Every finding on record at Majestic Oaks Rehabilitation and Nursing Center

Based on clinical record reviews, interviews with residents and staff and reviews of residents' menus and dietary policies and procedures, it was determined that the facility failed to ensure that a suitable nourishing snack was provided in the evening for 10 of 10 residents reviewed. (Residents: R26, R65, R23, R66, R84, R81, R104, R26, R121 and R112)Findings include: A review of the facility policy and procedure titled snacks, between meal and bedtime dated September 2001 revealed that the facility staff were responsible for providing the residents with adequate nutrition. The policy indicated that a staff member was responsible for recording the date and time that the snack was given to the resident, the amount of snack eaten by the resident, any special requests for snacks and if the resident refused the snack the reason for the refusal. The policy indicated that the supervisor was to be notified of the snack refusal. A group meeting held with alert and oriented residents (R65, R23, R66, R84, R81, R104, R26, R121 and R112) at 11:00 a.m., on March 3, 2026, revealed that residents were requesting to be offered a suitable nourishing snack in the evening. Clinical record review for Resident R121 revealed that this resident was not offered an evening snack regularly from February 3, 2026, through March 2, 2026. Clinical record review for Resident R104 revealed that this resident was not offered an evening snack regularly from February 4, 2026, through March 3, 2026. Clinical record review for Resident R23 revealed that this resident was not offered a suitable evening snack from February 2, 2026, through March 3, 2026. Interview with Resident R23 at 11:15 a.m., on March 3, 2026, revealed that this resident preferred variety of foods or fluids for an evening snack. Clinical record review for Resident R26 revealed that this resident was not offered an evening snack routinely from February 3, 2026, through March 4, 2026. Clinical record review for resident R81 revealed that this resident was not offered an evening snack regularly from February 3, 2026, through March 4, 2026. A review of the residents' menus as planned and approved, by the registered dietitian, for regular, mechanically altered and therapeutic diets revealed that there was no evening snacks planned outside the traditional meal service times. Interview with the registered dietitian, Employee E14, at 11:00 a.m., on March 3, 2026, confirmed that there were no preplanned menus for residents with regular, mechanically altered and therapeutic diets to include snack foods and fluids. The dietitian also confirmed that foods and fluids preferred as a suitable nourishing snack in the evening for each resident was not assessed and implemented into the nutritional care plan. Interview with the director of dietary services, Employee E13, at 11:15 a.m., on March 3, 2026, confirmed that there was no formal plan for nourishing evening snacks for residents receiving regular, mechanically altered and therapeutic diets. The director of dietary services said that bulk food items were set to the nursing stations based on food supplies in the kitchen. 28 PA. Code 211.10(a)(b)(c)(d) Resident care policies 28 PA. Code 211.12(d)(2)(3)(5) Nursing services 28 PA. Code 211.6(a) Dietary services

Based on observations, interviews with residents and staff, and review of the facility policy, it was determined that the facility failed to provide a clean, safe, comfortable and homelike environment in one of the three nursing units observed (4th floor Nursing Units).Findings include: A review of the facility policy titled Homelike Environment revised February 2021, revealed Residents are provided with a safe, clean and comfortable and homelike environment and encouraged to use their personal belongings to the extend possible. It further states, these characteristics include clean, sanitary and orderly environment, clean bed, bath linens that are in good condition, pleasant, neutral scents. On March 2, 2025, at 10:41 a.m., observation was conducted with the Maintenance Director, Employee E12 who confirmed the following observations: -room [ROOM NUMBER]: Bathroom baseboard coming off; ceiling tile was damage. -room [ROOM NUMBER]: Call bell wire came off; not functioning per maintenance staff. -room [ROOM NUMBER]: No toilet paper bar; Resident R129 had no privacy curtain; middle drawer missing from door bed. -room [ROOM NUMBER]: Baseboard missing around sink bathroom. -room [ROOM NUMBER]: Bathroom door needed sanding; bathroom had holes present allowing visibility; no baseboard; exposed sheetrock near toilet and bottom of wall. -room [ROOM NUMBER]: Wall near door peeling. -room [ROOM NUMBER]: Bathroom call bell ripped out with exposed wires in the bathroom; baseboard damaged. -room [ROOM NUMBER]: Musty odor present. -room [ROOM NUMBER]: Bathroom had holes in the wall and damage to sheetrock; missing baseboards; exposed wires, two ceilings water-stained; wall around sink damaged; missing soap dispenser; hole behind toilet. -room [ROOM NUMBER]: missing toilet paper bar. -room [ROOM NUMBER]: missing bottom drawer. -room [ROOM NUMBER]: Both bedside drawers were broken; one of the two bedside drawers was missing a drawer. -room [ROOM NUMBER]: Both bedside drawers/tables broken; no toilet paper bar. -room [ROOM NUMBER]: Call bell not functioning. 28 Pa Code 201.18(b)(1)(3)Management

