Every finding on record at Perry Health & Rehab Center

Based on review of facility policy, clinical record review, and staff interview it was determined that the facility failed to make certain necessary resident information was communicated to outside resources and that the necessary resident information was communicated to the responsible party for one of two residents reviewed (Resident R1).Findings include: Review of the facility policy Discharge Planning Policy dated 2/23/26, indicated: Transfers and discharges will meet regulatory requirements. The facility will take steps to ensure that the transfer or discharge is documented in the resident's medical record. Review of the clinical record indicated Resident R1 was admitted on [DATE]. Review of Resident R1's MDS dated [DATE], indicated diagnoses of a fib (an irregular and often very rapid heart rhythm) , hypertension (high blood pressure - when the pressure in your blood vessels is too high), and hyperthyroidism (when the thyroid gland doesn't make enough thyroid hormone) . Review of Resident R1's clinical record progress notes indicated the following: 6/29/26 - social services note 6/29/26 -Social worker met with Resident R1 to discuss discharge plans. Resident R1 advised she has something personal she needs to handle at home and expressed she would like to be discharged . Social worker questioned what date she wanted to discharge from the facility the resident responded as soon as possible. Social worker advised that she had spoken with the therapy team and has been advised that they are not recommending discharge at this time. Social worker expressed that per therapy resident is a max assist and is currently non-weight bearing. Social worker questioned if Resident R1 had equipment at home. Resident R1 voiced that she did not. Social worker acknowledged, social worker questioned if the Resident R1 would have any assistance at home and Resident R1 stated she will be able to do it. The resident expressed that she wanted to know if she had a follow up appointment scheduled for her foot. Social worker advised she would obtain necessary information and follow up. Social service note 7/10/26Re: D/C Details Spoke to her (Resident R1) nurse friend and she agrees that this is not a safe d/c - she is going to discuss not d/c today due to it not being safe for her to go home. I've talked to her extensively about d/c and how unsafe it is. I've enlisted her friends and family in trying to get her to stay for a couple more weeks to allow her foot to properly heal and continue therapy. Social service note 7/24/26Progress NoteSW met with Resident R1 to discuss discharge options. She was alert and oriented. Confirmed code status listed as full code. She would like to continue with this code status. Resident R1 is a 71 F with other fracture of left lower leg, subsequent encounter for closed fracture with routine healing, unspecified atrial fibrillation, essential (primary) hypertension, and hypothyroidism Resident R1 reports that she lives in a stand-alone 2 story home with bedrooms and full bathroom on the 2nd floor. She is a non-weight bearing patient and dependent for toileting, showers, getting dressed. She needs assistance transferring as well. She will have meals brought in through a local delivery service and people from her church will also support her. She has a ramp to get in and out of the house. She also has a company that will come in to help her walk her dog, [NAME]. She stated that she would have the door removed off the powder room in the downstairs bathroom so she can get in/out freely with her wheelchair. The sister and church friends believe she needs to go into an assisted living facility where she can transition accordingly with her condition and age. She wanted to leave ASAP due to her friends throwing her a birthday party the following day. Progress NoteSocial worker spoke with Resident R1 friend on 7/23/26, who advised she was calling to check the status of Resident R1's HHC (home health care). Social worker advised that Resident R1 refused home health care the day of discharge. Social worker voiced to Resident R1's friend that Resident R1 told social services that she had all of the following contingencies in place: ramp outside of home to get in/out effortlessly, bathroom door removed off of powder room, home delivered meals set up, dog walker ?in place and friends assisting her. Social worker voiced that Resident R1 had stated she had enough friends from the church to help her out. She just wanted out to go home and prepare for the birthday party they were throwing her at her house. Resident R1 friend voiced her understanding, and stated Resident R1, is stubborn and she believes there was a misunderstanding. Resident R1 friend voiced that, Resident R1; was under the impression she would have had to pay for the home health care services. Social worker informed Resident R1 friend that she thoroughly educated Resident R1 regarding home healthcare and assured that she would not be billed. Social worker stated that she also informed Resident R1 that HHC would come 2-3 times during the week and advised it would not be as extensive as therapy in the facility. Resident R1 friend, voiced understanding and questioned what she needed to do next to get HHC in place. Social worker advised that she would need to reach out to Resident R1 PCP and asked for a script for HHC for PT, OT and AIDE. Social worker advised that, the office would be able to send the script directly to a HHC facility or provide agencies for Resident R1 friend to contact. Resident R1 friend voiced her understanding and phone call was disconnected. Review of the clinical record failed to indicate contact with the family/friends notifying them that Resident R1 was discharging from the facility prior to Resident R1 discharging. Review of the clinical record failed to indicate contact with outside resources, (protective services) that Resident R1 had discharged against facility recommendations. During an interview on 8/18/26, at approx. 4:37 p.m. Social Services Employee E1 confirmed that there wasn't documentation showing that the family/friends were notified of Resident R1 discharge. During the same interview on 8/18/26, Social Service Employee E1 confirmed that protective services wasn't notified, and the facility and family/friends did not think discharge was in appropriate for Resident R1 at this time. During an interview on 8/18/26, at 4:37 p.m. Social Service Employee E1 was informed that the facility failed to make certain necessary resident information was communicated to outside resources and that the necessary resident information was communicated to the responsible party for Resident R1. 28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights

Based on review of facility provided documents, clinical record review, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents with pressure ulcers for one of four residents (Resident R1).Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set Assessments (MDS - periodic assessment of care needs) dated October 2025, indicated that Section V: Care Area Assessment (CAA) Summary instructions stated, For each triggered care area, Column B Care Planning Decision is checked to indicate that a new care plan, care plan revision, or continuation of the current care plan is necessary to address the issue(s) identified in the assessment of that care area. Review of facility policy Comprehensive Care Planning dated 2/23/26, indicated an interdisciplinary plan of care will be established and updated as indicated for every resident in accordance with state and federal regulatory requirements. The facility will develop a comprehensive person-centered care plan for each resident that includes measurable goals and timetables to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment. The comprehensive care plan will be developed within (7) days after completion of the comprehensive assessment (MDS). Review of the clinical record indicated Resident R1 was originally admitted to the facility 4/30/24, then readmitted [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/4/26, indicated diagnoses of quadriplegia (paralysis that affects all limbs and body from the neck down), osteomyelitis (bone infection) of vertebrae (backbone), sacrum (triangular bone at the base on the spine), and sacrococcygeal (area at base on spine where the sacrum meets the coccyx (tailbone)) region, and protein-calorie malnutrition. Review of Section M: Skin Conditions indicated resident is at risk of developing pressure ulcer/injuries and indicated the presence of a Stage III (full-thickness skin loss) pressure ulcer. Review of Section V: Care Area Assessment Summary indicated that the Pressure Ulcer Care Area was triggered with an X, and Care Planning Decision was triggered with an X, indicting the triggered care area is addressed in the care plan. Review of Resident R1's physician order dated 4/21/26, indicated right gluteal fold Special instructions: Cleanse with normal saline (sterile solution), pat dry, apply medical grade honey (sterile, clinically tested honey used to promote wound healing, fight infection, and support tissue repair), calcium alginate (natural, highly absorbent material), zinc oxide paste (skin protectant) to peri wound, apply border gauze (specialized wound dressing), as needed for soilage, once a day 23:00 (11:00 p.m.) - 07:00 (7:00 a.m.). Review of Resident R1's clinical progress note Skin and Wound note dated 5/5/25, indicated right gluteal fold, stage 3. Patient (R1) would like to resume service with doctor at wound center. Treatment has included medical honey/calcium alginate. Patient (R1) has refused debridement (medical removal of dead, damaged, or infected tissue to promote healing and reduce the risk of infection). Review of the current care plan on 6/9/26, failed to reveal a plan of care developed with goals and interventions for the risk that Resident R1 may develop pressure ulcer/injuries, and failed to reveal a plan of care developed with goals and interventions related to Resident R1 having an actual pressure ulcer. During an interview on 6/9/26, at 2:40 p.m., the Director of Nursing (DON) confirmed that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents with pressure ulcers for Resident R1. 28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly secure a medication cart for three of four medication carts (Second Floor B, C, G Hall Medication Cart, Third Floor Front Hall Medication Cart and Third Floor Back Hall Medication Cart).Findings include: Review of the facility policy General Dose Preparation and Medication Administration last reviewed 2/8/26, indicated the facility should ensure that medication carts are always locked when out of sight or unattended. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of Resident R7's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/10/26, indicated diagnoses of dementia (loss of cognitive functioning, remembering, and reasoning) asthma (chronic lung disease that makes it hard to breathe) and high blood pressure. Section C0500 Brief Interview for Mental Status (BIMS) score coded as 04 indicating severely impaired cognition. During an observation completed on 4/7/26, at 12:27 a.m. Resident R7 was seated in her wheelchair next to the medication cart near room [ROOM NUMBER]. Resident R7 reached up and removed an item that was sitting on top of the medication cart. The Speech Therapist (ST) Employee E3 observed her removing the item from the top of the cart and was attempting to redirect the resident and retrieve the item. The ST Employee E3 identified the item as someone's personal cell phone. The medication cart was found to be unlocked. During an observation and interview completed on 4/7/26, at 12:30 p.m. Registered Nurse (RN) Employee E4 returned to the medication cart and stated that the cell phone was hers that's mine and retrieved the phone off the resident. RN Employee E4 confirmed that the cell phone was left sitting on top of the medication cart and that the medication cart was left unattended and unlocked. RN Employee E4 identified the Medication Cart as the Second Floor B, C, G Hall Medication Cart. During an observation completed on 4/7/26, at 12:40 p.m. an unlocked medication cart was found sitting in the hallway near room [ROOM NUMBER]. During an interview completed on 4/7/26, at 12:43 p.m. Registered Nurse (RN) Employee E5 confirmed that the medication cart was left unattended and unlocked. RN Employee E5 identified the medication cart as the Third Floor Front Hall Medication Cart. During an observation completed on 4/7/26, at 12:45 p.m. an unlocked medication cart was in the hallway near room [ROOM NUMBER]. During an interview completed on 4/7/26, at 12:47 p.m. RN Employee E6 confirmed the medication cart was left unattended and unlocked. RN Employee E6 identified the medication cart as the Third Floor Back Hallway Medication Cart. During an interview completed on 4/7/26, at 1:15 p.m. the Director of Nursing confirmed that the facility failed to properly secure a medication cart for three of four medication carts (Second Floor B, C, G Hall Medication Cart, Third Floor Front Hall Medication Cart and Third Floor Back Hall Medication Cart). 28 Pa. Code: 201(a) Responsibility of licensee.28 Pa. Code: 211.9(a)(1) Pharmacy services.28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility provided documents and staff interviews, it was determined that the facility failed to ensure residents' records are readily accessible to the State Survey Agency which caused a delay in the survey process for one of three residents (Resident R3).Findings include: During an interview completed on 4/7/26, at approximately 12:15 p.m. upon asking the Director of Nursing (DON) concerning documentation prior to 12/1/25, informed State Agency that the Matrix (computer program) was just started on 12/1/25, with new ownership and that residents in the facility during the transition period on 12/1/25, have records in the Point Click Care (PCC-computer program). The facility does not have access to PCC, will have to contact corporate (corp) office to gain access. During an interview completed on 4/7/26, at 1:00 p.m. the Regional Registered Nurse (RN) Employee E1 stated they (corp) do not have access to PCC will contact them again to gain access. During an interview completed on 4/7/26, at 2:08 Regional Registered Nurse (RN) Employee E1 stated that corp had to contact legal in an effort to gain access to PCC and the program was still unavailable to State Agency. During an interview completed on 4/7/26, at 3:15 p.m. the PCC program was still not accessible to the State Agency. State Agency to return to facility on 4/8/26. During an interview on 4/8/26, at 8:45 a.m. the State Agency received access to the PCC system for record review. The DON stated, we had to have legal get involved as the prior ownership company took everything and would not give us access and confirmed the facility failed to ensure resident records are readily accessible to the State Survey Agency which caused a delay in the survey process for one of three residents. 28 Pa. Code: 211.5(f)(g)(h) Clinical records.

