Every finding on record at Maplewood Nursing and Rehab Center

Based on review of facility policy, facility documentation, clinical records, observations, and staff interviews it was determined the facility failed to ensure emergency equipment readily available for accidental extubation for a resident with a tracheostomy (An extubation creates an emergency situation that requires that an obturator be readily available that can be used by competent staff for reinsertion) for one of two residents reviewed (Resident R130). Facility staff were unaware of the location of emergency equipment or how to use it in case of accidental extubation, resulting in an Immediate Jeopardy situation (Resident R130). Findings Include: Review of facility policy regarding tracheostomy care, revised October 4, 2024, revealed it is the policy of the facility to establish standards for the care and maintenance of tracheostomy tubes. Following these standards will assist in maintaining a patent airway, reduce the risk for nosocomial infection (infection acquired in a healthcare setting that was not present at the time of a patient's admission), and help to prevent excoriation, breakdown, and infection of surrounding skin. Under the section PROCEDURE #1 revealed One sterile tracheostomy tube with obturator is kept at the patient's bedside for emergency use. Review of facility policy regarding accidental decannulation, revised August 4, 2026, revealed the purpose of the policy is to establish a standardized procedure for responding to accidental decannulation to ensure patient safety and effective management of the situation. Per facility policy, healthcare professionals must follow the outline procedure to ensure the patient is stabilized and the tracheostomy tube is reinserted promptly and safely. Continued review of facility policy on accidental decannulation, revised August 4, 2026, under section PROCEDURE revealed the following, #6. Preparation: Set up a clean surface for trach reinsertion of items and supplies. #7. Identify New Tube: Select an appropriate-sized tube (same or smaller size, uncuffed if the patient is not on a ventilator). #9. Remove Tube from Package: Remove the tube by the flange without touching the shaft, maintaining aseptic technique. #10. Insert Obturator: Remove the inner cannula from the trach tube and insert the obturator. Review of Resident R130's clinical record revealed the resident was admitted to the facility on [DATE], and has diagnoses of Bilateral Paralysis of Vocal Cords and Larynx, Chronic Obstructive Pulmonary Disease (group of lung diseases that block airflow and make it difficult to breathe), Asthma (condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe), Tracheostomy (surgical procedure in which a hole, or stoma, is created in the front of the neck into the windpipe to allow air to pass directly into the lungs). Review of Resident R130's clinical record revealed the following physician orders dated July 22, 2026:#6 Shiley Cuffless (size and type of tracheostomy)Change Inner Canula (6 Shiley) every 24 hours. Every day shift for infection control.Check and change trach ties every Monday and Thursday during day shift, AND as needed for dislodgementAmbu bag at bedside every shift Review of Resident R130's physician order dated July 23, 2026, revealed an order for a #4 Shiley Non-Cuffed/Non-Fenestrated replacement trach at bedside if trach becomes dislodged, as needed for dislodgement. Review of Resident R130's comprehensive care plan dated July 23, 2026, revealed the resident has a tracheostomy related to impaired breathing mechanics. Observations on August 4, 2026, at 10:40 a.m. revealed Resident R130 was in bed, awake, and responsive with tracheostomy in place. Further observations revealed five green plastic bags on the floor. Continued observations on August 4, 2026, at 10:40 a.m. failed to reveal evidence of a tracheostomy replacement set (pre-packaged set of sterile or single-use supplies designed to enable the safe removal and replacement of a tracheostomy tube), including no #4 or #6 trach, and no obturator at the bedside or anywhere in Resident R130's room. Further observations failed to reveal a Ambu bag (handheld medical device used to provide positive pressure ventilation to a person who is not breathing or not breathing adequately in tracheostomy care it is critical piece of emergency equipment used to manually pump oxygen or air directly into the lungs) was available in Resident R130's room. Interview conducted at the time of the above observation with Licensed Nurse, Employee E7, revealed Employee E7 was the nurse assigned to Resident R130 at the time of observation. Interview conducted on August 4, 2026, approximately 10:40 a.m. with Licensed Nurse, Employee E7, confirmed there was no tracheostomy replacement set, no #4 or #6 trach, or obturator at the bedside or anywhere in in Resident R130's surroundings within the room. Licensed Nurse, Employee E7 further confirmed there was no Ambu bag visible around Resident R130's room. Continued interview with Licensed Nurse, Employee E7, revealed the licensed nurse was unaware of the location where the tracheostomy replacement set, #4 or #6 trach, obturator, or Ambu bag were kept. Interview on August 4, 2026, at 10:47 a.m. with Unit Manager, Employee E3, confirmed there was no tracheostomy replacement set, no #4 or #6 trach, and no obturator on Resident R310's bedside table or anywhere in Resident R130's surroundings within the room. Further, Employee E3 confirmed there was no Ambu bag visible around Resident R130's room. Continued interview on August 4, 2026, at 10:47 a.m. with Unit Manager, Employee E3, revealed Employee E3 was unable to identify where the tracheostomy replacement set, #4 or #6 trach, obturator, or Ambu bag were located. Follow-up observations on August 4, 2026, at 10:56 a.m. with Licensed Nurse, Employee E7, and Unit Manager, Employee E3, revealed an Ambu bag was on the floor behind Resident R130's bedside table. Licensed nurse, Employee E7, and Unit Manager, Employee E3, searched Resident R130's room, including the bedside table, and the five green plastic bags found on the floor, and were still unable to locate a tracheostomy replacement set, #4 and #6 trach, or the obturator anywhere in Resident R130's room. Interview on August 4, 2026, at 10:56 a.m. with Unit Manager, Employee E3, revealed there is no tracheostomy replacement set, no #4 or #6 trach, or obturator available in Resident R130's room or on the unit. Interview on August 4, 2026, at 10:56 a.m. with Director of Nursing, Employee E2, confirmed there is no tracheostomy replacement set, no #4 or #6 trach, or obturator available in Resident R130's room or on the unit. Review of Resident R130's clinical record revealed that there was no documented evidence of a system in place to check for replacement tracheostomy at bedside. Review of Resident R130's TAR (Treatment Administration Record) revealed an entry for Ambu bag at bedside, every shift Nursing to check placement at bedside, Start Date: 07/22/2026 with an indication to mark Y for YES and N for NO for placement. Review of Resident R130's TAR revealed the entry was marked with an X every shift on August 1, August 2, and marked as X on the evening and overnight shift on August 3, 2026. Interview on August 4, 2026, at 10:58 a.m. with the Assistant Director of Nursing (ADON), Employee E8, confirmed there is no tracheostomy replacement set, no evidence of size 4 and size 6 trach, or an obturator in Resident R130's room or on the unit. Further the Assistant Director of Nursing, Employee E8, confirmed that was no documented evidence of a system in place to check/confirm for replacement tracheostomy at bedside. Continued interview with the ADON, Employee E8, confirmed the entry for the placement of the Ambu bag was consistently marked as X making it unclear whether the Ambu bag was in place at bedside. ADON, Employee E8, confirmed nursing staff should document Y for yes and N for no for consistent and accurate documentation. Further interview with Assistant Director of Nursing, Employee E8, revealed that the facility did not have any other system in place to check emergency equipment at resident's bedside at the beginning of every shift. Inspection of the second-floor medication room on August 4, 2026, at 11:00 a.m. with Unit Manager, Employee E3, revealed a tracheostomy replacement set, #4 and #6 tracheostomy, and obturator was still unable to be located. Interview on August 4, 2026, at 11:03 a.m. with other licensed nursing staff on the unit, Licensed Nurse, Employee E9, and Licensed Nurse, Employee E10, revealed staff were unaware what an obturator was. Inspection of the second-floor emergency cart conducted on August 4, 2026, at 11:48 a.m. failed to reveal any tracheostomy tube replacement kit, #4 or #6 replacement tracheostomy, or obturator. The facility failed to ensure that tracheostomy emergency equipment was readily available for accidental decannulation for a resident with a tracheostomy tube. Interviews with staff revealed facility staff were unaware of the location of emergency equipment or how to use it per interviews with other licensed nursing staff on the unit in case of an accidental extubation placing the resident in an immediate jeopardy situation. As a result of this failure Resident R130 was placed at risk of severe harm and potential death in the event of a decannulation. An Immediate Jeopardy template (document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, on August 4, 2026, at 3:30 p.m. The facility submitted a written plan of action on August 4, 2026, at approximately 6:00 p.m. and implemented the plan of action which included:Resident R130 was noted to be without a spare trach at bedside on August 4, 2026.On August 4, 2026, the facility was stacking trach supplies from the supply room and brought a spare trach to Resident R130's roomOn August 4, 2026, the facility contacted the contracted respiratory therapist who delivered two boxes of size four and size 6 trachs as extra which were placed in the medication rooms on floor two and three and in central supply.Facility audited all current residents (2) with a tracheostomy to ensure emergency equipment was available at bedside.The facility audited all current residents with a tracheostomy to ensure orders include checking and signing off every shift that there is emergency equipment available at the bedside.The facility reviewed and revised accidental decannulation policy to include adding an order for the nurse to sign off on every shift ensuring that there is emergency equipment available at bedside.Facility reeducated licensed nurses on ensuring there is emergency equipment available at bedside and where to find supplies if there are none available and how to care for residents who experience accidental extubation. Licensed nurses will be re-educated prior to the start of their next shift.The facility will continue ongoing weekly audits X 4 weeks of residents with tracheostomies to ensure emergency equipment is readily available at the bedside and orders are present to visualize equipment is present at the bedside every shift.Results of audits will be reviewed during facility's monthly Quality Assurance and Performance Improvement (QAPI) meeting to determine further auditing needs. Review of the facility documentation revealed the facility's action plan was immediately initiated. Follow-up observation of Resident R130's room conducted on August 4, 2026, at 3:50 p.m., revealed that a size 4 and size 6 Tracheostomy replacement kit, with an obturator, was available on the resident's bedside. Further observation revealed an Ambu bag was hanging next to Resident R130's bed. Follow-up observation of the second-floor medication room revealed size 4 and size 6 Tracheostomy replacement set was in stock. Interviews were conducted with licensed nursing staff across the day and evening shift on August 5, 2026, from 2:15 p.m. to 6:00 p.m. to assess staff knowledge on tracheostomy care, responses to an emergency decannulation, and tracheostomy replacement kit/obturator. Interviews revealed staff are knowledgeable on tracheostomy care, responses to an emergency decannulation, and tracheostomy replacement kit/obturator. Review of in-service records confirmed in-services provided on tracheostomy care, responses to an emergency decannulation, tracheostomy replacement kit/obturator. Interview with Director of Nursing, Employee E2, conducted on August 4, 2026, at 3:15 p.m. confirmed that the facility will in-service all licensed nursing staff that has not yet been in-serviced before the start of their next shift until all licensed nursing staff are in-serviced and that no licensed nursing staff will be allowed to work their shift until they have been in-serviced. The Immediate Jeopardy was lifted on August 5, 2026, at 3:45 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10 (d) Resident care policies

Based on review of facility policy, resident and staff interviews, and a review of facility documentation it was determined that the facility has failed to provide meals at a regular time each day and a nutritious snack at bedtime for two out of ten resident council members (Resident R80 and R187).Findings Include: Review of the facility policy titled, HS Snack last reviewed August 2026 states, Policy-All residents (unless NPO) will be offered a bedtime/HS snack based which will meet their dietary restrictions and needs. During the confidential resident group meeting held on August 6, 2026, at 11:00 a.m. there were concerns expressed by several residents about not receiving an evening snack. Resident R80 stated they have not received any snacks since being in the facility. Review of Resident R80's clinical record revealed an Minimum Data set (MDS - federally mandated resident assessment and care screening) dated May 7, 2026, with a BIMS (Brief Interview for Mental Status) score of 14 indicating no cognitive impairment. Review of Resident R80's clinical record revealed an HS snack record that was blank. Resident R187 stated they did not receive any snacks in the evening. Review of Resident R187's clinical record revealed an MDS dated [DATE], with a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. Review of Resident R187's clinical record revealed an HS snack record that was blank. An interview on August 6, 2026, at 1:20 p.m. with the unit manager on fourth floor, Employee E5 revealed that the kitchen only sends up labeled snacks for specific residents, and if a resident is hungry between meals they would have to call down to the kitchen for a snack, or if a labeled snack was refused and the diet was appropriate, they could give that out. Employee E5 reported that to her knowledge there were no extra evening snacks sent either. An interview on August 6, 2026, at 1:35 p.m. with the Food Service Director revealed that the facility only provides labeled snacks at 10 a.m., 2:00 p.m. and evenings for specific residents, and that there were no bulk snacks stocked on the units for residents who were hungry between meals or overnight. 28 Pa. Code: 201.14 (a) Responsibility of Licensee 28 Pa. Code: 201.18 (b)(1) Management 28 Pa. Code: 201.29 (a) Resident rights