Based on clinical record review and interviews with staff, it was determined that the facility failed to ensure that advanced directives were accurately reflected in residence records for two of 31 residents reviewed (Resident R6 and Resident R9).Findings:Review of facility policy titled Advance Directives, revised [DATE], states If the Resident Has an Advance Directive: 1. If the resident or the residents representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the residents medical record and are readily retrievable by any facility staff. 2. The director of nursing services (DNS) or designee notifies the attending physician of advance directives (or changes in advance directives) so that appropriate orders can be documented in the resident's medical record and plan of care. Review of Resident R9's clinical record revealed that resident was admitted to the facility on [DATE], with the diagnosis of intracerebral hemorrhage (a disease that occurs when blood vessels in brain burst). Review of Resident R9's physician order, dated February 28, 2026, indicates DNR/DNI (Do not resuscitate/ Do not intubate) and active order. Further review of Resident R9's physician order, dated [DATE], indicates Full code/ DNI and remained active through [DATE]. Review of Resident R9's comprehensive care plan, dated [DATE], indicates Resident's code status is Full Code/ DNI. Review of Resident R9's Pennsylvania orders for life sustaining treatment (POLST) Section A. Cardiopulmonary Resuscitation (CPR): CPR/ attempt resuscitation was checked. Section B. Medical Interventions: Person has pulse and/or is breathing Limited additional interventions: Do not use intubation, advanced airway interventions or mechanical ventilation was checked. Section C. Antibiotics: Use antibiotics if life can be prolonged was checked. Section D. Artificially Administered Hydration/Nutrition. Long term artificial hydration and nutrition by tube was checked. Section E. Discuss with patient was checked. Further review of Resident R9's POLST form revealed that the form was signed by the physician and signed by Resident R9's responsible party, dated [DATE]. Interview with Director of Nursing, on [DATE], at 11:32 a.m. confirmed that Resident R9 maintained 2 conflicting orders in clinical record. Confirmed no updated POLST (Pennsylvania orders for life sustaining treatment), family to sign upon coming to facility. Confirmed resident R9's care plan reflects that resident is a full code/DNI. Review of Resident R6's clinical record revealed that resident was admitted to the facility on [DATE], with diagnosis of chronic kidney disease and Heart Failure.Review of Resident R6's physician order, dated [DATE], indicated Full code/ DNI, with an end date of [DATE]. No active order related to code status. Review of Resident R6's Pennsylvania orders for life sustaining treatment (POLST) Section A. Cardiopulmonary Resuscitation (CPR): CPR/ attempt resuscitation was checked. Section B. Medical Interventions: Person has pulse and/or is breathing Limited additional interventions: Do not use intubation, advanced airway interventions or mechanical ventilation was checked. Section C. Antibiotics: Determine use or limitation of antibiotics when infection occurs with comfort as goal was checked. Section D. Artificially Administered Hydration/Nutrition. No hydration and artificial nutrition by tube was checked. Section E. Discuss with patient was checked. Further review of Resident R6's POLST form revealed that the form was signed by the physician and signed by Resident R6, dated [DATE]. 28 Pa Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement enhanced barrier precautions for one of five residents reviewed with an indwelling suprapubic urinary catheter (Residents R13) and failed to disinfect a medical equipment on two of the three residents observed during medication administration (Resident R2, and Resident R3).Findings include: Review of facility policy, undated, on Cleaning and Disinfection of Environmental Surfaces, indicated that environmental and medical equipment surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard. Review of the facility policy titled Enhanced Barrier Precautions, dated December 2024, revealed: Enhanced Barrier Precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multidrug-resistant organisms (MDROs) to residents. EBPs employ targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply. On March 2, 2026, at 9:09 a.m. Licensed Practical Nurse (LPN), Employee E22, was observed using a Sphygmomanometer (an instrument for measuring Blood Pressure), without disinfecting it, before and after checking Resident R2's blood pressure. Observation of on March 2, 2026, at 9:37 a.m., during medication administration of Resident R3, Employee E22, used the Sphygmomanometer, without disinfecting it, before and after checking the resident's blood pressure. On March 2, 2026, at 9:39 a.m., Employee E22 confirmed the above findings. Review of Resident R13's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnosis of gastrointestinal hemorrhage (bleeding occurs anywhere in the gastrointestinal tract). A physician's order dated July 10, 2025 for an indwelling suprapubic urinary catheter. The clinical record also included a physician's order dated April 21, 2025, for enhanced barrier precautions. Observation conducted on March 3, 2026, at 2:14 p.m., revealed nursing aide, Employee E4 providing direct care to Resident R13 without wearing personal protective equipment (PPE). On March 3, 2026, at 2:17 p.m., the observation was confirmed by the infection preventionist, Employee E5, who verified that nurse aide, Employee E4 was providing direct care without implementing enhanced barrier precautions. 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 a review of the facility assessment and staff interviews, the facility failed to ensure active involvement of direct care staff and input from residents, resident representatives, and family members in the development and revision of the facility assessment. Additionally, the facility failed to identify within the facility assessment a resident population with inappropriate sexual behaviors. The facility census was 154.Findings Included: Review of the facility's Facility Assessment revealed the most recent revision date was January 2026. The document did not indicate that direct care staff, residents, resident representatives, or family members were involved in the development or revision of the assessment. There was no documentation demonstrating that input from these individuals was obtained during the process. Further review of the facility assessment revealed that the document did not identify or address a resident population with inappropriate sexual behaviors, despite the presence of a resident in the facility who demonstrated sexually inappropriate behaviors. During an interview conducted on March 4, 2026, at 1:00 p.m., with the Nursing Home Administrator stated that the facility assessment was developed and revised by the leadership team. When asked whether direct care staff, residents, resident representatives, or family members provided input during the meetings in which the facility assessment was revised, the Nursing Home Administrator did not provide documentation or other evidence demonstrating their participation in the process. On March 5, 2026, at 11:46 a.m., facility Nursing Home Administration confirmed that the facility had a resident with inappropriate sexual behaviors and acknowledged that this resident population had not been identified or addressed within the facility assessment. 28 Pa. Code S 201.18(b)(3) Management.

Based on a review of the facility's nursing staff competencies and skills required to provide resident care, the facility failed to ensure complete competency documentation for four of the five nursing staff reviewed. (Employees E5, E7, E8, and E10) Findings Included: According to the facility policy titled Staffing, Sufficient and Competent Nursing, (revised August,2022) under the section Competent Staff, a competency is defined as a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. A review of the facility policy Staffing, Sufficient and Competent Nursing confirmed that competencies are intended to measure the knowledge, skills, and abilities necessary for staff to perform their roles effectively. A review of the facility's nursing staff competency records revealed that a Registered Nurse was hired on March 14, 2023. The competency records completed on June 6, 2023, were incomplete and did not show validation that the required tasks had been assessed, as neither the Met nor the Not Met column was checked. The incomplete competencies included Medication Observation, Hand Hygiene, Personal Protective Equipment (PPE), and Catheter Care, of Enteral Tubes, Wound Dressing, Resident Right, Tracheostomy, Tube Change, Lift Competency, and Shower Bath. On March 5, during an interview, the Educator, Employee E6, confirmed that the competency records were incomplete, as the required tasks were not checked as either Met or Not Met for Employees E5, E7, E8, and E10, indicating that validation of the competencies could not be verified. Due to the absence of documented determinations for these competency items, the facility was unable to demonstrate that the identified staff had successfully met the required competencies necessary to perform their assigned duties. 28 Pa. Code S 201.20 (6)(b) Staff Development.

Based on interviews and the review of clinical records, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of one resident reviewed receiving hemo-dialysis (Resident R5).Findings include:Review of Resident R5's clinical record revealed that the resident was admitted to the facility on [DATE], and with the diagnoses of End-Stage Renal Disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), and Dependence on Renal Dialysis (Renal Dialysis is the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Review of Resident R5's physician order, dated May 8, 2025, revealed Resident R5 received dialysis treatment at an outpatient dialysis facility on Mondays, Wednesdays, and Fridays. Review of Resident R5's Hemodialysis Communication Record named as Resident Facility + Dialysis Center Information Exchange, revealed that on uncountable days, in the months of February 2026, January 2026, and December 2025, it was lacking the signature of the Dialysis Facility Nurse on Part II portion of the communication log. Interview with the Director of Nursing, on March 3, 2026, at 11:14 a.m., confirmed incomplete Dialysis Communication Log of Resident R5. 28 Pa Code 211.5(f) Clinical records 28 Pa Code 211.12(d)(3) Nursing services

