Every finding on record at Oakwood Heights Village

Based on resident interviews, review of facility policy and resident council minutes, and resident and staff interviews, it was determined that the facility failed to respond to resident concerns identified during resident council minutes for three of three months reviewed (November 2025, December 2025, and January 2026).Findings include: Review of a facility policy entitled, Resident Council dated 1/28/26, indicated that a Resident Council Response Form will be utilized to track issues and their resolution and the facility department related to any issues will be responsible for addressing the item(s) of concern. During an interview on 2/04/26, at 10:45 a.m. Resident Council Members (Residents R5, R56, R58, R67, R79, and R86) confirmed they do not receive responses to previous Resident Council concerns and do not believe Resident Council concerns are resolved in a timely manner due to the number of ongoing concerns voiced by the group. Review of November 2025, Resident Council Meeting Minutes revealed: new business included a leaking faucet, broken call bell, and missing clothing; ongoing business included residents upset with dirty floors and bathrooms, windows needed cleaning, and staff wearing name tags; resolved business included a beautician was hired. There was no evidence that the facility utilized a Resident Council Response Form to track issues and their resolution, and that the department related to any issues addressed the item(s) of concern. Review of December 2025, Resident Council Meeting Minutes revealed: new business included the same broken call bell, requests of a Nurse Aid to help in the dining room, the beautician leaving; ongoing business included residents upset with dirty floors and bathrooms, the leaking faucet, and staff still not wearing name tags. There was no evidence resident concerns from the previous month's meeting were resolved and/or discussed, and there was no evidence that the facility utilized a Resident Council Response Form to track issues and their resolution, and that the department related to any issues addressed the item(s) of concern. Review of January 2026, Resident Council Meeting Minutes revealed: new business included poor floor care, wrinkled clothing, call bell response times, staffing, missing clothing, activities, room temperatures, and Administrator participation in the meetings. There was no evidence resident concerns from the previous month's meeting were resolved and/or discussed, and there was no evidence that the facility utilized a Resident Council Response Form to track issues and their resolution, and that the department related to any issues addressed the item(s) of concern. Review of facility Concern, Comment, Procedure Forms revealed: On 8/23/25, a concern was submitted that room [ROOM NUMBER] and the bathroom needed a deep clean and the floors were sticky, and that the resident needed help with eating. Facility findings included, the floor scrubber was broken. Corrective action included, Environmental Services Director and Administrator were notified and that the room would be cleaned. On 9/02/25, a concern was submitted that room [ROOM NUMBER]'s bathroom floor was dirty and that family cleaned it. The corrective action included, Environmental Services Director would handle this with his/her team. During an interview on 2/04/26, at 1:15 p.m. the Nursing Home Administrator confirmed that there was lack of evidence that the repeated concerns from Resident Council and/or Concern, Comment, Procedure Forms were resolved, and there was a lack of evidence that the Resident Council was informed of the concern outcomes and was satisfied with the outcomes by the facility. 28 Pa. Code 201.14(a) Responsibility of Licensee28 Pa. Code 201.18(b)(1)(3) Management28 Pa. Code 201.18(e)(1)(4) Management

Based on observations, review of facility policies and documents, and staff interviews, it was determined that the facility failed to provide housekeeping services necessary to maintain a clean environment for multiple resident rooms on the first floor (101, 102, 103, 104, 105, 107, 108, 109, 111, and 113) and multiple resident rooms on the third floor (303, 304, 305, 309, 316 and 317).Findings include:Review of facility policy entitled Homelike Environment dated 1/28/26, indicated residents are provided with a safe, clean, comfortable and homelike environment.Review of the facility admission Agreement page 10 revealed that the facility will provide clean lodging.A facility document entitled, Room Cleaning Process revealed that daily housekeeper tasks included remove trash, sweep/mop floor, clean bathroom surfaces then toilet, and sweep/mop bathroom.Observations on 2/03/26, between 10:50 a.m. and 1:15 p.m. and on 2/04/26, between 8:45 a.m. and 9:30 a.m. revealed resident Rooms 101, 102, 103, 104, 105, 107, 108, 109, 111, and 113 to have a removable build-up of a black substance covering much of the bedroom and bathroom floors.During an interview on 2/04/26, at 9:30 a.m. the Environmental Services Manager confirmed the presence of black substance and that it was removeable with minor effort.Observations on 2/3/26, between 10:00 a.m. and 12:45 p.m. and again on 2/4/26, between 8:30 a.m. and 9:17 a.m. revealed resident bathrooms in rooms 303, 304, 305, 309, 316 and 317 had large areas of a dry black substance on the bedroom and bathroom floors.During an interview on 2/4/26, at 9:17 a.m. Licensed Practical Nurse Employee E3 confirmed the black substance on the bedroom and bathroom floors and confirmed that it was removable with minimal effort. 28 Pa. Code 201.14(a) Responsibility of Licensee28 Pa. Code 201.18(b)(1)(3) Management28 Pa. Code 201.18(e)(2.1) Management

Based on review of facility documents, observations, and resident and staff interviews, it was determined that the facility failed to ensure residents access to petty cash on an ongoing basis, and to ensure have access to their funds from the resident's petty cash fund the same day for amounts less than $100.00 ($50.00 for Medicaid residents) and on weekends for all 89 of 89 residents in the facility. Findings include: Review of the facility Admissions Agreement Section 18 (iv) page 22 revealed the facility shall provide cash, if requested within one day of the request or a check, if requested within three days of the request. During interviews on 2/04/26, at 10:45 a.m. Residents R5, R56, R58, R67, R79 and R86 confirmed that they cannot access petty cash on the same day during the week and not at all on weekends. Residents stated that they must give at least 24-hour notice of cash requests to allow the Nursing Home Administrator (NHA) time to go to the bank. During an interview on 2/04/26, 1:15 p.m. the NHA confirmed the cash box contains $400 and is kept in the Business Office. Residents sign a receipt for the amount of money they wish, and the Business Office Manager (BOM) issues a check to the NHA to cash and reimburse the petty cash box, and there is no one in the building on weekends to access the petty cash to fulfill resident requests for money. Observation and confirmation from the BOM on 2/05/26, at 8:46 a.m. of the petty cash box revealed there was a $5 bill, a few $1 bills and change, receipts and resident checks dated in December. During an interview at that time the NHA confirmed that he/she has had the check to take to the bank since last week and that he/she hasn't gotten the chance to cash it. Review of facility Checking Account Statement printed 2/05/26, revealed that a check was issued to the NHA on 1/23/26, for $400. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(2)(3) Management28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 201.29(a) Resident rights

Based on review of facility policies, clinical records, and staff interviews it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day), and failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital, for four of four residents reviewed (Residents R11, R12, R76, and R90).Review of facility policy entitled Transfer and Discharge dated 1-28-26, indicated Provide a notice of transfer and the facility's bed hold policy to the resident and representative as indicated. And For a transfer to another provider, for any reason, the following information must be provided to the receiving provider:Contact information of the practitioner who was responsible for the care of the residentResident representative information, including contact informationAdvance directive informationAll other information necessary to meet the resident's needs.All special instructions and/or precautions for ongoing care.The residents' comprehensive care plan goalsAll other information necessary to meet the residents' needs which includes, but may not be limited to:Resident status.Diagnosis and allergiesMedicationsMost relevant labs. Review of Resident R11's clinical record revealed an admission date of 2/13/24, with diagnoses that included diabetes (a health condition that is caused by the body's inability to produce enough insulin), peripheral vascular disease (a condition when there is restricted blood flow to the limb, usually legs), and hypertension (high blood pressure). Review of Resident R11's progress notes revealed notes dated 9/3/25, and 9/20/25, indicating transfer to the hospital, the clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. His/her clinical record also lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfer on 9/20/25. Review of Resident R12's clinical record revealed an admission date of 10/9/24, with diagnoses that included chronic respiratory failure (a condition where your lungs don't exchange air properly), diabetes (a health condition that is caused by the body's inability to produce enough insulin), and congestive heart failure (the inability of the heart to maintain an adequate supply of blood to organs and tissues). Review of Resident R12's progress notes revealed notes dated 4/8/25, 9/6/25, 10/14/25, and 10/21/25, indicating transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. His/her clinical record also lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfer on 9/6/25, and 10/14/25. Review of Resident R76's clinical record revealed an admission date of 12/17/21, with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), hypertension (high blood pressure), and gastro esophageal reflux disease (a condition when stomach acid repeatedly flows back up into your throat). Review of Resident R76's progress notes revealed notes dated 12/26/25, and 1/31/26, indicating transfer to the hospital,. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. His/her clinical record also lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfer on 12/26/25. Review of Resident R90's clinical record revealed an admission date of 9/13/25, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and diabetes (a health condition that is caused by the body's inability to produce enough insulin). Review of Resident R90's progress notes revealed a note dated 11/18/25, indicating transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. During an interview on 2/5/26, at 3:00 p.m. the Director of Nursing confirmed that Resident's R11, R12, R76 and R90's clinical records lacked evidence that the necessary clinical information was provided to the receiving healthcare provider upon transfer. He/she confirmed that Resident's R11, R12, and R76's clinical records lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfer. He/she also confirmed when the transfers occurred clinical information should have been provided to the receiving healthcare provider and bed hold policy should be provided to the resident/representative upon transfer. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c.3)(2) Resident rights

Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to maintain proper care of respiratory equipment and failed to provide oxygen according to physician's orders for seven residents reviewed for respiratory care (Residents R12, R19, R22, R25, R56, R50, and R29). Findings include: Review of facility policy entitled Oxygen Administration dated 1/28/26, indicated Oxygen is administered under orders of a physician., and Keep delivery devices covered in plastic bag when not in use. Review of Resident R12's clinical record revealed an admission date of 10/9/24, with diagnoses that include chronic respiratory failure (a condition where your lungs don't exchange air properly), diabetes (a health condition that is caused by the body's inability to produce enough insulin), and congestive heart failure (the inability of the heart to maintain an adequate supply of blood to organs and tissues). Review of Resident R12's physician orders revealed an order for Oxygen at two liters/minute via nasal cannula (a thin tube with two prongs that fit into the resident's nostrils to deliver oxygen) every shift dated 11/18/25. Observations on 2/3/26, at 9:30 a.m., and again at 10:45 a.m. revealed Resident R12 lying in his/her bed with supplemental oxygen in place and the oxygen concentrator (machine used to deliver concentrated oxygen to patients) flow rate set at three liters/minute. Review of Resident R19's clinical record revealed an admission date of 2/25/25, with diagnoses that include chronic obstructive pulmonary disease (COPD-- when your lungs do not have adequate air flow) heart failure (the inability of the heart to maintain an adequate supply of blood to organs and tissues), and hyperlipidemia (high cholesterol). Observations on 2/3/26, at 10:00 a.m. and again at 12:22 p.m. revealed Resident R19's nasal cannula was connected to the oxygen concentrator and the prongs that go into Resident R19's nostrils were lying on the floor. Resident R22's clinical record revealed an admission date of 9/04/19, with diagnoses including heart disease/failure, COPD, and Type 2 Diabetes (condition when the body cannot use insulin correctly and sugar builds up in the blood). The clinical record revealed a physician's order dated 7/12/24, to use two liters/minute of supplemental oxygen via nasal cannula at night. Observations on 2/03/26 between 10:50 a.m. and 12:15 p.m. revealed Resident R22's oxygen tubing and nasal cannula hanging over the top of the oxygen concentrator and not in a plastic bag. Resident R25's clinical record revealed an admission date of 1/16/26, with diagnoses that included COPD, Type 2 Diabetes, communication deficit, and seizures. The clinical record also revealed a physician's order dated 1/21/26, for oxygen at four liters/minute every shift. Observations on 2/03/26 between 10:50 a.m. and 12:15 p.m. revealed Resident R25's oxygen tubing and nasal cannula laying on the floor and not in a plastic bag. Resident R29's clinical record revealed an admission date of 1/13/26, with diagnoses including Type 2 Diabetes, heart failure, difficulty swallowing, and long-term kidney disease, a physician's note dated 1/13/26, for oxygen at two liters/minute via nasal cannula as needed. Observations on 2/03/26 between 10:50 a.m. and 12:15 p.m. revealed Resident R29's oxygen tubing and nasal cannula hanging over the top of the oxygen concentrator and not in a plastic bag. Resident R50's clinical record revealed an admission date of 8/07/24, with diagnoses that included sudden and ongoing respiratory failure, COPD, irregular heartbeat, and heart failure. The clinical record also revealed a physician's order dated 2/14/25, for oxygen at two liters/minutes via nasal cannula as needed. Observations on 2/03/26, between 10:50 a.m. and 12:15 p.m. revealed Resident R50's oxygen tubing and nasal cannula laying on the floor and not in a plastic bag. Resident R56's clinical record revealed an admission date of 9/08/21, with diagnoses that included COPD, Alzheimer's Disease (brain disorder that slowly destroys a person's memory and thinking skills), asthma, and irregular heartbeat,. The clinical record also revealed a physician's order dated 7/01/25, for oxygen at two liters/minute via nasal cannula every night. Observations on 2/03/26 between 10:50 a.m. and 12:15 p.m. revealed Resident R56's oxygen tubing and nasal cannula hanging over the top of the bed rail and not in a plastic bag. During an interview on 2/3/26 at 12:55 p.m. Registered Nurse Employee E6 confirmed that Resident R12's oxygen flow rate was set at three liters per min and that Resident R19's nasal cannula was lying on the floor. He/she also confirmed that Resident R12's oxygen flow rate was not per physician orders and that Resident R19's nasal cannula should not be on the floor. During an interview on 2/03/26, at 12:45 p.m. Licensed Practical Nurse Employee E4 confirmed that Resident's R22, R25, R29, R50, and R56's oxygen tubing and nasal cannulas were lying on the floor and hanging over equipment and that the tubing and cannulas should be in plastic bags when not in use. During an interview on 2/03/26, at 12:47 p.m. the Director of Nursing confirmed that oxygen tubing and cannulas are to be stored in a plastic bag when not in use. 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.10(c) Resident care policies

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to ensure that the physician signed and dated all orders during visits for nine of 21 residents reviewed (Residents R4, R7, R10, R18, R19, R22, R23, R58, and R67). Findings include: Review of facility policy entitled Physician Visits and Physician Delegation dated 1/28/26, revealed The physician should: See resident within 30 days of initial admission to the facility. The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by physician or physician delegate as appropriate by state law. Sign and date all orders. Review of resident R4's clinical record revealed an admission date of 11/26/18, with diagnoses that included Alzheimer's disease (a progressive disorder that affects memory, thinking skills, and ability to perform simple tasks), diabetes (a chronic disease where the body does not produce enough insulin or cannot use it efficiently), and muscle weakness. Review of Resident R4's clinical record revealed that his/her physician orders were signed and dated 9/12/25, and not again until 1/26/26, which was beyond the required 60 days. Review of Resident R7's clinical record revealed an admission date of 1/7/25, with diagnoses that included asthma (a long term lung disease that causes the airways to narrow and make it difficult to breath), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and hypertension (high blood pressure). Review of Resident R7's clinical record revealed that his/her physician orders were signed and dated 9/12/25, and not again until 1/26/26, which was beyond the required 60 days. Review of Resident R10's clinical record revealed an admission date of 5/30/25, with diagnoses that included hypertension, hyperlipidemia (high cholesterol) and muscle weakness. Review of Resident R10's clinical record revealed that his/her physician orders were signed and dated 9/12/25, and not again until 1/26/26, which was beyond the required 60 days. Review of Resident R18's clinical record revealed an admission date of 12/1/24, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), diabetes, and chronic kidney disease. Review of Resident R18's clinical record revealed that his/her physician orders were signed and dated 9/12/25, and not again until 1/26/26, which was beyond the required 60 days. Review of Resident R19's clinical record revealed an admission date of 2/25/25, with diagnoses that included chronic obstructive pulmonary disease, heart failure (the inability of the heart to maintain an adequate supply of blood to organs and tissues), and hyperlipidemia. Review of Resident R19's clinical record revealed that his/her physician orders were signed and dated 9/12/25, and not again until 1/26/26, which was beyond the required 60 days. Resident R22's clinical record revealed an admission date of 9/04/19, with diagnoses including heart disease/failure, COPD, and Type 2 Diabetes (condition that happens when the body cannot use insulin correctly and sugar builds up in the blood). Review of Resident R22's clinical record revealed that his/her physician orders were signed on 9/12/25, and not again until 1/26/26, which was beyond the required 60 days. Review of Resident R23's clinical record revealed an admission date of 10/25/24 with diagnoses that included heart failure, hypertension, and atrial fibrillation (irregular heartbeat). Review of Resident R23's clinical record revealed that his/her physician orders were signed and dated 9/12/25, and not again until 1/26/26, which was beyond the required 60 days. Review of Resident R58's clinical record revealed an admission date of 4/8/22, with diagnoses that included hypertension, gastro esophageal reflux disease (a condition when stomach acid repeatedly flows back up into your throat), and hyperlipidemia. Review of Resident R58's clinical record revealed that his/her physician orders were signed and dated 9/12/25, and not again until 1/26/26, which was beyond the required 60 days. Review of Resident R67's clinical record revealed an admission date of 10/19/25, with diagnoses that included hypertension, chronic kidney disease, and muscle weakness. Review of Resident R67's clinical record revealed that his/her physician orders were signed until 1/26/26, which was beyond the required 60 days. During an interview on 2/5/26, at 2:06 p.m. the Director of Nursing confirmed that physician orders for Residents R4, R7, R10, R18, R19, R22, R23, R58, and R67 were not reviewed and signed by the physician in the required 60 days and confirmed that physician orders should be reviewed and signed with every physician visit on admission then every 30 days for the first 90 days then every 60 days. Refer to F841 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.5(f)(i) Medical records