Based on observation and interview with facility staff, it was determined that the facility failed to provide care and services to enhance resident dignity related to feeding assistance for one of 34 Residents reviewed (R140). Findings include: A review of the facility policy and procedure, titled, Activities of Daily Living (ADL'S) reviewed December 2024, states that it is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each residents quality of life by ensuring all staff across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident. Clinical record review for Resident R140 revealed that resident was admitted to the facility on [DATE], with a diagnosis of dysphagia (difficulty swallowing that can affect any stage of the swallowing process). Observation at 12:30 p.m. on August 4, 2026, in the 4th floor dining room revealed two nurse aides feeding Resident R140 while standing and performing other duties. Nurse aide, Employee E6, was feeding resident R140 while standing and would continue to pass trays in the dining room and checking on other residents in the dining room. Employee E6 then went out on the unit to pass room trays and Employee E7 took over and was also standing while feeding Resident R140. While nurse aide, Employee E7, was feeding Resident R140 she was also helping other residents in the dining room with feeding assistance all while standing. During an interview with Unit Manager, Employee E5, at 12:55 p.m. on August 6, 2026, confirmed that staff should be seated facing the resident while feeding. Interview with the Administrator, Employee E1, and Director of Nursing, Employee E2, on August 6, 2026, at 2:30 p.m. acknowledged the above findings. 28 Pa. Code: 201.18 (b)(1) Management 28 Pa. Code: 201.29 (a) Resident rights

Based on observations and staff interviews, and review of facility policy it was determined that the facility failed to ensure a resident received showers as scheduled for one of 34 residents reviewed (Resident R30). Findings include: Review of the facility policy titled Activities of Daily living last reviewed in December 2024, that states, The facility will provide care and services for the following activities of daily living that includes hygiene, bathing dressing grooming and oral care. During an interview and observation with Resident R30 on, August 4, 2026, at 10:30 a.m. the resident appeared unkept with hair looking dirty and greasy. Resident R30 said he/she has not received a shower or had his/her hair washed since being admitted and instead receives bed baths. Resident R30 reported he/she attempted to get out of bed once before and fell, so the facility told the resident he/she was not allowed to get out of bed and that's why he/she gets bed baths. Interview with Unit Manager, Employee E13, on August 4, 2026, at 1:00 p.m., and review of Resident R130's clinical record revealed no evidence the resident was offered and refused showers. Furthermore, interview and review of documentation revealed the last shower documented shower Resident R130 was given was on July 24, 2026. 28 Pa. Code 201.29 (j) Resident rights. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(1) Nursing services.

Based on observations, interviews with staff, review of clinical documentation, and review of facility policies, it was determined that the facility failed to ensure a resident received adequate supervision for one of 34 residents reviewed (Resident R14). Findings Include: Review of facility policy states, Smoking Safety Policy last revised April 7, 2026, states, Policy-It is the facility policy to provide a safe environment for our residents, staff and visitors by defining and enforcing safe smoking practices. Further review of the policy states, At the end of the smoking period the lighting materials will be collected and returned to their appropriate location. Review of the policy does not state that residents are allowed to keep their smoking materials in their possession. Review of Resident R14's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis of Congestive Heart Failure (a serious condition where the heart muscle does not pump blood well), Hypovolemic Shock (a life-threatening emergency where severe blood or fluid loss prevents the heart from pumping enough blood to the body), Hyperlipidemia (a medical condition involving an excess of lipids, or fats, circulating in the bloodstream), Hypertension (occurs when blood pushes too hard against your artery walls), Morbid obesity (having a Body Mass Index (BMI) of 40 or higher, a BMI of 35 or higher with serious health problems), and End Stage Renal Disease. Observation and interview with Resident R14 on August 5, 2026, at 2:00 p.m. observation was made of a vape pen on the head of the resident's bed. Resident R41 was laying with his/her head at the bottom of the bed. The licensed nurse, Employee E10, was alerted and he/she alerted another licensed nurse, Employee E5. Licensed nurse, Employee E5, went into Resident R14's room and quickly grabbed the vape pen off of the resident's bed without Resident R14 seeing. When Employee E5 was asked if he/she was allowed to store smoking materials Employee E5 stated, no he/she is one of my problem children. Employe E5 then discarded the vape pen in a regular trash can by the nurse's station. Observation made of Resident R14 revealed the resident ambulates in a power wheelchair. Observation made on Resident R5 on August 6, 2026, at the 10:30 a.m. smoke break revealed the resident came down to the employee in charge of smoking and obtained his/her vape pen. Resident R5 used his/her vape pen for several minutes before handing it back into the same employee. Review of the facility document Resident Smoking Agreement dated November 14, 2025, and was signed by the resident. The agreement states, Smoking and Lighting materials will be kept in a designated area and not in the resident's possession. Interview held with the Director of Nursing, Employee E2 on August 6, 2026, at 10:49 a.m. revealed the resident was recently allowed to keep smoking items in his/her possession in there was a care plan in place for it. Review of Resident R14's clinical record revealed a care plan with an intervention dated August 6, 2026, staying, Resident is able to: store smoking materials. Interview held with the Director of Nursing Employee E2 revealed the care plan was updated today because previously it stated Resident is able to: not light cigarette, which did not pertain to the resident due to the resident using oxygen, he/she does not smoke cigarettes. The facility was asked to provide proof of verification that the resident was safe to hold his/her own smoking materials and the facility was not able to provide additional evidence. There was no smoking assessment completed that determined the resident was safe to store his/her own smoking materials. 28 Pa. Code 201.18 (b)(3) Management 28 Pa. Code 211.10 (d) Resident care policies 28 PA. Code 211.12 (d)(1)(5) Nursing services

Based on review of clinical record, review of facility policy, and interview with staff it was determined that the facility failed to ensure that care and services were provided in accordance with physician orders for one of thirty-four residents reviewed (Resident R168).Findings Include: Review of facility policy on Administering Medications with a most recent revision date of August 2025, revealed that under section POLICY: Medications shall be administered in a safe and timely manner, and as prescribed. Under section PROTOCOL: #15. If a drug is withheld, refused or given at a time other than the scheduled time, the individual administering the medications shall document in the electronic health record per protocol. The resident's responsible party, if applicable, and Attending Physician will be made aware. Review of Resident R168's clinical record revealed that Resident R168 was admitted to the facility on [DATE], with a diagnosis of Type 2 Diabetes Miletus (body cannot regulate blood sugar leading to high blood sugar levels). Review of Resident R168's admission MDS (minimum data set- a federally required resident assessment completed at a specific interval) dated May 14, 2026, revealed that under section C0500. BIMS Summary Score revealed that resident was coded 13, suggesting that resident was cognitively intact. Review of section I2900. Diabetes mellitus (DM) was coded YES. Review of Resident R168's clinical record revealed a physician order dated May 9, 2026, for Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 30 unit subcutaneously one time a day for diabetes mellitus (DM). Further review of Resident R168's clinical record revealed a physician order dated May 8, 2026, for Metformin HCl Oral Tablet 500 MG (Metformin HCl) Give 1 tablet by mouth two times a day for diabetes mellitus and to take with meals. Further review of Resident R168's physician orders revealed an order for: Blood Glucose Monitoring before meals and at bedtime for Blood Glucose Monitoring and to notify MD (physician) if blood sugar is less than 70 or greater than 300. Review of Resident R168's July 2026 medication administration record (MAR) chart codes/follow-up codes revealed 5=Hold/See Nurse Note. Review of Resident R168's MAR (medication administration record) for July 2026 revealed that on July 12, 2026, at 9:00AM, Glargine Subcutaneous Solution 100 UNIT/ML was not administered and was coded as 5 on the MAR, indicating that Glargine Subcutaneous Solution 100 UNIT/ML was held. Further review of Resident R168's July 2026 MAR revealed that on July 12, 2026, at 8:00AM, Metformin HCl Oral Tablet 500 MG was not administered and was coded 5 on the MAR, indicating that Metformin HCl Oral Tablet 500 MG was held. Review of Resident R168's glucose monitoring revealed that on July 12, 2026, at 7:30AM Resident R168's blood glucose was 84 mg/dl (milligrams/deciliter). Review of Resident R168's progress note revealed no entry for July 12, 2026. Further, there was no documented evidence that the provider was notified that Glargine Subcutaneous Solution 100 UNIT/ML and Metformin HCl Oral Tablet 500 MG was held was held on July 12, 2026. Review of Resident R168's clinical record revealed that there was no documented indication for the reason for holding the Glargine Subcutaneous Solution 100 UNIT/ML. Interview with the Director of Nursing, Employee E2, conducted on August 6, 2026, at 3:05PM confirmed that Insulin Glargine Subcutaneous Solution 100 UNIT/ML was held on July 12, 2026, at 9:00AM with no documented reason and that the provider was not notified. Review of Resident R168's July 2026 MAR revealed that on July 13, 2026, at 4:00 p.m. Resident R168's blood glucose was documented as 317mg/dl. Review of Resident R168's July 2026 MAR revealed that on July 14, 2026, at 11:00 a.m. Resident R168's blood glucose was 306mg/dl. Review of Resident R168's July 2026 MAR revealed that on July 15, 2026, at 7:30 a.m., Resident R168's glucose was 316mg/dl. Review of Resident R168's clinical record revealed no documented evidence that the nurse informed the provider on July 13, 2026, July 14, 2026, or July 15, 2026, of the blood glucose above 300 mg/dl. Interview with ADON (assistant director of nursing) Employee E3 conducted on August 7, 2026, at 10:48AM confirmed Resident R168 had blood glucose readings above 300 mg/dl on July 13, July 14, and July 15, 2026, and further confirmed there was no documented evidence that the physician was notified 28 Pa. Code 211.9 (d) Pharmacy services. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of clinical records, interviews with resident and staff and review of facility policy, it was determined the facility failed to complete a comprehensive nutritional assessment on admission for one resident diagnosed with clinically severe weight loss and severe protein calorie malnutrition of 34 resident records reviewed (Resident R30). Findings include: Review of the facility's policy titled, Nutritional Assessment, revised October 2017 states, As part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. The policy further states that, The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission. The nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. Review of Resident R30's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated June 3, 2026, revealed the resident was admitted to the facility on [DATE], and has a diagnosis of, or is at risk for, malnutrition. Review of Resident R30's MDS dated [DATE], Section K: Swallowing/Nutritional Status revealed Holding food in mouth/cheeks or residual food in mouth after meals was marked as yes. Weight was documented as 140 pounds. Review of Resident R30's hospital records dated May 25, 2026, indicated the resident has a history of a 16-pound (10.7%) severe weight loss in one month and was diagnosed with severe protein calorie malnutrition (a life threatening form of undernutrition marked by severe loss of body fat and muscle, and very low energy intake) Review of Resident R30's clinical record revealed no documented evidence a detailed, comprehensive nutrition assessment was completed upon Resident R30's admission on [DATE]. Continued review of Resident R30's clinical record revealed a documented weight of 137.6 pounds on June 16, 2026, reflecting a 2.4-pound weight loss in two-weeks (since admission). Review of Resident R30's clinical record revealed the resident was transferred to the hospital on July 2, 2026, and readmitted back to the facility on July 13, 2026, documenting a further weight loss of 130.0 pounds. Review of Resident R30's clinical record revealed a comprehensive nutrition assessment was not conducted until after the resident's readmission back from the hospital on July 13, 2026. Interview on August 7, 2026, at 12:00 p.m. with facility Registered Dietitian, Employee E14, confirmed Resident R30's initial nutritional assessment was not completed on the resident's initial admission date of May 28, 2026. Registered Dietitian, Employee E14, stated the assessment should be done within the first few weeks of admission and with Resident R30 severe weight loss prior to admission should have been done within the first few days. 28 Pa. Code 211.12 (d)(5) Nursing services. 28 Pa. Code 211.10 (c) Resident care plan.

