Every finding on record at Oakwood Healthcare & Rehabilitation Center

Based on review of facility policy, review of clinical records, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to protect one resident from physical abuse for one of two resident incidents reviewed (Resident R2). This deficiency was identified as past non-compliance.Findings include: Review of undated facility policy titled, Abuse, Neglect and Mistreatment of Residents, revealed that each resident has the right to be free from mistreatment, neglect, and misappropriation of property. No one may subject residents to abuse including but not limited to facility staff, other residents, consultants, volunteers, staff of other agencies servicing the resident, family members, or legal guardians, friends or other individuals. Review of Resident R2's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of cerebrovascular accident (stroke - damage to the brain from interruption of its blood supply) and hemiplegia (one-sided paralysis). Review of Resident R2's Quarterly MDS (minimum data set - a comprehensive resident assessment) dated June 1, 2026, revealed that the resident was totally dependent for toileting, bathing, hygiene and lower body dressing (helper does all of the effort; resident does none of the effort to complete the activity). Review of facility documentation submitted to the state survey agency revealed on August 3, 2026, at approximately 10:30 a.m. nurse aide, Employee E19, self-reported to the Nursing Home Administrator, Employee E1, that he hit Resident R2 in the chest while providing care after Resident R2 became combative and made a racial slur. The incident occurred in Resident R2's room and was witnessed by three other staff members who were present in the room at the time of the incident: Nurse aide, Employee E22, Licensed Nurse, Employee E20, and Licensed Nurse, Employee E21. Review of statement by nurse aide, Employee E19, dated August 3, 2026, revealed that while providing care to Resident R2, the resident became aggressive, combative, and verbally aggressive. Nurse aide, Employee E19, reported that Resident R2 hit him and made a racial slur, so in response Nurse Aide, Employee E19, punched Resident R2 in the chest. Review of statement by nurse aide, Employee E22, dated August 4, 2026, revealed that he witnessed staff member, Employee E19, strike Resident R2. Nurse aide, Employee E22, reported that he and a coworker immediately intervened by verbally directing nurse aide, Employee E19, to stop and moving toward the resident to prevent any further harm. Nurse aide, Employee E22, reported that despite efforts, staff were unable to prevent the initial strike from occurring. Review of statement by licensed nurse, Employee E20, revealed on August 3, 2026, at approximately 9:45 a.m. during wound care, two nurse aides were assisting Resident R2 with personal care when the resident began yelling at Employee E19 calling him a racial slur. Per the statement, Employee E19 punched Resident R2 on the left side (flank region) while stating, Say that again, one more time, repeatedly. Licensed nurse, Employee E20, immediately intervened, instructed Employee E19 to leave the room, and positioned herself between Employee E19 and Resident R2. As Employee E19 was leaving the room, Resident R2 repeated the racial slur. Licensed nurse, Employee E20, continued to direct Employee E19 out of the room verbally and physically to prevent further physical contact. Resident R2 did not seem upset, and was asked if he/she was ok, to which Resident R2 responded being fine. Resident R2 denied any pain but was assessed with slight redness under his/her contracted arm on the left side. Employee E19 walked down the hall toward the Administrators office and licensed nurse, Employee E20, followed to ensure there were no other interactions. Review of statement by licensed nurse, Employee E21, revealed on August 3, 2026, 9:45 a.m. she was on orientation with the wound nurse [Employee E20] in Resident R2's room, with two nurse aides who were providing care for Resident R2. Resident R2 suddenly became very aggressive and verbally abusive using harsh words and insults. Employee E19 became upset and hit Resident R2 in the left side while saying, If you say that again I'll punch you!. Licensed nurse, Employee E21, reported it all happened so fast we could not get to him in time. The wound nurse [Employee E20] positioned herself between Employee E19 and Resident R2 and asked him to calm down. Before leaving the room Employee E19 punched the closet door and left the room alongside the wound nurse. Resident R2 was changed and the bed put into the low position. Interview with Resident R1 on August 20, 2026, at 10:25 a.m. revealed that he/she remembered the incident, but did not want to talk about it, as the resident was having trouble talking with the trach and ventilator and was frustrated with the equipment and condition. Interview with Resident R5 on August 11, 2026, at 12:30 p.m. confirmed that the incident had happened and that while the resident feels safe at the facility, he/she still thinks about the incident. Interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on August 20, 2026, at 1:15 p.m. confirmed that Employee E19 admitted to striking Resident R2 on August 3, 2026, while providing care. They also confirmed that the three eyewitnesses who were also in the room all saw Employee E19 strike Resident R2, and that they also interviewed Resident R2 who said that Employee E19 had struck him after he had called him a bad name. The NHA and DON confirmed that they had put an action plan into place according to their abuse procedure. Employee E19 was suspended pending the outcome of the investigation after giving his statement on August 3, 2026. Resident R2 was immediately assessed by a licensed nurse, and the physician were notified on August 3, 2026, at 10:45 a.m. A chest x-ray was ordered and obtained on August 3, 2026. Physician, who was in the facility, assessed the resident. Law enforcement and the Pennsylvania Department of Health were notified on August 3, 2026. Social Services visited the resident on August 3, 2026, and will visit him daily until August 7, 2026, and then weekly as needed. The resident is being monitored for pain and bruising. A psychiatric consult was obtained on August 4, 2026, and will monitor the resident over the next few weeks. Employee E19 was terminated on August 5, 2026, following completion of the investigation. The Local Area Agency on Aging was notified on August 4, 2026. Resident R2's care plan was reviewed and updated on August 3, 2026, to address behavioral approach and staff response during care. Resident's able to be interviewed were completed on August 3, 2026, no additional allegations identified; all other residents on Employee E19's assignment were given skin checks with no new bruising identified. Facility-wide re-education on abuse prevention, recognition and reporting, and management of residents began on August 4, 2026, with expected completion on August 7, 2026, with a sign-in roster maintained. NHA and DON will conduct random resident interviews weekly x 4 weeks, then monthly x2 months with results reported to the QAPI (Quality Assurance and Performance Improvement) Committee. The incidents and corrective actions will be referred to the QAPI Committee. A review of facility documentation revealed that education was completed, and an interview with NHA revealed that the facility reached 92% of staff educated on August 7, 2026. A review of facility documentation revealed that initial interviews and skin checks were completed on August 3, 2026. A review of facility documentation revealed that above audits were completed as planned for the past three weeks, and all agencies were notified as required. Review of Resident R2's medical record reveals that physician and family guardian were notified of the incident and car plan was updated on August 3, 2026. Review of Employee E19's records revealed he had all preemployment screenings and was up to date with abuse training, and that he was terminated on August 5, 2026, at the end of the investigation. This deficiency was identified as past non-compliance. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 201.18 (b)(3) Management. 28 Pa. Code 201.29 (c) Resident rights 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (c) Nursing services.

