Every finding on record at Locust Grove Retirement Village

Based on observation and staff interview, it was determined that the facility failed to store food in accordance with professional standards for food service safety in the facility's main kitchen.Findings include: Observation of the facility's main kitchen on Tuesday, July 7, 2026, at 10:13 AM, Employee 4 (Certified Dietary Manager) revealed the following: An opened box of single serving Italian dressing packets in refrigerator one with June 2024, recorded in black marker on the box. Employee 4 indicated that was the date received. There was no evidence when the product needed used by or when it expired. A small metal pan labeled tuna salad, discard by July 4, 2026, in the walk-in cooler. The walk-in freezer contained a steam-table style pan of lasagna labeled to be discarded by June 26, 2026, and another unlabeled/undated pan of which Employee 4 indicated was shrimp alfredo. Review of a temperature monitoring log for refrigerator two, for April 2026, revealed a corrective action is necessary for a temperature greater than 41 degrees Fahrenheit (F). Temperatures were documented as the following: April 4, 2026, 42.2 degrees F April 5, 2026, 44 degrees F Review of the temperature monitoring log for the walk-in freezer for May and June 2026, revealed a corrective action is necessary for a temperature greater than zero degrees F. Temperatures were documented as the following: May 29, 2026, morning, 5 degrees FMay 29, 2026, afternoon, 1 degrees FMay 31, 2026, afternoon, 2 degrees FJune 9, 2026, afternoon, 1 degrees FJune 10, 2026, afternoon, 1 degrees FJune 12, 2026, afternoon, 1 degrees FJune 15, 2026, afternoon, 1 degrees FJune 16, 2026, afternoon, 1 degrees FJune 17, 2026, afternoon, 1 degrees FJune 19, 2026, afternoon, 1 degrees FJune 21, 2026, morning, 30 degrees FJune 21, 2026, afternoon, 2 degrees FJune 22, 2026, afternoon, 1 degrees FJune 24, 2026, afternoon, 2 degrees FJune 26. 2026, afternoon, 2 degrees FJune 27, 2026, afternoon, 3 degrees FJune 28, 2026, afternoon, 4 degrees FJune 30, 2026, afternoon, 2 degrees F There was no evidence that any corrective action was documented or completed for the temperatures noted above as indicated as needed. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on July 9, 2026, at 1:20 PM. 28 Pa. Code 201.14 (a) Responsibility of Licensee

Based on observation and staff interview, it was determined that the facility failed to maintain adequate maintenance services to ensure a clean, comfortable, orderly, and homelike environment on one of four nursing units (100 Hall) and in facility's main activity room.Findings Include: Observations on July 8, 2026, at 11:15 AM of the activity room revealed residents were gathered around the tables. Large brown stains were noted scattered on the ceiling at various areas, the largest area was roughly round and measuring two feet in diameter. A dried brown area was also noted in the fluorescent light fixture. Further observation revealed there was water gathering on the ceiling and dripping into a bucket that was located between two tables with residents gathered around them. There was a round two-inch hole noted in the ceiling near roughly ten inches from where the water was gathering and dripping into a bucket on the ground. A second area, located further into the room revealed water pooling on the ceiling. A bucket/bin was not located below this area, and a small amount of water had started to gather on the floor below. Concurrent interview with Employee 1, Activities Director, revealed that the water was believed to be from condensation from the air condition lines located above the ceiling. Employee 1 indicated that repairs to the ceiling had been completed in the past and that the problem seemed to recur multiple times over the years she had been there. The Nursing Home administrator and the Director of Nursing were made aware of the above concerns during a meeting on July 9, 2026, at 2:30 PM. Observation of the shower room on the 100 Nursing Unit on July 9, 2026, at 9:38 AM revealed a section of the cove base missing (where the floor met the wall) with underlying brick visible. Further observation revealed a significant accumulation of dust on a ceiling vent. The above information for the shower room was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on July 10, 2026, at 10:56 AM. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management

Based on clinical record review and resident and staff interview, it was determined that the facility failed to develop a comprehensive person-centered care plan regarding dementia care for two of two residents reviewed (Residents 8 and 10).Findings Include: Clinical record review for Resident 8 revealed they had an active diagnosis of unspecified dementia (decline in cognitive ability) , unspecified severity, with other behavioral disturbance that was initiated on November 29, 2022. Further review of Resident 8's clinical record revealed a care plan (an outline of an individual's health needs, specific care requirements, and the actions necessary to achieve desired health outcomes) focus area initiated for the resident's impaired cognitive function updated May 15, 2026. Interventions for the focus area only included general statements such as asking yes/no questions, present just one thought, idea, or question at a time, and to document/report changes in cognitive function. Resident 8's care plan did not include any individualized information or any individualized interventions specific to resident to manage the resident's cognitive loss to aid staff caring for the resident. The Nursing Home administrator and the Director of Nursing were made aware of the above findings during a meeting on July 10, 2026, at 11:10 AM. The Nursing Home administrator and the Director of Nursing were made aware of the above findings during a meeting on July 10, 2026, at 11:10 AM. Clinical record review for Resident 10 revealed an active diagnosis of dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety dated September 18, 2025. Further review of Residents 10's clinical record revealed a care plan focus initiated July 16, 2024, for the resident's impaired cognitive function. Interventions included only general statements such as asking yes/no questions, cue, reorient and supervise as needed, communicate with the resident and family regarding capabilities and needs, educate on the disease process, and to keep care consistent. There was no evidence to indicate any individualized interventions specific to the resident's history, approaches or care needs were indicated for the resident's cognitive loss to aid in the resident's care. The above information regarding Resident 10 was reviewed with the Nursing Home Administrator and Director of Nursing on July 10, 2026, at 12:35 PM. The facility failed to develop comprehensive person-centered care plans for Resident 8 and 10's dementia diagnosis. 483.21(b)(1)(c)(3) Comprehensive Care Plans 28 Pa. Code 211.10 (a)(c)(d) Resident care policies

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure a medication error rate of less than five percent (Residents 38 and 72).Findings include: The facility's medication error rate was 12 percent based on 25 medication opportunities with three medication errors. Observations on July 9, 2026, at 8:54 AM of Resident 38's medication administration revealed Employee 2, licensed practical nurse, administered 12.5 mg (milligrams) Movantik (a medicine used for constipation, also known as Naloxegol Oxalate) oral tablet. Further observation revealed that the blister pack (a pre-formed plastic packaging used to store pharmaceuticals) had a yellow sticker that indicated taking the medicine on an empty stomach. Concurrent interview with Employee 2 revealed that the residents in the hallway had already eaten breakfast. Review of facility documents indicate that meal delivery times for breakfast on Resident 38's unit is 7:25 AM. The medication reference Drugs.com instructions regarding the administration of Movantik noted, Take this medicine on an empty stomach, at least 1 hour before or 2 hours after your first meal of the day. During an interview with Employee 2 on July 10, 2026, at 10:32 AM, she stated that she never noticed the sticker before. Resident 38 did not receive the medication within the above defined parameters. The Nursing Home administrator and the Director of Nursing were made aware of the above concerns during a meeting on July 10, 2026, at 11:30 AM. Resident 72's current physician orders contained the following medication order: Potassium Chloride (a medication used to treat or prevent low potassium levels in the blood) Crys ER (oral