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to provide resident privacy on one of five medication carts (Third floor 100 hall medication cart).Review of facility policy entitled Confidentiality of Information and Personal Privacy dated 1/28/26, revealed Ensure computer screens are in privacy mode or hidden when administering medications. Observations on 2/3/26, between 12:30 p.m. and 12:50 p.m. of the Third floor 100 hall medication cart revealed the medication cart sitting in the hallway against the wall with an open computer on top of the medication cart and resident health information visibly facing into the hallway. Continued observations revealed Licensed Practical Nurse (LPN) Employee E2 returned and walked away from the medication cart several times leaving resident health information visible while several visitors, residents and staff walked past the viewable health record. During an interview on 2/3/26, at 12:50 p.m. LPN Employee E2 confirmed that he/she left the medication cart with the computer open and did not cover resident health information. He/she also confirmed that resident information should be covered when not within view. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for one of 21 residents reviewed (Resident R4). Findings include: Review of facility policy entitled Psychotropic Medication Use dated 1/28/26, revealed that non-pharmacological approaches are used to minimize the need for medications, permit lowest possible dose, and allow for discontinuation of medications when possible. Review of Resident R4's clinical record revealed an admission date of 11/26/18, with diagnoses that included Alzheimer's disease (a progressive disorder that affects memory, thinking skills, and ability to perform simple tasks), diabetes (a chronic disease where the body does not produce enough insulin or cannot use it efficiently), and muscle weakness. The clinical record revealed that on 12/2/25, Resident R4's physician ordered Lorazepam (a medication ordered to treat anxiety) 0.5 milligrams (mg) every 4 hours PRN for anxiety. Review of Resident R4's December 2025 Medication Administration Record (MAR) and January 2026 MAR revealed that the PRN Lorazepam was used on 12/8/25,12/16/25,12/21/25,1/2/26, 1/14/26, 1/15/26, 1/17/26, and 1/22/26. Resident R4's clinical record lacked evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam for the eight administrations in December 2025 and January 2026. During an interview on 2/5/26, at 10:56 a.m. the Director of Nursing confirmed that Resident R4's clinical record lacked evidence that non-pharmacological interventions were attempted prior to the administration of a PRN psychotropic medication for the dates listed above and that non-pharmacological interventions should be attempted and documented in the clinical record. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to ensure the resident's initial visit was conducted by the physician and that the physician alternate required resident visits with the nurse practitioner or physician's assistant for two of 21 residents reviewed (Residents R22 and R29).Findings include: Facility policy entitled, Physician Visits and Physician Delegation dated, 1/28/26, revealed that the physician should: see the resident within 30 days of initial admission to the facility; date, write, and sign a progress note for each visit; at the option of the physician, required visits in skilled nursing facilities, after the initial visit, may alternate between personal visits by the physician and visit by a physician assistant, nurse practitioner, or clinical nurse specialist. Resident R29's clinical record revealed an admission date of 1/13/26, with diagnoses including Type 2 Diabetes (condition when the body cannot use insulin correctly and sugar builds up in the blood), heart failure, difficulty swallowing, and muscle weakness. Further review of Resident R29's clinical record revealed that on 1/25/26, a progress note indicated that the nurse practitioner conducted the initial assessment on Resident R29, and not the physician. Resident R22's clinical record revealed an admission date of 9/04/19, with diagnoses including heart disease/heart failure, Type 2 Diabetes, and chronic obstructive pulmonary disease, (group of lung disease that cause airflow blockage and breathing-related problems). Further review of Resident R22's clinical record lacked evidence that the resident had been seen by the physician since 1/31/25. Provider progress notes were completed and signed by the nurse practitioner on 3/18/25, 5/20/25, 6/17/25, and 8/26/25. During an interview on 2/06/26, at 9:00 a.m. the Director of Nursing confirmed that he/she could not determine the most recent date Resident R22 received a visit from the physician, and that Resident R29's initial visit at the facility was conducted by the nurse practitioner. Refer to F841 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3) Management28 Pa. Code 211.5(f)(ii)(vii) Medical records

Based on review of facility policies, observations and staff interviews, it was determined that the facility failed to appropriately discard outdated medications for two of three medication carts reviewed (First floor rehab and Second floor medication carts) and failed to prevent the opportunity for potential unauthorized access of medications on one of five medication carts observed (Third floor 100 hall medication cart).Review of facility policy entitled Administering Medications date 1/28/26, revealed When opening a multi-dose container, the date opened is recorded on the container. and During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. and The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. Review of facility policy entitled Labeling of Medications and Biologicals dated 1/28/26, revealed Labels for multi-dose vials must include: The date the vial was initially opened or accessed. Review of manufacturer's guidelines revealed that an open vial of Aspart Insulin must be used within 28 days after opening or be discarded. Manufacturer's guidelines for Trelegy Ellipta (medication used to treat Chronic Obstructive Pulmonary Disease [COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing] and Asthma [a long-term inflammatory disease of the airways that cause the airways to narrow and swell causing symptoms such as wheezing, coughing, chest tightness, and shortness of breath], indicated that Trelegy should be discarded six weeks after opening the foil tray or when the counter read 0, whichever comes first. Observation of drug storage on 2/3/26, at 10:53 a.m. of the First-floor rehab medication cart revealed a Trelegy Ellipta Diskus out of the foil package, in use and lacking an open date. During an interview on 2/3/26, at the time of observations, Licensed Practical Nurse (LPN) Employee E4 confirmed that the Trelegy Ellipta Diskus in use lacked an open date, and staff were unable to determine the discard date. He/she she also confirmed that the Trelegy Ellipta Diskus should have been discarded. Observations of drug storage on 2/3/26, at 11:22 a.m. of the Second-floor medication cart revealed an open vial of Aspart insulin lacking an open date. Further observations revealed in the second and third drawers of the medication cart were several loose random pills. During an interview on 2/3/26, at the time of observations, LPN Employee E5 confirmed that the open vial of Aspart insulin lacked an open date, and staff were unable to determine the discard date and there were several loose random pills in the second and third drawers. He/she also confirmed that the vial of Aspart insulin and the random loose pills should have been discarded. Observations on 2/3/26, between 12:30 p.m. and 12:50 p.m. revealed LPN Employee E2 preparing medications from the Third floor 100 hall medication cart parked in the hall against the wall with the drawers facing into the hallway. Continued observations revealed PLN Employee E2 walked away from the medication cart entering resident rooms, and the pantry several times. LPN Employee E2 did not securely lock the Third floor 100 hall medication cart. LPN Employee E2 was unable to view medication cart from resident rooms and the pantry. During an interview on 2/3/26, at 12:50 p.m. LPN Employee E2 confirmed that he/she left the medication cart unlocked which was out of view while in resident rooms and the pantry. LPN employee E2 also confirmed that the medication cart should be locked when out of view. 28. Pa. Code 201.18(b)(1) Management 28. Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in the main kitchen and failed to maintain sanitary conditions in one of three pantry refrigerators (First floor). Findings include:Review of a facility policy entitled, Dietary-Food Receiving and Storage dated 1/28/26, revealed that All foods stored in the refrigerator or freezer will be covered, labeled and dated. The policy also indicated that dining services, of other designated staff, will maintain clean food storage areas at all times. Observation on 2/03/26, at 9:30 a.m. in the main kitchen walk in cooler revealed two 48-ounce bottles of salsa, three 16 ounce jars of parmesan grated cheese and one bottle of sweet relish, all with no open dates. During an interview on 2/03/26, at 9:45 a.m. the Dietary Manager confirmed that the above food items should have been dated when opened. Observation on 2/03/26, 10:45 a.m. of the pantry refrigerator on First Floor revealed it had brown/tan dried liquid on the bottom floor of the main compartment and on the bottom shelf of the door. During an interview on 2/03/26, at 10:51 a.m. Housekeeping Employee E1 confirmed the above listed conditions in the First-Floor pantry refrigerator. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(e)(2.1) Management

Based on review of the Medical Director agreement, facility records, and staff interview, it was determined that the facility failed to ensure that the Medical Director fulfilled his/her responsibilities to develop, review, and improve resident care policies.Findings include:Review of the Medical Director agreement revealed he/she is expected to guide, approve, and help oversee the development, implementation, and monitoring/evaluation of the facility's resident care policies and procedures in several areas.Review of facility's annual policy reviews dated 1/28/26, revealed no signature by the Medical Director.Interview with the Nursing Home Administrator on 2/6/26, at approximately 12:12 p.m. revealed that the Medical Director was not present at the facility throughout the year to fulfill his/her responsibility in the development, review, and improvement of resident care policies and the Medical Director was not a part of the annual policy review. Refer to F711, F712, and F86828 Pa. Code 201.18(e)(1)(3) Management28 Pa. Code 211.10(c)(d) Resident care policies

