Every finding on record at Providence Health & Rehab Center

Based on review of policy, observation and staff interview, it was determined that the facility failed to properly label and date food products, creating the potential for food-borne illness in the main kitchen's standing cooler rack and dry storage area.Findings include: Review of the facility's Food Preparation and Handling Policy dated 5/4/26, indicated Potentially Hazardous Foods (PHF)/Time Temperature Control for Safety Food (TCS) foods are kept refrigerated except when being handled. Refrigerated foods will be:-Covered for storage.-Cooked timely following defrosting.-Appropriately labeled and dated. Observation in the Main Kitchen on 8/3/26 at 9:20 a.m. the following was revealed:-Standing cooler rack had a tray with three separate chef's salads, and seven sandwiches that were not labeled and dated.-The dry storage area had a container of chicken gravy/bouillon opened and not labeled or dated. Interview on 8/3/26, at 9:30 a.m. Dietary Supervisor Employee E5 indicated the salads were from last evening's dinner meal and they, along with the sandwiches, should have been labeled and dated. Dietary Supervisor Employee E5 confirmed the chicken gravy/bouillon should have been labeled and dated. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1) Management.

Based on facility policy, review of clinical records, observations and staff interviews, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for three of four residents (Resident R26, R178, and R179) and failed to provide the right to a dignified dining experience for one of two lunches observed (2B Nurse unit Lunch).Findings include: Review of facility policy Indwelling Urinary Catheter Care dated 5/4/26, indicated that clinical staff may provide urinary catheter care. Such care will help to prevent catheter association urinary tract infections. Check drainage tubing and bag to ensure that the catheter is draining properly, and no kinks are present. The urinary drainage bag must be placed below the bladder level, but not on the floor. Ensure drainage bag is covered with privacy/dignity bag. Review of admission record indicated Resident R26 was admitted to the facility on [DATE]. Review of Resident R26's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 7/15/26, indicated diagnoses of diabetes, high blood pressure, and coronary artery disease (damage or disease in the heart's major blood vessels). Review of Resident R26's physician orders dated 10/15/25, indicated catheter care: provide privacy cover for drainage bag, every shift. During an observation on 8/3/26, at 10:02 a.m. Resident R26's catheter draining bag was observed hanging on the bedframe without a privacy cover applied. Review of admission record indicated Resident R178 was admitted to the facility on [DATE]. Review of Resident R178's MDS dated [DATE], indicated diagnoses of diabetes, high blood pressure, and depression. Review of Resident R178's physician orders dated 8/2/26, indicated catheter care: provide privacy cover for drainage bag, every shift. During an observation on 8/3/26, at 10:10 a.m. Resident R178's catheter draining bag was observed hanging on the bedframe without a privacy cover applied. Review of admission record indicated Resident R179 was admitted to the facility on [DATE]. Review of Resident R179's MDS dated [DATE], indicated diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of Resident R179's physician orders dated 7/30/26, indicated catheter care: provide privacy cover for drainage bag, every shift. During an observation on 8/3/26, at 10:15 a.m. Resident R179's catheter draining bag was observed hanging on the bedframe without a privacy cover applied. During an interview on 8/3/26, at 10:38 a.m. Registered Nurse Employee E14 stated, They should be covered, and confirmed Resident R26, R178, and R179's catheter draining bags did not have a privacy cover and that the facility failed to ensure that care was provided in a way that maintained Resident R26, R178, and R179's dignity. Review of admission record indicated Resident R39 was admitted to the facility on [DATE]. Review of Resident R39's MDS dated [DATE], indicated diagnoses of high blood pressure, heart failure, and diabetes. Review of Resident R39's care plan dated 6/25/26, indicated staff to feed resident all meals. Review of Resident R39's physician orders dated 7/25/26, indicated staff feed. During a lunch observation on 2B Nursing floor on 8/3/26, at 12:30 p.m. Resident R39 was sitting upright in bed. Nurse Aide (NA) Employee E19 was standing beside the bed feeding the resident. During an interview on 8/3/26, at 12:36 p.m. NA Employee E19 stated, I should be sitting down while I'm feeding but I don't know where his chair is. During an interview on 8/3/26, at 2:00 p.m. Director of Nursing confirmed that the facility failed to provide the right to a dignified dining experience for one of two lunches observed (2B). Pa. Code: 211.10(d) Resident care policies. Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to conduct care plan conferences and failed to ensure a resident or resident representative was notified in advance of care conference meetings for three of three residents (Resident R26, R39, and R91).Findings include: Review of facility policy Comprehensive Care Planning dated 5/4/26, indicated an interdisciplinary plan of care will be established and updated as indicated for every resident. The interdisciplinary team includes the participation of the resident or representative. An explanation must be included in a resident's medical record if participation is determined not to be practicable for the development of the resident's care plan. Review of admission record indicated Resident R26 was admitted to the facility on [DATE]. Review of Resident R26's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/15/26, indicated the diagnoses of diabetes, high blood pressure, and coronary artery disease (damage or disease in the heart's major blood vessels). During a review of care plan conferences on 8/7/26, at 9:01 a.m. indicated that the last care conference held was on 1/29/26. Resident R26 failed to have a documented quarterly care conference in the following months: April 2026July 2026 Review of admission record indicated Resident R39 was admitted to the facility on [DATE]. Review of Resident R39's MDS dated [DATE], indicated the diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and diabetes. During a review of care plan conferences on 8/7/26, at 9:09 a.m. indicated that an admission care conference was held on 10/1/25, with no attendees list except the staff member. Resident R39 failed to have a documented quarterly care conference in the following months: January 2026May 2026 Review of admission record indicated Resident R91 was admitted to the facility on [DATE]. Review of Resident R91's MDS dated [DATE], indicated the diagnoses of insomnia (difficult sleeping), anxiety, and amyotrophic lateral sclerosis (ALS, a progressive neurological disorder which results in weakened muscles and deformity). During an interview on 8/4/26, at 11:07 a.m. Resident R91 stated he had only been to one care conference since admission and that he has not been invited to any other care conferences. During a review of care plan conferences on 8/7/26, at 9:16 a.m. indicated that an admission care conference was held on 6/4/25. Resident R91 failed to have a documented quarterly care conference in the following months: September 2025December 2025March 2026June 2026 During an interview on 8/7/26, at 9:26 a.m. the Social Worker Aide Employee E18 confirmed the above missing quarterly care conferences for Resident R26, R39, and R91. During an interview on 8/7/26, at 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to conduct care plan conferences and failed to ensure a resident or resident representative was notified in advance of care conference meetings for three of three residents (Resident R26, R39, and R91). 28 Pa. Code 201.29 (a) Resident rights.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three of five residents sampled with facility-initiated transfers (Residents R4, R10, and R72), failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for two of five resident hospital transfers (Residents R4 and R10), and failed to notify the Office of the State Long-Term Care Ombudsman upon transfer to the hospital for three of five resident hospital transfers (Residents R4, R10, and R72).Findings include: Review of facility policy Discharge Planning reviewed 5/4/26, indicated that the transfer or discharge is documented in the resident's medical record and necessary information is communicated to the receiving health care institution or provider. Review of admission record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/19/26, indicated the diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), depression, and multiple sclerosis (a disease that affects central nervous system). Review of the clinical record indicated Resident R4 was transferred to the hospital on 5/14/26, and returned to the facility on 5/19/26. Review of Resident R4's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility and failed to have documentation of a bed hold policy given to the resident or representative. During an interview on 8/6/26, at 12:08 p.m. Regional Director of Clinical Services Employee E3 confirmed that there was no evidence that the State Ombudsman office was notified for Resident R4's transfer to the hospital. Review of the clinical record indicated Resident R10 was admitted to the facility on [DATE]. Review of Resident R10's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/23/26, indicated diagnoses of diabetes, cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain), and depression. Review of the clinical record indicated Resident R10 was transferred to the hospital on 4/5/26, and returned to the facility on 4/6/26. Review of Resident R10's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility and failed to have documentation of a bed hold policy given to the resident or representative. During an interview on 8/6/26, at 12:10 p.m. Regional Director of Clinical Services Employee E3 confirmed that there was no evidence that the State Ombudsman office was notified for Resident R10's transfer to the hospital. Review of admission record indicated Resident R72 was admitted to the facility on [DATE]. Review of Resident R72's MDS dated [DATE], indicated the diagnoses of high blood pressure, chronic pain, and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Review of the clinical record indicated Resident R72 was transferred to the hospital on 6/10/26, and returned to the facility on 6/10/26. Review of Resident R72's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. During an interview on 8/4/26, at 9:44 a.m. Registered Nurse Employee E14 confirmed that the facility failed to document resident information sent to the acute hospital for Resident R4, R10, and R72's transfers and failed to document that a bed hold policy was given to resident or representative for Resident R4 and R10. During an interview on 8/6/26, at 12:14 p.m. Regional Director of Clinical Services Employee E3 confirmed that there was no evidence that the State Ombudsman office was notified for Resident R72's transfer to the hospital. During an interview on 8/6/26, at 2:00 p.m. the Director of Nursing confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three of five residents sampled with facility-initiated transfers (Residents R4, R10, and R72), failed to notify the resident or resident's representative of the facility bed-hold policy for two of five resident hospital transfers (Residents R4 and R10), and failed to notify the Office of the State Long-Term Care Ombudsman upon transfer to the hospital for three of five resident hospital transfers (Residents R4, R10, and Resident R72). 28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights.