extended release) 20 milliequivalents (MEQ); potassium chloride microencapsulated crystals extended release; give one tablet by mouth one time a day for hypokalemia (low potassium levels). Further review of Resident 72's physician orders revealed an order dated April 4, 2021, that crushable medications may be crushed, mixed, and administered together unless contraindicated. Observation of Resident 72's medication administration pass on July 9, 2026, at 9:18 AM revealed that Employee 3, licensed practical nurse (LPN), prepared the resident's medications prior to administration. Employee 3 proceeded to crush the tablets with a pill crushing device which included the Potassium Chloride ER tablet. Employee 3 then proceeded to place the medications in pudding and administer them to Resident 72. A follow-up interview with Employee 3 on July 9, 2026, at 11:10 AM confirmed that the LPN had crushed the resident's potassium. Review of the potassium administration pill pack for Resident 72 revealed a sticker on the medication card that indicated to not chew or crush before swallowing; may break or disintegrate in water, rinse down, do not chew particles. The above information for Resident 72 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on July 9, 2026, at 2:30 PM. The facility provided documentation titled, Drug Information, for Potassium Extended-Release Dispersible Tablet - Oral. The documentation noted a How To Use section that instructed (in part) to Do not crush, chew, or suck on the tablets. Doing so can release all of the drug at once, increasing the risk of side effects. A follow-up interview on July 10, 2026, at 11:00 AM with the Nursing Home Administration and Director of Nursing revealed that the Director of Nursing indicated that the potassium should not have been crushed. Further review of Resident 72's physician orders revealed an order for Breo Ellipta Aerosol Powder Breath Activated 100-25 micrograms (mcg) / inhalation (INH) Fluticasone Furoate - Vilanterol (a medication used to help reduce inflammation in the lungs and improve airflow); administer one puff inhale orally one time a day related to chronic obstructive pulmonary disease (COPD, a lung disease that causes inflammation and restricted air flow into and out of the lungs). Further observation of the medication pass for Resident 72 on July 9, 2026, at 9:40 AM revealed that Employee 3 administered an oral inhalation puff of the inhaler to the resident. Employee 3 did not instruct the resident to rinse their mouth after the medication use. The resident was then observed taking a drink and swallowing the liquid. A follow-up observation on July 9, 2026, at 11:10 AM revealed that the box for the Breo Ellipta revealed a yellow sticker affixed to the side that indicated to rinse mouth after each use. The manufacturer's instructions on the box also instructed to rinse mouth after each use. The above information for Resident 72 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on July 9, 2026, at 2:30 PM. The facility provided documentation titled, Drug Information, for the Breo Ellipta 100-25 mcg inhaler. The documentation noted a How To Use section that instructed (in part), To prevent dry mouth, hoarseness, and oral yeast infections from developing, gargle, rinse your mouth with water and spit out after each use. Do not swallow the rinse water. A follow-up interview on July 10, 2026, at 11:00 AM with the Nursing Home Administration and Director of Nursing revealed that the Director of Nursing indicated that the resident should have rinsed their mouth and spit out the rinse following medication administration of the Breo Ellipta. 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered medication parameters for two of 17 residents reviewed (Residents 32 and 51) and failed to provide comprehensive skin assessments that are consistent with professional standards of practice, to promptly identify skin changes and to promote healing for one of three residents reviewed for skin condition concerns (Resident 1). Findings include: Clinical record review for Resident 51 revealed a diagnosis list that included essential hypertension (high blood pressure). Review of Resident 51's current care plan revealed the resident has hypertension and an intervention included to give anti-hypertensive medications as ordered and monitor for side effects such as orthostatic hypotension (a sudden drop in blood pressure when a person stands up) and increased heart rate, and effectiveness. Resident 51's care plan also noted the resident has a potential for an altered cardiovascular status related to the medical history. A review of the current physician orders for Resident 51 revealed an order dated August 13, 2024, for Metoprolol Succinate ER Extended Release (a medication that is used to treat high blood pressure and/or heart rate) 25 milligrams (mg) give one tablet by mouth one time a day for essential hypertension. Hold for a systolic blood pressure (SBP, the top number of a blood pressure reading where the heart contracts) less than 100 and/or a heartrate less than 60. A review of the Medication Administration Record (MAR) for Resident 51 revealed that the Metoprolol was marked as administered outside of the physician specified parameters for the following: April 4, 2025: the resident's blood pressure was documented as 97/55. April 12, 2025: the blood pressure was documented as 97/61. April 14, 2025: the pulse was documented as 59. April 27, 2025: the blood pressure was documented as 93/51. May 7, 2025: the blood pressure was documented as 88/59. May 30, 2025: the blood pressure was documented as 82/47. June 10, 2025: the blood pressure was documented as 98/60. The above information for Resident 51 was reviewed in a meeting with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on June 26, 2025, at 11:00 AM. The NHA confirmed on June 27, 2025, at 9:35 AM that there was no documented evidence why the medication was administered outside of the physician ordered parameters. Clinical record review for Resident 32 revealed the following physician orders: On April 17, 2024, for staff to notify the physician if the blood sugar was less than 60 mg/dL (milligrams/deciliter) or greater than 400 mg/dL. On April 27, 2024, for staff to monitor their blood sugar before meals and at bedtime for diabetes (high blood sugar). Review of Resident 32's clinical documentation revealed the following: On May 3, 2025, at 8:00 PM 415 mg/dL. On May 6, 2025, at 5:00 PM 507 mg/dL. On May 6, 2025, at 8:00 PM 444 mg/dL. On May 8, 2025, at 12:30 PM 601 mg/dL. On May 8, 2025, at 5:00 PM 601 mg/dL. On May 8, 2025, at 5:00 PM staff documented NA (not applicable). On May 8, 2025, at 8:00 PM staff documented NA. On May 12, 2025, at 5:00 PM staff documented NA. On May 14, 2025, at 5:00 PM staff documented NA. On May 14, 2025, at 9:00 PM staff documented NA. On May 15, 2025, at 12:30 PM 539 mg/dL. On May 17, 2025, at 12:30 PM 586 mg/dL. On May 17, 2025, at 5:00 PM 541 mg/dL. On May 20, 2025, at 12:30 PM 493 mg/dL. On May 22, 2025, at 5:00 PM staff documented NA. On May 22, 2025, at 9:00 PM staff documented NA. On May 24, 2025, at 12:30 PM 439 mg/dL. On May 24, 2025, at 5:00 PM 400 mg/dL. On May 25, 2025, at 7:30 AM 405 mg/dL. On May 26, 2025, at 5:00 PM staff documented NA. On May 26, 2025, at 9:00 PM staff documented NA. On May 27, 2025, at 12:30 PM 485 mg/dL. On May 29, 2025, at 12:30 PM 500 mg/dL. On May 31, 2025, at 12:30 PM 537 mg/dL. On May 31, 2025, at 5:00 PM 592 mg/dL/. On May 31, 2025, at 8:00 PM 472 mg/dL. On June 1, 2025, at 11:30 AM 447 mg/dL. On June 3, 2025, at 12:30 PM 488 mg/dL. On June 5, 2025, at 5:00 AM 420 mg/dL. On June 5, 2025, at 12:30 PM 508 mg/dL. On June 7, 2025, at 12:30 PM 479 mg/dL. On June 12, 2025, at 12:30 PM 540 mg/dL. On June 14, 2025, at 12:30 PM 580 mg/dL. On June 14, 2025, at 5:00 PM 473 mg/dL. On June 15, 2025, at 11:30 AM 413 mg/dL. On June 17, 2025, at 12:30 PM 412 mg/dL. On June 19, 2025, at 12:30 PM 434 mg/dL. On June 19, 2025, at 5:00 PM 426 mg/dL. On June 20, 2025, 7:30 AM 559 mg/dL. On June 21, 2025, at 5:00 PM 406 mg/dL. On June 23, 2025, at 7:30 AM 525 mg/dL. On June 24, 2025, at 12:30 PM 478 mg/dL. The above information was reviewed during an interview on June 26, 2025, at 10:45 AM with the Nursing Home Administrator and Director of Nursing. There was no evidence that the facility notified the physician of the elevated blood sugars. Review of Resident 1's clinical record revealed a current physician's order initiated May 10, 2025, that indicated nursing staff were to use Medihoney (a wound gel that promotes healing and removes necrotic tissue) and border gauze to Resident 1's right glute (buttock) open area every day. There was no documented