Every finding on record at Phoenix Center for Rehabilitation and Nursing,The

Based on interview and observation, it was determined that the facility failed to provide a safe and sanitary environment for two medication rooms observed (first and second floor medication rooms).Findings include: Observation of the first-floor medication room behind the nursing station on August 19, 2026 at approximately 10:53 a.m. revealed missing ceiling tiles, ceiling tiles with brown stains, liquid leaking from the ceiling, two basins on the floor containing clear liquid, blistered paint on the wall against which shelves of supplies and a treatment cart where placed, brown streaks on the same wall that appeared to be dried leaks, two sinks with dried brown substance in them, an opened gallon jug labelled spring water with no open date and an expiry date of January 31, 2026, and clumps of black dust on the floor. A housekeeping log posted on the back of the door was last signed off on September 4, 2025. These observations were shared with LPN E3, who could not say how long the ceiling had been leaking but thought it might have been because of a recent heavy rain. These findings were shared with the DON (Director of Nursing) on August 21, 2026, at approximately 4:00 p.m. An observation of the Second-floor medication room was conducted on August 19, 2026, at 9:30 a.m., with the presence of licensed nurse Employee E8. The observation revealed the following: Two ceiling tiles with dark brown stain; A dark brown stain on the floor approximately one square foot in size; missing cabinet under the sink; missing cabinet under the refrigerator; Dark brown substance surrounding the faucet; and a rusty spatula on the sink. An interview was conducted with Employee E8 conducted on August 19, 2026, at 9:32 a.m. Employee E8 reported that housekeeping is responsible for cleaning the medication room. Employee E8 was unable to say when the medication room was last cleaned. A review of the medication room cleaning log posted behind the door revealed it was last cleaned on June 17, 2026, at 10:20 a.m. The above was conveyed with the Director of Nursing on August 21, 2026, at 1:00 p.m. 28 Pa. Code 211.12(d)(1)(5) Nursing Services 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management

Based on observation, facility record review, facility policy review and resident and staff interviews, it was determined the facility failed to ensure resident cigarettes and lighters were stored securely and monitored for 14 of 15 residents (Residents 3, 5, 10, 14, 16, 30, 38, 41, 54, 63, 82, 87, 98, and 102) on two units, and failed to ensure five of 15 residents were assessed for smoking safety timely. (Residents 10, 14, 30, 54, and 82).Findings include:Review of facility policy titled Smoking Policy Residents (Revised July 2017), revealed: The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include: Current level of tobacco consumption; Method of tobacco consumption; Desire to quit smoking, if a current smoker; Ability to smoke safely with or without supervision (per a Safe Smoking Evaluation). A resident's ability to smoke safely will be reevaluated quarterly, upon significant change (physical or cognitive) and as determined by staff . Residents are not permitted to give smoking articles to other residents. Residents who have independent smoking privileges are permitted to keep cigarettes .and other smoking articles in their possession.Review of facility document titled Smokers List, provided to the survey team on August 19, 2026, identified 15 residents who smoke. The residents identified as smokers were Residents 3, 5, 10, 14, 16, 30, 38, 41, 54, 63, 82, 87, 98, and Resident 102Interview with the DON (Director of Nursing) on August 19, 2025, at approximately 2:18 p.m. revealed residents in the building should not be assessed as independent smokers and confirmed all smoking residents keep the smoking materials including lighters with them, except for one resident.Review of Resident 5's clinical record revealed assessments to smoke safely with supervision completed on August 11, 2026, and August 20, 2026. Resident 5's smoking assessment failed to indicate why he needed supervision while smoking.Review of Resident 5's care plan revealed he was care planned to smoke cigarettes. Further review of Resident 5's care plan revealed Resident 5 is legally blind, but the care plan failed to include interventions regarding storage of smoking materials including the cigarette lighter.Review of Resident 5's admission MDS (minimum Data Set- periodic assessment of resident's needs) assessment dated [DATE], revealed Resident 5 has BIMS of 15 indicating full cognitive function and is legally blind. Resident 5 is able to ambulate independently in a wheelchair.Further review of the MDS assessment revealed Resident 5 has diagnoses including but not limited to Schizophrenia (mental condition characterized by loss of reality contact, delusions, hallucinations and/or feelings of persecution), Chronic Obstructive Pulmonary Disease (COPD disease process that causes decreased ability of lungs to perform), other lack of coordination, and Homicidal Ideations.Observation of Resident 5 on August 19, 2026, at approximately 9:45 am in his room revealed a pack of cigarettes on Resident 5's overbed table.Interview with the Licensed Nurse E5 at approximately 9:45am confirmed the box contained Resident 5's smoking materials including a lighter, but the materials are to be kept in a lockable drawer within the resident's side table.Subsequent observation of Resident 5 on August 19, 2026, at approximately 2:15 pm revealed the same box of cigarettes laying on Resident 5's overbed table while Resident 5 was sleeping.Review of Resident 10 clinical record including the census sheet revealed Resident 10 was admitted to the facility on [DATE], with a diagnosis of lack of coordination and Polyneuropathy (medical condition that happens when multiple peripheral nervesthe nerves outside of the brain and spinal cordmalfunction or become damaged at the same).Review of Resident 10's clinical record failed to reveal an assessment for smoking or a care plan for smoking initiated or implemented prior to August 20, 2026.Observation of Resident 14 on August 19, 2026, at 3:00 p.m. revealed the resident was outside smoking with activities staff.Review of Resident 14's clinical record revealed the last smoking assessment was completed August 13, 2025, indicating Resident 14 was safe to smoke under supervision but failed to identify reason for staff supervision need.Review of Resident 14 Quarterly MDS dated [DATE] revealed a BIMS of 4 (Brief Interview for Mental Status) indicating severe cognitive impairment and diagnoses including Metabolic Encephalopathy (general loss of brain function caused by a chemical imbalance, toxin buildup, or lack of energy supply to the brain due to an underlying illness elsewhere in the body),Epilepsy (seizure disorder), and Acute Respiratory Failure (life-threatening medical emergency where the lungs cannot properly move oxygen into the blood or remove carbon dioxide from it).Review of Resident 16's clinical record revealed smoking assessments completed January 23, 2025, April 26, 2025, July 29, 2025, and May 18, 2026, indicating Resident 16 was able to smoke only with supervision. Resident 16's smoking assessment failed to indicate why he needed supervision while smoking.Review of Resident 16's Annual MDS assessment, dated July 10, 2026, revealed Resident 16 had a BIMS of 0 indicating severe cognitive impairment. Further review of Resident 16's MDS assessment revealed diagnoses of Vascular Dementia (decline in thinking skills caused by conditions that block or reduce blood flow and oxygen to the brain), lack of coordination, and Epilepsy.Review of Resident 16's care plan reveals that Resident 16 is care planned to smoke with supervision but failed to identify reason for staff supervision.Observation of Resident 16 on August 19, 2026, at approximately 2:40 p.m., revealed Resident 16 had his/her lighter and a pack of cigarettes in the right back pocket of their pants.Interview conducted with Resident 30 on August 19, 2026, approximately 2:25 p.m. revealed when asked where the lighter and cigarettes are kept replied, Yes, I kept my smoking items with me; where else would I keep them?Review of Resident 30's diagnosis list revealed anxiety disorder (persistent and excessive worry) and Major Depressive Disorder -recurrent and unspecified (chronic mood disorder marked by repeated episodes of depression, causing significant impairment in daily functioning).Review of Resident 30's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated July 6, 2026, revealed resident had a BIMS (Brief Interview for Mental Status) score of 11, indicating mild to moderate cognitive impairment.Review of Resident 30's clinical record revealed smoking assessments completed on October 16, 2024, and August 20, 2026, which indicated Resident 30 was able to smoke safely only with staff supervision but failed to identify reason for the need of supervision. Further review of Resident 30's clinical record failed to reveal smoking assessments were completed between October 16, 2024, and August 20, 2026.Review of Resident 38's Quarterly MDS assessment dated [DATE], revealed a diagnosis of COPD (chronic obstructive pulmonary disease- long-term lung condition that makes it progressively harder to breathe) Acute Respiratory Failure with the resident on continuous oxygen. Further review of Resident 38's MDS revealed a BIMS score of 14 indicating the resident is cognitively intact.Review of Resident 38's clinical record revealed a smoking assessment completed May 18, 2026, indicating Resident 38 was able to smoke with staff supervision. Resident 38's smoking assessment failed to indicate why he needed supervision while smoking.Interview with Resident 38 on August 19, 2026, at approximately 11:00 a.m., revealed when asked about storage of cigarettes and lighter, I keep them in my room. People know better than to mess with my stuff. Further interview confirmed Resident 38 does not have a locked drawer in the room in which to keep the cigarettes and lighter.Review of Resident 41's diagnosis list revealed anxiety disorder (persistent and excessive worry) and Major Depressive Disorder, recurrent severe without psychotic features (debilitating mood disorder marked by repeated severe depressive episodes without hallucinations or delusions).Review of Resident 41's quarterly MDS assessment (Minimum Data Set - periodic assessment of resident needs) dated June 1, 2026, revealed Resident 41 had a BIMS (Brief Interview for Mental Status) score of 15, indicating intact cognitive function.Review of Resident 41's clinical records revealed a smoking assessment indicating Resident 41 was able to smoke only with staff supervision completed on May 18, 2026, and August 20, 2026, but failed to indicate the reason for the supervision. Interview with Resident 41 on August 19, 2026, at approximately 2:28pm revealed Resident 41 keeps their cigarettes and lighter in personal accessory. The surveyor observed the cigarettes and lighter in a bag hanging on the back of the wheelchair at the time of the interview.Observation conducted on August 19, 206, at 1:00 p.m., revealed Resident 54 laying on a Geri chair (specialized, padded medical recliner on wheels) on the patio with other residents who were smoking. Further observations revealed resident with a visitor beside them. The visitor was observed placing a cigarette on the resident's mouth and lighting it with a lighter.Interview was conducted with Resident 54's visitor on August 19, 2026, at 1:05 p.m. revealed visitor stating they were the resident's spouse. Further interview with resident's spouse revealed visits occur weekly and spouse takes Resident 54 to the patio to smoke since resident was admitted to the facility, January of 2026.Review of Resident 54's Quarterly Minimum Data Set assessment dated [DATE], revealed resident had mild cognitive impairment and was dependent on staff for most of their ADL's (Activities of Daily Living). The same MDS revealed Resident 54 was admitted on [DATE], and had a diagnosis of Cerebral Infarction (stroke).Review of Resident 54 clinical record failed to reveal Resident 54 was assessed for smoking safety until August 19, 2026, despite being identified by the facility as a smoker at admission on [DATE].Observation of Resident 63 on August 19, 2026, at 3:00 p.m. revealed the resident was outside smoking.Review of clinical record for Resident 63 revealed a smoking assessment completed May 21, 2024, indicating Resident 63 was evaluated for smoking but able to smoke under supervision. Resident 63's smoking assessment failed to indicate why he needed supervision while smoking.Review of Resident 63's care plan reveals interventions dated January 21, 2025, that staff will assess resident's ability to smoke safely and ensure that there is no lighter/cigarettes at bedside; staff will provide such during smoking time in the smoking room.Interview with Resident 63 on August 19, 2026, at 2:36 p.m. regarding their cigarettes and lighter reveals, I keep them. Further interview with Resident 63 revealed there is not a locked drawer available in the room.Observation conducted on August 19, 2026, at 3:00 p.m., revealed Resident 82 was sitting on the patio smoking with other residents. Resident 82 reported they just borrow cigarettes from other residents.Review of Resident 82's admission MDS assessment dated [DATE], revealed resident was admitted to the facility on [DATE]. The same MDS assessment indicated Resident 82 had severe cognitive impairment with a BIMS score of 6 and was independent with most of their ADL's.Review of Resident 82 clinical records, revealed Resident 82 was not assessed for safety of smoking until August 19, 2026; approximately six weeks after admission.Interview conducted with the Director of Nursing (DON) on August 21, 2026, at 1:00 p.m., confirmed Resident 54 and Resident 82's smoking assessments were not completed until August 19, 2026.Review of Resident 87's smoking assessment last completed on May 18, 2026, revealed resident was identified as safe to smoke under supervision. Resident 87's smoking assessment failed to indicate why he needed supervision while smoking.Review of Resident 87's quarterly MDS dated [DATE], revealed residents were cognitively intact and were independent with most of their ADL's. The same MDS assessment revealed Resident 87 had a diagnosis of Cerebral Infarction.Interview was conducted with Resident 87 on August 19, 2026, at 2:22 p.m. revealed Resident 87 confirmed he/she smokes daily and keeps cigarettes and lighter with him/her. When asked where they kept the lighter and cigarettes, Resident 87 pointed to a tote bag on the floor beside their bed and stated, I kept it all there.Review of Resident 98's clinical record revealed a diagnosis list including diagnoses of, fusion of spine, cervical region; other sequelae (long term effects) of cerebral infarction (stroke where blood flow to part of the brain is blocked leading to brain tissue damage) and Aphasia (language disorder that affects how you communicate) following cerebral infarction.Review of Resident 98's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated July 16, 2026, revealed the resident was admitted to the facility on [DATE]. Further review of the MDS revealed the resident had a BIMS (Brief Interview for Mental Status) score of 0 indicating severe cognitive impairment.Review of Resident 98's clinical records revealed a smoking assessment completed on April 8, 2026, and August 20, 2026, which indicated resident is able to safely smoke only under supervision. The smoking assessment failed to identify the reason Resident 98 was deemed safe to smoke under supervision.Interview with Resident 98 on August 19, 2026, at approximately 2:21 p.m. confirmed resident keeps their cigarettes and lighter with them.Observation of Resident 98 revealed the lighter and cigarettes were located in a pouch on the wheelchair.Review of Resident 102's smoking assessment last completed on March 12, 2026, revealed resident was evaluated and deemed safe to smoke under supervision.Review of Resident 102's quarterly MDS dated [DATE], revealed resident was cognitively intact and was independent with most of their ADL's. The same MDS revealed residents had a diagnosis of Cerebral InfarctionInterview was conducted with Resident 102 on August 19, 2026, at 2:42 p.m. Resident 102 confirmed they smoke daily and they kept their own cigarettes and lighters. When asked where they kept their smoking supplies, the resident showed the pack of cigarettes tucked on their left shirt pocket. When asked if they have a drawer to store it, the resident replied, I have a drawer, but it does not have a lock.Based on an interview with the NHA and DON licensed corporate employee E10 on August 21, 2025, at approximately 2:00 p.m. revealed they were unsure of how long the residents had their cigarettes and lighters with them when not smoking. Further interview revealed the facility was cited on their last recertification survey for not completing a smoking assessment and after the last recertification survey; the residents who smoke were allowed to keep their smoking materials with them per the facility's updated policy.28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(e)(1) Management28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on a review of the facility's policy, observations, and staff interview, it was determined that the facility failed to maintain the laundry dryer machine in safe operating condition. Findings: A review of the facility's policy titled Lint Trap Cleaning and Maintenance Policy, undated, revealed, All lint traps on laundry dryers must be checked and cleaned every hour while the laundry equipment is in operation. Hourly lint trap cleaning is mandatory and must be documented on the facility's designated Lint Trap Cleaning Log. The policy also stated, Lint accumulation presents a potential fire hazard and may reduce dryer performance. Proper and timely lint removal is essential to maintaining a safe laundry operation. An observation of the laundry room was conducted on August 21, 2026, at 3:36 p.m., with the presence of the housekeeping director, Employee E9. Machine #2 and #3 lint screens were observed covered with thick lint. Both machines had accumulations of lint on the bottom of the lint drawer. Further observations revealed both lint drawers had wires above the lint screen; the wiring was observed with scattered lint attached to it. An interview was conducted with Employee E9 on August 21, 2026, at 3:40 p.m. Employee E9 reported that the lint drawer must be checked, cleaned, and logged every hour. The cleaning log presented to the surveyor did not have any documented cleaning log for the month of August. Employee E9 reported that the laundry staff had already left at 2:00 p.m. Employee E9 does not know when the lint drawer for machines #2 and 3 were last checked and cleaned, but they agreed that both lint drawers were not cleaned recently. The facility failed to ensure laundry dryer machines #2 and #3 were maintained in a safe operating condition. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management

