Every finding on record at Logan Square Rehabilitation and Healthcare Center

Based on clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure that toileting hygiene and assistance was provided for two of six residents reviewed (Resident R2 and R3). Findings include:Interview on July 7, 2026, at 9:47 a.m. Resident R2 stated that toileting assistance is not provided timely, leading to prolonged sitting in soiled briefs and that staff will put two briefs on at a time (one brief inside of another). Resident R2 continued that he/she needs staff to change his/her briefs because he/she is unable to do it. Review of Resident R2's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated June 8, 2026, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including cancer, muscle weakness and difficulty in walking. Continued review revealed that the resident scored 15 on a BIMS (Brief Interview for Mental Status) assessment, indicative that the resident was cognitively intact. Further review revealed that the resident was dependent for toileting hygiene and always incontinent of bowel and bladder. Review of Resident R2's care plan, dated June 2, 2026, revealed that the resident had bowel and urinary incontinence related to generalized weakness. Interventions include to check the resident every two hours and provide incontinence care, apply moisture barrier cream and provide the appropriate size and type of incontinence product. Review of Resident R2's nurse aide documentation revealed that staff will document toiling hygiene provided every shift. Review of documentation from June 8 through July 6, 2026, revealed that toileting hygiene was marked as not applicable June 12, 21, and July 2, 2026, on the day shifts; June 20, 24, 25, 27, 28, 29, July 2, 3, 4, 5, and 6, 2026, on the evening shifts and June 11, 17, 18, 19, and July 1, 2026, on the overnight shifts. Continued review revealed no evidence that toileting hygiene was provided to Resident R2 on June 21, 2026, on the evening and overnight shifts; and June 12, 25, 27, 28, 29, July 3, 4, 5, and 6, 2026, on the overnight shifts. Review of Resident R2's nurse aide documentation revealed that staff will document preventative skin care with moisture barrier provided every shift. Review of documentation from June 8 through July 6, 2026, revealed that care was not provided during the day shift on June 10, 12, 15, 19, 24, and July 1, 2026; during the evening shift on June 9, 14, 15, and 24, 2026; and during the overnight shift on June 19, 20, 22, 23, and 24, 2026. Continued review revealed no evidence that preventative skin care with moisture barrier was provided to Resident R2 on June 21, 2026, during the evening shift; and on June 12, 21, 25, 27, 28, 29, July 3, 4, 5 and 6, 2026, during the overnight shift. Interview on July 7, 2026, at 12:22 p.m. Resident R2's nurse aide documentation was reviewed with the Director of Nursing and confirmed that there was no documented evidence that toileting hygiene and assistance was provided. Interview on July 7, 2026, at 9:32 a.m. Resident R3 stated that during the evening shifts that nurse aides take too long to provide toileting assistance, and that he/she is left sitting in soiled briefs for hours. Resident R3 also stated that he/she is not checked on every two hours for continence care. Review of Resident R3's Quarterly MDS assessment, dated May 11, 2026, revealed that the resident was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease (a progressive disorder of the nervous system that affects movement). Continued review revealed that the resident scored 15 on a BIMS assessment, indicative that the resident was cognitively intact. Further review revealed that the resident required maximal assistance for toileting hygiene, was frequently incontinent of bladder and always incontinent of bowel. Review of Resident R3's care plan, dated Nove January 5, 2026, revealed that the resident had bowel and urinary incontinence related to physical limitations. Interventions include to check the resident every two hours and provide incontinence care, apply moisture barrier cream and provide the appropriate size and type of incontinence product. Review of Resident R3's nurse aide documentation revealed that staff will document toiling hygiene provided every shift. Review of documentation from June 8 through July 6, 2026, revealed that toileting hygiene was marked as not applicable June 16, 29, and July 5, 2026, on the day shifts; June 12, 2026, on the evening shift; and June 15, 17, 18, 21, 25, July 1, 2 and 4, 2026, on the overnight shifts. Continued review revealed no evidence that toileting hygiene was provided to Resident R3 on June 20 and 21, 2026, on the day shift; June 17, 22, 27 and 28, 2026, on the evening shifts; and June 23 and July 5, 2026, on the overnight shifts. Follow-up interview on July 7, 2026, at 3:00 p.m. Resident R3's nurse aide documentation was reviewed with the Director of Nursing and confirmed that there was no documented evidence that toileting hygiene and assistance was provided. 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on clinical record reviews and interviews with residents and staff, it was determined that the facility failed to provide medications in accordance with physician orders and in a timely manner for one of six residents reviewed (Resident R2). Findings include: Interview on July 7, 2026, at 9:47 a.m. Resident R2 stated that sometimes evening medications are provided after midnight, sometimes as late as 2:30 a.m., which interrupts sleep and then feels tired the next day. Resident R2 also stated that eye drop medications are not provided. Review of Resident R2's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated June 8, 2026, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including cancer, renal insufficiency failure (a condition in which the kidneys lose the ability to remove waste and balance fluids), coronary artery disease (damage in the heart's major blood vessels), diabetes (ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose), and hyperlipidemia (high cholesterol). Continued review revealed that the resident scored 15 on a BIMS (Brief Interview for Mental Status) assessment, indicative that the resident was cognitively intact. Review of Medication Administration Records (MARs) for June and July 2026, revealed that Resident R2 was prescribed medications to be taken in the evening or at bedtime, including Atorvastatin (treats high cholesterol), Lantus (long acting insulin that lowers blood sugar levels), loratadine (treats allergies), melatonin (treats insomnia), tamsulosin (relieves urinary symptoms), carboxymethylcellulose sodium ophthalmic gel 1% (treats dry eyes), and nasal spray 0.65% saline (treats allergies). Review of Medication Administration Audit Report for June and July 2026, revealed that Resident R2 was scheduled to receive Atorvastatin, Lantus, loratadine, melatonin and tamsulosin at 7:30 p.m. Resident R2 was scheduled to receive carboxymethylcellulose sodium ophthalmic gel and saline nasal spray at 9:00 p.m. Continued review of the Medication Administration Audit Report revealed that Resident R2's evening and bedtime medications were administered at the following times: On June 8, 2026, medications scheduled for 7:30 p.m. and 9:00 p.m. were administered at 11:05 p.m.;On June 22, 2026, medications scheduled for 7:30 p.m. were administered at 11:50 p.m.;On June 22, 2026, medications scheduled for 9:00 p.m. were administered on June 23, 2026, at 1:20 a.m. and 2:13 a.m.;On June 23, 2026, medications scheduled for 7:30 p.m. and 9:00 p.m. were administered at 11:12 p.m.;On June 25, 2026, medications scheduled for 7:30 p.m. were administered on June 26, 2026, at 2:05 a.m.;On June 27, 2026, medications scheduled for 7:30 p.m. and 9:00 p.m. were administered at 11:30 p.m. and June 28, 2026, at 12:07 a.m.;On June 29, 2026, medications scheduled for 7:30 p.m. and 9:00 p.m. were administered on June 30, 2026, at 12:34 a.m.;On June 30, 2026, medications scheduled for 7:30 p.m. and 9:00 p.m. were administered at 11:00 p.m.;On July 3, 2026, medications scheduled for 7:30 p.m. were administered on July 4, 2026, at 3:02 a.m.;On July 3, 2026, medications scheduled for 9:00 p.m. were administered on July 4, 2026, at 12:59 a.m.;On July 4, 2026, medications scheduled for 7:30 p.m. were administered on July 5, 2026, at 12:22 a.m.;On July 4, 2026, medications scheduled for 9:00 p.m. were administered at 11:50 p.m.; [NAME] July 5, 2026, medications scheduled for 7:30 p.m. and 9:00 p.m. were administered on July 6, 2026, at 1:55 a.m. Continued review of MARs for June 2026, revealed that Resident R2 was prescribed to receive carboxymethylcellulose sodium ophthalmic gel 1% four times per day at 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. Further review revealed that Resident R2 did not receive the medication as prescribed on June 3, 4, 5, 8, 9, 10, 12, 13, 14, 17, 18, 19, 20, 21 and 22, 2026, for a total of 29 missed doses. Interview on July 7, 2026, at 1:00 p.m. Resident R2's Medication Administration Audit Report was reviewed with the Director of Nursing and confirmed that the resident's medications were administered late. Continued interview revealed that carboxymethylcellulose sodium ophthalmic gel 1% is a medication that is supplied by the facility, is readily available, and that the resident should not have missed any doses of the medication. 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on observations, policy and interviews with staff, it was determined that the facility failed to ensure sanitary food handling practices were followed by dietary staff. Findings include:Observations during food preparation and service, conducted on January 11, 2026, at approximately 9:30 a.m. with the Food Service Director (FSD), Employee E13, revealed the following staff were observed not adhering to required personal protective equipment and hygiene practices: Dietary aid, Employee E14, was observed handling ready-to-eat food without wearing gloves.Dietary aid, Employee E15 and Cook, Employee E16 was observed preparing food without a hair net.Dietary aide, Employee E17, was observed wearing a hair net that did not fully cover all hair. Dietary aid, Employee E18, was observed wearing a beard covering that did not fully contain facial hair while engaged in food preparation. Dietary aid, Employee E19 and Employee E20, were observed in the main kitchen area without a hair net. These observations occurred during active food preparation and handling of resident meals. Interview with the FSD during observations confirmed that staff are expected to wear hair nets, beard/facial hair coverings as applicable, and gloves when handling food. Continued interview confirmed that the facility does not currently utilize or indicate use-by or discard-by dates on prepared or opened food items. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policy, observations, and staff interviews, it was determined that the facility did not ensure posting of required State Survey Agency contact information was readily accessible on two of two nursing floors. (Second-Floor and Third-Floor Nursing Units) Findings Include: Review of facility policy titled, Resident Rights with a revised date of February 2011 states, Policy Statement- Employees shall treat residents with kindness, respect, and dignity. Further review of the policy states, Policy Interpretation and Implementation- 1. Federal and state laws guarantee basic rights to all residents of this facility. These rights include the resident's right to:.u. voice grievances to the facility, or other agency's that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal; v. have the facility respond to his or her grievances; w. examine survey results x. communication with outside agencies (e.g., local, state, or federal officials, state and federal surveyors, state long-term care ombudsman, protection or advocacy organizations etc.) regarding any matter. A tour was taken with the Director of Social Services, Employee E6 to look for required postings. During an observation of Second-Floor nursing unit on January 12, 2026, at 10:00 a.m. it was revealed there was no posting for the required Department of Health contact information. A tour of the dining room revealed there was a standard size page posted on the door that read DOH Field Office Contact Information 610 270 3485. During an observation of Third-Floor nursing unit on January 12, 2025 at 10:15 a.m. revealed there was no posting for the required Department of Health contact information. A tour of the dining room revealed there was a standard size page posted on the door that read DOH Field Office Contact Information 610 270 3485. A search revealed the number listed was for the Department of Health Building Safety Inspection. Interview held with Employee E1 the Nursing Home Administrator at 10:13 a.m. revealed they have had this sign up in the building since the last survey January 2025.The Director of Social Services Employee E6 and the Nursing Home Administrator confirmed at 10:15 a.m. that there were no postings for the required Department of Health contact information on either on the nursing units due to renovations of the units and the bulletin boards had been taken down. (Second-Floor and Third-Floor). It was determined that the facility did not ensure required postings including accurate Name, Addresses, and telephone number for the State Survey Agency were posted in prominent places throughout the facility including a statement that the resident may file a complaint with the State Survey Agency in relation to resident abuse, neglect, exploitation, misappropriation of resident property in the facility. 28 Pa. Code: 201.18(a)(e)(1) Management28 Pa. Code: 201.18(b)(1) Management

