Every finding on record at Luther Woods Nursing and Rehabilitation Center

Based on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement contact precautions for three of three resident rooms reviewed (room [ROOM NUMBER], 225, and 216).Findings include: Review of facility policy, dated February 6, 2020, titled Transmission Based Precautions (TBPs), indicated Transmission based precautions are designed for patients documented as suspected to be infected or colonized with highly transmissible or epidemiologically important pathogens for which additional precautions beyond standard precautions are needed to interrupt transmission. Further review revealed Contact precautions: In addition to standard precautions, for specified patients known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the patient (hand or skin-to-skin contact that occurs when preforming patient-care activities that require touching the patient's dry skin) or indirect contact (touching) with environmental surfaces or patient care items in the patient's environment. Use the contact precaution special enteric sign or patients with C difficile and/ or norovirus. Review of Contact Precaution sign, indicates Preform hand hygiene using soap and water and/or alcohol-based rub before entering and before exiting room. Wear gown when entering room, remove before exiting room. Wear gloves when entering room, remove before exiting room. Bag linen and discard trash to prevent contamination of self, environment or outside bag. Observation of Employee E7, Nurse Aide on May 13, 2026 at 11:15 a.m., preforming care by stripping bed in room [ROOM NUMBER]. Observation of door indicated resident on Contact precautions. Employee E7, Nursing Assistant observed with no gown. Employee E7, exited room holding soiled linens, not bagged, Employee E7 walked down hallway to linen cart to dispose of soiled linens. Interview with Employee E3, Assistant Director of Nursing on May 13, 2026 at 11:30 a.m., confirmed room [ROOM NUMBER] was on contact precautions and staff are required to wear gowns when entering room and all linens should be bagged prior to exiting the room. If one person in the room is on contact precautions, the whole room is on contact precautions to prevent any confusion with staff. Observation of Employee E6, Maintenance assistant on May 13, 2026 at 11:40 a.m., entered room [ROOM NUMBER], with contact precaution signage on door. Employee E6 did not wear gown or gloves and did not sanitize or wash hands upon entering or exiting room. Interview with Employee E6, Maintenance assistant on May 13, 2026 at 11:45 a.m., revealed I am not really taught about those signs, I don't really do that. Observation of Employee E5, Housekeeping assistant on May 13, 2026 at 12:15 p.m., in room [ROOM NUMBER], contact precaution sign visible on door. Employee E5 not wearing gown while in contact precaution room. Interview with Employee E5, Housekeeping assistant on May 13, 2026 at 12:20 p.m., revealed housekeeping only puts the gowns on if they have covid and housekeeping doesn't have to. Interview with Employee E3, Assistant Director of Nursing on May 12, 2026 at 12:30 p.m., confirmed resident rooms 210, 225 and 216 on contact precautions and infection prevention and control policy should be followed by all staff entering and exiting room. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(5) Nursing services. 28 Pa Code 211.12 (d)(1)(5) Nursing services

Based on staff interviews, review of facility's policy and the review of clinical records, it was determined that the facility failed to ensure that complete and accurate documentation for one of one resident reviewed for elopment risk (Resident R1).Findings include:Review of facility policy titled, Elopement/Seeking Behaviors, dated January 29, 2024, revealed, upon admission to the center, each patient will be assessed for elopement/exit seeking history and/or behaviors using the elopement Risk Tool Assessment.Review of Resident R1 clinical records revealed That Resident R1 was admitted to the facility on [DATE], with diagnosis including Alzheimer ' s Disease and had a BIMS score of five, indicating moderate cognitive impairment.Further review of Resident R1 ' s Elopement Risk evaluation, dated October 5, 2025, revealed a score of one, indicating low risk for elopement. Review of Resident R1 ' s care plan, date-initiated September 19, 2025, revealed that the resident is at risk for elopement related to dementia and had a wander prevention band to front walker. Continued review of the Elopement Evaluation Assessment tool, dated October 5, 2025, indicated that Resident R1 had no diagnosis of dementia/cognitive impairment. Interview with Licensed Practical Nurse, Employee E4, conducted on November 3, 2025, at 11:36 a.m. confirmed that Resident R1 has a standing diagnosis of Alzheimer ' s dementia and is cognitively impaired. Further interview confirmed Section F titled, Diagnosis ' , was coded incorrectly. 28 Pa Code 211.12(c) Nursing services

Based on clinical record review, facility policy and documentation, and interviews with staff, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of one residents reviewed for elopement risk (Resident R1). Findings include:Review of facility policy titled, Elopement/Seeking Behaviors, dated January 29, 2024, revealed, upon admission to the center, each patient will be assessed for elopement/exit seeking history and/or behaviors using the elopement Risk Tool Assessment.Review of Resident R1's clinical records revealed that Resident R1 was admitted to the facility on [DATE], with diagnosis including Alzheimer's Disease and had a BIMS score of five, indicating moderate cognitive impairment. Further review of Resident R1's Elopement Risk evaluation, dated October 5, 2025, revealed a score of one, indicating low risk for elopement. Review of Resident R1's care plan, date-initiated September 19, 2025, revealed that the resident is at risk for elopement related to dementia and had a wander prevention band to front walker.Review of incident report dated on October 27, 2025, revealed that on October 26, 2025, the receptionist hit the lock release button on the front door which allowed multiple visitors along with [Resident R1] to go through the entrance. [Resident R1's] wander guard alarmed when she re-entered the building. Review of undated witness statement by the Nurse Aide, Employee E3 revealed, [Employee E4] told me to run there is a resident left the building. She is in the parking lot. So I ran to the front door and the parking lot . I kept going to the road . when I got there, the resident was on the left side by the pool parking lot. Interview with the Director of Nursing, conducted on November 3, 2025, at 10:48 a.m. revealed that the incident occurred on October 26, 2025, at approximately 5:41p.m. and the resident had been located by Nurse Aide, Employee E3, on October 26, 2025, at approximately 5:44p.m.28 Pa. Code 201.14 (a) Responsibility of licensee.28 Pa. Code 211.10 (d) Resident Care Policies.28 Pa. Code 211.12 (d)(5) Nursing Services.

