Every finding on record at Quadrangle

Based on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Findings include: A tour of the Food Service Department was conducted on February 24, 2026, at 9:20 a.m. with Employee E4, Sous Chef, revealed the following concerns: Observation in the reach-in refrigerator revealed two shopping bags containing personal food/drink. Observation in the kitchen revealed two ice cream freezers with clear tops that were smeared with a milky-whiteish sticky substance and several of the 3-gallon ice cream containers were not covered. Observation in the walk-in refrigerator revealed a shelving unit with a broken bottom shelf with a container of food hanging off. The floor in the cooler was dirty and had debris. Observation in the walk-in freezer revealed a rack with fruit pies that were not covered. Observation of the convection ovens revealed heavy build-up of black baked-on food particles on the inside surface of the ovens, especially the top two ovens. Observation of other cooking equipment revealed the outside surfaces, especially the legs were spattered with dirt and debris. Observation in the dry storage area revealed no designated location for dented cans. Observation in the second floor pantry revealed a hole in the wall behind the dish sink adjacent to the dish machine. Interview with the Sous Chef on February 24, 2026, at 9:20 a.m. confirmed the above findings. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on clinical record review, review of professional literature, review of facility policies and interviews with staff, it was determined that the facility failed to assess a PICC (Peripheral inserted central catheter) in accordance with professional practice standards for two of two residents with IV (intravenous lines). (Resident R9 and Resident R46).Findings include: Review of the undated facility policy, Quick Reference Guide, PICC Lines revealed that when the resident moves in it is important to obtain and document the following information:The date the PICC line was insertedA baseline measurement of the upper arm circumference of the arm with the PICC lineThe length of the PICC line.The following interventions are recommended as a part of the resident's ISP:Indicate the resident's arm circumference and length of the PICC line. According to the standards of nursing practice guidelines in the Journal of the American Nurse's Association, dated November 2013, complications of a PICC line (Peripherally Inserted Central Catheter Line, type of IV used for long term use) includes, but is not limited to catheter-tip migration (assessed by external length of the catheter-amount of catheter tubing that is visible outside of the vein moves from original insertion and may cause medical complications). Clinical record review for Resident R9 revealed that the resident was admitted on [DATE], with a right upper arm PICC Line to be used for IV antibiotic therapy. Further review of the clinical record revealed a January 19, 2026, order for PICC line change dressing weekly on Wednesday evening shift. Review of January 2026's physician orders revealed that there was no order obtained to assess and document the external catheter length or the midarm circumference to avoid complications associated with PICC lines. Review of January and February 2026's Medication Administration Report (MAR) did not reveal documentation of the external catheter length or the mid arm circumference. A review of the nursing progress notes did not reveal any documentation of the external catheter length or the mid arm circumference on the days the PICC line dressing was changed or any other day. Interview with the Licensed Nurse, Employee E6, on February 24, 2026, at 11:25 a.m. revealed that she was not aware of documentation of the external catheter length and arm circumference for Resident R9. Review of Resident R46's clinical record revealed that the resident was admitted on [DATE], with a diagnoses of Pulmonary Hypertension (high lung pressure), and Asthma (breathing airway swelling). Continued review of the resident's clinical record revealed that Resident R9 was admitted with a right upper arm PICC line for IV antibiotic therapy. Observation conducted on February 24, 2026, at 1:00 p.m. revealed the resident had a Peripherally Inserted Central Catheter (PICC) line in the right upper arm. Further review of the clinical record revealed a physician's order to change the IV dressing and needleless connector (caps), and to measure the external catheter length and the circumference of the arm 3 centimeters above the IV insertion site weekly every Friday on the evening shift with each dressing change. Review of February 2026 Medication Administration Record (MAR) did not reveal a designated area to document the external catheter length or the mid-arm circumference. Review of January and February 2026 nursing progress notes did not reveal documentation of the external catheter length or the arm circumference on the days the PICC line dressing was changed or on any other date. Interview with the Director of Nursing, Employee E2 on February 26, 2026, at 2:05 p.m. confirmed that the facility did not document the external catheter length or mid arm circumference for Resident R9 or Resident R46.28 Pa. Code S211.5(f) Clinical records28 Pa. Code S211.12(d)(5) Nursing services.

Based on observation, record review, and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice of two of 18 residents reviewed (Residents R53, and R72).Findings include: Review facility policy title Oxygen, revealed that a nasal cannula (small tube that gives oxygen through the nose to help someone breathe easier), should labeled with date and your initials. Review of Resident R72's clinical record revealed the resident was admitted on [DATE], ,with diagnoses including hypo-osmolality (low salt level in the blood), other nonspecific abnormal finding of lung field, and hypertensive heart disease without heart failure (heart problems caused by high blood pressure without heart failure). Review revealed a January 18, 2026, physician's order revealed an order for oxygen at 2 liters per minute via nasal cannula. Observations conducted in Resident R72's room on February 24, 2026, at 9:52 a.m. revealed an oxygen concentrator (a machine that takes in room air and provides extra oxygen to help a person breathe easier) in use. The machine was set to deliver oxygen at 2 liters per minute through tubing connected to a nasal cannula, (a small soft tube placed in the resident's nostrils), The oxygen tubing was not labeled with the date or initial as indicated in the facility policy. Interview conducted on February 26, 2026, at 9:54 a.m. with Registered Nurse, Employee E17 confirmed that Resident R72's oxygen tubing and concentrator was not labeled per facility policy., Observations in Resident R53's room [ROOM NUMBER] on February 24, 2026, at 10:50 a.m. revealed a CPAP machine (continuous positive airway pressure, machine is one of the most common treatments for sleep apnea. It keeps airways open while you sleep so you can receive the oxygen you need) on the nightstand and two oxygen concentrators next to the nightstand. Interview with Resident R53 revealed that (she/he) was using the CPAP machine every night along with oxygen while sleeping and that the staff would make sure that (she/he) has fresh distilled water and put the mask on before going to sleep. Review of Resident R53's clinical record revealed an admission date of January 18, 2026, with diagnoses including obstructive sleep apnea (a common sleep disorder where the airway repeatedly becomes blocked during sleep, causing pauses in breathing and disrupted sleep). Further review revealed a January18, 2026, physician's order for oxygen at 2 lpm via nasal cannula at hour of sleep every evening and night shift. Exhaustive review of R53's physician orders revealed no order for CPAP. Interview with the Registered nurse, Employee E10 on February 26, 2026, at 1:28 p.m. confirmed that Resident R53 was using the CPAP machine at night with the oxygen, and that there was not order for the CPAP machine. Interview with the Director of Nursing on February 26, 2026, at 2:15 p.m. confirmed that there was no order for the CPAP machine for Resident R53. 28 Pa. code 211.12(d)(1)(2) Nursing Services