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care in accordance with professional standards of practice for four of six residents (Residents R2, R14, R135, and R155).Findings include: Review of facility policy Resident Weight Policy dated 7/20/26, and previously dated 5/4/26, indicated weights will be obtained routinely in order to monitor nutritional health over time. Each resident's weight will be determined upon admission/readmission to the facility, weekly for the first four weeks after admission/readmission, and monthly or more often if risk is identified, or as ordered. Weights will be recorded in the electronic health record. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/11/26, indicated diagnoses of high blood pressure, Parkinsons's Disease (neuromuscular disorder causing tremors and difficulty walking), and anxiety. During an observation on 8/3/26, at 9:58 a.m. Resident R2's right hand was observed wrapped with gauze and secured with tape. Review of Resident R2's active physician orders failed to include an order for a treatment for the resident's right hand. Review of a nursing progress note dated 7/25/26, stated, Overheard resident yelling Come on from inside of his room. Upon entering the room resident was laying diagonally in his bed with his legs hanging out. Resident said that he was trying to get himself out of bed because he was in his parent's room and didn't want to be there anymore. Told resident that this nurse would get his aide and that we would assist him into his chair. Resident began yelling at this nurse saying that he wanted out now and that he wasn't going to wait. Resident lifted his legs and began attempting to kick this nurse and made multiple attempts to grab/hit. CAN (Certified Nurse Aide) entered room and this nurse asked for assistance with hoyer (a mechanical lift). While hoyer pad was being placed under resident, resident showed this nurse a skin tear on his right hand. Resident then said that this nurse had given him the skin tear (partial or complete separation of the skin's outer layers from the underlying tissue) by digging claws into him. Resident also said that he had a pimple on his knee that this nurse gave to him as well. While hooking resident up to the hoyer, this nurse was grabbed again by resident while he attempted to pull this nurse towards the bed. Resident also began punching this nurse with his other hand and repeatedly said he wanted to get out of his bed. Attempted to calm resident and told him again that we were getting him out of his bed but that he would need to let go of this nurse. Resident was eventually placed in his w/c (wheel chair). Placed steri strips (thin adhesive bandages that help seal minor wounds by pulling skin edges together) on skin tear to right hand. Called and informed provider and emergency contact. Supervisor informed. During an interview on 8/6/26, at 12:25 p.m. Wound Nurse Employee E11 confirmed there was no physician order for a treatment to Resident R2's right hand skin tear and stated, Steri strips are the preferred treatment for skin tears. There should probably be an order to monitor the steri strips. During this interview, Wound Care Nurse Employee E11 confirmed that the facility failed to make certain Resident R2 was provided appropriate treatment and care. Review of the clinical record indicated Resident R14 was admitted to the facility on [DATE]. Review of Resident R14's MDS dated [DATE], indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fats in the blood), and depression. Review of a physician order dated 6/9/26, indicated to obtain weekly weight x 4 weeks, once a day on Monday. Review of Resident R14's June 2026 Medication Administration Record (MAR) revealed the weight was not obtained on the following: 6/22/26: the documented reason was Not Administered: unable to obtain 6/29/26: the documented reason was Not Administered: unable to obtain Review of Resident R14's clinical record failed to include additional documentation to indicate why the facility was unable to obtain the resident's weight on 6/22/26, and 6/29/26, as ordered by the physician. Review of the clinical record indicated Resident R135 was admitted to the facility on [DATE]. Review of Resident R135's MDS dated [DATE], indicated diagnoses of high blood pressure, hyperlipidemia, and mild cognitive impairment. Review of a physician order dated 6/11/26, indicated to obtain weekly weight x 4 weeks, once a day on Monday. Review of Resident R135's June 2026 MAR revealed the weight was not obtained on the following: 6/29/26: the documented reason was Not Administered: unable to obtain Review of Resident R135's clinical record failed to include additional documentation to indicate why the facility was unable to obtain the resident's weight on 6/29/26, as ordered by the physician. During an interview on 8/6/26, at 10:33 a.m. the Director of Nursing confirmed that the facility failed to make certain residents were provided appropriate treatment and care for Residents R14 and R135. Review of Resident R155's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R155's MDS dated [DATE], indicated diagnoses of hypertension (high blood pressure in the arteries), depression, and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). During a review of Resident R155's clinical record on 8/4/26, at 9:02 a.m. indicated that resident was admitted with marks and blisters to her body and no treatment was ordered. During a review of progress notes dated 7/30/26, indicated that a contracted wound company seen Resident R155 and recommended skin prep (a barrier applied to skin) to blisters on her body. During a review of physician orders on 8/4/26, at 9:15 a.m. failed to reveal orders for skin prep to blisters that were recommended. During an interview on 8/4/26, at 9:28 a.m. Wound Nurse Employee E11 stated, I don't see an order for skin prep. Typically skin prep is an order so they can sign off that it was completed. They must have missed it, and confirmed that the facility did not follow the recommendations of the contracted wound company. During an interview on 8/4/26, at 11:30 a.m. Registered Nurse Employee E14 stated, I remember whoever rounded with the practitioner, they said it was not necessary to have done so they did not follow the recommendations, however the facility failed to have documented evidence of speaking to the practitioner concerning treatment for the blisters and the reason why the recommendations were not followed for care and treatment of Resident R155's blisters. During an interview on 8/4/26, at 11:45 a.m. Wound Nurse Employee E11 confirmed that the facility failed to make certain that residents were provided appropriate treatment and care for one of three residents (Resident R155). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policy, clinical record review, observations, and staff interview, it was determined that the facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for three of five residents (Residents R2, R14, and R160).Findings include: Review of facility policy Bed Rail dated 7/20/26, and previously dated 5/4/26, indicated if a bed or side rail or bar is used, the facility will evaluate the potential risks associated with the use of bed rails including entrapment, prior to bed rail installation using the Bed and Bed Rail Safety Inspection Checklist. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/11/26, indicated diagnoses of high blood pressure, Parkinsons's Disease (neuromuscular disorder causing tremors and difficulty walking), and anxiety. Review of a physician order dated 3/6/26, indicated bariatric bed with bariatric mattress and bolster overlay, bilateral (both sides) assistive handrail to aide with positioning - check placement q (every) shift.Review of Resident R2's plan of care dated 9/25/25, indicated the resident is limited in ability to transfer self. Interventions included bariatric bed with bariatric mattress and bolster overlay, bilateral assistive handrail to aid with positioning - check placement q shift. During an observation on 8/3/26, at 9:58 a.m. bilateral enabler bars were observed on top of Resident R2's bed. Review of Resident R2's clinical record revealed the last Enabler-Restraint Observation 2 assessment was completed 10/6/25. Review of the clinical record indicated Resident R14 was admitted to the facility on [DATE]. Review of Resident R14's MDS dated [DATE], indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fats in the blood), and depression. Review of a physician order dated 10/6/25, indicated may use grab/assist bars on bed to promote independence and sense of safety/security. Review of Resident R14's plan of care dated 10/7/25, indicated resident at risk for falling R/T (related to) antidepressant and antipsychotic medication use. Interventions included may use grab/assist bars on bed to promote independence and sense of safety/security. During an observation on 8/3/26, at 9:26 a.m. bilateral enabler bars were observed on top of Resident R14's bed. Review of Resident R14's clinical record revealed the last Enabler-Restraint Observation 2 assessment was completed 10/6/25. Review of the clinical record indicated Resident R160 was admitted to the facility on [DATE]. Review of Resident R160's MDS dated [DATE], indicated diagnoses of high blood pressure, hyperlipidemia, and hemiplegia (paralysis on one side of the body). During an observation on 8/3/26, at 10:02 a.m. bilateral enabler bars were observed on top of Resident R160's bed. Review of Resident R160's clinical record failed to include an order or ongoing assessment for the resident's bilateral enabler bar usage. Review of Resident R160's comprehensive care plan failed to include measurable objectives and timetables with specific interventions/services for use of enabler bars. During an interview on 8/5/26, at 1:16 p.m. Regional Director of Clinical Services (RDCS) Employee E3 stated enabler bar assessments should be done quarterly. During an interview on 8/5/26, at 1:16 p.m. RDCS Employee E3 confirmed that the facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for three of five residents (Residents R2, R14, and R160). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of personnel records and staff interview, it was determined that the facility failed to complete annual performance evaluations at least once every 12 months for three of three nurse aide (NA) personnel records (NA Employee E23, NA Employee E24, and NA Employee E25).Findings include: Review of NA Employee E23's personnel file indicated a date of hire on 7/1/23. Review of NA Employee E23's personnel record failed to include an annual performance evaluation at least every 12 months as required. Review of NA Employee E24's personnel file indicated a date of hire on 7/1/23. Review of NA Employee E24's personnel record failed to include an annual performance evaluation at least every 12 months as required. Review of NA Employee E25's personnel record indicated a date of hire on 7/1/23. Review of NA Employee E25's personnel record failed to include an annual performance evaluation at least every 12 months as required. During an interview on 8/4/26, at 1:55 p.m. the Nursing Home Administrator confirmed that the facility failed to complete annual performance evaluations at least once every 12 months for three of three nurse aide personnel records (NA Employee E23, NA Employee E24, and NA Employee E25). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.19(2) Personnel records.

