Every finding on record at Midtown Oaks Health & Rehab Center

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for four of 45 residents reviewed (Resident's 4, 53, 102, 116). Findings include: The facility's policy regarding care plans, dated May 21, 2026, indicated that nursing staff and/or the interdisciplinary team were to initiate and/or update care plans for the resident as warranted. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated May 26, 2026, indicated that the resident was cognitively impaired, required extensive assistance from staff for daily care tasks, received tube feedings via a gastrostomy tube (tube into the stomach for nutrition), and had diagnoses that included dementia and cerebral infarction (stroke). Physician's orders for Resident 4, dated January 21, 2026, included an order for the resident to be NPO (no food by mouth) and to receive bolus tube feedings of Isosource (a high calorie nutritional liquid food) every four hours, and to keep the head of the bed elevated during feedings. Resident 4's current care plan, reviewed July 15, 2026, indicated that a suction machine was to be available while feeding the resident. Interview with the Registered Nurse 2 on July 15, 2026, at 1:32 p.m. confirmed that Resident 4 was admitted to the facility on [DATE], with a gastrostomy tube, requires tube feedings and takes nothing by mouth. She confirmed that there is a suction machine with the crash (emergency) cart located by the nurses' station, however, it was never associated with him for feedings and never taken to his room during feedings. In addition, she revealed that she does not know why the care plan would indicate a suction machine to be available during feedings. Interview with the Director of Nursing on July 15, 2026, at 2:37 p.m. confirmed that the tube feeding policy does not require a suction machine during feedings and Resident 4's care plan was not updated/revised to reflect that.A quarterly MDS assessment for Resident 53, dated June 4, 2026, indicated that the resident was cognitively intact and did not receive an antipsychotic medication. Physician's orders for Resident 53, dated September 5, 2025, included an order for the resident to receive 60 mg of Lurasidone (antipsychotic medication) once a day. The order was discontinued on September 16, 2025. Resident 53's current care plan, reviewed June 1, 2026, indicated that the resident received an antipsychotic medication. Interview with the Director of Nursing on July 15, 2026, at 3:09 p.m. confirmed that Resident 53's care plan was not updated to indicate that the antipsychotic medication had been discontinued. An annual MDS assessment for Resident 102, dated June 2, 2026, indicated that the resident was cognitively impaired, usually understands and sometimes understood, was dependent on staff for all staff for daily care tasks with bathing and hygiene has impairment on one side of the upper extremity, and had a diagnosis that included nontraumatic intracerebral hemorrhage (stroke). Resident 102's current activities of daily living care plan, dated July 19, 2023, indicated staff were to provide nail care by cutting the nails down straight across, without digging underneath, and may file nails on scheduled shower days on Monday and Thursdays. Interview and observations with Resident 102's Family Member 14 on July 12, 2026, at 12:55 p.m., revealed that she does not think facility staff were trimming the fingernails on the resident's right hand. Resident 102's right hand fingers are curled under and she has no ability to move that hand. The right hand has long fingernails that were curling over Resident 102's fingertips. Observations of Resident 102's right hand on July 15, 2026, at 12:13 p.m., revealed that the fingernails appeared unchanged from the last observation with fingernails that started to curl over the top of her fingertips. Interview with Nurse Aide 3 at the time of the observation, confirmed that Resident 102's nails did not appear to have been trimmed or filed with her last scheduled bathing day of July 13, 2026. Interview with the Director of Nursing on July 15, 2026, at 2:57 p.m. revealed that Resident 102 prefers to have long nails on her right hand but confirmed that Resident 102's care plan was not updated/revised to reflect her preference. A Comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 116, dated May 27, 2026, indicated that the resident was cognitively intact and required substantial assistance from staff for activities of daily living, including toileting and was frequently incontinent of bowel and bladder. A bowel care plan for Resident 116 dated May 16, 2026, revealed the resident was to be out of bed to a toilet or bedside commode when having a bowel movement. Interview with Resident 116 on July 15, 2026, at 8:20 a.m. revealed that she is unable to use a bedside commode or a toilet and prefers a bedpan that was to be kept in her bottom drawer in her nightstand. Interview with the Director of Nursing on July 15, 2026, at 3:10 p.m. confirmed that the resident's care plan was not updated for her use of a bedpan and should have been. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services

Based on a review of clinical records and staff interviews, it was determined the facility failed to ensure that a resident's drug regimen was addressed timely by the physician for two of 45 residents reviewed (Residents 7 and 78), resulting in the residents receiving unnecessary anti-infective medications. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated May 12, 2026, indicated that the resident was cognitively intact, required assistance with daily care needs, received application of ointments other than to feet, and had a diagnosis of diabetes. A physician's order for Resident 7, dated October 30, 2025, included an order for staff to apply nystatin powder topically to skin folds twice a day as needed for redness/excoriation. A pharmacy medication regimen review for Resident 7, dated April 30, 2026, indicated that the resident had received a topical anti-infective, Nystatin powder, since October 30, 2025, and recommended to discontinue the medication indicating that prolonged use may increase the risk of adverse consequences, including the development of drug-resistant organisms (difficult to treat). Review of the Medication Administration Record (MAR) for Resident 7, dated May and June 2026, revealed that the resident had received nystatin powder twice daily from May 1, 2026, through June 16, 2026. The resident was seen by the physician on May 22, 2026, and had another pharmacy review on May 31, 2026. The drug regimen review was not addressed by the physician until June 8, 2026, where the physician agreed to the recommendation to discontinue the nystatin powder. The nystatin powder was not discontinued until June 16, 2026. Interview with the Director of Nursing on July 15, 2026, at 3:53 p.m. confirmed that Resident 7's medication regimen review was not addressed timely, resulting in the unnecessary administration of nystatin powder from May 1, 2026, through June 16, 2026. A quarterly MDS assessment (a mandated assessment of a resident's abilities and care needs) for Resident 78, dated May 7, 2026, indicated that the resident was cognitively intact, was dependent on staff for toileting, bathing, dressing, and personal hygiene, received application of ointments other than to feet, and had a diagnoses of diabetes and chronic obstructive pulmonary disease. A physician's order for Resident 78, dated December 16, 2025, included an order for staff to apply nystatin powder topically to abdominal and breast folds twice a day as needed for redness/excoriation. A pharmacy medication regimen review for Resident 78, dated April 30, 2026, indicated that the resident had received a topical anti-infective, Nystatin powder, since December 16, 2025, and recommended the medication be discontinue indicating that prolonged use may increase the risk of adverse consequences, including the development of drug-resistant organisms. Review of the Medication Administration Record (MAR) for Resident 78, dated May and June 2026, revealed that the resident had received nystatin powder twice daily from May 1, 2026, through June 16, 2026. The resident had another pharmacy review on May 31, 2026. The drug regimen review was not addressed by the physician until June 8, 2026, where the physician agreed to the recommendation to discontinue the nystatin powder. The nystatin powder was not discontinued until June 16, 2026. Interview with the Director of Nursing on July 15, 2026, at 4:15 p.m. confirmed that Resident 78's medication regimen review was not addressed timely, resulting in the unnecessary administration of nystatin powder from May 1, 2026, through June 16, 2026. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set (MDS) assessments for six of 45 residents reviewed (Residents 1, 5, 53, 66, 84 and 95). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2025, indicated that the intent of Section N was to record the number of days, during the seven days of the assessment period, that any type of injection, insulin, and/or select medications were received by the resident. Section N0415C1 Antidepressant Medications, N0415E1 Anticoagulant Medications, N0415K1 Anticonvulsant Medications, and Section N0415I1 Antiplatelet Medications were to be coded if the resident took the medications during the seven-day lookback period. Physician's orders for Resident 1, dated June 12, 2026, included an order for the resident to receive 50 milligrams (mg) of Lacosamide (an anticonvulsant) twice a day. Review of the Medication Administration Record (MAR) for Resident 1, dated June 2026, revealed that staff administered the 50 mg of Lacosamide to the resident twice a day from June 12 through 30, 2026. However, a MDS assessment for Resident 1, dated June 18, 2026, revealed that Section N0415K1 was not coded, indicating that the resident did not receive an anticonvulsant medication during the seven-day look-back assessment period. Current physician's orders as well as a review of the Medication Administration Record (MAR) for Resident 5 for June 2026 revealed no documented evidence that the resident received an antidepressant medication. However, a quarterly MDS assessment for Resident 5, dated June 17, 2026, revealed that Section N0415C1 was coded, indicating that the resident received an antidepressant medication during the seven-day look-back assessment period. Physician's orders for Resident 53, dated June 12, 2026, included an order for the resident to receive 25 mg of Topiramate (an anticonvulsant) twice a day. Review of the MAR for Resident 53, dated June 2026, revealed that staff administered 25 mg of Topiramate to the resident twice a day from June 1 through 30, 2026. However, a quarterly MDS assessment for Resident 53, dated June 4, 2026, revealed that Section N0415K1 was not coded, indicating that the resident did not receive an anticonvulsant medication during the seven-day look-back assessment period. Physician's orders for Resident 66, dated December 16, 2025, included an order for the resident to receive 20 mg of Xarelto (an anticoagulant medication) once a day for a left lower extremity DVT (deep vein thrombosis- blood clots in deep veins). Review of the MAR for Resident 66, dated May 2026, revealed that staff administered the 20 mg tablet of Xarelto to the resident on May 1 through 7, 2026. However, a quarterly MDS assessment for Resident 66, dated May 7, 2026, revealed that Section NO415E1 was not coded, indicating that the resident to did not receive an anticoagulant medication during the seven-day look-back assessment period. Current physician's orders for Resident 84, included an order for the resident to receive 81 mg of Aspirin (an antiplatelet medication) delayed release daily. Review of the MAR for Resident 84, dated May and June 2026, revealed that staff administered 81 mg of Aspirin to the resident from May 28, 2026, through June 3, 2026. However, a quarterly MDS assessment for Resident 84, dated June 3, 2026, revealed that Section N0415I1 was not checked, indicating that the resident did not receive an antiplatelet medication during the seven-day look-back assessment period. Physician's orders for Resident 95, dated June 3, 2026, included an order for the resident to receive 10 mg of Eliquis (an anticoagulant) twice a day for a left lower leg DVT (deep vein thrombosis- blood clots in deep veins) and right lower lobe pulmonary embolism (blood clot in the lung). Review of the Medication Administration Record (MAR) for Resident 95, dated June 2026, revealed that staff administered the 10 mg tablet of Eliquis to the resident on June 3 through 8. 