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of three residents sampled with facility-initiated transfers (Residents R1 and R4) and failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for two of three resident hospital transfers (Residents R1 and R4) .Findings include: Review of the facility Discharge Planning Policy last reviewed 2/8/26, indicated the facility will take steps to ensure that the transfer or discharge is documented in the resident's medical record and necessary information is communicated to the receiving health care institution or provider. Review of the clinical record indicated resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/9/26, indicated diagnoses of high blood pressure, septicemia (infection in blood) and chronic obstructive pulmonary disease (makes it hard to breathe). Review of the clinical record indicated Resident R1 was transferred to the hospital on 3/21/26, and has not returned to the facility. Review of Resident R1's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. Review of Resident R1's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 3/21/26. Review of the clinical record indicated resident R4 was admitted to the facility on [DATE]. Review of Resident R4's MDS dated [DATE], indicated diagnoses of cancer, anemia (low iron in the blood) and high blood pressure. Review of the clinical record indicated Resident R4 was transferred to the hospital on 3/17/26, and has not returned to the facility. Review of Resident R4's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. Review of Resident R4's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 3/17/26. During an interview completed on 4/7/26, at 12:15 p.m. the Director of Nursing confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of three residents sampled with facility-initiated transfers (Residents R1 and R4) and failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for two of three resident hospital transfers (Residents R1 and R4) . 28 Pa. Code: 201.14(a)Responsibility of licensee.28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights.

Based on review of facility policy, facility documents, clinical record review, and resident, and staff interviews, it was determined that the facility failed to make certain call lights were answered timely for four of 12 residents as required (Resident R1, R2, R3, and R4).Findings include: The facility policy Call Light Resident Communication System Policy dated 2/8/26, indicated that staff will respond to call lights promptly. Review of Resident Council Meeting Minutes dated 2/18/26, revealed that Resident waiting to be changed. Review of Resident R1 concern dated 3/12/26, stated I have had my call light on for over an hour and staff are going past my room without evenings stopping. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident 1's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 2/3/26, indicated diagnoses of high blood pressure, anxiety, and depression. Review of Section GG: Functional Abilities GG0130, indicated that Resident R1 is dependent with toilet hygiene. (Helper does all of the effort. Resident does none of the activity), and section GG0170 indicated that resident is dependent with toilet transfers (helper does all of the effort). During an interview on 3/18/26, at 10:20 a.m. Resident R1, stated that call lights take long to answer during the night shift. Review of the clinical record revealed that Resident R2 was admitted to the facility on [DATE]. Review of Resident 2's MDS dated [DATE], indicated diagnoses of malnutrition (insufficient nutrients in the body), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Review of Section GG: Functional Abilities GG0130, indicated that Resident R2 is dependent with toilet hygiene. During an interview on 3/18/26, at 10:16 a.m. Resident R2, stated that response time to call lights is Slow after midnight. I've had to wait an hour. Review of the clinical record revealed that Resident R3 was admitted to the facility on [DATE]. Review of Resident 3's MDS dated [DATE], also indicated diagnoses of malnutrition, diabetes, and PVD. Review of Section GG: Functional Abilities GG0130, indicated that Resident R3 is dependent with toilet hygiene. During an interview on 3/18/26, at 10:56 am. Resident R3 stated It sometimes takes an hour and a half to answer call bell at night. Review of the clinical record revealed that Resident R4 was admitted to the facility on [DATE]. Review of Resident 4's MDS dated [DATE], indicated diagnoses of malnutrition, high blood pressure, and atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat). Review of Section GG: Functional Abilities GG0130, indicated that Resident R4 is dependent with toilet hygiene. During an interview on 3/18/26, at 12:51 p.m. Resident R4 stated They don't always come. I have to wait an hour to hour and a half. Especially at night. During an interview on 3/18/26 at 2:05 p.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed the facility failed to make certain call lights were answered timely. 28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on observation, and staff interview, it was determined that the facility failed to maintain a clean, safe, and homelike environment for three of six residents (Resident R1, R2, and R3) and one of two shower rooms on the second floor (Large Shower Room).Findings Include:Interview with the Nursing Home Administrator on 12/10/25, at 12:51 p.m. indicated the facility does not have a policy regarding homelike environment.Review of the clinical record indicated Resident R1 admitted to the facility on [DATE].Review of the clinical record indicated Resident R2 admitted to the facility on [DATE].Review of the clinical record indicated Resident R3 admitted to the facility on [DATE].Review of the Grievance Log dated December 2025, indicated on 12/8/25, Resident R1's family filed a grievance regarding a pipe in the room.Interview on 12/9/25, at 9:05 a.m. Registered Nurse (RN) Employee E2 indicated Resident R1 and Resident R2's room had a water leak from a pipe in the ceiling. RN indicated working last Friday, 12/5/25, and there was a large bin placed under the leaking pipe where water was dripping into the bin. Indicated the water was turned off to the pipe and the ceiling tile was removed.Interview on 12/9/25, at 9:10 a.m. Nurse Aide (NA) Employee E3 indicated that water was leaking in the room from a pipe in the ceiling since Friday. Indicated the leak was above the entrance to the bathroom door inside the room and that Resident R1 moved to another room on 12/8/25, when the plumber came to fix the pipe and they removed the large bin from the room.Observation of Resident R1 and Resident R2's room on 12/9/25, at 9:04 a.m. indicated Resident R1 was not in the room, and Resident R2 was in bed resting. A ceiling tile was missing from the ceiling, a silver pipe exposed facing downward into the room, directly outside the entrance to the resident room's bathroom.Observation and interview with the Director of Nursing on 12/9/25, at 9:15 a.m. confirmed the appearance of the exposed pipe and missing ceiling tile directly above the bathroom door and confirmed the residents should have been relocated until the pipe could be fixed.Interview with Resident R1 on 12/9/25, at 11:30 a.m. indicated that The ceiling was leaking for several days before they could get it fixed. There was water running down across the floor to my bed. I could hear water in the pipes and toilets flushing and thought to myself where is the water coming from? The staff would sop the water up in front of the bathroom door so that Resident R2 could go in the bathroom with the walker.Review of the timeline provided by Maintenance worker Employee E1 indicated on 12/4/25, during morning rounds a nurse reported a wet tile in Residents R1 and R2's room. The leak's origin could not be identified, and the ceiling tile was replaced. On 12/5/25, during morning rounds the nurse again reported the tile was wet. The leak's origin could be found but unable to be fixed by facility staff. On 12/8/25, the plumber was notified and fixed the issue. The Nursing Home Administrator was made aware and moved Resident R1 but failed to relocate Resident R2.Interview on 12/9/25, at 11:42 a.m. Resident R3 indicated they had been here for a while and they never have cleaned the privacy curtain to the right side of the resident's bed. Resident said, Look under my bed and along the walls, dresser, there's dirt and debris and my windowsill and blinds do not get cleaned.Observation on 12/9/25, at 11:43 a.m. Resident R3's room had a dirty privacy curtain with a white/brown stain on the bottom fold, debris and crumblike substances along the perimeter of the wall, under the bed, along the dressers, the windowsill was dusty along with the blinds covering the windows.Observation on 12/9/25, at 11:50 a.m. the large shower room on the second floor was noted to have the hose/shower head detached from the pipe in the wall and lying on the floor of the shower stall. There was a brown spot on the floor of the shower room stall.Interview on 12/9/25, at 11:51 a.m. Housekeeping Employee E4 confirmed the hose/shower head was detached from the pipe in the wall and the brown debris on the floor of the shower stall.Interview on 12/10/25, at 12:51 p.m. the Nursing Home Administrator confirmed that the facility failed to maintain a clean, safe, and homelike environment for three of six residents (Resident R1, R2, and R3) and one of two shower rooms on the second floor (Large Shower Room).28 Pa. code: 201.14 (b) Responsibility of licensee.28 Pa Code: 201.18 (e)(1)(2) Management. 28 Pa Code: 201.29 (a)(c) Resident Rights.

Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an allegation of abuse for one of three residents (Resident R4). This failure was determined to be past noncompliance as of 12/5/25.Findings include:Review of facility policy Pennsylvania Resident Abuse Policy dated 3/14/25, indicated the facility's policy is to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property and injuries of unknown source. Review of the admission record indicated Resident R4 was admitted to the facility on [DATE].Review of Resident R4's Minimum Data Set (MDS- a periodic assessment of care needs) dated 11/7/25, indicated the diagnoses of cachexia (a complex metabolic syndrome causing severe, unintentional weight loss), dysphagia (difficulty swallowing), and hypothyroidism (thyroid gland doesn't produce enough thyroid hormone). Section C0500 the Brief Interview for Mental Status (BIMS - is a screening test that aids in detecting cognitive impairment) indicated a score of 15, cognitively intact.Review of Resident R4's progress notes indicated the following:-11/15/25, at 1:34 a.m. found resident at approximately 11:30 p.m. on 11/14/25, crying with complaints of lower back pain, which resident verbalized the pain started when resident was turned when getting a brief changed by Nurse Aide (NA) at approximately 10:00 p.m.-11/17/25, at 11:20 a.m. family at nurses' station inquiring about phone call that she received from their mom regarding care from NA on Friday night. This nurse reported information to management for further review. Patient also has increase pain in lower back. -11/17/25, Provider note at 12:19 p.m. resident seen today at the request of the facility for acute onset lower back pain. Resident seen lying in bed. Resident states that pain originated during care. Resident feels that their leg was elevated too much, causing immediate pain that has persisted. X rays obtained without acute injury.-11/20/25, at 10:35 a.m. Physician note resident seen lying in bed in distress after having been changed and repositioned by staff complaining of severe lower back pain.Review of facility provided documentation dated 12/2/25, at 3:30 p.m. indicated the Director of Nursing was speaking with Resident R4's family. During the conversation family verbalized an occurrence involving an aide elevating resident's legs during incontinence care causing pain on the evening of 11/14/25.Interview on 12/10/25, at 12:51 p.m. the Director of Nursing confirmed the allegation of abuse was not reported to administration and the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an allegation of abuse for Resident R4 and requested past noncompliance status be reviewed for the event and handed over information on immediate interventions and education that had been completed regarding abuse policy and procedures once facility administration became aware.Review of facility's corrective action plan indicated on 12/2/25, the Director of Nursing became aware that facility was out of compliance with F607 Develop/Implement Abuse/Neglect Policies. In lieu of discovery facility immediately initiated the following:-On 12/2/25, the Director of Nursing called residents family to discuss status of patient who is currently admitted to hospital. During conversation, family verbalized an occurrence involving an aide elevating resident's legs during incontinence care causing pain on the evening of 11/14/2025.-Immediate investigation was initiated including the following:-Identified the aide that was assigned to the resident on date of noted incident with notification and statement attained.