Based on observations, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that drug records are in order and that an account of all controlled drugs is maintained and reconciled for two out of two residents reviewed. (R2, R3)Findings include:Review of facility policy, Storage of Controlled Substances dated 2025, revealed, Medication classified by the Drug Enforcement Administration (DEA) as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations . Review of facility submitted documentation to the state survey office via Event Reporting System (ERS) on October 23, 2025, a misappropriation of patient property reporting that on October 22, 2025, the license nurse, Employee E5 did a narcotic count at the end of her shift with oncoming nurse, Employee E6. Everything seemed good until oncoming license nurse, Employee E6 noticed that on the PRN Oxycodone sheet later in the morning that the count went from 14 to 12 with only 1 table being signed out. It also looked like that resident, who has been asking for her PRN Oxycodone less and less, received 3 doses during the night shift. Oncoming license nurse, Employee E6 asked Resident R3 how many she had requested her PRN oxycodone during the night shift, and the resident RR3 answered that she had not asked for it at all. Director of nursing called Employee E5 to come in for an interview, During the interview, Employee E5 admitted to taking oxycodone. Employee E5 was immediately suspended pending the outcome of an investigation. At no time was this resident, or any other, without pain medication either related to the diversion or not. A report was made to the Hersham Policy Department, and a complaint was made to the PA Nursing Licensing Board . A review of the internal investigation a written statement written on October 22, 2025, by the Administrator, Employee E1 revealed on October 22 it was brought to my attention that there has been a discrepancy with an oxycodone narcotic count on B Wing. The first issue involved a male Resident R2, who had PRN Oxycodone 5 mg ordered. The med was DCD on 10/15/2025 after the resident stated to his physician that he had not taken it in almost 2 months. It was noted that [NAME] had signed it out seven times during her night shift to administer it to him. This involved 7 doses. When this was discussed with Employee E5 she insisted she had given it to him because he had asked for it. At this time, there was no reason to believe that Employee E5 had diverted the medication. The second issue occurred in the morning of October 22, 2025. It was noted that Employee E5 had signed out PRN Oxycodone 10 mg 2x for a different Resident R3, to find out how many times she had asked for the oxy during the night shift. Resident R3 shard that she had not requested it at all. At his time, we reached out to Employee E5 and asked her to come in for a meeting. The meeting occurred at approximately 4:15 p, Unit Manager, Employee E4, Director of Nursing (DON), Employee E2 and Administrator, Employed E1 were in attendance with Employee E5. DON explained to Employee E5 that they were dealing with a narcotic medication issue. Employee E5 first asked her again about Resident R2 and his sharing that he had not asked for oxycodone for almost 2 months. Employee E5 reiterated that she had absolutely given it to him. Then DON, E2 shared that there also now had been a discrepancy in Resident ' R3 narcotic count that very morning. Employee E appeared to be very nervous at this time. Employee E1 to her that we would be taking her to a drug test. She immediately stated that she was agreeable. Then she hesitated and told us that we would find marijuana in her system. DON, E2 and Admin, E1 both told her that they were not looking for marijuana, be were looking specifically for oxycodone. At this point E5 became distraught and started shaking. E5 looked back and forth to each of us and stated that yes, she had taken the medications .DON, E2 then asked her if she had taken the medication for herself. E5 replied, I already admitted it, please don ' t ask me to say more. I am so ashamed . A written statement completed on October 23, 2025, by the DON, E2 revealed, [unit manager, E4] informed me that there was a narcotic discrepancy on B wing from night shift to day shift. She was informed by day [licensed nurse E6] who stated she counted the narcotics with [license nurse, Employee E5] from night shift and all seemed find until she was reviewing narcotic sheets later in her shift, she noticed that the count went from 14 to 12 on one the PRN Oxycodone sheets with only 1 table being signed out. On investigation, the nurse signed out the narcotic for 3 doses during the night shift: not according to the physician order. Upon investigation of the narcotic book that is assigned to [licnsed nurse, Employee E4] on her shift, it was noted that another resident had been given his PRN oxycodone medication regularly by [licensed nurse, Employee E4] for the month of October up until 10/15 when the medication was discontinued by the attending as the resident had stated to him that he hadn't taken the medication for 2 months. I had spoken with the [resident R2] who stated that he did not ask for his pain medication on the night shift and had not taken it for some time. [licnsed nurse, Employee E2 met with [Licensed nurse, Employee E4] the same afternoon alone with the [Administrator, E1] and [Unit Manager, Employee E5] and Employee E5] admitted to having taken the above medications. [Employee E5] was immediately suspended pending the outcome of the investigation, the incident was reported to the local police and state Board of Nursing . A review of the facility ' s investigation revealed that a written text message dated, October 28, 2025 was provided by Licensed Nurse, Employee E5, to the Director of Nursing, Employee E2, in which E5 admitted to diverting narcotics.A review of the physician note dated October 15, 2025, stated [Resident R3] has chronic headaches that are well controlled. [Resident R3] has not used oxycodone for the past few months and does not wish to take Mucinex. [Resident R3] feels well with no current headache concerns. Medication was discontinued on October 15, 2025. A review of the clinical file Resident R2 was admitted to the facility on [DATE], with diagnosis of chronic pain syndrome. A review of the Medication Administration Report (MAR) for October 2025 indicated a physician order on August 9, 2024, oxycodone give 5 mg by mouth every 4 hours as needed for pain related to migraine with aura intractable with status migraineurs. Based on October 2025 MAR Resident R2 marked as received the medication on: October 3, 2025, at 12:10AAM and 5:55 AM by licensed nurse, Employee E5 October 7, 2025, at 5:55 AM, by licensed nurse, Employee E5 October 8, at 1:35 AM am 6:03 AM, by licensed nurse, Employee E5 October 12, at 05:38 AM, by licensed nurse, Employee E5 October 13, at 1:56 a.m. am 6:16 AM, by licensed nurse, Employee E5Review of Controlled Substance Inventory Count Sheets for Resident R2 revealed that his oxycodone was signed off by the license nurse, Employee E5 on October 8, 9, 11, 12, 13, 2025. Showing medication discrepancies on October 9 and 11th. An interview with the unit manager, Employee E4, on November 3, 2025, at 11:10 a.m. revealed that Resident R2 is alert and oriented. When Resident R2 stated that he/she had not requested the medication on October 15, 2025, the facility suspected a possible diversion of medication. Employee E4 reviewed the narcotic book and found that Employee E5 was the only staff member signing out the medication; no other nurse had signed for it. Additionally, after reviewing the Medication Administration Record (MAR), E4 identified a discrepancy between what was documented in the narcotic book and what was signed off in the MAR. Employee E4 reported the allegation of medication diversion to the Director of Nursing, Employee E2, on October 15, 2025, when the physician discontinued the medication.A review of the clinical record for Resident R3 admitted to the facility on [DATE] with diagnosis of chronic migraine. A physician order dated January 24, 2025, for oxycodone oral table 10 mg; give 1 tablet by mouth every 4 hours as needed for Mild/Moderate Pain 1-4/7-10 . A review of the October 2025 MAR revealed this medication was given to Resident R3 on October 22, 2025, at 12:11 a.m. as one dose given. A review of the Controlled Substance Inventory Count Sheets for Resident R3 revealed that during the night shift on October 21, 2025 from11:00 p.m. to 7:00 a.m., Licensed Nurse, Employee E5, documented signing out two pills, reducing the count from 14 to 12. The oncoming Licensed Nurse, who began the morning shift on October 22, 2025 from 7:00 a.m. to 3:00 p.m., noticed the discrepancy in the count and notified the Director of Nursing, Employee E2.On November 3, 2025, at 9:58 a.m., an interview was held with registered nurse, Employee E7 who confirmed a review of the Controlled Substance Inventory Count Book for the B back Wing medication card revealed that there were no dual signatures from the oncoming and outgoing nurses for November 1, 2025 evening shift 3:00 p.m. to 11:00 p.m. and night shift 11:00 p.m. to 7:00 a.m., for any shifts on November 2, 2025, and for the day shift on November 3, 2025 from 7:00 a.m. to 3:00 p.m., resulting in a total of six missing shift signatures. When Employee E7 was asked why she had not signed the narcotic count that morning, she responded, I actually forgot about it. On November 3, 2025, at 10:02 a.m., an interview was held with license nurse, Employee E8 who confirmed a review of the Controlled Substance Inventory Count Book for the A front Wing medication card revealed that there were no dual signatures from the oncoming and outgoing nurses for total of two shifts on November 2, 2025, from evening shift 11p.m. to 7 a.m. and November 3, 2025 from 7 a.m. to 3 p.m. When Employee E8 was asked why she had not signed the narcotic count that morning, she responded, there ' s no reason. On November 3, 2025, at 10:14 a.m., an interview was held with license nurse, Employee E9 who confirmed a review of the Controlled Substance Inventory Count Book for the A back Wing medication card revealed that there were no dual signatures from the oncoming and outgoing nurses for total of 5 shifts on November 1, 2025 evening shift 3:00 p.m. to 11:00 p.m. and night shift 11:00 p.m. to 7:00 a.m., for any shifts on November 2, 2025, and November 3, 2025 from 7 a.m. to 3 p.m. There was no signature for the ongoing nurse. On November 3, 2025, at 11:55 a.m. an interview was held with the Humar Resources Director, Employee E10 who provided validation that license nurse, Employee E5 was terminated due to violation of company policies. 28 Pa Code 211.9(a)(1) Pharmacy services28 Pa Code 211.9(k) Pharmacy services

Based on review of clinical records, facility policy and interview with staff, it was determined that the facility failed to conduct a complete and through investigation for an allegation of missing potential narcotic medication for 1 out of 2 residents reviewed (Resident R2). Findings include:Review of the facility policy, Discrepancies, Loss and/or Diversion of Medications, with a effected date of September 2018 indicated that All discrepancies, suspected loss, and/or diversion of medications, irrespective of drug type or class, are immediately investigated and a report filed. A review of the physician note dated October 15, 2025, stated [Resident R3] has chronic headaches that are well controlled. [Resident R2] has not used oxycodone for the past few months and does not wish to take Mucinex. [Resident R2] feels well with no current headache concerns. Medication was discontinued on October 15, 2025. A review of Resident R2's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnosis of chronic pain syndrome. A review of the Medication Administration Report (MAR) for October 2025 indicated a physician order on August 9, 2024, oxycodone give 5 mg by mouth every 4 hours as needed for pain related to migraine with aura intractable with status migraineurs. Based on October 2025 MAR Resident R2 marked as received the medication on: October 3, 2025, at 12:10AM and 5:55 AM by Licensed nurse, Employee E5 October 7, 2025, at 5:55 AM, by Licensed nurse, Employee E5 October 8, at 1:35 AM am 6:03 AM, by Licensed nurse, Employee E5 October 12, at 05:38 AM, by Licensed nurse, Employee E5 October 13, at 1:56 a.m. am 6:16 AM, by Licensed nurse, Employee E5Review of Controlled Substance Inventory Count Sheets for Resident R2 revealed that the medication oxycodone was signed off by the license nurse, Employee E5 on October 8, 9, 11, 12, 13, 2025. Showing medication discrepancies on October 9 and 11, 2025. An interview with the unit manager, Employee E4, on November 3, 2025, at 11:10 a.m. revealed that Resident R2 was alert and oriented. When Resident R2 stated that he/she had not requested the medication on October 15, 2025, the facility suspected a possible diversion of medication. Employee E4 reviewed the narcotic book and found that Employee E5 was the only staff member signing out the medication; no other nurse had signed for it. Additionally, after reviewing the Medication Administration Record (MAR), Employee E4 identified a discrepancy between what was documented in the narcotic book and what was signed off in the MAR. Employee E4 reported the allegation of medication diversion to the Director of Nursing, Employee E2, on October 15, 2025, when the physician discontinued the medication.An interview with the Director of Nursing on November 3, 2025, at 11:15 a.m. revealed that the Unit Manager, Employee E4, had notified her of the suspected narcotic diversion on October 15, 2025, involving Licensed Nurse, Employee E5. The Director of Nursing stated that because the Administrator, Employee E1, was out of the office and Licensed nurse, Employee E5 was not scheduled to return until October 21, 2025, the facility did not initiate an investigation into the suspected diversion at that time. On October 22, 2025, the facility received another allegation of medication diversion involving Resident R3 by the same Licensed Nurse, and an investigation was initiated. On the same day, at 12:08 p.m., the Director of Nursing confirmed that the facility did not investigate when the initial suspicion of medication diversion arose on October 15, 2025.28 Pa. Code 201.14(a)(e) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3)(e)(1) Management28 Pa. Code 201.29(c) Resident rights28 Pa. Code 211.10(d) Resident care policies