Based on review of clinical records and staff interviews, it was determined that the facility failed to accurately code the Minimum Data Set (MDS-periodic assessment of resident care needs) and failed to ensure that the MDS assessment accurately reflected the status for three of 21 residents reviewed (Residents R11, R23 and R90).Findings include:Review of Resident R11's clinical record revealed an admission date of 2/13/24, with diagnoses that included diabetes (a health condition that is caused by the body's inability to produce enough insulin), peripheral vascular disease (a condition when there is restricted blood flow to the limb, usually legs), and hypertension (high blood pressure). Review of Resident R11's physician orders revealed an order for hospice with a start date of 12/30/25. Review of Resident R11's MDS dated [DATE], section O special treatments, procedures, and programs under O0110 hospice revealed Resident R11 was inaccurately coded yes. Review of Resident R23's clinical record revealed an admission date of 10/25/24, with diagnoses that included heart failure, hypertension, and atrial fibrillation (irregular heartbeat). Review of Resident R23's physician orders revealed an order for hospice with a start date of 10/25/24. Review of Resident R23's MDS dated [DATE], section O special treatments, procedures, and programs under O0110 hospice revealed Resident R11 was inaccurately coded no. Review of Resident R90's clinical record revealed an admission date of 9/13/25, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and diabetes. Review of Resident R90's discharge recapitulation of stay dated 12/15/25, under nursing services indicated that resident R90 was admitted to another facility. Review of Resident R90's MDS submissions revealed an MDS for a discharge return anticipated dated 11/18/25, MDS submissions lacked evidence that an MDS for return not anticipated was completed. During an interview on 2/5/26, at 10:47 p.m. the Registered Nurse Assessment Coordinator (RNAC) confirmed that Residents R11 and R23's MDS's were coded inaccurately for hospice services. During an interview on 2/6/26, at 10:47 a.m. the RNAC confirmed that Resident R90's discharge MDS was coded inaccurately. 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 201.14 (a) Responsibility of Licensee

Based on review of facility policy, facility records, and staff interview, it was determined that the facility failed to ensure the required attendance of the Medical Director or his/her designee to Quality Assurance and Performance Improvement (QAPI) Committee meetings for four of four quarterly QAPI Committee meetings reviewed.Findings include: Review of facility policy entitled Quality Assurance and Performance Improvement dated 1/28/26, revealed The QAA Committee shall be interdisciplinary and shall consist at a minimum of . The Medical Director or his/her designee. Review of the QAPI Committee Attendance Records from March 2025, through December 2025, revealed no evidence on the attendance sign-in sheets for all required QAPI meetings that included the Medical Director or his/her designee was in attendance. During an interview on 2/06/26, at approximately 10:30 a.m. the Nursing Home Administrator confirmed the facility lacked evidence that the Medical Director or his/her designee attended the Quarterly QAPI Committee meetings as required.Refer to F84128 Pa. Code 201.18(e)(1)(3) Management

Based on review of clinical records and facility policy, and staff interview, it was determined that the facility failed to have complete and accurate documentation regarding oral hygiene for one of three residents reviewed (Resident R1).Findings include: Review of facility policy entitled Mouth Care dated 1/14/25, revealed Documentation -The following information should be recorded in the residents clinical record: The date and time the mouth care was provided. Review of Resident R1's clinical record revealed an admission date of 5/28/21, with diagnoses that included diabetes (a health condition that is caused by the body's inability to produce enough insulin), dementia (a disease that affects short term memory and the ability to think logically) and hypertension (high blood pressure). Review of Resident R1's task (charting area in the clinical record where nursing assistant's document) under section GG oral hygiene every shift revealed that for day shift on 10/1/25, 10/4/25, 10/14/25, there lacked documentation that oral care was completed. On evening shift 10/2/25, 10/11/25, there lacked documentation that oral care was completed and Not Applicable (NA) was marked on 10/5/25, 10/10/25, 10/13/25. On the overnight shift on 10/11/25, there lacked documentation and NA was marked on 10/2/25, 10/3/25, 10/4/25, 10/5/25, 10/6/25, 10/8/25, 10/10/25, 10/12/25, 10/13/25, and 10/14/25 that oral hygiene was completed. During an interview on 12/3/25, at 9:55 a.m. the Director of Nursing (DON) confirmed that Resident R1's clinical record did not have complete documentation regarding oral hygiene. The DON also confirmed that oral hygiene should be done per the order/task and documented in the clinical record. 28 Pa. Code 211.5(f) Medical Records28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of clinical records and facility policy, and staff interviews, it was determined that the facility failed to accurately transcribe a physician's order to promote comfort during care and/or prevent discomfort for one of three residents reviewed (Resident R1). Findings include: Review of facility policy entitled Medication Orders dated 1/14/25, revealed PRN Medication Orders - When recording PRN medication orders, specify. the reason for administration. Review of facility policy entitled Medication and Treatment Orders dated 1/14/25, revealed Orders for medications must include. symptoms for which the medication is prescribed. Review of Resident R1's clinical record revealed an admission date of 5/28/21, with diagnoses that included diabetes (a health condition that is caused by the body's inability to produce enough insulin), dementia (a disease that affects short term memory and the ability to think logically)and hypertension (high blood pressure). Review of hospice physician's order dated 10/12/25, revealed an order to pre-medicate (premed) prior to care with Ativan (anti-anxiety medication) 0.5 mg (milligrams) every 2 hours as needed (PRN) and morphine 10 milligrams (mg) every two hours PRN. Review of facility transcribed physician orders revealed an order dated 10/12/25, transcribed at 2:30 p.m. for Lorazepam (Ativan) 0.5 mg every two hours PRN for premed prior to care. Another order dated 10/10/25, for Morphine 20 mg/ml (milliliter) give 0.5 ml every hour PRN and lacked instructions to premed prior to care as ordered on 10/12/25. Further review revealed a physician's order dated 10/12/25, to reposition Resident R1 every two hours. Review of Resident R1's Medication Administration Record r(MAR) revealed that on 10/12/25, PRN Ativan and PRN Morphine were administered at 4:38 p.m. and no other administration documented after that administration. On 10/13/25, PRN Morphine was administered at 1:53 a.m., 5:30 a.m., 1:15 p.m., 4:54 p.m., 5:22 p.m., then again on 10/14/25, at 9:15 a.m., 11:21 a.m., 2:00 p.m., 3:58 p.m., and 8:00 p.m., then again on 10/15/25 at 12:07 a.m., 4:18 a.m., 11:31 a.m., 2:07 p.m., 6:16 p.m.; the PRN Lorazepam was not administered with PRN morphine as ordered. Further review of Resident R1's MAR revealed that Resident R1 was repositioned on 10/12/25, at 6:00 p.m., 8:00 p.m., and 10:00 p.m., then again on 10/13/25, at 12:00 a.m., 2:00 a.m., 4:00 a.m., 6:00 a.m., 8:00 a.m., 10:00 a.m., and 12:00 p.m There was no evidence that Resident R1 was premedicated with his/her PRN Lorazepam and PRN Morphine prior to his/her care as ordered. Review of Resident R1's task (charting area where nursing assistants document in the clinical record) revealed that Resident R1 was repositioned on 10/13/25, at 10:00 p.m., then again on 10/14/25, at 12:00 a.m., 4:00 a.m., 6:00 a.m., 10:00 a.m., and 12:00 p.m., There was no evidence that Resident R1 was premedicated with his/her PRN Lorazepam and PRN Morphine prior to his/her care as ordered. Review of Resident R1's nursing progress notes revealed a note dated 10/12/25, at 11:23 p.m., indicating that Resident R1 appears comfortable other than when care is provided. Another nursing progress noted dated 10/13/25, at 5:02 p.m. indicated that Resident R1 had increased moaning and anxiety while repositioning and incontinence care being provided. During an interview on 12/3/25, at 9:55 a.m. the Director of Nursing confirmed that Resident R1's Morphine order lacked instructions to administer with Lorazepam prior to care as ordered. He/she also confirmed that the Morphine order should have been transcribed as it was written by the physician. 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, facility documentation, and clinical records, and staff interviews, it was determined that the facility failed to provide the required level of assistance with bed mobility (rolling side to side or turning in bed) as identified in the plan of care, task order summary, and in accordance with facility policy which resulted in actual harm of a laceration to the right forehead and an intraventricular hemorrhage (brain bleed) for one of 11 residents reviewed (Resident R1). This deficiency is cited as past non-compliance. Findings include: The Safe Resident Handling/Transfers policy, dated 1/14/25, revealed, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident . Resident R1's clinical record revealed an admission date of 8/18/19, with diagnoses that included Alzheimer's Disease (a progressive disorder that affects memory, thinking, and behavior), Parkinsonism (movement disorder which includes slowness of movement, muscle stiffness, and tremors), and muscle weakness. Resident R1's task order summary (a program used by nursing staff to verify resident bed mobility assist orders) revealed task order reviews dated 10/25/23, 1/16/24, and 7/30/25, all indicating to utilize an assist of two staff for rolling side to side. Resident R1's ADL (Activities of Daily Living) Self Care Performance Deficit care plan, date initiated 11/12/23, revealed, Bed Mobility: The resident is totally dependent on two staff for repositioning and turning in bed. Resident R1's clinical record revealed a nursing note written by Registered Nurse (RN) Employee E2, dated 8/5/25, at 5:56 a.m. CNA (Certified Nursing Assistant) was performing AM care with resident. When resident was rolled, he/she rolled out of bed and struck his/her head on the roommate's bed frame. Resident was assessed. 