Every finding on record at Norriton Square Nursing and Rehabilitation Center

Based on review of facility policy, review of clinical records, and staff interview it was determined that the facility failed to timely identify, implement, monitor, and modify interventions (as appropriate), consistent with the resident's assessed needs to maintain acceptable parameters of nutritional status for one of two residents reviewed (Resident R1). Findings include: Review of the facility policy, Weights and Heights, with a revision date of January 15, 2026, indicated that based on the patient's comprehensive assessment, the center will ensure that all patients maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the patient's clinical condition demonstrates that it is not possible for the patient's preferences to indicate otherwise. The policy also indicated that significant weight changes of 5% or more in a month will be reviewed by licensed nurse who will also notify the physician and dietitian of those changes. The policy also indicated that the licensed nurse will notify the patient/patient representative of the weight change and the dietitian recommendations. Review of Resident R1's clinical record revealed the following diagnoses: history of sudden cardiac arrest (heart attack); chronic obstructive pulmonary disease (COPD-a long-term lung condition that makes it progressively harder to breathe); hypertension (high blood pressure), and diabetes (a group of diseases that affect how the body uses blood sugar/glucose). Review of Resident R1's clinical record revealed a weight of 228.4 pounds documented on January 6, 2026. Further review of Resident R1's clinical record revealed a weight of 209.8 pounds documented on February 5, 2026, reflecting a significant weight loss of 18.6 pounds (-8.1%) in one month. Continued review of Resident R1's weight record, revealed no documented evidence that a re-weight was completed in a timely manner to confirm the resident's significant weight loss. Review of Resident R1's clinical record revealed a note by the nurse practitioner dated February 6, 2026, that documented the resident had a 19-pound weight loss and for dietary to follow up. Review of nurse practitioner note dated February 6, 2026, revealed, weight review shows 19lbs (pound) weight loss . dietary to follow up. Review of Resident R1's clinical notes after the recorded significant weight loss on February 5, 2026, the clinical notes did not show evidence that the resident's weight was acknowledged/assessed by the registered dietitian to ensure that the resident needs were reassessed and any appropriate interventions, as applicable, were implemented in a timely manner. Review of the clinical record revealed a note written by the Registered Dietitian on February 18, 2026, 13 days after the documented significant weight loss, addressing the significant weight loss and recommended that the resident receive weekly weights for 4 weeks. Review of Resident R1's clinical record revealed no documented evidence the weekly weights were implemented as recommended by the Registered Dietitian. During an interview with the Registered Dietitian on August 27, 2026, at 11:10 a.m. Resident R1's significant weight loss was discussed and acknowledged by the Registered Dietitian. It was discussed with the Registered Dietitian that Resident R1's weight was not timely assessed by the Registered Dietitian until 13 days later on February 18, 2026, and at that time requested Resident R1 be weighed weekly for four weeks. It was discussed during the above referenced interview that there was no documentation of any weekly weights in the clinical record that the Registered Dietitian requested from nursing staff to monitor the resident's progress. The Registered Dietitian was unable to provide any documented evidence that Resident R1's weight loss was assessed by the dietitian prior to February 18, 2026, and was not able to provide documented evidence that weekly weights were completed as recommended. 28 Pa. Code 201.18 (b)(1) Management28 Pa. Code 211.12(d)(1)(3) Nursing services

Based on observations, and staff interview, it was determined that the facility failed to follow acceptable infection control practices related to care and maintenance of bedside commode in one of two nursing floors. (Second floor) Findings include: Observations on March 16, 2026, at 11:35 a.m. on the Second floor in room [ROOM NUMBER] revealed the nurse aide, Employee E4 demonstrated how to empty the bedside commode. Employee E4 lifted out the urine collection basin and removed an unlabeled grey plastic bag from the commode which was dripping a reddish colored liquid. Employee E4 put the bag into the urine collection basin and went into the resident's bathroom. Nurse aide, Employee E4 took the bag out of the basin and put it into the resident's trash can in the bathroom and dumped the liquid into the toilet. Employee E4 then went to the hand sink in the bathroom and put the basin under the faucet and turned on the water filling the basin about halfway. Employee E4 then went back to the toilet and dumped this water into the toilet and flushed the toilet. Employee E4 then put the basin back into the commode without a bag stating that she would have to get another bag. Employee E4 then took off her gloves, washed her hands and took the plastic can liner out of the trash can in the bathroom, dropping a glove on the floor and was exiting the room when asked about leaving the glove on the floor she returned picked up the dirty glove with her bare hands and put it into the trash bag and went to the soiled utility room, disposed of the bag into the large trash can, washed her hands and went to look for a bag for the commode. Interview with the Unit Manager, Employee E3, on March 16, 2026, at 11:50 a.m. revealed that the nurse aide should have put the basin and anything else in the commode into a red biohazard bag and carried it all into the soiled utility room. Then she should have dumped the waste into the wall mounted service sink and used the spray hose to clean out the basin and use soap to clean the basin and rinse it and put it into a clean biohazard bag and place both into the commode. Interview with the Infection Preventionist, Employee E2, on March 16, 2026, at 11:50 a.m. confirmed that nurse aide, Employee E4 should not have taken the urine collection basin into the resident's bathroom, she should not have used the resident's sink or put the contents into the resident's trash can. Employee E2 stated that the nurse aide should have put all the soiled contents of the bedside commode into a red biohazard bag and took it to the soiled utility room as the Unit Manager stated. Interview with the Nursing Home Administrator on March 16, 2026, at 12:15 p.m. confirmed that nurse aide, Employee E4 did not follow facility infection control procedures. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1) Nursing services

Based on reviews of the established meal delivery schedule, interviews with dietary staff, observations of the food and nutrition services on the nursing units and a review of the dietary staffing schedules for the kitchen, it was determined that the facility failed to employ sufficient staff to carry out the functions of the dietary services department. Findings include: During the sanitation inspection of the main kitchen at 10:00 a.m., on January 20, 2026, the director of dietary services, Employee E7, reported that there were two dietary staff members that had called out of work on January 20, 2026. The only dietary staff working on January 20, 2026, were the director of dietary services, Employee E7, the cook, Employee E20 and a dietary aide, Employee E9. A review of the established meal delivery schedule from the food and nutrition services revealed that the third floor was to receive a meal cart at 11:40 a.m., and 11:50 a.m., daily and the dining room was to receive a food cart between noon and 1:00 p.m. A review of the established meal delivery schedule from the food and nutrition services revealed that the second-floor nursing unit was to receive a meal cart at 11:25 a.m., and 11:35 a.m. daily. Observations of the noon meal service on the second and third floor nursing unit revealed that the food carts containing the noon meals for the residents were not arriving to the nursing units in a timely manner. Observations on the third-floor nursing unit revealed that the food carts for the residents living on the A hall did not arrive on the nursing unit until 12:55 p.m. and the food carts for B hall did not arrive on the nursing unit until 1:00 p.m., on January 20, 2026. Observations on the second-floor nursing unit revealed that the food carts for the residents living on the A hall did not arrive on the nursing until 1:10 p.m., and the food carts for the B hall did not arrive until 1:15 p.m., on January 20, 2026. The late delivery of foods/meal trays for lunch on January 20, 2026, was attributed to the staffing shortages in the food and nutrition department. Interview with the director of dietary services, Employee E7, at 1:30 p.m., confirmed that the food and nutrition services department had insufficient support personnel to effectively carry out meal preparations, delivery and service of foods and beverages according to the facility's scheduled time for meals. A review of the dietary staffing schedules for January 14, 2026, through January 20, 2026, revealed that the food and nutrition services department staff had been calling out of work regularly for the week reviewed. Interview with the administrator, Employee E1 at 2:00 p.m., on January 21, 2026, confirmed the lack of dietary staff employees to effectively and safely carry out the functions of the dietary services. 28 PA. Code 201.14 (a) Responsibility of licensee 28 PA. Code 201.18(b)(1)(3)(e)(1)(3) Management

Based on observation, interview, and clinical record review, it was determined that the facility failed to correctly administer medications in accordance with physician orders for one of four residents observed during medication administration observation, resulting in significant medication error (Residents R65).Findings Include:On January 21, 2025, at 9:30 a.m., review of physician orders for Resident R74 indicated orders for the following among other medications:Lisinopril Oral Tablet 20 MG (Lisinopril), Give 1 tablet by mouth one time a day for HTN (Ordered on July 25, 2025)Venlafaxine HCl ER Oral Capsule Extended Release 24 Hour (Venlafaxine HCl), give 150 mg by mouth one time a day for depression (Ordered on July 25, 2025)Aspercreme Lidocaine External Cream 4 % (Lidocaine HCl), Apply to neck topically two times a day for pain (Ordered on August 11, 2025)Pataday Ophthalmic Solution 0.2 % (Olopatadine HCl), Instill 1 drop in both eyes one time a day for eye irritation (Ordered on September 5, 2025)Meloxicam Tablet 7.5 MG, give 1 tablet by mouth one time a day for OA (Ordered on October 3, 2025).On January 21, 2025, at 9:39 a.m., observed that Employee E18, a Licensed Nurse, decanted Lisinopril Oral Tablet 20 MG; Venlafaxine HCl,150 MG, Oral Capsule Extended Release; Meloxicam Tablet 7.5 MG into a medicine Disposable cup. Along with these medications, E18 gathered Aspercreme Lidocaine External Cream 4 %, and Pataday Ophthalmic Solution 0.2 %. E18 then approached Resident R65 in the resident room and checked R65's Blood Pressure. After noting the Blood pressure of R 65, E18 attempted to administer the gathered medications to R65, without verifying the identity of R65. At that moment, before administering the medications to R65, E18 was prevented from administering those medications to R65, as those medications were intended for R74, not for R65.Review of literature revealed as follows: Lisinopril 20 mg oral tablet is a commonly prescribed medicine to treat high blood pressure (hypertension); Venlafaxine HCl ER (extended-release) oral capsule is an antidepressant used to treat major depressive disorder (MDD), generalized anxiety disorder (GAD), social anxiety disorder, and panic disorder; Meloxicam 7.5 mg tablet is an anti-inflammatory drug prescribed to relieve pain, swelling, and stiffness from osteoarthritis, rheumatoid arthritis; Aspercreme Lidocaine External Cream 4% is a maximum-strength, topical analgesic used to temporarily relieve minor pain in muscles and joints, including backaches, arthritis, by using lidocaine to block pain signals; and Pataday Ophthalmic Solution 0.2% is an antihistamine used to treat itching and redness in the eyes caused by allergies.At the time of the observation, interview with Employee E18 confirmed the above findings.Pa Code:211.12(d)(1)(2)(5) Nursing Services.

Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for one of four residents observed during medication administration (Resident R65).On January 21, 2025, at 9:30 a.m., review of physician orders for Resident R74 indicated orders for the following among other medications:Lisinopril Oral Tablet 20 MG (Lisinopril), Give 1 tablet by mouth one time a day for HTN (Ordered on July 25, 2025)Venlafaxine HCl ER Oral Capsule Extended Release 24 Hour (Venlafaxine HCl), give 150 mg by mouth one time a day for depression (Ordered on July 25, 2025)Aspercreme Lidocaine External Cream 4 % (Lidocaine HCl), Apply to neck topically two times a day for pain (Ordered on August 11, 2025)Pataday Ophthalmic Solution 0.2 % (Olopatadine HCl), Instill 1 drop in both eyes one time a day for eye irritation (Ordered on September 5, 2025)Meloxicam Tablet 7.5 MG, give 1 tablet by mouth one time a day for OA (Ordered on October 3, 2025).On January 21, 2025, at 9:39 a.m., observed that Employee E18, a Licensed Nurse, decanted Lisinopril Oral Tablet 20 MG; Venlafaxine HCl,150 MG, Oral Capsule Extended Release; Meloxicam Tablet 7.5 MG into a medicine Disposable cup. Along with these medications, E18 gathered Aspercreme Lidocaine External Cream 4 %, and Pataday Ophthalmic Solution 0.2 %. E18 then approached Resident R65 in the resident room and checked R65's Blood Pressure. After noting the Blood pressure of R 65, E18 attempted to administer the gathered medications to R65, without verifying the identity of R65. At that moment, before administering the medications to R65, E18 was prevented from administering those medications to R65, as those medications were intended for R74, not for R65.Review of literature revealed as follows: Lisinopril 20 mg oral tablet is a commonly prescribed medicine to treat high blood pressure (hypertension); Venlafaxine HCl ER (extended-release) oral capsule is an antidepressant used to treat major depressive disorder (MDD), generalized anxiety disorder (GAD), social anxiety disorder, and panic disorder; Meloxicam 7.5 mg tablet is an anti-inflammatory drug prescribed to relieve pain, swelling, and stiffness from osteoarthritis, rheumatoid arthritis; Aspercreme Lidocaine External Cream 4% is a maximum-strength, topical analgesic used to temporarily relieve minor pain in muscles and joints, including backaches, arthritis, by using lidocaine to block pain signals; and Pataday Ophthalmic Solution 0.2% is an antihistamine used to treat itching and redness in the eyes caused by allergies.At the time of the observation, interview with Employee E18 confirmed the above findings.The facility incurred a medication error rate of 13.79%.Pa Code:211.12(d)(1)(2)(5) Nursing Services.

Based reviews of policies and procedures, clinical record reviews, observations of care and services, interviews with residents, staff and family members, it was determined that for one of four residents reviewed for emotional behavior, sensory, communication and dignity, the facility failed to ensure a fully functioning hearing device was available and used according to audiology assessment and care planning. (Resident R86)A review of the facility policy titled consultant agreements and responsibilities revealed that the facility was responsible for making arrangements for care and services for the residents that the facility does not employ as staff through a qualified professional outside service. According to the contract the consulting services were to be timely and the service was to be reported to the administrator through dated signed reports, implementation of plans and continued assessment of the resident. Observations of Resident R86 during the days of the survey, January 20, 2026, and January 22, 2026, revealed that the resident was in her room in a geriatric reclining chair. The resident was heard yelling out persistently. Residents R 58, R7, R92, R68, R84, and R72 living on the third-floor nursing unit reported that they were concerned for Resident R86. The residents reported being worried about resident R86thinking that she sounded distressed or in need of help. The residents also reported that the constant yelling, by Resident R86 was annoying for them. The residents were asking, could something be done to help the quality of life for Resident R86. Interviews with nursing staff revealed that Employee E11 and Employee E14 at 1:45 p.m., on January 20, 2026, revealed that Resident R86 would not yell if you spent time with her one on one. The nursing assistant, Employee E11 reported that it was difficult for her to meet the needs of Resident R86 with one-on-one daily since she had other residents that she had other residents that she was assigned to take care daily. Interview with the recreational activity's director, Employee E6 at 1:00 p.m., on January 21, 2026, revealed that Resident R86 had a difficult time hearing the rosary prayers being recited in the activities area. The director of activities reported that the amplification device that resident R86 had been issued was not picking up the sounds of the rosary session. Clinical record review revealed a comprehensive admission assessment MDS (an assessment of care needs) dated August 6, 2025, that indicated Resident R86 had a hearing aid or other hearing appliance. The assessment also indicated that this resident had non-Alzheimer's dementia, legal blindness and anxiety disorder. Clinical record review for resident R86 revealed a comprehensive quarterly assessment dated [DATE], that indicated this resident had highly impaired hearing. The assessment also said that this resident had cognitive skills that were modified (some difficulty in new situations only). Clinical record review revealed a psychiatrist progress note dated January 15, 2026, that indicated Resident R86 was persistently yelling, agitated cursing and statements of verbal aggression. The note indicated that the nursing staff were reporting that Resident R86 was still yelling, agitated and irritated. Clinical record review revealed an activity assessment that indicated that Resident R86's poor hearing affects her participation in the Rosary and Prayer, which she prefers to do. Clinical record review for Resident R86 revealed a care plan that indicated audiology assessment and care planning as needed and the use of an amplifier device. Clinical record review revealed an audiology consult dated December 31, 2025, that indicated Resident R86 was assessed with moderate to severe hearing loss bilaterally. The audiologist indicated that an amplification device or hearing aid was recommended for both ears. The audiologist indicated that the family would be consulted about what hearing aid (hearing aid or other hearing appliances) was best suited for this Resident R86. There was no documentation to indicate that the audiologist had spoken to the resident's responsible party as care planned about the assessment and recommendations on December 31, 2025, for hearing aids or a hearing device for Resident R86. Observations of Resident R86 with nursing assistant, Employee E11 at 10:30 a.m., on January 23, 2026, revealed that the amplification device used for Resident R86 was not consistently picking up on sound through the speaking component used by staff and visitors to communicate with this resident. The nursing assistant reported that at varies times when she tries to speak to Resident R86 with the hearing device, the device echoes her voice in the earphones. Observations of the battery holder for the hearing device revealed the batteries were being taped so that the batteries would not fall to the floor. The plastic used to secure the batteries was missing. Interview with the responsible party for Resident R86 at 2:00 p.m., on January 22, 2026, revealed that Resident R86 does not have hearing aids for her hearing deficits. The family member reported that she would be willing to try hearing aids or other hearing appliances to improve the quality of communication, hearing and quality of life for Resident R86. 28 PA. Code 211.10(a)(b)(c)(d) Resident care policies28 PA. Code 211.12(d)(1)(3)(5) Nursing services28 PA. Code 201.14(a) Responsibility of licensee. TIMCHO, [NAME] (86) [NAME], [NAME] (06525) - Comm-Sensory No NotesTIMCHO, [NAME] (86) [NAME], [NAME] (06525) - RESIDENT NOTE No Notes

Based on interviews and the review of clinical records, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of one Dialysis-Residents reviewed (Residents R9).Review of Resident 9's clinical records indicated that R9 was admitted in the facility on May 10, 2025, with Diagnoses including Dependence on Renal Dialysis (refers to the mandatory, long-term use of artificial filtration (hemodialysis or peritoneal dialysis) to replace lost kidney function).Review of physician order for R9, dated June 2, 2025, August 28, 2025, and January 16, 2026, revealed; Dialysis days: Tuesdays, Thursdays, and Saturdays. Time for Pick up: 5;30 a.m.Review of Resident R9 's Hemodialysis Communication Record revealed that it lacked the following information as required per the communication log:The portion on the Hemodialysis Communication Record marked to be completed by Center Licensed Nurse for Dialysis patient prior to hemodialysis treatment, on August 14, 2025; September 20, 2025; October 11, 2025; October 28, 2025; and November 6, 2025.The portion on the Hemodialysis Communication Record marked to be completed by Certified Dialysis Facility following Dialysis treatment and accompany patient on return to Center post-hemodialysis, on January 20, 2026.The portion on the Hemodialysis Communication Record marked to be completed by Center Licensed Nurse post-hemodialysis treatment, on June 5, 2025; June 7, 2025; June 10, 2025; June 12, 2025; June 21, 2025; June 26, 2025; July 1, 2025; July 8, 2025; July 10, 2025; July 12, 2025; July 15, 2025; July 24, 2025; July 26, 2025; August 8, 2025; August 12, 2025; August 14, 2025; August 23, 2025; August 28, 2025; August 30, 2025; September 9, 2025; September 19, 2025; September 20, 2025; October 9, 2025; October 11, 2025; October 18, 2025; October 25, 2025; and October 28, 2025.Interview with the Charge Nurse, a Licensed Nurse, Employee E17, on January 23, 2026, at 11:22 a.m., confirmed lack of information in the Hemodialysis Communication Record of R9.28 Pa Code 211.5(f) Clinical records