Based on a review of facility policies, medical records, observations, and interviews with residents and staff, it was determined that the facility failed to ensure proper infection prevention and control practices for three of five residents observed (Residents R31, R20, and R95). Specifically, the facility failed to implement Enhanced Barrier Precautions (EBPs) during wound care, medication administration via feeding tube, and personal care, placing residents at risk for transmission of multidrug-resistant organisms (MDROs).Findings include:The facility policy titled Enhanced Barrier Precautions (revised December 2024) states that EBPs are implemented to prevent the transmission of MDROs. EBPs are required for residents who are infected or colonized with CDC-targeted MDROs or who have wounds or indwelling medical devices, including feeding tubes, urinary catheters, central lines, or tracheostomies. The policy requires staff to wear gowns and gloves, in addition to standard precautions, during high-contact resident care activities such as dressing, bathing, hygiene and grooming, transfers, changing briefs or linens, assisting with activities of daily living, device care, and wound care. EBPs also apply outside of the resident's room when close physical contact is anticipated. The policy further requires staff education, appropriate signage outside resident rooms, and ready access to personal protective equipment (PPE) and alcohol-based hand rub.Review of Resident R31's quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was admitted on [DATE], with diagnoses including cerebrovascular accident (CVA) and malnutrition and requires a feeding tube.Review of Resident 31's clinical record revealed physician orders dated May 1, 2024, for Enhanced Barrier Precautions every shift.Observation January 11, 2025, at 9:20 a.m., of Resident R31's room revealed posted signage indicating the resident was on Enhanced Barrier Precautions and required staff to wear gloves and gowns during high-contact activities, including feeding tube care and wound care.Observation of medication pass observed on the same date and time, Licensed Nurse Employee E9 administered medications via the resident's feeding tube using a syringe and flush; licensed nurse employee E9 wore gloves and a mask only and failed to don a gown as required by policy.Review of Resident R20's clinical record and care plan dated April 29, 2025, revealed impaired skin integrity related to arterial ulcers on the toes and feet, with Enhanced Barrier Precautions required during high-contact care activities, including wound care. Observation on January 12, 2025, at 11:20 a.m. confirmed Enhanced Barrier Precaution signage was posted on the resident's room door.Observation on January 12, 2025, at 11:20 a.m., Licensed Nurse Employee E12 was observed providing wound care to Resident R20's toe while wearing gloves only and not wearing a gown. Interview with licensed nurse Employee E12 at time of observation, stated that gloves were sufficient for wound care, indicating a lack of adherence to facility policy.Review of Resident R95's annual MDS dated [DATE], revealed diagnoses of venous and/or arterial ulcers.Review of resident R95's Physician orders dated December 30, 2025, required Enhanced Barrier Precautions for this resident.Observation January 12, 2025, at 11:45 a.m., of Resident R95's room door revealed signage indicating Enhanced Barrier Precautions and the requirement for gowns and gloves during high-contact care. Observation on January 12, 2025, at 11:45 a.m., Nursing Assistant, Employee E11, was observed providing a bed bath to Resident R95 while wearing gloves only and not wearing a gown. Interview at the time of observation, Employee E11 stated that the Enhanced Barrier Precaution sign was not intended for Resident R95.During an interview on January 13, 2025, at 12:25 p.m., the Assistant Director of Nursing/Infection Preventionist (Employee E) stated that all employees had been educated on infection control practices and PPE use. The employee confirmed that wound care, personal care, and medication administration via feeding tube require the use of appropriate PPE, including gowns and gloves, and acknowledged that while staff are aware of the requirements, they do not always follow them. The employee stated that additional skills training would be provided to staff. 28 Pa. Code 201.20 (a)(6)(b) Staff Development 28 Pa. Code 211.10 (a)(c) Care Policies 28 Pa. Code 211.12 (d)(5) Nursing Services

