Every finding on record at Northern Dauphin Nursing and Rehabilitation Center

Based on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for four of 36 residents reviewed (Residents 1, 12, 43, and 103).Findings include: Review of facility policy, titled Care Plans, Comprehensive Person-Centered, dated March 2022, with a last review date of June 2, 2026, revealed 11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. Review of Resident 1's clinical record revealed diagnoses that included hypertension (high blood pressure) and cerebral infarction (a stroke-damage to the brain from interruption of its blood supply). Review of Resident 1's care plan revealed a care plan focus for resident has a respiratory infection, aspiration pneumonitis (occurs when substances such as food, liquid, or stomach contents are inhaled into the lungs, leading to inflammation), and sepsis (potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) dated April 23, 2026. Further review of Resident 1's clinical record failed to reveal any current active infections. During a staff interview with the Nursing Home Administrator (NHA), Director of Nursing (DON), and Assistant Director of Nursing (ADON) on July 8, 2026, at 2:06 PM, the ADON indicated that the care plan should have been revised when Resident 1's infection was determined to be resolved. She further indicated that Resident 1's care plan has been updated. Review of Resident 12's clinical record revealed diagnoses that included urinary retention (inability to fully empty the bladder) and chronic obstructive pulmonary disease (COPD-a type of progressive lung disease characterized by long term respiratory symptoms and airflow limitations). Review of Resident 12's care plan revealed a care plan focus for resident has an infection related to positive lab results; cystitis (inflammation of the bladder) bacteremia (presence of bacteria in the bloodstream dated April 13, 2026. Further review of Resident 12's clinical record failed to reveal any current active infections. During a staff interview with the NHA, DON, and ADON on July 8, 2026, at 2:05 PM, the ADON indicated that the care plan should have been revised when Resident 12's infection was determined to be resolved. She further indicated that Resident 12's care plan has been updated. Review of Resident 43's clinical record revealed diagnosis that included anxiety (occasional worry or fear) and hypertension. Observation of Resident 43 on July 6, 2026, at 12:49 PM, 1:02 PM, and 2:42 PM, revealed the Resident was lying in bed with her call bell wrapped underneath, out of reach of the Resident. Review of Resident 43's care plan revealed a focus area for the resident has a communication problem related to cognitive deficit, hearing deficit as evidenced by needs increased volume, needs time to finish thoughts and misses part of message intent dated January 31, 2024; with an intervention for call bell within reach, encourage resident to call for assistance, answer promptly dated January 31, 2024. Electronic mail correspondence with the NHA on July 7, 2026, at 3:33 PM, revealed that due to Resident 43's cognition, she cannot utilize her call bell. Interview conducted with the NHA on July 8, 2026, at 2:20 PM, he revealed he would have expected Resident 43's care plan to have been revised to indicate she was no longer able to use her call bell. Review of Resident 103's clinical record revealed diagnoses that included dementia (a decline in cognitive abilities, such as memory, reasoning, and communication, severe enough to impair daily life) and hypertension. Review of Resident 103's care plan revealed a care plan focus for the resident will not experience complications secondary to anticoagulation therapy dated June 13, 2024. Further review of Resident 103's clinical record failed to reveal the Resident was currently prescribed any anticoagulant medications. Further review of Resident 103's care plan revealed a care plan focus for The resident has a behavior problem: wandering- becomes aggressive at times when redirecting Constant pacing of hallways Wandering into other resident rooms Spitting on the floor, throwing items on the floor, constantly pushing items in hallway specifically chairs, urinating on the floor at nurses station dated June 5, 2024; with an intervention for 15 minute checks dated November 7, 2025. Further review of Resident 103's clinical record failed to reveal the Resident was receiving 15-minute checks. During a staff interview with the DON, NHA, and ADON on July 8, 2026, at 2:20 PM, the DON indicated Resident 103's care plan should have been revised when the Resident was taken off of 15-minute checks and when the Resident was no longer being administered anticoagulant medications. 211.12(d)(1)(2) Nursing services.

Based on facility policy review, observations, review of resident council minutes, and resident and staff interviews, it was determined that the facility failed to ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident on one of two nursing units observed (1st floor). Findings include: Review of facility policy, titled Answering the Call Light, last reviewed June 2, 2026, read, in part, The purpose of this procedure is to ensure timely responses to the resident's requests and needs. Answer the call system immediately. If a resident needs assistance, indicate the approximate time it will take for you to respond. During an interview with Resident 69 on July 6, 2026, at 11:02 AM, she revealed that staff are slow to answer call bells and are always short staffed. During an interview with Resident 72 on July 6, 2026, at 1:21 PM, he revealed the facility is often short staffed, and sometimes he waits so long for someone to respond to his call bell that he starts to bang on his bed enabler bar and yells out until someone comes. During a resident group meeting on July 7, 2026, at 10:00 AM, there were concerns with call bell response times, especially on night shift. It was also revealed that staff will respond to the call bell and turn it off without providing assistance, and they don't return. During an interview with Employee 9 on July 8, 2026, at 12:59 PM, she revealed residents often don't get up out of bed because there are not enough staff to get everyone up and out of bed. During an interview with Resident 154 on July 8, 2026, at 1:03 PM, he revealed the building is extremely short staffed and call bell responses are too long. Review of Resident Council meeting minutes for June 4, 2026, documented new business, call bells are often responded to by nursing staff turning of the bell without addressing the issue. The July 2, 2026, meeting documented under old business that the call bell concern [NAME] up in the June 2026 meeting was unresolved. Observation at the 1st floor nurses station on July 6, 2026, at 1:45 PM, revealed Residents 90 and 153 had their call lights activated down the 400 hallway. The call light system at the nurses' station was sounding. Employee 7 (Nurse Aide) was sitting at the nurses station on a tablet with her back to the 400 hall, while the call lights were illuminated and ringing. Observation on July 6, 2026, at 1:55 PM, revealed Resident 90's and 153's call bells remained activated and Employee 7 remained sitting at the nurses station on the tablet. Employee 5 (Nurse Aide) walked out of the 300 hallway in view of the 400 hallway and stated, I am going to go outside and smoke some cigarettes to Employee 6 (Nurse Aide). Employee 6 then stated, I will go with you. They exited the nursing unit approximately 2 minutes later. Further observation on July 6, 2026, at 2:02 PM, revealed Resident 90's and 153's call bells remained activated. Employee 8 (Nurse Aide) then approached Employee 7 and stated, you have a call light on. Observation of Employee 7 revealed she was playing a game on the tablet and was sitting with her back to her assigned hallway. Employee 7 then got up to answer Resident 153's call bell at 2:03 PM, 18 minutes after it had been observed to be active. Resident 90's call bell was answered by Employee 18 (Nurse Aide) at that time. Employees 6 and 7 returned to the floor at the same time at 2:19 PM. Observation of the 1st floor nurse's station call bell system on July 6, 2026, at 2:15 PM, revealed Resident 3's call bell had been on for 20 minutes before it was answered by a staff member. Observation of the 1st floor nurses' station call bell system on July 6, 2026, at 2:43 PM, revealed Resident 173's call bell had been on for 21 minutes and 20 seconds. Further observation at 2:49 PM, revealed staff going into the Resident's room and turning the call bell off, exiting the room and proceeded to get the Resident ice. The call bell had been on for 25 minutes and 41 seconds. During an interview with the Assistant Director of Nursing, in the presence of the Nursing Home Administrator and the Director of Nursing (DON), on July 7, 2026, at 2:08 PM, she revealed that the Residents came up with their own call bell expectations on an adequate time for staff to respond to them, which was not to exceed 15 minutes. During an interview with the DON on July 8, 2026, at 1:47 PM, she revealed it is the facility process on day shift to assign two nurse aides to either side of a hallway, depending on staffing needs. She stated staff should help each other if they aren't busy to answer call bells on each other's assignment, and staff members can help answer call bells on any assignment. She revealed nurse aides assigned to the same hallway should never go on break together, and they should always report to a nurse to request to go on break, to ensure their assignment is covered while they are away. She further revealed that the employees observed leaving to smoke together, as well as the employee playing a game on the tablet, are employed by a contracted company, and she will request that they do not return to the facility. During a follow up interview with the DON on July 9, 2026, at 10:40 AM, she revealed she is making changes to nurse management, and she thinks that will help with staffing concerns. No further information was provided. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management.28 Pa code 211.12(d)(1)(4)(5) Nursing services

Based on document review and staff interview, it was determined that the facility failed to ensure an annual performance review is completed for each nurse aide for five of five nurse aide performance evaluations reviewed (Employees 10, 11, 12, 13, and 14).Findings Include: Review of the facility's list of nurse aide staff revealed Employee 10 had a hire date of February 24, 2025; Employee 11 had a hire date of March 4, 2024; Employee 12 had a hire date of May 8, 2023; Employee 13 had a hire date of January 18, 2021; and Employee 14 had a hire date of March 18, 2009. Requests for the most recent yearly performance reviews revealed Employees 10, 11, 12, 13, and 14 did not have an annual performance review completed within the previous 12 months. During an interview conducted with the Nursing Home Administrator on July 8, 2026, at 2:21 PM, he confirmed the nurse aide performance evaluations had not been completed in the past year on the aforementioned nurse aides. 28 Pa. Code 201.14 (a) Responsibility of licensee28 Pa. Code 201.19 Personnel policies and procedures

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food and utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen and two of two nourishment areas.Findings include: Based on facility policy, titled Food from Outside Sources last reviewed June 2, 2026, read, in part, Visitors/family members will label food and beverages with the resident's name, room number, and date. All food is to be stored in a suitable container. Perishable foods with a use by date which is 3 days from the date that it was brought into the facility. Food or beverage items without manufacturers expiration date that have written dates should be thrown away 3 days after the date marked. Observation in the main kitchen on July 6, 2026, at 9:54 AM, revealed the ice machine had a line of dust clear across the top of the ice machine under the lid, and the top of the lid was dirty. Interview with Employee 4 (Director of Dining Services) on July 6, 2026, at 9:55 AM, revealed he was not aware of a formal cleaning schedule of the ice machine or when it was last cleaned. Observation of the June 2026 Dish Machine Temperature Log in the main kitchen on July 6, 2026, at 10:04 AM, revealed wash and rinse temperatures failed to be logged at breakfast and lunch on June 27-30, 2026. Observation of the July 2026 Dish Machine Temperature Log in the main kitchen on July 6, 2026, at 10:05 AM, revealed wash and rinse temperatures failed to be logged at breakfast and lunch on July 1-5, 2026; and dinner on July 2, 2026. Review of the January 2026 Dish Machine Temperature Log revealed wash and rinse temperatures failed to be recorded at breakfast on January 1-10, 12-16, and 19-30; at lunch on January 1-12, 14-17, and 19-30; and at dinner on 1-4, 6-11, 13, 15, 16, 18, 22, 23, 25, and 28-30. Observation in the 2nd floor pantry area ice machine on July 6, 2026, at 10:14 AM, revealed it was soiled with an orange substance and a spotty black substance on the white section directly above the ice. Observation in the 2nd floor pantry freezer on July 6, 2026, at 10:16 AM, revealed a Styrofoam cup of soft serve ice cream that was not dated; and two breakfast sandwiches from an outside source not dated. Observation in the 2nd floor pantry refrigerator on July 6, 2026, at 10:16 AM, revealed one container of perishable food from an outside source not dated. Observation in the 1st floor pantry freezer on July 6, 2026, at 10:28 AM, revealed one Styrofoam cup from an outside source with a red substance inside not labeled or dated; and soft serve ice cream in a plastic cup with a spoon inside not dated. Observation in the 1st floor pantry refrigerator on July 6, 2026, at 10:32 AM, revealed one container of perishable food from an outside source dated June 26, 2026; one container of perishable food from an outside source with a resident's name and date not legible; one bag with a resident's name containing three containers of perishable food, not dated; one container of perishable food from an outside source with a resident's name, dated June 29, 2026; and one bag with six containers of perishable food from outside sources with a resident's name, dated June 20, 2026. Review of email correspondence between the Nursing Home Administrator (NHA) and Employee 15 (Maintenance Director) on July 6, 2026, at 2:52 PM, revealed Kitchen ice machine was dumped by us and cleaned by housekeeping. Other two ice machines were checked an ok'd by housekeeping. Observation of the 2nd floor pantry area ice machine on July 7, 2026, at 9:38 AM, revealed it was soiled with the same orange substance and a spotty black substance on the white section directly above the ice. Interview with the NHA on July 7, 2026, at 1:42 PM, revealed it was the facility's expectation that expired items are discarded, foods items are labeled and dated per facility policy, and kitchen equipment is utilized in accordance with professional standards. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.6(f) Dietary services.

