Every finding on record at Pennypack Rehab and Care Center

Based on clinical record review and staff interview, the facility failed to ensure complete and accurate documentation related to a hospital discharged for 1 of 8 resident reviewed. (Resident 53) Findings Include: Review of Resident R53' s nursing notes dated March 13, 2026, at 12:51 p.m. revealed that the resident was transported for an Oncology appointment. Resident R53 was transferred to the local hospital from the Oncology appointment on March 13, 2026, at 6:33 p.m. due to a change in condition. Further review of nursing notes revealed no additional documentation or follow-up communication with the hospital, related to the resident admitting diagnosis, stay and discharge status. Interview with the Director of Nursing, Employee E2 on May 21, 2026, at 2:00p.m. confirmed that there was no follow up documentation related to Resident R53 transfer to the hospital. 28 Pa. Code 211.5(d) Medical records

Based on family interview, review of facility policy and review of clinical record, it was determined that facility did not ensure to timely notify resident representative after change in condition for one of 12 residents reviewed (Resident R5)Findings include: Review of facility policy 'Acute Condition Changes - Clinical Protocol,' revised March 2018, indicates that the policy did not include a protocol/process for notifying the resident representative of changes in the resident's status/condition, including who was responsible for notification, required timeframes, or documentation requirements. Review of Resident R5's clinical record revealed medical history of repeated falls, vascular dementia (progressive degenerative disease of the brain), glaucoma (increase eye pressure resulting in the inability of fluid do drain from the inner eye), acute and chronic respiratory failure, gait and mobility abnormalities, sick sinus syndrome (also called sinus node dysfunction- a group of heart rhythm problems caused by malfunction of the heart's natural pacemaker).Further review of Resident R5's clinical record revealed that on Monday, May 18, 2026, at approximately 2:30 pm, Resident R5 had a fall. Further review of Resident R5's progress notes revealed no evidence of facility notifying Resident R5's representative. Interview with Resident R5's representative (RP), on Tuesday, May 19, 2026, at 10:15 am, revealed no evidence of facility notifying RP of a fall incident; per RP's statement he was still waiting for nursing staff to inform him of what happened on May 18, 2026, since his mother (Resident R5 )has been complaining of knee pain and R5's roommate - Resident R23, expressed concern of R5's fall incident. Further review of Resident R5's clinical record revealed additional emergency contact, who was R5's spouse. Further interview with R5's RP revealed no indication that either one of emergency contacts, Resident R5's son or Resident R5's spouse, were notified of fall incident. 28 Pa. Code 211.12(d)(1) Nursing services

Based on interviews with staff and residents, reviews of clinical records, review of personal funds accounting records and facility's policies and procedures, it was determined that for one of eight residents reviewed, the facility failed to maintain separate accounting and records for each resident's personal funds entrusted to the facility on the resident's behalf. (Resident Cl1)Findings include:A review of the facility's policy titled accounting and records of resident funds dated April 2021 it was revealed that the business office manage was responsible for maintaining accounting records on resident funds. The policy also indicated that the business office manager was responsible for maintaining records of all financial transactions involving each resident's personal needs account. The policy said that individual accounting ledgers are to be maintained in accordance with generally accepted accounting principles. The date of the resident's admission was to be indicated. The date and amount of each deposit and withdrawal. The name of the person who accepted or withdrew the funds. Receipts for chargers imposed by the facility and interest earned. The policy indicated that the business office manager was to provide copies of the accounting records to the resident or the resident's representative for services charged. The policy indicated that the resident was to ask the business office manager or the nursing home administrator any questions or concerns about their resident's personal funds account. Clinical record review revealed that Resident CL1 was admitted to the facility on [DATE], and was discharged to another facility on November 14, 2024. Clinical record review revealed a physician's progress note dated November 14, 2024, that indicated Resident Cl1 was being discharged today to [facility's name] for continued close follow-up with the primary care physician. Clinical record review revealed a physician's progress note dated November 14, 2024, that confirmed Resident Cl1 was admitted to the facility on [DATE], after a hospital stay for cerebral vascular accident, right arm weakness and atrial fibrillation. The physician indicated that Resident Cl1 was alert and oriented and ordered rehabilitation services with physical therapy upon admission to the facility. Clinical record review revealed an admission comprehensive assessment MDS (an assessment of care needs) dated January 12, 2024, for Resident Cl1. The assessment indicated that this resident was admitted to a Medicare and/or Medicaid certified facility. The assessment also indicated that this resident was cognitively intact. A review of the personal funds accounting records for Resident Cl1 revealed that the facility did not establish and maintain a complete accounting of funds, according to generally accepted accounting principles for Resident Cl1.Resident Cl1 was admitted to the facility on [DATE]. There was no accounting documentation available for review that indicated Resident Cl1 was admitted on [DATE]. There was no documentation available for review that indicated the business office manager or facility administrator assisted Resident Cl1 to establish a personal funds account to paid for his stay during (January 8, 2024, through November 14, 2024). Interview with the administrator, Employee E1 and the business office manager, Employee E3, at 2:00 p.m., on January 2, 2026, confirmed that the facility had no documentation concerning the accounting records or financial transactions involving Resident Cl1's funds, although the facility did accept the responsibility for the resident's financial affairs. Interview with the administrator, Employee E1 and the business office manager, Employee E3, at 2:15 p.m., on January 2, 2026, revealed that they were both unaware what insurances, pensions and private pay funds were scheduled to be deposited into Resident Cl1's personal funds account to pay for his stay (January 8, 2024, through November 14, 2024).28 PA. Code 211.10(a)(b)(c)(d) Resident care policies28 PA. Code 201.14(a) responsibility of licensee28 PA. Code 201.18(b)(2)(3)(d)(e)(1)(1)(g)(h) Management