Based on observations and an interview with staff it was determined that the facility did not ensure that garbage and refuse was disposed of properly.Findings include: Observations in the receiving area conducted on November 18, 2025, at approximately 10:30 a.m. revealed piles of leaves covering multiple wooden pallets. Empty cans, dirty napkins, and cardboard boxes were observed mixed within the leaves. Further observations in the trash area revealed that the compactor and recycling containers were open, and black trash bags were exposed without lids. Furniture, including couches and chairs, was piled in the same area, with one couch positioned between the compactor and recycling box. Interview with Food Service Director, Employee E14 along duration of the tour confirmed observations of the receiving and dumpster area. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management

Based on review of facility policy, staff and resident interviews, and observation, it was determined that the facility did ensure a formal grievances process was in place for two of three units observed. (A Wing, B Wing). Findings Include: Review of the facility policy titled Grievances dated January 23, 2020 states, Policy- the patient has the right to voice/file grievances/complaints (orally, in writing or anonymously) without fear of discrimination or reprisal. The Administrator serves as the grievance official of the Center and is responsible for overseeing the grievance process and for receiving and tracking to their conclusion. A tour was taken with the facility Social Worker, Employee E9 on November 19, 2025 to identify where postings and grievance paperwork was located for residents. During the tour it was observed that A wing was missing grievance forms, the statement regarding the grievance process, and department of health posting information. A tour of B Wing revealed missing grievance forms, the statement regarding the grievance process, and department of health posting information. Social Worker, Employee E9 stated they no longer had the grievance forms available for residents or visitors on those units and could not specify how long they have not been up. In the lobby area there was one location where grievance forms were able to be found, but there was no posting about the grievance process, who the grievance official was, or how to form a grievance anonymously. A tour was taken on November 20, 2025 at 3:02 p.m. with Employee E1 the Nursing Home Administrator and it was confirmed the only place where the grievance forms were available was in the front lobby. When asked about the posting about how to form a grievance and who the grievance official was, Employee E1 stated, I didn't know there had to be something like that and I am the grievance official they can give the form to me, the social worker Employee E9, or place it in the box in the chapel. The box for anonymous grievances was observed in the chapel, and it was a box that was completely clear and not locked. The box currently being used would not be appropriate to allow to anonymous grievances as it is completely clear to access private information to anyone who enters the chapel. This was confirmed with the Nursing Home Administrator Employee E1. The facility did not have any postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing, the right to file grievances anonymously, the contact information of the grievance official with whom a grievance can be filed including, business address (mailing and email) and business phone number, a reasonable expected time frame for completing the review of the grievance, the right to obtain a written decision regarding his or her grievance, and the contact information of independent entities with whom grievances may be filed. Review of the facility Resident Council minutes dated September 26, 2025 states, Resident Rights Review- our grievance officer is Employee E9, our Social Worker. She will complete the grievance form with you and report to the Management Team and Investigate the issue. Grievance reports are completed within three days with the exception of missing items which is one month to allow time to search for the item. Employee E9 will report back to the resident and/or family when the report is closed. Interview held with awake, alert, and oriented residents on November 20,2025 and some residents had concerns about the grievance process. Six residents (Resident R1, R5, R24, R73, R149, and R150) stated that they were unsure about the formal grievance process or who the grievance official was. Some stated it was the social worker, some thought the nurse manager, and others thought the nursing home administrator. Interview held with the Nursing Home Administrator at 11:05 a.m. on November 21, 2025 confirmed that during Resident Council it was reviewed that residents could come to either me or {Social Worker, Employee E9]. 28 Pa. Code 201.18(b)(2) Management28 Pa. Code 201.29(a)(i) Resident rights

Based on observations, review of facility policy and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.Findings include: Review of facility policy titled, Cleaning dishes/Dish Machine undated, indicated that staff must check the dish machine gauges throughout the cycle to assure proper temperatures and sanitation. Observations conducted on November 18, 2025, at 10:12 a.m. revealed while the low-temperature dish machine was running, a review of the sanitizer ppm test strip with the Food Service Director (FSD), Employee E 14 revealed no color change, indicating no chlorine present. The acceptable range is 50-100 ppm. A second and third recheck were completed 3-5 minutes later with no change in color. Interview with dietary staff, Employee E15, revealed that she has been performing this task for 1-2 weeks, at least once per day, and does not check the chlorine when completing the dish machine task during her shift. Further observation of the dish room revealed it was not maintained in a sanitary condition. The soiled side of the dish room contained visible food debris on the counters and sink, and the prerinse station had buildup grime around the drain and backsplash. The floor in the area had scattered food particles, visible black dirt, and areas of black grime and residue. Mold or blackened residue was observed along the wall side up towards the dining room doors. The overall condition did not reflect routine cleaning practices. Interview with the Food Service Director, Employee E5, throughout the kitchen tour confirmed the above-mentioned findings. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policy, observations, review of clinical records, and interviews with staff and residents it was determined that the facility did not ensure to develop and implement comprehensive person-centered care plans for each resident and develop goals and interventions related to residents refusals, behaviors and residents diagnosed with Dementia, and PTSD for five of 26 resident records reviewed (Residents R3, R10, R11, R19, R136).Findings include:Review of facility policy titled Care Planning with a date of November 1, 2019 states, Policy- a licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health-related care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being of the patient. Further review of the policy revealed, .5. Care plans will be updated on an ongoing basis as changes in the patient occur and reviewed quarterly with the quarterly assessment.Review of the facility's policy titled, Care planning dated November 2019, states that the facility, Develops and implements an individualized care plan for each patient in order to provide effective person-centered care, and the necessary health-related care and serviced to attain or maintain the highest practical physical, mental and psychosocial well-being of the patient. Review of the facility's policy titled, Trauma Informed Care dated January 2020, states that the facility, Recognizes and acknowledges that residents who are trauma survivors may experience emotional, physical and/or psychological difficulties that should be addressed immediately, The same policy states, Immediately update the care plan to reflect information about trauma gathered from the patient. Resident R19 was admitted to the facility on [DATE], diagnosed with anxiety, major depression, and psychotic and mood disturbances (mental health diseases). Review of the facility's Trauma Informed assessment dated [DATE], for Resident R19 indicated the resident experienced domestic abuse and gun violence when the resident was previously shot in the leg.Review of a facility reported incident stated on July 16, 2025, Resident R19 was Found on the floor of her room lying next to her bed. The resident told staff that she had been having a nightmare/PTSD (post-traumatic stress disorder is a mental health condition that's caused by an extremely stressful or terrifying event - symptoms may include flashbacks, nightmares, severe anxiety about the event.) The resident sustained a small laceration on the resident's head at was sent to the hospital. Review of Resident R19 care plan revealed the PTSD incident focused on the fall not the actual PTSD. This was confirmed with the Director of Nursing on November 20, 2025, at 4:00 pm. that the facility failed to develop an appropriate care plan for the resident's PTSD. Review of Resident R136's clinical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Paraplegia (paralysis of the legs and lower body), Dementia with behavioral disturbances and mood disturbance (neuropsychiatric symptoms that accompany the syndrome of dementia, such as delusions, hallucinations, apathy, anxiety, depression, or disinhibition), lack of coordination (uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements), and Anxiety (an emotion characterized by apprehension and somatic symptoms of tension). Review of facility clinical progress notes for Resident R136 revealed the resident has been having aggressive behaviors (hitting) staffing and refusals as follows: September 6, 2025 note revealed, I asked resident if it was ok to complete his flush and he said okay. When I pulled the covers back he smacked my hand and told me to stop, get off of me.September 8, 2025 note reads, refused flush when I asked could complete it and asked me to get out. Review of Resident R136's physician order revealed a current order with an initial date of October 17, 2025, for paired care. Review of resident R136's current care plan dated September 15, 2025 did not include current goals or interventions to address Resident R136's aggressive behaviors (hitting) and refusals of medical care. Review of nursing notes and documented diagnoses for Resident R11, revealed that the resident was being followed by a psychiatrist and had a documented diagnosis of PTSD. Review of care plan revealed no care plan addressing Resident R11's PTSD, despite this diagnosis being noted in the hospital records dated January 4, 2025. Interview with the Director of Nursing, conducted on November 21, 2025, at 12:41 p.m. confirmed that no care plan for PTSD had been developed for Resident R11. A review of Physician Orders for Resident R3 revealed that the resident was ordered daily weights due to chronic systolic congestive heart failure, and nightly CPAP (a therapy device that delivers continuous air pressure to help individuals with sleep apnea breathe more easily during sleep). Review of the Medication and Treatment Administration documentation for the months of September, October, and November 2025 showed repeated refusals of both the daily weights and CPAP therapy. Progress notes dated August 17, 2025, indicated, MD (physician) notified of chronic refusals, and staff documented that they were unable to encourage compliance. Review of Resident R3's current care plan showed that no refusals care plan of individualized interventions was developed to address the ongoing noncompliance. Interview with the Director of Nursing, conducted on November 21, 2025, at 12:34 p.m. confirmed that there was no refusal care plan in place for Resident R3. Review of Resident R10's admission documentation revealed that Resident R10 was admitted in the facility on October 1, 2022, with the diagnosis of unspecified dementia (progressive degenerative disease of the brain). Review of Resident R10's current plan of care revealed that there was no care plan developed for Dementia Care.On November 20, 2025, at the time of the finding interview with the Director of Nursing confirmed the same.Review of Resident R84's admission documentation revealed that Resident R84 was admitted in the facility on May 2, 2022, with the diagnosis of Post-Traumatic Stress Disorder (PTSD). Review of Resident R84's current care plan revealed no care plan developed for Post-Traumatic Stress Disorder Care.On November 20, 2025, at the time of the finding interview with the Director of Nursing confirmed the same. 28 Pa. Code 211.10(c)(d) Resident care policies28 Pa. Code 211.12(d)(1)(5) Nursing services

