Every finding on record at Mountain View Rehabilitation and Senior Living CTR

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice for one of nine residents reviewed (Resident 7). Findings include: Clinical record review for Resident 7 revealed a practitioner progress note dated July 24, 2026, at 11:34 AM noting the resident was assessed due to a nursing staff report of hemoptysis (coughing or spitting up blood). The physician ordered a chest x-ray (imaging to take pictures of the inside of your body) that was completed on July 24, 2026. Review of Resident 7's chest x-ray report dated July 25, 2026, revealed a diagnosis of left basilar pneumonia (infection that inflames the air sacs in the lungs) and effusion (abnormal buildup of fluid in the space between the lungs and the chest wall). Nursing documentation dated July 25, 2026, at 8:33 PM revealed that the staff notified the physician of the chest x-ray result and an order was started on July 25, 2026, at 9:00 PM for doxycycline hyclate (an antibiotic that treats numerous bacterial infections) 100mg (milligrams) by mouth two times a day for left basilar pneumonia for seven days to end August 1, 2026. The order was discontinued on July 25, 2026, at 9:47 PM. Review of Resident 7's medication administration record (MAR, electronic documentation by licensed staff to attest to the administration of medication) dated July 2026, revealed staff administered one dose of doxycycline hyclate 100mg to Resident 7 on July 25, 2026. Resident 7 did not receive any doses of doxycycline hyclate on July 26, 2026, or the morning of July 27, 2026. Clinical record review for Resident 7 revealed a physician assistant progress note dated July 27, 2026, at 10:26 AM that noted the resident only received one dose of doxycycline due to nursing not confirming the order in the computer system and that the Director of Nursing was aware at that time. An order was then confirmed by nursing on July 27, 2026, for doxycycline monohydrate (version of the antibiotic doxycycline generally considered gentler on the stomach) 100mg capsule twice daily for seven days. Review of Resident 7's MAR dated July 2026, revealed that Resident 7 received a dose of the doxycycline medication the evening of July 27, 2026. Interview with Director of Nursing on August 6, 2026, at 3:35 PM revealed that the process for physician orders included the physician or physician assistant generates the order in the computer system themselves and then nursing staff must confirm the order before it appears on the medication administration record. In this situation for Resident 7, nursing staff did not confirm the order resulting in Resident 7 missing three doses of doxycycline to treat the resident's diagnosed pneumonia. 483.25 Quality of CarePreviously cited 5/1/26 28 Pa Code 211.12 (d)(1)(3)(5) Nursing Services

Based on observation and resident and staff interview, it was determined that the facility failed to ensure a clean, comfortable, and homelike environment on two of four open nursing units (F and G nursing units, Residents 5, 7, 8, and 10).Findings include: Observation of Resident 5's room on August 6, 2026, at 12:40 PM revealed him to be in bed with three black flying insects on his left leg. Observation of the area around his bed revealed that his garbage had not been emptied, there was a respiratory mask hanging (unbagged and uncovered) from a metal shelving unit on his bedside stand, and the floor did not appear mopped (with straws, straw papers, an emesis basin (a shallow, kidney-shaped, medical dish used to collect vomit or small medical waste at the bedside), the facility newsletter from August 4, 2026, and a used disposable glove on the floor). Interview with Resident 5 on the date and time of the observation revealed that he does not get out of bed. Resident 5 stated that staff drop things but do not pick them up. Interview with Employee 1 (nurse aide) on August 6, 2026, at 12:40 PM confirmed the above findings of Resident 5's room. Employee 1 removed Resident 5's garbage and loose items from the floor around his bed. Observation of Resident 5's roommate's (Resident 10) area revealed white linens balled on the floor under the head of his bed. Colored spillage was noted on the floor and touching the perimeter of a floor mat (a padded, high-density, floor mat placed next to a bed to cushion the impact and reduce injury severity if a person falls). The surveyor reviewed the environmental concerns for Residents 5 and 10 during an interview with the Nursing Home Administrator and the Director of Nursing on August 6, 2026, at 4:00 PM. Observation of Resident 8's bathroom on August 6, 2026, at 10:59 AM revealed a bed pan (a medical device used to collect urine and feces) on the floor next to the toilet. The bathroom was missing a toilet paper holder resulting in the roll of toilet paper sitting on the sink. The bathroom had an odor of feces, and the garbage can contained an incontinence brief and several wipes covered with feces. Observation of Resident 7's room on August 6, 2026, at 11:11 AM revealed the floor did not appear mopped (with straw paper, napkin, plastic cup lid, piece of broken green plastic with pointed ends). Resident 7 had bilateral fall mats at her bedside that had debris and black areas on the surface of the mats. A small trash can near her bed contained no trash liner but had gloves, cups, and straws inside. Resident 7's bathroom had a plastic spoon on the floor, and the paper towel holder was hanging by one nail. Interview with Employee 2 (licensed practical nurse) on August 6, 2026, at 11:22 AM confirmed the above findings for Residents 7 and 8. The surveyor reviewed the environmental concerns for Residents 7 and 8 during an interview with the Nursing Home Administrator and Director of Nursing on August 6, 2026, at 4:00 PM. 483.10(i)(1)-(7) Safe/clean/comfortable/homelike EnvironmentPreviously cited deficiency 5/1/26 28 Pa. Code 201.18(b)(3)(e)(2.1) Management

Based on a review of select facility policies and procedures, clinical record review, personnel record review, and staff interview, it was determined that the facility failed to protect a resident's right to be free from physical abuse by staff that resulted in actual harm with a serious injury of a rib fracture for one of seven residents reviewed (Resident 1).Findings include: The facility policy entitled, Abuse Prevention and Prohibition Program, Operational Manual, Abuse and Neglect, last reviewed February 3, 2026, noted that the purpose of the program is to ensure that the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. The procedure for Screening referred to the policy, Staff Screening training procedures included that covered individuals will be trained through orientation and on-going training sessions on topics that included abuse prevention and appropriate interventions to deal with aggressive and/or catastrophic reactions of residents. The facility policy entitled, Staff Screening, Operational Manual, Abuse and Neglect, last reviewed February 3, 2026, revealed that if the facility uses registry staff or permits students from affiliated academic programs to train on-site, the facility will validate that these individuals undergo the same screening as is required of individuals employed directly by the facility. Upon hire, facility employees will participate in orientation that includes, but is not limited to, training related to abuse and neglect, and resident rights. The facility will also offer orientation to volunteers, registry/temporary staff, students, and contractors/consultants to the extent it applies to their job function. Clinical record review for Resident 1 revealed his diagnoses list included the need for assistance with personal care and unspecified dementia with other behavioral disturbance (brain disorder that impairs memory, thinking, and the ability to perform everyday activities that contributes to behaviors such as agitation, aggression, delusions, and resistance to care). Review of Resident 1's plan of care initiated by the facility on May 4, 2026, to address his resistance to care revealed interventions that included, If resident resists with ADLs (activities of daily living), reassure resident, leave and return five to 10 minutes later and try again. Review of Resident 1's bedside Kardex (electronic documentation of care needs available to nurse aide staff providing direct care to the resident) dated June 5, 2026, revealed no directive to leave the resident when he is resisting care. Nursing documentation by Employee 2 (registered nurse) dated June 5, 2026, at 7:53 PM revealed that a nurse aide observed Resident 1, upside down on the bed, with Employee 1 (nurse aide) on top of Resident 1 while Resident 1 was yelling, out of breath, and shaking. The documentation indicated that Employee 1 was attempting to put Resident 1's incontinence brief on. The nurse aide asked Employee 1 to leave the room, after which he completed Resident 1's care. Employee 1 was escorted from the facility by the registered nurse. A skin assessment completed by Employee 2 dated June 5, 2026, at 7:25 PM noted that Resident 1 presented with, Red raised welts on abdomen and back, and lower ext. (extremities). Nursing documentation by Employee 3 (registered nurse) dated June 6, 2026, at 10:46 AM noted, Follow up skin assessment completed upon resident care, see skin assessment. Review of a Skin Observation/check dated June 6, 2026, at 11:00 AM identified 12 sites of bruising, abrasion, redness, swelling, or tenderness of Resident 1's scalp, chest, abdomen, back of head, right and left shoulders, back, buttock, wrist, rib, and lip as follows: Top of scalp, bruise, 2 cm (centimeters) by 2 cmChest, bruising to mid chest, 4 cm by 2 cmAbdomen, right lower quadrant scattered bruisingBack of head, bruise, 1 cm by 1 cmRight shoulder (front), red area, 2 cm by 0.5 cmLeft shoulder (rear), bruise, 1 cm by 1 cmLower back, bruise, 4 cm by 3 cmLeft wrist, red/purple area, 2 cm by 2 cmMiddle/left back, abrasion, 2 cm by 2 cmRight buttock, ecchymotic (bruised) area, 1 cm by 1 cmRight inner lip, bruise, 0.5 cm by 0.5 cm with small open area in the centerRight side rib cage, swelling and tender to touch with complaints of discomfort Nursing documentation by Employee 3 dated June 6, 2026, at 12:11 PM noted physician notification of Resident 1's skin assessment and complaints of discomfort to his right rib area for which the physician ordered an x-ray of Resident 1's right side/rib cage and chest. Nursing documentation dated June 8, 2026, at 11:14 PM noted that received x-ray results for Resident 1 included an Acute displaced fracture of the (right) 7th (seventh) rib (type of rib fracture where the broken ends of the rib are not aligned property, often caused by trauma). Review of the radiology report with an examination date of June 8, 2026, at 3:28 PM noted findings as, Acute displaced fracture of the lateral right seventh rib. A review of the facility's PB22 (Provider Bulletin 22 form, a standardized Pennsylvania Department of Health document used to report and investigate allegations of abuse, neglect, or misappropriation of property in long-term care facilities) investigation of the above incident noted that the facility substantiated the allegation of staff-to-resident physical abuse and removed Employee 1 from the facility. Review of available personnel record documentation for Employee 1 revealed no evidence that he completed education related to the facility's Abuse Prevention and Prohibition Program. Interview with the Director of Nursing on June 26, 2026, at 12:47 PM confirmed that nursing staff on the June 26, 2026, deployment schedule included several staff from the nurse staffing agency that employed Employee 1 without evidence of completion of the facility's Abuse Prevention and Prohibition Program education. The Director of Nursing immediately implemented on-the-spot in-servicing for all agency nurse staff present in the building and reported a plan for all agency employees to report to the nursing supervisor before their on-unit shift to complete the facility Abuse Prevention and Prohibition Program education. The interview also confirmed that the intervention to reapproach Resident 1 when refusing or resistant to care was not included on the bedside Kardex instructions until June 22, 2026. Interview with the Nursing Home Administrator on June 26, 2026, at 6:00 PM confirmed that staff scheduled to work in the facility through a contracted staffing agency are considered contractors and would be subject to orientation training regarding the facility's abuse prevention program. The facility did not have evidence of this training for Employee 1 or those staff on the nursing deployment schedules for the date of the onsite survey until following the surveyor's questioning. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1)(2)(e)(1) Management 28 Pa. Code 201.19(7) Personnel policies and procedures 28 Pa. Code 201.20(b)(d) Staff development 28 Pa. Code 201.29 (a)(c) Resident rights 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to provide written notice to a resident's responsible party before the resident's room change for one of seven residents reviewed (Resident 2).Findings include: The facility policy entitled, Room Change Policy, last revised February 3, 2026, revealed that when a room change does happen the patient will be notified prior to that move. The form utilized by the facility included dated signature lines for the Resident/Responsible Party. Clinical record review for Resident 2 revealed that her diagnoses list included Alzheimer's disease and dementia (progressive brain disorder that destroys memory and thinking skills); and that she resided on the secured nursing unit for residents with dementia-type diagnoses. Nursing documentation dated May 16, 2026, at 10:31 PM indicated that staff found Resident 2's roommate on top of her while she was in her bed. Staff assessed a bite mark on Resident 2's left hand without broken skin. Resident 2 stated that she had her hair pulled and that she was slapped in face. The staff contacted Resident 2's son (responsible party) to inform him of the incident, and the facility implemented one-to-one supervision for Resident 2's roommate. Nursing documentation created on May 22, 2026, at 8:38 AM for an effective date of May 19, 2026, at 8:36 AM indicated that the interdisciplinary team reviewed the above incident for Resident 2; and that the interventions post incident were focused on the aggressive resident (Resident 2's roommate). Nursing documentation dated May 29, 2026, at 12:31 PM revealed that Resident 2 stated that she was, scared of roommate, doesn't want to be in room with her anymore d/t (due to) recent incidents. Census information in Resident 2's medical record indicated that the facility moved her from her room to another room on the A nursing unit on June 1, 2026. Nursing documentation dated June 1, 2026, at 3:06 PM indicated that staff notified Resident 2's responsible party of the start of an antibiotic treatment and that Resident 2's responsible party was very upset about Resident 2's move to another room and requested that she go back to her previous room. Documentation by the Nursing Home Administrator on June 1, 2026, at 3:37 PM stipulated that facility staff did not notify Resident 2's responsible party before her room move. Social services documentation dated June 2, 2026, at 3:43 PM indicated that the Director of Nursing and social services staff met with Resident 2's family regarding her recent room move because of Resident 2 voicing that she was afraid of her roommate. The family wanted Resident 2 moved back to her original room. Resident 2's census information indicated that the facility moved her back to her previous room on June 3, 2026. Interview with the Nursing Home Administrator on June 26, 2026, at 2:30 PM confirmed that the facility failed to notify Resident 2's responsible party of her room move as evidenced above. 28 Pa. Code 201.14(a) Responsibility of licensee 29 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(3) Nursing services

Based on observations and staff interview, it was determined that the facility failed to prepare/serve food items in accordance with professional standards of practice in the facility's main kitchen.Findings include: Observation on May 1, 2026, at 11:15 AM of tray line (a structured system in foodservice operations for meal assembly and distribution) revealed improper use of hair nets. Employee 16, dietary cook, was observed walking between the tray line and the food preparation area, wearing a hair net and a beard net with long hair extending out from under the net, and the beard net pulled down under their mouth, exposing long beard hairs and a mustache above the netting. Employee 17, kitchen supervisor, was observed overseeing tray line with a beard net pulled down under their mouth, exposing a mustache above the netting. The above information was reviewed with the Nursing Home Administrator on May 1, 2026, at 12:15 PM. 483.60(i)(1)-(2) Food safety requirementsPreviously cited deficiency 5/2/25 28 Pa. Code 201.14(a) Responsibility of licensee