Based on review of facility policy, resident's clinical record, observation and interview with staff, it was determined that the facility failed to ensure the safety of the resident's environment related to razors and large accumulations of personal items which impaired mobility of residents around the room for three of 31 residents reviewed. (Resident R83, Resident R12 and Resident R5)Findings include: A review of the facility policy titled Hazardous Area, Devices and Equipment undated, revealed All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. Review of Resident R12's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses including Adjustment Disorder with Depressed Mood, (where a person has an excessive emotional and behavioral reaction, like sadness and hopelessness, to a specific stressor, such as job loss or divorce, causing significant problems in daily functioning), Bipolar Disorder ( a chronic mental health condition characterized by extreme mood swings, alternating between intense highs (mania/hypomania) and lows (depression), and unsteadiness in feet. On March 2, 2026, at 10:04 a.m., and on March 3, 2026, at 1:04 p.m., observation of Resident R12's room revealed an accumulation of clothes, jackets, shoes, pants and various personal items which hindered the mobility and safety of Resident R12 around the room. At the time of the finding on March 3, 2026, at 1:04 p.m., the same was confirmed with a licensed nurse, Employee E 21. Review of Resident R5's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses including Puckering of Macula, Right Eye (scarring of the macula, causing blurry or distorted central vision), Orthostatic Hypotension (a sudden drop in blood pressure upon standing; common symptoms include dizziness, lightheadedness, and fainting, caused by gravity pulling blood to the legs and inadequate compensation), and Anxiety Disorder (a mental health conditions characterized by excessive, persistent fear or worry that interferes with daily life, functioning, and relationships). On March 2, 2026, at 10:14 a.m., and on March 4, 2026, at 2:01 p.m., observation of Resident R5's room revealed an accumulation of clothes, jackets, shoes, pants and various personal items which obstructed the mobility and safety of Resident R5. At the time of the finding on March 4, 2026, at 2:01 p.m., the same was confirmed with a licensed nurse, Employee E 21. A review of Resident R13's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnosis of Wernicke's encephalopathy (neurological disorder the classic triad of confusion or altered mental status, loss of coordination and eye movement abnormalities), dementia with mood disturbance. Continued review of Resident R83's MDS assessment revealed a BIMS (Brief Interview of Mental Status) score of 13, indicating that the resident was cognitively intact. Further review of the MDS assessment indicated that Resident R83 requires supervision or hands-on assistance with toileting hygiene. Review of Resident R83's comprehensive care plan dated December 23, 2025, revealed that under grooming/bathing, Resident R83 demonstrated a decline in the ability to perform the following ADLs: inability to sequence or self-initiate ADLs and short-term memory loss. On March 2, 2026, at 12:00 p.m., an interview with Resident R83 revealed that the resident shaves his/her facial hair independently. When asked how this is done, Resident R83 indicated that he/she does it himself/herself and retrieved six disposable razors from the bedside table drawer. Resident R83 then demonstrated by applying a razor to his/her facial hair. When asked where the razors were obtained, the resident stated that they were provided by the facility. On March 2, 2026, at 12:03 p.m., an observation that Resident R83 had six shaving razors was confirmed by the unit manager, Employee E15. Employee E15 confirmed that Resident R83 should not have shaving razors at his/her bedside. On March 3, 2026, at 2:21 p.m., an interview with Resident R83 was conducted. The resident had no facial hair and was asked if he/she had shaved. Resident R83 reported that he/she had shaved him/herself using the shaving razors and retrieved two razors for demonstration. This observation was confirmed by the Unit manager, Employee E15. 28 Pa. Code 211.10 (d) Resident Care Policies28 Pa. Code 211.12 (d)(5) Nursing Services

Based on clinical record reviews, interviews with staff, observations of care and services, reviews of policies and procedures, it was determined that the facility failed to revise and implement the comprehensive person center care plan for one of five residents reviewed related to sexually inappropriate behavior. (Residents R139). Findings include: A review of the policy and procedure titled reporting and investigating abuse, neglect, exploitation or misappropriation of property dated April 2021, revealed that the facility staff was responsible for reporting abuse, neglect, exploitation or misappropriation of property to local and state agencies. The policy also indicated that the facility management staff was responsible for conducting a thorough investigation into abuse, neglect, exploitation or misappropriation of property maintaining documentation of the investigation. The policy indicated that all suspected abuse was to be reported by facility staff to management staff immediately. Upon receiving any allegation of abuse, neglect, exploitation or misappropriation of property the administrator of the facility was responsible for determining what actions are needed for the protection of each resident. The policy indicated that if the investigation revealed the allegation of abuse was founded, the employee was terminated. A review of the policy and procedure titled comprehensive person-centered care plan dated March 2022 revealed that the comprehensive person-centered care plan was to include measurable objectives and time frames to meet each resident's physical, psychosocial, medical and functioning needs. The policy indicated that the interdisciplinary care team was responsible to develop and implement a comprehensive person-centered care plan with interventions that were derived from a thorough analysis of information gathered as part of a comprehensive assessment of each resident. The comprehensive person-centered care plan was to include measurable objectives and goals. The comprehensive person-centered care plan was to describe the services to be furnished to obtain or maintain each resident's highest practicable physical, mental and psychosocial well-being. The comprehensive person-centered care plan for each resident was to reflect standards of practice for problem areas and conditions to be addressed. The comprehensive person-centered care was to provide services by qualified persons who were competently trained to meet each resident's needs and trauma informed. The policy indicated that the care plan and assessment of each resident was an ongoing and revised as needed to meet the resident's highest practicable physical, mental and psychosocial well-being while protecting each resident from abuse. Review of Resident R139's quarterly assessment dated [DATE], revealed that the resident was usually understood by others, usually understands others and cognition was moderately impaired with a brief interview of mental status (BIMS score of 3). The assessment indicated that this resident's functional range of motion had no impairment of upper and lower extremities and that the resident used a mobility device (wheelchair). The assessment indicated that Resident R139 was non-ambulatory. The assessment also indicated that Resident R139 had a diagnosis of schizophrenia (a severe mental disorder that affects how a person thinks, feels and behaves often leading to disorganized thinking). Review of Resident R41's quarterly assessment dated [DATE], revealed that the resident had memory impairment and that cognition was severely impaired. The assessment indicated that the resident had diagnoses of Alzheimer's disease (is a progressive neurodegenerative disease that destroys memory, thinking and behavior) aphasia (a disorder that affects language abilities due to brain damage). The MDS indicated that this resident was dependent on the assistance of two staff members for all activities of daily living, could walk ten feet with staff supervision and touching assistance. A review of information dated January 15, 2026, submitted by the facility to the State Survey Agency on January 15, 2026, revealed that Resident R139 with severe cognitive impairment was witnessed by staff in the dining room seated in the wheelchair. Resident R139 propelled the wheelchair to another table in the dining room. Resident R139 lifted the shirt of Resident R41, a severely impaired resident and grabbed the resident's breast. The information indicated that staff redirected Resident R139 and placed the resident in a separate area out of the dining room. An investigation was completed by the facility's administrative staff who determined that the incident was substantiated for sexual abuse. A review of Resident R139's care plan, revealed that Resident R139 had a history of inappropriate sexual behavior prior to admission to the facility in 2018. Review of Resident R139's care plan revealed no updated or revised behavioral care plan for Resident R139 related to supervise, monitor and protect the other female residents of the facility from inappropriate sexual behavior exhibited by Resident R139. 28 PA. Code 211.10(d) Resident care policies28 PA. Code 201.29(a)Resident rights28 PA. Code 201.14(a) Responsibility of licensee28 PA. Code 201.18(b)(1) Management28 PA. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of clinical records, facility policy, and interview with staff, it was determined that the facility failed to permit one of three residents reviewed to return to the facility after hospitalization (Resident R1). Findings include: Review of facility policy Bed Hold Policy, revised undated, revealed The Medical Assistance Program will make payment to your nursing facility to hold (reserve) your bed for you while you are away from the nursing facility for continuous 24 hour period because you are in the hospital or on therapeutic leave. A bed must be available for you when you return to the nursing facility. Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on [DATE] with a diagnosis that included chronic respiratory failure, morbid (severe) obesity, and type 2 diabetes mellitus (failure of the body to produce insulin). Review of Resident R1's clinical record revealed a nursing progress note, dated January 30, 2026, which revealed the resident stated he/she was not feeling well and requested for a full medical work up at the hospital. Resident R1 was sent to the hospital of Resident R1's choice per Resident R1's request. Resident R1 was then transferred to the hospital on January 30, 2026 at 12:00 a.m. and was admitted to the hospital. Interview on February 24, 2026 at 3:00 p.m. with hospital case manager revealed Resident R1 was admitted to the hospital on [DATE] and was medically cleared for discharge on [DATE]. Further interview on February 24, 2026 at 3:00 p.m. revealed the hospital case manager reached out the facility regarding Resident R1's readmission and the facility refused to readmit Resident R1 back to the facility, stating they were not able to meet Resident R1's care needs. Review of Resident R1's clinical record revealed no documented evidence that the facility was unable to meet Resident R1's care needs. Interview on February 24, 2026 at 12:25 Administrator, Employee E1, and Director of Nursing, Employee E2, confirmed the facility did not allow Resident R1 to return to the facility. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(2) Management