Falling under Comprehensive Resident Centered Care Plan- The facility did ensure services provided met professional standards related to medication administration for one resident.Number of residents sampled:Number of residents cited: Findings include:The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11(b), General Functions of the Registered Nurse (RN), and 21.14(a), Administration of Drugs, indicated that the RN is fully responsible for all actions as a licensed nurse and is accountable to patients for the quality of care delivered, and administers medication ordered for the patient in the dosage and manner prescribed. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145(a)(b), Functions of the Licensed Practical Nurse (LPN), indicated that the LPN functions as a member of the health-care team by exercising sound nursing judgement based on preparation, knowledge, experience in nursing and competency, and administers medication ordered for the patient. Review of Resident R3's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis of Anemia (condition in which the blood doesn't have enough healthy red blood cells) and Chronic Kidney Disease (Longstanding disease of the kidneys leading to renal failure). Review of Resident R3's clinical record revealed an order dated September 21, 2025, for Fluticasone-Salmeterol 100-50 MCG/ACT Aerosol Powder, breath activated, give 1 puff by mouth every 12 hours for Chronic Obstructive Pulmonary Disease related to Acute Chronic Diastolic (Congestive) Heart Failure.Observation on November 19, 2025, at 9:12 a.m., of Employee E13, a Licensed Nurse, administering medications to Resident R3, revealed that Licensed nurse, Employee E13 gave 1 puff of Fluticasone-Salmeterol 100-50 MCG/ACT Aerosol Powder, by the mouth to Resident R3. Resident R3 was no observed rinsing (his/her) mouth after inhaling Fluticasone-Salmeterol. It was observed that Licensed nurse, Employee E13 did not encourage or educate Resident R3 to rinse (his/her) mouth after inhaling Fluticasone-Salmeterol to prevent the side effects of the Fluticasone-Salmeterol 100-50 MCG/ACT Aerosol Powder. Review of Resident R14's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis of Chronic Obstructive Pulmonary Disease, COPD, (A condition caused by damage to the airways or other parts of the lung. This damage leads to inflammation and other problems that block airflow and make it hard to breathe), and Endocarditis (Inflammation of the endocardium - the inner lining of the heart chambers and valves. Endocarditis is a life-threatening disease. In endocarditis, clumps of bacteria or fungi from another part of your body get into your bloodstream and collect on the endocardium).Review of Resident R14's clinical record revealed an order dated July 15, 2024, for Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG/ACT (Fluticasone-Umeclidinium-Vilanterol), 1 puff inhale orally one time a day related to Chronic Obstructive Pulmonary Disease.Observation on November 19, 2025, at 9:25 a.m., of Employee E13, the Licensed Nurse, administering medications to Resident R14, revealed that E13 gave Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG/ACT (Fluticasone-Umeclidinium-Vilanterol), 1 puff to inhale to R14. Resident R14 did not rinse (his/her) mouth after inhaling Fluticasone-Salmeterol. It was observed that Licensed nurse, Employee E13 did not encourage or educate Resident R14 to rinse (his/her) mouth after inhaling Trelegy Ellipta Inhalation Aerosol Powder Breath Activated.Review of literature related to the use of Fluticasone-Salmeterol Aerosol Powder and of Trelegy Ellipta Inhalation Aerosol Powder indicated the following procedure after inhaling those inhalers: Rinse the mouth with water after breathing in the medicine, spit out the water, do not swallow it.Interview on November 19, 2025, at 9:27 a.m., with Licensed nurse, Employee E13, confirmed that she was not aware of the need to rinse the mouth after inhalation of Fluticasone-Salmeterol 100-50 MCG/ACT Aerosol Powder or that of Trelegy Ellipta Inhalation Aerosol Powder. 28 Pa. Code: 201.18(b)(1) Management.28 Pa. Code: 211.12(d)(3)(5) Nursing services.

Based upon interviews with the resident, resident's family and staff interviews, review of clinical records, facility documentation and policies it was determined that the facility failed to ensure a resident admitted with a pressure ulcer received the necessary treatment and services, in a timely manner, consistent with professional standards of practice, to promote healing and prevent infection for one of 26 resident records reviewed (Resident R148). Findings include:Review of facility policy titled, admission assessment dated [DATE] states the assessment is to be completed by a licensed nurse when the patient arrives at the facility, prior to the end of the shift. If all information cannot be obtained prior to the end of the shift, remaining data sections will be completed within 24 hours. Licensed nurses are responsible for completing a physical assessment. Review of facility policy for Wounds/Skin Assessments dated [DATE] states any wound and/or skin impairment will be routinely assessed and treated as ordered. A licensed nurse will assess patients for any skin impairments, including pressure ulcers, Notify provider and/or updates and/or changes to the skin impairments, Obtain new orders, and Provide treatments as ordered.Resident R148 was admitted to the facility on [DATE], diagnosed with Chronic pain syndrome, unspecified severe protein-calorie malnutrition, systemic lupus erythematosus (an autoimmune disease effecting many parts of the body), rheumatoid arthritis (a chronic autoimmune disorder affecting the joints, causing pain and swelling) and infection and inflammatory reaction due to internal left knee prothesis. Observation and interview with Resident R148 and the resident's spouse, on [DATE], at 1:00 p.m. indicated the facility did not obtain a treatment order for a pressure ulcer, located on the resident's lower, when first admitted . The spouse voiced his concerns, stating, I was so mad, she was here for days without any treatments. Then, the nurse started documenting that they were treating her wound, but they weren't. Review of Resident R148's initial admission assessment dated [DATE], assessed the resident with a pressure wound on the left heel and left calf, bruising on top of the resident's arm and reddened area on the buttocks, failing to assess the pressure area on the resident's lower back. Review of the skin assessment the next day, dated [DATE], assessed the resident with a pressure ulcer on the lower spine measuring, 4.2 x 4.2 x 0.1cm, described as black and necrotic (tissue that has died prematurely). Review of the treatment administration record revealed a physician order was not obtained, nor treated until [DATE], two days after being admitted to the facility.Review of the physician orders dated [DATE], instructed to cleanse wound to lower back with wound cleanser, pat dry, apply Santyl and cover with Border Gauze every evening shift for wound care.Interview with licensed nurse, Employee E3 On [DATE], at 1:00 p.m. during an interview with licensed nurse Employee E3, stated on, [DATE], the nurse observed the treatment dressing on Resident R148's lower spine that was dated [DATE]. Interview with the Director of Nursing on [DATE], confirmed the facility failed to initiate wound care the day of Resident R148's admission to the facility.28 Pa. Code 211.10(c) Nursing services211.12(d)(1)(5) Nursing services

Based on clinical record review, review of facility policy and interviews with residents and staff, it was determined that the facility did not ensure that physician's orders were obtained regarding oxygen therapy for one resident out of 26 residents reviewed. (Resident R45) Findings include: Review of facility policy, Respiratory Care and Oxygen Equipment, dated January 29, 2024, states, Oxygen therapy will be administered per provider's order according to standards of practice. Observations during the initial tour of Unit A on December 9, 2024, at 11:35 a.m. revealed Resident R45, in bed wearing a nasal cannula (a device that delivers extra oxygen through a tube and into your nose) connected to an oxygen concentrator (a medical device that pulls air from the room, separates and compresses oxygen from the air, while also removing nitrogen) running at 4 liters per minute. Interview with Resident R45 revealed that she had been on the oxygen since her recent hospitalization . Further observation of Resident R45 on December 10, 2024, at 9:21 a.m. and again on December 11, 2024, at 11:33 a.m. revealed that she was wearing the nasal cannula receiving oxygen at 4 liters per minute. Review of Resident R45's medical record revealed no physician's order for oxygen therapy. Interview with the Director of Nursing, DON, on December 11, 2024, at 12:56 p.m. confirmed that Resident R45 had returned from an emergency room visit on 4 liters of oxygen continuously that she was able to find on her hospital discharge summary. The DON confirmed that the nurse had not put the order in for the physician for the continuous oxygen therapy at 4 liters per minute for Resident R45. 28 Pa. Code:201.18(b)(1)(3) Management. 28 Pa. Code:211.12(d)(1)(5) Nursing services.