Based on review of facility records and resident interview, it was determined that the facility failed to ensure the resident received services to maintain vision in a timely manner for one of eight residents reviewed (Resident 2).Findings include: Interview with Resident 2 on August 19, 2026, at approximately 11:00 a.m. revealed that Resident 2 has cataracts and received a vision consultation close to the time he was admitted to the facility. Resident 2 reported that he was told by the person who did the exam that he needed a follow up with an ophthalmologist for his cataracts, but he heard nothing more about it. Review of Resident 2's admission MDS (Minimum Data Set - a mandatory assessment of a resident's physical condition and care needs) dated May 11, 2026, revealed that Resident 2 was cognitively intact and not assessed to have any vision deficit based on the response documented in Section B - Hearing, Speech, and Vision, Item B0100 Vision = 0 - adequate (sees find detail, such as regular print, in newspapers and books). Review of Resident 2's care plan initiated on May 12, 2026, revealed no vision deficit. Review of a vision consultation on May 15, 2026, revealed the following: mild dry eye syndrome in both eyes, moderate cataracts in both eyes, referred to ophthalmologist for possible cataract surgery. Review of Resident 2's medical chart revealed no evidence of a nursing note documenting this visit, notification of the physician of these findings, or a scheduled follow up exam, as per the consult recommendation. Interview with the NHA (Nursing Home Administrator) on August 20, 2026, at approximately 2:00 p.m. revealed an ophthalmology appointment had been scheduled for September 8, 2026, approximately three and a half months after the initial recommendation. These findings were shared with the DON (Director of Nursing) on August 21, 2026, at approximately 4:00 p.m. 28 Pa. Code 211.5 (f) (ix) Medical Records28 Pa. Code 212.12 (d) (1) (3) (5) Nursing Services

Based on a review of the facility's policy, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure foley catheter care was appropriately provided one of eight residents reviewed (Resident 6). Findings: A review of the facility's policy titled Urinary Catheter Care, undated, revealed, The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. A review of Resident 6's Quarterly Minimum Data Set (MDS- a standardized assessment tool that measures health status in long-term care residents) dated May 29, 2026, revealed the resident was cognitively intact. The same MDS revealed residents had an Indwelling Foley Catheter (A thin, flexible tube inserted into the bladder through the urethra to collect and drain urine) for diagnosis of Obstructive Uropathy (A blockage in the urinary tract that stops urine from flowing normally). A review of Resident 6's current care plan developed on October 23, 2025, revealed: Resident requires Foley catheter (18fr/10cc) secondary to Urinary retention. The care plan goal includes Resident will be free of signs and symptoms of infection related to catheter use through review date and Catheter will remain patent and intact 'til next review. The only interventions listed in the care plan were Irrigate for blockage as ordered A review of the nursing progress notes dated July 22, 2026, at 1:27 p.m., revealed the urine test result was reviewed by the physician, a new order to start Bactrim DS (An antibiotic used to treat infection) twice daily for seven days. An observation conducted on August 21, 2026, at 9:20 a.m., in the presence of Employee E6 revealed Resident 6 was lying on bed, wearing a shirt and incontinent pad. Further observation revealed a urinary (leg) bag was in bed attached to the resident's right leg with a white stretch band. The leg bag was connected to the resident's foley catheter with approximately 300-400 ml of dark yellow urine. An interview was conducted with Employee E6 on August 21, 2026, at 9:20 a.m. Employee E6 stated It's been there (pointing at the urinary bag) since this morning when I got here around 7:00 a.m. Employee E6 does not know if the night shift staff changed the resident's urinary bag. An interview with Resident 6 was conducted on August 21, 2026, at 9:35 a.m. The resident reported that they went to bed last night with a urinary leg bag. When asked if it was their preference, the resident answered No. The above was discussed with the Director of Nursing on August 21, 2026, at 9:40 a.m. The facility failed to ensure Resident 6's urinary drainage bag was properly positioned lower than their bladder to prevent further occurrence of urinary tract infection. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of facility policy and record review, the facility failed to implement a consistent method of weighing a resident, verifying the resident's weight upon admission, monitoring a resident's weight over time to identify weight loss/gain, and verifying weight measurements when changes in weight occur for two of eight residents reviewed (Residents 75 and 110).Findings include: Review of facility policy titled Weight Assessment and Interventions (revised April 2026) revealed: The nursing staff will measure resident weights on admission, and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measure monthly thereafter. Review of Resident 75's admission MDS (Minimum Data Set - a mandatory assessment of a resident's physical condition and care needs) dated July 29, 2026, revealed Resident 75 was admitted on [DATE], had cognitive deficits, required supervision/touch assistance to eat, and was at risk for malnutrition. Review of Resident 75's care plan initiated on July 28, 2026, revealed that Resident 75 was at risk for malnutrition related to dysphagia as evidenced by mechanically altered diet. Interventions included: Monitor/record/report to MD as needed signs and symptoms of malnutrition: emaciation, muscle wasting, significant weight loss. Review of Resident 75's orders revealed an order for weekly weights for 4 weeks to start on July 31, 2026. Review of Resident 75's admission weight on July 23, 2026, was 148 pounds and noted to be the hospital weight. Review of Resident 75's MAR (medication administration record) revealed that Resident 75 was 148 pounds on July 31, 2026, via a wheelchair scale. Review of Resident 75's MAR revealed that no weight was obtained on August 7, 2026. A review of nursing progress notes from August 7, 2026, revealed: weight will be done, aide haven't got around to it. Review of medical records failed to reveal evidence that a weight was obtained for Resident 75. Review of Resident 75's MAR revealed that no weight was obtained on August 14, 2026, because Resident 75 was out of the facility for a planned surgical procedure. Review of Resident 75's MAR for August 2026 revealed no evidence of orders to monitor the resident's weights after August 14, 2026. Review of Resident 110's medical chart revealed that Resident 110 was admitted on [DATE]. Review of Resident 110's admission weight revealed that Resident 110 weighed 120 pounds, with a note stating, hospital weight. Review of Resident 110's admission nutrition assessment dated [DATE], revealed Resident 110 was at nutritional risk due to dysphagia (difficulty swallowing) and severe protein-calorie malnutrition (insufficient intake of protein and energy leading to measurable changes in body composition), Parkinson's Disease (a movement disorder of the nervous system), and impaired skin. Review of Resident 110's medical record revealed that Resident 110 was readmitted to the hospital for seizure activity on July 31, 2026, and readmitted to the facility on [DATE]. Review of Resident 110's admission weight on August 18, 2026, was 101.1 pounds, with a note stating, hospital weight. Findings were reviewed with the DON (Director of Nursing) on August 21, 2026, at approximately 4:00 p.m. A review of Resident 111's admission Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated August 20, 2026, revealed resident was admitted to the facility on [DATE]. The same MDS revealed the resident had a feeding tube and an active diagnosis of Dysphagia (difficulty swallowing) following a Cerebrovascular accident (stroke). A review of Resident 111's weights and vitals revealed that the resident did not have a baseline weight taken upon admission on [DATE], instead, a weight of 167 pounds hospital weight, August 7, 2026, was documented. An interview was conducted with Employee E7 on August 20, 2026, at 12:57 p.m. Employee E7 confirmed that the baseline weight used to assess the resident was from the hospital (August 7, 2026). Employee E7 reported notifying nursing regarding missing admission weight but did not get a response thus, hospital weight was used instead to complete the resident's nutritional assessment. A review of Resident 111's weights and vital signs dated August 20, 2026, revealed a weight of 160.1 pounds, a seven pounds difference from the weight taken from the hospital. The above was discussed with the DON on August 21, 2026, at 1:00 p.m. 28 Pa. Code 212.12 (d) (2) Nursing Services

Based on observations, clinical records review and staff interviews, it was determined that the facility failed to provide appropriate treatment and monitoring of the enteral nutrition of residents with Gastrotomy Tube (GT- A medical device used to provide nutrition to people who cannot obtain nutrition by mouth) for one of one resident reviewed (Resident 111). Findings: A review of Resident 111's admission Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated August 20, 2026, revealed resident was admitted to the facility on [DATE]. The same MDS revealed the resident had a feeding tube and an active diagnosis of Dysphagia (difficulty swallowing) following a Cerebrovascular accident (stroke). The resident had severe cognitive impairment and was dependent of ADLs (activities of daily living). A review of Resident 111's weights and vitals revealed that the resident did not have a baseline weight taken upon admission on Augusts 14, 2026, instead, a hospital weight of 167 pounds was listed as the initial/baseline weight dated August 7, 2026. A review of the Resident 111's physician's order dated August 14, 2026, revealed an order for Enteral feed: Every shift Glucerna 1.5 at 55 cc/hour flush 200 cc every four hours. A review of Resident 111's August 2026 Medication Administration Record (MAR) revealed no documentation of the total feeding the resident received per shift and/or day. An observation conducted on August 19, 2026, at 9:50 a.m., revealed Resident 111 was lying in bed connected to a GT feeding. The feeding bag had a Sharpie writing 8/18 - 5:45 p.m. while the GT pump machine revealed a message Pump had been idle for more than 10 minutes. An interview was conducted with Employee E8 on August 19, 2026, at 9:55 a.m. Employee E8 does not know how long Resident Gt's feeding had been idle. Employee E8 restarted the feeding; the pump machine registered a total volume of 1663 milliliters. Employee E8 reported that the Resident's feeding was continuous and that the feeding bag is changed once consumed. When asked if the feeding machine is cleared after consuming the required GT feeding, Employee E8 reported that the machine was new. When asked how much total feeding the resident was supposed to get in a day, Employee E8 responded, I don't know, but everything was written on [their] order. While Employee E8 was looking for the resident's feeding order, the DON came to assist the employee. At 10:00 a.m., the DON confirmed that the total feeding volume was not indicated on the resident's order, the DON stated, I'll fix the order. A review of Resident 111's physician's order dated August 19, 2026, revealed an order every shift Glucerna 1.5 at 55 cc/hour water flush 200cc every 4 hours to equal 1320cc in 24-hour period A review of the Dietitian Employee E7 Nutritional Assessment, dated August 18, 2026, revealed the resident was NPO (Nothing Per Orem- nothing by mouth). The same note revealed that the baseline weight used was from the hospital. The note also revealed Glucerna 1.5 @55ml/hr continuous. Provides: 1980kcal, 110g protein. An interview was conducted with Employee E7 on August 20, 2026, at 12:57 p.m. confirmed that the baseline weight used to assess the resident was from the hospital (August 7, 2026). Employee E7 reported notifying nursing regarding missing admission weight but did not get a response thus, hospital weight was used instead to complete the resident's nutritional assessment. In addition, Employee E7 reported that the residents' feeding was continuous at 55cc per hour, total of 1320cc to provide the residents with 1980 Kcal. Employee E7 confirmed that the total feeding volume should have been documented to ensure residents receive the required nutrition. A review of Resident 111's weights and vital signs dated August 20, 2026, revealed a weight of 160.1 pounds, a seven pounds difference from the weight taken from the hospital. The above was discussed with the DON on August 21, 2026, at 1:00 p.m. The facility failed to ensure Resident 111 was provided with appropriate treatment and monitoring for GT feeding. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on interview and record review, the facility failed to ensure that residents were seen by a physician at least once every 30 days for the first 90 days and at least 60days after admission for two of 16 residents reviewed (Residents 85 and 91). Findings include: Review of Resident 85's admission MDS (Minimum Data Set - a mandatory assessment of a resident's physical condition and care needs) dated June 11, 2026, revealed that Resident 85 was admitted to the facility on [DATE]. Review of Resident 85's medical records revealed a physician history and physical assessment visit documented on June 9, 2026. Review of Resident 85's medical records revealed a physician visit documented on August 20, 2026. Interview with Medical Director E4 on August 20, 2026, at approximately 12:00 p.m. revealed that the dictation software that the providers use to transcribe their visit notes was not operational. The facility was unable to provide evidence of a physician visit for Resident 85 between June 9, 2026 and August 20, 2026. These findings were shared with the DON (Director of Nursing) on August 21, 2026 at approximately 4:00 p.m. Review of Resident 91's clinical record revealed diagnoses including but not limited to end stage renal disease (ESRD- failure of kidney function to remove toxins from blood). Review of Resident 91's clinical records revealed a physician visit documented on March 1, 2026. Further review of Resident 91's clinical records revealed no evidence of physician visit since March 1, 2026. An interview with Director of Nursing on August 21, 2026, at approximately 12:28 p.m. confirmed the above findings. 28 Pa. Code 211.2 (d) (10)

Based on review of clinical records, and staff and resident interviews, it was determined that the facility failed to ensure that a resident was assessed by a dentist for one of one resident. (Resident 7).Findings include:Review of Resident 7's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis of type 2 diabetes (insufficient production of insulin, causing high blood sugar), and chronic obstructive pulmonary disease, unspecified (a common lung disease causing restricted airflow and breathing problems).Interview with Resident 7 on August 19, 2026, at 6:15 p.m. revealed that the resident does not have dentures and had requested dentures.Review of Resident 7's clinical record revealed no evidence that the facility arranged for or followed up on dental services to obtain dentures.Interview on August 21, 2026, at 1:22 p.m. with Director of Nursing confirmed there was no documentation about dental consults for Resident 7.28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation and interview, the facility failed provide a sanitary environment to prevent the development of infection for two of 16 residents reviewed for infection control (Residents 2 and 6).Findings include: During observation of Resident 2's environment on August 19, 2026, at approximately 11:00 am, Resident 2's bipap machine (bilevel positive airway pressure machine is a non-invasive device that assists a resident to breathe) was observed sitting on his nightstand, running, partially covered by a fleece blanket and wet, soiled linen that had an odor of human waste. This observation was shared with E3, who donned gloves and removed the soiled linen from the nightstand. This finding was shared with the DON (Director of Nursing) on August 21, 2026, at approximately 4:00 p.m. An observation of Resident 6's bathroom conducted on August 21, 2026, at 9:30 a.m., in the presence of Employee E6 revealed three basins on the floor under the sink, one with a urinary drainage bag covered with multiple crumpled paper towel, second basin had dirty clothes covered with multiple crumpled paper towel, and the third basin was filled with crumpled paper towel. There was no garbage can observed on the resident's bathroom. An interview was conducted with Employee E6 on August 21, 2026, at 9:22 a.m. Employee E6 reported that the above observations had been present since they came in the morning around 7:00 a.m. When asked if the urinary bag on the floor belongs to Resident 6, Employee E6 responded yes. The above findings were shown to the Director of Nursing (DON) on August 21, 2026, at 9:25 a.m. 28 Pa. Code 211.12 (d) 1 Nursing Services