Based on observation, clinical record review, and resident, family, and staff interview, it was determined that the facility failed to ensure residents received proper treatment and assistive devices to maintain hearing abilities for three of five residents reviewed for vision/hearing concerns (Residents 3, 14, and 68).Findings include: Clinical record review for Resident 68 revealed a diagnoses list that included unspecified bilateral hearing loss since February 27, 2024. Review of a plan of care initiated by the facility on March 5, 2024, to address Resident 68's communication problem related to her hearing deficit revealed that she is to have bilateral hearing aids put in her ears in the morning and taken out at hour of sleep (HS). Interview with Resident 68 on April 28, 2026, at 3:02 PM revealed her claim that she was, deaf; and that she had been waiting for hearing aids. The surveyor had to speak loudly and state questions repeatedly to complete an interview with Resident 68 while she did not have hearing aids in her ears. An active physician's order dated September 1, 2024, instructed staff to apply Resident 68's hearing aids bilaterally in the morning and remove hearing aids and place the hearing aids on a charger in the medication room at bedtime. Review of Resident 68's medication and treatment administration records (MAR and TAR, electronic documentation completed by licensed staff to record care implemented) dated April 2026 noted that staff documented Resident 68's refusals to utilize old hearing aids while she waited for new hearing aids. Interview with Resident 68's daughter on April 29, 2026, at 11:36 AM indicated that Resident 68 was fitted for hearing aids before December 2025. She contacted the hearing aid company who reported to her that the facility did not forward payment for the hearing aids; therefore, they have hearing aids that they will not release until payment is made. Per Resident 68's daughter, the provider indicated that they are waiting for bill payment for two other residents as well. The surveyor requested any evidence of Resident 68's professional audiology services since December 2025 during an interview with the Nursing Home Administrator, the Director of Nursing, and Employee 1 (registered nurse corporate consultant), on April 29, 2026, at 2:00 PM. The Nursing Home Administrator provided a copy of a payment check dated April 30, 2026, at 10:00 AM (following the surveyor's questioning) made out to the facility's contracted audiology provider for $10,800.00 (ten thousand eight hundred dollars). Social services documentation dated April 30, 2026, at 11:12 AM (following the surveyor's questioning) revealed that the staff contacted the facility's contracted audiology services provider who stated that they will be in the facility on Wednesday May 6, 2026, regarding Resident 68's hearing aids. Clinical record review for Resident 3 revealed nursing documentation dated February 23, 2026, at 4:08 PM that Resident 3 arrived at the facility with hearing aids for both ears that staff locked in the medication cart as both, were dead. Nursing documentation dated February 24, 2026, at 3:11 PM indicated that Resident 3's bilateral hearing aids were in the medication cart; the licensed practical nurse charge nurse was instructed to replace the batteries and give them to the resident. Nursing documentation dated February 25, 2026, at 1:34 PM noted that Resident 3's right hearing aid was functioning, but her left hearing aid was not functioning. The writer indicated that social services staff were notified. Review of Resident 3's TAR and MAR dated April 2026 revealed no evidence that staff attested to the use of hearing aids. Observation and attempted interview with Resident 3 on April 28, 2026, at 2:19 PM revealed her to be hard of hearing and without any hearing aids. Interview with Employee 11 (nurse aide), Employee 12 (licensed practical nurse), and Employee 13 (licensed practical nurse) on April 28, 2026, at 2:19 PM confirmed that Resident 3 did not have any hearing aids and none were in the medication cart. Review of an admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated March 2, 2026, revealed that staff assessed Resident 3's hearing as adequate with the use of a hearing aid. The Care Assessment Area (CAA, critical component of the Minimum Data Set (MDS) that helps identify resident-specific issues and develop individualized care plans in long-term care settings) for Resident 3's communication needs triggered staff to proceed to a care plan as she was only sometimes understood and had impaired ability to understand. Review of plans of care developed by the facility determined no plan of care that included Resident 3's hearing aid use. A quarterly MDS assessment dated [DATE], indicated that staff completed Resident 3's assessment without the use of a hearing aid. Resident Assessment Instrument (RAI/MDS) instructions to complete Section B0200: Hearing of the MDS includes to, Ensure that the resident is using their normal hearing appliance if they have one. Hearing devices may not be as conventional as a hearing aid. Some residents by choice may use hearing amplifiers or a microphone and headphones as an alternative to hearing aids. Ensure the hearing appliance is operational. Interview with Employee 14 (licensed practical nurse/MDS reimbursement specialist) on April 30, 2026, at 12:00 PM indicated that she was not aware of the RAI instructions regarding ensuring a hearing device is used to complete the hearing assessment portion of the MDS. She confirmed that Resident 3 did not have a hearing aid for the March MDS assessment. The surveyor reviewed the above concerns regarding Resident 3's hearing aid use during an interview with the Nursing Home Administrator, the Director of Nursing, and Employee 1, on April 29, 2026, at 2:00 PM. Review of Resident 3's TAR dated April 2026 revealed that the facility initiated an intervention on April 30, 2026, at 6:00 AM (following the surveyor's questioning) that staff insert a hearing aid in Resident 3's right ear every morning and remove every evening. Staff are to document Resident 3's refusal to wear and keep the device in the medication room when not in use. Clinical record review for Resident 14 revealed a diagnoses list that included unspecified hearing loss since January 11, 2016. An active physician's order dated July 28, 2022, instructed staff to please utilize resident's hearing aids; in every morning, out at HS, and as needed per resident's request. Nursing documentation dated November 29, 2025, at 6:47 PM revealed that Resident 14 complained that his hearing aids were not working; and staff replaced the batteries. Review of an annual MDS assessment dated [DATE], indicated that Resident 14 had moderate difficulty hearing with the use of a hearing aid. A quarterly MDS assessment dated [DATE], indicated that staff assessed Resident 14 had moderate difficulty hearing; however, staff documented that a hearing aid was not used for the assessment. Review of Resident 14's TAR and MAR revealed that licensed staff initialed the implementation of Resident 14's hearing aids the morning of April 28, 2026. Interview with Resident 14 on April 28, 2026, at 1:35 PM revealed him to be very hard of hearing. The surveyor needed to speak loudly and repeat simple sentences/questions close to Resident 14's left ear to obtain resident responses. Resident 14 pointed to a charger on his bedside stand to indicate that he had hearing aids, but Resident 14 indicated that they needed battery replacement. Interview with nurse aide staff leaving Resident 14's room at the time stated, might have batteries at nurses' desk. Nursing documentation dated April 28, 2026, at 1:48 PM (after surveyor's above observation and interview) revealed that staff changed the batteries in Resident 14's hearing aids; however, they were not functioning per Resident 14. The nurse made social services aware. Nursing documentation dated April 29, 2026, at 2:11 PM revealed that Resident 14's hearing aids were, out for repair. Nursing documentation dated April 29, 2026, at 10:39 AM revealed that Resident 14's bilateral hearing aids were removed by social services and sent for repair. Social services documentation dated April 29, 2026, at 10:33 AM confirmed that staff contacted the Veteran's Administration (VA) regarding Resident 14's hearing aids that do not function; and that the staff sent the hearing aids to the front office to mail to the VA. Review of Resident 14's MAR and TAR dated April 2026 indicated that staff initialed Resident 14 had his hearing aids in use on April 28 and 30, 2026, although resident interview, observation, and clinical record documentation confirmed that was not accurate. The surveyor reviewed the above concerns regarding Resident 14's hearing aid services during an interview with the Nursing Home Administrator and Employee 1 on April 30, 2026, at 3:06 PM. 483.25 (a) HearingPreviously cited 5/2/25 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview it was determined that the facility failed to ensure that active physician orders incorporated resident or appropriate resident representative's wishes related to end-of-life care for seven of 14 residents reviewed for advance directives concerns (Residents 2, 3, 6, 13, 14, 22, and 71). Findings include: Clinical record review for Resident 3 revealed that the facility admitted her on February 23, 2026. Resident 3's profile information indicated that her niece was her responsible party, health care representative, and power of attorney for her care and finances. A Brief Interview for Mental Status (BIMS, an assessment tool with a numerical scoring system to determine cognitive deficits) admission assessment dated [DATE], at 10:35 AM assessed Resident 3's score as a four, severely impaired. An admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated March 2, 2026, indicated that Resident 3 only sometimes understood others and only sometimes was understood by others. The BIMS score was four, which indicated severe cognitive impairment. A POLST (Physician Orders for Life Sustaining Treatment, portable medical order form that records treatment wishes so that emergency personnel know what treatments the resident wants in the event of a medical emergency) signed by the medical practitioner on February 26, 2026, included only Resident 3's signature, not her responsible party's signature. The POLST implemented DNR (Do Not Resuscitate, do not provide chest compressions or assist with breathing), limited additional interventions (do not intubate or provide mechanical breathing assistance), care for Resident 3. Active physician orders for Resident 3 dated February 23, 2026, implemented DNR instructions in the event of a medical emergency. Interview with Employee 1 (registered nurse regional consultant) on April 30, 2026, at 12:48 PM confirmed that the facility did not have evidence that Resident 3's responsible party participated in advance directives planning on the POLST form for Resident 3. Clinical record review for Resident 14 revealed an active physician order dated November 7, 2019, for Full Code (chest compressions and breathing assistance). Resident 14's clinical record contained no POLST or advance directives documentation. The surveyor requested evidence that Resident 14 or his responsible party participated in the end-of-life care decisions during an interview with the Nursing Home Administrator on April 29, 2026, at 2:00 PM and April 30, 2026, at 2:15 PM. Nursing documentation dated April 30, 2026, at 8:45 AM (following the surveyor's questioning) indicated that a registered nurse spoke with Resident 14's brother to review a POLST with him. Clinical record review for Resident 71 revealed active physician orders for Full Code. Resident 71's clinical record contained no POLST or advance directives documentation. Resident 71's clinical record contained legal documentation that a court adjudicated him incompetent on August 8, 2023, and another party was awarded guardianship for Resident 71. The surveyor requested evidence that Resident 71's legal guardian participated in advance directive planning during interviews with the Nursing Home Administrator on April 29, 2026, at 2:00 PM, April 30, 2026, at 2:15 PM, and May 1, 2026, at 9:20 AM. No further evidence was provided during the onsite survey. Clinical record review revealed the facility admitted Resident 2 on December 3, 2025, with an active physician order for DNR order. Resident 2's clinical record contained no POLST, or advance directive documentation. Nursing documentation dated April 30, 2026, at 2:48 PM (following the surveyor's questioning) indicated that a registered nurse spoke with Resident 2's daughter to review a POLST with her. Clinical record review revealed the facility admitted Resident 22 on March 17, 2026, with an active physician order for full code. Resident 22's clinical record contained no POLST, or advance directive documentation. The above findings for Residents 2 and 22 were reviewed with the Nursing Home Administrator and Director of Nursing on May 1, 2026, at 9:31 AM. Clinical record review for Resident 6 revealed they were admitted on [DATE]. The most recent MDS completed on April 7, 2026, indicates that the resident is rarely/never understood, which has been the condition of the resident since their admission. The resident had a physician's order written on September 4, 2024, indicating they were a Full Code. Resident 6's clinical record contained no POLST, or advance directive documentation. Nursing documentation dated May 1, 2026, at 9:34 AM (following the surveyor's questioning) indicated that a staff member spoke with Resident 6's daughter to review a POLST with her, and the resident was to be a DNR. Clinical record review for Resident 13 revealed they were admitted on [DATE]. The most recent MDS completed on March 8, 2026, indicates that the resident is rarely/never understood, which has been the condition of the resident since their admission. The resident had a physician's order written on January 20, 2026, indicating they were a DNR. Resident 13's clinical record contained no POLST, or advance directive documentation. Documentation related to Resident 6's and 13's advanced directives were requested by the surveyor on April 29, 2026, at 2:15 PM, and again on April 30, 2026, at 2:45 PM, and no documentation was provided. The above findings for Residents 6 and 13 were reviewed with the Nursing Home Administrator and Employee 1, on May 1, 2026, at 10:30 AM, and they confirmed that no documentation for Resident 6 or 13 could be located. 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(1)(3)(5) Nursing service