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure that controlled drugs subject to abuse are stored and labeled in accordance with professional standards for one of two medication rooms observed (B wing medication room). Findings include: Review of Facility Policy on Policy: medication and biologicals are stored safely, securely, and properly, following manufacturer's recommendation or those of the supplier. The medication supply is accessible to licensed nursing personnel pharmacy personnel or staff members lawfully authorized to administer medications. Observation of the B wing Medication Storage room conducted on December 9, 2024, at 11:26 AM with Unit Manager Employee E8 revealed that the door to the medication room had a coded lock, further observation revealed that the code was written on the door jamb. Interview with unit manager Employee E8 conducted at the time of the observation confirmed that the pass code of the door lock was written on the door jamb. Observation of the medication refrigerator located inside the B wing medication room revealed that the medication refrigerator was not locked. Observation of the contents of the medication refrigerator revealed a transparent plastic box containing an opened bottle of Lorazepam 2m/ml with 30 ml of liquid inside. Further, the transparent plastic box containing an opened bottle of Lorazepam 2m/ml with 30 ml of liquid inside was not permanently affixed to the refrigerator. Interview with unit manager Employee E8 conducted at the time of the observation confirmed that the medication refrigerator door was not locked, and that the plastic box containing Lorazepam 2m/ml with 30 ml of liquid inside was not permanently affixed to the refrigerator. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code. 211.12(c) Nursing services 28 Pa. Code 211.12 (d)(1) Nursing services.

Based on observation, staff and resident interview, it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment for residents on two of three nursing units. (B Unit and C Unit ). Findings include: On August 21, 2024, at 10:10 a.m. tour observation was conducted with the unit manager, Employee E1 which confirmed the following observations: B Unit, room [ROOM NUMBER]'s bathroom had two bedpans exposed, while room [ROOM NUMBER] had three empty basins and four bedpans stored behind the toilet. room [ROOM NUMBER] had the entire baseboard removed and stored underneath the sink. The floors were being redone, with tiles missing near the toilet. Additionally, dirty linen was found behind the toilet, and there was a strong odor of feces in the restroom. The hallway across from the activity room, leading into the C wing resident area, had an exposed electrical baseboard heater approximately 30 feet long that was not properly covered. An observation in C Wing confirmed that Shower 1, located before the nursing unit, was cluttered with various items. The sink was filled with random objects, including a dirty hairbrush with brown hair, multiple briefs, single-use packs of zinc cream, a box of gloves, scissors, random socks, bottles of Vitamin D & A and cream, personal nightgowns, a sweatshirt, razors in a bucket, shoes on the floor, and boxes of briefs. The entire shower room was scattered with these items. The second shower in C Wing was being used as a storage space. It contained a sink with pink and brown substance, a standard mattress, a bariatric wheelchair equipped with an air mattress and pump, a geri- chair, a commode, and a large plastic bag filled with clothing. The floor was cluttered with shoes, socks, and a large floor mattress. The shower was completely filled with these items, rendering it unusable as a functional shower. These observations were confirmed by the unit manager, Employee E1. On August 21, 2024, at 10:40 a.m., an interview was conducted with Maintenance staff member, Employee E3. They confirmed the observation in room [ROOM NUMBER] regarding the missing tiles and the completely stripped baseboard, stating that the work had been started but was forgotten and left incomplete. Additionally, the shower in B Wing was noted to have a chipped tile on the baseboard edge, which was partially taped with tape. On August. 21, 2024 1:45 p.m. an interview was held with the Resident R13 who is resigning in room [ROOM NUMBER] reported that his bathroom floor and baseboard was ripped about two months ago and never finished. 28 Pa. Code 201.18(b)(1)(3) Management

Based on review of facility policy, review of clinical records, and interview with staff, it was determined the facility failed to provide pharmaceutical services to meet resident's needs including acquiring, receiving, and administering medications for one of 26 residents reviewed (Resident R45). Findings Include: Review of facility policy Medication Management/Medication Unavailability dated 04/21/2022 revealed the pharmacy provides and maintains written contractual services and procedures that ensure safe and effective drug therapy, distribution, control and use within the facility. If medications are determined to be unavailable for administration, the licensed nurse will notify the provider of the unavailability and request an alternate treatment if possible. The licensed nurse will document notification to the provider of the unavailability in the medical record. If alternate treatment is not available, then licensed nurse will activate backup pharmacy process and procedures. Review of Resident R45's physician order summary revealed an order dated February 10, 2024, to administer Pregabalin 50 milligrams (mg) two times a day, in the morning and at night (medication used to treat pain caused by nerve damage). Review of Resident R45's medication administration record revealed the resident did not receive the medication on 2/29/2024 morning dose, 03/01/2024 morning and night dose, 03/03/2024 night dose, and 03/04/2024 morning dose. Review of Resident R45's clinical record revealed nursing notes on the above dates that the medication was not administered because it was unavailable and awaiting delivery from the pharmacy. Continued review of Resident R45's clinical record revealed no documented evidence that the physician was made aware of the missed doses or that an alternate treatment was requested. Further review of the clinical record revealed no documented evidence the licensed nurse activated backup pharmacy process and procedures to obtain and administer the medication. Interview with the Director of Nursing, Employee E2, on March 21, 2024, at 2:24 p.m. confirmed Resident R45 missed doses of his medication and confirmed nursing staff did not follow policy and procedure to acquire and administer medication. 28 Pa. Code 211.9 (a)(1) Pharmacy Services. 28 Pa. Code 211.9 (d) Pharmacy Services. 28 Pa. Code 211.12 (d)(1) Nursing Services.

Based on review of facility documents and resident clinical record reviews and staff and resident interviews, it was determined that the facility failed to ensure a resident and resident's representative had the capacity to understand the terms of a binding arbitration agreement for four of 4 residents reviewed (Resident R35, R48, R93, R113,). Findings include: A review of the facility policy Binding Arbitration part 17. Revealed The resident and the facility agree that, unless prohibited by applicable federal or Pennsylvania law and except solely for any claims by the Facility regarding the Resident's failure to timely pay all amounts owed to the Facility under this Agreement, for which claim the Facility shall have the right specified in Section 21 and 22 , above any dispute whatsoever between or among the Resident the Responsible Party or any other of the Resident's representatives, guardians, heirs, executors and/or administrations and the Facility and/or its agents shall be resolved by binding arbitration. In the event of a dispute, the Resident and the Facility shall each select an attorney, both of which attorneys shall mutually agree upon an arbitrator who must be an attorney with an office in . Pennsylvania. The arbitrator shall investigate the facts and may, in his/her discretion, hold hearings at which the Resident and/or the Responsible Party may present evidence and arguments, be represented by counsel and conduct cross examination . The arbitrator shall render a written decision on the dispute as soon as practicable after her/his appointment. The arbitrator's decision, which may include equitable relief, shall be final and binding on the parties and judgment upon the decision may be entered in any court of competent jurisdiction. Review of admission record indicated Resident R35 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS- a periodic assessment of resident care needs ) dated February 15, 2024, indicated that a Brief Interview for Mental Status (BIMS) score of 15 - cognition intact. Review of Resident R35's Binding Arbitration Agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) indicated she signed the document on admission on September 17, 2019. Review of admission record indicated Resident R48 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS- a periodic assessment of resident care needs ) dated January 30, 2024, indicated that a Brief Interview for Mental Status (BIMS) score of 15 - cognition intact. Review of Resident R48's Binding Arbitration Agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) indicated she signed the document on admission on June 14, 2022 Review of admission record indicated Resident R93 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS- a periodic assessment of resident care needs ) effective January 30, 2024, indicated that a Brief Interview for Mental Status (BIMS) score of 15 - cognition intact. Review of Resident R93's Binding Arbitration Agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) indicated she signed the document on admission on April 3, 2023. Review of admission record indicated Resident R113 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS- a periodic assessment of resident care needs ) effective February 21, 2024, indicated that a Brief Interview for Mental Status (BIMS) score indicated 15 - cognition intact. Review of Resident R35's Binding Arbitration Agreement a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) indicated she signed the document on admission on February 9, 2023. On March 19, 2024, at 10:08 a.m. during entrance meeting Administrator, Employee E1 who reported that Admission Director, Employee E9 is the Lead on the Arbitration process. On March 20, 2024, at 10:30 a.m. a Resident Council meeting was held with 13 alert and oriented Residents (R31, R4, R48, R93, R21, R27, R55, R113, R35, R78, R36, R72). Four residents (R35, R48, R93, R113,) reported facility did not explain in the language that they would understand; therefore, they would like to revoke their signature from the arbitration agreement. On March 21, 2024, at 9:59 a.m. an interview was held with Admission Director, Employee E4, who confirmed that the arbitration agreement was missing the key elements of the arbitration it's not a condition of admission', the right to rescind the agreement within 30 calendar days of signing, and agreement may not contain any language that prohibits or discourages the resident or anyone else from communicating with federal, state, or local officials, including but not limited to federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long-Term Care ombudsman. Employee E4 also reported that she/he was not aware of the time frame to rescind the arbitration and Employee E4 would read the arbitration agreement to the Residents or Resident Representatives instead of to explain in the language that would they understand. 28 Pa. Code: 201.14(a)(c)(d)(e) Responsibility of licensee 28 Pa. Code: 201.18(e)(1) Management