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice for two of five residents reviewed with PTSD (Post Traumatic Stress Disorder) (Residents 8 and 90).Findings include: Review of facility policy, titled Trauma Informed Care and Culturally Competent Care, revised August 2022, revealed, Purpose: To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice. To Address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Review of Resident 8's clinical record revealed diagnoses that included PTSD, dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking), cerebral ischemia, and bipolar (a mental health condition alternating period of elation and depression). Review of Resident 8's care plan, revised on April 9, 2021, revealed a care plan focus area of the Resident has a potential behavior problem related to bipolar and PTSD (nothing regarding triggers followed). Further review failed to reveal that Resident 8's triggers were identified anywhere else on the plan of care. Review of Resident 8's Social Services Quarterly Assessments dated May 18, 2026; February 19, 2026; January 29, 2026; and October 20, 2025, all failed to document PTSD. Review of Resident 8's Minimum Data Sets (MDS- periodic assessment of resident needs), dated May 21, 2026; February 19, 2026; January 29, 2026; and October 31, 2025, documented in section I, Diagnoses, PTSD. Review of Resident 8's clinical record revealed Resident 8 was also followed by a psychiatrist for psychotropic medication management, which included Depakote utilized to treat bipolar and prazosin utilized to treat PTSD (no triggers noted). Interview with Employee 16 (Social Services Director) on July 9, 2026, at 11:00 AM, she stated she didn't complete the Social Services Evaluations, however, PTSD should've been marked. Email communication with the Nursing Home administrator (NHA) on July 9, 2026, at 8:25 AM, the surveyor informed the NHA of the concern that the Social Services Assessment failed to document a diagnosis of PTSD, and that triggers weren't addressed on the care plan or noted triggers unknown. No additional information was provided. Also, the surveyor requested a copy of the Trauma and Informed Care Assessment tool kit (was referenced in the Trauma informed Care and Culturally Competent Care policy), but it wasn't provided. Review of Resident 90's clinical record revealed diagnoses that included PTSD and depression (a group of conditions associated with the elevation or lowering of a person's mood). Review of Resident 90's care plan, revised on May 14, 2024, revealed a care plan focus area of: The Resident has a psychosocial well-being problem (actual or potential) related to history of personal trauma or PTSD with behaviors triggers by i.e. (nothing followed). Further review failed to reveal that Resident 90's triggers were identified anywhere else on the plan of care. Review of Resident 90's Social Services Evaluations dated November 13, 2025; February 12, 2026; March 9, 2026; and May 29, 2026, revealed that Resident 90 had a history of personal trauma. Further review revealed that the nature of the trauma was physical and sexual abuse/violence and that Resident 90's triggers include gaslighting, emotional abuse, and victim blaming. Interview with the NHA on July 9, 2026, at 10:45 AM, revealed that Resident 90's triggers, identified on the Social Services Evaluations, were not put on the care plan or in any place where they could be acted upon and thereby failed to address the needs of the Resident and minimize triggers and chances of re-traumatization. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on clinical record review and staff interviews, it was determined that the facility failed to notify the resident's representative of a medication change for one of six residents reviewed for unnecessary medications (Resident 179). Findings Include: Review of Resident 179's clinical record revealed diagnoses that included Alzheimer's Disease and hypertensive heart disease (complications of the heart caused by long-term, unmanaged high blood pressure). Review of Resident 179's pharmacy recommendation, dated February 27, 2026, revealed a recommendation for a gradual dose reduction (GDR) of the Resident's Memantine (also known as Namenda; a medication used to treat moderate to severe dementia associated with Alzheimer's Disease). Further review of the recommendation revealed that on March 6, 2026, the provider agreed with the GDR of Memantine, and wrote orders for the GDR. Review of a nursing progress note written by Employee 17 (Licensed Practical Nurse [LPN]), on March 8, 2026, revealed Medication Managers recommending d/c [discontinue] of Namenda [Memantine] as medication is no longer effective during end stage dementia. The note further stated that the provider agreed and new orders were received to titrate the Resident off of the medication. The note did not indicate that the Resident's Responsible Party was made aware of the GDR of the medication. There was no additional evidence in Resident 179's clinical record that Resident 179's Responsible Party was notified of the GDR and discontinuation of the Memantine. During an interview with Employee 17 on July 8, 2026, at 11:27 AM, she stated that she cannot recall if she made Resident 179's Responsible Party aware of the GDR. She stated that the facility should alert a resident's responsible party with any medication changes. During an interview with the Nursing Home Administrator and Director of Nursing (DON) on July 8, 2026, at 1:50 PM, the DON stated she would expect the Resident's Representative to be made aware of any medication changes. 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record reviews, observations, and resident and staff interviews, it was determined that the facility failed to follow physician orders for wound care for one of four residents reviewed (Resident 15); and failed to follow physician orders for obtaining weights and medication administration for one of 36 residents reviewed (Resident 100).Findings include: Review of facility policy, titled Wound Care, dated October 2010, and a last review date of June 2, 2026, revealed, in part, The following information should be recorded in the resident's medical record: 2. The date and time the wound care was given. 4. The name and title of the individual performing the wound care. 9. If the resident refused the treatment and the reason(s) why. 10. The signature and title of the person recording the data. Review of Resident 15's clinical record revealed diagnoses that included Diabetes Mellitus Type II (disease that occurs when your blood glucose, also called blood sugar, is too high) with a foot ulcer and hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting right dominant side. Review of Resident 15's physician orders revealed orders for wound care to right lateral foot diabetic ulcer, cleanse with wound cleanser; do wet to dry with gauze; secure with dry dressing; change every day and evening shift and as needed, dated July 1, 2026. Review of Resident 15's clinical record revealed that he originally developed the current diabetic foot ulcer on April 11, 2026. Review of Resident 15's care plan revealed a care plan focus for has potential for skin impairment related to right hemiparesis, limited mobility to reposition self, diabetes, incontinence, and presence of diabetic ulcer to right lateral foot last revised on July 1, 2026. Interventions included, but were not limited to, administer treatment to right plantar foot as ordered and observe for effectiveness with a revision date of April 21, 2026. In addition, he had a care plan focus for activities of daily living self-care deficit related to right hemiparesis, weakness, and lack of coordination, last revised on October 31, 2025. Interventions included, but were not limited to, transfer with platform walker and two-person assist, and the Resident is an early riser at 6:00 AM to be dressed and groomed, both dated October 26, 2025. Observation of Resident 15 on July 7, 2026, at 10:26 AM, revealed that he was sitting in his wheelchair in the hallway with no dressing on his right foot. His bare foot was resting on the footrest. During an immediate interview with Resident 15, he indicated that he did not know why staff had not put a dressing on his foot. Observation of Resident 15 on July 7, 2026, at 2:39 PM, revealed that he was sitting in his wheelchair in the downstairs activity /dining room with no dressing on his right foot. His bare foot was resting on the footrest. Resident 15 lifted his foot up off the footrest and a small amount yellowish drainage was noted to be oozing from the wound. During an immediate interview with Resident 15, he again indicated that he did not know why staff had not yet put a dressing on his foot. Follow-up observation of Resident 15 with the Assistant Director of Nursing (ADON) on July 7, 2026, at 2:48 PM, revealed that he was sitting in his wheelchair in the downstairs activity /dining room with no dressing on his right foot. His bare foot was resting on the footrest. During an immediate interview with the ADON, she confirmed that Resident 15 should have a dressing on his right foot. She said that the facility wound consultant saw Resident 15 that morning, and that typically she accompanies the wound consultant but did not do so today. The ADON further indicated that the wound consultant starts rounds at the facility at approximately 6:00 AM. She said that the nurse assigned to Resident 15 usually works night shift and that she would follow-up with Resident 15's assigned nurse. She directed a nurse to perform wound care for Resident 15. During a follow-up staff interview with the ADON on July 8, 2026, at 9:15 AM, she indicated that she followed up with the Licensed Practical Nurse the prior day who was assigned to Resident 15. She said that the nurse shared that she had not had time to do the dressing change yet. She indicated that she still needed to follow up with the aides who got him out of bed without a dressing on his foot. During a staff interview with the Nursing Home Administrator (NHA), Director of Nursing (DON), and the ADON on July 8, 2026, at 2:08 PM, the ADON confirmed that Resident 15's wound care should have been provided prior to staff transferring him out of bed to his chair. No additional information was provided regarding the nurse aides transferring Resident 15 out of bed without a dressing in place. Review of Resident 15's Treatment Administration Records for May 2026 and June 2026 revealed that his wound care was not documented as being completed (box was blank) on May 30, 2026, or June 30, 2026, evening shifts. Review of Resident 15's progress notes failed to reveal any documentation as to why the wound care was not performed as ordered. Email communication received from the NHA on July 9, 2026, at 11:41 AM, revealed that he had no additional information to provide as to why Resident 15's wound care was not completed as ordered on May 30, 2026, or June 30, 2026. The NHA further indicated that he would have expected Resident 15's wound care to have been completed as ordered. Review of Resident 100's clinical record revealed diagnoses that included hyperlipidemia (abnormally high levels of fats) and depression (a mood disorder characterized by persistent feelings of sadness, emptiness, and lack of interest in activities). Review of Resident 100's physician orders revealed an order for daily weights per hospice, give as needed (PRN) Lasix for weight gain of 3 pounds one time a day related to heart failure, with a start date of May 25, 2026. Review of Resident 100's June 2026 Medication Administration Record (MAR), revealed there were no weights taken on the Resident from June 1 through 25, 2026. Further review of Resident 100's June 2026 MAR revealed that the Resident weighed 191.2 pounds on June 29, 2026, and 194.6 pounds on June 30, 2026, and was not administered PRN Lasix on that day. During an interview conducted with the DON on July 8, 2026, at 12:51 PM, she confirmed that Resident 100 did not receive his PRN Lasix and he should have been administered it on June 30, 2026, after his 3-pound weight gain. Further interview conducted with the DON, NHA, and ADON on July 9, 2026, at 10:28 AM, the DON revealed that Resident 100's weight order was not put into the system correctly and confirmed that no weights were obtained from June 1 to 25, 2026. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policy review, product packaging review, clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that the medication error rate was not five percent or greater, based on three medication errors out of 29 opportunities.Findings include: Review of facility policy, titled Administering Medications, dated April 2019, with a last review date of June 2, 2026, revealed, in part, Medications are administered in accordance with prescriber orders; and the individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Observation of Employee 2 (Licensed Practical Nurse) on July 8, 2026, at 9:25 AM, revealed that she was preparing medications to administer to Resident 62. Review of the medication packaging for the ordered medication donepezil indicated Do Not Crush. Employee 2 was observed to crush the medication and administer it to Resident 62. Observation of Employee 2 on July 8, 2026, at 9:41 AM, revealed that she was preparing medications to administer to Resident 50. Review of the medication label on a bottle of Biotene Dry Mouth Moisturizing Spray indicated to give 15 milliliters by mouth one time a day swoosh and spit. Employee 2 was observed to administer two sprays of the Biotene into the mouth of Resident 50. During a staff interview with Employee 2 on July 8, 2026, at 10:03 AM, Employee 2 confirmed that she had crushed the donepezil and administered it to Resident 62 and said that she did not see the instruction on the packet to not crush the medication. In addition, Employee 2 confirmed that she had administered the two sprays of the Biotene spray since it was what the pharmacy had provided and confirmed that there were no directions on how many sprays should have been administered. Observation of Employee 3 (Licensed Practical Nursing) on July 8, 2026, at 10:20 AM, revealed that she was preparing medications to administer to Resident 160. Review of the medication packaging for the ordered medication mirabegron extended-release tablet indicated Do Not Crush. Employee 3 was observed to crush the medication and administer it to Resident 160. During a staff interview with Employee 3 on July 8, 2026, at 10:03 AM, Employee 3 confirmed that she had crushed the mirabegron and administered it to Resident 160. Employee 3 further indicated that Resident 160 will spit out pills that are too big. During medication administration observations, there were 3 errors and 29 opportunities, resulting in a medication error rate of 10.34%. During a staff interview with the Nursing Home Administrator and Director of Nursing (DON) on July 9, 2026, at 10:44 AM, the DON confirmed that she would expect nursing staff to administer medications as ordered and to follow all special instructions for safe medication administration. 28 Pa. Code 211.9(a)(1) Pharmacy services.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policy review, Centers for Disease Control and Prevention (CDC) guidelines, observations, and resident and staff interviews, it was determined that the facility failed to provide a safe and sanitary environment to prevent the development and spread of communicable diseases and infections by not covering a wound known to be infected by a multi-drug resistant organism for one of four residents reviewed (Resident 15).Findings include: Review of facility policy, titled Transmission Based Precautions, dated June 14, 2019, with a last review date of June 2, 2026, revealed, in part, Part of routine infection control practices, standard precautions include wearing gloves for situations involving known or anticipated contact with blood, body fluids, tissue, mucous membranes, or nonintact skin. You should combine standard precautions with transmission-based precautions for patients with confirmed or suspected infection with highly transmissible pathogens. Transmission-Based Precautions Contact: To prevent the spread of epidemiologically important infectious organisms through direct patient contact or indirect contact with the patient's environment. According to the Centers for Disease Control and Prevention (CDC), contact precautions are transmission-based isolation measures used to prevent the spread of pathogens that are transmitted by direct or indirect contact with contaminated surfaces or objects and are indicated for patients with infections or conditions that can be spread through direct contact (e.g., skin-to-skin, wound-to-skin) or indirect contact (e.g., touching contaminated surfaces). Contact precautions should be used for patients with known or suspected infections that represent an increased risk for contact transmission; and limit transport and movement of patients outside of the room to medically-necessary purposes. When transport or movement is necessary, cover or contain the infected or colonized areas of the patient's body. Review of Resident 15's clinical record revealed diagnoses that included Diabetes Mellitus Type II (disease that occurs when your blood glucose, also called blood sugar, is too high) with a foot ulcer, local infection of the skin and subcutaneous tissue (the body's deepest skin layer, stores fat, contains larger blood vessels and nerves), and hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting right dominant side. Review of Resident 15's physician orders revealed orders for wound care to right lateral foot diabetic ulcer, cleanse with wound cleanser; do wet to dry with gauze; secure with dry dressing; change every day and evening shift and as needed, dated July 1, 2026; and contact precautions every shift, dated June 22, 2026. Review of Resident 15's clinical record revealed that he originally developed the diabetic foot ulcer on April 11, 2026. In addition, he was currently being treated for an infection to his diabetic foot ulcer by an