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide a dependent resident with activities of daily living assistance for two of five residents reviewed (Residents 84 and 64). Findings include: Observation of Resident 84 on May 26, 2026, at 11:58 AM revealed that her hair appeared unkempt. Clinical record review revealed the facility admitted Resident 84 on October 3, 2025. Review of Resident 84's most recent quarterly MDS (Minimum Data Set, an assessment completed at specific intervals to determine resident care needs) dated March 30, 2026, noted staff assessed Resident 84 as dependent on staff for bathing. Review of Resident 84's Kardex (documentation system used by staff to organize and reference key resident information essential for resident care) revealed she is to receive a bath every Wednesday and Saturday. Review of a Documentation Survey Report (electronic documentation completed by nurse aide staff for the completion of ADL care) from January 1 to May 1, 2026, revealed there was no documentation that staff assisted Resident 84 with a shower after March 19, 2026 (44 days). The findings were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on April 29, 2026. The Director of Nursing confirmed the above findings for Resident 84 on May 1, 2026, at 9:51 AM. Observation of Resident 64 on April 28, 2026, at 1:23 PM revealed he had a full beard on his face. Resident 64 was asked if this was their preference, and the resident shook their head no. Review of Resident 64's clinical record revealed that they had a care plan (outline of an individual's health needs, specific care requirements, and the actions necessary to achieve desired health outcomes) that includes a focus of ADL (activity of daily living) Self Care Performance Deficit initiated on April 28, 2023, and a corresponding intervention initiated on May 19, 2025, that states the resident prefers to have a mustache. The above information related to Resident 64 was reviewed with the Nursing Home Administrator and Employee 1, RN Regional Consultant on April 30, 2026, at 2:45 PM. 483.24(a)(2) ADL Care Provided for Dependent ResidentsPreviously cited deficiency 5/2/2025 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to implement interventions to prevent resident fall recurrence for one of nine residents reviewed for falls (Resident 3); and failed to ensure an environment free from potential accident hazards on three of four open nursing units (F Unit, Residents 3, 26, 68, 74, and 166; B and E common lounge area, and Cranberry common dining area).Findings include: Clinical record review for Resident 3 revealed nursing documentation dated February 23, 2026, at 4:08 PM that Resident 3 arrived at the facility and that she had scabs (unhealthy, leathery, often black tissue that covers a wound surface) on her left knee and shin from falling. An admission fall risk assessment dated [DATE], indicated that staff assessed Resident 3 at a high risk for falls (score of 19). Nursing documentation dated March 15, 2026, at 5:07 PM revealed that staff found Resident 3 on the floor in her room and that she complained of left leg pain. Nursing documentation dated March 15, 2026, at 4:25 PM revealed that x-ray results determined Resident 3 had a hip fracture. Staff notified the physician who instructed staff to send Resident 3 to the emergency room. Nursing documentation dated March 16, 2026, at 9:17 AM revealed that the interdisciplinary team reviewed Resident 3's fall, determined she lost her balance and fell, and that the facility would, follow up upon return to facility. Nursing documentation dated March 20, 2026, at 2:22 PM revealed that Resident 3 returned to the facility from the hospital. Review of the plan of care initiated by the facility on February 23, 2026, to address Resident 3's risk for falls revealed no new fall prevention interventions dated from March 15, 2026 (date of her fall and fracture) and March 20, 2026 (date of her return from the hospital). Documentation Survey Report data dated after Resident 3's return from the hospital on March 20, 2026, revealed that Resident 3 required the assistance of two staff and a roller walker for ambulation in her room and transfers with weight bearing as tolerated on her left lower extremity. Nursing documentation dated March 29, 2026, at 8:30 AM revealed that staff found Resident 3 on the floor in front of her wheelchair by the nurses' desk. Nursing documentation dated March 30, 2026, at 10:04 AM revealed that the interdisciplinary team reviewed Resident 3's fall in the hallway, determined that she fell from her wheelchair, that she was receiving skilled therapy services, and that they would try a different chair for Resident 3 when she was out of bed. Nursing documentation dated April 1, 2026, at 10:15 AM revealed that the licensed practical nurse called the registered nurse to the unit to report that while Resident 3 was in the bathroom, with 2 (two) staff members present, she stood up to turn and pivot into her wheelchair and through (sic) her body down to the floor, as staff was able to support her and lower her to the floor. Review of the facility's investigation of Resident 3's April 1, 2026, fall revealed that the facility determined that although Resident 3 required the assistance of two staff with transfers, only one staff member was present in the bathroom with her at the time of her fall. The investigation determined that during the transfer, Resident 3, threw self backwards knocking the wheelchair back out of reach and at that time the staff member was unable to reach the wheelchair. The facility suspended the nurse aide pending the investigation; and asserted that the nurse aide would return to work after she received individual (one-to-one) education on resident care plans, following resident plans of care, and the importance of utilizing two-assist techniques when a resident's transfer status dictates such. Interview with the Nursing Home Administrator on April 30, 2026, at 11:50 AM confirmed that the facility had no evidence of care plan revisions implemented after Resident 3's fall on March 15, 2026, until her subsequent fall on March 29, 2026. The interview confirmed that Resident 3 sustained a fall on April 1, 2026, when staff failed to implement Resident 3's plan of care for two staff to assist with transfers. The interview confirmed that the facility did not have evidence that the employee who was suspended following Resident 3's fall on April 1, 2026, completed required education upon her return to work on April 9, 2026. The interview also confirmed that the facility did not address the incorrect documentation by the registered nurse on April 1, 2026, that reported two staff were present with Resident 3 on April 1, 2026, when she fell in the bathroom. Interview with Employee 18, maintenance director, on April 30, 2026, at 9:57 AM, confirmed that an outlet located near a water source should be equipped with GFCI (Ground-Fault Circuit Interrupter, can interrupt or cut off electricity in the event of an electrical problem). Observation of the F Unit on April 30, 2026, at 1:12 PM revealed the bathroom shared by Resident 68, Resident 74, and Resident 3 was equipped with an electrical outlet to the left of the sink in the bathroom. The electrical outlet near the sink was not a GFCI outlet. Observation of the F Unit on April 30, 2026, at 1:14 PM revealed that the bathroom in Resident 166's room was equipped with an electrical outlet with a working nightlight to the left of the sink in the bathroom. The electrical outlet near the sink was not a GFCI outlet. Observation of the F Unit on April 30, 2026, at 1:17 PM revealed that the bathroom in Resident 26's room was equipped with an electrical outlet with a working nightlight to the left of the sink. The electrical outlet near the sink was not a GFCI outlet. The surveyor reviewed the above F Unit electrical outlet concerns during an interview with the Nursing Home Administrator on April 30, 2026, at 2:15 PM. Observation of the B and E common lounge area on April 30, 2026, at 1:05 PM revealed an electrical outlet adjacent to a sink and accessible by residents that was not a GFCI outlet. Observation of the Cranberry common dining area on April 30, 2026, at 1:06 PM revealed three electrical outlets adjacent to a sink and accessible by residents that were not a GFCI outlet. Concurrent interview with Employee 18 and Employee 33, maintenance staff, and observation of the B and E common lounge and Cranberry common dining area on April 30, 2026, at 3:18 PM confirmed that the outlets were not GFCI protected and unsure if there was a GFCI breaker. Cross refer F908 483.25(d)(1)(2) Free of Accident Hazards/supervision/devicesPreviously cited deficiency 5/2/25 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility documentation, observation, clinical record review, and resident and staff interview, it was determined that the facility failed to implement interventions to promote acceptable parameters of nutrition for three of 13 residents reviewed for nutritional concerns (Residents 12, 18, and 84); and provide nutritional supplements as per the physician order to promote acceptable parameters of nutrition for three of 13 residents reviewed for nutritional concerns (Residents 29, 107, and 170). Findings include: Current physician orders for Resident 29 revealed an order dated March 7, 2025, for Med Pass 2.0 (a type of nutritional supplement) four ounces give four times a day 120 milliliters (ml). Review of the current care plan for Resident 29 revealed the resident has a nutritional problem or potential nutritional problem related to the medical history. An intervention included to provide and serve supplements as prescribed; 2.0 120 ml QID (four times a day). Review of the medication administration record (MAR) for Resident 29 for March 2026 revealed the Med Pass 2.0 was not documented as administered per the physician order on the following dates/times: 9:00 AM dose:March 11; March 21-24; March 27; March 29-31. 1:00 PM dose:March 21-23; March 27; March 29; March 31. 5:00 PM dose:March 21-22; March 29. 9:00 PM dose:March 29 Review of the MAR documentation for March 2026 revealed the following Administration Notes for the Med Pass 2.0 for Resident 29: March 21, 2026, at 8:03 AM: not availableMarch 21, 2026, at 12:21 PM: unavailableMarch 21, 2026, at 5:41 PM: unavailableMarch 22, 2026, at 9:13 AM: unavailableMarch 22, 2026, at 12:20 PM: unavailableMarch 22, 2026, at 4:42 PM: unavailableMarch 23, 2026, at 10:32 AM: UAMarch 23, 2026, at 1:13 PM: UAMarch 24, 2026, at 9:11 AM: unavailableMarch 25, 2026, at 1:14 PM: Med Pass 2.0 unavailable Boost given, MD awareMarch 26, 2026, at 3:01 PM: Med Pass unavailable. Boost given. MD awareMarch 26, 2026, at 3:02 PM: Med Pass unavailable. Boost given. MD awareMarch 27, 2026, at 1:02 PM: not availableMarch 27, 2026, at 9:50 PM: Med Pass 2.0 unavailable or boost/neither is available facility is waiting on a shipment from pharmacy.March 29, 2026, at 10:03 AM: not available in facilityMarch 29, 2026, at 12:19 PM: not available facility awareMarch 29, 2026, at 4:53 PM: not available, MD awareMarch 29, 2026, at 8:57 PM: not available, MD awareMarch 30, 2026, at 9:06 AM: unavailable, Boost given, MD made aware.March 30, 2026, at 12:08 PM: Med pass unavailable. Boost given, MD made awareMarch 31, 2026, at 10:38 AM: unavailable, MD awareMarch 31, 2026, at 1:23 PM: unavailable A nutrition progress note for Resident 29 dated April 2, 2026, at 12:05 PM noted an intervention of 120 m Med Pass 2.0 QID (each provides 255 calories and 10 grams / protein). The documentation did not address the availability of the Med Pass 2.0 or that the dietary staff were aware that the resident had missed multiple doses of the prescribed Med Pass 2.0. Current physician orders for Resident 107 revealed an order dated February 5, 2026, for Med Pass 2.0 four ounces give two times a day 120 milliliters (ml). Review of the current care plan for Resident 107 revealed the resident has a nutritional problem or potential nutritional problem related to the medical history. An intervention included to provide and serve supplements as prescribed; MED pass 2.0 4 oz bid (two times a day). Review of the medication administration record (MAR) for Resident 107 for March 2026 revealed the Med Pass 2.0 was not documented as administered per the physician order on the following dates/times: 9:00 AM dose:March 11; March 21-24; March 26-27; March 29-31 9:00 PM dose:March 21; March 29 Review of the MAR documentation for March 2026 revealed the following Administration Notes for the Med Pass 2.0 for Resident 107: March 21, 2026, at 8:11 AM: unavailableMarch 21, 2026, at 10:49 PM: unavailableMarch 22, 2026, at 8:04 AM: unavailableMarch 23, 2026, at 10:21 AM: UAMarch 24, 2026, at 8:54 AM: unavailableMarch 25, 2026, at 1:07 PM: Med Pass 2.0 unavailable Boost given, MD awareMarch 26, 2026, at 2:43 PM: Med pass unavailable. Boost given. MD aware.March 27, 2026, at 12:41 PM: unavailableMarch 29, 2026, at 9:57 AM: not available in buildingMarch 29, 2026, at 8:49 PM: not available, MD awareMarch 30, 2026, at 8:03 AM: Med Pass unavailable, boost given, MD aware.March 31, 2026, at 10:20 AM: unavailable Review of physician orders for Resident 170 revealed an order dated March 4, 2026, at 9:00 PM and discontinued on March 16, 2026, for Juven (a type of nutritional supplement) 0.97 ounce packet give two times a day and mix packet with 240 ml of water or beverage of choice. Review of the medication administration record (MAR) for Resident 170 for March 2026 revealed the Juven was not documented as administered per the physician order on the following dates/times: 9:00 AM dose:March 5 - 16 9:00 PM dose:March 5 - 9; March 11; March 13-15 Review of the MAR documentation for March 2026 revealed the following Administration Notes for Juven for Resident 170: March 5, 2026, at 2:08 PM: awaiting deliveryMarch 5, 2026, at 10:11 PM: awaiting deliveryMarch 6, 2026, at 9:09 AM: not availableMarch 6, 2026, at 8:58 PM: not availableMarch 7, 2026, at 8:06 AM: awaiting deliveryMarch 7, 2026, at 9:51 PM: med not availableMarch 8, 2026, at 9:46 AM: awaiting deliveryMarch 9, 2026, at 9:19 PM: none in houseMarch 10, 2026, at 9:38 AM: awaiting deliveryMarch 10, 2026, at 9:41 PM: supplied chocolate boost as that was the supplement we have on the unitMarch 11, 2026, at 9:43 AM: awaiting deliveryMarch 11, 2026, at 9:09 PM: unavailableMarch 12, 2026, at 9:17 AM: awaiting deliveryMarch 13, 2026, at 9:45 AM: awaiting delivery/response from MD to change orderMarch 13, 2026, at 9:43 PM: supplied a boost as juven is not availableMarch 14, 2026, at 10:20 AM: awaiting response for md to change orderMarch 14, 2026, at 8:22 PM: awaiting response for md to change order, not availableMarch 15, 2026, at 11:48 AM: u/aMarch 15, 2026, at 11:31 PM: Awaiting response for therapeutic exchange for house stock supplement(s).March 16, 2026, at 8:21 AM: awaiting order for substitute Documentation dated March 12, 2026, at 3:12 PM for Resident 170 noted, Resident also ordered Juven, but is unavailable. Requested to change to Prosource. Awaiting response. The above missing doses of physician ordered supplements for Residents 29, 107, and 170 were reviewed in a meeting with the Nursing Home Administrator and Employee 1, registered nurse regional consultant, on April 30, 2026, at 2:30 PM. The facility stated they would have to investigate the matter further. The above information for Residents 29, 107, and 170 were reviewed again in a meeting with the Nursing Home Administrator and Director of Nursing on May 1, 2026, at 9:46 AM and Employee 1 on May 1, 2026, at 9:56 AM. The facility was still looking into the matter. The facility provided documentation on May 1, 2026, at 2:15 PM titled, Item history by facility by weekly, which indicated Nutren 1.5 24/8 oz and listed a quantity of two for the date range of March 1-7, 2026. Med Pass 2.0 vanilla 24/8 oz was documented as four for quantity for the date range of March 1-7, 2026, and a quantity of two for the date range of March 29 - April 4, 2026. There was also a purchase order for Med Pass 2.0 vanilla (quantity two) with an approval date of March 27, 2026; a Med Pass 2.0 vanilla 12/32 oz purchase order approved March 30, 2026, for a quantity of four. There was no documentation provided by the facility for Residents 29, 107, and 170 to indicate why the residents had missed multiple doses of their physician ordered supplementation on the dates above (i.e. a supply issue, problem with order, failure to order, etc.). The facility failed to provide nutritional supplements as per the physician order to promote acceptable parameters of nutrition for Residents 29, 107, and 170. The facility policy entitled Impaired Nutrition/Unplanned Weight Loss- Clinical Protocol, last reviewed without changes January 30, 2026, revealed the nursing staff will monitor and document the weight and dietary intakes of residents in a format which permits comparisons over time. The staff and physician will define the individual's current nutritional status and identify individuals with significant weight loss or gain, or significant risk for impaired nutrition. The physician will consider whether any assessment including additional diagnostic testing is indicated to help clarify the severity or consequences of significant weight loss and/or impaired nutrition. The staff will report to the physician significant weight gains or losses, or any abrupt or persistent change from baseline appetite or food intake. Determination of significant weight loss will be assessed and reported to the physician if greater than five percent body weight loss in the last 30 days, or greater than 10 percent body weight loss in the last 180 days. Clinical record review revealed the facility admitted Resident 18 on May 22, 2025. Further review of Resident 18's clinical record revealed the following weight assessments: January 7, 2026, 199.9 poundsFebruary 18, 2026, 178.8 pounds (a 21.1-pound, 10.55 percent significant weight loss)March 4, 2026, 182.5 pounds There was no evidence that staff obtained a re-weight or notified Resident 18's physician after the February 18, 2026, significant weight loss. A weight change note dated March 6, 2026, at 10:52 AM confirmed Resident 18 had a significant weight loss over the past 90 and 180 days. She added Med Pass 2.0 to help support nutritional needs and stabilize pattern. Clinical record review revealed the facility admitted Resident 84 on June 30, 2025. Further review of Resident 84's clinical record revealed the following weight assessments: February 4, 2026, 126.4 poundsMarch 9, 2026, 101.6 pounds (a 24.8-pound, 19.62 percent significant weight loss)March 26, 2026, 107.9 pounds There was no evidence that staff obtained a re-weight or notified Resident 84's physician after the March 9, 2026, significant weight loss. A nutrition progress note dated March 27, 2026, at 1:07 PM revealed Employee 34 (certified dietary manager) documented that he notified Resident 84's physician of a 11.2 percent significant weight loss in less than 90 days. He recommended to start 120 ml Med Pass 2.0 twice daily to promote weight stability, and weekly weights. Clinical record review revealed the facility admitted Resident 12 on February 28, 2025. Further review of Resident 12's clinical record revealed the following weight assessments: January 7, 2026, 178.8 poundsFebruary 24, 2026, 126.2 pounds, (a 52.6 pound, 29.41 percent severe weight loss)February 25, 2026, 124.8 poundsMarch 4, 2026, 128.2 pounds Further review of Resident 12's clinical record revealed no assessment of Resident 12's severe weight loss, or any interventions addressing the severe weight loss until March 6, 2026. The registered dietitian documented a weight change note on March 6, 2026, noting the possible cause was unknown at this time. The registered dietitian added health shakes with Resident 12's meals and weekly weights for additional monitoring. There was no documentation that Resident 12's physician was notified timely of the severe weight loss. The surveyor reviewed the above nutritional concerns with Residents 18, 84, and 12, with the Nursing Home Administrator and Employee 1 (registered nurse regional consultant) during a meeting on April 30, 2026, at 2:40 PM. The above findings for Residents 18, 84, and 12 were reviewed with Employee 34 on May 1, 2026, at 11:03 AM, and he was unable to provide any further documentation. 483.25(g)(1) Maintains acceptable parameters of nutritional statusPreviously cited 5/2/25 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide food in accordance with resident preference and physician ordered diets on one of four open nursing units (F Unit, Residents 4, 26, 71, 127, and 175).Findings include: Interview with Resident 175 on April 28, 2026, at 1:56 PM revealed that he frequently receives meals from the kitchen that are not according to his preferences or his physician ordered diet. Resident 175 provided the tray ticket from his meal tray that indicated that he was to maintain a 2000 milliliter fluid restriction; however, Resident 175 stated that he no longer had that restriction. Resident 175 stated that he often does not receive double portions that is specified on his meal tray ticket. Clinical record review for Resident 175 revealed a discontinued physician's order (in effect as of December 16, 2024) that included a 2000 milliliter fluid restriction. The order was discontinued on October 12, 2025. An active physician order dated October 12, 2025, no longer included a 2000 milliliter fluid restriction. The surveyor reviewed Resident 175's dietary concerns during an interview with Employee 1 (registered nurse regional consultant) and the Nursing Home Administrator on April 30, 2026, at 2:15 PM. Interview with Resident 127 on April 28, 2026, at 1:56 PM revealed that he stopped attending resident council or food committee meetings because the facility did not make any changes or improvements. Resident 127 stated, they do what they want. During an interview with Resident 71 on April 29, 2026, at 9:40 AM he stated, They promise you stuff and don't deliver. Resident 71 continued to provide examples of meal items on the planned menu that do not arrive on his tray such as, Promised oatmeal and get grits (Cream of Wheat), promised cinnamon buns and they don't come. Resident 71 stated that he compares the piece of paper (that) comes with tray (tray ticket), to what is on the meal tray and knows that the meals are not provided as per the planned menu. During an interview with Resident 4 on April 28, 2026, at 12:46 PM she stated that the kitchen staff, switch, menu items. Resident 4 stated that she is not supposed to get any vegetables except cauliflower; that they knew about it ever since been here, years.the only vegetable I like is cauliflower. Observation of Resident 4's lunch tray during the interview revealed a large, uneaten, portion of green beans. Review of Resident 4's meal ticket revealed no indication to omit vegetables except cauliflower. Observation of the lunch meal provided to Resident 4 on April 29, 2026, at 12:30 PM revealed a portion of beef that was covered in gravy. Resident 4 provided her meal ticket delivered with the tray that instructed that she was not to have gravy. The surveyor reviewed Resident 4's concerns that her preferences are not honored by dietary staff during an interview with the Nursing Home Administrator, the Director of Nursing, and Employee 1 on April 29, 2026, at 2:00 PM. Interview with Resident 26 on April 30, 2026, at 1:17 PM revealed that she did not receive the lunch meal that she was supposed to receive. Resident 26 stated that she was to receive a turkey entree, but she received a ham entree that she was not going to eat. Resident 26 stated that she was supposed to receive gravy on the side and she did not receive it. Resident 26 stated that staff had to call to get her gravy. Interview with Employee 11 (nurse aide) on April 30, 2026, at 1:25 PM confirmed that Resident 26 did not receive gravy per her meal tray ticket. Employee 11 stated that staff, always have to call for gravy for her because the kitchen does not send it per her tray ticket. Interview with Employee 3 (nurse aide) on April 30, 2026, at 1:35 PM confirmed that Resident 26 is supposed to receive a side of gravy on her meal tray; however, she had to call the kitchen to have a portion sent to her after she received her meal. Employee 3 stated that she called the kitchen to have turkey provided for Resident 26 as per her meal ticket; however, she was told that they did not have any left and she would receive the ham alternative. Employee 3 stated that Resident 26 would not eat the ham entree. Interview with Employee 15 (food service director) on May 1, 2026, at 11:48 AM confirmed that the kitchen ran out of the turkey entree before all residents were served; and Resident 26 received a substitute ham entree. Employee 15 denied knowledge that Resident 26 had repeated concerns that she did not receive a side of gravy as per her preference. Employee 15 stated that nursing unit staff are to call kitchen staff for meal concerns and kitchen staff document these calls on a log. Employee 15 provided a log with only one entry that reported Resident 26's gravy concern (dated April 30, 2026). The log did not reflect numerous calls regarding Resident 26's desired gravy condiment as reported by Resident 26 and the nurse aides that work on her unit. 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) (e)(1)(2)(4) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.6(a) Dietary services

