATE], at 12:58 PM indicated Resident CR1 was assessed by the provider on that day for nausea and vomiting and the resident continued to receive Zofran every eight hours for three days, labs were to be completed the next day, and clear liquids were to be given for 24 hours. A review of Resident CR1's physician orders revealed the following orders on [DATE]: 7:00 AM encourage 120 milliliters of fluid every shift 7:00 AM clear liquids for 24 hours 12:45 PM KUB (an Xray/scan of the urinary system) 12:45 PM CBC, BMP, and LFT's (diagnostic testing of complete blood count, basic metabolic panel, and liver function testing) A review of physician assistant (PA) documentation for [DATE], for an encounter with Resident CR1 on [DATE], revealed the resident was noted as seen for evaluation of nausea and vomiting and the PA was asked to see the resident after having developed symptoms of nausea and vomiting yesterday, ([DATE], even though the nausea and vomiting started on [DATE]), and upon evaluation had vomited once on [DATE], prior to the visit. The resident indicated to the PA that his bowels were moving normally, and he did not have a fever. It was noted staff reported the resident had coffee ground emesis on [DATE], however, the registered nurse reported it was slightly brown in color but did not feel it was coffee ground emesis. The PA noted the resident's blood sugar was over 200 for the day and his blood pressure from ,d+[DATE] was ,d+[DATE] mmHg. The encounter note indicated the PA reviewed the most recent facility's vitals for the resident and due to the discrepancy reports on the coffee ground emesis would check the CBC, BMP, LFT's, continue the Zofran, clear liquid diet, check KUB given slightly hypoactive bowel sounds, and recheck on [DATE], after KUB was reviewed. The time of the PA's visit was not indicated on the encounter visit report although per interview with the Director of Nursing on [DATE], at 3:45 PM indicated the PA reported she had visited the resident around 11:00 AM on [DATE]. The note was electronically signed by the PA on [DATE], at 2:49 PM. A nursing note dated [DATE], at 2:30 PM noted the nurse was called to Resident CR1's room as the resident was again vomiting and cool to tough. He was alert and speaking. The resident's blood sugar was noted as high at 476 mg/dL, and the provider was consulted, and the decision was made to send the resident to the emergency department for further evaluation. It was noted emergency medical services was called, and the resident expired at 2:20 PM, noting emergency medical services was updated upon arrival. An additional note from the PA with an encounter date of [DATE], electronically signed by the PA on [DATE], at 12:41 PM, noted a few hours after the PA had seen Resident CR1, the registered nurse came to the PA's office indicating the resident had several more episodes of vomiting since she has seen him and seemed to be declining. The registered nurse reported the resident's color did not look good and the resident seemed diaphoretic, also reporting his blood pressure was low. The registered nurse reported that there were a few spots of bright red blood on the resident's sheet but on assessment concluded it to be from a sacral wound. The PA advised to call emergency medical services and have the resident transferred to the emergency department. The PA noted the registered nurse then called her moments later and reported the resident was not responsive and had signs of respiratory distress, the nurse confirmed the resident did have a pulse and the resident's code status was reviewed and confirmed the resident was a do not resuscitate/do not intubate. The nurse was advised if the resident still had a pulse to call 911. It was noted the nurse called again a few moments later and reported 911 had been called; however, the resident was now pulseless and ceased to breathe. Emergency staff arrived just after they hung up the phone, and the nurse pronounced the resident. A physician's note dated [DATE], at 12:11 PM as a death pronouncement noted the resident's date of expiration was [DATE], with a cause of death as aspiration pneumonia, acute hypoxic respiratory failure, with secondary diagnosis listed of diabetes type 2, peripheral vascular disease, ventral hernia, neurogenic bladder, major depressive disorder, and intellectual disability. The note only referenced on [DATE], the resident was noted to have nausea and vomiting, and a GI virus had been affecting other residents in the facility. It noted symptoms continued [DATE], and the resident was evaluated by the medical team and noted to be at baseline mental state, stating he was feeling nauseous and tired. It was noted there had been some concerns of coffee ground emesis but on further evaluation of emesis by nursing was not found to be the case, more consistent with bilious/stomach acid. It was noted later that afternoon the resident had a worsening of status, emergency services were called for transfer to the emergency department, and unfortunately while they were enroute the resident was noted to have agonal breathing, respiratory distress, became pulseless, and no code blue (emergency