Based on review of facility policy, review of clinical records, and interviews with residents and staff, it was determined that the facility failed to identify, implement, monitor, and modify interventions consistent with the resident's assessed needs to maintain acceptable parameters of nutritional status for two of two residents reviewed for weight loss (Resident R65 and R30). Findings include: Review of the facility policy titled Weight Monitoring and Tracking dated November 1, 2019, revealed the procedure for weight loss is as follows: the director of nursing is responsible for ensuring patients are weighed in a timely manner using proper techniques, an electronic system will be utilized for recording tracking and reporting weights and weight variances, weight will be verified within five days of a weight variance of five pounds since last weight or when a significant weight loss is identified , the significant weight loss will be identified and discussed by a interdisciplinary team, and the committee will investigate the possible causes of weight change, discuss interventions and document a progress note in the residents medical record. Review of Resident R65's clinical record revealed that Resident R65 was admitted to the facility on [DATE] with the diagnosis of schizoaffective disorder bipolar type (a mental health disorder that is marked by a combination of schizophrenia mood disorder of bipolar disorder), chronic respiratory failure (a condition where there is not enough oxygen or too much carbon dioxide in the body), COPD (Chronic obstructive pulmonary disease is a chronic disease that causes obstructed airflow from the lungs), type 2 diabetes (long term medical condition in which the body does not use insulin properly, resulting in unusual blood sugars), chronic kidney disease(also known as chronic kidney failure, a gradual loss of kidney function), chronic diastolic (congestive ) heart failure (a clinical syndrome of heart failure with a preserved left ventricular ejection fraction) peripheral vascular disease(a circulation disorder caused by narrowing, blockage or spasms in blood vessels), Major depressive disorder (a mood disorder that causes a persistent feeling of sadness) and as of February 6, 2024 an above the knee amputation of her right leg. Continued review of Resident R65's clincial record revealed a critical weight loss presented in the resident's documented history of vitals. Resident R65 had a documented weight loss begining on November 10, 2023, the resident's weight was documented as 190.2 pounds. The next weight documented for Resident R65 was December 6, 2023, which the significant loss was evident, the resident weight 164.4 pounds (a weight loss of 25.8 pounds in one month). The resident was re-weighed five days later and on December 11, 2023, and still exhibited weight loss at a weight documented of 163.8pounds. Resident R65 was not re-weighted until January 6, 2024 at that time, revealed a continued trend of weight loss, the resident weighed 155 pounds (a loss of 35.2 pounds). Resident R65 continued to show gradual weight loss as of March 4, 2024. Resident R65's documented weight was 141.0 pounds. Further review of Resident R65's dietary note dated December 20, 2023, two weeks after documented weight loss of twenty-five pounds, revealed that resident R65 was triggered for significant weight loss. The notation declared that Resident R65 weight loss was unplanned and unfavorable. It has been evident that Resident R65 has had decrease of intakes at meals. Likely contributing to the weight loss. The professional recommendation of this weight loss was to recommend adding magic cup 4oz three times a day (290kcal, 9g each) at meals to meet kcal needs. The goals of this dietary intervention were that the resident will maintain current weight without any significant changes and the Resident R65 will consume >75% of each meal without refusals. Interview with Register Dietician, Employee E6 and Regional Registered Dietician, Employee E5 on March 21, 2024 at 2:05 p.m., revealed that they were both aware of Resident R65 weight loss , it was believed to be contributed by the resident's leg amputation. Residents leg amputation was two months after the initial weight loss. Employee E6 was unable to comment to why this weight loss was not assessed and lack of any intervention in a timely manner. Review of Resident R30's quarterly Minimum Data Set (MDS - federally mandated resident assessment) dated February 4, 2024, revealed the resident had diagnoses of dementia (loss of cognitive functioning that interferes with daily life and activities) and dysphagia (swallowing difficulties). Review of Resident R30's comprehensive care plan revised March 19, 2024, revealed the resident was at risk for malnutrition (condition that develops when the body is deprived of vitamins, minerals and other nutrients it needs to maintain healthy tissues and organ function) related to dementia, dysphagia, and low BMI (body mass index - a measure of body fat based on height and weight). Review of Resident R30's weight history revealed a documented weight of 170.4 pounds on September 6, 2024. Review of Resident R30's clinical record revealed the resident was readmitted to the facility, from the hospital, on September 25, 2024. Review of Resident R30's nutrition assessment dated [DATE], completed by Employee E6, Registered Dietitian, revealed the readmission weight was pending and would further assess when available. Further review of the assessment revealed the resident was at risk for malnutrition and interventions included to monitor weekly weights as ordered. Review of Resident R30's physician order summary revealed weekly weights were ordered September 25, 2024. Review of Resident R30's clinical record revealed no documented evidence weekly weights were completed as ordered. Review of Resident R30's clinical record revealed the facility did not obtain a re-admission weight for the resident until October 2, 2024, seven days after readmission. Readmission weight obtained on October 2, 2024, revealed the resident weighed 160.4 pounds, reflecting a significant weight loss of 10 pounds and 5.8% in one month. Continued review of Resident R30's clinical record revealed the Registered Dietitian did not reassess the resident and modify interventions consistent with the residents needs until October 18, 2024, sixteen days after the identified weight loss. Further review of Resident R30's clinical record revealed the resident had a documented weight of 143 pounds on January 8, 2024, reflecting a 10 pound and 6.5% significant weight loss in one month (in comparison to a documented weight of 153 pounds on December 5, 2023). Review of Resident R30's clinical record revealed nutrition note dated January 15, 2024, by Registered Dietitian, Employee E6. Review of the nutrition note revealed it did not address Resident R30's significant weight loss on January 8, 2024. Resident R30's nutritional status was not accurately assessed to identify and modify interventions consistent with the resident's needs to maintain acceptable parameters of nutritional status. Continued review of Resident R30's clinical record revealed the Registered Dietitian did not reassess the resident and modify interventions consistent with the residents needs until January 24, 2024, 16 days after the identified weight loss. Interview was conducted with the Registered Dietitian, Employee E6, on March 13, 2024, at 2:13 p.m. Registered Dietitian, Employee E6, was unable to explain why the weights and nutritional status were not being monitored or addressed in a timely manner. 28 Pa. Code 201.18 (b) Management 28 Pa. Code 211.10 (c) Care policies 28 Pa. Code 211.12 (d)(5) Nursing services