Based on observations, review of facility documentation, and staff interviews it was determined that the facility failed to establish an effective pest control program in the main kitchen. Findings Include: Review of pest control report dated March 4, 2025, revealed pest control inspected and treated the kitchen areas, storage areas, and dishwasher room for occasional invaders. Per the pest control report, mice droppings were observed in the kitchen food storage room. Pest control recommended a door sweep in the kitchen doors and replacing doors to the small room outside, next to the dumpster, as te doors are rotten. A tour of the main kitchen was conducted on March 17, 2025, at 9:22 a.m. with the Food Service Director, Employee E5. Observations revealed double doors adjacent to the main kitchen where food deliveries are accepted and lead out to where the dumpsters are stored. There was a visible gap located at the bottom of the door allowing easy access to the main kitchen for common household pests (mice, roaches, flies, ants). Observations on March 19, 2025, at 12:15 p.m. in the main kitchen revealed a significant amount of mouse droppings on top of an empty plastic rack dolly (designed for transporting dish racks) that was placed directly outside the entry for the dish room amongst the other plastic rack dolly used to store clean dishes. Observations of the mouse droppings were confirmed by the Food Service Director, Employee E5. Further observations on March 19, 2025, at 1:55 p.m. with the Food Service Director, Employee E5, revealed the facility did not follow through on recommendations made from pest control company and the small room next to the dumpsters still had rotten/broken doors with large holes at the bottom of the doors. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on observations and interviews with staff, it was determined that the facility did not ensure that that trash was properly disposed of in the receiving and dumpster area. Findings Include: A tour of the main kitchen was conducted on March 17, 2025, at 9:22 a.m. with the Food Service Director, Employee E5. Observations revealed double doors adjacent to the main kitchen where food deliveries are accepted and lead out to where the dumpsters are stored. Observations in the receiving area outside revealed trash, food, and debris on the ground surrounding the dumpsters. On one dumpster, the lid was open, and trash was exposed. 28 PA Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management

Based on observations in the main kitchen and staff interview it was determined that the facility failed to ensure that food was stored, prepared, and served in accordance with professional standards for food service safety. Findings include: A tour of the Food Service Department conducted on March 17, 2025, at 9:22 a.m. with Employee E5, Food Service Director, revealed the following concerns: Observations of the walk-in freezer revealed two tortillas loosely wrapped in plastic wrap with no dates. Observations of the dry storage room revealed the juices used for the juice machine were stored in this room. Two juice bags (fruit punch and orange juice) were taken out of the box and placed directly on a visibly dirty/dusty metal wrack. One juice was not hooked up (cranberry juice) and the tubing was on the floor and backed up with stagnant juice in the tubing. Observations revealed the drainpipe behind the ice machine was placed directly into the floor drain with no air gap. To prevent sewer water backup, all ice machine drains require an air gap of a few inches between the ice machine ' s drain point and the facility's drain access point. Observations were confirmed by the Food Service Director, Employee E5, throughout the duration of the kitchen tour. 201.14 (a) Responsibility of licensee.

Based on review of facility protocol, observations, interview ,and review of clinical records, it was determined that the facility failed to implement proper use of personal protective equipment (PPE) for one resident on enhanced barrier precautions during morning care and wound observation of 31 resident records reviewed (Resident R102). Findings include: Review of the facility policy for Enhanced Barrier Precautions (EBP) revised December 2024 states it is used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms to residents. EBP employ targeted gown and glove use during high contact resident care activates EBP are indicated for residents with wounds and or indwelling medication devices. Resident R102 was initially admitted to the facility on [DATE], diagnosed with spastic quadriplegic cerebral palsy, major depressive and anxiety disorder, dysphagia (difficulty swallowing) , and had a gastrostomy (a surgical tube place in the abdominal wall and into the stomach used to provide nutrients and medications when a person cannot eat or drink adequately). Resident R102's had orders to use EBP and was care planned for use while maintaining tube feedings, incontinence care and wound care. On March 17, 2025, at 10:00 a.m. it was observed nursing assistant Employee E14, aide was providing incontinence care without the use of EBP. On March 18, 2025, at 11:30 a. m. during wound observation Unit manager Employee E12 provided care without the use of EBP. On March 18, 2025, at 3:36 p.m. the Assistant Director of Nursing Employee E13 was made aware and confirmed EBP use with care. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on observations, interviews with residents and staff, and review of the facility policy, it was determined that the facility failed to provide a clean, safe, comfortable and homelike environment in three of the three nursing units observed (2nd, 3rd, 4th floor Nursing Units). Findings include: A review of the facility policy titled Homelike Environment revised February 2021, revealed Residents are provided with a safe, clean and comfortable and homelike environment and encouraged to use their personal belongings to the extend possible. It further states, these characteristics include clean, sanitary and orderly environment, clean bed, bath linens that are in good condition, pleasant, neutral scents. On March 17, 2025, at 11:47 a.m., an interview with Resident R146 who lives in room [ROOM NUMBER] revealed that his mattress is peeling, and he collects the peeling material in a cup. Additionally, observation showed that there are five ceiling tiles with large brown stains. On March 17, 2025, at 11:51 a.m., an observation in room [ROOM NUMBER] reveled no restroom mirror and restroom are missing baseboard on the bottom of the wall. On March 17, 2025, at 11:58 a.m., observation in room [ROOM NUMBER] had a large picture leaning against the wall does not hang up, large brown substance that is spilled on the floor between the two beds. On March 17, 2025, at 12:16 p.m., observation next to room [ROOM NUMBER] has a hole in the tile ceiling. Day room which as across had a broken sanitizer with no cover. room [ROOM NUMBER] had a urine odor. License nurse, Employee E5 confirmed these observations. On March 17, 2025, at 12:38 p.m., a tour with the Maintenance Director, Employee E6 confirmed the above observations in room [ROOM NUMBER], 413, 404, 409 and 418 had broken baseboard that was not attached to the wall next to the entrance door and dry wall was peeling off from the wall. On March 18, 2025, at 12:09 p.m., observation in room [ROOM NUMBER] revealed a hole in the bathroom wall, exposing insulation. Drywall was also obsvered on the bathroom floor. Observations on March 17, 2025, at 12:53 p.m. in the 2nd floor dining room during the lunch time meal revealed Resident R82 and R366 were served lunch on paper plates. Interview with nurse aide, Employee E6, confirmed residents received paper products and was not sure why. Further observations on March 17, 2025, at 1:50 p.m. revealed Resident R1, in room [ROOM NUMBER]D, was served thickened juice in a Styrofoam cup. The beverage was leaking through the bottom of the cup, creating a sticky mess on the residents overbed table where he was eating. Interview with nurse aide, Employee E6, confirmed the observations and was unsure why resident was served in a Styrofoam cup. During a test tray on the 2nd floor nursing unit with the Food Service Director, Employee E5, on March 19, 2025, at 12:28 p.m., coffee was served in a Styrofoam cup. The Food Service Director, Employee E5, reported the kitchen is short on coffee mugs and subsequently the second floor (last unit to be served lunch) would be served in Styrofoam cups. Observations on March 20, 2025, at 12:50 p.m. revealed Resident R141 and R111, who both resided on the 2nd floor, were served coffee in Styrofoam cups. 28 Pa Code 201.18(b)(1)(3)Management