Based upon review of clinical records, interviews with staff and residents and reviews of policies and procedures, it was determined the facility did not ensure residents receive treatment and care in accordance with professional standards of practice, by failing to follow the physician's orders for daily weights for one of twenty-two residents reviewed. (Resident R35)Findings Include: Review of facility policy titled, Weights and Heights with a revision date of June February 1, 2023 states, Obtaining and Documenting Weight- 1.1.4 If the body weight is not as expected, re-weigh the patient. Resident R35 was admitted to the facility July 1, 2025 with the following diagnosis: Hypertension (a chronic condition where blood forces against artery walls is consistently too high), Pressure Ulcer Stage 2 (a partial-thickness skin loss involving the epidermis and dermis), Anemia (a condition where your blood lacks enough healthy red blood cells to carry adequate oxygen to your body's tissues), Heart Failure (a chronic, manageable condition where the heart cannot pump enough blood to meet the body's needs, often causing fatigue, fluid buildup, and shortness of breath), and Dysphagia (difficulty swallowing). Review of Resident R35's clinical record revealed the resident had a physician order for , Daily weight-Notify the provider if: gain over 2 pounds in 1 day or 5 pounds in a week that was dated and started on December 23, 2025. Review of the facility Weights and Vitals log revealed no daily weight on the following dates: December 26, December 27, December 30, January 1, January 3, January 4, January 5, January 8, January 9, January 10, January 13, January 14, January 15, January 17, January 18, and January 19. Further review of the resident's clinical record revealed no documentation that the physician was ever notified of the weight increase on January 16, 2025. Further review of the resident clinical record revealed no re-weight to ensure accurate weight on January 16, 2026. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on observation, clinical record review, review of facility documentation and staff interview, it was determined that the facility failed to adhere to acceptable standards of nursing practice related to medication administration for one of four residents observed during medication administration (Resident R65). Findings include:The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11(b), General Functions of the Registered Nurse (RN), and 21.14(a), Administration of Drugs, indicated that the RN is fully responsible for all actions as a licensed nurse and is accountable to patients for the quality of care delivered, and administers medication ordered for the patient in the dosage and manner prescribed. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145(a)(b), Functions of the Licensed Practical Nurse (LPN), indicated that the LPN functions as a member of the health-care team by exercising sound nursing judgement based on preparation, knowledge, experience in nursing and competency, and administers medication ordered for the patient.On January 21, 2025, at 9:30 a.m., review of physician orders for Resident R74 indicated orders for the following among other medications:Lisinopril Oral Tablet 20 MG (Lisinopril), Give 1 tablet by mouth one time a day for HTN (Ordered on July 25, 2025)Venlafaxine HCl ER Oral Capsule Extended Release 24 Hour (Venlafaxine HCl), give 150 mg by mouth one time a day for depression (Ordered on July 25, 2025)Aspercreme Lidocaine External Cream 4 % (Lidocaine HCl), Apply to neck topically two times a day for pain (Ordered on August 11, 2025)Pataday Ophthalmic Solution 0.2 % (Olopatadine HCl), Instill 1 drop in both eyes one time a day for eye irritation (Ordered on September 5, 2025)Meloxicam Tablet 7.5 MG, give 1 tablet by mouth one time a day for OA (Ordered on October 3, 2025).On January 21, 2025, at 9:39 a.m., observed that Employee E18, a Licensed Nurse, decanted Lisinopril Oral Tablet 20 MG; Venlafaxine HCl,150 MG, Oral Capsule Extended Release; Meloxicam Tablet 7.5 MG into a medicine Disposable cup. Along with these medications, E18 gathered Aspercreme Lidocaine External Cream 4 %, and Pataday Ophthalmic Solution 0.2 %. E18 then approached Resident R65 in the resident room and checked R65's Blood Pressure. After noting the Blood pressure of R 65, E18 attempted to administer the gathered medications to R65, without verifying the identity of R65. At that moment, before administering the medications to R65, E18 was prevented from administering those medications to R65, as those medications were intended for R74, not for R65.Review of literature revealed as follows: Lisinopril 20 mg oral tablet is a commonly prescribed medicine to treat high blood pressure (hypertension); Venlafaxine HCl ER (extended-release) oral capsule is an antidepressant used to treat major depressive disorder (MDD), generalized anxiety disorder (GAD), social anxiety disorder, and panic disorder; Meloxicam 7.5 mg tablet is an anti-inflammatory drug prescribed to relieve pain, swelling, and stiffness from osteoarthritis, rheumatoid arthritis; Aspercreme Lidocaine External Cream 4% is a maximum-strength, topical analgesic used to temporarily relieve minor pain in muscles and joints, including backaches, arthritis, by using lidocaine to block pain signals; and Pataday Ophthalmic Solution 0.2% is an antihistamine used to treat itching and redness in the eyes caused by allergies.At the time of the observation, interview with Employee E18 confirmed the above findings.The facility incurred a medication error rate of 13.79%.The facility failed to adhere to acceptable standards of nursing practice related to medication administration.28 Pa. Code: 201.18(b)(1) Management.28 Pa. Code: 211.12(d)(3)(5) Nursing services.

Based on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan for one of 32 Residents reviewed (R44).Findings Include: Review of Resident R44's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included Encephalopathy (Encephalopathy is a term for any diffuse disease of the brain that alters brain function or structure), Anxiety disorder (Anxiety disorders are a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation), Bipolar disorder (Bipolar disorder is a mental illness that causes clear shifts in a person's mood, energy, activity levels, and concentration), Chronic Pain Syndrome (A condition where pain persists for 3-6 months or longer, typically extending beyond the expected healing time of an initial injury or illness) , and Depression (Depression is a common, serious mood disorder characterized by persistent sadness, loss of interest in activities, and, in many cases, significant physical, cognitive, and emotional impairment).Review of physician order for R44, dated January 9, 2026, indicated an order for Wander Guard/Wander Elopement Device due to poor safety awareness, every shift check the placement of the device and in supplemental document the location; and every night shift check function and document in supplemental documentation; Expiration date: June 2027; update the order with the new date when the bracelet is changed.Review of the care plan for R44, on January 22, 2026, at 10:11 a.m., revealed that there were no focus, outcomes (goals), and interventions, care- planned for Wander Guard/Wander Elopement Device administration.on January 22, 2026, at 10:24 a.m., interview with the DON confirmed the above findings.28 Pa Code 211.10 (c)(d) Resident care policies28 Pa Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, interviews with staff, and review of facility policies it was determined that the facility failed to ensure prevention of accidents and hazards related to medications found at bedside for one of twenty-two residents reviewed. (Resident R3) Findings Include: Review of facility policy titled, Medication Administration with a date of 2007 states, Policy- Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Further review of the Medication Administration policy revealed, Medication Administration. 4. Medications are administered at the time they are prepared. 5. The person who prepares the dose for administration is the person who administers the dose. On January 20, 2026, at 12:05 p.m. Resident R3's room was observed and Resident R3's father was interviewed due to the resident sleeping. During the interview the surveyor observed a plastic medication cup with several pills on a tray table that was over the bed for resident R3. When Resident R3's father was asked about the medication he stated the nurse left them for the resident to take when he woke up because he did not want to wake Resident R3 due to being in a deep sleep. The Director of Nursing Employee E3 was called to the room at 12:10 p.m. and confirmed at 12:14p.m. that two medications for the resident's medications were left by the licensed Nurse Employee E19 in a plastic medication cup on the resident's tray table for the resident. Interview held with the Director of Nursing on January 22, 2025, at 12:55 p.m. confirmed the licensed nurse Employee E19 is an agency staff and did leave the medications bedside for the resident to take once he woke up. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policies, review of facility documentation, review of personnel files and interviews with staff, it was determined that the facility failed to ensure that nursing staff received training on abuse, neglect, exploitation and misappropriation of resident property as required for two of three nursing staff reviewed (Employees E4 and E8). Findings include: Review of facility policy, Abuse Prohibition dated October 24, 2022, revealed, Training and reporting obligations will be provided to all employees through orientation, code of conduct training and a minimum of annually. Interview on September 4, 2025, at 10:19 a.m. Employee E4, agency licensed nurse, stated that it was her first day working at the facility. Employee E4, agency licensed nurse, stated that when she arrived for her shift, she was given report from the night nurse and showed around the nursing unit. Employee E4, agency licensed nurse, stated that she completed some online training prior to working at the facility but was unable to specify what topics were reviewed. Review of facility documentation submitted to the Pennsylvania Department of Health on September 2, 2025, revealed that on September 1, 2025, Employee E7, licensed nurse, discovered that 30 tablets of oxycodone (opioid pain medication) for Resident R1 were unaccounted for in the narcotic drawer. The facility identified Employee E8, agency licensed nurse, as the alleged perpetrator. An interview with Employee E8, agency licensed nurse, was requested, however, the employee has not responded to any requests. Abuse training records for Employees E4 and E8, agency licensed nurses, were requested, but were not provided at any time during the survey. Interview on September 4, 2025, at 2:48 p.m. the Director of Nursing revealed that agency staff are expected to complete required trainings through their agencies. The Director of Nursing was unable to retrieve training records specific to abuse, neglect, exploitation and misappropriation of resident property for Employees E4 and E8, agency licensed nurses, and stated that she was still waiting for the staffing agency to provide the training records. The Director of Nursing was unable to verify if Employees E4 and E8, agency licensed nurses, had completed any training specific to abuse, neglect, exploitation and misappropriation of resident property. 28 Pa Code 201.19(7) Personnel policies and procedures 28 Pa Code 201.20(a)(b) Staff development

Based on observations, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for two of three residents reviewed (Residents R1 and R2). Findings include: Review of facility policy, Management of Controlled Drugs dated January 31, 2025, reveled, A complete count of all Schedule II-IV controlled substances is required at the change of shifts per state regulation or at any time in which the narcotic keys are surrendered from one licensed nursing staff to another. The count must be performed by two licensed nurses. Review of Resident R1's physician orders revealed an order, dated August 29, 2025, for oxycodone (opioid pain medication) 5 m.g (milligrams) give one tablet two times a day for chronic pain. Review of Controlled Substance Inventory Count Sheets revealed that Employee E7, licensed nurse, worked on the 3A medication cart on August 29, 2025, from 3:00 p.m. through August 30, 2025, at 7:00 a.m. During the 11:00 p.m. to 7:00 a.m. shift, Employee E7, licensed nurse, documented that she received a container of oxycodone 5 m.g tablets and a Controlled Drug Record sheet for Resident R1. Review of the Pharmacy Shipping Manifest revealed that 30 tablets of oxycodone 5 m.g tablets for Resident R1 were delivered to the facility on August 29, 2025. Continued review of Controlled Substance Inventory Count Sheets revealed that Employee E7, licensed nurse, worked on the 3A medication cart again on August 30, 2025, from 3:00 p.m. through August 31, 2025, at 7:00 a.m. Employee E7, licensed nurse, signed the Controlled Substance Inventory Count Sheet at the end of her shift documenting that there were 14 containers of medications in the narcotic drawer and 13 corresponding controlled drug record sheets. Employee E8, agency licensed nurse, signed the Controlled Substance Inventory Sheet that she was the oncoming nurse on August 31, 2025, at 7:00 a.m. and documented that there were 13 containers of medications in the narcotic drawer and 13 controlled drug record sheets. Further review of Controlled Substance Inventory Count Sheets revealed that Employee E7, licensed nurse, worked on the 3A medication cart again on August 31, 2025, as the oncoming nurse at 11:00 p.m. and documented that there were 13 containers of medications in the narcotic drawer and 12 controlled drug record sheets. There was no signature or count from Employee E8, agency licensed nurse, when she left the shift at 11:00 p.m. Interview on September 4, 2025, at 1:58 p.m. Employee E7, licensed nurse, was unable to explain to discrepancy on the Controlled Substance Inventory Count Sheets for Resident R1. Continued review of Resident R1's physician orders revealed an order, dated May 23, 2025, for oxycodone 5 m.g give one tablet every 12 hours as needed for pain. Review of Resident R1's Controlled Drug Record sheets for oxycodone 5 m.g tablets revealed that the resident was administered a dose on August 11, 2025, at 6:00 p.m. Review of Resident R1's Medication Administration Records for August 2025, revealed no indication that the resident was administered the medication at that time. Continued review of Resident R1's Medication Administration Records revealed that the resident was administered oxycodone 5 m.g on August 29 and 30, 2025, at 9:00 p.m. Review of Resident R1's Controlled Drug Record sheets for oxycodone 5 m.g tablets revealed no indication that the resident was administered the medication at those times. Review of physician's orders for Resident R2 revealed orders, dated July 8, 2025, and August 22, 2025, for oxycodone 10 m.g tablets give one tablet every eight hours as needed for pain. Review of Resident R2's Controlled Drug Record sheets for oxycodone 10 m.g revealed that the resident was administered the following doses:August 5, 2025, at 12:00 a.m.;August 11, 2025, at 10:00 a.m.;August 15, 2025, at 2:00 a.m.;August 20, 2025, at 9:00 p.m.;August 21, 2025, at 2:20 a.m.;August 23, 2025, at 7:00 p.m.;August 28, 2025, at 9:00 a.m.; andAugust 30, 2025, at 1:00 p.m Review of Resident R2's Medication Administration Records for August 2025, revealed no indication that the resident was administered the medication at those times. Interview on September 4, 2025, at 2:48 p.m. the Director of Nursing was unable to explain the discrepancies on Resident R1 and R2's Controlled Drug Record sheets and Medication Administration Records. 28 Pa Code 211.9(a)(1) Pharmacy services 28 Pa Code 211.9(k) Pharmacy services