Based on staff interviews, review of clinical records and review of facility documents, it was determined that the facility failed to ensure residents were assessed and monitored after fall incidents for one out of two residents reviewed (Resident R1).Findings include:Review of the facility policy, Assessing Falls and Their Causes, with a revision date of March 2018 indicated that the purpose of the policy is to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. The policy also stated that if a resident has a fall, or is found on a floor without a witness to the event, that staff is to be evaluated for possible injuries to the head, neck, spine and extremities; obtain and record vital signs as soon as it is safe to do so; notify the physician; provide appropriate first aide and/or obtain treatment immediately if there is evidence of injury; observe for delayed complications of a fall for approximately 48 hours.document any observed signs or symptom of pain, swelling, bruising, deformity, and any changes in level of responsiveness/consciousness and overall function. The policy also indicated that an incident report for the fall should be completed by the nursing supervisor on duty and the time, and submitted to the Director of Nursing. Continued review of the policy indicated that the resident's physician and family are to be notified in an appropriate time. Review of the November 2025 physician orders for Resident R1 included the diagnoses of dementia (progressive degenerative disease of the brain); anxiety; mild intellectual disabilities; lack of coordination; dysphagia (difficulty with swallowing). Review of the clinical record also indicated that the resident required the use of a wheelchair for mobility. Review of a nursing note dated November 1, 2025, at 7:23 p.m. stated that the resident was transferred to the emergency room due to swelling and bruising to the lower right extremity. Review of an incident report dated November 1, 2025, completed by the nursing supervisor (Employee E3) stated that the nursing supervisor was called to the resident's room and discovered scattered purpose bruising from the abdomen to the knee. The incident report indicated that the residents could not offer any information regarding the bruised areas.During an interview with the Director of Nursing (DON) on November 13, 2025 at 11:15 a.m. the DON reported that she was notified by the nursing supervisor (Employee E3) on November 1, 2025 of the bruised area on the resident and during the investigation of the bruise that was reported to her on November 1, 2025 by nursing supervisor (Employee E3). DON stated that she was notified that the resident had sustained a fall (s). Review of an interview dated November 3, 2025 that the Director of Nursing (DON) conducted with the nursing supervisor (Employee E3) for the 3:00 p.m. through the 11:00 p.m. nursing shift on October 29, 2025, Employee E3 revealed that during the 3:00 p.m. through the 11:00 p.m. nursing shift on October 29, 2025, at approximately 10:55 p.m. she heard a grunt and when she went to investigate, she saw the resident sitting on the floor in front of his wheelchair. The nursing supervisor reported in her statement that she did not complete a nursing assessment on the resident that she found on the floor because that fall occurred on 11:00 p.m. through the 7:00 a.m. nursing shift and the nurse for that shift needed to complete it. Review of interview dated November 5, 2025 conducted by the DON with Employee E5 (licensed nurse on the 10:45 p.m. through the 7:00 p.m. nursing shift) revealed that Employee E5 reported that he came in the building on October 29, 2025 and was in the process of putting his belongings away when he witnessed the resident sliding off the chair. Employee E5 reported that both he and a nurse aide picked the resident off the floor. Employee E5 also stated that the resident had a 2nd fall 20-25 minutes after the first fall. Continued interview revealed that when asked what he did after the falls, the licensed nurse reported that he did not do anything. Review of the resident's clinical record provided no evidence of a clinical note regarding any of the 2 reported falls, and no evidence that the resident was assessed by nursing staff (e.g. changes in resident's cognition; vital signs such as pulses, blood pressure and respiratory rate; assessing the resident's range of motion, skin integrity, pain, etc.) regarding any of the 2 reported falls.Review of the resident's clinical record did not show evidence that the physician was notified for any of the above referenced 2 falls that were reported by nursing staff to have occurred by licensed nursing staff. During an interview with the Director of Nursing on November 13, 2025, at 12:11 p.m. it was discussed and confirmed that nursing staff did not notify the physician of Resident R1 by facility staff after the 2 falls that nursing staff reported that he had.During an interview with the resident's attending physician on November 14, 2025, at 11:03 a.m. the physician confirmed that he was not notified by nursing staff that Resident R1 had a fall (s) on October 29, 2025 until November 1, 2025.28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on the review of clinical records, and interviews with staff, it was determined that the facility failed to inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate for one of 5 residents reviewed. (Resident R1).Findings Include:Review of clinical record revealed that Resident R1 was admitted to the facility on [DATE].Review of admission agreement for Resident R1 signed by resident and facility staff, at the time of resident's admission, revealed that the charges for the services including charges for residents stay at the facility when not covered under Medicare/Medicaid or insurance was not informed to the resident. The section where the charges should be described was left empty.Facility did not provide any documents that informed Resident R1 services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid.Interview with Employee E3, Business office manager, on August 21, 2025, at 11:00 a.m. stated the rate should be provided to residents upon admission with admission agreement.28 Pa. Code 201.18(e)(1) Management.