Based on clinical record review, and staff interview, it was determined that the facility failed to ensure the resident and the residents representative received a written transfer notice that included all required details for one of three closed records reviewed (Resident R112). Findings include: Review of Resident R112's medical records revealed that on December 11, 2025, the resident was admitted to the hospital following a fall. Although documentation indicated that a notification was provided, continued review failed to reveal that the written notice specified the required elements, including detailed reason for the transfer and required regulatory information, in a manner and language the resident or representative could understand. Interview with the Assistant Director of Nursing, Employee E4, conducted on January 14, 2025, at 12:50 p.m. confirmed that the written notification provided for the transfer did not include required details as outlined by regulation. Continued interview with Employee E4 further confirmed that it is not facility practice to ensure transfer notices consistently contain all required regulatory elements. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights

Based on observations, interviews with staff, and review of facility policies it was determined that the facility failed to ensure prevention of accidents and hazards related to medications found at bedside for one of thirty-three residents reviewed. (Resident R62)Findings Include: Review of facility policy titled, Administer Medications with a date of April 2019 states, Policy Statement- Medications are administered in a safe and timely manner, and as prescribed. Further review of the facility policy revealed, 21. For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR may be flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medication. Review of Resident R62's record revealed the resident was admitted to the facility on [DATE]. The resident had the following medical diagnosis: Parkinsons Disease (Progressive nervous system disorder affecting movement, characterized by tremors, rigidity, bradykinesia (slowness), and postural instability), Dissection of Vertebral Artery (a tear in the inner lining of the vertebral artery, allowing blood to enter and separate the layers, potentially leading to stroke), Spinal Stenosis (the narrowing of the spinal canal, causing compression of the spinal cord or nerves), and Hyperlipidemia (excessively high levels of fats specifically LDL cholesterol and triglycerides in the blood). Observation on January 11, 2026 of the third-floor nursing unit was made. During observation Resident R62 was interviewed. During the resident interview it was noted that there was a round orange pill on the resident's bedside table. Next to the orange pill was a white plastic pill cup. The surveyor alerted Resident R62's nurse licensed Nurse Employee E9 who came to the room at 10:05 a.m. Employee E9 visualized the orange pill and then moved around items on the bedside table and found one other round white pill. The two pills were placed in the pill cup and taken to the nurse's medication cart. The medication found was identified by the nurse as being an Aspirin tablet and Bromide tablet. It was determined that the facility failed to ensure prevention of potential accidents and hazards related to the medications found bedside. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on a review of facility policy and resident clinical records, it was determined that the facility failed to ensure timely and effective follow-up of consultant pharmacist medication regimen review (MRR) recommendations for two of four residents reviewed. (resident R 137, and R7) This failure had the potential to result in inappropriate medication use and medication errors.Findings include:Review of the facility policy titled Medication Regimen Reviews, dated July 2025, revealed that a licensed consultant pharmacist reviews each resident's medication regimen upon admission and at least monthly, or more often if clinically indicated. The policy requires identification and resolution of medication errors, irregularities, adverse effects, interactions, inappropriate dosing, and lack of monitoring. The policy further requires non-life-threatening irregularities to be reported in writing to the physician within three business days, physician responses to be documented in the medical record, and medication-related issues to be monitored through quarterly reports and incorporated into the facility's QAPI program.Review of Resident R137's clinical record revealed a physician order dated December 18, 2025, for Risperdal (risperidone) 2 mg by mouth at bedtime for anxiety. Review of the consultant pharmacist's medication regimen review dated October 15, 2025, revealed a recommendation to the provider noting the resident was receiving an antipsychotic medication without an allowable supporting diagnosis. The pharmacist identified that acceptable diagnoses include schizophrenia, schizoaffective disorder, delusional disorder, mania, bipolar disorder, refractory major depression with psychosis, or delirium with manic or psychotic symptoms. Review of the clinical record revealed no evidence that the identified irregularity was resolved.Review of Resident R7's clinical record revealed a physician order for Diclofenac Sodium 1% topical gel to be applied to the left arm and thigh every eight hours as needed for pain. Review of the consultant pharmacist's MRR dated November 21, 2025, revealed a recommendation to clarify the order to specify the amount to be applied (2 grams) and include administration instructions to prevent medication errors. The physician responded on December 5, 2025; however, review of the medical record revealed no evidence that the order was modified to include the recommended clarifications.28 Pa. Code 211.2(d)(9) Medical Director28 Pa. Code 211.9 (a)(1) Pharmacy Services

Based on review on observations, interviews, review of clinical documentation, and review of facility policy it was determined that the failed did not ensure accurate documentation related to pharmacy reviews for one of 22 residents reviewed. (Resident R75)Review of Resident R75 Consultant Pharmacist MMR Recommendation to Prescriber, dated October 15, 2025, indicated Resident has two order(s) for the following: acetaminophen 500mg and Acetaminophen 325mg for mild pain. Please discontinue duplicate order, if appropriate. If both orders are to be given concurrently, please add the total mg dose to each order. Further review revealed a Physician/ Prescriber response to discontinue 325mg and continue with 500mg for scale 1-4 pain. Review of Resident R75 clinical record revealed a physician order for Acetaminophen 500mg discontinued on December 19, 2025. Further review revealed Acetaminophen 325mg order active. Interview with Employee E2, Director of Nursing, on January 14, 2026 at 12:00pm, confirmed incorrect Acetaminophen dose discontinued.