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate and report to the appropriate agencies an incident of resident abuse for one of one resident reviewed for resident-to-resident abuse concerns (Resident 2); and failed to implement abuse prevention policies related to screening newly hired employees for three of five employees reviewed (Employees 4, 6, and 8). Findings include: The facility policy entitled, Resident Abuse and Neglect Prevention Program, last reviewed January 30, 2026, revealed that it is the policy of the facility to screen potential employees for a history of abuse. All reasonable efforts will be made by the facility to obtain information from previous and/or current employers in an attempt to screen for history of abuse, neglect, or mistreatment of residents. A criminal background investigation will be conducted on all prospective employees utilizing the State police, and Federal Bureau of Investigation (FBI) if required. This includes but is not limited to contacting the State's nurse aide registry and verification of professional licensure status. The check will be initiated prior to the employee's date of hire. An FBI background investigation is required if the potential candidate has not resided in the state of Pennsylvania for the past two years. Results of the criminal background investigation shall be available within 30 days of hire for State police reports, and within 90 days for FBI reports. New employees shall not be permitted to continue working if the report results are not received within the appropriate time frame. Verification of current Pennsylvania professional licensure status or nurse aide registry with a copy of a valid certification, registry number or professional license is required prior to the first day of employment. Potential employees shall be required to provide at least three references on the application for employment. The three references will be a combination of work or personal. All new employees are required to attend an orientation program which includes a minimum of two hours of training related to Abuse and Neglect Prevention, Identification/Reporting of Abuse and Techniques for Caring for the Cognitively Impaired Resident. The employee signs a statement of receipt of education once completed which is then maintained in the employee file. The Identification and Investigation of Suspected Abuse/Neglect/Misappropriation, section of the policy noted that any individual(s) observing an incident of abuse or suspects abuse has a responsibility to intervene immediately so that the safety of the resident can be ensured. All management and staff are jointly and individually responsible to ensure that any complaint, allegation, or suspicion of abuse, or witnessed resident abuse, is reported immediately to the supervisor of the area. The registered nurse supervisor will notify the appropriate personnel of the incident. An incident report will be completed documenting the alleged abuse and results of the physical examination (any physical injuries noted to the resident(s). Upon receiving a report of abuse or alleged abuse, the registered nurse supervisor, Director of Nursing/assistant director of nursing, or Nursing Home Administrator will begin the investigation. The Regulatory Reporting, section of the policy noted that the facility will report alleged and substantiated incidents to the Pennsylvania Department of Health, additional state agencies, and/or local authorities per federal and state requirements. Interview with Employee 9 (human resources) and Employee 10 (human resources) on April 30, 2026, at 3:50 PM, revealed that the verbiage in the facility's currently utilized attestation of Pennsylvania residency completed by new hires notes, Have you be (sic) a resident of Pennsylvania for 2 or more years? The document does not have the prospective employee provide the dates of residency or attest that he/she resided in the state of Pennsylvania consecutively for the past two years. Review of personnel records for newly hired employees with Employee 9 and Employee 10 on April 30, 2026, at 3:50 PM revealed the following concerns: Employee 4 (nurse aide) was hired by the facility on January 19, 2026. The available documentation in Employee's personnel records revealed no evidence that the facility obtained Employee 4's nurse aide registry verification or that Employee 4 completed Abuse and Neglect Prevention, Identification/Reporting of Abuse, and Techniques for Caring for the Cognitively Impaired Resident training. Employee 4's personnel record contained an attestation signed December 11, 2025, that she was a resident of Pennsylvania for two or more years. The attestation, or other evidence in Employee 4's available personnel records (e.g., dates of current or previous addresses), did not stipulate that the two years of Pennsylvania residency were the previous two consecutive years. Employee 6 (licensed practical nurse) was hired by the facility on February 9, 2026. Information available in Employee 6's personnel file did not include the dates that she worked at the employment locations listed. Interview with Employees 9 and 10 on the date and at the time of the review confirmed that the facility could not thoroughly verify Employee 6's alleged employment history without knowing the dates she was allegedly employed. Employee 8 (social worker) was hired by the facility on March 16, 2026. Evidence of Employee 8's abuse prevention education indicated that he received the education on March 23, 2026 (one week after his date of hire). Interview with Employee 10 on May 1, 2026, at 12:00 PM indicated that the facility could not provide evidence that Employee 8 did not have resident contact during the week before his documented abuse training. Information available in Employee 8's personnel record revealed that the Pennsylvania criminal background verification was not obtained until April 30, 2026 (following the surveyor's request for Employee 8's personnel record). Interview with Employee 10 on May 1, 2026, at 12:00 PM confirmed that the facility could not provide evidence of an attempt to obtain Employee 8's criminal background verification before, or within 30 days, of his date of hire. The surveyor reviewed the above concerns regarding pre-employment screening for Employees 4, 6, and 8, during an interview with the Nursing Home Administrator and the Director of Nursing on May 1, 2026, at 9:20 AM. The facility policy entitled Abuse Investigation and Reporting, last reviewed without changes January 30, 2026, revealed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be thoroughly investigated by facility management. Allegations of abuse and neglect will be reported to local, state, and federal agencies (as defined by current regulations. All alleged violations involving abuse or neglect will be reported by the facility Administrator, or his/her designee to the State licensing/certification agency responsible for surveying/licensing the facility, the local/state ombudsman, the resident's representative, law enforcement officials, and the resident's attending physician. An alleged violation of abuse, neglect, exploitation or mistreatment will be reported immediately, but not later than two hours if the alleged violation involves abuse or resulted in serious bodily injury, or 24 hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. Clinical record review revealed the facility admitted Resident 2 on December 3, 2025. Nursing documentation dated March 17, 2026 (late entry documented on March 20, 2026), at 7:15 PM noted the nurse on A nursing unit heard Resident 117 say something about Resident 2 being on his bed. Documentation revealed on the nurse's way to Resident 117's room a thud was heard. Upon arrival Resident 117 was witnessed standing in the doorway and Resident 2 was lying on his back on the floor. Documentation revealed Resident 117 stated I am not a wussy, he kicked me and swung at me, so I put him down. When the nurse asked Resident 2 what happened he stated, he hit me once and I went down. Documentation revealed a resident witness was interviewed and he stated they were wrestling and the one resident was hunched over and then started to fall. He tried to catch himself but couldn't. Documentation revealed that everything was reported to the Director of Nursing. Interview with Employee 1 (registered nurse regional consultant) on May 1, 2026, at 12:14 PM, confirmed that the facility did not complete an investigation, obtain witness statements, notify law enforcement, or notify the Department of Health related to the resident-to-resident allegation of physical abuse with Resident 2. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1)(3)(e)(1) Management 28 Pa Code 201.19(1)(3)(8)(10) Personnel policies and procedures 28 Pa. Code 201.20(b)(d) Staff development 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of select facility policies and procedures, clinical record review, observation, and resident, family, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection on one of four open nursing units (F Unit, Residents 3, 4, 68, and 74).Findings include: Observation of a medication administration pass for Resident 4 on April 29, 2026, at 10:31 AM with Employee 21 (licensed practical nurse) revealed Employee 21 donned gloves to administer an eye drop to Resident 4's right eye. Employee 21 removed her gloves after the eye drop administration, placed the eye drop medication back in the medication cart drawer, typed on the computer on the medication cart, before she moved the medication cart to the nurses' station. Employee 21 did not perform hand hygiene after removing her gloves. Interview with Employee 21 on April 29, 2026, at 10:49 AM confirmed that she did not perform hand hygiene after removing her gloves. Employee 21 pointed to the alcohol hand sanitizer on her medication cart; and stated that she had been trained to perform hand hygiene after removing gloves. The facility policy entitled, Categories of Transmission-Based Precautions, last reviewed January 30, 2026, revealed that transmission-based precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. Contact Precautions are for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Examples of infections requiring Contact Precautions include diarrhea associated with Clostridium difficile (C. diff, a species of bacteria that can infect the colon and cause severe diarrhea). If a private room is not available, the Infection Control Coordinator will assess various risks associated with other resident placement options (e.g., cohorting). Wear gloves when providing any care to the resident. Remove gloves before leaving the room and wash hands immediately with an antimicrobial agent or waterless antiseptic agent. Wear a gown for all interactions that may involve contact with the resident or potentially contaminated items in the resident's environment. Remove the gown and perform hand hygiene before leaving the resident's environment. When possible, dedicate the use of non-critical resident-care equipment items such as a stethoscope or bedside commode to a single resident to avoid sharing between residents. If use of common items is unavoidable, then adequately clean and disinfect them before use for another resident. The above policy did not address appropriate hand hygiene after Contact Precautions implemented for organisms not affected by alcohol-based sanitizers such as C. diff. The facility policy entitled, Enhanced Barrier Precautions (EBP), last reviewed January 30, 2026, revealed that to minimize the transmission of germs transferring from residents to staff hands and clothing, staff will wear gown and gloves when providing care to residents that require significant physical contact and are at high risk of acquiring or spreading multi-drug resistant organisms (MDROs). EBP, refers to an infection control intervention designed to reduce transmission of MDROs that requires staff to wear a gown and gloves while performing high-contact care activities with all residents who are at higher risk of acquiring or spreading an MDRO. High-contact resident care activities include transferring residents from one position to another, providing hygiene, changing bed linens, and assisting with toileting. A physician's order for EBP will be obtained. Residents who are on EBP due to colonization with a target MDRO will only be cohorted with another resident infected or colonized with the same organism. The nursing staff and/or infection preventionist will ensure that staff are aware of a resident requiring EBP. The facility policy entitled, Handwashing/Hand Hygiene, last reviewed January 30, 2026, revealed that the facility considers hand hygiene as the primary means to prevent the spread of infections. Use an alcohol-based hand rub or soap and water after contact with objects in the immediate vicinity of the resident, after removing gloves, and before and after entering isolation precautions settings. Wash hands with soap and water for the following situations: When hands are visibly soiledBefore eatingAfter using the bathroomAfter contact with a resident with infectious diarrhea including, but not limited to infections caused by C. diff Observation of the doorway to Resident 68 and 74's room on April 28, 2026, at 2:32 PM revealed a sign labeled Contact Precautions and a sign labeled Enhanced Barrier Precautions. An organizer on the door contained isolation gowns and gloves. The Contact Precautions sign noted that everyone must clean their hands before entering the room and wash them with soap and water when leaving the room; staff must use dedicated equipment. Clinical record review for Resident 68 revealed an active physician order (dated February 18, 2026) for EBP every shift for history of ESBL (Extended Spectrum Beta Lactamase, enzymes produced by certain bacteria that confer resistance to a wide range of antibiotics, making infections caused by these bacteria difficult to treat) in her urine. Interview with Resident 68 on April 28, 2026, at 2:40 PM revealed that she takes herself to the bathroom in her room. Resident 68 stated that she has had an occasion when the resident in the room next door opens the door while she is in there. Resident 68 stated that her roommate is also independent in the room and uses that bathroom. Clinical record review for Resident 74 revealed the following active physician orders: Enhanced Barrier Precautions (EBP) every shift related to ESBL Resistance, dated April 14, 2026.Contact precautions for C. diff, every shift for diarrhea; discontinue C. diff contact precautions if C. diff negative, dated April 24, 2026. Observation of a medication administration pass for Resident 74 on April 29, 2026, at 11:09 AM revealed Employee 22 (licensed practical nurse) entered Resident 74's room without donning a gown or wearing gloves to administer her medications. Employee 22 sorted through Resident 74's belongings to find respiratory treatment equipment to administer additional medication to Resident 74. Employee 22 used a stethoscope that she kept on her person to listen to Resident 74's lungs. Employee 22 did not wash her hands with soap and water before leaving Resident 74's room. Employee 22 used an alcohol pad to clean the earpieces and bell of her stethoscope before draping the stethoscope around her neck. Alcohol-based sanitizers are ineffective against C. diff because the bacterium forms spores that are resistant to alcohol. Continued observation of Employee 22 on April 29, 2026, from 11:12 AM to 11:19 AM revealed her to leave the medication cart, go to the medical supply storage room behind the nurses' station, obtain new tubing for Resident 74's respiratory treatment equipment, and return to Resident 74's bedside without donning PPE. While in Resident 74's room on April 29, 2026, at 11:21 AM Employee 22 noted that her roommate's (Resident 68) oxygen tubing was not applied correctly in her nose. Employee 22 adjusted Resident 68's nasal oxygen tubing, used alcohol-based hand sanitizer (that is ineffective against C. diff), and left the nursing unit to go to the supervisor's office to obtain medication from the stock supply. Employee 22 returned to Resident 74's room on April 29, 2026, at 11:46 AM, applied a gown and gloves to enter the room, and began the administration of Resident 74's respiratory treatment. During Resident 74's treatment, Resident 68's daughter was sitting on Resident 68's bed, observed Resident 74's respiratory treatment, and asked, does she have something contagious that I should know about? Continued observation of Resident 68 and 74's room on April 29, 2026, at 11:58 AM revealed Resident 68's daughter assisted her mother to ambulate to the bathroom. Resident 68's daughter was not wearing a gown or gloves. Interview with Resident 68's daughter on May 4, 2026, at 12:22 PM revealed that she received no education or instruction from facility staff regarding special precautions or additional care necessary when visiting her mother (e.g., handwashing, avoiding direct contact with environmental surfaces in the room such as her bed, or wearing gloves). Resident 68's daughter indicated that she requested that the facility obtain testing of her mother's urine; and that the doctor ordered an antibiotic for her mother last week for a urinary tract infection. Interview with Resident 74 on April 29, 2026, at 12:00 PM confirmed that she independently utilizes the same bathroom in the room as needed. Interview with Employee 24 (licensed practical nurse) on April 30, 2026, at 1:12 PM confirmed that Residents 3, 68, and 74 use the same bathroom. Clinical record review for Resident 3 revealed no diagnoses of C. diff or history of ESBL infection or colonization. Observation on April 29, 2026, at 11:59 AM revealed Employee 23 (nurse aide) entered Resident 68 and 74's room to provide a new incontinence pad on Resident 68's bed because it was reportedly wet from urinary incontinence. Employee 23 wore gloves to change the pad but did not don a gown. Interview with Employee 23 on the date and time of the observation indicated that she believed the PPE signage and equipment on the room door was for Resident 74, not Resident 68. Observation of Employee 22 completing Resident 74's respiratory treatment on April 29, 2026, at 11:56 AM revealed that she cleaned the oxygen tubing at the sink in the room, bagged the equipment, used her stethoscope to listen to Resident 74's lungs, removed her gown and gloves, performed hand hygiene at the sink in the room, and exited the room to the medication cart. Employee 22 did not utilize an effective method to clean her stethoscope after use with Resident 74. Nursing documentation dated April 30, 2026, at 3:33 PM noted that the physician reviewed Resident 68's laboratory results from urine testing and provided a new order to start Macrobid (an antibiotic) twice daily for seven days. Interview with Employee 26 (licensed practical nurse/infection control prevention coordinator) on April 30, 2026, at 9:20 AM confirmed that Employee 22 should have used the wipes that contain bleach to clean her stethoscope that was not dedicated equipment for Resident 74. Employee 26 also confirmed that the facility should have implemented a bedside commode for Resident 74 until the suspected C. diff infection was ruled out. Employee 26 stated that the facility did not consider Resident 3's (not diagnosed with a history of ESBL or C. diff) use of the bathroom that was used by Residents 68 and 74 (on EBP for a history of ESBL and contact precautions for C. diff). Observation of Resident 68's room on April 28, 2026, at 2:32 PM revealed that she used supplemental oxygen. A respiratory mask not in use at the time of the observation was stored on top of Resident 68's bedside stand. The mask was not bagged or otherwise protected from potential environmental contaminants. Interview with Resident 68 indicated that she received respiratory medication through the mask three times a day. Clinical record review for Resident 68 revealed medication administration records dated April 2026 that indicated that she received Albuterol Sulfate Inhalation Nebulization Solution (Albuterol Sulfate, medication inhaled to dilate the airways or prevent spasms of the airways in residents who have lung conditions) three times a day at 8:00 AM, 1:00 PM, and 9:00 PM. The surveyor requested the facility's policy or procedure regarding the storage of oxygen equipment when not in use during an interview with the Nursing Home Administrator and the Director of Nursing on April 29, 2026, at 2:00 PM. The facility policy provided, entitled, Oxygen Storage, reviewed January 30, 2026, did not address measures the facility staff would take to protect oxygen equipment such as face masks when not in use to prevent potential environmental contamination. Interview with Employee 22 on April 29, 2026, at 11:19 AM confirmed Resident 68's respiratory equipment was not bagged in an antimicrobial bag as per the facility's practice. The surveyor reviewed the above infection control concerns during an interview with the Nursing Home Administrator and Employee 1 (registered nurse regional consultant) on April 30, 2026, at 2:15 PM. 483.80(a)(1)(2)(4)(e)(f) Infection Prevention and ControlPreviously cited deficiency 5/2/25 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility documentation and staff interview it was determined that the facility failed to maintain documentation of staff COVID-19 vaccination status, for two of two staff reviewed (Employees 27 and 28). Findings include: Interview with Employee 27 (nurse aide) on April 29, 2026, at 9:29 AM revealed that she declined the COVID vaccination that the facility offered last year. Interview with Employee 28 (nurse aide) on April 29, 2026, at 9:31 AM revealed that she received COVID vaccinations in the past but declined the COVID vaccination the facility offered last year. Interview with Employee 26, (infection preventionist) on May 1, 2026, at 11:23 AM revealed that she was unable to provide evidence that she maintained staff documentation of their current COVID-19 vaccination status. Review of Employees 27 and 28's employee health files also revealed no evidence of their vaccination status. The surveyor reviewed the above noted findings with the Nursing Home Administrator on May 1, 2026, at 11:51 AM. 483.80 Infection controlPreviously cited 5/2/2025 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of select facility policy and procedure, clinical record review, and staff interview, it was determined that the facility failed to provide care consistent with professional standards of practice, for a resident who required dialysis services for one of two residents reviewed for dialysis concerns (Resident 7).Findings include: Review of the facility policy titled, Dialysis - Renal Dialysis Policy, last reviewed on January 30, 2026, noted (in part) a section titled, Post-Dialysis Care. This section of the policy noted that staff are to evaluate the dialysis access site for bleeding, signs/symptoms of infection, intact placement, etc. Document the observation of the access site. The policy also noted that if a shunt is present, assess the presence or absence of a bruit (a sound produced by blood flow) and thrill (a palpable vibration). Clinical record review for Resident 7 revealed a diagnoses list that included chronic kidney disease stage four (an advanced stage of kidney disease indicating severe damage to the kidneys which filter waste and excess fluid from the blood) and dependence on renal dialysis (a machine that performs a basic function of the kidney by cleansing the blood of impurities). A current care plan for Resident 7 revealed the resident needs dialysis related to renal (kidney) failure and has an arteriovenous (AV) fistula (surgically created connection between an artery and a vein to provide access for hemodialysis) in the left arm. The care plan indicated Resident 7 received hemodialysis three times a week at a dialysis center. Review of nursing documentation for Resident 7 dated April 21, 2026, at 10:08 AM revealed a nursing progress note that noted left arm fistula pulsatile with a positive bruit and thrill. Further clinical record review for Resident 7 revealed no documentation that staff had assessed the AV fistula site for a bruit and thrill routinely or upon post-dialysis care as indicated in the facility policy. The facility failed to provide appropriate assessment for the dialysis fistula for Resident 7. The findings regarding Resident 7's dialysis fistula were confirmed during a meeting with the Nursing Home Administrator and Director of Nursing on May 1, 2026, at 9:46 AM. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for one of one resident reviewed for mood and behaviors (Resident 9).Findings include: Clinical record review revealed the facility admitted Resident 9 on October 14, 2024, with diagnoses including, Alzheimer's Dementia (disease that affects memory, thinking and behavior) and Post Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event). Review of Resident 9's care plan-initiated April 30, 2025, revealed a mood problem related to chronic PTSD, noting Resident 9 has a history of unspecified childhood trauma, exposed to multiple childhood events that she does not like to discuss, or provide details, including her triggers noting she also has Alzheimer's and vascular dementia. A MDS (Minimum Data Set, an assessment completed at specific intervals to determine resident care needs) dated January 16, 2026, revealed staff assessed Resident 9 as having severe cognitive impairment. Review of Resident 9's clinical record revealed there were four family members listed as her emergency contacts. There was no evidence the facility attempted to determine Resident 9's triggers by interviewing Resident 9's family, reviewing previous history and physical reports, or physician assessments, to help identify Resident 9's triggers to prevent re-traumatization. Reviewed the above findings for Resident 9 with the Nursing Home Administrator and Director of Nursing during a meeting on April 30, 2026, at 2:21 PM. Interview with Employee 1 (registered nurse regional consultant) on May 1, 2026, at 9:27 AM confirmed the above findings for Resident 9 and was unable to provide any further documentation. 483.25(m) Trauma-informed care Previously cited 5/2/2025 28 Pa Code 211.12 (d)(3)(5) Nursing services

Based on observation and resident and staff interview, it was determined that the facility failed to ensure a clean, comfortable, and homelike environment on two of four open nursing units (G unit emergency exit doorway, and F unit, Residents 4, 95, and 127). Findings include: Interview with Resident 4 on the F unit hallway on April 28, 2026, at 12:50 PM revealed that she requested the surveyor observe her room. Observation of Resident 4's room on April 28, 2026, at 12:52 PM revealed personal possessions that blocked the door to the bathroom, blocked access to the handwashing sink, blocked access to her and her roommate's closet, covered the majority of dresser and furniture surfaces, and covered a large portion of the floor space. Resident 4 stated on the date and time of the observation that she required staff assistance to organize her room and remove two of the storage totes that were present in the room. Resident 4's manual wheelchair (not in use while she sat in a motorized wheelchair) was stored on her roommate's side of the room (in front of the closets). Resident 4's storage totes also were stored on her roommate's side of the room. Items on Resident 4's floor included personal cleaning wipes and a roll of toilet paper. The bifold door for the closet was broken from the mounting track and hung open into the room. Interview with Employee 2 (housekeeping/laundry director) on April 29, 2026, at 10:03 AM indicated that she made a list twice over two months for activities staff to go through Resident 4's possessions with her. Employee 2 stated that she was on the unit at this time to take storage totes from Resident 4's room. Employee 2 confirmed that the number of possessions that covered surfaces in Resident 4's room prevented housekeeping staff from effectively cleaning the room. The surveyor reviewed the above findings regarding Resident 4's room with the Nursing Home Administrator and the Director of Nursing on April 29, 2026, at 2:00 PM. Interview with Resident 127 on April 29, 2026, at 12:00 PM revealed that he believed Resident 95 stored food in his bedside stand that was unsafe for him to eat. Observation of Resident 95's bedside stand with Employee 3 (nurse aide) on April 29, 2026, at 12:39 PM revealed a sandwich bun with ketchup wrapped loosely in a napkin stored directly in his bedside stand drawer. Employee 3 removed several packets of undated packets of mayonnaise, and an empty (and uncleaned) bowl that looked to have contained fruit. Employee 3 removed two bowls of what appeared to be prepared hot cereal (Cream of Wheat) that had no date of preparation or expiration. Employee 3 also removed two containers of apple juice that had no expiration date indicated, and a container of lemonade that had no expiration date on the container. Employee 3 also removed a lidded cup that contained liquid that Employee 3 believed was cold coffee. The surveyor reviewed the findings related to Resident 95's room during an interview with Employee 1 (registered nurse corporate consultant) and the Director of Nursing on April 30, 2026, at 9:35 AM. Observation on April 29, 2026, at 10:05 AM of the G unit revealed an emergency exit door in the hallway was rusted at the base of the door on both sides. A 0.5-inch gap was noted where the outdoor sidewalk was clearly visible. The 0.5-inch gap extended from the threshold of the door, two feet up towards the door handle. At the base of the wall to the left of the door the baseboard was peeled away, revealing painted drywall that was peeling and bubbling. Around the threshold of the door was noted dust, debris including food crumbs, a piece of chocolate candy, and three needle cap seals (round, 0.5-inch coverings that are removed from needle packaging prior to use). The above information regarding the G unit emergency exit doorway was reviewed with the Nursing Home Administrator and the Director of Nursing on April 29, 2026, at 2:15 PM. 483.10(i)(1)-(7) Safe/clean/comfortable/homelike EnvironmentPreviously cited 5/2/25 and 9/17/25 28 Pa. Code 201.18(b)(3)(e)(2.1) Management