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide evidence medication regimen reviews (MRRs) were reviewed by the resident's attending physician monthly for three of five residents (Residents R2, R4 and R7). Findings include: Review of facility policy Medication Regimen Review dated 7/20/26, and previously dated 5/4/26, indicated the consultant pharmacist will provide the resident's MRRs to the facility identified personnel who will ensure that the attending physician, medical director, director of nursing and other necessary facility staff receive the recommendations. Facility should encourage physician/prescriber or other responsible parties receiving the MRR and the director of nursing to act upon the recommendations contained in the MRR. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/11/26, indicated diagnoses of high blood pressure, Parkinsons's Disease (neuromuscular disorder causing tremors and difficulty walking), and anxiety. Review of Resident R2's MRR dated 1/23/26, indicated the following recommendation from pharmacist to physician: The resident receives Seroquel (Quetiapine Fumarate), 100 mg (milligrams) am (in the morning) and hs (at night) for expressions or indications of distress related to dementia (e.g., dementia with psychosis). Please attempt a gradual dose reduction (GDR) of Quetiapine Fumarate 75 mg AM and 100 mg HS as a small GDR. Review of Resident R2's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 1/23/26. On 2/5/26, facility CRNP Employee E27 addressed the MRR, stating, Already being done and failed to indicate if the recommendation was accepted or declined. During an interview on 8/5/26, at 10:15 a.m. Medical Records Employee E2 confirmed CRNP Employee E27 addressed Resident R2's MRR dated 1/23/26, and that the facility failed to provide evidence that the MRR was reviewed by the resident's attending physician. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's MDS dated [DATE], indicated diagnoses diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), multiple sclerosis (a disease that affects central nervous system), and depression. Review of Resident R4's MRR dated 9/12/25, indicated the following recommendation from pharmacist to physician: PRN (as needed) indication missing. Oxycodone (used to treat pain) needs pain severity. Cephalexin (used to treat infections) without a stop date. Please document the stop date. Review of Resident R4's MRR dated 11/18/25, indicated the following recommendation from pharmacist to physician: PRN Tramadol (used to treat pain) needs pain severity Voltaren gel (a cream used to treat pain) needs amount in directions Review of Resident R4's MRR dated 1/2/26, indicated the following recommendation from pharmacist to physician: PRN orders have not been used for Hydroxyzine Pamoate (used to treat itching) and Meclizine (used to treat dizziness) with in the previous 30 days. Please consider discontinuing due to lack of use. Review of Resident R4's MRR dated 7/29/26, indicated the following recommendation from pharmacist to physician: Please reevaluate pain status. If pain is inadequately controlled, please consider adjustments to the current regimen. During an interview on 8/5/26, at 10:15 a.m. Medical Records Employee E2 confirmed that the facility failed to provide evidence that the MRR's were reviewed by the resident's attending physician for Resident R4. Review of Resident R7's MDS dated [DATE], indicated diagnoses of high blood pressure, anxiety, and arthritis (swelling and pain in one or more of your joints). Review of Resident R7's MRR dated 1/27/26, indicated the following recommendation from pharmacist to physician: The resident receives multiple antidepressants for depression with similar mechanism of actions. SNRI (serotonin and norepinephrine reuptake inhibitor) and SSRI (selective serotonin reuptake inhibitors) concomitantly (at the same time) without documentation in the medical record of an in adequate response to monotherapy. Please evaluate if resident could be titrated to a single agent reducing risk for serotonin related side effects. Possibly duloxetine 60mg daily could be titrated. Review of Resident R7's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 1/27/26. On 2/6/26, facility CRNP Employee E28 addressed the MRR, stating, accepted and decreased the duloxetine to 40mg. During an interview on 8/5/26, at 10:08 a.m. Medical Records Employee E2 confirmed CRNP Employee E28 addressed Resident R7's MRR dated 1/27/26, and that the facility failed to provide evidence that the MRR was reviewed by the resident's attending physician. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.5(f) Medical records. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications in four of five medications carts (2C2 Medication Cart, 2A Medication Cart, 2B Medication Cart, and 1B Medication Cart) and one of six resident rooms (Resident R74).Findings include: Review of facility policy Storage and Expiration Dating of Medications and Biologicals dated 7/20/26, previously dated 5/4/26, indicated once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (i.e., vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened. If a multi-dose vial of an injectable medication has been opened or accessed (e.g., needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. Review of United States Food and Drug Administration (FDA) approved manufacturer prescribing information for Lantus (insulin glargine) for the 10 mL (milliliter) multiple-dose vial and 3 mL single-patient-use prefilled pen, dated 6/2023, indicated to store unused Lantus in a refrigerator between 36 degrees F (Fahrenheit) and 46 degrees F. Review of the United States FDA approved manufacturer prescribing information for Humalog (insulin lispro) for the 3 mL single-patient-use prefilled pen, dated 5/2025, indicated to store unopened Humalog (insulin lispro) in a refrigerator between 36 degrees F and 46 degrees F. Review of the United States FDA approved manufacturer prescribing information for Novolog (insulin aspart) for the 3 mL single-patient-use prefilled pen, dated 2/2023, indicated to store unopened Novolog (insulin aspart) in a refrigerator between 36 degrees F and 46 degrees F. During a medication pass observation on 8/4/26, at 9:01 a.m. Registered Nurse (RN) Employee E13 walked into a resident's room and failed to lock and secure the 2B Medication Cart. During an interview on 8/4/26, at 9:07 a.m. RN Employee E13 confirmed that the 2B Medication Cart was not locked and left unattended. During a medication cart review on 8/4/26, at 9:40 a.m. the narcotic drawer on 2C2 Medication Cart was not locked and secured. During an interview on 8/4/26, at 9:45 a.m. RN Employee E14 confirmed that 2C2 Medication Cart was sitting in the hallway unattended and that the narcotic drawer was not locked and secure. During an observation on 8/5/26, at 9:08 a.m. of the 2A Medication Cart revealed the following: Resident R14's Lantus insulin (long-acting insulin) vial was unopened in the box, the vial still contained the manufacturer seal and was not stored in the refrigerator prior to opening Resident R14's insulin lispro pen (a pre-filled pen containing rapid-acting insulin), no open date noted Resident R14's open Lantus insulin vial, no open date noted Resident R84's Troujeo pen (insulin glargine, a pre-filled pen containing long-acting insulin), no open date noted Resident R85's insulin lispro pen, no open date noted Resident R95's insulin glargine pen (a pre-filled pen containing long-acting insulin), no open date noted Resident R95's insulin glargine pen not open, still contained the manufacturer seal and was not stored in the refrigerator prior to opening Resident R97's insulin glargine pen, no open date noted Resident R127's Novolog insulin pen (a pre-filled pen containing rapid-acting insulin), no open date noted Resident R158's Trelegy inhaler (a medication used to prevent and treat respiratory distress), no open date noted Resident R158's Albuterol inhaler (a medication used to relax muscle in the airways), no open date noted Resident R186's Polymyxin B (an antibiotic used to treat bacterial infections in the eye) eye drops, no date noted During an interview on 8/5/26, at 9:25 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed the above observations and that the facility failed to properly store medications in the 2A Medication Cart. During an observation on 8/5/26, at 9:57 a.m. of the 1B Medication Cart revealed the following: Latanoprost 0.05% eye drops dated 6/8/26. Interview on 8/5/26, at 9:58 a.m. LPN Employee E29 confirmed the eye drops were dated 6/8/26. Review of the admission record indicated Resident R74 admitted to the facility on [DATE]. Observation of Resident R74 on 8/3/26, at 11:42 a.m. indicated two bottles of eye drops at bedside. Neither bottles were labeled with an open date as required. Interview and observation on 8/3/26, at 11:45 a.m. Registered Nurse (RN) Employee E4 confirmed the eye drop bottles failed to be labeled with an open date as required. 28 Pa. Code: 201(a) Responsibility of licensee.28 Pa. Code: 211.9(a)(1) Pharmacy services.28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policy, resident records, a facility tour, observations, and staff interview it was determined that the facility failed to utilize proper food handling procedures during the lunch meal creating the potential for cross contamination for one out of five residents (Residents R97), failed to prevent cross contamination during a medication administration for one of five med pass observations (2B Med Pass), failed to follow proper use of personal protective equipment (PPE) for one of four residents (Resident R91), and failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for eight of twelve months (September 2025, through April 2026). Findings include: Review of the facility's Food Preparation and Handling Policy dated 5/4/26, indicated in order to avoid cross-contamination, single-use gloves will be used when handling ready-to-eat food directly with hands. Review of facility policy Transmission Based Precautions and Isolation dated 5/4/26, indicated precautions will be used when a potential for transmission of infectious agents are present. Contact precautions are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the patient or the environment. Gloves, gowns are to be worn and masks, if needed. Review of facility policy Infection Prevention and Control Program dated 5/4/26, indicated it is the policy to maintain an organized, effective facility-wide program designed to systematically prevent, identify, control, and reduce the risk of acquiring and transmitting infections. To conduct surveillance of communicable disease and infectious outbreaks. Particular focus of the program will be on conducting risk assessment, surveillance, reducing health care associated infections, limiting transmission of disease, immunization, promoting antibiotic stewardship, and reporting as necessary. Review of the admission record indicated Resident R97 admitted to the facility on [DATE]. Observation of the lunch meal service in the main dining area of the first floor on 8/4/26, at 11:40 a.m. Transportation Aide Employee E9 was observed assisting Resident R97 by opening a dinner roll from its package and opening a sandwich wrapped in plastic wrap. The employee failed to utilize gloves and touched the food directly with her hands. Interview on 8/4/26, at 11:45 a.m. the Director of Nursing was informed of the observation for Resident R97's lunch assistance. During a medication pass observation on 2B hallway on 8/4/26, at 9:01 a.m. Registered Nurse (RN) Employee E13 pushed the medications out of the blister packs onto an ungloved hand and put the medication into a medicine cup to administer to the resident. During an interview on 8/4/26, at 9:07 a.m. RN Employee E13 confirmed not having gloves on when handling resident medications and that the facility failed to prevent cross contamination during a medication administration for one of five med pass observations (2B Med Pass). Review of admission record indicated Resident R91 was admitted to the facility on [DATE]. Review of Resident R91's MDS dated [DATE], indicated the diagnoses of insomnia (difficult sleeping), anxiety, and amyotrophic lateral sclerosis (ALS, a progressive neurological disorder which results in weakened muscles and deformity). Review of Resident R91's physician orders dated 7/24/26, indicated Isolation/Transmission-Based Precautions: Contact Isolation. During an observation on 8/4/26, at 10:11 a.m. Resident R91 had contact isolation signage hanging on the door and PPE was available for staff use. On 8/4/26, at 10:42 a.m. Licensed Practical Nurse (LPN) Employee E12 entered Resident R91's room and failed to apply appropriate PPE, as ordered. During an interview on 8/4/26, at 10:50 a.m. LPN Employee E12 confirmed that she failed to apply PPE and follow proper use of PPE to prevent the spread of infections for Resident R91. Review of the facility's Infection Control Program on 8/5/26, at 10:15 a.m. for September 2025, through July 2026, failed to include documented evidence of infection surveillance and tracking for the facility for eight of twelve months (September 2025, through April 2026). During an interview on 8/5/26, at 3:16 p.m. Director of Nursing (DON) reviewed the facilities infection control documents with State Agency (SA) and was unable to provide evidence of the facilities infection control surveillance and tracking of infections in the facility. DON stated, I haven't been here that long. I started to oversee the Infection Control in May. If we don't have anything in these binders, then we don't have it. That is how we can monitor all the infections we have and provide education if needed. During an interview on 8/7/26, at 12:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to implement an infection control program that included a system of surveillance/tracking to identify possible communicable diseases or infections for eight of twelve months (September 2025, through April 2026). 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.28 (b)(1)(e)(1) Management. 28 Pa Code: 211.10 (d) Resident care policies.