Based on review of facility policies, clinical record review, review of facility documentation and interviews with staff, it was determined that the facility failed to ensure a resident was free from misappropriation related to missing medication for one of three residents reviewed (Resident R1). Findings include: Review of facility policy, Abuse Prohibition dated October 24, 2022, revealed, Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/patient property, and exploitation for all residents. Continued review revealed, Misappropriation of patient property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a patient's belongings or money without the patient's consent. Review of Resident R1's Annual MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated June 4, 2025, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including cancer and chronic pain. Continued review revealed that the resident frequently has pain that interferes with sleeping and day-to-day activities. Review of Resident R1's care plan, dated initiated November 11, 2019, revealed that the resident is at risk for alterations in comfort related to chronic pain with interventions including encouraging the resident to request pain medication before pain becomes severe and to medicate the resident as ordered. Review of Resident R1's physician orders revealed an order, dated August 29, 2025, for oxycodone (opioid pain medication) 5 m.g (milligrams) give one tablet two times a day for chronic pain. Review of facility documentation submitted to the Pennsylvania Department of Health on September 2, 2025, revealed that on September 1, 2025, Employee E7, licensed nurse, discovered that 30 tablets of oxycodone for Resident R1 were unaccounted for in the narcotic drawer. The facility identified Employee E8, agency licensed nurse, as the alleged perpetrator. Review of Controlled Substance Inventory Count Sheets revealed that Employee E7, licensed nurse, worked on the 3A medication cart on August 29, 2025, from 3:00 p.m. through August 30, 2025, at 7:00 a.m. During the 11:00 p.m. to 7:00 a.m. shift, Employee E7, licensed nurse, documented that she received a container of oxycodone 5 m.g tablets and a Controlled Drug Record sheet for Resident R1. Review of the Pharmacy Shipping Manifest revealed that 30 tablets of oxycodone 5 m.g tablets for Resident R1 were delivered to the facility on August 29, 2025. Continued review of Controlled Substance Inventory Count Sheets revealed that Employee E7, licensed nurse, worked on the 3A medication cart again on August 30, 2025, from 3:00 p.m. through August 31, 2025, at 7:00 a.m. Employee E7, licensed nurse, signed the Controlled Substance Inventory Count Sheet at the end of her shift documenting that there were 14 containers of medications in the narcotic drawer and 13 corresponding controlled drug record sheets. Employee E8, agency licensed nurse, signed the Controlled Substance Inventory Sheet that she was the oncoming nurse on August 31, 2025, at 7:00 a.m. and documented that there were 13 containers of medications in the narcotic drawer and 13 controlled drug record sheets. Further review of Controlled Substance Inventory Count Sheets revealed that Employee E7, licensed nurse, worked on the 3A medication cart again on August 31, 2025, as the oncoming nurse at 11:00 p.m. and documented that there were 13 containers of medications in the narcotic drawer and 12 controlled drug record sheets. There was no signature or count from Employee E8, agency licensed nurse, when she left the shift at 11:00 p.m. Interview on September 4, 2025, at 1:58 p.m. Employee E7, licensed nurse, stated that she worked Saturday, August 30, 2025, from 3:00 p.m. through 7:00 a.m. the next morning. Employee E7, licensed nurse, stated that Employee E8, agency licensed nurse, relieved her on Sunday morning and that Employee E8 worked on August 31, 2025, from 7:00 a.m. through 11:00 p.m. Employee E7, licensed nurse, stated that she relieved Employee E8, agency licensed nurse, on Sunday night August 31, 2025, at 11:00 p.m. Employee E7, licensed nurse, continued that while counting Sunday night during shift change, Employee E8, agency licensed nurse, was in a rush and that after counting narcotic medications they went straight into report (process of informing oncoming staff of resident status). Employee E7, licensed nurse, stated that she does not remember what time during her shift when she signed the Controlled Substance Inventory Count Sheet and confirmed that Employee E8, agency licensed nurse, did not sign the sheet at the end of her shift. Employee E7, licensed nurse, stated that she performs a narcotic count for herself prior to the end of her shift in preparation for shift change and that's when she realized that the count was not correct. Employee E7, licensed nurse, stated she remembered that Resident R1 had received a card (30 tablets) of oxycodone a few day prior and that the medications and corresponding controlled drug record sheet were missing. Employee E7, licensed nurse, immediately reported this to the supervisor. An interview with Employee E8, agency licensed nurse, was requested, however, the employee has not responded to any requests. Interview on September 4, 2025, at 2:48 p.m. the Director of Nursing confirmed that misappropriation of Resident R1's oxycodone occurred because the medication went missing due to controlled drug procedures not being followed. The Director of Nursing confirmed that the medication went missing during Employee E8's shift, stated that the medication was not found in the facility and had to be replaced through the pharmacy. The Director of Nursing also stated that Employee E8, agency licensed nurse, has not responded to any requests from the facility for interview. 28 Pa Code 201.18(b)(2) Management 28 Pa Code 211.9(a)(1) Pharmacy services 28 Pa Code 211.12(d)(5) Nursing services

Based on observation, and staff interview, it was determined that the facility failed to ensure that essential equipment was maintained in safe and operating conditions related to the refrigerators in dining rooms for two of two floors reviewed. (Second and Third Floors). Findings Include: An initial tour of the third floor Dining Room was made on 11:55 a.m. on July 2, 2025. Observation of the dining service area for the third floor revealed the ice machine was leaking and had a towel on floor that was saturated as well as visible water around the area, this was confirmed by the Dietary staff, Employee E4. When asked what happens when there is a leak, Employee E4 stated, well, I do not know, that is a different department. Further review of the service area revealed two refrigerators not currently operable. One refrigerator underneath the counter had a Do Not Use sign on it and it had wet condensation on the outside of it. The other clear display refrigerator was in the front of the service area. Employee E4 stated they have not been working. An initial tour of the second floor Dining Room was made on 12:07 p.m. on July 2, 2025. Observation of the dining service area for the second floor revealed three refrigerators not currently operable. There were two refrigerators under the cabinets and one clear display refrigerator in the front of the service area. When asked how long they have been inoperable Dietary staff, Employee E5 stated they have not been working for at least a few months. Observation of the second floor Dining Room lunch service revealed dietary staff expressing Resident R1 at 12:20 p.m. needed a turkey and cheese sandwich due to both main courses being protein options he does not eat. The dining room service refrigerator was broken therefore there were no cold sandwiches on hand. The sandwich was requested to the Director of Dining Employee E3, and a sandwich was deliver to the resident from the dietary department brought by Dietary staff, Employee E3 at 12:32 p.m. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on observations, interviews with staff, and a review of facility policy, it was determined that the facility failed to store food, in accordance with professional standards for food service safety. Findings Include: Review of facility Policy titled, Food Storage: Cold Foods, last revised February 2023 states, Policy Statement- All Time/Temperature Control for Safety (TSC) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. Procedures- 5. All foods will be stored wrapped or covered in containers, labeled and dated, and arranged in a manner to prevent cross contamination. A tour of the facility kitchen area was conducted on July 2, 2025, at 10:05 a.m. with the Director of Dining Employee E3. During observation several items were observed in the walk-in refrigerator undated or labeled improperly. The first item was a container of prepared shredded carrots that had a labeled date of June 10, 2025 but no Use By date. When asked if the food is supposed to be labeled Employee E3 stated, I was told that we didn't need to label the fresh items, but we do throw them out when they look like they start getting slimy. When the container of carrots were uncovered they did appear to be very dry with some having with residue on them. Continued review of the walk-in refrigerator revealed, a large portion of deli ham unsliced with a date of June 30, 2025, but no Use By date label. A container of finely chopped mix ham and cheese with a date of June 27, 2025, but no Use By date label. A container with a block of deli cheese with a date of June 30, 2025, but no Use By date label. A container thawed raw ground beef with a date of July 2, 2025, but no Use By date label. A package of hard-boiled eggs with a Use By label of June 30, 2025. A container of finely chopped fresh fruit small with a date of June 30, 2025, but no Use By date. A container of prepared peas with a date of June 30, 2025, but no Use By date label. A container with raviolis with an Opened date labeled June 26, 2025, but no Use By date. A container of finely chopped herbs with a use by date of June 12, 2025. The Director Dining Services Employee E3 confirmed at 10:21 a.m. that the herbs and hard-boiled egg should have been discarded, and the other items were labeled incorrectly. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management