evidence to indicate that the facility completed a skin assessment to determine the status or measurement of Resident 1's open buttock area on May 10, 2025 or after. There was no documented evidence on Resident 1's Medication Administration Record (MAR, a form used to document the administration of medications) or Treatment Administration Record (TAR, a form used to document the administration of treatments) to indicate that the treatment ordered to her right buttock on May 10, 2025, was completed as ordered. The above findings for Resident 1 were reviewed during an interview with the Administrator of June 26, 2025, at 2:00 PM. 483.25 Quality of Care Previously Cited 5/3/2024 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered pain medications for one of three residents reviewed (Resident 32) Findings include: Review of Physiopedia's and Wikipedia's definition of the numeric pain rating scale (parameters) from zero to 10 indicated that no pain was identified as zero, mild pain was identified as one to three, moderate pain was identified as four to six, and severe pain was identified as seven to 10. Clinical record review for Resident 32 revealed physician's orders for the following pain medications: Ordered on May 3, 2025, and discontinued on May 6, 2025, Acetaminophen (Tylenol, for mild pain) 325 milligrams (mg) 2 tablets by mouth (PO) every 6 hours as needed (PRN) for pain (1-5). Ordered on May 5, 2025, and discontinued on May 12, 2025, Acetaminophen 325 mg 2 tablets PO every 4 hours PRN for pain (1-5). Ordered on May 12, 2025, Acetaminophen 325 mg 2 tablets PO every 6 hours PRN for mild pain. Review of Resident 32's MARs (medication administration record, a form to document medication administration) revealed the following: Staff administered the following PRN pain medications: Acetaminophen 325 mg 2 tablets PO every 6 hours PRN for pain (1-5). May 5, 2025, at 9:15 AM for a pain level of 9. Acetaminophen 325 mg 2 tablets PO every 4 hours PRN for pain (1-5). May 7, 2025, at 2:30 PM for a pain level of 8. May 8, 2025, at 4:33 AM for a pain level of 8. Acetaminophen 325 mg 2 tablets PO every 6 hours PRN for mild pain. May 22, 2025, at 4:32 AM for a pain level of 9. May 22, 2025, at 1:30 PM for a pain level of 8. May 25, 2025, at 12:10 PM for a pain level of 5. May 29, 2025, at 4:23 AM for a pain level of 7. May 31, 2025, at 4:38 AM for a pain level of 8. June 4, 2025, at 11:30 AM for a pain level of 8. June 8, 2025, at 11:30 AM for a pain level of 5. June 12, 2025, at 4:29 AM for a pain level of 8. June 18, 2025, at 1:50 PM for a pain level of 7. The surveyor reviewed the above information during an interview with the Nursing Home Administrator and Director of Nursing on June 26, 2025, at 10:45 AM. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to implement a comprehensive person-centered care plan regarding behaviors for one out of three residents reviewed for behaviors (Resident 54). Findings Include: Review of Resident 54's clinical record revealed that the facility admitted her on March 14, 2023. A Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated March 20, 2023, indicated that the facility assessed her as having behaviors, such as refusal of care and agitation. The facility implemented a plan of care to address Resident 54's behaviors on March 17, 2023. There was no documented evidence in Resident 54's plan of care regarding interventions for staff to utilize if Resident 54 exhibits those behaviors during care. Review of Resident 54's plan of care for behaviors dated June 1, 2023, revealed that the facility added additional exhibited behaviors such as slapping and being combative with staff. There was no documented evidence in Resident 54's plan of care regarding interventions for staff to utilize if Resident 54 exhibits those behaviors during care. Nursing documentation on January 28, 2025, at 12:08 PM revealed that Resident 54 bit a staff member during care, leaving bite marks. Nursing documentation dated March 13, 2025, at 9:21 PM revealed that Resident 54 was combative with staff during a shower. Nursing documentation dated April 1, 2025, at 12:44 AM revealed that it took four staff members to provide incontinence care to Resident 54. Resident 54 was kicking, spitting, and biting at staff. There was no documented evidence in Resident 54's plan of care to indicate that the facility implemented individualized interventions regarding her behaviors, since its inception upon admission. The findings for Resident 54 were reviewed during an interview with the Administrator and Director of Nursing on June 25, 2025, at 2:00 PM. 28 Pa. Code 211.10 (a)(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, observations, and staff interview, it was determined that the facility failed to implement preventative measures to prevent pressure ulcers for one of three residents reviewed for pressure ulcer concerns (Resident 67). Findings include: Clinical record review revealed the facility admitted Resident 67 on November 19, 2024. Review of Resident 67's admission assessment noted that she had no open areas on her feet. A nursing progress note date January 4, 2025, at 6:26 AM revealed that Resident 67's left heel had bleeding and bruising noted. New orders were received for skin prep (applied to the skin to create a film to protect the skin) to bilateral heels, and to elevate heels while in bed. Further clinical record review revealed a wound clinic note dated February 3, 2025, that indicated Resident 67 had a new left heel deep tissue injury (DTI, skin injury that occurs beneath the surface of the skin due to sustained pressure) with current measurements of 5.5 cm (centimeter) x 6.5 cm, 100% eschar. The note indicated to cleanse with Dakin's (an antimicrobial cleanser) 1.25%, then apply Dakin's-soaked fluffed gauze to the wound, cover with an ABD (abdominal gauze pads used to absorb discharges from draining wounds) pad, and change twice a day and as needed. Clinical record review of Resident 67's Braden scale (a scale used to predict pressure sore risk) dated December 3, 2024, revealed Resident 67 was assessed at a Braden score of 19 indicating that she was not at risk for pressure ulcer development. Further review revealed a Braden scale dated December 10, 2024, that indicated Resident 67 was assessed at a Braden score of 17, indicating she was at risk for pressure ulcer development. Review of Resident 67's care plan revealed a care plan entitled at risk for skin break down and pressure ulcer development, initiated on November 20, 2024, and last revised on November 24, 2024, revealed current interventions of a preventative mattress and turn and reposition as needed. Interview with the Nursing Home Administrator on June 27, 2025, at 10:10 AM revealed that the preventative mattress on Resident 67's bed was not a specialty mattress. Further review of Resident 67's care plan revealed that there were no new preventative pressure interventions initiated after her Braden scale assessment on December 10, 2024, that indicated her at-risk score decreased and she was at risk for pressure ulcer development. The facility failed to initiate preventative pressure ulcer interventions for Resident 67, after her Braden score assessment on December 10, 2024, determined she was as risk for pressure ulcer development, and she developed a DTI to her left heel on January 4, 2025. The Nursing Home Administrator and Director of Nursing were made aware of the above noted findings related to Resident 67's pressure ulcer on June 26, 2025, at 2:30 PM. 83.25(b)(1)(i)(ii) Treatment/svcs to Prevent/heal Pressure Ulcer Previously cited deficiency 5/3/24 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, clinical record review, and staff and resident interview, it was determined that the facility failed to implement a physician ordered device utilized to prevent further decline in range of motion for one of five residents reviewed (Residents 5). Findings include: Clinical record review for Resident 5 revealed a current physician's order for Restorative passive range of motion (PROM) to her left upper extremity and to place a carrot in the left hand after passive range of motion was complete. Observation of Resident 5 on June 24, 2025, at 12:20 PM revealed she was in bed. She acknowledged that she has limited motion on her left side to include her left hand. She did not have a carrot device in her left hand during this interaction. Review of documentation revealed that PROM was completed on this date. Observation of Resident 5 on June 26, 2025, at 11:40 AM revealed she was out of bed in her chair, and she did not have a carrot device in her left hand. Review of documentation revealed that PROM was completed on this date. Concurrent interview with Resident 5 revealed that the staff had not been putting anything in her left hand for about a week or so. Interview of the Nursing Home Administrator on June 27, 2025, at 10:35 AM revealed that the order for the carrot device for Resident 5's left hand did not get carried through in the clinical record for the nurse aides to complete. 