alert for a patient in cardiac arrest) was called as the patient was a known do not resuscitate/do not intubate. There was no evidence the PA or the resident's physician was made aware Resident CR1's nausea and vomiting had actually started as documented late on [DATE] into the early morning hours of [DATE], as the PA referenced in the note as symptoms started on [DATE], per staff, or that the either was aware the resident had loose stools identified in bowel records also beginning [DATE], and significantly decreased intakes of meals due to nausea and vomiting beginning [DATE], not one day before on [DATE]. The PA's note did not reflect being made aware of the resident's significant decrease in blood pressure as it was obtained on [DATE], in the morning at 8:49 AM as the PA's note reflected the resident's blood pressure from the day before ([DATE]) in normal range in the visit on [DATE]. The PA did not reference being made aware of any low blood pressure until the later encounter with the registered nurse on [DATE], as noted above when the resident rapidly declined in the afternoon. Facility staff were not able to provide any evidence to the surveyor to indicate Resident CR1's providers were made aware the resident's change in condition began late on [DATE], greater than 24 hours prior, and not [DATE], as indicated in provider reports. Additional diagnostics were not ordered until [DATE], after the PA visited the resident. There was no evidence of any follow up to the resident's condition on [DATE], as emesis was noted in the very early morning hours, the resident had loose stools documented, and the resident's meal intakes reflected significant decline for the day with refusal of dinner, until emesis was documented on [DATE]. Resident CR1 expired on [DATE], at 2:20 PM prior to any of the ordered diagnostic testing being completed. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on [DATE], at 3:45 PM. Cross Refer F578 483.25 Quality of Care Previously cited deficiency [DATE] 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, clinical record review, review of facility documents, and staff interview, it was determined that the facility failed to protect the rights of a resident to be free from neglect by not providing the services necessary to avoid physical harm resulting in injury for one of four residents reviewed that sustained two fractures (Resident 1). Findings include: An observation of Resident 1 on March 1, 2023, at 12:45 PM revealed the resident lying in bed with a sling on her left arm. Clinical record review for Resident 1 revealed the [AGE] year-old resident had resided in the facility since 2012, and had resided in the same room on the same Unit 2 since October 2021. A progress note dated February 22, 2023, at 5:43 AM noted the resident was observed to be sitting on her buttocks with her feet in front of her outside the shower room on Unit 2 and was assessed with no injuries. The note also indicated the fall was witnessed and her aide stated the resident got away from her and she couldn't catch her fast enough. It was noted the resident had non-slip socks on both her feet, the resident had just been showered, and a gait belt was not around her waist. The note indicated staff was educated on the proper usage of her gait belt and signed education on looking up a resident's ambulation and transfer ordered and following them. A review of Resident 1's physician orders revealed the resident was ambulated and transferred with assist of one with hand-held assist and a black gait belt ordered on July 19, 2021. An annual MDS (Minimum Data Set, an assessment completed at periodic interval to assess resident care needs), completed on February 3, 2023, for Resident 1, revealed facility staff assessed the resident as having severe cognitive impairment, and needing extensive assistance for transfers, walking in room, and limited assistance of one for walking in the corridor. A nursing note dated February 22, 2023, at 11:42 AM noted a new order for Resident 1 for a left should x-ray as the resident was guarding and indicated pain when the arm is moved. A follow up note on February 22, 2023, at 8:51 PM noted the x-ray results were received for Resident 1, and a distal left clavicular fracture was noted with new orders to immobilize the arm, apply a sling to the left arm, and follow up with orthopedics. Review of the x-ray report dated February 22, 2023, at 3:22 PM for Resident 1 indicated a distal left clavicular fracture. A nursing note dated February 23, 2023, at 2:36 PM noted Resident 1 now had swelling to the left side of her face, and was guarding and saying ouch, when her legs were moved. A follow up note at 3:18 pm noted a new order for a left hip x-ray. A final x-ray report dated February 24, 2023, at 9:50 AM for Resident 1 indicated an impacted left sided sub capital femoral neck fracture, underlying osteopenia, and mild degenerative changes of both hips. A nursing note dated February 24, 2023, at 3:38 PM noted the provider spoke with Resident 1's responsible party about fractured hip, and family has decided not to have surgery on hip and resident to be comfortable. After consulting