Based on observations, review of facility policies, review of facility grievances, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to administer medications in a timely manner for five of five residents reviewed (Residents R1, R2, R3, R4 and R5). Findings include:Review of facility policy, Guideline for Administration of Medications undated, revealed, This guidance is to assist in the timely administration of medications based on time critical and non-time critical scheduled medications. Non-time critical medications will be scheduled for administration in AM, Afternoon, Evening and HS [bedtime] utilizing extended administration times to accommodate the resident's customary routines. Continued review revealed that medications that are prescribed as daily will be defined as In the Morning with medication administration times from 6:30 a.m. through 11:00 a.m.; In the Afternoon medication administration times are 1:00 p.m. through 5:30 p.m.; Evening medication administration times are 6:30 p.m. through 11:00 p.m.; and Bedtime medication administration times are 7:30 p.m. through 11:00 p.m. Continued review revealed that medication ordered as two times per day will be administered between 6:30 a.m. to 11:00 a.m. and 6:30 p.m. to 11:00 p.m. Further review of the policy revealed, Medications that are time critical will be administered within 1 hour of the ordered time. Interview on August 28, 2025, at 9:00 a.m. Resident R2 stated that he often receives medications late. Observation on August 28, 2025, at 10:30 a.m. revealed that Employees E4 and E5, licensed nurses, were still administering morning medications to residents. Employees E4 and E5 confirmed that the medications were late and stated that they just have too much work to do to get medications administered on time. Review of facility grievances revealed a grievance filed by Resident R1 on July 29, 2025, which alleged that the resident had to wait a long time to receive her pain medication. Review of Resident R1's physician orders for August 2025, revealed that the resident was scheduled to receive a blood sugar check at bedtime, montelukast (used to prevent asthma attacks) in the evening, and atorvastatin (treats high cholesterol) at bedtime. Continued review revealed that Resident R1 was scheduled to receive gabapentin (treats nerve pain) and tramadol (opioid pain medication) every eight hours at 6:00 a.m., 2:00 p.m. and 10:00 p.m. Review of Resident R1's Medication Administration Audit Report for August 2025, revealed:On August 7, 2025, the resident's scheduled 6:00 a.m. gabapentin and tramadol were not administered until 8:28 a.m.;On August 14, 2025, the resident's scheduled 2:00 p.m. gabapentin and tramadol were not administered until 5:26 p.m.;On August 14, 2025, the resident's scheduled 10:00 p.m. gabapentin and tramadol were not administered until 11:30 p.m.;On August 15, 2025, the resident's scheduled 10:00 p.m. gabapentin and tramadol were not administered until August 16, 2025, at 12:40 a.m.;On August 15, 2025, the resident's bedtime blood sugar check was not administered until August 16, 2025, at 1:09 a.m.;On August 16, 2025, the resident's bedtime blood sugar check, evening montelukast and bedtime atorvastatin were not administered until August 17, 2025, at 2:53 a.m.;On August 16, 2025, the resident's scheduled 10:00 p.m. gabapentin and tramadol were not administered until August 17, 2025, at 2:50 a.m. Review of Resident R2's physician orders for August 2025, revealed that the resident was scheduled to receive lamotrigine (treats bipolar disorder), quetiapine fumarate (antipsychotic medication used to treat bipolar disorder), rosuvastatin (treats high cholesterol), and ingrezza (treats body movement disorders) at bedtime. Review of Resident R2's Medication Administration Audit Report for August 2025, revealed:On August 2, 2025, the resident's bedtime lamotrigine, quetiapine fumarate, rosuvastatin, and ingrezza were not administered until 11:58 p.m.;On August 9, 2025, the resident's bedtime lamotrigine, quetiapine fumarate, rosuvastatin, and ingrezza were not administered until August 10, 2025, at 12:25 a.m.;On August 14, 2025, the resident's bedtime lamotrigine, quetiapine fumarate, rosuvastatin, and ingrezza were not administered until August 15, 2025, at 12:44 a.m.;On August 15, 2025, the resident's bedtime lamotrigine, quetiapine fumarate, rosuvastatin, and ingrezza were not administered until August 16, 2025, at 12:22 a.m.;On August 16, 2025, the resident's bedtime lamotrigine, quetiapine fumarate, rosuvastatin, and ingrezza were not administered until August 17, 2025, at 1:18 a.m. Review of Resident R3's physician orders for August 2025, revealed that the resident was scheduled to receive atorvastatin (treats high cholesterol) in the evening. Review of Resident R3's Medication Administration Audit Report for August 2025, revealed:On August 6, 2025, the resident's evening atorvastatin was not administered until August 7, 2025, at 3:03 a.m.;On August 15, 2025, the resident's evening atorvastatin was not administered until August 16, 2025, at 12:51 a.m.;On August 26, 2025, the resident's evening atorvastatin was not administered until August 27, 2025, at 4:45 a.m. Review of Resident R4's physician orders for August 2025, revealed that the resident was scheduled to receive gabapentin (treats nerve pain) every eight hours at 6:00 a.m., 2:00 p.m. and 10:00 p.m. and atorvastatin (treats high cholesterol) at bedtime. Review of Resident R4's Medication Administration Audit Report for August 2025, revealed:On August 6, 2025, the resident's scheduled 2:00 p.m. gabapentin was not administered until 3:27 p.m.; On August 6, 2025, the resident's scheduled 10:00 p.m. gabapentin and bedtime atorvastatin were not administered until August 7, 2025, at 4:06 a.m.;On August 13, 2025, the resident's scheduled 10:00 p.m. gabapentin was not administered until August 14, 2025, at 2:05 a.m.;On August 14, 2025, the resident's scheduled 2:00 p.m. gabapentin was not administered until 5:29 p.m.; On August 14, 2025, the resident's scheduled 10:00 p.m. gabapentin and bedtime atorvastatin were not administered until August 15, 2025, at 12:07 a.m.;On August 16, 2025, the resident's scheduled 10:00 p.m. gabapentin and bedtime atorvastatin were not administered until August 17, 2025, at 2:59 a.m. Review of Resident R5's physician orders for August 2025, revealed that the resident was scheduled to receive famotidine (treats acid reflux) two times a day, metoprolol (treats high blood pressure) two times a day, atorvastatin at bedtime and Tylenol every six hours for hip fracture pain at 6:00 a.m., 12:00 p.m., 6:00 p.m. and 12:00 a.m. Review of Resident R5's Medication Administration Audit Report for August 2025, revealed:On August 4, 2025, the resident's scheduled 12:00 a.m. Tylenol was not administered until 4:39 a.m.; On August 6, 2025, the resident's scheduled 12:00 p.m. Tylenol was not administered until 2:32 p.m.; On August 6, 2025, the resident's famotidine, metoprolol and atorvastatin were not administered until August 7, 2025, at 1:00 a.m.On August 8, 2025, the resident's scheduled 12:00 a.m. Tylenol was not administered until 3:15 a.m.; On August 10, 2025, the resident's scheduled 12:00 a.m. Tylenol was not administered until 2:52 a.m.; On August 14, 2025, the resident's scheduled 12:00 a.m. Tylenol was not administered until 1:59 a.m.;On August 15, 2025, the resident's scheduled 12:00 p.m. Tylenol was not administered until 2:30 p.m.; On August 16, 2025, the resident's scheduled 12:00 p.m. Tylenol was not administered until 4:09 p.m.; On August 16, 2025, the resident's famotidine, metoprolol and atorvastatin were not administered until August 17, 2025, at 2:47 a.m.On August 17, 2025, the resident's scheduled 12:00 a.m. Tylenol was not administered until 2:46 a.m.; On August 21, 2025, the resident's scheduled 12:00 a.m. Tylenol was not administered until 6:48 a.m.; On August 22, 2025, the resident's scheduled 12:00 a.m. Tylenol was not administered until 7:08 a.m.; On August 23, 2025, the resident's scheduled 12:00 a.m. Tylenol was not administered until 2:19 a.m. Interview on August 28, 2025, at 2:53 p.m. the Director of Nursing reviewed the facility's Administration of Medications policy including the flexible administration times and confirmed that medications are expected to be administered within those timeframes. The Medication Administration Audit Reports for Residents R1, R2, R3, R4 and R5 were reviewed with the Director of Nursing and confirmed the above findings. 28 Pa Code 211.12(d)(5) Nursing services

Based on the observation, review of facility policy and procedure, review of manufacturers guidelines, and interviews with staff, it was determined that the facility failed to properly label medications upon opening for ophthalmic solutions found on two of three medications carts observed. (third floor carts one and two) Findings: Review of facility policy titled Medication Labeling and Storage revealed the facility stores all medications and biologicals under proper temperature, humidity, and light controls. Only authorized personnel have access to keys. The nursing staff is responsible for maintaining medications storage and preparation areas they clean safe and sanitary manner. Multi dose vials that have been opened or at accessed are dated and discarded within 28 days unless the manufacturer specifies a sure they're longer date for the open vial. Observation of medication pass with Employee Licensed nurse, Employee E5 on January 12, 2024, during med pass, inspection of third floor medication cart one revealed seven boxes of multi-use eye drops without any date written on the box of date of opening. Interview with Employee E5 at time of the above observation confirmed that seven boxes of multi-use eye drops did not contain the date of opening on the box. Observation of medication pass with Licensed nurse, Employee E6 on January 12, 2024, during med pass, inspection of third floor medication cart two revealed two boxes of multi-use eye drops without any date of opening on the box. Interview with Employee E6 at time of the above observation confirmed that the two boxes of multi-use eye drops did not contain the date of opening on the box. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d0(1) Nursing services

Based on observations, review of clinical records, and staff interview it was determined that the facility failed to provide reasonable accommodation of needs for two of 30 residents reviewed (Resident R215 and R165). Findings Include: Review of Resident R215's clinical record revealed the resident was admitted to the facility on [DATE]. Height and weight measurements dated December 11, 2024, revealed Resident R215 was 6 feet 3 inches tall and weighed 225 pounds. Review of Resident R215's clinical record revealed a nursing note dated December 11, 2024, at 11:49 p.m. that a TELS (an electronic system used to enter, manage, and track maintenance requests) request was placed for a bed extender (increases the length and/or width of existing bed to provide more space and comfort). During an interview on January 12, 2025, at 11:35 a.m. Resident R215 reported that the bed was too small (Resident R215 was too tall for the bed) causing his feet to press against the footboard while lying in bed and subsequently causing his feet to feel numb. Observations confirmed Resident R215 appeared uncomfortable in bed as he needed to keep his legs bent and pulled to the side to keep them from pressing against the footboard. Observations on January 12, 2025, at 11:35 a.m. revealed the width of the bed was also too small leaving little room for Resident R215 to reposition in bed. Resident R215 reported feeling fearful of falling out of bed when being turned and repositioned due to the little space and no bed enablers to hold onto. Interview on January 12, 2025, at 12:07 p.m. with Nursing Supervisor, Employee E3, confirmed the bed was too small for Resident R215 and that the facility was working on getting a bed extender for the resident's bed. Interview on January 12, 2025, at 12:12 p.m. with Nursing Home Administrator, Employee E1, confirmed the facility was still working on getting the resident a bed extender and was unsure why a proper fitting bed was not available on the day Resident R215 was admitted . Observations on January 12, 2025, at 11:00 a.m. of Resident R165's room revealed the resident was laying on the bed. Residents foot was on top of the footboard with a pillow under the ankle area. Resident R165 stated the bed was short for him and he could not raise the head of the bed without placing foot on the bed. Further observation revealed that there was no bed extender placed on the bed. Interview with Administrator on January 12, 2025, at 2:00 p.m. stated facility could utilize bed extender for residents if the bed was short for them. Observation with Administrator confirmed that the bed for R165 was short and he placed his foot on the foor board. 28 Pa. Code 201.29 (a) Resident Rights. 28 Pa. Code 211.10 (d) Resident care policies.