Based on observations, clinical records review, and staff and resident interviews, it was determined that the facility failed to develop a comprehensive care plan for smoking for two of 15 residents reviewed (Resident 54 and 82). Findings: An observation conducted on August 19, 206, at 1:00 p.m., revealed Resident 54 lying on a geri chair (A specialized, padded medical recliner on wheels) on the patio with other residents who were smoking. Further observations revealed the resident had a female visitor beside them. The visitor was observed placing a cigarette on the resident's mouth and lighting it with a lighter. An interview was conducted with Resident 54's visitor on August 19, 2026, at 1:05 p.m. The visitor reported that they were the resident's spouse. Further interview with the resident's spouse revealed that they visit the resident weekly, and they take them to the patio to smoke since they were admitted to the facility last January 2026. A review of Resident 54's active care plan revealed the resident did not have a smoking care plan developed until August 19, 2026. An observation conducted on August 19, 2026, at 3:00 p.m., revealed Resident 82 was sitting on the patio smoking with other residents. A review of Resident 82's admission MDS dated [DATE], revealed the resident was admitted to the facility on [DATE]. A review of Resident 82's active care plan revealed the resident did not have a smoking care plan developed until August 19, 2026. A review of the facility's Smokers List provided to the surveyor on August 19, 2026, revealed Residents 54 and 82 were smokers. The above was conveyed to the Director of Nursing on August 21, 2026, at 1:00 p.m. The facility failed to ensure Resident 54 and 82's smoking care plan was developed on time. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on a clinical records review, hospital records review, and staff interview, it was determined that the facility failed to follow a laboratory order for one of eight residents reviewed (Resident 6). Findings: A review of Resident 6's hospital records, Emergency Department Notes, dated June 16, 2026, revealed the resident was seen for urinary retention. The resident was sent back to the facility with an Indwelling Foley Catheter (A thin, flexible tube inserted into the bladder through the urethra to collect and drain urine). A review of Resident 6's nursing progress notes dated July 8, 2026, at 2:27 p.m. revealed the resident reported not feeling well and feeling tired. The same note stated that the resident developed a blank stare and [their] legs became weak. Vitals were as follows: blood pressure - 103/64 mmHg; heart rate- 44 beats per minute; respirations - 18 per minute; and blood oxygen saturation level could not be obtained. The Director of Nursing (DON) was notified. A review of Resident 6's nursing progress notes dated July 8, 2026, at 5:08 p.m., completed by the DON, revealed MD (physician) made aware of resident stating not feeling well and previous nurse's findings. New order received to obtain urine for CS (culture and sensitivity). Obtained by this nurse. First contact aware of all the above. There was no documentation of the laboratory result, of the urine collected by the DON on July 8, 2026. A review of Resident 6's physician's order dated July 10, 2026, at 10:05 a.m., revealed an order for UA (urinalysis-A medical test that checks the physical, chemical, and microscopic properties of urine) C&S. There was no documented evidence that the laboratory order made July 10, 2026, for a UA C&S was followed. A review of Resident 6's physician's order dated July 14, 2026, at 9:59 a.m., revealed an order for UA (urinalysis-A medical test that checks the physical, chemical, and microscopic properties of urine) C&S. A review of Resident 6's laboratory results for the UA and C&S revealed that the urine was collected on July 17, 2026, and the urine was received on July 19, 2026. UA result dated July 19, 2026, revealed the following: urine was cloudy (normal-clear); +1 Leukocyte (white blood cells in the urine, which indicates the body is fighting an infection), normal- Negative; +3 Protein (normal-Negative); and +1 blood (normal-Negative). The C&S result dated July 20, 2026, revealed Positive Culture >= 100,000 Klebsiella pneumoniae, and >= Proteus mirabilis (A type of bacteria). An interview was conducted with the DON on August 20, 2026, at 1:00 p.m. The DON reported that they collected the resident's urine on July 8, 2026, the DON reported that they will check with the laboratory. On August 21, 2026, at 11:00 a.m., the DON was unable to provide an explanation as to why there were no laboratory results from a urine that was collected on July 8, 2026. The DON also did not have an answer as to why the repeat urine order made on July 10, 2026, was not collected until July 17, 2026. The facility failed to ensure Resident 6's laboratory orders were followed on time. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on record review, the facility failed to provide required notification of transfer to the state long term care ombudsman for three of 16 residents reviewed for transfer (Residents 3, 11, 38, and 107). Findings include: Review of Resident 3's admission MDS (Minimum Data Set - a mandatory assessment of a resident's physical condition and care needs) revealed that Resident 3 was admitted to the facility on [DATE], for rehabilitation after surgery. Review of Resident 3's medical record revealed that Resident 3 was sent to the hospital on July 13, 2026, after a fall and was admitted to the hospital. Review of Resident 3's medical record revealed that the facility failed to notify the state long term care ombudsman of this transfer. Findings were shared with the DON (Director of Nursing) on August 21, 2026, at approximately 4:00 pm. [NAME], [NAME] (3) Review of Resident 11's clinical record revealed Resident 11 was transferred to the hospital on May 31, 2026, after sustaining a fall at the facility. Further review of Resident 11's clinical record revealed Resident 11 was readmitted to the facility on [DATE]. Review of Resident 11's clinical record and facility documentation failed to reveal evidence that the State Ombudsman's office was notified of Resident 11's transfer and admission to the hospital. Review of Resident 38's clinical record revealed Resident 38 was transferred to the hospital on April 28, 2026, with a diagnosis of acute respiratory distress. Further review of Resident 38's clinical record revealed Resident 38 was readmitted to the facility on [DATE]. Review of Resident 38's clinical record and facility documentation failed to reveal evidence that the State Ombudsman's office was notified of Resident 38's transfer and admission to the hospital. Interview with the Nursing Home Administrator on August 21, 2026, at approximately 4:00 p.m. confirmed that notification of Resident 38 and Resident 11's transfer and admission to the hospital was not sent to the State Ombudsman's office as required. Review of Resident 107's Discharge Planning Progress Note on May 22, 2026, at 12:15 p.m., reveals that Resident was picked up for discharge at approximately 10:00 a.m Review of Resident 107's clinical record fails to reveal a physician discharge summary. Interview with the Nursing Home Administrator and Medical Director on August 21, 2026, at approximately 4:00 p.m., confirms that a physician discharge summary was not completed within 30 days of Resident 107's discharge from the facility. Review of Resident 107's Discharge Planning Progress Note on May 22, 2026, at 12:15 p.m., reveals that, Resident signed discharge papers and received medication instructions. Resident left the facility with all belongings; however, resident did not see the nurse to receive the remaining medications prior to leaving. Further review of Resident 107's clinical record fails to reveal medication reconciliation and disposition documentation. Interview with the Nursing Home Administrator on August 21, 2026, at 11:50 a.m. confirms that there is no medication reconciliation and disposition documentation for Resident 107. 28 Pa Code 211.5 (d) Medical Records 28 Pa Code 211.9 (j.1, 4) Pharmacy Services

Based on a review of clinical records, and staff interview, it was determined that the facility failed to monitor the resident's behaviors, and medication side effects, for residents receiving a psychotropic medication for one of seven residents reviewed (Resident 9).Findings include: A review of Resident 9's physician order dated August 22, 2025, revealed an order for Risperidone (Atypical anti-psychotic) Oral Tablet 0.5 mg 1 tablet. Give 1 tablet by mouth two times a day for schizophrenia A review of Resident 9's Medication Administration Records and progress notes medication revealed side effects were not monitored since the Risperidone medication started on August 22, 2025. An interview with the Director of Nursing on August 21, 2026, at 10:02 a.m., confirmed that Resident 9's behavior and medication side effects were not monitored. 28 Pa. Code 211.12(c)(1)(3)(5) Nursing services 28 Pa Code 211.5 (f) Clinical record

Based on a clinical records review, hospital records review, and staff interview, it was determined that the facility failed to notify the responsible party and the physician of a change in condition for two of eight residents reviewed. (Resident 6 and Resident 98). Findings Include: A review of Resident 6's diagnosis list includes Chronic kidney disease (decrease functioning of the kideny), Obstructive uropathy (A blockage that stops urine from flowing normally through any part of the urinary tract), and urinary retention (inability or decreased ability to empty the bladder). A review of Resident 6's hospital records, Emergency Department Notes, dated June 16, 2026, revealed the resident was seen for urinary retention. The resident had an Indwelling Foley Catheter (A thin, flexible tube inserted into the bladder through the urethra to collect and drain urine). A review of Resident 6's nursing progress notes dated June 24, 2026, at 11:41 p.m., revealed Resident observed with involuntary movements and verbalize I don't feel well. The same note revealed Abdomen noted to be distended (enlarged) upon assessment. The supervisor was notified, resident positioned for comfort and encouraged to report any worsening symptoms. There was no documentation that the physician was notified of the resident's change in condition. An interview with the Director of Nursing, conducted on August 21, 2026, at 11:00 a.m., confirmed that the physician was not notified of Resident 6's change in condition identified on June 24, 2026. The facility failed to ensure physicians were notified of Resident 6's involuntary movements, report of not feeling well and distended abdomen (with the presence of a foley catheter). Review of Resident 98's quarterly MDS assessment (Minimum Data Set - periodic assessment of resident needs) dated July 16, 2026, revealed resident had a BIMS (brief interview for mental status) of 00 indicating Resident 98's to have severe impairment of cognition. Review of Resident 98's physician order for Risperidone (Atypical anti-psychotic) 0.25 MG Give 1 tablet by mouth at bedtime for bipolar started on February 15, 2026, and discontinued May 15, 2026. Review of Resident 98's clinical record revealed a progress note on May 13, 2026, stating physician order to discontinue Risperidone. Further review of Resident 98's clinical record and documents provided by the facility, revealed email correspondence between the responsible party and the facility dated July 30, 2026. Review of the email correspondence revealed no evidence that the responsible party was notified of the discontinuation of Risperidone in timely manner. An interview with the Director of Nursing on August 21, 2026, at 10:20 a.m., confirmed that the above findings. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on clinical record reviews and staff interviews, it was determined that the facility failed to obtain informed consent for antipsychotic medication use from the legal representative of one of eight residents reviewed. (Resident 9)Findings include:Resident 9 has medical diagnoses that include traumatic brain injury (injury to brain) and Schizophrenia (a mental health condition where a person experiences fixed, false beliefs or delusions). A review of Resident 9's physician order dated August 22, 2025, revealed an order for Risperidone (Atypical anti-psychotic) Oral Tablet 0.5 mg 1 tablet. Give 1 tablet by mouth two times a day for schizophreniaReview of Resident 9's clinical record revealed an informed consent form signed by Resident 9's legal representative on June 12, 2025, documenting consent and understanding of the risks and benefits of psychotic medication.Further review of Resident 9's clinical record failed to reveal evidence of informed consent for the use of Risperidone.An interview with the Director of Nursing on August 21, 2026, at 10:02 a.m., confirmed that Resident 9's behavior and medication side effects were not monitored.28 Pa. Code 201.29 (a)(c) Resident Rights 28 Pa. Code 211.10(c) Resident care policies

Based on review of facility policy, observations, review of facility documentation and staff interviews, it was determined the facility failed to ensure hot water temperatures in residents' room and shower rooms were maintained at a safe temperature on one of three nursing units (Third floor). This failure placed the residents at risk of serious injury from a burn and resulted in an Immediate Jeopardy Situation. Findings include:Review of facility policy, Safety of Water Temperatures, revised December 2018, indicated tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 110-120 degrees Fahrenheit or the maximum allowable temperature per state regulation. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a maintenance log. Observations conducted May 19, 2026, from 9:50 - 10:15 a.m. with Maintenance Employee E4 revealed the following water temperatures: 3rd floor:Resident room [ROOM NUMBER] - 128.5 degrees FahrenheitResident room [ROOM NUMBER] - 138.0 degrees Fahrenheit Interview with Employee E4 at that time, revealed water temperatures are checked weekly in random rooms and should be around 110 degrees Fahrenheit. Employee E4 also revealed the mixing valve (plumbing device that blends hot and cold water to create a safe, consistent output temperature) was replaced last month, but the water temperatures have been inconsistent. Interview with Maintenance Director, Employee E5, on May 19, 2026, at 10:30 a.m. revealed water temperatures have not been tested since April 11, 2026. Employee E5 also indicated that on May 3, 2026, the Nursing Home Administrator (NHA) had inquired via text about the water temperatures and Employee E5 replied it was hit or miss. Employee E5 also revealed a plumber was supposed to come to the facility on May 9, 2026, to address concerns, but the plumber did not come. The plumber was scheduled again for today (May 19, 2026) but had not arrived, yet. Review of TELS system (maintenance management system) documentation revealed water temperatures were last checked on April 8, 2026. Based on the above findings, Immediate Jeopardy to the safety of the residents was identified to the Director of Nursing (DON) on May 19, 2026, at 1:10 p.m. for failure to ensure safe hot water temperatures were maintained on the nursing unit and proper monitoring was conducted routinely. The DON was provided with the Immediate Jeopardy template on May 19, 2026, at 1:17 p.m. and an immediate action plan was requested. On May 19, 2026 at 3:47 p.m. the facility provided the following corrective action plan:Plumber was scheduled to come to the facility on May 19, 2026, to address concerns related to the water temperature systemAll other rooms in the facility that have had hot water temperatures taken and residents affected will be continuously assessed every shift to ensure that no signs and symptoms of hyperthermia are present to include vital signs, skin assessments along with any other relevant assessments related to hyperthermia.Facility staff will be educated on ensuring that water temperatures are checked appropriately before using the water for resident care and it if it out of range to stop use of water immediately and notify the appropriate parties.Facility water temperatures will be checked every shift by the maintenance director or manger on duty/facility administration to ensure that the temperatures are within appropriate range along with resident interviews to ensure that they are comfortable with the current temperatures.If the water temperature when checked does not meet and maintain the appropriate temperatures the facility will initiate the emergency plan to include closure of the shower rooms and providing residents with bed baths, allowing the water to reach appropriate temperatures before beginning.An Ad Hoc QAPI meeting was held on May 19, 2026 to discuss the events surrounding the facility's failure to ensure that the water temperature in the facility were maintained between 105 and 110 degrees Fahrenheit, to identify the root cause, and to initiate improvements to the facility's processes and procedures regarding ensuring that water temperatures are appropriately maintained in the facility, the facility has a plan in place when water temperatures are mot maintained and to ensure that the system responsible for water temperatures has routine maintenance. Interview with the Nursing Home Administrator (NHA) on May 20, 2026, at 10:50 a.m. indicated the NHA was not aware of any issues with high water temperatures until yesterday, May 19, 2026. Interviews were conducted with seven staff members on May 20, 2026, and facility staff were able to confirm education was provided on the appropriate water temperature range; to notify maintenance and/or Nursing Home Administrator if water temperatures are too high and showering was currently suspended. Review of facility documentation of hot water temperatures revealed the facility is currently monitoring the temperature of the hot water. Following the verification of the immediate action plan the Immediate Jeopardy was lifted on May 20, 2026, at 11:40 a.m. 483.25 Free of Accident Hazards/Supervision/Devices28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 205.63 (c) Plumbing & Piping Systems-Hot Water Outlets28 Pa. Code 211.10 (d) Resident Care Policies28 Pa. Code 211.12 (d) (1)(2)(5) Nursing Services