Based on review of clinical records, facility policy and interviews with staff it was determined that the facility failed to provide on-going assessments and care in accordance with professional standards of practice for one resident that required intravenous (IV) access for one of 34 residents reviewed (Resident R30). Findings include: Review of the facility policy titled, Catheter insertion and Care, revised January 2019, states, Central vascular access devices (CVADs) include Peripherally Inserted Central Catheter (PICC). Catheter insertion is a potential entry site for bacteria that may cause a catheter-related infection. Sterile dressing change using transparent dressings is performed, 24 hours post-insertion or upon admission, at least weekly, and/or if the integrity of the dressing has been compromised. The policy states nurses' assessment of the vascular access site is performed upon admission, during dressing changes, at least every 2 hours during continuous therapy, before and after administration of intermittent infusions, at least once every shift when not in use, routinely for signs and symptoms of infusion related complications at a frequency based on patient condition, age, type of medication and rate of flow. Assessment of entire arm with indwelling vascular access device (VAD) for infusion related complications is to include, but is not limited to, the absence or presence of erythema, drainage, swelling or induration and/or change in skin temperature at site tenderness at the site or along vein, integrity admitted from the hospital on of transparent dressing, numbness or tingling during PICC insertion or dwell-remove catheter immediately and report to physician/LIP. The length of external catheter is obtained, 24 hours post insertion or upon admission, during dressing changes, upon suspicion in change of length, if signs or symptoms of complications are present, and for PICCs, upper arm circumference (10 cm above antecubital fossa) is obtained during insertion procedure, upon admission if no insertion measurement available, then weekly, if signs or symptoms of complication are present. The same policy states to compare to baseline measurement to detect possible catheter-associated venous thrombosis; a 3-cm increase in arm circumference and edema were associated with upper-arm deep vein thrombosis. Documentation in the medical record includes, but is not limited to, date and time, site assessment, length of external catheter, reason for dressing change, patient response to procedure and patient/significant other teaching. Review of Resident R30's clinical record revealed the resident was admitted to the facility on [DATE], with a Peripherally Inserted Central Catheter (PICC) line to administer intravenous (IV) antibiotic solution due to a urinary tract infection once a day for 11 days. Continue review of Resident R30 medication administration record and/or nursing progress note and assessments, failed to reveal evidence of documentation in the medical record that the PICC dressing was changed and the site was assessed on admission, that included baseline measurements of the upper arm circumference and length of the external catheter. Review of Resident R30's clinical record revealed the resident was transferred to the hospital on July 2, 2026, and returned to the facility on July 13, 2026, with a diagnosis of with bacteremia and admitted with a PICC used to infuse IV antibiotics. Continued review of Resident R30 medication administration record and/or nursing progress note revealed no evidence of documentation in the medical record that the PICC dressing was changed and the site was assessed on admission, including baseline measurements of the upper arm circumference, and length of the external catheter.On August 6, 2026, at 10:00 a.m. it was brought to the attention to Resident R30's Unit Manager Employee E13 to provide evidence of the PICC dressing changes and/or measurements. No further documentation was received. On August 7, 2026, at 2:30 p.m. during an interview with the Nursing Home Administrator and the Director of Nursing also confirmed the facility was unable to obtain additional assessments and or documentation related to the PICC dressing change and/or missing measurements. 28 Pa. Code 201.14 (a) Responsibility of licensee.28 Pa. Code 211.12 (d)(5) Nursing services.

Based on observations, interviews with resident and staff, and review clinical records it was determined the facility failed to provide pain management and reassess effectiveness of new interventions in accordance with resident needs for one of 34 residents reviewed (Resident R30). Findings include: Review of Resident R30's physician progress notes revealed the resident was admitted to the hospital on [DATE], and readmitted back to the facility on July 13, 2026, for possible osteomyelitis (bone infection) or discitis (infection of the spinal disc) in resident lower back. Resident R30 was initially admitted to the hospital due to sepsis (blood infection) secondary to bacteremia (bacteria in the urine), lumbar spine osteomyelitis, and prostate abscess and underwent multiple abscess drainages by Interventional Radiology, with cultures growing multi-drug-resistant bacteria. During an interview with Resident R30 on August 4, 2026, at 10:30 a.m. the resident complained of pain All over his/her body but severe pain in the lower back and legs. Resident R30 was observed to lay in bed with his/her knees bent and stated he/she couldn't straighten them without pain. Resident R30 stated he/she complains of pain during therapy, but They don't do anything about it. The resident stated that he/she started taking Gabapentin for the pain but stated it is not working. The resident stated it was very difficult to get Tylenol from the nurses. Interview on August 5, 2026, Resident R30's Unit Manager Employee E13 stated, The resident does not complain of pain. However, subsequent observations when the Unit Manager, Employee E13, attempted to adjust Resident R30 slowly to his/her side to assess his lower back, the resident was not able to move because the pain was too intense and the task could not be completed. Resident R30 stated to the Unit Manager, Employee E13, and surveyor that he/she has no pain at rest, but any minor adjustments to his/her body causes severe pain of 10/10. Review of Resident R30 physical therapy note dated July 27, 2026, documented the resident's pain 0 with rest and 8/10 pain level with movement. The resident described the right lower extremity pain as sharp and constant, that pain limited the resident's functional activities related to bed mobility. The resident's pain increased when placed sitting up on the edge of the bed and then quickly laid down. The resident was educated of the risk of contractures from lying in bed constantly with lower extremity in flexion (bending knees). Review of Resident R30 occupational therapy note dated July 29, 2026, described pain at rest or movement 10/10. Review of Resident R30's clinical record revealed a new order for pain medication was ordered on July 29, 2026, for Gabapentin 300 milligrams (mg) give three times a day. Review of Resident R30 occupational therapy note dated August 5, 2026, indicated the pain level was 10/10 at rest and with movement in the resident's sciatica left leg, with pain being intermittent stabbing describing the pain as very painful. Interview with the Director of Therapy on August 7, 2026, at 12:00 p.m. agreed the resident cannot advocate for self when it comes to pain. Director of Therapy reported Resident R30's pain has hindered his/her progress in therapy. Director of Therapy confirmed Resident R30 has constant pain and is requesting neurologist referral. Resident R30 continues to have extreme pain on movement and will address the resident's pain management further. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of facility policy and observations it was determined that the facility failed to ensure medications labeled in accordance with professional standards. Findings Include: Review of facility policy on Medication Storage with a most recent revision date of December 17, 2024, revealed that under section POLICY: Medications will be stored in a manner that maintains the integrity of the product, ensures the safety of the residents and is in accordance with the Department of Health guidelines. Review of facility Policy on Medication labeling with a most recent revision date of December 17, 2024, revealed that under section PURPOSE: To ensure that all medications within the facility are labeled and are labeled in a consistent manner. Under section POLICY: All medications dispensed and/or provided by the Provider Pharmacy and/or another pharmacy will be labeled in accordance with all federal and state regulations. Observation of the second-floor medication room conducted on August 4, 2026, at 12:00 p.m. together with the second-floor unit manager, Employee E13, revealed one vial of Tuberculin, Purified Protein Derivative, Diluted Aplisol 5TU/0.1ml in the medication refrigerator. Inspection of the vial of Tuberculin, Purified Protein Derivative, Diluted Aplisol 5TU/0.1ml revealed the vial was opened. Further, the vial did not have an open date affixed to it. Interview with unit manager Employee E13 conducted at the time of the observation confirmed that the vial of Tuberculin, Purified Protein Derivative, Diluted Aplisol 5TU/0.1ml in the medication refrigerator was open and that the vial was not dated with the date it was opened. 28 Pa. Code 211.9 (a)(1) Pharmacy services. 28 Pa. Code 211.12 (d)(1) Nursing services.

Based on staff interviews and a review of employee credentials, it was determined that the facility failed to employ a qualified director of food and nutrition services (Employee E4). Findings include: An interview on August 4, 2026, at 9:45 a.m. with Employee E4, Food Service Director (FSD), revealed that his responsibilities included oversight of ordering, receiving, storing, preparation and service of food. Further interview with the FSD confirmed that he was not currently a certified dietary manager (CDM); or a certified food manager (CFM); or had a national certification for food service management and safety from a national certifying body; and that he had not received frequently scheduled consultations from a qualified dietitian. A review of Employee E4's credentials revealed that the employee did not meet the statutory qualifications of a director of food and nutrition services. During an interview on August 5, 2026, at 2:15 p.m. with Employee E1, Administrator, the FSD's personnel file and his qualifications were discussed which revealed he had been working at the facility for over a year and was not a Certified Dietary Manager or Certified Food Manager. Employee E1 confirmed that the FSD had not completed these requirements. Interview with Registered Dietitian, Employee E14, reported he/she was not full time at the facility and also covered other buildings. The Nursing Home Administrator was unable to provide evidence that the FSD was Certified, and therefore unqualified to direct the dietary department. 28 Pa Code 201.18 (b)(3) Management

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide food in accordance with resident preference and physician ordered diets for one of 34 residents reviewed (Resident R172).Findings Include: Interview with resident R172 on August 4, 2026, at 10:55 a.m. revealed that he/she frequently receives meals from the kitchen that are not according to his/her preferences and that often the items listed on the ticket at not on his/her lunch tray. Resident R172 stated that he/she is losing weight and that the meals here are so small, it is not even enough for a child. Clinical record review for Resident R172 revealed a nutrition assessment completed on July 23, 2026. Under the Nutrition Orders and Intake section it states under Supplement Order/Intake - Large Portions. Observations on August 6, 2026, during the lunch meal revealed Resident R172's meal ticket specified DOUBLE PORTIONS listed at the top of the meal ticket. For the meal listed it reads, Turkey [NAME] Wrap (1.5 each) Chilled Pasta Salad with Italian Dressing (1 cup). Observations of Resident R172's lunch meal revealed the resident did not receive double portions as ordered for the lunch meal on August 6, 2026. Observation of the resident's lunch tray revealed a plate with only half of a Turkey Caesar wrap and a small scoop of pasta salad. Interview held with Food Services Director, Employee E4, on August 6 at 12:56 p.m. revealed the staff was unsure of how many halves of the Turkey [NAME] wrap the resident was supposed to get. Employee E4 looked up the specifications for the portions and it listed Roast Sliced Turkey and the portion size as three ounces. Employee E4 confirmed that Resident R172 did not receive double portions of the Turkey [NAME] wrap since Resident R172 only received a half of a wrap. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b)(3) Management. 28 Pa. Code 201.29(a) Resident rights