Based on review of the facility policy and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for eight of 12 months (September 2025, through April 2026). Findings include: Review of facility Antimicrobial Stewardship Program policy dated 5/4/26, indicated facility will focus on avoiding unnecessary or inappropriate use. It will be overseen by Infection Preventionist, Medical Director, Pharmacist, nursing, and leadership.Review of facility Infection Prevention and Control Program policy dated 5/4/26, indicated it is the policy to maintain an organized, effective facility-wide program designed to systematically prevent, identify, control, and reduce the risk of acquiring and transmitting infections. To conduct surveillance of communicable disease and infectious outbreaks. Particular focus of the program will be on conducting risk assessment, surveillance, reducing health care associated infections, limiting transmission of disease, immunization, promoting antibiotic stewardship, and reporting as necessary. Review of the facility's Infection Control Program for September 2025, through July 2026, failed to include documented evidence that antibiotic monitoring and appropriate usage was completed from September 2025, through April 2026. During an interview on 8/5/26, at 3:16 p.m. Director of Nursing reviewed the facilities infection control documents with State Agency (SA) and was unable to provide the facilities antibiotic stewardship program and stated, I haven't been here that long. I started to oversee the Infection Control in May. If we don't have anything in these binders, then we don't have it. During an interview on 8/7/26, at 8:30 a.m. Regional Director of Clinical Services Employee E3 stated, I found an antibiotic stewardship binder in one of the offices last night and confirmed that it had reports from the lab in it and failed to include any facility tracking of antibiotics and had previous survey information in it. During an interview on 8/7/26, at 12:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to implement an antibiotic stewardship program eight of 12 months (September 2025, through April 2026). 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to the Pneumonia vaccine for three of five residents (Resident R4, R26, and R72).Findings include: Review of facility policy Resident Vaccination dated 5/4/26, indicated resident or responsible party will be asked about prior vaccinations at admission. Prior doses of influenza, pneumococcal, COVID (respiratory illness), and other vaccines will be documented in the immunization portal in the electronic health record. Vaccinations will be administered by provider's orders. Review of admission record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/19/26, indicated the diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), depression, and multiple sclerosis (a disease that affects central nervous system). MDS Section O- Special treatment, Procedures, and Programs, O0300 Pneumococcal vaccine up to date is coded as a no. Reason is coded as a 3, not offered. During a review of Resident R4's immunization record on 8/6/26, at 10:10 a.m. indicated that on 10/30/25, the consent was not obtained and the reason listed was status to be determined. Education provided to the resident or the representative was not checked. The facility failed to provide documented evidence that the pneumococcal vaccine was offered and that education was provided. Review of admission record indicated Resident R26 was admitted to the facility on [DATE]. Review of Resident R26's MDS dated [DATE], indicated the diagnoses of diabetes, high blood pressure, and coronary artery disease (damage or disease in the heart's major blood vessels). MDS Section O- Special treatment, Procedures, and Programs, O0300 Pneumococcal vaccine up to date is coded as a no. Reason is coded as a 3, not offered. During a review of Resident R26's immunization record on 8/6/26, at 10:17 a.m. indicated that on 10/29/25, the consent was not obtained and the reason listed was unable to obtain data. The facility failed to provide documented evidence that the status of the pneumococcal vaccine was discussed with the attending physician. Review of admission record indicated Resident R72 was admitted to the facility on [DATE]. Review of Resident R72's MDS dated [DATE], indicated the diagnoses of high blood pressure, chronic pain, and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). MDS Section O- Special treatment, Procedures, and Programs, O0300 Pneumococcal vaccine up to date is coded as a no. Reason is coded as a 3, not offered. During a review of Resident R26's immunization record on 8/6/26, at 10:24 a.m. indicated that on 10/30/25, the consent was not obtained and the reason listed was status to be determined. Education provided to the resident or the representative was not checked. The facility failed to provide documented evidence that the pneumococcal vaccine was offered and that education was provided. During an interview on 8/6/26, at 10:32 a.m. the Director of Nursing stated, We should have followed up with vaccinations, and confirmed that the facility failed to provide accurate and timely documentation related to the Pneumonia vaccine for three of five residents (Resident R4, R26, and R72). 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy and documents, resident and staff interviews, it was determined that the facility staff failed to provide services in the facility with reasonable accommodation of resident needs and preferences for enabler bars for one of five residents (Resident R105).Findings include:Review of the facility policy Facility Resident Handbook last reviewed 5/4/26, indicated reasonable accommodation as the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health and safety of the resident or other residents. Review of the admission record indicated Resident R105 admitted to the facility on [DATE]. Review of Resident R105's Minimum Data Set (MDS- a periodic assessment of care needs) dated 7/27/26, indicated the diagnoses of heart failure (heart doesn't pump blood as well as it should), high blood pressure, and renal insufficiency (a condition in which the kidneys lose the ability to remove waste and balance fluids). Review of Occupational Therapy Evaluation dated as start of care 7/22/26, indicated Functional Assessment Bed Mobility: Resident requires assistance, however, will not currently address in treatment plan (minimal assistance for bed mobility, would be able to complete with stand by assistance if assist bars are present). Review of Resident R105's clinical record on 8/5/26, failed to include an observation for enabler bars. Observation on 8/3/26, at 9:20 a.m. Resident R105 was lying in bed. Interview on 8/3/26, at 9:20 a.m. Resident R105 indicated she wanted enabler bars to help position herself in the bed. She indicated she has asked for enabler bars but has not heard back since her admission on [DATE]. Observation and interview on 8/3/26, at 9:30 a.m. Registered Nurse (RN) Employee E4 confirmed Resident R105 did not have enabler bars on the bed and would look into it. Observation on 8/5/26, at 12:37 p.m. Resident R105 was resting in bed, and enabler bars were not present. Interview on 8/5/26, at 12:45 p.m. Occupational Therapy (OT) Employee E6 indicated the process for obtaining enabler bars as follows: therapy will determine on their evaluations whether residents can use their upper extremities. Then they notify nursing to put an observation (assessment of risk) in to have enabler bars put on if appropriate. Then a maintenance request is filled out. It can take a few days to a week to obtain the enabler bars. Interview on 8/5/26, at 12:50 p.m. OT Employee E7 referenced her OT Evaluation dated 7/22/26, and indicated the resident would benefit from enabler bars and indicated the observation probably never got put in the computer. The facility uses a verbal notification for the observations to be completed. 28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, resident family interviews and documentation, and staff interviews it was determined that the facility failed to assist a resident family with forming a family group for three of three resident families (Resident Family Representatives FR116, FR121, and Resident Family Representative FR300). Findings include: The facility Resident Handbook-resident groups document last reviewed 7/20/26, indicated that the resident has a right to organize and participate in resident groups. The facility must provide a resident or family group, if one exists, with private space, and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings. The facility must consider the views of a resident or family group and act promptly. Review of the facility family council minutes dated 8/20/25, indicated that families were informed of several upcoming events, families shared suggestions during the meeting, families were thanked for their attendance, and the next family council meeting would be announced at a later date. Review of Family Group meeting minutes dated 8/20/25, failed to include documentation that resident families had discussed not wanting to continue with future meetings or that communication was provided by the facility that the facility would cease to conduct Family Group meetings. During an interview on 8/6/26, at 10:22 a.m. Resident Family R116 and Resident Family R121 indicated the facility no longer provides a family meeting and had previously provided a family meeting monthly. During a phone interview on 8/6/26, at 12:56 p.m. Resident Family Representative FR300 was interviewed and stated the following: The last Administrator in her tenor there, she stopped the family council meeting. They would have the meeting every quarter. She eliminated that. She said it was best to address the issue with the appropriate apartment at the time. We are lacking feedback because the meeting has stopped. About 2 to 2.5 years ago they offered meetings every month. A lot of things did not get addressed. Facility administration made them every 3 months and eliminated the meeting around Thanksgiving and Christmas. I spoke to Activities Director Employee E16 and spoke to another staff, and they said the family meeting was not occurring any longer. During an interview on 8/6/26, at 1:41 p.m. the Nursing Home Administrator (NHA) stated, August 2025 was the last Family Council meeting, the previous administration did not want to continue the meetings. We are going to be sending out communication asking family's desire to continue the meetings. The prior administration did not move forward with the practice; the practice has not officially been disbanded from the facility. During an interview on 8/6/26, at 1:55 p.m. Activities Director Employee E16 was asked when last family council meeting was and who stopped the meeting, she stated: it was August of 2025. The prior administrator stopped it. Family council met every three months. It was quarterly prior. The family did ask previous Administrator about the family meetings; I was told we were not having them and there was no formal communication to families. During an interview on 8/6/26, at 2:11 p.m. information was disseminated to the Nursing Home Administrator (NHA), Director of Nursing (DON), and Regional Director of Clinical Services Employee E3 that the facility failed to assist a resident family with forming a family group for four of four resident families as required. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(4)Management.

Based on resident clinical records, facility documents, and staff interview it was determined that the facility failed to provide a Skilled Nursing Advanced Beneficiary Notice of Non-coverage (SNF-ABN) with the estimated amount of nursing services that will be charged for one of three sampled resident records (Resident R120).Findings include: Review of Resident R120's admission record indicated he was originally admitted on [DATE]. Review of Resident R120's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 6/18/26, indicated he had diagnoses that included artificial hip joint, cellulitis (bacterial infection of the skin causing redness, aches, and swelling), and dysphagia (difficulty swallowing). Review of Resident R120's census document (a form showing room number and payor source) indicated that he was admitted on Medicare Part A on 3/27/26, and his payor changed on 4/19/26 to private pay. Review of Resident R120's social services note dated 4/17/26, indicated he was provided a NOMNC form (Notice of Medicare Non-Coverage NOMNC: a form provided to residents to inform them of the facilities determination to end a Medicare based services). The note indicated that the form was verbally reviewed with his wife as well. Resident R120 was unable to sign. Both he and his family acknowledge and agree with the NOMNC and do not intend to appeal. Review of Resident R120's social services notes and clinical nurse notes did not indicate that Resident R120 or his wife were provided with a SNF-ABN form (Skilled Nursing Facility Advanced Beneficiary Notice of non-coverage: SNF-ABN-a form to inform those residents of items and services no longer deemed eligible for coverage under Medicare Part A) reviewing services no longer covered under Medicare Part A. During an interview on 8/5/26, at 10:19 a.m. Regional Director of Clinical Services Employee E3 confirmed that the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of non-coverage (SNF-ABN) form to inform Resident R120 or his family of items and services no longer deemed eligible under Medicare Part A as required. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(2)(3) Management.

Based on review of facility policy, observations, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of five medication carts (2B Medication Cart). Findings include: Review of facility policy HIPAA Privacy dated 5/4/26, indicated the facility will treat Protected Health Information (PHI) in accordance with these policies. Facility may not use or disclose PHI. During a medication pass observation on 8/4/26, at 9:03 a.m. the Registered Nurse (RN) Employee E13 left the medication cart unattended in the hallway with the computer screen open displaying resident information. During an interview on 8/4/26, at 9:07 a.m. RN Employee E13 confirmed that the 2B Medication Cart computer screen was left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information and that the facility failed to maintain the confidentiality of residents' medical information on one of five medication carts (2B Medication Cart). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.29(c.3) Resident Rights. 28 Pa. code: 211.5(b)(1)(2) Medical records. 28 Pa. Code: 211.12(d)(1)(3) Nursing services.

Based on observations and staff interview it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for one of three floors (Second floor). Findings include: During a tour with the Maintenance Employee E9 on 8/5/26, at 11:00 a.m. on the Second Floor (2B), the following were observed: Resident R171 room was found with a missing part of a baseboard under the window.Left side of the hallway were missing baseboards periodically down the hall.Right side of the hallway were missing baseboards periodically down the hall. During an interview on 8/5/26, at 11:12 a.m. Maintenance Employee E15 stated that the machine must be hitting them and they took them off and confirmed that the facility failed to provide a clean, safe, comfortable, and homelike environment for one of three floors (Second floor). 28 Pa. Code 201.18(b)(3)(e)(2) Management. 28 Pa code 211.12(d)(1) Nursing services.