Based on observations, review of facility documentation and interviews with staff, it was determined that the Nursing Home Administrator failed to effectively manage the facility related to hot water temperatures which resulted in an Immediate Jeopardy situation.Findings include: Review of the job description for the Nursing Home Administrator revealed that the Nursing Home Administrator is to manage the facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities and to ensure the highest degree of quality is provided to residents.Observations in the facility on May 19, 2026, revealed that water temperatures were above 110 degrees Fahrenheit on the third floor. Interview with the Maintenance Employee E4 on May 19, 2026, after the observation confirmed the water temperatures were above 110 degrees Fahrenheit. There was no documented evidence provided to the surveyor that the water temperatures were being monitored since April 8, 2026. Interview with Employee E5 on May 19, 2026, at 10:45 indicated that the Nursing Home Administrator was made aware on May 3, 2026, of inconsistent water temperatures and that a plumber was scheduled for May 9, 2026, but did not come to the facility and no other interventions were put into place to address the hot water temperatures.This failure placed residents at risk for serious injury from a burn and resulted in an Immediate Jeopardy situation.Based on the deficiencies identified in this report the NHA failed to fulfill essential duties and responsibilities of their position, contributing to the Immediate Jeopardy situation.Refer to F68928 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management

Based on observations and staff interviews it was determined that the facility failed to provide a clean environment for 15 of twenty-three residents located on the 3rd floor care unit. (Resident 1's, Resident 2's, Resident 3's, Resident 4's, Resident 5's, Resident 6's, Resident 7's, Resident 8's, Resident 9's, Resident 10's, Resident 11's. Resident 12's, Resident 13's, Resident 14's, and Resident 15's rooms)Findings Include:Observations made on April 22, 2026, between 10 a.m. and 12 p.m., of resident rooms on the 3rd floor care unit revealed Resident 1, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11. Resident 12, Resident 13, Resident 14, and Resident 15 had window curtains that were soiled or had brown stains on them.Observations on April 22, 2026 at 10 a.m. made of Resident 1's room revealed wallpaper peeling off the wall behind bed B. Wallpaper was also observed missing on portions of the wall and behind both beds. Observation of Resident 2's shower on April 22, 2026 at 10:15 a.m. revealed a brown substance on the floor. During an interview with Resident 2 stated that staff flushes his/her roommates bed pan in the toilet and sometimes rinses the bedpan in the shower, leaving brown substances in the shower without cleaning and/or disinfecting the shower. Resident 2 stated he/she has not been able to use the shower because it has not been sanitized.Observations of the 3rd floor lounge area on April 22, 2026 at 11:45 a.m. revealed there were dark stains and paper debris on the carpet.Observations of the window curtains, wallpaper, shower and carpet were made with the Director of Nursing on April 22, 2025, at approximately 2:00 p.m. Interview conducted with Nursing Home Administrator (NHA) and Director of Nursing (DON) on April 22, 2026, at 2:30 p.m., when the above information was presented, the NHA stated the resident residing in room [ROOM NUMBER]B never leaves the room making it difficult for maintenance to repair the wall. The DON confirmed the observations and stated sometimes residents eat lunch in the lounge area.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3) (e)(3) Management.28 Pa. Code 207.2(a) Administrator's responsibility

Based on observation, a review of clinical records, and interviews with residents and staff, it was determined that the facility failed to provide a homelike environment for one of the three residents reviewed (Resident 1).Findings include:A review of Resident 1's admission assessment dated [DATE], revealed the resident was readmitted to the facility from the hospital for diagnosis of Congestive Heart Failure (CHF-A weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). The same assessment revealed that the resident was alert and oriented, and had skin openings on both legs.During an observation on September 2, 2025, at 11:52 a.m. Resident 1 was observed sitting on a chair beside the bed. The mattress was only half covered with a white flat sheet. The sheet covering the bottom part of the mattress had large dried brown stains and multiple dried red stains in different sizes. Additional observation revealed two loose white sheets on top of the bed, also with multiple dried dark yellow to light brown stains in different sizes.An interview with Resident 1 was conducted on September 2, 2025, at 11:55 a.m. Resident 1 reported that the brown stains on the bottom of the bed were from coffee spills, the red stains were blood from his/her legs, and the stains on the other sheets were from juice and food spills that occurred several times since he came back last August 29, 2025. The resident was unable to recall when the spills and blood stains occurred but reported that his bed sheets had not been changed since he/she arrived at the facility last Friday, August 29, 2025.An interview conducted with Nursing Assistant, Employee E1, on September 2, 2025, at 11:59 a.m., revealed that she/he was an agency staff member and did not know when the last time Resident 1's bed sheets were last changed. Employee E1 reported that Resident 1's bed sheets had not been changed since this morning because she /he did not get a chance to do it yet. The above was conveyed with theDirector of Nursing on September 2, 2025, at 12:05 p.m.The facility failed to ensure Resident 1 was provided with a homelike environment.28 Pa. Code 204.5(f) resident rooms

Based on review of facility policy, facility documentation, observations, and staff interviews, it was determined the facility failed to ensure hot water temperatures in residents' room and shower rooms were maintained at a safe temperature on three of three nursing units (First, Second and Third floors). This failure placed the residents at risk of serious injury from a burn and resulted in an Immediate Jeopardy Situation. Findings Include: Review of facility policy and procedure titled Test and Log the Hot Water Temperatures, undated, stated for burn prevention, federal guidelines advise that you keep domestic water temperatures below 120 degrees Fahrenheit, although this temp can still cause burns if exposure reaches five minutes. Many states have even stricter standards that set maximum temperatures lower than 120 degrees Fahrenheit is considered a safe water temperature for bathing. Test temperature in shower areas. Test temperature at the mixing valve. Check resident rooms at the end of each wing on a rotating basis or per facility policy. Common area bathrooms, public bathrooms and any other areas having since should be checked and recorded as well Record results in the water temperature log. Note any discrepancies. Adjust water heater setting as required. Retest as necessary. Observations conducted on May 30, 2025 at 10:52 a.m. with Maintenance Employee E3 revealed the following water temperatures: 1st floor Resident room [ROOM NUMBER]- 127 degrees Fahrenheit 1st floor shower room- 129 degrees Fahrenheit 2nd floor Resident room [ROOM NUMBER]- 126 degrees Fahrenheit 2nd floor shower room- 126 degrees Fahrenheit 3rd Floor Resident room [ROOM NUMBER]- 124 degrees Fahrenheit Resident room [ROOM NUMBER]- 125 degrees Fahrenheit 3rd floor shower room [ROOM NUMBER] degrees Fahrenheit Interview with Maintenance Employee E3 on May 30, 2025 at 11:12 a.m. after determine water temperatures were confirmed, Employee E3 confirmed the water temperatures were too high in each location, and the temperature should have been under 110 degrees Fahrenheit to comply with Commonwealth of Pennsylvania regulations of a maximum temperature of 110 degrees Fahrenheit. Maintenance Director Employee E3 stated he checks the water temperature daily choosing random rooms on each unit and documenting the temperature in the TELS system (maintenance management system). Further interview with Maintenance Employee E3 revealed the facility had two boilers, one for the domestic water supply the residents use and one for the service areas of the kitchen and laundry. The boiler for the residential water was broken and waiting for a part to complete service. The boiler for the service areas was being used to heat the water for both the service areas and the residential areas while the facility maintenance team were waiting for the necessary part to complete the needed maintenance on the boiler for the residential areas. Observation of the boilers on May 30, 2025 at 11:25 a.m. revealed the water was leaving the boiler at a temperature of 135 degrees Fahrenheit. Interview with Maintenance Employee E3 at the time of the observation revealed that 135 degrees Fahrenheit was the lowest temperature facility maintenance personnel could get the water to coming out of the boiler. Further interview with Maintenance Employee E3 on May 30, 2025 at 11:30 a.m. revealed that he had started at the facility on May 5, 2025 and noticed issues with the water temperatures on his second day of working which was May 7, 2025. Review of facility documentation revealed a Consolidated Service Report dated May 9, 2025 indicating the boiler system needs a new control board. Interview with maintenance Employee E3 on May 30, 2025 at 12:15 p.m. confirmed this is the part the facility maintance staff were waiting to have installed in the residential boiler, and they had been using the service area boiler for all areas of the facility since this time to provide heated water for the residents. Interview with the Nursing Home Administrator on May 30, 2025 at 12:30 p.m. revealed he had been absent from of the facility due to illness and was not made aware of the water temperatures until his return on May 22, 2025 when he signed a Service Repair Proposal for a Diagnostic Board Replacement for the boiler. Interview with the Nursing Home Administrator and Maintenance Employee E3 on May 30, 2025 at approximately 4:45 p.m. revealed the part needed to repair the boiler would not be available until Monday June 2, 2025. The facility was asked to provide water temp logs from May 1, 2025. The facility was unable to provide any documented evidence that water temperatures were being taken, recorded, or monitored to ensure safe temperatures in resident care areas. Observation of the 2nd floor shower room on May 30, 2025 at 10:56 a.m. while taking water temperature, revealed there was no thermometer in the shower room or logs to record the temperature of the water prior to a shower. Interview conducted with Nursing Assistant Employee E4 on May 30, 2025 at 11:30 a.m. revealed, that prior to providing a shower for a resident, staff would spray the water on the resident and ask them if it were comfortable. When asked how staff would ensure a safe water temperature for a resident who was nonverbal or cognitively impaired staff were unable to provide an answer. Interview with Nursing Assistant Employee E5 on May 30, 2025 at 11:35 a.m. revealed prior to providing a shower for a resident, staff would spray the water on the resident and ask them if it were comfortable. When asked how they would ensure a safe water temperature for a resident who was nonverbal or cognitively impaired, Employee E5 was unable to provide an answer. Interview with Nursing Assistant Employee E6 on May 30, 2025 at 11:38 p.m. revealed they would use a thermometer to test the water before providing a shower to the resident and make sure it was under 110 degrees. Nursing Assistant Employee E6 was asked to show this surveyor the thermometer staff would use to determine safe temperature of the shower water, but staff were unable to locate the thermometer. Interview with the Nursing Home Administrator on May 30, 2025 at 12:30 p.m. revealed, staff were expected take water temperature with a thermometer and document the temperature of the water in a log in the shower room. The Nursing Home Administrator was asked multiple times on May 30, 2025 and again on June 2, 2025 for the policy for staff were to follow to ensure safe water temperatures prior to showers and none was able to be provided to the surveyor. Based on the above findings, Immediate Jeopardy to the safety of the residents was identified to the Nursing Home Administrator on May 30, 2025, at 1:27 p.m. for failure to ensure safe hot water temperatures were maintained on the nursing unit and proper monitoring was conducted routinely and prior to providing residents with showers. The Nursing Home Administrator was provided with the Immediate Jeopardy template on May 30, 2025 at 1:30 p.m. and an immediate action plan was requested. On May 30, 2025 at 4:32 p.m. the facility provided the following corrective action plan: - Shower rooms were placed out of service and thermometers were placed in the shower rooms. - [Mechanical Company] on sight on May 30, 2025, to address concerns related to the water system - All other rooms in the facility have had hot water temperatures taken and residents affected will be continuously assessed every shift to ensure that no signs and symptoms of hyperthermia are present to include vital signs, skin assessments along with any other relevant assessments related to hyperthermia. - Facility staff will be educated on ensuring that water temperatures are checked appropriately before using the water for resident care and it if it out of range to stop use of water immediately and notify the appropriate parties. - Facility water temperatures will be checked every shift by the maintenance director or manger on duty/facility administration to ensure that the temperatures are within appropriate range along with resident interviews to ensure that they are comfortable with the current temperatures. - If the water temperature when checked does not meet and maintain the appropriate temperatures the facility will initiate the emergency plan to include closure of the shower rooms and providing residents with bed baths, allowing the water to reach appropriate temperatures before beginning. - An Ad Hoc QAPI meeting was held on May 30, 2025 to discuss the events surrounding the facility's failure to ensure that the water temperature in the facility were maintained between 105 and 110 degrees Fahrenheit, to identify the root cause, and to initiate improvements to the facility's processes and procedures regarding ensuring that water temperatures are appropriately maintained in the facility, the facility has a plan in place when water temperatures are mot maintained and to ensure that the system responsible for water temperatures has routine maintenance. Interviews were conducted with 15 staff members between May 31, 2025 and June 2, 2025 and Facility staff were able to confirm education was provided on the appropriate water temperature range; to use a thermometer to test the water prior to usage; notify maintenance and/or Nursing Home Administrator if water temperatures are too high and showering was currently suspended. Review of facility documentation of hot water temperatures revealed the facility is currently monitoring the temperature of the hot water. Following the verification of the immediate action plan the Immediate Jeopardy was lifted on June 2, 2025 at 3:58 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 205.63 (c) Plumbing & Piping Systems-Hot Water Outlets 28 Pa. Code 211.10 (d) Resident Care Policies 28 Pa. Code 211.12 (d) (1)(2)(5) Nursing Services