-Aide was suspended pending investigation and removed from schedule.-All other residents on unit that are able to be interviewed were interviewed with no care concerns noted.-Per investigation look back at the initial x-ray was negative of any acute findings. A CT scan (advanced imaging test that uses X rays and a computer to create detailed, cross-sectional pictures of the inside of the body) was completed on 11/20/25, during a hospital transfer with an indeterminate L4 (fourth vertebrae of the lower spine) compression fracture (break or collapse) that was reviewed by the in house Nurse Practitioner and could not be verified as acute.-Education was completed on abuse and the timeliness of reporting concerns/customer service timely.-Skin sweeps are being completed on all residents in the facility Adult Protective Services is aware at this time.-Audits will be completed twice weekly for one month with random residents for any care/concern issues.-Facility is not substantiating abuse or neglect related to statements attained and results of investigation.-PB22 was completed.-Facility came back into compliance on 12/5/25, when education was completed.On 12/10/25, at 12:51 p.m. it was verified that the facility had implemented its corrective action plan, and education was verified for 121 facility employees on abuse and the timeliness of reporting concerns timely. Exit interview on 12/10/25, at 12:51 p.m. information was provided to the Nursing Home Administrator and the Director of Nursing that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an allegation of abuse and that the facility had successfully met the task of Past Non-Compliance effective 12/5/25, when the corrective actions were achieved by the facility. 28. Pa Code 201.14(a) Responsibility of licensee.28. Pa Code 201.18(b)(1)(e)(1) Management.28. Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, resident clinical records, facility provided documents, reports submitted to the State, and staff interview it was determined that the facility failed to report an allegation of abuse for one of three residents (Resident R4).Findings include:Review of facility policy Pennsylvania Resident Abuse Policy dated 3/14/25, indicated the facility's policy is to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property and injuries of unknown source. Facility must immediately report all such allegations to the Administrator who will immediately begin an investigation and notify applicable local and state agencies in accordance with the procedures in this policy.Review of the admission record indicated Resident R4 was admitted to the facility on [DATE].Review of Resident R4's Minimum Data Set (MDS- a periodic assessment of care needs) dated 11/7/25, indicated the diagnoses of cachexia (a complex metabolic syndrome causing severe, unintentional weight loss), dysphagia (difficulty swallowing), and hypothyroidism (thyroid gland doesn't produce enough thyroid hormone). Section C0500 the Brief Interview for Mental Status (BIMS - is a screening test that aids in detecting cognitive impairment) indicated a score of 15, cognitively intact.Review of Resident R4's progress notes indicated the following:-11/15/25, at 1:34 a.m. found resident at approximately 11:30 p.m. on 11/14/25, crying with complaints of lower back pain, which resident verbalized the pain started when resident was turned when getting a brief changed by Nurse Aide (NA) at approximately 10:00 p.m.-11/17/25, at 11:20 a.m. family at nurse's station inquiring about phone call that they received from their mom regarding care from NA on Friday night. This nurse reported information to management for further review. Patient also has increase pain in lower back. -11/17/25, Provider note at 12:19 p.m. resident seen today at the request of the facility for acute onset lower back pain. Resident seen lying in bed. Resident states that pain originated during care. Resident feels that their leg was elevated too much, causing immediate pain that has persisted. X rays obtained without acute injury.-11/20/25, at 10:35 a.m. Physician note resident seen lying in bed in distress after having been changed and repositioned by staff complaining of severe lower back pain.Review of facility provided documentation (State report) dated 12/2/25, at 3:30 p.m. indicated the Director of Nursing was speaking with Resident R4's family. During the conversation family verbalized an occurrence involving an aide elevating resident's legs during incontinence care causing pain on the evening of 11/14/25.Interview on 12/10/25, at 12:51 p.m. the Director of Nursing confirmed the allegation of abuse was not reported to administration and the facility failed to report an allegation of abuse for one of three residents (Resident R4) and requested past noncompliance status be reviewed for the event and handed over information on immediate interventions and education that had been completed regarding abuse policy and procedures once facility administration became aware.Review of facility's corrective action plan indicated on 12/2/25, the Director of Nursing became aware that facility was out of compliance with F609 Reporting of Alleged Violations. In lieu of discovery facility immediately initiated the following:-On 12/2/25, the Director of Nursing called residents family to discuss status of patient who is currently admitted to hospital. During conversation, family verbalized an occurrence involving an aide elevating resident's legs during incontinence care causing pain on the evening of 11/14/2025.-Immediate investigation was initiated including the following:-Identified the aide that was assigned to the resident on date of noted incident with notification and statement attained.-Aide was suspended pending investigation and removed from schedule.-All other residents on unit that are able to be interviewed were interviewed with no care concerns noted.-Per investigation look back at the initial x-ray was negative of any acute findings. A CT scan (advanced imaging test that uses X rays and a computer to create detailed, cross-sectional pictures of the inside of the body) was completed on 11/20/25, during a hospital transfer with an indeterminate L4 (fourth vertebrae of the lower spine) compression fracture (break or collapse) that was reviewed by the in house Nurse Practitioner and could not be verified as acute.-Education was completed on abuse and the timeliness of reporting concerns/customer service timely.-Skin sweeps are being completed on all residents in the facility Adult Protective Services is aware at this time.-Audits will be completed twice weekly for one month with random residents for any care/concern issues.-Facility is not substantiating abuse or neglect related to statements attained and results of investigation.-PB22 was completed.-Facility came back into compliance on 12/5/25, when education was completed.On 12/10/25, at 12:51 p.m. it was verified that the facility had implemented its corrective action plan, and education was verified for 121 facility employees on abuse and the timeliness of reporting concerns.Exit interview on 12/10/25, at 12:51 p.m. information was provided to the Nursing Home Administrator and the Director of Nursing that the facility failed to report an allegation of abuse for one of three residents (Resident R4) and that the facility had successfully met the task of Past Non-Compliance effective 12/5/25, when the corrective actions were achieved by the facility. 28 Pa Code: 201.14 (a)(c )(e ) Responsibility of management28 Pa Code: 201.18 (b)(1) (e)(1) Management.

Based on review of facility documents, facility policy, clinical records, and staff interview, it was determined that the facility failed to conduct a thorough investigation of an allegation of abuse for one of three residents (Resident R4).Findings include:Review of facility policy Pennsylvania Resident Abuse Policy dated 3/14/25, indicated the facility's policy is to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property and injuries of unknown source. Review of the admission record indicated Resident R4 was admitted to the facility on [DATE].Review of Resident R4's Minimum Data Set (MDS- a periodic assessment of care needs) dated 11/7/25, indicated the diagnoses of cachexia (a complex metabolic syndrome causing severe, unintentional weight loss), dysphagia (difficulty swallowing), and hypothyroidism (thyroid gland doesn't produce enough thyroid hormone). Section C0500 the Brief Interview for Mental Status (BIMS - is a screening test that aids in detecting cognitive impairment) indicated a score of 15, cognitively intact.Review of Resident R4's progress notes indicated the following:-11/15/25, at 1:34 a.m. found resident at approximately 11:30 p.m. on 11/14/25, crying with complaints of lower back pain, which resident verbalized the pain started when resident was turned when getting a brief changed by Nurse Aide (NA) at approximately 10:00 p.m.-11/17/25, at 11:20 a.m. family at nurses' station inquiring about phone call that they received from their mom regarding care from NA on Friday night. This nurse reported information to management for further review. Patient also has increase pain in lower back. -11/17/25, Provider note at 12:19 p.m. resident seen today at the request of the facility for acute onset lower back pain. Resident seen lying in bed. Resident states that pain originated during care. Resident feels that their leg was elevated too much, causing immediate pain that has persisted. X rays obtained without acute injury.-11/20/25, at 10:35 a.m. Physician note resident seen lying in bed in distress after having been changed and repositioned by staff complaining of severe lower back pain.Review of facility provided documentation (State report) dated 12/2/25, at 3:30 p.m. indicated the Director of Nursing was speaking with Resident R4's family. During the conversation family verbalized an occurrence involving an aide elevating resident's legs during incontinence care causing pain on the evening of 11/14/25.Interview on 12/10/25, at 12:51 p.m. the Director of Nursing confirmed the allegation of abuse was not reported to administration and the facility failed to conduct a thorough investigation for an allegation of abuse for one of three residents (Resident R4) and requested past noncompliance status be reviewed for the event and handed over information on immediate interventions and education that had been completed regarding abuse policy and procedures once facility administration became aware.Review of facility's corrective action plan indicated on 12/2/25, the Director of Nursing became aware that facility was out of compliance with F610 Investigate/Prevent/Correct Alleged Violation. In lieu of discovery facility immediately initiated the following:-On 12/2/25, the Director of Nursing called residents family to discuss status of patient who is currently admitted to hospital. During conversation, family verbalized an occurrence involving an aide elevating resident's legs during incontinence care causing pain on the evening of 11/14/2025.-Immediate investigation was initiated including the following:-Identified the aide that was assigned to the resident on date of noted incident with notification and statement attained.-Aide was suspended pending investigation and removed from schedule.-All other residents on unit that are able to be interviewed were interviewed with no care concerns noted.-Per investigation look back at the initial x-ray was negative of any acute findings. A CT scan (advanced imaging test that uses X rays and a computer to create detailed, cross-sectional pictures of the inside of the body) was completed on 11/20/25, during a hospital transfer with an indeterminate L4 (fourth vertebrae of the lower spine) compression fracture (break or collapse) that was reviewed by the in house Nurse Practitioner and could not be verified as acute.-Education was completed on abuse and the timeliness of reporting concerns/customer service timely.-Skin sweeps are being completed on all residents in the facility Adult Protective Services is aware at this time.-Audits will be completed twice weekly for one month with random residents for any care/concern issues.-Facility is not substantiating abuse or neglect related to statements attained and results of investigation.-PB22 was completed.-Facility came back into compliance on 12/5/25, when education was completed.On 12/10/25, at 12:51 p.m. it was verified that the facility had implemented its corrective action plan, and education was verified for 121 facility employees on abuse and the timeliness of reporting concerns.Exit interview on 12/10/25, at 12:51 p.m. information was provided to the Nursing Home Administrator and the Director of Nursing that the facility failed to make certain to conduct a thorough investigation of an allegation of abuse for one of three residents (Resident R4) and that the facility had successfully met the task of Past Non-Compliance effective 12/5/25, when the corrective actions were achieved by the facility. 28 Pa Code: 201.14 (a)(c )(e ) Responsibility of management28 Pa Code: 201.18 (b)(1) (e)(1) Management.

