Every finding on record at Manor at Penn Village, The

Based on employee personnel record review and staff interview, it was determined that the facility failed to complete a performance evaluation of each nurse aide at least once every 12 months for three of three nurse aides reviewed (Employees 9, 10, and 11).Findings include: The facility noted the following hire dates for three employees reviewed for performance evaluations (EPR, employee performance review): Employee 9's hire date of November 2, 2021. Employee 10's hire date of August 9, 2023. Employee 11's hire date of April 30, 2024. The annual performance evaluations for Employee 9, 10, and 11, revealed EPRs dated as completed on December 5, 2025. Further requests to view the previous EPRs completed prior to December 5, 2025, revealed no documented evidence that the facility completed performance evaluations for Employees 9, 10, and 11 (nurse aides) at least once every 12 months. Interview with the Nursing Home Administrator on December 5, 2025, at 12:19 PM confirmed that performance evaluations were not completed annually on the three employees requested. 28 Pa. Code 201.19 (2) Personnel policies and procedures

Based on review of facility documentation and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of residents who utilize a gastric tube for two of two employees reviewed for competencies (Employees 7 and 8).Findings include: A review of the facility documentation revealed that the facility had a total of 2 residents with a feeding tube (G-tube, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications; also known as a PEG tube). A request for nursing staff competencies for G-tubes revealed the facility was unable to provide any competencies in this area for Employees 7 (licensed practical nurse), and 8 (registered nurse). The findings were reviewed with the Nursing Home Administrator on December 5, 2025, at 1:30 PM. On December 8, 2025, at 10:40 AM the Nursing Home Administrator confirmed the facility could provide no documentation that ensured Employees 7 and 8 had specific competencies and skill sets to care for the residents needs listed above. Cross reference F0693 Tube Feeding mgmt./Restore Eating Skills 28 Pa. Code 201.20 (a) Staff Development

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide respiratory care consistent with professional standards of practice for two of two residents reviewed for respiratory concerns (Residents 5 and 54). Findings include: Clinical record review revealed the facility admitted Resident 5 on November 6, 2025. A physician's order initiated on November 7, 2025, instructed staff to administer Resident 5 continuous oxygen at three liters per minute (LPM) by nasal cannula (medical tubing that delivers supplemental oxygen directly to the nose). Observations of Resident 5 on December 3, 2025, at 10:53 AM, and 2:17 PM, and December 4, 2025, at 9:59 AM revealed she was receiving supplemental oxygen via nasal cannula. Each observation revealed the oxygen was being administered at one LPM, not three LPM as ordered by her physician. Interview with Resident 5 on December 3, 2025, at 10:53 AM revealed that she doesn't know why they keep putting the oxygen on her. She stated that she did not use any oxygen at home, and that she is not short of breath. The findings for Resident 5 were reviewed during a meeting with the Nursing Home Administrator and Director of Nursing on December 4, 2025, at 11:30 AM. Observation of Resident 54's oxygen tubing on December 3, 2025, at 10:46 AM revealed that there was no date on the oxygen tubing to indicate when the tube was last replaced. Observation of Resident 54's oxygen tubing on December 4, 2025, at 8:13 AM revealed there was still no indication of when the oxygen tubing was last changed located on the tubing. A concurrent observation of the nebulizer machine (specialized compressor utilized to administer aerosolized medication through specialized tubing, a medication cup, and a mask) located on a table next to the bed revealed a nebulizer mask, tubing, and medication cup that remained connected to the machine. The medicine cup and mask appeared cloudy, with droplets of clouded liquid dried inside the medicine cup. The nebulizer tubing was dated November 24, 2025. A bag containing a new mask and tubing was located beside the nebulizer machine and dated November 30, 2025. A concurrent interview with Resident 54 revealed that she had left the nebulizer mask there after her last treatment, which she indicated she uses only as needed. The resident stated that staff did not throw away her old mask when they brought in her new mask. Review of Resident 54's clinical record revealed the last administered dose of medication that required the nebulizer machine was November 29, 2025, at 7:18 PM. A review of Resident 54's clinical record revealed a current physician's order dated August 23, 2025, that stated change tubing, mask and/or nasal cannula weekly, may change sooner as needed. as needed for hygiene AND every night shift every Sat. The above information was reviewed with the Nursing Home Administrator and the Director of Nursing on December 4, 2025, at 12:36 PM. 483.25(i) Respiratory CarePreviously cited 2/4/25 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation and staff and resident interview, it was determined that the facility failed to provide a clean, comfortable, homelike environment on one of three open nursing units (Unit F and Residents 44 and 91) and failed to maintain the facility environment to protect the health and safety of residents, personnel and the public (two of two elevators, the area outside the elevators, and the main hallway after the lobby entrance).Findings include: Observations of Resident 44's room on December 3, 2025, at 11:06 AM revealed multiple light tan and brown colored stains on the privacy curtain in the resident's room. Observation of Resident 91's room on December 3, 2025, at 11:18 AM revealed the privacy curtain had brown colored stains and what appeared to be dried liquid on the privacy curtains. Observations of Elevator 2 on December 4, 2025, at 8:15AM revealed that the carpet on the floor had 2 areas of rippling/bubbling, causing the carpet to be elevated at the elevator door entrance. Further inspection revealed that there were many fraying fibers around the edge of the carpeting near the elevator walls. Concurrent observation revealed that Elevator 1 also had elevated carpet areas where the carpet appeared to have bubbles. Elevated carpet areas were also noted immediately after the lobby area at the hallway intersection, leading to the Kitchen and the Recreation room. The carpet outside of the elevators on the first floor had an 8-inch, round stain with a brown center measuring 1.5 inches, to the left of the elevator doors and near the wall when facing the doors. The above information was relayed to the Nursing Home Administrator and the Director of Nursing on December 4, 2025, at 12:30 PM. 483.10(i)(1)-(7) Safe/clean/comfortable/homelike EnvironmentPreviously cited deficiency 3/26/2025 28 Pa. Code 201.18(b)(3)(e)(2.1) Management

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding Transmission Based Precautions for three of 32 residents reviewed (Residents 19, 31, and 42) and failed to provide a safe and sanitary environment to help prevent development and transmission of disease and infection for one of 32 residents reviewed (Resident 10). Findings include: Observation of the room shared by Resident 31 and Resident 42 on December 3, 2025, at 2:20 PM revealed a sign on the door that directed visitors to Stop due to Contact Precautions (measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment). The sign instructed that everyone must clean their hands, put on gloves, put on a gown before room entry, and use dedicated or disposable equipment. Further observation of the room revealed a sign on the right doorframe that indicated Enhanced Barrier Precautions (EBP, utilized for residents with chronic wounds or indwelling medical devices [i.e., indwelling urinary catheters] during high-contact resident care activities regardless of their multidrug-resistant organism status; high-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care). An interview with Employee 3, licensed practical nurse, on December 3, 2025, at 2:23 PM revealed that Resident 31 was on contact precautions due to ESBL (Extended-Spectrum Beta-Lactamase; a type of bacteria that is resistant to certain antibiotics). Clinical record review for Resident 31 revealed an order dated November 20, 2025, for enhanced barrier precautions related to a suprapubic catheter (medical tubing used to drain urine from the bladder through the abdomen) and a wound. There was no order noted for contact precautions. Resident 31's care plan initiated on November 26, 2025, revealed the resident has an infection of the suprapubic catheter site and an intervention dated November 26, 2025, included to maintain universal precautions when providing resident care. The care plan did not specify to utilize contact precautions. Resident 31's Kardex (documentation by nursing to note important information and care planning and facilitate resident care) did not indicate to staff that the resident was on contact precautions. A wound culture for Resident 31 obtained on November 25, 2025, revealed multiple bacterial including ESBL in the sample. The above information for Resident 31 was reviewed with the Director of Nursing on December 3, 2025, at 2:50 PM. An interview with Employee 1, registered nurse, on December 3, 2025, at 3:00 PM confirmed that Resident 31 was on contact precautions and the order was not placed in the medical record and did not carry over to the resident's care plan and Kardex. Follow-up review of Resident 31's electronic health record revealed an order dated December 3, 2025, at 10:00 PM for contact isolation related to bacteria in the suprapubic wound drainage. Observation of Resident 19's room on December 5, 2025, at 8:23 AM revealed a sign outside the door to the resident's room that directed visitors to Stop due to Contact Precautions. The sign instructed that everyone must clean their hands, put on gloves, put on a gown before room entry, and use dedicated or disposable