Every finding on record at Peters Township Post Acute

Based on review of facility policy, resident observations, resident interviews and confidential staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of eight of eleven residents (Resident R1, R2, R3, R4, R5, R6, R7, and R8).Findings Include: Review of the facility policy Staffing dated 9/11/25, indicated Our facility provides adequate staffing to meet needed care and services for our resident population. Review of the facility policy Answering the Call Light dated 9/11/25, indicated the facility will ensure timely responses to the resident's requests and needs. During an interview on 4/6/26, at 12:40 p.m. when asked if she thought the facility maintained sufficient staffing to care for residents, Resident R1 stated, No. My thing is, when I need to go to the bathroom, I have to wait and wait. Resident R1 confirmed that she has urinated while waiting for a bed pan to be provided. When asked about receiving showers, Resident R1 stated, I haven't had a shower in I don't know how long. I feel [NAME]. Review of Resident R1's bathing record for 3/12/26, through 4/5/26, confirmed Resident R1 has only received bed baths. During an interview and observation on 4/6/26, at 12:50 p.m. Resident R2's room smelled strongly of urine. When asked about call light response, Resident R2 stated, Depends. Quicker in the day than in the night. Resident R2 confirmed he has urinated while waiting for assistance to be provided. During an interview and observation on 4/6/26, at 12:50 p.m. when asked about call light response, Resident R3 stated, Depends on what is going on. During an interview on 4/6/26, at 12:58 p.m. Resident R4 stated that she waited nine hours to get back into bed on the previous Friday (4/3/26). Observation at this time revealed Resident R4's fingernails to have a brown substance under the nails. During an interview and observation on 4/6/26, at 1:25 p.m. when asked if she thought the facility maintained sufficient staffing to care for residents, Resident R5 stated, Not enough, especially in the evening. During an interview and observation on 4/6/26, at 1:29 p.m. when asked if she thought the facility maintained sufficient staffing to care for residents, Resident R6 stated, I think they are understaffed. During an interview and observation on 4/6/26, at 1:30 p.m. when asked if she thought the facility maintained sufficient staffing to care for residents, Resident R7 stated, I don't think so. When asked if call light response time were long, Resident R7 stated, Sometimes, yes. During an interview on 4/6/26, at 1:40 p.m. when asked if she thought the facility maintained sufficient staffing to care for residents, Resident R8 stated, No. They are way understaffed. When asked if call light response times were long, Resident R8 stated, Oh my God, yes. Hours and sometimes never. I don't know why they give them to us if they don't answer. During an interview on 4/6/26, at approximately 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of eight of eleven residents. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(e)(6) Management. 28 Pa. Code: 201.20(a) Staff development.28 Pa. Code: 211.12(a)(c)(d)(1)(2)(3)(4) Nursing services.

Based on review of facility policy, facility provided documents, clinical records, and staff interviews, it was determined the facility failed to ensure a resident was free from mental abuse and intimidation for one of two residents reviewed (Resident R63), which resulted in psychosocial harm and mental anguish related to the reasonable person concept. Findings Include: Review of the facility policy Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, dated 9/11/25, with a previous review date of 1/20/25, indicated that the facility will document, investigate and report all reports of resident abuse; the Administrator determines what actions are needed to protect the resident involved. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2025, indicated that a Brief Interview for Mental Status (BIMS), is a screening test that aids in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of Resident R63's clinical record revealed Resident R63 was admitted to the facility on [DATE]. Review of Resident R63's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 9/28/25, included diagnoses of diabetes (chronic condition where body can't make enough insulin and blood glucose (sugar) levels are high), muscle weakness, high blood pressure and vascular dementia (a decline in thinking skills causing problems with planning, memory, judgement and mood). Review of Section C: Cognitive Patterns indicated Resident R63 had a BIMS score of 12 - moderately impaired at the time of the incident (6/12/25), her score as of 9/28/25, has dropped to 6-severely impaired. Review of the facility provided documents dated 6/12/25, revealed that Resident R63's son was called and notified that a CNA (Certified Nurse Aide (NA) Employee E4) had been physically and verbally aggressive, when Resident R63 was interviewed she stated a woman came into my room and was mean. This woman hit me in the shoulder, so I hit her back, NA Employee E4 was calling me names and saying I was a bitch and was worthless and threatened to come back with a baseball bat. Review of facility investigation documents revealed via employee statement that CNA Employee E3 was in the room assisting Resident R63's roommate behind the curtain and overheard a slap, but was unsure of who slapped who, NA Employee E3 did hear NA Employee E4 become verbally aggressive with Resident R63, NA Employee E3 immediately told nursing supervisor Registered Nurse (RN) Employee E5. Review of progress notes dated 6/12/25, indicated a full body audit was conducted with no new skin issues or bruising noted, followed on 6/13/25 with no issues. Resident R63 was also reassured that NA Employee E4 would not be returning to the facility and that she was safe in the facility, if needed a psych consult would be ordered. Further review of the medical record did not indicate that a psych consult was ordered. Review of facility submitted Report Form for Investigations of Alleged Abuse, Neglect, Misappropriation of Property form dated 6/12/25, indicated that the facility investigation substantiated the abuse investigation. NA Employee E4 had been suspended pending investigation and then was terminated at the conclusion of the investigation. Review of facility investigation revealed that the police were not notified of suspected abuse as per facility policy for all suspected abuse and abuse training was not conducted with staff for review after the incident. During a confidential interview with NA Employee E53 on 12/8/25, at approximately 10:30 a.m., indicated they were aware of the event because NA Employee E53 heard it through the grapevine but were not educated or re-educated on the facility abuse policy. NA Employee E53 could not believe that someone would speak to a resident like that. During an interview of 12/8/25 at 10:45 a.m., NA Employee E17 indicated to not engage a resident when things escalate, go back and try again or even see if they will respond to a different staff member. NA Employee E17 also indicated that there was no re-education on the facility abuse policy. NE Employee E17 also indicated she felt really bad for the resident. During an interview on 12/9/25, at approximately 1:30 p.m., the Nursing Home Administrator, Director of Nursing and Regional Director of Clinical Services confirmed the facility failed to protect Resident R63 from mental abuse and intimidation. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.20 (a)(b) Staff Development. 28 Pa. Code 201.29 (a)(c)(d) Resident Rights.

Based on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly label and date food, store food in accordance with professional standards for food service safety and failed to have food service staff wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food. Findings include: Review of the facility policy Food Receiving and Storage dated 9/11/25, with a previous review date of 1/20/25, indicated that food shall be stored in a manner that complies with safe food handling practices. Review of the facility policy Food Prep and Service dated 9/11/25, with a previous review dare of 1/20/25, indicated food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc) so that hair does not contact food. During observation of the main kitchen on 12/07/25, from 9:00 a.m. through 9:15 a.m. the following was observed: Dietary Supervisor Employee E2 did not have hair restraint covering hair.Dietary Aide Employee E8 had headphones on phone talking with someone with no beard guard covering facial hair.Observation of the freezer identified two open boxes of vegetables exposed to possible frostingObservation of the cooler identified a cart with three shelves of pudding bowls undated.During an interview on 12/7/25, at 9:15 a.m., the Dietary Supervisor Employee E2 confirmed that the facility failed to properly label and date food, store food in accordance with professional standards for food service safety and failed to have food service staff wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food. 28 Pa. Code: 211.6(c) Dietary services.

Based on review of facility policy, clinical records, facility documents, and staff interviews it was determined that the facility failed to fully investigate allegations of physical/verbal abuse and an injury to one of three residents (Resident R63). Finding include:Review of the facility policy Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating dated 9/11/25, previously reviewed 1/20/25, indicated all reports of resident abuse (including injuries of unknown origin), neglect, exploitation or theft/misappropriation of resident property are reported to local, state and federal agencies (as requested by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2025, indicated that a Brief Interview for Mental Status (BIMS), is a screening test that aids in detecting cognitive impairment). The BIMS total score suggests the following distributions:13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of the clinical record indicated Resident R63 was admitted to the facility on [DATE].Review of Minimum Data Set (MDS-periodic assessment of resident care needs) dated 9/28/25, included diagnoses of diabetes (chronic condition where body can't make enough insulin and blood glucose (sugar) levels are high), muscle weakness, high blood pressure and vascular dementia (a decline in thinking skills causing problems with planning, memory, judgement and mood). Review of Section C: Cognitive Patterns indicated Resident R63 had severe cognitive impairment.Review of the facility provided investigation documents dated 6/12/25, revealed that Resident R63's son was called and notified that a CNA (Certified Nurse Aide (CNA) Employee E4) had been physically and verbally aggressive, when Resident R63 was interviewed she stated a woman came into my room and was mean. This woman hit her in the shoulder, so she hit her back, Employee E4 was calling me names and saying Resident R63 was a bitch and was worthless and threatened to come back with a baseball bat.Review of facility investigation documents revealed another CNA (Employee E3) was in the room and overheard a slap but was unsure of who slapped who but did hear Employee E4 become verbally aggressive with Resident R63, Employee E3 immediately told nursing supervisor Employee E5.Review of facility submitted Report Form for Investigations of Alleged Abuse, Neglect, Misappropriation of Property dated 6/12/25, indicated that the facility investigation substantiated the abuse investigation.Review of facility investigation revealed that the police were not notified of suspected abuse, resident/family were not given option to file a report as per facility policy for all suspected abuse and abuse training was not conducted with staff after the incident.During an interview on 12/9/25, at approximately 1:30 p.m. the Nursing Home Administrator (NHA), Director of Nursing (DON) and Regional Director of Clinical Services (RD) confirmed that the facility failed to protect residents from a staff member physically and verbally abusing a resident for one of three residents.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 201.20(a)(b) Staff Development.28 Pa Code 201.29(a)(c)(d) Resident Rights.