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to identify a bolster (a long, thick cushion) as a possible restraint and failed to assess the functional status of the individual resident to determine if the use of a bolster is a restraint for two of four residents (Residents R2 and R87).Findings include: Review of facility policy Restraint Policy dated 7/20/26, previously dated 5/4/26, indicated a physical and/or chemical restraint will be initiated only after a comprehensive review determines that they are necessary to treat the resident's medical symptoms that warrant their use. A physical restraint is any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/11/26, indicated diagnoses of high blood pressure, Parkinsons's Disease (neuromuscular disorder causing tremors and difficulty walking), and anxiety. Review of a physician order dated 3/6/26, indicated bariatric bed with bariatric mattress and bolster overlay, bilateral (both sides) assistive handrail to aide with positioning - check placement q (every) shift.Review of Resident R2's plan of care dated 9/25/25, indicated the resident is limited in ability to transfer self. Interventions included bariatric bed with bariatric mattress and bolster overlay, bilateral assistive handrail to aid with positioning - check placement q shift. During an observation on 8/3/26, at 9:58 a.m. Resident R2 was observed lying in bed and the mattress had bilateral raised edges on the top and bottom portions. Further review of Resident R2's clinical record failed to identify any assessments or ongoing evaluations for the usage of bolsters on the resident's mattress.Review of the clinical record indicated Resident R87 was admitted to the facility on [DATE].Review of Resident R87's MDS dated [DATE], indicated diagnoses of hemiplegia (paralysis on one side of the body), anxiety, and depression. Review of a physician order dated 11/29/23, indicated resident to use bilateral bed rail bolsters while in bed as tolerated. Review of Resident R87's plan of care dated 12/26/23, indicated the resident has a history of falling R/T (related to) decreased safety awareness, alteration in cognition, impulsivity. Interventions included keep bed in lowest position with brakes locked. Floor mat to door side of bed, contour mattress with bolster overlay, bilateral foam wedges for positioning, every shift, as tolerated. During an observation on 8/3/26, at 10:26 a.m. Resident R87 was observed lying in bed and the mattress had bilateral raised edges on the top and bottom portions. Further review of Resident R87's clinical record failed to identify any assessments or ongoing evaluations for the usage of bolsters on the resident's mattress. During an interview on 8/5/26, at 1:16 p.m. Regional Director of Clinical Services Employee E3 confirmed that the facility failed to assess the functional status of the individual resident to determine if the use of a bolster is a restraint for two of four residents (Residents R2 and R87). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, personnel records and staff interview, it was determined that the facility failed to conduct an FBI background check on agency personnel prior to working on the nursing unit for one out of six personnel records (Agency Nurse aide (NA) Employee E20). Findings include: The facility Personnel abuse policy dated 8/25/25, and last reviewed 7/20/26, indicated that the facility will not employe or otherwise engage individual s who have been found guilty of abuse, neglect or mistreatment of residents. It is the policy to undertake background checks of all employees. The facility will do the following prior to hiring a new employee and conduct background checks in accordance with State law. Review of Agency Nurse aide (NA) Employee E20's personnel record indicated he was hired to work at the facility on 7/15/26, his orientation was completed at the facility on 7/15/26, and Agency Nurse aide (NA) Employee E20's worked on two shifts (7/26/26 and 8/1/26). Review of Agency Nurse aide (NA) Employee E20's indicated the staff had lived outside of Pennsylvania within the past two years. Review of Agency Nurse aide (NA) Employee E20's personnel record indicated an FBI background check dated 6/1/23. Review of Agency Nurse aide (NA) Employee E20's personnel record did not include an updated FBI background check prior to this start date at the facility. During an interview on 8/6/26, at 10:00 a.m. the Director of Human Resources Employee E21 confirmed that Agency Nurse aide (NA) Employee E20 had in fact lived outside of Pennsylvania within the past two years. During an interview on 8/6/26, at 2:11 p.m. information was disseminated to the Nursing Home Administrator (NHA), Director of Nursing (DON), and Regional Director of Clinical Services Employee E3 that the facility failed to conduct an FBI background check on Agency Nurse aide (NA) Employee E20 prior to working on the nursing unit as required. 28. Pa Code 201.14(a) Responsibility of licensee. 28. Pa Code 201.18(b)(1)(e)(1) Management. 28. Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, resident records, resident council minutes, facility investigation documents, incidents submitted to the local State field office, resident interview, and staff interviews it was determined that the facility failed to submit a report of an allegation of verbal abuse for one of four sampled resident records (Resident R9). Findings include: The facility Personnel abuse policy dated 8/25/25, and last reviewed 7/20/26, indicated that abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse. Verbal abuse is the use of oral, written or gestured language that willfully includes disparaging and derogatory terms. All allegations of abuse must be reported immediately to the Administrator and to the applicable State agency. Review of Resident R9's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R9's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs), dated 6/10/26, indicated she had diagnoses that included hypertension (a condition impacting blood circulation through the heart related to poor pressure), anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry), and hyperlipidemia (elevated lipid levels within the blood). Review of Resident Council meeting minutes dated 6/30/26, indicated that Resident R9 told staff that a staff-person had yelled at her. Review of June 2026 grievance documentation did not indicate a grievance related to the allegation. Review of facility investigation documents indicated a disciplinary action dated 6/29/26 for Nurse aide Employee E26 related to this incident, and a retraining related to effective communication. Review of reported incidents of abuse to the State did not include Resident R9's verbal abuse allegation. During an interview on 8/5/26, at 9:53 a.m. the Activities Director Employee E16 was asked if Resident R9's allegation of verbal abuse occurred during council and if it was reported, and she stated: yes. that happened. Resident R9 was not upset, but Director of Human Resources Employee E21 did speak with the aide. During an interview on 8/5/26, at 9:56 a.m. the Director of Human Resources Employee E21 was asked if she recalled retraining an aide or discussing a Resident R9 verbal abuse allegation in June 2026, and she stated: no. I do not recall. During an interview on 8/5/26, at 10:00 a.m. Resident R9 was interviewed about the verbal abuse allegation mentioned during the June 2026 resident council meeting and stated: yes, that was taken care of. She was loud. I did get mad. I cursed her back. The aide did not resign. During an interview on 8/5/26, at 10:40 a.m. the Director of Nursing (DON) confirmed that the facility failed to submit a report of Resident R9's allegation of verbal abuse as required. 28 Pa Code: 201.18 (e)(1)(2) Management 28 Pa Code: 201.29 (a )(c)(d) Resident Rights 28 Pa Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing services

Based on review of facility policy, facility documents, clinical record review, and staff interviews, it was determined that the facility failed to ensure proper supervision for a resident (Resident R1) resulting in an elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge) from the facility. This failure created an immediate jeopardy situation (IJ) for all residents identified as an elopement risk.Findings include: Review of facility policy Elopement Unauthorized Absence dated 5/4/26, indicated the facility will identify residents with potential and/or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. In the event of a resident elopement the facility will implement its policies and procedures to locate the resident in a timely manner. All residents will be assessed for the risk of elopement using the Elopement Observation on admission, quarterly, and as needed. Residents identified at risk will have interventions promptly implemented to reduce the risk of elopement. The resident's physician will be notified of risk and recommend interventions. The resident's responsible party will be informed of potential risk and interventions being implemented to provide for the resident's safety. Residents identified at risk will have their picture and face sheet or the demographic form placed in a binder that is kept in an area accessible by staff. Upon determining that a resident cannot be located a headcount will be conducted. If resident is still missing Code [NAME] using the resident name, room number, and unit name will be announced. Announce three times. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and hyperlipidemia (high levels of fats in the blood). Review of Resident R1's NSG - Admission/readmission Observation 3 assessment dated [DATE], stated, His caretaker brought him and told him they were just going to visit a friend. He knows the truth now and is very upset. Further review of Resident R1's NSG - Admission/readmission Observation 3 assessment dated [DATE], indicated an Elopement Observation was completed, which consisted of the following questions and documented answers: Is resident ambulatory or independent in wheelchair locomotion?YesDoes the resident have any of the following risk factors?New admission who has made statements questioning the need to be here - yesIs there been known history of attempted or actual elopement or unsafe wandering - noNot accepting present residency situation/location - noResident wanders without a sense of purpose - noDoes the resident have a history of substance abuse History (SUD) that may result in leaving the building - noResident exhibits exit seeking behaviors - noResident verbalizes, wanting to go home, going on a trip, going to meet someone - yesResident wanders in and out of other resident rooms and/or rummages in other's belongings - noCurrent acute change in cognition/confusion - noNone of the above criteria are currently exhibited - noPotential elopement risk identified, requires further review immediate intervention(s) implemented to address the identified risk factor(s) fillable sectionYesNo identified risk(s) for elopementNoImmediate intervention(s)On the 3rd floor due to more controlled environment. Has a TV (television) in room due to watching TV at home. Express wanting to be home but no prior elopement risk in the community. Score 4 - Level: currently potential risk for elopement risk for elopement Review of Resident R1's baseline care plan dated 5/7/26, indicated the resident was at risk for wandering. Interventions include resident will be monitored to minimize risk of wandering and/or elopement. Review of a progress note dated 5/7/26, at 3:21 p.m. stated, Patient very agitated because he wants to leave the facility. Patient care giver is with him trying to calm him down. He is yelling at her. He called his son to try to calm him but it was unsuccessful. Review of a progress note dated 5/7/26, at 7:10 p.m. stated, Patient continues to be agitated about being here. Advised him he will leave in 5 days. Review of a progress note dated 5/9/26, at 1:54 p.m. stated, Resident does wander hallways ad lib (as desired). Transfers independently. Review of a progress note dated 5/10/26, stated, Resident R1 experienced an elopement event on 05/10/2026. Resident R1 was admitted on [DATE] for a 5-day respite stay (a short-term stay in a care facility that provides temporary professional care for a loved one while giving the primary caregiver a break) under the services of hospice with no known prior history of elopement behaviors. At approximately 12:20 PM, staff identified that the resident could not be located after last being observed at the third-floor nursing station at approximately 12:00 PM. The RN (Registered Nurse) Supervisor was notified immediately, an Elopement Code was initiated, and staff conducted a search of the center and surrounding grounds. After the resident could not be located, the Administrator and local police department were notified at approximately 12:44 PM. The resident was later found safely seated on the porch of a residence located at [0.5 miles away from the facility] and was retrieved without incident by the Director of Nursing Services (DON) and Maintenance Director. Upon return to the facility, at 1:31PM a full head-to-toe assessment identified no injuries or acute concerns. Emotional support was provided without signs or symptoms of distress observed or voiced. Family and physician were notified of the event. Immediate corrective actions included reassessment of the resident's elopement risk status, implementation of a WanderGuard (a wearable electronic monitoring device) device, and updating of the resident's care plan to reflect increased supervision and interventions related to elopement prevention. Review of a staff witness statement dated 5/10/26, completed by Nurse Aide (NA) Employee E7 stated, I noticed the resident missing after I went to pass his lunch tray and couldn't find him. I searched all the rooms and bathrooms and shower room. Then my coworkers started looking. Code [NAME] was called, we went outside to look for him. 2 coworkers and I drove around looking for him unfound. Went back to facility told supervisor where we looked and started picking up trays. Review of a staff witness statement dated 5/10/26, completed by NA Employee E8 stated, I went on my break around 11:37 a.m. When I left the nurses station Resident R1 was standing at the nurses station. I came back on the unit at 12:00 p.m. As soon as I came back I started help passing lunch trays. I was down the hall passing lunch trays when NA Employee E7 ask if Resident R1 was down the hall. I told her I had not seen him. She check C-Side (nursing unit) again. She came down A-Hall (nursing unit) saying he wasn't over there. So I started checking rooms and bathrooms. I could not find him. I checked back on to 3rd (floor) to see if he was found. He was not, so I went and drove around the area to see if I could help find him. Review of a staff witness statement dated 5/10/26, completed by Licensed Practical Nurse (LPN) Employee E3 stated, Resident was observed at desk before lunch trays. Staff and myself started passing trays. When we got to Resident R1's tray he was not in his room. Staff began searching unit for resident. When he was not on unit Code [NAME] called, supervisor noted myself and another staff member, then got in her car and began to search the blocks around the facility. Supervisor notified police