Based on facility policy and procedure review, clinical record review, staff interviews, facility documentation review and observations, it was determined the facility failed to enact interventions to contain and mitigate the spread of COVID-19 by ensuring staff and visitors were thoroughly screened, or that residents and staff were cohorted per COVID-19 status, and that proper PPE was utilized during the care for these residents. These failures in proper infection control practices had the potential to affect all residents in the facility through the development and transmission of COVID-19 and other communicable diseases. It was determined the provider's non-compliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm, impairment or death to residents for four of 15 residents reviewed (R1, R2, R3, and R4) and four of four units in the facility (2 long hall, ACU, 3 long hall and 3 short hall). The Immediate Jeopardy was related to §480.80 Infection Control. Findings include: The DOH 2020 - PAHAN - 492 - 4-3-ALT Alert: Universal Masking of Healthcare Workers and Staff in Congregate Care Settings, dated April 3, 2020, revealed that minimizing transmission of COVID-19 into and within health care facilities and congregate care facilities is critical. Universal Masking: As the supply chain permits, continue to use Recommended PPE (personal Protective Equipment N095 respirator or higher, gown, gloves, and eye protection) for confirmed COVID-19 cases and aerosol generating procedures. Consider the utility of creating a designated COVID-19 unit, creating a separate area of the building or a designated unit with the plan to move COVID-19 positive residents there upon diagnosis, may be an option in some facilities. If employed, this strategy must be used in conjunction with maintaining the original unit under all precautions; many residents of that unit might already be COVID-positive. The DOH 2020 - PAHAN - 496 - 4-14-ALT Advisory: Universal Message Regarding Cohorting of Residents in Skilled Nursing Facilities, dated April 14, 2020, revealed that cohorting of residents with COVID-19 in dedicated units within skilled nursing facilities can be an effective transmission prevention strategy, but it must be done deliberately to be effective. Once COVID-19 is identified in a nursing care facility, there are three types of residents to consider: Cases: Those with confirmed or probable COVID-19. This includes residents who were exposed to COVID-19 and are exhibiting symptoms consistent with COVID-19 but have not yet been tested or will not be tested , Exposed: Those who have been exposed to COVID-19 but are not yet exhibiting symptoms, and Unexposed: Those who are not known to have been exposed to COVID-19. Cohorting decisions should consider all three groups of residents, with the first priority being to restrict the mixing of residents who are cases or are exposed, with those who are thought to be unexposed. Cohorting decisions should consider all three groups of residents. The primary goal of cohorting is to restrict mixing of residents who are cases or are exposed with those who are thought to be unexposed. Separating cases from exposed residents is a secondary goal of cohorting. Older adults with COVID-19 may not show typical symptoms such as fever or respiratory symptoms. With regard to moving residents and cohorting residents, it is imperative that facilities follow the guidance in PA-HAN 492. Consider all residents in units with COVID-19 cases as exposed and potentially infectious. Recent information about COVID-19 spread in Long Term Care Facilities (LTCF) shows about half of residents testing positive for COVID-19 are not symptomatic. Spread of [MEDICAL CONDITION] could have been occurring undetected long before a positive test is reported. The first positive COVID-19 resident is identified in a unit where there are also other residents with possible symptoms, or several positive residents are identified in the same unit within a few days. This suggests transmission has likely occurred to many others in the unit. Moving the positive residents to a dedicated unit, even a unit that already has several positive COVID-19 residents, has minimal benefit. All residents in the original unit must be treated as infectious and cared for using full personal protective equipment (PPE - gown, gloves, mask, and eye protection) per PA-HAN 492. In most facilities using this process, newly identified symptomatic residents present over the following week, and moving residents becomes no longer feasible. Urgent room changes may negatively impact the health and well-being of the residents and should occur when benefits outweigh the risk. Review of the facility's policy and procedure titled, Protocol for COVID-19, undated, revealed the following: Admission: The facility will continue to accept admissions. As room availability allows, all new residents will be kept isolated for a two-week period. Surveillance: All residents are to have a temperature check and a pulse oximetry check each shift; any abnormalities are to be reported to the physician. Testing: Residents are tested based on any single or combination of the following, temperature greater than 100.4 Farenheit (F), low pulse oximetry, shortness of breath, physician order. Suspected Cases: In the event a resident is suspected to be positive for COVID-19, immediately implement droplet precautions, and notify the physician for further orders. Obtain physician's orders [REDACTED]. Cohorting of residents suspected or having tested positive for COVID-19: The designated COVID-19 unit will be on the first floor. When possible, all residents that are suspected of, or who have tested positive. Dedicated staff will be utilized when practical, care will be provided to Residents without COVID prior to providing care to COVID positive residents. Droplet precautions will be implemented, PPE will be available on covered carts outside of rooms. Signs will be placed on resident room doors, to alert staff of the required precautions. Review of Facility listing of employees who became infected with COVID-19 revealed Licensed Nursing Employee E6 started with symptoms on April 8, 2020, and was tested on [DATE]. Review of documentation provided to the facility by the(NAME)County health department revealed the Licensed Nursing employee E6 was tested for COVID-19 on April 10, 2020 and had a positive result that was reported to the facility on [DATE]. Interview with Licensed Nursing Employee E6 on April 9, 2020 at 2:30 p.m. revealed that she first became sick on April 8, 2020, and that was her last day of work, on April 10, 2020, she went to the hospital and they gave her a paper stating she was to quarantine for 14 days due to COVID-19. She took this paper to the facility the same day and handed it to the DON, ADON, and an employee from HR and they told her to go home and not to come back to work for the 14 days. Review of Electronic Event report submitted to the state agency on April 22, 2020, revealed Licensed Nursing Employee E6 reported to the facility on [DATE], that she was positive for COVID-19. She stated she had a cough and should be tested . The follow-up actions listed were to continue screening measures that were currently in place for staff and residents and consider the 3S unit as a possible exposed unit and limit staff to that area as needed only. Continue all infection prevention practices in place. Review of the timecard and schedules for Licensed Nursing Employee E6 from April 2020, revealed she had worked on April 8, 2020, the date of the onset of symptoms, from 2:50 p.m. to 10:46 p.m. on the third floor. On April 7, 2020, she worked a double shift from 2:44 p.m. until 7:16 a.m. the following morning on April 8, 2020. On the 3 p.m-11 p.m. shift she was on the 3rd floor and on the 11 p.m.-7 a.m. shift she was on the second floor. On April 6, 2020, she worked from 2:46 p.m. until 10:45 p.m. on the third floor. Interview with Employees E10, E11, E12, E13 and E14 on June 10, 2020, between 10:30 a.m. and 11:30 a.m. all confirmed they had not been informed by the facility that a co-worker had tested positive for COVID-19 in April, and they had not been interviewed concerning if they had any contact with any staff members or not related to COVID-19. Interview with the Director of Nursing (DON) on April 10, 2020, at 11:42 a.m., confirmed that Licensed Nursing Employee E6 had dropped off a document from the hospital signed by a physician, stating she was not to work for 14 days due to COVID-19. The DON further stated Licensed Nursing Employee E6 was tested at the hospital on April 10, 2020, and there was no follow up investigation to determine the extent to which Employee E6 could have possibly spread COVID-19 through the facility. Further interview with the DON revealed there was no documented evidence that employees, residents or resident responsible parties were notified that there could have been a possible exposure to COVID-19 by coming in close contact with an employee who had tested positive for COVID-19. An interview with the DON on June 11, 2020, at 3:32 p.m., revealed that the Third Floor Short Hall Unit rooms 315 to 322 was the designated COVID Unit in the facility. The unit was tarped, and zip walls were placed on April 19, 2020. A review of Resident R1's progress notes dated April 13, 2020, at 8:00 p.m., revealed that the Resident was transferred to the hospital due to abnormal blood work, the Resident was admitted to the hospital with [REDACTED]. A review of an event submitted by the facility on April 22, 2020, revealed that Resident R1 had tested positive for COVID-19 on April 17, 2020, while at the hospital. A review of Resident R1's clinical census, revealed that Resident R1 was readmitted to the facility on [DATE], into a room on a non-designated COVID unit. An interview with the DON on June 11, 2020, at 3:35 p.m., revealed that Resident R1 was placed on a non-designated COVID unit upon readmission to the facility on [DATE], despite Resident R1 being positive for COVID-19 due to the verbal information provided by the Infection Preventionist from the hospital that Resident R1 had been asymptomatic during the entire hospitalization . The DON confirmed that she did not check Resident R1's hospital records to confirm that the Resident had been asymptomatic during entire hospitalization . The DON also confirmed that Resident R1 was placed in a room with his previous roommate Resident R2 upon readmission to the facility. A review of Resident R2's clinical records, vital signs reports, and progress notes revealed that the Resident had not had any symptoms related to COVID-19. Resident R2 was not tested for COVID-19. A review of Resident R1's vital signs, revealed that Resident R1 had a temperature of 99.4 degrees Fahrenheit (normal range 97-99) on May 2, 2020, at 1:46 a.m., and 100.5 May 2, 2020, at 8:15 a.m. No documented evidence that any additional precaution was immediately implemented upon identifying Resident R1's symptoms of an increased temperature. A review of Resident R1's clinical census, revealed that the Resident was transferred to the COVID unit on May 5, 2020. A review of Resident R3's clinical census revealed that the Resident was in a room on a non-designated COVID unit. A review of Resident R3's vital signs report revealed that the Resident had a temperature of 100.3 F on April 22, 2020, at 7:41 p.m., 100.0 F on April 23, 2020, at 12:50 p.m., 103.3 F on April 26, 2020 at 4:10 a.m., and 100. 2F on April 26, 2020, at 4:36 p.m. A review of Resident R3's progress notes dated April 26, 2020, at 4:10 a.m., revealed that the Resident was experiencing chills and slight shortness of breath (SOB). A review of Resident R3's progress notes dated April 27, 2020, at 4:28 p.m., revealed that the Resident had no pain but had a fever, SOB, and temperature in the last seven days with use of oxygen due to COVID exposure. There was no documented evidence that an additional precaution was immediately implemented upon identifying Resident R3's symptoms on April 22, 2020. An interview with the DON on June 11, 2020, at 4:00 p.m., revealed that Resident R3 was not tested for COVID because the Resident had refused. The facility was unable to provide documented evidence that the Resident had refused COVID test. A review of Resident R3's April and May 2020, physician's orders [REDACTED]. A review of Resident R3's clinical census, revealed that Resident R3 was transferred to a non-designated COVID unit and placed in a room with Resident R2, a resident who was asymptomatic and never displayed symptoms while at the facility, on May 5, 2020, only 8 days after exhibiting symptoms related to COVID-19. A review of Resident R4's clinical census, revealed that the Resident was in a room on a non-designated COVID unit. A review of Resident R4's nursing progress notes dated April 16, 2020, at 12:30 p.m., revealed that the Resident was confused and exit seeking. Further review of the same progress notes revealed that the Resident had tried to get on the elevators and go down the stairs behind staff. The resident has a Wanderguard in place (a device that alarms/sounds when the person attempts to leave the unit where the egress doors are also alarmed). A review of Resident R4's progress notes dated April 17, 2020, at 9:03 p.m., revealed that the Resident was administered [MEDICATION NAME] (medication for fever and pain) 325 mg two tablets for a temperature of 100.7 F. A review of Resident R4's progress notes dated April 19, 2020, at 5:09 p.m., revealed that the Resident was swabbed for COVID on April 17, 2020, due to fever and the swab was sent on April 19, 2020. Resident remained free of any further respiratory symptoms, all COVID precautions remain in place for all residents and staff. A review of Resident R4's progress notes dated April 22, 2020, at 7:26 a.m., revealed that the resident's son was notified of the positive COVID results. A review of Resident R4's clinical census, revealed that the Resident was transferred to the designated COVID unit on April 19, 2020, two days after symptoms related to COVID were identified. An interview with the DON on June 11, 2020, at 4:10 p.m., revealed that Resident R4 was not moved to the designated COVID unit April 19, 2020, because the facility was not sure if the Resident needed to move. The DON stated, I guess we should have moved him sooner. A facility tour with the Assistant Director of Nursing on June 9, 2020, at 8:40 a.m., revealed that the facility currently has two residents positive for COVID. Both Residents were in the same room. The room had a neon pink signage to alert staff regarding precautions needed upon entering the room. The door of the room was wide open. An observation on June 9, 2020, at 10:10 a.m., revealed Resident R4 entered the room of the COVID residents by self-propelling his wheelchair. Resident R4 was observed opening the drawers located between the bed of Resident R5 and R6 inside the room. Two staff, Employee E15, and Employee E16 were observed walking in the hallway passing the room while Resident R4 was inside the room of the COVID positive Residents. At 10:15 a.m., Employee E4, entered the room of the COVID positive residents only wearing a surgical facemask. Employee E4 took Resident R4 out of the COVID positive room and wheeled the Resident back to his/her room located in front of the COVID positive room. An interview with Employee E4 on June 9, 2020, at 1:00 p.m., revealed that she was aware of the PPE that she should have been wearing when entering a COVID positive room but since she did not do direct care, then it was not necessary to wear the full PPE. An observation on June 11, 2020, at 6:30 p.m., revealed the room of the residents positive for COVID was wide open. Resident R5 was observed naked from the waist up. At 6:31 p.m., Employee E17 and Employee E18 were observed entering the room of the COVID positive Residents only with a surgical mask and gloves. Both employees stayed inside the room. At 6:33 p.m., Employee E17 went out of the room, opened the PPE box drawer with a glove on, grabbed an isolation gown, and closed the door. Both employees came out of the COVID positive room at 6:43 p.m. wearing a surgical mask. An interview with Employee E17, and E18 on June 11, 2020, at 6:44 p.m., confirmed that complete PPE should have been worn upon entering a COVID positive room. Employee E18 stated that she did not wear a respirator mask (N-95) because the mask that was provided by the facility was too small for her. Review of facility policy and procedure titles Protocol for COVID-19, undated, revealed all employees, physician, and any other persons entering the facility must complete the COVID-19 questionnaire and have temperature taken prior to the start of each shift, if abnormalities are found, the employee, physician, or other person are required to leave the facility, and notify their physician, and follow physician recommendations. Employees that miss work, or are sent home, due to suspected COVID-19 must have a physician's note to return to work. Upon entrance to the facility by this surveyor on June 10, 2020, at 8:30 a.m., Employee E5 used an infrared thermometer to take a temperature by pointing it at my forehead and got 95.9 degrees Farenheit (F) (normal range 97-99 degrees F). Employee E5 documented the temperature on the questionnaire titled, Information for Essential Visitors, and allowed me to enter the facility. Review of the Information for Essential Visitors completed in April 2020, revealed two temperatures were recorded as 94.8 degrees Fahrenheit, four temperatures were recorded between 95.0 and 95.3 degrees Fahrenheit and three questionnaires were blank for temperature and Pulse Oximeter (measures the proportion of [MEDICATION NAME] hemoglobin in the blood). Review of the Information for Essential Visitors completed in June of 2020, revealed two temperatures were recorded as 94.6 and 94.8 respectively and there were 12 temperatures recorded between 95.0 and 95.9. Review of the manufacture's information for the thermometer in use provided by the facility revealed the thermometer has a laboratory accuracy of +/- 0.4 degrees Fahrenheit. Interview with Employee E5 on June 10, 2020, at approximately 11:00 a.m. revealed she had no medical background or training. Employee E5 stated she had no formal training from the facility and was handed the thermometer and told to fill out the Information for Essential Visitor Form for everyone visitor and vendor that walks through the door before they go into the facility. If they have a temperature above 100.4 degrees Fahrenheit, she was to report that to the Director of Nursing. She stated she was never educated about the normal range of a temperature or what to do if the temperature was low. Interview with the Director of Nursing on June 10, 2020, at 2:45 p.m. confirmed there was no documented evidence that Employee E5 had received formal training how to screen visitors before entering the facility. Further interview with the DON revealed there was no member of the staff assigned to audit the Information for Essential Visitor forms to ensure accuracy and completeness. An immediate jeopardy situation was identified and the Nursing Home Administrator and the Director of Nursing were notified on June 11, 2020, at 6:50 p.m. for the facilities failure to ensure the proper surveillance and cohorting of residents and staff, and the proper utilization of PPE, to control and potentially mitigate the spread of Covid-19 through the facility. The facility submitted and completed an immediate action plan which included educating all nursing staff on appropriate surveillance and cohorting of residents that are showing signs and symptoms of COVID-19 and to promptly cohort the residents as soon as they are exhibiting signs and symptoms of COVID-19. The facility staff were immediately educated on the proper use of PPE for residents exposed to COVID-19. The facility will also assess all resident to determine that they are cohort correctly and are currently not exhibiting signs and symptoms of COVID-19. At the beginning of all other staffs shift they will be educated on the red, yellow, & green zones and donning and doffing of proper PPE. The staff that is working in the red and yellow zones will don full PPE including N95 face mask. The staff will be cohort correctly to prevent the potential spread of COVID-19. The facility will attempt to have staff work on the same zone and not cross over to another zone as per PPHN 509 provided they change all their PPE and perform hand hygiene when going from one zone to another. The Administrator or designee will do daily audit of all residents to ensure anyone who is displaying signs and symptoms of COVID-19 is immediately cohorted correctly and that staff is wearing the correct PPE. There will also be a daily audit to ensure that all staff were appropriately screened and are not exhibiting signs and symptoms of COVID-19 and to ensure that the staff are cohorted correctly. This action plan was accepted June 11, 2020, at 11:57 p.m. On June 12, 2020, a review of audits, documentation of completed employee education, observations of staff providing care to COVID-19 positive and exposed residents and interviews with 18 staff member revealed the facility had completed the interventions developed for the action plan. The Immediate Jeopardy was lifted on June 12, 2020, at 4:28 p.m. after confirmation the immediate action plan was implemented, and the Nursing Home Administrator was informed the residents were no longer in Immediate Jeopardy. 42 CFR 483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review, it was determined that the facility failed to provide appropriate interventions for the prevention of pressure ulcers and failed to timely identify a pressure ulcer resulting in actual harm to Resident CL5, who developed an unstageable pressure ulcer to the sacrum for one of 11 residents reviewed (Resident CL5). Findings include: Review of Resident CL5's clinical record revealed the resident was admitted to the facility on [DATE] after sustaining a fall and a subsequent right femur fracture which required surgical repair. Review of Resident CL5's Admission Minimum Data Set (MDS - periodic assessment of resident needs) dated August 20, 2019 revealed Resident CL5 had a Brief Interview for Mental Status Score of 8 indicating moderately impaired cognition, was frequently incontinent of bowel and bladder, and required extensive assistance from two staff members to reposition in bed. Further review of Resident CL5's Admission MDS also revealed the resident was at risk for developing pressure ulcers. Review of Resident CL5's Physical Therapy Evaluation and Plan of Treatment dated August 13, 2019 identified the resident as needing moderate assistance for repositioning in bed. Review of Resident CL5's care plan dated August 13, 2019 identified the resident as at risk for skin breakdown related to immobility with interventions including keep skin clean and dry, provide a pressure reducing mattress/air mattress when available and check the function every shift, and provide a well balanced diet. There were no interventions in place on the resident's risk for impaired skin breakdown addressing the resident's immobility and need for assistance with repositioning. Review of Resident CL5's August 2019 Treatment Administration Record (TAR) revealed staff were documenting applying barrier cream to the resident's buttocks every shift starting on August 13, 2019. Review of Resident CL5's admission assessment from August 13, 2019 identified the only skin concern as the resident's surgical incision to the right hip. Review of Resident CL5's weekly skin assessment from August 20, 2019 identified no new skin concerns. Review of Resident CL5's progress notes revealed a note dated August 26, 2019 which revealed Resident CL5 was now noted with unstageable sacral wound measuring 3cm ((centimeters)) x 2.5cm x 0.1 cm with 100% slough ((separation of dead tissue from living tissue, yellow, tan, gray, green or brown)) noted at wound base. No drainage or odor noted. No complaint of pain at wound site. (Physician) and family aware. New orders noted. Air mattress to bed when available. Cleanse wound with (normal saline) apply [MED] (([MEDICATION NAME] agent)) and cover with dry dressing (daily), consult with wound care team, dietary consult. The resident's care plan dated August 13, 2019 indicated providing an air mattress when available, however 13 days later, on August 26, there was no air mattress in place and new orders for an air mattress were written on August 26, 2019. Further review of Resident CL5's care plan revealed that the resident's plan of care for risk for impaired skin integrity was updated on August 26, 2019, the same day the sacral wound was discovered, with the intervention to encourage the resident to be out of bed during different intervals during the day and to encourage the resident to turn and reposition self every 2 hours. Prior to discovery of the sacral wound no interventions for repositioning were in place, despite Physical Therapy assessment which identified the resident as needing moderate assistance for repositioning in bed, and the MDS dated [DATE] noting the resident's frequent incontinence of bowel and bladder, and that the resident required extensive assistance from two staff members to reposition in bed. The facility failed to provide appropriate interventions, including turning and repositioning, to prevent pressure ulcers from developing for Resident CL5, who was documented as needing moderate assisatance to extensive assistance with two staff members for bed mobility, and who was identified as being at risk for skin impairment due to immobility and frequent incontinence. The air mattress noted to be necesary on the care plan dated August 13, 2019 was not in place and was ordered again on August 26, 2019 when the unstagebale sacral wound was discovered, 13 days later. The facility also failed to identify and treat Resident CL5's sacral pressure ulcer before it became unstageable, even though staff documentation showed the application of barrier cream to the resident's buttocks area three times daily. This resulted in actual harm to Resident CL5 who developed an unstageable pressure ulcer to the sacrum. The above information was conveyed to the Nursing Home Administrator and Director of Nursing on October 2, 2019 at approximately 3:15 p.m. 28 Pa. Code: 201.14(a) Responsibility of licensee Previously cited 2/13/18, 8/28/18 28 Pa. Code: 201.18(b)(1) Management Previously cited 8/28/18, 10/19/18, 2/22/19 28 Pa. Code: 211.5(f) Clinical records Previously cited 2/22/19, 12/7/18, 10/19/18, 8/28/18, 2/13/18, 10/27/17 28 Pa. Code: 211.10(c) Resident care policies Previously cited 3/15/18, 8/28/18, 10/19/18, 10/27/17 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 2/22/19, 8/28/18, 10/19/18, 4/16/18, 3/15/18, 2/13/18, 10/27/17, 10/5/17