483.25(c) Mobility Previously cited 5/3/24 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to thoroughly investigation a resident's accident in an attempt to prevent future incidents and implement interventions to prevent falls injuries for one of five residents reviewed for falls (Resident 3). Findings include: Clinical record review for Resident 3 revealed a physician's order dated February 25, 2025, for staff to implement a tab alarm (alarm that sounds when a person moves too far away from the alarm, releasing the magnetic catch, and causing the alarm to sound) when in bed or chair and to check for function and placement every shift for safety. Review of facility and nursing documentation revealed that Resident 3 fell on May 1, 2025, at 4:00 PM. Resident 3 was found in his room on his knees beside the bed. The fall was unwitnessed. Resident 3 was assisted back to bed with alarms on (after the fall occurred). Review of a staff witness statement dated May 1, 2025, revealed that staff heard Resident 3 shouting while walking past the resident's room. They saw Resident 3 on the floor, on the ground, while holding onto the corner of the bed to keep himself upright. Staff called for the licensed practical nurse who came to Resident 3's room and requested additional help to assist with Resident 3. The witness statement did not indicate that a tab alarm was placed on Resident 3, nor did the statement indicate that any alarms were sounding at the time of the fall. Review of Resident 3's task documentation revealed that on May 1, 2025, the day shift (6:00 AM to 2:00 PM) staff indicated that Resident 3's tab alarm was placed and functioning at 1:44 PM. On May 1, 2025, evening shift (2:00 PM to 10:00 PM) did not assess that Resident 3's tab alarm was placed and functioning until 9:58 PM, almost six hours after Resident 3's fall. There was no documentation at the time of the fall that Resident 3's tab alarm was on and functioning (sounding) and no documentation that evening staff checked for function and or placement until after Resident 3's fall. The surveyor reviewed this information during an interview with the Director of Nursing home on June 26, 2025, at 1:57 PM 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of select facility policies, clinical record review, observation, and staff interview, it was determined that the facility failed to implement physician ordered interventions for a resident's suicidal ideations for one of one resident reviewed (Resident 31). Findings include: Review of the facility policy entitled Resident Expressing Suicidal Ideations, last reviewed on January 23, 2025, revealed it is the policy of the facility to ensure the safety of any resident that expresses the desire to harm themself. Clinical record review revealed that the facility admitted Resident 31 on May 30, 2025, with diagnosis of anxiety (feeling of worry, nervousness, or unease), major depressive disorder (a disorder characterized by a depressed mood, loss of interest in activities causing significant disruption in daily life), and dementia with behavioral disturbances (confusion with other symptoms such as depression, anxiety, agitation, and aggression). Clinical record review revealed a physician's order dated June 25, 2025, that indicated Resident 31 was to be on suicide precautions for 48 hours. Staff were to remove sharp objects from her room, and she was to have a cordless call bell. Resident 31 indicated to staff that she was going to kill herself by ripping her veins out and then she started pinching at the veins in her arms. Observation of Resident 31 during a medication administration pass on June 26, 2025, at 9:07 AM revealed she had a corded call bell attached to her bed, while she was in bed. Observation of Resident 31 on June 26, 2025, at 11:15 AM revealed she was in bed with a corded call bell attached to her sheet next to her in bed. Interview with Employee 5, nurse aide, who was exiting Resident 31's room on June 26, 2025, at 11:20 AM revealed that Resident 31 had thrown her call bell on the floor several times and she had to keep putting it back on the bed. Interview with Employee 4, LPN (Licensed Practical Nurse) and 5, at 11:22 AM revealed that they both were aware that Resident 31 was on suicidal precautions and that she should not have a corded call bell. The Nursing Home Administrator and Director of Nursing were made aware of the concerns noted above related to Resident 31's suicide precautions. 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by one of 3 residents reviewed (Resident 67). Findings include: Clinical record review for Resident 67 revealed the facility admitted her on November 19, 2024, with a diagnosis including Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 67's current care plan entitled, Impaired cognitive function or impaired though processes related to dementia revealed that there was no indication that the facility had implemented an individualized person-centered care plan to address the resident's dementia and cognitive loss needs. The findings were reviewed with the Nursing Home Administrator and Director of Nursing on June 27, 2025, at 12:10 PM. 483.40(b)(3) Dementia Treatment and Services Previously cited 05/03/24 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered medications for five of five residents (Residents 1, 2, 3, 4, and 5) and provide incontinence care for one of five residents reviewed (Resident 1). Findings include: Clinical record review for Resident 1 revealed physician orders for staff to administer the following medications: Metoprolol Tartrate 25 mg (milligrams) by mouth (PO) twice daily (BID) for hypertension (high blood pressure) Gabapentin 100 mg PO three times daily (TID) for venous insufficiency Hydralazine 25 mg PO TID for hypertension Lasix 60 mg PO in the morning for edema Escitalopram Oxalate 10 mg PO daily (QD) for major depression Aspirin EC Delayed Release 325 mg PO QD for cerebral infarction (stroke) Allopurinol 300 mg PO QD for gout Pramipexole Dihydrochloride 0.25 mg PO QD for restless legs Vitamin D3 25 mcg 5 tablets in the morning for vitamin deficiency Alphagan P Ophthalmic Solution 0.15% 1 drop bilateral (b/l) eyes BID for glaucoma Fluticasone Propionate 50 mcg/act 1 spray both nostrils (nose) BID Review of Resident 1's September 2024 MAR (medication administration record, a form to document medication administration) revealed that there was no documentation that staff administered their medications on September 8, 2024, for the 6:00 AM and 8:00 AM administration times. Clinical record review for Resident 2 revealed physician orders for staff to administer the following medications: Clearlax powder 17 grams/scoop 17 grams PO in the morning for constipation Cranberry tablet 450 mg PO in the morning related to urinary incontinence Divalproax Sodium delayed release 500 mg 3 tablets in the morning for mood disorder Loratidine 10 mg PO QD for allergic rhinitis Omeprazole 20 mg PO QD for indigestion Metformin HCL 1000 mg BID for Diabetes with meals Acetaminophen 325 mg 4 tablets PO TID for compression vertebra fracture Repaglinide 1 mg PO before meals for Diabetes Artificial Tears 1% 1 drop in right eye four times daily (QID) for severe dry eyes Barrier cream to groin TID and as needed (PRN) with brief changes for irritation to groin Review of Resident 2's September 2024 MAR revealed that there was no documentation that staff administered their medications on September 8, 2024, for the 6:00 AM. 7:30 AM, and 8:00 AM administration times. Clinical record review for Resident 3 revealed physician orders for staff to administer the following medications: Finasteride 5 mg Po QD related to benign prostate hyperplasia (BPH, prostate enlargement) Omeprazole 20 mg PO QD related to reflux Prozac 10 mg PO QD for major depression Tamsulosin HCL 0.4 mg PO QD for BPH Zonisamide 100 mg 4 capsules PO QD for epilepsy (seizures) Keppra 100 mg/ml 15 mg PO BID for epilepsy Miralax 17 grams PO BID for constipation Phenobarbital 97.2 mg 0.5 tablet PO BID for epilepsy Senna S 8.6-50 mg 2 tablets PO BID for constipation Ursodiol 300 mg PO BID for retained cholelithiasis (gallstones in the abdomen after surgery) Review of Resident 3's September 2024 MAR revealed that there was no documentation that staff administered their medications on September 8, 2024, for