Based on observations, review of facility policy and staff interviews, it was determined that the facility failed to ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Findings include: Review of the facility's undated Food Storage Policy, indicated that the Food Service Director and/or Cook(s) will ensure that all food items are stored properly, labeled and dated, and have 2 date system, which is the prepared date and use by date. Continued review of the policy also indicated that the Food Service Director and or cook(s) will ensure that all food items are stored properly by being in an air-tight container and labeled (if not in the original package) and dated with the receive date and then with opened and use by dates). During a tour of the dietary department on June 5, 2025 at 11:30 a.m. with the Food Service Director various food items were observed to have been opened, but not properly dated as follows: -a bag of frozen cut green beans observed in the freezer were dated as being opened on June 5, 2025, but there was no use by date listed on the bag by the dietary staff. -a bag of frozen carrots observed in the freezer were dated as being opened on June 5, 2025, but there was no use by date listed on the bag by the dietary staff. -a pack of frozen hamburgers observed in the freezer were dated as being opened on May 5, 2025, but there was no used by date listed on the package by the dietary staff. -a gallon of milk observed in the refrigerator was dated as being opened on June 5, 2025, but there was no use by date listed on the container by the dietary staff. -a container of Italian dressing observed in the refrigerator had an open date of June 3, 2025, but there was no use by date listed on the container by the dietary staff. -a container of soy [NAME] sauce observed in the refrigerator that had been used by facility staff to prepare food was in observed in the refrigerator without an open date, and without a use by date. During an interview with the Food Service Director on June 5, 2025 during the tour which started at 11:30 a.m. the food service director reported that the food items should display a date that the food item was opened by the food service staff and a and a use by date should also be displayed. 28 PA Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management