Based on observations, review of facility policy and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment on two of three nursing units (Vintage and Heritage Nursing Units).Findings include:Review of the facility policy Homelike Environment dated 9/11/25, with a previous review date of 1/20/25, indicated residents are provided with a safe, clean, comfortable and homelike environment.During an observation on 12/7/25, at 9:25 a.m., the following was observed: Main hallway of Vintage nursing unit near rooms [ROOM NUMBERS] had a brown substance that was dried on floor with gnats and bugs crawling through and had been tracked further down hall.During an interview Housekeeper Employee E1 confirmed that the facility failed to provide a clean homelike environment for the residents of the Vintage nursing unit.During an observation on 12/8/25, at 9:30 a.m., the following was observed:Main hallway railing near room [ROOM NUMBER] had a brown substance on railing and wall above.The Vintage dining room had broken cabinetry.The [NAME] heater vents had bingo chips and gray fuzzy material inside vents.The shower room of Vintage nursing unit had holes on wall.During an interview on 12/8/25, at 9:38 a.m., the Nursing Home Administrator confirmed that the facility failed to provide a safe, clean, comfortable homelike environment for the residents of two of three nursing units (Vintage and [NAME] nursing units).28 Pa. Code: 207.2(a) Administrator's responsibility.28 Pa. Code: 201.29(k) Resident rights.

Based on review of facility policy, facility records, resident, and staff interviews, it was determined that the facility failed to make certain call lights were answered timely for ten of thirteen residents as required (Resident R31, R69, R115, R700, R703, R704, R706, R707, R708, and R709).Findings include: The facility policy Answering the Call Light dated 9/11/25, indicated Answer the resident call system immediately. When answering an auditory request for assistance, identify yourself and politely respond to the resident by his/her name (e.g., This is Mrs. [NAME]. Mr. [NAME], how may I help you?). If the resident needs assistance, indicate the approximate time it will take for you to respond. During a resident group interview, on 12/7/25 at approximately 1:30 p.m., when asked does the staff respond to your call lights timely? The group asked to be confidential. The group consensus of the residents indicated, there is a wait time to get your call light answered and this occurs often. The waiting time can be 20, 30 minutes or longer. The group stated this occurs mostly in the evenings, weekends, and with agency staff. Review of Resident R704's clinical record, with a request for confidentiality (identifiers of dates and diagnosis are intentionally omitted).Review of Resident R704's most recent Minimum Data Set (MDS - a periodic assessment of care needs). Review of Section GG: Functional Abilities GG0130, indicated that Resident R704 is supervision or touch assistance with toileting hygiene (helper provides verbal cues and/or touching/steadying and /or contact guard assistance as resident completes activity), and GG0170 toilet transfers indicated that Resident R704 is supervision or touch assistance with toileting hygiene (helper provides verbal cues and/or touching/steadying and /or contact guard assistance as resident completes activity). During an interview and observation on 12/7/25, at approximately 2:00 p.m. Resident R704 stated wait times for 20 minutes or longer on different occasions when using the call light. Resident R704 stated, recently after needing to have a soiled brief changed, using the call light without response, after a while started yelling for help without response and then throwing some items out into the hall to get someone's attention and staff arrived to provide care. Resident 704 stated when this occurs it usually the evening and weekend agency staff. Review of Resident R706's clinical record, with a request for confidentiality (identifiers of dates and diagnosis are intentionally omitted). Review of Resident R706's most recent MDS. Review of Section GG: Functional Abilities GG0130, indicated that Resident R706 is dependent (helper does all of the effort), and GG0170 toilet transfers indicated that Resident R706 is dependent (helper does all of the effort). During an interview and observation on 12/7/25, at approximately 2:10 p.m. Resident R706 stated wait times of 20 minutes or more occur when using the call light usually at night and weekends it sure seems to be the agency staff. Resident R706 stated, recently after needing to have a soiled brief changed, used the call light without response, after a while started hollering for help and a staff member came in and said to keep the noise down and provided the resident care. Review of Resident R707's clinical record, with a request for confidentiality (identifiers of dates and diagnosis are intentionally omitted). Review of Resident R707's most recent MDS. Review of Section GG: Functional Abilities GG0130, indicated that Resident R707 is dependent (helper does all of the effort), and GG0170 toilet transfers indicated that Resident R706 is dependent (helper does all of the effort). During an interview and observation on 12/7/25, at approximately 2:17 p.m. Resident R707 stated wait times for 20 minutes or even longer when using the call light are not uncommon. Resident R707 stated recently her oxygen tubing fell off and onto the floor, using the call light without response, after a while started banging on her table to get a response. Staff arrived to assist Resident 707 and reportedly told the resident to keep the noise down. Resident 707 stated she was without her oxygen for approximately 30 minutes. Resident 707 stated the delays with the call lights are mainly the evenings and weekends with the agency staff. Review of Resident R69's clinical record indicated admission to the facility on [DATE]. Review of Resident R69's MDS dated [DATE], indicated diagnoses of Parkinson's disease (brain disorder symptoms of tremors, stiffness, slow movement and balance issues), hypertension (high blood pressure), and malnutrition (imbalance of energy, protein, and other nutrients). Review of Section GG: Functional Abilities GG0130, indicated that Resident R69 is substantial/max assistance with toileting hygiene (helper does more than half the effort) and GG0170 toilet transfers indicated that Resident R69 is substantial/max assistance with toileting hygiene (helper does more than half the effort). During an interview and observation on 12/8/25, at approximately 10:07 a.m. Resident R69 stated there is a wait time when you use your call light, it can take twenty to thirty minutes depending on the time of day, it's not all the time but enough of the time. I am getting discharged so it doesn't matter to me anymore. Review of Resident R115's clinical record indicated admission to the facility on [DATE] with diagnoses of unilateral osteoarthritis, right knee (pain, stiffness, and reduced mobility) type 2 diabetes mellitus (high blood sugar) and dementia (decline in memory, thinking and social abilities). Review of Resident R115's MDS dated [DATE], contained the admission assessment documentation, additional ongoing assessment details were not yet required at the time of the survey. During an interview and observation on 12/8/25, at approximately 10:30 a.m. Resident R115 stated, you have to wait about a half hour when you ring for help, I have only been here a couple of days. Review of Resident R31's clinical record indicated initial admission to the facility on [DATE]. Review of Resident R31's MDS dated [DATE], indicated diagnoses of endocarditis (inflammation of the inner lining of the heart's chambers and valves), morbid obesity (body mass index of 40 or higher associated with health complications), and a right below knee amputation. Review of Section GG: Functional Abilities GG0130, indicated that Resident R31 is substantial/max assistance with toileting hygiene (helper does more than half the effort) and GG0170 toilet transfers indicated that Resident R31 is dependent (helper does all of the effort). During an interview and observation on 12/8/25, at approximately 10:42 a.m. Resident R31 stated his infusion pump that delivers his antibiotic will start to beep (some potential reasons for the beeping; a line blockage, air in the line, low battery, or infusion completed). Resident R31 stated it takes twenty minutes sometimes longer to have someone come in and take care of it. Resident R31 stated the regular staff here are quick to respond and work hard, it seems to be the weekend and evenings with the agency staff that you wait. During an interview on 12/8/25 at 3:30 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(,)(1)(2)(3)(5) Nursing services. 28 Pa Code: 201.29 (I)(o) Resident rights.

Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to properly secure the Intravenous (IV) medication and supply cart for one of four carts observed (IV medication and supply cart).Findings include:Review of the facility policy Storage of Medications reviewed 9/11/25, indicated medications and biologicals are stored safely, securely, and properly. The medication supply is accessible only to licensed nursing personnel. Drugs and biologicals used in the facility are stored in locked compartments. Only persons authorized to prepare and administer medications are permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access.During an observation on 12/7/25, at 9:10 a.m. the IV medication and supply cart was located in the unlocked conference room with the cart unlocked and the key left in the lock. The cart included the following medications and supplies:- One bag IV levofloxacin (antibiotic) 250 milligrams (mg)/50 milliliter (ml) D5W (5 % dextrose in water).- Two bags of levofloxacin 500 mg/100 ml of D5W.- Three bags of metronidazole (antibiotic) 500 mg/100 mg normal sterile saline (NSS).- 20 IV needles sized 20 G (gauge - size number is related to the thickness of the needle).- Six IV needles sized 22 G.- Seven IV needles sized 24 G.- One butterfly IV needle sized 20G.- Five IV start kits.- Ten IV-line supplies- 18 NACL (sodium chloride) 0.9% 100 ml bags- Four NACL 0.9% 250 ml bags- Two lactated ringers (used to restore body fluids and lost electrolytes) 1000 ml bags.- Two potassium chloride (KCL) 20 mEq (milliequivalent - unit for measuring electrolytes in medicine).- Three NACL 0.45% 1000 ml bags- Two D5W 1000 ml bags.During an interview on 12/7/25, at 10:01 a.m. the Infection Preventionist Employee E6 confirmed the IV medication and supply cart should be secured when unattended.28 Pa. Code: 211.9(a)(1)(k) Pharmacy services.28 Pa. Code: 211.10(c) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility clinical records, observations and staff interview, it was determined that the facility failed to make certain that resident assessments were accurate for one of four residents (Resident R15).Findings include:Review of CMS's RAI Version 3.0 Manual Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS - periodic assessment of resident care needs) assessments, dated October 2024, define MDS as a core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. Review of facility policy Care Plans, Comprehensive Person-Centered reviewed 9/11/25, indicated the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive care plan includes measurable objectives and timeframes, describes that services that are to be furnished to attain pr maintain the resident's highest practicable physical, mental, and psychosocial well-being.Review of the clinical record indicated that Resident R15 was admitted to the facility on [DATE], with diagnoses that included diabetes, depression, and obstructive and reflux uropathy (urine flow is blocked, causing back up and kidney damage).Review of the MDS dated [DATE], indicated the diagnoses remain current.Review of physician orders dated 3/6/25, indicated resident R15 had an indwelling foley catheter (a hollow flexible tube that is inserted through a narrow opening in the body cavity for removing fluid). Review of physician orders indicated on 6/16/25, the order was discontinued due to hospitalization. Further review of Resident R15's physician orders failed to indicate the indwelling foley catheter was re-inserted.Review of the MDS dated [DATE], Section H: Bladder and Bowel, Question H0100 Appliances, indicated Resident R15 had an indwelling catheter. Review of the MDS dated [DATE], Section H: Bladder and Bowel, Question H0100 Appliances, indicated Resident R15 had an indwelling catheter.Review of Resident R15's care plan dated 3/6/25, interventions were still active for an indwelling catheter.During an interview on 12/8/25, at 9:25 a.m. the Registered Nurse Assessment Coordinator (RNAC) Employee E7 confirmed the facility failed to complete an accurate assessment for Resident R15.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of two nursing floors.Findings include: Review of the facility's Resident Rights Policy dated 9/11/25, indicated the unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues. During an observation on 12/7/25, at approximately 9:15 a.m. an unsecured/unlocked bin containing resident records, was identified in the second-floor nursing unit conference room. The conference room was not locked or labeled in a manner to restrict access to the room or its contents. During an interview on 12/7/25, at 10:30 a.m. the Nursing Home Administrator and Director of Nursing confirmed the above observation 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.

Based on observations and a staff interview, it was determined the facility failed to post contact information, Adult Protective Services (APS), Medicaid Fraud Unit, and a statement the resident may file a complaint with the State Agency as required, in the building two of two locations where postings are located (first and second floor hallways). Findings include: The facility must post, in a form and manner accessible and understandable to residents, resident representatives; a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit. Observations conducted on 12/8/25, at approximately 11:30 a.m., in the hallways in and around the nursing units, revealed the facility did not have the required elements (agency name, address, email address, and phone number) of Adult Protective Services (APS), Medicaid Fraud Unit, and a statement the residents may file a complaint with the State Agency posted or accessible to residents or resident representatives. During rounds and an interview with the Nursing Home Administrator (NHA) on 12/9/25, at 8:30 a.m., the NHA confirmed the facility failed to post required information for Adult Protective Services (APS), Medicaid Fraud Unit, and a statement the residents may file a complaint with the State Agency as required, in the building. 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 201.18(e) Management.

Based on facility policy, clinical record review, resident and staff interviews, it was determined that the facility failed to make certain discharge planning is part of the resident care plan for one of five residents (Resident R1). Findings include: Review of facility policy Discharge Summary and Plan dated 1/20/25, indicated every resident has an individualized discharge plan, which begins at admission and is part of the comprehensive care plan. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 4/28/25, included diagnoses of hip fracture, hypertension (high blood pressure), and cerebrovascular disease (condition that affects blood flow to the brain). During an interview with Resident R1 on 6/12/25, at 11:00 a.m., the following was stated: I want to go home when my physical therapy is done. My son lives with me, we want to get services at home. Review of Resident R1's clinical record revealed no documented evidence that the facility had a care plan for discharge or discharge planning. During an interview on 6/12/25, at approximately 1:00 p.m. the Director of Nursing and Registered Nurse Assessment Coordinator (RNAC) Employee E1 confirmed the facility failed to make certain discharge planning, is part of the resident care plan for one of five residents (Resident R1). 28 Pa. Code: 201.29 (a)(c)(3)(2) Resident rights.

Based on a review of facility policy, federal regulation and staff interview, it was determined that the facility failed to provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division for eleven of 11 months (December 2023 and January, February, March, April, May, June, July, August, September, and October 2024). Findings include: Review of the facility policy Discharge and Transfer dated 1/6/24, indicated a monthly list will be sent to the Ombudsman of residents who were facility-initiated transfer or discharged . Review of Title 42 Code of Federal Regulations S483.15(c)(3) Notice Before Transfer: indicates, before a facility transfers or discharges a resident, the facility must (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. Federal Regulations further define emergency transfers as, When a resident is temporarily transferred on an emergency basis to an acute care facility, this type of transfer is considered to be a facility-initiated transfer. During an interview on 11/19/24, at 2:29 p.m., the Nursing Home Administrator confirmed the facility failed to provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division since 12/31/23. 28 Pa. Code 201.18(b)(3)(e)(2) Management.

Based on review of facility policy, review of clinical records, facility documentation, and staff interviews, it was determined that the facility failed to protect residents from an accident of a roll out of bed for one of three residents (Resident R1). Findings include: Review of the facility policy Accidents/ Incidents last reviewed on 6/26/24, with a previous review date of 10/4/23, indicated that the Center will report, review and investigate all accidents/incidents which occur. Any accident/incident that may be considered an allegation of abuse/neglect, etc. will be managed in accordance to the Abuse Prohibition Policy. An accident is defined as an unexpected incident that may result in injury. Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses which included severe unspecified dementia without behavioral disturbance, bacteremia, sepsis, a stroke, speech and language deficits and other brain infarcts. A Minimum Data Set (MDS - periodic assessment of a resident's abilities and care needs) dated 7/7/24, indicated the diagnoses remained current. Section GG of the MDS also indicated that Resident R1 was dependent for rolling left to right. Dependent on staff (meaning that the helper does all of the effort. Resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity). Review of Resident R1's plan of care for ADL Self Care Performance Deficit related to Dementia active on 7/3/24, failed to include in the interventions what level of staff assistance Resident R2 required for transferring to bed from her wheelchair and for dressing/undressing. The care plan was not updated to reflect the physician's order for transfer and assistance. Review of the facility provided documentation dated 7/8/24, indicated Licensed Practical Nurse(LPN) Employee E1 turned Resident R1 onto her side towards her, then left her to go into the hall to look for Registered Nurse(RN) Employee E2 who was bringing in wound care supplies, leaving Resident R1 on her side and unassisted and Resident R1 rolled onto the floor. Review of a written statement by LPN Employee E1 dated 7/8/24, indicated, I was doing last rounds, RN Employee E2 came into the room and was going to do Resident R1's coccyx treatment. I had positioned Resident R1 on her left side towards me. I was waiting for RN Employee E2 to return and I stepped away from the bed and looked back to see Resident R1 sliding off the bed. I hurried back to attempt to catch her but she rolled out of bed. Review of a written statement by RN Employee E2 dated 7/8/24, indicated, Resident R1 was on her left side when I exited the room to gather supplies for her wound care. When I re- entered the room, LPN Employee E1 was standing in the doorway and I walked in to find Resident R1 had rolled off the bed striking her head on the night stand. During an interview on 7/24/24, at 10:08 a.m., LPN Employee E3 stated that she is agency but would look on her chart. I asked if she had access to the computer, she indicated she did and after prompting, stated oh yea, the kardex. During an interview on 7/24/24, at 10:11 a.m., 6/2/24, at 3:34 p.m. NA Employee E4 stated she reviews the the resident's kardex for residents bed mobility and transfer status in the computer, that everyone has access. During an interview on 7/24/24, at 10:15 a.m., RN Employee E5 stated that there are cheat sheets for the Nurse Aides she would look at, then the residents kardex in the computer for their transfer status. During an interview on 7/24/24, at approximately 11:30 a.m. the Director of Nursing stated that the LPN walked away for Resident R1's bed to go into hall to look for the RN leaving the resident on her side. During an interview on 7/24/24, at approximately 12:10 p.m., the Nursing Home Administrator, Director of Nursing and Assistant Director of Nursing confirmed that facility failed to protect Resident R1 from an accident that involved a roll out of bed. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.29(a)(c)(d)(j) Resident Rights 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(3) Nursing services.