infectious diseases specialist, the facility wound consultant, and his primary care provider, which started around May 20, 2026. Review of Resident 15's care plan revealed a care plan focus for: has potential for skin impairment related to right hemiparesis, limited mobility to reposition self, diabetes, incontinence, and presence of diabetic ulcer to right lateral foot, last revised on July 1, 2026. Interventions included, but were not limited to, administer treatment to right plantar foot as ordered and observe for effectiveness, with a revision date of April 21, 2026; and contact precautions, dated May 18, 2026. In addition, he had a care plan focus for activities of daily living self-care deficit related to right hemiparesis, weakness, and lack of coordination, last revised on October 31, 2025. Interventions included, but were not limited to, transfer with platform walker and two-person assist, and the Resident was an early riser at 6:00 AM to be dressed and groomed, both dated October 26, 2025. Observation of Resident 15 on July 7, 2026, at 10:26 AM, revealed that he was sitting in his wheelchair in the hallway with no dressing on his right foot. His bare foot was resting on the footrest. During an immediate interview with Resident 15, he indicated that he did not know why staff had not put a dressing on his foot. Observation of Resident 15 on July 7, 2026, at 2:39 PM, revealed that he was sitting in his wheelchair in the downstairs activity/dining room with no dressing on his right foot. His bare foot was resting on the footrest. Resident 15 lifted his foot up off the footrest and a small amount yellowish drainage was noted to be oozing from the wound. During an immediate interview with Resident 15, he again indicated that he did not know why staff had not yet put a dressing on his foot. There were approximately 20 other residents noted to be in the room. Follow-up observation of Resident 15 with the Assistant Director of Nursing (ADON) on July 7, 2026, at 2:48 PM, revealed that he was sitting in his wheelchair in the downstairs activity /dining room with no dressing on his right foot. His bare foot was resting on the footrest. During an immediate interview with the ADON, she confirmed that Resident 15 should have a dressing on his right foot and that contact precautions were not being followed. She said that the facility wound consultant saw Resident 15 that morning, and that typically she accompanies the wound consultant but did not do so today. The ADON further indicated that the wound consultant starts rounds at the facility at approximately 6:00 AM. She said that the nurse assigned to Resident 15 usually works night shift and that she would follow up with Resident 15's assigned nurse. She directed a nurse to perform wound care for Resident 15. During a follow-up staff interview with the ADON on July 8, 2026, at 9:15 AM, she indicated that she followed up with the Licensed Practical Nurse the prior day who was assigned to Resident 15. She said that the nurse shared that she had not had time to do the dressing change yet. She indicated that she still needed to follow up with the aides who got him out of bed without a dressing on his foot. During a staff interview with the Nursing Home Administrator, Director of Nursing, and the ADON on July 8, 2026, at 2:08 PM, the ADON confirmed that Resident 15's wound care should have been provided prior to staff transferring him out of bed to his chair and that contact precautions should have been followed. No additional information was provided regarding the nurse aides transferring Resident 15 out of bed without a dressing in place. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policy review, clinical record review, review of facility investigation, and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice for six of eight residents reviewed (Residents 1, 2, 3, 4, 5, and 6). Findings Include: Review of facility policy, titled Administering Medications, dated April 2019, revealed Medications are administered in a safe and timely manner, and as prescribed. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. Review of facility policy, titled Controlled Substances, dated November 2022, revealed The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976).Review of Resident 1's clinical record revealed diagnoses that included chronic pain syndrome and osteoarthritis of the left hip (a form of arthritis that occurs when the protective cartilage that cushions the ends of the bones wears down over time). Review of Resident 1's physician orders revealed an order, with a start date of December 18, 2024, for oxycodone (narcotic pain medication), 5 mg (milligrams), five times a day, related to the presence of a left artificial hip joint and oxycodone, 10 mg, every morning at 4:00 AM, related to the presence of a left artificial hip joint. Review of a grievance form completed by Resident 1, dated December 8, 2025, revealed that Resident 1 did not receive his 12:00 AM dose of oxycodone. Resident 1 further stated on the grievance that at 3:00 AM, he was provided two white tabs that were look alikes for 5 mg oxycodone, but he stated they had imprints of G 10 on the pills, which he stated were generic Claritin, which is loratadine (non-drowsy allergy medicine). Review of a statement by the ADON (Assistant Director of Nursing), dated December 8, 2025, revealed that on December 8, 2025, at approximately 7:15 AM, she was made aware that Resident 1 reported that he did not receive his scheduled medication at 12:00 AM and his 4:00 AM medication was given at 3:00 AM, however, it was not the medication he is prescribed. Upon further investigation, it was discovered that he received 2 loratadine tablets instead of his scheduled oxycodone.Review of facility reported incident, dated December 8, 2025, revealed that on December 8, 2025, at 7:30 AM, Resident 1 reported that his 4:00 AM dose of oxycodone that he was provided was not oxycodone. Resident 1 saved the two pills he was provided to show as proof, as he firmly believes the two pills were loratadine. Resident 1 also reported that he did not receive his 12:00 AM dose of oxycodone. The facility reported incident further stated that the nurse was identified as Employee 1 (Licensed Practical Nurse [LPN]) and the medication believed to be provided to Resident 1 was over the counter loratadine. Review of the manufacturer package insert for loratadine 10 mg, revealed it is a round, white, 6 mm (millimeter) pill, with an imprint code of G 10. During an interview with Resident 1 on December 22, 2025, at 12:15 PM, he stated that when he asked Employee 1 about not receiving his 12:00 AM dose of oxycodone, she told him that she shook him and called his name, but he wouldn't wake up to take the medication. Resident 1 stated that he is a light sleeper and a light tap would have woken him up. Resident 1 further stated that he used to be a pharmacy technician, so he knew the 4:00 AM dose of oxycodone he was provided was not oxycodone and knew it was loratadine. He stated that he saved the pills as evidence that he was not provided his oxycodone. Review of facility's controlled substance record form (a form used to maintain accurate records of all controlled substances that are being administered), revealed a signature for the nurse dispensing the medication, the date, time and amount dispensed, and the amount of medication remaining. Review of Resident 1's controlled substance record for the oxycodone, 5 mg, one tablet five times a day, revealed Employee 1 signed that the medication was dispensed on December 7, 2025, at 4:00 PM; December 7, 2025, at 8:00 PM; and December 7, 2025, at 12:00 AM.Review of Employee 1's time card report revealed she was not working on December 7, 2025, at 12:00 AM. Review of Resident 1's controlled substance record for the oxycodone, 10 mg at 4:00 AM, revealed Employee 1 signed that the medication was dispensed on December 7, 2025, at 4:00 AM.Review of Employee 1's time card report revealed she was not working on December 7, 2025, at 4:00 AM.Review of a typed statement by Employee 1, undated, in reference to the shift worked on December 7, 2025, 3:00 PM-7:00 AM, revealed At approximately 3:30 AM, I administered [Resident 1] his ordered medication and directly observed him taking it. The statement mentioned nothing about the 12:00 AM dose, in which Resident 1 stated he did not receive. During an interview with the Director of Nursing (DON) on December 22, 2025, at 11:40 AM, she stated that Employee 1 was an agency nurse and the DON notified the agency of the allegation and notified the agency that the nurse was not to return to the facility to work. She further stated that the police were notified but she has not yet received an update regarding their investigation. The DON stated that she called Employee 1 in for a face-to-face interview and for a drug test, but Employee 1 was a no-show. Review of Resident 2's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD-a condition caused by damage to the airways or other parts of the lung, leading to inflammation and other problems that block airflow and make it hard to breathe) and Type 2 Diabetes Mellitus (when the body cannot use insulin correctly and sugar builds up in the blood). Review of Resident 2's MAR revealed an order for oxycodone 5 mg, give one tablet every 12 hours as needed for pain. Review of Resident 2's oxycodone drug record revealed the oxycodone was signed out as being dispensed by Employee 1 on the following dates and times, with review of the corresponding MAR for those dates and times:-December 7, 2025, at either 2:30 PM or 4:30 PM. The time was illegible. Review of Employee 1's timecard revealed she did not clock in on December 7, 2025, until 2:47 PM. Review of the MAR revealed the oxycodone was not signed off as being administered at 2:30 PM nor 4:30 PM. -December 7, 2025, at 4:47 PM-signed off on the MAR at 4:47 PM. -December 8, 2025, at 4:40 AM-not signed off on the MAR as being given. Review of a statement from Resident 2, dated December 8, 2025, revealed that Resident 2 stated the last time he asked for his oxycodone was on December 6, 2025.Review of Resident 2's MAR revealed he received his oxycodone on December 6, 2025, at 2:13 AM. During an interview with Resident 2 on December 22, 2025, at 1:38 PM, he stated his chart says that he received pain medication when he didn't. He stated the incident happened a couple of weeks ago. Review of Resident 3's clinical record revealed diagnoses that included COPD and anxiety disorder (persistent, excessive worry about everyday things). Review of Resident 3's December 2025 MAR revealed an order for oxycodone 5 mg, give one tablet every 3 hours as needed for pain. Review of Resident 3's oxycodone drug record revealed the oxycodone was signed out as being dispensed by Employee 1 on the following dates and times, with review of the corresponding MAR for those dates and times:-December 2, 2025, at 4:15 PM- signed off on the MAR as being administered at 4:03 PM, prior to the medication being dispensed-December 2, 2025, at 8:15 PM- signed off on the MAR at 7:15 PM, one hour prior to the medication being dispensed-December 2, 2025, at 11:20 PM- signed off on the MAR at 11:25 PM-December 3, 2025, at 2:50 AM and December 3, 2025, at 6:15 AM. There was no corresponding time on the MAR for the 2:50 AM dose nor the 6:15 AM dose. There was an entry on the MAR for the oxycodone being given at 4:41 AM, but there was no corresponding time on the controlled substance record that an oxycodone was dispensed at or around 4:41 AM. Review of facility interview with the Resident, dated December 8, 2025, revealed Resident 3 stated she only takes her oxycodone at bedtime to help her sleep. During an interview with Resident 3, on December 22, 2025, at 1:51 PM, she stated that she doesn't take her oxycodone every night and if she does take it, she does not take it more than once a night. Resident 3 was asked if she can recall a night that she took it more than once, and she denied a time that she took her oxycodone more than one time in a night. Review of Resident 3's MARs for November 2025 and December 2025, revealed that with the exception of December 2 and 3, 2025, Resident 3 did not receive her oxycodone more than one time a day/night. Review of Resident 4's clinical record revealed diagnoses that included Type 2 Diabetes Mellitus and COPD. Review of Resident 4's December 2025 MAR revealed an order for oxycodone 5 mg, give 3 tablets every four hours as needed for severe pain. Review of Resident 4's oxycodone drug record revealed the oxycodone was signed out as being dispensed by Employee 1 on the following dates and times, with review of the corresponding MAR for those dates and times:-December 7, 2025, at what appears to be 4:30 PM, although the time was illegible- signed off on MAR at 5:38 PM, one hour and eight minutes after the medication was dispensed -December 7, 2025, at 8:00 PM, which the initial time was scribbled out and 8:00 PM was written at the side-signed off on MAR at 9:48 PM, one hour and 48 minutes after the medication was dispensed -December 8, 2025, at 12:00 AM, which the initial time was scribbled out and 12:00 AM was written at the side-nothing signed off on the MAR as being given-December 8 at 3:00 AM- signed off on the MAR at 3:05 AM. Review of Resident 4's statement, dated December 8, 2025, revealed that on December 7, 2025, he stated he received pain medications around 5:30 PM and 9:30 PM. During an interview with Resident 4, on December 22, 2025, at 1:42 PM, he stated that on December 7, 2025, his last dose of pain medication was between 9 and 9:30 PM. He stated that the next day, on December 8, 2025, the unit manager had him fill out a statement of when he had his pain medication last. He stated that he really has to be in pain to ask for pain medications in the middle of the night and he rarely does that. He again confirmed that the last time he received pain medication on December 7, 2025, was between 9 and 9:30 PM. Review of Employee 1's typed statement, undated, revealed that during the 3:00 PM-11:00 PM portion of her shift, Resident 4 requested his pain medication at 4:00 PM and again at 8:00 PM. The ordered medication was retrieved and provided as requested. The statement further stated that during the 11:00 PM-7:00 AM portion of the shift, she was notified by a nurse aide that Resident 4 reported pain and requested his pain medication at 12:00 AM and 3:00 AM. Employee 1 stated I retrieved the ordered medication both times and placed it on his bedside table per his prior request. After approximately 10-15 minutes, I returned to check whether he had taken the medication, and the medication cup was no longer present on the table during both checks.Review of Resident 5's clinical record revealed diagnoses that included anxiety disorder and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident 5's December 2025 MAR revealed an order for oxycodone, 5 mg, give one tablet every 12 hours as needed for pain. Review of Resident 5's oxycodone drug record revealed the oxycodone was signed out as being dispensed by Employee 1 on the following dates and times, with review of the corresponding MAR for those dates and times:-December 1, 2025, although the date was barely legible, at 4:30 PM-nothing signed off on the MAR on December 1. Review of Employee 1's timecard revealed she did not work on December 1, 2025. -December 2, 2025, at 9:00 PM- signed off on MAR at 9:09 PM. Resident 5 was unable to be interviewed.Review of Resident 5's December MAR, as of December 22, 2025, revealed that the only time the oxycodone was documented as being given in December 2025 was on December 2 at 9:09 PM. Review of Resident 6's clinical record revealed diagnoses that included high blood pressure and Type 2 Diabetes Mellitus. Review of Resident 6's December 2025 MAR revealed an order for oxycodone, 5 mg, give 10 mg every four hours as needed for severe pain. Review of Resident 6's oxycodone drug record revealed the oxycodone was signed out as being dispensed by Employee 1 on the following dates and times, with review of the corresponding MAR for those dates and times:-December 6, 2025, at 2:30 PM- signed off on the MAR at 3:35 PM. Employee 1 did not clock in until 2:42 PM on December 6-December 6, 2025, at 6:30 PM- signed off on the MAR at 7:26 PM, almost one hour after the medication was dispensed-December 6, 2025, at 10:30 PM- signed off on the MAR at 10:30 PM. Resident 6 was discharged from the facility on December 18, 2025, and therefore was unable to be interviewed. Review of Employee 1's typed statement, undated, revealed that during her December 7, 2025 shift, from 3:00 PM-7:00 AM, revealed All medications given during the shift were documented and signed off in both the electronic medication administration record and the paper medication book immediately after administration. During an interview with the Nursing Home Administrator, DON, and ADON, on December 22, 2025, at 2:23 PM, the DON and ADON stated that nurses should give and document controlled substances within a couple minutes of dispensing the medication, not an hour or more later. They further stated that medications should be documented every time they are given. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, review of facility investigation documentation, and resident and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure each resident the right to be free from abuse, which resulted in actual harm as evidenced by multiple skin tears and penetrating wounds to the back of the head and neck after a resident to resident altercation for one of three residents reviewed (Resident 2). Findings Include:Review of facility policy, titled Abuse Policy, undated, revealed, in part, the resident has the right to be free from abuse. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.Review of Resident 1's clinical record revealed diagnoses that included paranoid schizophrenia (a serious mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior) and anxiety disorder (intense, excessive and persistent worry and fear about everyday situations). Review of Resident 2's clinical record revealed diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a stroke, hypertension (elevated blood pressure), and gastroesophageal reflux disease (GERD-acid reflux). Review of Resident 2's clinical record revealed a progress note written by Employee 1 (Registered Nurse [RN]), dated October 15, 2025, revealed that Employee 1 heard other staff yelling Resident 1's name and No. Employee 1 and Employee 2 (RN) both ran to Resident 2's room, where it was observed that staff were separating Resident 1 from Resident 2. The note further stated that Resident 1 was attacking Resident 2 with a pen. Resident 2 was immediately assessed for injury and was found with multiple skin tears and penetrating wounds to the back of the head/neck, with the tip of the pen found lodged inside one of the penetrating wounds. The pen tip was removed from Resident 2's neck, area was cleansed with NSS (normal saline solution) and TAO (triple antibiotic ointment) was applied. Further review of the note revealed that when Resident 2 was asked what happened, she stated [Resident 1] followed me in here. I said 'This is my room' and she told me 'I don't care', then started punching on me. Review of facility investigation revealed that the residents were immediately separated, the pen was removed from Resident 1 and Resident 1 was placed on a 1:1. At approximately 6:22 PM, Resident 1 was transferred to the emergency department on a 302 (an emergency psychiatric hold for individuals who are deemed a danger to themselves or others because of a mental illness).Review of Employee 3's witness statement dated October 15, 2025, revealed that Resident 2 was yelling for help. Staff ran to help and observed Resident 1 holding the back of Resident 2's wheelchair with her left hand and swinging at the back of Resident 2's head. It was then observed that Resident 1 had a pen in her hand. The statement further states that Employee 3 grabbed the pen while another staff member was directing Resident 1 away from Resident 2. Review of Employee 5's witness statement dated October 15, 2025, revealed that at 4:00 PM, after the Resident's smoke break, Employee 5 heard screaming. Employee 5 entered Resident 2's room and observed Resident 1 behind Resident 2's chair, and Employee 5 observed what appeared to be Resident 1 punching Resident 2 in the head. Employee 5 stated that as the residents were separated, Employee 5 noticed Resident 1 had a pen in her hand and had been stabbing Resident 2 in the neck. Employee 5 said she observed multiple marks on the back of Resident 2's neck as well as a mark on the back of her head. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on October 22, 2025, at 11:21 AM, they stated that they are unaware of any prior interactions between Resident 1 and Resident 2. They stated that the attack on Resident 2 was unprovoked and occurred right after both Residents attended smoking club. During an interview with Employee 6 (Activities Director), on October 22, 2025, at 12:20 PM, she stated that on October 15, 2025, during smoking club, there were no altercations between Residents 1 and 2. She stated that everyone seemed to be in a good mood and that Residents 1 and 2 did not even speak to each other. She further stated that where they sit during smoking club, they don't even face each other. At this time, Employee 7 (Activities) added that she was also present during smoking club on October 15, 2025. She stated that it was a normal smoking club activity and nothing was out of the ordinary involving either resident. During a surveyor interview with Resident 2 on October 22, 2025, at 12:28 PM, Resident 2 stated that Resident 1 came into Resident 2's room. Resident 2 told Resident 1 that wasn't her room and then Resident 1 pushed Resident 2 into her bed. Resident 2 stated that Resident 1 then started stabbing her. Resident 2 said at first, she thought Resident 1 was punching her but then realized she was being stabbed with a pen. Resident 2 stated that she immediately yelled for help and staff immediately came in to separate the residents. Resident 2 told the surveyor, I don't know what I did. I didn't do anything. Resident 2 stated that just prior to the incident, both her and Resident 1 were outside in smoking club together. She stated that they did not speak to each other and that she did not even look at Resident 1.Review of Resident 2's clinical record revealed that immediately after the incident, Resident 2 was offered to be sent to the hospital, but she declined. Resident 2 did agree to receive a Tetanus shot, which was administered on October 16, 2025. Review of Resident 2's physician orders revealed an order dated October 15, 2025, to cleanse the back of the head and neck with NSS, apply TAO and cover with a dry dressing. Further review revealed an order for alert charting, monitor wounds on the back of the neck for signs and symptoms of infection and monitor healing. On October 22, 2025, at 2:41 PM, the NHA and DON provided the facility's plan of correction that was put into place as a result of the facility's investigation, in which Resident 1 stabbed Resident 2 with a pen. The facility's education and audits were reviewed during the survey. As of October 20, 2025, facility staff were educated on identifying resident triggers, interventions and behaviors, and how to respond to and report any concerns. As of October 20, 2025, audits were completed for all residents to determine any behaviors, triggering events, and specific interventions utilized for those behaviors. Care plans were reviewed and updated as needed. Prior to the abbreviated survey, the facility failed to ensure residents were free from abuse, resulting in harm to Resident 2 as evidenced by multiple skin tears and penetrating wounds to the back of her head and neck after being stabbed with a pen by Resident 1. The facility reported the incident timely, investigated the incident thoroughly and initiated interventions in an effort to prevent a future incident. Review of facility documentation revealed that on October 20, 2025, the facility had completed education for staff and continued audits to ensure compliance. During the abbreviated survey, audits and staff education were reviewed. Staff interviews, resident interviews, resident record review, and observations revealed no abuse concerns. 28 Pa. Code 201.14 (a) Responsibility of licensee28 Pa. Code 201.18 (b)(1) Management28 Pa. Code 201.29 (a) Resident rights

Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide resident-directed care and services in accordance with professional standards of practice, and consistent with the resident's physician orders, to ensure the resident's highest level of well-being for three of 32 residents reviewed (Residents 93, 136, and 264). Findings include: Review of Resident 93's clinical record revealed diagnoses that included depression (a mood disorder characterized by a persistent feeling of sadness, loss of interest, and changes in thinking, sleep, and appetite) and hypertension (high blood pressure). Interview conducted with Resident 93 on June 10, 2025, at 9:09 AM, revealed that they have been working on getting an appointment scheduled for both of her knees for several months now so that she can get surgery on them to walk again, but has not heard anything about it being scheduled yet. Resident 93 revealed she is not able to walk due to issues with her knees. Review of Resident 93's clinical record revealed a nursing progress note written on August 28, 2024, at 2:57 PM, with text that read, in part, the Resident would like surgery on her bilateral knees for flexion contractures, and a call was placed to a doctor office schedule an appointment to discuss surgical options. Further review of Resident 93's clinical record revealed a nursing progress note written on November 1, 2024, at 4:45 PM, that read, in part, the Resident was transported to the doctor's office for testing, however, it was not able to be completed due to the Resident not being able to straighten their legs for the testing, and a recommendation was placed for the physician to review. Further review of Resident 93's clinical record revealed a nursing progress note written on January 15, 2025, at 11:26 AM, that read, in part, a second orthopedic opinion was to be scheduled for the Resident. Review of Resident 93's current active physician orders revealed an order to schedule orthopedic second opinion per Resident request for bilateral flexion contractures, the Resident wanted to have orthopedic surgery to fix them. Per last orthopedic, surgery is not an option. Schedule with a different office in surrounding area, with an active date of January 15, 2025. Review of Resident 93's clinical record revealed a nursing progress note written on June 11, 2025, at 10:59 AM, that read, in part, staff called an orthopedic office to schedule a second opinion where the Resident requested to be seen for a consult, and the office stated that they did have the Resident's referral scanned into their system but were unsure why it was never scheduled. A consult was scheduled for a second opinion on June 17, 2025. Interview conducted with the Nursing Home Administrator (NHA) on June 11, 2025, at 2:16 PM, revealed that five months seemed like a long time for an orthopedic consult to be scheduled for a resident. Further interview conducted with the NHA on June 12, 2025, at 11:56 AM, revealed that the original referral was sent to the orthopedic office in January 2025 to schedule an appointment for Resident 93, and that they would expect the facility to have followed up within a week or so if they did not hear back from the office to have to appointment scheduled. The NHA revealed that the unit manager is responsible for follow up on resident's medical appointments being scheduled in a timely manner, and that Resident 93's referral fell through the cracks. Review of Resident 136's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), unspecified lack of coordination, and muscle weakness. Review of Resident 136's physician orders revealed an order for GI (Gastroenterology) Consult, with a start date of January 23, 2025. Review of select facility documentation provided on June 12, 2025, revealed an appointment/consult sheet dated June 11, 2025, that read, GI consult [for] vomiting and syncope (fainting) with bowel movement. Review of Resident 136's nursing progress notes revealed a note on June 11, 2025, that stated MD notified that GI consult has not been scheduled. We are moving forward with scheduling appointment. Interview with the NHA on June 12, 2025, at 11:31 AM, revealed he does not have any information to provide as to why the order for the GI consult from January had not been responded to earlier than the day prior. Review of Resident 136's physician orders revealed the following: CBC and CMP (Complete Blood Count and Comprehensive Metabolic Panel- lab measures) Friday in the AM one time only for monitoring for 1 day, completed date of May 16, 2025. CBC and CMP, Urinalysis with reflex culture (UA C&S- medical test of urine) for abdominal pain one time only, completed on May 20, 2025. Review of an email correspondence from Employee 4 (Licensed Practical Nurse Unit Manager) on June 11, 2025, at 1:25 PM, revealed On May 16, 2025, a CBC and CMP was ordered for [Resident 136], a nurse signed the order in the TAR (Treatment Administration Record- documentation for treatments/medication administered or monitored) and wrote CBC BMP (Basic Metabolic Panel- lab measure) on the lab sheet, which was obtained and already provided. The order was replaced on May 16, 2025, again for CBC CMP this time with UA C&S, this was signed off in the TAR but never written on the lab sheet or rescheduled. Review of select facility documentation provided revealed a fax to the physician on June 11, 2025, asking if he would like the labs completed that were not drawn the previous month per physician order. During an interview with the NHA on June 12, 2025, at 11:31 AM, he revealed he would expect the original labs orders to be completed per physician order, and that they had not yet heard back from the physician if he would like new labs drawn. Review of Resident 136's clinical record revealed a note written by Employee 6 (Nurse Practitioner) on May 29, 2025, that stated Monitor blood pressure every shift. Review of Resident 136's clinical record revealed blood pressures every shift failed to be recorded since May 24, 2025, and review of her physician orders revealed she had an active order for blood pressures once weekly, with a start date of February 27, 2024. During an interview with Employee 6 on June 12, 2025, at 10:10 AM, he revealed he would have wanted the blood pressure monitoring every shift to be implemented but the measurements were not obtained. Interview with the NHA on June 12, 2025, at 11:32 AM, revealed the providers should be communicating orders from their notes to nursing staff to be entered, or enter them themselves, rather than just noting orders in their assessments, and he would expect physician orders to be implemented and followed. Review of facility policy, titled Medication Administration- General Guidelines, reviewed April 11, 2025, revealed 1) The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications. 6) If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (e.g. the resident is not in the facility at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the MAR for that dosage administration is initialed and coded appropriately. An explanatory note is entered in the record. If two consecutive doses of a vital medication are withheld or refused, the physician is notified. Review of Resident 264's clinical record revealed that he was admitted to the facility on [DATE], with diagnoses that included hyperlipidemia (high cholesterol) and hypertension (elevated blood pressure). Review of Resident 264's Medication Administration Record (MAR) dated May 2025, revealed the following orders: Ambien, 5 mg (milligrams), give two tablets by mouth at bedtime for insomnia; Patiromer Sorbitex Calcium Oral Packet, 8.4 GM (grams), give one packet by mouth daily for hyperkalemia (elevated potassium), with instructions to keep in refrigerator; and Fondaparinux Sodium Subcutaneous solution 2.5mg/0.5mL (milliliters), inject one application subcutaneously (an injection that is given in the fatty tissue, just under the skin) daily for DVT (deep vein thrombosis-blood clot). Further review of Resident 264's May 2025 MAR, revealed no documentation that the Ambien was given on May 14, 2025, at 9:00 PM, as the MAR was blank. On May 21, 2025, the Patiromer Sorbitex Calcium was signed off on the MAR as 16, meaning Hold/See nurse's note. On May 24, 2025, the Fondaparinux Sodium was signed off on the MAR as 16. Review of Resident 264's nursing progress note dated May 15, 2025, at 8:57 AM, revealed that that pharmacy was contacted regarding Resident 264's Ambien and that the prescription was filled and would be sent with the next delivery. Review of Resident 264's form titled Controlled Substance Record, revealed the Ambien was signed off as being received on May 15, 2025. Review of Resident 264's corresponding progress note for the Patiromer Sorbitex Calcium dated May 21, at 1:53 PM, revealed that the medication was on order, awaiting arrival of the medication from the pharmacy. Review of Resident 264's corresponding progress note for the Fondaparinux Sodium dated May 24, 2025, at 10:31 AM, revealed that the medication was reordered on this date. Review of Resident 264's clinical record revealed no evidence that the physician was made aware of Resident 264 not receiving his medications on the aforementioned dates and times. In an email correspondence forwarded from the NHA to the surveyor on June 11, 2025, at 12:12 PM, it was revealed that the pharmacy received Resident 264's physical Ambien prescription on May 14, 2025, at 12:26 PM; the Patriomer Sorbitex Calcium was delivered on May 13, 2025, with all of the doses being delivered; and a four day supply of the Fondaparinux Sodium was sent on May 13. On May 15, a 10 day supply was sent of the Fondaparinux Sodium. The medication was then reordered on May 23 and was not delivered until May 24 on the second run, as the pharmacy had to order the medication before it could be sent to the facility. During an interview with Employee 3 (Assistant Director of Nursing) and the NHA on June 11, 2025, at 2:02 PM, Employee 3 stated she would look into why the Ambien was not signed off as being given on May 14, 2025. Employee 3 stated that the Patriomer Sorbitex should have been at the facility, since all doses were sent from the pharmacy. She further stated that since it was to be kept in the refrigerator, the nurse may not have looked there and assumed the medication was not available. She also stated that for the Fondaparinux Sodium, since it is ordered daily and was delivered later on May 24, 2025, nursing staff should have reached out to the physician stating that the medication was not available during the scheduled time of 9:00 AM on May 24, for orders from the physician whether to give the dose later on May 24, when the medication was received, or to skip the dose. In a follow up email from Employee 3 on June 12, 2025, at 10:00 AM, it was revealed that the pharmacy delivers twice a day Monday through Friday, at approximately 2:00 AM and 3-3:30 PM, and there is one delivery on Saturdays and Sundays at around midnight. No additional information was provided regarding the Ambien not being signed off on the MAR on May 14, 2025, or why the Ambien was not received until May 15, 2025. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on facility policy review, observations, clinical record review, and resident and staff interview, it was determined that the facility failed to provide services necessary to maintain adequate personal grooming of residents dependent on staff for assistance with these activities of daily living for four of 32 residents reviewed (Residents 7, 26, 93, and 118). Findings Include: Review of the facility policy, titled Activities of Daily Living (ADL), Supporting with a last revised and reviewed date of April 2025, revealed, in part, 3. 