Based on staff interviews and a review of employee credentials, it was determined that the facility failed to employ a qualified director of food and nutrition services. Findings include: An interview on February 24, 2026, at 9:20 a.m. with Employee E3, Sous Chef, revealed that the department had no Food Service Director (FSD) since the beginning of January, 2026, when the FSD left employment. Further the Executive Chef had quit without notice just before Christmas 2025. The Sous Chef (Employee E 4) indicated that he and the other Sous Chef were running the kitchen together at this time, splitting the duties of food orders, production schedules and managing the staff. He indicated that he was not a Certified Dietary Manager (CDM), and that the CDM for the healthcare side was on her way into the facility. Interview with Employee E8, listed on the facility phone list as Dietary Manager/CDM, on February 26, 2026, revealed that she is in charge on the nursing home side. She was asked to provide a copy of her CDM Certificate. Interview with the Administrator on February 27, 2026, at 11:45 a.m. confirmed that Employee E8 was not currently a certified dietary manager (CDM); or a certified food manager (CFM); or had a national certification for food service management and safety from a national certifying body; and that she had not received frequently scheduled consultations from a qualified dietitian. The Administrator further confirmed that the building has not had a CDM since the FSD retired in early January 2026. 28 Pa. Code 211.6(c)(d) Dietary services28 Pa Code 201.18(e)(1)(6) Management

Based on observations and an interview with staff it was determined that the facility did not ensure that garbage and refuse was disposed of properly.Findings include: An initial tour of the Food Service Department was conducted on February 24, 2026, at 9:20 a.m. with Employee E4, Sous Chef, which revealed the following: Observation in the outdoor receiving area revealed 5 wooden pallets piled near the wall to the left of the door, and another was standing on edge to the right of the door with two old chairs. Further observation in the receiving area revealed a trash compactor with a broken latch on the gate and the trash pit with bags of garbage exposed and the ram and cover in the open position. When the compactor was activated the ram compacted the garbage and the cover closed and when the process was complete the door opened again revealing the exposed trash in the pit. Interview with the Sous Chef (Employee E4) at 9:30 a.m. on February 24, 2026, confirmed the above findings and that he thought that the reason you could still see the trash was that maybe the compactor was full, and that the chairs were supposed to be discarded. Interview with the Facilities Manager, Employee E7 on February 27, 2026, at 11:00 a.m. confirmed that the latch on the gate was broken and that the compactor was in the open position with trash exposed. 28 PA Code: 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

Based on observations, review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to Transmission Based Precautions for two of two residents reviewed (Residents R1and R2) and an Infection Preventionist.Findings include:Review of facility policy, Infection Prevention and Control Program revised in July 2022, revealed that it is the community's policy to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Centers for Disease Control and Prevention (CDC) and the Association of Professionals in Infection Control and Epidemiology (APIC). Further review of policy revealed that The Skilled Nursing Administrator (SNA)/ Director of Nursing Services (DNS) designates a Registered Nurse as the Infection Preventionist (IP). The IP will: A. Be qualified by education, training, experience or certification B. work at least part-time at the facility; and C. have completed specialized training in infection prevention and control, D. be a member of the community's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis. The infection preventionist (IP) evaluates the infection prevention and control program to validate required components with include. A. Fundamental Principles of Infection Control B. Infection Control Program and Infrastructure C. Team member and Resident Safety D. Surveillance and Disease Reporting E. Standard Precautions F. Transmission Based Precautions G. Resident Suite Assignment H. Environmental Cleaning I Safe Injection Practices and Point of Care Testing J. Medication Storage and Handling K. Antibiotic Stewardship program.Interview with Director of Nursing, Employee E1 on September 3, 2025 at 9:05am revealed No infection preventionist in the building, someone is hired however there is not one currently. Interview with Nursing Home Administrator, Employee E2 on September 3, 2025 at 9:45am revealed Facility uses a Regional Registered Nurse, Employee E4, as their Infection Preventionist and she comes to facility a couple times a month. Review of Facility Assessment revealed Frequency relative to Benchmark is High related to infections including, Multidrug-resistant organism, Pneumonia, Septicemia, Urinary Tract Infection, Viral Hepatitis, and Wound Infection. Review of meeting notes for QAPI (Quality Assurance Performance Improvement Plan), no documented evidence of Employee E4, Infection Preventionist in attendance for meetings dated August 27, 2025. Interview with Director of Nursing, Employee E1, on September 3, 2025 at 1:30pm confirmed the Infection Preventionist was not in attendance for the QAPI meetings dated August 27, 2025. Review of facility's documentation revealed the last time the Infection Preventionist, Employee E4 was present at the facility was August 7, 2025. Review of Resident R1's clinical record revealed that resident was admitted on [DATE], with the diagnosis of Obstructive Uropathy (obstruction of urine flow). Review of Resident R1's care plan, date-initiated August 5, 2025, revealed Enhanced Barrier Precautions needed related to Suprapubic Catheter. Review of Resident R2's clinical record revealed that resident was admitted on [DATE], with diagnoses of Urinary Tract infection.Review of Resident R2's physician orders, dated August 22, 2025, revealed Enhanced Barrier Precautions.Review of Resident R2's care plan, date-initiated August 26, 2025, revealed The resident has potential for impairment in skin integrity, intervention initiated Enhanced Barrier Precautions. Observations conducted on September 3, 2025 at 11:00am, revealed signage for Enhanced Barrier Precautions on the room doors of Resident R1 and Resident R2. Further observation revealed that the isolation supply bin in front of room did not contain necessary isolation equipment including isolation gowns or gloves. Interview with Employee E3, Registered Nurse on September 3, 2025 at 11:05am confirmed findings of isolation supply bin in front of room did not contain necessary isolation equipment including isolation gowns or gloves 28 Pa Code 201.14(a) Responsibility of licensee28 Pa Code 201.18(d) Management

Based on review of facility policy, observation, and interviews with residents and staff, it was determined that the facility failed to ensure that residents and/or their representatives could file a grievance/concern anonymously by failing to ensure that grievance boxes were in place for residents or their representatives to anonymously drop their grievances/complaints for two of two units reviewed. (First floor and Second floor) Findings: Review of facility admission packet provided to residents and/or resident family upon admission revealed Resident Grievance Procedure included in the admission packet. Review of the Resident Grievance Procedure revealed that under section PROCEDURE: #1. Complete a Grievance form. Forms are in the Lobby, Activities room, Bistro, and Family Room. Resident /Family members can anonymously deliver their grievance for in the out-going box outside of the Activities Room on the second floor. The form will be addressed by the Grievance Coordinator. Observation of the first-floor lobby area in front of the elevator, and observation of all the public areas of the first floor conducted on June 12, 2025, at 10:45 AM revealed no grievance boxes. Observation of the second-floor lounge area in front of the elevator, and observation of all the public areas of the second floor conducted on June 12, 2025, at 10:52 AM revealed no grievance boxes. Interview with Facility Administrator Employee E1 conducted on June 12, 2025, at10:58m AM revealed that the grievance box was located outside of the social worker's office. Observation of the social worker's office conducted on June 12, 2025, at 11:04 AM together with