Based on observation and review of facility policy, it was determined that the facility failed to ensure that the residents right to privacy was protected for two of 30 residents reviewed. (Resident R Findings include: Review of facility policy titled Confidentiality of Information and Personal Privacy dated October 2017, revealed that the facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. The facility will strive to protect the resident's privacy regarding his or her accommodations, medical treatment, written communication, personal care, visits, and family group meetings. Observation on the third floor activity room on January 13, 2025 at 10:53, the room included eleven residents and two employees, Registered nurse, Employee E8 was observed evaluating a resident's vital signs. registered nurse Employee E8 was overheard relaying the vital measurements to the resident. 28 Pa. Code 201.18(b)(2) Management

Based on review of clinical records, staff and resident interviews, it was determined that the facility failed to ensure that a written summary of the baseline care plan was provided to the resident and/or the resident's representative that included initial goals based on admission orders, physician orders, therapy services and social services for one of 22 residents reviewed (Resident R164). Findings include: Review of clinical record revealed that the resident was admitted to the facility on [DATE], with diagnosis including progressive neurological condition and cerebrovascular accident (stroke) and Parkinson's disease (progressive disease of the central nervous system). Interview with Resident R164 and with resident's family on January 12, 2025 at 11:25 a.m. stated she was admitted to the facility 9 days ago and she was not sure if she was getting all her medications. Continued interview with Resident R164 and resident's family stated they were not provided a written summary of the baseline care plan that included initial goals based on admission orders, physician orders, therapy services and social services. Review of the care plan and the clinical record revealed no documented evidence that the resident representative received a written summary of the baseline care plan that included initial goals based on admission orders, physician orders, therapy services and social services. A request was made to the Social Service Director on January 15, 2025, at 11:44 a.m., for a copy of the baseline care plan for Resident R164 and evidence that resident/resident representative received a copy of the baseline care plan. Interview with Social Service Director on January 15, 2025, at 11:44 a.m., stated facility did not conduct a baseline care plan meeting with Resident R164 and a written summary of the baseline care plan was provided to the resident and/or the resident's representative. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring and administering of medications) to meet the needs of each resident for one of 22 residents reviewed (Resident R34). Findings Include: Review of facility policy Unavailable Medication dated June 2021 revealed in conjunction with the contracted pharmacy, the facility will make every effort to ensure that a medication ordered for the resident is available to meet their needs. Continued review of facility policy Unavailable Medication revealed in the event that a medication ordered for a residents is noted to be unavailable near or at the time it is to be dispensed, nursing staff shall contact the pharmacy regarding the unavailable medication, attempt to obtain the medication from the facility's automated medication dispensing system, notify the physician of the unavailable medication, report the date of the expected delivery, and obtain new orders. Review of Resident R34's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated December 21, 2024, revealed the resident was cognitively intact and had diagnoses of polycythemia vera (a rare blood cancer that causes too many red blood cells, thickening the blood and increasing the risk of blood clots) and atrial fibrillation (an irregular heart rhythm that can lead to stroke, heart failure and other complications). Further review of the MDS revealed Resident R34 was taking an anticoagulant (also referred to as a blood thinner - medications that reduces the formation of blood clots). Review of Resident R34's care plan dated December 18, 2024, revealed the resident was on anticoagulant therapy for blood clot prevention. Intervention dated December 18, 2024, included to provide medication as ordered. Review of Resident R34's medication administration record revealed Warfarin 2.5 mg (milligrams) (an anticoagulant medication) was due in the evening on January 4, 2025. The medication was signed out as drug/treatment not administered. Review of Resident R34's clinical record revealed a medication administration note for the Warfarin 2.5 milligerams (mg) dose due on January 4, 2025, that revealed waiting on pharmacy. Review of Resident R34's clinical record revealed no documented evidence the nurse called the pharmacy to determine an expected delivery date and no documented evidence the physician was made aware of the missed medication and subsequent new orders on how to proceed. Further review of Resident R34's medication administration record revealed Warfarin 2mg was due in the evening on January 6, 2025, and January 12, 2025. The medications were signed out as drug/treatment not administered on both dates. Review of Resident R34's clinical record revealed a medication administration note for the Warfarin 2mg dose due on January 6, 2025, that revealed awaiting pharmacy. Review of Resident R34's clinical record revealed a medication administration note for the Warfarin 2mg dose due on January 12, 2025, that revealed awaiting pharm. Interview on January 15, 2025, at 10:48 a.m. with Registered Nurse, Employee E4, revealed missed medications were due to the pharmacy not delivering medications in a timely manner. 28 Pa. Code 211.9 (a)(1) Pharmacy services.

Based on review of facility policy, review of clinical records, observations and staff interviews, it was determined the facility failed to provide adaptive equipment for 1 of 18 residents observed during dining on the third-floor dining room. Findings: Policy titled Assistive Devices and Equipment revealed the facility maintains and supervises the use of assisted devices and equipment for residents. Devices and equipment that assist with residents' mobility, safety and independence are provided for residents these may include but are not limited to specialized eating utensils and equipment. Recommendations for the use of devices and equipment are based on comprehensive assessment and documented in the residence care plan. Staff and volunteers are trained to demonstrate competency in the use of devices and equipment prior to assisting or supervising residents. Review of Residents R83's quarterly minimum data set (mds- a federal mandated assessment tool for all residents) dated December 9, 2024. Resident R83 entered the facility June 30 2023 with diagnosis' including malnutrition(imbalance between the nutrients the body needs to function and the nutrients it gets), hemiplegia (paralysis or weakness to one side of the body), aphasia (loss of ability to understand or express speech ), stroke (a condition in which poor blood flow to the brain and caused cell death). Resident R83 has been assessed as having a brief interview mental for mental status) score of three, indicating that resident R83 has severe cognitive impairment. Review of resident's physicians order dated January 4, 2024, revealed an order for buildup utensils with meals. Interview with Resident R83's family on January 12, 2024 at 12:05 p.m. in the third-floor dining room revealed that resident is supposed to have special utensils but was not given them. She said she asked a staff member for them but has not received them. Observation of lunch third floor January 12, 2025, at 12:10 p.m. rrevealed Rsident R83 has order for step up utensils, observed at lunch the resident given regular utensils. Interview with Nurse aide, Employee E8 confirmed that resident is supposed to be given build up utensils and has not received them at this meal. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12 (d)(1) Nursing services

Based on review of facility documents of Quality Assurance meeting attendance and staff interviews, it was determined that the facility failed to ensure that the Director of Nursing Services attended a quarterly Quality Assurance Process Improvement (QAPI) committee meeting for nine of nine QAPI meeting documentations reviewed (February 2024 through October 2024). Findings Include: A review of QAPI committee meeting attendees list for the month of February 2024, March 2024, April 2024, May 2024, June 2024, July 2024, August 2024, September 2024 and October 2024 revealed that it lacked Director of Nursing as attendee for the meetings. This information was confirmed by the facility Regional Staff during a meeting on January 15, 2025, at 1:13 p.m. Facility documentation provided at the time of the survey did not have evidence that the director of nursing attended the meetings. There was no sign in sheet or meeting minutes information available for July of 2024 that any of the required members attended the meeting. Facility did not provide this information at the time of the survey. A request for copies of the original QAPI sign in sheet provided at the time of the survey was requested however was not submitted. 28 Pa. Code 201.18 (1)(3) Management.