Based on clinical record review and staff interview, it was determined that the facility failed to monitor the use of psychotropic medications for one of five residents reviewed for potentially unnecessary medications (Resident 2).Findings include: Clinical record review for Resident 2 revealed active physician orders for staff to administer the following psychotropic medications: Lexapro (an antidepressant medication) 10 milligrams (mg), two tablets in the morning for depression.Trazadone (an antidepressant medication) 50 mg, half a tablet in the morning and one tablet at bedtime for depression.Seroquel (an antipsychotic medication) 25 mg, one tablet two times a day for psychosis. A physician order dated January 9, 2026, instructed staff to monitor Resident 2's behavior related to agitation and anxiety. There was no documentation in Resident 2's clinical record that staff monitored Resident 2's behaviors related to his psychosis and depression. Resident 2's clinical record failed to provide evidence that the facility was monitoring for potential side effects from Resident 2's use of the above-mentioned psychotropic medications. Interview with Employee 1 (registered nurse regional consultant) on May 1, 2026, at 1:06 PM confirmed the above findings for Resident 2. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, clinical record review, review of select facility documents, and staff and resident interview, it was determined that the facility failed to provide resident assistance to attend activities of interest for one of two residents reviewed for activities (Resident 140).Findings include: Interview with Resident 140 on April 28, 2026, at 12:55 PM, revealed that they enjoyed some of the activities, especially bingo which was scheduled for that day at 2:00 PM. Resident 140 stated that they are dependent on staff to take them to the activities, and often they do not come to get them. Observation on April 28, 2026, at 3:15 PM, revealed that bingo was ongoing, but Resident 140 was not present. Concurrent interview with Resident 140 revealed that they did not change their mind and they still wanted to attend Bingo today, but staff did not come to take them. Review of Resident 140's clinical record reveals they have a care plan (outline of an individual's health needs, specific care requirements, and the actions necessary to achieve desired health outcomes) Focus that was initiated on August 18, 2020, that states the resident is dependent on staff for activities. Interview with Employee 25, activities director, on April 30, 2026, at 9:30 AM, revealed that Resident 140 was supposed to be brought to the bingo activity on April 28. 2026, by an aide, however the aide did not bring them. The above information was reviewed with the Nursing Home Administrator and Employee 1, RN Regional Consultant on April 30, 2026, at 2:45 PM. 28 Pa. Code 201.29 (a) Resident rights

Based on clinical record review, review of facility documentation, and staff and resident interview, it was determined that the facility failed to provide the highest practical care regarding physician ordered medications, allergies, and devices for three of 35 residents reviewed (Residents 53, 116, and 140).Findings include: During an interview with Resident 140 on April 28, 2026, at 12:55 PM, they stated that they had increased pain in their right shoulder because the nurse had not applied their pain patch. The resident allowed the surveyor to assess the resident's shoulders, and no patch could be located on either shoulder. Clinical record review for Resident 140 revealed that the resident had an active physician order for a topical pain patch written April 10, 2026, that stated, Aspercreme Lidocaine External Patch 4 % (Lidocaine) apply to right shoulder topically one time a day for right shoulder pain and remove per schedule. Further review revealed that the patch was signed in the MAR (Medication Administration Record) as completed for April 28, 2026, indicating that the patch was applied during the 9:00 AM medication administration. Clinical record review revealed that the patch was documented as removed on the resident's MAR on April 28, 2026, during the 9:00 PM medication administration, but no documentation was found indicating that the patch was not present or that it had been located and applied/reapplied throughout the day. On April 28, 2026, at 4:16 PM, it is documented that Resident 140 reported pain of an eight out of ten (severe pain) and was administered an as needed pain medication Oxycodone (an opioid medication used to manage severe pain) 5mg (milligram) tablet. The above information related to Resident 140 was reviewed with the Nursing Home Administrator and the Director of Nursing on April 29, 2026, at 2:15 PM. Review of Resident 53's clinical record revealed that they had an allergy to adhesive active since January 28, 2026. Further review of the resident's clinical record revealed a progress note written on April 14, 2026, by a licensed practical nurse, that stated, Ileostomy continues to leak. stoma powder and adhesive attempted. The above information regarding resident 53 was reviewed with the Nursing Home administrator and Employee 1, RN Corporate Consultant, on May 1, 2026, at 10:30 AM. Clinical record review for Resident 116 revealed a diagnoses list that included the presence of a neurostimulator. Hospital documentation for Resident 116 revealed an implant list that included an implantable pulse generator implanted on May 24, 2019, and a kit pulse generator implanted on September 25, 2020. Further review of the clinical record for Resident 116 revealed no evidence that the facility addressed the neurostimulator or implemented a person-centered care plan related to the device (addressing the type of neurostimulator, assessments, complications, etc.). The above information for Resident 116 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on April 29, 2026, at 2:40 PM. 483.25 Quality of CarePreviously cites 5/2/25, 7/14/25 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to protect residents from staff neglect resulting in a fall from a wheelchair with serious injury for one of seven residents reviewed (Resident CR1). This deficiency is cited as past noncomplianceFindings include: Closed clinical record review for Resident CR1 revealed a diagnosis list that included vascular dementia (a type of dementia caused by reduced blood flow to the brain and leading to cognitive impairments such as memory loss, loss of judgment, and loss of complex motor skills). Review of facility documentation titled, Fall Risk, dated July 18, 2025, at 1:09 PM revealed that the facility assessed Resident CR1 as a score of 11, which indicated a category of High Risk. Facility staff documented the resident's fall risk predictive factors that included the LOC (level of consciousness) as poor recall, judgement, and safety awareness. Review of Resident CR1s care plan revealed the resident had care plans that addressed the following: impaired cognitive function related to the medical history; a communication problem related to dementia; an activity of daily living (ADL) self-care deficit related to activity intolerance, impaired balance, and limited mobility; and a potential for falls related to deconditioning and gait/balance problems. Further clinical record review for Resident CR1 revealed a quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated July 22, 2025, that noted facility staff assessed the resident as having a BIMS (Brief Interview for Mental Status) of 0, which indicated cognitive impairment. Further review of the MDS revealed that facility staff assessed the resident's functional status as follows: roll left and right (the ability to roll from lying on back to left and right side, and return to lying on back on the bed) as dependent on staff; sit to lying (the ability to move from sitting on side of bed to lying flat on the bed) as dependent; lying to sitting on side of bed (the ability to move from lying on the back to sitting on the side of the bed and with no back support) as dependent; sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed) as dependent on staff; chair/bed-to-chair transfer (the ability to transfer to and from a bed to a chair or wheelchair as dependent; and walking was marked as not applicable. Physical therapy documentation for Resident CR1 noted a PT (physical therapy) Evaluation and Plan of Treatment dated July 8, 2025. In the section titled, Initial Assessment/Current Level of Functioning and Underlying Impairments, therapy staff documented precautions as assist with two with arm-in-arm technique for transfers; out of bed to wheelchair with leg rests and foot buddy. Wheelchair mobility documented the resident as dependent on staff to wheel 50 feet with two turns. The bilateral lower extremity strength was documented as impaired. Further review of physical therapy documentation for Resident CR1 revealed a PT Discharge summary dated [DATE], that noted a functional reach assessment documented as two inches that therapy staff noted as predictive of falls, an elderly mobility scale documented as 0 out of 20 (an assessment that indicated the resident needs assistance from staff for mobility), standing balance with upper extremity support as poor to poor. The documentation further noted the resident was dependent on staff for bed mobility, transfers, sit to lying, lying to sitting on side of bed, chair/bed-to-chair transfer, and wheel 50 feet with two turns. The therapy tab in Resident CR1's electronic health record (EHR) noted precautions that included (PT) assist x2 with arm in arm technique for transfers, OOB (out of bed) to wheelchair with leg rests and foot buddy. An interview with the Director of Nursing on September 17, 2025, at 3:30 PM revealed that Resident CR1 did not self-propel in the wheelchair. Nursing documentation for Resident CR1 dated September 6, 2025, at 5:05 PM revealed that staff had notified the registered nurse that a resident had fallen out of her wheelchair. The resident was observed laying on her left side in the hallway. Bleeding was observed from a laceration on the left side of the resident's head above the eye. Emergency medical services (EMS) were called and the resident was transported to the hospital for evaluation. Review of the facility Incident/Accident form noted an Employee Statement with a date of event as September 6, 2025. The resident's name was noted as Resident CR1. The written and signed employee statement from Employee 2 (the staff members signature was identified by the Nursing Home Administrator), licensed practical nurse, noted in summary that Employee 1, nurse aide, came around the corner going very fast and flying the resident to the side and thrusted out of the wheelchair and onto the floor headfirst. The resident's head immediately started bleeding. Employee 2 noted the nurse aide was advised that she was going way too fast. Review of the facility documentation revealed a form titled, Employee Statement Regarding Knowledge of Resident Incident, that was dated September 6, 2025. The resident involved was noted as Resident CR1. Employee 3 noted they heard others stating, she had no leg rests, they were pushing with no leg rests, they always have to have leg rests. Employee 3 continued up the hall and noted the registered nurse was on the floor the resident with bloody towels. Employee 3 was asked to call 911. Review of the facility Incident/Accident form noted a written and signed statement from Employee 1 noted the employee proceeded to wheel resident CR1 back to her room. Employee 1 made a turn down the hallway and the resident fell face first. Employee 1 tried to grab the resident's cardigan and the resident fell. The resident's left side of her head started to bleed, and the employee applied pressure to the wound to stop the bleeding until the nursing staff stepped in. Hospital documentation for Resident CR1 dated September 6, 2025, at 8:47 PM revealed that the resident presented to the Emergency Department (ED) for evaluation of a fall at the nursing home. Documentation noted the resident fell and hit her forehead. The ED course noted a CT scan (computed tomography; a type of medical imaging test that creates a scan of the body using x-ray technology) of the head and brain that indicated few foci of intraparenchymal hemorrhage (IPH, bleeding that occurs within the brain) in the right frontal lobe most pronounced posteriorly; there was an associated small volume subarachnoid (a space located around the brain) component. Hospital documentation for Resident CR1 dated September 6, 2025, at 11:22 PM noted the resident was transferred for trauma evaluation from a previous hospital. The resident had a fall forward out of her wheelchair and was found to have a brain bleed. The CT was notable for intraparenchymal hemorrhage and subarachnoid hemorrhage. The physical exam noted a large left forehead laceration with notable frontal bone exposed. The resident was admitted to the hospital. Hospital Documentation for Resident CR1 dated September 8, 2025, at 6:14 AM documented, Injury Complex / Problems as the following: fall, scalp lac (laceration), subarachnoid hemorrhage, and intraparenchymal hemorrhage. The associated diagnosis list included the same as active problems. Information provided to the Department on September 7, 2025, noted the date of the event for Resident CR1 as September 6, 2025. The factual description noted the resident was being pushed by the nurse aide down the hallway when the resident planted her feet on the ground causing the resident to fall forward out of the wheelchair. The resident had sustained a laceration to the left side of the forehead and was transported to the ED. Initial whole house audit completed on all moveable chairs to ensure they have leg rests/leg rest bags. Education started for all staff regarding need for leg rests when transporting residents in moveable chairs. Review of the facility Incident/Accident form noted an Employee Statement with a date of event as September 5, 2025. The resident name was blank. The written and signed employee statement from Employee 4, licensed practical nurse, noted the staff member did not witness the event, but was told by other staff members that Employee 1 was involved with pushing a resident fast in a wheelchair. Employee 4 instructed Employee 1 to never push a resident without leg rests and never push a resident very fast. The documentation noted Employee 1 was instructed on giving care with caution and patience, transporting properly, and proper leg rests. Review of the facility Incident/Accident form noted a Statement from Employee 5, licensed practical nurse, that on September 5, 2025, the nurse aide was seen by staff running in the hallway with another resident in a wheelchair and the nurse spoke with the staff member about running with residents in a wheelchair and about them not having leg rests. An interview with the Nursing Home Administrator and Director of Nursing on September 17, 2025, at 12:31 PM revealed that Employee 1 was educated on September 5, 2025 (the day prior to Resident CR1's fall), by the licensed practical nurse, about using leg rests and not pushing residents fast. On September 6, 2025, Employee 1 was pushing Resident CR1 without leg rests on the wheelchair when she fell and sustained an injury. The facility failed to ensure that staff appropriately implemented resident interventions necessary to prevent falls or injury after staff members identified the initial concerns with Employee 1 on September 5, 2025. The facility identified the concern with Resident CR1 on September 6, 2025, and as a result, disciplinary action was taken against Employee 1. The facility conducted full house audits on each nursing unit on September 6, 2025. The facility provided full house education from September 6 to 7, 2025, to all staff regarding the use of leg rests when pushing a resident in a wheelchair. Follow-up audits were conducted on September 10 and September 16, 2025, by the facility to ensure leg rests are intact if a resident is being pushed by a staff member and does not self-propel, and foot rests are available on the back of the wheelchair or Broda chair if the resident does self-propel in case the resident is needed to be pushed in the chair by a staff member. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on September 17, 2025, at 3:40 PM. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to implement interventions related to fall injury prevention and failed to provide adequate supervision resulting in a fall with injury for one of three residents reviewed (Resident CR1).This deficiency is cited as past noncomplianceFindings include: Closed clinical record review for Resident CR1 revealed a diagnosis list that included Alzheimer's Disease with Late Onset (a progressive brain disorder that affects memory, thinking, and language), the need for assistance with personal care, and lack of coordination. Review of facility documentation titled, Fall Risk, dated July 18, 2025, at 4:57 PM revealed that facility staff assessed the resident as a score of 10, which indicated a category of High Risk. Facility staff documented the resident's fall risk predictive factors that included the LOC (level of consciousness) as Poor recall, judgement, safety awareness. Review of Resident CR1's care plan revealed the resident had care plans that addressed the following: impaired cognitive function related to the medical history that was initiated on March 12, 2021; an activities of daily living (ADL) self-care deficit related to the medical history that was initiated on March 3, 2021; and resistive to care at times, will refuse medications, and hearing aids and will attempt to get out of bed and transfer independently if environment around her is not calm or quiet to remove herself from environment that was initiated November 23, 2021. Further review of Resident CR1's care plan revealed that the resident was at risk for falls related to the medical history dated as initiated on March 3, 2021. An intervention included having the bed in the lowest position at all times while in bed initiated on May 16, 2025 A review of the task list (located in the electronic health record where staff document specific care related events for a resident) for Resident CR1 revealed there was a Fall Prevention task. It included having the bed in the lowest position at all times while in bed and also included to reinforce the resident's toileting program. A K noted next to the task indicated that the task shows on the Kardex (documentation by nursing to note important information and care planning and facilitate resident care). Nurse aide staff were also noted as documenting under this specific task. Closed clinical record review for Resident CR1 revealed a quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated May 19, 2025, that noted facility staff assessed the resident as rarely/never understood. Further review of the MDS noted that facility staff assessed the resident as needing substantial/maximal assistance to roll left and right (The ability to roll from lying on back to left and right side and return to lying on back on the bed); however, was not marked as dependent on staff to roll. Review of facility documentation revealed a form titled Incident/Accident and noted Employee Statement with a date of event noted as August 2, 2025, at 0650 [6:50 AM]. The resident name was noted as Resident CR1. The written and signed employee statement from Employee 1, nurse aide, noted the staff member was giving morning care to the resident who was a Hoyer lift (a mechanical lift used to transfer residents). After washing and dressing the resident, the staff member noted, .I went to get a Hoyer from the shower room. Upon return, Employee 1 found the resident on the floor, face down. Clinical nursing documentation for Resident CR1 dated August 2, 2025, at 10:20 AM from Employee 2, registered nurse, revealed Employee 2 was alerted to the resident's room by the nurse aide who entered the room to discover the resident lying face down on the floor. A three centimeter (cm) by two cm laceration was noted above the resident's right eye and a 1 cm laceration to the bridge of the resident's nose. The resident was unable to give a description of the event due to advanced dementia, per the documentation. The documentation further noted that the nurse aide who reported the fall, .stated he was providing care to the resident and left her room to get the Hoyer to transfer her out of bed after care was finished. Upon arrival to the room, it was noted by nursing staff that the bed was still in a high position, and it had been left in a high position when the aid left to obtain the Hoyer. The resident has a history of attempting to transfer herself from her bed and chair though she is not able to do so safely. The documentation noted, .it would appear likely she attempted to stand up from her bed and fell forward. The documentation noted the resident was sent to the hospital for evaluation and treatment. An interview with Employee 2 on August 26, 2025, at 1:28 PM revealed that Employee 2 was the nursing supervisor at the time. Employee 2 stated the licensed practical nurse (LPN) reported that the bed was in the high position. Employee 2 further reported that Resident CR1 was able to scoot around in bed. Review of the facility Incident/Accident form noted Employee Statement with a date of event as August 2, 2025, at 0650. The resident name was noted as Resident CR1. The written and signed employee statement from Employee 3, licensed practical nurse, indicated in part that, Hoyer lift was at the foot of the bed and bed was raised in high position. A phone interview with Employee 3 on August 26, 2025, at 1:50 PM revealed that the bed was in the high position and described as around three feet off the floor from the floor to the top of the mattress. This was observed post fall for Resident CR1. Hospital documentation for Resident CR1 dated August 2, 2025, at 7:58 AM revealed that the resident presented to the Emergency Department (ED) for evaluation of a fall and laceration to the nose and right forehead. The resident presented, .from nursing home after fall out of bed. The patient is unable to provide history. The physical examination documented a laceration to the forehead and bridge of nose. The documentation further noted, The patient underwent CT scans (computed tomography; a type of medical imaging test that creates a scan of the body using x-ray technology) that found a nasal bone (a bone of the nose) fracture and left intertrochanteric hip fracture (a type of fracture of the hip). Clinical impressions included trauma; closed intertrochanteric fracture of hip, left; open fractur of nasal bone; and laceration of forehead. The resident was admitted to the hospital. Nursing documentation for Resident CR1 dated August 5, 2025, at 4:33 PM revealed the resident returned to the facility via ambulance and litter (stretcher). Information provided to the Department on August 3, 2025, noted the date and time of the event for Resident CR1 occurred on August 2, 2025, at 6:55 AM. The factual description noted the resident had an unwitnessed fall out of bed and was found by the nurse aide lying face down on the floor. The resident was noted as non-compliant with transfer status due to advanced stage Alzheimer's Disease with poor safety awareness. The report noted that upon investigation it was found that the resident's bed was left in high bed state while Employee 1 left the room to get supplies while performing care. The facility failed to implement an intervention of a low bed related to fall injury prevention and failed to provide adequate supervision upon leaving the room. Resident CR1 then had a fall with sustained injury. The facility identified the concern with Resident CR1 on August 2, 2025, and as a result, disciplinary action was taken against Employee 1. A full house audit was conducted to identify if an order was in place for the bed to be in the lowest position for residents at all times while in bed and rounds completed to check if the beds were in the lowest position while the residents were in bed. The facility conducted staff education on August 2, 4, 5, and 8, 2025, that included Bed position. The facility conducted a whole house audit and checked the beds facility-wide on August 2, 2025. The above information was reviewed during an interview with the Nursing Home Administrator and Director of Nursing on August 26, 2025, at 4:45 PM. 483.25(d)(1)(2) Free of Accident Hazards/supervision/devicesPreviously cited deficiency 5/2/2025 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of select facility policies and procedures, clinical record review, and resident and staff interview, it was determined that the facility failed to protect a resident's right to be free from neglect by staff that resulted in actual harm with a serious injury of an ankle fracture for one of 10 residents reviewed (Resident 1). Findings include: The facility policy entitled, Resident Abuse and Neglect Prevention Program, last reviewed July 24, 2024, revealed that each resident has the right to be free from verbal, sexual, physical, and mental abuse. Management and staff are jointly and individually responsible to ensure each resident will be free from abuse, neglect, and misappropriation of property. The facility has a plan in place to assure appropriate steps are taken to protect each resident from mistreatment, neglect, abuse, and misappropriation of property. The policy defines neglect as the failure to provide goods and services necessary to avoid physical harm. Clinical record review for Resident 1 revealed nursing documentation dated October 7, 2024, at 9:27 PM that she was lowered to the floor in the shower room. Resident 1 complained of left leg discomfort at this time. Nursing documentation dated October 9, 2024, at 2:52 PM revealed that Resident 1 was requesting to get an x-ray of her left foot. The facility received a physician's order for Resident 1 to get an x-ray on October 11, 2024, which showed a nondisplaced fracture of her left ankle. Nursing documentation dated October 16, 2024, at 10:34 PM revealed that Resident 1 returned from her orthopedic appointment with new orders to wear a left leg immobilizing boot. Resident 1 is to return for an orthopedic appointment in six weeks. Review of Resident 1's clinical record revealed that the facility admitted her on May 28, 2024. A Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated September 2, 2024, indicated that the facility determined that she was cognitively intact. Review of Resident 1's task list (a list of care tasks to be performed) indicated that starting May 31, 2024, Resident 1 was assessed to require the assistance of two staff members for all care every shift. Review of Resident 1's plan of care dated June 3, 2024, indicated that Resident 1 required the assistance of two staff members for all care. Interview with Resident 1, on November 15, 2024, at 10:00 AM revealed that Employee 1, nurse aide, insisted on completing her shower by herself despite Resident 1 telling Employee 1 several times that she required the assistance of two caregivers. Resident 1 indicated that Employee 1 said, It will be okay, let's just get it done. Resident 1 indicated that Employee 1 transferred her to a shower chair by herself, and when the shower was completed, Employee 1 asked Resident 1 to stand to dry her off. Resident 1 indicated that as soon as she tried to stand, she fell to the ground. Resident 1 indicated that is when Employee 1 went to get help. Resident 1 also indicated that she feels like the pain in her ankle is getting worse and not better. Review of the facility's investigation into Resident 1's fall on October 7, 2024, revealed a witness statement by Employee 1 dated October 10, 2024, indicating that she was aware Resident 1 required the assistance of two staff members but provided Resident 1 a shower on her own anyway. Interview with the Director of Nursing and Employee 2 (assistant director of nursing) on November 15, 2024, at 12:45 PM confirmed that the facility could not provide evidence that the facility implemented any measures after Resident 1's incident that occurred on October 7, 2024, to ensure that staff received training on the number of staff members needed to ensure the physical health of all its residents. The facility only indicated that Employee 1 could not return to the facility for assignments. The facility failed to ensure care was provided in a safe manner to Resident 1, resulting in a fracture. 483.12 Freedom from Abuse, Neglect and Exploitation Previously cited 7/24/24 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1)(2)(e)(1) Management 28 Pa. Code 201.19(6)(7)(8) Personnel policies and procedures 28 Pa. Code 201.29 (a)(c) Resident rights 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on a review of select facility policies and procedures, clinical record review, personnel record review, and staff interview, it was determined that the facility failed to protect a resident's right to be free from physical abuse by staff that resulted in actual harm with a serious injury of a facial fracture for one of nine residents reviewed (Resident 1, Unit A). Findings include: The facility policy entitled, Resident Abuse and Neglect Prevention Program, last reviewed August 21, 2023, revealed that each resident has the right to be free from verbal, sexual, physical, and mental abuse. Management and staff are jointly and individually responsible to ensure each resident will be free from abuse, neglect, and misappropriation of property. The facility has a plan in place to assure appropriate steps are taken to protect each resident from mistreatment, neglect, abuse, and misappropriation of property. The facility has set forth the following policies and procedures, included in this Resident Abuse and Neglect Prevention Program are the components of: Screening, Training, Prevention, Identification, Investigation, Protection, Reporting, and Conclusion of the Investigation. The definitions of abuse include the willful infliction of injury with resulting physical harm, pain, or mental anguish. Physical abuse includes the use of physical force that may result in bodily injury, physical pain, or impairment. Employees are expected to provide appropriate and quality care to the residents according to training and facility policies/procedures. The component Screening of New/Potential Employees included that it is the policy of the facility to screen potential employees for a history of abuse, neglect, mistreatment, or misappropriation of property. A criminal background investigation will be conducted on all prospective employees utilizing the State Police, and FBI if required. The check will be initiated prior to the employee's date of hire. The component Employee Abuse Prevention and Training included that the facility has implemented a program of education designed to train employees in the prevention and recognition of resident abuse, neglect, and misappropriation. Orientation and annual training will include abuse prohibition practices such as appropriate interventions to deal with aggressive and/or catastrophic reactions of residents, how to recognize signs of burnout/frustration/stress, which may lead to abuse and violations of resident rights. All new employees are required to attend an orientation program, which includes a minimum of two hours of training related to Abuse and Neglect Prevention, Identification/Reporting of Abuse, and Techniques for Caring for the Cognitively Impaired Resident. Agency and/or contract staff will read and acknowledge receipt of the facility Abuse Prevention Program General Policy Statement and Allegation, Suspicion or Witnessed Abuse, Neglect or Misappropriation Intervention, and Reporting policies prior to the initiation of services. The employee signs a statement of receipt of education once completed, which is then maintained in the employee file. Clinical record review for Resident 1 revealed nursing documentation dated July 20, 2024, at 5:34 AM that staff observed fresh bruising, edema (swelling), and blood from an unknown origin. Resident 1's right eye was bruised and edematous, the left eye was bruised and edematous, she had nasal edema, and a very scant amount of blood noted from the nares (nasal passageway). Nursing documentation by Employee 5 (licensed practical nurse, LPN) dated July 20, 2024, at 5:49 AM revealed that the writer and another nurse heard this resident yelling while at the nurses' station. One nurse aide that was assigned to the room was seen entering the room at the time. Resident 1 was seen in the hallway by this writer with blood noted from the tip of her nose. Resident 1's bilateral eyes were swollen with fresh bruising noted. Nursing documentation dated July 20, 2024, at 8:00 AM revealed that the Director of Nursing, Area Agency on Aging, and the police were notified by the supervisor of Resident 1's injuries. Nursing documentation dated July 20, 2024, at 8:45 AM revealed that Resident 1 left via ambulance for evaluation. An Investigation of Incident Other Than Fall document dated July 20, 2024, at 6:53 AM for Resident 1, revealed that Resident 1 had swelling and bruising around her eyes and nose reported by Employee 5, that Employee 2 (nurse aide) was a witness, that potential abuse was a possible cause, and that a suspected staff member was asked to leave the facility. An unsigned incident/accident witness statement dated July 20, 2024, noted that the writer and another nurse on the Unit A nursing unit heard Resident 1 yelling and the writer saw Employee 1 (nurse aide) leave the resident's room around 4:40 AM. Within a few minutes, the writer was walking down the hall and observed Resident 1 walking with her head down with blood on the tip of her nose, blood coming out of her nose, and that her bilateral eyes were swollen with deep purple bruising to the right eye. The writer called the supervisor to the unit. The supervisor and the writer entered Resident 1's room and noted fresh blood on the bed linen next to the head of her bed. The writer was approached by Employee 2 (nurse aide) who asked to speak to the supervisor. Employee 2 was reportedly upset and almost in tears. Employee 2 stated that she witnessed Employee 1 forcefully grab Resident 1 by the arm, drag her into the room, shut the door, and throw (Resident 1) forcefully onto the bed face down and held her knees down on her. Interview with the Director of Nursing on July 24, 2024, at 4:27 PM indicated that the unsigned witness statement referenced above was written by Employee 5. A review of Employee 2's witness statement dated July 20, 2024, revealed that Employee 2 witnessed the aide that was assigned rooms one through eight (Employee 1) grab Resident 1 on her arm, drag her to her room, and put her face forward on the bed. An incident/accident witness statement dated July 20, 2024, by Employee 6 (LPN) revealed that during the medication pass at 4:30 AM, Resident 1 was walking in the hall. Employee 1 said, This is my fifth time getting her, something needs to be done. Employee 6 was at the cart at the nurses' station when Employee 6 reportedly heard yelling from Resident 1's room. Physician progress notes from the emergency department (ED) dated July 20, 2024, at 9:59 AM revealed that Resident 1 presented to the ED for evaluation of assault. EMS (Emergency Medical Services) stated that the patient was seen potentially being abused by a member of staff that morning. Imaging was positive for an acute, displaced, nasal bone fracture. Patient is suspected victim of an assault or aggressive behavior at her SNF (skilled nursing facility). Police are involved as is SNF administration. A nasal bone fracture was noted on CT imaging (CT, computed tomography, an imaging scan that uses a series of X-rays and a computer to create detailed images of bones and soft tissues). A CT imaging report dated July 20, 2024, for Resident 1, revealed an acute, displaced, nasal bone fracture. Review of Employee 1's personnel record revealed that she began employment at the facility on July 14, 2024. Employee 1's accounting of hours worked revealed that she worked on July 14, 15, 16, 17, 18, 19, and 20, 2024. Employee 1's personnel record provided by the facility revealed no evidence that the employee received training on the facility's abuse prevention program before providing care to Resident 1; or that the facility initiated a State criminal background check prior to Employee 1's date of hire. Interview with the Nursing Home Administrator and Employee 3 (human resources) on July 24, 2024, at 4:34 PM confirmed the above findings related to Employee 1's personnel record. The interview indicated that Employee 1 was a contracted agency employee. The contracted agency provides staffing who are often from other states in the country. Interview with the Nursing Home Administrator, the Director of Nursing, and Employee 4 (assistant director of nursing), on July 24, 2024, at 5:30 PM confirmed that the facility continues to utilize the contracted staffing company who provides employees who are often from other states in the country. The facility could not provide evidence that the facility implemented any measures before or after Resident 1's incident that occurred on July 20, 2024, to ensure that contracted staff receive training on the facility's abuse prevention program before providing care to its residents. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1)(2)(e)(1) Management 28 Pa. Code 201.19(6)(7)(8) Personnel policies and procedures 28 Pa. Code 201.20(b)(d) Staff development 28 Pa. Code 201.29 (a)(c) Resident rights 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on clinical record review, review of facility documentation, review of select facility policies, and staff interviews, it was determined that the facility failed to implement interventions to prevent a resident fall that resulted in a serious injury of a [MEDICAL CONDITION] wrist and to implement interventions to prevent further falls for another resident for two of four residents reviewed (Residents 171, and 367). This deficiency is cited as past non-compliance (Resident 171). Findings include: Review of facility policy entitled Falls/Prevention and Management, last reviewed on (MONTH) 11, (YEAR), revealed the facility prevents accidents by providing an environment that is free from hazards over which the facility has control. The facility identifies each resident at risk for accidents and/or falls and adequately plans care and implements procedures to prevent accidents. The care plan is reviewed and revised on a quarterly basis, at the time of significant changes, and following each fall. The policy also indicated a licensed nurse completes an incident report, ensures adequate documentation of evaluation and management in the resident clinical record, and reviews and updates the care plan. Clinical record review for Resident 171 revealed the resident was readmitted to the facility on (MONTH) 6, (YEAR), after a hospital stay. A physician's orders [REDACTED]. Clinical record review for Resident 171 revealed a nurse's note dated (MONTH) 10, (YEAR), at 7:19 AM which noted the resident had a fall being transferred from bed with assistance of one and the use of a cane, attempted to ambulate to the bathroom and was lowered to the floor on the left side of the bathroom door, and left side of the bed. The resident was not transferred as orders indicated on (MONTH) 6, (YEAR), as noted above. Resident 171 was transferred to the emergency roiagnom on (MONTH) 10, (YEAR), after the fall for an evaluation of the resident's left wrist. The resident was diagnosed with [REDACTED]. Clinical record review of Resident 171's task list (a guide for nurse aides to provide appropriate care to a resident), revealed the resident had a task for transfers initiated on (MONTH) 3, (YEAR), indicating the resident was to transfer with assistance of one. A task indicating the resident was to transfer with assistance of two with a quad cane was not initiated until (MONTH) 10, (YEAR), after the resident fell . The task list was not updated at the time the order was received on (MONTH) 6, (YEAR), changing the resident's transfer status from one to two-person assistance with the quad cane. Review of facility documentation revealed Employee 7 (Licensed Practical Nurse), who received Resident 171's order to change the transfer status for the resident on (MONTH) 6, (YEAR), failed to carry over the resident's order to the resident's task list to indicate the change to the nurse aides providing care to the resident. Employee 8 (Licensed Practical Nurse), also completed a chart check of Resident 171's chart on (MONTH) 6, 7, and 9, (YEAR), and did not identify that Resident 171's change in transfer status was not carried over to the nurse aide task list after the order on (MONTH) 6, (YEAR). The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on (MONTH) 14, (YEAR), at 1:11 PM. This deficiency is cited as past non-compliance. On (MONTH) 10, (YEAR), the facility disciplined Employee 7, (Licensed Practical Nurse), with a written oral warning for failure to complete documentation regarding placing an order change of transfer status in Point Click Care (electronic charting system), and not updating the nurse aide task list for the resident. Employee 7, (Licensed Practical Nurse), also received written, oral, and visual education on placing the order in the electronic charting system and completing the task updates. Employee 8, (Licensed Practical Nurse), was disciplined with a written oral warning for failure to complete the chart check for Resident 171 accurately and not identifying Employee 7's error of not placing Resident 171's new order in the nurse aide task list. The facility in-serviced all Licensed Practical Nurse and Registered Nurse staff on (MONTH) 14, (YEAR), on procedures for taking off resident orders and placing them in the appropriate area of the resident record including the resident's task list. A facility wide audit was completed as part of the facility's corrections in response to Resident 171's fall in (MONTH) (YEAR), to ensure transfer orders/tasks/care plans were completed. Clinical record review for Resident 367 revealed licensed practical nurse (LPN) documentation dated (MONTH) 25, (YEAR), at 4:27 PM indicating that a nurse aide called the writer to Resident 367's room after Resident 367 lost her balance going to the bathroom and fell into her wheelchair. Staff noted a reddened area on Resident 367's forehead above her left eyebrow; the documentation did not include any additional assessment of the reddened area (e.g. size, condition of skin, etc.). The writer indicated that instructions were given to the nurse aide to use two staff to help Resident 367 transfer. Interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 13, (YEAR), at 1:46 PM revealed that the facility had no investigation regarding Resident 367's fall on (MONTH) 25, (YEAR). Review of Resident 367's task list directions available to nurse aide staff that provided her care revealed that the facility reduced the number of staff required for transfers and mobility from two to one on (MONTH) 24, (YEAR). This instruction remained unchanged until Resident 367's discharge from the facility on (MONTH) 5, (YEAR). There was no evidence that the facility increased Resident 367's level of staff assistance with transfers and mobility after her fall on (MONTH) 25, (YEAR). Interview with Employee 12 (Assistant Director of Nursing), the Nursing Home Administrator, and the Director of Nursing on (MONTH) 14, (YEAR), at 9:31 AM revealed that the facility could provide three staff witness statements regarding Resident 367's fall on (MONTH) 25, (YEAR). The statements included the event date that staff were providing information for; however, did not include a date that the staff provided the statement. The statement completed by the registered nurse stipulated that staff were aware to use two staff for assistance if needed. The statement from the licensed practical nurse who made the clinical record entry on (MONTH) 25, (YEAR), at 4:27 PM failed to address the reddened area injury sustained by Resident 367 as per the clinical record documentation. The interview confirmed that the facility had no evidence of any interventions taken to prevent fall recurrence for Resident 367 except for increasing the level of assistance required for transfers. The interview confirmed that the intervention regarding two staff assistance for transfers did not get translated to Resident 367's task list information to ensure all nurse aide staff were aware of the requirement. 483.25(a)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 7/27/18, 2/10/17 28 Pa. Code 201.18(b)(1) Management Previously cited 7/27/18, 11/6/17, 2/10/17 28 Pa. Code 201.18 (b)(3) Management Previously cited 2/10/17 28 Pa. Code 201.18(e)(1) Management Previously cited 1/26/18, 2/10/17 28 Pa. Code 211.10(d) Resident care policies Previously cited 7/27/18, 1/26/18, 2/10/17 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 8/23/18, 7/27/18, 5/3/18, 1/26/18, 2/10/17 28 Pa. Code 211.12 (d)(2) Nursing services Previously cited 7/27/18