Based on review of resident clinical records, facility policy and staff interviews it was determined the facility failed to provide care and treatments related to dialysis care for one of two residents (Resident R10), and failed to provide consistent and complete communication with the dialysis center for two of two residents (Resident R10 and R245). Findings include: Review of the facility policy Hemodialysis Catheters - Access and Care of dated 10/4/23, indicated the AV fistula (arteriovenous fistula - a connection made by a surgeon of an artery to a vein for vascular access for dialysis) to prevent infection and clotting, keep the access site clean at all times, do not use the access limb to take blood pressure, do not use the access site limb to take blood samples, administer IV fluid or give injections, check for signs of infection at the access site while providing routine care and at regular intervals, and palpate the site to feel the thrill (a vibration caused by blood flowing through the fistula), or use a stethoscope (an instrument used to hear sounds produced within the body) to hear the whoosh or bruit (a whooshing sound that can be heard in the fistula) of blood flow through the access. Review of the facility policy Care of Central Dialysis Catheters dated 10/4/23, indicated the central catheter site must be kept clean and dry at all times. Bathing and showering are not permitted with this device. Catheter lumens (the tubes that come out of the skin) should be capped and clamped when not in use. The nurse should document every shift the following: location of the catheter, condition of dressing (interventions if needed), any part of report from dialysis nurse post dialysis being given and observations post dialysis. Review of the facility policy Dialysis Hemodialysis (HD) - Communication and Documentation dated 10/4/23, indicated the center staff will communicate with the dialysis facility regarding the ongoing assessment of the patient's condition by monitoring for complications before and after hemodialysis treatments received at the dialysis facility. Review of the clinical record indicated Resident R10 was admitted to the facility on [DATE]. Review of Resident R10's Minimum Data set (MDS - a periodic assessment of care needs) dated 11/15/23, indicated the diagnoses of End Stage Renal Disease (kidneys cease to function on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), high blood pressure, and anemia (the blood doesn ' t have enough healthy red blood cells). Section O-0100 J indicated dialysis while a resident. Review of Resident R10's physician orders on 11/28/23, at 1:00 p.m. failed to indicate orders for the care and monitoring of an access device for hemodialysis. Review of Resident R10's care plan dated 8/28/23, indicated do not draw blood or take blood pressure in arm with graft. Review of Resident R10's Hemodialysis Communication Records indicated 21 of the last 23 hemodialysis communication sheets were incomplete either prior to leaving the facility, entries during care at the dialysis center, and assessments upon return to the facility. Interview on 11/28/23, at 1:10 p.m. Registered Nurse (RN) Manager Employee E2 confirmed the facility failed to provide consistent and complete communication with the dialysis center for Resident R10 on 21 of 23 days. Review of Resident R10's physician orders on 11/28/23, at 1:00 p.m. failed to indicate orders for the care and monitoring of an access device for hemodialysis. Review of Resident R10's care plan dated 8/28/23, indicated do not draw blood or take blood pressure in arm with graft. Review of Resident R10's Hemodialysis Communication Records indicated 21 of the last 23 hemodialysis communication sheets were incomplete either prior to leaving the facility, entries during care at the dialysis center, and assessments upon return to the facility. Interview on 11/28/23, at 1:10 p.m. Registered Nurse (RN) Manager Employee E2 confirmed the facility failed to provide consistent and complete communication with the dialysis center for Resident R10 on 21 of 23 days. Observation of Resident R10's right arm on 11/28/23, at 1:05 p.m. indicated the presence of an AV fistula and a tessio catheter to the chest. Interview with Resident R10 on 11/28/23, at 1:06 p.m. indicated the right arm device no longer works, the catheter in his chest can be used, and the AV fistula is now in his left thigh and it was used for dialysis treatment this past Monday. Interview with the Director of Nursing on 11/28/23, at 1:15 p.m. confirmed the facility did not have physician orders to monitor the failed right arm device, the tessio catheter to the chest, and the AV fistula to the left thigh and failed to provide care and treatments related to dialysis care for one of two residents (Resident R10). Review of Resident R245's clinical record indicated the resident was admitted to the facility on [DATE]. Diagnoses included end stage renal disease and dependence on renal dialysis. Review of Resident R245's current physician orders dated 11/30/23, indicated dialysis treatments on Tuesday, Thursday and Saturday, effective 11/21/23, check dialysis form prior to departure in a.m. to make sure entire form is completed, and check dialysis book upon return from the facility and complete nurse section. Review of Resident R245's care plan initiated 11/18/23, included a care focus of renal failure/insufficiencies with interventions to coordinate dialysis care with dialysis treatment center. Review of Resident R245's progress note dated 11/21/23, indicated the resident's vital signs were taken prior to dialysis. Review of Resident R245's Hemodialysis Communication Records indicated a hemodialysis communication sheet was not completed prior to leaving the facility, entries during care at the dialysis center, and assessments upon return to the facility. During an interview on 11/30/23, at 11:35 a.m. Registered Nurse (RN) Unit Manager Employee E4 confirmed the facility failed to provide consistent and complete communication with the dialysis center for Resident R245 on 11/21/23. Interview on 11/30/23, at 2:15 p.m. the Director of Nursing confirmed the facility failed to provide care and treatments related to dialysis care for one of two residents (Resident R10), and failed to provide consistent and complete communication with the dialysis center for two of two residents (Resident R10 and R245). 28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services. 28 Pa. Code 211.10 (c) Resident Care policies

Based on facility policies, observations and staff interviews, it was determined that the facility failed to perform hand washing to prevent the potential for cross contamination in the Main Kitchen and failed to perform handwashing between tasks in the main dining room during meal service. Findings include: Review of the facility policy Food Handling last reviewed on 8/1/23 and 11/13/23, indicated food is prepared with a minimal of handling. Employees wear disposable gloves when handling food and are considered single-use items and are discarded when damaged, soiled, and after each use. Employees must wash their hands before putting on disposable gloves. Review of the facility policy Hand Washing last reviewed on 8/1/23 and 11/13/23, indicated handwashing is preformed before preparing or handling food, before putting on disposable gloves to begin a task that involves food, during food preparation, as often as necessary to clean soiled hands, and when moving from one task to another. During an observation of tray line service in the main kitchen on 11/27/23, from 10:55 a.m. through 12:00 p.m. the following was observed: Dietary Aide Employee E9 did not wash her hands, donned disposable gloves, removed her cell phone from her pants pocket to check the time, replaced the cell phone in her pocket, and proceeded to start tray line placing silverware on the trays wearing the same gloves and not washing her hands. Dietary Cook Employee E7 started tray line with disposable gloves on, removed the lids from the food and began plating foods. Dietary Cook Employee E7 walked away from tray line twice to walk across the kitchen to retrieve hanging portion servers, returned and continued tray line without washing her hands and changing gloves. Dietary Cook Employee E6 placed bottom portions of plates on heater to warm, one fell on the floor and was picked up with left hand and placed to the side. Dietary Cook Employee E6 removed disposable glove from left hand and continued to heat the plates with the gloved right hand. Then, without washing her hands or changing her gloves, she then left the tray line, went to the refrigerator, removed two slices of American cheese and proceeded to cook a grilled cheese. Once the grilled cheese was finished, it was plated and placed for Dietary Cook Employee E7 to serve. Dietary Cook Employee E6 then returned to tray line to resume heating plates without washing her hands and changing gloves between tasks. Dietary Aide Employee E8 did not wash his hands, donned disposable gloves, and was placing the loaded plates onto trays and loaded the food carts for delivery on the floor. When the food carts were full, he pushed the carts out to the hallway to be delivered to the units touching the food cart, and door, then returned to load more plates onto trays and load more into food carts without washing his hands or changing his disposable gloves between tasks. During an interview on 11/27/23, at 11:20 a.m. the Dietary Manager Employee E3 confirmed the facility failed to prevent the potential for cross-contamination during tray line. 28 Pa. Code: 211.6(c)(d)(f) Dietary services.