Based on a review of the facility policy, observations, and an interview with staff, it was determined that the facility failed to ensure that the most recent Department of Health Survey results were readily accessible to residents and visitors in three of three nursing floors and lobby (Second Floor, Third Floor, and Fourth Floor). Findings include: The facility's policy titled Examination of Survey Results, dated April 27, 2017, states, Survey reports and plans of correction are readily accessible to residents, family members, resident representatives, and the public. It further specifies under Bulletin 2: A copy of the most recent survey report and any plans of correction are kept in a binder in the resident's day room. During a resident council meeting held on March 18, 2025, at 10:30 a.m., with 12 residents (R62, R13, R35, R129, R70, R49, R6, R4, R96, R92, R93), who were identified as alert and oriented, it was revealed that the residents were unaware of the recent Department of Health Survey results. On March 19, 2025, at 9:31 a.m., a facility tour was conducted with the Director of Social Services, Employee E4, to observe the placement of the Department of Health Survey binder in the facility. Upon observing the lobby, it was noted that the Department of Health Survey results binder was outdated, with the last survey results recorded as of November 2024. Additionally, the second, third, and fourth-floor nursing units did not have survey result binders available. On March 19, 2025 at 2:45 p.m., during an interview with the Administrator, Employee E1 confirmed that the facility possessed two more recent Department of Health Survey results, but these were not included in the binder in the front lobby. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on observations during dining and resident interviews it was determined that the facility failed to serve food that was palatable and attractive to meet resident needs for 20 of 20 residents reviewed (Resident R62, R13, R35, R129, R70, R49, R6, R4, R96, R92, R93, R30, R9, R120, R122, R81, R108, R83, R58, and R139). Findings Include: During a Resident Council meeting on March 18, 2025, at 10:30 a.m. with 11 alert and oriented residents (R62, R13, R35, R129, R70, R49, R6, R4, R96, R92, R93) residents reported that the chicken being served is dry. Review of the facility menu revealed chicken was on the menu for lunch on March 18, 2025. Observations on March 18, 2025, at approximately 12:30 p.m. on the 2nd floor nursing unit during the lunch time meal revealed the following: Observations and interview at 12:38 p.m. revealed Resident R30 refused to eat the chicken served for lunch because it was dry. Observations and interview at 12:50 p.m. revealed Resident R9 and R120 refused to eat the chicken because it was served cold. Observations and interview at 12:51 p.m. revealed Resident R122 refused to eat the chicken because it was served dry. Observations at 12:53 p.m. revealed Resident R81 was being fed lunch by nurse aide, Employee E16. Interview with nurse aide, Employee E16, reported Resident R81 spit the chicken out and refused to eat it. Interview at 12:55 p.m. with alert and oriented Resident R108 revealed the chicken was hard as a rock and that the resident could not finish eating it. Interview at 12:56 p.m. with alert and oriented Resident R83 revealed the chicken was served dry. Observations and interview at 12:57 p.m. revealed Resident R92 had an un-eaten thin, overcooked piece of chicken on her plate. Resident R92 reported being unable to cut the chicken and subsequently not being able to eat it. Interview at 12:58 p.m. with alert and oriented Residents R58 and R139 revealed the chicken was served very dry and was inedible. 28 Pa. Code 211.10(c) Resident care policies

Based on a resident group interview, resident interview, review of facility policy and staff interview, it was determined that the facility failed to ensure that prompt efforts were made to resolve grievances for one of thirty-one residents (Resident R30) and effectively communicate the resolutions of grievances for 11 of thirty-one residents (R4, R6, R13, R35, R49, R62, R70, R92, R93, R96, R129) Findings include: A review of the facility policy titled Grievances/Complaints, Filing, revised on April 2023, stated under Policy Statement The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. Further review, in section Policy Interpretation and Implementation, part 12, it states that The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the finding of the investigation and the actions that will be taken to correct any identified problems Review of Facility document titled Grievance Form, updated on April 6, 2017, revealed that All grievance forms must be resolved within 7 days from the original date of notification from the department that is responsible. During a Resident Council meeting on March 18, 2025 at 10:30 a.m., 11 residents (R62, R13, R35, R129, R70, R49, R6, R4, R96, R92, R93), all of whom were alert and oriented, expressed concerns that when they file grievances, the facility does not provide them with information regarding the resolution after the investigation is completed. Review of Resident R30's clinical record revealed that Resident R30 was admitted to the facility on [DATE] with diagnoses of but not limited to Heart Failure, Cellulitis (bacterial infection of the skin and the tissue beneath the skin), and Type 2 Diabetes (failure of the body to produce insulin). Review of R30's MDS (Minimum Data Set- assessment of resident care needs) Section C- Cognitive Problems, dated January 23, 2025, revealed that the Resident had a BIMS (Brief interview for metal status) score of 15 (intact cognitive response). Interview with Resident R30 on March 18, 2025 at 10:03 am, revealed Resident R30 was missing clothing. Resident stated that clothing was taken to be washed and never returned to her. The resident filed a grievance, but it has not been resolved and she has been using hospital gowns because she doesn't have any other belongings with her. Review of Resident R30's Grievance Form, dated February 25, 2025, confirmed the clothing was sent to laundry in a bag labeled with her name and room number on it and was not returned to the resident. Further review, under Plan for Resolution stated Social worker met with Resident R30 who picked a new outfit out of catalog. Follow up interview with Resident R30 on March 19, 2025 at 10:25 am, revealed over 2 weeks ago, Social Worker met with Resident to choose items out of catalog. Resident confirmed that items were selected and provided to the social worker for purchase. Interview with Social Worker, Employee E3 on March 19, 2025 at 10:39 am, confirmed that grievance was placed on February 25, 2025. Further confirmed clothing has not been ordered. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)Resident rights

Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to identify the placement of beds against the wall as a restraint and failed to assess the functional status of an individual resident to determine the use of the restraint for one of 31 residents reviewed. (Residents R5). Findings Include: Review of facility policy titled Use of Restraints, revised 2017, revealed the definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which staff applied it given that resident's physical condition (i.e, side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint. Clinical record review revealed Resident R5 was admitted to the facility May 24, 2022 with a diagnosis that included but not limited to hemiplegia and hemiparesis affecting left non-dominant side (muscle weakness on one side of the body), acute respiratory failure (inability of lungs to exchange oxygen and carbon dioxide properly, causing insufficient oxygen in the blood), and abnormal posture. Observation on March 18, 2025 at 9:28 a.m. revealed Resident R5 lying in bed and the bed (right side) against the wall. Review of Resident R5's nursing progress note, dated February 4, 2025 at 9:36 a.m., revealed resident bed will be adjusted and padded to avoid resident irritating wound by rubbing it against the wall Review of Resident R5's nursing progress note, dated February 18, 2025 at 7:54 a.m., revealed during change of shift around 11:15 p.m. resident was heard calling for 3-11 nursing aide. When nurse entered the room, resident was found on the floor in a fetal position between the bed and the wall. Resident aware of the fall, but not how it happened in detail. Further review of Resident R5's nursing progress note, dated February 18, 2025 at 11:01 a.m., revealed resident bed was against the wall. Resident pushed with legs pushing bed away from wall. Resident fell between bed and wall. The resident was returned to bed via mechanical lift. Interview on March 18, 2025 at 9:30 a.m. with Licensed Practical Nurse, Employee E7, confirmed Resident R5's bed was against the wall. 28 Pa. Code 211.8(e)(f) Use of Restraints. 28 Pa. Code:211.12(d)(1)(5) Nursing services.