equipment. Observation during medication pass for Resident 19 on December 5, 2025, at 8:23 AM revealed Employee 3, licensed practical nurse, entered the room without donning (putting on) an isolation gown as instructed by the signage. An interview with Employee 3 on December 5, 2025, at 9:02 AM revealed that Resident 19 is on enhanced barrier precautions due to a wound. Employee 3 revealed that staff would check the physician orders to see if the resident is on enhanced barrier precautions or contact isolation. Upon checking the resident's chart, Employee 3 revealed there was no order for contact precautions or enhanced barrier precautions. A review of Resident 19's current physician orders revealed no order for contact precautions or enhanced barrier precautions. Resident 19's care plan revealed that the resident has a history of open wounds on the bilateral lower extremities. An intervention dated November 19, 2025, revealed the resident was on enhanced barrier precautions related to the wounds. There was no documentation in Resident 19's clinical record that indicated the resident was on contact precautions as the sign indicated. An interview with Employee 1, infection control, on December 5, 2025, at 9:33 AM stated the discrepancy was corrected. Follow-up review of Resident 19's electronic health record revealed an order dated December 5, 2025, for enhanced barrier precautions related to leg wounds. The above information for Residents 19 and 31 was reviewed with the Nursing Home Administrator and Director of Nursing on December 5, 2025, at 2:15 PM. An observation of Resident 10's bathroom on December 3, 2025, at 2:51 PM revealed a carboard box with several open and unopened packs of briefs and incontinence pads stored directly on the floor under the sink. The above information regarding the storage of Resident 10's incontinence products was reviewed with the Nursing Home Administrator and Director of Nursing on December 4, 2025, at 11:45 AM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to maintain clinical records that were complete, accurate, and readily accessible for one of 32 residents reviewed (Resident 31).Findings include: Clinical record review for Resident 31 revealed a diagnosis list that included weakness and difficulty in walking. Current physician orders for Resident 31 revealed an order dated June 9, 2025, at 2:48 PM for a restorative ambulation program that the resident will ambulate 50 to 100 feet with a rollator (a type of walker), contact guard (a type of assistance used in physical therapy), and a wheelchair to follow. Further review of the current physician orders for Resident 31 revealed an order dated April 28, 2025, at 11:28 AM for a restorative program to include an active range of motion to the bilateral upper extremities on all plains and joints for three sets of 10 repetitions. The task list (located in the electronic health record where staff document specific care related events for a resident) for Resident 31 revealed a task dated March 29, 2025, that included the following: RESTORATIVE: ambulate 20-40 feet with rollator. This task did not match the parameters noted in the current physician orders. A review of the documentation for the restorative program in the task list for the past 30 days revealed that staff were documenting the task as the following: Not applicable on November 6, 7, 10, 11, 12, 14, 19, 21 (at 8:42 PM), 23, 24, 25, 28, 29, 2025; December 1 and 4. Resident refused was documented by staff on November 15 (at 1:43 PM) and staff completed passive range of motion at 9:59 PM. Ambulation and locomotion documented as completed on November 21, 2025, at 8:48 AM. Ambulation and locomotion documented as completed on November 22, 2025, at 11:36 AM. Resident refused was documented by staff on November 27 and 30, 2025. An interview with Employee 4, Director of Rehab, on December 5, 2025, at 9:19 AM revealed that Resident 31 is currently on physical and occupational therapy and the resident should be discharged from the restorative program before being placed on therapy. Employee 4 revealed that the resident has been on both physical therapy since October 18, 2025, and occupational therapy since October 16, 2025. Nursing staff oversee restorative therapies. The above information for Resident 31 was reviewed with the Nursing Home Administrator and Director of Nursing on December 4, 2025, at 11:30 AM and December 5, 2025, at 2:15 PM. 483.70(h) Medical RecordsPreviously cited deficiency 2/4/2025 28 Pa. Code 211.5(i) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, review of select facility policies and procedures, observation, and resident and staff interview, it was determined that the facility failed to properly store resident medications and treatments on one of three nursing units (First Floor Nursing Unit; Resident 3). Findings include: The policy entitled Medication Storage, last reviewed on December 3, 2025, revealed all drugs and biologicals will be stored in locked compartments under proper temperature controls. Observation of Resident 3's room on December 3, 2025, at 10:12 AM and 1:40 PM revealed a bottle of H-Clor 12 0.125 percent solution (topical antiseptic used for wound care and skin infections) on his windowsill. Resident 3 stated it has been there awhile. He was unaware what the solution was used for. Observation of Resident 3's room on December 4, 2025, at 10:08 AM revealed a bottle of DermaSeptin ointment (skin protectant used to soothe skin irritations and promote healing) on his over bed table. Resident 3 was not in the room at this time. The above findings were reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on December 4, 2025, at 11:30 AM. 28 Pa. Code 211.9 (a)(1)(k) Pharmacy services 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that pain management was provided that was consistent with professional standards of practice for two of three residents reviewed for pain (Residents 3 and 5).Findings include: Clinical record review for Resident 3 revealed a care plan-initiated on May 22, 2025, noting Resident 3 has chronic pain related to his physical disabilities, immobility, contractures, history of multiple traumatic injuries, and a Stage IV (full thickness tissue loss with exposed muscle, tendon, or bone) sacral wound. Further review of Resident 3's clinical record revealed current physician's orders for the following pain medications: Tylenol 325 milligrams (mg), two tablets every four hours as needed for mild painTramadol (opioid medication used to treat moderate to severe pain) HCl 50 mg, one tablet every six hours as needed for moderate pain (4-7)Oxycodone (opioid medication used to treat moderate to severe pain) HCl 5 mg, one tablet every 12 hours as needed for severe pain (8-10) Review of Resident 3's Medication Administration Record (MAR, a form utilized to document the administration of medications) dated November 2025, revealed that he received Tylenol as follows: November 1, 2025, for a pain level of 6November 2, 2025, for a pain level of 4November 6, 2025, for a pain level of 4November 9, 2025, for a pain level of 5November 11, 2025, for a pain level of 5November 18, 2025, for a pain level of 5November 19, 2025, for a pain level of 4November 20, 2025, for a pain level of 4November 21, 2025, for a pain level of 5November 23, 2025, for a pain level of 6November 28, 2025, for a pain level of 5November 30, 2025, for a pain level of 6 The facility failed to follow Resident 3's physician ordered pain medication for the level of pain. Interview with Resident 5 on December 3, 2025, at 11:54 AM revealed she has frequent pain from her fall with a fracture at home. Clinical record review revealed the facility admitted Resident 5 on November 6, 2025, and a plan of care was initiated on November 8, 2025, that noted Resident 5 has pain related to arthritis and a right femur fracture. Review of Resident 5's clinical record revealed current physician's orders for the following pain medications: Tylenol 325 mg, two tablets every four hours as needed for mild painTramadol HCl 50 mg, one tablet every six hours as needed for moderate painOxycodone HCl 5 mg, one tablet every six hours as needed for severe pain Review of Resident 5's MARs dated November and December 2025, revealed that she received Tylenol as follows: November 9, 2025, for a pain level of 4November 10, 2025, for a pain level of 5November 19, 2025, for a pain level of 4November 29, 2025, for a pain level of 10December 3, 2025, for a pain level of 5December 4, 2025, for a pain level of 5 Interview with the Nursing Home Administrator and Director of Nursing on December 4, 2025, at 11:35 AM confirmed the above noted findings related to Resident 3 and 5's pain. They were unable to provide any further documentation to ensure that pain medications were administered according to physician orders. 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(1) Nursing services

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide appropriate treatment and services for a resident who is fed by enteral means to prevent potential complications for one of one resident reviewed for tube feeding concerns (Resident 6).Findings include: Observation of Resident 6 On December 3, 2025, at 3:24 PM revealed the presence of a feeding tube (G-tube, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications; also known as a PEG tube) connected to a feeding pump (a mechanical device used to pump a specialized liquid nutrition source referred to as feed, through a G-tube at a pre-set rate). A concurrent observation of the feeding pump revealed that the pump rate was set to administer 50 milliliters (ml) of feed per hour. Clinical record review revealed that Resident 6 had a physician's order written on November 20, 2025, stating 42ml/hr continuous feed via PEG- until (4) 250ml container received x 24 hours via PEG. Observation on December 5, 2025, at 7:45 AM revealed that the feeding rate remained at 50ml/hr. A concurrent interview with Employee 5, licensed practical nurse, confirmed that the feeding rate set on the pump did not match the physician's order in Resident 6's chart. A request for the nursing competencies for Employee 7, licensed practical nurse, and Employee 8, registered nurse, were requested on December 4, 2025, at 12:30 PM. The nursing competencies specifically related to G-tubes were requested from the Nursing Home Administrator for Employees 7 and 8 on December 5, 2025, at 9:15 AM, 12:45 PM. On December 8, 2025, at 10:40 AM the Nursing Home Administrator confirmed that the facility could not locate any competencies for Employees 7 and 8 related to G-tubes. Cross refer F0726 Competent Nursing Staff 28 Pa. Code 211.10(a)(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing service