Based on review of facility policy, review of clinical records, and staff and resident interviews, it was determined that the facility failed to ensure that each resident was offered an influenza immunization for two of seven residents reviewed for immunizations (Resident R34 and R315). Findings Include: Review of Resident R34's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated December 21, 2024, revealed the resident was admitted to the facility on [DATE], and was cognitively intact. Interview on January 14, 2025, at 1:38 p.m. with Resident R34 the resident denied being offered the influenza immunization on admission but admitted being willing to accept the vaccine if suggested by the physician. Review of Resident R34's entire clinical record, including immunization history, revealed no documented evidence the resident was offered the immunization on admission or documentation that the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. Review of Resident R315's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated December 17, 2024, revealed the resident was admitted to the facility on [DATE], and was cognitively intact. Interview conducted on January 13, 2025 at 10:35 p.m. with Resident R315 revealed the facility did not offer the resident the influenza immunization on admission. Resident R315 stated she has been requesting the influenza immunization and would like to receive it before discharge Review of Resident R315's entire clinical record, including immunization history, revealed no documented evidence the resident was offered the immunization on admission or documentation that the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. 28 Pa. Code 211.5 (f)(iv) Medical records. 28 Pa. Code 211.12(d)(1) Nursing services

Based on observations, review of clinical record, and staff and resident interviews it was determined that the facility failed to provide a sanitary and comfortable environment for two of 30 residents reviewed (Resident R220 and R164). Findings Include: Review of Resident R220's clinical record revealed a physician order dated January 1, 2024, for an antibiotic medication to be administered intravenously (medical technique that administers medications directly into the vein) one time per day. Observations on January 15, 2024, at 11:56 a.m. with Director of Nursing, Employee E2, revealed Resident R220's IV pole (a device that holds a bag of intravenous fluids or medications in place as it is being administered to a patient) was soiled at the base of the pole with what appeared to be old tube feeding formula. Interview with Resident R164 and with resident's family on January12, 2025 at 11:25 a.m. stated she had an over the head light that would not turn off. She stated it was broken when she was admitted to the facility nine days ago. Resident stated she had been sleeping with the lights on for every day since her admission. Resident's family stated the cord that turns the light on and off did not work properly and the light did not turn off. Continued interview with Resident 164 stated some facility staff did try to fix it and left without fixing it. Observation of the over the head light revealed that the light string was broken and had only 2 inches left from the fixture. The light could not be turned off. Review of clinical record revealed that the resident was admitted to the facility on [DATE] with diagnosis including progressive neurological condition and cerebrovascular accident(stroke) and Parkinson's disease. Interview with Administrator on January 12, 2025, at 2:00 p.m. confirmed that overhead light for Resident R164 was broken.

Based on a review of clinical records and facility provided documentation, and interview with staff, it was determined that the facility failed to provide the required advanced notice, through a Notice of Medicare Non-Coverage (CMS 10123), regarding the termination of Medicare services for one of three residents sampled (Residents R1) Findings include: Review of Resident's R1 clinical record it revealed admitted on February 7, 2024, for short term rehabilitation. Resident's R1 funding source was Medicare skilled A services. Conntinued review of the clinical record revealed that Resident R1 was discharge from the facility on March 15, 2024. Then, Resident R1 was readmitted from the local hospital on March 19, 2024 with Medicare Part A benefits. On March 26, 2024, at 12:21 p.m. an interview was held with the Social Worker Director who revealed that Resident R1 was discharged as the Medicare service benefits were exhausted. It was further reported when Medicare funding exhausted therefore, Resident R1 did not receive Notice of Medicare Non-Coverage (NOMNC) cms-10123 the right to appeal a denial of Medicare services. On March 26, 2024, at 2:11 p.m. an interview was held with Administrator, Employee E1 and Business Director, Employee E6 who reported that Resident R1 was discharge mistakenly. Resident's R1's admitted was entered currently however, facility system started calculating Medicare remaining benefit days that were used from the Resident's R1 prior admitted in 2023; therefore, it gave a report to the facility that Resident's R1 Medicare benefits were exhausted versus facility determined that a resident no longer qualifies for Medicare Part A. Employee E1 confirmed that Resident R1 should have not been discharged on [DATE]. And if Resident R1 was appropriately qualified to be discharged Notice of Medicare Non-Coverage (NOMNC) cms-10123 should have been issued. 28 Pa Code 201.29(a) Resident rights