Based on review of food safety standards, observations, and staff interview it was determined that the facility failed to ensure beverages were stored in accordance with standards for food service safety.Findings Include: Review of Refrigeration & Food Safety guidelines by the United States Department of Agriculture (USDA), Food Safety and Inspection Service, revealed cold food should be kept at or below 40 degrees Fahrenheit (F). Further review of guidelines by the USDA revealed the danger zone is defined as temperatures between 40 and 140 degrees F where bacteria grow most rapidly. A tour of the main kitchen conducted on May 4, 2026, at 9:30 a.m. with the Food Service Director, Employee E11, and District Manager, Employee E12, revealed the following: Observations of the milk cooler revealed the gasket (a sealing component used to keep the milk at correct temperatures by maintaining an airtight seal between the cooler's body and its lid) was broken and needed to be replaced. Observations inside the milk cooler revealed it was fully stocked with a fresh delivery of individual milk cartons that was reportedly delivered at approximately 8:00 a.m. The thermometer inside the milk box was broken and therefore the temperature of the milk cooler was unable to be determined. Subsequently, District Manager, Employee E12, checked the temperature of two individual milk cartons (one pulled from the top and the other from the bottom), both reading 50 degrees Fahrenheit. 28 Pa. Code 201.14 (a) Responsibility of Licensee

Based on observation and staff interview, the facility failed to ensure medications were stored according to required temperature ranges and failed to maintain refrigeration equipment in a sanitary and operational condition.Findings Included: Review of Medication Room Temperature Log states, temperature are to remain between 36-41 degrees. Defrost freezer monthly on the fifteenth. Observation conducted on May 4, 2026, at 10:30 am, with Nurse Manager, Employee E4 of Medication Room Refrigerator revealed two out of three days the refrigerator temperature exceeded the acceptable range of 36-41 degrees. The facility failed to notify maintenance of the temperature variance and failed to remove or quarantine medications exposed to out of range temperatures. On Monday May 4, 2026, at 10:30 am, with Nurse Manager, Employee E4 observation of Medication Room Refrigerator revealed approximately five inches of ice accumulation in the freezer compartment. The facility failed to notify maintenance of excessive ice buildup and failed to defrost the refrigerator. 28 Pa. Code 201.18(b)(1) Management

Based on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement Enhanced Barrier Precautions for one of two residents reviewed who had a tracheostomy, feeding tube, and an indwelling urinary Foley catheter (Resident R2).Findings include:Review of facility policy and procedure titled Enhanced Barrier Precaution (EBP) revealed All applicable employee to adhere to Enhanced Barrier Precautions, per guidelines. Under Process: A physician order for enhanced barrier precautions is entered in the EHR. The order will contain the a reason for the EBP. EBP will be Care Planned and tasked out to the Care Kardex. An Enhanced Barrier Precautions sign will be posted on the door/outside of the room, of Residents that required Enhanced Barrier Precautions. A red Dot (Sticker) will be placed on the affected Resident's door tag to indicate which Resident requires Enhanced Barrier Precautions. The Unit Manger is responsible for: Updating and completion of the Enhanced Barrier Precautions log, Providing the IP or designee an updated EBP log weekly, Enhanced Barrier Precautions signage on the door, A red Dot (Sticker)placed on the affected Resident's door tag. Unit round audits checking for: Proper Signage/Dots, Staff adherence to precautions. A review of Resident R2's clinical record revealed an admission date of January 23, 2026, with diagnoses including chronic respiratory failure with hypoxia, epilepsy, tracheostomy (surgically created opening in the neck into trachea to assist with breathing) , dysphagia (difficulty swallowing). A review of physician orders revealed an order dated January 24, 2026, for a suction tracheostomy, change trach ties every shift. Maintain transmission Based Precautions: Enhance Barrier Precautions due to: trach, foley, peg tube, history ESBL (urine). On May 4, 2026, at 11:30 a.m., an observation conducted with Licensed Nurse, Employee E3, revealed a sign posted outside Resident R2's room stating, Enhanced Barrier, which indicated that anyone providing direct care was required to wear a gown and gloves when touching the resident. Employee E11 was asked to assist certified nursing assistants (CNAs), Employees E10 and E6, with transferring Resident R2 from the bed to a wheelchair. During the transfer, Employees E11, E10, and E6 wore gloves only and did not wear gowns as required. Both CNAs transferred resident using a Hoyer lift, while Licensed Nurse Employee E11 assisted with the tracheostomy, oxygen, and feeding tube during the transfer. Employee E11 also unhooked the trach and disconnected the feeding tube to facilitate the transfer. On May 6, 2026, at 9:07 a.m., an observation of a licensed nurse, Employee E5, who was providing tracheostomy care to Resident R2, revealed that she was not wearing an appropriate PPE gown. The Unit Manager, Employee E4, confirmed that Licensed Nurse E5 was not wearing PPE while providing tracheostomy care. On May 6, 2026, at 2:47 p.m. Director of Nursing confirmed that that Employee E5 was not wearing appropriate PPE when providing tracheostomy care to Resident R2. 28 Pa. Code 211.10 (d) Resident care policies 28 Pa. Code 211.12 (d)(5) Nursing services