Based on clinical record review, review of facility documents, and staff interview, it was determined that the facility failed to implement interventions to aid in fall prevention for one of five residents reviewed for falls (Residents 69).Findings include: Clinical record review for Resident 69 revealed the resident had a history of falls in the facility. A review of Resident 69's active plan of care for the risk of falls revealed an intervention listed was to keep the resident's bed in low position when in bed, bilateral body pillows when in bed, floor mats on the right side of the bed, left side of the bed against the wall, and the bed needs to be locked down, with a date initiated of November 22, 2025, and revision date of November 23, 2025. Further review of resident 69's fall risk plan of care intervention above revealed a history of changes to the above intervention, but bilateral body pillows were listed as part of the intervention since August 18, 2024. Clinical record review for Resident 69 revealed a progress note dated November 22, 2025, that indicated the resident was not moving her left arm or shoulder and also had complaints of left hip pain with movement and due to the timing for a mobile x-ray the resident's responsible party wanted the resident sent to the emergency room. Transportation was arranged at that time. A progress note dated November 23, 2025, at 7:21 AM for Resident 69 by Employee 6, registered nurse, noted the nurse was on the unit and heard a scream coming from the resident's room and noted the resident was found lying on the floor on her left side between the dresser and floor mat. It was noted two skin tears were identified on the resident's left arm, and the resident was not able to perform range of motion on her left arm having severe pain when moving it. The physician was made aware, and the oncoming registered nurse would continue to assess and call for an x-ray. Facility staff indicated this note was in reference to Resident 69's fall that occurred on November 22, 2025, but due to change of shift it did not get documented until November 23, 2025, by Employee 6. Review of a progress note for Resident 69 dated November 23, 2025, at 6:31 AM revealed facility staff had contact with the hospital, and the resident was noted to have sustained a fracture of her left humerus (arm), and a fracture of an iliac bone that extends to the left hip socket. Review of a facility fall report for Resident 69 dated November 22, 2025, at 8:55 PM revealed the resident was found on the floor in her room at the end of the bed noting the resident got out of bed and walked over her fall mats and then fell. The report noted the resident's left shoulder and arm pain and that the resident's responsible party wanted the resident sent to the hospital. The report also indicated that the resident got out of bed unassisted and was in a low bed with a right fall mat and no body pillow, noting it was sent to laundry due to soiling. Review of a statement by Employee 12, nurse aide, regarding Resident 69's fall noted above dated November 22, 2025, revealed that a fall mat and slippers were in place at the time of the fall, but the body pillow was taken down to wash. Review of an additional statement dated November 22, 2025, for Resident 69's fall, with the author not identified on the statement noted slippers and fall mats were in place but the body pillow was in laundry. The above information regarding Resident 69's fall risk intervention of a body pillow not being present at the time of the fall sustained on November 22, 2025, was reviewed with the Nursing Home Administrator and Director of Nursing on December 5, 2025, at 9:30 AM. On December 5, 2025, at 11:00 AM the Director of Nursing provided an additional statement from Employee 6, dated December 5, 2025, noted a clarification to the employee's observation of Resident 69 at the time of the November 22, 2025, fall to now add that there were pillows on the resident's bed at the time of the fall. In a follow up interview with Employee 6, on December 5, 2025, at 11:24 AM Employee 6 stated Resident 69's fall happened at the end of her shift and she was the one who initially assessed the resident and knew that when she and the other staff who assisted her put the resident back into her bed there was not a body pillow on the bed, but there were other regular pillows, which she used to position under the resident. Employee 6 could not confirm if staff had utilized pillows to function in place of the required body pillow to extend down the resident's side as she only saw the resident after the fall and knew that regular pillows were on the bed when she helped position the resident. Employee 6 indicated that the body pillow is a long pillow, which extends down the side of the resident and is not the same as regular pillows. Employee 6 indicated the facility has a supply of body pillows and could obtain another pillow if one was being laundered. Resident 69 did not have a body pillow per her plan of care at the time of the fall on November 22, 2025, in which the resident sustained an injury. The above findings for Resident 69 were reviewed with the Director of Nursing on December 5, 2025, at 12:15 PM. 483.25 (d)(1)(2) Free of Accident Hazards/Supervision/DevicesPreviously cited 2/4/25, 9/11/25 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff and resident interview, it was determined that the facility failed to implement a comprehensive, person-centered care plan regarding a cardiac pacemaker for one of 32 residents reviewed (Resident 24). Findings Include: Clinical record review for Resident 24 revealed a diagnosis list that included the presence of a cardiac pacemaker (an electronic device to help regulate the beating of the heart) and complete atrioventricular block (a disorder of the heart that impacts the electrical signals between the upper and lower chambers). Hospital documentation for Resident 24 dated July 29, 2025, at 7:16 AM revealed that the resident's electrocardiogram (EKG, a test to measure the electrical rhythm of the heart) had a ventricularly (referring to the lower chambers of the heart) paced cardiac rhythm. An interview with Resident 24 on December 5, 2025, at 11:30 AM confirmed that the resident had a pacemaker and an electronic transmittal device on the bedside dresser the resident reported was for remote monitoring. Review of Resident 24's care plan revealed no current comprehensive, person-centered care plan that addressed the resident's pacemaker, any pertinent assessments related to the pacemaker and/or clinical care, precautions, or the transmittal device care. An interview with Employee 2, licensed practical nurse, on December 5, 2025, at 12:12 PM confirmed that there was no comprehensive, person-centered care plan associated with Resident 24's pacemaker. The above information for Resident 24 was reviewed with the Nursing Home Administrator and Director of Nursing on December 5, 2025, at 2:15 PM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to implement interventions to decrease the potential for resident elopements for one of four residents reviewed (Resident 1). Findings include: Clinical record review for Resident 1 revealed a progress note date August 1, 2025, at 6:19 PM that indicated she was exit seeking twice during the shift. Clinical record review for Resident 1 revealed a nursing progress note dated August 17, 2025, at 10:11 PM that indicated Resident 1 was anxious and exit seeking. The physician was notified and a one time dose of Seroquel (a medication used to treat psychosis) 25 milligrams was ordered. A nursing progress note dated August 21, 2025, at 12:08 AM revealed that Resident 1 was pacing in the hallway and set off the wander guard system at the elevators once. A nursing progress note dated August 21, 2025, at 6:22 PM revealed that Resident 1 was restless and wandering. She wanted to leave. She was on the elevator twice and activated the alarm. Clinical record review for Resident 1 revealed a progress dated August 22, 2025, at 12:06 PM that indicated Resident 1 had eloped and walked out the front door of the building. Resident 1 was followed by staff and was on the grass at the right of the facility on the corner at the redlight near the highway. Staff redirected Resident 1 back into the facility. The note indicated that Resident 1's wander guard (a wearable bracelet that works with a wander guard system sounding an alarm to assist with elopement prevention) was working and sounded the alarm when she was brought back into the facility, and when she got off the elevator back onto the nursing unit. The note also indicated that Resident 1's physician was notified of the incident and new orders were received for lab work, an abdominal ultrasound, and urinalysis with culture and sensitivity. Review of the facility's investigation into Resident 1's elopement dated August 22, 2025, at 10:34 AM revealed that the facility initiated 15-minute checks on Resident 1 that would progressively lengthen in time over the weekend until they were hourly checks and then would remain in effect for 72 hours. Further clinical record review for Resident 1 revealed a progress note dated August 23, 2025, at 10:00 PM that indicated the alarm by the elevators activated and noted that Resident 1 was on the elevator as the elevator door closed. The nurse took the other elevator to the first floor and found Resident 1 near the front door with the wander guard alarm on that floor activated. Resident 1 was safely returned to her unit. The facility discontinued every one hours checks and initiated checks every 15-minutes. A nursing progress note dated September 1, 2025, at 9:49 PM revealed that Resident 1 attempted to leave the unit but was easily redirected. A nursing progress