Based on review of facility documentation and staff interview it was determined that the facility failed to include active involvement from direct care staff and input from residents in the facility assessment process.Findings Include: Review of facility documentation titled, Facility Assessment dated August 11, 2025, has four members involved in completing the assessment. None of the members listed were a resident, their representative(s), family members or a representative of the direct care staff. The facility did not include active input from residents, their representative(s), family members, and did not include a representative of the direct care staff when formulating their facility assessment. Interview on August 7, 2026, at 10:50 a.m. with Nursing Home Administrator, Employee E1, confirmed no documentation was available to support evidence of active involvement from direct care staff or input from residents from the facility assessment. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on observations, clinical record review, resident interviews, and staff interviews, it was determined that the facility did not ensure residents were free from foreseeable accidents and hazards related to smoking for four of ten residents reviewed. (Resident R1, R2, R4, R5)Findings Include: Review of facility policy titled, Smoking Safety Policy last revised April 7, 2026 states, It is the facility policy to provide a safe environment for our residents, staff and visitors by defining and enforcing safe smoking practices. Residents who smoke will be permitted to smoke in the designated outside smoking area. They must agree to and comply with the safe smoking practices and the conditions of the Smoking Safety Policy and Procedure. Further review of the policy states, New admissions shall be informed upon admission that we enforce a smoking safety policy and procedure through the admission agreement. They will be informed to not give smoking paraphernalia to any residents including their loved one. All smoking materials are to be delivered to the staff for proper storage. Review of clinical records revealed resident R1 was admitted to the facility on [DATE] with the following diagnosis: Anemia, Asthma, Hyperlipidemia, Psychoactive substance dependence, Chronic Kidney Disease, Muscle Weakness, and Cognitive Communication Deficit. Review of clinical records revealed resident R2 was admitted to the facility on [DATE] with the following diagnosis: Cellulitis of right lower limb, Atrial Fibrillation, Biventricular Heart Failure, Prescence of a prosthetic heart valve, Type Two Diabetes, Anemia, Hypertension, and Hyperlipidemia. Review of clinical records revealed resident R4 was admitted to the facility on [DATE] with the following diagnosis: Dysphagia, Alcohol Abuse, Major Depressive Disorder, Paranoid Schizophrenia, and Muscle Weakness. Review of clinical records revealed resident R5 was admitted to the facility on [DATE] with the following diagnosis: Muscle Weakness, Paraplegia, Anemia, Asthma, and Cocaine Dependence. Observation of the common area inside on May 7, 2026 at 1:04 p.m. right by the smoking area for the patio Resident R4 was seen coming into the area heading towards the smoking patio with a full cigarette already in his/her mouth. The Activities Director Employee E6 confirmed that Resident R4 did have a whole cigarette walking out to smoke break at 1:05 p.m. which should not be occurring. Once the residents were outside, they should be given their cigarettes from a locked box. Resident R4 was assisted once getting outside to the smoking are with having his cigarette lit. The Activities Director Employee E6 stated, We don't know where the cigarettes are coming from, staff, family or someone from outside. Right now, we have family or someone that the resident knows purchases them cigarettes and then bring them in for the resident. No one from the facility purchase the cigarettes for the residents anymore. Resident R5 pulled the surveyor aside at 1:11 p.m. Resident R5 was in the common area right by the smoking area for the patio and had half a smoked cigarette in his/her hand. After we were done talking, he/she went outside to the smoking area and staff assisted him/her with lighting his/her half of a cigarette. Interview held with resident R1 on May 7, 2026 at 11:35 a.m. The resident stated that he/she smokes cigarettes and he/she had missed the last smoked break on April 29, 2026. Due to missing smoke break he/she decided to smoke half a cigarette in his/her bathroom and admitted to having a lighter in his/her possession along with a cigarette. He/she stated he/she smoked half a cigarette in his/her bathroom and then sprayed a body spray to conceal the smell. He/she stated the next morning the staff came in and searched his/her room and sent him/her to the hospital to get a drug screen. The resident did not admit to using or having any illicit substance in his/her possession. Interview held with the Activities Director Employee E6 on May 7, 2026 at 12:55 p.m. Employee E6 stated that he was outside on April 30, 2026 during morning smoke break when he saw Resident R2 outside attempting to smoke marijuana from an older style pipe. Employee E6 stated that he/she approached Resident R2 and told him/her you can't smoke that here. Employee E6 stated that Resident R2 was confrontational during the interaction. Employee E6 stated he/she told Resident R2 not to light up the pipe and Resident R2 did not. Employee E6 stated that Resident R2 does not smoke cigarettes. Employee E6 stated that he/she went inside after smoke break and immediately notified the unit manager licensed nurse Employee E3 about what occurred. Review of Resident R1's hospital record dated April 29, 2026 does show that he/she tested positive for cocaine. Resident of Resident R2's hospital record dated April 29, 2026 does show that he/she tested positive for cannabinoids. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of facility policy, staff interviews, resident interviews, and observations it was determined that the facility did not ensure a resident was free from exploitation for one of nine residents reviewed. (Resident R3)Findings Include: Review of facility policy titled, Abuse last revised October 24, 2022 states, Definitions of Abuse and Neglect- Abuse and neglect exist in many forms and to varying degrees. The following are the approved CMS definitions of abuse and neglect from the Draft State Operations Manual Appendix PP effective November 28, 2016. Further review of the policy states, a. Mistreatment means inappropriate treatment or exploitation of a resident. Review of Resident R3's clinical record revealed the resident was admitted to the facility on [DATE] with the following diagnosis: Type Two Diabetes (a chronic metabolic condition where the body develops insulin resistance, causing high blood sugar levels because cells cannot properly absorb glucose), Injury of the Head, Muscle Weakness (a reduction in physical strength, characterized by difficulty initiating movement, fatigue, or limited muscle function), Zygomatic fracture (common facial injury caused by blunt force trauma, such as car accidents, falls, or assaults), and Post-Traumatic Stress Disorder (a mental health condition triggered by experiencing or witnessing terrifying, life-threatening, or harmful events). Interview held with Resident R3 on May 7, 2026 at 11:45 a.m. During the interviews Resident R3 was asked about his resident rights. Resident R3 stated that one time he/she felt like his/her rights weren't respected when he/she was asked to open a package with staff present due to suspicion of the contents. Resident R3 stated the he/she liked health drinks and that they were sea moss drinks. Resident R3 stated that he/she likes to help out the other residents and staff here by selling drinks and snacks. Resident R3 showed the surveyor several opened boxes of individually packed chips in his/her room. As the interview was occurring there was a knock at Resident R3's door and nurse aide Employee E4 entered the room and asked to purchase a soda. Resident R3 asked what kind and Employee E4 asked what kind do you have. Resident R3 stated, grape ginger ale, and orange. The staff member handed over cash to Resident R3 and asked for a grape soda which he/she was handed by Resident R3. Continued interview with Resident R3 revealed he/she has been doing this for several weeks after hearing frustrations from staff and residents about the prices of the vending machines. Resident R3 confirmed he/she currently is having snacks and drinks shipped to the facility and then is selling them to both residents and staff. Interview held with nurse aide Employee E5 at 12:11 p.m. confirmed that Resident R3 has been selling drinks and snacks from his room. When asked how long Resident R3 has been selling the drinks and the snacks, nurse aide Employee E5 states, about three weeks or so now. Interview held with nurse aide Employee E4 at 12:14 p.m. confirmed that Resident R3 has been selling drinks and snacks from his room. Employee E4 stated, the prices in the vending machines are outrageous and people have been telling them that. Interview held with the unit manager, licensed nurse Employee E3 at 12:58 p.m. who stated she was unaware that this was going on with Resident R3. Licensed nurse Employee E3 confirmed that staff should not be purchasing any sort of snacks or drinks from any resident in the facility. Interview held with the Nursing Home Administrator Employee E1 and the Director of Nursing Employee E2 at 2:01 p.m. who confirmed this should not be occurring. Employee E1 and Employee E2 both stated that they were unaware this was occurring. 28 Pa. Code: 211.12 (d)(1)(5) Nursing services. 28 Pa. Code: 201.29(j) Resident rights.

Based on observations, interviews, review of facility policy, and review of facility documentation it was determined that the facility did not ensure to report the results of all investigations to state officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and did not have evidence that all alleged violations were thoroughly investigated for two of ten residents reviewed. (Resident R1 and Resident R2)Findings Include: Review of facility policy titled, Smoking Safety Policy last revised October 22, 2022 states, Policy- it is the facility policy to provide a safe environment for our residents, staff and visitors by defining and enforcing safe smoking practices. Further review of the policy states, New Admissions shall be informed upon admission that we enforce a smoking safety policy and procedure through the admission agreement. They will be informed to not give smoking paraphernalia to any residents including their loved one. All smoking materials are to be delivered to the staff for proper storage. Staff members and volunteer workers should not purchase or give smoking paraphernalia to any residents unless it is coordinated via activities department. Review of clinical records revealed resident R1 was admitted to the facility on [DATE] with the following diagnosis: Anemia, Asthma, Hyperlipidemia, Psychoactive substance dependence, Chronic Kidney Disease, Muscle Weakness, and Cognitive Communication Deficit.Review of Resident R1's MDS (Minimum Data Set) completed on December 10, 2025 the resident had a BIMS (Brief Interview for Mental Status) score of 13. Review of clinical records revealed resident R2 was admitted to the facility on [DATE] with the following diagnosis: Cellulitis of right lower limb, Atrial Fibrillation, Biventricular Heart Failure, Prescence of a prosthetic heart valve, Type Two Diabetes, Anemia, Hypertension, and Hyperlipidemia. An interview was held during entrance conference with the Nursing Home Administrator Employee E1 and the Director of Nursing Employee E2. They were both asked if any residents had gone out to the hospital recently on suspicion of drugs. The Director of Nursing Employee E2 stated that two residents had been, Resident R1 and Resident R2. Resident R1 had his roommate reported about Resident R1 smoking in the bathroom and being up overnight. Employee E2 stated then there was an incident of Resident R1 smoking a substance which was observed by licensed nurse Employee E3. The Director of Nursing Employee E2 stated there was a search of the resident's room and he/she was found with a glass pipe and an unknown rock substance in a bag. Resident R2 was observed smoking marijuana during a morning smoke break and it was told to the unit manager Employee E3. When asked if any other residents were found with any illicit substances of paraphernalia, the Director of Nursing Employee E2 states, yes Resident R9 was found with what appeared to be loose tobacco during the room searches. The Director of Nursing Employee E2 and the Nursing Home Administrator were asked what was being done after. The Director of Nursing Employee E2 stated that they completed audits on substance use disorder, completed education on substances, residents were given smoking violations, and both residents were sent out to the hospital for evaluation and to have a urine drug screen completed. When asked about what the facility is doing for prevention of staff or how were they notifying the resident visitors or not bringing in illegal substance or paraphernalia into the building, the Nursing Home Administrator replied that he/she was getting ready to send out an e-mail blast today through their electronic records system, but it had not yet been sent out. Interview held with licensed nurse and unit manager Employee E3 on May 7, 2026 at 10:47 a.m. During the interview Employee E3 was asked about her involvement with resident R1 and R2 being found with drugs in their possession. Employee E3 stated that Resident R1's roommate came up to him/her early in the morning around 8:30 and stated that they believe Resident R1 was up a lot last night and could have been smoking in the bathroom. Employee E3 stated that he/she immediately when to Resident R1's room and Resident R1 was coming out of the bathroom, his/her eyes were popping out of their head, he/she was sweating, fidgeting and their mental status was altered. Employee E3 attempted to complete an assessment but Resident R1 refused vital signs. Employee E3 stated he/she contacted the Director of Nursing Employee E2 and that Resident R1's room was searched with him/her present. Resident R1 was asked prior to the search if he/she had anything he/she was not supposed to have and Resident R1 admitted to having a pack of cigarettes in his/her possession. Upon discovery of the cigarette pack in the rollator pouch, Employee E3 noticed a separate cigarette pack. The resident was asked to hand over the second cigarette pack which was found to contain a glass pipe with a sponge insert and a separate bag of a white rocky substance. Interview held with licensed nurse and unit manager Employee E3 on May 7, 2026 at 11:00 a.m. regarding Resident R2. Employee E3 stated that Resident R2 on April 30, 2026 was at the designated smoking area for morning smoke break. Smoke break was explained to be run by the Activities Director Employee E6 and conducted with the help of the activities aide. The Activities Director came up to Employee E3 after smoke break and reported that Resident R2 was smoking something that was not cigarettes and believed to be marijuana during smoke break. The licensed nurse and unit manager Employee E3 stated that she immediately went to Resident R2's room to assess him/her. Upon assessment his/her pupils were dilated and he/she had an altered mental status. At that point Employee E3 called the doctor and had an order to have him/her sent out. Employee E3 stated that Resident R2 was upset about being sent out and was upset about him room being searched. Employee E3 stated that she was not a part of Resident R2's room search. Interview held with resident R2 at 11:00 on May 7, 2026. The resident admitted that he smokes weed, and I keep telling these people I have smoked weed for the longest time When asked about being sent out to the hospital last he stated, yes they sent me out to have a drug test, and searched my room. The resident was asked if he had taken an illegal substance that day and he admitted to smoking marijuana. The resident was asked where he had gotten the marijuana and he stated, There was a black market for that since before I got here, but I'm not telling nobody. Interview held with resident R1 on May 7, 2026 at 11:35 a.m. The resident stated that he/she smokes cigarettes and he/she had missed the last smoked break on April 29, 2026. Due to missing smoke break he/she decided to smoke half a cigarette in his/her bathroom and admitted to having a lighter in his/her possession along with a cigarette. He/she stated he/she smoked half a cigarette in his/her bathroom and then sprayed a body spray to conceal the smell. He/she stated the next morning the staff came in and searched his/her room and sent him/her to the hospital to get a drug screen. The resident did not admit to using or having any illicit substance in his/her possession. Review of Resident R1's hospital record dated April 29, 2026 does show that he/she tested positive for cocaine. Resident of Resident R2's hospital record dated April 29, 2026 does show that he/she tested positive for cannabinoids. Review of the facility investigation file revealed a Smoking Violation Review form for Resident R2 that states, Level 1: First Offense- NHA (Nursing Home Administrator) observed resident smoking marijuana during the evening smoke break at 6 p.m. Resident was provided with warning and education regarding smoking rules and contract that was previously signed. Dated September 17, 2025. Level 2: Second Offense- Resident observed smoking in room. Dated March 5, 2026. Level 3: Third Offense- resident was observed smoking marijuana in violation of facility protocol. Dated April 30, 2026. Interview held with nurse aide Employee E4 at 12:14 p.m. confirmed that he/she was here and worked on the hallway where Resident R1 and Resident R2 reside the day they were found with illicit substances. Employee E4 was asked if he/she was interviewed following the incident that occurred with Resident R1 and Resident R2. Nurse aide Employee E4 stated that I worked that hallway, but no one came from administration to talk with any of us about it. The completed facility investigation was given and reviewed. Review of witness statements provided by the facility on May 7. 2026, revealed lack of handwritten statements from any staff involved in the incident. Both the licensed nurse Employee E3 and Activities Director Employee E6 were direct witnesses to the incidents. There were no handwritten statements from either of these staff included in the facility investigation. There were no handwritten statements from the second-floor staff including the dietary staff, nurse aides, or housekeeping. Interview with the Nursing Home Administrator Employee E1 and the Director of Nursing Employee E2. When asked if the facility investigation related to the incident was finalized the Nursing Home Administrator Employee E1 stated, yes, as complete as it can be I mean we aren't going to not still try to figure out what happened. When asked about witness statements not being included in the investigation, Employee E1 confirmed that there was no handwritten witness statements required to be submitted by the staff at the time of the incident. The Nursing Home Administrator Employee E1, stated, if you want me to go around and get the statements I still can. Employee E1 and Employee E2 did confirm that Resident R1 and Resident R2 were found to be using illicit substances while in the facility. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure medications were delivered by a licensed nurse, who has the skills, experience and knowledge to administer medications for one of four residents reviewed (Resident R1).Findings Include: Review of Facility's medication administration policy revealed only persons licensed or permitted by this state to prepare, administer and document the administration of medication may do so. Review of the facility grievance log revealed Resident R1 reported a concern on February 23, 2026. Resident R1 stated that Licensed nurse, Employee E4 did not give (him/her) medications. Continued review of the grievance revealed that Licensed nurse, Employee E4 stated Resident R1 will not accept medication from (her/him). Review of Medication Admin Audit Report revealed Licensed nurse, Employee E4, was removed from Resident R1's nursing unit on February 21, 2026. Resident R1 alleged that Licensed nurse, Employee E4 was unprofessional and instructed a Nurse aide to administer medications due to an ongoing conflict. The medication Admin Audit Report indicated Licensed nurse, Employee E4 was reassigned to another unit and that Employee E4 had not administered medications to Resident 1 since February 21, 2026. Interview with Resident 1 on 3/17/26 at 11:19 AM revealed (he/she) that Licensed nurse, Employee E4 gave my medications to an aide to hand to me, because we were not getting along. Resident R1 reported an ongoing conflict ( back and forth) with Licensed nurse, Employee E4. Telephone interview with Licensed nurse, Employee E4 on 3/17/26 at 11:23 AM confirmed she instructed a Nurse aide to administer medications to Resident 1, stating she remained nearby during the administration while the nursing assistant handed ResidentR1 the medications. Licensed nurse, Employee E4 further stated she did not know the name of the Nurse aide involved. Resident 1 also stated they did not recall the name of the Nursing assistant and did not want the aide to get in trouble. 28 PA. Code 211.129(c)(d)(1)(5) Nursing services