2026. However, a quarterly MDS assessment for Resident 95, dated, June 7, 2026, revealed that Section NO415E1 was not coded, indicating that the resident did not receive an anticoagulant medication during the seven-day look-back assessment period. Interview with Director of Nursing on July 15, 2026, at 9:11 a.m. and 11:47 a.m. respectively, confirmed that Resident 1, 5, 53, 84 and 95's MDS's were coded inaccurately. Interview with Registered Nurse Assessment Coordinator (RNAC - oversees and coordinates resident MDS assessments) on July 15, 2026, at 1:50 p.m. confirmed that Resident 66's MDS's was coded inaccurately. 28 Pa. Code 211.5(f) Medical records

Based on review of policies, observations, and staff interviews, it was determined that the facility failed to ensure that food was served under sanitary conditions, in accordance with professional standards for food service safety.Finding Include: The facility's policy regarding storage of refrigerated foods, dated May 21, 2026, indicated that refrigerators in the facility used to store facility purchased food for residents should be equipped with an internal thermometer, even when equipped with an external thermometer. All perishable foods will be stored in order to maximize food safety and quality. Observations in the main kitchen on July 12, 2026, at 9:10 a.m. revealed a milk cooler containing four partial crates of milk that did not have an internal temperature gage. The walk in cooler had four containers of Dannon vanilla yogurt. One container was broken and the yogurt was leaking on the other three containers of yogurt. Observations of the ice machine at 9:30 a.m. revealed a pink slimy removable substance inside of the ice compartment. Interview with Dietary Aide 6 at 9:28 a.m. confirmed that the milk cooler should have an internal temperature gage and stated the cooler was recently cleaned and staff probably forgot to put it back in. Dietary Aide 6 removed the yogurt and confirmed that it should be cleaned up. Interview with the Assistant Dietary Director on July 12, 2026 at 9:31 a.m. indicated that the ice machine was cleaned by maintenance, and confirmed that the pink removable substance should not be in the ice machine. The Assistant Dietary Director confirmed that the yogurt should not have been spilled over the other yogurt cups. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders regarding medication administration were followed for three of 45 residents reviewed (Residents 10, 116 and 118). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated May 5, 2026, indicated that the resident was cognitively intact and required assistance for daily care needs. Physician's orders for Resident 10, dated November 3, 2025, included orders for the resident to receive 10 milligrams (mg) of midodrine (used to treat low blood pressure) three times a day for hypotension (low blood pressure) and to hold the medication if the resident's systolic blood pressure (SBP-top number on a blood pressure reading) was greater than 130 millimeters of mercury (mm/Hg). Review of the Medication Administration Record (MAR) for Resident 10, dated April and June 2026, indicated that 10 mg of midodrine was administered to the resident on April 14 at 12:00 p.m. when the resident's SBP was 134/78 mm/Hg; April 18 at 6:00 p.m. when the resident's SBP was 136/86 mm/Hg; April 19 at 12:00 p.m. when the resident's SBP was 140/72 mm/Hg; April 25 at 6:00 p.m. when the resident's SBP was 138/88 mm/Hg; June 24 at 12:00 p.m. when the resident's SBP was 134/72 mm/Hg; and June 26 at 12:00 p.m. when the resident's SBP was 132/68 mm/Hg. Interview with the Director of Nursing on July 15, 2026, at 2:12 p.m. confirmed that Resident 10 was administered midodrine when it should have been held per physician's orders for a SBP greater than 130 mm/Hg. An admission MDS assessment for Resident 116, dated May 21, 2026, indicated that the resident was cognitively intact, required assistance for daily care needs, and had diagnoses that included heart failure. Physician's orders for Resident 116, dated May 14, 2026, included orders for the resident to receive 5 mg of midodrine three times a day for hypotension (low blood pressure) and to hold the medication if the resident's systolic blood pressure (SBP-pressure within the arteries during heart compression) was greater than 120 mm/Hg. Review of the MAR for Resident 116, dated June and July 2026, indicated that 5 mg of midodrine was administered to the resident on June 1 at 12:00 p.m. when the resident's SBP pressure was 121 mm/Hg; June 8 at 12:00 p.m. when the resident's SBP was 122 mm/Hg; June 14 at 7:00 a.m. when the resident's SBP was 124 mm/Hg; June 17 at 12:00 p.m. when the resident's SBP was 122 mm/Hg; June 21 at 5:00 p.m. when the resident's SBP was 125 mm/Hg; June 28 at 12:00 p.m. when the resident's SBP was 128 mm/Hg; June 30 at 7:00 a.m. when the resident's SBP was 124 mm/Hg; June 30 at 5:00 p.m. when the resident's SBP was 124 mm/Hg; July 6 at 7:00 a.m. when the resident's SBP was 122 mm/Hg; July 9 at 7:00 a.m. when the resident's SBP was 132 mm/Hg; and July 13 at 5:00 p.m. when the resident's SBP was 140 mm/Hg. Interview with the Director of Nursing on July 15, 2026, at 10:18 a.m. confirmed that Resident 116's midodrine was not held according to the ordered parameters on the dates and times mentioned above. A quarterly MDS assessment for Resident 118, dated May 25, 2026, indicated that the resident was cognitively intact, required assistance for daily care needs, and had diagnosis that included orthostatic hypotension (low blood pressure when changing positions quickly). Physician's orders for Resident 118, dated May 20, 2026, included orders for the resident to receive 5 mg of midodrine three times a day and to hold the medication if the resident's SBP was greater than 120 mm/Hg. Review of the MAR for Resident 118, dated April, May, June and July 2026, indicated that 5 mg of midodrine was administered to the resident on April 7 at 12:00 p.m. when the resident's SBP was 136/84 mm/Hg and at 6:00 p.m. when the resident's SBP was 142/78 mm/Hg; April 10 at 6:00 a.m. when the resident's SBP was 162/90 mm/Hg; April 11 at 6:00 a.m. when the resident's SBP was 126/77 mm/Hg and at 12:00 p.m. when the resident's SBP was 138/88 mm/Hg; April 15 at 6:00 p.m. when the resident's SBP was 140/96 mm/Hg; April 16 at 6:00 a.m. when the resident's SBP was 166/84 mm/Hg; April 18 at 6:00 a.m. when the resident's SBP was 148/86 mm/Hg and at 12:00 p.m. when the resident's SBP was 134/74 mm/Hg; April 19 at 12:00 p.m. when the resident's SBP was 124/80 mm/Hg; April 20 at 12:00 p.m. when the resident's SBP was 148/88 mm/Hg; April 21 at 12:00 p.m. when the resident's SBP was 146/88 mm/Hg and at 6:00 p.m. when the resident's SBP was 136/70 mm/Hg; April 25 at 12:00 p.m. when the resident's SBP was 126/74 mm/Hg; April 27 at 12:00 p.m. when the resident's SBP was 136/76 mm/Hg; May 2 at 6:00 p.m. when the resident's SBP was 129/61 mm/Hg; May 4 at 6:00 p.m. when the resident's SBP was 126/76 mm/Hg; May 9 at 12:00 p.m. when the resident's SBP was 126/70 mm/Hg; May 11 at 12:00 p.m. when the resident's SBP was 136/80 mm/Hg and at 6:00 p.m. when the resident's SBP was 136/80 mm/Hg; May 22 at 12:00 p.m. when the resident's SBP was 122/68 mm/Hg; May 29 at 12:00 p.m. when the resident's SBP was 122/70 mm/Hg; June 2 at 12:00 p.m. when the resident's SBP was 132/82 mm/Hg; June 6 at 12:00 p.m. when the resident's SBP was 123/60 mm/Hg; June 9 at 12:00 p.m. when the resident's SBP was 128/86 mm/Hg; June 12 at 12:00 p.m. when the resident's SBP was 122/70 mm/Hg; June 17 at 12:00 p.m. when the resident's SBP was 140/71 mm/Hg; June 20 at 6:00 a.m. when the resident's SBP was 122/60 mm/Hg; June 25 at 6:00 a.m. when the resident's SBP was 128/74 mm/Hg; June 26 at 12:00 p.m. when the resident's SBP was 122/70 mm/Hg; June 29 at 12:00 p.m. when the resident's SBP was 128/70 mm/Hg and at 6:00 p.m. when the resident's SBP was 122/68 mm/Hg; July 4 at 6:00 p.m. when the resident's SBP was 122/68 mm/Hg; July 7 at 12:00 p.m. when the resident's SBP was 142/88 mm/Hg and at 6:00 p.m. when the resident's SBP was 136/78 mm/Hg; July 13 at 12:00 p.m. when the resident's SBP was 136/76 mm/Hg and at 6:00 p.m. when the resident's SBP was 128/76 mm/Hg; and July 14 at 12:00 p.m. when the resident's SBP was 132/88 mm/Hg and at 6:00 p.m. when the resident's SBP was 138/84 mm/Hg. Interview with the Director of Nursing on July 15, 2026, at 2:12 p.m. confirmed that Resident 118 was administered midodrine when it should have been held per physician's orders for a SBP greater than 120. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policies and clinical record reviews, as well as resident and staff interviews, it was determined that the facility failed to implement a comprehensive behavior management program for one of 45 residents reviewed (Resident 90).Findings include: The facility's behavior management program, dated May 21, 2026, indicated that the goal of the program was to improve the quality of life for their residents through management of behaviors and reduction in the use of unnecessary psychoactive medications. Noted behaviors would be tracked, monitored, and documented. The interdisciplinary team (IDT) would review residents with existing and new behaviors during resident reviews. After the review and discussion, the IDT would develop resident specific care plans focused on the use of nonpharmacological interventions. Care plans and profiles would be updated. An interview with Resident 53 on July 12, 2026, at 11:30 a.m. revealed that there was a guy across the hall that screamed and yelled all the time, and the police came in one time. An interview with Resident 116 on July 12, 2026, at 11:35 a.m. revealed there was a guy who screamed. An interview with Resident 95 on July 12, 2026, at 11:37 a.m. revealed there was a guy that yelled all the time and it scared her. An interview with Resident 43 on July 12, 2026, at 11:45 a.m. revealed there was a guy down the hallway that screamed all the time. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) assessment for Resident 90, dated May 4, 2026, revealed that the resident was understood and could understand others, had moderately impaired decision making, was independent with daily care needs, had verbal behaviors, other behavior symptoms not directed towards others, and had diagnoses that included cerebral palsy (group of conditions that affect movement and posture caused by damage that occurs to the developing brain, most often before birth). A current care plan revealed the resident had behaviors, anxiety, and depression, and would slam doors, yell and curse at others, refused medications and care, and was noncompliant with the smoking policy. Staff were to assess if the behavior endangered the resident or others and to intervene if necessary, maintain a calm environment and approach to the resident, obtain a psych consult/psychosocial therapy, praise resident when behavior was appropriate, when the resident became socially inappropriate/disruptive staff were to move him to a quiet, calm environment, encourage the resident to complete/participate in care and taking medications as ordered, reapproach resident as needed, avoid power struggles with resident, refocus conversation when resident becomes verbally abusive, when the resident became verbally abusive staff were to stop and try the task later, acknowledge to the resident that the current situation must be difficult, allow resident to express feelings, encourage resident to become involved with activities that he prefers (bingo, word searches, watching television, reading, listening to music, working on arts/crafts, animal visitation, spending time with friends/family), and staff were to provide reassurance and monitor and chart for changes in emotional, behavioral, and cognitive well-being. A nursing note dated March 3, 2026, at 4:22 a.m. revealed the resident was loudly yelling from his room. The resident stated, leave me alone, I don't care what you want. A nursing note, dated March 26, 2026, at 10:00 a.m. revealed the resident had behaviors of yelling out, screaming, swearing, and then when asked if he was going to hurt himself, he replied yes and get the fuck out. Crisis was called; however, the resident made no comments about wanting to hurt himself or others and didn't have any suicidal grounds for admission. A nursing note dated April 1, 2026, at 9:21 a.m. revealed the resident had numerous outbursts in the morning. At 9:41 p.m. the resident was yelling out very loudly, cussing, slamming doors, and not able to direct due to resident yelling even louder. A nursing note dated April 16, 2026, 9:42 a.m. revealed the resident could be heard yelling and swearing during two outbursts. A nursing note dated April 23, 2026, at 3:02 p.m. revealed she was on the floor when she observed the resident slam his door. At 8:03 p.m. the resident was screaming cuss words for the past two hours and talking to himself. A nursing note dated April 24, 206, at 12:00 p.m. revealed the resident yelled to the nurse aide do you want me to f******g kill you!. The nurse aide reported the behavior to the registered nurse supervisor. When she went to see how the resident was doing the resident stated that they were all bulls******s. Anytime the registered nurse supervisor attempted to talk to the resident, he yelled very loudly get the f**k out of my room and f**k off. At 8:46 p.m. the resident spent most of the shift screaming out loud and talking to himself. The resident could be heard threatening someone in his room; however, there was no one in his room besides himself. A nursing note dated May 2, 2206, at 12:25 a.m. revealed the resident had periodic outbursts of yelling out nonsensical statements with profanities and slamming the bathroom door starting from approximately 8:45 p.m. A nursing note dated May 4, 2026, at 7:07 p.m. revealed the resident continued to intermittently yell out and slam doors in his room. The police came to the facility to speak to the resident. A nursing note dated May 5, 2026, at 3:35 p.m. revealed the resident was intermittently yelling out and slamming doors throughout the day. A nursing note dated May 8, 2026, at 5:53 p.m. revealed the resident started yelling and shouting, using profane language. A nursing note dated May 12, 2026, at 3:57 a.m. revealed the resident yelled out and slammed the door loudly. A nursing note dated May 14, 2026, at 8:30 a.m. revealed the resident was yelling and screaming swear words in his room very loudly. This could be heard even with the door closed. At 6:20 p.m. the resident had been screaming and yelling until approximately dinner time. A nursing note dated May 15, 2026, at 6:38 a.m. revealed the resident was yelling out obscenities and slamming a door. Staff were unable to redirect the resident. At 10:06 a.m. the resident was heard screaming and slamming a door. The resident had slammed a staff member's foot in the door. The police were notified and requested to come see the resident. At 10:50 a.m. the police arrived to speak with the resident. The resident remained agitated during the conversation with the officer, swearing toward the officer, and calling him a condescending jerk. A nursing note dated June 4, 2026, at 6:27 p.m. and June 5, 2026, at 1:55 a.m. revealed the resident had numerous episodes of slamming doors and yelling out. A social service note dated June 5, 2026, at 4:20 p.m. revealed the resident declined a meeting with and yelled at a person who was there to assist him with transitioning to the community. A nursing note dated June 11, 2026, at 1:41 a.m. revealed the resident was in his room yelling loudly you f*****g b***h, you're a retard, and was slamming doors. When staff approached the resident he became more agitated and told them to get the f**k out. At 4:45 p.m. the resident began to scream very loudly, slamming doors, and using foul language. A nursing note dated June 17, 2026, at 11:16 a.m. revealed the resident was yelling and slamming his door. A psychiatry note dated June 18, 2026, at 7:25 a.m. revealed the resident became argumentative and started yelling. He continued to refuse to talk with the provider and screamed for the provider to get out of his room. The resident was currently not receiving any psychotropic medications. The resident was discharged from the provider's caseload. A nursing note dated June 19, 2026, at 10:34 p.m. revealed the resident was yelling out profane language from his room, lasting about five minutes. A nursing note dated June 25, 2026, at 2:05 p.m. revealed the resident was yelling and screaming with a few times of slamming his door. A nursing note dated June 29, 2026, at 7:00 p.m. revealed the resident was showing explosive anger, yelling, and slamming doors. He screamed profanities at the registered nurse to get out of his room. A nursing note dated July 1, 2026, at 5:13 p.m. revealed the resident was having outbursts shortly after lunch, continuing through dinner. He continued to prop his door open and call out staff and walking bystanders. He started barking like a dog and making inappropriate comments.A nursing note dated July 6, 2026, at 3:37 a.m. revealed the resident was noted to be screaming in his room throughout the night. The resident was yelling profanities at staff in his room. A nursing note dated July 12, 2026, at 2:27 p.m. revealed the resident had an episode of agitation where he was slamming doors. When staff went to check on him, he slammed the door in their faces and was yelling out that lasted for five minutes. There was no documented evidence that all interventions were tried or that other interventions care planned, such as pain management, were tried. There were no new interventions added to the care plan since March 26, 2026. Interview with Nurse Aide 1 on July 14, 2026, at 9:35 a.m. revealed that Resident 90 would holler out, scream, slam doors, and would yell go away. She indicated that nothing worked to prevent his behaviors. Interview with Nurse Aide 5 on July 14, 2026, at 9:54 a.m. revealed that Resident 90 called staff names, slammed his doors, and yelled loudly. She indicated that there was nothing that worked for his behaviors and she would report his behaviors to the nurse. Interview with Registered Nurse Supervisor 6 on July 14, 2026, at 12:27 p.m. revealed that Resident 90 yelled out a lot, slammed his doors, and if you would try to go in his room it would make it worse. She reported that Crisis had been called and the police had come in before. She indicated that it's scary because the door slams and the resident refuses to take his medications or see psychiatric services. Interview with the Social Service Director on July 14, 2026, at 2:15 p.m. revealed that Resident 90 yelled out, would swear, and slam doors. She reported that this occurred at all hours of the day and that everything triggered his behaviors. The resident refused his medications, psychiatric services and transitional services, and the best option was to leave the resident alone. She stated that she was trying to get the resident discharged to a hotel, but they didn't have a room with a handicap bathroom. She confirmed that she had not contacted any other hotels that he could afford or any other services since he refused. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on review of the facility's plans of correction and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending February 27, 2026, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending July 15, 2026, identified repeated deficiencies related to failure to correct deficient practices related to quality care, safe environment free from accident hazards, and storage and labeling of medications. The facility's plan of correction for a deficiency regarding services meeting professional standards, cited during the survey ending February 27, 2026, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F658, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding quality of care. The facility's plans of correction for deficiencies regarding quality of care, cited during the survey ending February 27, 2026, revealed that the facility developed plans of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding a safe environment that is free of accident hazards. The facility's plans of correction for deficiencies pharmacy services, procedures and records, cited during the survey ending February 27, 2026, revealed that the facility developed plans of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F755, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding storage and labeling of medications. Refer to F658, F684, F755 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 45 residents reviewed (Resident 7). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated May 12, 2026, indicated that the resident was cognitively intact, required assistance with daily care needs, had pain occasionally, received as needed pain medications, and received an opioid medication (controlled medications used to treat pain). Physician's orders for Resident 7, dated October 7, 2025, included an order for the resident to receive 50 milligrams (mg) of Tramadol (opioid medication) every four hours as needed for pain. Review of Resident 7's Medication Administration Record (MAR) for April and July 2026, revealed that the resident received 50 mg of Tramadol on April 1 at 7:34 a.m.; April 3 at 7:40 a.m.; July 1 at 9:03 p.m.; and July 12 at 11:22 a.m. However, there was no documented evidence on the resident's controlled medication record (a form that accounts for each tablet/pill/dose of a controlled drug) from April and July to verify the administration of 50 mg of Tramadol on the above-mentioned dates and times. Interview with the Director of Nursing on July 15, 2026, at 12:32 p.m. confirmed that there was no documented evidence on Resident 7's controlled medication record from April and July to verify the administration of 50 mg of Tramadol on the above-mentioned dates and times. 28 Pa Code 211.5(f) Clinical Records. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on a review of facility policies, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide care in a manner that maintained dignity for one of 45 residents reviewed (Resident 116).Findings include: The facility's policy regarding Resident Rights, dated May 21, 2026, indicated that a resident has the right to a dignified existence and will be treated with dignity. A Comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 116, dated May 27, 2026, indicated that the resident was cognitively intact and required substantial assistance from staff for activities of daily living, including toileting and was frequently incontinent of bowel and bladder. Observations of Resident 116 on July 15, 2026, at 7:42 a.m. revealed the resident was lying in bed and was incontinent of urine and bowel at as a result of not being provided a bed pan when requested. Interview with Resident 116 on July 15, 2026, at 7:42 a.m. revealed that the resident requested a bed pan from Nurse Aide 1 around 7:00 a.m. and the nurse aide came back in and stated that she did not have a bed pan. Nurse Aide 1 left and did not return and the resident was left to have a bowl movement in her brief. Interview with Nurse Aide 1 on July 15, 2026, at 8:12 a.m. revealed that the resident had requested a bed pan earlier that morning around 7:00 a.m. and the resident did not have one in her room, and she went to get one from supply on the floor ,and they did not have one. She then told the 3rd shift LPN that they were out of bed pans. She was not aware that she was able to go to central supply herself, and stated that she did not follow up or recheck on Resident 116 to see if she received a bedpan. Nurse Aide 1 stated she did not tell anyone else that they were out of bed pans, and she should have followed up and made sure Resident 116 was provided a bedpan. Interview with the Director of Nursing on July 15, 2026, at 9:12 a.m. confirmed that Nurse Aide 1 did not provide Resident 116 with a bed pan resulting in the resident becoming incontinent of urine and feces causing an undignified experience. 28 Pa. Code 201.29(j) Resident rights.

Based on a review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 45 residents reviewed (Resident 105).Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. A facility policy for administering medication patches (when medication is delivered through the skin to slowly release active medication) dated May 21, 2026, indicated that the individual administering the patch will document the date, time of administration, and their initials on the medication patch at the time of administration. A Comprehensive Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 105 dated May 15, 2026, indicated that the resident was cognitively intact, and required assistance with daily care needs. A physician's order for Resident 105 dated July 9, 2026, revealed the resident was to receive a 14mg transdermal (through the skin) nicotine patch once a day. Observations of Licensed Practical Nurse 4 on July 14, 2026, at 7:57 a.m. revealed she administered a 14milligram (mg) Nicotine Patch (a wearable, adhesive patch used in assisting individuals to stop smoking) to Resident 105, and she did not place the date, time of administration her initials on the 14mg nicotine patch. Interview with Licensed Practical Nurse 4 on July 14, 2026, at 7:58 a.m. revealed that she was unsure if she should have placed the date, time, and her initials on the nicotine patch when it was administered to Resident 105. Interview with the Director of Nursing on July 14, 2027, at 10:37 a.m. revealed that LPN 4 should have put her initials and date and time of administration on the patch when it was administered. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of clinical records, observations, shower schedules, as well as staff and resident interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for one of 45 residents reviewed (Resident 36).Findings include: A comprehensive Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 36, dated June 22, 2026, revealed that the resident was cognitively impaired, was able to understand others and was understood, was dependent on staff for showers/bathing and was usually incontinent of bowel. Physician's orders for Resident 36 dated June 6, 2026, revealed the resident was to have a shower on Sundays, Tuesdays and Thursdays during the day shift, and the medical director was to be notified if the resident refused a shower. Review of the activities of daily living (ADL) documentation for Resident 36 for June 2026, revealed that partial bed baths were documented as given on June 7,8,10,13, 25, and 27th in the ADL documentation. However, there was no documented evidence that the resident was offered and refused showers on the dates listed or that the medical director was notified of any refusals. Interview with the Director of Nursing on July 15, 2026, at 9:20 a.m. confirmed that there was no documented evidence that Resident 36 received and/or refused showers on the dates above. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on a review of facility policies, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide the resident with requested bed pan resulting in bowel incontinence for one of 45 residents reviewed (Resident 116).Findings include: A Comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 116, dated May 27, 2026, indicated that the resident was cognitively intact and required substantial assistance from staff for activities of daily living, including toileting and was frequently incontinent of bowel and bladder. Observations of Resident 116 on July 15, 2026, at 7:42 a.m. revealed the resident was lying in bed and was incontinent of urine and bowel at the time of observations as a result of not being provided with a bed pan when requested. Interview with Resident 116 on July 15, 2026, at 7:42 a.m. revealed that the resident requested a bed pan from Nurse Aide 1 around 7:00 a.m. and the nurse aide came back in and stated that she did not have a bed pan. Nurse Aide 1 did not return and the resident was left to have a bowl movement in her brief. Interview with Nurse Aide 1 on July 15, 2026, at 8:12 a.m. revealed that the resident had requested a bed pan earlier that morning around 7:00 a.m. and the resident did not have one in her room, and she went to get one from supply on the floor and they did not have one she then told the 3rd shift LPN that they were out of bed pans. She was not aware that she was able to go to central supply herself and stated that she did not follow up or recheck on Resident 116 to see if she received a bedpan. She stated that she would be able to let the Registered Nurse Supervisor know, but she did not tell anyone else that they were out of bed pans and she should have followed up with the resident's request. Interview with the Director of Nursing on July 15, 2026, at 9:12 a.m. confirmed that Nurse Aide 1 did not provide Resident 116 with a bed pan resulting in the resident becoming incontinent of urine and feces.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for two of 45 residents reviewed (Residents 7 and 53). Findings include: The facility's policy regarding medication administration, dated May 21, 2026, revealed that the facility will document the administration of controlled substances in accordance with applicable law. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated May 12, 2026, indicated that the resident was cognitively intact, required assistance with daily care needs, had pain occasionally, received as needed pain medications, and received an opioid medication (controlled medications used to treat pain). Physician's orders for Resident 7, dated October 7, 2025, included an order for the resident to receive 50 milligrams (mg) of Tramadol (opioid medication) every four hours as needed for pain. A controlled drug accountability record (tracks each dose of a controlled medication) for Resident 7's Tramadol revealed that one tablet was signed out on the controlled drug log on April 1 at 9:00 p.m.; May 7 at 7:00 a.m.; and July 12 at 7:35 a.m. There was no documented evidence in the clinical record to indicate that the signed-out doses of Tramadol were administered to the resident on the above-mentioned dates and times. Interview with the Director of Nursing on July 15, 2026, at 12:32 p.m. confirmed that there was no documented evidence that staff administered the Tramadol to Resident 7 on the above-mentioned dates and times. A quarterly MDS assessment for Resident 53, dated June 4, 2026, indicated that the resident was cognitively intact, had pain occasionally, received as needed pain medications, and received an opioid medication. Physician's orders for Resident 53, dated July 3, 2026, included an order for the resident to receive 5-325 mg of hydrocodone-acetaminophen (opioid medication) every six hours as needed for moderate to severe pain. A controlled drug accountability record for Resident 53's hydrocodone-acetaminophen revealed that one tablet was signed out on the controlled drug log on May 26 at 8:30 p.m.; June 2 at 8:00 a.m.; June 10 at 8:50 p.m.; June 30 at 7:09 a.m.; and July 2, 2026, at 8:06 a.m. There was no documented evidence in the clinical record to indicate that the signed-out doses of Tramadol were administered to the resident on the above-mentioned dates and times. Interview with the Director of Nursing on July 15, 2026, at 11:14 a.m. confirmed that there was no documented evidence that staff administered the hydrocodone-acetaminophen to Resident 53 on the above-mentioned dates and times. 28 Pa. Code 211.9(a)(1) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to label medications in accordance with currently accepted professional principles by including the expiration date on liquid medication in one of two medication carts reviewed (3rd floor long hall).Findings include: A facility policy regarding medication storage, dated May 21, 2026, indicated that multi-dose medications would be discarded per manufacturer's recommendations or expiration date. Observations of the 3rd floor medication cart on July 14, 2026, at 1:03 p.m. revealed a multi-dose bottle of Pro-Stat Liquid protein that was opened and undated. Interview with the Director of Nursing on July 14, at 3:42 p.m. confirmed that the bottle of Pro-Stat should have been dated when opened. 28 Pa. Code 211.9(a)(1) Pharmacy Services. 28 Pa. Code 211.12(d)(1) Nursing Services.