Based on review of facility documentation, review of policy and procedures, review of clinical records, review of hospital records, observation and interviews with staff, it was determined that the facility failed to provide adequate supervision to a resident with a history of over-the-counter medication usage. The facility failed to conduct a thorough assessment of the resident's environment to ensure that the resident was not in possession of over-the-counter medication for one of seven residents reviewed (Resident R31), which resulted in an Immediate Jeopardy situation. Findings include: Review of facility policy, Visitation, revised September 2022, revealed, Our facility permits residents to receive visitors subject to the resident's wishes and the protection of the rights of others in the facility. 1. Some visitation may be subject to reasonable clinical and safety restrictions that protect the health, safety, security, and or rights of the facility's residents. Restriction of Individual Visitors 6. If it is determined that an illegal substance (s) has been brought into the facility by a visitor, it is immediately reported to the charge nurse or supervisor. The supervisor and the Director of Nursing Services determine whether the situation warrants a referral of law enforcement. b. If items or illegal substances are in plain view, and these pose a risk to the residents' health and safety, the items may be confiscated by facility staff. The circumstances, description of the item(s), and rationale for confiscating are documented in the resident's record. c. Facility staff does not conduct searches of a resident or their personal belongings, unless the resident or representative agrees to the search and understands the reason for the search. Review of facility policy, Administering Medication, revised April 2019, revealed, Medications are administered in a safe and timely manner, and as prescribed. 27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. Review of facility policy, Personal Property, revised August 2022, revealed, Residents are permitted to retain and use personal possessions, including furniture and clothing, as space permits, unless doing so would infringe on the rights or health and safety of other residents. 8. If items or illegal substances that belong to the resident are in plain view, and these pose a risk to the residents' health and safety, the items may be confiscated by facility staff. The circumstances, description of the item{s), and the rationale for confiscating are documented in the resident's record. 9. Facility does not conduct searches of a resident or their personal belongings, unless the resident or representative agrees to the search and understands the reason for the search. Review of clinical record for Resident R31 revealed that the resident was admitted to the facility on [DATE], with the diagnoses of metabolic encephalopathy (altered mental status); hepatic encephalopathy (a loss of brain function as a result of failure in the removal of toxins from the blood due to liver damage); chronic obstructive pulmonary disease (disease process that causes decreased ability of the lungs to perform); protein calorie malnutrition; cognitive communication deficit; muscle weakness; major depressive disorder (major loss in interest in pleasurable activites); alcohol dependence; unspecified dementia; history of falling; shortness of breath; insomnia; anxiety disorder, hypertension (high blood pressure) and atrial fibrillation (irregular and rapid heart beat). Review of a Nurse Practitioner note dated June 25, 2023, at 1:06 p.m. revealed seen today for an acute visit requested by nursing for increased anxiety, screaming out, and fixating on Tylenol dosage. Per nursing, behavior started a few days ago. Patient asks for Tylenol every two hours. Nursing educated patient on Tylenol regimen and daily limit of 3 mg ( milligrams). Patient then begins with agitation, anxiety and yelling out not controlled with redirection. Of note, patient's family member bring her OTC (over the counter) Tylenol found by nursing and removed from room multiple times. Nursing supervisor previously educated family member about policy and protocol of patient self medicating. Patient Currently on Klonopin BID (twice a day) for hx (history of) anxiety. On assessment, patient reports wanting Tylenol or chronic pains. Agreeable to Q6H (every 6 hours) regimen. Review of nurse practitioner note for Resident R31 on September 7, 2023 at 12:39 p.m. revealed, Eighty-one year old long term care female seen today for an acute visit requested by nursing for altered mental status described as increased lethargy, weakness and garbled speech. On assessment, patient lying in bed, easy to arouse, uncomprehendable speech (not baseline), generalized weakness throughout. Pupils 4mm brisk b/l. Facial features symmetrical. BP (blood pressure)180/70; heart rate 110; temperature 96.0 rectal. Of note, nursing reports new Tylenol bottle found in patient's room. 125 tablets missing, unclear when she obtained bottle and how much was taken. Patient has history of this occurrence with Tylenol overdosing. Rapid Covid-19 is negative. Resident was transported to hospital 911 with altered mental status, hypothermia (a condition of having a lower body temperature than normal body temperature) and possible Tylenol overdose. All emergency contacts called with no replies, unable to leave a voicemail, resident is responsible party. Review of hospital toxicology revealed, Acetaminophen level is 173.3. Acetaminophen level elevated. Will start NAC (N-Acetyl Cysteine which comes from the amino-acid L-cysteine. Amino acids are building blocks of protein). Spoke with Poison Control Center. Initiate NAC). Will admit. Further review of Resident R31's clinical record revealed Resident R31 was discharged from the hospital and readmitted to the facility on [DATE]. Review of Resident R31's updated care plan revealed that I am at risk for medication overdose related to history of overdose of Tylenol. The goal was I will be free of overdose related to Tylenol Medication. The interventions listed included Assess resident's pain level; Psych consult; Staff to observe environment for safety concern. Continued review included: Physician's order update: Monitor resident's room for medication not prescribed. Further review of Resident R31's clinical record of December 4, 2023, revealed, During AM care, Resident R31 was found with a bag of pills, marked Tylenol ER (about 45 pills in total). Resident would not give explanation about why she has the pills or who gave them to her. The resident stated, 'I did not take any tonight.' Assessed the resident and resident is AAO X 3 (alert to person, time and place), able to make own needs per baseline vital signs. Message left for MD (physician) and house supervisor was made aware. Attempted to educate resident on harmful amount of Tylenol, and self administration without MD and staff aware, and resident did not verbalize understanding and may need further teaching and reinforcement. Nursing will continue to monitor. Review of Nurse Practitioner's note of December 4, 2023 revealed, seen today for an acute visit requested by nursing after a bag of OTC Tylenol found in patient's room. This is a reoccurring issue with this patient, in which visitors bring patient large amounts of Tylenol and patient self-administers over the recommended amount (3G daily). This is evidenced by previous hospitalization for AMS 2/2 to Tylenol overdose. At that time, patient found with large quantity of Tylenol in her room. Unclear how many Tylenol she ingested, but Tylenol level at hospital was 173.3, poison control involved at that time and NAC (N-acetylcysteine) given. Today, patient observed lying in bed, alert and conversing STAT (immediate) Tylenol level ordered. Collection Date: December 4, 2023 11:00 Reported Date: 12/07/2023 15:07: 121 ug/ml Ref. Range 10-30 There is no follow up note to review. Review of Nurse Progress note of December 20, 2023, revealed, Resident was found with a large bag of pills in her bed, approximately 50 white oblong pills that appear to be Tylenol ES. Resident refuses to report where the pills came from or how many if any were taken. Resident appears stable at baseline. House Supervisor made aware and Nurse Practitioner. NP (Nurse Practitioner) ordered a stat Tylenol level. Resident ordered to be seen by Psych. (Tylenol stat level revealed: none detected) Review of care plan Follow-up Action: I am at risk for medication overdose related to history of overdose of Tylenol. Goal: I will be free of overdose related to Tylenol medication. Interventions: Assess resident's pain level; Grandson educated on the importance of supplying resident with Tylenol without facility/doctor's approval. Grandson educated on risk of resident taking additional medications; Psych consult; Staff to observe environment for safety concerns; stat Acetaminophen level ordered. Review of Psych note of December 20, 2023, revealed, There is concern that somebody brought her Tylenol She continuously complains of pain and that she needs Tylenol. Does not remember when she last received and insists 'I did not have it' when asked about her pain she is very non-specific. She becomes more irritated with continuous questions. Relates she is depressed and wants to go to the 'other place'. Medication change was made. (Ariprizole 2-3 mg may help better treat the anxiety in collaboration with duloxetine). An interview on January 23, 2024, at 1:00 p.m. with Employee E17, Regional [NAME] President, revealed, We were unable to find the supplier. Staff reports that this resident does not have visitors. We were unable to reach any of the emergency contacts. Resident is her own responsible party. Finally, on December 20, 2023, the Unit Manager saw the resident's grandson visiting. The nurse spoke with grandson to see if he knew how resident was receiving outside Tylenol. Grandson stated that he had been bringing them in because resident calls him and says that she needs them due to her being in pain. Grandson educated on resident receiving prescribed Tylenol and that she has a scheduled time that she receives them. Grandson reported that she tells him that she does not receive Tylenol at all and that Tylenol is the only thing that helps with her pain. Grandson educated on Tylenol toxicity affects on the body, including lethargy, nausea and vomiting as well as abdominal pain. Grandson voiced understanding and apologized. He stated that no matter how much she calls and begs, he will not bring her anymore Tylenol. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on January 23, 2024, at 3:29 p.m. for the facilities failure to provide adequate supervision to a resident with a history of over the counter medication usage. The facility failed to conduct a thorough assessment of the resident's environment to ensure that the resident was not in possession of over the counter medication. An IJ template was provided to the facility The facility submitted a written plan of action on January 23, 2024, at 8:18 p.m. and implemented the the plan of action which included: 1. Resident has been assessed by the physician for pain management and psychosocial support. No changes were made to the pain medication regimen and the Geripsychologist was contacted for a follow up bedside visit. The diagnosis of PTSD (Post Traumatic Stress Disorder) was added with interventions for psychosocial support. Additionally, interventions were added for evaluation, management and compliance with pain medication regimen. All care plans have been updated. Completed 1/21/2024. 2. Licensed Nursing Home Administrator completed a visual audit of all resident rooms for both nonprescription and prescription medications. Any variances were reported to the physician for clarification and orders for self-medication, if appropriate. Completed 1/19/2024. 3. Immediate Actions/Education -Nursing Administration completed an audit of all residents to ensure anyone identified with similar concerns was assessed and provided immediate treatment and care planning. Any identified variances were immediately referred for physician evaluation. Completed 1/21/2024. -Nursing Administration completed a 7 day look back in EHR(Electronic Health Record) to identify any omission of documentation or any medication administered outside of parameter/indication for usage. Any variances were reported to the physician for follow up. Completed 1/21/2024. -LNHA, DON and ADON were educated on ERS (Electronic Reporting System) and requirements for reporting. Completed 1/21/2024. -Staff have been educated in visually inspecting rooms during care and in room visits for the presence of prescription and non-prescription medications at the bedside, in room searches as resident allows, greeting all visitors and monitoring for items brought in and the reporting requirements. Completed 90% by 1/21/2024. The remainder will be completed by 1/24/2024. -Resident has an updated pain assessment and care plan mapping the pathway for pain control including PRN medications with specific indications for usage. Completed 1/20/2024. -A mattress audit has been completed to ensure all are in good shape and maintaining pressure reduction. This audit was completed in an attempt to eliminate all causes of discomfort/pain. Any variances were reported to Plant Operations for installation of new mattress. Completed 1/21/2024. -Resident has an updated trauma informed care evaluation and care plan mapping the pathway for individualized psychosocial care. Completed 1/20/24. -Social Service designee will review all diagnoses and behavioral indicators to ensure anyone identified with similar concerns was assessed and provided immediate treatment and care planning. Completed 1/20/2024. 4. Ongoing Compliance will be monitored by: -Visual audit of all resident rooms for both non-prescription and prescription medications every shift for three days, then daily for three days, the three times per week for two weeks, weekly for two weeks then monthly for two months. Any variance will be reported to the RN Supervisor on duty for immediate follow-up. -Review of PCC dashboard on all PRN usage for any patterns/trends every shift for three days, then daily for three days, then three times a week for two weeks, weekly for two weeks then monthly for two months. Any variance will be reported to the RN Supervisor on duty for immediate follow-up. On January 24, 2024, the Action Plan was reviewed and interviews were conducted with nursing staff to confirm the in-service education was completed. Following the verification of the immediate action plan, the Nursing Home Administrator was notified that the Immediate Jeopardy was lifted on January 24, 2024 at 3:50 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3) Nursing services