Based on review of facility policies and clinical records and staff interviews, it was determined that the facility failed to ensure that a written summary of the baseline care plan was provided to the resident and/or the resident's representative for one of two residents reviewed (Resident R151).Findings include:Interview Resident R151 on August 26, 2025, at 11:00 a.m. stated he was not provided a copy of the baseline care plan or medication list since his admission.A review of Resident R151's clinical record reviewed that the resident was July 28, 2025.Review of the clinical record for Resident R151 revealed no evidence that the facility provided a written summary of baseline care plan and a medication list to the resident or the resident representative.Interview with the Social Service Director, Employee E8 on August 28, 2025, at 9:54 a.m. confirmed that the facility did not provide a written copy of baseline care plan to Resident R151 or his representative. Employee E9 also stated that the facility did not have a process of providing a copy of the baseline care plan or medication list28 Pa Code 211.10(a) Resident care policies.

Based on staff and resident interviews and review of clinical records, it was determined that the facility failed to ensure that documented room change notifications to the resident and/or emergency contact were provided for one out of 33 residents reviewed (Resident R133).Findings include:During an interview with Resident R133 on August 27, 2025, at 2:07 p.m. stated facility moved his room without providing prior notice. The resident stated the staff came into his room and asked him to move. The resident stated he was not prepared and did not pack his belongings, and staff did not give him the opportunity to do it himself because it was important for him to pack his belongings himself.Review of room change notification for Resident R133 dated February 19, 2025, revealed that resident had room change on February 19, 2025, and the date of notification was on February 19, 2025. The question for written copy provided to was answered N/A (Not Applicable Resident is alert and oriented X3.Further review of clinical records revealed no evidence that the facility provided written notice to the resident prior to the room change.Interview with Administrator on August 28, 2028 at 11:00 a.m. confirmed that the facility did not provide written notice to Resident R133 when his room was changed on February 19, 2025. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.29(c.3) (1) Resident rights

Based on clinical record review and staff interview, it was determined that the facility failed to update resident's physician orders related to dialysis schedule for one of one resident review receiving hemodialysis treatment (Resident R8). Findings Include: Review of the medical record revealed that Resident R8 was admitted on [DATE], with diagnosis including, but not limited to end stage renal disease (the final stage of chronic kidney disease, where kidneys can no longer function adequately, requiring dialysis or a kidney transplant for survival). Further review of the clinical record for Resident R8 revealed a July 25, 2025, physician's order for hemo dialysis at a local dialysis center with a 10:00 a.m. chair time every Monday, Wednesday and Friday. Interview with the Unit Clerk, Employee E7 on the second floor on August 28, 2025, at 9:30 a.m. revealed that Resident R8 was not on the floor and was at dialysis. When asked why he was at dialysis on a Thursday when his order was for Monday, Wednesday and Friday, she indicated that Resident R8 has been going four days a week for the past few weeks. When asked about the physician's order she got the Unit Manager, Employee E4, who confirmed that the order needed to be updated to include four days a week adding Thursdays to the order. A review of Resident R8's nursing progress notes revealed that the resident was at dialysis on Thursday August 14, 2025, and Thursday August 21, 2025. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(c) Nursing services

Based on review of facility policy, review of facility documentation, review of clinical records, and interviews with residents and staff, it was determined that the facility failed to ensure that the resident environment remained free of accident hazards by failing to monitor the temperature of hot water beverages served to a resident. This failure resulted in actual harm to Resident R1 who spilled a hot water beverage and sustained an abdominal and chest burn injury, for one of five residents reviewed. (Resident R1) Findings include: Review of facility policy on Hot Liquid with a most recent revision date of January 17, 2019, revealed that under section Policy: Residents will be served coffee, hot water, soup, or any hot liquid at a palatable temperature that will not burn the skin. Under section Purpose: To ensure residents are served coffee, hot water, soup, or any liquid that will not burn the skin if spilled on a resident. Under section Guidelines: #1. Coffee will be brewed at recommended and soup will be cooked to appropriate temperature. #2 Coffee, hot water, soup or any hot liquid is to leave kitchen at a range of 140 to 168 . #3 Coffee, hot water, soup, or any hot liquid temperature at point of service should be at or below 145 . #4. If coffee, hot water, soup, or any hot beverage is served to resident at a different time other than at meals, temperature should be taken before service and not served above 145 F. Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses of CVA (cerebrovascular accident) with right sided weakness, Bipolar disorder, and COPD (chronic obstructive pulmonary disease) Review of Resident R1's quarterly Minimum Data Set (MDS- assessment of resident needs) dated May 29, 2024, revealed a BIMS (brief interview for mental status) score of 15 suggesting that Resident R1 was cognitively intact. Review of Resident R1's care plans revealed that the resident was care planned for impairment related to safety awareness, reduced independence with activities of daily living, and difficulty navigating the SNF (skilled nursing facility) environment. Resident R1 has impaired cognitive function/dementia or impaired thought processes related to Dementia. Continued review of the resident's care plan revealed a care plan developed on August 11, 2024 related to a 2nd degree burn to resident's right upper quadrant and right breast. Interventions included to keep area clean and dry, assistance with handling all meals trays and treatments done as ordered. Review of Resident R1's nursing note dated July 29, 2024, time stamped 2:58 p.m. revealed that Resident R1 was brought to the 3rd floor and stated she spilled hot water on herself in the main dining room. RUQ (right upper quadrant) abdomen and R (right) breast noted with redness. Resident stated she was holding tray and spilled hot water on herself. A&D applied to area; pain medication offered resident denied. MD (physician) notified, to monitor area q (every) shift. Review of Resident R1's wound progress notes dated August 8, 2024, revealed that Resident R1 was seen by wound care for an assessment and treatment recommendation for a burn secondary to hot water on right breast, RLQ (right lower quadrant)/RUQ (right upper quadrant) ABD (abdominal). Wounds present < 1 week. Patient initially had pain, now improved. No s/s (sign/symptom) of infection. Right breast burn: 1.8 x 0.8 x 0.05 centimeters, right abdominal burn: 8 x 8 x 0 centimeters. Interview with Resident R1 conducted on August 14, 2024, at 12:07 p.m revealed that she forgot the date of the incident but on the day of the incident, she requested to have lunch in the main dining room on the first floor. Resident R1 revealed that she asked Dietary aide, Employee E4 to bring her lunch to the dining room. Resident R1 further revealed that she was in the lobby area in front of the front desk waiting for Employee E4 to bring her lunch. When employee E4 brought her lunch in a tray. Resident R1 alleged that she asked Dietary aide, Employee E4 to bring the tray to the dining room but Dietary aide, Employee E4 refused to bring the tray to the dining room stating that she didn't have time to do it. The resident then carried the tray herself while propelling herself with her feet on the wheelchair. Further, Resident R1 also alleged that she asked Dietary aide, Employee E4 to take the hot water out of the tray but Dietary aide, Employee E4 left it on the tray. Resident R1 then carried tray and spilled the cup of hot water on herself on her way to the dining room which caused her to get burned on her chest. Interview with Dietary aide, Employee E4 conducted on August 14, 2024, at 1:13 p.m. revealed that when preparing the food trays that go to the unit, she puts the food together according to the menu. Coffee and hot water is poured, then it goes in the truck, goes upstairs then nurse aides served the tray. Further Dietary aide, Employee E4 revealed that she was never assigned to check the temperature. Continued interview with Dietary aide, Employee E4 revealed that Resident R1 normally eats in Main Dining Room on the first floor but that day she wanted to eat upstairs. However, Resident R1 changed her mind and decided to eat in the main dining room. Lunch service was already finished at the time, so Resident R1 requested for a special lunch tray. Employee E4 also revealed that she had to prepare a special tray for Resident R1. Further interview with Dietary aide, Employee E4 confirmed that she did not check the temperature of the food that she prepared for Resident R1. Employee E4 revealed that when she took Resident R1's tray out of the kitchen, resident was in the lobby at the front desk and that she handed the tray to Resident R1, the resident took the tray from her hand. Dietary aide, Employee E4 revealed that the front desk Receptionist, Employee E8 and Social Worker, Employee E6 were near the front desk. Social Worker, Employee E6 offered to take the tray from Resident R1 and offered to carry it to the dining room but Resident R1 refused. Social Worker, Employee E6 attempted to take the tray from Resident R1 but resident refused. Employee E4 further revealed that when she left Resident R1 was still in front of the front desk and that she was not aware the resident had burned herself until later. Interview with Director of Dietary, Employee E3 conducted on August 14, 2024, at 1:26 p.m. confirmed that Dietary aide, Employee E4 did not check the water temperature before taking the tray to Resident R1. Employee E3 stated that the cooks conduct a random food temperature check during tray line and performs a random check the coffee and water temperatures upon poring and then 15 minutes later. Interview with Social Worker, Employee E6 conducted on August 14, 2024, at 1:37 pm revealed that she was in the lobby at the time of the incident. Social Worker, Employee E6 revealed that she saw Dietary Aide, Employee E4 coming out from the kitchen area and Resident R1 was sitting at the front desk. Employee E6 revealed that she saw Dietary aide, Employee E4 handed Resident R1 a lunch tray. Employee E6 also revealed that she asked Resident R1 if she can carry the tray for her and that Dietary aide, Employee E4 then also offered to take tray for Resident R1, but Resident R1 insisted that she can do it. Employee E6 revealed that she left after and did not see the incident and did not know where it happened. She found out about it later. Interview with front desk Receptionist, Employee E8 conducted on August 14, 2024, at 12:18 p.m. revealed that he was manning the front desk at the time of the incident. Receptionist, Employee E8 revealed that he saw Dietary aide, Employee E4 give Resident R1 something but didn't know what it was and that he was busy doing something else at the time. Interview with Recreation aide, Employee E7 conducted on August 14, 2024, at 1:44 p.m. revealed that on July 29, 2024 she was going through dining room and saw Resident R1 outside the dining room in the lobby area and she had a tray on lap and the tray had food on it, asked if she needed help and she refused. Stated I got it. Recreation aide, Employee E7 then proceeded to go into the dining room and left Resident R1 outside the dining room area. Review of cooling/heating log for July 28, 2024, to August 10, 2024, revealed that coffee temperature was checked every day for starting temp and 15 minutes after every day for breakfast, lunch, and dinner Review of security camera located in the lobby area revealed that the camera orientation was facing the entrance of the lobby and shows one of the doorways leading to the kitchen. Further review of the lobby security camera revealed that at 1:56 p.m. resident was seen wheeling herself to the front desk and stayed in front of the front desk. At 1:58 p.m Dietary aide, Employee E4 was seen walking out of the kitchen door with a tray in her hands. Dietary aide, Employee E4 approached the front desk and handed the tray to resident. Social Worker, Employee E6 was seen approaching Resident R1 and what appears to be a verbal interaction between Resident R1 and Social Worker, Employee E6 occurred. Dietary aide, Employee E4 and Social Worker, Employee E6 was then seen walking away from the Resident R1 and Resident R1 wheeled herself towards the direction of the entrance to the dining room door. There was no video coverage for area leading towards the dining room. The facility failed to test the temperature of a hot water beverage prior to providing it to Resident R1. This failure resulted in actual harm to Resident R1 who spilled the hot water beverage and sustained a second degree abdominal and chest burn. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.6(c)(d) Dietary Services