Based on facility policy, clinical record review, observation, and staff interviews, it was determined that the facility failed to properly monitor residents in room personal refrigerator temperatures for two of three residents (Residents R33 and R46) which created the potential for food borne illness, failed to implement appropriate transmission-based precautions for nine of 18 residents (Residents R46, R55, R75, R92, R102, R153, R163, R169, and R173), and failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R46). Findings include: Review of the facility policy Storage of Resident Food dated 3/14/25, indicated residents must allow staff to monitor and log the refrigerator temperatures and expiration of food items. Review of the Pennsylvania Department of Health Toolkit for Control of Norovirus Outbreaks in Long-Term Care Facilities dated 10/11/24, and expanded from infection prevention and control guidance from the Centers for Disease Control and Prevention (CDC) for nursing homes and Long-Term Care Facilities revealed the following: GI Illness Outbreak Recommendations Checklist - GI (gastrointestinal) Illness - illnesses that can be caused by a variety of different disease-causing microbes and germs. Common symptoms may include diarrhea, nausea, vomiting, abdominal cramps, and fever. - LTCF (long-term care facilities) GI Illness Outbreak - an occurrence of two or more similar GI illnesses resulting from a common exposure- Place patients with suspected norovirus gastroenteritis on contact precautions until symptom-free for at least 48 hours. Review of the CDC (Centers for Disease Control and Prevention) Guidelines indicated Contact Precautions are measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. Contact Precautions require the use of gown and gloves on every entry into a resident's room, regardless of the level of care being provided to the resident. Review of facility policy Enhanced Barrier Precautions dated 3/14/25, indicated Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employs hand hygiene, targeted gown and glove use during high contact resident care activities that include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care: any skin opening requiring a dressing. Review of the admission record indicated Resident R33 admitted to the facility on [DATE]. Review of Resident R33's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/30/25, indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), high blood pressure, and depression. Observation on 10/20/25, at 11:26 a.m. of Resident R33's in room personal refrigerator indicated a temperature log dated October 2025. The log indicated to record temperatures once per day. The log was blank on 10/2/25, 10/3/25, 10/4/25, 10/5/25, 10/9/25, 10/10/25, 10/11/25, and 10/12/25. Interview on 10/20/25, at 11:35 a.m. Licensed Practical Nurse (LPN) Employee E3 confirmed Resident R33's temperature log was not consistently monitored and logged as required. Review of the admission record indicated Resident R46 was admitted to the facility on [DATE]. Review of Resident R46's MDS dated [DATE], indicated the diagnoses of anemia, high blood pressure, and heart failure (heart doesn't pump blood as well as it should). Observation on 10/20/25, at 11:30 a.m. of Resident R46's in-room personal refrigerator indicated a temperature log dated October 2025. The log indicated to record temperatures once per day. The log was blank from 10/5/25, through 10/20/25. Interview on 10/20/25, at 11:35 a.m. LPN Employee E3 confirmed Resident R46's temperature log was not consistently monitored and logged as required and that the facility failed to properly monitor residents in room personal refrigerator temperatures for two of three residents (Residents R33, and R46) which created the potential for food borne illness. Review of Resident R46's clinical record revealed a Nurse Practitioner (NP)/PA (Physician Assistant) Progress Note dated 1/15/25, that stated, Patient notes a few days prior she began experiencing diarrhea with acute onset. Patient does not recall eating anything different from her typical diet. This is likely a viral etiology as there has been an outbreak of an acute gastrointestinal illness across the entire building. Review of Resident R46's clinical record failed to reveal documentation to indicate the resident had been placed on Contact Precautions. Review of the clinical record indicated Resident R55 was admitted to the facility on [DATE]. Review of Resident R55's MDS dated [DATE], indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fats in the blood), and anxiety. Review of a nursing progress note dated 1/13/25, stated, Sudden digested food emesis. Denies nausea today at all. CNA (Certified Nurse Aide) reports loose stool also. Afebrile (without fever). Denies chills, cough. Review of Resident R55's clinical record failed to reveal documentation to indicate the resident had been placed on Contact Precautions. Review of the clinical record indicated Resident R75 was admitted to the facility on [DATE]. Review of Resident R75's MDS dated [DATE], indicated diagnoses of anemia, high blood pressure, and hemiplegia (paralysis on one side of the body). Review of a NP/PA Progress Note dated 1/15/25, stated, Patient seen today at the request of staff for refusal of meals and meds on 1/14. Patient had acute vomiting, diarrhea the day prior, likely of viral etiology. Review of Resident R75's clinical record failed to reveal documentation to indicate the resident had been placed on Contact Precautions. Review of the clinical record indicated Resident R92 was admitted to the facility on [DATE]. Review of Resident R92's MDS dated [DATE], indicated diagnoses of high blood pressure, anxiety, and muscle weakness. Review of a progress note dated 1/13/25, stated, Lethargy noted today when trying to communicate. Several loose stools noted during morning shift. Resident refused lunch due to nausea, medicated per as needed orders which has been effective. Review of Resident R92's clinical record failed to reveal documentation to indicate the resident had been placed on Contact Precautions. Review of the clinical record indicated Resident R102 was admitted to the facility on [DATE]. Review of Resident R102's MDS dated [DATE], indicated diagnoses of anemia, high blood pressure, and history of falling. Review of a NP/PA Progress Note dated 1/13/25, stated, Patient seen today for acute GI symptoms on 1/11 - nausea/vomiting/diarrhea, body aches. Review of Resident R102's clinical record failed to reveal documentation to indicate the resident had been placed on Contact Precautions. Review of the clinical record indicated Resident R153 was admitted to the facility on [DATE]. Review of Resident R153's MDS dated [DATE], indicated diagnoses of anemia, high blood pressure, and other lack of coordination. Review of a NP/PA Progress Note dated 1/17/25, stated, Patient seen acutely per staff request for nausea, vomiting, and diarrhea symptoms that began acutely overnight. Other residents with similar secondary to viral illness. Review of Resident R153's clinical record failed to reveal documentation to indicate the resident had been placed on Contact Precautions. Review of the clinical record indicated Resident R163 was admitted to the facility on [DATE]. Review of Resident R163's MDS dated [DATE], indicated diagnoses of high blood pressure, weakness, and unsteadiness on feet. Review of a NP/PA Progress Note dated 1/13/25, stated, Patient seen today for acute GI symptoms over the weekend. Patient noted to have watery stools, roommate with similar, current norovirus suspected. Review of a physician order dated 1/12/25, indicated to send stool specimen for norovirus one time only for diarrhea. Review of Resident R163's clinical record failed to reveal documentation to indicate the resident had been placed on Contact Precautions. Review of the clinical record indicated Resident R169 was admitted to the facility on [DATE]. Review of Resident R169's MDS dated [DATE], indicated diagnoses of high blood pressure, hyperlipidemia, and hemiplegia. Review of a NP/PA Progress Note dated 1/13/25, Patient seen today acutely for GI symptoms over the weekend, concern for possible norovirus. Review of a physician order dated 1/12/25, indicated to send stool specimen for norovirus one time only for diarrhea. Review of Resident R169's clinical record failed to reveal documentation to indicate the resident had been placed on Contact Precautions. Review of the clinical record indicated Resident R173 was admitted to the facility on [DATE]. Review of Resident R173's MDS dated [DATE], indicated diagnoses of anemia, hyperlipidemia, and anxiety. Review of a NP/PA Progress Note dated 1/13/25, stated, Patient seen today acutely for symptoms of diarrhea, nausea, vomiting, chills, started over weekend, concern for Norovirus. Review of a physician order dated 1/12/25, indicated to send stool specimen for norovirus one time only for diarrhea. Review of Resident R173's clinical record failed to reveal documentation to indicate the resident had been placed on Contact Precautions. During an interview on 10/22/25, at 2:16 p.m. Infection Preventionist Employee E2 stated, We cannot officially call it norovirus because no stools were ever able to be obtained for testing, they had firmed up. I want to say yes people were placed in contact precautions, I'm not sure. If they were, it would be in the physician orders or progress notes. During an interview on 10/22/25, at 2:16 p.m. Infection Preventionist Employee E2 confirmed that the facility failed to implement appropriate transmission-based precautions for nine of 18 residents (Residents R46, R55, R75, R92, R102, R153, R163, R169, and R173). Review of Resident R46's clinical record revealed the following physician orders: - Ordered 8/20/25, wound care: cleanse left heel with NSS (normal sterile saline), apply saline moistened hydrofera blue (an antibacterial wound dressing that promotes a healing environment), cover with bordered foam dressing every evening shift every other day for wound care. - Ordered 9/12/25, enhanced barrier precautions related to: when dressing/bathing, showering/transferring in room or therapy gym/personal hygiene, changing linen, providing hygiene, changing briefs or assisting with toileting. Left heel wound every shift for wound care. During a wound care dressing change observation on 10/23/25, from 10:16 a.m. to 10:33 am. Wound Care Nurse Employee E3 and LPN Employee E4 only donned gloves and did not don a gown while providing care to Resident R46 per physician order. During an interview on 10/23/25, at 10:35 a.m. Wound Care Nurse Employee E3 confirmed Resident R46 is ordered EBP during wound care and that the facility failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R46). 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1)(e)(1) Management.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services

Based on review of facility policy, review of clinical records, observations and staff interview, it was determined that the facility failed to determine whether it was safe to self-administer medications for two of three residents (Resident R42 and R62).Findings include: Review of the facility policy Resident Self-Administration of Medications dated 3/14/25, indicated residents in the facility who wish to self-administer their medications may do so if the interdisciplinary team has determined that this practice is clinically appropriate. Assessments will include addressing the following and documenting in the care plan: storage of the medication, responsible party for storage of medication, documenting the administration of drugs, and location of where the drugs will be administered. Review of the admission record indicated Resident R42 was admitted to the facility on [DATE]. Review of Resident R42's Minimum Data Set (MDS- a periodic assessment of care needs) dated 10/2/25, indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), high blood pressure, and peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs). Observation on 10/20/25, at 10:45 a.m. of Resident R42's room indicated a bottle of Dakin's solution (a diluted antiseptic wound cleansing solution), a tube of zinc oxide (skin protectant), and a tube of Medi Honey (medical grade honey used for wound care). Review of Resident R42's clinical record failed to have a physician order, assessment, or plan of care addressing self-administration of medications. Interview on 10/20/25, at 10:45 a.m. Licensed Practical Nurse (LPN) Employee E3 confirmed the medications were stored in the resident room inappropriately and that Resident R42 failed to have an assessment, physician order, or plan of care for self-administration of medications. Review of the admission record indicated Resident R62 was admitted to the facility on [DATE]. Review of Resident 62's Minimum Data Set (MDS- a periodic assessment of care needs) dated 9/27/25, indicated the diagnoses of dysphagia (impairment in the production of speech resulting from brain disease or damage), hypertension and constipation. Observation on 10/20/25, at 10:15 a.m. of Resident R62's room indicated a bottle of Tum's (over-the-counter antacid). Review of Resident R62's clinical record failed to have a physician order, assessment, or plan of care addressing self-administration of medications. Interview on 10/20/25, at 10:15 a.m. Registered Nurse (RN) Employee E13 confirmed the medications were stored in the resident room inappropriately and that Resident R62 failed to have an assessment, physician order, or plan of care for self-administration of medications. 28 Pa code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to accommodate the call bell needs for one of five residents (Resident R91).Findings include: Review of facility policy Resident Rights dated 3/14/25, indicated call light or bell access will be within reach of the resident as one method to communicate needs to staff. Review of the clinical record indicated Resident R91 was admitted to the facility on [DATE]. Review of Resident R91's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/24/25, indicated diagnoses of high blood pressure, hemiplegia (paralysis on one side of the body), and anemia (too little iron in the blood). Review of Resident R91's care plan, dated 4/24/24, indicated to place touch pad call bell in reach of resident at all times. During an observation on 10/20/25, at 10:57 a.m. Resident R91 was observed laying in their bed. Resident R91's touch pad call bell was observed on the resident's dresser, out of the resident's reach. During an interview on 10/20/25, at 10:59 a.m. Registered Nurse Employee E1 confirmed Resident R91's call bell was not accessible and unavailable for use to the resident and that the facility failed to accommodate Resident R91's call bell needs. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on clinical record review, and staff interviews, it was determined that the facility failed to ensure the physician was appropriately notified of missed medication doses for one of five residents reviewed (Resident R1).Findings include: Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/10/25, indicated diagnoses of high blood pressure, left knee pain, and difficulty in walking. Review of a physician order dated 9/8/25, indicated to provide Resident R1 with levothyroxine (medication used to treat an underactive thyroid) 100 micrograms, 1 tablet by mouth in the morning every Tuesday, Wednesday, Thursday, Friday, Saturday, and Sunday. Review of Resident R1's September 2025 Medication Administration Record revealed the scheduled medication was not administered on the following dates:- Tuesday 9/9/25-Wednesday 9/10/25 During an interview on 10/23/25, at 2:27 .m. the Assistant Director of Nursing (ADON) stated that the facility had the medication in the facility, however as resident had a reported allergy to dyes used in the medication, the facility had to wait until the pharmacy was able acquire an appropriate medication without dyes for Resident R1, and had missed doses on 9/9/25, and 9/10/25 as ordered. During an interview on 10/24/25, at 11:40 a.m. the Director of Nursing stated the facility was unable to provide documentation that the physician was made aware of Resident R1's medication being unavailable and that the facility failed to ensure the physician was appropriately notified of missed medication doses for Resident R1. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.10 (c)(d) Resident Care policies.28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of facility documentation and staff interview it was determined that the facility failed to provide in a timely manner, notice of Skilled Nursing Facility Advance Beneficiary Notice (SNF-ABN), Form CMS - 10055 for one of two residents reviewed (Resident R142).Findings include: Review of the clinical documentation indicated Resident R142 was discharged from skilled services on 5/11/25. Review of facility documentation failed to include a SNF-ABN form prior to discharge from skilled services. During an interview on 10/24/25, at 12:32 p.m. Business Office Employee E16 confirmed that the facility failed to provide in a timely manner, SNF-ABN form CMS-10055 for Resident R142. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of eight medication carts (second floor cart).Findings include: Review of the facility's Health Insurance Portability and Accountability Act (HIPAA) dated 3/14/25, indicated HIPAA requires providers and others to implement security measures to guard the integrity and confidentiality of medical information. During an observation on 10/21/25, at 11:16 a.m. a medication cart by the nurse's station was left unattended with a paper nursing report sheet with identifiable information any passerby could see resident personal and confidential information. During an interview on 10/22/25, at 8:51 a.m. Registered Nurse Employee E5 confirmed the above observation and that the facility failed to maintain the confidentiality of residents' medical information as required. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.29(c.3) Resident Rights.28 Pa. code: 211.5(b) Medical records.28 Pa. Code: 211.12(d)(1)(3) Nursing services.