'Unavoidable decline' may occur if the resident: c. refuses care and treatment to restore or maintain functional abilities and: (3) the refusal and details of the interventions refused are documented in the resident's clinical record. (5) Appropriate care and services are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, grooming, and oral care). Review of Resident 7's clinical record diagnoses included hemiplegia (total or partial paralysis on one side of the body), abnormal posture, contracture left hand (shortening and hardening of muscles, tendons, or other tissue leading to deformity and rigidity of joints), bilateral cataract (a clouding of the eye's natural lens, which can lead to blurred vision), and anxiety (a normal human emotion characterized by feelings of worry, unease, and nervousness). Interview with Resident 7 on June 9, 2025, at 1:30 PM, it was revealed that she had a shower that morning and she does require assistance. Her shower schedule is Monday and Thursday on day shift, at times receives a bed bath and prefers a shower. Per Resident 7 she prefers to be shaved and does not wish to have facial hair. Observations on June 9, 2025, at 1:30 PM , and June 11, 2025, at 12:22 PM, revealed Resident 7 had white facial hair on chin and lower jaw. Further review of Resident 7's clinical record documented showers are scheduled on Monday and Thursday on day shift. On the following dates a bed bath was provided vice a shower: May 15th, 19th, 22nd, 29th, 2025; and June 5th,m2025. Review of progress notes failed to revealed showers were refused. Interview with the Nursing Home Administrator (NHA) on June 12, 2025, at 11:45 AM, it was revealed that shaving should be offered with showers or bathing. Interview with the Employee 3 (Assistant Director of Nursing) on June 12, 2025, at 11:44 AM, revealed the Resident's preference for shower vice a bed bath should be honored. Review of Resident 26's clinical record revealed diagnoses that included need for assistance with personal care and muscle weakness. Observation of Resident 26 on June 9, 2025, at 10:58 AM, and June 11, 2025, at 12:07 PM, revealed she had half of an inch of facial hair on her chin. Review of Resident 26's care plan had a focus area for an ADL (activities of daily living-hygiene, grooming, etc.) care deficit with an intervention for ensure the resident is well groomed and appropriately dressed, last revised on July 8, 2024. Review of Resident 26's nurse aide task documentation revealed she has a preferred shower schedule of Tuesday and Friday during evening shift. Further review of Resident 26's nurse aide task documentation revealed she hadn't received a shower since May 29, 2025. During an interview with the NHA on June 12, 2025, at 11:39 AM, he revealed Resident 26 has been shaved, and he would expect personal hygiene care including shaving to be offered on shower days and as preferred. Follow-up interview with the NHA on June 12, 2025, at 2:14 PM, he revealed it was likely that Resident 26 had refused a shower since May 29, 2025, and he would expect that to be documented and documentation to indicate the Resident had been reapproached at another time. Review of Resident 93's clinical record revealed diagnoses that included depression (a mood disorder characterized by a persistent feeling of sadness, loss of interest, and changes in thinking, sleep, and appetite) and hypertension (high blood pressure). Interview conducted with Resident 93 on June 10, 2025, at 9:09 AM, revealed she does not always receive a shower twice a week as she is scheduled to, and will receive a bed bath instead. Resident 93 revealed that she prefers to take showers over bed baths. Review of Resident 93's comprehensive care plan revealed an ADL focus area with an intervention for: Bathing: provide the Resident with a sponge bath when a full bath or weekly shower cannot be tolerated; and Bathing: the Resident requires staff participation with bathing/shower; both with an initiation date of March 19, 2024. Review of Resident 93's clinical record revealed that she is to receive showers on Wednesdays and Saturdays. Further review of Resident 93's shower task review for the past 30 days (May 14, 2025 - June 12, 2025) revealed that the Resident received a bed bath on May 17 and 24, 2025; and June 7, 2025. Review of Resident 93's clinical record failed to reveal any progress notes or documentation indicating that the Resident refused a shower on May 17 and 24, 2025; and June 7, 2025. Interview conducted with the NHA on June 12, 2025, at 10:39 AM, revealed the proper protocol if a resident refuses a shower is to reapproach the resident at another time, and if they continue to refuse to offer a bed bath, notify the nurse, and document the refusal in the resident's clinical record. The NHA revealed he had no additional documents to provide indicating why Resident 93 did not receive a shower on May 17 and 24, 2025, and June 7, 2025. The NHA revealed he would expect the residents to receive a shower on their scheduled shower days if that is their preference. Review of Resident 118's clinical record revealed diagnoses that included need for assistance with personal care and muscle weakness. Observation of Resident 118 on June 9, 2025, at 11:13 AM, and June 11, 2025, at 12:18 PM, revealed she had a quarter of an inch of facial hair on her chin. Review of Resident 118's care plan had a focus area for an ADL care deficit with an intervention for ensure the resident is well groomed and appropriately dressed, initiated on November 3, 2023. Review of Resident 118's nurse aide task documentation revealed she has a preferred shower schedule of Tuesday and Friday during day shift. During an interview with the NHA on June 12, 2025, at 11:39 AM, he revealed Resident 118 has been shaved, and he would expect personal hygiene care including shaving to be offered on shower days and as preferred. 28 Pa. Code 201.29(j) Resident rights 28 Pa Code 211.12(a)(c)(d)(1)(3)(5)Nursing services

Based on facility policy review, CDC guidance review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents were offered any current COVID-19 vaccinations as required for four of five residents reviewed (Residents 5, 18, 26, and 37). Findings Include: Review of facility policy, titled Coronavirus Disease (COVID-19)- Infection Prevention and Control Measures, reviewed April 11, 2025, revealed This facility follows infection prevention and control (IPC) practices recommended by the Centers for Disease Control and Prevention [CDC] to prevent the transmission of COVID-19 within the facility. The infection prevention and control measures that are implemented to address the SARS-CoV-2 pandemic are incorporated into the facility infection prevention and control plan. These measures include: a. encouraging staff, residents and visitors to remain up-to-date with all COVID-19 vaccine doses; b. providing resources and counseling about the importance of receiving the COVID-19 vaccine;. Review of current CDC guidelines for staying up to date with COVID-19 vaccines dated June 6, 2025, revealed CDC recommends a 2024-2025 COVID-19 vaccine for most adults ages 18 and older .Vaccine protection decreases over time so it is important to get your 2024-2025 COVID-19 vaccine .Getting the 2024-2025 COVID-19 vaccine is especially important if you: Are living in a long-term care facility. Review of Resident 5's clinical record revealed an admission date of January 8, 2016. Review of Resident 5's vaccination history revealed her most recent COVID-19 vaccine was the Fall 2023 vaccine, administered on November 28, 2023. Review of Resident 18's clinical record revealed an admission date of February 23, 2022. Review of Resident 18's vaccination history revealed his most recent COVID-19 vaccine was the Fall 2023 vaccine, adminstered on January 17, 2024. Review of Resident 26's clinical record revealed an admission date of July 2, 2024. Review of Resident 26's vaccination history revealed no documentation that Resident 26 ever received or offered any COVID-19 vaccinations. Review of Resident 37's clinical record revealed an admission date of April 3, 2019. Review of Resident 37's vaccination history revealed her most recent COVID-19 vaccine was the Fall 2023 vaccine, administered on November 28, 2023. Review of the clinical records for Residents 5, 18, 26, and 37 failed to reveal any evidence that the Resident was offered or were educated on the risks and benefits of the most recent 2024-2025 COVID-19 vaccine. During an interview with Employee 3 (Infection Preventionist/Assistant Director of Nursing) on June 11, 2025, at 1:14 PM, she confirmed that the aforementioned dates for the most recent COVID-19 vaccines were correct for the residents and stated she was unsure why the most recent COVID-19 vaccines have not been offered. On June 11, 2025, at 2:08 PM, the Nursing Home Administrator was made aware of the concern that the most recent COVID-19 vaccinations had not been offered. No additional information was provided. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(2)(5) Nursing services

Based on review of facility policy, clinical record review, and resident and staff interviews, it was determined the facility failed to assist residents in obtaining routine and emergency dental care for two of 32 residents reviewed (Residents 5 and 93). Findings: Review of facility policy, Dental Services, effective date March 2015, read, in part, dental services will be available to all resident requiring routine and emergency dental care. All requests for dental services should be directed to social services to assure that appointments can be made in a timely manner. For Medicaid residents, the facility will provide the resident without charge, all emergency dental services as well as those routine dental service that are covered under the State plan. Review of Resident 5's clinical record documented diagnoses that included diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), schizophrenia (mental disorder involving a breakdown in the relation between thought, emotion, and behavior leading to faulty perception, inappropriate actions and feelings, affects a person's ability to think, feel and behave clearly), mild intellectual disabilities, obsessive compulsive disorder, lack of coordination, anxiety (a feeling of worry, nervousness, or unease), and dysphagia (difficulty swallowing). Interview on June 9, 2025, at 1:19 PM, with Resident 5, the Resident stated that she received a salad for lunch but that she was not able to chew it and, therefore, didn't eat it. It was also revealed that she needs to see the dentist, she had teeth removed and was supposed to have dentures made, but that had not occurred. Further review of the clinical record documented Resident 5's payor source is managed care Medicaid program since October 1, 2022. Review of Resident 5's care plan included altered dentition and/or mucus membranes related to oral surgery on October 10, 2024, now edentulous, being fitted for dentures, revised on November 25, 2024. Review of Resident 5's Minimum Data Set (MDS- a comprehensive assessment of a resident's functional capabilities and helps nursing home staff identify health problems) dated March 23, 2025, and February 22, 2025, documented yes for discomfort or difficulty with chewing. Review of Resident 5's progress notes documented oral surgery to remove several teeth on October 10, 2024, and the diet texture was downgraded. Review of MDS note dated November 21, 2024, noted edentulous awaiting dentures. Review of nutrition note dated January 8, 2025, noted a 5% weight loss in 30-days, meal intake 0 to 100%, diet texture down grade could contribute to weight loss. Interview with Employee 3 (Assistant Director of Nursing) on June 12, 2025, at 11:42 AM, it was revealed that the oral surgery consult didn't note for the Resident to be fitted for dentures, which may be why the consult for new denture wasn't initiate. It was also revealed that the timeframe from surgery to obtain dentures was excessive. Review of Resident 93's clinical record revealed diagnoses that included depression (a mood disorder characterized by a persistent feeling of sadness, loss of interest, and changes in thinking, sleep, and appetite) and hypertension (high blood pressure). Interview conducted with Resident 93 on June 9, 2025, at 11:07 AM, revealed that her two top front teeth are loose, and she has requested but has not been seen by the dentist yet. Review of Resident 93's comprehensive care plan revealed a focus area for: Resident is at risk for altered detention and/or mucus membranes related to two top front teeth loose, with an initiation date of March 22, 2024; and an intervention to obtain dental consult as necessary, with an initiation date of March 22, 2024. Review of Resident 93's active physician orders revealed an order to consult dental - evaluate and treat as needed, with an active date of March 15, 2024. Review of Resident 93's clinical record revealed a nursing progress note written on November 5, 2024, at 9:49 AM, that read, in part, the Resident has her own teeth, her two front top teeth are loose, and the unit secretary was called to add the Resident to see the house dentist. Further review of Resident 93's clinical record revealed a nursing progress note written on January 15, 2025, at 10:38 AM, that read, in part, the Resident has her own teeth, her two front top teeth are loose, and the unit secretary was called to add the Resident to see the house dentist. Further review of Resident 93's clinical record revealed a nursing progress note written on April 16, 2025, at 11:09 AM, that read, in part, the Resident has her own teeth, her two front top teeth are loose, and the unit secretary was called to add the Resident to see the house dentist. Interview conducted with the Nursing Home Administrator (NHA) on June 12, 2025, at 10:16 AM, revealed they were not able to provide a previous dental consult that was completed for Resident 93, indicating the Resident has not been seen by the dentist. Review of Resident 93's clinical record revealed a nursing progress note written on June 12, 2025, at 7:55 AM, that read, in part, staff spoke with the Resident due to complaints of loose teeth and offered to add the Resident to the dental list to see the dentist next time they are in the facility. The Resident agreed and was added to the dental list. Interview with the NHA on June 12, 2025, at 12:10 PM, confirmed that Resident 93 has been added to the list to see the in-house dentist next time they are in the facility, and that he would have expected Resident 93 to have been seen prior. 28 Pa Code 211.15(a)(b) Dental Services

Based on review of facility policy, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status, including monitor resident weights per physician order and inform the physician of significant weight loss, for four of 32 residents reviewed (Resident 5, 123, 136, and 152). Findings include: Review of facility policy, titled Weight Assessment and Intervention, revised March 2022, read, in part, residents are weighed at intervals established by the interdisciplinary team, and are recorded in the medical record. Unless notified of significant weight change, the dietitian will review the weight record monthly to follow individual weight trends over time. Undesirable weight change is evaluated by the physician and multidisciplinary team and are to identify conditions and medications that may be causing weight loss. Review of Resident 5's clinical record documented diagnoses that included diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), schizophrenia (mental disorder involving a breakdown in the relation between thought, emotion, and behavior leading to faulty perception, inappropriate actions and feelings, affects a person's ability to think, feel and behave clearly), mild intellectual disabilities, obsessive compulsive disorder, lack of coordination, anxiety (a feeling of worry, nervousness, or unease), and dysphagia (difficulty swallowing). Interview on June 9, 2025, at 1:19 PM, Resident 5 stated that she received a salad for lunch but stated that she was not able to chew it and, therefore, didn't eat it. The Resident was unsure if she has had any weight loss. Review of Resident 5's physician orders included weekly weights secondary to weight loss every Tuesday day shift, started January 14, 2025. Resident 5's weight history revealed: October 3, 2024, =185.8lb, November 4, 2024,=183.8lb; December 4, 2024,= 180.4lb; January 8, 2025,= 172.5lb; February 6, 2025,=175.2lb; March 7, 2025= 171lb; April 3, 2025,= 168lb; May 1, 2025,= 166.8lb; June 3, 2025,= 165.8lb. A 14 lb weight loss in 6 months (not significant), weight stable over the past 30 days. Weekly weights were not obtained/documented. Weight change note dated January 8, 2025, read, in part, Resident presents with significant weight loss, physician made aware of all information with the following new orders received for discontinue monthly weights and initiate weekly weights. Interview with the Nursing Home Administrator (NHA) on June 12, 2025, at 12:55 PM, it was revealed the order for weekly weights was not entered into the electronic record to display on the Medication Administration Record, therefore, the weekly weights were not obtained, and they should've been. Review of Resident 123's clinical record revealed diagnoses that included dementia, dysphagia (difficulty swallowing), and muscle weakness. Review of Resident 123's clinical record revealed she had a significant weight loss of 6.9% from March 6 to April 1, 2025. Further review of Resident 123's clinical record failed to reveal documentation to indicate the physician was notified of the significant weight loss. Review of Resident 123's nursing progress notes revealed a note written on April 3, 2025, by Employee 8 (Registered Nurse) that read, in part, Resident's weight re-checked today due to significant weight loss since last month. Re-weight is 110.4 pounds in a wheelchair scale which is further off from last month's weight. Further review of Resident 123's clinical record revealed a note written by Employee 2 (Registered Dietitian 1) on April 5, 2025, with a weight assessment in response to the weight obtained on April 1, 2025, with a request for a reweigh measure to verify the weight loss. The note failed to respond to the re-weigh measure in the nursing note from April 3, 2025. Review of Resident 123's progress notes revealed a dietitian note dated April 21, 2025, that read, in part, Recommend weekly weight x 4 for monitoring. Review of Resident 123's clinical record failed to reveal weekly weight measures documented on the weeks of May 5 or 12, 2025. Interview with the NHA on June 12, 2025, at 11:57 AM, revealed that he was not able to locate any documentation indicating the physician was notified of the Resident's weight loss in April 2025, the weekly weights were not obtained because there was a transcription error when the order was entered, and that he would expect doctor notification of weight loss and weekly weights would be obtained as ordered. He further revealed that the reweigh measure obtained on April 3, 2025, was missed by Employee 2 for her assessment review on April 5, 2025, because it was not recorded properly in the electronic health record, and he would expect weights to be recorded properly and communicated to the dietitian. Review of Resident 136's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), unspecified lack of coordination, and muscle weakness. Review of Resident 136's clinical record revealed she had a significant weight loss of 5.3% from April 1 to April 15, 2025. Further review of Resident 136's clinical record failed to reveal documentation to indicate the physician was notified of the significant weight loss. Review of Resident 136's progress notes revealed a dietitian note dated April 22, 2025, that read, in part, Continuing to monitor adherence to diet and weekly weights. Review of Resident 136's physician orders revealed an order for Weekly Weights every day shift every Tuesday for health monitoring, with a start date of January 14, 2025, and an end date of May 14, 2025. Review of Resident 136's clinical record failed to reveal weekly weight measures documented on April 22 or 29, 2025. Interview with the NHA on June 12, 2025, at 11:32 AM, revealed that he was not able to locate any documentation indicating the physician was notified of the Resident's weight loss in April 2025, or that the weekly weights were obtained as ordered; and he would expect doctor notification of weight loss and weekly weights would be obtained as ordered. Review of Resident 152's clinical record revealed diagnoses that included bipolar disorder (a mental illness that causes extreme mood swings) and dementia. Review of Resident 152's comprehensive care plan revealed a focus area that the Resident may be nutritionally at risk related to weight loss, date initiated on October 31, 2024, and last revised on December 18, 2024, with an intervention to record and monitor weights, dated initiated on November 5, 2024. Review of Resident 152's clinical record revealed a dietary progress note written on April 15, 2025, at 11:47 PM, that indicated the Resident had a 13.3% weight loss, and their weight dropped from 150 pounds on March 14, 2025, to 133 pounds on March 21, 2025. Further review of Resident 152's clinical record revealed a dietary progress note written on May 14, 2025, at 10:32 PM, that indicated the Resident shows a 21.7% weight loss within 180 days, weighing 129.8 pounds on May 7, 2025. Further review of Resident 152's clinical record failed to reveal any documentation indicating the physician was notified of the Resident's weight loss in April 2025 and May 2025. Interview conducted with the NHA on June 12, 2025, at 1:05 PM, revealed that he was not able to locate any documentation indicating the physician was notified of the Resident's weight loss in April 2025 and May 2025, and would have expected the physician to have been notified of the weight loss. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews were completed at least once a month by a consultant pharmacist and responded to in a timely manner by the attending physician or prescriber in a timely manner for two of five residents reviewed (Residents 23 and 72). Findings include: Review of facility policy, titled Medication Regimen Review (Monthly Report), without revision date, failed to reveal an expectation for a timeframe for the medical director or other physician to answer the medication regimen review. Review of Resident 23's clinical record revealed diagnoses of major depressive disorder (a mental disorder characterized by persistent sadness, loss of interest, and a range of other symptoms that significantly interfere with daily life), anxiety (a normal human emotion characterized by feelings of worry, unease, and nervousness), and intellectual disabilities. Review of facility provided pharmacy recommendations dated January 28, 2025, consider discontinuing as needed ondansetron (medication used to prevent nausea and vomiting) and April 30, 2025, consider adding amlodipine (medication used to lower elevated blood pressure) 2.5 milligrams once daily. No documented physician response for the aforementioned recommendations from pharmacy. Review of Resident 23's June 2025, physician orders included ondansetron 8 milligrams every 8 hours as needed for nausea start December 11, 2024, and failed to include an order for amlodipine. Electronic mail communication with the Nursing Home Administrator (NHA) on June 13, 2025, at 8:34 AM, revealed proof of physician response was not available for the aforementioned pharmacy recommendations for Resident 23. Review of Resident 72's clinical record revealed diagnoses of major depressive disorder and anxiety. Review of Resident 72's physician's orders reveal a physician's order for Mirtazapine (antidepressant medication) 15 mg daily with a start date of February 23, 2023, for major depressive disorder. Review of Resident 72's electronic medical record failed to reveal that there was a medication regimen review completed on March 30, 2025, with a recommendation to perform a gradual dose reduction of Resident 72's Mirtazapine. Further review of the medication review revealed it was not addressed by the physician until June 10, 2025, after an inquiry was made for the physician's response to the medication regimen review. Interview with the NHA on June 12, 2025, at 10:45 AM, revealed that they would expect a physician to review and respond to the medication regimen review in a timely manner. 28 Pa. Code 211.10(c) Resident care policies

Based on observations, review of facility policy, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in two of two nourishment pantries. Findings include: Review of facility policy, Food Storage Areas, revised July 2023, read, in part, all foods should be labeled, dated, and consumed by their safe use by dates. Review of facility policy, Food from Outside Sources, revised July 2023 read, in part, label food and beverages with the resident's name, room number, and date. Observation in the second-floor nourishment pantry on June 9, 2025, at 10:01 AM, revealed one container of 46 ounce moderately thick water and one container of 48-ounce prune juice were open with contents partially removed and not date marked. Packaging on both products documented the products to be good for seven days once opened. observations also revealed three boxes and two metal container with holiday decoration, and one box of smoked sausages that contained no resident identifier and not date marked. On top of refrigerator was two ice cream cones in an open plastic sleeve, not date marked. Interview with Employee 1 (Food Service Director) it was revealed that resident items should contain a resident identifier and be date marked. And when beverage containers are opened, they should be date marked. Observation and interview with Employee 1 on June 9, 2025, at 10:17 AM, revealed one container of 48-ounce prune juice that was open with contents partially removed and not date marked. Employee 1 confirmed that the juice should be date marked when opened. Interview with the Nursing Home Administrator on June 10, 2025, at 2:10 PM, it was revealed that the aforementioned items should be date marked and contain a resident identifier. 28 Pa code 211.6(f) - Dietary Services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to identify pressure ulcers and to promote healing and prevent infection of a pressure ulcer for one of one resident reviewed for pressure ulcers (Resident 2). Findings include: Review of Resident 2's clinical record revealed diagnoses that included hypokalemia (low levels of potassium in the blood) and hyperlipidemia (having high levels of fats in the blood). Further review of Resident 2's clinical record revealed that she had an incontinence associated dermatitis (IAD) on her sacrum that was acquired on February 11, 2025. Resident 2 was seen by the wound clinic on February 18, 2025, with a treatment plan to cleanse the wound daily and as needed with soap and water, pat dry, and treat with medical grade honey, calcium alginate, and cover with bordered gauze. Review of Resident 2's February 2025 Medication Administration Record (MAR) revealed a physician's order for medical grade honey wound and burn dressing external paste, apply to sacrum topically every day shift for masd (moisture-associated skin damage), cleanse sacrum with soap and water, pat dry, apply medical grade honey, calcium alginate and cover with bordered gauze daily and as needed, with a start date of February 19, 2025, and an end date of March 13, 2025. Further review of Resident 2's February 2025 MAR revealed there was no documentation that she received the treatment ordered above on February 20, 2025, as the box was left blank, indicating the treatment was not completed. Review of Resident 2's March 2025 MAR revealed there was no documentation that she received the treatment ordered above on March 8, 2025, as the box was left blank, indicating the treatment was not completed. Review of Resident 2's clinical record revealed she was seen by the wound clinic on March 11, 2025, where it refers to the wound on the resident's sacrum as an unstagable pressure ulcer. During a staff interview with the Nursing Home Administrator on May 5, 2025, at approximately 1:30 PM, revealed she was unable to provide an explanation as to why Resident 2's MAR documentation was blank on February 20, 2025, and March 8, 2025, and would expect staff to be documenting after they have completed treatment on a resident. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on clinical record review, select document review and staff interview, it was determined that the facility failed to prevent accident hazards for one of five residents reviewed (Resident 2). Findings include: Review of Resident 2's clinical record revealed diagnoses that included heart failure (a serious condition that occurs when the heart is unable to pump enough blood and oxygen to the body's organs) and chronic kidney disease (a long-term condition where the kidneys gradually lose their ability to filter blood properly). Review of a fall incident report that occurred on November 1, 2024, at 11:30 PM, revealed that a nurse aid (NA) found Resident 2 while answering the roommate's call bell, lying prone position in the bathroom. The fall resulted in a hematoma to Resident 2's face, and Resident 2 was transported to the hospital. Further review of the fall incident report, revealed a witness statement by the nurse aid (NA 1) that found Resident 2, with the following description of occurrence, Just seen her at 11:00 PM in her rest room having loose bowel movements. Resident was found face down in bathroom. Review of Resident 2's care plan revealed a focus area for falls, initiated on February 9, 2023, with an intervention for 15-minute checks, initiated on May 1, 2024, and provide staff education that the Resident must transfer and ambulate with assist of one to prevent falls, initiated on May 17, 2024. Review of Resident 2's care plan revealed a focus area for activities of daily living (ADLs), with an initiation date of February 8, 2023, and an intervention that Resident 2 requires staff participation to use toilet, initiated on February 8, 2023, and transfer with rolling walker and assist of 2, initiated on February 16, 2023. Review of Resident 2's clinical record ADL toilet use: support provided task for the past 30 days (November 10, 2024 - December 9, 2024) revealed that Resident 2 either required 1-person physical assist or 2-persons physical assist to use the toilet. Review of Resident 2's clinical record ADL toilet use: self-performance task for the past 30 days (November 10, 2024 - December 9, 2024), revealed that Resident 2 either required limited staff assistance, extensive staff assistance, or total staff dependence to use to toilet. During an interview with the Nursing Home Administrator on December 9, 2024, at approximately 1:55 PM, revealed that if Resident 2 was seen in the bathroom by staff, she would have expected them to stay with her until she is done and assist her back to bed. 28 Pa. Code 201.18(b)(1)(2)Management 28 Pa. Code 211.12(d)(3)(5)Nursing services

Based on facility policy review, clinical record review, and interviews with residents and staff, it was determined that the facility failed to implement a process to ensure effective safety measures to prevent elopement, prior to and following incident of resident elopement, for two of 26 residents reviewed who are permitted to go outside independently (Residents 1 and 2). This failure placed Residents 1 and 2 at high risk for injury and resulted in an Immediate Jeopardy situation. Findings Include: Review of facility policy, titled Elopement, with a revision date of June 2023, revealed, It is the policy of this facility to provide a safe and secure environment for our residents and to be proactive in preventing resident elopement. Residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement is defined as a resident leaving the premises of the facility without the knowledge and supervision of facility staff .Post Elopement/upon return to the facility, the Director of Nursing Services or Charge Nurse shall: Examine the resident for injuries; Notify the Attending Physician; Notify the resident's responsible party of the incident; Complete and file an Incident Report; and Document the event in the resident's medical record. Any resident with a successful elopement will be reassessed and additional interventions will be identified and included with the Plan of Care. Review of facility policy titled, Signing Residents Out, revised March 2019, revealed, Each resident leaving the premises (excluding transfers/discharges) must be signed out. The duration of the LOA [Leave of Absence] must be communicated to the resident's charge nurse. Review of Resident 1's clinical record revealed diagnoses that included atrial fibrillation (Afib - an irregular, often rapid heart rate, that commonly causes poor blood flow), hypertension (elevated blood pressure), and chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe). Further review of Resident 1's clinical record revealed a BIMS (brief interview for mental status) score on August 23, 2023, of 13 out of a possible 15, meaning Resident 1 is cognitively intact. Review of Resident 1's care plan revealed that he is at risk for injury/falls related to weakness, ambulatory dysfunction, and difficulty walking. This care area was initiated on June 2, 2021. Review of Resident 1's care plan also revealed that he experienced a fall on September 14, 2023. Further review of Resident 1's care plan revealed that he uses a single point cane for ambulation. This was noted to be effective August 24, 2021. Review of Resident 2's clinical record revealed diagnoses that included Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), hypertension, atrial fibrillation, and history of falling. Further review of Resident 2's clinical record revealed a BIMS score on August 9, 2023, of 7 out of a possible 15, suggesting severe cognitive impairment. Review of Resident 2's care plan revealed that she is at risk for falls/injury related to Alzheimer's dementia, history of falls, low back pain, and neuropathy (nerve damage or impairment that often affects the hands or feet). This care area was initiated March 10, 2021. Review of Employee 4's (Receptionist) statement, dated October 1, 2023, revealed, [Resident 1] + [Resident 2] were already sitting in the family room when I came in at 7:45. They sat till around 8:30 AM and their ride did not come. [Resident 1] got up and said I guess they aren't coming so, they went back to their room. At around 8:40 the car that picks them up came, didn't see them and left. [Resident 1] + [Resident 2] came back up + went outside - thought just going out for fresh air until Pastor of the church up the road called and said they were there and would have someone bring them back after the service. Marked it in the sign-out book. During an interview with Employee 4 on October 3, 2023, at 2:39 PM, she reiterated the above information. She confirmed that Resident 1 and 2 were on the list of residents who are considered safe to go outside independently. She revealed that she observed Residents 1 and 2 going outside sometime between 8:30 AM and 8:45 AM on October 1, 2023. She revealed that she was not certain of the actual time, but shortly thereafter she received a call from the Pastor at the nearby church. Additionally, she revealed that when the Pastor called to inform the facility that Residents 1 and 2 were there, he asked if they were permitted to stay for the service. Employee 4 stated that she told that Pastor that she assumed it was okay. Employee 4 revealed that she did not notify nursing staff of Resident 1's and Resident 2's whereabouts, or that they had walked to church. Employee 4 confirmed that she signed Residents 1 and 2 back in at 11:03 AM, when they were returned to the facility by a Parishioner. During an interview with Employee 3 (Registered Nurse) on October 3, 2023, at 2:06 PM, revealed that she was the house supervisor on October 1, 2023. Employee 3 revealed that, on that morning, she