note dated September 3, 2025, at 2:29 PM revealed that Resident 1 attempted to get on the elevator one time that morning. A nursing progress note dated September 4, 2025, at 5:53 PM revealed that Resident 1 was exit seeking three times that shift. A nursing progress note dated September 6, 2025, at 3:23 PM revealed that Resident 1 was at the elevator with an arm full of clothes and pushed the elevator button and the alarm sounded, but the nurse intervened. A nursing progress note dated September 8, 2025, at 2:31 PM revealed that Resident 1 was walking down the hallway with some of her clothes towards the elevator and she was redirected by staff. A nursing progress note dated September 8, 2025, at 4:57 PM indicated that Resident 1 entered the elevator with visitors. The wander guard alarm activated. Resident 1 continued in the elevator and got off on the first floor where staff intervened as she was exiting the front of the building. Resident 1 was returned to the nursing unit and one-to-one was initiated. A progress note dated September 11, 2025, at 10:04 AM revealed that Resident 1 continued on 15-minute checks and she is also on one to one; however, that was discontinued at 10:00 AM. On September 11, 2025, at 9:00 AM the surveyor entered the facility and there was no receptionist at the front desk. The office doors in the general area were all closed. The surveyor waited from until 9:06 AM and then went to find staff. When the surveyor arrived back to the lobby area, there was still no receptionist. As the surveyor walked towards the front doors of the facility, they opened up allowing an exit from the facility without the assistance of staff. An interview with the Nursing Home Administrator on September 11, 2025, at 11:30 AM revealed that the wander guard system is not tied into the doors or the elevator. The NHA indicated that when a resident wearing a wander guard are near the wander guard system, it sets the alarm off but does not lock the elevator or doors. The NHA also indicated that the front doors of the facility are locked from 8:00 PM until 8:00 AM. He confirmed that if a resident with or without a wander guard bracelet came down in the elevator and staff were not there to intervene, that the resident could walk right out the front doors between the hours of 8:00 AM and 8:00 PM. The NHA also confirmed that if Resident 1 entered the elevator the alarm would go off, but she could still get to the first floor and out the front doors if staff did not respond to the alarms timely. There was no evidence that the facility implemented effective interventions to prevent the potential for resident elopements. The above information was reviewed with the Nursing Home Administrator on September 11, 2025, at 2:30 PM. 8 Pa. Code 201.18(b)(1)(e)(1) Management28 Pa. Code 211.10(c)(d) Resident care policies28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, comfortable, and homelike environment on two of four nursing units (Nursing Units C, and F; Residents 1, 2, 3, 4, 5, and 6). Findings include: Observation of Nursing Unit C (second floor) on March 26, 2025, at 10:33 AM revealed the following findings: A wheelchair in the hallway with no resident identifier had a significant accumulation of crumbs and debris under the seat cushion on the chair. There was also an unidentified piece of metal on the seat of the chair. A concurrent interview with Employee 1, nurse aide, revealed the wheelchair belonged to Resident 1. Resident 2's wheelchair had an accumulation of crumbs and debris under the seat cushion on the wheelchair. Resident 3's wheelchair had an accumulation of crumbs and debris under the seat cushion on the wheelchair. Another wheelchair with no resident identifier had an accumulation of crumbs and debris under the seat cushion on the wheelchair. A concurrent interview with Employee 1 revealed it was unclear who the wheelchair belonged to. Observation of the Nursing Unit C shower room on March 26, 2025, at 10:53 AM revealed the following: There were multiple tears in the padding on the shower gurney exposing the underlying foam padding. One of the tears was six inches in length. A shower chair had five resident lift slings of various sizes piled on the seat. Another sling was draped over the backrest of the chair. There was a blue-colored padded foam heel boot amongst the slings. A pink colored basin held various shower supplies that included skin moisturizer and soap. At least two different resident initials were noted on two of the items. One of the items had leaked. There was an unused, folded brief in the basin. The item had leaked onto several of the other items including the brief and the bottom of the basin. Observation of the Nursing Unit F (third floor) shower room on March 26, 2025, at 11:04 AM revealed the following: A bucket used for a bedside commode was on the floor in the shower stall partially full of a brownish-tinged liquid. The bucket contained a brown colored object that appeared to be from a bowel movement floating in the water. A black colored hair comb was located on a shelf above the sink. The teeth of the comb had a significant accumulation of white flakes and several strands of hair in it. The comb was placed with multiple other combs that appeared to be unused. Observation of Nursing Unit F on March 26, 2025, at 11:11 AM revealed the following: Resident 4's wheelchair was wet with an unidentified liquid under the seat cushion of the wheelchair. A concurrent interview with Employee 3, nurse aide, revealed that the wheelchair would be cleaned immediately. Resident 5's Geri-chair had plastic collapsible trays on bilateral sides of the chair. The edges of both trays were broken exposing jagged edges of plastic. Observation of Resident 6's wheelchair on March 26, 2025, at 2:58 PM revealed debris in the cupholder. There was a missing protective cap on the metal frame on the front left side of the wheelchair. There was an accumulation of dirt and debris in the missing cap. There was rust on the frame of the wheelchair. The above information was reviewed in a meeting with the Nursing Home Administrator and the Director of Nursing on March 26, 2025, at 3:20 PM. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed pharmacy recommendations for three of five residents reviewed (Residents 77, 20, and 63). Findings include: The policy entitled Monthly Drug Regimen Review, last reviewed on December 16, 2024, indicates that during a drug regimen review, the consultant pharmacist is to identify drug regimen irregularities. Reports are to be addressed by the attending physician within one to 21 days, unless urgent. If follow up to the consultant pharmacist recommendations are not completed within the specified time frame, this should be reported to the Medical Director. Review of Resident 77's clinical record revealed a pharmacy form entitled Consultation Report dated June 21, 2024, indicating that the consultant pharmacist identified that Resident 77 was taking Ativan (for anxiety) 0.5 mg (milligrams) as needed longer than 14 days without a stop date. There was no documented evidence that Resident 77's physician reviewed or responded to the recommendation from the pharmacist. The facility did not obtain a physician's order to stop Resident 77's Ativan until November 4, 2024, five months after the recommendation. A pharmacy form entitled Consultation Report dated July 31, 2024, indicated that the consultant pharmacist identified that Resident 77 was taking an activating antidepressant (which can act as a stimulant) at bedtime, and recommended that the dose be switched to a morning administration time. There was no documented evidence that Resident 77's physician reviewed or responded to the recommendation by the pharmacist. A pharmacy form entitled Consultation Report dated November 27, 2024, indicated that the consultant pharmacist again identified that Resident 77 was taking an activating antidepressant at bedtime, and recommended that the dose be switched to a morning administration time. There was no documented evidence that Resident 77's physician reviewed or responded to the recommendation by the pharmacist. The facility obtained a physician's order on January 30, 2025, to switch Resident 77's antidepressant to a morning administration, six months after it was first recommended and after questioning by this surveyor. Interview with the Administrator and Director of Nursing on January 31, 2025, at 10:30 AM confirmed the above findings for Resident 77. Clinical record review for Resident 20 reveled a pharmacist monthly consultation recommendation report dated April 20, 2024, to evaluate the resident's medications of Aripiprazole (used for schizoaffective (mental health) disorder,), Clozapine (used for schizophrenia), Bupropion (an antidepressant), Lorazepam (used for anxiety), Melatonin (used to help sleep), and Sertraline (an antidepressant), for an annual dose reduction. Facility staff were not able to produce any evidence Resident 20's physician reviewed/responded to the pharmacy recommendation. Additional pharmacy consultation reports for Resident 20 dated May 2, 2024, recommending a trial dose reduction of the resident's Aripiprazole and Bupropion, and another dated October 15, 2024, recommending medications be evaluated as possible causes or contributors to a fall, were identified with no evidence provided of any physician review/response to the recommendations within 30 days or of the recommendation. The above information was confirmed with the Nursing Home Administrator on January 31, 2025, at 12:33 PM. Clinical record review for Resident 63 revealed a pharmacy consultant note dated October 31, 2024, at 5:29 PM that revealed irregularities with the medication regimen review and, See report for any noted irregularities. Documentation titled Consultation Report for Resident 63 revealed a pharmacy recommendation dated October 31, 2024, that indicated the resident received methenamine (a medication used to treat or prevent urinary tract infections) for urinary tract infection prophylaxis (preventatively). The recommendation from the pharmacist included to reevaluate use and, if appropriate, discontinue the medication while monitoring for signs and symptoms of recurrent urinary tract infections. The