Based on observation, review of facility policies, facility documentation and interviews with staff, it was determined that the facility failed to ensure that water temperatures in resident bathroom hand sinks and shower rooms were maintained at a safe temperature for three of three nursing units (Second, Third and Fourth Floor Nursing Units). This failure placed residents on the (Second, Third and Fourth Floor Nursing Units) at risk for serious injury from a burn and resulted in an Immediate Jeopardy situation. (Second, Third and Fourth Floor Nursing Units). Findings Include: Review of facility policy titled, Water Temperature with a revision date of November 24, 2024 revealed The facility should insure that plumbing fixtures that supply hot water and are accessible to the residents shall be thermostatically controlled so the water temperature at the fixture does not exceed one hundred ten degrees Fahrenheit. Observation conducted on January 9, 2024 at 10:30 a.m. in Resident R132's hand sink revealed that the hot water felt uncomfortably too hot to the touch. The Director of Maintenance, Employee E3 was called to Resident R132's room to take the temperature of the water at the hand sink. The temperature of the water measured 129 degrees Fahrenheit. Observation and testing of the hot water was completed on the Second floor. The testing was made with Director of Maintenance Employee E3 at 11:15 a.m. on January 9, 2024. The following hot water temperatures were found to be above safe hot water temperature: Shower room hand sink measured at 129 degrees Fahrenheit. room [ROOM NUMBER] measured at 129 degrees Fahrenheit. room [ROOM NUMBER] measured at 142 degrees Fahrenheit. room [ROOM NUMBER] measured at 122.6 degrees Fahrenheit. room [ROOM NUMBER] measured at 124.4 degrees Fahrenheit. room [ROOM NUMBER] measured at 124 degrees Fahrenheit. room [ROOM NUMBER] measured at 123 degrees Fahrenheit. On January 9, 2024 at 12:02 p.m. observation was made of the boiler room with the Director of Maintenance Employee E3. The thermometer from the valve to the resident's rooms was reading 125 degrees Fahrenheit. When asked what it was supposed to be set at the Director of Maintenance replied 110 degrees Fahrenheit. When asked if anyone checks the temperatures regularly, Employee E3 stated that it was checked each morning Monday through Friday. When asked how often the Director of Maintenance, Employee E3 had to adjust the flow of the hot/cold water to the mixing valve he replied, daily. When asked who usually brings it to his attention Employee E3, replied the nurses let me know if it is too hot or too cold. On January 9, 2024 at 12:18 p.m. Director of Maintenance, Employee E3 stated he has the cold set up as much as possible, and as it goes on more in the day the water will be cooled down. He stated that he has had to continue to adjust the water temperatures at the facility daily. On January 9, 2024 at 12:20 p.m. additonal water temperatures were taken with Director of Maintenance, Employee E3 on the second floor. The following hot water temperatures were found to be above 110 degrees: room [ROOM NUMBER] measured at 127.7 degrees Fahrenheit. room [ROOM NUMBER] measured at 144 degrees Fahrenheit. room [ROOM NUMBER] measured at 117.5 degrees Fahrenheit. room [ROOM NUMBER] measured at 115.8 degrees Fahrenheit. Observation and testing of the water on the Third floor were made on January 9, 2024 at approximately 12:28 p.m. Hand sink #1 in shower room measured at 145 degrees Fahrenheit. Hand sink #2 in shower room measured at 156 degrees Fahrenheit. Shower room [ROOM NUMBER] measured at 180 degrees Fahrenheit. Shower room [ROOM NUMBER] measured at 145 degrees Fahrenheit. room [ROOM NUMBER] measured at 155 degrees Fahrenheit. room [ROOM NUMBER] measured at 150 degrees Fahrenheit. room [ROOM NUMBER] measured at 150- degrees Fahrenheit. room [ROOM NUMBER] measured at 155 degrees Fahrenheit. Observation and testing of the water on the Fourth floor were made on January 9, 2024 at approximatley 12:28 p.m. Shower room [ROOM NUMBER] was 132 degrees Fahrenheit. Shower room [ROOM NUMBER] was 124.7 degrees Fahrenheit. room [ROOM NUMBER] measured at 122 degrees Fahrenheit. Rooms 428 measured at 138 degrees Fahrenheit. Rooms 422 measured at 135 degrees Fahrenheit. Further observations of the shower roomsat the time the water temperatures were taken revealed the following: The second floor shower room had no thermometers in Shower room [ROOM NUMBER]. The Third floor had no thermometers in either of the shower rooms (Shower room [ROOM NUMBER] or Shower room [ROOM NUMBER]). The fourth floor had a hanging thermometer that only went up to 105 degrees Fahrenheit. Interview held with Nurse Aide, Employee E32 at 12:45 p.m stated that there are thermometers hanging in the shower room that we use to check the water. I aim for 95-96 degrees. Anything over 100 I consider too hot. If the water is too hot, I shut it off, remove the resident from the shower room and inform the nurse. Interview held with Nurse aide, Employee E30 on January 9, 2024 at 1:33 p.m. revealed it was her first day back to work and she did not know about the showers or how to test the water. Interview held with Nurse aide, Employee E31 on January 9, 2024 at 1:35 p.m. revealed she was an aide and when asked about checking the temperature of the shower water Employee E31 stated that she tests the water out on herself and then adjusts the hot water. She also stated that the resident will also tell us if it's too hot or cold if they are oriented. Interview held with Licensed nurse, Employee E22 on January 9, 2024 at approximately 12:35 p.m. revealed that she complained a few days ago to the maintenance department that the water was too cool in room [ROOM NUMBER] and in the nurses' breakroom. Interview held with Nurse aide, Employee E33 on January 9, 2024 at approximately 12:39 p.m. revealed that she thought between 100 to 120 degrees Fahrenheit was the safe range, they had no complaints about the water and all residents had a bed bath today. Employee E33 stated they use the thermometer to test the water. Interview held with Nurse aide, Employee E13 revealed that she works as unit clerk and also works the 3-11 shift. Employee E13 stated that she did not know the correct temperatures. Employee E13 stated they always mix the hot and the cold and puts her hand underneath to test. Based on the above findings Immediate Jeopardy to the safety of the residents was identified to the Nursing Home Administrator on January 9, 2024 at 2:05 p.m. for failure to ensure that safe hot water temperatures were maintained on the Second, Third and Forth Floor Nursing units. The Nursing Home Administrator was provided with the Immediate Jeopardy template on January 9, 2024 at 2:09 p.m. and an immediate action plan was requested. The following action plan was received and accepted on January 9, 2024 at 5:23 p.m. -Immediately shut down the hot water system- completed 1/9/24 -Notified the administrator- completed 1/9/24 -Notified staff that residents should not use the hot water- completed 1/9/24 -Notified residents to not use the hot water- completed 1/9/24 -Notified the vendor of hot water system issue, vendor on site, assessed issue. Repairs in progress, Plan is to have repair completed by 1/9/24. -Audits initiated to ensure residents are not using the hot water- completed 1/9/24 -Immediately initiated education for staff prior to the start of the next shift that water temperatures should not exceed 110 degrees-80% completed 1/9/24 100% completed 1/10/24 -Ensure thermometers are available on the units and in showers rooms- completed 1/9/24 -If water temperatures are found to be 100 degrees the hot water will be shut off, administration will be notified. -Wipes will be provided for all care during the hot water repair. -Water temperature policy was updated to ensure safe processes for monitoring water temperatures- completed 1/9/24 -Facility staff education prior to the start of the next shift on the revised water temperature policy and appropriate water testing methods 80% completed 1/9/2024, 100% completed 1/10/2024 -Maintenance director of designee will audit water temperatures every two hours for three days in two random areas on each of the three resident room floors. -Maintenance director or designee will audit water temperatures three times a day for three days. -Maintenance director or designee will audit water temperatures twice a day for three days. -Maintenance director or designee will audit water temperatures daily ongoing A review of water temperature audits was completed on January 10, 2024. Hot water temperatures were found not to exceed 110 degrees. Interviews were conducted on January 10, 2024, between 9:15 a.m. and 9:40 a.m., with facilty staff revealed that they were able to verify the implementation of the immediate action plan. Nursing staff were able to verbalize to facility's updated policy, including that water temperatures should not exceed 110 degrees Fahrenheit, what to do if water temperatures were found to be too hot, how is the temperature of the water tested , if a therometer was not available where can a thermometer be found and who to notify if the temperature of the hot water was found over 110 degrees Fahrenheit. The hot water at residents' hand sinks and shower rooms on the Second, Third and Fourth Floor were tested and verified that they did not exceed 110 degrees Fahrenheit. Water temperature logs were reviewed and revealed appropriate water temperatures. Following verification of the implementation of the immediate action plan, review of water temperature logs and review of staff education documentation, the Immediate Jeopardy was lifted on January 10, 2024 at 3:52 p.m. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.18(b)(3) Management 28 Pa Code 205.63(c) Plumbing and piping systems required for existing and new construction 28 Pa Code 211.12(d)(5) Nursing services