Based on review of facility policy, clinical records, facility documents, observations, and staff interviews, it was determined that the facility failed to identify the use of bolsters (a long, thick cushion) on a bed as a possible restraint, failed to obtain a physicians order, failed to develop a person-centered plan of care for the use of physical restraints, and failed to provide ongoing re-evaluation of the need for physical restraints for one of two residents reviewed (Residents R15).Findings include: Review of facility policy Restraint- Use and Management dated 3/14/25, indicated physical restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Before a resident is restrained, the facility will determine the presence of a specific medical symptoms that would require the use of restraints, and determine:a. How the use of restraints would treat the medical symptom.b. The length of time the restraint is anticipated to be used to treat the medical symptom, who may apply the restraint, and the time and frequency that the restraint will be released.c. The type of direct monitoring and supervision that will be provided during the sue of the restraint.d. How the resident will request staff assistance and how his/her needs will be met while the restraint is in place.e. How to assist the resident in attaining or maintaining his/her highest practicable level of physical and psychosocial well-being. Review of the clinical record indicated Resident R15 was admitted to the facility on [DATE]. Review of Resident R15's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 8/31/25, indicated diagnoses of high blood pressure, right elbow contracture, and decreased white blood cell count. Section P0100 indicated that no restraints were in use. During an observation on 10/21/25, at 8:54 a.m. Resident R15 was observed lying in bed and the mattress had bilateral (on both sides) raised edges on top and bottom portions. Review of Resident R15's active physician orders on 10/22/25, failed to include an order for bolsters or a concave mattress. Review of Resident R15's comprehensive care plan on 10/22/25, failed to reveal goals and interventions related to the usage of bolsters or a concave mattress. Review of Resident R15's clinical record failed to identify any assessments or ongoing evaluations for the usage of bolsters or a concave mattress. During an interview on 10/23/25, at 9:17 a.m. Physical Therapist (PT) Employee E15 stated that therapy was not involved in ordering, evaluating, or placing bolsters on Resident R15's bed. PT Employee E15 stated that air mattress sometimes comes with bolsters zipped into the mattress, and When we have to get them [residents] out of bed, we have to unzip the mattress cover to remove the bolsters, so they can get out of bed. During an interview on 10/23/25, at 11:17 a.m. the Director of Nursing confirmed that the facility failed to identify the use of bolsters (a long, thick cushion) on a bed as a possible restraint, failed to obtain a physicians order, failed to develop a person-centered plan of care for the use of physical restraints, and failed to provide ongoing re-evaluation of the need for physical restraints for one of two residents reviewed (Residents R15). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.8(e) Use of restraints.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of two residents sampled with facility-initiated transfers (Residents R1).Findings include: Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/10/25, indicated diagnoses of high blood pressure, left knee pain, and difficulty in walking. Review of the clinical record indicated Resident R1 was transferred to the hospital on 9/10/25. Review of Resident R1's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. During an interview on 10/24/25, at 11:40 a.m. the Director of Nursing confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of two residents sampled with facility-initiated transfers (Residents R1). 28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights.

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident care needs for one of five residents (Resident R119).Findings include: Review of facility policy Plan of Care Overview dated 3/14/25, indicated the Plan of Care, also Care Plan is the written treatment provided for a resident that is resident-focused and provides for optimal personalized care. Review of the clinical record indicated Resident R119 was admitted to the facility on [DATE]. Review of Resident R119's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/7/25, indicated diagnoses of high blood pressure, unsteadiness on feet, and malnutrition (lack of sufficient nutrients in the body). Question B0300 Hearing Aid was coded 1 for yes, hearing aid or other hearing appliance used. Review of a physician order dated 7/1/25, indicated bilateral (both sides) hearing aids. Remove at HS (night) and place in container. Insert in ears in AM (morning) every day and evening shift. During an observation on 10/20/25, at 10:52 a.m. Resident R119 was observed wearing her bilateral hearing aids. Review of Resident R119's current care plan failed to include the development of goals and interventions related to the resident's bilateral hearing aid usage. During an interview on 10/24/25, at 11:56 a.m. the Director of Nursing confirmed that the facility failed to develop a comprehensive care plan to meet resident care needs for Resident R119. 28 Pa Code: 201.14(a) Responsibility of licensee.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on a resident's interview, clinical record review and review of the facility policy, it was determined that the facility failed to provide assistance with application of a stump shrinker resulting in a resident's inability to attend therapy for ambulation for one of three residents (Resident R46). Findings include: Review of the facility policy Routine Resident Care dated 3/14/25, indicated routine daily care by a certified nursing assistant with specialized training in rehabilitation/restorative care including but not limited to assisting with special devices such as prosthesis (denoting an artificial body part) and eating devices. Providing an environment that contributes to a positive self-image preserves dignity and promotes privacy. Review of the admission record indicated Resident R46 was admitted to the facility on [DATE]. Review of Resident R46's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/21/25, indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), high blood pressure, and heart failure (heart doesn't pump blood as well as it should). Section C0500 a Brief Interview for Mental Status (BIMS - is a screening test that aids in detecting cognitive impairment) indicated a score of 15, cognitively intact. Review of Resident R46's physician order dated 9/29/25, indicated Physical Therapy three times per week for thirty days for therapeutic exercise and gait training. Review of Resident R46's care plan dated 8/21/25 indicated resident has an activities of daily living (ADL) self-care performance deficit and requires assistance with ADLs due to weakness, deconditioning, and right below the knee amputation. Intervention resident to wear gel liner and sock when out of bed at all times. Only wearing prosthetic for transfers. Interview on 10/20/25, at 10:20 a.m. Resident R46 indicated the staff on evening shift did not put on the stump shrinker (a compression garment worn by amputees to reduce swelling, shape the residual limb, and prepare it for a prosthetic) when asked to yesterday and today resident is unable to apply the prosthetic leg due to swelling of the limb. The Resident had to refuse therapy for the day because therapy is working on ambulation, and resident is unable to participate without the prosthetic in place. Interview with Resident R46 and the Director of Nursing confirmed the limb was swollen and the facility failed to provide assistance with application of a stump shrinker resulting in a resident's inability to attend therapy for ambulation for one of three residents (Resident R46). 28 Pa. Code 211.10d) Resident care policies28 Pa. Code 211.12(c)(d)(1) Nursing services

Based on review of facility policies, clinical records, and staff interviews it was determined that the facility failed to ensure the appropriate assistance for bed mobility was provided for one of seven residents (Residents R1), which resulted in actual harm when Resident R1 fell out of bed and sustained a right hip fracture and head contusion.Review of the facility policy Fall Prevention and Management dated 3/4/25, reviewed 3/14/25, stated it is the policy of this facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. Fall prevention and management is the process of identifying risk factors that can minimize the potential for falls and also a process to manage resident's care if a fall occurs. A fall assessment should be completed upon admission, quarterly, and with any significant changes. The care plan should address how the resident can be transferred up and out of bed as well as how the resident can ambulate and move around the facility. Review of the facility policy Incidents/Accidents dated 5/13/25, stated it is the policy of the facility to provide a safe and healthy environment for residents by minimizing possible exposure to safety hazards. Review of the facility policy Routine Resident Care dated 6/11/25, indicated it is the facility policy to promote resident centered care by attending to the total medical, nursing, physical, emotional, mental, social, and spiritual needs and honor resident's preference while in the care of this facility. Licensed staff will provide care planning and implementation and provide access to resident care policies for any staff providing care. Nurse aides are to provide routine daily care including toileting, and assisting with ambulation, transfers, and repositioning. Review of Residents R1's admission record revealed the resident was admitted on [DATE], with diagnoses of cancer, anxiety, and depression. Review of Residents R1's care plan dated 5/11/23, revealed the resident required assistance of two persons with bed mobility. Review of Resident R1's Fall Risk Observation Tool dated 4/29/25, revealed the resident was bedrest, non-ambulatory, and required a total mechanical lift for all transfers. The resident was identified to be at risk for falls. Review of Residents R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/21/25, indicated the diagnoses were current. Section GG- Functional Abilities revealed the resident was dependent with rolling left to right and required the assistance of two or more helpers. Review of Resident R1's progress note dated 6/29/25, at 9:15 p.m. entered by Registered Nurse (RN), Employee E1 stated around 9:15 p.m. a nurse aide (NA) was changing Resident R1's brief and the resident rolled out to the left side and fell from the bed to the floor. The resident sustained a right temporal injury measuring about 2.5 centimeters (cm), a right upper arm and right knee skin tear. The resident was sent to the emergency room for sutures. Review of Resident R1's post fall evaluation dated 6/29/25, revealed the resident fell on 6/29/25, around 9:20 p.m. The resident sustained head and skin injuries following a witnessed fall while NA, Employee E3 was changing the resident. The height of the bed was in normal position. A left lateral temporal laceration measuring 2.5 cm x 0.25 cm x 0.15 cm. was observed. The resident also had a left upper arm skin tear that measured 6 cm x 1 cm and a left lateral knee skin tear that measured 2 cm x 2cm. It was revealed the resident complained of pain, and the pain was new to the resident. The resident had a temporal injury with pain. The resident's pain was rated 5/10 and described it as hurting. Review of Resident R1's progress note dated 6/29/25, entered by Nurse Practitioner, Employee E2 revealed Resident R1 was assessed via a telehealth visit after a fall. The NA was present at the bedside and reported while changing the resident, the NA went to grab a sheet, and the resident rolled out of bed. The resident had a large 2.5 cm right forehead laceration and a skin tear to the right arm. The resident was ordered to be transferred to the hospital for sutures.Review of Resident R1's hospital records dated 6/29/25, revealed Resident R1 presented to the emergency department secondary to a fall. Resident R1 apparently had fallen out of bed and was found down on the ground. The resident sustained a hematoma/contusion to the right occipital (back of brain) parietal (top and back of brain) portion of the scalp as well as abrasions to the right upper arm and right lower leg. The resident's daughter arrived at the emergency room and was concerned that the facility staff indicated the resident had right leg shortening. On reevaluation, the resident's leg was slightly shorter on the right than the left. An x-ray of the right hip and pelvis was completed and revealed an impacted sub capital fracture (intracapsular neck of femur fracture that typically results from falls or direct trauma to the hip). Surgical options were discussed, and it was decided to not have the resident hospitalized or to undergo surgery. Review of Resident R1's Radiology Report dated 6/29/25, revealed a hip with pelvis x-ray was performed due to a fall. It was revealed the resident sustained a right lateral impacted sub capital fracture. Review of Resident R1's progress note dated 6/30/25, revealed the resident was due to return after receiving sutures but the hospital subsequently found that the resident had a right hip fracture and are awaiting a stretcher to return the resident. Review of information submitted to the Department of Health on 6/30/25, indicated on 6/29/25, Resident R1 was having their draw sheet changed and rolled off the bed onto the floor. The resident was transferred to the hospital. Upon investigation it was determined that Nurse Aide, Employee E3 turned Resident R1 on their side to change their brief.NA, Employee E3 reached for the linen and the resident slid off the mattress onto the floor. The resident received a laceration to the temple. Family and physician were notified, and the resident was transferred to the hospital. It was determined the resident had a fracture right hip. Staff were educated on the importance of using two people for turning as the Kardex indicates. Review of the facility's investigation on 7/16/25, revealed NA, Employee E3's witness statement dated 6/29/25, that stated NA, Employee E3 was doing care on Resident R1. Resident R1 was rolled onto their side, and when NA, Employee E3 turned around to grab a clean draw sheet and a brief, the resident rolled back over and fell on the floor hitting their head and right hip on the ground. RN, Employee E1's witness statement dated 6/29/25, stated around 9:15 p.m. the nurse aide was changing Resident R1's brief and the resident rolled out of bed and sustained a temporal injury measuring about 2.5 centimeters, a 6 cm right upper arm skin tear, and right lateral knee skin tear that measured 2cm x 2cm. A dressing was applied, and the supervisor was informed. The resident was sent to the emergency room for sutures.During a phone interview on 7/16/25, at 10:06 a.m. NA, Employee E3 stated they have been employed since the beginning of May 2025. Around 9:00 p.m. on 6/29/25, NA, Employee E3 stated while doing care, Resident R1 was rolled on their right side towards the window. NA, Employee E3 went to grab a sheet, and the resident rolled back from their right side and Resident R1 hit her head on the floor and hit her right side, her hip. NA, Employee E3 notified the nurse, and the nurse wrapped her up and we waited for the ambulance to come. NA, Employee E3 indicated the resident may have struck the nightstand or bed side table when going down. NA, Employee E3 indicated she was not aware the Resident required an assist of two persons in bed and stated She is like 70 pounds, she is not a heavy lady, I do her by myself all the time. It was literally something that happened. I did not intentionally let her fall or was being negligent. She just rolled. During an interview on 7/16/25, at 10:42 a.m. NA, Employee E4 stated a resident's transfer status can be found in the Kardex. NA, Employee E4 stated if a resident is ordered an assist of two person, to never transfer with only one or leave the resident on their side unattended. During an interview on 7/16/25, 11:01 a.m. NA, Employee E5 stated the level of assistance required for resident's with bed mobility should be in the Kardex, and if not, I ask a nurse for clarification. If a resident requires two people for assistance, two people must always assist the resident and must never be left on their side unattended. During an interview on 7/16/25, 1:10 p.m. RN, Employee E1 stated they were called to Resident R1's room on 6/29/25, and observed Resident R1 on the floor and their head was bleeding on the right side. The supervisor was informed and 911 was notified. The resident was not moved until paramedics arrived. RN, Employee E1 stated according to NA, Employee E3's statement, Resident R1 was put on one side, and as the NA was putting bed sheets on the other side, the NA pulled the bed sheet, then the resident fell down. It was indicated the resident was very small. RN, Employee E1 indicated Resident R1 was asked if she had pain and she said yes but was unable to express the level of pain.During an interview on 7/16/25, at 2:10 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to ensure the appropriate assistance for bed mobility was provided for one of seven residents (Residents R1), which resulted in actual harm when Resident R1 fell out of bed and sustained a right hip fracture and head contusion. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(e)(1) Management.28 Pa. Code: 207.2(a) Administrator's responsibility.28 Pa. Code: 211.10(d) Resident care policies.