physician's response section of the form revealed no response from the physician. Clinical record review for Resident 63 revealed a pharmacy consultant note dated June 21, 2024, at 9:21 PM that revealed irregularities with the medication regimen review and, See report for any noted irregularities. Documentation titled, Consultation Report, for Resident 63 revealed a pharmacy recommendation dated June 21, 2024, that indicated the resident received methenamine (a medication used to treat or prevent urinary tract infections) for urinary tract infection prophylaxis. The recommendation from the pharmacist included to reevaluate use and, if appropriate, discontinue the medication while monitoring for signs and symptoms of recurrent urinary tract infections. The physician's response section of the form revealed no response from the physician. Clinical record review for Resident 63 revealed a pharmacy consultant note dated April 16, 2024, at 2:12 PM that revealed irregularities with the medication regimen review and, See report for any noted irregularities. Documentation titled, Consultation Report, for Resident 63 revealed a pharmacy recommendation dated April 16, 2024, that indicated the resident received three or more central nervous system active medications, which can cause and increased risk for falls and fractures. The listed medications included the following: Venlafaxine Hydrochloride (a medication used to treat depression and/or anxiety), Quetiapine Fumarate (an antipsychotic medication), and Gabapentin (a medication used to treat certain things such as seizures and nerve pain). The recommendation from the pharmacist included to reevaluate the combination and consider a trial dose reduction of one of these medications. The physician's response section of the form revealed no response from the physician. An interview with Employee 1, assistant director of nursing, on January 31, 2025, at 10:30 AM confirmed the pharmacist recommendations for Resident 63 and no documented evidence that the physician reviewed or responded to the recommendations. The Administrator was also present during the interview. 483.45(c) Drug Regimen Review Previously cited 1/26/24 28 Pa. Code 211.9 (k) Pharmacy services 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide physician ordered services to maintain a resident's mobility for two of three residents reviewed (Residents 73 and 98) and maintain a resident's restorative nursing program for two of three residents reviewed (Residents 85 and 98). Findings include: Clinical record review for Resident 85 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated November 11, 2024, that indicated the resident had a BIMS (Brief Interview for Mental Status) score of 3 that indicated a severe cognitive impairment level. Review of the Tasks list for Resident 85 revealed the following restorative nursing program (a formal, planned, and organized care program designed to restore lost abilities or maintain potentially deteriorating functions): Ambulation/locomotion; patient will ambulate 100 to 150 feet with a rolling walker and supervision. A physical therapy discharge summary for Resident 85 dated September 25, 2024, at 9:55 AM revealed the resident was discharged from therapy with a reason noted as maximum potential achieved, referred for a restorative nursing program/functional maintenance program. Review of facility documentation titled, Therapy Communication to Restorative Nursing Program, dated September 27, 2024, revealed recommendations from therapy that included the resident will ambulate 200 to 300 feet with a rolling walker and supervision. An interview with Employee 4, Director of Rehabilitation, on January 30, 2025, at 1:29 PM confirmed that the above program was recommended by physical therapy for Resident 85 upon discharge from therapy on September 25, 2024. Employee 4 further stated that the nurse aides complete the restorative programs with the resident. A review of the task documentation for Resident 85's restorative nursing program for October 2024, November 2024, and December 2024, revealed that there was only one date (November 7, 2024) that was documented as having the program completed until the resident went back on active physical therapy on January 10, 2025. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on January 30, 2025, at 2:25 PM. There was no further clinical documentation provided by the facility for Resident 85 to indicate the restorative program was completed or why the restorative program was entered differently into the electronic health record than what therapy had recommended. Interview with Resident 73 on January 28, 2025, at 12:45 PM revealed that she was no longer receiving skilled therapy services, and staff were supposed to walk with her twice a day. Resident 73 stated that she could not recall the exact day when staff last walked with her, but it was during the previous week. Resident 73 stated that staff said to her, .why don't (skilled therapy staff) come up and walk you? Clinical record review for Resident 73 revealed an active physician's order dated January 9, 2025, that instructed staff to complete a restorative nursing program for Resident 73 to ambulate 100 feet with a roller walker with supervision, verbal cues, and a brace (due to risk for hip dislocation). Review of a Documentation Survey Report (electronic documentation completed by nurse aide staff to record care and services provided) dated January 2025, revealed that staff did not complete the restorative ambulation program with Resident 73 twice daily on any day since the physician's order on January 9, 2025. The documentation indicated that staff did not complete the program at least once a day on the following days: January 15, 2025 (staff documented not applicable for day shift) January 16, 2025 January 18, 2025 January 21, 2025 January 23, 2025 January 25, 2025 January 26, 2025 January 28, 2025 The surveyor reviewed the above concerns regarding Resident 73's restorative ambulation program during an interview with the Director of Nursing and the Nursing Home Administrator on January 30, 2025, at 1:46 PM. In an interview and observation of Resident 98 on January 28, 2025, at 2:15 PM, the resident stated he had finished his therapy last week, and that he had come to the facility almost paralyzed (partially incapable of movement) but was now walking with the use of a walker and staff assistance. Resident 98 stated since his therapy ended last week no one has walked him on the unit. Resident 98 indicated he had walked once because he went by himself to the nursing station. Review of a physical therapy discharge summary for Resident 98 dated January 23, 2025, revealed the physical therapist discharged the resident on January 23, 2025, with a diagnosis of gait impairment and recommendations for a restorative nursing program, noting the resident's prognosis to maintain his current level of functioning was good with consistent staff follow-through. In an interview with Employee 4, on January 31, 2025, at 10:13 AM, Employee 4 indicated when therapy is finished with a resident and recommending a restorative nursing program a form is completed and provided to nursing staff to order and to implement the program that is indicated on the nursing units. A Therapy Communication to Restorative Nursing Program form for Resident 98 dated January 23, 2025, indicated the resident's functional status on that date was ambulating 200-250 feet with a rolling walker and contact guard (caregiver places one to two hands on the resident to help with balance) assistance, and transfers with assistance. The recommendation on the form was for the resident to be ambulated up to 250 feet using a rolling walker and staff assistance for mobility and to perform other active range of motion therapeutic exercises to the resident's bilateral lower extremities in three sets of 10. There was no evidence provided to indicate Resident 98's restorative nursing program to include mobility and range of motion was ordered/implemented or completed at all since his discontinuation of therapy on January 23, 2025. An interview with the Nursing Home Administrator on January 31, 2025, at 10:35 AM confirmed the above findings regarding Resident 98. 483.25(c)(1)-(3) Increase/prevent Decrease In Rom/mobility Previously cited: 1/26/2024; 3/6/2024 28 Pa. Code 211.10(a)(c)(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on employee personnel record review and staff interview, it was determined that the facility failed to complete a performance evaluation of each nurse aide at least once every 12 months for two of three nurse aides reviewed (Employees 8 and 9). Findings include: The facility noted the following hire dates for two employees reviewed for performance evaluations: Employee 8's hire date: May 29, 2013. Employee 9's hire date: October 27, 1998 A request to review the annual performance evaluations revealed no documented evidence that the facility is completing the evaluations at least once every 12 months. Interview with Employee 10, human resources, on January 31, 2025, at 11:15 AM confirmed that performance evaluations were not completed on the two employees. 483.35(d)(7) Nurse Aide Perform Review-12 Hr/yr In-Service Previously cited 1/26/2024 28 Pa. Code 201.19 (2) Personnel policies and procedures