facility administrator Employee E1 and Social Worker Employee E3 revealed that an out-going wall basket outside the social worker's office. Further, the out-going wall basket was mounted at chest level of a standing person. Further, the basket was not accessible to a person sitting in the wheelchair. Further, the basket did not have any label. Interview with the social worker Employee E3 conducted at the time of the observation revealed that she usually takes all complaints and grievances and writes the form for the residents. The forms are then addressed accordingly. Further Employee E3 also revealed that if the resident wants to file the grievance on their own, they can fill out the grievance form and drop it in the out-box located outside the social worker's office. Observation of the Activities Room on the second floor conducted on June 12, 2025, at 11:50AM revealed that there was no out-going box anywhere outside of the activities room or within the vicinity of the activities room. Interview with Employee E4 conducted at the time of the observation confirmed that there was no out-going box outside of the activities room. Further, Employee E4 revealed that there is an out-going box outside the social worker's office on the first floor where residents can submit their grievances. Interviews on June 12, 2025, with five randomly selected resident revealed that four of the five residents interviewed (Resident R1, R2, R3, and R4) did not know where the grievance box was located. One resident revealed that the location was in the papers provided to her upon admission. 28 Pa. Code 201.14(a)Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)Resident rights

Based on observations, review of facility policy and staff interviews, it was determined that the facility failed to ensure that food was stored, prepared, distributed and served food in accordance with professional standards for food service safety. Findings include: Review of the facilities, Food Storage, Preparation and Service policy with a revision date of April 11, 2022 indicated that food storage areas included walk in and reach in refrigerators and freezers, under the counter refrigeration and freezer units, bistro and common area refrigerator and freezer units, and any dry storage area units. The policy also state that all food items are labeled, dated and rotated to maintain a system of First In First Out. Continued review of the policy indicated that all refrigeration, freezer and dry storage areas are outfitted with a properly calibrated thermometer. Observation of the 3rd floor kitchen on April 2, 2025 at 11:00 a.m. with the Director of Culinary Services (Employee 23), the Director of Maintenance (Employee E24) and the Nursing Home Administrator revealed the following: There were two ice cream freezer units with various flavors of ice cream them with no thermometer present in them. The temperature of the ice cream in the units could not be determined. The walk in freezer contained an ice cream container that had a brown paper-like lid that was torn, undated and not properly covering the ice cream resulting the ice cream being partially exposed. The container did not contain a date that it was opened by dietary staff, and did not contain a documented expiration date identified by dietary staff. A coffee flavored ice cream container in the walk in freezer had an opening date of March 18th written in by facility staff, but year documented on it, and no expiration date documented and identified on it by dietary staff. A [NAME] flavored ice cream container in the walk in freezer had an opening date as what appeared to be March 27th or March 29th, but no year documented on it and no expiration documented or identified on it by dietary staff. A butter pecan reduced fat ice cream in the walk in freezer has a brown paper like lid that was saturate with a wet red-like colored substance. The lid was just lying on top of the ice cream container and did not properly fit it, and appeared to be too big to fit the ice cream container. Although the ice had been open and used, there was no date documented by facility staff on the container indicating when it was opened, and no expiration date documented and identified by dietary staff. A box of crab legs were observed in the walk in freezer had been open, but there was no date documented by dietary staff on the container indicating when it was opened, and no expiration date documented ad identified by dietary staff. A box of croissants were observed in the walk in freezer were open, but there was no date documented by dietary staff on the container indicating when it was opened, and no expiration date documented and identified by dietary staff. A box of apple pastries were observed in the walk in freezer were open, but there was no date documented by dietary staff on the container indicating when it was opened, and no expiration date documented and identified by dietary. 28 PA Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management

Based on observations, it was determined that the facility failed to properly dispose of garbage and refuse. Findings Include: Observations on April 2, 2026 with the Culinary Director (Employee E23), the Director of Maintenance (Employee E24), and the Nursing Home Administrator on April 2, 2025 at 11:35 a.m. near the trash compactors (areas on the sides of , front of, back of, and underneath of the trash compactors) located near the loading dock receiving area revealed the following: Various trash items such as tops to jars, cans, sugar packets bottles and cardboard boxes were seen in the above referenced areas. The presence of fall leaves and 1 dinner plate was even also among the trash/debris. Various other trash items had been present for so long that they turned black, appeared moist, and the type of trash/debris it once was could not be determined due to its diminished appearance. A Styrofoam food container whose food compartments were filled with dark stagnant water, in addition to other trash/debis. A paper scattered around the trash compactors, in addition to plastic gloves, a white face or bath towel, and a cigarette butt. A clear plastic bag was observed in the back of one of the trash compactors filled with stagnant, black water. A strong stench was also present in the area of the trash compactors, in addition to grime (soot, smut, or dirt adhering to or embedded in a surface) present on the ground areas on the sides of, front of, back of, and underneath of the trash compactors. All of the above-referenced parties were present for the above referenced tour and observations regarding trash and debris in the in front of, on the side of, and in back of the trash compactors. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 207.2(a) Administrator's responsibility

Based on review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to ensure that the Office of the State Long-Term Care Ombudsman was notified of facility-initiated transfers and discharges, and failed to ensure that a 30-day discharge notice included required information, for four of four residents reviewed for discharge notices (Residents R57, R16, R59 and R58). Findings include: Review of facility documentation, Admission/Discharge To/From Report revealed that Resident R16 was transferred to the hospital on January 10, 2025; that Resident R59 was transferred to the hospital on January 17, 2025; and that Resident R58 was transferred to the hospital on January 9, 2025. Clinical record review for Resident R16 revealed a Transfer/Discharge note, dated January 10, 2025, at 10:56 a.m. which indicated that the facility was unable to meet the resident's needs and was transferred to the hospital. The resident was noted to be lethargic with acute change in mental status and the physician ordered for the resident to be transferred to the hospital. Clinical record review for Resident R59 revealed a Transfer/Discharge note, dated January 17, 2025, at 2:21 p.m. which indicated that the facility was unable to meet the resident's needs and was transferred to the hospital. The resident was noted with abnormal labs and the physician ordered for the resident to be transferred to the hospital. Clinical record review for Resident R58 revealed a Transfer/Discharge note, dated January 9, 2025, at 11:19 a.m. which indicated that the facility was unable to meet the resident's needs and was transferred to the hospital. The resident was noted with low blood oxygen levels, flank pain and elevated heart rate; the