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate incidents and implement interventions to prevent resident accidents for two of 30 residents reviewed (Residents 140 and 100); and prevent a resident accident which resulted in a fracture for one of 30 residents reviewed (Resident 164). Findings include: The facility policy entitled, Falls/Prevention and Management, last reviewed without changes on January 6, 2017, revealed that the facility prevents accidents by providing an environment that is free from hazards over which the facility has control. The facility identifies each resident at risk for accidents and/or falls and adequately plans care and implements procedures to prevent accidents. An individualized care plan is developed for each resident at risk for falls. The care plan is reviewed and revised following each fall. The purpose of the policy is to ensure appropriate medical and multi-disciplinary assessment of falls and fall risk factors, coordinate management of acute and recurrent falls, and provide measures to help prevent falls. The policy did not include the facility's process to ensure that staff complete a thorough investigation of resident accidents in an effort to implement appropriate interventions based on identified causative factors (obtaining witness statements from those with pertinent information, investigating the absence of alarms, resident non-compliance with safety measures, etc.). Review of an annual Minimum Data Set (MDS - an assessment tool completed at specific intervals to determine care needs) assessment dated [DATE], revealed that Resident 164 scored a 14 on her Brief Interview for Mental Status (BIMS - indicates cognitive function, 13-15 is defined as cognitively intact). Review of Incident/Accident Reports for Resident 164 revealed that on January 6, 2016, at 11:20 PM Resident 164 rolled out of her bed. The report indicated that the interdisciplinary team (IDT) implemented a perimeter-defining mattress to aid Resident 164 in her awareness of the edge of the bed. Review of Resident 164's plan of care implemented by the facility to address her risk for falls indicated that the facility initiated the perimeter mattress on January 7, 2016. Review of nursing documentation and Incident/Accident Reports for Resident 164 revealed that Resident 164 sustained falls on the following dates and times: May 17, 2016, at 8:00 PM; July 25, 2016, at 8:30 PM; July 27, 2016, at 4:45 PM; and August 18, 2016, at 1:30 PM. For each incident, the IDT included resident re-education to request staff assistance/use assistive devices (cane). The staff completing the incident investigation for the July 27, 2016, fall stipulated that Resident 164 refuses to ask for help; that she is very proud. Review of a quarterly MDS assessment dated [DATE], revealed that Resident 164 scored an 11 on her BIMS (8-12 is defined as moderately impaired). The clinical record review for Resident 164 revealed nursing documentation dated August 31, 2016, at 8:57 AM indicating that while passing medications, the staff found Resident 164 kneeling on the floor. Review of the facility's investigation of Resident 164's fall on August 31, 2016, at 8:57 AM revealed that the IDT changed Resident 164's mobility and transfer status from independent in her room to requiring the assistance of one staff. The IDT implemented an alarm to Resident 164's bed and chair (to alert staff of Resident 164's attempt to transfer without assistance). Nursing documentation dated September 1, 2016, at 12:42 PM revealed that the Licensed Practical Nurse was called to Resident 164's room because Resident 164 was found on her left side on the right side of her bed. The facility's investigation dated September 1, 2016, determined that Resident 164 fell out of bed. The one staff statement obtained indicated that the staff walked in Resident 164's room and found her on the floor before calling for the nurse. The investigation indicated that safety alarms were not applicable (despite the initiation of bed and chair alarms in response to Resident 164's fall the day before). The facility could provide no evidence of an investigation regarding the lack of safety alarms at the time of the fall. The IDT's recommendation to prevent future falls was to implement a perimeter mattress. An interview with the Nursing Home Administrator, the Director of Nursing, and Employee 1 (a Registered Nurse/Assistant Director of Nursing) on February 10, 2017, at 11:25 AM confirmed that the facility could not provide evidence that staff implemented safety alarms at the time of Resident 164's fall on September 1, 2016. The facility also failed to provide evidence that Resident 164's perimeter mattress was in place at the time of the fall despite the facility implementing this intervention following Resident 164's fall on January 6, 2016. Nursing documentation dated September 2, 2016, at 11:32 AM revealed that when the Licensed Practical Nurse entered the room to obtain an Accucheck (testing of blood glucose from a small sample of capillary blood), she found Resident 164 kneeling on the right side of her bed. Resident 164 stated that she slid off the bed. The documentation indicated that Resident 164 took herself to bed and had the alarms turned off. The IDT's recommendation to prevent future falls was to implement a bed bolster until the availability of a perimeter mattress (noted as implemented following Resident 164's fall on January 6, 2016, and September 1, 2016). The IDT's recommendations did not address Resident 164's ability to tamper with the alarms (necessary to alert staff of her attempts to transfer without assistance). Nursing documentation dated September 2, 2016, at 9:13 PM, September 3, 2016, at 5:38 PM, and September 6, 2016, at 11:27 AM, noted Resident 164's non-compliance/removal of safety alarms. Nursing documentation dated September 6, 2016, at 12:30 PM revealed that Resident 164 refused to sit in her wheelchair until the staff discontinued the safety alarm. An interview with the Nursing Home Administrator on February 10, 2017, at 12:58 PM confirmed that the facility continued to deem Resident 164 unable to independently transfer at the time that the staff discontinued the chair alarm. The interview confirmed that the facility could provide no evidence that the IDT implemented an intervention to alert the staff when Resident 164 attempted to independently transfer after discontinuing the alarm. The interview also confirmed that the facility did not implement any interventions to limit Resident 164's ability to independently transfer. Review of a quarterly MDS assessment dated [DATE], revealed that Resident 164 scored a 7 on her BIMS (0-7 is defined as severe impairment). Documentation by the Licensed Practical Nurse dated September 25, 2016, at 8:15 AM revealed that while passing Resident 164's room, the staff noted Resident 164 sitting on the floor. Resident 164 stated that she slid from her chair. Documentation by the Registered Nurse dated September 25, 2016, at 8:20 AM reiterated that Resident 164 was non-compliant with requesting staff assistance (Resident 164 was assessed as being severely cognitively impaired). Review of the facility's investigation and the IDT recommendations in response to Resident 164's fall on September 25, 2016, failed to provide evidence that the facility implemented an intervention to alert the staff when Resident 164 attempted to independently transfer from her chair, or limit Resident 164's ability to independently transfer from her chair. Review of the nurse aide electronic task list printed September 25, 2016, at 8:57 AM listed a safety alarm to Resident 164's bed among the ongoing interventions in her plan of care. Restorative nursing documentation dated October 3, 2016, at 8:55 AM revealed that Resident 164 showed frequent bladder incontinence and that, per her patterning documentation, the staff would implement a toileting program to include toileting her upon arising in the morning and as needed on the 10:00 PM to 6:00 AM shift. Nursing documentation dated October 11, 2016, at 7:18 AM revealed that the Nurse Aide alerted the Licensed Practical Nurse at 6:55 AM that Resident 164 was on the floor in the bathroom, on her left side, with her left leg contracted, unable to straighten her leg, and complaining of left thigh pain. The staff contacted Resident 164's physician and arranged to transfer her to the emergency room . Nursing documentation dated October 11, 2016, at 9:03 AM revealed that the emergency room admitted Resident 164 for a left femoral neck (left hip) fracture. Review of the facility's investigation of Resident 164's fall on October 11, 2016, revealed that safety alarms were present but not sounding at the time of the incident. The investigation noted that Resident 164 was last toileted by the night shift (10:00 PM to 6:00 AM); however, did not note the exact time or location (i.e. bed) that the night shift staff assessed Resident 164. The investigation only included one witness statement. This witness statement, provided by the day shift (6:00 AM to 2:00 PM) Nurse Aide, included no pertinent information except that the Nurse Aide heard Resident 164 fall in the bathroom. The investigation noted that Resident 164 was last seen (prior to the occurrence) taking herself to the bathroom at 6:55 AM. It did not include the name of the person seeing or caring for Resident 164. The investigation did not determine if the 6:00 AM to 2:00 PM staff toileted Resident 164 upon rising as per her plan of care. The investigation did not determine the appropriate application of the bed alarm as per her Nurse Aide task list interventions. Although the facility repeatedly indicated that Resident 164 was non-compliant with requesting staff assistance before transferring/ambulating, the facility failed to implement interventions to ensure adequate supervision to prevent Resident 164's fall with serious injury. Documentation submitted by the facility on October 11, 2016, at 6:52 PM indicated that a Nurse Aide heard a noise coming from Resident 164's room and upon entering the room found Resident 164 on the bathroom floor. The notification stipulated that the resident has repeatedly been educated to call for assistance upon any transfer yet remains non-compliant consistently (the facility did not acknowledge that Resident 164 had severe cognitive impairment as evidenced by her BIMS assessment). Although the report indicated that the facility transferred Resident 164 to the emergency room , the report did not include that Resident 164 sustained a hip fracture (known to the facility as of 9:03 AM that day). Clinical record review for Resident 140 revealed current physician's orders [REDACTED]. Nursing documentation dated May 29, 2016, at 11:00 AM revealed that staff on the unit heard another resident say, There's an emergency in here. The staff responded to find Resident 140 on the bathroom floor. The staff assessed bruising to Resident 140's left elbow measuring 2.5 cm (centimeters) by 2 cm; 3 cm by 1.5 cm; and 5 cm by 3.5 cm. Review of the facility's investigation of Resident 140's fall on May 29, 2016, revealed that the staff failed to ensure the correct application of the pressure sensitive alarm on Resident 140's wheelchair; the alarm was not turned on. Clinical record review for Resident 140 revealed a facsimile to her physician dated December 26, 2016, at 7:00 AM indicating that Resident 140 crawled out of her bed onto the fall mat. Nursing documentation dated December 26, 2016, at 8:06 AM revealed that the housekeeper walked past Resident 140's room at 6:55 AM and saw Resident 140 on the fall mat. Although the nursing documentation above and the facility's investigation of the incident indicate that Resident 140's alarm sounded at the time of the incident, the witness statement provided by the housekeeper notes only, Walked by resident's room and saw her on the fall mat. I reported it to nurse and CNAs (Nurse Aides). The facility's investigation of the incident did not thoroughly investigate this discrepancy relating to Resident 140's fall on December 26, 2016. An interview with the Nursing Home Administrator and the Director of Nursing on February 9, 2017, at 2:00 PM confirmed the above findings for Resident 140. Clinical record review for Resident 100 revealed she had 20 falls between February 24, 2016, and December 28, 2016. The facility assessed Resident 100 to be at high risk of falls on March 2; May 2; June 3, 8, 15; August 19, 20; December 1, 7, 20, 24, and 28, 2016. The facility assessed Resident 100 to be at moderate risk of falls on March 11; and November 7 and 13, 2016. Review of the investigations into the falls reveal the following: On February 24, 2016, at 6:30 PM Resident 100 stood up from her wheelchair and fell hitting her head on the workroom door, and slid to the floor. There were no injuries noted. Staff added an alarm to her chair and offered to ambulate her when she was restless. On February 25, 2016, at 10:00 AM Resident 100 was yelling for help. Staff found her in her room kneeling on her knee beside her bed. There were no known injuries. Staff were to assist resident to get up before breakfast and offer her a nap after breakfast. On March 3, 2016, at 7:40 AM staff found Resident 100 on the floor in her room on the left side of her bed. There were no known injuries. Staff added a perimeter mattress to her bed. On March 10, 2016, at 10:05 AM staff found Resident 100 on the floor in the hallway by the nurse's station. She was attempting to ambulate unassisted. There were no known injuries. Staff added auto lock brakes to her wheelchair. On May 1, 2016, at 5:45 PM staff found Resident 100 sitting on the floor at the bottom of her bed. There was no known injuries. Staff were to provide closer supervision and assist of two staff for transfers. On June 2, 2016, at 9:00 PM staff found Resident 100 in the doorway of her room in the midst of falling. She hit her head on the doorway frame causing a hematoma. On June 8, 2016, at 9:20 AM staff found Resident 100 on the floor in her room. Her alarms were not turned on. There was no known injury. Staff believed that Resident 100 might be turning her alarm off. Staff were inserviced on checking all alarms at the beginning and end of each shift to make sure they were functioning properly. On June 14, 2016, at 3:13 PM staff found Resident 100 on the floor in another resident's room. There was no known injury. Staff were to keep her at the nurse's station if possible. Offer to lay down after lunch. On August 19, 2016, at 3:45 AM staff found Resident 100 sitting on the floor at the bottom of her bed. She was holding her alarm. There were no known injuries. Staff added fall mats to each side of the bed. On August 20, 2016, at 9:40 AM staff found Resident 100 in another resident's room on the floor. There were no known injuries. On August 20, 2016, at 6:30 PM staff found Resident 100 on the floor in her room. There were no known injuries. Staff were to offer her a nap after supper. On September 24, 2016, at 12:00 PM staff found Resident 100 on the floor in the shower room. There was no known injuries. Staff were to ensure the shower room is locked. On November 7, 2016, at 1:45 PM staff found Resident 100 on the floor beside her bed. There were no known injuries. Staff had previously been instructed to return Resident 100 to her bed for a nap after lunch. On November 13, 2016, at 9:30 AM Resident 100 threw herself to the floor while receiving a shower. In the future, there are to be two staff to provide her showers. On December 1, 2016, at 11:20 AM staff found Resident 100 on the floor in her room. There were no apparent injuries. Staff felt she had turned off her alarm. Staff were previously instructed to place the alarm out of the resident's reach. On December 7, 2016, at 10:35 AM staff heard Resident 100 saying, Hey help me. She was sitting on the floor in the doorway of her room. The alarm was not sounding. Staff were once again in-serviced to keep the alarm out of the resident's reach. On December 7, 2016, at 3:00 PM staff found Resident 100 on the floor in her room. No known injuries. Her alarm was turned off. Staff was to apply slipper socks daily. On December 20, 2016, at 6:10 AM staff found Resident 100 on the fall mat beside her bed. There were no known injuries. Posey wedges (small lateral wedge to provide positioning and support in bed) were implemented. On December 24, 2016, at 11:43 AM staff found Resident 100 on the floor in her room. There were no apparent injuries. On December 28, 2016, at 1:40 PM staff found Resident 100 sitting on the floor mat in her room. There were no apparent injuries. The wedges and low bed were discontinued. The perimeter mattress was reordered. During a meeting with the Director of Nursing and Employee 1 (the Assistant Director of Nursing) on February 10, 2017, at 9:30 AM the surveyor reviewed the above information regarding Resident 100's falls. The facility failed to provide supervision and interventions to prevent Resident 100's numerous falls. 483.25(d)(1)(2)(n)(1)-(3) Free Of Accident Hazards/supervision/devices Previously cited deficiency 11/9/16, 1/29/16 28 Pa. Code 201.18 (b)(1)(e)(1) Management Previously cited 11/9/16, 1/29/16 28 Pa. Code 211.10 (d) Resident care policies Previously cited 11/9/16, 1/29/16 28 Pa. Code 211.11(d) Resident care plan Previously cited 1/29/16 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 11/9/16, 9/15/16, 7/29/16, 1/29/16 28 Pa. Code 211.12(d)(2) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 11/9/16, 1/29/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 11/9/16, 9/15/16, 9/7/16, 7/29/16, 6/22/16, 1/29/16