Based on review of facility policy and review of clinical records, it was determined that the facility failed to develop and implement a baseline care plan for one of six new admissions reviewed (Resident R19). Findings Include: Review of facility policy on Care Plans-Baseline revealed that under section Policy Statement A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. Under section Policy Interpretation and Implementation #1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b. Physician orders. c. Dietary orders. #2. The baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan (no later than 21 days after admission). The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed. #3. A comprehensive care plan may be used in place of the baseline care plan providing the comprehensive care plan is developed within 48 hours of the resident's admission and meets the requirements of a comprehensive assessment. Review of Resident R19's clinical record revealed that Resident R19 was admitted to the facility on [DATE], with diagnosis of Severe Protein Calorie Malnutrition. Further review of Resident R19's clinical record revealed that Resident R19 was transferred to a local hospital on December 20, 2025, was readmitted to the facility on [DATE], and was transferred back to a local hospital on December 31, 2024, and was readmitted back to the facility on January 5, 2025. Further review of Resident R19's clinical record revealed no documented evidence that a baseline care plan addressing Resident R19's severe protein calorie malnutrition and weight status was developed and implemented until January 8, 2025, when a comprehensive care plan was developed. Interview with facility dietician Employee E3 conducted on June 4, 2025, at 2:45 p.m. confirmed that there was no baseline care plan for nutrition. 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(5) Nursing services

Based on a review of clinical records and facility policies and procedures, observations, and interviews with staff, it was determined that the facility failed to provide respiratory care and supplemental oxygen according to physician's order for one of seventeen residents reviewed. (Resident R40). Findings include: Review of facility Policy on Oxygen Administration under section Purpose The purpose of this policy is to provide guidelines for safe oxygen administration. Under section Preparation #1. Verify that there is a physician's order for this procedure. Review the physician's orders for oxygen administration. Under section Steps in the Procedure #8. Turn on the Oxygen. Unless otherwise ordered, start the flow of the oxygen at the rate of 2 to 3 liters per minute. Review of Resident R40's clinical record revealed that Resident R40 was admitted to the facility on [DATE], with diagnoses of chronic obstructive pulmonary disease. Review of Resident R40's physician's orders revealed an order for; 02 (Oxygen) at 3 Liters via nasal cannula, every shift for SOB (shortness of breath) Observation conducted on Resident R40 during the tour of the facility conducted on June 3, 2025, at 12:24 p.m. revealed that Resident R40 was sitting up on her bed with nasal cannula connected to an oxygen concentrator. Observation of the oxygen concentrator revealed that the oxygen guage was set at 2 liters/minute. Interview with Resident R40 conducted at the time of the observation revealed that she did not know that her oxygen was at 2 liters and did not know who adjusted it. Interview with licensed nurse Employee E7 conducted on June 3, 2025, at 12:30 p.m. confirmed that the oxygen order for Resident R40 was oxygen at 3 Liters via nasal cannula, every shift for SOB (shortness of breath). Follow-up observation of Resident R40 conducted together with Employee E7 on June 3, 2025, at 12:38p.m. confirmed that Resident R40's oxygen was set at 2 liters/ minute. Employee E7 then proceeded to adjust Resident R40's oxygen concentrator to 3 liters/minute. 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure physician visits were completed as required for one of 19 residents reviewed (Resident R4). Findings include: Review of Resident R4's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool) dated May 2, 2025, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including cancer, heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), renal failure (a condition in which the kidneys lose the ability to remove waste and balance fluids) and dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). Review of progress notes for Resident R4 revealed that there were no physician or practitioner notes from November 2024 through June 2025 available for review at the time of the survey. Continued review revealed that the last time the resident was seen by a physician was August 2, 2024. Interview on June 5, 2025, at 9:41 a.m. the Director of Nursing confirmed that there were no notes in Resident R4's clinical record from Resident R4's attending physician and that there were no notes from any physician or practitioner since August 2024 available for review at the time of the survey. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa code 211.2 (d)(3) Medical Director