physician ordered for the resident to be transferred to the hospital. Interview on April 2, 2025, at 9:28 a.m. with Employee E7, Social Services Coordinator, revealed that the list of transfers and hospitalizations for January and February 2025, were not sent to the Office of the State Long-Term Care Ombudsman until March 31, 2025, at 5:07 p.m. after the information was requested by State Agents. Continued interview revealed that no notices were sent to the Office of the State Long-Term Care Ombudsman of facility-initiated transfers or discharges for October, November or December 2024. Employee E7, Social Services Coordinator, confirmed that notices for Residents R16, R59 and R58 were not sent to the Office of the State Long-Term Care Ombudsman in a timely manner as required. Clinical record review for Resident R57 revealed a social services note, dated March 11, 2025, at 1:20 p.m. which indicated that the resident had not made any payments towards his private pay bill. The resident was presented with a 30-day discharge notice with intent to discharge due to non-payment. Review of Resident R57's 30-day discharge notice, dated March 11, 2025, revealed that the resident had an outstanding balance of $15, 600 and that as a result of non-payment, the facility informed the resident that he was required to vacate the premises within 30 days of the date of the Notice. The notice stated that if the resident failed to leave, that the facility's attorneys will file a Complaint with the Magisterial District Judge seeking your eviction. The notice provided the resident with the contact information for the local county ombudsman office. On April 2, 2025, at 9:59 a.m. Resident R57's 30-day discharge notice was reviewed with the Nursing Home Administrator (NHA). The NHA confirmed that the notice did not contain the date of anticipated discharge; the address location of the anticipated discharge; information regarding the resident's right to appeal and well as how to file for an appeal; the contact information for the Office of the State Long-Term Care Ombudsman; and the contact information for the Pennsylvania Protection and Advocacy Agency for developmentally disabled or mentally ill individuals. Continued interview confirmed that the 30-day discharge notice was not sent to the Office of the State Long-Term Care Ombudsman at the time it was issued to the resident, as required. 28 Pa. Code 201.18(b)(2) Management

Based on clinical record reviews, review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that a resident was informed of charges for services not covered under Medicare, for one of three residents reviewed (Resident R61). Findings include: Clinical record review for Resident R61 revealed a social services note, dated October 14, 2024, at 3:18 p.m. which indicated that the resident was issued a NOMNC (Notice of Medicare Non-Coverage) with a last cover date of October 17, 2024. The note indicated that either discharge or alternate payor was due after that date. Continued review of social services notes for Resident R61 revealed a note, dated October 18, 2024, at 2:52 p.m. which indicated that the resident would discharge to an assisted living facility on October 21, 2024. Review of Resident R61's census data revealed that on October 17, 2024, the resident's Medicare A coverage ended and that on October 18, 2024, the resident paid out-of-pocket (privately paid) for skilled services until October 21, 2024, when the resident discharged from the facility. Continued review of facility documentation for Resident R61 revealed that the resident/resident's responsible party was not notified of the costs for skilled care after Medicare A coverage ended. Costs of care, as well as the election to receive those services, are required to be provided, in writing, on a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN). Interview on April 2, 2025, at 9:28 a.m. with Employee E7, Social Services Coordinator, revealed that Resident R61's responsible party should have been issued a SNF ABN, since the resident stayed at the facility and continued to receive skilled services that were paid for out-of-pocket. Employee E7, Social Services Coordinator, confirmed that Resident R61's responsible party did not receive the notice as required. 28 Pa Code 201.18(b)(2) Management

Based on review of facility policies, clinical record reviews, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to ensure that residents were free from abuse and neglect for two of 25 residents reviewed (Residents R16 and R57). Findings include: Review of facility policy, Abuse, Neglect and Exploitation - Prevention, Reporting and Investigation dated revised February 14, 2022, revealed, Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Continued review revealed, Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Further review revealed, 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. Interview on March 31, 2025, at 12:31 p.m. Resident R16 stated that there was an incident with a nurse a few weeks ago; his pain pill fell , the pill got lost and the nurse refused to replace the pain pill. Review of Resident R16's care plan, dated initiated November 22, 2024, revealed that, The resident is on pain medication therapy related to osteomyelitis (bone infection) with a goal that the resident will be free of pain. Review of facility documentation submitted to the Pennsylvania Department of Health on March 11, 2025, at 9:38 p.m. revealed, Resident and family allege that on March 10, 2025, [Employee E17, licensed nurse] attempted to administer a requested oxycontin pill [opioid pain medication] to resident but it dropped. Staff looked for it without success. Nurse did not provide replacement med. Review of progress notes for Resident R16 revealed a nurses note, written by Employee E17, licensed nurse, on March 10, 2025, at 10:40 p.m. which stated, This nurse received notification that resident was in need of pain medication and when given the medication was dropped. This nurse and nursing supervisor went in to locate the lost pill without success. Continued review of progress notes for Resident R16 revealed a nurses note, written by Employee E18, licensed nurse, on March 10, 2025, at 11:58 p.m. which indicated that Resident R16 complained of not receiving his oxycodone at 10:00 p.m. due to it dropping on the floor during administration . Resident stated that he was not offered a replacement at that time . He complained of pain 8/10 [numeric pain scale, score of 8 indicates severe pain] . This nurse called the nurse who was on duty at the time and it was confirmed that resident did not receive his oxycodone at 10:00 p.m. due to it dropping on the floor and its inability to be located. Review of facility documentation related to the event revealed a statement, written by Employee E17, licensed nurse, dated March 11, 2025, which stated, This nurse was told by staff that [Resident R16] needed pain medication. The resident received the medication but dropped it due to hand tremors. I stopped to look for the medication but was unsuccessful . I left the room and did not return because I was very uncomfortable by then the shift was over and I went home. Review of facility documentation related to the event revealed a statement, written by Employee E19, licensed nurse, dated March 18, 2025, which stated, On March 10th [Employee E17, licensed nurse] came and ask me to help her locate a pill that the resident drop while attempting to take it . After searching for a while we came to the conclusion that the pill was lost - so we wasted the pill. And I suggested to re check the severity of his pain and give him Tylenol to take the edge off until he was due again. Review of Resident R16's Controlled Drug Record for oxycodone 5 m.g (milligram) tablets revealed that on March 10, 2025, at 10:00 p.m. that one tablet was wasted by Employees E17 and E19, licensed nurses. Review of Resident R16's Medication Administration Record (MAR) for March 2025, revealed that on March 10, 2025, that the resident received a dose of oxycodone 5 m.g at 12:56 p.m. for pain 9/10 (severe pain) and that the next dose was administered at 11:45 p.m. for pain of 8/10 (severe pain) by Employee E18, licensed nurse. Continued review revealed that there was no indication on the Medication Administration Record that any doses were administered by Employee E17, licensed nurse, on March 10, 2025. Review of facility documentation, Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property, dated