Based on review of clinical records, observations and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for one of two sampled residents (Residents R2).Findings include:A review of Resident R2's clinical record revealed an admission date of January 23, 2026, with diagnoses including chronic respiratory failure with hypoxia, epilepsy, tracheostomy (surgically created opening in the neck into trachea to assist with breathing), dysphagia (difficulty swallowing). A physician's order dated January 23, 2026, revealed, Administer oxygen at 5 liters per min via trach continuously. A comprehensive care plan, last revised on January 26, 2026, revealed, oxygen as ordered via trach mask. On May 4, 2026, at 11:24 a.m., an observation was conducted with Licensed Nurse, Employee E3, who confirmed that Resident R2's oxygen was set at 1.5 liters, which was inconsistent with the physician's order. On May 5, 2026, at 2:0 p.m., an observation was conducted with the Unit Manager, Employee E4, who confirmed that Resident R2's oxygen was set at 4 liter, which was also inconsistent with the physician's order of 5 liters continuously. 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on a review of clinical records, and interviews with residents, family members, and staff, it was determined that the facility failed to provide the necessary assistance with activities of daily living (ADLs) to maintain proper grooming for five of the five residents reviewed (Residents R24, R53, R33, R93, R433) Findings: Review of Resident 24's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of muscle wasting and atrophy, heart failure, need for assistance with personal care, other abnormalities of gait and mobility, disorder of muscle, adult failure to thrive, difficulty in walking, muscle weakness. A review of Resident R24's annual Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 14, reflecting cognitive intact. The functional abilities section of the MDS indicated that Resident R24 requires partial/moderate assistance with toileting hygiene tasks. An interview conducted on June 2, 2025, at 12:35 p.m. revealed that Resident R24 reported pressing the call bell at 2:00 a.m. during the previous night shift due to being wet with urine and needing a brief change. However, the resident was not changed until 5:00 a.m. Resident R24 stated that she reported the incident to the current morning charge nurse, Employee E6, who advised her that she would notify the Director of Nursing, Employee E2 Review of Resident 93's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis Parkinson's disease, muscle wasting and atrophy right and left ankle and foot, lack of coordination, dementia (memory loss) , difficulty in walking. A review of Resident R93's quarterly Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 8, indicating the resident is moderately cognitively impaired. The functional abilities section of the MDS indicated that Resident R93 partial/moderate assistance with toileting hygiene tasks. On June 2, 2025, at 12:45 p.m. an observation of Resident R93 was conducted revealing facial hair on the chin. License nurse, Employee E4 confirmed the observations. Review of Resident 33's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of dementia, muscle weakness, muscle wasting and atrophy, contracture right hand, disorder of muscle, difficulty in walking. A review of Resident R33's annual Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident is severely cognitively impaired. The functional abilities section of the MDS indicated that Resident R33 dependent with toileting, hygiene tasks. A comprehensive care plan dated March 21, 2023, revealed routine nail care and as needed. On June 2, 2025, at 12:50 p.m. an observation was conducted of Resident R33 revealing long nails. Director of Nursing confirmed the observations and reported that staff will attempt to cut it. Resident R33 is nonverbal. A telephone interview with the family, conducted on June 2, 2025, at 1:32 p.m., revealed that the family desires for Resident R33 to have her nails kept short. Review of Resident 53's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of dementia, muscle wasting. On May 1, 2025, Resident R53 was diagnosed with a fracture of the distal end of the right radius, with unspecified fracture morphology, and was provided with an arm sling for healing. A review of Resident R53's quarterly Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 4, indicating the resident is severely cognitively impaired. The functional abilities section of the MDS indicated that Resident R53 requires setup or clean-up assistance with toileting, hygiene tasks. An interview conducted on June 2, 2025, at 1:12 p.m. revealed that Resident R53 had long nails and was wearing an arm sling for her right fracture. Resident R53 wanted them to be cut. License Nurse, Employee E6 confirmed the observation. Review of Resident 433's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of adult failure to thrive, muscle wasting and atrophy, acquired absence of left leg above knee, and muscle spasm. A review of Resident R433's admission Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 15, reflecting cognitive intact. The functional abilities section of the MDS indicated that Resident R433 requires substantial/maximal assistance with toileting hygiene tasks. On June 4, 2025, at 10:30 a.m., a resident council meeting was held with 12 alert and oriented residents (R7, R112, R104, R84, R26, R113, R56, R35, R87, R82, R68, R97). The residents reported that, on many occasions, nursing aides would turn off call bells without providing assistance, stating, I'm not your aide. They also noted that call bell response is worst during the shift change between 2:00 p.m. and 4:00 p.m., as well as during the evening shift from 3:00 p.m. to 11:00 p.m. On June 5, 2025, at 10:35 a.m., a family interview was conducted for Resident R433. The interview revealed that earlier that morning, Resident R433 had been sitting in urine for approximately two hours while eating her breakfast. She was not changed until the nursing aides finished collecting breakfast trays. This concern was communicated to the unit manager, employee E5 who apologized. On June 5, 2025, at 10:40 a.m., an interview was conducted with Resident R433, who reported that she pressed the call bell between 7:00 a.m. and 7:30 a.m. because she was wet with urine and needed a change. A nursing aide responded to the call bell but stated that it was breakfast time, and she needed to finish passing trays. Resident R433 expressed frustration, as she had to eat breakfast while sitting in urine. At approximately 8:30 a.m., Resident R433 pressed the call bell. A nursing aide entered the room and stated that she was not sure if Resident R433 was on her assignment and then turned off the call bell. At 8:50 a.m., the same nursing aide returned, confirmed that Resident R433 was on her assignment, and proceeded to provide care. On June 5, 2025, at 10:50 a.m., an interview with the unit manager, Employee E4, confirmed that she was aware of the situation involving Resident R433. 28 Pa. Code 211.10 (d) Resident care policies 28 Pa code 211.12.(d)(1)(5) Nursing services

Based on review of facility policy, review of clinical records, and interview with staff, it was determined that the facility failed to implement non-pharmacological interventions in accordance with professional standards for one of 26 residents reviewed (Resident R120). Findings include: Review of facility policy Pain Evaluation and Management Policy, revised December 12, 2020, revealed that The comprehensive pain evaluation is reviewed by the nurse and the physician, and interventions are implemented as appropriate. Care plans will be developed to include both pharmacologic and non- pharmacologic interventions. Care plans will be reviewed and revised as new interventions are needed. Review of Resident R120's clinical record revealed the resident was admitted to the facility on [DATE], and had diagnoses including fracture of left femur(left hip fracture) with orthopedic aftercare. Review of Resident R120's care plan revised May 2, 2025, revealed the resident was at risk for pain related to the diagnosis of left femur fracture. The care plan did not include any non-pharmacological interventions. Review of physician orders for Resident R120 dated April 29, 2025, revealed an order for Oxycodone(opioid pain medication) 5 mg every 4 hours as needed for severe pain. Review of clinical record for Resident R120 revealed no documented evidence that the resident was offered or received non-pharmacological interventions. Review of Medication Administration Record for Resident R120 revealed that Resident R120 received 39 doses of oxycodone in May 2025. Review of Medication Administration Record for Resident R120 revealed that Resident R120 received 3 doses of oxycodone from June 2 to June 4. Interview with Director of Nursing, Employee E2, on June 5, 2025, at 11:00 a.m. confirmed that Resident R120 was not receiving any non-pharmacological interventions and stated staff should attempt non-pharmacological interventions prior to administering pharmacological interventions. 28 Pa Code 211.12(d)(3)(5) Nursing services