the 10:00 AM administration time. Clinical record review for Resident 4 revealed physician orders for staff to administer the following medications: Aspirin 81 mg PO QD for peripheral vascular disease (PVD) Calcium and Vitamin D3 600-100 mg-mcg PO in the morning as a supplement Clopidogrel 75 mg PO QD for PVD Multivitamin 1 tablet PO QD as a supplement Polyethylene powder 17 gram PO in the morning for constipation Potassium Chloride ER 10 mEq (milliequivalent) PO in the morning for low potassium Senna-S 8.6-50 mg PO QD for constipation House supplement 4 ounces TID between meals as a supplement Review of Resident 4's September 2024 MAR revealed that there was no documentation that staff administered their medications on September 8, 2024, for the 10:00 AM administration time. Clinical record review for Resident 5 revealed physician orders for staff to administer the following medications: Cholestyramine Light powder 4 grams PO BID with meals Levetiracetam 100 mg/ml (milliliter) 5 ml PO BID for encephalopathy (brain disfunction) Lorazepam 0.5 mg BID for anxiety Omeprazole 20 mg 2 capsule PO BID for reflux Prednisone 5 mg PO BID for encephalopathy Pyridostigmine Bromide 60 mg PO TID for myasthenia gravis (autoimmune muscle weakness) Sucralfate 1 gram PO QID for gastrointestinal bleed Review of Resident 5's September 2024 MAR revealed that there was no documentation that staff administered their medications on September 8, 2024, for the 6:00 AM, 8:00 AM, and 10:00 AM administration times. Clinical record review for Resident 1 revealed that staff completed an MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) on August 3, 2024. Staff indicated that Resident 1 was cognitively intact, frequently incontinent of bladder, was able to transfer to and from the toilet with supervision/touch assistance but required substantial/maximum assistance with toileting abilities to maintain perineal (groin) hygiene and adjust clothes before and after voiding. Review of Resident 1's September and October 2024, task intervention documentation (an action intended to improve the resident's health and comfort) regarding toileting revealed that staff were to provide toileting every two hours. Staff documented that Resident 1 usually accepted toileting utilizing limited assistance of one staff person. Review of October 5, 2024, and October 6, 2024, toileting documentation revealed that staff documented the following: Toileting refusals- October 5, 2024, at 2:00 AM, 12:00 PM, 2:00 PM, and 6:00 PM October 6, 2024, at 2:00 AM, 6:00 AM, 08:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, and 6:00 PM Staff documented that toileting Resident 1 was not applicable on October 5, 2024, at 6:00 AM and 8:00 AM. There was no documentation that indicated nurse aide staff notified their charge nurses regarding Resident 1's frequent toileting refusals. Interview with Resident 1 on October 9, 2024, at 10:50 AM revealed that they did not have any concerns with staff or the care that they provided, however, she indicated that when staff call off it takes longer for staff to respond to her call bell and care needs. Review of facility staff scheduling revealed that on October 5, 2024, only three nurse aides worked during day shift and only 2.88 nurse aides worked during the evening shift for a census of 64 residents. The facility provided an average of 2.73 hours of direct nursing care to residents on October 5, 2024. On October 6, 2024, only 3.63 nurse aides worked during the day shift, 2.5 nurse aide worked during the evening shift, and three nurse aides during the overnight shift for a census of 64 residents. The facility provided an average of 2.45 hours of direct nursing care to residents on October 6, 2024. The facility did not provide sufficient staff to provide direct nursing care and services to residents. The surveyor reviewed the above information during an interview on October 9, 2024, at 2:15 PM with the Nursing Home Administrator. 483.25 Quality of Care Previously cited 5/3/24 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services

Based on clinical record review and staff interview it was determined that the facility failed to obtain dental care for one of six residents reviewed for dental concerns (Resident 1). Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE]. A review of the diagnoses list for Resident 1 included the following: severe intellectual disabilities, a mixed receptive-expressive language disorder, and the need for assistance with personal care. Review of the current physician orders for Resident 1 included the following: Dental as needed and nothing by mouth, both dated February 26, 2024. Review of the current Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) for Resident 1 dated April 6, 2024, revealed that the resident is rarely/never understood and is dependent on staff for personal hygiene. An admission MDS for Resident 1 dated March 4, 2024, revealed that the staff assessed the resident has having obvious or likely cavity or broken natural teeth. Nursing documentation for Resident 1 dated March 4, 2024, at 9:15 AM revealed the resident has her own teeth with some missing and some cavity like areas. Nursing documentation for Resident 1 dated June 4, 2024, at 6:42 AM revealed the resident has natural teeth with some missing and some cavity like areas. Observation of Resident 1 on June 18, 2024, at 11:30 AM with the Director of Nursing (DON) revealed that the resident had natural teeth. There were some teeth missing. The gums appeared erythematous (reddened) in a thin line just above the front teeth on at least two of the teeth in the upper jaw. The teeth were discolored. The exam was limited based on resident movement. Further clinical record review for Resident 1 revealed no evidence that the facility offered the resident's responsible party routine dental services since admission or addressed the concerns related to the nursing documentation and MDS that assessed the resident's teeth as some missing and some cavity like areas. An interview with the DON on June 18, 2024, at 1:03 PM revealed that the resident is on the dental list for an upcoming appointment in July 2024. However, the facility had no further documentation to indicate the resident's responsible party was offered or refused dental services. The DON further noted the dental provider comes to the facility every three months and was last here in March 2024. The resident was not seen at that time per the DON. A review of the facility documentation for upcoming appointments revealed that the resident was added by the facility to the July 2024 appointment list on June 18, 2024, after being discussed with the surveyor. An interview with the Nursing Home Administrator (NHA) on June 18, 2024, at 3:01 PM confirmed that there was no evidence to indicate the Resident 10's responsible party was offered any routine or emergency dental services or refused the services. The NHA further noted at the time of the interview that there was no evidence in Resident 10's admission packet to indicate any dental services were discussed, offered, or refused by Resident 10's responsible party. The facility failed to offer, provide, or obtain routine dental services to meet the needs of Resident 10. The above information was reviewed in a meeting with the NHA and DON on June 18, 2024, at 3:36 PM. 28 Pa. Code 211.12(d)(3) Nursing services

Based on observation, clinical record review, review of facility documents, and resident 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 related to a sustained fracture on one of two nursing units, (Unit 100-300, Resident 33). This deficiency is cited as past noncompliance Findings include: Observation and interview with Resident 33 on May 1, 2024, at 9:49 AM revealed the resident was in bed. Resident 33 stated one person gave her a couple fractures and stated, She tried to get me into bed, she didn't use the lift. Resident 33 stated she hurt after that, and it was her fault, referencing the staff member. Resident 33 said her knee was broken. Clinical review for Resident 33 revealed an active physician's order dated November 8, 2023, for the resident to use a full mechanical lift as her transfer status. Review of Resident 33's plan of care revealed the resident requires a mechanical lift with two staff assistance for transfers initiated on the plan of care on October 13, 2022. A nursing note dated March 24, 2024, at 2:24 PM noted the resident began complaining of left knee pain that hurt after being bumped during transfer the day before. The note indicated there was no concern or swelling noted of the knee. An x-ray of Resident 33's left knee completed on March 25, 2024, revealed the resident had an acute