submitted April 3, 2025, revealed that the facility concluded that, Nurse [Employee E17, licensed nurse] failed to provide requested pain medication to resident with 8/10 reported pain. Nurse failed to report resident pain and lack of medication to oncoming shift or physician. Nurse failed to properly document on MAR administration of pain medication at the time the pill was lost. This nurse has been found to be neglectful of appropriately managing the resident's pain. Interview on April 2, 2025, at 11:55 a.m. the Nursing Home Administrator revealed that Employee E17, licensed nurse, was terminated from employment at the facility for withholding Resident R16's pain medication and that the facility determined that the outcome of the investigation was substantiated neglect. Review of Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property revealed that the nature of abuse investigated by the facility was verbal abuse. Review of Description of Incident revealed the following: On January 5, 2025, at 6:45 PM, Resident R57 reported that the previous evening, January 4, 2025, Nurse's Aide, Employee E20 was complaining about having to change Resident R57 again. Resident R57 then pointed his finger at Employee E20 and stated to Employee E20 that He doesn't want to be here but wants to get better and to be able to walk again. Employee E20 then grabbed Resident R57's finger tightly for several seconds. Review of Findings of Facility Investigations revealed that the allegation was substantiated. Employee E20 was no longer employed at the facility and was not available for interview. The Director of Nursing who investigated the incident was no longer employed at the facility and was not available to interview 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.29(a)(c) Resident rights 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(c) Nursing services 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on clinical record reviews and interviews with staff, it was determined that the facility failed to accurately complete an MDS assessment for one of three closed records reviewed (Resident R55). Findings include: Clinical record review for Resident R55 revealed a Discharge Note, dated January 5, 2025, at 2:10 p.m. which indicated that the resident discharged home with family. Review of Resident R55's Discharge MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated January 5, 2025, revealed that the resident was discharged on [DATE], to a short-term general hospital. Interview on April 3, 2025, at 11:58 a.m. Employee E11, nurse assessment coordinator, confirmed that Resident R55 discharged home and that the discharge MDS assessment was not completed accurately. 28 Pa Code 211.5(i) Medical records

Based on review of facility policy, facility documents, clinical records, and interview with staff, it was determined the facility failed to develop a comprehensive care plan and interventions related to pain management, foot care and compression stocking for two of 17 resident clinical record reviewed (Resident R42 and Resident R47). Findings include: A review of the undated facility policy titled, Individualized Care Plan, revealed, the IDT develops comprehensive care plan addressing the residents most acute problems. The comprehensive care plan will include services that are to be furnished to attain or maintain the residents highest practicable physical, mental and psychological well-being. Review of Resident R43 revealed that Resident R43 was admitted to the facility on [DATE], with diagnoses of Central Cord Syndrome at C4 level, Spinal stenosis Lumbar Region, displaced fracture of acromial process, left shoulder. Observation of Resident R43 conducted on April 1, 2025, at 9:04 a.m., revealed that Resident R43 was in bed awake with left arm in a sling. Interview with Resident R43 conducted during the observation revealed that he had a left shoulder fracture. Further Resident R43 revealed that he takes pain medications for pain on his shoulder. Review of Resident R43's physician's ordered revealed an order for Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen), Give 2 tablet by mouth every 12 hours for 1000 milligrams (mg) Max 3G/day-order date of March 14, 2025. Review of Resident R43's current care plan revealed that there was no care plan develop for pain management. Review of the resident's Inpatient Discharge Summary dated 2/6/2025 indicated that the resident was admitted to the hospital on January 30, 2025 after having a fall at home. The resident was transferred to the facility on [DATE] for rehabilitation services. Review of the April 2025 physician orders for Resident R47 included the following diagnosis: diabetes (a condition characterized by elevated levels of blood glucose ,and a condition that makes an individual with the diagnosis at greater risks for developing foot problems ); hypertension (high blood pressure); hyperlipidemia (high cholesterol.) and sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts), and morbid obesity. Continued review of the physician orders indicated that the resident was also being administered medication for the treatment of edema (swelling caused due to excess fluid accumulation in the body tissues, often the feet, legs and ankles). During an interview with Resident R47 on April 2, 2024 at 11:30 a.m., Resident R47 reported that she had been at the facility since February 2025, had diabetes, had requested on a number of occasions to see the podiatrist, but stated that the facility had not followed up on her request to see the podiatrist. Review of the resident's physician orders included a physician's order dated February 12, 2025 for the resident to have a consultation with the podiatrist for missing toenails on the resident's 2nd and 3rd right toes, Podiatry consult for missing toenails on 2nd and 3rd Rt (right) toes. Review of the April 2025 physician orders also included a physician's order dated February 14, 2025 for the resident to see podiatry for neuropathy (a condition that often causes weakness, numbness and pain in the hands and feet) for bilateral lower extremities, Podiatry consult for neuropathy BLE (bilateral legs). Continued review of the resident's April 2025 physician orders included a third physician's order dated March 20, 2025 for the resident to have a podiatry consult to have her toe nails clipped, Podiatry consult for nail clipping. Continued review of the resident's clinical record did not show evidence that the resident was seen by the podiatrist, as ordered, to ensure that such care is provided to Resident R47 to avoid podiatric complications that Resident R47 ma be prone to due to her diabetes diagnosis . During an observation of the resident's feet on April 3, 2025 at 1:45 p.m. the resident's toe nails were observed as long, hard and yellowish. Review of the resident's person-centered plan of care did not include a plan of care related for the resident's foot care to ensure appropriate care and services are provided to the resident with a diagnosis of diabetes. During an interview with Employee E22 (licensed nurse) on April 3, 2025 at 11:47 a.m.it was confirmed that there was no person-centered plan of care for foot care for Resident R47. Review of the resident's April 2025 physician orders included a physician's order in March 2025 for the resident to wear compression stockings throughout the day (compression stockings- also known as compression socks, are specially made socks that fit tighter than normal so they gently squeeze an individual's legs. Compression stockings help improve an individual's blood flow and reduces pain and swelling in an individual's legs. They can also lower an individual's chances of getting deep vein thrombosis (DVT), a kind of blood clot, and other circulation problems). A physician's order dated March 3, 2025 indicated that the resident was to have compression stockings put on her legs in the morning. Compression stockings on in the am in the morning. Continued review of the April 2025 physician orders included a physician's order dated March 3, 2025 for the resident to take the compression stockings off at night. Compression stockings off at night at bedtime. During an interview with Employee E22 (licensed nurse) on April 3, 2025, at 11:47 a.m. the licensed nurse reported that she was the regularly assigned nurse for the resident and reported that the resident has reported that the compression socks were too tight. When asked if she ever notified that physician regarding the resident's concern that her compression stockings were too tight, the licensed nurse confirmed that she could provide no evidence that she notified that physician to assess the resident's complaint that the compression stockings were too tight for her to wear, as ordered. Review of the March 2025 Treatment Administration Record (TAR) revealed that the compression socks were not applied to that resident from March 3, 2025 through March 30, 2025. On March 3, 2025, the code UT, which means Unable to Tolerate, was coded for that date. March 4, 2025-March 30, 2025, were all blank, indicating that they were not applied. During an interview with Employee E22 (licensed nurse) on April 3, 2025 at 11:47 a.m it was confirmed that there was no person-centered plan of care for compression stockings for Resident R47. 28 Pa. Code 201.18(e)(1) Management 28 Pa Code 211.10(d) Resident care policies 28 Pa. Code 211.12 (c)(d)(1) Nursing Services