with orthopedics, the provider gave new orders for the resident to be non-weight bearing of left hip. Review of a witness statement from Employee 1, nurse aide, who was assisting Resident 1 at the time of the fall on February 22, 2023, Employee 1 noted she was walking the resident back to her room when Resident 1 pulled away from her to grab the bar on the wall and she went down. A review a PB-22 report submitted by the facility on February 24, 2023, indicated Employee 1 ambulated Resident 1 from the shower room with assist of one and hand-held assistance and Employee 1 reported she received ambulation information from the licensed practical nurse (LPN) verbally, and Employee 1 was immediately educated on protocol of checking resident profile orders prior to performing tasks. In a phone interview conducted by the Director of Nursing with Employee 2, LPN, noted above as providing verbal instruction on Resident 1's ambulation status, on March 1, 2023, at 9:45 AM, Employee 2, LPN, indicated she was asked by Employee 1 on February 22, 2023, the ambulation status of Resident 1, and replied, I've seen them take her to the bathroom and shower with only one person. Employee 2 indicated she did not check the physician order at the time as she was in the middle of passing medications, and we have five other computers, usually when someone is not sure, they go and check. Employee 2 did not instruct Employee 1 to go and check the orders, and everyone is responsible to see if there are changes in the computer orders. Employee 1 and Employee 2 signed off on immediate education dated February 22, 2023, the day of Resident 1's fall, regarding checking a resident's profile in the computer for care needs. The facility followed with whole house re-education on reviewing a resident's profile for care needs. Employee 1 received a final written warning disciplinary action for not following the resident's orders, which was signed on March 1, 2023, after the surveyor's entry for the onsite visit. Employee 2 was to sign verbal disciplinary action when reporting for her shift on March 1, 2023, for not reviewing orders prior to providing instruction to the nurse aide or instructing Employee 1 to review the resident's profile when the ambulation status was not known. In an interview with the Director of Nursing on March 1, 2023, at 8:30 AM she indicated all the nurse aides/staff must sign off each shift that they have completed a task of reviewing the resident's profile that they are assigned to during that shift, and Employee 1 completed that task for Resident 1 on February 22, 2023, the shift the fall occurred. A review of the facility's electronic medical record system revealed each resident has an electronic profile, which includes active orders for care including ambulation and transfer status of the resident. A task was identified for each resident each shift for the caregiver to sign off each shift that they have read the resident's profile with a yes or no response. A random review of facility staff who identified their roles as nurse aides working the nursing units of the facility during the onsite visit on March 1, 2023, revealed that although staff needed to leave a resident's room/leave a resident, and utilize a computer located at the nursing station, the staff could log into a resident's record, view a resident profile, and were able to access the task, which required staff to sign off yes or no as to whether the profile was reviewed during the shift. The task could be reviewed at any time during the shift and did not need to be completed prior to providing care. Staff were able to select that yes, they reviewed the resident's profile, without clicking on the profile first. Random interviews indicated the nurse aides, know the resident's needs, because they work with them all the time, and that there is no time to review the profiles for all residents under their care prior to providing care. A review of personnel information for Employee 1 revealed Employee 1 had been hired on January 30, 2023, completed nurse aide orientation to the facility on [DATE], and had worked five shifts on Unit 2 where Resident 1 resided prior to the morning of the incident on February 22, 2023. A review of Employee 1's orientation/competency check list prior to working independently on a nursing unit revealed Employee 1 demonstrated the appropriate use of gait belts on February 6, 2023, and that she understood the computer/KIOSK, on February 8, 2023. A Care Assist Documentation sheet was provided as included with the orientation, which included where to find individual resident orders by clicking the resident profile, and that the profile must be read each shift. There was no competency regarding accessing the resident profile to indicate whether Employee 1 was competent in that duty prior to working on the nursing unit independently. Resident 1's active orders indicated a change in transfer status to a Hoyer lift and non-weight bearing to her left leg on February 24, 2023, and no ambulation as of February 27, 2023, due to the two fractures sustained during the fall on February 22, 2023, in which the resident was being ambulated without a black gait belt as ordered. In an interview with the Nursing Home Administrator and Director of Nursing on March 2, 2023, at 3:30 PM the above findings were reviewed. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights

Based on closed clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to implement assessed interventions to prevent accidents for one of two residents reviewed for falls, resulting in harm with a fractured femur (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed the resident was admitted to the facility on [DATE], with a diagnosis of dementia, abnormal gait and mobility, and a history of falling. Repeated falls was listed as a diagnosis on [DATE]. Closed clinical record review for Resident CR1 revealed the resident did have a history of frequent falls with evidence of the resident having 13 falls since [DATE] ([DATE]; February 9; [DATE]; [DATE]; [DATE], 28; [DATE]; [DATE]; and [DATE], 2022, with no major injury reported). Resident CR1 fell again on [DATE], and sustained a fractured femur. A comprehensive MDS (Minimum Data Set, an assessment completed a periodic intervals of time to determine resident care needs) dated [DATE], revealed facility staff assessed the resident with a BIMS (Brief interview for mental status) score of three, indicating severe cognitive impairment, and requiring assistance of one person physical assistance for transfers. A review of Resident CR1's plan of care for falls initiated on February 28, 2020, revealed an intervention of placing the resident's bed against the wall with the head of the bed facing the doorway was initiated on [DATE]. A physician's order dated [DATE], also ordered the resident to have her bed against the wall and the head of the bed facing the doorway. A physician's order dated [DATE], ordered anti-skid strips to be placed in front of the resident's recliner chair, toilet, and the open side of the bed. An updated physician's order and plan of care intervention dated [DATE], indicated anti-skid strips in front of the toilet and open side of the bed. Nursing documentation dated [DATE], at 3:24 PM noted the staff member was called to Resident CR1's room at 2:00 PM for a fall, and the resident was observed laying on her back on the floor with her head partially under the end of her bed by the wheel of the bed. The resident's left leg was internally rotated and on palpitation the resident screamed in pain. Upon contacting the resident's physician, the resident was transferred to the emergency room at 2:20 PM. Review of Resident CR1's fall investigation report dated [DATE], revealed the resident was in bed prior to the fall, and a corrective action measure was to replace non-skid strips on the floor beside the bed, and noted the floor was tacky, recently waxed, and non-skid strips not replaced after floors waxed. Closed clinical record review for Resident CR1 revealed a new intervention was added to the resident's plan of care on [DATE], which indicated, fall from bed to floor - replace non-skid strips at bedside. The investigation also indicated staff placed the resident in bed at 1:45 PM. In an interview with the Director of Nursing on [DATE], at 10:00 AM she indicated Resident's CR1's floor was waxed earlier in the day by housekeeping on [DATE], and the non-skid strips were not put back on the floor prior to the resident's return to the room. In an interview with Employee 1, Director of Environmental services, at 12:27 PM she indicated room Resident CR1's room was waxed on [DATE], and the non-skid strips were not placed back on the floor on the resident's open side of the bed (other side against the wall as ordered) prior to the resident returning to the room. Employee 1 provided the schedule of room waxing for [DATE], and Resident CR1's room was listed for [DATE]. A review of resident CR1's CT (computerized tomography) scan provided to the facility obtained on [DATE], at 3:15 PM revealed the resident sustained an acute impacted comminuted intertrochanteric and subtrochanteric fracture of the left proximal femur. A nursing note dated [DATE], at 5:48 PM noted a facility staff member was notified Resident CR1 was positive for a fracture and that the resident would be transferred to another acute care facility for further evaluation. A nursing note dated [DATE], at 6:02 PM revealed the facility was notified Resident CR1 had expired at the hospital. An interview with the Nursing Home Administrator and Director of Nursing on [DATE], at 3:15 PM confirmed the above findings regarding Resident CR1's fall on [DATE], resulting in a fracture, and the non-skid strips were not on the floor beside the resident's bed at the time of the fall. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of select facility policies, facility documentation, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents were free from neglect for one of six residents reviewed that resulted in harm for a resident that sustained a fractured right ankle (Resident 117). Findings include: The facility policy entitled, Abuse, last reviewed in (MONTH) (YEAR), without changes, revealed that each resident has the right to be free from abuse, including neglect. Abuse of residents will not be tolerated. Violation of this standard will subject employees to disciplinary action, including dismissal. Active neglect is the willful deprivation of goods or services, which are necessary to maintain physical or mental health. Passive neglect is the deprivation of goods or services, which are necessary to maintain physical or mental health, without a conscious attempt to inflict physical or emotional distress. Clinical record review for Resident 117 revealed that the facility completed an initial MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) on (MONTH) 24, (YEAR), indicating that Resident 117 is alert, oriented, and capable of making her own decisions. The facility documentation revealed that on (MONTH) 1, (YEAR), at 8:40 PM Employee 1, nurse aide, transferred Resident 117 by himself. During the transfer, Resident 117's legs gave out/buckled and she sustained a fracture of her right ankle. The facility investigation revealed that Resident 117's transfer status was changed on (MONTH) 1, (YEAR), at 1:22 PM from a Hoyer (mechanical) lift to a 2 person assist with a front wheeled walker (a walker with front wheels to assist in transfers and/or ambulation) and gait belt (a belt to allow staff to provide resident stability) for transfers. Employee 2 acknowledged this change of transfer status on (MONTH) 1, (YEAR), at 5:28 PM. Review of Resident 117 and facility witness statements revealed that Resident 117 indicated that she told Employee 1 that she had to use the restroom. Employee 1 indicated that the others were on break so he couldn't currently help take her to the bathroom. Resident 117 then indicated that if she didn't go now, she would be incontinent. Employee 1 assisted her to the bathroom. Review of nurse staffing revealed that there were three nurse aides and one licensed practical nurse (LPN) assigned to Resident 117's unit with a house registered nurse supervisor and a house treatment LPN. Review of Employee 2's, treatment LPN, statement revealed that she was with Resident 115 taking the resident's vital signs, heard a loud crash, responded promptly, and witnessed next door Resident 117 on the floor at the foot of the bed. Review of the facility's roster confirmed that Resident 115 resides next door to Resident 117. Review of an X-ray report dated (MONTH) 1, (YEAR), at 9:53 PM revealed that Resident 117 sustained a fracture and lateral (outside) dislocation of her right ankle as a result of her fall. Review of a surgical report revealed that Resident 117 had an open reduction internal fixation (surgical intervention) with screws to her right ankle on (MONTH) 8, (YEAR). Interview with Resident 117 on (MONTH) 10, (YEAR), at 11:35 AM revealed that Employee 1 did not attempt to get other staff assistance prior to transferring her by himself. Resident 117 indicated that her ankle currently hurt at a pain level of 8 (severe pain) and requested pain medication, which the facility provided. Employee 1 neglected to follow the transfer instructions for Resident 117, which resulted in harm to the resident. The findings were reviewed during an interview on (MONTH) 10, (YEAR), at 11:10 AM with the Director of Nursing and at 2:45 PM with the Nursing Home Administrator. 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 211.10(c)(d) Resident care policies Previously cited 7/20/18, 8/3/17 28 Pa. Code 211.12(c) Nursing services Previously cited 7/20/18 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 7/20/18, 8/3/17

Based on clinical record review, review of select facility policies, and staff interview, it was determined that the facility failed to maintain adequate nutrition for one of 24 sampled residents (Resident 86). Findings include: The facility policy entitled "Weights," last updated January 2012, revealed that if weight loss is occurring, significant or not, the dietitian will review resident meal intake percentages. Clinical record review for Resident 86 revealed that the facility transferred Resident 86 to the hospital on June 6, 2012, following a fall. Resident 86 returned from the hospital on June 14, 2012. Resident 86's weight record revealed that the facility recorded the following weights: June 5, 2012, 141 pounds June 14, 2012, 134.2 pounds June 15, 2012, 137 pounds June 24, 2012, 126.6 pounds. June 25, 2012, 126 pounds. This is an 8 percent severe weight loss in 10 days. Review of Resident 86's daily intake and output records revealed that from May 18, 2012 to June 6, 2012, Resident 86 consumed 75 percent or more of her daily meals. The daily intake and output records from June 14, 2012 to June 25, 2012 revealed the following consumption percentages: June 14, 2012: 0 percent June 15, 2012: 25 percent June 16, 2012: 41 percent June 17, 2012: 0 percent June 18, 2012: 25 percent June 19, 2012: 41.7 percent June 20, 2012: 25 percent June 21, 2012: 0 percent June 22, 2012: 58.3 percent June 23, 2012: 33 percent June 24, 2012: 33.3 percent June 25, 2012: 25 percent Nursing documentation dated June 16, 2012, revealed that staff was instructed to feed Resident 86 due to her confusion. Nursing documentation dated June 17, 2012, revealed