Based on facility policy review, personnel file review, and staff interview, it was determined that the facility failed to perform Elder Abuse and Resident Rights training upon hire for one of five personnel files reviewed (Employee E4). Findings Include: Review of the personnel file for Cook, Employee E4 on March 20, 2025 at 12:02 pm revealed employee hire date on December 5, 2024. Further review indicated that there was no documented evidence for completion of Elder Abuse training upon hire. An interview was conducted with Business Office/ HR, Employee E5, on March 20, 2025 at 12:13 pm, confirmed Employee E4's Elder Abuse training incomplete. 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 201.19(8) Personnel policies and procedures

Based on facility policies, clinical record review and staff interviews, it was determined that the facility failed to communicate to the resident's physician assistant the refusal of a prophylactic anticoagulant medication for one of eight residents reviewed. This failure resulted in actual harm to Resident R86 who missed nine doses of an anticoagulant medication and development of Deep Venous Thrombosis. (Resident R86) Findings include: Review of facility policy titled Documentation of Medication Administration dated October 20, 2023, revealed that A nurse shall document all medications administered to each resident on the resident's medication administration record (MAR). Documentation must include, as minimum: name and strength of drug, dosage, method of administration, date and time of administration, reasons why a medication was withheld, not administered, or refused, and signature and title of person administering the medication. Review of facility policy titled Requesting, Refusing and /or Discontinuing Care or Treatment revealed a resident and resident representatives have the right to request and or discontinue treatment. Treatment refers to medical care, nursing care, and interventions provided to maintain or restore health and wellbeing, improve functional level and improve symptoms. Continued review of this policy states that If a resident / representative requests, discontinues or refuses care of treatment, an appropriate member of the interdisciplinary team with meet with the resident / representative to determine why he or she is requesting, refusing, or discontinuing care or treatment. The interdisciplinary team will try to address his or her concerns and discuss alternative options and discuss potential outcome or consequences of the decision. The decision to refuse or discontinue treatment results in a significant change of condition, a reassessment will occur, and appropriate changes will be made to the resident's care plan. Detailed information relating to the requests, refusal or discontinuation of treatment are documented in the resident's medical record. Documentation must include date and time, residents' response, the date, and time the practitioner was notified as well as the practitioner's response. Review of Resident R 86's clinical record revealed that Resident R86 was admitted to facility on August 30, 2021. This resident has a diagnosis of fracture of neck of left femur (left hip fracture), vascular dementia (decreased blood flow to brain tissue causing memory problems), atherosclerotic heart disease (hardening of arteries), unspecific hearing loss, bilateral hearing loss of both ears), anxiety disorder (mental disorder characterized by excessive uncontrollable feeling of worry and fear). Review of Resident R86's significant change Minimum Data Set (MDS-a federal mandated assessment used to summarize residents' health status) assessment dated [DATE], revealed that the resident had a BIMS (Brief Interview for mental status) of 99 which indicated that this resident was unable to complete the assessment. The resident was assessed by the staff with short and long term memory impairment. Continued review of Resident R86's clinical record exposed that Resident R86 sustained a fall January 9, 2024, resulting in a left hip fracture. This resident was hospitalized and discharged back to the facility January 12, 2023. Review of Resident R86's hospital discharge documentation dated January 12, 2024, reveled that during the hospital stay Resident R86 underwent surgery, operative fixation of intertrochanteric hip fracture. Further review of this hospital document revealed that Resident R86 was prescribed Enoxaparin (Lovenox) an anticoagulant, 30mg/0.3 ml to be injected every twenty-four hours for one month to reduce the chance of blood clots following surgery. Review of Resident R86's January 2024, physician orders revealed that an order was obtained on January 12, 2024, for Enoxaparin sodium injection solution prefilled syringe 30 (milligrams) mg/0.3 ml, inject 0.3 ml subcutaneously one time a day for hip fracture. Review of physician note dated February 12, 2024, by Employee E19 who was Resident R86's medical practitioner stated that Resident R86 was being seen for exam, nursing notes noted that this resident was assessed with left lower edema (swelling). Patient noted with pain and swelling, unable to wear shoe on left foot. On review of patient's chart, it appears patient has not had Lovenox (Enoxaparin) for the last three days and was also not administered on February 5, 2024, February 7, 2024 and February 9, 2024, it is unclear why she has not received the medication, whether to refusal or other reason. Employee E19 gave orders to obtain a venous doppler (a special ultrasound that evaluates blood flow) to rule out a DVT (deep vein thrombosis, blot clot usually found in the legs that can travel through the bloodstream to heart of lungs causing a life-threatening complication) given pain, swelling, warmth, and reduced peripheral pulses. Order to continue the Lovenox(Enoxaparin). Review of Resident R86's doppler scan result completed on February 16, 2024, reported on February 20, 2024, concluded that the Left lower extremity venous ultrasound including Doppler with result of positive for segment of thrombus in the anterior tibial vein. Review of Resident R86's February 2024 Medication Administration Record (MAR) revealed that Resident R86 had missed 9 doses of the blood clot prophylactic medication Lovenox (Enoxaparin). The code number (2) was documented on the February 2024 MAR for refused: February 5, 2024, February 7, 2024, February 9, 2024, February 10, 2024, February 11, 2024, February 18, 2024, and February 19, 2024. There was no documentation on the MAR related to the administration of the Lovenox on February 13, 2024, and February 16, 2024. Interview with Licensed nurse, Employee E5 on May 24, 2024, at 9:45 a.m. revealed that this employee was educated and trained of the facility policy of medication refusal. Licensed nurse, Employee E5 described that is it the facility protocol that when a resident refuses medication must be documented, notifies the doctor, and notify the family. Licensed nurse, Employee E5 confirmed that this employee did not administer the prophylactic medication Lovenox to Resident R86 on numerous days because the resident refused. Licensed nurse, Employee E5 reported that the resident seems fearful of the injection by displaying restlessness and screaming when attempting to administer the injection. Licensed nurse, employee E5 confirmed that she did not administer the medication and did not document why it was not given. Employee E5 stated that the refusal was reported verbally to the medical doctor and the family but neglected to document the notifications. Interview with former medical practitioner, Employee E19 on May 23, 2024, at 2:00 p.m. confirmed that she was employed at the facility as a physician assistant and treated Resident R 86. Employee E19 conveyed that this employee was never made aware of the refusal until after the resident was assessed with sign and symptoms of a possible DVT (Deep Vein Thrombosis- blood clot). Employee E19 stated that the refusals were never discussed with her; it was not until she reviewed the resident's record and noticed that the medication has not been given. After receiving in the ultrasound result, the resident was ordered an oral blood thinner Eliquis. The facility failed to communicate to Resident R86's former medical practitioner, Employee E 19 that the resident was refusing the prophylactic anticoagulant medication, which resulted in the resident missing 9 doses of Lovenox. This failure resulted in actual harm to Resident R86 who development of Deep Venous Thrombosis. 28 Pa Code 201.18 (b)(1) Management 28 Pa. Code 211.10 (c) Resident care policies 28 Pa. Code 211.12 (c)(d)(1)(3) Nursing services