fracture of the left lateral tibial plateau. The facility initiated an investigation on March 26, 2024, into Resident 33's acute knee fracture and upon resident interview dated March 26, 2024, the resident stated a staff member got her out of bed by herself and twisted her knee while lifting her. Review of staff statements obtained by the facility revealed the resident had mentioned several different staff members as individuals who transferred her independently. Based on a staff statement from Employee 15 (resident assistant) dated March 26, 2024, revealed that Employee 16 (nurse aide) was witnessed getting Resident 33 out of bed by just picking her up and putting her in the wheelchair to got to the dining area on March 23, 2024. Review of a telephone interview documented by facility staff dated March 26, 2024, with Employee 16 indicated the nurse aide indicated she did get Resident 33 out of bed, but indicated she used the Hoyer lift by herself to get the resident out of bed and indicated she knew two people were to be used with the lift. Employee 16 stated the resident did not express pain during the transfer but did hear a pop when she rolled her in bed when lunch was over. A review information submitted by the facility on March 28, 2024, indicated the facility had completed an investigation into Resident 33's reported knee pain and allegation of only being transferred with one person, and sustaining a fracture. The facility interviewed all staff working in the time frame surrounding the incident and determined Employee 16 did not follow Resident 33's plan of care regarding the mechanical lift for transfers with two people, and Employee 16 admitted there was not a second person present. Employee 16 was terminated from the facility on March 26, 2024. The facility provided staff education on using the correct transfer status when providing residents with care and transfers on March 26, 2024. Review of a facility implemented plan of correction, signed by facility administration during an Ad Hoc quality assurance (QA) meeting on March 26, 2024, revealed that the facility implemented the following: Random audits of transfers will be completed by the director of clinical services or their designee. The results will be reported at the April 18, 2024, QAPI meeting. Review of the audits dated March 26 and 27, 2024, revealed that staff were appropriately transferring residents utilizing the required staff. Review of the QAPI meeting dated April 25, 2024, revealed that the transfer audits were reviewed with no trends noted. Random audits on each shift will continue for another month. These results will be reviewed at the May QAPI meeting for further recommendation. The Ad Hoc meeting also indicated that staff continue to be educated on proper transfer status at orientation and as needed. The above findings were confirmed with the Nursing Home Administrator and Director of Nursing on May 3, 2024, at 11:30 AM. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights

Based on review of select facility policies and procedures, observation, clinical record review, and resident and staff interview, it was determined that the facility failed to implement appropriate enhanced barrier transmission-based precautions on two of two nursing units (400, and 100/200/300 nursing unit; Residents 65, 74, 231, and 232). Findings include: Review of the memo entitled Enhanced Barrier Precautions (EBP, gown and glove use) in Nursing Homes to Prevent the Spread of Multi-drug Resistant Organisms released by the Center for Medicaid and Medicare Services (CMS) on March 20, 2024, with an implementation date of April 1, 2024, revealed that nursing care facilities are to use EBP for residents with chronic wounds or indwelling medical devices (i.e., indwelling urinary catheters) during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care. Review of the CDC (Centers for Disease Control) informational poster entitled, Enhanced Barrier Precautions (EBP) Steps, revealed that the last step is to dispose of the gown and gloves in the room. An observation of Resident 65 on April 30, 2024, at 12:20 PM revealed the resident was in his room sitting in a wheelchair with a catheter in place. There was no evidence of any enhanced barrier precautions sign prior to or upon entering the resident room or additional personal protective equipment (PPE) such as gowns, in or around the room to care for the resident. Clinical record review for Resident 65 revealed a physician's order for the resident to have a foley catheter since the resident's admission to the facility on [DATE]. In a follow up observation and interview with Resident 65 on April 30, 2024, at 1:18 PM Resident 65 stated he has had a catheter since January, and the staff do not wear gowns when caring for him, just normal clothes. Further observation on May 1, 2024, at 9:22 AM and May 2, 2024, at 11:40 AM of Resident 65 revealed the resident still did not have any evidence of EBP in place (signage or additional PPE available in or near the room). In a concurrent interview on May 2, 2024, of a nurse aide (Employee 14) working in Resident 65's hallway, the nurse aide stated other than gloves, no additional PPE was needed to care for Resident 65. When asked if anything extra was needed besides the gloves due to the resident having a catheter, the nurse aide stated, she was not sure as some residents with catheters have signs and PPE bins in their room, but others do not. The nurse aide then stated when there is a sign for additional precautions, she follows the precautions listed, and since Resident 65 did not have a sign, she would not need to utilize additional PPE other than the gloves. The nurse aide confirmed Resident 65 has had a catheter and no EBP were implemented for the resident. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on May 2, 2024, at 2:30 PM. The facility policy entitled, Enhanced Barrier Precautions, last reviewed without changes on March 29, 2024, revealed that signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. PPE is available outside of the resident rooms. Observation of Resident 231 on April 30, 2024, at 3:48 PM revealed she was in bed with her foot wrapped in white gauze. Observation of the gauze revealed two small circular areas of orange discoloration. Resident 231 stated that she was not sure if the areas were indicative of wound drainage or the color of the betadine (liquid antiseptic and disinfectant used for the treatment and prevention of infections in wounds and cuts) treatment used on her wounds. Observation of Resident 231's room revealed no evidence that the facility implemented EBP for her. Observation Resident 231's room on May 2, 2024, at 11:50 AM revealed no evidence of EBP measures. Interview with Resident 232 on April 30, 2024, at 2:23 PM revealed that she recently had brain surgery and had wounds on her head. Resident 232 removed a crocheted cap, which resulted in a gauze wrap falling from her head and exposing gauze stuck to an area of the right side of her head. Observation of Resident 232's room revealed no evidence that the facility implemented EBP for her. Observation of Resident 232's room on May 2, 2024, at 11:50 AM revealed no evidence of EBP measures. Interview with Employee 7 (licensed practical nurse, LPN) on May 2, 2024, at 11:55 AM confirmed that Residents 231 and 232 have wounds; however, neither resident have EBP measures in place. Observation of Resident 74's room on April 30, 2024, at 1:35 PM revealed an enhanced barrier precautions sign on the door and a plastic bin of PPE outside the door. Clinical record review for Resident 74 revealed a physician's order dated April 9, 2024, for staff to implement enhanced barrier precautions. Observation of Resident 74's room on May 1, 2024, at 1:40 PM revealed a sign indicating that EBP were required to enter and/or provide care to Resident 74. Observation of an administration of an intravenous medication for Resident 74 on May 1, 2024, at 1:40 PM revealed Employee 7 used hand sanitizer and donned an isolation gown and gloves to begin the medication administration via Resident 74's PICC line (PICC, long, thin, tube that is inserted through a vein in the arm and passed through to a larger vein near the heart. The line requires careful care and monitoring for complications including bleeding, infection, and blood clots.). Continued observation of Resident 74's treatment on May 1, 2024, at 1:46 PM revealed Employee 7 left Resident 74's room to the hallway outside his door to remove her isolation gown and gloves. Employee 7 held the isolation gown as a ball in her hands, walked to the other hallway on the nursing unit to the soiled utility room, used her hands to open the