Based on review facility policy, review of facility documentation, review of clinical records, interview staff, it was determined that the facility failed to ensure that a resident was free of neglect related to provision of incontinence care for one of twelve residents reviewed. (Resident R12) Findings: Based on review of facility policy titled Abuse Prohibition dated October 24, 2022, revealed the center prohibits abuse mistreatment, neglect, misappropriation of resident property, exploitation for all patients this is includes but not limited to freedom from corporal punishment and voluntary seclusion and any physical or chemical restraint, potential hires, training of employees, prevention of occurrences, identification of possible incidents or allegations which need investigation. Review of facility policy titled Neglect and Abuse revealed neglect is defined as a failure, in difference, or disregard of the center, its employees or service providers to provide care, comfort, safety, goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This includes a failure to implement an effective communication system across all shifts for communicating necessary care and information between the center, patient, practitioners, and patient representatives. Training will be provided to all employees through orientation, code of conduct training, and a minimum of annually which will include the abuse prohibition policy, appropriate interventions to deal with aggressive residents, recognize signs of burnout, frustration and stress that may lead to abuse, effective communication skills with patient's caregivers and patient representatives, what constitutes abuse, neglect and misappropriation of property. Review of Resident R12's clinical record revealed the resident had diagnosis of non-displaced intertrochanteric fracture of left femur (minimal displacement of the upper part of the left thigh bone), chronic embolism and thrombosis of vein (blood clot in the veins) diabetes with neuropathy (nerve damage caused by diabetes), personal history of TIA (transient ischemic attack temporary blockage of blood flow to the brain, minor stroke). Review of Resident R12's admission Minimum Data Set (MDS- assessment of resident's needs) dated February 14, 2025 revealed that the resident was assessed with a BIMS (brief interview of mental status) score of 6, which indicated that the resident had severe cognitive impairment. Review of Resident R12's care plan dated February 11, 2025, revealed that the resident was dependent for toileting hygiene related to left hip fracture, which included the following interventions: to monitor for skin irritation and redness when assisting with personal hygiene with a goal the patient will be able to maintain personal hygiene. Resident is at risk for skin breakdown related and or has actual skin breakdown stage three pressure ulcer of her sacrum dated February 10, 2025, with interventions to turn and reposition everyone to two hours. Review of facility documentation submitted to the State survey agency on February 12 2025, revealed Resident R12 was observed soiled with urine. The charge nurse Employee E5 was performing wound care and found the wound dressing was soiled as well as two briefs and linen. The perpetrator was identified as nursing assistant Employee E3. The facility conducted an investigation and found that the report of neglect was found substantiated and Employee E3 was terminated. Review of statement given by Nursing aide, Employee E3 revealed that I had eighteen patients and may have overlooked the resident (Resident R12) This was unintentional as I need help and there was not enough. Interview with Nursing Home Administrator, Employee E1 one March 20, 2025, at 12:50 p.m. revealed as soon as she was notified of the incident this employee initiated an investigation, interviewed residents cared for on the floor by Nurse aide, Employee E3 during the shift and found the allegation substantiated. This employee stated that Nurse aide, Employee E3 had worked for the facility for years and confirmed she had some prior disciplinary actions related to care concerns. Employee was terminated. 28 Pa. Code 211.12(d) Nursing Services 28 Pa.Code 201.18(e)(1)Management

Based on review facility policy, review of facility documentation, review of clinical records, interview with residents and staff, it was determined that the facility failed to ensure adequate number of nurse aides to meets the needs of residents on one of two nursing floors (2nd Floor) one of twelve residents reviewed. (Resident R12) Findings: Review of Resident R12's clinical record revealed the resident had diagnosis of non-displaced intertrochanteric fracture of left femur (minimal displacement of the upper part of the left thigh bone), chronic embolism and thrombosis of vein (blood clot in the veins) diabetes with neuropathy (nerve damage caused by diabetes), personal history of TIA (transient ischemic attack temporary blockage of blood flow to the brain, minor stroke). Review of Resident R12's admission Minimum Data Set (MDS- assessment of resident's needs) dated February 14, 2025 revealed that the resident was assessed with a BIMS (brief interview of mental status) score of 6, which indicated that the resident had severe cognitive impairment. Review of Resident R12's care plan dated February 11, 2025, revealed that the resident was dependent for toileting hygiene related to left hip fracture, which included the following interventions: to monitor for skin irritation and redness when assisting with personal hygiene with a goal the patient will be able to maintain personal hygiene; resident is at risk for skin breakdown related and or has actual skin breakdown stage three pressure ulcer of her sacrum dated February 10th, 2025, with interventions to turn and reposition everyone to two hours. Review of facility documentation submitted to the state survey agency on February 12 2025, revealed Resident R12 was observed soiled with urine. The charge nurse Employee E5 was performing wound care and found the wound dressing was soiled as well as two briefs and linen. The perpetrator was identified as nursing assistant Employee E3. The facility conducted an investigation and found that the report of neglect was found substantiated and Employee E3 was terminated. Review of statement given by Nursing aide, Employee E3 revealed that I had eighteen patients and may have overlooked the resident (Resident R12) This was unintentional as I need help and there was not enough. Review of daily staffing sheet for February 12, 2025, during the 7-3 shift revealed that nurse aide, Employee E3 was scheduled on the second floor. Continued review of daily staffing sheet revealed that a total of eight nurse aides were schedule for the 7- 3 shift with a census of 95 which was below the required State regulation. Interview with DON employee E2 on March 20, 2025 at 4:00p.m. confirmed on the day February 12, 2025 the facility did not have the appropriate number of staff per ratio. 28 Pa. Code 211.12(d) Nursing Services 28 Pa.Code 201.18(e)(1)Management

Based on observations, clinical record review, and interviews with staff and residents, it was determined that the facility failed to provide reasonable accommodations of needs relating to a bariatric bed and a functioning heater for two of 31 residents reviewed.(Residents R251 and R248) Findings include: Review of Resident R251's Minimum Data Set (MDS-federal mandated assessment for all residents) dated February 12, 2025 revealed that Resident R251 was admitted into the facility on [DATE] with diagnosis' including respiratory failure (respiratory system cannot maintain normal levels of oxygen and carbon dioxide in the body), chronic congestive heart failure(long term condition , the heart is unable to pump blood effectively), type 2 diabetes(condition that occurs when blood glucose is too high) and morbid (severe) obesity (health condition that results from abnormally high body mass that is diagnoses by having a body mass index(BMI) greater then 40). Review Resident R251's lift transfer evaluations dated February 6, 2025, revealed Resident R251's weight dated February 6, 2025, was assessed at 316 pounds (lbs) and Resident R251's height as 65 inches. This resident is assessed of not being able to independently turn or reposition in bed or the chair, the resident requires extensive total assistance to turn reposition of two or more staff. Review of facility assessment revealed that equipment and supply inventories this facility currently has adequate equipment to supply all therapies. Medical and non-medical equipment required hospital beds with bariatric capability, and Hoyer lifts with bariatric capability. Observation of Resident 251 on February 9, 2025, at 11:05 am, revealed Resident R251 lying in a regular sized hospital bed. Maintance Director, Employee E11 fixing resident bed by releasing extender to lengthen the bed while resident was still occupying the bed. The bed was observed with extender and regular mattress (too small for bed frame). Interview with resident at time of observation revelaed Resident R251 vocalized discomfort. Interview with Maintance Director, Employee E11 at time of the above observations revealed that he has a new mattress to install but cannot move the resident. Employee E11 was just notified on this day that the residents bed needed adjustment. Further observation of Resident R251 on February 9, 2025, at 11:35 a.m. was observed four staff members assisting in lifting resident from bed with Hoyer lift while Maintance Director, Employee E11, extended the bed frame width and switched the mattress to accommodate for large mattress to fit bariatric bed setting. The resident bed was made to a bariatric setting three days after he was admitted into the facility. Observation of Resident R248 February 10, 2024, at 10:42 a.m. revealed resident sitting in chair with sheet wrapped around her. Further observation revealed cool air coming from heater unit in the resident's room. Interview with resident at time of observation revealed that resident stated she was cold and requested a blanket. Interview with Maintance Director, Employee E11 at time of observation revealed that the heater is supposed to blow cool air temporality, its not broke that is how it works. This employee deferred all other questions to Regional Maintenance Director Employee E12. Interview with Regional Maintance Director, Employee E12 on February 10, 2024, at 11:05a.m. revealed that the heater unit has a safety mechanism that prevents the system form overheating and the cold air will only blow for a short time. During this interview Employee E12 demonstrated that the heater would turn to hot air,. Employee E12 dismantled the heater unit and determined that this unit was not functioning properly. Employee E12 confirmed that the heater unit in Residents R 248's room was not functioning. 28. Pa. Code 201.29(j) Resident rights 28. Pa. code 211.12(d)(1) Nursing services

Based on clinical record reviews and interviews with staff, it was determined that the facility failed to follow physician orders related to diabetes management for one of 24 residents reviewed (Resident R24). Findings include: Review of Resident R24's Annual MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated January 20, 2025, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including diabetes (ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose). Review of physician orders for Resident R24 revealed an order, dated May 23, 2023, to check the resident's blood glucose level and notify the physician if greater that 400. Review of Resident R24's blood glucose levels revealed the following: On January 24, 2025, at 4:36 p.m. blood glucose level was 416; On January 1, 2025, at 8:32 p.m. blood glucose level was 416; On December 29, 2025, at 4:18 p.m. blood glucose level was 423; On December 27, 2025, at 8:17 a.m. blood glucose level was 427; On December 25, 2025, at 8:29 a.m. blood glucose level was 427; On December 17, 2025, at 4:38 p.m. blood glucose level was 416; and On November 15, 2025, at 8:56 p.m. blood glucose level was 407. Review of medication administration records and progress notes for Resident R24 revealed that there was no indication that the physician had been notified of the above blood glucose levels. Interview on February 11, 2025, at 10:53 a.m. Employee E13, unit manager, confirmed the above findings. 28 Pa Code 211.12(d)(5) Nursing services