Based on observations, staff interviews and the review of clinical records, it was determined that the facility failed to follow a physician's order related to the application of compression stockings, and failed to clarify/notify the physician of the expected time of the completion of an ultrasound study for 2 out of 17 residents reviewed (Resident R47 and Resident R35). Findings include: Review of the resident's Inpatient Discharge Summary dated 2/6/2025 indicated that the Resident R47 was admitted to the hospital on January 30, 2025 after having a fall at home. The resident was transferred to the facility on [DATE] for rehabilitation services. Review of the April 2025 physician orders for Resident R47 included the following diagnoses diabetes (a condition characterized by elevated levels of blood glucose ,and a condition that makes an individual with the diagnosis at greater risks for developing foot problems); hypertension (high blood pressure); hyperlipidemia (high cholesterol.) and sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts, and morbid obesity. Continued review of the physician orders indicated that the resident was also being administered medication for the treatment of edema (swelling caused due to excess fluid accumulation in the body tissues, often the feet, legs and ankles). During an interview with Resident R47 on April 2, 2024 at 11:30 a.m., Resident R47 reported that she had been waiting for compression stockings that fit. Resident R47 was observed with no compression stockings on during group. She then stated, The ones (compression stockings) they give me are very small. Do you see how big my ankles and legs are? I need to wear them, but they want me to wear compression stockings for someone who's ankles and legs are her size (pointed to another resident whose ankles and legs were smaller than Resident R47's). Review of the resident's April 2025 physician orders included a physician's order for the resident to wear compression stockings throughout the day (compression stockings- also known as compression socks, are specially made socks that fit tighter than normal so they gently squeeze an individual's legs to help improve an individual's blood flow, educe pain and swelling in an individual's legs and lower an individual's chances of getting DVT, a kind of blood clot, and other circulation problems). A physician's order dated March 3, 2025 indicated the use of compression stockings to be on in the morning. Continued review of the April 2025 physician orders included a physician's order dated March 3, 2025 for the resident to take the compression stockings off at night. Compression stockings off at night at bedtime. During an interview with Employee E22 (licensed nurse) on April 3, 2025, at 11:47 a.m. the licensed nurse reported that she was the regularly assigned nurse for the resident and reported that the resident has reported to her that the compression stockings were too tight and that the resident did not want to wear them. When asked if she ever notified that physician regarding the resident's concern that her compression stockings were too tight, the licensed nurse confirmed that she could provide no evidence that she notified that physician to assess the resident's complaint that the compression stockings were too tight for her to wear, as ordered. Review of the March 2025 Treatment Administration Record (TAR) revealed that the compression stockings were not applied to the resident from March 3, 2025 through March 30, 2025. On March 3, 2025, the code UT, which means Unable to Tolerate, was coded by nursing staff for that date. March 4, 2025-March 30, 2025, were all blank, indicating that they were not applied. Review of March 2025 physician orders for Resident R47 included a physician order dated February 28, 2025 for a venous Doppler (a test used to identify any blockages or clots that may be signs of diseases such as deep vein thrombosis (DVT-a blood clot usually in the leg). Review of physician notes dated February 28, 2025 at 9:28 a.m. documented that Resident R47 reported that she was experiencing left leg pain at the calf . The physician prescribed Tylenol to the resident for her pain. Review of the Doppler Report for Resident R47 revealed that the doppler study was not completed until March 2, 2025 inspite of the resident experiencing pain on the calf area. Continued review of the clinical record did not show evidence that the facility clarified with the physician if the doppler test should be completed sooner for Resident R47 due to calf pain. Review of March 2025 physician orders for Resident R35 include the following diagnoses diabetes; hypertension (high blood pressure) and repeated falls and colon cancer. Continued review of physician orders included a physician's order dated March 14, 2025 for the resident to have a [NAME] Doppler completed to her bilateral lower extremities to rule out the resident having a DVT. Review of a physician's note dated March 14, 2025 at 12:51 p.m. revealed that during the physician's examination the physician assessed the resident's bilateral lower extremities as having edema, increased warmth, with erythema (redness of the skin) . The physician indicated in the notes that a bilateral venous doppler to rule out a DVT would be ordered. Review of a nursing note dated March 17, 2025 at 12:38 p.m. indicated that the resident complained of pain in her bilateral lower extremities, and when assessed by nursing the resident bilateral lower extremities were warm to touch. Review of a physician's note dated March 18, 2025 at 4:38 p.m. indicated that the [NAME] doppler was ordered on March 14, 2025 but will note be done until March 18, 2025. The physician documented in the progress note that during the assessment of the resident, the resident reported some pain down her right leg. Review of the Doppler Report for Resident R35 and dated March 18, 2025 indicated that the test was completed on March 18, 2025. Continued review of the clinical record did not show evidence that the facility clarified with the physician if the doppler test should be completed sooner for Resident R35 due to the health implications associated with a DVT. During an interview with the Regional Nurse, Employee E5 on April 3, 2025 at 12:08 p.m. it was discussed that review of the clinical records for Resident R35 and R47 did not show evidence of other precautions that were to be put in place for possible dvt for both residents and that the physician was contacted related to time frame of the completion of the doppler studies. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, interviews and the review of clinical records, it was determined that the facility failed to ensure that podiatrist services were provided for 1 out of 17 residents reviewed (Resident R47). Findings include: Review of the resident's Inpatient Discharge Summary dated 2/6/2025, indicated that the resident was admitted to the hospital on January 30, 2025 after having a fall at home. The resident was transferred to the facility on [DATE] for rehabilitation services. Review of the April 2025 physician orders for Resident R47 included the following diagnoses of diabetes (a condition characterized by elevated levels of blood glucose ,and a condition that makes an individual with the diagnosis at greater risks for developing foot problems ); hypertension (high blood pressure); hyperlipidemia (high cholesterol). During an interview with Resident R47 on April 2, 2024 at 11:30 a.m., Resident R47 reported that she had been at the facility since February 2025, had diabetes, had requested on a number of occasions to see the podiatrist, but stated that the facility had not followed up on her request to see the podiatrist. Review of the resident's physician orders included a physician's order dated February 12, 2025 for the resident to have a consultation with the podiatrist for missing toenails on the residents 2nd and 3rd right toes, Podiatry consult for missing toenails on 2nd and 3rd Rt (right) toes. Review of the April 2025 physician orders also included a physician's order dated February 14, 2025 for the resident to see podiatry for neuropathy (a condition that often causes weakness, numbness and pain in the hands and feet) for bilateral lower extremities, Podiatry consult for neuropathy BLE (bilateral legs). Continued review of the resident's April 2025 physician orders included a third physician's dated March 20, 2025 for the resident to have a podiatry consult to have her toe nails clipped, Podiatry consult for nail clipping. Continued review of the resident's clinical record did not show evidence that the resident was seen by the podiatrist. During an observation of the resident's feet on April 3, 2025 at 1:45 p.m. the resident's toe nails were observed as long, hard and yellowish. During a discussion with Employee E5 (Regional Nurse) on April 3, 2025 at 12:08 p.m. the Regional Nurse, Employee E5 confirmed that the resident had not been seen by the podiatrist, as ordered by the physician. 28 Pa Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and interviews with staff, it was determined that the facility failed to obtain orders for urinary catheter for one of two clinical records of residents with urinary catheters reviewed (Resident R46). Findings include: Review of Resident R46's clinical record revealed that resident was admitted to the facility on [DATE], with diagnoses of but not limited to Chronic Urinary Tract Infection, Chronic Tubulo-interstitial Nephritis, Benign Prostatic Hypertrophy with Lower Unitary Tract Symptoms, Bladder Neck Obstructions and Uro-genital Implant Further review of Resident R46's clinical record revealed that Resident R46 was discharged to the hospital on March 25, 2025, and was readmitted to the facility on [DATE]. Review of Resident R46's clinical record (service evaluation and health assessment) dated March 29, 2025, revealed that resident R46 was admitted s/p (status post) pyelonephritis recurrent UTI (urinary track infection), has foley- (indewelling urinary catheter) intact and patent. Further review of Resident R46's physician orders revealed an order for: Chronic indwelling Foley catheter - 18F replaced in hospital 3/5/25-ordered 3.21.25 and was discontinued on 3.25.25- Further Review of Resident R46's clinical record revealed no order for an indwelling foley catheter when the resident was readmitted to the facility on [DATE]. Observation of Resident R46 conducted on March 31, 2025, at 10:24 a.m. during the tour of the first-floor unit revealed that Resident R46 was in bed asleep. Further observation revealed that Resident R46 had a clear tubing connected to a urine bag located under Resident R46's bed. Interview with Senior DNS (Director of Nursing Services) Employee E4 conducted on April 2, 2025, at 1:55 p.m. confirmed that Resident R46 has a foley catheter and that there was no order for catheter for Resident R46 upon his return from the hospital on March 29, 2025. 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on observations, review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure that intravenous (IV) devices were maintained in accordance with professional standards of practice for one of one residents reviewed for intravenous therapy (Resident R106). Findings include: Review of facility policy, Vascular Access Devices and Infusion Therapy Procedure, Peripherally Inserted Central Line Catheter (PICC)[ a thin soft tube inserted in a vein in the arm with the tip of the tube positioned in a large vein that carries blood to the heart] dated October 2024, revealed, Measure circumference of upper arm before insertion or on admission as a baseline and when clinically indicated to assess for the presence of edema [excess fluid] and possible deep vein thrombosis [blood clot]. Measure 10 c.m. [centimeters] above the insertion site. Measure external length of PICC catheter at insertion or on admission, with each dressing change, and when clinically indicated if catheter dislodgement is suspected. Review of Resident R106's care plan revealed that the resident was admitted to the facility on [DATE], to receive intravenous antibiotic therapy due to sepsis (infection in the blood). Review of Resident R106's physician orders revealed an order, dated March 25, 2025, to change the IV dressing, caps, measure the external catheter length and arm circumference every week, starting with the day the resident arrived at the facility and continuing every Tuesday. Continued review revealed an order, dated March 25, 2025, to administer cefazolin (antibiotic mediation) intravenously every 12 hours for bloodstream infection. Continued review of Resident R106's clinical record, including March and April 2025 Medication and Treatment records, as well as progress notes, revealed no indication that the dressing on the PICC was changed or that the catheter length or arm circumference were measured at any time since the resident was admitted to the facility. Observation on March 31, 2025, at 12:42 p.m. revealed that Resident R106 had a PICC line in his right upper arm; the dressing on the PICC was dated March 24, 2025. Resident R106 stated that he received antibiotic medication through the PICC line twice per day. Observation on April 2, 2025, at 2:30 p.m. revealed that Resident R106's PICC line dressing was still dated March 24, 2025. Resident R106 stated that the dressing had not been changed at any time since his admission to the facility. Observation and interview on April 2, 2025, at 2:46 p.m. the Director of Nursing confirmed that the dressing on Resident R106's PICC line was dated March 24, 2025, and that it was overdue to be changed. 28 Pa Code 211.12(d)(5) Nursing services

Based on clinical record review and interviews with staff, it was determined that the facility failed to obtain orders for oxygen for one of 17 clinical records reviewed (Resident R21). Findings include: Review of Resident R21's clinical record revealed that Resident R21 was admitted to the facility on [DATE], with diagnoses of Chronic Respiratory failure with Hypoxia (low levels of oxygen). Further review of Resident R21's clinical record revealed a care plan for oxygen therapy related to chronic heart failure date initiated: 03/11/2025. Further review of Resident R21's clinical record revealed that there was no physician's orders for oxygen. Review of Resident R21's Daily Skilled Evaluation dated March 26, 2025 revealed that under section Skilled Services, 7a, #1:Oxygen was coded yes and 7c. Respiratory management: document evaluation and response to above selected services (may include respiratory pattern changes, lung sounds, O2 sat monitoring, endurance levels, shortness of breath upon exertion, shortness of breath lying flat, shortness of breath at rest, oxygen rate/route, tracheostomy care/status, notable change in respiratory status)had the following notation: The resident is on continuous O2-2L via nasal cannula, no s/s (signs/ of respiratory distress. Breo, 1 PUFF BY MOUTH DAILY FOR ASTHMA. Observation on Resident R21 conducted on March 31, 2025, at 10:55 a.m. during the tour of the first-floor unit revealed that Resident R21 was in bed, awake. Further observation revealed that Resident R21 was on an oxygen concentrator via nasal canula at 2 liters/minute. Interview with Resident R21 revealed that the resident used oxygen and stated having been on oxygen for a while. Interview with licensed nurse Employee E21 confirmed that Resident R21 was on oxygen at 2 liters/minute. Further, Employee E21 also revealed that the oxygen tubing is changed every Sunday during the 3-11 shift. Interview with Senior DNS (Director of Nursing Services) Employee E4 conducted on April 2, 2025, at 1:57 p.m. confirmed that there was no order for oxygen for Resident R21. 