Based on review of clinical records, review of facility policies and interviews with staff, it was determined that the facility failed to obtain physician's orders related to the administration of a [MEDICAL CONDITION] medication, which resulted in actual harm to Resident R38, who did not receive [MEDICAL CONDITION] medication, experienced a [MEDICAL CONDITION], was transferred to the hospital via Emergency Medical Services and hospitalized for [REDACTED]. The facility failed to ensure that a blood thinner medication was administered as order by the physician for two of 26 residents reviewed. (Resident R8) Findings include: Review of the facility policy, Medication Pass Policy date revised, January 09, 2020, revealed, The rights of medication administration are important points to check for the medication managers when assisting with medications. Checking these points helps to protect the resident's right to: The Right Drug - When assisting with medications, always be sure that you give the correct drug. Compare the information about the drug on the MAR indicated [REDACTED]. Review of Resident R38's quarterly Minimum Data Set (MDS- a periodic assessment of resident needs) dated September 29, 2019, revealed the resident had [DIAGNOSES REDACTED]. Further review of the MDS revealed that Resident R38 needed extensive assistance with bed mobility, transfers, dressing, toileting, hygiene and was totally dependent on staff with baths. Review of Resident R38's summary of neurology visits related to her [MEDICAL CONDITION] disorder dated August 9, 2019, indicated that the physician wanted to continue Resident R38's [MEDICAL CONDITION] medication, [MEDICATION NAME] ([MEDICATION NAME]), in titrating doses (gradually increasing the dose on a schedule) as follows: Weeks 1+2 (7/30/19 - 8/12/19): take 25 milligrams (mg) daily Weeks 3+4 (8/13/19 - 8/26/19): take 25 milligrams (mg) every 12 hours Week 5 (8/27/19 -9/2/19): take 50 mg every 12 hours Week 6 (9/3/19 -9/9/19): take 100 mg in the morning and 50 mg in the evening Week 7 (9/10/19 -9/16/19): take 100 mg every 12 hours Further review of this neurologist visit revealed, Please follow-up after titration completed. Review of Resident R38's neurological visit summary dated September 13, 2019, stated Week 7: take 100 mg twice a day and continue at this dose. Review of Resident R36's September 2019 Medication Administration Record [REDACTED]. Review of the nursing progress note dated September 25, 2019 at 11:40 a.m. revealed, The charge nurse called to room, res (Resident R38) having a [MEDICAL CONDITION]. Res remains lethargic and unresponsive. The resident was transferred via Emergency Medical Services 9-1-1 to the hospital. Review of the facility incident investigation dated September 25, 2019, noted charge nurse called to room resident having a [MEDICAL CONDITION] while sitting on the toilet. Resident didn't hit her head resident held for safety. Resident placed on floor by CNA (nursing assistant) and charge nurse for safety while resident still having a [MEDICAL CONDITION]. Res (resident) airway maintained. Vital signs and O2 (oxygen) applied. Review of the hospital report, signed by the doctor on September 27, 2019 stated per the facility . patient stopped [MEDICATION NAME] on 9/16/19 due to miscommunication between outpatient neurologist and facility; outpatient neurologist did recommend continuing [MEDICATION NAME] on 9/13 visit. Interview with the Director of Nursing on February 26, 2019 at 11:30 a.m., confirmed that the facility failed to obtain Resident R38's [MEDICAL CONDITION] medication order, following the resident's neurology appointment on September 13, 2019. This resulted in serious harm to the resident, who did not receive the medication for a period of nine days, experienced a [MEDICAL CONDITION] and was subsequently hospitalized . The facility failed to communicate and obtain orders for the resident's physician's related to the administration of a [MEDICAL CONDITION] medication, which resulted in actual harm to Resident R38, who did not receive [MEDICAL CONDITION] medication beyond September 16, 2020, experiencing a [MEDICAL CONDITION] on September 25, 2020 requiring transfer to the hospital via Emergency Medical Services and hospitalization . Review of the clinical record for Resident R8 revealed the resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident R8's admission Minimum Data Set (MDS-periodic assessment of resident needs) dated July 7, 2019, revealed that the resident had a BIMS (Brief Interview for Mental Status, a brief screening tool that aids in detecting cognitive impairment) score of 3, indicating the resident was severely cognitively impaired. Review of Resident R8's July 2019 Medication Administration Record [REDACTED]. Review of the electronic order dated July 9, 2019 to August 18, 2019 revealed an order for [REDACTED]. Further review of the Medication Administration Record [REDACTED]. Interview with the Director of Nursing on February 29, 2020 at 11:20 a.m. revealed that the facility changed their process from paper charting for medication administration to electronic charting of medication administration on July 23, 2019. Further interview with the Director of Nursing revealed that Resident R8's order for Xarelto was incorrectly categorized in the new electronic system and was not seen during medication administration. The facility failed to ensure that Resident R8 received the blood thinner as ordered by the physician. 28 Pa Code 201.18(b)(1) Management 28 Pa Code 211.10(e) Resident care policies 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on observations, interviews with staff, and review of facility policies, procedures and clinical records, it was determined that the facility failed to ensure physician's orders were implemented related to adequate supervision and assistance during meals related to the consistency of liquids, resulting in actual harm to one resident (Resident CL1). FINDINGS INCLUDE: Review of the Resident's physician's orders, dated [DATE], revealed [DIAGNOSES REDACTED]. He was admitted to the facility on [DATE]. Review of the physician's orders dated July, 2013 revealed that the resident was on a regular diet supported by his physician's verbal order, dated [DATE], stating that all liquids be of a honey thicken consistency. Interventions for his plan of care during meals included staff assistance while eating and drinking. Resident CL1's Skill Nursing Progress Notes, dated [DATE], revealed that his bed was elevated to position him to receive his breakfast assisted by Employee E1, nurse aide. The resident was served eggs and orange juice that was not thickened. During the meal, he began to choke. The Resident became stressed and Employee E1 left the room to search for help. When she returned to the room Employee E2, licensed nurse, was suctioning egg contents from his mouth. Employee E1 admitted failing to compare his meal ticket to the items on his tray before giving him the orange juice to drink. She stated he drank the entire glass of orange juice before he began to choke. Emergency Services 911 was notified immediately. According the Resident's progress notes, dated [DATE], when EMS arrived, the Resident was intubated and found to have food in his airway. Resident was not responding and CPR was initiated. Epinephrine (drug to treat a severe allergic reaction) was administered IV and oxygen provided. He was immediately transported to Hahnemann University Hospital for care and treatment. According to the hospital emergency records, Resident CL1 was examined at 9:44 a.m. at the hospital. He was diagnosed to be in cardiac arrest. There was no palpable pulse or heart sounds. He expired at 9:51 a.m., [DATE]. The facility failed to monitor and supervise this resident by failing to follow the resident's plan of care to ensure safe eating techniques as prescribed by the physician. This failure resulted in actual harm to this resident. 28 Pa. Code: 201.18(b) (1) Management. 28 Pa. Code: 201.18 (e) (1) Management. 28 Pa. Code: 211.12(d) (5) Nursing Services