and other responsible parties of incident. Returned to unit and awaited response from management. Review of a staff witness statement dated 5/10/26, completed by NA Employee E9 stated, I was charting in the hall waiting for lunch when an aide got off the elevator and she asked if we saw him. At that time she gave me his description while heading out the main door. I walked about 4 blocks down, looking down the alleys, streets, between houses and cars. I walked back a different way doing the same but wanted to get back to touch base. Review of a staff witness statement dated 5/10/26, completed by Maintenance Director Employee E10 stated, I along with the DON went to pick up Resident R1 at [a residence located 0.5 miles away from the facility] where his daughter told her he was. The resident was there sitting on the porch with the lady who lived there. We were able to get him into the car and back to the facility without incident. Review of a typed staff witness interview dated 5/10/26, indicated Receptionist Employee E1 stated, At approximately noon she observed a shorter gentleman in a ball cap and jacket near the front entrance area. She reported that the individual stated, Well I think I will go out for a while, and then exited through the facility front door. She stated she believed the individual was a visitor leaving the building and did not recognize the person as a resident at the time of the occurrence. She stated, I thought he was a visitor leaving, people do that all the time. She reported she did not observe signs of distress, urgency, or unusual behavior at the time the individual exited the building. She further stated she was unaware at that time that the individual was a resident of the facility. Review of Resident R1's clinical record revealed an Elopement Observation dated 5/10/26, which consisted of the following questions and documented answers: Is resident ambulatory or independent in wheelchair locomotion?YesDoes the resident have any of the following risk factors?New admission who has made statements questioning the need to be here - yesIs there been known history of attempted or actual elopement or unsafe wandering - yesNot accepting present residency situation/location - noResident wanders without a sense of purpose - noDoes the resident have a history of substance abuse History (SUD) that may result in leaving the building - noResident exhibits exit seeking behaviors - yesResident verbalizes, wanting to go home, going on a trip, going to meet someone - yesResident wanders in and out of other resident rooms and/or rummages in other's belongings - noCurrent acute change in cognition/confusion - noNone of the above criteria are currently exhibited - noPotential elopement risk identified, requires further review immediate intervention(s) implemented to address the identified risk factor(s) fillable sectionYesNo identified risk(s) for elopementNoImmediate intervention(s)Wander guard Score 8 - Level: currently has potential risk for elopement Review of facility-provided documents revealed a Root Cause Analysis that stated, Upon completion of the facility investigation, the interdisciplinary team determined the root cause of the event to be a breakdown in secured access control and monitoring during visitor/family movement through the Memory Care Unit, elevator access area. During visitor/family movement through the Memory Care Unit elevator area, the resident was able to follow through the elevator access point unnoticed, resulting in unauthorized exit from the Memory Care Unit. Review of facility-provided documents revealed a Plan of Correction dated 5/11/26. The document indicated employees were re-educated regarding elopement prevention, visitor management, and Code [NAME] procedures. Reinforcement was provided that door codes of the center and Memory Impaired Unit are confidential and intended for employee use only. Elopement prevention and visitor management practices were incorporated into ongoing employee education and orientation. During an interview on 5/19/26, at 11:42 a.m. LPN Employee E2 and LPN Employee E3 stated, Usually the RN Supervisor does the elopement assessments, we haven't done one in a while. Supervisors do the new admission assessments for all shifts. I'm not sure what the elopement assessment score is. I don't remember the score being address in the elopement education. During an interview on 5/19/26, at 11:48 a.m. Receptionist Employee E11 stated, We have an elopement binder at the front desk. It gets updated when there is a new admission identified as an elopement risk. The supervisor will let us know when it's updated. During an interview on 5/19/26, at 11:56 a.m. RN Employee E4 stated, I don't know what the score means on the elopement evaluations. The supervisor is usually who completes the assessments. During an interview on 5/19/26, at 12:00 p.m. LPN Employee E6 stated, I've never done one of the elopement assessments. Initial assessments for new admissions are done by the supervisor. Usually the supervisor does the quarterly assessments. I'm not sure what the elopement score means. During an interview on 5/19/26, at 12:01 p.m. RN Manger Employee E5 stated, During day shift, usually the unit manager or supervisor will complete the assessments. On the 3 p.m. - 11 p.m. shift there is only one supervisor and the majority of the admissions come on 3-11 so the other staff members will pick up tasks like vitals, height, weight, belongings, medication orders. Usually it's one person doing the assessment, but all nurses are able to complete the assessments. Everyone works together to get it done. Every resident is a bit different, the elopement assessment questions asks if residents are stating they don't want to be here, is there a history of wandering, are they ambulatory. You can pretty much tell who is going to be a risk and who isn't. I'm not sure what the magic score number is, I think it might be 5. During an interview on 5/19/26, at 12:48 p.m. the Nursing Home Administrator (NHA) and DON stated, There is no hard score for the elopement assessment, per the policy. It doesn't state that if you score X, you are automatically an elopement risk. Anyone can do the assessments, it's not just the supervisor completing the assessments. During an interview on 5/20/26, at 9:03 a.m. the NHA stated all staff members received education on elopement prevention, visitor management, and Code [NAME] procedures. During an interview on 5/20/26, at 9:20 a.m. Regional Director of Clinical Services Employee E13 confirmed the facility policy Elopement Unauthorized Absence does not include guidance on how to identify a resident as an elopement risk or follow-up direction for staff after a resident has been identified as an elopement risk. On 5/20/26, at 9:36 a.m., the NHA was made aware that Immediate Jeopardy (IJ) was called due to the elopement of Resident R1 on 5/10/26. The NHA was provided an Immediate Jeopardy template, and a corrective action plan was requested. On 5/20/26, at 10:48 a.m. the facility provided a list of in-house staff members with documentation indicating the facility had 129 in-house staff members. 117/129 of in-house staff members had documentation that they received education on elopement prevention, visitor management, and Code [NAME] procedures on 5/11/26. On 5/20/26, at 11:17 a.m. the facility provided additional documentation indicating 127/129 in-house staff members received education on elopement prevention, visitor management, and Code [NAME] procedures on 5/11/26. On 5/20/26, at 11:18 a.m. Human Resources Employee E14 provided a list indicating the facility had six agency staff members and seven therapy services staff members. Facility-provided documentation indicated 6/6 agency staff members and 7/7 therapy services staff members had received education on elopement prevention, visitor management, and Code [NAME] procedures on 5/10/26, 5/11/26, and 5/12/26. On 5/20/26, at 4:47 p.m. an acceptable Corrective Action Plan was received which included the following interventions: The elopement policy was reviewed without revision by the Administrator and Director of Nursing Services on 5/10/26. All residents had new observations completed and interventions put in place by the Social Services Director and/or Administrative Nurse Representatives on 5/10/26. All care plans and orders were implemented/revised in accordance with new elopement observations by the Director of Social Services and/or Licensed Nurse Representatives on 5/10/26. Additional review of care plans were conducted, reviewing and revising as needed to support increased individuality in approaches and interventions. By the Director of Nursing and/or Licensed Nurse Representatives on 5/20/26. Staff including those working onsite and offsite on received required education, off site staff were individually notified and educated upon contact. Completed by the Administrator and Mangers on 5/10/26. Reception staff was educated on sign in/sign out expectations related to reception by the Business Office Manager on 5/20/26. Staff including those working onsite and offsite on received required education, off site staff were individually notified and educated upon contact. Completed by the Administrator and Managers on 5/10/26. The center implemented and educated on a licensed nurse elopement risk monitoring and intervention process for residents identified as at risk for wandering or elopement. The implemented process includes enhanced expectations for timely reporting and communication of wandering behaviors, completion of licensed nurse observations in response to identified behaviors or triggering events, and development and implementation of individualized interventions based upon resident-specific risk factors and behaviors. As part of the new process, licensed nurses were provided with standardized education, intervention examples, and an elopement prevention resource toolkit intended to support ongoing assessment, monitoring, documentation, and individualized care planning practices. Education and implementation of the new process were completed by the Director of Nursing and/or Administrative Nurse Representatives to be completed by 5/20/26. Additional reviews of care plans were conducted, reviewing and revising as needed to support increased individuality in approaches and interventions on 5/10/26. All care plans and orders were implemented/revised in accordance with new elopement observations by the Director of Social Services and/or Licensed Nurse Representatives, on 5/10/26. Root Cause Analysis: residents were not reassessed at risk for elopement after expression of wanting to leave the center, in addition to unattended elevator access and reception intervention as determined by the Administrator and Director of Nursing. Daily elopement prevention and access monitoring audits are being conducted by the Director of Nursing/Designee to monitor compliance with elopement prevention practices, visitor and employee access procedures, staff assistance practices and education completion to ensure reasonable and practicable precautions are maintained to reduce a foreseeable risk. 5/11/26 and 5/19/26 QAPI (Quality Assurance and Performance Improvement) ad hoc (done as needed) review of audits have demonstrated success results during the review period. As completed by the Administrator and Director of Nursing implemented 5/10/26. On 5/21/26, at 9:15 a.m. it was verified 168/168 residents had new elopement observations completed on 5/10/26. 16/168 residents were identified as at risk for elopement. 16/16 resident physician orders were verified for an electronic monitoring bracelet. 16/16 care plans were reviewed and updated to include interventions to prevent elopement. On 5/21/26, at 9:24 a.m. it was verified 34/35 licensed nurse staff received additional education regarding elopement risk monitoring and intervention process for residents identified as at risk for wandering or elopement. 8/8 staff members identified as receptionists or fill-in receptionists received education related to visitor sign in/sign out expectations related to elopement prevention and center safety. Review of facility-provided documents on 5/21/26, at 9:30 a.m., revealed the facility had 129 employees, six agency employees, and seven therapy services employees. 140 employees signed they received formal education on elopement prevention, visitor management, and Code [NAME] procedures on 5/10/26, 5/11/26, and 5/12/26. During employee interviews on 5/21/26, from 10:09 a.m. through 1:30 p.m. 37 employees confirmed they had received education on the facility's elopement prevention, visitor management, Code [NAME] procedures, and elopement risk monitoring and intervention process for residents identified as at risk for wandering or elopement. During employee interviews on 5/21/26, the State Agency identified two staff members who stated they worked through a staffing agency and denied they had received education from the facility regarding elopement prevention, visitor management, and Code [NAME] procedures. Review of the facility-provided agency employee list failed to include the names of the two identified staff members. During an interview on 5/21/26, at 11:15 a.m. the State Agency requested an accurate list from the facility containing all staff members who work through a staffing agency. During an interview on 5/21/26, at 12:45 p.m. Human Resources Employee E14 stated an updated agency list was being printed at that time. During an interview on 5/21/26, at 1:47 p.m. the State Agency still had not been provided an accurate list containing all agency staff members, which had previously been requested on 5/21/26, at 11:15 a.m. During this interview, the NHA stated, I was not aware that all agency staff members needed to be educated. During this interview, the NHA confirmed that the facility did not provide education to all agency staff members on elopement prevention, visitor management, and Code [NAME] procedures as previously stated by the facility. On 5/21/26, at 2:08 p.m. it was verified the facility had 14 residents currently identified as elopement risks. 14/14 resident physician orders were verified for an electronic monitoring bracelet. 14/14 care plans were reviewed and updated to include resident-centered interventions to prevent elopement. On 5/21/26, at 3:20 p.m. a list was provided to the State Agency containing 40 employees who work through a staffing agency. 22/40 agency employees had signed that they received education on elopement prevention, visitor management, Code [NAME] procedures, and elopement risk monitoring and intervention process for residents identified as at risk for wandering or elopement. Human Resources Employee E14 stated phone messages were left for the remaining 18 agency employees and those employees would receive education prior to working their next scheduled shift at the facility. The Immediate Jeopardy was lifted on 5/21/26, at 3:27 p.m. when the action plan implementation was verified. During an interview on 5/21/26, at 3:27 p.m. the NHA confirmed that the facility failed to ensure proper supervision for a resident (Resident R1) resulting in an elopement from the facility, resulting in Immediate Jeopardy. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(3)(e)(1) Management.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(5) Nursing Services.