Based on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of eleven residents (Resident R1). This failure created an immediate jeopardy situation for 1 of 124 residents. Review of the facility policy Elopement Prevention and Management Overview dated 10/24/24, defined elopement as when a resident/patient leaves the premises or a safe area without authorization and/or any necessary supervision and places the resident at risk for harm or injury. Unsafe wandering is defined as when a resident/patient enters an area that is physically hazardous or contains potential safety hazards. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 3/19/25, included diagnoses aphasia (language disorder that affects communication and difficulty speaking), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and history of a stroke. Review of Section B: Hearing, Speech, and Vision indicated Resident R1 rarely understands and is rarely understood. Review of the Nursing Admission Evaluation(s) dated 12/13/24, 12/20/25, and 1/24/25, indicated Resident R1 is at risk for elopement or unsafe wandering. Review of a Wandering Observation Tool completed on 3/20/25, indicated Resident R1 did not have a history of wandering. Review of a Wandering Observation Tool completed on 3/31/25, indicated Resident R1 did have a history of wandering. Review of the physician's orders dated 12/13/24, through 3/29/25, failed to include orders related to wandering or risk of elopement. Review of Resident R1's plan of care for [Resident R1 is an elopement risk] initiated 12/13/24, indicated that Resident R1 will not exit property if unsafe to navigate community. Review of a progress note dated 3/30/25, at 3:20 p.m. indicated, Called by CNA (nurse aide) that resident is outside of the facility, went directly outside, saw resident with the CNA, assisted back to the facility. Contacted [Doctor's] office ordered to send resident to ED (emergency department) for further evaluation. DON (Director of Nursing) made aware. Sister contacted. 911 activated. EMS (emergency medical service) transported resident via stretcher. Review of a progress note dated 3/30/25, at 10:00 p.m. indicated that Resident R1 returned to the facility at 8:00 p.m. Review of facility submitted documentation dated 3/31/25 by the Director of Nursing (DON), indicated that on 3/30/25, at 2:30 p.m. [Resident R1] was discovered outside in front of the building on the road. He was talking with a passerby. At that time two CNAs were walking around the building and saw two men talking in the road. It looked like they were arguing. They recognized the one man as [Resident R1]. They went to him and after some encouragement convinced him to go with him into the building, He was still agitated, upon entering the building the RN (Registered Nurse) Supervisor completed a head to toe assessment. The only injury that was found was a small open area on his right wrist, 1cm x 2cm. Family and physician were notified, an order was obtained to send the resident to the emergency room for a workup to evaluate for cause of altered mental status. Resident returned from the emergency room (ER) later that evening. Upon return from the ER the resident was assessed for wander risk due to his increase in agitation, he was assessed as being a wander risk and a Wanderguard (electronic monitoring bracelet) was place on the resident, the consultant pharmacist was asked to evaluate the residents medication regimen, to check for drug interactions that might have a negative effect. Family being contacted to get a consent for psych consult. On 4/1/25, the report was updated to include that the resident exited the side door. His last elopement risk assessment was done on 3/20/25 and showed he was not at risk. He was last seen by his nurse at 2:15 p.m. The weather was 60 degrees with light drizzle. The resident had on a long sleeve shirt and pants. Review of an employee statement dated 3/30/25, written by the Licensed Practical Nurse (LPN) Employee E1 indicated, Resident with me this shift (7-3). Followed with medication pass. Pacing up and down halls quickly. No attempts to seek exit. [Resident R1] was agitated, unable to sit for 2 minutes. He was pale and looked very perplexed; very short conversations not baseline. Medications were taken along with prn (as needed) Ativan (medication for anxiety), noted Ativan not to be effective as usual, as improving his agitation and speech. Resident's foley (urinary catheter) was patent and emptied often. At end of the shift, [Resident R1] remained agitated, but we were able to redirect him. Seen him last at 2:15 p.m. at nurses station. Review of an employee statement dated 3/30/25, written by Nurse Aide (NA) Employee E2 indicated, Before rounding, [Resident R1] was doing his normal pacing back and forth. I finished my round and everything was normal. I never heard the alarm because I was in a room with the door closed. I went on a 15-minute break. I was walking with a co-worker around the building. I spotted two people in the middle of the road tussling. I noticed it was [Resident R1] because of his clothes. I ran over to help, the resident was fighting the man. I asked him to let go of the resident and I would take over. I then tried talking to the resident to calm him down and let the man go. He wouldn't so I moved the man out the way and allowed the resident to grab hold of me. He was screaming and hitting me so I walked behind him up the hill while he bent my fingers back. I got him to the sidewalk near the front door where supervisor and aides were running. They took him from there. Review of an employee statement dated 3/30/25, by NA Employee E3 indicated, After doing last rounds I went to the restroom in break area. When finishing up I heard two stairwell alarms going off. One was for [NAME] Tower the other was for Chadsworth. When I came out of the breakroom they turned off. Me and another aide then went on a smoke break. As we were walking around the building we noticed two people in the middle of the street tussling. We were walking to help and noticed it was [Resident R1]. My coworker and I then ran over to help. The resident was fighting the man, as I was calling for help my coworker took over from the man to help [Resident R1]. Once my coworker allowed resident to grab a hold of her, he was screaming and hitting her. I got in touch with the supervisor and supervisor and aides came running out the building. During an interview on 4/2/25, at approximately 2:25 p.m. the DON confirmed that the facility's investigation concluded that Environmental Services Employee (EVS) E4 had silenced the alarm, without checking in the stairwell to ensure no residents were present. During an interview on 4/2/25, at approximately 3:15 p.m. EVS Employee E4 stated that he had been in the bathroom, and the alarm had been sounding for approximately five minutes. EVS Employee E4 stated that he did look into the stairwell, but did not observe any residents. EVS Employee E4 confirmed that he did not inform any other staff of the alarm being silenced. The NHA and the DON were made aware that an Immediate Jeopardy situation existed for residents on 4/2/25, at 3:44 p.m. and a corrective action plan was requested. The Immediate Jeopardy template was provided to the facility administration at 3:50 p.m. On 3/26/25, at 6:13 p.m. an acceptable Corrective Action Plan was received which included the following interventions: -On 3/30/25 at 2:30 p.m. Affected Resident was escorted back into the facility. Wanderguard was then placed on resident immediately. Physician was notified at 2:47 p.m. Body assessment completed and skin tear to resident's right wrist was discovered. Treatment applied. Resident was transferred to ED for evaluation and treatment. Resident returned that evening with a positive UA (urinalysis) but not being treated. -On 3/30/25 at 3:00 p.m. Facility Wide Headcount was conducted by nursing department and all residents were accounted for. -On 3/30/25 at 3:15 p.m. All Alarming Doors were audited to ensure functionality. -On 3/30/25 at 8:00 p.m. after return from hospital immediate intervention of 1:1 was placed on resident and will be until adjustment to new medications is accomplished. -On 3/30/25 at 5:00 p.m. Elopement Books were updated to include affected resident. -On 3/31/25 at 7:30 am Elopement Care plan and Orders were updated on all like residents. -On 4/2/2025 at 3:00 p.m. Whole House Education was completed on Elopement Policy, Responding to Alarms, Code [NAME] and inspecting any stairwells or any exit path by Nurse Educator/designee. -On 3/31/2025, Pharmacist Consultant reviewed medications, no medication changes. On 4/1/2025, Psychiatric consultation was made, and medication adjustments were made. Resident was prescribed Lexapro (a medication used to treat depression and anxiety). -Newly admitted residents are screened for elopement risk upon admission, quarterly and as needed and care plans and assessments done accordingly. Any resident deemed at risk for elopement will have a Wanderguard placed. -On 4/2/2025, Facility Medical Director was notified of the Immediate Jeopardy and Abatement Plan. -Daily Door Alarm Audits will continue by Maintenance Department or designee daily. -Elopement Drills will be conducting weekly for two months, alternating shifts for two months. -The Plan of Correction will be monitored at the Monthly QAPI Committee Meetings monthly for the next three months. Reviewing all door audits, elopement drills, new admissions for elopement assessments and reviewing the Elopement Policy as needed. -Results will be submitted to QAPI. Review of the clinical record indicated Resident R1 received a psychiatric evaluation on 4/1/25. Review of the clinical record indicated Resident R1 received a pharmacist review of medications on 4/2/25. On 4/3/25, the elopement binder was verified as complete and accurate. On 4/3/25, updated elopement assessments, care plans, and orders for residents identified as elopement risks were verified as completed. On 4/3/25, daily door alarm audits were verified as completed for 3/31/25, through 4/3/25. On 4/3/25, review of facility documents revealed on 3/31/25, an elopement drill was held on evening shift. On 4/1/25, elopement drills were held on day and overnight shifts. During staff interviews on 4/3/24, between 1:30 p.m. and 3:00 p.m. and on 4/4/25, between 9:00 a.m. and 10:30 a.m. 34 facility staff members from multiple departments were interviewed, and confirmed that they had received education on elopement prevention, door alarms, and actions to take in the event of a suspected or confirmed resident elopement. The Immediate Jeopardy was removed on 4/4/25, at 10:45 a.m. when the action plan implementation was verified. During an interview on 4/4/25, at approximately 11:00 a.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide adequate supervision to prevent elopement for one of eleven residents. This failure created an immediate jeopardy situation for 1 of 124 residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.20(a)(1) Staff Development. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on clinical record review, review of facility policy and staff interview, it was determined the facility failed to implement interventions to prevent falls for one out of five residents reviewed (Resident R128), resulting in harm from sustaining a fall, transfer to the hospital and diagnosis of a hip fracture; failed to provide adequate supervision during bed mobility for one of two residents (Resident R9), and failed to assess the risk for smoking for two of two residents (Residents R60 and R124). Findings include: Review of facility policy, Fall Prevention and Management last reviewed 3/1/22, revealed fall prevention and management is the process of identifying risk factors that can minimize the potential for falls and a process to manage a resident's care if a fall occurs. If the resident is identified to be at risk for falls, a care plan should be initiated that includes a plan to potentially diminish the risk for falls. The care plan can include interventions that address environmental factors, ADL factors, risk factors that result from dementia and other mental diagnosis, medical diagnosis that put the resident at higher risk. Issues such as toileting, eating, transferring and impulsiveness should be considered. The care plan can address furniture arrangements, footwear, medications that can cause dizziness, drowsiness, and instability. The care plan should also address how the resident can be transferred in and out of bed as well as how the resident can ambulate and move around the facility. The care plan should be reviewed and updated as needed with each change of condition. Post fall intervention: Attempt to identify why the resident fell and put an immediate intervention in place. And The team should have a way to inform all care givers of any new interventions placed in the care plan. During a clinical record review on 11/7/22, documentation revealed Resident R128 sustained four falls during the period from 7/25/22 through 9/7/22. Resident R128 was admitted the facility on 7/12/22, with diagnoses that included osteomyelitis (infection of the bone) left foot, hypertension, and non-Alzheimer's dementia. Review of the MDS (Minimum Data Set- a periodic review of care needs) dated 7/19/22, indicated