Based on observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure appropriate enteral feeding practices related to labeling and implementing dietician recommendations for one of two residents reviewed related to enteral feeds (Resident R33). Findings include: Review of facility policy, Medical Nutrition Therapy: Assessment and Care undated, revealed, The Registered Dietician/Nutritionist (RDN) or other clinically qualified nutrition professional's recommendations for changes in the nutrition plan of care will be communicated to the licensed nursing team and Dining Services Director via the summary recommendations sheet. The RDN or other clinically qualified nutrition professional will be responsible for ensuring follow up and appropriate documentation of recommended changes in the plan of care. Observation on June 3, 2025, at 11:17 a.m. revealed Resident R33's enteral tube feeding (nutrition delivered directly into the gastrointestinal tract through a tube) of Glucerna 1.5 was infusing via a pump at 40 ml/hr (milliliters per hour) with water flushes of 74 ml every two hours. Continued observation revealed that there was no date on the bottle of when the Glucerna was opened and no name or date label on the bag for water flushes. Interview on June 3, 2025, at 11:19 a.m. Employee E5, licensed nurse, stated that Resident R33 receives continuous tube feedings, that the Glucerna was already infusing when she started her shift and that she did not know when the bottle was opened. Continued observation on June 4, 2025, at 9:34 a.m. revealed that Resident R33's tube feeding of Glucerna 1.5 was infusing via a pump at 40 ml/hr with water flushes of 74 ml every two hours. Review of physician order for Resident R33 revealed an order, dated May 7, 2025, for Glucerna 1.5 via continuous feed at 40ml/hr. Continued review revealed another order, date May 16, 2025, for water flushes of 75ml every two hours via auto flush (via feeding pump). Further review revealed an order, dated May 5, 2025, to delegate the task of writing dietary orders to a clinically qualified nutrition professional. Clinical record review for Resident R33 revealed a nutrition note, dated May 16, 2025, at 11:42 a.m. which indicated that the resident had weight loss and the registered dietician recommended to increase the tube feeding to Glucerna 1.5 at 50 ml/hr for 22 hours per day. Interview on June 4, 2025, at 2:31 p.m. the Director of Nursing stated that when the dietician makes recommendations, the dietician is expected to enter the order and then the nursing department verifies the order. Interview on June 4, 2025, at 2:45 p.m. Employee E3, dietician, stated that when she makes recommendations, she either verbally informs or emails the Director of Nursing, and that the Director of Nursing then reviews the recommendations and enters the order. Continued interview revealed that Employee E3, dietician, was unaware that her recommendations to increase Resident R33's tube feedings were not implemented and that the resident's water flushes were not set at the correct rate on the feeding pump. 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(3)(5) Nursing services

Based on staff interviews and review of facility documentation, it was determined that the facility failed to conduct a complete and thorough investigation related to an allegation of potential abuse/neglect for 1 out of 13 residents reviewed (Resident R101) Findings include: Review of the June 2025 physician orders for Resident R101 included the following diagnosis: diabetes (a disease characterized by elevated levels of blood glucose); hypertension (high blood pressure); pressure ulcer of left hip (a bedsore that develops due to prolonged pressure on that particular area of the body), and heart failure (the heart is unable to pump enough blood to meet the body's needs). Review of information submitted from the facility and to the State Survey Agency on November 20, 2024 indicated that on November 20, 2024 Resident R101 reported that a nurse aide (Employee E8) shoved a bed pan under him which hit his pressure ulcer, causing him to have severe pain during the 3:00 p.m. -11:00 p.m. nursing shift. The resident also indicated that the nurse aide delayed providing him care by telling the resident that he/she would return to assist him after the resident told the nurse aide that he just had a bowel movement. Review of the undated witness statement submitted by nurse aide, Employee E8 indicated I care for the resident as I should of and never abused any resident. Continued review of the undated statement did not show evidence that the facility asked nurse aide, Employee E8 about the resident's allegations to ensure a complete and through investigation into the resident's allegations. Continued review of the investigation revealed two witness statements from 2 licensed nurses (Employee E9 and Employee E10) regarding the alleged incident. Review of the nursing schedule provided by the facility for the 3:00 p.m. through the 11:00 p.m. nursing shift on November 20, 2024 indicated that there were 4 additional nursing staff members who were working on the floor during that time who were not interviewed (licensed nurse Employee E11; nurse aide E12; nurse aide E13 and nurse aide E14). Continued review of the facility's investigation regarding the resident's allegations provided no evidence of documentation of any interviews with the above referenced staff on the 3:00 p.m. through the 11:00 p.m. shift regarding the resident's allegations against Employee E8. During an interview with the Director of Nursing (DON) on June 6, 2025 at 1:22 p.m. Employee E8's statement was reviewed with the DON and the above referenced concerns regarding the statement from the alleged perpetrator was discussed. It was also discussed during the interview with the DON that the facility did not have any statements from the 4 referenced nursing staff members who worked on the 3:00 p.m. through the 11:00 p.m. nursing shift on November 20, 2024. 28 Pa. Code 201.14(a)(e) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.29(c) Resident rights