Based on review of facility policy, facility documentation and clinical record, and resident and staff interviews, it was determined that the facility failed to ensure that one of two residents reviewed (Resident R1) was free of neglect during care which resulted in actual harm of a fracture of the distal right tibia (fracture of the shin bone near the ankle). This deficiency is cited as past non-compliance. Findings include: Review of facility policy entitled Pennsylvania Resident Abuse, dated 1/19/24, indicated that the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. It is the facilities policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property and injuries of unknown source. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019 indicated that a Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of Resident R1's admission record indicated that Resident R1 was admitted to the facility 4/5/23. Review of Resident R1's Minimum Data Set (MDS - an assessment tool used to facilitate the management of care) assessment dated [DATE], indicated diagnoses of hypertensive heart and chronic kidney disease with heart failure, and atrial fibrillation (disease of the heart characterized by irregular or often faster heartbeat). Further review of MDS indicated that Resident R1 is dependent for chair/bed-to-chair transfers in which helper does all of the effort; resident does none of the effort to complete the activity; Or the assistance of two or more helpers is required for the resident to complete the activity. Further review of MDS indicated BIMS score of 15 cognitively intact. Review of active physician orders indicated that on date 6/28/23, Resident R1 was ordered a Transfer status: full body mechanical lift every shift. Review of Resident R1's care plan with an identified Problem focus category ADL's Functional Status/Rehabilitation Potential, with an initiated date of 10/19/23, indicated under approach, Resident R1 is to be provided full body mechanical lift assistance for transfers. An additional approach initiated 11/29/23, indicated Resident R1's transfer status hoyer lift (a device that helps caregivers transfer patients with limited mobility from one place to another). Review of current Resident Profile (an easy reference of resident care needs for the nursing assistants to reference), indicated that on 10/19/23, Resident R1 is to be provided full body mechanical lift assistance for transfers; further indicated that on 11/29/23, Resident R1's transfer status hoyer lift. Review of Resident R1's clinical record revealed a nursing note dated 3/13/24, at 12:29 p.m., which revealed her complaining about her right leg and how it was hurting. Right shin was found to be shiny, red, edematous (swelling) and warm to touch. Patient (Resident R1) states it was hit last night being put to bed. Review of Resident R1 nursing note dated 3/13/24, at 4:15 p.m., revealed resident was assessed by a Registered Nurse (RN) Employee E1 due to complaints of right lower extremity pain. Resident R1 was found to have a 10x6 cm (centimeter) raised area that was firm to touch and painful to palpitation and movement. Per note, physician was made aware with new order for stat x-ray (diagnostic test that captures images of the structures inside the body). Review of Resident R1 nursing note dated 3/14/24, at 12:28 a.m., revealed that x-ray results received identified a comminuted nondisplaced fracture of the distal right tibia. Per note, new order by physician to make appointment with Orthopedics (branch of medicine dealing with the correction of deformities of bones or muscles) as soon as possible for 3/14/24. Review of Resident R1 nursing note dated 3/15/24, at 12:51 p.m., Resident R1 consulted with Orthopedic physician, follow-up in one week, and that short leg cast applied at visit. Review of facilities investigation revealed that on 3/14/24, at 4:00 p.m., Resident R1 was interviewed by the Director of Nursing stating that one lady lifted her from her wheelchair to the bed mangled my leg hit it on something done there as she motioned to the bed frame below her. An additional interview was conducted with Resident R1 at 9:45 p.m., by the DON, who stated a women was putting her (Resident R1) to bed. She (NA Employee E2) just grabbed me up and she (Resident R1) told her (NA Employee E2) she couldn't walk. She (NA Employee E2) put my (Resident R1) feet on top of hers and moved me. Then she (NA Employee E2) bumped her (Resident R1) right leg off of the bed. Review of the facility's investigation revealed that on 3/15/24, at 2:45 p. m., the Nursing Home Administrator (NHA) interviewed Resident R1 who stated that a woman (Employee E2) tried to put me in bed without a hoyer. She (NA Employee E2) got in front of her (Resident R1), picked her up, and told her (Resident R1) to hold her (NA Employee E2) around the neck. Resident R1 further stated that the bed was not at the right height and my leg hit the bed. Review of the facility's investigation revealed an interview with Employee E2 was conducted on 3/14/24, at 9:01 p.m., by the NHA and DON, indicated which unit she (NA Employee E2) was working on (1B), was using the sit-to-stand (a type of mobility device) with Resident R1, without assistance, and that she (Resident R1) complained of her legs hurting. NA Employee E2 further stated in interview that who she took report from said she (Resident R1) was a sit-to-stand, and that her (Resident R1) transfers change all the time, and that she (NA Employee R2) doesn't think she bumped her (Resident R1) leg at all. Review of the facility's investigation witness statement dated 3/15/24, NA Employee E3 stated that she did give NA Employee E2 report, but doesn't recall giving report of specific transfer status for Resident R1, and that she (NA Employee E3) has always only transferred Resident R1 with a hoyer lift. Review of documentation submitted by the facility dated 3/14/24, revealed that the facility initiated an investigation, regarding resident abuse on 3/13/24. The investigation revealed that NA Employee E2 was terminated. Interview conducted with NHA on 3/20/24, at 3:40 p.m., confirmed that NA Employee E1 failed to transfer a resident properly who required full body mechanical lift assistance with a hoyer lift. The facility failed to ensure that Resident R1 was free from neglect resulting in actual harm of a fracture of the distal right tibia from the improper transfer which required the use of a hoyer lift. This deficiency is cited as past non-compliance. On 3/15/24, the facility initiated education for all nursing staff including Registered Nurse's (RN's), Licensed Practical Nurses (LPN's), and NA's to ensure that resident transfers are performed per resident care plans. This plan included the following: Termination of Employee E2 on 3/15/24. Immediate education regarding abuse, neglect, and exploitation, in addition to following proper transfer protocol was provided to nursing staff which included RN's, LPN's, and NA's, which occurred on 3/14/24, through 3/15/24. Education included how to access Care plan and Resident Profile to review transfer status prior to transfers. Immediate NA competency questionnaire was obtained and re-education was provided for those NA's who were identified as having concerns related to location of residents transfer status, or concerns regarding their level of comfort with transfers protocols, which occurred 3/14/24, through 3/15/24. Review of all resident transfer status compared with resident care plan and Resident Profiles was completed on 3/15/24. Interview questionnaire with alert and oriented residents was conducted regarding abuse, care needs being met, witnessing and reporting abuse, and how transferred from bed to chair, which occurred 3/14/24. Facility conducted whole house skin checks/audits to determine any other injuries due to improper transfers, which occurred 3/14/24. Interviews with LPN Employees E4, E5, and E6 and Na Employees E3, E7, E8, E9, E10, and E11 on 3/20/24, confirmed that the facility initiated education on 3/14/24, which included reporting abuse, neglect, and exploitation timely, following proper transfer protocols, and how to check a residents current transfer status. Audits were conducted to ensure residents are transferred per their care plan/Resident Profile which occurred on 3/15/24, through 3/20/24. Per interview with the NHA these audits will be reviewed by the Quality Assurance Performance Improvement (QAPI) Committee meeting and will continue until determined otherwise by the QAPI committee. During an interview with the NHA 3/21/2024 at 1:15 p.m. and review of the facility's immediate actions, education, audits, and QAPI monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction to ensure residents are free from neglect regarding transfer status of residents and had achieved substantial compliance as of 3/16/24. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, facility documentation, and resident and staff interviews, it was determined that the facility failed to provide adequate supervision and implement effective transfer interventions as per physician order to promote resident safety, resulting in a preventable accident and actual harm when the resident received a fracture of the distal right tibia, one of two residents reviewed (Resident R1). This deficiency is cited as past non-compliance. Findings include: Review of facility policy entitled Incident/Accident Policy, dated 1/19/24, indicated an incident/accident is any occurrence which is not consistent with the routine care of a particular resident. An incident/accident can occur anywhere and be discovered by anyone (resident, visitor, employee or volunteer). All incident/accidents involving residents will be analyzed and reported. Review of facility policy entitled Mechanical Lift Policy, dated 1/19/24, indicated a mechanical lift may be used for transferring residents that cannot be safely transferred by themselves or with staff assistance. Lift devices are available for general nursing care units and may be utilized by staff that have demonstrated competency. Residents ' transfer status will be assessed on admission, quarterly and as needed with any change in the resident ' s transfer ability. It will be determined if a mechanical lift and which type of lift is required. The decision will be based on nursing judgement and/or therapy evaluation and recommendation. Two staff person assist/oversight is required for total body lifts while one person assist is satisfactory for sit-to-stand lifts. A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019 indicated that a Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment ). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of Resident R1's admission record indicated that Resident R1 was admitted to the facility 4/5/23. Review of Resident R1's Minimum Data Set (MDS - an assessment tool used to facilitate the management of care) assessment dated [DATE], indicated diagnoses of hypertensive heart and chronic kidney disease with heart failure, and atrial fibrillation (disease of the heart characterized by irregular or often faster heartbeat). Further review of MDS indicated that Resident R1 is dependent for chair/bed-to-chair transfers in which helper does all of the effort; resident does none of the effort to complete the activity; Or, the assistance of two or more helpers is required for the resident to complete the activity. Further review of MDS indicated BIMS score of 15 cognitively intact. Review of active physician orders indicated that on date 6/28/23, Resident R1 was ordered a Transfer status: full body mechanical lift every shift. Review of Resident R1's care plan with an identified Problem focus category ADL's Functional Status/Rehabilitation Potential, with an initiated date of 10/19/23, indicated under approach, Resident R1 is to be provided full body mechanical lift assistance for transfers. An additional approach initiated 11/29/23, indicated Resident R1's transfer status hoyer lift (a device that helps caregivers transfer patients with limited mobility from one place to another). Review of current Resident Profile (an easy reference of resident care needs for the nursing assistants to reference), indicated that on 10/19/23, Resident R1 is to be provided full body mechanical lift assistance for transfers; further indicated that on 11/29/23, Resident R1's transfer status hoyer lift. Review of Resident R1's clinical record revealed a nursing note dated 3/13/24, at 12:29 p.m., which revealed her complaining about her right leg and how it was hurting. Right shin was found to be shiny, red, edematous (swelling) and warm to touch. Patient (Resident R1) states it was hit last night being put to bed. Review of nursing notes dated 3/13/24, at 4:15 p.m., revealed Resident R1 was assessed by a Registered Nurse (RN) Employee E1 due to complaints of right lower extremity pain. Resident R1 was found to have a 10x6 cm (centimeter) raised area that was firm to touch and painful to palpitation and movement. Per note, physician was made aware with new order for stat x-ray (diagnostic test that captures images of the structures inside the body). Review of nursing notes dated 3/14/24, at 12:28 a.m., revealed that x-ray results received identified a comminuted nondisplaced fracture of the distal right tibia. Per