Based on clinical record reviews, observations and resident and staff interviews, it was determined that the facility failed to honor food preferences for one of 45 residents reviewed (Resident 116). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 116, dated May 27, 2026, indicated that the resident was cognitively intact, could make her needs known and required assistance from staff for activities of daily living. A nutritional care plan for Resident 116, dated May 18, 2026, indicated that the resident was at increased hydration and nutrition risk and that staff were to respect and honor her food choices. Interview with Resident 116 on July 12, 2026, at 11:30 a.m. revealed that she did not like sausage but would receive sausage. The food preferences sheet for Resident 116, dated May 14, 2026, indicated that she disliked milk, pork chops, hamburgers, and sausage patties. Observations of Resident 116 during breakfast on July 15, 2026, at 8:12 a.m. revealed that she had a breakfast sandwich with egg, cheese, and sausage patty on a croissant roll. Interview with Resident 116 at that time revealed that she requested not to have sausage because it upsets her stomach; however, she was hungry and was going to eat it that day and suffer with the consequences of eating the sausage patty. Interview with the Dietary Manager on July 15, 2026, at 10:30 a.m. confirmed that Resident 116 should have been given sausage. 28 Pa. Code 201.18(b)(1) Management.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident was offered and/or received the pneumococcal immunization for four of 38 residents reviewed (Residents 2, 16, 36, 45). Findings include:The facility's policy regarding the pneumococcal vaccine, dated April 29, 2025, indicated that the resident would be offered the pneumococcal vaccination if they were eligible for it. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated January 26, 2026, revealed that the resident was cognitively impaired and did not have the pneumococcal vaccine offered.Review of the immunization records for Resident 2 revealed no documented evidence that the resident was offered, received, or refused a pneumococcal vaccine since admission on [DATE]. A quarterly MDS assessment for Resident 16, dated January 14, 2026, indicated that the resident was cognitively impaired and that the resident was not offered the pneumococcal vaccination.Review of the immunization records for Resident 16 revealed no documented evidence that the resident was offered, received, or refused a pneumococcal vaccine. A quarterly MDS assessment for Resident 36, dated January 19, 2026, indicated that the resident was cognitively impaired and that the resident was not offered the pneumococcal vaccination. Review of the immunization records for Resident 36 revealed no documented evidence that the resident was offered, received, or refused a pneumococcal vaccine.An admission MDS assessment (a mandated assessment of a resident's abilities and care needs) for Resident 45, dated February 12, 2026, revealed that the resident was cognitively impaired and did not have the pneumococcal vaccine offered.Review of the immunization records for Resident 45 revealed no documented evidence that the resident was offered, received, or refused an influenza vaccine since admission on [DATE]. Interview with the Infection Preventionist on February 27, 2026 at 10:56 a.m. confirmed that Residents 2, 13, 36, and 45 were not offered a pneumococcal vaccine and that they should have been.28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.12(d)(1)(5) Nursing Services.Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident was offered and/or received the pneumococcal immunization for four of 38 residents reviewed (Residents 2, 16, 36, 45). Findings include:The facility's policy regarding the pneumococcal vaccine, dated April 29, 2025, indicated that the resident would be offered the pneumococcal vaccination if they were eligible for it. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated January 26, 2026, revealed that the resident was cognitively impaired and did not have the pneumococcal vaccine offered.Review of the immunization records for Resident 2 revealed no documented evidence that the resident was offered, received, or refused a pneumococcal vaccine since admission on [DATE]. A quarterly MDS assessment for Resident 16, dated January 14, 2026, indicated that the resident was cognitively impaired and that the resident was not offered the pneumococcal vaccination.Review of the immunization records for Resident 16 revealed no documented evidence that the resident was offered, received, or refused a pneumococcal vaccine. A quarterly MDS assessment for Resident 36, dated January 19, 2026, indicated that the resident was cognitively impaired and that the resident was not offered the pneumococcal vaccination. Review of the immunization records for Resident 36 revealed no documented evidence that the resident was offered, received, or refused a pneumococcal vaccine.An admission MDS assessment (a mandated assessment of a resident's abilities and care needs) for Resident 45, dated February 12, 2026, revealed that the resident was cognitively impaired and did not have the pneumococcal vaccine offered.Review of the immunization records for Resident 45 revealed no documented evidence that the resident was offered, received, or refused an influenza vaccine since admission on [DATE]. Interview with the Infection Preventionist on February 27, 2026 at 10:56 a.m. confirmed that Residents 2, 13, 36, and 45 were not offered a pneumococcal vaccine and that they should have been.28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of polices and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for three of 38 residents reviewed (Resident 42, 44 and 66). Findings include:An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated February 10, 2026, revealed that the resident was cognitively intact, was dependent on staff for daily care needs and had a diagnosis of disorder of the circulatory system (a condition affecting the heart resulting in impaired blood flow throughout the body). Physician's orders for Resident 42 dated February 14, 2026, included an order for the resident to have surgical wounds of his left inner calf, left lateral calf, right lateral calf and right medial calf cleansed with normal saline, apply oil emulsion gauze over exposed area of the wound then sprinkle collagen particles throughout the wound bed over top of oil emulsion gauze to base of the wound, secure with ABD (abdominal pad) and rolled gauze, change daily. Observations of Resident 42's wound care on February 26, 2026, at 1:12 p.m. revealed that Licensed Practical Nurse 3 used hand sanitizer, put on gloves, sprayed wound cleanser on the old dressing, removed the old dressing, removed gloves, used hand sanitizer, put on gloves, applied oil emulsion gauze over exposed area of the wound then sprinkled collagen particles throughout the wound bed over top of oil emulsion gauze to base of the wound, secured with ABD and rolled gauze. Interview with Licensed Practical Nurse 3 on February 26, 2026, at 1:44 p.m. confirmed that she should have cleansed the wounds with normal saline and she did not. Interview with the Director of Nursing on February 27, 2026, at 11:10 a.m. confirmed that Resident 42's wounds should have been cleansed with normal saline per physicians orders and they were not.An annual (MDS) assessment for Resident 44, dated November 25, 2025, revealed that the resident was cognitively intact, required moderate assistance from staff for daily care tasks, had a care plan that indicated the resident had altered skin integrity, and had diagnoses that included venous ulcers to the left lower leg.Physician's orders for Resident 44, dated October 27, 2025, included orders for staff to apply ACE (an all cotton elastic breathable bandage which provides support, reduces swelling and aides in circulation) wraps to the resident's left lower leg; on in the morning and off in the evening.Observations of Resident 44 on February 24, 2026, at 2:37 p.m., February 25, 2026 at 10:00 a.m. and 2:00 p.m., February 26, 2026, at 10:10 a.m. and 12:43 p.m. revealed that she was sitting in her wheel chair beside her bed, the ACE wraps were lying on the blankets at the bottom of the bed and not on her left lower leg as ordered. Interview with Resident 44 on February 26, 2026, at 12:43 p.m. indicated that she is to wear her ACE wraps when she is out of bed, and that some staff put them on and some do not. Interview with Nurse Aide 4 on February 26, 2026, at 12:54 p.m. confirmed that Resident 44's ACE wraps were not on her left lower leg. She further indicated that she did not realize the ACE wraps were to be on the resident and that if they were ordered then they should be in place.Interview with the Director of Nursing on February 27, 2026, at 2:26 p.m. confirmed that Resident 44's ACE wraps were not placed on her left lower leg as per physician's orders, and they should have been.The facility's medication administration policy, dated April 29, 2025, indicated that staff were to verify each time a medication was administered that it was the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, and for the correct resident. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 66, dated December 9, 2025, indicated that the resident was cognitively impaired, received insulin, and had diagnoses that included diabetes. A care plan, dated July 31, 2023, indicated that the resident had diabetes and her medications were to be administered as ordered by the physician. Physician's orders for Resident 66, dated September 10, 2025, included an order for the resident to receive 26 units of Insulin Lispro subcutaneously once a day for diabetes. The insulin was to be held if the resident's blood sugar was less than 100 milligrams/deciliter (mg/dL).The Medication Administration Record (MAR) for Resident 66 for October and November 2025, and January and February 2026, revealed that the resident received 26 units of Insulin Lispro during the 4:00 p.m. to 7:00 p.m. medication pass on October 14 for a blood sugar of 75 mg/dL; on November 14, 2025 for a blood sugar of 82 mg/dL; on January 5 for a blood sugar of 82 mg/dL; on January 11 for a blood sugar of 93 mg/dL; and on February 18, 20216 for a blood sugar of 76 mg/dL.Interview with the Director of Nursing on February 25, 2026, at 11:47 a.m. confirmed that there was no documented evidence that Resident 66's Insulin Lispro was held when the resident's blood sugar was less than 100 mg/dL on the dates and times mentioned above. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 38 residents reviewed (Resident 2) who had a feeding tube.Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated January 26, 2026, indicated that the resident was cognitively impaired, required assistance from staff for daily care tasks, and had a feeding tube. A care plan, dated January 21, 2026, revealed that staff were to administer the resident's tube feeding as ordered.Physician's orders for Resident 2, dated January 21, 2026, included orders for the resident to receive Isosource (a tube feeding formula) continuously at 65 cubic centimeters (cc's) per hour for 20 hours per day via a feeding tube pump and staff were to record the amount of formula provided every shift.The Medication Administration Records (MAR's) for Resident 2 for January and February 2026 revealed that staff administered the resident's tube feeding; however, there was no documentation of the amount of formula provided every shift as ordered.Interview with the Director of Nursing on February 27, 2026, at 1:05 p.m. confirmed that staff were not documenting the amount of formula provided every shift as ordered and they should have been. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for two of 38 residents reviewed (Resident 10, 113).Findings include:The facility's policy regarding medication administration, April 29, 2025, indicated that staff were to document the administration of controlled substances in accordance with applicable law and document the necessary medication administration/treatment information (e.g., when medications are opened, when medications are given, injection site of a medication, if medications are refused, PRN medications, application site) on appropriate forms.The facility's policy regarding disposal of medications, April 29, 2025, indicated that facility staff would destroy and dispose of medications in accordance with facility policy and applicable state law, and applicable environmental regulations. Facility staff were to destroy controlled substances in the presence of a registered nurse and a licensed professional or in accordance with facility policy or applicable state law.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated November 16, 2025, revealed that the resident was cognitively intact, had pain frequently, received pain medication as needed, and received an opioid (a controlled pain medication). Physician's orders, dated April 19, 2025, included an order for the resident to receive five milligrams (mg) of Oxycodone every six hours as needed for severe pain.A review of Resident 10's controlled drug record for January and February 2026 revealed that staff signed out 5 mg of Oxycodone on January 11, at 8:34 p.m., January 16, at 9:30 a.m., January 22, at 10:00 p.m., and February 16, 2026 at 9:15 a.m. However, review of the resident's Medication Administration Records (MAR's), dated January and February 2026, revealed no documented evidence that the 5 mg of Oxycodone was administered to the resident on those dates and times. Interview with the Director of Nursing on February 27, 2026, at 1:03 p.m. confirmed that there was no evidence on the Medication Administration Records of the Oxycodone being administered to Resident 10.An admission MDS assessment for Resident 113, dated February 17, 2026, revealed that the resident was cognitively intact, received pain medication routinely, and received an opioid. Physician's orders, dated February 15, 2026, included an order for the resident to have a 50 microgram per hour (mcg/hr) Fentanyl (controlled medication used to treat pain) patch applied every 72 hours.A nursing note, dated February 11, 2026, at 6:30 p.m. revealed the resident was admitted to the facility and had a Fentanyl patch on his left upper arm.Review of Resident 113's MAR for February 2026 revealed that a Fentanyl patch was applied to the resident on February 15, 18, 21, and 24, 2026.A controlled drug count record for Resident 113's Fentanyl patches revealed that one patch was signed out on the controlled drug log on February 18, 21, and 24, 2026. There was no documented evidence that a registered nurse and another licensed professional signed that the old patch was destroyed after removal on February 11, 15, 18, and 21.Interview with the Director of Nursing on February 27, 2026, at 1:05 p.m. confirmed that there were not two witness signatures, by a registered nurse and another licensed professional, for the destruction of Fentanyl patches on the dates listed above.28 Pa. Code 211.9(a)(h) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed during medication administration for one of 38 residents reviewed (Resident 13), and during wound care for two of 38 residents reviewed (Residents 8, 69).Findings include:The facility's policy regarding medication administration, dated April 29, 2025, indicated that staff were not to touch the medications with their bare hands.Physician's orders for Resident 13, dated January 16, 2026 included an order for the resident to receive 667 milligrams (mg) calcium acetate (vitamin) three times per day with meals.Observations of Licensed Practical Nurse 1 on February 25, 2026 at 2:02 p.m. revealed that he poured the calcium acetate out of the bottle and into his bare hand. He then attempted to pour the pill into a medicine cup, however, it missed the cup and landed on the medication cart. He picked the pill up with is bare hand and then administered it to Resident 13.Interview with Licensed Practical Nurse 1 on February 25, 2026 at 2:04 p.m. revealed that he should not have touched the pill with his bare hand.Interview with the Director of Nursing on February 25, 2026 at 3:01 p.m. confirmed that staff were not to touch residents' medications with their bare hands.The facility's dressing change policy, dated April 29, 2025, indicated that after gloves were removed, hands were to be sanitized to avoid transfer of microorganisms. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of the resident's abilities and care needs) for Resident 8, dated January 1, 2026, revealed that the resident was cognitively intact, was understood, able to understand, required assistance with care needs, had multiple wounds that included the left ankle, right heel, right posterior thigh and calf and a pressure ulcer to the sacrum/coccyx area, and was seen weekly by a nurse practitioner from Wound Healing Partners.Observations of Resident 8's wound care on the left toe and right calf area on February 26, 2026, at 12:56 p.m. was as follows; Licensed Practical Nurse 5 donned gloves, cleansed the left toe area with dermal cleanser, cut and placed a piece of petroleum based xeroform on the area and covered with a boarder gauze, doffed gloves and without hand sanitizing, donned new gloves. She then removed the dressing from the calf area, and without removing her gloves, she cleaned the area with derma cleanser, cut and placed xeroform, then covered with an adhesive foam dressing, removed gloves and without hand sanitizing, she dated the dressing, and donned gloves and cleaned two small wounds on the coccyx are with dermal cleanser and 2x2's, then with her gloved finger she mixed hydrogen gel and collagen and placed it inside the wounds, removed her gloves and without hand sanitizing she donned gloves and placed a petroleum gauze dressing on one of the coccyx wounds and then covered both sites with an abdominal pad, removed her gloves and hand sanitized.Interview with Licensed Practical Nurse 5 on February 26, 2026, at 1:40 p.m. confirmed that during wound care, she did not change gloves when moving from a dirty to a clean area, and did not hand sanitize after doffing her gloves and donning new gloves.A quarterly MDS assessment for Resident 69, dated December 3, 2025, revealed that the resident cognitively intact, was understood, able to understand, required assistance with care needs, had a history of multiple venous ulcers and had diagnoses that included venous insufficiency (decreased blood flow in the legs) and currently had a chronic non-pressure ulcers of the right lower leg. Observations of Resident 69's wound care on the right calf on February 26, 2026, at 1:32 p.m. was as follows; Licensed Practical Nurse 5 donned gloves and removed the dirty dressing on her right calf, and without changing gloves, she cleaned the area with dermal cleaning spray, cut a piece of dressing that was impregnated with calcium alginate and Silvadene, and placed it on the wound bed, covered it with rolled gauze and an abdominal pad, taped and dated it. She then removed her gloves and hand sanitized.Interview with Licensed Practical Nurse 5 on February 26, 2026, at 1:40 p.m. confirmed that during wound care, she did not change gloves when moving from a dirty to a clean area.Interview with the Director of Nursing on February 26, 2026, at 3:15 p.m. confirmed that when providing wound care on Resident 8 and 69, staff did not change their gloves when moving from a dirty to a clean area, and hand sanitize after doffing their gloves, and they should have. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow a physician's recommendations for one of 45 residents reviewed (Residents 13) resulting in a deterioration of the wound with increased size, and there was no documented evidence that physician's orders were followed for two of 45 residents reviewed (Residents 12, 86). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated June 29, 2024, revealed that the resident was understood, could understand others, was cognitively intact, required assistance from staff for care needs, and had a Stage IV pressure ulcer (a wound with full-thickness skin loss that extends through into the muscle, exposing the bone, tendon, or joint) upon admission. A wound healing consult for Resident 13 (outside the facility), dated July 5, 2024, revealed that the resident had a Stage 4 pressure injury with bone exposed on the sacral area. Recommendations included a high protein diet, a low air loss mattress, frequent scheduled repositioning, a wound vacuum on the wound (uses negative pressure to help wounds heal faster), and a follow-up appointment to be scheduled in four to six weeks. Until the wound vacuum could be obtained, it was recommended that the resident receive 15 milliters (ml) of Dakins (a solution used to clean pressure ulcers) irrigation to the wound and patted dry, fluffed Dakins moistened gauze into the wound space to address all undermining areas, then cover with a dry gauze and secure with tape to be changed daily or as needed. The order for the wound vacuum was to clean the area with soap and water, pat dry, then irrigate the wound with 15 ml of Dakins, pat dry, apply skin prep to the periwound (the skin that surrounds the wound), cut and apply black granufoam (specialized foam dressing) to fit inside of the wound and depth, seal the dressing and bridge the dressing (technique can be used to prevent pressure to the area) to the left or right hip to keep pressure off the area, and to run at 125 millimeters of mercury (mmHg) continuous suction. The wound vacuum dressing was to be changed once a week or as needed. Physician's orders for Resident 13, dated July 6, 2024, only included orders for the resident to have a Dakins wet-dry dressing. Irrigate the wound with 15 ml of Dakins and pat dry, fluff Dakins moistened gauze into the wound space to address