that Resident 86 continued to eat poorly. There is no other nursing documentation indicating that the facility acknowledged Resident 86's poor nutritional intakes until July 25, 2012, when nursing staff reported an 11.1 pound weight loss to Resident 86's physician. A review of Resident 86's laboratory reports revealed that on May 9, 2012, Resident 86's [MEDICATION NAME] level (a test to evaluate nutritional status) was 3.2 g/dL (normal range is 3.8 to 5.0 grams per deciliter, g/dL). A review of laboratory reports dated June 25, 2012, revealed that Resident 86's [MEDICATION NAME] level was 2.8 g/dL, indicating a decline in her nutritional status. A review of dietary documentation dated May 11, 2012, revealed that dietary assessed Resident 86 as consuming 80 percent of her meals. Dietary documentation dated June 21, 2012, revealed that the dietitian completed a nutritional assessment on June 21, 2012, seven days after her return from the hospital, recommending a physician's orders [REDACTED]. The dietitian failed to assess and implement interventions for Resident 86's decreased intakes and weight loss upon return to the facility on [DATE]. The facility transferred Resident 86 to the hospital on June 25, 2012. The hospital physician determined that Resident 86 required a PEG tube (feeding tube surgically placed in the stomach to facilitate tube feeding), due to her decreased intakes and weight loss. The physician hospital report lists Resident 86's [DIAGNOSES REDACTED]. Interviews with the Nursing Home Administrator and the Director of Nursing on July 26, 2012, at 2:00 PM, and July 27, 2012, at 10:30 AM and 1:00 PM, confirmed that the facility had no evidence indicating that the facility initiated any interventions to prevent Resident 86's 8 percent severe weight loss in 10 days, prior to the insertion of a feeding tube. 28 Pa. Code 211.6(d) Dietary services. Previously cited 6/29/11 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.10 (c)(d)(2) Nursing services. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited 6/29/11

Based on clinical record review, review of select facility policies, and staff interview, it was determined that the facility failed to maintain adequate hydration for one of 24 sampled residents (Resident 86). Findings include: The facility policy entitled "Hydration," last reviewed January 2012, revealed that it is the facility policy that all residents be included. Dietary staff gives residents fresh water as per their schedule. The policy fails to indicate what measures staff take when residents are not meeting their fluid needs. Clinical record review for Resident 86 revealed that the facility transferred Resident 86 to the hospital on June 6, 2012, following a fall. Resident 86 returned from the hospital on June 14, 2012. Review of Resident 86's daily intake and output records from June 14, 2012 to June 25, 2012, revealed the following daily fluid consumption: June 14, 2012: 0 cubic centimeters (cc) of fluid. June 15, 2012: 180 cc of fluid. June 16, 2012: 1020 cc of fluid. June 17, 2012: 180 cc of fluid. June 18, 2012: 300 cc of fluid. June 19, 2012: 480 cc of fluid. June 20, 2012: 260 cc of fluid. June 21, 2012: 120 cc of fluid. June 22, 2012: 710 cc of fluid. June 23, 2012: 340 cc of fluid. June 24, 2012: 220 cc of fluid. June 25, 2012: 240 cc of fluid. A review of the Nutrition assessment dated [DATE], revealed that Resident 86's fluid needs are 1555 to 1866 cc of fluid per day. The assessment revealed no indication that Resident 86's fluid intake was below her daily needs. Review of Resident 86's clinical record revealed laboratory reports dated May 9, 2012, indicating that Resident 86's BUN (Blood urea nitrogen, lab data indicative of assessing hydration status), was normal 19 milligrams per deciliter (mg/dL, the normal range is 6-20 mg/dL). Laboratory results for Resident 86 dated June 25, 2012, revealed that Resident 86's BUN was now elevated at 50 mg/dL, indicating a decline in her hydration status. A review of nursing documentation revealed that on June 18, 2012, nursing staff indicated that Resident 86 has poor fluid intake. Nursing documentation dated June 25, 2012, revealed that Resident 86's physician ordered intravenous fluids for Resident 86 based on her laboratory results. The facility sent Resident 86 to the hospital after failing to start the intravenous fluids at the facility. Resident 86's physician's readmission documentation dated July 2, 2012, revealed that Resident 86 was treated for [REDACTED]. Resident 86's clinical record contains no evidence that the facility attempted interventions to increase Resident 86's fluid intake to prevent Resident 86's dehydration. An interview with the Director of Nursing and the Nursing Home Administrator on July 26, 2012, at 2:00 PM, and July 27, 2012, at 10:30 AM and 1:00 PM, confirmed that the facility failed to implement interventions to prevent Resident 86's dehydration. 28 Pa. Code 211.6 (d) Dietary services. Previously cited 6/29/12 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(2) Nursing services. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services. Previously cited 6/29/12.