Based on review of facility policy, manufacturer's recommendations, observation, clinical record and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for one of two residents (Resident R45). Findings include: Review of facility policy, Insulin Pens dated 10/4/23, indicated practice standards included insulin pens (pens that come preloaded with insulin- a medication used to control blood sugar) be primed prior to each use to prevent the collection of air in the insulin reservoir (a place where something is kept). Review of manufacturers guidelines for Insulin Lispro (a short acting, manmade version of human insulin) indicated to prime the Pen before each injection. Priming the Pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the Pen is working correctly. If the Pen is no primed before each injection, the resident may get too much or too little insulin. Review of Admission record indicated Resident R45 admitted to the facility on [DATE]. Review of Resident R45's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/10/23, indicated the diagnoses of anemia (blood doesn't have enough healthy red blood cells), high blood pressure, and diabetes (too much sugar in the blood). During a medication administration observation on 11/27/23, at 12:18 p.m. Licensed Practical Nurse (LPN) Employee E1 indicated Resident R45 required Lispro two units subcutaneously injected, dialed the Novolog pen to two units, then injected Resident R45, failing to prime the needle prior to administration. During an interview on 11/27/23, at 12:20 p.m. LPN Employee E1 indicated she was not aware of the practice to prime the needle prior to administration. During an interview on 11/27/23, at 12:35 p.m. Registered Nurse Manager (RN) Employee E2 confirmed that LPN Employee E1 failed to prime the Lispro pen when administering insulin and confirmed the facility committed a significant medication error for one of two residents reviewed (Residents R45). 28 Pa. Code: 211.12(d)(5) Nursing services.

Based on a review of facility policy, resident interviews, staff interviews and observations it was determined the facility failed to provide the residents with food and drink that is palatable and at a safe and appetizing temperatures for two of two lunch meals observed (Lunch Meals on 11/29/23, on [NAME] Unit and Medbridge/TCU units). Findings include: Review of facility titled Food and Nutrition Services Policies and Procedures last reviewed 11/13/23, informed foods are stored, prepared and served in a safe and sanitary manner to prevent bacterial contamination. Hazard Analysis Critical Control Points (HACCP) flow charts are used when handling, preparing, cooling, storing, reheating, and reserving food. Review of the HACCP flow chart informed the hot holding temperature for beef is 145 degrees Fahrenheit of above. Review of the HACCP flow chart in formed the hot holding temperature for vegetables, rice, pasta, legumes is 135 degrees Fahrenheit or above. Review of the HACCP flow chart informed the cold holding temperature for cold ready to eat foods is 40 degrees Fahrenheit or below. During an interview on 11/27/23, at 10:45 a.m. Resident R252 reported the food is served cold. During an interview on 11/27/23, at 1:40 p.m. Resident R11 reported the food is served cold at dinner time. During a group interview conducted on 11/28/23, at 1:30 p.m. Residents R500, R501, R502, R503, R504, R505, R506, R507, R508, R509, R510, R511 and R512 reported the meals are served cold and ice cold. Review of the Resident Council Minutes dated 11/20/23, revealed complaints/comments of residents requesting a microwave on each unit, and menu and requests ideas/suggestions of food carts that plug in to keep food warm. During a [NAME] Unit test tray observation on 11/29/23, at 11:45 a.m. the following temperatures were observed: Meat loaf - 139.5 degrees Fahrenheit Milk - 55.9 degrees Fahrenheit During a Medbridge/TCU Unit test tray observation on 11/29/23, at 12:05 p.m. the following temperatures were observed: Meat loaf - 130.2 degrees Fahrenheit Mashed potatoes - 125.1 degrees Fahrenheit Milk - 56.3. degrees Fahrenheit During an interview on 11/29/23, at 12:08 p.m. the Food Service Director Employee E confirmed the temperatures of the test tray and that the facility failed to provide the residents with food and drink that is palatable and at a safe and appetizing temperatures. 28 PA Code: 211.6(b)(c)(d) Dietary services.

Based on review of facility policy, observation, and staff interviews it was determined that the facility failed to follow proper infection control technique during a dressing change (Resident R298). Findings: Review of the facility policy Wound Dressings: Aseptic last reviewed 10/4/23, indicated no touch technique is a method of changing surface dressings without directly touching the wound or any surface that might come in contact with the wound. Clean gloves are used along with sterile solution/supplies/dressings that are maintained as clean. The nurse should clean and disinfect the over-bed table. Perform hand hygiene. If a break in aseptic technique occurs, stop the procedure, remove gloves, perform hand hygiene, and apply clean gloves. Unused supplies are discarded according to infection control procedure or remain dedicated to the patient and stored appropriately. During an observation of a dressing change on 11/29/23, at 10:30 a.m. with Licensed Practical Nurse (LPN) Employee E10 the following was observed: -LPN donned gloves, cleansed the scissors. -removed gloves, gathered supplies at the cart and taken into resident ' s room. -resident ' s door was closed for privacy. -LPN placed a towel on the resident ' s bed and placed supplies on towel. -LPN placed a bag containing Dakin ' s solution (antiseptic solution developed to treat infected wounds), and a bottle of wound packing on the resident ' s nightstand. -LPN washed hands and donned gloves. -old dressing was removed from left buttock wound, saline solution (a mixture of salt and water often used to clean wounds because it is gentle and does not damage the tissue) was removed from the clean towel, wound cleansed. LPN failed to cleanse hands and change gloves when moving from a dirty surface to a clean surface. -Alcohol Based Hand Sanitizer (ABHS) was used and gloves changed. - dressing supplies opened -skin prep applied around wound, treatment cut to size with scissors. -LPN reached into her pocket to get a pen, wrote initials and date on the bordered gauze, returned her pen to her pocket. -treatment was placed on wound and covered with border gauze. LPN failed to cleanse hands and change gloves when moving from a clean surface, to a dirty one, and back to the clean surface. -ABHS used and gloves changed. Towel on resident ' s bed picked up and moved to other side of the bed for next wound. -bag of Dakins solution and packing removed from nightstand to over-bed table. -LPN failed to cleanse the over-bed table prior to placing items. -Dakin ' s solution placed in medicine cup and packing cut to size and placed in Dakin ' s solution using cotton-tipped applicators. -old dressing removed from right buttocks wound. saline and gauze removed from towel, wound cleansed. -LPN failed to cleanse hands and change gloves when moving from dirty surface to clean surface. -ABHS used, gloves changed. -wound dried, skin prep applied around wound edges, packing placed in wound with cotton-tipped applicator. -border gauze opened, LPN reached into her pocket for her pen, initialed and dated the border gauze, then replaced pen back in pocket. -border gauze applied to wound. LPN failed to cleanse hands and change gloves when moving from a clean surface, to a dirty one, and back to the clean surface. -bag with Dakins solution and bottle of packing was taken to cart and placed back into the treatment cart. During an interview on 11/29/23, at 11:00 a.m. LPN Employee E10 confirmed she failed to cleanse hands prior to switching between dirty and clean surfaces. During an interview on 11/29/23, at 12:20 p.m. the Nursing Home Administrator confirmed the facility failed to follow proper infection control technique during a dressing change for Resident R298. 28 Pa. Code: 211.10(d) Resident Care Policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing Services.