3 cm (centimeter) x 0.6 cm laceration to right forehead with bruising observed. Wound was cleansed with normal saline, steri-strips (thin adhesive bandages used to close small shallow wounds by sealing the edges of the wound together) were applied with good approximation of skin. Bleeding was controlled. Neuro-checks (assessments completed to check overall brain function) initiated per facility protocol. PCP (Primary Care Provider) and family updated.Resident R1's clinical record revealed a nursing note written by RN Employee E10, dated 8/5/25, at 10:16 a.m. that identified Resident continues to be in a great deal of pain following his/her fall and the injury to his/her forehead. Resident continues to cry in pain. Tylenol administered per order. After assessment of the open area this resident MD (Medical Doctor) contacted, and order received to transfer to hospital for eval and treatment with possible stitches. Residents HOB (head of bed) placed at 30 degrees. Neuro checks continue and are WNL (within normal limits). Family notified. Will continue to monitor.Resident R1's clinical record revealed a nursing note written by Licensed Practical Nurse (LPN) Employee E3, dated 8/5/25, at 2:38 p.m. that included call received from the local hospital's Emergency Department PA-C (Certified Physicians Assistant) stating that resident had a CT scan (Computed Tomography Scan- an imaging test used to see detailed pictures of organs, bones, and body tissues) done of his/her head and that it showed a small hemorrhage. Physicians Assistant stated that normally they would send resident to larger hospital for observation and consult with neurosurgery, but due to CMO (Comfort Measures Only) status residents family does not want him/her sent and that resident would be sent back to facility for us to monitor and keep comfortable as needed. RN phoned and updated on phone call. Resident R1's clinical record revealed CT scan results dated 8/5/25, at 1:50 p.m. indicating acute (new) very low volume bilateral intraventricular hemorrhage. The facility investigation revealed RN Employee E2 emailed the Director of Nursing (DON) a statement on 8/6/25 at 9:30 a.m. indicating he/she was called to the third floor for a resident who had fallen. Once he/she arrived in the room Resident R1 was laying supine in his/her bed with a significant laceration on his/her right forehead. RN Employee E2 asked agency CNA Employee E1 what had happened. Agency CNA Employee E1 stated that he/she was standing between Resident R1's bed and his/her roommates' bed and when agency Employee E1 went to roll Resident R1 towards him/her he/she did not realize how stiff Resident R1 was and Resident R1's torso rolled out of the bed and struck his/her forehead on the bed frame of the roommates' bed. Agency Employee E1 was asked to wait at the nurse's station at that time, and he/she was relieved of his/her duties and left the building. The facility investigation revealed that agency CNA Employee E1 provided a written statement with an incident date of 8/5/25, which revealed, As he/she was turning Resident R1 his/her head hit the other bed because it was so close, and nobody told him/her that Resident R1 was so stiff. Resident R1 hit his/her head on the edge of the bed and agency CNA Employee E1 called for help. The facility investigation revealed that CNA Employee E4 provided a written statement with an incident date of 8/5/25, indicating he/she was assisting another Resident when he/she heard several bangs coming from Resident R1's room. He/she went to Resident R1's room to see what was going on. The agency CNA Employee E1 was sitting on Resident R1's bed facing the windows with Resident R1 laying across his/her lap. Resident R1's upper half was laying on the bed, his/her mid-section was on the agency CNA Employee E1's lap, and his/her legs were out of the bed towards the roommate's bed. Upon his/her arrival the agency CNA Employee E1 indicated that Resident R1 fell out of bed. Employee E4 then left the room to call the RN and when he/she returned Resident R1 was completely in bed bleeding from his/her forehead. The facility investigation revealed that Resident R1 was non-verbal and could not provide a statement or any details related to the incident. Documentation submitted by the facility, dated 8/5/25, revealed that the facility initiated an investigation and the agency CNA Employee E1 was asked to leave the facility immediately and would not be returning. During interviews on 10/21/25, with RN Employees E2 and E9, LPN Employees E3, E5, and E6, and CNA Employees E7 and E8, all confirmed that Resident R1 was always and assist of two for transfers/bed mobility rolling side to side and the information could be found under the task orders. During an interview on 10/21/25, at approximately 9:30 a.m. the DON confirmed that the agency CNA Employee E1 had attempted to roll Resident R1 independently and did not follow the task orders and care plan which indicate Resident R1 required two for bed mobility rolling side to side. The facility failed to ensure that Resident R1 was provided adequate assistance in accordance with their task orders and care plan to utilize two staff for bed mobility rolling side to side, causing a laceration to the right forehead and an intraventricular hemorrhage. This deficiency is cited as past non-compliance. On 8/6/25, the facility-initiated education for all nursing staff including RN's, LPN's, and CNA's to ensure that resident transfers and bed mobility care are performed per resident care plans and facility task orders. This plan included the following: Immediate Suspension and Do Not Return of agency CNA Employee E1 Immediate education regarding checking transfer status/ bed mobility before providing care was provided to nursing staff which included RN's, LPN's, and CNA's, which occurred from 8/6/25, through 8/7/25. Review of all resident transfer/bed mobility statuses completed by the DON on 8/6/25. All staff included in the education also completed competencies conducted by the Management Team. Interviews with RN Employees E2 and E9, LPN Employees E3, E5, and E6, and CNA Employees E7 and E8, confirmed the facility-initiated education and competencies starting 8/6/25, which included education on checking transfer status/ bed mobility before providing resident care and performing a return demonstration to ensure proper knowledge and technique. Audits were conducted to ensure residents are transferred per their care plans and task orders, which occurred on all shifts and on all units from 8/11/25, through 10/10/25 with all transfers/bed mobility rolling side to side performed appropriately. The facility has demonstrated compliance with using correct transfer/bed mobility status for residents since 9/8/25. During an interview with the NHA and the DON on 10/22/25, at approximately 2:30 p.m. and review of the facility's immediate actions, education, competencies, and audits, it was verified that the facility had implemented a plan of correction to ensure residents are free from harm/injury regarding transfer status/bed mobility rolling side to side of residents and had achieved substantial compliance. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, facility documentation, and clinical records, and staff interviews, it was determined that the facility failed to ensure that one resident was free of neglect during care which resulted in actual harm of a laceration to the right forehead and an intraventricular hemorrhage (brain bleed) for one of 11 residents reviewed (Resident R1).Findings include: The Abuse, Neglect, and Exploitation policy, dated 1/14/25, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Resident R1's clinical record revealed an admission date of 8/18/19, with diagnoses that included Alzheimer's Disease (a progressive disorder that affects memory, thinking, and behavior), Parkinsonism (movement disorder which includes slowness of movement, muscle stiffness, and tremors), and muscle weakness. Resident R1's task order summary (a program used by nursing staff to verify resident bed mobility assist orders) revealed task order reviews dated 10/25/23, 1/16/24, and 7/30/25, all indicating to utilize an assist of two staff for rolling side to side. Resident R1's ADL (Activities of Daily Living) Self Care Performance Deficit care plan, date initiated 11/12/23, revealed, Bed Mobility: The resident is totally dependent on two staff for repositioning and turning in bed. Resident R1's clinical record revealed a nursing note written by Registered Nurse (RN) Employee E2, dated 8/5/25, at 5:56 a.m. CNA (Certified Nursing Assistant) was performing AM care with resident. When resident was rolled, he/she rolled out of bed and struck his/her head on the roommate's bed frame. Resident was assessed. 3 cm (centimeter) x 0.6 cm laceration to right forehead with bruising observed. Wound was cleansed with normal saline, steri-strips (thin adhesive bandages used to close small shallow wounds by sealing the edges of the wound together) were applied with good approximation of skin. Bleeding was controlled. Neuro-checks (assessments completed to check overall brain function) initiated per facility protocol. PCP (Primary Care Provider) and family updated.Resident R1's clinical record revealed a nursing note written by RN Employee E10, dated 8/5/25, at 10:16 a.m. that identified Resident continues to be in a great deal of pain following his/her fall and the injury to his/her forehead. Resident continues to cry in pain. Tylenol administered per order. After assessment of the open area this resident MD (Medical Doctor) contacted, and order received to transfer to hospital for eval and treatment with possible stitches. Residents HOB (head of bed) placed at 30 degrees. Neuro checks continue and are WNL (within normal limits). Family notified. Will continue to monitor.Resident R1's clinical record revealed a nursing note written by Licensed Practical Nurse (LPN) Employee E3, dated 8/5/25, at 2:38 p.m. that included call received from the local hospital's Emergency Department PA-C (Certified Physicians Assistant) stating that resident had a CT scan (Computed Tomography Scan- an imaging test used to see detailed pictures of organs, bones, and body tissues) done of his/her head and that it showed a small hemorrhage. Physicians Assistant stated that normally they would send resident to larger hospital for observation and consult with neurosurgery, but due to CMO (Comfort Measures Only) status residents family does not want him/her sent and that resident would be sent back to facility for us to monitor and keep comfortable as needed. RN phoned and updated on phone call. Resident R1's clinical record revealed CT scan results dated 8/5/25, at 1:50 p.m. indicating acute (new) very low volume bilateral intraventricular hemorrhage. The facility investigation revealed RN Employee E2 emailed the Director of Nursing (DON) a statement on 8/6/25 at 9:30 a.m. indicating he/she was called to the third floor for a resident who had fallen. Once he/she arrived in the room Resident R1 was laying supine in his/her bed with a significant laceration on his/her right forehead. RN Employee E2 asked agency CNA Employee E1 what had happened. Agency CNA Employee E1 stated that he/she was standing between Resident R1's bed and his/her roommates' bed and when agency Employee E1 went to roll Resident R1 towards him/her he/she did not realize how stiff Resident R1 was and Resident R1's torso rolled out of the bed and struck his/her forehead on the bed frame of the roommates' bed. Agency Employee E1 was asked to wait at the nurse's station at that time, and he/she was relieved of his/her duties and left the building. The facility investigation revealed that agency CNA Employee E1 provided a written statement with an incident date of 8/5/25, which revealed, that as he/she was turning Resident R1 his/her head hit the other bed because it was so close, and nobody told him/her that Resident R1 was so stiff. Resident