Based on clinical record reviews, review of facility policies and interviews with staff, it was determined that the facility failed to complete a discharge MDS assessment for one of 19 residents reviewed (Resident R9). Findings include: Review of facility policy, Resident Assessments dated March 2022, revealed, The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews. Clinical record review for Resident R9 revealed that the resident was admitted to the facility on [DATE], for short term rehabilitation. Review of progress notes revealed that the resident discharged home on February 3, 2025. Review of MDS (Minimum Data Set - a mandatory periodic resident assessment tool) assessments for Resident R9 revealed that a discharge MDS assessment had not been completed. Interview on June 5, 2025, at 9:03 a.m. the Director of Nursing confirmed that a discharge MDS had not been completed for Resident R9. 28 Pa Code 201.14(a) Responsibility of licensee

Based on observations, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that personal foods were stored and labeled in accordance with food safety standards for one of one medication rooms reviewed (A/B Wing medication room). Findings include: Review of facility policy, Medication Storage and Labeling dated 2001, revealed, Medications are stored separately from food and are labeled accordingly. Review of facility policy, Foods Brought by Family/Visitors dated March 2022, revealed, Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that it is clearly distinguishable from facility-prepared food. Observation of the A/B wing medication storage room on June 3, 2025, at 9:47 a.m. with Employee E5, licensed nurse, revealed a container of food, that was unlabeled and undated, stored in a refrigerator that contained vaccines. Interview, at the time of the observation, Employee E5, licensed nurse, confirmed the above finding and stated that she did not know who the food belonged to or when it was from. 28 Pa Code 205.25(b) Kitchen

Based on observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to follow physician orders during medication administration for one of five residents observed during medication administration (Resident R34). Findings include: Review of facility policy, Administering Medications dated April 2019, revealed, Medications are administered in accordance with prescriber orders. Observation on June 3, 2025, at 9:37 a.m. of morning medication pass revealed Employee E5, licensed nurse, prepare a lidocaine 4% patch (pain medication applied to the skin) and apply it to Resident R34's left shoulder. Review of physician's orders for Resident R34 revealed an order dated February 9, 2025, for lidocaine 5% patch, apply to left shoulder in the morning. Interview on June 3, 2025, at 2:10 p.m. Employee E5, licensed nurse, confirmed that Resident R34 was ordered a lidocaine 5% patch and that she administered a lidocaine 4% patch. Employee E5, licensed nurse, stated that there were only lidocaine 4% patches available in the medication cart and that she did not know where to get a lidocaine 5% patch. 28 Pa Code 211.9(a)(1) Pharmacy services 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(5) Nursing services

Based on review of clinical record, review of facility policy, and interview with facility staff, it was determined that the facility failed to ensure that residents were free of significant medication errors for one of five newly admitted resident reviewed (Resident R1). Findings Include: Review of facility policy titled Medication and Treatment Orders and dated July 2016, revealed the following; 15. Upon admission, the admitting nurse will review the transfer record of the newly admitted patient. The admitting nurse will then notify the attending physician or on-call physician to review admission medications on the transfer record. After medications are reviewed with the physician, the admitting nurse or designee will input the approved medications from the transfer record into the PCC Emar system. The admitting nurse will need to review the transfer record against the Emar record after all medications have been transcribed to ensure all medications are transcribed correctly. Review of the clinical record for Resident R1 revealed that the patient was admitted to the facility on [DATE], for skilled nursing care following discharge from an acute care hospital. The admitting diagnoses included cerebral edema (swelling of the brain), pulmonary embolism (a blockage in the lungs caused by a blood clot), diabetes (inability of the body to produce enough insulin or to use it effectively), seizure disorder (abnormal electrical activity in the brain), cushing's syndrome (caused by prolonged exposure to group of medications known as glucocorticoids). Review of the hospital discharge summary revealed that the list of prescribed medications included Depakote 500 milligrams 1,000 two tablets by mouth every 12 hours. The last time the medication was administered was on October 20, 2024 at 8:51 a.m. Review of Resident R1's nursing note dated October 20, 2024 at 3:30 p.m. revealed New order received to continue medication as per hospital discharged summary papers. Review of Resident R1's October 2024 Medication Administration Record revealed that the medication Depakote 500 milligrams was not transcribed into the resident's orders and Medication Administration Record per physician instructions. An interview was conducted with Interim Director of Nursing, Employee E4 on November 7, 2024, at 11:00 a,m. Employee E4 confirmed that the the transcription error. 28 Pa. Code 211.9 (a)(1) Pharmacy Services 28 Pa. Code 211.9 (d) Pharmacy Services