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for three of six residents reviewed (Residents 69, 77, and 85). Findings include: Review of Resident 69's clinical record revealed a physician's order dated January 5, 2025, that indicated nursing staff may administer Ativan (for anxiety) 0.5 mg (milligrams) every six hours as needed for agitation or anxiety. There was no documented evidence that Resident 69's physician documented a rational for the continued use of the Ativan beyond a 14-day period. The facility obtained a physician's order on January 30, 2025, to discontinue the use of the Ativan after the surveyors questioning. Review of Resident 77's clinical record revealed a physician's order dated May 21, 2024, that indicated nursing staff may administer Ativan 0.5 mg every six hours as needed for agitation or anxiety. There was no documented evidence that Resident 77's physician documented a rationale for the continued use of the Ativan beyond a 14-day period. The facility obtained a physician's order to discontinue the Ativan on November 4, 2024, almost six months after it being initiated. Interview with the Administrator and Director of Nursing on January 31, 2025, at 10:30 AM confirmed the above findings for Residents 69 and 77. Clinical record review for Resident 85 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated November 11, 2024, that indicated the resident had a BIMS (Brief Interview for Mental Status) score of 3 that indicated a severe cognitive impairment level. Review of the Medication Administration Record (MAR) for Resident 85 revealed an order for Lorazepam (Ativan, a medication used to treat anxiety) dated December 16, 2024, and discontinued January 4, 2025, that noted: Lorazepam 0.5 mg; give 0.25 mg by mouth three times a day. Facility documentation dated December 31, 2024, revealed an FYI (for your information) written to the physician that noted, Please review narc (narcotic) sheet. Med errors noted. Ordered Lorazepam 0.5 mg, give 0.25 mg three times a day and 0.5 mg as needed every eight hours. Please note and advise. The physician acknowledged that they were aware and signed and dated the document on January 4, 2025. No further orders were noted on the documentation. Nursing documentation for Resident 85 dated January 3, 2025, at 6:35 PM noted the staff member observed an FYI to the physician regarding the family's concern for lethargy and an Ativan medication error from December 28-31, 2024. Resident was receiving double doses of Ativan. The staff member also made the family aware of, .med errors. Nursing documentation for Resident 85 dated January 3, 2025, at 11:14 PM noted a late entry for 12/31/2024. The staff member reported the registered nurse (RN) who was being relieved informed of, Ativan med errors she noted during the 1600 (4:00 PM) med pass. Nursing documentation for Resident 85 dated January 3, 2025, at 11:47 PM noted an assessment that indicated resident excessively sleeping. Nursing documentation for Resident 85 dated January 6, 2025, at 2:03 PM revealed that on one card the regular and as needed orders were merged. The combined orders were discontinued. The medication card that was delivered from the pharmacy on December 11, 2024, were 0.5 mg tablets and the directions noted to give 0.5 (half) tablet for a total dose of 0.25 mg per dose. The tablets that were sent were not scored and could not be cut in half. New cards are to be sent with the new clarified order. Nursing documentation for Resident 85 dated January 6, 2025, at 2:32 PM noted that on the evening of January 3, 2025, it was reported to nursing that something didn't look right with the medication card / sheet for the resident. This was documented as discussed with the RN supervisor who investigated and reported it was more of a transcription issue due to the way the card came from pharmacy and was very confusing. The documentation further noted that the order, as it was initially written in the electronic health record, combined both the routine and the as needed order onto one order and so it was filled in that manner from the pharmacy, which led to confusion. A review of the facility document (the documentation that comes with the pharmacy medication packs to track administration and accountability of the controlled medication) titled, Controlled Medication Utilization Record, revealed the following medication instructions for Resident 85: Give 0.5 (half) tab (0.25 mg total) by mouth every 8 hours routine and one tab by mouth every eight hours as needed for anxiety. The following administrations for the Lorazepam were marked on the Controlled Medication Utilization Record: December 28, 2024: 1:00 PM, 5:00 PM; dose given at each timestamp indicated one December 29, 2024: 10:00 AM, 1:00 PM, 5:00 PM; dose given at each timestamp documented as one December 30, 2024: 10:00 AM, 1:00 PM, and a second 1:00 PM was documented; doses given at each timestamp documented as one December 31, 2024: 10:00 AM, 1:00 PM; dose given at each timestamp documented as one December 31, 2024: 5:00 PM; dose given documented as one with 1/2 (half) marked as wasted. There was only one instance during the time of December 28, 2024, to December 31, 2024, (which was December 31, 2024, at 5:00 PM), where half a tablet of Ativan was wasted as indicated in the directions on the Controlled Medication Utilization Record to administer a half tab for the routine dose (0.25 mg). An interview with the Director of Nursing (DON) on January 29, 2025, at 1:45 PM revealed that Resident 85 was getting a double dose of Ativan. There was no further clinical documentation provided by the facility to indicate that Resident 85 was not being administered a double dose of Lorazepam during the medication administration dates from December 28-31, 2024, or any investigative report related to a medication error as indicated by the staff in the nursing documentation and documentation to the physician. 483.45(c) Drug Regimen Review Previously cited 1/26/24 28 Pa. Code 211.9(k) Pharmacy services 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (C Nursing Unit and F Nursing Unit; Residents 40 and 66). Findings include: The facility's medication error rate was 10 percent based on 30 medication opportunities with three medication errors. Observation of Resident 40's medication administration pass on January 30, 2025, at 9:00 AM revealed that Employee 7, licensed practical nurse (LPN), prepared the medications prior to administration. Employee 7 proceeded to place the resident's medications in a disposable medication pouch and crush them with a tablet crusher and then mix them in pudding. Clinical record review for Resident 40 revealed a physician/'s order dated May 20, 2024, that noted crushable medications may be crushed, mixed, and administered together unless contraindicated. Physician orders for Resident 40 dated April 25, 2022, revealed Isosorbide Mononitrate (a medication used to help widen the blood vessels and prevent chest pain) ER (extended release) 30 milligrams (mg), give one tablet by mouth one time a day. The pill package (the package from pharmacy which contained the medications) for the Isosorbide Mononitrate noted, Do not chew or crush before swallowing. A physician's order for Resident 40 dated January 14, 2025, for Pantoprazole Sodium Oral Tablet Delayed Release (DR) (a medication used to treat certain stomach problems), give 20 mg by mouth one time a day. Employee 7 administered 40 mg of the medication instead of 20 mg as noted in the order. The pill package for the Pantoprazole noted, Do not chew or crush. The medication was also crushed by Employee 7 prior to administration. An interview with Employee 7 on January 30, 2025, at 12:29 PM confirmed the medications were crushed for Resident 40 and Employee 7 administered 40 mg of Pantoprazole. The pill package for the 20 mg of Pantoprazole was found in the bottom drawer of the medication cart. The above information was reviewed in a meeting with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on January 30, 2025, at 2:00 PM. Facility documentation titled, Common Oral Dosage Forms That Should Not Be Crushed, provided by the facility on January 31, 2025, revealed that both the Isosorbide ER and Pantoprazole DR were on the list. Clinical record review for Resident 66 revealed an active physician's order for staff to administer 10 units from a Humalog Kwikpen (a disposable single-patient-use prefilled pen containing 300 units of Humalog, an injectable hormone used to lower blood sugar. You can give more than one dose from the pen) before meals. Instructions regarding the use of a Humalog Kwikpen (https://pi.lilly.com/us/humalog-kwikpen-um.pdf) stipulate that the user is to prime the pen before each injection. Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step six of the instructions note to turn the insulin pen dose knob to two units. Step seven instructs to hold the pen with the needle pointing up and tap the cartridge holder gently to collect air bubbles at the top. Step eight is to continue holding the pen with the needle pointing up, push the dose knob in until it stops, and a zero is seen in the dose window; there should be insulin visible at the tip of the needle. Then the user can select the desired dose. Observation of a medication administration pass on January 28, 2025, at 11:37 AM revealed Employee 2 (LPN)prepared medications for administration. Employee 2 obtained a Humalog Kwikpen and a disposable needle from the medication cart. Employee 2 applied the needle to the tip of the Humalog Kwikpen and dialed 10 units for administration to Resident 66. Employee 2 entered Resident 66's room and administered the insulin medication into Resident 66's right upper arm. Employee 2 did not prime the needle before administration of Resident 66's insulin medication. Interview with Employee 2 on January 28, 2025, at 11:53 AM confirmed that she did not prime the needle before administering Resident 66's insulin. The surveyor reviewed the above concerns regarding Resident 66's insulin administration during an interview with the NHA, DON, and Employee 1 (assistant director of nursing) on January 30, 2025, at 2:16 PM. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide necessary dental services for one of one resident reviewed for dental concerns (Resident 20). Findings include: In an interview and observation of Resident 20 on January 28, 2025, at 12:46 PM the resident was observed to have visible black/decayed appearance of her lower teeth with multiple teeth missing. Resident 20 stated she did not recall seeing a dentist since she had been at the facility. Clinical record review for Resident 20 revealed the resident was admitted to the facility on [DATE]. Review of an annual MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated June 20, 2024, revealed the resident was assessed as having natural teeth with no likely cavities or broken natural teeth. A review of Resident 20's active plan of care revealed the resident has a care plan initiated on February 5, 2019, indicated the resident has oral/dental health problems related to poor nutrition and poor dentition. The plan of care indicated interventions of the same date to coordinate arrangements for dental care, transportation as needed/ordered. A review of a facility Request for Service form dated March 3, 2023, for Resident 20 revealed the resident selected yes as wishing to be seen for dental care. Facility staff did not provide any evidence to indicate Resident 20 had seen a dentist, or evidence the resident refused a dentist since a confirmed dental visit on August 26, 2019. The Nursing Home Administrator confirmed in an interview on January 31, 2025, at 10:38 AM there was no evidence Resident 20 had services coordinated to see a dentist since 2019. Facility staff provided an email notification with the facility's dental provided dated January 30, 2025, indicating Resident 20 was added to the list to be seen with the next dentist visit to the facility, after it was brought to the facility staff's attention. 