R1 hit his/her head on the edge of the bed and agency Employee E1 called for help. The facility investigation revealed that CNA Employee E4 provided a written statement with an incident date of 8/5/25, indicating he/she was assisting another Resident when he/she heard several bangs coming from Resident R1's room. He/she went to Resident R1's room to see what was going on. The agency CNA Employee E1 was sitting on Resident R1's bed facing the windows with Resident R1 laying across his/her lap. Resident R1's upper half was laying on the bed, his/her mid-section was on the agency CNA Employee E1's lap, and his/her legs were out of the bed towards the roommate's bed. Upon his/her arrival the agency CNA Employee E1 indicated that Resident R1 fell out of bed. Employee E4 then left the room to call the RN and when he/she returned Resident R1 was completely in bed bleeding from his/her forehead. The facility investigation revealed that Resident R1 is non-verbal and could not provide a statement or any details related to the incident. A review of employment documents revealed that agency CNA Employee E1 signed the nursing agency's orientation policy related abuse and neglect to ensure safe care of all residents on 9/7/24. Documentation submitted by the facility, dated 8/5/25, revealed that the facility initiated an investigation and the agency CNA Employee E1 was asked to leave the facility immediately and would not be returning. During interviews on 10/21/25, with RN Employees E2 and E9, LPN Employees E3, E5, and E6, and CNA Employees E7 and E8, all confirmed that Resident R1 was always an assist of two for transfers/bed mobility rolling side to side and the information could be found under the task orders. The facility failed to ensure that Resident R1 was free from neglect resulting in actual harm of a laceration to the right forehead and an intraventricular hemorrhage. During an interview on 10/21/25, at approximately 9:30 a.m. the DON confirmed that the agency CNA Employee E1 did not ask for assistance, did not follow the task orders, and did not follow the care plan which indicated Resident R1 required two staff for bed mobility/rolling side to side and attempted to roll Resident R1 independently causing harm to Resident R1. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, investigation documents, and clinical records, and staff interviews, it was determined that the facility failed to maintain a safe environment regarding mechanical lift sling sizing for one of three residents that utilize a mechanical lift reviewed (Resident R46), that resulted in actual harm and required staple repair for a head laceration. Findings include: The facility's policy Safe Resident Handling/Transfers, dated 1/14/25, indicated that residents are to be transferred safely to prevent or minimize risks for injury. The policy further indicated that the facility will ensure that there are appropriate amounts of varying sizes of slings to accommodate residents and that residents will be measured correctly as per manufacturer's instructions on proper sling sizing. Review of Resident R46's clinical record revealed an admitted [DATE], with diagnoses that included respiratory failure, heart failure, anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and diabetes mellitus (high blood sugars). Review of Resident R46's Quarterly Minimum Data Set (MDS - an assessment tool used to facilitate the management of care for residents) assessment dated [DATE], revealed under section GG 0170 E, that Resident R46 was dependent on staff for transfer from chair to bed. The Quarterly MDS also revealed that Resident R46 was cognitively intact. Review of Resident R46's active physician's orders revealed an order for transfers by use of maxi lift (type of mechanical lift). Review of Resident R46's Care Plans under Activities of Daily Living (ADLs) revealed resident transfers with the maxi lift. Review of information submitted by facility dated 2/22/25, and interview with the Director of Nursing revealed Resident R46 was incorrectly transferred with a Hoyer lift (type of maxi lift) and sling that was too large. Resident R46 was transferred to the hospital related to a head laceration. Review of the facility's investigation revealed that Nurse Aide (NA) Employees E10 and E11 utilized a blue extra-large sling on 2/21/25, when they transferred Resident R46 and the resident fell through the sling. Hospital documentation dated 2/21/25, revealed that Resident R46 slipped out of the Hoyer lift and fell and sustained a hematoma (bruise) and laceration to the back of the head with two staples to repair the laceration. During an interview on 2/25/25, at 9:00 a.m. Resident R46 revealed that staff had used a blue sling (extra-large) and not the normal medium size. During interviews on 2/24/25, at approximately 1:55 p.m. NA Employees E6, E7, and E9 all indicated that there was no process or documentation in the resident's clinical record to indicate what sling size to use when utilizing the Hoyer lift. During an interview on 2/25/25, at 10:45 a.m. the Director of Nursing confirmed that NA Employees E10 and E11 transferred Resident R46 by Hoyer lift using a blue sling that was too big and Resident R46 fell through the sling that resulted in harm of a head laceration. The DON also confirmed that there was not a process in place to ensure appropriate sling size determination. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policies, observations, and staff interview, it was determined that the facility failed to serve food in a safe and sanitary manner during tray line and ensure that food was stored in accordance with standards for food safety in the main kitchen, and resident pantries (First and Third floor). Findings include: Review of facility policy entitled Dietary-Food Preparation and Service dated 1/14/25, indicated Gloves must be worn when handling food directly. However, gloves can also become contaminated and/or soiled and must be changed between tasks. Review of facility policy entitled Labeling and dating procedure for food and beverage dated 2/14/25, indicated We now have a total of 5 days to keep foods that are taken out of their original package. A product that is left in its original container can be used up to 7 days or the use by date whichever comes first. and The day that you open something is day 1 . Review of facility policy entitled Dietary-Food Receiving and Storage dated 2/14/25, indicated All foods belonging to residents must be labeled with resident's name, room number, the item and the use by date. And Pesticides and other toxic substances . will not be stored in storerooms for food . Review of facility policy entitled Foods Brought By Family-Visitors dated 2/14/25, indicated containers will be labeled with the resident name, the item, and the use by date. and Staff is responsible for discarding perishable foods on or before the use by date. Observations during kitchen tour on 2/23/25, at 9:00 a.m. revealed in the refrigerators a metal pan containing barbecue pork with a prepared date of 2/18/25, a metal pan containing chili with a prepared date of 2/18/25, a clear plastic tub containing three hard boiled eggs with a prepared date of 2/14/25, two cartons of potato salad with open dates of 2/11/25, and 2/13/25, a plastic tub of coleslaw with an open date of 2/13/25, and two open plastic tubs of strawberry yogurt with open dates of 2/12/25, and 2/15/25. During an interview with Dietary [NAME] Employee E1 at the time of observations, he/she expressed that food not kept in their original containers is discarded within five days and food that is open and kept in their original container are discarded within seven days or by the expiration date whichever comes first. He/she confirmed that the pan of barbecue pork, pan of chili, container of hard boiled eggs, cartons of potato salad, tub of coleslaw, and tubs of yogurt were beyond their use by date and/or expiration date. He/she also confirmed that the items should have been discarded by or before their use by date or expiration date. Observations on 2/23/25, at 1:00 p.m. of a refrigerator in the First Floor pantry used for residents revealed a jar of homemade jelly with no resident name and an open date of 10/22/23, observations of the freezer in the pantry revealed food items sitting next to ice packs that are used for treatments on residents and one of the ice packs remained in the cloth cover sitting on top of food items. During an interview at the time of observations with the Director of Nursing (DON), he/she confirmed that the homemade jelly in the refrigerator lacked a resident name and was beyond the use by date and that there were ice packs used for treatments on residents being stored in the same freezer with food. He/she also confirmed that food items should be labeled and discarded by the use by date, and ice packs used on residents should not be stored with food. Observation on 2/23/25, at 1:10 p.m. of a refrigerator in the Third Floor pantry used for residents revealed a loaf of homemade bread wrapped in tin foil with no resident name or date, and a pizza box with two pieces of pizza in the box with no date on the pizza box. During an interview at the time of observations, the Dietary Manager Employee E3 confirmed that the homemade bread lacked a resident name or date, and the pizza box lacked a date. He/she also confirmed that food items should have a resident's name and should be discarded by the use by date. Observations on 2/23/25, at 12:10 p.m. during tray line, revealed Homemaker Employee E2 washed his/her hands and placed gloves on then proceeded to take temperatures of the food, then picked up a three ring binder and pen and wrote the temperatures down, then proceeded to move residents tray tickets around on the steam table, then started to place food on the resident's plate, then took the plate and sat it on the counter, then held onto the food with his/her gloved hand and cut the meat. Homemaker Employee E2 failed to remove his/her gloves and wash his/her hands after touching several items before touching the resident's food. During an interview at the time of the observations, Homemaker Employee E2 confirmed that he/she touched several items then touched the resident's food with the same gloves. He/she also confirmed that they should have removed his/her gloves washed their hands and applied new gloves before touching the resident's food. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policy and documentation and clinical record, and staff interviews, it was determined that the facility failed to ensure that one of five residents reviewed (Resident R1) was free of neglect during care which resulted in actual harm of a fracture of the right clavicle (collar bone). Findings include: Review of a facility policy entitled, Skilled Nursing-Abuse last reviewed 5/11/22, indicated that each resident will be free from all forms of abuse, neglect, exploitation and misappropriation of resident property, and that the community (facility) will educate staff in techniques to protect all parties, and indicated that the facility defined neglect as the failure to provide services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the job description entitled, Licensed Practical Nurse, Skilled revised 12/2020, indicated that Licensed Practical Nurses (LPNs) are expected to provide leadership and direction to Nurse Aids (NAs) to deliver and maintain quality care within established policies and procedures and guidelines of the Pennsylvania Nurse Practice Act. Review of the job description entitled, Certified Nurses' Aide revised 2/2020, indicated that NAs are expected to provide nursing care and related services to residents according to each resident's comprehensive assessment and plan of care. Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included stroke with left-sided weakness, right and left-hand contractures (fixed tightening of muscle, tendons, ligaments, or skin that prevents normal movement), and muscle weakness. Review of Resident R1's Quarterly Minimum Data Set (MDS - an assessment tool used to facilitate the management of care) assessment submitted 11/15/22, revealed that Section G0110 Activities of Daily Living (ADL), revealed Resident R1's bed mobility (how a resident moves from lying to sitting, side-to-side, and foot of bed to head of bed) was a 4 for self-performance identifying the resident was totally dependent (full staff performance every single time during a seven day look back period). In addition, Resident R1's bed mobility was a 3 for support identifying the resident required two or more persons for physical assist. A review of Resident R1's day planner (facility document used to communicate specific Resident ADL/Daily Care List to floor staff) revealed that the Interdisciplinary Team indicated on 9/07/22, that Resident R1 required the assistance of two staff for bed mobility. Review of a facility document entitled, Bed Mobility Assist X 2 dated 11/17/22, revealed that Resident R1 required the assistance of two staff members for bed mobility. Review of a Situation, Background, Assessment, and Recommendation (SBAR) form dated 11/29/22, 7:30 p.m., revealed that during the provision of personal care to Resident R1, LPN Employee E2 left the resident's room and left NA Employee E1 alone in Resident R1's room and that NA Employee E1 continued to provide care without assistance and rolled Resident R1 onto his/her side in bed, and Resident R1 fell out of bed. Review of a progress note in Resident R1's clinical record dated 11/30/22, at 6:09 a.m. revealed that Resident R1's right shoulder was swollen and painful to the touch, and at 7:39 a.m. the physician assessed the right shoulder and ordered x-rays. Review of diagnostic x-ray results dated 11/30/22, 2:06 p.m. revealed a fractured right clavicle. Review of the facility's investigation dated 11/30/22, 2:45 p.m. revealed that NA Employee E1 and LPN Employee E2 were providing care to Resident R1 in bed, LPN Employee E2 left the room to complete additional tasks, while LPN Employee E2 was out of the room NA Employee E1 continued to provide care to Resident R1 and placed him/her on his/her side, and NA Employee E1's hand slipped off of Resident R1 and Resident R1 fell to the floor. Further documentation revealed that NA Employee E1 and LPN Employee E2 were both aware that Resident R1 required the assistance of two staff members for bed mobility. Review of facility documents dated 8/10/22, and 9/29/22, revealed that LPN Employee E2 and NA Employee E1 completed competencies regarding changing an incontinence pad on an occupied bed independently. During an interview on 12/12/22, at 11:40 a.m. the Nursing Home Administrator and Director of Nursing confirmed that LPN Employee E2 and NA Employee E1 knew that Resident R1 was to have two staff members to assist with bed mobility and that there should have been two staff members with Resident R1 when he/she was rolled onto his/her side to prevent Resident R1 from falling out of bed. The facility neglected to utilize the appropriate level of assistance with bed mobility for a resident identified as requiring the assistance of two staff members, which placed the resident at risk for injury from an improper bed mobility method. As a result, there was actual harm to Resident R1 of a right clavicle fracture requiring medical treatment. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(2) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies and documentation, clinical records, and staff interviews, it was determined that the facility failed to provide adequate supervision during care resulting in death for one of five residents reviewed (Resident R1). Findings include: Review of the Resident Assessment Instrument (RAI) 3.0 User's Manual effective October 2019, indicated that bed mobility is defined as how resident moves to and from lying position, turns side or side, and positions body while in bed or alternate sleep furniture. The RAI further indicated that How a resident turns from side to side, in the bed, during incontinence care, is a component of Bed Mobility and should not be considered as part of Toileting. Review of the Fall Risk Assessment policy dated 10/15/21, revealed that the facility is to provide a safe environment for residents. Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Each resident's risk factors and environmental hazards will be analyzed for the development of the care plan and revised as needed. Review of Nurse Aide (NA) Employee E2's job description for Certified Nurses' Aide, signed by employee on 5/23/22, indicated that all resident care provided will meet the resident's physical, mental, and psychosocial needs and will enable the resident to attain and maintain the highest practical level of functioning. Review of facility documentation revealed that NA Employee E2 had received training on neglect, abuse, and resident rights on 5/23/22, received training on falls on 7/13/22, and on-the-job training form dated 6/20/22, revealed that NA Employee E2 received training in conducting initial and ongoing data relevant to the resident's needs, receiving and giving report at change of shift, delivering incontinence care at least every two hours and as needed, and monitoring for fall precaution needs. Review of Resident R1's clinical record, revealed an admitted [DATE] with diagnoses of [CONDITION(S)] (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dementia (condition related to loss of cognitive [thinking, remembering, and reasoning] to such an extent that it interferes with a person's daily life and activities), and hypertensive heart disease (long-term condition that develops over many years in people who have high blood pressure). Review of the annual MDS Resident Assessment and Care Screening dated 12/1/21, and the quarterly MDS dated [DATE], Section G G0110, Activities of Daily Living, revealed Resident R1's bed mobility was coded a 3 for requiring extensive assistance (resident involved in activity, staff provide weight-bearing support, and requiring two or more persons, physical assist. Review of the facility Fall Risk Assessment Tool dated 5/20/22, indicated that Resident R1 was a high fall-risk. Review of Resident R1's care plan dated 11/2/17, identified a risk of falling due to [CONDITION(S)] and weakness. Interventions on the care plan included I need staff to increase frequency of safety checks when appropriate, Be sure to check on me frequently at night, and I need transfers per physican order of full body lift assist X 2 [assist of two people]. Review of information submitted by the facility dated 8/5/22, revealed that Prior to incident, resident required assistance with bed mobility due to her diagnosis. She received assistance from either 1 or 2 staff members, depending on the type of care being provided. During an interview on 8/17/22, at 9:30 a.m. the Nursing Home Administrator (NHA) revealed that the interdisciplinary team for the annual MDS did not care plan for bed mobility. An interview with the Licensed Practical Nurse Assessment Coordinator (LPNAC) on 8/17/22 at 2:50 p.m., revealed that bed mobility is not care planned unless a resident has multiple behaviors or medical orders that necessitate it be care planned. An interview with the NHA on 8/17/22, at 9:30 a.m. revealed that nurse aides are to comprehend residents' bed mobility by having consistent assignments and discussing it during shift report (before starting their assignments). An interview with the LPNAC on 8/17/22, at 2:50 p.m. revealed that nurse aides are to comprehend residents' bed mobility by having consistent assignments and communication among team members. During an interview on 8/17/22, at 3:30 p.m. NA Employee E1 indicated that nurse aides talk about residents' bed mobility during shift report. Review of the facility documentation, Incident Report Documentation dated 8/5/22, revealed that Resident R1 was receiving care from NA Employee E2 at 2:05 a.m. when Resident R1 was found on the floor. Review of facility documentation, witness statement signed by NA Employee E2 but not dated, indicated that around 2:00 a.m., he/she was providing care to Resident R1. I placed myself on her left and rolled her on her right to pull the tucked pad. I had my left hand on her hip thinking it would be enough and the motion of the pull was when she went head first. During an interview on 8/17/22, at 3:05 p.m. NA Employee E2 was interviewed about the level of staff assistance to provide care to Resident R1 in bed and stated that everybody knows he/she is an assist of one. NA Employee E2 also stated that Resident R1 was a petite lady, had contracted arms and legs, and that there were no issues with providing care in bed to her. Review of facility documentation revealed an interview with NA Employee E1 by the NHA dated 8/5/22. The documentation indicated that when NA Employee E1 entered Resident R1's room, NA Employee E2 was on the left side of the bed and Resident R1 was on the floor between the bed and the windows. He/she stated that when NA Employee E2 explained what had happened, it didn't make sense to her she fell off the bed head first. During an interview on 8/17/22, at 3:30 p.m. NA Employee E1 revealed that he/she was answering call bells while NA Employee E2 was providing incontinence care to Resident R1. NA Employee E1 heard a loud noise and went into Resident R1's room where he/she saw Resident R1 lying on the floor and NA Employee E2 standing on the left side of the bed. Review of a progress note from the Nurse Practioner dated 8/5/22 at 7:00 a.m. revealed that Resident R1's color was pale, there were three distinct hematomas (injury that causes blood to collect and pool under the skin; bad bruise) on the left parietal region (located near the back and top of the head). His/her pupils were unequal and had no verbal response to tactile or verbal stimuli. Review of Resident R1's radiology report for an x-ray of the skull dated 8/5/22, at 11:16 a.m., indicated that the skull x-ray was essentially unremarkable with no fracture. Review of Registered Nurse Employee E3's progress note dated 8/10/22, at 8:32 p.m., revealed that Resident R1 ceased to breathe on 8/10/22, at 8:15 p.m. Review of the Certificate of Death for Resident R1, revealed that the immediate cause of death was complications of [MEDICATION(S)] force trauma to the head as a consequence of a fall. The facility failed to provide adequate supervision during care resulting in a fall with actual harm to Resident R1 which resulted in his/her death. 28 Pa. Code 210.14(a) Responsibility of licensee 28 Pa. Code 211.12(a)(d)(1)(3)(5) Nursing services