Based on clinical record review, review of select facility policies and staff interview, it was determined that the facility neglected to provide planned services, which were necessary to avoid physical harm for one of 29 sampled residents (Resident 121). Findings include: The policy entitled, Incident and Accident Reports, Resident last reviewed October 12, 2015, does not indicate that the facility participates in routine monitoring of staff during transfers to ensure that staff are following interventions that the facility has implemented to prevent accidents. The policy entitled, Resident Abuse and Neglect Prevention Program last reviewed on October 12, 2015, identifies that the facility has a plan in place to assure appropriate steps are taken to protect each resident from neglect. The policy indicated that neglect might result through a failure of inattentiveness, carelessness, or omission to provide timely, consistent, safe, adequate, and appropriate services. Clinical record review for Resident 121 revealed that the facility admitted the resident on January 21, 2015, with mild cognitive impairment. Review of an MDS assessment (Minimum Data Set, an assessment tool completed at specific intervals to determine care needs) dated July 5, 2015, indicated that Resident 121 required staff assistance for all transfers. Resident 121's current Kardex (a card that summarizes a resident's care) indicated that the staff are to transfer Resident 121 with a Hoyer Lift (allows a person to be lifted and transferred with a minimum of physical effort). Nursing documentation dated August 28, 2015, indicated that the staff noted Resident 121 was complaining of right arm pain and that she was tearful. Review of the document entitled, Incident/Accident Report dated August 28, 2015, revealed that Resident 121 was in her room calling and crying to the staff in the hallway. Review of the PB-22 (Provider Bulletin-22, a report form for investigation of alleged abuse, neglect, and misappropriation of property for facilities to communicate to the Department), dated September 2, 2015, indicated that on August 28, 2015, Employee 9, Nurse Aide (NA), transferred Resident 121 out of the shower chair with a sit-to-stand lift (used to transfer residents from one seating surface to another. It is designed to support only the upper body of the resident and requires that the resident have some weight-bearing capability), without assistance. Review of the radiology report dated August 28, 2015, revealed that Resident 121 sustained an oblique [MEDICAL CONDITION] humeral shaft (elbow) on the right side. According to facility documentation, Employee 9 had asked Employee 12, NA, for help in transferring Resident 121 with the sit-to-stand lift into the shower chair before the resident's shower. There were no issues with this transfer. Then, Employee 9 transferred Resident 121 independently with the sit-to-stand lift after her shower; however, Resident 121's Kardex instructs the staff to use the Hoyer Lift with 2 assists for all transfers. Resident 121 reported that she heard a, pop and experienced arm pain when Employee 9 attempted to transfer her after her shower. Employee 9 was provided education on December 12, 2014, regarding safe transfer of residents, including having at least 2 caregivers present during lift transfers as well as instructions to review transfer status. When the NA's are charting on the resident detail page (where NA's document care that was provided during their shift), it also indicates the resident transfer status. Interview with the Nursing Home Administrator and the Director of Nursing on January 27, 2016 at 1:30 PM, confirmed that Employee 9 failed to transfer Resident 121 using the correct lift and without assistance on August 28, 2015, resulting in a fracture. 28 Pa. Code 201.18 (b)(1)(e)(1) Management Previously cited 2/27/15 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.10 (d) Resident care policies Previously cited 9/25/15, 2/27/15 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services Previously cited 9/25/15, 2/27/15