note, new order by physician to make appointment with Orthopedics (branch of medicine dealing with the correction of deformities of bones or muscles) as soon as possible for 3/14/24. Review of nursing note dated 3/15/24, at 12:51 p.m., Resident R1 consulted with Orthopedic physician, follow-up in one week, and that short leg cast applied at visit. Review of the facility's investigation revealed that on 3/14/24, at 4:00 p.m., Resident R1 was interviewed by the Director of Nursing stating that one lady lifted her from her wheelchair to the bed mangled my leg hit it on something done there as she motioned to the bed frame below her. An additional interview was conducted with Resident R1 at 9:45 p.m., by the DON, who stated a women was putting her (Resident R1) to bed. She (NA Employee E2) just grabbed me up and she (Resident R1) told her (NA Employee E2) she couldn't walk. She (NA Employee E2) put my (Resident R1) feet on top of hers and moved me. Then she (NA Employee E2) bumped her (Resident R1) right leg off of the bed. Review of the facility's investigation revealed that on 3/15/24, at 2:45 p.m., the Nursing Home Administrator (NHA) interviewed Resident R1 who stated that a women (Employee E2) tried to put me in bed without a hoyer. She (NA Employee E2) got in front of her (Resident R1), picked her up, and told her (Resident R1) to hold her (NA Employee E2) around the neck. Resident R1 further stated that the bed was not at the right height and my leg hit the bed. Review of the facility's investigation revealed an interview with Employee E2 was conducted on 3/14/24, at 9:01 p.m., by the NHA and DON, indicated which unit she (NA Employee E2) was working on (1B), was using the sit-to-stand (a type of mobility device) with Resident R1, without assistance, and that she (Resident R1) complained of her legs hurting. NA Employee E2 further stated in interview that who she took report from said she (Resident R1) was a sit-to-stand, and that her (Resident R1) transfers change all the time, and that she (NA Employee R2) doesn't think she bumped her (Resident R1) leg at all. Review of the facility's investigation witness statement dated 3/15/24, NA Employee E3 stated that she did give NA Employee E2 report, but doesn't recall giving report of specific transfer status for Resident R1, and that she (NA Employee E3) has always only transferred Resident R1 with a hoyer lift. Review of documentation submitted by the facility dated 3/14/24, revealed that the facility initiated an investigation, regarding resident abuse on 3/13/24. The investigation revealed that NA Employee E2 was terminated. Interview conducted with NHA on 3/20/24, at 3:40 p.m., confirmed that NA Employee E1 failed to transfer a resident properly who required a total/full body mechanical lift assistance with a hoyer lift, which requires assistance of 2 staff members. The facility failed to ensure that Resident R1 was provided adequate supervision and implement effective transfer interventions and was free from an avoidable accident/injury resulting in actual harm of a fracture of the distal right tibia from the improper transfer which required the use of a hoyer lift, with assistance of 2 staff members. This deficiency is cited as past non-compliance. On 3/15/24, the facility initiated education for all nursing staff including Registered Nurse's (RN's), Licensed Practical Nurses (LPN's), and NA's to ensure that resident transfers are performed per resident care plans. This plan included the following: Termination of Employee E2 on 3/15/24. Immediate education regarding abuse, neglect, and exploitation, in addition to following proper transfer protocol was provided to nursing staff which included RN's, LPN's, and NA's, which occurred on 3/14/24, through 3/15/24. Education included how to access Care plan and Resident Profile to review transfer status prior to transfers. Immediate NA competency questionnaire was obtained and re-education was provided for those NA's who were identified as having concerns related to location of residents transfer status, or concerns regarding their level of comfort with transfers protocols, which occurred 3/14/24, through 3/15/24. Review of all resident transfer status compared with resident care plan and Resident Profiles was completed on 3/15/24. Interview questionnaire with alert and oriented residents was conducted regarding abuse, care needs being met, witnessing and reporting abuse, and how transferred from bed to chair, which occurred 3/14/24. Facility conducted whole house skin checks/audits to determine any other injuries due to improper transfers, which occurred 3/14/24. Interviews with LPN Employees E4, E5, and E6 and Na Employees E3, E7, E8, E9, E10, and E11 on 3/20/24, confirmed that the facility initiated education on 3/14/24, which included reporting abuse, neglect, and exploitation timely, following proper transfer protocols, and how to check a residents current transfer status. Audits were conducted to ensure residents are transferred per their care plan/Resident Profile which occurred on 3/15/24, through 3/20/24. Per interview with the NHA these audits will be reviewed by the Quality Assurance Performance Improvement (QAPI) Committee meeting and will continue until determined otherwise by the QAPI committee. During an interview with the NHA 3/21/24 at 1:15 p.m. and review of the facility's immediate actions, education, audits, and QAPI monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction to ensure residents are free from accidents/incidents regarding transfer status of residents and had achieved substantial compliance as of 3/16/24. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and records, and staff interviews, it was determined that the facility failed to provide adequate supervision that resulted in actual harm of fractures of the right tibia and fibula (lower leg bones) for one of four residents reviewed (Resident R1). Findings include: Review of the Resident Assessment Instrument (RAI) 3.0 User's Manual effective October 2019, indicated that bed mobility is defined as how resident moves to and from lying position, turns side or side, and positions body while in bed or alternate sleep furniture. The RAI further indicated that How a resident turns from side to side, in the bed, during incontinence care, is a component of Bed Mobility and should not be considered as part of Toileting. The Manual further indicated that a Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of American Congress of Rehabilitation Medicine - Caregiver Guide and Instructions for Safe Bed Mobility published 4/28/17, indicated bed mobility refers to activities such as scooting in bed, rolling, side-lying to sitting, and sitting to lying down. Review of facility document entitled, Fall Guidelines dated 6/27/22, indicated the facility will promote resident safety by identifying residents at risk for falls and implementing resident specific interventions to reduce the risk of falls. Review of Resident R1's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated 7/5/22, indicated diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), [CONDITION(S)] (chronic disease in which a person has a body mass index (BMI) of 40 or higher or a BMI of 35 or higher and is experiencing obesity-related health conditions), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Resident R1's MDS assessments, Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R1's score to be 6, severe impairment. Review of Resident R1's MDS assessments, Section G - Functional Status, Questions G0110A, ADL Assistance for bed mobility, dated 2/10/21, 3/23/21, 6/8/21, 9/8/21, 10/19/21, 1/9/22, 4/5/22, and 7/5/22, indicated that Resident R1 required extensive assistance of two or more staff members. Review of the Therapy Progress and Discharge Summary document, dated 7/8/22, that for the functional deficit of rolling left and right, Resident R1 was documented as: Dependent-Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Review of the physician's orders effective on 7/20/22, failed to reveal an order related to bed mobility. Review of Resident R1's fall risk assessments revealed that she had been consecutively assessed as a high fall risk 12 times, from 5/19/20, through 7/8/22. Review of Resident R1's plan of care for ADL (activities of daily living) Self-care performance deficit initiated 10/18/19, indicated that on 4/9/20, the care plan was updated to reflect that Resident R1 required the assistance of two persons for bed mobility. Review of hospital discharge paperwork dated 7/22/22, indicated that Resident R1 was treated for a fractured tibia and fibula, with the notation of overall patient has poor prognosis because of dementia and being a poor candidate for any surgery or rehab, will recommend transition to palliative care (medical caregiving approach aimed at optimizing quality of life and mitigating suffering among people with serious, complex, and often terminal illnesses) at rehab facility if no improvement in functional status after two weeks. She is also high risk for bleeding and falls, poor risk for anticoagulation. Review of a progress note written by Registered Nurse (RN) Employee E7 dated dated 7/20/22, at 9:30 p.m. indicated while providing evening care, resident had a large bowel movement, while in the process of cleaning resident she her left leg slipped to the side of the mattress, the left leg was then placed back onto the bed, then while removing soiled linens, resident proceeded to roll out of her bed landing on her right side, resident cognitive status at her baseline, noted a large laceration to her left hand, also noted her right foot was completely turned around, resident yelling out stating she was in severe pain, unable to thoroughly assess resident due to the fact that it was not safe to change the resident's position, resident was laying on her right side, she had her left hand laying across the floor was a significant laceration, area cleaned and [MEDICATION(S)] (non-adherent dressing pad) placed and gauze wrapped, her right hand and arm was placed under her head, her left leg was placed over her right leg, resident unable to state whether she had hit her head, resident's cognitive status at her baseline, resident unable to give any details of incident. Review of an electonic communication on 8/22/22, at 10:51 a.m. indicated that (NA Employee E1) was rolling resident (Resident R1) to change her soiled brief and the resident started rolling out of bed. NA Employee E1 was unable to stop her from rolling out of the bed and the resident rolled onto the floor. During the investigation, NA Employee E1 stated resident would assist by grabbing bilateral assistive handrails to assist with turning. During an interview on 8/12/22, at 12:50 p.m. NA Employee E3 was asked how she would know the bed mobility status for a resident. When asked if she used the electronic charting system, she stated that she would not, and that she uses the facility's Safety Equipment Sheet. NA Employee E3 provided a copy of the third-floor sheet to the surveyor, dated 8/4/22. During an interview on 8/12/22, at 12:54 p.m. NA Employee E4 was asked how she would know the bed mobility status for a resident. NA Employee E4 confirmed that she uses the facility's Safety Equipment Sheet. During an interview on 8/12/22, at 1:02 p.m. NA Employee E2 was asked how she would know the bed mobility status for a resident. NA Employee E2 confirmed that she uses the facility's Safety Equipment Sheet in addition to the electronic charting system. During an interview on 8/12/22, at 1:05 p.m. NA Employee E5 was asked how she would know the bed mobility status for a resident. NA Employee E5 confirmed that she uses the facility's Safety Equipment Sheet. NA Employee E3 provided a copy of the second-floor sheet to the surveyor, dated 8/11/22. During an interview on 8/12/22, at 1:25 p.m. NA Employee E6 was asked how she would know the bed mobility status for a resident. When asked if she used the electronic charting system, she stated that she would not, and that she uses the facility's Safety Equipment Sheet. NA Employee E3 provided a copy of the first-floor sheet to the surveyor, dated 8/11/22. Review of the first-, second-, and third-floor Safety Equipment Sheets indicated only safety and positioning equipment to be used, it failed to reveal any bed mobility statuses. During an interview on 8/12/22, at approximately 2:00 p.m. the Director of Nursing confirmed that only one nurse aide provided care during Resident R1's fall on 7/20/22. During an interview on 8/12/22, at approximately 2:15 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide adequate supervision that resulted in actual harm of a fractures of the right tibia and fibula (lower leg bones) for one of four residents. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited: 10/29/21. 28 Pa. Code 201.18(b)(1) Management. Previously cited: 9/22/20, 10/29/21. 28 Pa. Code 201.18(e)(1) Management. Previously cited: 10/29/21. 28 Pa. Code 201.20(b) Staff Development. Previously cited: 10/29/21. 28 Pa. Code 211.10(c) Resident care policies Previously cited: 10/29/21. 28 Pa. Code 211.10(d) Resident care policies Previously cited: 9/22/20, 10/29/21. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa Code 211.12(d)(1)(2)(5) Nursing services. Previously cited: 9/22/20, 10/29/21.