Based on facility policy review, clinical record review, and staff interviews, it was determined the facility failed to develop and implement a comprehensive person-centered care plan to attain or maintain the highest practicable level in reference to communication for one of 26 residents reviewed (Resident 75). Findings include: Review of facility policy, titled Resident Assessment & Care Planning, effective date November 1, 2019 read, A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health -related care and services to attain or maintain the highest practical physical, mental and psychosocial well-being of the patient. Review of Resident 75's clinical record revealed admitted [DATE] with the diagnoses of Corticobasal degeneration (CBD) (a rare neurodegenerative disorder characterized by a progressive loss of nerve cells (neurons) in certain areas of the brain), paralysis of the vocal cords and larynx, bilaterally, [NAME] disease (a rare and progressive neurological disorder that primarily affects the central nervous system, particularly the brain) Review of Resident 75's care plan revealed a focus on increase communication between resident/family/caregivers about care and living. Review of the Resident R75's quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated February 11, 2024, indicated that the resident's BIMS (Brief Interview of Mental Status) is cognition intact. On March 20, 2024, at 9:34 a.m. an interview with the unit manager, Employee E3 reported that Resident R75 does communicate via paper and writing, but Resident R75 is nonverbal. On March 21, 2024, at 10:44 a.m. an interview with Resident R75 revealed that the resident prefered the use of paper and pen to communicate. On Resident's R75 tray a communication list was available and when surveyor tried to use it to communicate with Resident R75 became frustrated and started screaming noise. Nursing aide, Employee E8 came in and had to calm Resident R75 down by repeating that Resident R75 needs to write what she desires and not get frustrated. Employee E8 reported that Resident R75 only prefered to use paper and pen to write her needs and wants. Resident R75 did not like to use the communication board nor the ipad that a spouse obtained for her. On March 21, 2024 at 11:15 a.m. an interview was held with speech therapist, Employee E13 who concurred that Resident R75 exhibited a preference for communicating using traditional paper and pen rather than utilizing modern communication aids such as a communication board or an iPad. Despite efforts to provide alternative means of communication for quicker expression of needs, the resident remains resistant to these methods and continues to favor the use of paper and pen. On March 21, 2024, at 12:34 a.m. an interview with the unit manager, Employee E3 confirmed that Resident R75 has a strong preference to use paper and pen to communicate her needs and the comprehensive care plan did not provide any preference nor interventions to support the Resident R75 in the communication efforts. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on observations and interviews with staff, it was determined that the facility failed to promote care for residents that maintains or enhances dignity and respect related to dining for eight of 16 dining tables observed. Findings include: Observations of the main dining room on May 15, 2023, at 12:15 p.m. revealed the following: Three tables with two residents seated at each table, only one of two residents was served a meal. Further observations revealed three tables with three residents seated at each table, two residents were served a meal and one was not. Follow-up observations of the main dining room on May 16, 2023, at 12:08 p.m. revealed the following: Four tables with two residents seated at each table, one resident was served a meal and one resident was not. Another table with three residents seated at each table, only one of two residents were served a meal. Interview with nursing staff Employees E19, E20, E9, E10 on May 17, 2023, at 12:08 p.m. confirmed the above-mentioned findings. Further interview revealed residents were being served meals this way for at least three weeks. 28 Pa. Code 201.29(d) Resident Rights

Based on observations, staff and resident interviews, and facility documentation, it was determined that the facility did not provide a safe, clean, comfortable and homelike environment for two of 25 residents. (Residents R36 and R74) Findings include: A review of clinical record of Resident 74 revealed she was admitted to the facility on [DATE] with the diagnoses of unsteadiness on feet, muscle weakness and difficult in walking. Review of Resident R74's Admission Minimum Data Set (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) assessment dated , March 28, 2023, indicated that the resident's cognition was intact. Continued review of the MDS assessment revealed the resident was totally dependent of staff for bed mobility, transfer, dressing, personal hygiene, and toilet use with the assistance of two staff member. On May 15, 2023 at 11:02 a.m. and interview was held with Resident R74 who reported that the facility has a sit and stand Hoyer lift (mechanical device use to transfer a resident from one surface to another) which often are out of batteries. Resident R4 indicated that on May 14, 2023 the staff was using the standing lift and they got me on to stand, I told them the batteries will die and it did, they had 4-5 batteries to try that were not strong enough to keep me standing. Resident R74 further reported that she was not steady on her feet and the standing lift was not operating poorly as the batteries aren't strong enough. On May 17, 2023, at 9:46 a.m. an interview and observation conducted with Licensed nurse, Employee 4 who went to use the standing lift revealed that Employee 4 had to swap batteries as the battery that was on the lift wasn't working. Surveyor requested to test all standing and Hoyer and standing lift on B unit. The hoyer lift located in the B shower room was tested and did not work. Another unlabeled standing lift which was in the shower room was not working. Employee E4 had to go into the med storage room where they had batteries charging station to pull two batteries and see if this will get the standing lift to work. On May 17, 2023, at 7:58 a.m. an interview with Maintenance Director, Employee E13 reported that he ordered extra batteries and new replacing stations with 25 volts power and two weeks ago. It's a battery issues versus a lift issues. He brought a brand new battery to check the lifts that were not working and those started to work. On May 17, 2023, at 11:12 a.m. an interview was held with nursing assistant, Employee E26 who reported that there was rotation with charging B wing batteries. They established a protocol that shift from 11-7 will charge all the batteries after their use. Therefore when 7-3 morning shift comes in all batteries are ready to be used. However, night shift nurse aides who are agency staff and not always carry out the the protocol. Employee E26 stated that we have a total of 3 Hoyer and 2 standing lifts and when our shift is done we place batteries on the charging station; however, next shift which often is not regular staff the protocol might not be implemented. On May 15, 2023, at 12:01 p.m. observation was made of Resident R36 who was sitting in the wheelchair. The wheelchair was soiled with layer of grey dust around the wheels, Resident's R36 seat was rusted around the seat cushion When questioned Resident R38 if she has noticed that her wheelchair was extremely dirty with layers of grey disk and rusted seat Resident R36 replied that's what they gave me I don't like it but that's what I have. On May 17, 2023 at 12:10 p.m. an observation was made with Licensed staff, Employee E4 who confirmed the observation of Resident R36's chair was soiled with layers of grey dust and her seat was rusty. 28 Pa Code 201.18(b)(3) Management 28 Pa Code 207.2(a) Administrator's responsibility

Based on review of clinical records and interview with staff, it was determined that the facility failed to notify the physician in a timely manner of a change in the medical condition for one of 11 residents reviewed, resulting in actual harm to the resident who experienced a delay in treatment and was admitted into the hospital with [MEDICAL CONDITION] (Resident R1). Findings include: Review of the clinical record for Resident R1 revealed that the resident was admitted to the facility on (MONTH) 30, (YEAR) with diagnoses, including but not limited to, Cerebral Infarct (stroke), Flaccid [MEDICAL CONDITION] (weakness of one side of the body as a result of the stroke), Diabetes, [MEDICAL CONDITION] (loss of ability to understand or express speech, caused by brain damage), and Depression. An annual Minimum Data Set (MDS-assessment of care needs) dated (MONTH) 19, (YEAR), indicated that the resident had moderately impaired cognition and required extensive assistance from staff for personal care. Review of Resident R1's clinical record revealed progress notes dated (MONTH) 30, (YEAR), at 2:42 p.m. which indicated that the resident had been given Tylenol 650 milligrams for a temperature elevation of 101.7 degrees Fahrenheit (normal body temperature- 98.6 degrees Fahrenheit). Continued review of the progress notes indicated that within one half hour of receiving the Tylenol medication the resident was noted with a temperature of 103.7 degrees Fahrenheit. There was no documentation in the progress notes that nursing staff had contacted either the nursing supervisor and/or the resident's physician to notify them of the resident's initial temperature elevation of 101.7 or the later elevation of 103.7 degrees Fahrenheit. Continued review of nursing progress notes dated (MONTH) 30, (YEAR), revealed that the resident's temperature had decreased to 100.6 an hour later. It was further noted that the residents' SpO2 (oxygen concentration level in the bloodstream) was 96% (normal 98-100%) and that the resident had not eaten any lunch. Further review of the clinical record dated (MONTH) 30, (YEAR), at 10:50 p.m. approximately eight hours after the resident's first noted temperature elevation, revealed that Resident R1 was found to be clammy (skin-cool and damp to touch) had a temperature of 96.0 degrees Fahrenheit, that she was lethargic (abnormal drowsiness) and slow to respond. Additionally, the clinical record indicated that the resident did not eat or drink anything during the dinner meal. Additional review of Resident R1's clinical record revealed progress notes dated (MONTH) 31, (YEAR), at 12:50 a.m. ten hours after the resident's first temperature elevation, revealed that nursing staff had found the resident in bed unresponsive (not responding to external stimuli such as talking or touching the skin), clammy, and sweaty. The progress notes further indicated that Resident R1 was arousable only by hard sternal rub (pressure applied to the center of the chest using a closed fist to arouse someone who does not respond to verbal stimuli). The resident was noted to fall back to sleep after a few seconds. Additionally, the progress notes on (MONTH) 31, (YEAR), at 12:50 a.m. indicated that the night nurse (11 p.m.- 7 a.m. shift) received a shift report (review of the days events for each resident) from the evening shift nurse (3 p.m.-11 p.m.) that the resident had been this way all day and hadn't take any food, fluids, or medications today. Further review of the progress notes at 12:50 a.m. noted that Resident R1's vital signs were blood pressure of 94/68 (normal 120/80), pulse 104 (normal value 60 -100), temperature of 94.0, and oxygen percentage of 96%. The clinical record further indicated that the nurse then contacted a physcian about the resident's change in medical condition. The physician ordered the resident to be transferred to the emergency room for further evaluation and treatment. The resident was subsequently transferred to the emergency room at 12:30 a.m. on (MONTH) 31, (YEAR), approximately ten hours after the resident had experienced an acute change in their medical condition. Continued review of the clinical record for Resident R1 revealed that the resident was subsequently admitted into the critical care unit of the hospital with a [DIAGNOSES REDACTED]. Interview with the Director of Nursing on (MONTH) 3, 2019, at 3:00 p.m confirmed that the physician should have been informed of the change in the resident's condition when her temperature rose to 103.7 degrees Fahrenheit. The facility failed to ensure that a physican was notified of one resident's change in medical condition in a timely manner, resulting in actual harm to the resident. The resident who experienced a temperature elevation and a change in the level of their consciousness for a period of ten hours, before it was reported to the physician, experienced a delay in treatment and was subsequently admitted into the hospital's critical care unit with a [DIAGNOSES REDACTED]. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 03/20/18, 09/21/17 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 03/20/18, 09/21/17, 02/09/17 28 Pa. Code 201.18(e)(1) Management Previously cited 09/21/17, 02/09/17 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Previously cited 03/20/18, 09/21/17, 02/09/17 28 Pa. Code 211.12 (d)(2) Nursing services Previously cited 03/20/18, 02/09/17 28 Pa. Code 211.12 (d)(3) Nursing services Previously cited 09/21/17, 02/09/17