Based on observation, review of facility policy and procedures and interview with staff, it was determined that the facility failed to maintain an effective infection control program related to the transportation, sorting, washing, and drying of soiled resident clothing and the storage of clean linens and residents' clothing in the laundry room. Findings include: Review of facility Policy on Infection prevention and control program revealed that infection prevention and control program (IPCP) was established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Review of facility document entitled Clean Linen Storage and Handling revealed; sort, transport, and store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens, or other soiled items. Observation on August 20, 2024 at 10:20 AM in the presence of the Food Service Director and the Director of Housekeeping revealed that the facility's outside dumpster area contained large blue containers filled with dirty hospital gowns. The Director of Housekeeping indicated the facility used a laundry service and the gowns were waiting to be picked up tomorrow for their services. Observation of the laundry room located in the basement conducted on August 26, 2024, at 10:48 a.m. revealed that the basement was accessible from inside the facility through a door leading to a wooden staircase, which was covered with dust and particles of stains. Further observation revealed that to reach the laundry room, used for the laundry service of the personal clothing of the residents, multiple congested areas, filled with various obsolete- looking pieces of gadgets had to be walked behind, and there was only one door to the laundry area. The laundry room measured approximately 18 x 15 feet in size. In the laundry room, there were three dryers (non-commercial). There were two washing machines (non-commercial) adjacent to the wall facing the door. On the corner of the room, near the entrance wall, and near the washing machines and the dryers, were a big pile of clear plastic bags of clothing on the floor reaching to the same height as the washing machines. Continued observation of the laundry area revealed that to the left of the room (left wall) was a desk with computer and printer, and further down the left wall was kept, housekeeping supplies, and tools seems like scrubbing pads for floor stripping machines, and mop heads. Further, observation of the Laundry room revealed that there was a large pile of sweeper mop cloths. Additional observation revealed that the floor of the Laundry room was dirty with black colored sticky particles, peeled paintings, rusted metal parts. Also observed that the laundry room was congested with gadgets like materials, clean and soiled items, personal clothes, and mop heads which were not sufficiently separated. Interview with Housekeeping staff, Employee E6 confirmed that the pile of sweeper mop cloths were items that had already been washed. Observation of the laundry room revealed that there were no clear designated area for soiled items, and clean items. Additionally, the congested space in which the soiled clothing and other soiled items were transported, delivered, sorted, washed, dried, folded and stored, did not allow for the prevention of contamination of the clean clothing by the soiled items. Observation of the shower room, located near the resident room B6, conducted on August 26, 2024, at 11:23 a.m., revealed that clean linens were stored in racks without doors, but with covering drapes. Further observation revealed that soiled lines were stored in the same shower room, in plastic bags. At the time of the finding, it was confirmed with the Housekeeping Director, Employee E6. Observation of the shower room, located near the resident room A10, conducted on August 26, 2024, at 11:33 a.m., revealed that clean linens were stored in racks without doors, but with covering drapes. Further observation revealed that soiled lines were stored in the same shower room, in plastic bags. At the time of the finding, it was confirmed with the Housekeeping Director, Employee E6. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a)(3) Management

Based on clinical record review and staff interview, it was determined that the facility failed to notify the representative of the Office of the State Long Term Care Ombudsman for two of 16 resident records reviewed (Residents R2, R36). Finding include: Review of Resident R2's clinical record revealed that the resident was admitted to the facility on [DATE], diagnosed with neuromuscular dysfunction of the blader and infection and inflammatory reaction due to indwelling urethral catheter. Review of Resident R2's nursing progress note dated May 21, 2024, revealed the resident was transferred to the hospital when there was a complaint of severe abdominal pain and blood noted in urine. Further review of the resident's record revealed the resident was transferred to the hospital on June 6, 2024, due to acute kidney failure. Resident R36 was admitted to the facility on [DATE], for aftercare following a joint replacement. Review of Resident R36's nursing progress notes dated July 13, 8 and 7, 2024 indicated the resident was transferred to the hospital due to a change in condition. Interview on August 23, 2024, at 2:00 p.m. the Nursing [NAME] Administrator confirmed that there were no written notices of the hospital transfers given to the State Long Term Care Ombudsman upon transfer out of the facility for Resident R2, and Resident R36. . 28 Pa. Code 201.29(h) Resident rights