was was notified that there was a woman waiting there to talk to her. The woman (the Parishioner who returned Residents 1 and 2 to the facility) informed her that Residents 1 and 2 had been up to the church. Employee 3 stated that Residents 1 and 2 typically went to church every Sunday, so she didn't understand at that point that there was anything out of the ordinary. Employee 3 stated it was their normal routine to be out of the building on Sunday mornings. Employee 3 stated that she went ahead and assessed Residents 1 and 2 since they had been on LOA. Employee 3 stated that, once she realized that Residents 1 and 2 did not attend their normal church but instead walked to the neighboring church, she spoke to Resident 1 about the incident and asked him to inform staff if their ride does not come so that alternate transportation could be arranged. Employee 3 confirmed that she was not informed by Employee 4 that the Pastor had called the facility to notify them of Resident 1's and Resident 2's whereabouts. Employee 3 stated that she did not consider the incident an actual elopement. During an interview with Resident 1 on October 3, 2023, at 9:40 AM, he revealed that after his normal ride to church did not show, he and Resident 2 just went out and walked. We didn't let anyone know. We just pushed on until we found a church. Resident 1 stated that he did not think about the need to notify staff. He stated, We were in a lost position. We were in a land we weren't familiar with. It just happened. It was nothing that was planned. Resident 1 stated that he and Resident 2 used the roadway when walking to the church. During a later interview with Resident 1 on October 3, 2023, at 1:55 PM, Resident 1 stated that he did not recall if someone had educated him on not leaving the premises once he and Resident 2 returned from church. He stated, My memory is very, very bad. I don't control my memory. It controls me. Resident 1 also stated that he did not recall anyone ever informing him of where he can and can't go. He stated, If someone told me to not walk up the road, I wouldn't have walked up the road. Per googlemaps.com, the distance between the facility and the church was noted to be 0.5 miles. Observation of the roadway between the facility and the church on October 3, 2023, at 6:00 PM, revealed the speed limit to be 35 miles per hour. Additionally, observation revealed the roadway is utilized by a church, the facility, and a medical center. Review of Resident 1's and Resident 2's clinical record, including assessments, progress notes, and care plan, failed to reveal any notation of the elopement incident, evaluation/plan for safety, re-assessment of elopement risk, notification of the physician or responsible party, updated care plan interventions, or any documented re-education provided to Residents 1 or 2. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on October 3, 2023, at 1:01 PM, they revealed that they did not consider the October 1, 2023 incident involving Residents 1 and 2 as an elopement since less than 10 minutes had elapsed between the time Residents 1 and 2 were last seen and the time that the Pastor notified the facility of their whereabouts. They revealed that, consequently, they considered the incident as a LOA and, therefore, did not report the incident or treat it as an elopement following the event. The NHA and DON were provided the immediate jeopardy template on October 3, 2023, at 1:01 PM, and an immediate action plan was requested. On October 3, 2023, at 4:53 PM, the facility's immediate action plan was accepted, which included: 1. Staff member sent outside to sit with current Residents that are outside at 1320 (1:20 PM) on October 3, 2023. 2. Main entrance placed on lock down and the receptionist stationed at the front door. Receptionist manually opens door for all visitors, staff, and residents entering and exiting the facility. 3. Head count of all residents completed, all accounted for and safe. 4. Education to employees regarding Safe Outside List to be supervised at all times by a staff member. 5. [Resident 1's and Resident 2's] care plans have been updated to include verification of transportation to church weekly. 6. The above will be completed by 10/3/2023. On October 3, 2023, at 5:47 PM, the Immediate Jeopardy was lifted after ensuring that the immediate action plan had been implemented. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a)(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, review of select facility documentation, and staff and resident interviews, it was determined that the facility failed to implement interventions to ensure resident safety during transport, which resulted in actual harm, evidenced by an acute tibia (shin bone) fracture for one of three residents reviewed (Resident 2). Findings include: Review of Resident 2's clinical record revealed diagnoses that included hemiplegia and hemiparesis following cerebrovascular disease affecting left side (inability to move, severe weakness, or rigid movement on either side of the body that occurs when blood flow to a part of the brain is suddenly stopped and oxygen cannot get to that part, causing damage to the brain cells) and muscle weakness. Review of Resident 2's current physician orders revealed an order to use a wheelchair with a left elevating leg rest when out of bed, effective October 4, 2022. Review of Resident 2's current care plan revealed a focus area related to Resident's self-care performance deficit due to limited range of motion, history of stroke, and left-sided hemiplegia. Further review revealed an active intervention to use a wheelchair with a left elevating leg rest when out of bed, effective August 23, 2022. Review of facility form, Skin Impairment Root Cause Investigation Report, dated October 31, 2022, at 9:00 PM, revealed that it was noted during care that the Resident had a bruise on the left shin. At that time, the nurse aide reported that Resident 2's leg was caught under the wheelchair while being wheeled to the shower room at the beginning of the shift. An order was obtained for an X-ray. Review of the X-ray report revealed the presence of a left tibial fracture. During an interview with Resident 2 on November 29, 2022, at 12:50 PM, she revealed that, on the date of the incident, a nurse aide took off her left leg brace and also removed the leg rest off of her wheelchair. Resident 2 stated, she should never have done that. She knows better. She should not have taken my footrest off. I cannot hold my foot up. Resident stated that when the nurse aide started to take her to the shower, her foot got caught under the chair, and that she yelled because it hurt. Resident stated that the nurse aide stopped, pulled her foot out, and proceeded to the shower room. Resident 2 stated that she later found out her leg was fractured. Review of Employee 1's (Nurse Aide) witness statement dated November 11, 2022, revealed that [Employee 2]asked for assistance with [Resident 2's] shower and when I got to her room to help [Employee 2] with her shower I got behind her chair. She was facing the door and her leg rest was off. So [Employee 2] was to left of the chair holding up her left leg and when we got the doorway of her room [Employee 2] left go of her leg. I turned her chair to the right. [Employee 2] said stop her leg is cot (sic). I stopped and [Employee 2] fixed her leg pulled her leg up so I could turn her to take her to the shower room backwards and we hoyered her onto the shower bed. During an interview with Employee 1 on November 29, 2022, at 1:50 PM, she revealed that she was familiar with Resident 2's care and is often assigned to her hall. Employee 1 stated that she was asked by Employee 2 to stay after the end of her shift to help shower Resident 2. Employee 1 stated that when she arrived at Resident 2's room, Resident 2's left leg brace and left wheelchair leg had already been removed. Resident 2 was in her wheelchair and was facing the doorway. Employee 2 was on the left side of the resident until they reached the door. Employee 2 was holding Resident 2's left leg. When they reached the doorway, because there wasn't enough room for the wheelchair and Employee 2, Employee 2 put Resident 2's leg down. When Employee 1 pushed her forward, her leg got caught under the chair. Employee 1 stated she could not see the way in which it was caught as she was behind the chair. Employee 1 stated that when Employee 2 informed her what had happened, she stopped right away. Employee 1 revealed that she then took Resident 2 backwards from there to the shower room, where she assisted with showering Resident 2 and placing her back into bed. Employee 2 stated that she did not visualize any marks or bruising on Resident 2, and that Resident 2 did not indicate that she was in any pain during that time. Employee 1 revealed that when she transports Resident 2 at other times she has her left leg rest on, and that she requires a leg rest because she is paralyzed and cannot hold her leg up. Employee 1 also confirmed that, after the incident, she received education on leaving Resident 2's leg rest on. Review of Employee 2's witness statement, dated October 31, 2022, revealed, I was showering [Resident 2] with [Employee 1]. I took off her leg rest. My plan was to turn her backwards since she cannot hold her leg up. While going out of her room I lifted her paralyzed leg up. When we got to the door [Employee 1] swerved causing [Resident 2's] leg to twist under the chair. I said, 'Stop, her leg is caught.' I took over the chair and took her in the shower room for her shower. During a telephone interview with Employee 2 on November 29, 2022, at 2:59 PM, she stated that Employee 1 offered to assist with Resident 2's shower. Employee 2 stated that she went into Resident 2's room and asked her if she was ready for her shower. She then took the leg rest off of her wheelchair. Employee 1 was behind the Resident and, when they reached the door, Employee 1 swerved to the right in an attempt to turn Resident 2's chair so she could transport her backwards. At that time, the resident's leg got caught behind the front wheel. Per Employee 2, Resident 2 stated ow. Employee 2 stated that she told Employee 1 to stop, and then she untangled Resident 2's leg. Employee 2 stated that when asked, Resident 2 said she was ok and that she just wanted to get her shower. Employee 2 stated that they proceeded with the shower, with no visible injury or complaints of pain from Resident 2. Employee 2 revealed that it was not until her final rounds around 9:30 PM that bruising was noted on Resident 2's left leg. At that time she notified the supervisor of the incident earlier in the shift. Employee 2 stated that she is often assigned to Resident 2 for care. She revealed that Resident 2 has one leg rest on her wheelchair on the left side. She also revealed that removing this leg rest was not something she would normally have done when preparing Resident 2 for her shower, and that she did not know why she took it off. Employee 2 stated that it was an honest mistake and she knows she should not have removed the leg rest because Resident 2 struggles to lift her legs. During an interview with Employee 3 (Director of Therapy) on November 29, 2022, at 4:02 PM, she revealed that, at the time of the incident, Resident 2 was only utilizing a left leg rest on her wheelchair and that it should have been on at all times when she was in her chair. She confirmed that use of the left leg rest was noted in Resident 2's physician orders and care plan. Review of a written statement provided by the Director of Nursing (DON) dated November 11, 2022, revealed that, on that date, she provided verbal education to both Employees 1 and 2 during individual meetings to discuss the incident from October 31, 2022. Further review of the statement revealed, Per the conversation with both employees, they were instructed that moving forward leg rests need to be present when transporting a resident from one place to another and if another incident occurs that this was not done that the employee would receive discipline action. Both employees verbalized understanding. During a phone interview with the Director of Nursing on December 2, 2022, at 12:30 PM, she revealed the expectation that Employee 1 and 2 should have utilized the wheelchair leg rest when transporting Resident 2. The facility failed to implement interventions, in place, to assure Resident safety during transport, resulting in a fractured tibia. 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and a review of facility documentation, facility policy and procedure, and staff interviews, it was determined that this constituted a past non-compliance situation when the facility failed to follow the physician's orders [REDACTED]. Findings include: On January 17, 2017, the Director of Nursing was asked for a policy regarding the application of alarms used to alert staff when residents rise from their chair. The facility was unable to provide such a policy. A review of Resident 3's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 3's care plan revealed a section related to the potential for injury due to poor safety awareness. The care plan was initiated on January 1, 2016 and referenced contributing factors as, dementia with confusion, poor communication/comprehension, physical restraint use, psychoactive drug use, vision problems, wandering, incontinence, a history of falls, and arthritis. The care plan further revealed that the resident was to have an alarming seat belt to the wheelchair to promote safety. Review of the KARDEX (a document provided to the nursing staff with the current care orders for each resident) revealed that the resident was to have a, self-releasing, alarming seat belt to the wheelchair to promote safety-frequent checks. Review of an annual Minimum Data Set assessment (MDS - a periodic review of the resident's needs) dated January 1, 2016, revealed that Section C Cognitive Patterns, C0100 Should Brief Interview for Mental Status (BIMS - a series of questions used to assess a resident's cognitive status) be Conducted, was coded as a 0 (indicating no, resident was rarely/never understood). The instructions then say to skip to and complete Section C0700-C1000, Staff assessment for Mental Status. Section C0700 Short Term Memory, was coded as a 1 (memory problem), Section C0800 Long Term Memory, was coded as a 1 (memory problem), Section C 0900 Memory Recall Ability, was coded as a Z (none of the above was recalled), and Section C1000 Cognitive Skills for Daily Decision Making, was coded as a 2 (moderately impaired-decisions poor, cues/supervision required). Review of the MDS Section G Functional Status revealed under G0400 Functional Limitation in Range of Motion, assessment B Lower extremity was coded as a 3 (two plus persons physical assist). Section G0120 Bathing-Self Performance was coded as a 2 (impairment on both sides). G0600 Mobility Devices, Section C-wheelchair was coded as normally used. Review of the physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. A review of the nurses' notes dated April 2, 2016, at 1:09 p.m. revealed that Registered Nurse (RN) 1 was called to the 500 hallway for a resident on the floor. The notes stated, The resident was lying on her left side. The resident was unable to state what happened due to [DIAGNOSES REDACTED]. The alarm was not sounding. The resident was checked for injuries and none were noted. Hoyer lift (a mechanical device used to move residents who are unable to move themselves) was used to assist the resident to the wheelchair for close supervision. The resident was able to move all extremities without difficulty. The floor was dry. The hipsters were not on. The nursing note also revealed that the staff were educated on turning the alarms to on. The physician was called and an X-ray was ordered. The nurses' note dated April 2, 2016, at 6:09 p.m. revealed that the X-ray results were received at 4:00 p.m. and identified a pelvic fracture (a disruption of the bony structure of the pelvis). The physician was again contacted and he gave new orders for the resident to be transferred to the hospital for surgical evaluation. Review of NA 1's written statement dated April 4, 2016, revealed that she had given Resident 3 a shower and, after shower recall reattaching belt but forgot to push the on button. Replaced hipsters after shower only one hip pad in hipsters-did not ask nurse for another pad to correct. The facility suspended NA 1 on April 2, 2016, during the investigation, and reinstated the Nurse Aide on April 8, 2017, six days after the incident. NA 1 was given a ten day re-orientation with a preceptor and was provided education on abuse/neglect with competency and training on the use of electronic documentation devices to access resident care needs and care plan. An interview with the Director of Nursing on January 17, 2017, confirmed that NA 1 was hired on January 6, 2016. A review of the nurse aide orientation program check list revealed that the employee demonstrated competence in the importance of insuring resident and unit safety at all times, during her training period. Further review of NA 1's orientation program revealed she demonstrated competence in providing nursing care consistent with residents needs and following the plan of care, during her orientation time. An interview with the Director of Nursing on January 17, 2017, at 1:40 p.m. revealed that the facility expectation is that all alarms and safety equipment should be in place, and functioning, as ordered. The facility failed to ensure that the physician's orders [REDACTED]. 42 CFR 483.24, 483.25(k)(l) Provide Care/services For Highest Well Being. Previously cited 4/19/16, 6/22/16, 5/21/15. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 10/6/16, 7/13/16, 4/19/16, 5/21/15. 28 Pa. Code 201.18(b)(3) Management. Previously cited 9/19/16, 7/13/16, 5/21/15. 28 Pa. Code 211.10(a) Resident care policies. Previously cited 4/19/16, 6/22/16. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 4/19/16, 5/21/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 10/6/16, 4/19/16, 6/22/16, 6/25/15, 5/21/15.