Based on review of observations, facility policies and documentation, and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program by failing to follow infection control guidelines from the Centers for Disease Control and Prevention (CDC) and the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections and prevent cross-contamination during the COVID-19 pandemic. This failure placed the facility in an Immediate Jeopardy situation for six of six residents reviewed (Residents R2, R4, R6, R9, R10, and R11). Findings include: Pennsylvania Health Alert Network (PA-HAN) - 530, regarding Long-Term Care Facility Guidance for Testing and Cohorting (for outbreaks and exposure to COVID-19 - a contagious [MEDICAL CONDITION] disease that can cause a variety of symptoms, including breathing problems, fever and cough), dated October 7, 2020, indicated that residents needed to be cohorted (grouped together) to separate units in three zones, based on test results: - COVID-19 positive residents (Red Zone) were residents with a positive test and still within the parameters for transmission-based precautions. - Potentially exposed residents (Yellow Zone) were residents with a negative COVID-19 test who remained asymptomatic but were within 14 days of possible exposure to COVID-19. - Unexposed (Green Zone) were any residents in the facility who were not tested and were thought to be unexposed to COVID-19. - Zones were to be clearly marked with limited access signs or temporary barriers to prevent unnecessary foot traffic to the area. Review of CDC guidance Responding to Coronavirus (COVID-19) in Nursing Homes, dated 4/30/20, indicated that residents of nursing homes who have a confirmed COVID-19 infection, regardless of symptoms, should be transferred to a designated COVID-19 care unit. Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for COVID-19 fourteen days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). Exposed residents may be permitted to room share with other exposed residents, if space is not available for them to remain in a single room. Review of facility document entitled, Updated Guidance for all Campuses and Service Lines, dated 1/04/21, indicated that: for resident rooms without a solid wall between beds the facility should not move the roommate out of the room of anyone who tested positive, because chances are they have already been exposed. Facilities are to keep the residents together and try to minimize their ongoing exposure to each other by closing privacy curtains, minimizing contact with each other, masking both residents when one is out of bed and facing away from each other during meals. Review of room assignments and review of the requested facility line listing for residents indicated that exposed/negative residents remained in the room with diagnosed positive residents. The facility employs the [MEDICATION NAME] testing which confirms positive or negative results within 15 minutes. Resident R7 tested positive on 1/02/21, and experienced weakness, and remained with Resident R10 who tested positive on 1/06/21, and experienced lethargy. Resident R8 tested positive on 1/02/21, and who was asymptomatic, and remained with Resident R9 who tested positive on 1/06/21, and experienced lethargy. Resident R12 tested positive on 1/06/21, and experienced weakness, and remained with Resident R11 who tested positive on 1/08/21, and who was asymptomatic. Resident R1 tested positive on 1/06/21, and experienced weakness, and remained with Resident R2 for 2 days, who is negative. Resident R3 tested positive on 1/06/21, who was asymptomatic, and remained with Resident R4 for 2 days, who is negative. Resident R5 tested positive on 1/06/21, and experienced weakness, and remained with Resident R6 for 2 days, who is negative. Observations on 1/08/21, at 1:20 p.m. revealed that there were double-layered zippered plastic barriers at the entrance to rooms [ROOM NUMBER]. Further observation on 1/08/21, at 1:30 p.m. of Rooms 206, and 215 revealed that in both rooms, the COVID positive residents were also located near the door and the COVID negative residents were furthest in the room near the window and required staff to walk through the COVID positive resident's to provide care to the COVID exposed/negative resident. During an interview on 1/08/21, at 12:30 p.m. the Administrator confirmed that the [MEDICAL CONDITION] outbreak is limited to the second floor, and that the facility is not moving COVID positive residents, and the facility has set up double layered plastic zippered barriers at each doorway to the rooms containing a positive resident. During an interview on 1/08/21, at 1:25 p.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that those three rooms contain one positive and one exposed/negative resident. He/she also confirmed that the privacy curtain is pulled between the residents in room [ROOM NUMBER] to provide isolation and that the COVID positive resident was located closest to the door, and the COVID exposed/negative resident was located further into the room near the window. He/she also confirmed that in order to provide care to the exposed/negative resident, you must walk by the COVID positive resident's bed to the other side of the privacy curtain. During an interview on 1/08/21, at 1:45 p.m. the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that cohorting COVID positive with COVID exposed/negative roommates was a result of recommendations from the Regional Congregate Care Assistive Team (RCAT) consultant/Raven (Reduce Avoidable hospitalization s using Evidence-based interventions for Nursing Facility Residents) Nurse to prevent spreading [MEDICAL CONDITION], and based on facility policy entitled, Updated Guidance for all Campuses and Service Lines. The Administrator and ADON were made aware that Immediate Jeopardy existed for six of six residents in the facility on 1/08/21, at 9:06 p.m. and a corrective action plan was requested. On 1/08/21, at 11:25 p.m. an acceptable corrective action plan was approved which included the following interventions: 1. The three residents who were considered to be in immediate danger were relocated to other rooms away from the roommate that had recently tested positive. 2. The three residents considered to be in immediate danger were moved out of the room with a positive roommate (red zone) and placed in a room either alone or with a roommate that has not tested positive (yellow zone). 3. A review of all other residents shows that they are appropriately cohorted at this time in either a red zone room or yellow zone room. In addition, residents are being monitored twice daily for signs/symptoms of COVID-19 and anyone presenting with symptoms is [MEDICATION NAME] tested . 4. Staff and leadership present this evening were all educated on the need to immediately relocate the roommate of a resident that tests positive if the roommate tests negative. In addition, signage is present to denote a red zone area from a yellow zone area. Education will continue so that all staff are updated on this protocol. 5. ADON provided education tonight in writing to staff. 6. This education is posted as a read and sign and nurses are asked to review with CNAs (nurse aides) and pass through to next shift. 7. NHA, DON and ADON will consult with Medical Director and CRNP (Certified Registered Nurse Practitioner)/RCAT consultant to review current status and determine how to create a specific red zone separate from yellow zone following the guidance in PA HAN 530. The current floor plan of the neighborhood will be assessed to determine proper placement in zones. Additional room changes may need to occur to physically separate rooms in red and yellow zones. This will occur on 1/9/21. Observation on 1/09/21, at 11:30 a.m. revealed the facility was utilizing the unit floor plan to determine the progression of resident room changes to establish a Red Zone and the Immediate Jeopardy was removed on 1/09/21, at 3:00 p.m when the action plan implementation was verified. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure adequate safety measures were implemented by attaching foot rests (supportive device attached to a wheelchair for the feet to rest upon) to the wheelchair during transport that resulted in actual harm of a left femur (thighbone) fracture to one of five residents reviewed (Resident R1). Findings include: The clinical record for Resident R1 revealed diagnoses of polyosteoarthritis (four or more joints in the body become painful and inflamed), [CONDITION(S)] (slow and progressive circulation disorder), difficulty in walking, and muscle weakness. The Quarterly MDS, dated [DATE], revealed that Resident R1 had a Brief Interview for Mental Status (BIMS) with a score of 12/15, interpreted as moderate impairment. Resident R1 also was identified as needing extensive assistance from staff for moving on the unit. Resident R1 had an incident on 11/12/20 at 6:20 p.m. where he/she was being transported from the bathroom to the bed in a wheelchair without foot rests and his/her left foot dropped to the floor causing discomfort. On the incident report, it was noted that Resident R1 stated that it was the fourth time her feet dropped to the floor that day while being transported in a wheelchair. The Director of Nursing (DON) documented on 11/13/20 at 6:24 a.m. that she reviewed the incident report. Resident R1's care plan was updated to include on 11/13/20 that staff are to utilize foot rests when pushing him/her in the wheelchair. Resident R1 had another incident on 11/17/20 at 4:20 p.m. where he/she was being pushed in a wheelchair without foot rests and his/her left leg went onto the floor and curled under the wheelchair. He/she immediately reported left knee pain. Resident R1 received an x-ray on 11/18/20 at 12:30 p.m. with results of a left femur fracture. A witness statement from the Nurse Aide Employee E1 who was pushing Resident R1 on 11/17/20 at 4:20 p.m. stated that as I was pushing her out of her room to the shower room she was holding her legs up for me .when we were going down the hall her legs dropped and folded under the wheelchair .resident yelled out in pain. During an interview on 12/18/20, at 1:20 p.m. the DON confirmed that Resident R1 was being pushed in a wheelchair on 11/17/20, without the required foot rests attached to the wheelchair during transport which resulted in actual harm of a left femur fracture. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.19(d) Resident rights 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services