Based on clinical record review and interview with staff, it was determined that the facility did not ensure that care plans were revised in a timely manner related to fall interventions for one of three records reviewed for falls. (Resident R5). Findings include: Review of facility policy, Care Plans, Comprehensive Person Centered, revised March 2022, indicated that care plans are revised as information about the resident's change. Review of clinical documentation revealed that Resident R5 was readmitted to the facility on [DATE], had diagnoses including, but not limited to, muscle wasting, difficulty walking and atrophy, and muscle weakness. Review of Progress Note dated, October 15, 2024, revealed Resident R5 had an unwitnessed fall and was observed sitting on the floor next to her bed. Further review revealed that on October 16, 2024, Resident R5 complained of right femur pain post fall yesterday. On October 17, 2024, Resident R5 was admitted to the hospital with diagnosis of right femur fracture. Review of Resident R5's current Care Plan revealed that Fall care plan was initiated on December 27, 2025; and interventions including, assisting resident out of bed and monitoring for toilet needs were dated to be initiated on January 9, 2025. Interview with the Director of Nursing conducted on June 4, 2025, at 1:51 p.m. confirmed that the residents care plan had not been updated timely post fall. 28 Pa. Code 211.10 (d) Resident care policies 28 Pa. Code 211.12 (d)(5) Nursing services

Based on review of facility policy and procedures, observations, and staff interviews, it was determined that the facility failed to follow acceptable infection control practices related to the use of appropriate personal protective equipment for one of three nursing units on transmission-based isolation precautions. (B unit) Findings include: Review of a undated facility policy titled Managing Residents with COVID-19, revealed 1. Use of standard and transmission-based precautions for COVID-19, per current guidelines, with appropriate PPE use and signage. 2. Place in a single-person room when able. 3. If single-room quarantine is unavailable due to limited single rooms or multiple residents are identified as COVID-19 positive, resident~ positive for COVID-19 will be cohorted. 5. Restrict the resident to their room when[ possible. 6. Provide the resident with a surgical mask if they need to leave their room. 7. Restrict residents to medically necessary outings during the isolation period Review of CDC guidelines for COVID-19 revealed that Residents placed in Transmission-Based Precautions for acute respiratory infection should primarily remain in their rooms except for medically necessary purposes. If they must leave their room, they should practice physical distancing and wear a facemask for source control. HCP who enter the room of a resident with signs or symptoms of an unknown respiratory viral infection that is consistent with SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Review of an isolation precaution sign placed outside Resident R120 room revealed instruction to wear N-95 masks, goggles/eye wear, and gowns. Observation of the B nursing unit on June 4, 2025, at 10:33 a.m. revealed that Employee E5, Nurse Aide, was transporting Resident R120 in the hallway towards the shower room. The aide was not wearing a gown or eye protection. Resident R120 did not wear facemask. Continued observation revealed that the aide took the resident back to the room. The aide was helping the resident inside the room without wearing a gown or eye protection. Interview with the Unit Manager, Employee E6 on June 4, 2025, at 10:40 a.m. confirmed that the resident was on respiratory isolation precaution and all staff should wear N-95 masks, goggles/eye wear, and gowns when entering resident room or providing care. Employee E6 stated when residents on respiratory isolation goes outside the room, they should wear N-95 mask. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility did not ensure that all allegations of abuse and neglect were reported immediately to the Pennsylvania Department of Health for two of 26 residents reviewed. (Resident R24, R433) Findings Include: A review of the facility policy titled Oakwood Health and Rehabilitation Center Policy and Procedure, revised September 2023, revealed the following under Section #6, Investigating and Reporting: Once an allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator of Nursing immediately and initiate gathering the requested information. An investigation must be directed by the Administrator or designee immediately. Review of Resident 24's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of muscle wasting and atrophy, heart failure, need for assistance with personal care, other abnormalities of gait and mobility, disorder of muscle, adult failure to thrive, difficulty in walking, muscle weakness. A review of Resident R24's annual Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 14, reflecting cognitive intact. The functional abilities section of the MDS indicated that Resident R24 requires partial/moderate assistance with toileting hygiene tasks. An interview conducted on June 2, 2025, at 12:35 p.m. revealed that Resident R24 reported pressing the call bell at 2:00 a.m. during the previous night shift due to being wet with urine and needing a brief change. However, the resident was not changed until 5:00 a.m. Resident R24 stated that she reported the incident to the current morning charge nurse, Employee E6, who advised her that she would notify the Director of Nursing, Employee E2. On June 2, 2025, at 2:45 p.m., the surveyor informed the Director of Nursing, Employee E2, that Resident R24 had made an allegation of neglect, which had been reported to Employee E6. Employee E2 stated she was not aware of the allegation and would begin an immediate investigation. It was confirmed that the charge nurse, Employee E6, did not report the allegation of neglect to the Director of Nursing. Review of Resident 433's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of adult failure to thrive, muscle wasting and atrophy, acquired absence of left leg above knee, and muscle spasm. A review of Resident R433's admission Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 15, reflecting cognitive intact. The functional abilities section of the MDS indicated that Resident R433 requires substantial/maximal assistance with toileting hygiene tasks. On June 5, 2025, at 10:35 a.m., a family interview was conducted for Resident R433. The interview revealed that when concerns are brought to the charge nurses, they remain at the nursing level and are not communicated to the administration. Earlier that morning, Resident R433 had been sitting in urine for approximately two hours while eating breakfast. She was not changed until the nursing aides had finished collecting breakfast trays. This concern was communicated to the Unit Manager, Employee E5, who apologized. On June 5, 2025, at 10:40 a.m., an interview was conducted with Resident R433, who reported that she pressed the call bell between 7:00 a.m. and 7:30 a.m. because she was wet with urine and needed a change. A nursing aide responded to the call bell but stated that it was breakfast time, and she needed to finish passing trays. Resident R433 expressed frustration, as she had to eat breakfast while sitting in urine. On June 5, 2025, at 10:50 a.m., an interview was conducted with the Unit Manager, Employee E5. She reported that she was aware of the allegation of neglect involving Resident R433 but did not report it to the Director of Nursing. On June 5, 2025, at 11:10 a.m., an interview with the charge nurse, Employee E6, revealed that she was aware of the allegation of neglect reported by Resident R24 and understood it needed to be reported within two hours. However, she failed to report it to the Director of Nursing due to the presence of surveyors on-site. 28 Pa. Code: 201.14(a)(c) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management.