Based on observations, staff interviews, review of facility documentation and review of facility policy, it was determined that the facility failed to store perishable food in the walk-in refrigerator below 41 degrees Fahrenheit to prevent potential food borne illness. This failure created an Immediate Jeopardy (IJ) situation for 93 of 93 residents. Findings include: Review of the facility policy title Refrigeration/ Freezer Temperature Standards dated June 15, 2018, stated that refrigerators and freezers operate within an acceptable temperature range. The purpose was to ensure food held in refrigerated equipment is maintained at a safe temperature. The Director of Dining Service/Director of Culinary Services or designee observes and records the temperatures of refrigerators and freezers on a daily basis using the refrigerator/freezer temperature log. Temperatures are not taken during the defrost cycle. If temperatures fall outside of the acceptable range, the Maintenance Department is notified immediately. If repair is delayed, consideration must be made regarding the relocation of perishable items. Acceptable ranges are refrigerators: 32 to 40 Fahrenheit and Freezers -10 to 0 Fahrenheit. Completed refrigeration/freezer temperature logs are maintained for 30 days. Review of the facility census documentation revealed that the facility has a resident census of 93 residents in house. Observation of the kitchen on August 24, 2022, at approximately 9:50 a.m. with the Food Services Director, Employee E2, revealed two thermometers inside the walk-in refrigerator. Each thermometer registered a temperature of 50-51 degrees Fahrenheit. The Food Services Director, Employee E2 reported it was due to the delivery of the food in the refrigerator. Review of the refrigerator temperature log for August 2022, revealed that no temperatures were recorded in the morning or afternoon from August 1-21, 2022. Further review of the refrigerator temperature log revealed that on August 22, 2022 and August 23, 2022, the temperature taken was 40 degrees Fahrenheit in the morning and 41 degrees Fahrenheit in the afternoon. Observations conducted on August 25, 2022, at approximately 1:35 p.m. of the walk-in refrigerator revealed that one thermometer registered 50 degrees Fahrenheit and the other 49 degrees Fahrenheit. One of the food service staff indicated that it was due to the pre-made food and drinks that were just put in for dinner time and confirmed that the temperature was above 41 degrees Fahrenheit. Inside the refrigerator were vegetables, fruits, cooked chicken, dairy items, pre-made drinks, pre-made desserts. A follow up observation was conducted on August 25, 2022, at 2:00 p.m. with the Food Service Director, Employee E2. During observation it was confirmed that the thermometers inside the walk-in refrigerator registered a temperature of 49 and 50 degrees Fahrenheit. Observation of the fan inside the walk-in refrigerator revealed frosted ice on the pipes behind the fan. Food Service Director, Employee E2 reported that it was due to the door latch being broken and the refrigeration needing to be defrosted. Surveyor asked for the working order to be provided, Food Service Director, Employee E2 reported that she was going to have the Maintenance Director, Employee E11 write a work order. Review of the working order revealed temps are on the rise, unit is frosted due to humidity and the door being left open advised to empty and defrost, install new plastic curtains, and make repairs to the door so that it closes and latches on its own. Interview conducted on August 25, 2022, at 3:12 p.m. with Food Service Director in reference to the work order which revealed that the Maintenance Director was verbally informed the walk-in refrigerator was not holding temperature and needed to be fix on August 22, 2022. However, there was no written work order completed. It was not until August 25, 2022, that Food Service Director, Employee E2 asked the Maintenance Director, Employee 11 to write a work order. Follow up observation of the walk-in refrigerator on August 25, 2022, at 3:56 p.m. with the Food Service Director, Employee E2, and Director of Nursing, Employee E3 revealed that the temperature of the milk stored in the refrigerator was 46.5 degrees Fahrenheit. The Director of Nursing directed the dietary staff to discard all food in the walk-in refrigerator. New food items were to be stored and sent to another long term care facility affiliated with the facility, until the walk-in refrigerator was repaired. All perishable food of concern were discarded in the presence of surveyor. Observations of the walk-in refrigerator on August 26, 2022, at approximately 9:00 a.m. with Nursing Home Administrator revealed that the temperature of both thermometers registered 50 degrees Fahrenheit. Nursing Home Administrator reported that the temperature was 40 degrees Fahrenheit earlier in the morning. Inside the refrigerator, the following dairy items were stored: eggs, cheese, milk, shakes, and butter. Nursing Home Administrator and Food Service Director, Employee E2, reported that they just put these dairy items in the refrigerator. Surveyor checked the temperature of the shakes, and it was recorded at 49 degrees Fahrenheit. Nursing Home Administrator and Food Service Director, Employee E2 then agreed to discard all perishable food. The facility failed to ensure that perishable foods were stored in the walk-in refrigerator below 41 degrees Fahrenheit. The facility failed to ensure that the refrigerator was maintained in proper working condition. This failure resulted in an Immediate Jeopardy situation. Based on the above findings, an Immediate Jeopardy to the safety of the residents was identified to the Nursing Home Administrator on August 26, 2022, at 11: 23 a.m. and an immediate action plan was requested. The Immediate Jeopardy template was provided to the Nursing Home Administrator on August 26, 2022, at 11:23 a.m. On August 26, 2022, at 2:58 p.m. the facility's immediate action plan was accepted. The facility's action plan included the following: 1. All Dairy products, vegetables, and pre-cooked food above 41 degrees were discarded. Door latch was ordered and will be replaced upon arrival. The door latch was not in correlation to refrigerator temperatures. All food was removed from the walk-in refrigerator and stored in alternate refrigerators (therapy gym and nursing units) in the facility and off-site at an affiliated long term care facility. Menus will be substituted if applicable. The walk-in refrigerator was unplugged, defrosted, and the fan was cleaned 2. Dining Services District Manager Immediately re-educated all dining services staff in the facility currently and prior to the start of their next shift on the proper storage temperatures of all dairy products, vegetables, and pre-cooked food. 3. Dining Services Director or Designee will initially audit the walk-in refrigerator temperatures every 8 hours for 24 hours to ensure it is holding a temperature of 41 degrees or below prior to any food being placed back in the walk-in refrigerator. 4. Once food is placed back in the refrigerator, Dining Services Director or designee will audit the walk-in refrigerator every 4 hours during Dining Services hours for 24 hours to ensure it is holding a temperature of 41 degrees or below. 5. Dining Services Director or designee will audit the walk-in refrigerator temperature per policy, twice/day, to ensure it is holding a temperature of 41 degrees or below. 6. NHA or designee will review findings at monthly QAPI meeting. Interviews were conducted with facility staff on August 27, 2022, at approximately 2:07 p.m. to verify the implementation of the action plan. Dietary staff interviewed were able to confirm that refrigerators were to be kept at a temperature of 41 degrees Fahrenheit or below. Per the Nursing Home Administrator, the walk-in refrigerator was serviced and the thermometer was calibrated. She reported that the walk-in refrigerator has been holding 30 degrees as its temperature. Nursing Home Administrator reported that if the refrigerator was still holding 30 degrees at 4:00 p.m. today (August 27th) food was going to be placed back in the refrigerator. Dairy was to be placed in the refrigerator the next day Sunday (August 28th). Nursing Home Administrator also reported that parts for the door was scheduled for delivery August 28, 2022, after 5:00 p.m. and the remaining parts to arrive sometime during the week of August 29th. Observations were conducted on August 27, 2022, with the Nursing Home Administrator in the kitchen at approximately 2:30 p.m. The temperatures of the refrigerator in the kitchen on Saturday, August 27, 2022, were recorded at 30 degrees (thermometer closer to the refrigerator) and 26 degrees Fahrenheit, the thermometer on the far end. The refrigerator contained no food items. The ice was defrosted, and the cold air was detected behind the fans. The Nursing Home Administrator reported that the fans were blowing at 27 degrees Fahrenheit. Following the verification of the immediate action plan, the Immediate Jeopardy was lifted on August 27, 2022, at 3:11 p.m. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 207.2(a) Administrator's responsibility 28 Pa. Code 211.6(c) Dietary services (Cont)