Based on clinical record review, hospital record review, interviews with staff and review of policies and procedure, it was determined that the facility failed to ensure that a benzodiazepine medication was administered as ordered by the physician which resulted in actual harm to Resident R3, who experienced a tonic clonic seizure and was diagnosed with a closed head injury and left frontal scalp hematoma for one of four residents reviewed. (Resident R3) Findings include: Review of the facility policy and procedure titled Medication Administration dated April, 2007, revealed that it was the responsibility of the licensed professional to document all medications administered to each resident as prescribed by the physician. The policy also stated that a signature and title of the person administering the medication was required to be documented on the medication administration record of the clinical record for each resident. Review of Resident R3's physician note dated February 8, 2024, indicated that the resident was under hospice care for protein calorie malnutrition. The physician also indicated that this resident had diagnoses of seizure disorder (a sudden, uncontrolled burst of electrical activity in the brain. It can cause changes in behavior, movements, feelings, and levels of consciousness)/ epilepsy (a neurological disorder characterized by recurrent epileptic seizures. These seizures result from abnormal, excessive, and synchronized electrical discharges in the neurons of the brain) and anxiety disorder. Review of hospice physician orders revealed an order for Lorazepam (Ativan) 2 mg by mouth every 15 minutes as needed for seizures; give 1mg Lorazepam orally every 15 minutes as needed for seizure activity and until seizure activity had stopped times four doses. Review of Resident R3's care plan initiated on December 15, 2022, revealed that care plan was developed related to the resident being at risk for seizures. The interventions included to administer the as needed medication Ativan with seizure activity. Continued review of Resident R3's care plan indicated that this resident had an alteration in neurological status. The approach listed on the care plan for alteration in neurological status was to give the medications as ordered by the physician to treat the resident's neurological disorder. Review of Resident R3's physician's progress note dated March 1, 2024, revealed that the resident was admitted to the hospital emergently on February 25, 2024 for a witnessed collapse and onset of a tonic clonic seizure. Resident R3 had head trauma with the seizure activity and collapse. The physician indicated that an electroencephalogram of the brain was preformed at the hospital and was remarkable for diffuse slow wave activity. The physician's progress note also indicated that prescribed as needed medication Diazepam (a medication used to treat epilepticus) rectally for seizure activity was not administered to Resident R3 at the seizure onset. Continued review of the physician progress note revealed that the resident was missing at least two doses of scheduled Lorazepam on February 24, 2024 and February 25, 2024 prior to the onset of the seizure activity. The physician indicated that the omission of medication for Resident R3 prior to seizure onset contributed to the seizure activity experienced by this resident on February 25, 2024. The physician noted that the root cause of the seizure and fall was due to benzodiazepine withdrawal symptoms shown by Resident R3 on February 25, 2024. Review of Resident R3's February 2024, Medication Administration Record (MAR) confirmed that the resident was to be administered Lorazepam 2 milligrams (mg) by mouth every 6 hours daily at midnight; 6:00 a.m.; 12:00 p.m. and 6:00 p.m. and 12:00 a.m. Continued review of the MAR revealed that on February 24, 2024 the 12:00 a.m. and 6:00 a.m. dose was coded 5 (hold/see nurses notes). The 12:00 p.m. dose was administered and there was no documented evidence that the 6:00 p.m. dose was administered. On February 25, 2024 the 12:00 a.m. and 6:00 a.m. dose was again coded 5 hold/see nurses notes. Review of nursing notes for the entire month of February 2024, revealed no documentation related to the omission of the medication Lorazepam. Review of nursing note dated February 25, 2024, indicated that Resident R3 was being assisted with eating while the resident was sitting down. Resident R3 jumped up and began seizure for three to five seconds. Resident R3 then fell and hit his head. Resident appeared alert, pupils were responsive to light. Vital signs and neurological checks were within normal limits. Resident R3 was found to have a large hematoma to the left forehead. Review of Resident R3's hospital documentation confirmed that Resident R3 was admitted to the hospital on February 25, 2024, as a trauma alert and was diagnosed with a closed head injury (left frontal scalp hematoma). Interview with the Director of Nursing, Employee E2, on April 22, 2024, at 2:00 p.m., confirmed that the medications Lorazepam were not given as prescribed by the physician for Resident R3 on February 24, 2024 and February 25, 2024. Further interview with the Director of Nursing, Employee E2 on April 24, 2024, at 11:00 a.m., confirmed that Resident R3 had a tonic clonic seizure on February 25, 2024 and sustained a fall and head trauma; after medications used to treat seizure disorder and anxiety disorder were omitted from administration by the nursing staff on February 24, 2024 and February 25, 2024, causing Resident R3 to experience symptoms of Lorazepam withdrawal (grand mal seizure). 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.10(a)(b)(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services 28 Pa. Code 211.9(a)(1)(b) Pharmacy services 28 Pa. Code 211.5(f)(iii)(vii)(ix)(x) Medical records