Based on observations, a review of the clinical record, interviews with staff, and review of facility policy, it was determined that the facility failed to develop a person- centered care plan related to contractures of Resident R67's hands. This failure resulted in actual harm to Resident R67 who developed one abscess on the crease of the left wrist requiring antibiotic therapy and the development of a second abscess on the palm of the right hand requiring a surgical debridement and intravenous antibiotic therapy for one of 34 residents reviewed. (Resident R67) Findings include: Review of the facility's Wound Prevention policy dated April 2022, stated The purpose of this program is to assist the facility in the care, services and documentation related to the occurrence, treatment and prevention of pressure as well as non-pressure related wounds. Review of Resident R67's clinical record revealed the resident was admitted to the facility on [DATE], with the diagnoses of osteomyelitis (bone infection), heart failure, anoxic brain damage, chronic respiratory failure requiring a tracheostomy for breathing, seizures (abnormal brain activity), stage four pressure ulcer (damage from the layers of the skin to exposed bone) in the sacral region, Type 1 diabetes mellitus (autoimmune disease), and a gastrostomy (a feeding tube for nutritional support). Review of Resident R67's Admission Minimum Data Set (MDS- an assessment of residents' care needs) dated April 13, 2022, revealed the resident had short and long term memory impairment, and that the resident required extensive assistance of two people for bed mobility, transfers, dressing and personal hygiene. Resident R67's wound consultation dated April 7, 2022, for the management of the resident's sacral wound noted the resident with bilateral footdrop, (weakness or paralysis of the muscles near the front of your foot) and left and right contracted hands (rigidity and deformity of the hand). Review of Resident R67's April 2022, admission care plan revealed that there was no care plan developed with intervention to address the resident's footdrop and bilateral hands contractures. Continued review of Resident R67's clinical records revealed a note from the Nurse Practioner (NP) dated, September 1, 2022, noting the resident had contractures in all limbs including hands and bilateral foot drop. The note stated, Resident with left wrist abscess in crease of contracture. Moderate serosanguinous fluid (clear fluid mixed with blood), measuring 2.0 x 2.0 cm. Will start on Keflex (antibiotics) for 5 days. Progress noted from the wound care nurse dated September 8, 2022, noted the wound was closed. Review of Resident R67's care plan revealed the facility failed to develop a plan of care to maintain skin integrity related to Resident R67's after the abscess formed in the resident's left wrist and to prevent further wounds from developing. Review of Resident R67's MDS dated [DATE], revealed the resident that the resident required total assistance of two people for bed mobility, transfers, dressing and personal hygiene. Review of NP note on October 25, 2022, indicated a new abscess on the resident's right hand, in the lateral palm area noted with erythema (redness of the skin occurring with infection or inflammation). Review of the October 27, 2022, initial wound consultation for Resident R67's right palm was documented as a quarter size fluid filled blister measuring 5. X 3. X 0. cm., draining moderate amount of serosanguinous (clear fluid mixed with blood). Review of the November 9, 2022, Wound Specialist documentation revealed Resident R67's Right palm blister had 80% slough and measured 4 x 3 x 0 cm. noted with serosanguinous drainage. The wound was surgically debrided (removing infected necrotic dead tissue) Review of the November 15, 2022, nursing note stated Resident R67 was seen by the wound nurse and was observed with swelling to the right arm and an odor from the wound. The resident's lower extremities were cold to touch and unable to palpate. Physician was made aware and the note indicated an order was obtained for a midline (for intravenous access of antibiotic fluids) and antibiotics, meropenem 1 gram every 12 hours for severe skin infection. Review of NP note dated November 17, 2022, Nurse placed soft rolls in resident's hands to prevent nails from digging in skin. Wound consult dated November 23, 2022, noted an improvement in the wound and recommended to place rolled gauze in bilateral hands for prevention and keep nails trimmed short for prevention. Review of resident's care plan revealed no evidence that the resident's care plan was reviewed and revised to include interventions to address the resident's infected wound on the right hand. Continued review of Resident R67's clinical record revealed the wound specialist debrided the wound on December 14, 21 and 28, 2022, with treatment recommendation to included rolled gauze in bilateral hands and keeping nails short for prevention. Review of NP note dated January 3, 2023, indicated Resident R67 was ordered the intravenous antibiotics, Vancomycin 500 milligrams and Cefepime HCL Solution Reconstituted 1 gram given two times a day for the resident's right palm cellulitis (potentially serious bacterial skin infection) that was started on December 28, 2022, and ordered to end on January 4, 2023. Review of the would consults notes dated February 15, 2023, stated, The right palmer abscess wound was resolved but continue Skin Prep for prevention, continue rolled gauze in bilateral palms. Review of Resident R67's clinical record revealed that it was not until February 16, 2023, that the facility developed a care plan related to the resident's contractures with interventions to include the use of gauze in bilateral palms. On February 15, 2023, at 10:25 a.m. the wound treatment nurse Licensed Nurse, Employee E38 stated, The right hand is documented as being healed as of today by wound consult. I believe it (the wound) happened because her nails grew into her palm. They must cut her nails and keep a gauze roll in her hands for prevention. At this time with Licensed Nurse, Employee, E38 the resident was observed lying in bed, her nails appeared long with no preventative measures taken to protect her bilateral palms. Licensed Nurse, Employee, E38 confirmed the resident's nail were long, needed trimming and the bilateral gauze rolls were not in use. The facility failed to develop a person- centered care plan related to contractures of Resident R67's hands. This failure resulted in actual harm to Resident R67 who developed one abscess on the crease of the left wrist requiring antibiotic therapy and the development of a second abscess on the palm of the right hand requiring a surgical debridement and intravenous antibiotic therapy. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.11(b) Resident care plan 28 Pa. Code 211.11(c) Resident care plan 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services

Based on observations, staff interview and facility documentation, and review of facility policy, it was determined that facility failed to ensure that treatment was provided to Resident R67's bilateral hand contractures with the use of hand gauzes to prevent the development of bilateral hand wounds. This failure resulted in actual harm to Resident R67 who developed one abscess on the crease of the left wrist requiring antibiotic therapy and the development of a second abscess on the palm of the right hand requiring a surgical debridement and intravenous antibiotic therapy for one of 34 residents reviewed (Resident 67). The facility failed to follow physician's orders related to the administration of insulin medication for one of 34 residents reviewed. (Resident R14) Findings include: Review of the facility's Wound Prevention policy dated April 2022, stated The purpose of this program is to assist the facility in the care, services and documentation related to the occurrence, treatment and prevention of pressure as well as non-pressure related wounds. Review of Resident R67's clinical record revealed the resident was admitted to the facility on [DATE], with the diagnoses of osteomyelitis (bone infection), heart failure, anoxic brain damage, chronic respiratory failure requiring a tracheostomy for breathing, seizures (abnormal brain activity), stage four pressure ulcer (damage from the layers of the skin to exposed bone) in the sacral region, Type 1 diabetes mellitus (autoimmune disease), and a gastrostomy (a feeding tube for nutritional support). Review of Resident R67's Admission Minimum Data Set (MDS- an assessment of residents' care needs) dated April 13, 2022, revealed the resident had short and long term memory impairment, and that the resident required extensive assistance of two people for bed mobility, transfers, dressing and personal hygiene. Resident R67's wound consultation dated April 7, 2022, for the management of the resident's sacral wound noted the resident with left and right contracted hands (rigidity and deformity of the hand). Continued review of Resident R67's clinical records revealed a note from the Nurse Practioner (NP) dated, September 1, 2022, noting the resident had contractures in all limbs including hands and bilateral foot drop. The note stated, Resident with left wrist abscess in crease of contracture. Moderate serosanguinous fluid (clear fluid mixed with blood), measuring 2.0 x 2.0 cm. Will start on Keflex (antibiotics) for 5 days. Progress noted from the wound care nurse dated September 8, 2022, noted the wound was closed. Review of Resident R67's quarterly MDS dated [DATE], revealed the resident that the resident required total assistance of two people for bed mobility, transfers, dressing and personal hygiene. Review of NP note on October 25, 2022, indicated a new abscess on the resident's right hand, in the lateral palm area noted with erythema (redness of the skin occurring with infection or inflammation). Review of the October 27, 2022, initial wound consultation for Resident R67's right palm was documented as a quarter size fluid filled blister measuring 5. X 3. X 0. centimeter (cm) draining moderate amount of serosanguinous (clear fluid mixed with blood). Review of the November 9, 2022, Wound Specialist documentation revealed Resident R67's Right palm blister had 80% slough and measured 4 x 3 x 0 cm. noted with serosanguinous drainage. The wound was surgically debrided (removing infected necrotic dead tissue) Review of the November 15, 2022, nursing note stated Resident R67 was seen by the wound nurse and was observed with swelling to the right arm and an odor from the wound. The resident's lower extremities were cold to touch and unable to palpate. Physician was made aware and the note indicated an order was obtained for a midline (for intravenous access of antibiotic fluids) and antibiotics, meropenem 1 gram every 12 hours for severe skin infection. Review of NP note dated November 17, 2022, Nurse placed soft rolls in resident's hands to prevent nails from digging in skin. Wound consult dated November 23, 2022, noted an improvement in the wound and recommended to place rolled gauze in bilateral hands for prevention and keep nails trimmed short for prevention. Review of resident's care plan revealed no evidence that the resident's care plan was reviewed and revised to include interventions to address the resident's infected wound on the right hand. Continued review of Resident R67's clinical record revealed the wound specialist debrided the wound on December 14, 21 and 28, 2022, with treatment recommendation to included rolled gauze in bilateral hands and keeping nails short for prevention. Review of NP note dated January 3, 2023, indicated Resident R67 was ordered the intravenous antibiotics, Vancomycin 500 milligrams and Cefepime HCL Solution Reconstituted 1 gram given two times a day for the resident's right palm cellulitis (potentially serious bacterial skin infection) that was started on December 28, 2022, and ordered to end on January 4, 2023. Review of the would consults notes dated February 15, 2023, stated, The right palmer abscess wound was resolved but continue Skin Prep for prevention, continue rolled gauze in bilateral palms. On February 15, 2023, at 10:25 a.m. the wound treatment nurse Licensed Nurse, Employee E38 stated, The right hand is documented as being healed as of today by wound consult. I believe it (the wound) happened because her nails grew into her palm. They must cut her nails and keep a gauze roll in her hands for prevention. At this time with Licensed Nurse, Employee, E38 the resident was observed lying in bed, her nails appeared long with no preventative measures taken to protect her bilateral palms. Licensed Nurse, Employee, E38 confirmed the resident's nail were long, needed trimming and the bilateral gauze rolls were not in use. The facility failed to ensure that treatment was provided to Resident R67's bilateral hand contractures with the use of hand gauze to prevent the development of bilateral hand's wound. This failure resulted in actual harm to Resident R67 who development one abscess on the crease of the left wrist requiring antibiotic therapy and the development of a second abscess on the palm of the right hand requiring a surgical debridement and intravenous antibiotic therapy. Review of Resident R14's clinical record revealed the diagnosis of type 2 diabetes (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells) Review of Resident R14's February 2023 physician's orders revealed an order for HumaLOG (Lispro) Solution 100 unit/milliters 4 units to be administered before meals related to type 2 diabetes mellitus. Observation conducted during medication administration pass on February 14, 2023, at 11:13 a.m. with Licensed Nurse, Employee E12, revealed that Employee 12 administered 4 units of insulin Lispro and attempted to sign out this medication for the 7:30 a.m. dose at 11:13 a.m. When asked Licensed nurse, Employee R12 regarding Resident R14 scheduled insulin administered prior to breakfast meal, Employee R12 confirmed that the scheduled insulin medication before breakfast was not administered and stated I guess it will be for 11:00 a.m. then. Additional review of Resident R14's February 2023 Medication Administration Record revealed that scheduled insulin Lispro for 7:30 a.m. was administered at 12:45 p.m. and signed out as administered at 12:47 p.m. Refer to F656 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.11(b) Resident care plan 28 Pa. Code 211.11(c) Resident care plan 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services