Based on observation, and staff interview, it was determined the facility failed to maintain a clean homelike environment for four of eight resident rooms (Resident room [ROOM NUMBER]B, room [ROOM NUMBER]B, room [ROOM NUMBER]B, and room [ROOM NUMBER]B). Findings Include: Review of the facility policy Accommodation of Needs last reviewed 10/4/23, indicated the residents are provided with a safe, clean, comfortable, and homelike environment. Review of the admission record indicated Resident R45 in room [ROOM NUMBER], was admitted to the facility on [DATE]. Observation of Resident R45's room [ROOM NUMBER] on 11/30/23, at 10:49 a.m. indicated the privacy curtain hanging in between the two resident beds was soiled with a brown substance on the entire lower half of the curtain. Review of the admission record indicated R12 in room [ROOM NUMBER]B was admitted to the facility on [DATE]. Observation of Resident R12's room [ROOM NUMBER]B on 11/30/23, at 9:25 a.m. indicated a privacy curtain soiled with brown speckled debris. Review of the admission record indicated Resident R11 in room [ROOM NUMBER]B admitted to the facility on [DATE]. Observation of Resident R11's room on 11/30/23, at 9:27 a.m. indicated a privacy curtain with brown substance along the base of the curtain and half way up. Review of the admission record indicated Resident R38 in room [ROOM NUMBER]B admitted to the facility on [DATE]. Observation of Resident R38's room on 11/30/23, at 9:30 a.m. indicated a privacy curtain with brown substance along the base of the curtain and scattered other areas of curtain with brown substance. Tour on 11/30/23, at 10:49 a.m. with Registered Nurse (RN) Employee E5 confirmed the privacy curtains in Rooms 118B, 125B, 126B, and 127B were soiled with a brown substance in varying degrees. Interview on 11/30/23, at 2:15 p.m. the Nursing Home Administrator confirmed the facility failed to maintain a clean homelike environment for four of eight resident rooms (Resident room [ROOM NUMBER]B, room [ROOM NUMBER]B, room [ROOM NUMBER]B, and room [ROOM NUMBER]B). 29 Pa. Code 201.29 (j) Resident Rights

Based on review of facility policies, clinical records, and staff interview, it was determined that the facility failed to prevent injury while pushing a wheelchair resulting in fractures of the cervical spine (C1 and C2 - cervical vertebrae, C1 and C2, form the top of the spine [neck] at the base of the skull) and bilateral nasal bones for one of five residents (Resident R1). Findings include: A review of the facility policy Falls Management reviewed 2/1/23, indicated residents will be assessed for risk of falling as part of the nursing assessment process and interventions to reduce risk and minimizing injury will be implemented. A review of the facility policy Activities of Daily Living reviewed 2/1/23, indicated residents are provided with assistive devises as needed, and to allow sufficient time for the resident to complete tasks independently. A review of the facility procedure Wheelchair: Use of reviewed 2/1/23, indicated the resident would be evaluated to determine need for wheelchair, to educate resident on proper use and safety, and to adjust the foot pieces. A review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included dementia (group of symptoms that affects memory, thinking and interferes with daily life), high blood pressure, and depression. A review of the Minimum Data Set (MDS-periodic assessment of care needs) dated 4/13/23, indicated the diagnoses remain current. Further review of the MDS dated [DATE], Section C: Cognitive Patterns; C0500 indicated Resident R1's Brief Interview of Mental Status (BIMS) score was 10, indicating moderate impairment. Section G: Functional Status; G0110, F: Locomotion off unit indicated Resident R1 was able to wheel herself off the nursing unit with supervision (oversight, encouragement or cueing). A review the MDS dated [DATE] (most recent with this section completed) Section GG Functional Ability Tool , Resident R1 was able to wheel 150 feet with set up assistance only. A review of the care plan initiated 10/4/22, indicated Resident R1 was at risk for falls due to unsteady gait/slid from wheelchair and to encourage to transfer and change positions slowly, had generalized pain due to arthritis, and was at risk for loss of range of motion related to physical limitation and left sided weakness. Further review of the care plan inititiated 11/2/22, indicated the resident had a self-care deficit and to encourage wheelchair mobility, was at risk for falls. A review of a progress note dated 5/8/23, at 12:28 p.m., indicated Licensed Practical Nurse (LPN) Employee E1 entered Resident R1's room to take her to the dining room, while pushing her wheelchair through the doorway, the resident fell forward as she put her feet on the floor and hit the front of her head when she fell at 11:40 a.m. Bright red blood noted to resident ' s face and floor from nose due to split at the bridge and the right side from resident ' s glasses making impact with the skin. Large hematoma (a pocket of blood inside the body caused by hemorrhage, rapid blood loss) was noted to the right side of the head. 911 was called and Resident R1 was sent to the local emergency room for evaluation. A review of a progress note dated 5/8/23, at 1:00 p.m. indicated Resident R1 was assessed by the Nurse Practitioner and due to the extent of injury and fraility and concern for nasal deformity; post nasal bleed and inability to pass air through the right nasal passage the resident was sent to the local emergency room for further imaging and treatment. A review of the hospital record CT scan report dated 5/8/23, indicated bilateral nasal bone deformities and fracture deformities involving the nasal septum, nondisplaced bilateral posterior C1 vertebra arch fractures (C1 vertebra arch is a closed ring of the first spinal bone that supports the skull, fracture of a closed ring necessarily results in at least two areas ) and Type II dens fracture (fracture occurring at the base of the odontoid [toothlike projection from the second cervical vertebra on which the first vertebra pivots] as it attaches to the body of C2) and mild translocation (describes the movement of fractured bones away from each other). Resident R1 was required to wear a soft cervical collar on return to the facility. During an interview on 5/16/23, at 11:50 a.m. LPN Employee E2 stated when she pushes a resident that self-propels their wheelchair, she uses leg rests. During an interview on 516/23, at 11:55 a.m. Nurse Aide (NA) Employee E3 stated she would look on the kiosk or in the Kardex to find residents transfer status, and she uses leg rests for residents that self-propel their wheelchair if she is going to push them. During an interview on 5/16/23, at 11:56 a.m. LPN Employee E1 stated the long hall nurse (LPN Employee E1's shift assignment) goes into the dining room to assist with feeding residents. Resident R1 was the only resident not in the dining room so she offered to go get her and bring her to the dining room. Resident R1 was already in her wheelchair as she usually brings herself to the dining room. She offered to help Resident R1 and she agreed to the assistance. She did not place the leg rests on the wheelchair, she instructed the resident to lift her legs. As she was pushing Resident R1 through the doorway out of her room, Resident R1 planted her feet on the floor. She is unable to walk. When she put her feet down, she went forward and fell on her face. She twisted herself over on the floor and noticed the blood. LPN Employee E1 stated she was unsure if leg rests were in Resident R1's room, and it slipped my mind to use the leg rests. During an interview on 5/16/23, at 12:05 p.m. NA Employee E4 stated she looks in the Kardex or asks a nurse if she does not know the transfer status of a resident, and if she pushes a resident in a wheelchair, she uses leg rests. During an interview on 5/16/23, at 12:06 p.m. Registered Nurse (RN) Employee E5 stated some residents are able to hold legs up and some need the leg rests. She just knows them to determine who needs and who does not need the leg rests. During an interview on 5/16/23, at 12:07 p.m. NA Employee E6 stated they look at the Kardex to find the transfer status of a resident, and they use leg rests when pushing a wheelchair. During an interview on 5/16/23, at 12:09 p.m. NA Employee E7 stated they look at the Kardex, ask the supervisor, director of nursing, or therapy about the resident's transfer status, and they always use leg rests when pushing a wheelchair. During an interview on 5/16/23, at 12:10 p.m. LPN Employee E8 stated they use leg rests when pushing a wheelchair. During an interview on 5/16/23, at 12:11 p.m. NA Employee E9 stated they look in the Kardex to find the transfer status of a resident, they don't always use leg rests if the resident is high functioning and can keep their legs lifted up. During an interview on 5/16/23, at 12:12 p.m. RN Employee E10 stated she never pushes the wheelchairs without leg rests because too many times they put their legs down. During an interview on 5/16/23, at 12:13 p.m. NA Employee E11 she asks a nurse or looks in the Kardex to find the resident's transfer status, and she would assist a resident in a wheelchair without putting leg rests on first. During an interview on 5/16/23, at 12:15 p.m. NA Employee E12 stated they look in the Kardex to find the transfer status, and they never push a wheelchair without leg rests. During an interview on 5/16/23, at 12:16 p.m. NA Employee E13 stated they look in the Kardex or care plan to find resident's transfer status, and it depends on the resident whether they would use leg rests when pushing a wheelchair. During an interview on 5/16/23, at 12:20 p.m. LPN Employee E14 stated she uses leg rests even if she knows the resident because she worked somewhere else and it was a big deal so she always uses the leg rests. During an interview on 5/16/23, at 12:20 p.m. NA Employee E15 stated she looks at the Kardex to find the transfer status, and she only pushes wheelchairs with leg rests unless the resident can hold their feet up for a long time. During an interview on 5/16/23, at 12:23 p.m. Rehab Director Employee E16 stated the residents are assessed for wheelchair use on admission and the chair is positioned so the resident can place their feet flat on the floor. If staff are pushing a self-propelling resident in their wheelchair, they should have leg rests on. Every resident should have leg rests in their room unless they are confused and try to stand on them. During an interview on 5/16/23, at 4:00 p.m. the Director of Nursing confirmed the facility failed to prevent injury while transporting a resident in a wheelchair resulting in actual harm for Resident R1. 28 Pa Code: 201.14 (a)(c)(d)(e) Responsibility of licensee. 28 Pa Code: 201.18(b)(1)(3) (e)(1) Management. 28 Pa Code: 211.10 (a) Resident care policies. 28 Pa Code: 211.12 (d)(1)(2)(5) Nursing services.