Based on a review of clinical records, review of facility documentation, review of facility policy, and interviews with staff, it was determined that the facility failed to ensure residents were free from sexual abuse which resulted in actual harm to Residents R1 who was subjected to nonconsensual sexual activity by Resident R2 and R3 for three of five resident records reviewed (Resident R1, R2, and R3). Findings include: Review of facility policy Abuse and Neglect - Clinical Protocol, revised July 2017 revealed: 1. Abuse is defined at 483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual including a caretaker, of goods or services that are necessary to attain or maintain, physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. 3. Sexual abuse is defined at 483.5 as non-consensual sexual contact of any type with a resident. Review of Resident R1's clinical record revealed the resident was diagnosed with rhabdomyolysis (breakdown of skeletal muscle), dementia (impaired cognition), aphasia (difficulty to comprehend or formulate language), weakness and difficulty in walking. Resident R1's Annual MDS (Minimum Data Set, an assessment of resident's needs) dated August 11, 2022 revealed the resident had severe cognitive impairment, was impairement on both sides of her upper and lower body, dependent on staff for transfers, toileting, and bathing, required extensive assistance for bed mobility, dressing, eating and personal hygiene. Review of Resident R2's clinical record revealed the resident was admitted on [DATE], with the diagnoses of alcohol dependence with alcohol induced persisting amnestic disorder (loss of memory and the ability to create new memories or to learn new information), unspecified dementia with behavioral disturbances, restlessness, and agitation. Resident R2's Admission MDS dated [DATE], revealed severe cognitive impairment, required extensive assistance with bed mobility, transfers, dressing toileting and personal hygiene and required limited assistance with walking and ambulated without an assistive device. Review of Resident R2's clinical record revealed a care plan for potential risk of physical behaviors related to his poor impulse control dated August 4, 2022, interventions included monitor/document/report to MD (physician) of danger to self or others and a care plan for impaired cognitive function/dementia or impaired thought process r/t related to disease process ETOH (Alcohol) abuse. The interventions included administer medications as ordered and monitor/document/report to MD of danger to self or others. Review of Resident R3's clinical record revealed Resident R3 was admitted on [DATE], with the diagnoses of Dementia with behavioral disturbances, Major depressive disorder, recurrent with severe psychotic symptoms (a specific presentation of depression that involves psychosis (deranged) during episodes of depression), Mixed receptive expressive language disorder (problems expressing and/or understanding what people say) and unspecified symbolic dysfunction (social impairment). Review of Resident R3's Quarterly MDS, dated [DATE], revealed the resident was cognitively impaired, required extensive assistance with hygiene and toileting, limited assistance for bed mobility and transfers, and supervision when walking. Further review of Resident R3's clinical records revealed a care plan dated February 3, 2021 for wandering into residents' rooms. Interventions inlcuded to redirect the resident from entering the residents' rooms. Further review of the resident's care plan revealed a care plan for behavioral problems dated March 31, 2021 that included agitation, verbal behaviors, and aggression towards others. Interventions included to intervene to protect the rights and safety of others and involve safety checks as needed (revised June 16, 2022). Further review of Resident R3's clinical records revealed progress note dated June 13, 2022, where the physician noted that the resident was sent to the emergency department for aggression after he was found with his hands down another resident's brief. On June 26, 2022, Resident R3 grabbed a resident's wrist. It was reported that he had such a tight grip on her arm the staff had to pry his hands off her wrists. Review of the facility's incident report, dated August 5, 2022, Registered Nurse (RN), Employee E5, reported being alerted by Hospice Nursing Assistant (NA), Employee E3 that Resident R3 and another resident (Resident R2) were in Resident R1's room at the side of the bed removing her Cover, nightgown, and diaper. On August 24, 2022 at 11:30 a.m. during an interview with Hospice Nursing Assistant, Employee E3, stated the last time she saw Resident R1 prior to the incident on August 5, 2022 was at 1:00 p.m. During that time the Nursing Assistant finished her care with Resident R1 and went to care for her next hospice patient, Resident R6. She explained Resident R6's wife came to visit so she left the room to give them privacy. She stated that when she left Resident R6's room at 1:30 p.m. she observed two men with Resident R1 in her room. The NA stated, I observed Resident R2 standing by the bed and Resident R3 lying in bed with Resident R1, her gown was pulled up to her neck, her diaper was undone, she was fully exposed as the two men rubbed her breasts. The first thing I did was to get them out of the room, dress [Resident R1], close the door and I ran and hollered for help. I called out for help but I had to find help because no one was around. On August 24, 2022, at 12:46 p.m. during an interview with Licensed Practical Nurse (LPN) Employee E4 stated, Both residents (Resident R2 and R3) were up and down the hallway in every room that day and Resident R3 has a history of sexual aggression. The facility failed to ensure that Resident R1 was free of sexual abuse from Resident R2 and R3 who wandered into the female resident's room which resulted in nonconsensual sexual activity. 483.13 Resident behavior and facility practices 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on the review of clinical records, facility documentation, and interviews with staff, it was determined that the facility failed to ensure adequate supervision to Resident R2 and R3 which resulted in harm to Resident R1, who was subjected to nonconsensual sexual activity by Resident R2 and R3 for one of five resident records reviewed (Resident R1). Findings include: Review of Resident R1's clinical record revealed the resident was diagnosed with rhabdomyolysis (breakdown of skeletal muscle), dementia (impaired cognition), aphasia (difficulty to comprehend or formulate language), weakness and difficulty in walking. Review of Resident R1's annual MDS (minimum data set, an assessment of resident's needs) dated August 11, 2022, revealed the resident had severe cognitive impairment, with impairment on both sides of her upper and lower body, dependent on staff for transfers, toileting, and bathing, required extensive assistance for bed mobility, dressing, eating and personal hygiene. Review of Resident R2's clinical record revealed the resident was admitted on [DATE], diagnosed with alcohol dependence with alcohol induced persisting amnestic disorder (loss of memory and the ability to create new memories or to learn new information), unspecified dementia with behavioral disturbances, restlessness, and agitation. Review of Resident R2's admissions MDS dated [DATE], revealed severe cognitive impairment, required extensive assistance with bed mobility, transfers, dressing toileting and personal hygiene and required limited assistance with walking and ambulated without an assistant device. Further review of Resident R2's clinical record revealed a care plan for potential risk of physical behaviors related to his poor impulse control sated August 4, 2022. Review of Resident R2's clinical record revealed a care plan developed dated August 4, 2022, for potential risk of physical behaviors related to the resident's poor impulse control. The interventions included monitor/document/report to MD (physician) of danger to self or others. Continue review of the resident's care plan revealed a care plan for impaired cognitive function/dementia or impaired thought process related to disease process ETOH (Alcohol) abuse interventions included administer medications as ordered and monitor/document/report to MD of danger to self or others Review of Resident R3's clinical record revealed Resident R3 was admitted to the facility on [DATE], diagnosed with Dementia with behavioral disturbances, Major depressive disorder, recurrent, with severe psychotic symptoms (a specific presentation of depression that involves psychosis (deranged) during episodes of depression), Mixed receptive expressive language disorder (problems expressing and/or understanding what people say) and unspecified symbolic dysfunction (social impairment). Review of Resident R3's Quarterly MDS, dated [DATE] revealed the resident was cognitively impaired, required extensive assistance with hygiene and toileting, limited assistance for bed mobility and transfers, and supervision when walking. Further review of Resident R3's clinical records revealed a care plan dated February 3, 2021 for wandering into residents' rooms. Interventions inlcuded to redirect the resident from entering the residents' rooms. Further review of the resident's care plan revealed a care plan for behavioral problems dated March 31, 2021 that included agitation, verbal behaviors, and aggression towards others. Interventions included to intervene to protect the rights and safety of others and involve safety checks as needed (revised June 16, 2022). Further review of Resident R3's clinical records revealed progress notes noting increased aggressiveness in Resident R3. On June 4, 2022, Resident R3 was seen putting both hands on the chest of a resident then pushing her to the floor. On June 13, 2022, the physician noted that the resident was sent to the emergency department for aggression after he was found with his hands down another resident's brief. Progress note dated June 20, 2022, revealed the resident attempted to take a water jug off the medication cart and pushed the nurse when trying to intervene. On June 26, 2022, Resident R3 grabbed a resident's wrist. It was reported that he had such a tight grip on her arm the staff had to pry his hands off her wrists. That day 911 was called and Resident R3 was admitted to the hospital for his aggressive behaviors. Once readmitted on [DATE] (nineteen days later) a physician's response after reviewing the hospital records indicated that Resident R3 was Fairly aggressive and agitated during his stay and had to be Restrained through most of his time at the hospital. The resident was noted to be lethargic since his return from the hospital, and orders were received to reduce his psychiatric medications. Progress note dated August 1, 2022 from a Certified Registered Nurse Practitioner (CRNP) indicated Resident R3's Klonopin and Ativan (both used for anxiety) were discontinued last week due to lethargy. The same note indicated the resident was more alert, awake, and walking around but also stated, Some concerns of previous aggression and agitation. Will need to monitor closely. Review of the facility's incident report dated August 5, 2022, Registered Nurse (RN), Employee E5, reported being alerted by Hospice Nursing Assistant (NA), Employee E3 that Resident R3 and another resident (Resident R2) were in Resident R1 room at the side of the bed removing her Cover, nightgown, and diaper. On August 24, 2022 at 11:30 a.m. during an interview with Hospice Assistant, Nursing Assistant, Employee E3, stated the last time she saw Resident R1 prior to the incident on August 5, 2022 was at 1:00 p.m. During that time the Nursing Assistant finished her care with Resident R1 and went to care for her next hospice patient, Resident R6. She explained Resident R6's wife came to visit so she left the room to give them privacy. She stated that when she left Resident R6's room at 1:30 p.m. she observed two men with Resident R1 in her room. The Nursing Assistant stated, I observed Resident R2 standing by the bed and Resident R3 lying in bed with Resident R1, her gown was pulled up to her neck, her diaper was undone, she was fully exposed as the two men rubbed her breasts. The first thing I did was to get them out of the room, dress [Resident R1], close the door and I ran and hollered for help. I called out for help but I had to find help because no one was around. On August 24, 2022 at 12:46 p.m. during an interview with Licensed Practical Nurse (LPN) Employee E4 stated, Both residents (Resident R2 and R3) were up and down the hallway in every room that day and Resident R3 has a history of sexual aggression. The facility failed to ensure proper supervision and monitoring of Resident R2 and Resident R3 which resulted in actual harm to Resident R1, who was subjected to a nonconsensual sexual activity by Resident R2 and R3. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services