Based on review of clinical records, review of facility documentation, review of facility policies and procedures, and interviews with resident and staff, it was determined that the facility failed to provide appropriate assistance during bed mobility to prevent a fall for one of 19 residents reviewed. This failure resulted in actual harm to Resident R60 who fell off the bed and sustained a right femur fracture. This failure was identified as past non-compliance. (Resident R60) Findings include: Review of documentation revealed a facility policy titled Safe Resident Handling/Transfer Equipment revised November 1, 2019. Facility policy revealed staff may use Safe Resident Handling equipment, such as lifts or repositioning equipment, for patients when needed. Patients will be assessed to determine the correct equipment to use. Staff will be trained in the use of each type of equipment. Continued review of facility documentation revealed an undated Safe Resident Handling Program which indicated that a resident's transfer status can be found in the following places: door name tag, care plan, and tasks (feature available for nursing staff on the resident's electronic medical record). Continued review of the facility Safe Resident Handling Program revealed that the facility follows a sticker communication system. Review of the sticker communication system revealed that resident door name tags are labeled with a sticker that has a letter, number, and color to indicate a resident's transfer status. During an interview with Resident R60 on August 18, 2021 at 10:30 a.m. the resident revealed he had a fall out of bed in February of 2020, which resulted in a fracture. Review of Resident R60's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses of amputation of left leg above the knee, major depressive disorder (major loss of interest in pleasurable activities), [CONDITION(S)], [CONDITION(S)] (reduced blood flow to brain- causes memory loss in older adults), and chronic pain syndrome. Continued review of clinical record for Resident R60 revealed a Lift Transfer Reposition assessment dated [DATE] indicating that the resident required two staff members for repositioning in bed. Review of Resident R60's nursing note dated February 10, 2020 revealed the resident sustained a fall during bed repositioning and incontinence care (involuntary loss of urine or bowel movements). X-ray ordered due to pain in right lower extremity. Send to ER (emergency room ) per patient request. Continued review of nursing note for Resident R60 dated February 10, 2020 revealed the resident was subsequently transferred to the hospital and admitted for a right femur fracture. Review of Resident R60 x-ray results dated February 10, 2020 confirmed Resident R60 sustained a right femur fracture status post fall. Review of facility documentation revealed that written statements were obtained by nursing aide, Employee E4, and Licensed nursing staff, Employee E5. Review of written statement by nurse aide, Employee E4, dated February 10, 2020, revealed the employee went into Resident R60's room at about 5:30 a.m. on February 10, 2020 to provide [incontinence] care for the resident. While Employee E4 was rolling the resident, the resident stated he was secure in grabbing the bed rail, but Resident R60 swung his left leg over too fast which caused Resident R60's weight to shift and the resident to fall out of the bed. Review of written statement by Licensed nursing staff, Employee E5, dated February 13, 2020, revealed at 5:30 a.m. on February 10, 2020 Employee E5 was called to Resident R60's room by nurse aide, Employee E4. Licensed nursing staff, Employee E5 revealed that upon arrival to the room, Resident R60 was observed on the floor, and nurse aide, Employee E4 stated the resident had fallen out of bed while [Employee E4] changing and repositioning the resident. Review of facility investigation revealed that when nurse aide, Employee E4 was providing care for Resident R60, on February 10, 2021, the employee failed to provide two-person assistance for bed mobility, as determined necessary on the resident's care plan, door sticker, and Lift Transfer Reposition assessment, resulting in the resident falling to the floor, and sustaining a right femur fracture. This deficiency was identified as past non-compliance. On February 10, 2020, the facility initiated a plan of correction to address the inadequate supervision provided during bed mobility. Facility plan of correction included the following: 1) Employee E4 was re-educated on safe resident handling and sicker communication system at the time of occurrence. 2) Resident R60 was transferred to the hospital for evaluation and treatment of injury. 3) Facility-wide education on safe resident handling, initiated February 10, 2020. 4) Facility-wide audit preformed on lift transfer assessments and sticker communication system, initiated February 11, 2020. 5) The facility terminated Employee E4 on February 14, 2020 for failure to follow resident care plan resulting in harm to the resident. Interviews conducted on August 20, 2021 at 11:15 a.m. with nurse aide, Employee E8 and licensed nurse, Employee E10, confirmed that employees were educated on safe resident handling and sticker communication system. Observations on August 20, 2021 at 11:30 a.m. confirmed that the sticker on Resident R60's doorway, matched the transfer status as indicated in the clinical record. Continued observations revealed doorway stickers matched resident clinical records for appropriate transfer status. An interview with Nursing Home Administrator, on August 19, 2021 at 11:30, confirmed that nursed aide, Employee E4 failed to provide Resident R60 with two-person assistance for bed mobility as indicated on the resident's plan of care. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on review of clinical records, review of facility documentation, review of facility policies and procedures, and interviews with resident and staff, it was determined that the facility failed to ensure one resident was free from staff neglect for one of 19 residents reviewed, which resulted in actual harm to Resident R60 who was not provided with two-person assistance for bed mobility as indicated on the resident's plan of care. Resident R60 sustained a right femur fracture. This failure was identified as past non-compliance. (Resident R60) Findings include: Review of facility policy titled Abuse Prohibition date revised April 09, 2021, revealed the center prohibits abuse, mistreatment, neglect, misappropriate of resident/patient property, and exploitation for all patients. The facility policy defines neglect as the failure of the center, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physician harm, pain, mental anguish, or emotional distress. Review of facility documentation revealed an undated Safe Resident Handling Program which indicates that a resident's transfer status can be found in the following places: door name tag, care plan, and tasks (feature available for nursing staff on the resident's electronic medical record). Continued review of the facility Safe Resident Handling Program revealed that the facility follows a sticker communication system. Review of the sticker communication system revealed that resident door name tags are labeled with a sticker that has a letter, number, and color to indicate a resident's transfer status. During an interview with Resident R60 on August 18, 2021 at 10:30 a.m., the resident revealed they had a fall out of bed in February of 2020, which resulted in a fracture. Review of Resident R60's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of clinical record for Resident R60 revealed a Lift Transfer Reposition assessment dated [DATE] indicating that the resident required two staff members for repositioning in bed. Review of Resident R60's nursing note dated February 10, 2020 revealed the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . X-ray ordered due to pain in right lower extremity. Send to ER (emergency room ) per patient request. Continued review of nursing note for Resident R60 dated February 10, 2020 revealed the resident was subsequently transferred to the hospital and admitted for a right femur fracture. Review of Resident R60 x-ray results dated February 10, 2020 confirmed Resident R60 sustained a right femur fracture. Review of facility documentation revealed that written statements were obtained by nursing aide, Employee E4, and Licensed nursing staff, Employee E5. Review of written statement by nurse aide, Employee E4, dated February 10, 2020, revealed the employee went into Resident R60's room at about 5:30 a.m. on February 10, 2020 to provide [incontinence] care for the resident. While Employee E4 was rolling the resident, the resident stated he was secure in grabbing the bed rail, but Resident R60 swung his left leg over too fast which caused Resident R60's weight to shift and the resident to fall out of the bed. Review of written statement by Licensed nursing staff, Employee E5, dated February 13, 2020, revealed at 5:30 a.m. on February 10, 2020. Employee E5 was called to Resident R60's room by nurse aide Employee E4. Employee E5 revealed that upon arrival to the room, Resident R60 was observed on the floor next to the bed, and Employee E4 stated the resident had fallen out of bed while [Employee E4] changing and repositioning the resident. Continued review of written statement by Employee E5 revealed before I could educate [Employee E4] on lift/transfer repositioning policy, he said I know I shouldn't have been doing this by myself, I'm so sorry. Review of facility documentation revealed that the facility failed to protect the rights of one resident to be free from neglect by not providing 2-person assistance with bed mobility as indicated on the resident's plan of care, door sticker, and Lift Transfer Reposition assessment, which resulted in actual harm to Resident R60, sustaining a right femur fracture after falling out of the bed. This deficiency was identified as past non-compliance. On February 10, 2020, the facility initiated a plan of correction to address the substantiated neglect related to inadequate supervision provided during bed mobility. Facility plan of correction included the following: 1) Employee E4 was re-educated on safe resident handling and sicker communication system at the time of occurrence. 2) Resident R60 was transferred to the hospital for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 4) Facility-wide audit preformed on lift transfer assessments and sticker communication system, initiated February 11, 2020. 5) The facility terminated Employee E4 on February 14, 2020 for failure to follow resident care plan resulting in harm to the resident. Interviews conducted on August 20, 2021 at 11:15 a.m. with nurse aide, Employee E8 and licensed nursing staff, Employee E10, revealed that employees were educated on safe resident handling and sticker communication system. Observations on August 20, 2021 at 11:30 a.m. confirmed that the sticker on Resident R60's doorway, matched the transfer status as indicated in the clinical record. Continued observations revealed doorway stickers matched resident clinical records for appropriate transfer status. An interview with Nursing Home Administrator, on August 19, 2021 at 11:30, confirmed that Employee E4 failed to provide Resident R60 with two-person assistance for bed mobility as indicated on the resident's plan of care. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.12(c) Nursing services

Based on review of facility policy, clinical records and facility documentation and interviews with staff, it was determined that the facility failed to ensure that residents were free from abuse, when one resident was sexually assaulted (Resident R2) by another resident (Resident R1) for two of nine residents reviewed (Resident R1 and Resident R2). Findings include: Review of facility policy, Abuse Prohibition, dated (MONTH) 1, (YEAR), revealed Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental or psychosocial well-being. Instances of abuse of all patients, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical condition, cause physical harm, pain, or mental anguish. The purpose is to ensure that facility staff are doing all that is within their control to prevent occurrences of abuse, mistreatment, neglect, and exploitation. Actions to prevent abuse, neglect, and exploitation included identifying, correcting, and intervening in situations in which abuse and neglect is more likely to occur and establishing a safe environment that supports, to the extent possible, a patient's consensual sexual relationship. Review of Resident R1's clinical record revealed that the resident was admitted to the facility on (MONTH) 23, (YEAR), with [DIAGNOSES REDACTED]. loss of consciousness with an inability to maintain postural tone that is followed by spontaneous recovery), muscle weakness (generalized), weakness, unspecified abnormalities of gait (style of walking) and mobility. Review of the clinical record for Resident R1 revealed a comprehensive Minimum Data Set assessment (MDS-an assessment of care needs) dated (MONTH) 29, (YEAR), which indicated that the BIMS (Brief Interview for Mental Status, a brief screen that aids in detecting cognitive impairment) and the section for the mood assessment was incorrectly coded with a dash to indicate the assessments had not been completed. Continued review of the MDS indicated that the resident required the physical assistance of one staff person for transfers (moving from one area to another). The assessment further indicated that Resident R1 required the use of a wheelchair as a mobility device. Review of facility document, Social History & Initial Assessment v2, dated (MONTH) 30, (YEAR), revealed that the BIMS (Brief Interview for Mental Status-a brief screen that aids in detecting cognitive impairment) score for Resident R1 was four indicating that the resident was severely cognitively impaired. Review of Resident R1's clinical record revealed a cardiac consultation dated (MONTH) 30, (YEAR), which revealed that the resident appears very depressed - consider Psych consult. Review of Resident R1's clinical record nurse progress note dated (MONTH) 14, (YEAR), revealed that the resident's gait (style of walking) was unsteady, and that he uses his wheelchair, incorrectly, as a walker (assistive device to aid in walking) to ambulate to the bathroom and propels himself in the wheelchair in the hall and outside. Further review of Resident R1's clinical record revealed no evidence of a care plan related to the resident's cognitive impairment, depressed mood, or behavior monitoring. An interview with the Nursing Home Administrator (NHA) on (MONTH) 6, (YEAR), at 3:15 p.m. confirmed that the resident had a BIMS score of four and that the resident was noted to be depressed on admission. Further interview with the NHA confirmed there was no documented evidence that a person centered care plan had been developed for the resident related to the resident's cognitive impairment and/or depression. Interview with Employee E7, LPN, on (MONTH) 6, (YEAR), at approximately 10:50 a.m., revealed that Resident R1 was a jokester and flirty in nature. He would talk about going to Florida and I would tell him he wasn't my type. He would flirt with other residents as well. Interview with Employee E8, Social Worker,on (MONTH) 6, (YEAR), at approximately 10:00 a.m. revealed that Resident R1 was outgoing; flirty; he was in the Navy. He would say, you look nice today. Review of Resident R2's clinical record revealed that the resident was admitted to the facility on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. tract infection (infection of the urinary system), difficulty in walking, muscle weakness (generalized) and lack of coordination. A review of the Minimum Data Set assessment dated (MONTH) 18, (YEAR), for Resident R2 revealed that the resident had a BIMS score of 11 indicating that the resident was moderately cognitively impaired. Review of Resident R2's clinical record revealed a nurse progress note dated (MONTH) 24, (YEAR), which revealed Observations: Res (Resident) is alert and oriented to name with confusion, needs extensive assist of one with bathing, dressing, toileting, incontinent of B&B (bowel and bladder), OOB (out of bed) daily to w/c (wheelchair), propels her w/c, feeds herself, has to be redirected many times, able to make her needs known. Review of Resident R2's plans of care revealed a focus area for the resident that included exhibits or is at risk for distressed/fluctuating mood symptoms related to: Sadness/depression caused by functional changes as well as a [DIAGNOSES REDACTED]. The intervention for the resident included to encourage the resident/patient to seek staff support for distressed mood and to refocus the resident/patient to something positive. Further review of Resident R2's clinical record revealed a nurse progress note dated (MONTH) 18, (YEAR), which indicated there was a change in condition related to an alleged sexual assault. Review of the facility's internal investigation documentation revealed that on (MONTH) 18, (YEAR) at approximately 5:30 p.m. staff found Resident R1 in Resident R2's room. Resident R1 was lying on top of Resident R2 and both residents were naked from the waist down. Review of Resident R1's clinical record revealed a nurse progress note dated (MONTH) 18, (YEAR), which revealed taken away in police custody, Resident refused all night medication except for insulin. Resident states, I don't need any of those meds, just give me my insulin. Resident sent with snack. Review of the facility's internal investigation revealed a signed witness statement by Employee E3, Nursing Assistant (NA), dated (MONTH) 18, (YEAR), which revealed that the employee had observed Resident R1 in Resident R2's room, standing at the bedside fidgeting with his pants. The employee also noted that Resident R2 was lying in her bed with her pants and brief completely off. The employee then left both residents in the room and went to get a nurse. Further review of the facility's internal investigation revealed a signed witness statement by Employee E4, LPN, dated (MONTH) 18, (YEAR), which revealed that upon entering Resident R2's room the employee also observed Resident R1 lying on on top of Resident R2. Resident R1 was observed thrusting himself against Resident R1. The residents were separated and Employee E3 then reported what she had witnessed to the supervisor. Continued review of the facility's internal investigation revealed a signed witness statement by Employee E5, NA, dated (MONTH) 18, (YEAR), which revealed that Resident R 1 had indicated to the employee that I f****d up. In further interview Resident R1 stated that one of the nurses had caught him having sexual relations and wanted to know why the police were at the facility. Interview with the Nursing Home Administrator (NHA) on (MONTH) 6, (YEAR), at 3:15 p.m. confirmed that Employee E3, NA, observed Resident R1 standing on the right side of Resident R2's bed, fidgeting with his pants and saw Resident R2 laying in her bed, on her back with her pants and brief completely off. The NHA confirmed that Employee E3, NA, then left both residents alone together in the room, while she went to get help. Employee E4, LPN, upon entering the room observed Resident R1 on top of Resident R2. Neither resident was wearing briefs or pants at the time of the observation. Resident R1 was observed thrusting himself against Resident R2. The NHA stated that the police came after the event and removed Resident R1 from the facility and Resident R1 remains incarcerated. The NHA stated that Resident R2 reported to police detectives that a man came into her room and attempted to rape her. Resident R2 was subsequently sent out to an acute care hospital for a physical evaluation and testing with a rape kit. The facility failed to protect one cognitively impaired resident from the sexual advances of another resident. This failure resulted in actual harm to Resident R2, who was sexually assaulted by Resident R1 who was subsequently incarcerated as a result. Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) - Previously cited 11/08/18, 05/15/18, 03/09/17 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 11/08/18, 05/16/18, 03/09/17 28 Pa. Code 201.18(b)(1) Management Previously cited 11/08/18, 05/16/18, 03/09/17 28 Pa. Code 201.18(b)(3) Management Previously cited 05/16/18, 03/09/17 28 Pa. Code 201.18(e)(1) Management Previously cited 11/08/18 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.10(d) Resident care policies Previously cited 11/08/18, 05/16/18 28 Pa. Code 211.11(a) Resident care plan Previously cited 05/16/18 28 Pa. Code 211.11(c)(d) Resident care plan 28 Pa. Code 211.12(c) Nursing services Previously cited 05/16/18 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 05/16/18, 03/09/17 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 11/08/18, 05/16/18 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 11/08/18, 05/16/18, 03/09/17