Based on clinical record review, observation, review of select policies and procedures, and staff interview, it was determined that the facility failed to adequately supervise and provide planned functional safety measures to prevent a resident from choking for one of three sampled residents. The facility also failed to provide the physician ordered diet and ensure that safety measures were implemented to prevent self-harm (Resident 19). Findings include: The facility's policy entitled, Aspiration Precautions, identified by the Director of Nursing as the most recent policy, revealed that all residents on aspiration precautions have precautions in place in order to prevent aspiration of food and/or fluids into the lungs. Residents receiving intake by mouth must be monitored by staff for all intake unless otherwise specified by the physician. Clinical record review for Resident 19 revealed [DIAGNOSES REDACTED]. Review of Resident 19's plan of care indicated that the staff are to provide full supervision with meals and adhere to aspiration precautions at all times. Resident 19's physician's orders [REDACTED]. The facility's Mechanical Soft Diet data sheet indicated that it is based on the National Dysphagia Diet (NDD). The diet consists of foods that are easy to chew with varying textures. Meats, fish, and poultry are served ground, moist and with gravy. Breads are any well-moistened breads, biscuits, muffins, etc. Staff needs to add adequate syrup, jelly, margarine, butter, etc. to moisten well. Staff should avoid dry bread and tough, crusty breads. Resident 19's dinner card for [DATE], indicated that he was on a mechanical soft diet. The meal card indicated that Resident 19 received ground pork steak, a honey biscuit, seasoned broccoli, and golden peach crumble. There was no indication that the ground pork was moistened or that gravy was added. Nursing documentation dated [DATE], at 6:08 PM, revealed that Employee 6, a Licensed Practical Nurse (LPN), documented that, While eating supper res (resident) began choking, unresponsive, cyanotic, absence of Vs (vital signs), Heimlich Maneuver performed, expelled pieces of chicken. Nursing documentation dated [DATE], at 8:14 PM, revealed that Employee 4, a Registered Nurse (RN), was called to the unit because Resident 19 was choking. Employee 4 observed that Resident 19 was seated in a wheelchair in the hallway with his tray table in front of him. Employee 4 noted that Resident 19 was slumped over and his head and face were red. Employee 4 attempted to do the Heimlich maneuver (a procedure used to expel debris during choking) and Resident 19 became unresponsive and was not breathing. Resident 19 did not have a carotid pulse (heartbeat felt through the walls of the artery) when Employee 4 started CPR (cardiopulmonary resuscitation is an emergency procedure performed in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest). Employee 4 observed a, huge piece of food in Resident 19's mouth, which was removed. CPR continued for 8 to 10 minutes when Resident 19 coughed and responded. The emergency medical service staff arrived and transported the resident to an acute care hospital where staff admitted him. The facility's investigation into the incident revealed that Employee 1's (Nurse Aide) statement indicated that he came around the desk and noticed that Resident 19's head was leaning on his tray. He immediately approached Resident 19 but could not get him to respond so he called out for help. The supervisor (Employee 4) responded and did the Heimlich Maneuver and Employee 2 (Nurse Aide) began chest compressions (a procedure used to start the heart beating). Employee 1 began scooping food from the resident's mouth. Employee 2's statement of the incident indicated that she was coming around the corner when she heard another staff member yelling for help. Resident 19 was choking and turning blue. Employee 2 and other staff lowered Resident 19 to the floor and swept his mouth for foreign objects. Employee 2 indicated she removed bread and small pieces of meat. Employee 2 began performing chest compressions. In a later statement, Employee 2 indicated that she was monitoring the hall and checked on Resident 19 and other residents but did not realize he was in distress until another staff member alerted her. She further stated that she checks on residents periodically throughout the meal. Employee 3's (a LPN) statement of the incident revealed that Resident 19 was sitting in his wheelchair with his head down resting on his chest, he was cyanotic (turned blue) and unresponsive. Heimlich Maneuver performed and he expelled a small piece of chicken. Resident 19 returned to the facility on [DATE], with physician's orders [REDACTED]. Observation of Resident 19 on [DATE], at 11:02 AM, with the Director of Nursing revealed he was in his room, sitting in his wheelchair. On his bedside table that was accessible to him, was a Styrofoam cup half full of thin water, not the nectar thick consistency that the physician ordered. Further review of his plan of care indicated that he was not to have a corded call bell due to history of a suicide attempt. Observation of Resident 19 on [DATE], at 10:55 AM, with the Director of Nursing revealed that he had a corded call bell and a corded device to position his bed within his reach. An interview with the Director of Nursing on [DATE], at 11:30 AM, confirmed the above findings. She also revealed that in the past, Resident 19 had wrapped a call bell cord around his neck in an attempt to harm himself. The facility failed to provide full supervision to Resident 19 while he was eating. Staff refered to his supervision as, checking on him or checking on him periodically. The facility failed to provide his physician ordered diet. Employee 4 referred to Resident 19 expelling a, huge piece of food after administering the Heimlich Maneuver, which would indicate that the meal provided was not mechanical soft. The lack of supervision and wrong diet resulted in a choking incident in which Resident 19 became cyanotic, stopped breathing, and did not have a pulse and that required the Heimlich Maneuver, CPR, and admission to an acute care hospital. Upon return from the acute care hospital, the facility failed to provide the physician ordered liquid consistency in an unsupervised room. The facility provided a corded call bell and corded device to position his bed putting him in danger of self harm. 28 Pa. Code 211.6(a) Dietary services. Previously cited [DATE], [DATE] 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited [DATE], [DATE] 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited [DATE], [DATE]

Based on review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to provide the necessary treatment and services to prevent new pressure ulcers and promote ulcer healing for one of 30 sampled residents (Resident 116). Findings include: The facility policy entitled, Pressure Ulcer-Risk Assessment, Prevention of Skin Breakdown, and Skin Care Management, last reviewed without changes September 10, 2014, revealed that the nurse aide completes a weekly full body inspection on each resident's skin condition during the shower/bath. The staff performing routine personal care inspects residents' skin condition daily and changes are reported to the charge nurse prior to the end of the shift. The charge nurse will evaluate the reported change prior to the end of the shift. The Interdisciplinary Team shall develop a resident-specific care plan for prevention of loss of skin integrity and revise as needed. The facility policy entitled, Skin Integrity Inspections-Performed by Certified Nursing Assistant, last reviewed without changes September 10, 2014, revealed that it is the policy of the facility to complete a full body skin inspection during the resident shower/bath. The nurse aide completing the shower/bath is responsible for the skin check and completion of the Skin Integrity Inspection Form. Nurse aides will also perform skin checks on his/her assigned residents daily and report any new skin problems to the charge nurse immediately. The facility noted the purpose of the policy as, To complete a full body skin inspection regularly in order to identify new problems in order that an assessment and initiation of necessary treatment occurs in a timely manner. The charge nurse will note the condition on the form and inspect the area prior to the end of the shift, recording all information on the form. Any treatment required will be initiated by the charge nurse/licensed nurse according to facility policy and procedure. The worksheet is collected and sent to the supervisor's office for review by the Director of Nursing/designee. The Wound Care Nurse will be informed of any changes in skin integrity. The policy did not stipulate what staff informs the Wound Care Nurse of any changes. Clinical record review for Resident 116 revealed a Braden Scale for Predicting Pressure Sore Risk form (standardized assessment used to determine a resident's risk for pressure ulcer development) dated September 15, 2014, that assessed Resident 116 as a score of 14 (at moderate risk). A plan of care developed by the facility to address Resident 116's pressure ulcer development listed interventions in place at the time of the above assessment that included weekly skin assessments during regularly scheduled bath/shower times, and nurse notification of any new areas of skin breakdown. A weekly Skin Integrity Inspection Form dated October 12, 2014, noted no abnormal findings. Nursing documentation by Employee 4 (Registered Nurse/Wound Care Nurse) dated October 13, 2014, at 11:34 AM, noted Resident 116 had an irregular area of immediately blanchable redness to both right, and left inner buttocks. The skin was intact and without drainage or odor. The documentation noted that the skin immediately above the rectal area appeared moderately macerated, lighter pink in color, and moist. The facility notified the physician and obtained an order dated October 13, 2014, for a Signal dressing (opaque [MEDICATION NAME] dressing used for Stage I and Stage II pressure ulcers; [MEDICATION NAME] form a gel under the dressings that provides a moist environment for wound healing) to the lower coccyx reddened area. There was no evidence that the facility implemented a Skin Site Sheet (form utilized by the facility to document a wound's stage, size, appearance, improvement/worsening, etc., on a routine basis) or revised Resident 116's plan of care in response to this change. Licensed Practical Nurse (LPN) documentation dated October 17, 2014, at 10:10 PM, noted an area of sloughing (shedding of dead surface cells from the skin) without drainage to Resident 116's right buttock that measured 2 centimeters (cm) by 4 cm (the nurse included no depth measurement of the wound). The same nurse documented notification to Resident 116's physician and the receipt of a physician's orders [REDACTED]. There was no indication in the clinical record why the LPN believed she needed and obtained another physician's orders [REDACTED]. Interview with the Director of Nursing and Employee 4 on February 28, 2015, at 1:10 PM, were unable to clarify any treatment difference between the Signal dressing and DuoDERM dressing orders. Employee 4 confirmed that she was not aware of any openings in Resident 116's skin integrity following the LPN's assessment. There was no evidence that the facility implemented a Skin Site Sheet, revised Resident 116's plan of care, or sent notification to the facility's Wound Care Nurse, in response to the change identified in Resident 116's right buttock skin integrity. The facility also did not reassess Resident 116's Braden score/risk following this change in condition. LPN documentation dated October 20, 2014, at 10:39 AM, noted that Resident 116's, butt (buttock) duoderm off area cleansed for sc (unclear what the abbreviation indicates) bloody drg (drainage) signal dressing applied. The October 20, 2014, documentation indicated that staff used the Signal and DuoDERM dressings interchangeably. A weekly Skin Integrity Inspection Form signed by both the nurse aide and the LPN on October 22, 2014, indicated that Resident 116 had an open ulcer on her buttock. There was no evidence that the facility implemented a Skin Site Sheet, revised Resident 116's plan of care, or sent notification to the facility's Wound Care Nurse, regarding Resident 116's buttock skin integrity as of this date. There was also no evidence in Resident 116's clinical record that staff measured or documented an assessment of the buttock skin integrity since October 17, 2014. A weekly Skin Integrity Inspection Form signed by both the nurse aide and the LPN on October 26, 2014, indicated that Resident 116 had an open ulcer on her buttock. There was no evidence that the facility implemented a Skin Site Sheet, revised Resident 116's plan of care, or sent notification to the facility's Wound Care Nurse, regarding Resident 116's buttock skin integrity as of this date. There was also no evidence in Resident 116's clinical record that staff measured or documented an assessment of the buttock skin integrity since October 17, 2014 (nine days earlier). Documentation by Employee 4, dated October 27, 2014, at 11:52 AM, noted that Resident 116 now presented with a pressure area to her right inner buttock that was unstageable due to brown/black attached eschar (dead tissue) in the superior wound bed. The area measured 5 cm by 3 cm with a scant odor that diminished with cleansing. A superficial open area appearing as a partial thickness loss of dermis (second skin layer, classified as a Stage II pressure ulcer) distal to the eschar measured 3 cm by 3 cm. The entire area measured 8 cm by 3 cm by 0.2 cm. There was a small amount of serosanguinous (blood tinged) drainage. Employee 4 confirmed that this right buttock area was the site she previously assessed and initiated the [MEDICATION NAME] dressing for protection (on October 13, 2014). Review of Skin Site Sheets for Resident 116 revealed that the facility did not initiate this wound tracking until Employee 4 assessed the ulcer on October 27, 2014. Documentation on the form beginning December 24, 2014, described this ulcer as initially acquired in the hospital. Interview with the Director of Nursing on February 27, 2015, at 9:20 AM, confirmed that the ulcer documentation incorrectly identified this ulcer as acquired in the hospital. Review of a Braden Scale for Predicting Pressure Sore Risk form dated October 29, 2014, now assessed Resident 116 as a score of 12 (at high risk). Review of Resident 116's plan of care to address her pressure ulcer development revealed that the facility did not revise care interventions (such as limiting time out of bed to two hours, repositioning only side to side while in bed, and wound physician consult) until November 5, 2014. Current physician orders [REDACTED]. Product information documentation provided by the facility cautioned that because a slight transient [DIAGNOSES REDACTED] (redness) has been noted occasionally in the surrounding tissue, particularly when the ointment was not confined to the wound, the ointment should be applied carefully within the area of the wound. Observation of wound care treatment to Resident 116's right buttock ulcer on February 26, 2015, at 11:39 AM, revealed that Employee 5, LPN, utilized cotton-tipped applicators and a tongue depressor to apply Santyl ointment to the wound bed. The Santyl ointment thickness varied over the wound bed with no obvious effort to maintain a nickel-thick application over the surface. Employee 5 utilized the wound edge to slide the Santyl ointment off the tongue depressor and in to the wound causing ointment application to the healthy skin surrounding the wound. Interview with Employee 5 at the time of the above observation revealed that staff, .try our best .but it (Santyl ointment) does get on there (surrounding skin). Employee 5 made no effort to clean the surrounding skin. Employee 5 finished the application of dressings to the wound, repositioned, and covered Resident 116 in bed. Employee 5 did not apply the physician ordered [MEDICATION NAME] to the surrounding skin of Resident 116's ulcer. Interview with Employee 5 on February 26, 2015, at 11:40 AM, revealed that she confirmed and would correct the omission of the [MEDICATION NAME] at that time. Observation of the [MEDICATION NAME] application on February 26, 2015, at 11:43 AM, revealed Santyl ointment oozing from the proximal area of the wound (the site where Employee 5 used the wound edge to slide the ointment off the tongue depressor). Interview with Employee 5 at that time confirmed that she noted the oozing ointment but that it was her opinion that, it won't hurt. Employee 5 did not attempt to clean the excess ointment from the surrounding skin before applying the [MEDICATION NAME] cream. Employee 5 failed to complete Resident 116's ulcer treatment per the physician's orders [REDACTED]. 483.25 (c) Pressure Sores. Previously cited deficiency 1/31/14. 28 Pa. Code 211.10 (c)(d) Resident care policies. Previously cited 1/31/14. 28 Pa. Code 211.11 (d) Resident care plan. 28 Pa. Code 211.12 (d)(1)(5) Nursing services. Previously cited 1/31/14.

Based on select policies and procedures, clinical record review, observation, and staff and resident interviews, it was determined that the facility failed to assess, monitor, and provide interventions to prevent skin breakdown for one of 30 sampled residents (Resident 54). Findings include: The policy entitled, "Pressure Ulcer-Risk Assessment, Prevention of Skin Breakdown and Skin Care Management," last reviewed January 9, 2014, revealed that the purpose of the policy is to identify residents that are at risk for alteration in skin integrity, provide interventions to reduce the risk of skin breakdown, to prevent pressure ulcer development, and to prevent further skin breakdown. The policy entitled, "Restorative Nursing Splint/Brace Procedure," last reviewed January 9, 2014, indicated that the purpose of the policy is to maintain proper alignment and prevent skin breakdown. Any splint/brace worn over two hours will be checked every two hours. At this time, the licensed nurse will perform an assessment of the resident's skin and circulation. Clinical record review for Resident 54 revealed that the facility admitted him on October 11, 2013, with a [DIAGNOSES REDACTED]. During an Orthopedic appointment on November 25, 2013, the physician removed Resident 54's cast and replaced it with a CAM boot (according to the manufacturer it is a device used to stabilize the ankle including post cast. It may be removed for bathing and sleeping. The skin underneath should be checked frequently for irritation and pressure). Nursing documentation dated December 17, 2013, indicated that Resident 54 was complaining of his right heel burning. On December 30, 2013, Resident 54 returned from an Orthopedic appointment with a report from the physician indicating that he had a pressure sore on his right lateral heel. During a follow up Orthopedic appointment on January 27, 2014, the physician indicated that Resident 54's heel and ankle showed improvement and recommended that he wear normal shoes with open backs to avoid rubbing. An interview with Resident 54 on January 29, 2014, at 9:15 AM revealed that the boot he was wearing rubbed the back and bottom of his foot causing a sore that was causing him pain. During a meeting with the Nursing Home Administrator and Director of Nursing on January 29, 2014, at 2:15 PM the surveyor requested information regarding Resident 54's pressure sore on his right heel. They were not aware of the pressure sore but would review his clinical record. An interview with the Director of Nursing on January 30, 2014, at 9:30 AM revealed that the facility was not aware of Resident 54's pressure sore until the surveyor brought it to their attention. Staff failed to observe the pressure sore or the physician's consults indicating that there was a pressure sore. There was no documentation indicating measures were in place to prevent the pressure sore. Observation of Resident 54's right heel on January 30, 2014, at 11:35 AM with Employee 8 (licensed practical nurse) revealed that the CAM boot was still in place. Employee 8 removed the boot. On Resident 54's right heel was a blackened area the size of a half dollar. Resident 54 was complaining of severe pain. The facility failed to put measures in place to prevent Resident 54's pressure sore and failed to assess the skin under the CAM boot to identify and treat the pressure sore. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 2/1/13 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited 2/1/13 and 8/16/13

Based on clinical record review, review of select facility policy and procedures, and staff interview, it was determined that the facility failed to promote sufficient fluid intake to maintain hydration for one of 30 residents sampled (Resident 149). Findings include: The policy entitled "Hydration," reviewed October 8, 2010, indicates that the facility will closely monitor residents who experience a sudden decline of fluid intake for dehydration. The facility will screen all residents for increased risk of dehydration upon admission, readmission, and quarterly. The facility will present the results of the hydration screen to the interdisciplinary team to determine the residents risk for dehydration. The facility will make a decision regarding interventions and the need to monitor the resident's fluid intake. Possible interventions for residents at risk for dehydration can include high fluid content foods, additional fluids between meals, additional fluids with meals and between medication pass, and notification to staff of a residents need for increased fluid intake via a different colored napkin on a meal tray. Review of Resident 149's clinical record revealed nursing documentation dated November 19, 2010, at 8:10 AM, that indicated nursing staff assessed Resident 149 as having fairly moist mucous membranes and fair skin turgor (dry mucous membranes and poor skin turgor could indicate a deficit in hydration status). Review of Resident 149's laboratory results dated [DATE] indicated that his blood urea nitrogen (BUN, if elevated could be an indicator of dehydration) was normal at 24 mg/dl (milligrams/deciliter). Resident 149's most recent Hydration Risk Evaluation completed on September 17, 2010, indicated that the dietitian assessed Resident 149 as needing between 1659 cc and 1980 cc (cubic centimeters) of fluids per day. The dietitian also indicated on the assessment that Resident 149 was not meeting his fluid needs. There was no evidence in Resident 149's clinical record to indicate that the facility used this information to implement additional interventions to promote hydration for Resident 149. Review of Resident 149's daily fluid intakes between November 18, 2010 and November 27, 2010, revealed the following totals: November 18, 2010, 720 cc November 19, 2010, 570 cc November 20, 2010, 690 cc November 21, 2010, 960 cc November 22, 2010, 420 cc November 23, 2010, 870 cc November 24, 2010, 290 cc November 25, 2010, 720 cc November 26, 2010, 1080 cc November 27, 2010, 240 cc Resident 149 did not meet his fluid requirements for 10 consecutive days. There was no evidence in Resident 149's clinical record to indicate that the facility implement additional interventions to promote his hydration status. Nursing documentation dated November 23, 2010, at 8:00 AM indicated that Resident 149's skin turgor was now fair to poor, his oral mucous membranes were somewhat moist, and his urine was cloudy amber. Nursing documentation dated November 27, 2010, at 1:30 PM now indicated that Resident 149's condition is poor, has poor skin turgor, and that he is declining. On November 28, 2010, at 8:40 AM nursing documentation indicated that Resident 149 is not opening his eyes and that nursing staff are unable to obtain an oxygen saturation level. Nursing staff notified Resident 149's physician at this time and received an order to send Resident 149 to the emergency room . Review of the hospital emergency room examination dated November 28, 2010, at 3:23 PM, indicated that Resident 149 was sent to the emergency room for changes in mental status and was diagnosed with [REDACTED]. Laboratory results obtained in the emergency room now indicated that Resident 149's BUN was abnormally high at 107 mg/dl. There was no evidence in Resident 149's clinical record to indicate that the facility implemented interventions to promote hydration status when he was not meeting his fluid needs from November 18, 2010 to November 27, 2010. Interview with the Director of Nursing, on December 9, 2010, at 10:40 AM, revealed that there was no evidence to indicate that the facility implemented their hydration protocol or implemented additional interventions to promote hydration status for Resident 149. 28 Pa. Code 211.10(a) Resident care policies. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 12/4/09 28 Pa. Code 211.12(d)(3)(5) Nursing services. Previously cited 12/4/09 and 5/26/10