Based on review of clinical record reviews and interviews with staff, it was determined that the facility failed to follow the physician orders related to medication administration for one of 26 residents reviewed (Residents R433). Findings include: Review of Resident 433's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of adult failure to thrive, muscle wasting and atrophy, acquired absence of left leg above knee, and muscle spasm. A review of Resident R433's admission Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 15, reflecting cognitive intact. A review of the clinical progress notes indicated a progress physician note dated on May 16, 2025 indicated resident admitted to the facility. She is alert and oriented. All medication were reviewd and verified with physician, [Employee E3]. Review of hospital's physician orders indicated that Resident R433 was prescribed Insulin Aspart Flex Pen 100 unit/ml Sopn inject 15-18 units under the skin in the morning and 15-18 units at noon and 15-18 units in the evening. Inject before meal take 15 u with breakfast and 18 units with lunch and dinner. Last time this was given: May 16, 2025, at 9:01 a.m. Sliding scale 200-250 =2 units, 251-300= 4 units, 301-350= 6 units, 351-400=8 units, call MD if BS<60 or >400 upon discharge on [DATE]. On June 5, 2025, at 10:50 a.m., an interview was conducted with the Unit Manager, Employee E5, who confirmed that the Medication Administration Record (MAR) for May 2025 did not reflect that the sliding scale insulin order from the physician was created or administered until May 21, 2025. A review of the progress notes showed no changes in the insulin orders by the facility's physician. The sliding scale insulin order should have been created and administered upon the resident's admission to the facility on May 16, 2025, as indicated in the hospital discharge documentation. On June 5, 2025, at 11:30 a.m., an interview with the Director of Nursing confirmed that the facility failed to follow the physician's order to administer insulin based on a sliding scale. The facility did not have a sliding scale insulin order in place until May 21, 2025. 28 Pa Code 211.12(d)(5) Nursing services

Based on clinical record review, facility policy, and staff interview, it was determined that the facility failed to ensure complete and accurate medication administration for one of 9 residents reviewed (Resident CR1). Findings include: The Facility Policy titled Administering Medication revised on [DATE], revealed Mediations are administered in a safe and timely manner, and as prescribed. It further under policy interpretation and implementation 23. states As required or indicated for a medication, the individual administering the medication records in the resident's medication record. A. the date and time the medication was administered, b. the dosage, c. the route of administration, d. the injection site (if applicable), e. any complaint or symptoms for which the drug was administered, f. any results achieved and when those results were observed, and g. the signature and title of the person administering the drug. Clinical record review revealed the facility admitted Resident CR1 on [DATE], and expired on [DATE]. Resident CR1 had the following diagnosis of sequelae of cerebral infarction ( complications from a stroke), Parkinson's disease without dyskinesia without mention of fluctuations, dementia with other behavioral disturbance. Review of Resident CR1's physician orders revealed that the order for Acetaminophen Table 500 milligrams give 1 table by mouth every 4 hours as needed for Temp >100 Fahrenheit. A clinical progress note documented on [DATE], by the license nurse, Employee E6 revealed that Resident CL1 received in bed awake alert . resident temp is 100.3 Tylenol was given with cold compress, fever decrease to 99.1. [Medical Physician, Employee E7] was in the facility new order given for chest X-ray, call placed stat (immediate) with claim number Start Levaquin 500 mg one time a day for 7 days for infections no adverse reaction. Review of the Medication Administration for [DATE] did not show any medication administration of the Acetaminophen Table 500 as it stated per the progress note. On [DATE], at 12:27 p.m. an interview with the license nurse, Employee E6 reveled that she did provide the Acetaminophen (Tylenol); however, did not document in the medication administration record. On [DATE], at 2:47 p.m., an interview with the Director of Nursing, Employee E2, confirmed that licensed nurse, Employee E6, did not document the complete and accurate administration of Acetaminophen. 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of staffing schedules, facility documentation, and staff interview, it was determined that the facility failed to ensure sufficient nursing staff to assure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being for 3 of 26 residents reviewed (Residents R78, R100, R32). Findings include: A review of the clinical record revealed Resident 78 was admitted to the facility on [DATE]. Review of Quarterly Minimum Data Set (MDS-a periodic assessment of care needs) dated August 222, 2024, indicated that the Brief Interview for Mental Status (BIMS) score of 14-cognition intact On August 26, 2024, at 10:40 a.m., an interview was conducted with Resident R78, who expressed feeling very upset and began crying. Resident R78 stated, They don't answer the call bell and make me wait for an hour to be changed. The last time I was changed was at 6:00 a.m. this morning. The surveyor asked her to press the call bell, but it was not functioning, as the indicator light did not turn on. The surveyor then approached licensed nurse, Employee E4, who was distributing medications outside the door. Employee E4 confirmed that the call bell was indeed not working. When asked if the resident had received her morning care, Employee E4 responded, No, explaining that they were short-staffed. The A wing has 44 residents, but only three nursing assistants and two nurses to cover the area. Some residents require the assistance of two staff members or the use of lifts. Employee E4 further confirmed that Resident R78, who is incontinent, was wet and required assistance with Activities of Daily Living (ADL). On August 26, 2024, at 12:15 p.m., observations were made in the main dining room, where approximately 10-12 residents were seated, waiting for lunch to be served. No staff members were present in the dining room at that time. At 12:29 p.m., the regional RN, Employee E25, was interviewed regarding supervision requirements in the dining area inthe company of the Assistance Nursing Home Administrator, Employee E1. It was reported that activity staff member or nursing personnel should always be present to oversee the dining room. The Assistance Nursing Home Administrator further stated that the Director of Nursing's (DON) office and the Administrator's office are located outside of the dining hall, allowing them to help if necessary. Review of the admission record indicated Resident R100 was admitted to the facility on [DATE]. Review of Quarterly Minimum Data Set (MDS-a periodic assessment of care needs) dated August 20, 2024, indicated that the Brief Interview for Mental Status (BIMS) score of 15-cognition intact. On August 26, 2024, at 1:45 p.m., an interview was conducted with Resident R100, who reported receiving care at 5:30 a.m. that morning. He stated that he is typically placed in his wheelchair by 10:30 a.m. or 11:00 a.m., but on this day, Resident R100 was still in bed because no one had come to assist him into his wheelchair. Resident R100 pressed the call bell, and a nursing aide, Employee E25, responded. Employee E25 confirmed that they were behind schedule due to staffing shortages, noting that there were 44 residents and only three nursing aides. She also mentioned that she was responsible for 15 residents that day and give four showers. An assignment sheet was provided as evidence, confirming that Employee E25 was assigned to residents in rooms A6-1, A8-1, A8-2, A9-1, A9-2, A10-1, A10-2, A11-1, A11-2, A12-A, A12-2, A13-1, A13-2, A15-1, and A15-2. An interview was held with the Resident R32 on August 26, 2024, at 1:57 p.m. that she unable to hear and reported also it's been months for me to get cataract surgery. I had an appointment but did not go because there was no one who could go with me. On August 26, 2024, at 2:03 p.m. a nursing assistant, Employee E7 was interviewed and reported that she was assigned to 14 residents and was behind on providing care. On August 27, 2024, at approximately 8:00 a.m., there were no staff members present on the A wing when the surveyor approached the nursing station. All the nursing aides (Employee E7, and E21) assigned to the unit were observed having breakfast. When the surveyor inquired why the residents had not yet received their morning care, a licensed nurse Employee E15 responded that she had not yet completed the assignment sheet to allocate specific room coverage to the nursing aides. On August 27, 2024, at 10:36 a.m. a resident group meeting was held with nine alert and oriented residents ( R75. R115, R83, R83, 51, R55, R34, R4, R99, R48) who reported that Sunday, August 25, 2024, a dining room was closed due to shortage of staffing. The facility one main dining room and residents were told due to shortage of staffing they had to eat lunch and dinner in their rooms. It was further revealed by medical record, Employee E11 who confirmed that Resident R32 had an early cataract appointment schedule for July 29, 2024, at 7:15 a.m.; however, due to staffing shortage there was no available staff to accompany the resident and it was canceled. It was further communicated that transportation showed up at 7:15 a.m. However, there was no staff to accompany the resident. It was rescheduled for September 16, 2024. 28 Pa Code 211.12 (d)(4) Nursing services 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1)(3) Management