Resident R128's cognitive status was moderately impaired and required extensive assistance of two persons for bed mobility and transfers. Review of the care plan dated 7/13/22, indicated Resident R128 is at risk for falls related to gait/balance problems, medications, incontinence, poor safety awareness, weakness related to disease processes and impulsive. Review of the clinical record indicated that on 7/25/22, Resident R128 fell . Review of the facility investigation dated 7/25/22, indicated Resident is a known fall risk. Poor safety awareness. As part of the IDT (IDT- Interdisciplinary team) meeting states, Resdient was rolled up in his covers (sheets and blankets). Resident is confused by the situation and stating he doesn't like all the blankets tucked in and wants them removed and that staff had removed the blankets and were aware that Resident R128 did not wish to have blankets on his bed. Review of the clinical record dated 8/17/22, indicated Resident R128 was found sitting on his wheelchair leg rests. Review of the facility investigation, dated 8/17/22, indicated Resident R128 slid from his wheelchair onto the wheelchair leg rests for unknown reason. The IDT meeting states medical workup being done to check for anything going on medically that would cause confusion. There was no documented evidence that the results of the medical work up identified any additional contributing factors and the facility failed to implement any further measures to prevent falls. Review of the clinical record indicated on 8/25/22, Resident R128 was found on the floor next to his bed. Review of the facility investigation dated 8/25/22, indicated Resident R128 was attempting to get up in his chair. Review of Resident R128's care plan on 11/7/22, did not identify any changes and/or ongoing changes to the care plan to include removing blankets from the bed. Review of Resident R128's care plan on 11/7/22, revealed medical workup in progress initiated on 8/18/22, to rule out medical cause for falls. Review of Resident R128's care plan on 11/7/22, revealed the intervention offer resident out of bed at breakfast time, as resident allows initiated on 8/26/22. Review of Resident R128's Kardex (an electronic record of basic care orders utilized by nursing assistants) failed to identify any interventions of getting the resident out of bed at breakfast time. Review of the clinical record on 11/7/22, failed to identify any documentation Resident R128 was being offered out of bed for breakfast was being completed. Review of the clinical record indicates on 9/1/22, Resident R128 was found on the floor on his right side next to his wheelchair. Review of the facility investigation dated 9/1/22, indicated Patient is confused, unable to recall what occurred Conclusion: Resident is a known fall risk. Resident is a two-person max assist. Residents brief was soiled at the time. Review of Resident R128's care plan on 11/7/22, revealed the intervention Offer toileting at bedtime, as resident allows. and therapy to screen initiated on 9/2/22. Review of Resident R128's Kardex failed to identify any interventions of toileting the resident at bedtime. Review of the clinical record on 11/7/22, failed to identify any documentation Resident R128 was being toileted at bedtime. Orders for therapy to assess Resident R128 for services were initiated and completed on 9/6/22. On 9/7/22, at approximately 12:15 p.m. Resident R128 was found on the floor next to the bed and was transferred to the hospital where it was discovered that Resident R128 was found to have a right hip fracture. Review of Resident R128's facility Kardex failed to identify any new interventions/tasks from 7/12/22, to 9/7/22. Review of the physician orders failed to identify orders for removing blankets, out of bed for breakfast, or toileting at bedtime. During an interview with the Regional Director of Clinical Operations (RDCO) Employee E28 on 11/3/22, at 3:35 p.m. it was identified that the care plan was updated, but the system failed to add the interventions to the tasks in the Kardex system or orders for staff to view or implement. During an interview on 11/7/22, at 2:21 p.m. Nurse Aide Employee E20 reported that aides do not have access to the full care plan, only the parts that appear on their Kardex system. During an interview on 11/7/22, at 3:20 p.m. the NHA and DON confirmed that the facility failed to implement interventions to prevent Resident R128 from repeated falls, one of which resulted in harm, involving a fractured femur. Review of the clinical record revealed that Resident R9 was admitted to the facility on [DATE]. The MDS dated [DATE], included diagnoses of weakness, low back pain, and diabetes mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) . Review of the facility care plan dated 5/9/22, indicated that Resident R9 required extensive assistance of one staff while in bed. Resident R9 utilized a mechanical lift for transfers utilizing a hoyer (a mechanical lift which utilizes a large sling called a hoyer pad to lift a resident). During an interview on 11/2/22, at 10:29 a.m. Resident R9 reported that she sustained a skin tear to her right arm while being cared for several weeks ago when she was injured by the hoyer sling while being moved in bed. Review of the clinical records dated 9/15/22, indicates that Resident R9 sustained a skin tear to her right antecubital area (inner elbow) region. During an interview on 11/8/22, NA (Nurse Aide) Employee E20 reported that she was moving Resident R9 in bed on 9/14/22, and pulling out the hoyer pad from underneath her, when the hoyer pad pulled at the skin causing a skin tear. NA Employee E20 stated that at the time she was told to be more careful and was educated to check to make sure the resident was clear of the hoyer before attempting to pull the pad out from under a resident. During an interview on 11/8/22, at 3:15 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to ensure Resident R9 was free from accidents and hazards, resulting in a skin tear. During the Entrance Conference interview on 10/31/22, at 9:40 a.m. the Nursing Home Administrator indicated that the facility is non-smoking; and confirmed there are no smoking related policies and procedures. A review of Resident R60's clinical record indicated an admitted [DATE]. A Review of the Minimum Data Set (MDS - periodic assessment of resident needs) dated 8/2/22, indicated diagnoses that included diabetes mellitus, and heart failure. Review of Resident R60's MDS dated [DATE], Section J: Health Conditions, Question J1300 Current Tobacco Use indicated an answer of No. During an observation on 11/6/22, at 6:30 p.m. Resident R60 was noted to be smoking a cigarette at the front entrance of the building, unsupervised. Review of Resident R60's clinical record and plan of care reviewed 11/7/22, failed to indicate any assessments for assessments of the hazards or risks for smoking, or goals and interventions related to non-compliance with the facility's non-smoking policy. A review of Resident R124's clinical record indicated an admitted [DATE]. Review of the MDS dated [DATE], indicated diagnoses that included diabetes mellitus and high blood pressure. Review of Resident R124's MDS dated [DATE], Section J: Health Conditions, Question J1300 Current Tobacco Use indicated an answer of No. During an observation on 11/7/22, at 1:00 p.m. Resident R124 was seen smoking a cigarette at the front entrance of the building, unsupervised. Review of Resident R124's clinical record and plan of care reviewed on 11/7/22, failed to indicate any assessments of the hazards or risks for smoking, or goals and interventions related to non-compliance with the facility's non-smoking status. During an interview on 11/8/22, at 2:20 p.m. the Director of Nursing confirmed that Residents R60 and R124 were non-compliant with the facility's non-smoking status, the facility was aware of the residents smoking and failed to assess or evaluate the hazard and risk, implement interventions, or care plan for non-compliance creating the potential for injury during smoking. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services.

Based on review of facility policy, clinical records, incident reports, and staff interview, it was determined that the facility failed to make certain that residents were free from neglect by not providing the necessary services, which resulted in actual physical harm (15-centimeter laceration) for one of four residents (Resident R2). Findings include: The facility's Abuse, Neglect, & Misappropriation policy dated 3/4/21, and updated 3/1/22, indicated that neglect is the 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, emotional. A review of the clinical record revealed that Resident R2 was admitted to the facility on [DATE]. The Minimum Data Set (MDS - periodic assessment of care needs) dated 12/23/21, included diagnoses of atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots), diabetes (metabolic disorder in which the body has high sugar levels for prolonged periods of time), sciatica (severe pain that radiates from the back into the hip and outer side of the leg caused by compression of the sciatic nerve), and spinal stenosis (a narrowing of the spaces within the spine). Review of Section G: Activities of Daily Living (ADL) Assistance indicated Resident R2 required extensive assistance of two or more persons for transfers. A review of Resident R2's plan of care for ADL self-care performance deficit, initiated 11/17/21, revealed that Resident R2 was required to be transferred with a mechanical lift. A review of the physician order dated 12/1/21, indicated that Resident R2 is required to be transferred with a mechanical lift. A review of an incident note written by Employee E13 dated 2/10/22, at 9:07 p.m. stated, NA (Nursing Assistant Employee E9) came to notify me that when transferring resident from wheelchair to bed, he noticed blood on his clothing. Upon entering resident's room, I noticed a laceration on left outer calf bleeding. Measurements 10.5 x 6 x 3.2. Supervisor notified and came immediately to assess .Administered tramadol (a narcotic pain reliever) for pain. A review of a physician's assistant note dated 2/10/22, at 9:12 p.m. stated, Noted to have a large laceration to left leg during transfer, new with bleeding. The note further stated, Laceration 10 cm by 6 cm gaping with adipose tissue (fat tissue) of left lateral calf. Transfer to the ER for laceration management. A review of hospital discharge paperwork dated 2/10/22, at 10:35 p.m. indicated that Resident R2 was seen for a large left lower extremity laceration. The wound was described as a 15 cm laceration of the left lateral leg with exposed fascia (flat band of tissue below the skin that covers underlying tissue) .significant tissue defect. Resident R2 was noted to have received an x-ray and a tetanus/diphtheria/pertussis vaccination (to prevent infection of tetanus, a type of bacterial infection, that can be transferred through lacerations or wounds). The wound was noted to be a complex laceration repair requiring multi-layer closure. The subcutaneous tissue (tissue under the skin) was closed using absorbable suture, and the skin was closed suing sutures and staples. A review of an employee statement written by NA Employee E9 on 2/10/22, indicated I locked the brakes on the chair and put bother of her feet flat on the floor. The resident didn't' have foot rests on her chair. I stood in front of the resident and placed my arms under her arm pit ans asked her to lean forward. I counted to three and lifted the resident up and pivoted her to the bed then lowered her down to the bed. I placed right hand on her back and my left hand under her knees and turned her on the bedding down on her back. I felt something wet on my forearm and saw it was blood. A review of a progress note dated 2/11/22, at 2:40 p.m. stated that Resident R2 returned from the emergency room and stated her pain was seven out of ten. A review of an employee statement written by RN Employee E10 dated 2/11/22, at 2:00 p.m. indicated that she had been notified by nursing staff of an injury to Resident R2. When RN Employee E10 entered Resident R2's room, two nurses (RN Employees E13 and E14) were applying pressure to Resident R2's left calf with towels and that blood was observable on the bed sheets. RN Employee E10 indicated that Resident R2's wheelchair was at the foot of the bed, with the Hoyer Lift (an assistive device that allows patients to be transferred between a bed and a chair or other similar resting places, by the use of electrical or hydraulic power) blanket on the wheelchair, and the Hoyer Lift was outside the resident's room door. RN Employee E10 noted a laceration on the shin, measuring in centimeters 10.2 x 6.0 x 3.2, with some tissue and skin torn out of their normal placement, creating a jagged outline. Resident R2 was sent to the hospital at around 9:30 p.m. A review of an employee statement written by NA Employee E8 dated 2/12/22, stated, I asked (NA Employee E9) to help me put the Resident R2 to bed because she is a Hoyer lift and he said he had it and lifted her and sat her on the bed. I didn't see her leg hit anything but when he lifted her legs to lay her down there was blood on his arm and her left calf was bleeding. Review of facility provided documentation on 3/23/22, indicated NA Employee E9 was suspended pending an investigation for an injury sustained to a resident. NA Employee E8 requested assistance from NA Employee E9 to Hoyer a resident back to bed. NA Employee E9 came into the room to assist NA Employee E8. NA Employee E8 advised NA Employee E9 that they needed to use the Hoyer to transfer the resident back to bed. NA Employee E9 stated to NA Employee E8, Don't worry I got this. NA Employee E9 proceeded to transfer the resident by bear hug method to the bed. The resident sustained a deep skin tear requiring being sent out to the hospital to staple the wound. During an interview on 3/23/22, at 1:30 p.m. the Nursing Home Administrator confirmed that NA Employee E9 had been trained that Resident R2 required transfer by Hoyer lift and opted not to do so of his own accord. During an interview on 3/24/22, at 2:15 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to make certain that residents were free from neglect by not providing the necessary services, which resulted in actual physical harm for one of four residents 42 CFR 483.12(a)(1) Free From Abuse and Neglect 28 Pa. Code 201.14(a) Responsibility of Licensee. Previously cited: 5/19/21, 11/11/21, 1/27/22. 28 Pa. Code 201.18(b)(1) Management. Previously cited: 7/8/20, 5/19/21, 11/11/21, 1/27/22. 28 Pa. Code 201.18(b)(3) Management. Previously cited: 11/11/21, 1/27/22. 28 Pa. Code 201.29(a) Resident Rights Previously cited: 11/11/21. 28 Pa. Code 201.29(c)(d) Resident Rights. 28 Pa. Code 201.29(j) Resident Rights. Previously cited: 5/19/21. 28 Pa. Code 211.10(c) Resident Care Policies. Previously cited: 11/11/21 28 Pa. Code 211.10(d) Resident Care Policies. Previously cited: 7/8/20, 5/19/21, 11/11/21 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited: 7/8/20, 5/19/21, 11/11/21, 1/27/22 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited: 5/19/21, 11/11/21, 1/27/22