483.55(b)(1)(3)(5) Routine/emergency Dental Services Previously cited deficiency 1/26/24 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents were educated, offered, and received the COVID-19 vaccine if they consented for five of five residents reviewed for immunizations (Residents 4, 16, 21, 53, and 85) and failed to screen, educate, and offer the COVID-19 vaccine for one of one employee reviewed (Employee 12). Findings include: The policy entitled, COVID-19 Vaccine, Resident, last reviewed on December 16, 2024, indicates that residents or their representatives will be educated about and offered the COVID-19 vaccine. The vaccines will be offered to residents per CDC (Centers for Disease Control and Prevention) and/or FDA (Food and Drug Administration) guidelines unless such an immunization is medically contraindicated, the individual has already been immunized during this time or the individual refuses to receive the vaccine. The policy entitled COVID-19 Vaccine, Staff, last reviewed on December 16, 2024, indicates that employees will be offered the COVID-19 vaccine in accordance with state and local health departments and the CDC. The facility will screen new employees to determine their eligibility, offer the COVID-19 vaccine, and provide education including the risks and benefits of the vaccine. The CDC (Centers for Disease Control) recommendations for COVID-19 vaccines (https://www.cdc.gov/vaccines/covid-19/downloads/COVID-19-immunization-schedule-ages-6months-older.pdf) indicate that for people [AGE] years of age and older should have one additional dose administered at least eight weeks following the last recommended dose of 2023-24 COVID-19 Vaccine. Review of Resident 4's clinical record revealed that her last COVID-19 vaccine was provided on November 10, 2022. There was no documented evidence that the facility offered Resident 4 or her responsible party an updated COVID-19 vaccine or provided education regarding its risks and benefits. Review of Resident 16's clinical record revealed that her last COVID-19 vaccine was prior to her admission to the facility in 2022. There was no documented evidence that the facility offered Resident 16 or her responsible party an updated COVID-19 vaccine or provided education regarding its risks and benefits. Review of Resident 21's clinical record revealed that her last COVID-19 vaccine was provided on February 16, 2023. There was no documented evidence that the facility offered Resident 21 or her responsible party an updated COVID-19 vaccine or provided education regarding its risks and benefits. Review of Resident 53's clinical record revealed that his last COVID-19 vaccine was provided on February 16, 2023. There was no documented evidence that the facility offered Resident 53 or his responsible party an updated COVID-19 vaccine or provided education regarding its risks and benefits. Review of Resident 85's clinical record revealed that the facility admitted her on August 18, 2024. There was no documented evidence that the facility obtained a COVID-19 vaccination history, offered Resident 85 the COVID-19 vaccine, or provided education regarding its risks and benefits. Review of Employee 12's, registered nurse, personnel record revealed that she was hired on September 17, 2024. There was no documented evidence to indicate that the facility screened Employee 12 for eligibility of the vaccine, offered the vaccine, or educated her about the risks and benefits of the vaccine. Interview with Employee 1, infection control preventionist, on January 31, 2025, at 10:33 AM confirmed the above findings for Residents 4, 16, 21, 53, 85, and for Employee 12. 483.80(d)(3) COVID-19 Immunization Previously cited 1/26/24 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, review of select facility policies, review of facility documentation, and staff interview, it was determined that the facility failed to ensure that residents were free from neglect for one of one resident reviewed resulting in a severe injury (a fractured left humerus) (Residents 67). This deficiency is cited as past non-compliance. Findings include: The policy entitled Abuse, Neglect, Exploitation, and Misappropriation, last reviewed without changes on May 22, 2020, defines neglect as the failure of an employee to provide goods or services to a resident that is necessary to avoid physical harm. The policy further indicates that an example of neglect would be failing to take precautionary measures to protect the safety of the resident. Review of Resident 67's clinical record revealed that the facility developed a plan of care dated July 27, 2020 indicating that she was at risk for falls. Resident 67's plan of care indicated that on August 21, 2020, the facility implemented a personal safety alarm at all times while Resident 67 is in bed to alert staff of unsupervised ambulation. A Minimum Data Set Assessment (MDS, an assessment tool completed at specific intervals to determine care needs) completed on November 20, 2020, indicated that the facility assessed her as needing the extensive assistance of two care givers for bed mobility, transfers, and toileting. Nursing documentation dated November 27, 2020, at 9:24 PM revealed that Resident 67 was noted lying face down on the floor in her bathroom. Resident 67 complained of pain in her left shoulder area. The facility notified Resident 67's physician and she was sent to the emergency room . Nursing documentation dated November 28, 2020, at 10:34 AM indicated that the facility received an update from the hospital regarding Resident 67, revealing that she sustained a fracture of her upper left humerus bone. Review of Resident 67's fall investigation dated November 27, 2020, indicated that Resident 67's last known location was in her bed sleeping. A witness statement indicated that nursing staff assigned to Resident 67's care did not attach the personal safety alarm box to her bed. The alarm box was still attached to Resident 67's wheelchair. Review of the facility's immediate plan of correction starting November 30, 2020, revealed that the facility counseled the nursing staff member who did not place the alarm box on Resident 67's bed while she was in bed, indicating that alarm placement and functioning must be checked and verified at the beginning of each shift while doing rounds and/or care. The facility also conducted house wide education to all nursing personnel regarding alarm placement, reporting requirements, and types of abuse and neglect on November 30, 2020. The facility continued to conduct auditing of alarm placement and functioning for two weeks ending on December 14, 2020. This deficiency is cited as past non-compliance. The surveyor reviewed the above findings during an interview with the Administrator on January 15, 2021, at 9:30 AM. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate resident accidents and implement interventions to prevent resident accidents for three of four sampled residents (Residents 67, 114, and CR1). Findings include: The facility policy entitled, Accident and Incident Investigation, last reviewed [DATE], revealed that certain accidents and incidents, would be investigated to determine root cause and provide for opportunity to decrease future occurrences of the event. The events that warrant the completion of designated investigative forms includes falls. The investigation will include interviews with the resident, all staff involved (directly or indirectly), any family, visitors, or volunteers, which may have had contact with the resident and may help with the investigation. The facility obtains statements as deemed necessary. The facility must use its Performance Improvement process for problem identification and corrective action when necessary. Clinical record review for Resident 67 revealed current recapitulation orders that included a personal safety alarm (device used to alert staff of a resident's unsafe attempts at unassisted transfers) at all times to the bed and chair (order origination date of [DATE]). Clinical record review for Resident 67 revealed nursing documentation dated [DATE], at 2:45 PM that staff found Resident 67 on the floor next to the bed. The documentation did not include what prompted the staff to go in to Resident 67's room. Staff assessed an abrasion to the left knee measuring 2 centimeters (cm) by 3 cm, skin tear to the right upper arm 4 cm by 2 cm, a purple raised hematoma to the forehead 4 cm by 4 cm, non-reacting right pupil, and pinpoint left pupil, and complaints of right lower quadrant pain exhibited by strong wincing reaction when touched. Staff contacted the physician who gave the order to send Resident 67 to the emergency room . Review of the facility's investigation for Resident 67's fall on [DATE], revealed that although a nurse aide is identified by the writer as the person who found Resident 67 on the floor, the facility did not obtain a witness statement from this staff member. The licensed practical nurse noting what happened did not mention the presence of an alarm that alerted staff of Resident 67's fall. The registered nurse's conclusion, entered 17 days after the fall, is the first documentation that suggests staff entered the room due to an alarm sounding. The notation does not indicate which staff heard and responded to an alarm. Nursing documentation dated [DATE], at 5:25 AM indicated that Resident 67's alarm was sounding and that staff found