Based on review of facility policy, facility documentation, review of clinical records, observations, and staff interviews, it was determined that the facility failed to appropriately determine the effectiveness of interventions for a resident who was assessed as an elopement risk for one of the 26 residents reviewed (Resident R78) Findings include: A review of the facility policy titled Elopement Risk Evaluation Policy revised 12/12 revealed It is the policy of the facility that all residents will be evaluated upon admission, re-admission quarterly and with any changed in the resident's status to assess their risk for elopement. The Elopement Risk Evaluation will be reviewed and completed. Under procedure number 4. Interventions will be developed and implemented by the interdisciplinary Care Plan Team. The Interdisciplinary Team will re-evaluate interventions with each Elopement Risk Evaluation care conference and with any change in the resident's status. A review of the clinical record revealed Resident 78 was admitted to the facility on [DATE], with diagnoses of depression, anxiety disorder, borderline personality disorder, and narcissistic personality disorder. Review of Quarterly Minimum Data Set (MDS-a periodic assessment of care needs) dated August 22, 2024, indicated that the Brief Interview for Mental Status (BIMS) score of 14-cognition intact. A review of a physician order, initially dated August 21, 2024 revealed the resident had a wander guard (device that is place on ankle or wrist that activate the locking mechanism on doors to the outside of the facility) to back/right armrest of W/C (wheelchair). A review of Resident R78's clinical record did not indicate an Elopement Risk Evaluation was completed. A review of progress notes dated, August 21, 2024, written by the license nurse, Employee E16 revealed resident continuously refused to take her meds. Resident has an increase aggression physically and verbally to staff. Resident was screaming/yelling/swinging at staff. Resident is at risk for elopement, stated I'm going to get out of here, and I'm not going back to this place and tends to stay by the exit door. An interview with the Resident R78 on August 26, 2024, at 10:54 revealed that she doesn't like the wander guard on the back right side of her armrest of the wheelchair and yesterday she cut it off with a butter knife. License Nurse, Employee E4 confirmed that the Resident's R78's wheelchair did not have a wander guard. On August 29, 2024, at 1:34 p.m. with the license nurse, Employee E13 confirmed that for Resident R78's wheelchair does not have a wander guard and the resident unwilling to place the wander guard on Resident R78's wheelchair. It was confirmed that intervention to prevent elopment was ineffective. On August 29, 2024, at 1:52 p.m. an interview with the unit manager, Employee E15 confirmed there was no other interventions explored by the facility besides the wander guard. Employee E15 confirmed that wander guard intervention was ineffective, and she has removed the physician order. An elopement assessment was requested to see if facility evaluated the significant risk for the resident for elopement. On August 30, 2024, at 2:00 p.m. Director of Nursing, Employee provided a Quarterly Evaluation which was created on August 21, 2024, documented that\ Resident R78 had an attempt in the last 30 days to elope and at risk to elope. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interviews, it was determined the facility failed to develop person-centered care plans related to elopement for one out of 26 residents sampled (Resident 78). Findings include: A review of the clinical record revealed Resident 78 was admitted to the facility on [DATE], with diagnoses of depression, anxiety disorder, recurrent, borderline personality disorder, narcissistic personality disorder. A review of a physician order, initially dated August 21, 2024 revealed the resident had a wanderguard (device that is place on ankle or wrist that activate the locking mechanism on doors to the outside of the facility) to back/right armrest of W/C (wheelchair). A review of progress notes dated, August 21, 2024, written by the license nurse, Employee E16 revealed resident continuously refused to take her meds. Resident has an increase aggression physically and verbally to staff. Resident was screaming/yelling/swinging at staff. Resident is at risk for elopement, stated I'm going to get out of here, and I'm not going back to this place and tends to stay by the exit door. A review of the current resident's plan of care revealed the resident's care plan failed to identify the resident's is an elopement risk and interventions develop on the resident's care plan to prevent elopment. An interview with the Resident R78 on August 26, 2024, at 10:54 a.m. revealed that she doesn't like the wander guard on the back right side of her armrest of the wheelchair and yesterday she cut it off with a butter knife. License Nurse, Employee E4 confirmed that the Resident's R78's wheelchair did not have a wander guard. Interview with the Director of Nursing on August 29, 2024, at approximately 1:30 p.m. confirmed the facility failed to ensure that comprehensive care plans were developed. 28 Pa. Code 211.12 (d)(5) Nursing services