all areas, then cover with a dry gauze and secure with tape changed daily or as needed; however, there was no documented evidence in the clinical record to indicate that the wound vacuum machine and treatment was ordered, and no documented evidence to indicate that the follow-up appointment for four to six weeks was made. A wound consult for Resident 13 (outside of the facility) dated July 23, 2024, revealed that the wound was a Stage 4 with stalled wound healing and measured 3 centimeters (cm) by 2 cm with a depth of 1 cm. There was a 0.4 cm undermining from 11 o'clock to 1 o'clock. The exposed bone was palpable (able to be touched). A wound consult report (conducted within the facility) for Resident 13, dated July 31, 2024, revealed that the resident was not seen or evaluated by the wound team because she was out at dialysis. A wound consult (conducted within the facility) for Resident 13, dated August 7, 2024, revealed that the resident was not seen or evaluated by the wound team because she was out at dialysis. The wound consult recommended that she be referred to the local wound center due to conflicting schedules; however, there was no documented evidence in the clinical record to indicate that the referral was made. A registered nurse progress note and wound assessment for Resident 13, dated August 21, 2024, revealed that the Stage 4 sacral wound measured 4 centimeters (cm) by 2.5 cm with a depth of 1.5 cm with undermining. A review of the clinical record for Resident 13 revealed no documented evidence that a wound vacuum was ordered, applied, or that wound consultant recommendations were followed for negative pressure wound therapy. There was no documented evidence that the resident returned to the outside wound clinic in four to six weeks for follow-up as recommended, and there was no documented evidence that an outside wound clinic appointment was scheduled until August 22, 2024, after it was brought to the facility's attention by the surveyor. Interview with the Assistant Director of Nursing on August 22, 2024, at 1:30 p.m. revealed that she spoke with the wound clinic and Resident 13 was to follow up with them on August 7, 2024; however, Resident 13 was a no-call no-show for that appointment and was not seen. Interview with the Director of Nursing on August 22, 2024, at 10:49 a.m. and 1:22 p.m. confirmed that the facility failed to follow through with orders for a wound vacuum, failed to ensure that the resident went to a follow-up wound appointment, and failed to make an additional referral to the wound clinic for ongoing treatment and evaluation due to scheduling conflicts. She also confirmed that Resident 13's wound was last assessed on July 23, 2024, and was not provided the wound vacuum as recommended or weekly wound assessments, and the wound declined. The facility's policy for personal care, dated July 1, 2024, indicated that the nursing assistant will observe all areas of the resident's skin and indicate any abnormalities or changes, and the nurse will address any findings in the clinical record and appropriate interventions will be initiated. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated June 19, 2024, revealed that the resident was cognitively intact, understood, could usually understand others, and required maximum assistance from staff for care. A physician's order for Resident 12, dated March 19, 2024, included an order for weekly skin checks to be completed and documented in the resident's clinical record. A review of the clinical record for June and July for Resident 12 revealed no documented evidence that skin checks were being completed for June and July. An interview with the Assistant Director of Nursing on August 22, 2024, at 3:43 p.m. confirmed that there was no documented evidence that skin checks were being completed for Resident 12. An annual MDS assessment for Resident 86, dated July 22, 2024, revealed that the resident was cognitively intact, understood, could understand others, required maximum assistance from staff for care, and had a foley catheter (a tube placed in the bladder and drains urine into a collection bag). A physician's order for documentation on urinary output, dated March 1, 2024, revealed that the total amount of urine output in the bag was to be documented in the clinical record each shift. A review of the clinical record for March 1, 2024, to August 20, 2024, for Resident 86 revealed no documented evidence that the urine output was documented in the clinical record each shift. An interview with the Director of Nursing on August 20, 2024, at 2:37 p.m. confirmed that there was no documented evidence that urinary output was being documented and should have been. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to provide necessary treatment and services for a Stage 4 pressure ulcer for one of 45 residents reviewed (Resident 13) resulting in a deterioration of the wound. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated June 29, 2024, revealed that the resident was understood, could understand others, was cognitively intact, required assistance from staff for care needs, and had a Stage IV pressure ulcer (a wound with full-thickness skin loss that extends through into the muscle, exposing the bone, tendon, or joint) upon admission. A wound healing consult for Resident 13 (outside the facility), dated July 5, 2024, revealed that the resident had a Stage 4 pressure injury with bone exposed on the sacral area. Recommendations included a high protein diet, a low air loss mattress, frequent scheduled repositioning, a wound vacuum on the wound (uses negative pressure to help wounds heal faster), and a follow-up appointment to be scheduled in four to six weeks. Until the wound vacuum could be obtained, it was recommended that the resident receive 15 milliters (ml) of Dakins (a solution used to clean pressure ulcers) irrigation to the wound and patted dry, fluffed Dakins moistened gauze into the wound space to address all undermining areas, then cover with a dry gauze and secure with tape to be changed daily or as needed. The order for the wound vacuum was to clean the area with soap and water, pat dry, then irrigate the wound with 15 ml of Dakins, pat dry, apply skin prep to the periwound (the skin that surrounds the wound), cut and apply black granufoam (specialized foam dressing) to fit inside of the wound and depth, seal the dressing and bridge the dressing (technique can be used to prevent pressure to the area) to the left or right hip to keep pressure off the area, and to run at 125 millimeters of mercury (mmHg) continuous suction. The wound vacuum dressing was to be changed once a week or as needed. Physician's orders for Resident 13, dated July 6, 2024, only included orders for the resident to have a Dakins wet-dry dressing. Irrigate the wound with 15 ml of Dakins and pat dry, fluff Dakins moistened gauze into the wound space to address all areas, then cover with a dry gauze and secure with tape changed daily or as needed. A wound consult for Resident 13 (outside of the facility), dated July 23, 2024, revealed that the wound was a Stage 4 with stalled wound healing and measured 3 centimeters (cm) by 2 cm with a depth of 1 cm. There was a 0.4 cm undermining from 11 o'clock to 1 o'clock. The exposed bone was palpable (able to be touched). A wound consult report (conducted within the facility) for Resident 13, dated July 31, 2024, revealed that the resident was not seen or evaluated by the wound team because she was out at dialysis. A wound consult (conducted with in the facility) for Resident 13, dated August 7, 2024, revealed that the resident was not seen or evaluated by the wound team because she was out at dialysis. The wound consult recommended that she be referred to the local wound center due to conflicting schedules. A review of the clinical record revealed that as of August 21, 2024, there was no documented evidence in the clinical record to indicate that Resident 13's Stage 4 sacral wound had been assessed by a registered nurse or the wound team since July 23, 2024; no documented evidence that a wound vacuum was ordered, applied, or that wound dressing recommendations were followed for the negative pressure wound therapy; no documented evidence that the resident returned to the outside wound clinic in four to six weeks for a follow-up as recommended; and no documented evidence that the recommendation for an outside wound clinic appointment was made due to conflicting schedules until it was brought to the facility's attention by the surveyor. A registered nurse progress note and wound assessment for Resident 13, dated August 21, 2024, revealed that the Stage 4 sacral wound measured 4 centimeters (cm) by 2.5 cm with a depth of 1.5 cm with undermining. Observations and interviews with Resident 13 on August 22, 2024, at 6:17 p.m. revealed that she was awake, eating, and lying in bed. She was positioned on her left side with a wedge toward the window. She stated that she received wound changes daily and was told that the wound was deep. She was comfortable at that time without the additional positional pressure on the wound area. She stated that she finds the wound to be very painful and very uncomfortable when she has to sit in a chair at dialysis and she is unable to offload the pressure or reposition. Interview with the Assistant Director of Nursing on August 22, 2024, at 1:30 p.m. revealed that she spoke with the wound clinic and Resident 13 was to follow up with them on August 7, 2024; however, Resident 13 was a no-call no-show for that appointment and was not seen. Interview with the Director of Nursing on August 22, 2024, at 10:49 a.m. and 1:22 p.m. confirmed that the facility failed to obtain a wound vacuum, failed to ensure that the resident went to a follow-up wound appointment, and failed to make an additional referral to the wound clinic for ongoing treatment and evaluation due to scheduling conflicts. She also confirmed that Resident 13's wound had not been assessed since July 23, 2024, was not provided the wound vacuum or weekly wound assessments and the wound declined. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policy and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that the call bell system was adequately equipped to allow residents to call for staff assistance, by failing to ensure that the call bell system was working. This failure put 15 of 22 residents reviewed who need to utilize their call bell for staff assistance in an Immediate Jeopardy situation. Findings include: The facility's policy regarding resident communication system and call lights, dated April 30, 2024, revealed that it was the policy of the facility to provide residents with a means of communicating with staff. A call system is installed in each resident room and toilet/bath area. The facility will respond to resident needs and requests. A review of Resident Council meeting minutes, dated April 2024, May 2024, and June 2024, revealed that the residents were concerned about the call bell wait time and that they felt the wait time for a call bell to be answered was excessive, sometimes up to an hour. Observations on July 2, 2024, from 10:13 a.m. to 10:30 a.m. revealed that the residents' call lights were recessed in the ceiling above their room and not visible from a couple of rooms away. There was no sound activated when a call bell was pressed. Interview with Licensed Practical Nurse 5 on July 2, 2024, at 10:23 a.m. revealed that she relies on the nurse aides to answer the call bells, and that she will answer them if she knows they are on. She said that they do not make a sound anywhere. She did not have any device on her that alerted her if a call bell was pressed. Interview with Registered Nurse 6 on July 2, 2024, at 10:23 a.m. revealed that she is not sure where the call bells sound to. She said that the nurse aides are responsible for answering the call bells and that she does try to help. She is new to the facility and not aware of any device that the nursing staff carries to alert them of any call bell. Interview with Nurse Aide 4 on July 2, 2024, at 10:30 a.m. revealed that she tries to watch for the lights above the resident's door ways to indicate that the resident's call bell is on. She said there is no sound, and she does not know of any device that she should carry that would alert her that the call bell is on. She said the resident's have complained to her that they have waited too long, but she does not know how long their call bells were actually on because they do not make a sound. Interview with Nurse Aide 7 on July 2, 2024, at 10:38 a.m. revealed that the call bells do not make a sound anywhere in the hall or at the nurse's station, and she did not have any device that alerted her that the resident's call bell was on. Interview with the Nursing Home Administrator (NHA) on July 2, 2024, at 2:53 p.m. revealed that, in the past, the staff were supposed to carry a pager that would alert them when a resident's call bell was pressed. She stated that, at some point, the staff stopped charging the pagers and stopped carrying them. She stated that she purchased mini kiosks for the staff to be able to sit in the hallways and do their charting so they could visualize the recessed light above the resident's door when the resident would press their call bell. She was not sure why the staff that were interviewed were not aware that they were to be charting in the hallways and watching for call bells to light up. She said she was aware that the call bells were not sounding at the nurse's station because the current system did not function that way. She said that there was a system where the staff wore a pager and it would alert them when a call bell was pressed and that the nurse aide would be alerted first, and then the nurses would be alerted if the nurse aides did not answer the bell in an allotted time. However, she stated the pagers were misplaced or not charged and the staff were not carrying them. On July 3, 2024, at 10:46 a.m. the NHA was informed that the health and safety of residents were in Immediate Jeopardy due to registered nurses, licensed practical nurses, and nurse aides not knowing when the residents were calling for assistance. The NHA was provided with the IJ template at 10:46 a.m. The facility submitted and implemented an immediate plan to ensure resident safety by providing each resident with a tap bell or a cow bell that, when sounded, staff could audibly hear. The facility also placed hall monitors in each of the four halls so that the residents' bells could be heard and staff would be alerted as to who needed assistance. Staff were educated regarding the temporary system. The facility was able to locate pagers, replace the batteries, and pass them out to staff for use. The pagers will be signed in and out each shift, and maintenance will replace the batteries once a month. The Immediate Jeopardy was lifted on July 3, 2024, at 4:36 p.m. when it was confirmed that each resident had a tap bell or a cow bell that was audible to staff; that over 90 percent of the nursing staff received education regarding the temporary call bell system, with the remaining staff scheduled to receive the education prior to the start of their next shift; and that the facility contacted a contractor to purchase a new call bell system or change the current one to a system that makes sounds at a central location. 28 Pa. Code 207.2(a) Administrator's Responsibility. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies, clinical records, and facility investigative documents, as well as staff interviews, it was determined that the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents, by failing to ensure that care-planned interventions were in place for one of seven residents reviewed (Resident 7), resulting in a fractured tibia and fibula (lower leg bones) and a fracture of the fibular head (leg bone under knee cap) for the resident. Findings include: The facility's policy regarding fall investigations, dated April, 2023, indicated that the fall committee leader will be responsible for evaluating current interventions, updating fall care plans, and developing new interventions as appropriate. A significant change Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 7, dated April 19, 2023, indicated that the resident could usually understand, was usually understood, required extensive assistance from staff for daily care, and had diagnoses that included dementia. Physician's orders for Resident 7, dated April 8, 2023, included an order for the resident to have an Air Force One Mattress with bolster overlay (specialty air mattress with built up sides). Resident 7's care plan, dated April 20, 2022, revealed that she was to have constant supervision and be out of bed for her meals. A nursing note for Resident 7, dated May 17, 2023 at 1:15 p.m., revealed that the resident was found on the floor lying on her back with her head at the bottom of the bed. The facility's investigation report, dated May 17, 2023, revealed that the resident was observed in bed eating her lunch five minutes prior to being found on the floor. There was no documented evidence that Resident 7 was out of bed for her lunch meal or that she had constant supervision. There was no documented evidence that the resident was assessed for safety prior to the use of the air mattress, or that the air mattress was ruled out as a contributing factor in causing the resident to fall out of bed, or that the resident was assessed for safety with the air mattress after the fall. A nursing note for Resident 7, dated May 17, 2023 revealed that the resident's left shin was discolored from a previous fall earlier that day. An x-ray for Resident 7, dated May 18, 2023, revealed that the resident had a fracture of the fibular head as well as the tibia and fibula. Interview with the Director of Nursing on May 30, 2023, at 9:48 p.m. confirmed that the resident was in bed eating her lunch without supervision when she fell out of bed. The facility's investigation did not determine why the resident was in bed eating her lunch without supervision at the time of her fall, nor did the investigation rule out that the air mattress could have contributed to the resident's fall or if the resident was safe to remain on the air mattress after her fall. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of clinical records and investigative information, as well as staff interviews, it was determined that the facility failed to ensure that the staff followed physician-ordered transfer procedures to prevent resident neglect for one of one residents reviewed (Resident R1), which resulted in harm for the resident. Findings include: Resident R1's clinical record revealed that he was admitted to the facility on [DATE], at 4:00 p.m. with [DIAGNOSES REDACTED]. The admission orders [REDACTED]. A fall report and investigation for Resident R1, dated August 16, 2016, revealed that the resident was sitting at a table in the alcove near the nursing station at 10:00 p.m., and he stated that he needed to use the restroom. Licensed Practical Nurse (LPN) 1 assisted him to stand and used a walker to stabilize him. The resident took a few steps forward and fell , landing on his left hip. Upon assessment, the resident was not able to straighten out his left leg and had a skin tear on his right forearm. He was transported to the hospital and admitted with a left [MEDICAL CONDITION]. A statement written by LPN 1, dated August 16, 2016, revealed that she was asked to toilet the resident and was told that he used a walker. LPN 1 stood the resident up with the walker, turned the chair alarm off, and the resident fell . A gait belt was not in place and she stated that she was not aware of the physician's orders [REDACTED]. Interview with the Director of Nursing on August 27, 2016, at 3:00 p.m. confirmed that LPN 1 did not use a gait belt at the time of Resident R1's fall. She stated that LPN 1 should have reviewed the resident's orders because he was a new admission. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 2/19/16, 12/16/15, 11/7/15, 7/3/15, 5/13/15, 3/5/15.

Based on review of clinical records and investigative information, as well as staff interviews, it was determined that the facility failed to ensure that residents were transferred using safe techniques as ordered by the physician for one of one residents reviewed (Resident R1), which resulted in harm for the resident. Findings include: Resident R1's clinical record revealed that he was admitted to the facility on [DATE], at 4:00 p.m. with [DIAGNOSES REDACTED]. The admission orders [REDACTED]. A fall report and investigation for Resident R1, dated August 16, 2016, revealed that the resident was sitting at a table in the alcove near the nursing station at 10:00 p.m., and he stated that he needed to use the restroom. Licensed Practical Nurse (LPN) 1 assisted him to stand and used a walker to stabilize him. The resident took a few steps forward and fell , landing on his left hip. Upon assessment, the resident was not able to straighten out his left leg and had a skin tear on his right forearm. He was transported to the hospital and admitted with a left hip fracture. A statement written by LPN 1, dated August 16, 2016, revealed that she was asked to toilet the resident and was told that he used a walker. LPN 1 stood the resident up with the walker, turned the chair alarm off, and the resident fell . A gait belt was not in place, and she stated that she was not aware of the physician's orders [REDACTED]. Interview with the Director of Nursing on August 27, 2016, at 3:00 p.m. confirmed that LPN 1 did not use a gait belt at the time of Resident R1's fall. She stated that LPN 1 should have reviewed the resident's orders because he was a new admission. 28 Pa. Code 211.12(d)(1) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 2/19/16, 12/16/15, 11/7/15, 7/3/15, 5/13/15, 3/5/15. 28 Pa. Code 211.10(d) Resident care policies.