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to notify physicians of elevated Capillary Blood Glucose (CBG) levels, failed to assess residents for [CONDITION(S)] (high blood glucose) and [CONDITION(S)] (low blood glucose), and failed to educate staff on facility policies related to [CONDITION(S)] and [CONDITION(S)] for 5 of 9 Residents (Residents R8, R11, R53, R81, and R257), resulting in immediate jeopardy. Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-[MEDICATION(S)]) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. [CONDITION(S)] is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, [CONDITION(S)] may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Review of the facility policy [CONDITION(S)]: Treatment dated 1/25/21, states: Symptoms of [CONDITION(S)] (blood glucose level 400mg/dl or above): Decreased level of consciousness, dehydration, increased urination, deep/rapid breathing, increase thirst, increased appetite, changes in vision, fruity odor on breath -Recognize hyperglycemic symptoms -Obtain blood glucose result. -Assess clinical status using A, B, Cs (airway, breathing, circulation). Be prepared to activate EMS and transport if condition deteriorates or does not improve -Monitor vital signs every 5-15 minutes until stable -Notify physician of clinical condition, including vital signs and blood glucose level. Do not leave patient unattended -Verify physician's order and administer insulin as ordered -Monitor blood glucose level every 15 minutes until results within normal limits for patient or per physicians' orders. Review of the facility policy [CONDITION(S)]: Treatment dated 1/25/21, states: Symptoms of [CONDITION(S)] (blood glucose level 60 mg/dl or lower): Mild [CONDITION(S)]- Hunger, pallor (paleness), weakness, shakiness, sweating, [CONDITION(S)] or palpitations (rapid/irregular heartbeat), and headache. Moderate [CONDITION(S)]- inability to concentrate, confusion, slurred speech, change in behavior/restlessness, blurred vision, extreme fatigue. Severe [CONDITION(S)]- becoming argumentative or combative, disorientation, Loss of consciousness, seizures Includes the following interventions (procedure): Recognize [CONDITION(S)] symptoms, Obtain Blood glucose result. LOW BLOOD GLUCOSE (60 mg/dL or below) AND ASYMPTOMATIC OR SYMPTOMATIC (with or without symptoms): Follow physician's orders for Blood Sugar parameters and treatment such as: If alert - milk, orange or apple juice, or commercially prepared glucose tablets or gel If not alert - give 1 amp (25g) of D 50 IV(intravenous glucose infusion), if no IV access, administer 1mg [MEDICATION(S)] ([MEDICATION(S)]) (injectable glucose medication) intramuscularly(in the muscle) or subcutaneously(under the skin) 2. Repeat finger stick as ordered per physician, usually every 15 minutes LOW BLOOD GLUCOSE (50 mg/dL or below) AND SYMPTOMS OF SEVERE [CONDITION(S)]: Repeat finger stick Assess clinical status using A, B, Cs (airway, breathing, circulation) Monitor vital signs every 5-15 minutes until stable. Do not leave patient unattended Notify physician of clinical condition including vital signs and blood glucose level Administer physician's orders for emergency treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -3 to 6 commercially prepared glucose tablets, or gel/liquid if patient can swallow -[MEDICATION(S)] 1mg (subcutaneously or intramuscularly) - IV bolus of 50 cc or 50% dextrose solution (intravenous glucose infusion) if no response to [MEDICATION(S)](tablets or gel) within 15 minutes Monitor blood glucose levels every 10 minutes until within acceptable range -If acceptable range is not reached in reasonable period of time or condition deteriorates, activate EMS and prepare for emergency transport. -If acceptable range is reached and patient begins to respond, provide protein snack such as cheese and crackers Review of the facility policy Change in Condition dated 1/25/21, states: PURPOSE: To provide guidance in the identification of clinical changes that may constitute a change in condition and require intervention and notifications. NOTE: CMS requires, -A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is: -An accident involving the resident which results in injury and has the potential for requiring physician intervention; -A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); -A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or decision to transfer or discharge the resident from the facility. -According to the American Medical Directors Association (AMDA) Clinical Practice Guidelines Acute Changes in Condition in the Long-Term Care Setting, immediate notification is recommended for any symptom, sign or apparent discomfort that is acute or sudden in onset and a marked change in relation to usual symptoms and signs, or is unrelieved by measures already prescribed Review of Resident R8's clinical record indicated resident was readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R8's physician orders dated 10/31/21, indicated to check CBG four times daily with sliding scale coverage of insulin with instructions to call the physician with CBG 451 or greater. Additional physician orders included injectable [MEDICATION(S)] for not alert resident; and Glucose Gel by mouth for alert responsive resident, both for CBG less than 70, according to facility policy. Resident R8 also had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident R8's Medication Admission Record (MAR) revealed that the resident's CBG's were as follows: On 12/23/21, at 6:12 a.m., CBG was noted to be 478. Review of Resident R8's MAR and clinical progress notes indicated for the above listed date the resident was not assessed for symptoms of [CONDITION(S)], and the physician was not notified. On 11/15/21, at 4:27 p.m., CBG was noted to be 60. No assessment was completed for evaluation of [CONDITION(S)]. No interventions were noted in the progress notes. On 12/28/21, at 4:25 p.m., CBG was noted to be 49. No assessment was completed for evaluation of [CONDITION(S)]. No interventions were noted in the progress notes. Review of Resident R11's clinical record indicated resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident R11's physician orders dated 11/26/21, indicated that resident R11 had orders to check CBG four times daily with sliding scale coverage of insulin with instructions to call the physician with CBG 340 or greater. Additional physician orders included injectable [MEDICATION(S)] for not alert resident; and Glucose Gel by mouth for alert responsive resident, both for CBG less than 70, according to facility policy. Resident R11 also had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident R11's MAR revealed that the resident's CBG's were as follows: 12/16/21, at 4:25 p.m., CBG was 341 01/09/22, at 5:33 p.m., CBG was 344 Review of Resident R11's MAR and clinical progress notes indicated for the above listed dates the resident was not assessed for symptoms of [CONDITION(S)], and the physician was not notified. Review of Resident R53's clinical record indicated that resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident 53's physician orders dated 8/25/21, to check CBG two times daily with sliding scale coverage of insulin and instructions to call the physician with CBG less than 70 or greater than 401. Resident R53 was also using a long-acting insulin daily. Review of Resident R53's MAR revealed that the resident's CBG's were as follows: 10/30/21, at 4:00 p.m., CBG was 449 10/31/21, at 4:27 p.m., CBG was 426 11/7/21, at 4:51 p. m., CBG was 570 11/25/21, at 4:00 p.m., CBG was 447 12/26/21, at 4:00 p.m., CBG was 420 Review of Resident R53's MAR and clinical progress notes indicated for the above listed dates the resident was not assessed for symptoms of [CONDITION(S)], and the physician was not notified. Review of Resident R53's MAR revealed that the resident's CBG's were as follows: 10/2/21, at 11:23 a.m., CBG was 57 10/16/21, at 8:07 a.m., CBG was 63 10/17/21, at 11:42 a.m., CBG was 69 10/27/21, at 5:37 p.m., CBG was 62 11/2/21, at 11:37 a.m., CBG was 62 11/4/21, at 9:18 p.m., CBG was 65 12/7/21, at 11:45 a.m., CBG was 68 Review of residents R53's MAR and clinical progress notes indicated for the above listed dates the resident was not assessed for symptoms of [CONDITION(S)], and the physician was not notified. Review of Resident R81's clinical record revealed that resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident R81's physician orders dated 7/5/21, to check CBG before meals with sliding scale coverage of insulin and instructions to call the physician with CBG 401 or greater. Additional physician orders included: injectable [MEDICATION(S)] for not alert resident; and Glucose Gel by mouth for alert responsive resident, both for CBG less than 70, according to facility policy. Resident R81 also had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident R81's MAR revealed that the resident's CBG's were as follows: 10/19/21, at 5:12 a.m., CBG was 525 11/30/21, at 5:58 a.m., CBG was 456 12/10/21, at 9:43 p.m., CBG was 401 12/29/21, at 5:18 a.m., CBG was 517 1/9/22, at 6:09 a.m., CBG was reading HI (manufacturer guidelines for the CBG meter indicates blood glucose level may be above 600). Review of Resident R81's MAR and clinical progress notes indicated