Based on clinical record review, observations, and staff interviews, it was determined that the facility failed to provide appropriate tracheostomy care for one of 26 residents (Resident R71). Findings include: Review of the clinical record indicated that Resident R71 was admitted to the facility on [DATE], with a diagnosis of encounter for attention to tracheostomy (a surgically created opening in the neck that allows direct access to the trache for breathing), chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), acute respiratory failure hypoxia (is an emergency where the lungs are unable to supply enough oxygen to the blood, leading to dangerously low oxygen level (hypoxia). A review of Resident R71's Quarterly Minimum Data Set (MDS), a periodic assessment of care needs, dated July 21, 2024, showed that the Brief Interview for Mental Status (BIMS), which assesses cognitive function, returned a score of unknown, indicating that the resident's cognitive status could not be assessed at that time. On August 26, 2024, at 1:12 p.m., an observation was conducted with Infection Preventionist Employee E3 in Resident R71's room to assess tracheostomy supplies. Based on the physician's order dated April 25, 2024, Resident R71 was to have the following supplies at the bedside: Ambu bag, syringe, spare trach tubes (same trach size/type 6 and smaller trach size/type 4), and water-based lubricant. During the observation, it was confirmed that the required size 6 trach tube was not present at the bedside. Employee E3 then checked the medication cart, but the size 6 trach tube was not available there either. On August 26, 2024, at approximately 2:05 p.m., a surveyor observed a family member repeatedly entering and exiting Resident R71's room, requesting to speak with the assigned licensed nurse, Employee E5. When the surveyor approached the family member for an interview, it was revealed that Resident R71 had taken a shower earlier that morning, and the trach collar had not been changed, leaving it wet. The surveyor inquired how the family member knew the collar was wet and needed to be changed. The resident's faily memeber confirmed this by touching the collar and stating it was soaking wet and should have been changed after the shower. Family member further reported that a license nurse who was providing care it's not her regular nurse and most likely forgot to change her trach collar after a shower was given. The surveyor then went to the nursing station to locate Employee E5, only to be informed that Employee E5 was on a break outside the building. At 2:46 p.m., same day Employee E5 returned to change the collar. On August 29, 2024, at 11:45 a.m., licensed nurse Employee E12 was observed performing a tracheostomy treatment on Resident R71, which included changing the resident's trach collar. During the procedure, Resident R71 required suctioning; however, Employee E12 did not have a disposable inner cannula readily available, either at the bedside or in the medication cart. Another licensed nurse, Employee E17, had to retrieve the cannula from the medication storage room. On August 29, 2024, at approximately 2:30 p.m., these observations were confirmed by Infection Preventionist Employee E3 and Director of Nursing Employee E2. 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on review of facility provided documentation, and review of clinical record, it was determined that the facility did not ensure to have attending physician address and document pharmacist's identified irregularities for one of 26 residents reviewed (Resident R127) Findings include: Review of facility provided policy 'Pharmacy Consultant Recommendations,' revised December 16 (unknown year), indicates that the attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. Review of R127's clinical record on August 29, 2024 at 12:00 PM, revealed Resident R127 was admitted to facility July 26, 2024 with BIMS (Brief Interview of Mental Status) score of 5, which indicated that the resident was cognitively impaired. The resident's diagnoses included of depression, subsequent encounter of falls, muscle wasting and atrophy, dementia with mood disturbance, difficulty swallowing, difficulty walking, transient ischemic attack (stroke), anemia, vitamin D deficiency. Further review of Resident R127's clinical record revealed an active order for Trazadone HCL oral tablet 50 mg on August 5, 2024 at 10:47 AM, to give 25 mg (milligrams) by mouth every 12 hours as needed for anxiety/insomnia. Review of Resident R127's pharmacy review 'comments report' dated August 12, 2024, completed by pharmacist - Employee E9, states that a duration must be specified for as needed (PRN) psychoactive medications. First order is limited to only 14 days, but if rationale documented by prescriber to continue order, then next duration may be for longer, i.e. 30, 60, or 90 days. Please update order for trazadone per CMS regulations. Further review of Resident R127's clinical record revealed no evidence of whether the attending physician identifying the need for and continuing use of Trazadone medication identifying and addressing adverse consequences related to medication. 28 Pa Code 211.2(a)Physician Services

Based on observation, and staff interview, it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of three nursing units (Unit A Medication Cart). Findings include: During an observation on August 26, 2024, at 12:50 p.m. the Infection Preventionist, Employee E3 confirmed Medication Cart that was assigned to license nurse, Employee E5 which revealed to be left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information. Employee E3 was not in the hallway nor near her medication cart. During an observation on August 26, 2024, at 2:25 p.m. the license wound nurse, Employee E8 confirmed Medication Cart that was assigned to license nurse, Employee E5 which revealed to be left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information. Employee E5 was not in the hallway nor near her medication cart. On August 29, 2024, at 11:44 a.m. an Administrator, Employee E1 confirmed observation on A wing that Medication Cart which was assigned to registered nurse, Employee E13 revealed to be left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information. Employee E13 was not in the hallway or nearby. During an interview on August 29, 2024, at approximately 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to maintain the confidentiality of residents' medical information as required. 28 Pa Code 211.5(b) Medical records