secured soiled utility room door, and discarded the isolation gown. Employee 7 confirmed that there were no receptacles in Resident 74's room or in the hallway to put the reusable isolation gown when removed. Employee 7 performed hand hygiene after disposing of the gown. The surveyor reviewed the above findings regarding Residents 231, 232, and 74 during an interview with the Nursing Home Administrator and the Director of Nursing on May 2, 2024, at 1:45 PM. 28 Pa. Code 201.18(b)(3)(d)(e)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, review of select policies and procedures, and staff interview, it was determined that the facility failed to secure medications and biologicals on one of two nursing units (One, Two, Three Hall nursing unit). Findings include: Review of the policy entitled Storage and Expiration of Medications, Biologicals, Syringes, and Needles, last reviewed on March 29, 2024, indicates that the facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or in a medication room that is inaccessible by residents and visitors. The policy indicates that the facility should ensure that medications and biologicals are stored at appropriate recommended temperatures. Observation of the One, Two, Three hall nursing unit on April 30, 2024, at 9:45 AM revealed medications laying on the counter to include Zofran (anti-nausea medication), Celexa (treats major depression), Buspar (treats anxiety), Incruse Ellipta inhaler (used to treat chronic lung conditions), and a bottle of liquid Keppra (used to treat seizures). The medications were available to non-licensed staff, visitors, and residents. Interview with the Director of Nursing on April 30, 2024, at 9:50 AM confirmed the above observations. Observation of the One, Two, Three hall nursing unit on May 2, 2024, at 12:45 PM revealed an unlocked room containing an unlocked treatment cart. Medications available to non-licensed staff, residents, and visitors included Lidocaine cream (used for pain), Diclofenac Sodium (used for pain), Hydrocortisone cream (topical steroid), Nystatin powder (used to treat fungal infections), Triamcinolone (treats skin conditions), Ketoconazole shampoo (an anti-fungal), and a combination cream containing Silvadene, Zinc, and Nystatin (used to treat skin conditions). Two of the creams had labels that indicated the facility should be storing them in the refrigerator. Interview with Employee 8, Licensed Practical Nurse, on May 2, 2024, at 12:50 PM confirmed the above findings and indicated that the treatment cart should have been locked, and that medications requiring refrigeration should have been in the refrigerator. 28 Pa. Code 211.9 (k) Pharmacy services 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on clinical record review, review of facility documents, and resident, family member, and staff interview, it was determined that the facility failed to have sufficient nursing staff to meet resident's needs for four of 24 residents reviewed (Resident 28, 33, 52, and 64). Findings include: A review of a facility complaint/grievance form dated March 6, 2024, noted a resident concern regarding call bell response times. The investigation to the concern was noted as completed on March 25, 2024, by a registered nurse, and indicated, Call bell response times have increased due to staffing shortages, response times are monitored and while it is found to have increased response time, it is not because staff are choosing to not respond it is simply because that are extremely busy. The concern form had not yet been noted as resolved as of May 3, 2024. Facility nurse staffing was reviewed for the week of March 22 - March 28, 2024, which included the March 25, 2024, date the grievance investigation was completed and reflected the facility had an average staffing of 2.66 hours per patient day, below the state minimum of 2.87. The facility only met the minimum one day during the week and fell below on the dates indicated below: March 22, 2024, 2.48 March 23, 2024, 2.64 March 24, 2024, 2.74 March 25, 2024, 2.53 March 26, 2024, 2.78 March 28, 2024, 2.38 In an interview with Resident 13, on April 30, 2024, at 11:40 AM the resident indicated she will often wait when she rings her call bell for care to be completed but was patient and understood because the facility was short staffed, and the staff are really busy. Resident 13 did not wish to provide specifics on call bell wait times. In an interview with Resident 33 on May 1, 2024, at 9:52 AM the resident stated she is to get showered on Tuesdays and Fridays, during the day, and doesn't refuse them, but stated she had a fracture and, that's maybe why she wasn't getting them. Clinical record review for Resident 33 did reveal the resident had sustained a fracture in her leg in March 2024, and was scheduled to receive showers on Tuesdays and Fridays on the 2-10:00 PM shift and as needed. A review of Resident 33's bathing records for April 2024, revealed the resident was totally dependent on staff for bathing, and did receive a shower on April 2 and April 9, 2024, on her scheduled shower days after her fracture, but had only received a bed bath on April 5, 23, and 26; a partial bed bath on April 19 and 30; and April 16 was noted as response not required. There was no evidence Resident 33 could not receive a shower due to her fracture nor any documented showers on an as needed basis outside of her scheduled shower days. In a follow up interview with Resident 33 on May 3, 2024, at 10:45 AM regarding only receiving a partial bed bath on April 30, 2024, the resident stated she could not get a shower because there was only one. When the resident was asked one what? the resident stated, one girl, referencing the staff. Interview with Resident 28 on April 30, 2024, at 11:34 AM revealed that the facility is short-staffed. He stated it could take a long time for staff to respond to his call bell due to not having enough staff. Resident 28 stated that he has waited for 30 to 45 minutes for the staff to take him to the bathroom. A review of facility staffing for the resident's scheduled shower day of April 30, 2024, revealed the facility did not meet state minimum requirement for nurse staffing for the day as follows: Dayshift: 5.0 nurse aides, required 6.58. 2.0 licensed practical nurses, required 3.16. Evening shift: 1.5 nurse aides, required 6.58. The facility's nursing hours per patient day for April 30, 2024, was 2.13 below the state minimum of 2.87. Interview with Resident 52 on April 30, 2024, at 12:06 PM revealed that she is not getting her showers. Resident 52 indicated it might be because the facility never has enough staff. Interview with Resident 64's responsible part on April 30, 2024, at 12:45 PM revealed that his mother has to wait a long time for call bells because they don't have enough staff. Interview with the Director of Nursing on May 2, 2024, at 10:50 AM revealed that the facility accepted a new admission on May 1, 2024, despite not being able to meet the minimum number of staff required for the current census. The above concerns regarding grievance response and resident care completion with staffing was reviewed with the Nursing Home Administrator and Director of Nursing on May 3, 2024, at 11:38 AM. Refer to 677 28 Pa. Code 201.18(e)(1)(6) Management 28 Pa. Code 211.12(d)(1)(3)(4)(5) (f)(f.1)(2)(3)(4) (i)(1) Nursing services

Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide bathing assistance for a resident dependent on staff assistance for five of seven residents reviewed for activities of daily living (Residents 33, 39, 47, 52, and 63). Findings include: Interview with Resident 33 on May 1, 2024, at 9:52 AM revealed she is to get showered on Tuesdays and Fridays, during the day, and she doesn't refuse them, but stated she had a fracture and maybe that's why she wasn't getting them. Clinical record review for Resident 33 did reveal the resident had sustained a fracture in her leg in March 2024, and was scheduled to receive showers on Tuesdays and Fridays on the 2-10:00 PM shift and as needed. A review of Resident 33's bathing records for April 2024, revealed the resident was totally dependent on staff for bathing, and did receive a shower on April 2 and April 9, 2024, on her scheduled shower days after her fracture, but had only received a bed bath on April 5, 23, and 26; a partial bed bath on April 19 and 30; and April 16 was noted as response not required. There was no evidence Resident 33 could not receive a shower due to her fracture nor any documented showers on an as needed basis outside of her scheduled shower days. In a follow up interview with Resident 33 on May 3, 2024, at 10:45 AM regarding only receiving a partial bed bath on April 30, 2024, the