Based on review of facility documents and policy, clinical records, and staff interviews, it was determined that the facility failed to obtain physician-ordered medications, causing medications to not be administered as ordered, which resulted in actual harm of changed mental status and three hospital transfers for one of three residents (Resident R1) Findings include: A review of facility policy Provider Pharmacy Requirements dated 3/1/22, previously reviewed 3/4/21, indicated reliable pharmaceutical services will be provided to the residents. Review of Resident R1's admission record indicated he was initially admitted to the facility on [DATE]. A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 2/19/22, included diagnoses of Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), non-traumatic brain dysfunction (injury to the brain that was not caused by an external physical force), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and a seizure disorder. Review of the document named Admission Med List uploaded to the electronic medical record on 2/7/22, was dated as having been printed on 1/4/22, at 12:28 p.m. During an interview on 3/23/22, at 10:00 a.m. surveyors requested the hospital discharge paperwork for Resident R1's admission on 2/7/22. During an interview on 3/23/22, at 11:15 a.m. the Director of Nursing (DON) stated that Resident R1 had multiple scheduled admitted s, that continued to be pushed back by the hospital. The DON confirmed that the admission orders used for Resident R1's actual admission on 2/722, were received for a previously scheduled admission, and did not include all Resident R1's required medications. Review of the facility provided After Visit Summary dated 2/7/22, signed as confirmed by the facility medical provider, indicated that Resident R1 was to be ordered: -Atorvastatin (medication used to lower cholesterol) 10 mg (milligrams) at bedtime. -Baclofen (medication used to treat muscle spasms, pain, and stiffness) five mg, three times per day. -Benztropine (medication used to treat Parkinson's disease and side effects caused by other medications) 0.5 mg, two time per day. -Carbidopa-levodopa 25-100 mg, two tablets, three times per day. -Carbidopa-levodopa 25-100 mg, controlled release, at bedtime. -Clozapine 50 mg nightly. -Famotidine (medication used to reduce stomach acid) 20 mg, two times per day. -Furosemide (medication used to treat fluid retention) 20 mg, daily. -Hydralazine (medication to treat high blood pressure) 25 mg, three times per day. -Insulin glargine (medication used to treat high blood sugar) 20 units, two times per day. -Lamotrigine (medication used to treat seizures) 50 mg, two times per day. -Levetiracetam (medication used to treat seizures) 1000 mg, two times per day. -Magnesium chloride extended release (mineral supplement) 64 mg, daily. -Propranolol (medication used to treat high blood pressure) 20 mg, four times per day. -Spironolactone (medication used to treat high blood pressure and fluid retention) 12.5 mg, daily. Review of physician's orders indicated that only medications that appeared on the outdated admission orders (1/4/22) were ordered on 2/8/22, (famotidine, hydralazine, insulin glargine, lamotrigine, levetiracetam, magnesium chloride, and propranolol). Review of the non-ordered medications indicated the following: -Atorvastatin, ordered 2/9/22, first dose given documented as provided on 2/9/22, at bedtime. Review of pharmacy receipts indicated that Resident R1 did not receive his order of atorvastatin from the pharmacy until 2/13/22, at 2:01 p.m. Review of the facility provided list of medications stored the Omnicell (an automated medication dispensing machine used to access ordered medications on an emergency basis) indicated that atorvastatin was in the inventory available to be dispensed, if needed. Review of the transactions completed through the Omnicell on 2/9/22, indicated no atorvastatin was dispensed. First actual dose provided by the facility was 2/13/22, at 8:41 p.m. -Baclofen, ordered 2/9/22, first dose given documented as provided on 2/9/22, at bedtime. Review of pharmacy receipts indicated that Resident R1 did not receive his order of baclofen from the pharmacy until 2/13/22, at 2:01 p.m. Review of the facility provided list of medications stored the Omnicell indicated that baclofen was not in the inventory to be dispensed. First actual dose of baclofen provided by the facility was 2/13/22, at 2:43 p.m. -Benztropine, ordered 2/9/22, first dose given documented as provided on 2/9/22, at bedtime. Review of pharmacy receipts indicated that Resident R1 did not receive his order of benztropine from the pharmacy until 2/13/22, at 2:01 p.m. Review of the facility provided list of medications stored the Omnicell indicated that benztropine was not in the inventory to be dispensed. First actual dose of benztropine provided by the facility was 2/13/22, 2:41 p.m. -Carbidopa-levodopa, non-extended release, ordered 2/9/22, two tablets three times per day, and additional one tablet at bedtime. (Incorrect order, the one tablet at bedtime should have been ordered as extended release). Review of the facility provided list of medications stored the Omnicell indicated that carbidopa-levodopa was in the inventory available to be dispensed, if needed. Resident R1 received two tablets of non-extended release carbidopa-levodopa on 2/9/22. -Carbidopa-levodopa, non-extended release, correctly ordered 2/13/22, first dose give 2/13/22 at 2:42 p.m. (7:00 a.m. dose), 4:14 p.m. (5:00 p.m. dose), and at 8:30 p.m. (9:00 p.m. dose). -Carbidopa-levodopa, extended release concurrently ordered to be provided at bedtime. Resident R1 is documented as having received the extended-release doses, as of 2/13/22. Per facility provided pharmacy receipts, Resident R1 did not received extended-release doses from the pharmacy until 2/25/22, at 1:42 a.m. Review of the facility provided list of medications stored the Omnicell indicated that carbidopa-levodopa (extended-release) was not in the inventory available to be dispensed. -Clozapine, ordered 2/9/22, first dose given documented as provided on 2/9/22, at bedtime. Review of pharmacy receipts indicated that Resident R1 did not receive his order of clozapine from the pharmacy until 2/9/22, at 11:34 p.m. Review of the facility provided list of medications stored the Omnicell indicated that clozapine was not in the inventory to be dispensed. First actual dose of clozapine provided by the facility was 2/14/22. -Furosemide, ordered 2/12/22, at 7:07 p.m. (five days after admission). First dose given documented as provided on 2/13/22, in the morning. Review of pharmacy receipts indicated that Resident R1 did not receive his order of furosemide from the pharmacy until 2/13/22, at 2:01 p.m. Review of the facility provided list of medications stored the Omnicell indicated that furosemide was in the inventory available to be dispensed, if needed. First actual dose provided by the facility was 2/13/22, at 2:43 p.m. -Magnesium chloride, ordered 2/7/22, at 9:36 p.m. Discontinued on 2/11/22, at 12:31 a.m. Reordered on 2/12/22, at 7:16 p.m. First dose of magnesium chloride documented as provided by the facility was 2/17/22, in the morning. -Spironolactone, ordered 2/12/22, at 7:16 p.m. (five days after admission). First dose given documented as provided on 2/13/22, in the morning. Review of pharmacy receipts indicated that Resident R1 did not receive his order of spironolactone from the pharmacy until 2/13/22, at 2:01 p.m. Review of the facility provided list of medications stored the Omnicell indicated that spironolactone was in the inventory available to be dispensed, if needed. First actual dose provided by the facility was 2/13/22. Review of a progress note dated 2/8/22, at 6:47 a.m. indicated Resident R1 was shaking like a leaf. Review of a nurse practitioner progress note dated 2/8/22, at 12:40 p.m. indicted that Resident R1 was on no medications for Parkinson's disease. Review of a nurse practitioner progress note dated 2/9/22, at 4:14 p.m. indicted that Resident R1 was on no medications for Parkinson's disease. Review of a progress noted on 2/9/22, at 10:01 p.m. indicated that the pharmacy had called with concern about clozapine order. Information entered in physician's communication book. Review of a progress notes dated 2/10/22, at 12:27 p.m. indicated that Resident R1 reported not feeling well, was clammy and experiencing tremors. Resident R1 requested to go to the hospital and emergency services were contacted. Review of a physician's note dated 2/10/22, at 2:02 p.m. indicated, Apparently, there was a medication discrepancy due to incomplete medical record review on admission. Patient's sister has been in contact with facility, upset regarding this. Nursing staff have resolved the issue, medication list is reviewed and updated. Review of the hospital After Visit Summary dated 2/12/22, at 10:38 a.m. indicated that Resident R1 was admitted to the hospital for altered mental status. Review of a progress note dated 2/13/22, at 3:44 a.m. indicated Resident R1 left the facility to return to the hospital at 3:45 a.m., per request of Resident R1's sister. Review of a progress note dated 2/12/22, at 11:31 p.m. indicated that Resident R1 had been readmitted on [DATE], at 3:30 p.m. Review of a nurse practitioner note dated 2/14/22, at 1:38 p.m. indicated that Resident R1 had been ordered clozapine, and that the psychiatric provider was consulted, who would see the resident this week. Review of a progress note dated 2/15/22, at 9:29 a.m. indicated Resident R1 was noted to have slow speech and inability to form sentences. The progress note further indicated that Resident R1 was transferred to the hospital. Review of the hospital After Visit Summary dated 2/15/22, at 4:42 p.m. indicated that Resident R1 was seen in the hospital for a medication change. Review of a social services note dated 2/15/22, at 5:12 p.m. indicated Resident R1 would return to the facility later in the evening. Review of a nurse practitioner note dated 2/17/22, at 11:10 a.m. indicated when patient was admitted to the facility initially, there was a discrepancy with his medications, and he did not get his psych meds for a few days likely contributing to the altered mental status prompting this (2/10/22) emergency department visit. The progress note further indicated, Resident R1 has been sent to the emergency department twice since admission for change in mental status and altered speech. He has history of schizophrenia and Parkinson's and had a medication discrepancy when initially admitted prompting initial emergency room trip. Resident R1 became increasingly anxious in facility and was sent out again this week when his speech was stuttered and difficult to interpret. During an interview on 4/5/22, at 12:00 p.m. the Nursing Home Administrator confirmed that Resident R1 did not receive the doses that were documented as having been provided on 2/9/22. During an electronic interview on 4/6/22, at 11:16 a.m. the Nursing Home Administrator confirmed that the facility failed to obtain physician-ordered medications, causing medications not being administered as ordered, which resulted in actual harm of changed mental status and three hospital transfers for one of three residents. 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited: 7/8/20, 5/19/21, 11/11/21, 1/27/22 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited: 5/19/21, 11/11/21, 1/27/22