Based on review of clinical record, review of policy and procedure, and interviews with staff and residents, it was determined that the facility failed to investigate an allegation of possible abuse and neglect and report to the State survey agency the result of the investigation for one of 26 clinical records reviewed. (Resident R44) Findings include: Review of Resident R44's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses of schizophrenia (mental disease characterized by loss of reality contact), major depression, muscle spasticity, low back pain with sciatica (pain going from the lower back down the leg), IV (intravenous) drug abuse. Review of Resident R44's February 2024 physician orders revealed that the resident was ordered May 3, 2023, the pain/ narcotic medication Oxycodone 5 milligrams (mg) by mouth five times a day for severe pain and on May 5, 2023 Baclofen 10 mg by mouth ever six hours as needed for muscle spasms. Clinical record review revealed that on February 9, 2024 the nursing note indicated that Resident R44 was found unresponsive to verbal and painful stimuli. The staff attempted to arouse Resident R44 several times with no positive effect. The physician was contacted and ordered the staff to administer Naloxone nasally 4mg. After administration of the naloxone the nursing staff documented that the resident was aroused but had slurred speech and was unaware of time of place. The physician then ordered the nursing staff to send the resident to the hospital emergency room . Hospital record review revealed that on February 9, 2024 Resident R44 was examined by the emergency room physician who documented that Resident R44 had oxycodone and baclofen use and had an unintentional overdose with these medications. The physician had documented that Resident R44 had experienced hypercapnic respiratory failure and unintentional overdose or polypharmacy. Upon interview Resident R44 told the hospital examining physician that he was given oxycodone and Baclofen at the same time causing him to become unresponsive. Resident R44 reported to the hospital physician that he took two doses of baclofen incidentally with oxycodone and then went to sleep. Clinical record review on February 12, 2024 for Resident R44 revealed the diagnosis of poisoning by unspecified drugs, medications and biological substances. Clinical record review for Resident R44 revealed a psychiatry assessment on July 29, 2024 that indicated Resident R44 had diagnoses of depression and schizophrenia. The psychiatrist indicated that Resident R44 was alert and oriented and reporting that nursing staff may have given him too much narcotics because he was diagnosed with medication poisoning at the hospital, last time he was there. Interview with licensed nursing staff, Employee E15 at 10:00 a.m., on August 29, 2024 revealed that Resident R44 was found unarousable between 9:00 a.m., and 10:00 a.m., on February 9, 2024. The licensed practical nurse, Employee E15 also said that the physician ordered the administration of naloxone HCL nasal spray to be administered to Resident R44 for medication overdose on February 9, 2024. Employee E15 documented neurological checks as low blood pressure 81/53 and low pulse 56 for Resident R44 on February 9, 2024. The licensed nurse, Employee E15 reported that she called for emergency transport to the hospital for Resident R44 on February 9, 2024 as directed by the physician. Further interview with Employee E15 at 10:30 a.m., on August 29, confirmed that Resident R44 left the facility unescorted by staff for a cardiology appointment on January 16, 2024 and February 29, 2024. Interview with the Nursing Home Administrator and Director of Nursing at 10:00 a.m., on August 28, 2024 confirmed that there was no investigation into a case of possible neglect for Resident R44; who was found diagnosed at the hospital with unintentional overdose. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(d)(4)(e)(1) Management 28 Pa. Code 211.12(c)(d)(1) Nursing services

Based on clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that residents receive proper treatment and assistive devices to maintain hearing and vision abilities for one of 26 residents reviewed (Resident R32). Findings include: Review of the clinical record indicated that Resident R32 was admitted to the facility on [DATE], with diagnoses to include anxiety disorder, major depressive disorder, rheumatoid arthritis (chronic autoimmune disorder which effects joints, causing inflammation, pain and swelling), osteoporosis (bones loose density, making them thinner and less durable). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R32, dated, July 18, 2024 revealed that the resident was cognitively intact. Review of Resident R32's inhouse new Audiology summary dated January 25, 2024, indicated a recommendation for the Resident R32 for in office visit for myringotomy treatment (a surgery performed by an ear, nose, and throat (ENT) specialist to drain fluid from your middle ear). A follow ENT was conducted inhouse on June 26, 2024, for Resident R32 recommending the same treatment as it was not completed. On July 23, 2024, another hearing assessment report was conducting Resident's R32 hearing decreased; however, there was no documentation that Resident R32 was taken for the myringotomy treatment. Further review of the clinical record for Resident R32 revealed a vision consultation occurred on June 18, 2024 with a recommendation of bilateral cataracts surgery for left eye. An interview was held with the Resident R32 on August 26, 2024, at 1:57 p.m. that she unable to hear and reported I want to know about my hearing appointment, also it's been months for me to get cataract surgery. I had an appointment but did not go because there was no one who could go with me. Surveyor had to speak closely to Resident's R32's ear as Resident R32 was unable to hear. License nurse, Employee E24 who came in to administered medication confirmed that Resident R32 was unable to hear. On August 28, 2024, approximately 11:30 a.m. Director of Nursing, Employee E2 brought in Audiology summary assessment and reported that an appointment has been scheduled for September 5, 2024, by the medical record, Employee E11 for resident to go for myringotomy appointment and another appointment was scheduled for the resident to get her cataracts treatment for her vision on September 16, 2024. An interview with the medical record, Employee E11 on August 28, 2024, at 1:25 p.m. who reported that it's her responsibility to schedule appointments and she was not aware of the need for myringotomy treatment and scheduled her an appointment on August 27, 2024 when surveyor questioned the recommendation. The protocol she would get a communication request from the unit manager to schedule an appointment for residents and then she calls to schedule. In this case she received a request for the myringotomy appointment request yesterday on August 27, 2024 from the unit manager. It was further revealed by Employee E11 who confirmed that an early cataract appointment was schedule for July 29, 2024, at 7:15 a.m.; however, due to staffing shortage there was no available staff to accompany the resident and it was canceled. It was further communicated that even transportation showed up at 7:15 a.m. However, there was no staff to accompany the resident. It was rescheduled for September 16, 2024. On August 29, 2024, at 8:51 a.m., an interview was conducted with the unit manager, Employee E15, who was responsible for communicating the need for appointments to the medical record staff. Employee E15 confirmed that Resident R32 had originally received a recommendation on January 26, 2024, for myringotomy treatment; however, the appointment was not scheduled until August 27, 2024, following an inquiry by the surveyor. Employee E15 was also unaware that Resident R32's cataract appointment had been canceled by the facility due to a staffing shortage. 28 Pa. Code 211.10(a)(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(3) Nursing services.