for the above listed dates the resident was not assessed for symptoms of [CONDITION(S)], and the physician was not notified. Review of Resident R81's MAR revealed that the resident's CBG's were as follows: 10/2/21, at 11:23 a.m., CBG was 57 10/16/21, at 8:07 a.m., CBG was 63 10/17/21, at 11:42 a.m., CBG was 69 10/27/21, at 5:37 p.m., CBG was 62 11/2/21, at 11:37 a.m., CBG was 62 11/4/21, at 9:18 p.m., CBG was 65 12/7/21, at 11:45 a.m., CBG was 68 Review of Resident R81's MAR and clinical progress notes indicated for the above listed dates the resident was not assessed for symptoms of [CONDITION(S)], and no interventions were noted in the progress notes. Review of Resident R257's clinical record revealed that resident was admitted to the facility 12/16/21, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident R257's physician orders dated 1/3/22, and revised 1/11/22, indicated that Resident R257 had orders to check CBG before meals and at bedtime with sliding scale coverage of insulin with instructions to administer coverage and call the physician with CBG 349 or greater. Review of Resident R257's MAR revealed that the resident's CBG's were as follows: 1/8/22, at 4:19 p.m., CBG was 378 1/8/22, at 8:31 p.m., CBG was 399 1/12/22, at 5:52 a.m., CBG was 370 1/12/22, at 11:39 a.m., CBG was 392 Review of Resident 257's MAR and clinical progress notes indicated for the above listed dates the resident was not assessed for symptoms of [CONDITION(S)], and the physician was not notified. During an interview on 1/13/22, at 11:40 a.m., with Certified Registared Nurse Practioner (CRNP) Employee E1 (reference to Resident R257) reported that she was the CRNP in the building on 1/12/22, denied being informed of the 5:52 a.m. CBG, and was not informed of the 4:19 p.m. CBG even though she was currently in the building at that time. During an interview at the same time, CRNP Employee E2 reported that they expect staff to call according to the physician orders. During a telephone interview on 1/13/22, at 5:17 p.m., LPN Employee E7 reported that she didn't see the call MD notation next to the Resident R257's sliding scale orders as the type (writing/font) was kind of small and didn't document because a hundred things happen at once and some things just get away from you. Interviews referring to staff knowledge of facilities process of treating hyper- and hypo-glycemic residents and what good practice in treating such residents revealed the following: During an interview on 1/13/22, at 10:32 a.m., RN Employee E4 stated that if a resident was at or above 400, she would call the Doctor and await orders. During an interview on 1/13/22, at 10:33 a.m., RN Employee E5 reported she would call the doctor if a resident was hypoglycemic or hyperglycemic greater than 450 even if there was no order. During an interview on 1/13/22, at 10:35 a.m., LPN Employee E6 reported she would call the MD for greater than 400 and under 20. During an interview on 1/13/22, 10:30 a.m., RN Employee E3 reported that if someone is hyperglycemic, she would check the order and call the MD, and would still call the MD if the CBG was over 400 even if there wasn't an order. During an additional interview at 1:15 p.m., RN Employee E3, who failed to notify the physician or the CRNP who was in the building at the time of the CBG of 392 on Resident R257 stated, I have no excuse and that she should have called. During a telephone interview on 1/13/22, at 5:34 p.m., LPN Employee E8 upon inquiry regarding Resident R11's elevated CBG, stated she did not remember and when things like that happen, she usually notifies the supervisor and he may have texted the MD, and it was all my fault I didn't document anything. During a telephone interview on 1/13/22, at 5:44 p.m., LPN Employee E9 reported don't remember Resident R53's elevated blood sugar, but would have immediately reacted if they were symptomatic. During a telephone interview in 1/13/22, at 6:10 p.m., RN Employee E20 stated that she didn't remember resident R53's elevated CBG as it was almost two months ago, but usually give the highest dose of insulin and call the Dr. and /or monitor and if no change, call the Dr. back. Doesn't remember why she did not have any documentation. During an interview on 1/13/22, at 6:22 p.m., Unit Manager Employee E21 stated that she did not notify the physician of resident R257's high blood sugar as another resident went into respiratory distress. She reported that the insulin was given with intent to call and just forgot. During an interview on 1/13/22, at 6:27 p.m., LPN Employee E22 reported that she didn't remember and would have likely given Resident R81 something to eat for a low CBG, and didn't know why she did not call or document any interventions. During an interview on 1/13/22, at 6:37 p.m., RN Employee E23 reported she would have given Resident R81 a snack (for the low CBG), would have assessed him and rechecked his CBG levels as he is a very labile (hard to control) diabetic. She reported that she likely became distracted and just forgot to document interventions. The NHA and DON were made aware that Immediate Jeopardy existed due to the failure of the facility to monitor, evaluate and/or revise the resident's response to interventions which placed the residents at risk by failing to assess and document signs or symptoms of [CONDITION(S)] and [CONDITION(S)], notify physicians of acute condition changes, follow physician orders, and educating staff on facility policies: related to [CONDITION(S)] and [CONDITION(S)] for the residents in the facility on 1/14/22, at 10:31 a.m., and a corrective action plan was requested; and the IJ template was provided at that time. On 1/14/22, at 1:28 p.m., an acceptable Corrective Action Plan was approved which included the following interventions: Corrective Action Taken: -The Director of Nursing and unit managers were educated by the Quality Assurance Consultant on 1/13/22, at 10:15 am including Change of Condition, [CONDITION(S)], and [CONDITION(S)] nursing procedures including notification of physician, documentation of the notification, and care plan revision as indicated. -Licensed staff, registered nurses and licensed practical nurses, education was initiated on 1/13/22, at 10:30 am by the Director of Nursing/ designee including Change of Condition, [CONDITION(S)], and [CONDITION(S)] nursing procedures including notification of physician, documentation of the notification, and care plan revision as indicated. -The 5 identified residents had their MARs reviewed, and the physician was notified of glucometer results outside of ordered parameters. Like residents: A comprehensive review of current residents who receive insulin was completed on 1/13/22, at 3:40 pm to ensure there were no other instances of glucometer readings outside of parameters without physician notification. Areas identified for correction initiated. System Revision: -Immediate education of licensed nursing staff, registered nurses and licensed practical nurses, was initiated by the Director of Nursing/ designee on 1/13/22, at 10:30 a.m. of the Change in Condition, [CONDITION(S)], and [CONDITION(S)] nursing procedures including notification of physician, documentation of the notification, and care plan revision as indicated. Education will be completed by 1/14/22, at 9:00 a.m. Licensed nursing staff, registered nurses and licensed practical nurses, who have not received the education at that time will not be permitted to work until the education is received. -Including notification of the physician of a change in resident condition related to [CONDITION(S)] or [CONDITION(S)] and care plan revision as indicated. -Documentation of the notification of the physician in the medical record and the response of the physician Licensed nursing staff will not be permitted to work until the education is completed. Ongoing Monitoring: -Utilizing the Diabetic Monitoring QAPI tool, Current residents and new admissions who receive insulin will be reviewed to ensure physician was notified of glucometer results outside of ordered parameters and it is documented. -The facility QAPI committee through Ad Hoc or full QAPI shall monitor for four weeks to review any trends and findings, issues or concerns, and develop a plan of action for follow up and resolution. During observations, interviews, and document review the facility in serviced all staff and provided education offsite by telephone. Interviews of staff members in person and by telephone was ongoing and review of signature sheets verified the training sessions. The Immediate Jeopardy was removed on 1/14/22, at 1:28 p.m., when the action plan implementation was verified. During an interview on 1/14/22, at 1:22 p.m., the Director of Nursing confirmed the facility failed to assess Residents R8, R11, R53, R81, and R257 for symptoms of [CONDITION(S)] and [CONDITION(S)], implement measures, and notify the physicians as ordered placing the residents in Immediate Jeopardy. 28 Pa. Code 201.18 (b)(1) Management Previously cited 9/9/20 28 Pa. Code 201.29(d) Resident Rights 28 Pa. Code 211.10 (c) Resident Care policies 28 Pa. Code 211.10(d) Resident Care Policies Previously cited 9/9/20 28 Pa. Code 211.12 (d)(1)(2)(3) Nursing services Previously cited 9/9/20 28 Pa. Code 211.12 (d)(5) Nursing Services