Based on clinical record review, a review of facility documention and facility policy and procedure and staff interviews, it was determined that the facility failed to ensure that residents were protected from the potential for harm regarding an improper transfer for one of five residents reviewed (Resident R1) which caused left shoulder pain requiring an X-ray and follow up orthopedic consultation. This occurrence created an Immediate Jeopardy situation to resident health and safety. Findings include: Review of the facility policy titled Safe Resident Handling/Transfer Equipment revised November 30, 2015, and reviewed March 1, 2016, revealed that the use of the sit to stand lift requires two staff members. A review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's care plan titled, resident at risk for falls dated November 6, 2015, revealed that the resident was to be transferred by a sit to stand lift (a mechanical piece of equipment that assists with transferring a resident from the bed to the chair). The resident was to have an assist of two staff members while being transferred. Review of a quarterly Minimum Data Set assessment (MDS - a periodic review of the resident's needs) dated October 6, 2016, revealed that the resident was independent in decision making abilities. The resident also needed extensive assistance with transfers and the assistance of two staff members when being transferred. A review of the nurses' notes dated October 23, 2016, at 2:49 p.m. revealed that the resident was lowered to the floor because she was unable to grip the sit to stand grips. A nursing assessment was completed at the time and the resident had no complaints. Further review revealed that the resident later complained of left shoulder pain. The physician was called and a left shoulder X-ray was ordered. The nurses' note dated October 23, 2016, at 11:16 p.m. revealed that the X-ray showed a questionable fracture of the left arm. The physician ordered an orthopedic (a physician that specialized in the bones) follow up. The area remained bruised and the resident was receiving Tylenol (a pain medication). Documentation indicated that the resident was seen by the orthopedic physician who ordered a follow up X-ray and a sling to be worn. A review of that report dated November 3, 2016, indicated there was no acute fracture or dislocation. Review of the Medication Administration Record (MAR) revealed that the resident continued to receive Tylenol. A review of facility documentation indicated that the resident had a history of [REDACTED]. Review of the facility investigation dated October 25, 2016, for the incident occuring on October 23, 2016, revealed that Employee E17, the Unit Manager, interviewed Employee E18 (the staff member that transferred the resident). Employee E18 stated, I was using the sit to stand lift when she (Resident R1) slid out. Employee E17 then asked Employee E18, Did you have a spotter? (a second staff member) and Employee E18 responded, No. Review of Employee E18's written statement dated October 28, 2016, revealed that Employee E18 stated, I used the sit to stand to get the resident out of bed, the resident let go of the grips, and her knees buckled so I lowered her to the floor. Employee E18 also stated, I was transporting the resident not knowing that two people were to assist with the sit to stand. An interview with the Director of Nursing on December 3, 2016, confirmed that Employee E18 was hired on October 15, 2015. A review of the nurse aide orientation program check list revealed that the employee had training on the use of the lifts on October 19, 2015, and was able to demonstrate the use of lifts on October 20, 2015. No other documentation was available for review indicating that the employee had been re-inserviced after October 15, 2015. An Immediate Jeopardy situation was identified to the Nursing Home Administrator and the Director of Nursing on December 3, 2016, at 2:40 p.m. related to the safety of the residents being transferred using the sit to stand lift by one staff member when they should have been transferred with the assist of two staff members. An interview with the Nursing Home Administrator and the Director of Nursing on December 3, 2016, at 3:00 p.m. revealed that the facility failed to re-educate the nursing staff regarding the correct number of staff to be used when transferring a resident with the mechanical lifts. An immediate corrective action plan was requested from the Nursing Home Administrator and the Director of Nursing on how re-education was going to be provided to all nursing personnel regarding the safe and proper use of the lifts. An acceptable corrective action plan was received from the facility that included re-educating staff on the proper transfer of residents according to their needs. The Immediate Jeopardy was removed on December 5, 2016, at 12:15 p.m. after the implementation of the corrective action plan was verified. 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 02/25/16, 04/15/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 02/25/16, 04/15/16, 08/01/16

Based on clinical record review, review of facility documention and facility policy and procedure and staff interviews, it was determined that the facility failed to ensure that the residents were protected from neglect resulting in the potential for harm regarding an improper transfer for one of five residents reviewed (Resident R1) which caused left shoulder pain requiring an X-ray and follow up orthopedic consultation. This occurrence created an Immediate Jeopardy situation to resident health and safety. Findings include: Review of the facility policy titled, Safe Resident Handling/Transfer Equipment, revised November 30, 2015, and reviewed March 1, 2016, revealed that the use of the sit to stand lift requires two staff members. A review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's care plan titled, resident at risk for falls dated November 6, 2015, revealed that the resident was to be transferred by a sit to stand lift (a mechanical piece of equipment that assists with transferring a resident from the bed to the chair). The resident was to have an assist of two staff members while being transferred. Review of a quarterly Minimum Data Set assessment (MDS - a periodic review of the resident's needs) dated October 6, 2016, revealed that the resident was independent in decision making abilities. The resident also needed extensive assistance with transfers and the assistance of two staff members when being transferred. A review of the nurses' notes dated October 23, 2016, at 2:49 p.m. revealed that the resident was lowered to the floor because she was unable to grip the sit to stand grips. A nursing assessment was completed at the time and the resident had no complaints. Further review revealed that the resident later complained of left shoulder pain. The physician was called and a left shoulder X-ray was ordered. The nurses' note dated October 23, 2016, at 11:16 p.m. revealed that the X-ray showed a questionable [MEDICAL CONDITION] arm. The physician ordered an orthopedic (a physician that specialized in the bones) follow up. The area remained bruised and the resident was receiving Tylenol (a pain medication). Documentation indicated that the resident was seen by the orthopedic physician who ordered a follow up X-ray and a sling to be worn. A review of that report dated November 3, 2016, indicated there was no acute fracture or dislocation. Review of the Medication Administration Record [REDACTED]. A review of facility documentation indicated that the resident had a history of [REDACTED]. Review of the facility investigation dated October 25, 2016, for the incident occuring on October 23, 2016, revealed that Employee E17, the Unit Manager, interviewed Employee E18 (the staff member that transferred the resident). Employee E18 stated, I was using the sit to stand lift when she (Resident R1) slid out. Employee E17 then asked Employee E18, Did you have a spotter? (a second staff member) and Employee E18 responded, No. Review of Employee E18's written statement dated October 28, 2016, revealed that Employee E18 stated, I used the sit to stand to get the resident out of bed, the resident let go of the grips, and her knees buckled so I lowered her to the floor. Employee E18 also stated, I was transporting the resident not knowing that two people were to assist with the sit to stand. An interview with the Director of Nursing on December 3, 2016, confirmed that Employee E18 was hired on October 15, 2015. A review of the nurse aide orientation program check list revealed that the employee had training on the use of the lifts on October 19, 2015, and was able to demonstrate the use of lifts on October 20, 2015. No other documentation was available for review indicating that the employee had been re-inserviced after October 15, 2015. An Immediate Jeopardy situation was identified to the Nursing Home Administrator and the Director of Nursing on December 3, 2016, at 2:40 p.m. related to the safety of the residents being transferred using the sit to stand lift by one staff member when they should have been transferred with the assist of two staff members. An interview with the Nursing Home Administrator and the Director of Nursing on December 3, 2016, at 3:00 p.m. revealed that the facility failed to re-educate the nursing staff regarding the correct number of staff to be used when transferring a resident with the mechanical lifts. An immediate corrective action plan was requested from the Nursing Home Administrator and the Director of Nursing on how re-education was going to be provided to all nursing personnel regarding the safe and proper use of the lifts. An acceptable corrective action plan was received from the facility that included re-educating staff on the proper transfer of residents according to their needs. The Immediate Jeopardy was removed on December 5, 2016, at 12:15 p.m. after the implementation of the corrective action plan was verified. 28 Pa. Code 201.20(a) Staff development 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 02/25/16, 04/15/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 02/25/16, 04/15/16, 08/01/16