Based on observations, review of clinical records and facility documentation, and interviews with staff, it was determined that the facility failed to maintain an environment free from accident hazards on one of three nursing units, and failed to provide adequate supervision for three of 27 residents reviewed (Residents R41, R98 and R57), causing actual harm (a laceration of the left index finger that required ten stitches to Resident R41). Findings include: Review of the clinical record for Resident R41 revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set assessment (MDS - an assessment of resident care needs) dated November 25, 2016 revealed that Resident R41's cognitive skills for daily decision making was severely impaired. Further review of Resident R41's clinical record revealed that the plan of care initiated October 14, 2016, identified that the resident was to receive nutritional supplements with supervision. The plan of care stated that the resident was to receive nectar thick liquid and the designated supplement was identified as a Glucerna shake. Review of a facility incident report dated November 30, 2016, revealed that on that date, at 11:20 p.m. Resident R41 was discovered by a member of the nursing staff with his left index finger stuck inside the opening of a Glucerna shake can. The staff members responding to the event were unable to remove Resident R41's finger from the can without causing further injury. Upon physician notification, a verbal order was given to transfer Resident R41 to the Emergency Department for evaluation and treatment. Review of the witness statements revealed that it was a common practice to give the resident his supplement and allow him to finish it at his own pace without supervision. There were no prior incidents of Resident R14 sticking his finger in the can of supplement. Review of the discharge summary from the Emergency Department revealed that Resident R41 was treated at the hospital for a laceration of the left index finger that was approximately six centimeters long and required ten stitches to close. Resident R41 was discharged from the hospital with instructions to continue his current medications, including Tylenol, as needed, for pain. An interview with Employee E4, the Assistant Director of Nursing, on November 14, 2016, at 1:00 p.m. confirmed that Resident R41 was given his nutritional supplement at approximately 8:00 p.m. on November 30, 2016. The resident was not discovered with his finger stuck inside the opening of the can until 11:20 p.m. that same day. An interview with Employee E15, the Speech Therapist, on November 14, 2016, at 3:35 p.m. confirmed that the nutritional supplement, Glucerna, did not have the consistency to be considered a nectar thick liquid as ordered by the physician. The facility failed to provide adequate supervision resulting in actual harm to resident R41, who sustained a laceration to his left index finger, requiring transfer to the emergency room and ten stitches. During the initial tour of Second Floor Nursing Unit on December 13, 2016, at 9:45 a.m. observation of the linen cart in the A Hall revealed that on the side pocket of the linen cart was a reach-in plastic bag holder which contained seven blue Bic disposal razors and approximately 30, 5 gram packets of Vitamin A and D Ointments. Continued initial tour of the Second Floor Nursing Unit, in the B Hall, revealed another linen cart. Further observation of the linen cart revealed a reach-in plastic bag holder which contained eight blue Bic disposal razors and approximately 15, 5 grams packets of Vitamin A and D Ointments. At the time of each observation of both linen carts in the presence of Employee E24, a Licensed Nurse, indicated that the blue Bic disposal razors and the Vitamin A and D Ointment packets left in the side pockets of the linen carts did not provide a safe and accident free environment to all Of the residents on the Second Floor Nursing Unit. Employee 24 further indicated that leaving the blue Bic disposal razors and the Vitamin A and D Ointment packets in the side pockets of the linen carts was for the convenience of the nursing staff. During the same interview, Employee E24 also revealed that the blue Bic disposal razors and the Vitamin A and D Ointment packets are to be secured in the medication room on the nursing unit. Resident R98 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of information dated November 13, 2016, submitted by the facility showed that Resident R98 was manually transferred from the wheel chair to the bed by two nurses aides, (NA). The report stated that the transfer should have been done using a Hoyer lift (a mechanical device which allows a person to be lifted and transferred with minimum physical effort) as recommended by the Physical Therapy Department. Review of the facility's undated policy and procedure related to transfer/lifting residents indicated that the nursing assistant was responsible for assuring the mode of transfer prior to the transfer of a resident. During an interview with Resident R98 on December 13, 2016, at 1:45 p.m. he/she confirmed that the NA, transferred him/her from the wheel chair to the bed manually without using the Hoyer lift. Resident R98 stated that he/she reported it to the facility. Review of the documentation completed by the facility related to the incident showed that the transfer was done by two nurse assistants (NA), Employees E9 and E10. According to the investigation when Employee E9 was asked whether he/she used the lift for transfer, Employee E9 stated, No, because there was no Hoyer pad underneath him. I didn't know how to put it under him. An interview with NA's Employees E5, E6, E7, and E8 revealed that the employees did not know how to access the transfer instructions for Resident R98. Employee E5 stated that he/she would go to the care plan for Resident R98. Employee E6 stated that he/she used to get information during the shift report and that he/she never used to look in the computer. Employees E7 and E8 stated that they would go to the care plan for Resident R98. During an interview with the Assistant Director of Nursing (ADON) on December 14, 2016, at 11:15 a.m. revealed that Employee E4 asked Employee E7 to access the transfer details of Resident R98 from the computer and Employee E7 could not access the transfer details. Employee E4 asked Employee E7 how to pull up transfer details for the residents and Employee E7 replied that it was from care plan. Employee E4 stated that the transfer details were to be accessed from the Kardex (a set of instructions for the care givers detailing how to provide care to a resident to complete the activities of daily living including mode of transfer, incontinence care et cetera) of the residents accessed through the Kardex tab. Employee E4 stated that the NA's were trained many times how to pull up the Kardex. Review of clinical record for Resident R57 revealed an admission physician's order dated October 17, 2016, that indicated [DIAGNOSES REDACTED]. A review of a psychiatry progress note dated, November 18, 2016, indicated that Resident R57, expressed a desire to the Psychiatrist (a medical doctor who specializes in mental health) for a prescription for a Benzos medication, (a type of medication such as, tranquilizers and/or sleeping pills, otherwise known as a sedative, that depresses or slows down your central nervous system, such as Klonopin). Further review of the psychiatry note, indicated that Resident R57's primary physician indicated that Resident R57, is not allowed any Benzos medications, such as Klonopin, because of drug seeking behaviors. The psychiatry note revealed that Resident R57, indicated to the psychiatrist, Will go to another facility to get a prescription for Klonopin. A review of the facility policy and procedure titled, Resident Leave of Absence, dated, June 7, 2013, revealed the purpose of the policy is, To provide continuum of care for residents when they are out of the facility with family, friends or for medical purposes for a period of time that extends beyond their next medication administration time. Further review of Resdient R57's clinical record revealed a verbal physician's order dated December 1, 2016, which indicated that Resident R57, may go on leave of absence if cleared by social services, physical therapy and nursing. An interview with Employee E16, a Licensed Nurse, on December 15, 2016, at 10:30 a.m. revealed that Resident R57 had drug seeking behaviors. Employee E16 revealed that the reason for the physician's order written on December 1, 2016, indicating that Resident R57, needed to be cleared by social services and nursing for leave of absence from the facility was because of Resident R57, having a risk for falls, because of muscle weakness and that Resident R57's physician wanted physical therapy to clear Resident R57 for a planned leave of absence. A nursing note dated December 4, 2016, written at approximately 2:00 p.m. revealed that Resident R57 was leaving the facility for a leave of absence with the daughter on the indicated date and would return to the facility on [DATE], at 5:00 p.m. Review of the nursing progress note dated December 7, 2016 written, at approximately 3:30 p.m. this is earlier than the resident was expected back, is this time right?***YES THIS IS WHAT'S WRITTEN IN THE N.N. revealed that nursing attempted to place a call to Resident R57's mother because Resident R57 did not return to the facility as indicated at the time of the leave of absence on December 4, 2016. Further review of the progress note indicated that Resident R57's mother indicated to nursing staff, She was unable to contact daughter and was unaware of daughter's where about's. At the time of the clinical record review on December 13, 14 and 15, 2016, there was no indication that Resident R57 was cleared by social services, physical therapy and/or nursing to go on the planned leave of absence for December 4 - 7, 2016. An interview with Employee E25, the Director of Social Services, on December 16, 2016, at 9:30 a.m. confirmed the review of the social service progress note dated December 16, 2016, written at approximately 8:00 a.m. for Resident R57's planned leave of absence for December 4 - 7, 2016, was not a timely assessment for Resident R57's leave of absence which occurred. An interview with Employee E26, the Director of Physical Therapy, revealed that therapy was not made aware of the physician's order for Resident R57 to be cleared by therapy for a leave of absence from the facility. Employee E26 indicated during the interview that Resident R57 was assessed by Physical Therapy, on December 2, 2016, 4 days before the planned leave of absence and it was determined that Resident R57 required supervision with all ambulation because of an decrease awareness of safety awareness and an increase risk of falls. Employee E26 further indicated that Physical Therapy would not have cleared Resident R57 for a leave of absence from the facility as requested by the physician. Review of nursing progress note dated, December 8, 2016, written at 2:13 p.m. revealed that Resident R57 returned to the facility at 12:30 p.m., (19 1/2 half hours late) and appeared with blood shot eyes and Marijuana smell apparent. Review of a nursing progress note dated December 8, 2016, written at approximately 6:00 p.m. revealed that Resident R57 was transferred to the local hospital for evaluation and treatment for [REDACTED]. An interview with Employee E16, a Registered Nurse on December 15, 2016, confirmed that Resident R57's leave of absence from the facility December 4 - 8, 2016, was not appropriately planned and approved by all facility disciplines as required in the physician's order written on December 1, 2016. The facility failed to provide adequate supervision while providing care for a cognitively impaired resident to prevent injury from an accident or hazardous situation. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 01/14/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 01/14/16 28 Pa. Code 201.18(b)(1) Management Previously cited 12/11/14, 01/14/16, 02/24/16 28 Pa. Code 201.18(e)(1) Management Previously cited 01/14/16 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 01/14/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 12/11/14, 01/14/16

Based on a review of a clinical record , facility documentation, and staff interviews, it was determined that the facility failed to provide an environment free of accident hazards resulting in actual harm for one of 27 residents. (Resident R 59). Findings include: A clinical record review of the Resident R 59 ' s MDS (minimum data set) periodic assessment, dated September 18 and November 8, 2013, indicated that the resident had a deficit in cognition (mental function), needed extensive assistance with care needs and did not ambulate. An observation of Resident R 59 on January 2, 2014, at 12:25 p.m., in the dining room, revealed that the resident was in a geriatric chair being fed lunch and that the resident had limited mobility. Review of plan of care indicated that resident required extensive assist of two during showers. An Occupational Therapy assessment dated [DATE] revealed that this resident required maximum assistance of two for repositioning. Review of facility documentation related to a fall on September 9, 2013, at 8:30 p.m. revealed that during a shower, the resident fell to the floor when turned to the side while on the shower stretcher for the CNA to wash the resident's back. Additionally, during the fall the side rail on the shower stretcher broke. A review of facility documentation in the incident report confirmed that the CNA did not follow the plan of care in providing the appropriate assistance of two while showering this resident. The fall resulted in a laceration to the head caused by the broken rail and multiple skin tears with bruising and lacerations to the left top and lateral shoulder and left breast area. The resident had complained of pain and was transferred to the hospital and admitted following an X-ray which revealed a fracture to the fibula (lower leg bone) plateau. The facility failed to adequately monitor and supervise in order to avoid accidents with this resident sustaining a fall causing serious injury and actual harm. 483.25(h) Free of Accident Hazards/Supervision/Devices Previously cited 5/24/13. 28 Pa. Code: 201.18 (a)(b)(1) Management. 28 Pa. Code: 211.11 (b) Resident care plan. 28 Pa. Code: 211.12 (d)(1)(5) Nursing services.