resident stated she could not get a shower because there was only one. When the resident was asked one what? the resident stated, one girl, referencing the staff. Resident 33 again stated she would not refuse to be showered per her preference. There was no evidence Resident 33 received a shower since April 9, 2024. The above concerns regarding Resident 33's bathing being completed per the resident's bathing preference were reviewed with the Nursing Home Administrator and Director of Nursing on May 3, 2024, at 11:38 AM. Review of Resident 47's clinical record revealed a Minimum Data Set Assessment (MDS, an assessment tool completed at specific intervals to determine care needs) dated October 12, 2023, that the facility assessed her as being dependent on staff assistance for bathing. An MDS dated [DATE], determined that it was very important for Resident 47 to be able to decide on whether she gets a bed bath or shower. Review of Resident 47's bathing documentation dated April 2024, revealed that she has not received a shower since April 9, 2024. There was no documented evidence in Resident 47's clinical record to indicate that the facility determined her preferences for bathing. Review of Resident 52's clinical record revealed an MDS dated [DATE], that indicated the facility determined she was dependent on staff assistance for bathing. An MDS dated [DATE], determined that it was very important for Resident 52 to be able to decide on whether she gets a bed bath or shower. Interview with Resident 52 on April 30, 2024, at 12:00 PM revealed that she is not getting her showers like she is supposed to. Resident 52 indicated that she is supposed to get a shower two times a week. Review of Resident 52's bathing documentation dated April 2024, revealed that she has not received a shower since April 18, 2024. Review of Resident 63's clinical record revealed an MDS assessment dated [DATE], that indicated the facility assessed him as being dependent on staff assistance for bathing. Review of Resident 63's bathing documentation dated April 2024, revealed that he has not received a shower since April 9, 2024. Resident 63 has only received partial bathing since April 16, 2024. There was no documented evidence in Resident 63's clinical record to indicate his preferences regarding receiving a bed bath or a shower. Interview with the Administrator and Director of Nursing on May 2, 2024, at 1:45 PM acknowledged the above findings for Residents 47, 52, and 63, and confirmed that the facility has not obtained any resident preferences for bathing. Review of Resident 39's clinical record revealed his most recent quarterly MDS dated [DATE], revealed that the facility assessed him as being dependent on staff assistance for bathing. Resident 39 was unable to be interviewed due to his current cognitive status. A review of Resident 39's task documentation (ADL, activities of daily living charting) revealed he preferred to receive a shower/bath/bed bath two times a week on the second shift. A review of Resident 39's task documentation revealed that he only received one shower in the last month, he received eight partial, or bed baths. There was no documented evidence in Resident 39's clinical record to indicate his preferences regarding the type of shower, tub bath, or bed bath he preferred to receive. Interview with the Administrator and Director of Nursing on May 2, 2024, at 1:45 PM acknowledged the above findings for Resident 39 and confirmed that the facility has not obtained any resident preferences for bathing. Refer to F725. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to establish clear and consistent resident's wishes regarding advance directives (written instruction, such as a living will or durable power of attorney, relating to the provision of healthcare, for a time when a resident may be incapacitated and not able to make decisions) for one of one resident reviewed (Resident 16). Findings include: Review of Resident 16's clinical record revealed that the facility admitted her on February 26, 2024. A physician's order dated February 26, 2024, indicated that Resident 16 was to be a full code, which would include CPR (cardiopulmonary resuscitation). Review of 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) form signed by Resident 16's responsible party on [DATE], indicated that she wished for Resident 16 to be a DNR (Do Not Resuscitate, not to perform cardiopulmonary resuscitation if breathing stops). Resident 16 continued to have both a full code physician order and a DNR on her paper POLST until [DATE], when the surveyor brought it to the attention of the facility. Interview with the Administrator and Director of Nursing on [DATE], at 2:00 PM confirmed the above findings for Resident 16. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.29(a) Resident rights

Based on observation, clinical record review, resident interview and staff interview, it was determined that the facility failed to ensure one of 15 residents was free of accident hazards, resulting in actual harm to Resident 6. Findings include: Review of the clinical record for Resident 6 revealed [DIAGNOSES REDACTED]. Review of Resident 6's annual Minimum Data Set assessment (MDS- assessment of resident care needs) dated February 23, 2016, revealed that Resident 6's Brief Interview for Mental Status to assess the resident's cognitive status was 15 out of 15 (highest measure of cognitive status). Review of the clinical record for Resident 6 revealed nursing notes dated for March 13, 2016, which revealed the entry, Also during supper Resident (6) claimed that he wasn't eating his pasta salad because there was something in it. We looked and there was a lancet (a small medical implement with a small blade or needle used to make punctures, such as a fingerstick, to obtain small blood specimens) in his bowl. The nurse aide (NA 4) gave Resident 6 his tray and did not see anything in the bowl at that time, that she gave him his tray. Review of the, Concern form, documenting a facility investigation in regards to the above noted incident, completed by Social Services (SW) 1 as taken from an interview with Resident 6 revealed, found glucometer lancet in pasta salad and bit down on it. Lancet was a used lancet as it was pushed down. States he (Resident 6) used his fork to eat pasta salad. He states he scooped it up with his fork and put it in his mouth and bit down on it and hurt the right bottom tooth. Review of the, Concern form investigation for this incident revealed a witness statement by Licensed Practical Nurse (LPN) 4 which revealed I (LPN 4) tested (Resident 6's) blood sugar at 5:00 p.m., at the back window in the dining room of the 400 hall. I took all of my equipment that I used for the blood sugars and disposed of it in the sharps container (a container that is filled with used medical needles). Review of Resident 6's Medication Administration Record (MAR) for the month of March 2016, revealed that Novolog Insulin (a medication used to treat Diabetes Mellitus) 26 units subcutaneously (underneath the skin) with supper was administered on March 13, 2016, to Resident 6's right abdominal area at approximately 4:30 p.m. The same MAR revealed that an Accucheck was completed to determine Resident 6's blood sugar level at approximately 4:00 p.m. In an interview with Resident 6 on March 24, 2016 at approximately 10:10 a.m., Resident 6 was asked to describe the typical routine that would be used for how his dinner time Accuchecks and insulin administration were completed. Resident 6 revealed that these are done in the dining room during the dinner meal and that the nurse checks his blood sugar with the lancet, lays the used supplies including the lancet on the dining table, gives him his insulin in his abdomen, and then takes all the used supplies and puts in a bin on the medication cart. Further interview with Resident 6 on March 24, 2016 at approximately 10:10 a.m., Resident 6 revealed that he had, no idea where the lancet might have come from. Review of a, Request for Consultation form for Resident 6 completed by the facility's physician requesting a dental consult, revealed that it was determined by the dentist that Resident 6 required a replacement filling (completed March 21, 2016) as a result of a broken tooth. Review of the completed, Incident Investigation related to Resident 6 biting down on the lancet on March 13, 2016, revealed that the facility was unable to determine how the lancet ended up in Resident 6's pasta salad bowl. 28 Pa. Code 201.18(b)(1) Management. Previously cited 2/26/15, 3/27/14. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 3/27/14. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 8/18/14, 6/3/14, 3/27/14.