Based on observations, clinical record review, review of facility documents and staff interviews, it was determined that the facility failed to revise the care plan for fall prevention, for one of 24 residents reviewed (Resident R25). Findings include: Review of Resident R25's clinical record revealed that the Resident was admitted in the facility on April 10, 2019. R25's diagnoses included, Unspecified Dementia (Dementia is a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), Anxiety Disorder (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), Unspecified Glaucoma (A condition in which there is a build-up of fluid in the eye, which presses on the retina and the optic nerve. The retina is the layer of nerve tissue inside the eye that senses light and sends images along the optic nerve to the brain. Glaucoma can damage the optic nerve and cause loss of vision or blindness), Muscle Wasting and Atrophy (Muscular Atrophy is the decrease in size and wasting of muscle tissue), Unspecified Lack of Coordination (Lack of Coordination can be due to damage to brain, nerves, or muscles). Review of Clinical Nursing Progress Note, dated April 3, 2024, for R25, indicated that Resident fell at about 11:35 a.m., outside of another resident's room, resident found lying on her left side, it was observed during assessment that resident had hematoma on left-side of forehead, and per physician-order Resident R25 was sent to the hospital for evaluation and treatment. Resident R25 was readmitted from the hospital on April 8, 2024. Further review of clinical progress notes dated April 8, 2024, indicated the Fall Risk Evaluation for Resident R25, resulted in Fall Risk Score of 21.0. Review of the care plan for Resident R25, indicated that the resident's fall- prevention- care plan, initiated on January 5, 2023, with the target date of April 2, 2024, was not updated, or revised, to reflect the interventional status, based on the fall risk evaluation or the fall occurred on April 3, 2024. On August 26, 2024, at 1:17 p.m., the Director of Nursing, confirmed that the findings regarding the lack of revision and updating of the care plan for Resident R25, related with the fall was accurate. 28 Pa Code 211.5(f) Clinical records 28 Pa Code 211.11(d) Resident Care Plan 28 Pa Code 211.12(c)(d)(3) Nursing services 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed for one of 24 residents reviewed (Resident R16). Findings include: The PASRR (Preadmission Screening Resident Review) was created in 1987 through language in the Omnibus Budget Reconciliation Act (OBRA) and it has three goals: to identify individuals with mental illness and/or intellectual disability, to ensure they are placed appropriately, whether in the community or in a nursing facility, and to ensure they receive the services they require for their mental illness or intellectual disability. The PASRR Level 1 must be completed on all persons who are considering admission to a Medicaid certified nursing facility. Review of Resident R16's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis to include Major Depressive Disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Post-Traumatic Stress Disorder (A disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), Schizoaffective Disorder (Schizoaffective disorder is a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder), and Anxiety Disorder (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of Resident R16's clinical record revealed a Pennsylvania Preadmission Screening Resident Review Identification Level I Form (PASRR) which indicated; for section VIII- PASRR LEVEL I Screening Outcome, the resident was not checked off for the outcomes that may or may not lead to chronic disability. Interview on August 26, 2024, at 11:30 a.m., with the Director of Nursing, confirmed the finding. 28 Pa Code 211.5(f) Clinical records 28 Pa Code 211.16(a) Social services

Based on review of clinical records, facility documentation, and interviews with staff, it was determined that the facility failed to issue the resident/resident representative a Notice of Medicare Non-Coverage (NOMNC) prior to termination of Medicare A services, as required, for one of three residents' records reviewed (Resident R25). Findings include: Review of Facility policy on Medicare Advance Beneficiary and Medicare Non-coverage Notices, indicated that if the resident's Medicare covered Part A stay or when all of Part B therapies are ending, a Notice of Medicare Non-coverage (CMS form 10123) is issued to the resident at least two calendar days before benefits end. Review of the clinical record for Resident R25 revealed that the resident was admitted to the facility on [DATE], with Medicare insurance coverage for skilled nursing care. Further review of the record revealed that Resident R25's Last Covered Day of Part A Service was June 28, 2024. Review of clinical records revealed that the Notice of Medicare Non-Coverage (NOMNC - written notice to the resident, beneficiary, or resident representative, of the right to an expedited review of a Medicare service termination) was issued to Resident R25 or the resident's representative only on July 17, 2024. Interview with the Nursing Home Administrator on August 26, 2018, at 12:30 p.m., confirmed that the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) to Resident R25 prior to the termination of the Medicare A service. The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) prior to termination of Medicare A services, as required. 28 Pa. Code 201.29(f) Resident rights