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to ensure one of 5 residents reviewed was free of accident hazards, which resulted in actual harm to Resident #23 sustaining a fall, requiring transfer to the hospital. Findings include: Review of facility policy and procedure titled, Accidents and Incidents last revised on (MONTH) 1, 2011, indicated, the facility strives to ensure that residents/patients, visitors, and/or volunteers will not experience undue discomfort and/or have their health and safety placed in jeopardy due to an unusual occurrence (accident/incident). The facility defines an accident/incident as an event, occurrence, or happening that may produce an actual or potential undesirable outcome. Review of the facility policy and procedure titled, Proper Technique When Providing Personal Care, (undated) included areas such as skin care, bed bath, shower and mouth care. The nursing assistant is to gather all equipment prior to providing care and ensure bed is in low position when resident is unattended. Review of Resident #23's [DIAGNOSES REDACTED]., [MEDICAL CONDITION] ([MEDICAL CONDITION] - poor circulation of the extremities), anxiety disorder (intense,excessive and persistent worry and fear about everyday situations), Major [MEDICAL CONDITION] (major loss of interest in pleasurable activities, characterized by change in sleep patterns, appetite and or daily routine) and spinal stenosis (a narrowing of the spinal canal). Review of Resident #23's quarterly Minimum Data Set assessment (MDS - periodic assessment of resident needs) dated (MONTH) 21, (YEAR), revealed the resident had a Brief Interview for Mental Status (BIMS) of 11 out of 15 which reflects a moderately impaired cognitive status. The resident required extensive assistance for bed mobility of two persons, extensive assistance for transfers, toileting and personal hygiene of one person and total dependence for dressing with the assistance of one person. Resident #23 was identified as requiring the use of a wheelchair for locomotion on and off the nursing unit. Review of Resident #23's care plan initiated on (MONTH) 15, (YEAR), identified the resident's physical functioning deficit related to mobility and self care impairment requiring extensive assistance of two with bed mobility, transfers, toileting and extensive assistance of one for dressing. Further review of the resident's care plan indicated the risk for falls related to the history of falls, use of [MEDICAL CONDITION] medication and non-ambulatory status. The interventions revealed the call light and/or personal items should be available and in easy reach or provide a reacher (a device that enables a disabled or elderly person to pick up objects that are difficult to reach), to keep environment well lit and free of clutter and to observe for side effects of medications. Review of the facility's investigation documentation dated (MONTH) 4, (YEAR), revealed the Director of Nursing, Employee E13 stated, At (YEAR) (8:15 p.m.), I heard overhead page, 'Supervisor to the 3rd floor stat (immediate).' Upon arriving to 3rd floor, in Resident #23's room. I found resident, lying on the floor next to the wall by the door with her head facing night stand. resident sustained [REDACTED]. RN (Registered Nurse) assessment done, vital signs within normal limits, neurological checks also within normal limits and resident was able to move all extremities. Resident stated, 'I don't know what happened. I just fell .' Physician and responsible party were notified. 911 (Emergency Medical Services) was called and resident was transferred to hospital emergency room for evaluation and treatment. Environmental room check performed. Bed was found in high position. Nursing assistant stated, 'I was in the bathroom wetting a wash cloth.' Nursing assistant had left the resident unattended. Further review of the facility investigation documentation dated (MONTH) 4, (YEAR), revealed Nursing Assistant, Employee E8 stated, (Resident #23) was laying flat on her back in her bed with the bed high up. The resident has a tendency of leaving her bed high up. I went into her bathroom to wet the washcloths when suddenly I heard a hard bump. I yelled for help and the nurses came. Review of the written witness statement provided by the Director of Nursing, Employee E13, dated (MONTH) 4, (YEAR), revealed, environmental room check performed. Bed was found in high position, NA (nursing assistant) stated I was in the bathroom wetting a washcloth . NA left resident unattended. Further review of the facility investigation revealed resident, received laceration to the apex (highest point) and back of the head. Resident remained on the floor until paramedics arrived. Review of the documentation submitted by the facility on (MONTH) 5, (YEAR), noted that, pressure was applied by charge nurse and resident remained on floor until 911 arrived at which time applied to affected areas of head. The physican was notified and resident was transferred to the hospital. Further review of documentation submitted revealed that when Nursing Assistant, Employee E8 was asked why the bed was in the high position, nursing assistant responded, She plays with the controls. The Director of Nursing, Employee E13, also asked Nursing Assistant, Employee E8, why she did not have the supplies prepared to provide care, Employee E8 did not respond. Review of the hospital discharge instructions dated (MONTH) 4, (YEAR), at 10:07 p.m. confirmed the [DIAGNOSES REDACTED]. Review of the hospital Transition of Care, documentation dated (MONTH) 4, (YEAR), at 10:18 p.m. confirmed that the resident required twenty-one (21) staples to the right posterior scalp. Observation and interview conducted on (MONTH) 18, (YEAR), at 12:20 p.m. with Resident #23 revealed that when Resident #23 was asked if she was able to move her bed up and down using the bed control, she was able to raise the head of the bed up and down, only. Resident was unable to understand surveyor when asked to lower and raise the whole bed. On all five days of the survey, observations of the resident's bed height was approximately sixteen (16) inches off the floor. An interview with the Director of Nursing on (MONTH) 19, (YEAR), at 1:30 p.m. confirmed that the nursing assistant did not follow facility policy by leaving the resident's bed in a high position and left the resident unattended while wetting a washcloth in the bathroom to provide bedtime care. The facility failed to ensure that Resident #23 was free of accidents which resulted in actual harm to Resident #23 sustaining a fall from bed, requiring a transfer to the hospital via emergency medical services and [DIAGNOSES REDACTED]. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 8/28/18, 2/13/18, 2/27/17 28 Pa. Code 201.18(b)(1) Management Previously cited 8/28/18, 2/13/18, 1/19/18, 2/27/17 28 Pa. Code 201.18(b)(3) Management Previously cited 2/13/18, 10/27/17, 2/27/17 28 Pa. Code 201.18(e)(1) Management Previously cited 2/13/18, 1/19/18, 10/27/17 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.5(f) Clinical records Previously cited 8/28/18, 2/13/18, 10/27/17, 10/5/17, 2/27/17 28 Pa. Code 211.10(d) Resident care policies Previously cited 8/28/18, 2/27/17 28 Pa. Code 211.11(d) Resident care plan Previously cited 2/13/18 28 Pa. Code 211.12(c) Nursing Services Previously cited 4/16/18, 2/13/18, 2/27/17 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 8/28/18, 4/16/18, 3/15/18, 2/13/18, 10/27/17, 10/5/17, 2/27/17 28 Pa. Code 211.12(d)(5) Nursing Services Previously cited 8/28/18, 4/16/18, 3/15/18, 2/13/18, 10/27/17, 10/5/17, 2/27/17

Based on review of clinical records, facility investigation reports and staff interview, it was determined that the facility failed to provide adequate interventions and supervision to prevent accidents for one of 19 residents reviewed, resulting in actual harm to the resident (Resident CL5). Findings include: Review of Resident CL5's [DIAGNOSES REDACTED]. (in this resident's case affecting swallowing) and a history of a pulmonary emboli (a blockage in one of the arteries of the lungs). Review of Resident CL5's clinical record revealed that Resident CL5 was receiving speech therapy from [DATE], until February 3, 2016, with the goal to safely provide hydration and nutrition. Further review of Resident CL5's speech therapy notes and discharge summary dated [DATE], revealed that the physician's referral to speech therapy was due to, a decline in swallowing function due to Alzheimer's disease, exacerbated GERD, esophageal dysphagia, and a recent increase in coughing. Review of Resident CL5's [DATE] physician's orders [REDACTED]. Review of Resident CL5's Minimum Data Set assessment (MDS- a periodic assessment of resident care needs) completed on [DATE], revealed a BIMS (a Brief Interview for Mental Status - structured cognitive test used to determine a residents cognitive status) score of four out of fifteen, assessing the resident with severe cognitive impairment. Review of CL5's behavioral plan of care dated [DATE], revealed that Resident CL5 had behaviors that included, but was not limited to, stealing food. Review of CL5's chewing difficulty plan of care dated [DATE], through [DATE], revealed that due to the resident being edentulous (lack of teeth), and having dysphagia and Alzheimer's disease, a goal was in place to prevent Resident CL5 from having choking episodes. The care plan listed interventions included a, chin tuck while drinking thin liquids, no straw with fluids, and proper positioning at meals. Review of CL5's, swallowing difficulty plan of care listed interventions for nursing to, monitor resident for signs and symptoms of aspiration (the act of inhaling a foreign material) and for, assistance with meals and to observe for altered ability to swallow. Review of the facility documentation revealed that on [DATE], at approximately 7:15 pm. Resident CL5 was seated in the dining room with two other residents at the table. Of the two residents at the table with Resident CL5, one was given a peanut butter and jelly sandwich and the other a milkshake snack. Resident CL5 was not given a snack. Further review of the facility documentation revealed that the licensed employee left the dining room for, five minutes and returned to find Resident CL5 choking on the other resident's peanut butter and jelly sandwich. The Heimlich Maneuver (a procedure for dislodging an obstruction from a person's windpipe in which a sudden strong pressure is applied on the abdomen, between the navel and the rib cage) and a finger sweep (using the finger to sweep through the mouth in an attempt to remove food) produced a portion of the sandwich. Cardio-Pulmonary Resuscitation (CPR - a medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation and breathing) was initiated but stopped due to a Do Not Resuscitate order, (a legal order withhold cardiopulmonary resuscitation or advanced cardiac life support in respect of the wishes of a resident in case the heart was to stop or the resident was to stop breathing) and subsequently Resident CL5 expired. The facility investigation revealed that Resident CL5's cause of death was due to, aspiration. An interview on [DATE], at approximately 2:00 p.m. with the Assistant Director of Nursing and the Nursing Home Administrator revealed that all residents were screened by speech therapy, and that the staff have received education that include residents with a modified textured diet are to be seated in the dining room and supervised. The facility failed to ensure that Resident CL5 with a [DIAGNOSES REDACTED]. 42 CFR 483.25(h) Free of Accident hazards/supervision/Devices Previously cited [DATE] 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 201.18(b)(1) Management Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 211.12(c) Nursing services Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 211.12(d)(1) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 211.12(d)(5) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE], [DATE]