Based on review of a clinical record and facility documentation, and interviews with facility staff, it was determined that the facility failed to provide adequate and safe supervision related to a transfer of one resident reviewed, resulting in actual harm to that resident (Resident R1). Findings include: A review of Resident R1's clinical record revealed a Minimum Data Set (MDS - assessment of need), dated June 30, 2017, that indicated that this resident had severely impaired vision and that he had impairment of both upper extremities (shoulder, elbow, wrist and/or hand). This MDS also indicated that Resident R1 was totally dependent on staff and required the physical assistance of two staff persons for transfers. Review of the facility's policy, Stand Lift, (a mechanical lift device to raise and/or transfer a resident who is not able to do so without assistance), undated, revealed that two nursing staff members must be present and assisting/spotting when the stand lift is being utilized. Review of the clinical record for Resident R1 revealed a nursing note, on August 3, 2017, that indicated that this resident fell from a mechanical lift being utilized by Employee E1 for a transfer and that, as a result of the fall, the resident suffered a laceration to the back of his head. Review of the facility's documentation, dated August 3, 2017, revealed that Resident R1 was transported to the hospital where he received 13 staples to the back of his head. Review of facility documentation, Staff In-Service Record, dated June 30, 2017, revealed that Employee E1 had been in-serviced on that date on the proper techniques to be utilized when transferring a resident with a mechanical lift. In a interview with the Director of Nursing, at approximately 1:00 p.m. on September 21, 2017, it was confirmed that Employee E1 had been aware of the requirement for two staff persons to be present when utilizing a mechanical lift, but that only one member of the nursing staff had been present and assisting Resident R1 when he fell . The facility failed to ensure adequate and safe care for one resident during a transfer between a wheelchair and bed, resulting in actual harm to Resident R1 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 2/9/17 28 Pa. Code 211.10(d) Resident care policies Previously cited 2/9/17 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 2/9/17

Based on observations of resident care, clinical record reviews, hospital record review, interview with staff and reviews of policies and procedures, it was determined that the facility failed to assess, care plan and provide adequate supervision to prevent accidents for one of twenty-four residents reviewed (Resident R76). Findings include: The comprehensive assessments (an assessment of care needs) dated October 29 and January 26, 2016 for Resident R76 indicated that this resident was totally dependent on staff for bathing needs, required extensive assistance of staff for dressing needs and had a history of [REDACTED]. Observations of Resident R76 at 9:00 a.m., on March 4, 2016 revealed that this resident required extensive assistance of staff for activities of daily living (transfer, bed mobility, ambulation, dressing and personal hygiene). Nursing progress notes indicated that on November 5, 9, 10, 15, 21 and 28, 2015, Resident R76 was with a private companion E8, at various times during the day. On November 28, 2015 clinical record documentation indicated that the companion had given Resident R76 a bath. While in the shower room with the companion E8 Resident R76 fell from her wheelchair to the floor. The resident sustained [REDACTED]. The hospital records indicated that Resident R76 was treated for [REDACTED]. The nursing progress note dated November 29, 2015 indicated that Resident R76 returned to the facility with seven staples to the head. A review of the facility's policy and procedures for private companions indicated that the companions were not instructed/inserviced/trained or required to provide bathing assistance or dressing support for the residents. Interview with the director of nursing at 1:00 p.m., on March 3, 2016, confirmed that companion E8, brought Resident R76 to the shower room, gave the resident a shower and dressed the resident on November 28, 2015. While companion E8 was alone in the shower room with Resident R76, the resident fell and sustained a head injury. The event detail report submitted to the Department of Health on November 28, 2015 indicated that care planning to prevent further occurances of falls and maintain safety in the shower room for Resident R76, the facility was to provide two staff members to assist Resident R76 while the resident was receiving shower. A review of the clinical record for Resident R76 revealed that despite the resident's history of falls and falls with injury; there was no documented care plan in place for providing assistance during bathing/showering and dressing to prevent falls. The lack of care planning to provide adequate supervision to prevent accidents for Resident R76 was confirmed during an interview with the director of nursing at 1:30 p.m., on March 3, 2016. 28 PA. Code: 211.10(a)(b)(d) Resident care policies. 28 PA. Code: 211.10(c)Resident care policies. previously cited 4/30/15. 28 PA. Code: 211.10(a)(b)(c)Resident care plan. 28 PA. Code: 211.10(d) Resident care plan. previously cited 4/30/15. 28 PA. Code: 211.12(a)(c)Nursing services. 28 PA. Code: 211.12(d)(1)(2)(3)(4)(5)Nursing services. previously cited 4/30/15.

Based on review of the clinical records and interviews with staff, it was determined that the facility did not identify areas of skin breakdown prior to an advanced stage, to accurately assess a resident for pressure ulcers following hospitalization , and to obtain orders for the treatment of [REDACTED]. Findings include: Review of the clinical record revealed a Minimum Data Set (MDS - assessment of resident needs), dated September 10, 2013, that indicated Resident CL1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. This MDS also indicated that the resident had a poor appetite and that she was incontinent of bowel and bladder as well as having [MEDICAL CONDITION] and hallucinations. A nutritional assessment, dated August 30, 2013, identified the resident as being nutritionally at risk due to her poor intake. A nursing note , at 10:30 p.m. on September 10, 2013, indicated that an open area measuring 2.5 by 3 centimeters was noted on the resident's left bottom buttock. A progress note on September 11, 2013, notes a sacral wound. A nursing note on this date at 11:45 a.m. indicates that an unstageable pressure ulcer on the sacrum, measuring 1.5 x .9 centimeters and an unstageable wound on the right posterior thigh, were found. Review of the skin record sheets revealed that Resident CL1 was noted to have, in addition to a Stage II pressure ulcer on her left buttock found on September 10, 2013, on September 11, 2013, two advanced stage pressures ulcers were found: an unstageable pressure ulcer on her sacrum, measuring 1.5 x .9 centimeters, and right posterior thigh, measuring .2 x .7 centimeters. A nursing note, at 2:00 p.m. on September 13, 2013, revealed that the resident was admitted to a hospital behavioral health unit on this date. This same nursing note also referenced wounds present on the sacrum, right posterior thigh, and buttock. Review of the hospital records revealed a progress note, dated September 20, 2013, that indicated this resident had multiple pressure ulcers, including those on her sacrum and ischium. Upon readmission to the facility on [DATE], no pressure ulcers were noted on the Resident-Data Collection sheet reflecting assessment of the resident ' s skin. A nursing note (undated), identified as a late entry for September 20, 2013, indicated that the resident was noted to have a Stage 2 on her buttock measuring 4 x 1.5 centimeters, a Stage II wound on her left buttock measuring .5 X 1 centimeters. A nursing note dated September 23, 2013 at 6:30 a.m., indicates that the resident had open areas on the sacrum as well as right and left buttocks. Further review of the clinical record review revealed a wound care consultation, dated October 11, 2013, that indicated this resident had wounds that included an unstageable wound of the left ischium that had been sharply debrided (surgical procedure to cut away dead tissue) that day, and a Stage III sacral wound with a Stage II wound in the surrounding tissue. Review of the clinical record revealed that no treatments were ordered and administered for the resident ' s pressure ulcer wounds from the time of readmission from the hospital on September 20, 2013 until September 23, 2013. The delay in identifying this resident ' s wounds and obtaining and administering treatment orders resulting in a delay in treatment was confirmed in an interview with the Director of Nursing at 2:30 p.m. on November 12, 2013. The failure to identify pressure ulcers prior to an advanced stage and the delay in obtaining and administering treatment orders resulted in actual harm. 28 Pa. Code: 201.18(b)(1) Management. Previously cited 4/19/2011 & 2/24/12 28 Pa Code: 211.12 (d)(5) Nursing Services. Previously cited 4/19/2011 & 2/24/12