Based on clinical record review and a review of facility documentation, 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 harm by failing to ensure that safety equipment was turned on and functioning properly for one of 3 residents reviewed. This resulted in a past non-compliance harm situation because actual harm occurred to one resident (Resident 3) who sustained a fractured pelvis when the resident fell . Findings include: On January 17, 2017, the Director of Nursing was asked for a policy regarding the application of alarms used to alert staff when residents rise from their chair. The facility was unable to provide such a policy. A review of Resident 3's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 3's care plan revealed a section related to the potential for injury due to poor safety awareness. The care plan was initiated on January 1, 2016 and referenced contributing factors as, dementia with confusion, poor communication/comprehension, physical restraint use, psychoactive drug use, vision problems, wandering, incontinence, a history of falls, and arthritis. The care plan further revealed that the resident was to have an alarming seat belt to the wheelchair to promote safety. Review of the KARDEX (a document provided to the nursing staff with the current care orders for each resident) revealed that the resident was to have a, self-releasing, alarming seat belt to the wheelchair to promote safety-frequent checks. Review of an annual Minimum Data Set assessment (MDS - a periodic review of the resident's needs) dated January 1, 2016, revealed that Section C Cognitive Patterns, C0100 Should Brief Interview for Mental Status (BIMS - a series of questions used to assess a resident's cognitive status) be Conducted, was coded as a 0 (indicating no, resident was rarely/never understood). The instructions then say to skip to and complete Section C0700-C1000, Staff assessment for Mental Status. Section C0700 Short Term Memory, was coded as a 1 (memory problem), Section C0800 Long Term Memory, was coded as a 1 (memory problem), Section C 0900 Memory Recall Ability, was coded as a Z (none of the above was recalled), and Section C1000 Cognitive Skills for Daily Decision Making, was coded as a 2 (moderately impaired-decisions poor, cues/supervision required). Review of the MDS Section G Functional Status revealed under G0400 Functional Limitation in Range of Motion, assessment B Lower extremity was coded as a 3 (two plus persons physical assist). Section G0120 Bathing-Self Performance was coded as a 2 (impairment on both sides). G0600 Mobility Devices, Section C-wheelchair was coded as normally used. Review of the physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. A review of the nurses' notes dated April 2, 2016, at 1:09 p.m. revealed that Registered Nurse (RN) 1 was called to the 500 hallway for a resident on the floor. The notes stated, The resident was lying on her left side. The resident was unable to state what happened due to [DIAGNOSES REDACTED]. The alarm was not sounding. The resident was checked for injuries and none were noted. Hoyer lift (a mechanical device used to move residents who are unable to move themselves) was used to assist the resident to the wheelchair for close supervision. The resident was able to move all extremities without difficulty. The floor was dry. The hipsters were not on. The nursing note also revealed that the staff were educated on turning the alarms to on. The physician was called and an X-ray was ordered. The nurses' note dated April 2, 2016, at 6:09 p.m. revealed that the X-ray results were received at 4:00 p.m. and identified a pelvic fracture (a disruption of the bony structure of the pelvis). The physician was again contacted and he gave new orders for the resident to be transferred to the hospital for surgical evaluation. Review of the facility's investigation dated April 2, 2016, for the incident occurring on April 2, 2016, revealed that Nurse Aide (NA) 1 transferred the resident to her wheelchair after a shower, and applied the safety belt, but forgot to turn the alarm on, and did not apply a full set of hipsters as ordered. The resident subsequently fell and suffered a pelvic fracture. Review of NA 1's written statement dated April 4, 2016, revealed that she had given Resident 3 a shower and, after shower recall reattaching belt but forgot to push the on button. Replaced hipsters after shower only one hip pad in hipsters-did not ask nurse for another pad to correct. The facility suspended NA 1 on April 2, 2016, during the investigation, and reinstated the Nurse Aide on April 8, 2017, six days after the incident. NA 1 was given a ten day re-orientation with a preceptor and was provided education on abuse/neglect with competency and training on the use of electronic documentation devices to access resident care needs and care plan. An interview with the Director of Nursing on January 17, 2017, confirmed that NA 1 was hired on January 6, 2016. A review of the nurse aide orientation program check list revealed that the employee demonstrated competence in the importance of insuring resident and unit safety at all times, during her training period. Further review of NA 1's orientation program revealed she demonstrated competence in providing nursing care consistent with residents needs and following the plan of care, during her orientation time. An interview with the Director of Nursing on January 17, 2017, at 1:40 p.m. revealed that the facility expectation is that all alarms and safety equipment should be in place, and functioning, as ordered. The facility failed to ensure that the residents were protected from neglect resulting in a past non-compliance situation. The facility caused harm by failing to ensure that safety equipment was turned on (alarming seat belt) and were correctly applied (the hipsters) as ordered, resulting in the resident sustaining a pelvic fracture following a fall, being transferred to the hospital and requiring a surgical consult with an orthopedic physician. 28 Pa. Code 201.20(a) Staff development. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 10/6/16, 7/13/16, 4/19/16, 5/21/15. 28 Pa. Code 201.18(b)(3) Management. Previously cited 9/19/16, 7/13/16, 5/21/15. 28 Pa. Code 211.10(a) Resident care policies. Previously cited 4/19/16, 6/22/16. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 4/19/16, 5/21/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 10/6/16, 4/19/16, 6/22/16, 6/25/15, 5/21/15.

Based on review of policies and clinical records, observations and staff interviews, it was determined that the facility failed to complete assessments to ensure that the residents' environment was free from accident hazards from the use of side rails with any mattress for 120 of 120 residents with side rails reviewed. The facility also failed to ensure that the residents' environment remained free of accident hazards from the use of side rails in conjunction with a 5900 Air Mattress for seven of eight residents reviewed (Residents 1, 5, 6, 7, 8, 9, 10, and 11), placing the safety of the residents in Immediate Jeopardy, resulting in death for one resident (Resident 1). Findings include: Review of the policy for, Side Rail (a metal bar of various designs that can be elevated or lower on each side of the bed) Screening (instructions to the staff on the use of side rails) revealed that on admission and quarterly all residents would be screened for the use of side rails as an enabler (helping device) vs. restraint (a device used to prevent movement or confine). A side rail tool will be performed on admission and quarterly by nursing using the admission and/or quarterly data. If the side rail is deemed as a restraint, the Interdisciplinary Team (a group of different type care providers) will review. A consent form will be signed per the restraint policy (a required document to use a restraint). The Care Plan (a tool used to provide information as to how the resident is to be cared for) will be updated with approaches and desired outcomes. An interview with the Director of Nursing (DON) on October 5, 2016, at 9:30 a.m. revealed that the facility does not have a policy for the use of side rails with an air mattress or that an assessment was done for the safety of the residents when an air mattress and side rails are used, to prevent entrapment. Review of Resident 1's clinical record revealed medical [DIAGNOSES REDACTED]. Review of Resident 1's, Side Rail Screening done on September 8, 2016, the date the resident was admitted to the facility, revealed that side rails were to be used as an enabler. Review of the physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. The clinical record for Resident 1 revealed no evidence that an assessment for resident safety was done for the use of an air mattress with side rails. Review of Resident 1's Minimum Data Set assessment (MDS - an assessment tool utilized to evaluate physical, mental and psychosocial needs), dated September 15, 2016, revealed a BIMS (Brief Interview for Mental Status - a tool used to assess long and short term memory and the ability to understand) was a 12, indicating moderate cognitive impairment. Review of the MDS, Functional Status (ability to perform activities of daily living) revealed Resident 1's bed mobility (how a resident turns side to side and to and from a lying position) required extensive assistance by staff to complete the task and requires the physical assistance of two staff members for support to complete the task. Review of Resident 1's transfer status (how a resident moves between surface including to or from a bed, chair, wheelchair or standing position) revealed Resident 1's bed mobility (how a resident turns side to side and to and from a lying position) requires extensive assistance by staff to complete the task and requires the physical assistance of two staff members for support to complete the task. Review of an, Occurrence Report form (a form used by the facility to provide information on an event that occurred with a resident) dated October 3, 2016, at 1:00 p.m. written by License Practical Nurse (LPN) 1 stated, observed resident on floor aside of his bed, neck was inside rail, buttocks on the floor, legs outstretched in front of him, no respirations (breathing), no heartbeat, non-responsive, called supervisor and DON assessed and immediately removed resident from side rail and placed in bed. During an interview on October 4, 2016, at 3:05 p.m. with Registered Nurse (RN) 1, it was revealed that RN 1 was called to Resident 1's room at approximately 1:00 p.m. RN 1 revealed that a friend had come to visit and reported to the staff that someone in the room was on the floor. RN 1 indicated that Resident 1 was on the left side of the bed with his arms down and his legs out. The left side of his neck was hooked in the 1/2 side rail (bottom of side rail). His head was on the inside of bed rail and he was sitting on the floor. Resident 1's chin was on the inside of the bed rail and it was hyperextended (stretched). The nurse aides came in to assist. RN 1 assessed for a pulse (heart beat), and she stated that the resident was obviously dead. The DON came in and assessed. The resident's head could not be moved. The bed was tilted and the mattress pulled out to relieve some pressure. Then the resident's body was pulled out. During an interview on October 4, 2016, at 3:18 p.m. with Licensed Practical Nurse (LPN) 1, it was revealed that LPN 1 was made aware by a visitor that there was someone in the room on the floor. LPN 1 stated that she went down to the room and found that Resident 1 was laying on the floor from his butt (buttock) to legs. The resident's neck was in the side rail. Resident 1 was on the left side of the bed closest to the door. His butt was on the floor, his legs were out stretched in front. The 1/2 bed side rail was up, the resident's chin was on the inside of the lower part of the bed side rail, his neck was hyperextended and his body weight was hanging on his neck. LPN 1 touched Resident 1 and he was cold and clammy (moist) with no pulse (heart beat) and no breaths. The other side of the bed had to be lifted and the mattress lifted to pull him out. Resident 1's neck was between the mattress and the bed rail. His chin was inside rail. An interview with the Director of Nursing (DON) on October 5, 2016, at 9:30 a.m. revealed that Resident 1's bed had to be lifted off the floor from the left side in order to get Resident 1's chin from within the lower end of the side rail and the mattress During a second interview with RN 1 on October 5, 2016, at 12:10 p.m. RN 1 stated that the head of Resident 1's bed was raised at a 45 degree angle or a tad (small amount) less. During an interview with the Director of Nursing on October 5, 2016, at 12:10 p.m. she stated, when asked if anyone does any measurements when side rails are used with an air mattress or any mattress, the response was, I don't know maintenance usually puts the mattress on. During an interview with the Director of Environmental Services on October 5, 2016, at 12:25 p.m. it was revealed that no safety measurements are done with side rails and mattresses to prevent entrapment. During an observation on October 5, 2016, at 2:15 p.m. with the Nursing Home Administrator (NHA) and the Director of Environmental Services in the room of Resident 1, a measurement was done on Resident 1's bed by the Director of Environmental Services. With Director of Environmental Services sitting on the left side of the bed next to the lower end of the left 1/2 side rail and with the head of the bed elevated approximately 45 degrees, it was discovered that there was a measured gap between the inside edge of the side rail across to the mattress of 2 and 3/4 inches. The Director of Environmental Services stated he weighed approximately 150 pounds and the weight of Resident 1 documented in the clinical record was 145 pounds. Review of the Food and Drug Administration (FDA) Guidance document titled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment date March 10, 2006, revealed Zone (location of the side rail) 4 (under the rail, at the ends of the rail) the space is the gap that forms between the mattress compressed by the patient, and the lower most portion of the rail (side rail). The space pose a risk for entrapment of a patients' neck. It may change with different rail height positions and as the head or foot sections of the bed are raised and lowered. The FDA recommendation is a dimension of less than 2 and 3/8 inches dimensional limit for this space to reduce the risk of neck entrapment. The 1/2 side rails that were used on Resident 1's bed were rectangular in shape. The facility failed to assess the safety of using a 1/2 side rail with an air mattress, for Resident 1 resulting in Resident 1's neck becoming entrapped with his chin inside the lower end of a 1/2 side rail and his neck between the mattress and the side rail resulting in the resident being found, by staff, dead. The facility also failed to provide any evidence that a safety assessment for using 1/2 side rails with any type of mattress was completed on 120 of 120 residents with side rails reviewed as disclosed by an interview with the Director of Environmental Services and the DON. On October 5, 2016, at 1:40 p.m. the NHA was notified that the facility was in an Immediate Jeopardy (IJ) status related to failing to provide the residents with an environment that was free of hazard related to the use of side rails. The NHA was informed that they must submit a corrective action plan for approval immediately. On October 5, 2016, at 4:06 p.m. the corrective plan of action was presented by the facility which provided details of how the IJ was to be corrected including a complete sweep of all residents with specialty mattresses with side rails, if side rails required safety measures to prevent entrapment, staff education on side rail use with specialty mattresses and to measure for entrapment, re-evaluate current residents with side rails and the need for usage, provide residents and their responsible party education on the risks and benefits of side rails. Maintenance was to be educated on the process for measuring the zone gap to ensure safety of the residents and that the gap does not exceed 2 and 3/8 inches between the lower end of the side rail and the mattress. New admissions and readmissions will be evaluated for side rail usage. Side rail evaluations will be done quarterly, and audit survey will be completed and reviewed by the Quality Assurance Committee monthly. On October 5, 2016, at 4:10 p.m. the NHA was notified that the corrective action plan was accepted. On October 6, 2016, at 9:00 a.m. audits, education and documented results of interventions were reviewed and a tour of the facility with the NHA was completed to ensure that the interventions were done. Staff were interviewed to determine if they received education. On October 6, 2016, at 3:30 p.m., the NHA was notified that the IJ was lifted after observations and interviews and review of the documentation that the interventions were implemented. On October 6, 2016, at 3:30 p.m. the NHA was notified that the IJ was lifted. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 7/13/16, 4/19/16, 6/25/15, 5/21/15 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited 7/13/16, 4/19/16, 5/21/15 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 6/22/16, 4/19/16, 6/25/15, 5/21/15