Based on observation, review of facility policies, review of clinical records and staff interviews, it was determined that the facility failed to provide emergency treatment and physician notification in a timely manner to provide one resident with needed care and services resulting in a delayed transfer to the hospital for the resident who sustained actual harm for one of 19 residents reviewed (Resident F10). The facility also failed to follow the physician's orders regarding the completion of neurological checks for three of 19 residents reviewed (Residents B1, D3, F10) and the completion of Accu-Cheks for one of 19 residents reviewed (Resident CL4). Findings include: Review of the facility policy entitled, Notification of Change in Resident Health Status, last reviewed on November 11, 2015, indicated that the center will consult the resident's physician, nurse practitioner or physician assistant, and if known notify the resident's legal representative or an interested family member when there is: (A) An accident which results in injury and has the potential for requiring physician intervention. Notification: Within 24 hours from the time an assessment has been made indicating there may be a potential for physician intervention. (B) Acute illness or a significant change in the resident's physical, mental, or psychosocial status (i.e. deterioration in health, mental, psychosocial status in either life-threatening conditions or clinical complications.) Criteria: Clinical complications are such things as onset or recurrent periods of [MEDICAL CONDITION] or persistent decline in psychosocial status. Appropriate notification time: immediate. Review of Resident F10's [DIAGNOSES REDACTED]., [MEDICAL CONDITION] ([MEDICAL CONDITION] - involves the enlargement of the prostate gland), [MEDICAL CONDITION] (potassium level in your blood that's higher than normal), Major [MEDICAL CONDITION] (major loss of interest in pleasurable activities, characterized by change in sleep patterns, appetite and or daily routine), Diabetes Mellitus (DM-failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment), [MEDICAL CONDITION] (a condition in which there are high levels of fat particles in the blood), blind, hypertension (high blood pressure) and nocturia (the need to wake and pass urine at night). Review of a nurses' note dated July 1, 2016, at 2:29 p.m. revealed, resident is having a decreased appetite, refused to get out of bed today, complaining of pain. A nurses' note dated July 1, 2016, at 9:46 p.m. revealed, resident stated he did not want to come out of his room for dinner, because he was not eating, not up to it. Review of a nurses' progress note dated July 2, 2016, revealed, resident lethargic (sluggish) this shift, no by mouth intake with food, minimal fluid PO (oral) intake, would spit water/juice back out, had to crush meds that could be, difficulty swallowing medications. VSS (vital signs) 22 heart rate 58 apical regular, roommate stated he hasn't eaten all day and last night. Attempted to give snack, resident refused. A nurses' note dated July 3, 2016, at 10:16 a.m. revealed, resident in bed this shift. Very lethargic, no food or fluid intake this shift. Refused medications and meals. Minimal response to verbal stimulation noted. Will continue to monitor. Review of a nurses' change in condition note dated July 3, 2016, at 7:20 p.m. revealed, resident has not been eating or drinking, change in mental status. The last 3 days staff observed resident has had a decline in eating and drinking, refuses meals, does take fluids by mouth when given, will not get out of bed or walk as he usually does. Resident also complains of chest pain when asked about pain. Supervisor assessed resident, who was having chest pain and snorting while breathing. Vital signs were obtained and agreed that resident needed to be sent to emergency room for evaluation. Review of the next nursing note completed by the nursing supervisor dated July 3, 2016, at 10:05 p.m. revealed, resident was admitted to hospital with left rib fracture, a left scapular fracture (the shoulder blade that connects the humerus (upper arm bone) with the clavicle (collar bone)), a pneumothorax (a collapsed lung) and [MEDICAL CONDITION] (a condition in which the body is deprived of adequate oxygen supply to the tissue level). Review of the facility investigation dated July 3, 2016, into the incident of Resident F10's poor oral intake over the last three days and complaints of chest pain, revealed an interview with the Licensed Nursing Supervisor which indicated that after reviewing a nurses' note on July 3, 2016, at approximately 4:30 p.m. which related that the resident had not eaten, had not had anything to drink or taken his medication today and was minimal responsive to stimuli, This was a concern, nobody had called the doctor. The interview note proceeded to indicate that the Licensed Nursing Supervisor assessed the resident, who was in bed holding his left arm to his chest. The resident indicated that he had pain and agreed to go to the hospital. The resident was also assessed, by the Licensed Nursing Supervisor, snorting (often associated with a blockage in the airway passage) and at that time the process to send the resident to the emergency room was initiated. The facility failed to timely assess and provide appropriate treatment for [REDACTED]. Review of the facility policy, Neurological Checks, dated December 1, 2015, revealed that neurological checks (the assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired) shall be performed following an unwitnessed fall or known head injury. Additionally, the policy indicated that neurological checks should be performed periodically for at least 72 hours. Review of Resident B1's nursing note for January 24, 2016, revealed an unwitnessed fall as the resident was observed on the fall mat by the bedside. Review of the neurological checks for this unwitnessed fall revealed that they were started on January 24, 2016, and stopped on January 25, 2016. An interview with the Director of Nursing (DON) on September 30, 2016, confirmed that the neurological checks were not completed according to the facility policy after an unwitnessed fall. Review of Resident D3's nursing notes for August 7, 2016, revealed an unwitnessed fall as the resident was found sitting on the floor in his bathroom. There was no evidence of any neurological checks performed after this fall. Further review of the nursing notes revealed that on August 26, 2016, the resident was found kneeling on the floor by his bed. Review of the neurological checks for this unwitnessed fall revealed that the checks were started on August 26, 2016, but were not completed for August 27 and August 28, 2016. An interview with the DON on September 29, 2016, at approximately 10:30 a.m. confirmed that the neurological checks for this resident after two unwitnessed falls were not completed according to the facility policy. Review of Resident CL4's closed clinical record revealed [DIAGNOSES REDACTED]. dated May 13, 2016, for Accu-Cheks (a medical device for determining the approximate concentration of glucose in the blood) every morning on Monday, Wednesday and Fridays and to call the attending physician if the blood glucose level is 150 milligrams/deciliter (mg/dl) or above. Review of Resident CL4's Medication Administration Record [REDACTED]. The Medication Administration Record [REDACTED]. Review of the MAR for September 2016 documented that the resident's Accu-Chek measurement result for date September 5, 2016, was above 150 mg/dl. There was no evidence in Resident CL4's closed clinical record that the facility followed the physician's order for notifying the physician of the abnormal results of Resident CL4's glucose check for the aforementioned dates. 42 CFR 483.25 Provide Care/Services For Highest Well Being Previously cited 09/11/14, 10/16/15 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 09/11/14, 10/09/14, 10/16/15 28 Pa. Code 201.18(b)(1) Management Previously cited 09/11/14, 10/16/15, 08/12/16 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.5(f) Clinical records Previously cited 09/11/14, 10/06/15, 08/23/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 09/11/14, 05/05/16, 08/23/16 28 Pa. Code 211.12(c) Nursing services Previously cited 09/11/14, 10/16/15, 05/05/16 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 09/11/14, 10/09/14, 03/02/15, 10/16/15, 05/05/16, 08/23/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 09/11/14, 10/09/14, 10/16/15, 05/05/16, 08/23/16