Resident 67 on the floor on the right side of her bed. Review of the facility's investigation for Resident 67's fall on [DATE], revealed that although a nurse aide is identified as the staff member who found Resident 67, the facility did not interview or obtain a witness statement from this staff member. The only description of the events details is provided by a registered nurse who notes that she was called to the floor due to the fall. The report indicated that no staff who were actually present during Resident 67's fall provided an interview or statement. Clinical record review for Resident 114 revealed nursing documentation dated [DATE], at 2:25 PM that staff found him on the floor on the left side of his bed with a reddened area to his right forehead measuring 3 cm by 4 cm, a reddened bruised area to his lower center back 3 cm by 1 cm, and a reddened area to his lower right back 10 cm by 4 cm. Resident 114 complained of shooting pain upon sitting up from the floor. Nursing documentation dated [DATE], at 5:00 PM revealed that the physician instructed staff to send Resident 114 to the emergency room for evaluation. Review of the facility's investigation dated [DATE], at 1:45 PM revealed that another resident's family member alerted staff that someone was lying on the floor. The nurse aide then ran to find Resident 114 on the floor. The only staff members noted as providing knowledge of the event are two licensed practical nurses. The facility's investigation did not include interviews with the nurse aide identified as the one who found the resident; or the visitor who alerted staff that Resident 114 was on the floor. Nursing documentation dated [DATE], at 9:15 PM revealed that Resident 114 returned to the facility from the emergency room at 8:00 PM. Nursing documentation dated [DATE], at 10:00 PM noted a new physician's orders [REDACTED]. Nursing documentation dated [DATE], at 10:05 PM revealed that staff again found Resident 114 on his knees on the right side of his bed with a skin tear to his left knee. Review of the facility's investigation dated [DATE], at 10:05 PM revealed that the nurse aide alerted the licensed practical nurse that she found Resident 114 on the floor. The note did not include the presence of a personal safety alarm. The investigation did not include any statement from the nurse aide identified as the one who found Resident 114. According to the report, immediate actions taken by the facility following the fall included adjustment of the bed height (low bed, positioning of the bed lower to the floor than is the typical height). Registered nursing documentation dated [DATE], at 1:35 AM revealed that staff found Resident 114 on the floor following his sensor alarm sounding. Review of the facility's investigation dated [DATE], at 1:35 AM revealed that the licensed practical nurse called the registered nurse to assess Resident 114 after finding him on the floor. The narrative note on the occurrence report did not indicate the presence of a sensor alarm. The investigation contained no signed statements from staff with potential knowledge of the incident. According to the report, immediate actions taken by the facility following the fall included exchanging the sensor boxes for a louder one. Nothing in the investigation indicated that there was a sensor alarm failure to provide a rationale for this intervention. This was the only new intervention implemented in response to the fall when compared to the facility's response to Resident 114's falls on [DATE]. Nursing documentation dated [DATE], at 8:00 PM revealed that someone called the writer (registered nurse) to assess Resident 114 lying on the floor on the right side of the bed. The nurse assessed an abrasion to Resident 114's left knee measuring 4 cm by 3 cm. The documentation noted, Supervision of resident @ (at) mealtimes and anytime tray or food is in front of him. Review of the facility's investigation dated [DATE], at 8:00 PM revealed that Resident 114's bed was raised to allow the tray table under the bed (not in the low position as per his plan of care). Immediate actions taken in response to the fall again included adjust bed height (low bed). Staff failed to ensure Resident 114's appropriate low bed positioning at the time of the fall. Nursing documentation dated [DATE], at 7:55 PM revealed that staff called the registered nurse to the unit to assess Resident 114 on the floor. The documentation revealed that Resident 114 reported that he pushed his tray table away after having a snack. The documentation noted that the nurse aide reported that she raised Resident 114's bed and positioned the tray table over the bed to give Resident 114 his snack. The registered nurse noted finding Resident 114's bed in a normal position (not a low bed as per his plan of care). Review of the facility's investigation dated [DATE], at 7:55 PM revealed that the staff completing the report erroneously documented that the low bed positioning was a preventative measure at the time of the fall. The investigation did not include any statement from the nurse aide identified as the one who failed to implement the low bed intervention per Resident 114's plan of care. Interview with the Nursing Home Administrator and Director of Nursing on [DATE], at 3:00 PM; the Nursing Home Administrator on [DATE], at 1:40 PM; and the Director of Nursing on [DATE], at 2:45 PM; revealed that the facility was unable to provide evidence of staff education regarding ensuring staff knowledge that Resident 114's bed was always to be in the low position when he was in it unattended. Nursing documentation dated [DATE], at 8:00 PM revealed that staff observed Resident 114 on the bathroom floor with a 3 to 4 cm abrasion to the back of the left side of his head. Review of the facility's investigation dated [DATE], at 7:45 PM revealed that the new intervention implemented in response to the fall was a pull tab alarm when he is in the wheelchair. The investigation determined that the staff heard an alarm sound at the time of the fall. The investigation did not include a rationale as to why another alarm was an appropriate intervention to prevent future falls for Resident 114. Nursing documentation dated [DATE], at 12:35 AM revealed that someone called the writer to the floor to assess Resident 114 who was found on the floor. Review of the investigation dated [DATE], at 12:35 AM revealed that although it was a nurse aide who found Resident 114 on the floor, the facility did not obtain a statement from this staff member. During an interview with the Nursing Home Administrator and Director of Nursing on [DATE], at 9:15 AM, the surveyor requested all fall incident/accident investigations for Resident CR1 for May and [DATE]. Closed clinical record review of nursing documentation dated [DATE] (error by writer with indecipherable name and discipline, determined to be 2016), at 5:45 AM, noted that staff found Resident CR1 on the floor on his roommate's fall mat. Review of the facility's investigation of the fall revealed that one licensed practical nurse recorded all the information regarding the fall. The completed report noted, N/A (not applicable), for the conclusion and root cause general follow-up procedures section. There was no evidence that the facility included an interdisciplinary team or its Performance Improvement process for problem identification and corrective action in response to this fall. Closed record review for Resident CR1 revealed registered nursing documentation dated [DATE], at 10:45 PM indicating that the writer was called to the unit to find Resident CR1 lying on the floor in front of his recliner. Registered nursing documentation dated [DATE], at 2:25 AM noted that someone called the writer to assess Resident CR1 who was found sitting on the floor at the foot of his recliner. The surveyor repeated requests for fall incident/accident investigations for Resident CR1 for [DATE] and 22, 2016, with the Nursing Home Administrator on [DATE], at 2:05 PM, and with the Director of Nursing on [DATE], at 2:30 PM. Interview with the Nursing Home Administrator and Director of Nursing on [DATE], at 3:00 PM confirmed that the facility could not provide an investigation regarding Resident CR1's falls on [DATE], at 10:45 PM, and [DATE], at 2:25 AM. The facility provided one witness statement pertaining to the fall on [DATE], at 10:45 PM. The facility failed to conduct interviews and obtain statements from staff knowledgeable of details pertinent to Resident CR1's fall on [DATE]. The registered nurse, who was not on the unit at the time of the falls, was the only staff who recorded documentation of the events. Nursing documentation dated [DATE], at 3:00 AM revealed that someone called the registered nurse to the floor and that Resident CR1 was found sitting on the floor. The writer assessed two skin tears to his right elbow and one to his right wrist. Nursing documentation dated [DATE], at 1:30 PM revealed that Resident CR1 was very agitated and yelling that he needed an x-ray. The facility obtained a physician's orders [REDACTED]. Nursing documentation dated [DATE], at 5:45 PM revealed that nursing staff received a phone call from the hospital informing the facility that Resident CR1 was admitted with a fracture. A physician's discharge summary signed [DATE], noted that Resident CR1 fell and suffered a hip fracture. He was admitted to the hospital where he developed complications and expired. Review of the facility's investigation dated [DATE], at 3:00 AM revealed that although it is noted that the nurse aide found Resident CR1, the registered nurse (who was not on the floor at the time of the fall) was the only staff who documented details of the fall. Although the registered nurse notes that the nurse aide stated that she heard a sensor alarm and responded, the nurse aide did not attest to this information in any part of the investigation. Interview with the Nursing Home Administrator and Director of Nursing on [DATE], at 3:00 PM revealed that if the facility obtains staff statements, the facility destroys them after another staff member enters the information in the electronic event report. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(5) Nursing services. Previously cited [DATE] and [DATE].