Based on clinical record review, staff interview, and facility policy review it was determined the facility failed to address significant changes in residents conditions timely for three of 24 residents (Residents B3, G7, A3 ) resulting in actual harm to two residents (Resident B3, G7). The facility failed to consistently address appropriate pain medication for one of 24 residents. (Resident A3). In addition, the facility failed to follow the facilities bowel protocol for two of 24 residents reviewed resulting in actual harm to three residents. (Residents D1 & I2). Findings include: Review of resident B3s [DIAGNOSES REDACTED]. Review of resident B3;s quarterly Minimum Data Set (MDS- periodic assessment of resident needs and status) dated December 19, 2013 revealed the resident had a Brief Interview for Mental Status score of 3 of 15 which indicates severe cognitive impairment. Review of resident B3s progress notes revealed an entry dated March 22, 2014 at 2:55 p.m. stating the resident had an unwitnessed fall in the shower room. The resident complained of right knee pain and unable to perform range of motion (ROM- the distance and direction a joint can move between the flexed position and the extended position) to the residents affected leg. The doctor was made aware and the resident was ordered to have an X-ray of both knees. Review of Resident B3 ' s the Radiology Report dated March 22, 2014 at 2:14 p.m. revealed there was no [MEDICAL CONDITION]. Further review of the progress notes revealed entries on March 23, 2014 at 6:35 a.m. and March 23, 2014 at 8:44 a.m. indicating the resident was resisting care. An entry dated March 23, 2014 at 9:18 revealed the resident continues to be resistive with care and expressed pain at the left knee and surrounding area. The resident was not in any pain at rest but was anxious and yelling with touch or movement. Further review of Resident B3's progress notes revealed an entry dated March 23, 2014 at 1:38 p.m. that the resident continued with severe pain with movement, indicating moderate pain at rest, facial expression tense, extremities tense, continues to be resistive with care. New order was given for x-rays of hip and pelvis and for PRN (as needed) [MEDICATION NAME] (Pain Reliever). Review of Resident B3's Radiology Report dated March 23, 2014 at 8:25 p.m. revealed the resident had a [MEDICAL CONDITION] femoral neck ([MEDICAL CONDITION]). Review of the progress notes revealed an entry dated March 23, 2014 at 11:00 p.m. that the result of the x-ray indicating the [MEDICAL CONDITION] were phoned to the medical doctor and no new orders were given at that time. As per the medical doctor the physician's assistant will be in tomorrow and would assess the resident then. Further review of Resident B3's progress notes revealed there was no indication that the physician's assistant was in to see the resident on March 24, 2013 as indicated they would be when the physician was called on March 23, 2014 at 11:00 p.m. Review of the physician progress notes [REDACTED]. A nursing note dated March 25, 2014 at 1:13 p.m. revealed the resident was sent to the hospital. Review of Resident B3's progress notes revealed an entry dated March 25, 2014 at 9:20 p.m. stating the resident was admitted to the hospital with [REDACTED]. Review of Resident B3's Activities of Daily Living (ADL-a measurement of the functional status of a person) report revealed on March 21, 2014 the resident was able to move around the unit independently with only setup help. After the fall on March 22, 2014 this activity did not occur for the resident and progress notes entered on March 23, 2014 at 8:44 a.m., March 23, 2014 at 11:00 p.m., March 24, 2014 at 6:21 a.m., March 24, 2014 at 2:49, p.m. March 25, 2014 at 6:37 a.m. all stated that the resident was in bed indicating a marked decrease in ADL function after the fall on March 22, 2014. Interview with the director of nursing (DON) on September 9, 2014 at approximately 11:00 a.m. revealed that Resident B3 was able to self-propel in a wheel chair around the unit and this is how he was able to get into the bathroom before the fall. After the fall on March 22, 2014 the resident had a decrease in ADLs, increase in pain and confusion, and had x-rays on March 23, 2014 showing that the resident had a [MEDICAL CONDITION] however it wasn't until March 25, 2014 that the resident was sent to the hospital for treatment Interview with the DON on September 10, 2014 at 10:00 a.m. confirmed a delay in treatment for [REDACTED]. Review of Resident G7's progress note dated April 20, 2014 at 2:52 p.m., indicated resident reported to staff that his right ankle had pain. On examination, the ankle and foot were swollen and the skin was red and purple. Resident G7 complained of pain while touching and raised area noted on foot. Resident reported that he bumped his foot a couple of days before. The physician was notified and was requested to do an x-ray that day, but the physician ordered ice to be applied and an x-ray for the next day. Progress note of April 20, 2014, at 5:40 p.m. revealed ice pack applied to ankle at resident's request. Review of x-ray of the right foot and ankle dated April 21, 2014, revealed soft tissue swelling, no acute fracture. The report indicated that if there are unexplained symptoms, follow-up radiography is suggested. Review of Resident G7 ' s progress note dated April 22, 2014, at 10:45 p.m. revealed right foot swollen and bruised. Resident is unable to bear weight on the right foot. Progress note indicated Tylenol was given for discomfort, but is not documented on the medication administration record. Progress note of April 23, 2014, at 6:40 a.m. indicated resident continued with right foot swollen. Tylenol administered on April 23, 2014 at 7:36 a.m. for leg pain. Review of progress note of April 25, 2014, at 11:50 a.m. revealed resident complained of excruciating pain of the right foot. Right ankle and foot were swollen and ecchymotic (discolored area of skin), red and warm to touch. New order was to send to the hospital for evaluation. Review of hospital records dated April 25, 2014, revealed non-displaced fractures of the third, fourth, and fifth metatarsals (foot bones) of the right foot and [MEDICAL CONDITION] distal fibula (ankle). Review of the clinical record revealed no follow up after April 22, 2014, when Resident G7 was unable to bear weight and the swelling continued, until April 25, 2014 resulting in a delay in evaluation and treatment and actual harm to the resident. This information was presented to the Director of Nursing on September 10, 2014, at approximately 3:00 p.m. Review of Resident A3's progress dated May 5, 2014 at 8:45 p.m., indicated resident was found on May 4, 2014 lying on left side on floor at the foot of her bed. Resident A3 reported that she hit her head. Resident was complaining of pain in left hip, groin and knee with increased pain when left leg was flexed (abnormal posturing of leg). The physician was notified and x-rays of the left hip, pelvis (a sturdy ring of bones that protects the delicate organs of the abdominopelvic cavity) and knee was ordered to be done the next morning (May 5, 2014). X-ray Company was called and x-rays were scheduled for morning. Progress note of May 4, 2014 at 9:45 p.m. revealed resident was status [REDACTED]. [MEDICATION NAME]-[MEDICATION NAME] (medications used for pain) 37.5-325 milligrams was administered with effectiveness. Review of Resident A3 ' s progress note dated May 5, 2014 at 8:30 a.m. revealed resident leaving unit with transportation accompanied with her two sons to her scheduled neurology appointment. Prior to resident leaving medications were administered, which resident refused by spitting them out. Review of Resident A3 ' s progress note dated May 5, 2014 at 12:36 p.m. revealed the resident returned to facility from neurology appointment. Resident assisted into bed with the assistance of two staff members. X-ray Company was in facility to take x-rays of the left pelvis, hip and knee as ordered. X-ray report revealed resident had a left femur fracture (longest, thickest, and strongest bone in the body. It extends from pelvis to top of knee). Physician was notified and gave order to send resident to hospital emergency room to be evaluated. Nurses' note dated May 5, 2014 at 2:57 p.m. stated transport arrived at 2:30 p.m. for hospital. Tylenol 650 milligrams for left hip pain was given with a pain score of 8 (Pain score 10 being the worse). Interview with the director of nursing (DON) on September 10, 2014 at 10:10 a.m. confirmed that x-rays should have been obtained prior to Resident A3 leaving building for a neurology appointment, resulting in a delay in evaluation for treatment to this resident after the fall on May 4, 2014 at 8:45 p.m. and the x-ray completed May 5 at 12:36 p.m. Review of Resident A3 ' s progress note dated May 5, 2014 at 7:11 p.m. resident returned from hospital. Son does not want mother to have surgery, and would like his mother placed on Hospice and made comfortable. [MEDICATION NAME] (medication used for moderate to severe pain) 5 milligrams was ordered every 4 hours when needed for pain. Nurses notes dated May 5, 2014 at 10:31 p.m. stated left foot was observed to be externally rotated out. [MEDICATION NAME] applied to right chest. Nurses' note dated May 4, 2014 at11:52 p.m. stated resident very restless, attempting to climb out of bed. Nurses noted dated May 7, 2014 at 6:48 p.m. stated resident confused, appetite poor, started to slowly become agitated. Although Resident A3 ' s family refused surgery for [REDACTED]. needed (stronger pain medication) prior to transport to the ER for evaluation resulting in pain not being relieved . Review of facility policy title Bowel Protocol, undated, revealed the following protocol will be used for assessing all residents for constipation. Milk of Magnesia (MOM) (laxative) 30 cc PO (by mouth) every third day on 7-3 shift if no bowel movement. [MEDICATION NAME] Suppository 1 (10mg) rectally every fourth day on the 3-11 if MOM ineffective or no bowel movement. Fleet enema rectally every fifth day if [MEDICATION NAME] ineffective or no bowel movement on 11-7. Notify MD if bowel regimen is ineffective for BM. Responsibility for this protocol is as follows: 11-7 is to run the BM list from Care Tracker at the end of their shift and give to 7-3 shift to start protocol. Results are to be followed up as per protocol on the next two shifts. Review of resident D1 [DIAGNOSES REDACTED]. Review of the Bowel detail report for resident D1 revealed the resident had no bowel movement June 19, 2014 night shift (11-7) until June 23, 2014 night shift for a total of 13 shifts. Review of the Medication Administration record for the month of June revealed there was a dose of MOM give on day shift (7-3) of June 23, 2014 ; however, according to the bowel protocol this should have been given on the day shift of June 22, 2014. Further review of the Bowel Detailed report for Resident D1 revealed from July 17, 2014 night shift to July 22, 2014 night shift, The resident did not have a bowel movement for a total of 16 shifts. Review of the MAR for the month of July, 2014 revealed MOM was administered on July 7, 2014 on dayshift as per the protocol but was ineffective and [MEDICATION NAME] suppository was not given as per protocol. Further review of the Bowel detailed report for resident D1 revealed the resident had no bowel movement from July 31, 2014 on night shift until August 4, 2013 on day shift a total of 14 shifts. Review of the MAR for the month of August revealed the resident did receive a dose of MOM on August 4, 2014 at 11:40 a.m. ; however, according to the bowel protocol this should have been given on the dayshift of August 3, 2014. These findings were communicated to the DON and Administer on September 11, 2014 at 2:45 p.m. Review of Resident I2's [DIAGNOSES REDACTED]. Review of the Bowel Record detailed report for Resident I2, revealed the resident had no bowel movement from February 18, 2014 day shift (7-3) until February 25, 2014 evening shift (3-11) for a total of 22 shifts. Review of the Medication Administration Record (MAR) for the month of February, 2014 revealed there was no documented evidence that Milk of Magnesium, a [MEDICATION NAME] suppository or a Fleet enema had been given. According to the bowel protocol Milk of Magnesium should have been given on day shift of February 21, 2014 and a [MEDICATION NAME] suppository should have been given on the evening shift of February 22, 2014 followed by a Fleet enema rectally on night shift (11-7) February 23, 2014 due to the in effectiveness of the [MEDICATION NAME] Suppository and no recorded bowel movement. Review of the Bowel Record detailed report for Resident I2, revealed the resident had no bowel movement from March 7, 2014 night shift until March 11, 2014 day shift for a total of 13 shifts. Review of the Medication Administration Record for the month of March, 2014 revealed there was no documented evidence that Milk of Magnesium, a [MEDICATION NAME] suppository or a Fleet enema had been given. According to the bowel protocol Milk of Magnesium should have been given on day shift of March 9, 2014 and a [MEDICATION NAME] suppository should have been given on the evening shift of March 10, 2014 followed by a Fleet enema rectally on night shift of March 11, 2014 due to the in effectiveness of the [MEDICATION NAME] Suppository and no recorded bowel movement. Further review of the Bowel Record detailed report for Resident I2, revealed the resident had no bowel movement from March 30, 2014 evening shift until April 5, 2014 evening shift for a total of 18 shifts. Review of the Medication Administration Record for the months of March/April, 2014, revealed there was no documented evidence that Milk of Magnesium, a [MEDICATION NAME] suppository or a Fleet enema had been given. According to the bowel protocol Milk of Magnesium should have been given on day shift of April 2, 2014 and a [MEDICATION NAME] suppository should have been given on the evening shift of April 3, 2014 followed by a Fleet enema rectally on night shift of April 4, 2014 due to the in effectiveness of the [MEDICATION NAME] Suppository and no recorded bowel movement was available. Review of the Bowel Record detailed report for Resident I2, revealed the resident had no bowel movement from April 11, 2014 night shift until April 14, 2014 evening shift for a total of 12 shifts. Review of the Medication Administration Record for the month of April, 2014 revealed there was no documented evidence that Milk of Magnesium had been given. According to the bowel protocol, Milk of Magnesium should have been given on day shift of April 13, 2014 due to no recorded bowel movement. Review of the Bowel Record detailed report for Resident I2, revealed the resident had no bowel movement from June 13, 2014 day shift until June 17, 2014 day shift for a total of 13 shifts. Review of the Medication Administration Record for the month of June, 2014 revealed there was no documented evidence that Milk of Magnesium had been given. According to the bowel protocol Milk of Magnesium should have been given on day shift of June 16, 2014 due to no recorded bowel movement. These findings were communicated to the DON and Administrator on September 11, 2014 at 2:45 p.m. 483.25 Quality of Care Previously cited 8/2/14 28 Pa Code: 201.14(a) Responsibility of licensee 28 Pa Code: 201.18(b)(1) Management Previously cited 11/1/13, 8/2/13 28 Pa Code: 211.10(c) Resident care policies 28 PA Code 211.5(f) Clinical records Previously cited 8/2/13 28 PA Code 211.12(d)(1)(5) Nursing services Previously cited 11/1/13, 8/2/13

Based on review of clinical records, observations, review of facility policy and procedure, facility documentation and interviews with staff, it was determined that the facility failed to ensure that all staff were educated on how to remove a bariatric (morbidly) obese resident in a diaster, that would require evacuation from the second floor of the building. (The facility failed to ensure that the residents room was located in an area accessible to an exit.) Placing the health and safety of the resident in immediate jeopardy. (Resident C23) Findings include: Review of the facility submitted Event Reporting System (ERS) entry to the State Agency dated July 24, 2011, for resident C23 revealed that the resident was alert and oriented and fell out of bed while a nursing assistant was providing care. Documentation revealed that while the resident was holding onto the side rail to allow for the removal of a bedpan, the bed tipped over with the resident in the bed. Documentation related that the nursing assistant attempted to stop the bed from tipping over but was unable to do so. The resident sustained [REDACTED]. The resident's weight was documented as 322 pounds as of July 5, 2011. Review of the care plan dated August 3, 2011, revealed that a bariatric bed (a bed for obese residents) was ordered. Observation of the resident on August 3, 2011, at 11:15 a.m., revealed that the resident was in a bariatric bed on the second floor. Review of the facility's disaster plan for the evacuation of residents in bariatric beds dated March 2010, which was given to the surveyor for review by the administration on August 4, 2011, revealed that the structure of the building would permit that a bariatric bed/resident could only be placed on the first floor/hall and as close to an exit door as possible. Review of Resident C23's Quarterly Minimum Data Set (MDS, an assessment tool completed periodically to identify resident care needs) assessment, dated May 26, 2011, revealed that the resident was cognitively intact and non-ambulatory. Review of the August 2011 physician's orders [REDACTED]. Review of the current care plan revealed that the resident required a Hoyer (mechanical) lift with two person assist for transfers. The care plan also indicated interventions for evacuation of the resident in a bariatric bed which included using the MaxiSlide (a flat sheet sliding system designed to transfer a resident from the bed to a wheelchair/stretcher) and then lowering the resident to the floor for a blanket carry (method to transfer resident in an emergency). Interview with the Dietitian on August 9, 2011 at 1:15 p.m. confirmed that the resident's height was 5 feet 5 inches and her most recent weight was 316 pounds on August 2, 2011 which gave her a body mass index (a key index for relating a person's body weight to their height) of 52.72. The National Institutes of Health indicated that a person with a body mass index over 40 is morbidly obese. Observation of the resident on August 3, 2011, at 11:15 a.m., revealed that the resident was in a bariatric bed and resided on the second floor of the facility. A sign was observed on the wall above the resident's bed which indicated that the resident should be evacuated in the wheelchair. Interview with nursing assistant Employee E4, caregiver for the resident on August 4, 2011, at 2:30 p.m., revealed that she was unclear how she would evacuate the resident from the second floor to the first floor. Employee E4 stated, "I would get the resident into her wheelchair using the Hoyer lift, which usually takes about 10 minutes, but I have no idea how I would get the resident down the stairs, maybe use a sheet." This employee also indicated that she had personally questioned, in her own mind, whether the resident should be residing on the second floor. Interview with Employee E5, licensed staff, on August 9, 2011 at 11:20 a.m. revealed that she was unaware of the sign in the resident's room indicating that in an evacuation, the resident was to be placed in a wheelchair. When Employee E5 came to the resident's room with the surveyor, she saw the sign and stated, " I have not been trained in the technical aspects of transporting residents down the stairs in a wheelchair so I would have to ask my supervisor." She also stated, " I had extensive training in evacuating non-ambulatory residents who had bariatric beds but that training was regarding evacuations from ground level floors." . When asked how she would evacuate the resident right then, she stated, " I guessed I would use a physical lift with six to eight staff, carry the resident to the stairs and then carry her down the stairs with six to eight staff." During an interview with Employee E6, licensed staff, on August 9, 2011 at 12:00 p.m., she stated, "I would probably use a blanket with four to six people to get her down the stairs." She also indicated that she had not been oriented regarding the evacuation. During an interview with Nursing assistant, Employee E8 on August 9, 2011 at 11:15 a.m., she stated, " I would use the Hoyer lift to place the resident in the wheelchair and if the firemen couldn't get there on time, I would take her down the stairs on a sheet using four staff." During an interview with Nursing assistant, Employee E9, who worked on Resident C23's unit, on August 9, 2011 at 11:20 a.m., she stated, " I would use the Hoyer lift to place the resident in the wheelchair, take her away from the fire but I have no idea how I would get her down the steps and would pray for the firemen to arrive." Also, this caregiver stated, "I would somehow get her on a blanket and take her down the stairs." During an interview Nursing assistant, Employee E10, on August 9, 2011 at 11:30 a.m., this employee stated, "the sign in the resident's room read to put her in the wheelchair so I would do that and then put her on a sheet and take her down the steps." Employee E10 also stated that she thought there was an in-service two weeks before but that they had not gotten to her yet. None of the interviewed staff indicated knowledge of the care plan interventions that were put in place for the evacuation of this resident. An interview with the Nursing Home Administrator, Assistant Administrator, Director of Nursing and the RN Corporate Nurse on August 9, 2011 at 1:15 p.m. revealed that the most updated policy and procedure regarding the evacuation plan had not been given to the surveyors, and they produced the most recent revision of the policy and procedures which was issued in January 2011. A review of this policy noted that it did not specifically state that bariatric beds could not be placed above the first floor. The fire policy indicated that until the fire department arrives, all associates will follow the direction of the associate in charge. The unplanned (emergency) evacuation policy indicated that the executive director or associate in charge should determine areas in immediate danger and direct the evacuation of those areas first. Review of the facility summary report of training for August 8, 2011, which listed a summary of the meeting and a listing of staff in attendance, revealed that the MaxiSlide (sliding system for low friction transfers) was to be used for the evacuation of bariatric residents. The MaxiSlide was to be used to slide the resident safely off the bed, on to a blanket or mattress, and then the staff would drag the blanket/mattress down the hall to the stairs and use the blanket or mattress to go down the stairs head first and with the resident's head elevated. Review of the facility summary report of training for August 9, 2011, which listed a summary of the meeting and a listing of the staff in attendance, revealed that if the resident is in a bariatric bed and if the resident is able, the staff will safely transfer the resident to a wheelchair and follow the designated evacuation route via exit signs to the nearest safe zone (area in facility away from immediate harm). If the resident is in a bariatric bed and is not able to be removed from the bed, staff will remove the resident from the room by pulling the mattress off the bed, and dragging the resident down the stairs head first. If the mattress will not come off the bed, the staff would drag the resident down the stairs in a blanket, head first. Interview with the Assistant Nursing Home Administrator on August 9, 2011 at 11:00 a.m., revealed that the facility procedure for notifying caregivers of any changes in the resident's care plan was to in-service the staff. Resident C23's bari-evacuation care plan was developed on August 3, 2011. Interview with the Assistant Nursing Home Administrator on August 9, 2011 at 3:15 p.m., revealed that the facility could provide no evidence of an in-service to the staff regarding evacuation procedures or specific care plan interventions for the Resident C23 evacuations. The Nursing Home Administrator was informed on August 9, 2011, at approximately 12:00 p.m., that the health and safety of the resident was in immediate jeopardy due to the facilities failure to implement a safe evacuation plan for Resident C23 and failure to educate the staff who were providing care for the resident, with directions for the safe evacuation of the resident in the event of a fire or other emergency requiring evacuation. The facility submitted and implemented an acceptable plan of action and the immediate jeopardy was removed on August 9, 2011 at 3:30 p.m. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(3)(e)(1) Management. Previously cited 08/27/09. 28 Pa. Code: 201.20(a) Staff development. 28 Pa. Code: 211.10(a) Resident care policies. Previously cited 08/27/09. 28 Pa. Code: 211.12(c) Nursing services. Previously cited 08/27/09. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services. Previously cited 09/17/10, 08/27/09.