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on observations, review of clinical records, facility documentation, and interviews with residents and staff, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care of residents with intravenous (IV) devices for two of five employees reviewed for IV skills competencies (Employees E15 and E16). Findings include: Observation on March 31, 2025, at 12:42 p.m. revealed that Resident R106 had a PICC (intravenous) line in his right upper arm. Resident R106 stated that he received antibiotic medication through the PICC line twice per day. Review of Resident R106's care plan revealed that the resident was admitted to the facility on [DATE], to receive intravenous antibiotic therapy due to sepsis (infection in the blood). Review of Resident R106's physician orders revealed an order, dated March 25, 2025, to administer cefazolin (antibiotic mediation) intravenously every 12 hours for bloodstream infection. Continued review revealed an order, dated March 25, 2025, to flush the resident's IV line with 10 m.l. (milliliters) of normal saline every shift for IV patency. Review of Resident R106's Medication Administration Records for March 2025, revealed that Employees E15 and E16, licensed nurses, administered Cefazolin and flushed the resident's PICC line. Review of facility documentation related to IV skills evaluations revealed that there was no documentation available for review at the time of the survey to indicate that Employees E15 and E16, licensed nurses, were evaluated to ensure competency of IV administration. Interview on April 2, 2025, at 12:29 p.m. Employee E4, regional nurse, confirmed that the facility was not able to provide evidence that Employees E15 and E16, licensed nurses, were evaluated to ensure competency of IV administration. 28 Pa Code 201.19(7) Personnel policies and procedures 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on review of facility policy, clinical record, facility documentation, and interviews with staff, it was determined the facility failed to check the temperature of the hot water provided to Resident R1 which resulted in actual harm to Resident R1, of spillage of hot water on the left upper and outer thigh, and developing a blister on the left thigh for one of six residents. (Resident R1) Findings include: Review of the facility's police title Safe holding and serving temperature for hot beverages last revised May 2, 2017, revealed the temperatures that hot beverages should be served at are governed by palatability and by the risk for a burn. Under Procedure A, it further states Serve the hot beverages between 140 and 155 degrees. Dietary should record hot beverage temperatures for every meal. Review of information dated December 24, 2024 and submitted to the State Survey Office on December 24, 2024, indicated, After having dinner on 12/23/2024 at 6:00 p.m. [Resident R1] was enjoying a cup of hot tea. She/he was putting sugar in the teacup and attempting to stir it in when the tea spilled onto her lap. [Resident R1] is independent with feeding. [Resident R1]spilled the cup of tea on [his/her] lap, the tea hit [his/her] left upper inner thigh area. Continued review of the report revealed Liquids temperatures are logged for each meal, The hot beverage temperature for the tea that was logged on 12/23/24 evening was at 139 degrees. Resident R1 does not require adaptive feeding utensils. Review of Resident R1's clinical record revealed an admitted [DATE]. Review of the Minimum Data Set assessment (MDS - periodic assessment of resident care needs) dated December 21, 2024, revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated the resident was cognitively intact. Review of the Resident R1's occupational therapy assessment dated [DATE], indicated Resident R1 was independent with eating. Review of Resident R1's clinical nursing note documented on December 23, 2024, at approximately 10:12 p.m. after having dinner [Resident R1] was enjoying a cup of hot tea. [Resident R1] spilled a cup of tea on [his/her] lap. Hitting [her/his] left upper inner thigh area. Supervisor on duty went to assist resident and applied a cool compress. About 45 minutes later nurse went into check on resident and notice blisters on the area. Physician was notified and prescribed Silvadene. Review of the clinical nursing note documented by the Assistant Director of Nursing, Employee E12 on December 24, 2024, revealed [Resident R1] seen by this nurse and NP (Nurse Practitioner) seen resident and assessed burns [she/he] sustained last night from spiling hot tea. Left upper and outer thigh noted with redness and open blister to inner left thigh, 14 cm x 10 (centimeter) cm. No drainage noted, deep redness 8x2 cm on outer thigh. NP ordered to continue Silvadene to area. Review of the facility's investigation revealed a written statement from Nurse Aide, Employee E4, which indicated On 12/23/24 I take care of [Resident R1]. Around 5:00 p.m. dietary passed dinner trays and Resident R1 got hot water in the tray but no tea bag and no sugar. Resident R1 ring the bell and I went in room to help [her/him]. Resident R1 ask [her/him] for tea bag and sugar. I ask dietary girl, [Employee E5] to bring it. Employee E5 bring another hot water in red mug and tea bag and sugar. [Resident R1] was mixing sugar when the tea fell on [her/him]. I heard [Resident R1] screaming and ring the call bell. I took [her/his] pants off and gave [her/him] cold wash cloth and let the supervisor know. An observation of the hot water dispenser and an interview was conducted on January 16, 2025, at 10:14 a.m. with the Dietary Manager, Employee E3 and Nursing Home Administrator, Employee E1. During the interview Dietary Manager, Employee E3 measured the hot water dispenser temperature at 140 Fahrenheit (F). Dietary Manager, Employee E3 explained that the facility's protocol for serving hot beverages was for the hot beverage to be poured into a cup approximately 10 minutes before the serving line is prepared, and its holding temperature is measured. While the beverage cools, the serving line is prepped. Once the serving line is ready, the beverage temperature is measured again to ensure it is within the safe range of 140 F or below. Only then is the beverage placed on the resident's tray. Review of the temperature log sheet for the dinner meal on December 23, 2024, indicated the serving temperature of the hot beverage tea dispenser was documented at 135 F. Dietary Manager, Employee E3 further explained that Resident R1 resided on the first floor, while the kitchen, where the food was prepared, was located on the second floor. Resident R1 consistently ate all meals in [her/his] room. Consequently, on December 23, 2024, Resident R1's meal was placed in a food truck and delivered directly to [her/his] room. When Resident R1 requested sugar or a tea bag from Nurse aide, Employee E4, the standard protocol was for the staff to notify the kitchen. The kitchen staff would then deliver the missing items to the resident's room. On January 16, 2025, at 11:35 a.m., a telephone interview was conducted with Dietary aide, Employee E5, who served the hot beverage to Resident R1 on December 23, 2024. During the interview Dietary aide, Employee E5 confirmed that she had received a call from Nurse aide, Employee E4, reporting that [Resident R1] was missing either a hot tea bag or a cup of hot water. During the interview, Dietary manager, Employee E3 entered the room while interview was being conducted with documents for the surveyor. The surveyor requested that Dietary manager, Employee E3 remain for the rest of the phone interview with Dietary aide, Employee E5. Employee E5 was informed that Dietary manager, Employee E3 would be joining the conversation. Dietary aide, Employee E5 disclosed that when asked to assist the resident, she went to the kitchen, took an empty cup, and poured hot water from the hot water dispenser. When the surveyor inquired whether she measured the temperature of the hot water, Dietary aide, Employee E5 admitted , No. She further revealed that, prior to this incident, she had not been measuring the temperatures of hot beverages. However, following the incident, all staff members were educated on proper procedures and now measure the temperatures of hot beverages to ensure safe handling. Dietary manager, Employee E3, confirmed the hot water provided to Resident R1 by Dietary aide, Employee E5 had not been checked to verify if it was at safe serving temperature. On January 16, 2025, at 11:41 a.m., the lunch meal service was observed with Dietary Manager, Employee E3. The temperature of the hot water dispenser was measured prior to serving lunch and recorded at 169.5 F holding temperature. On January 16, 2025, at 11:45 a.m., four dietary aides-Employees E6, E7, E8, and E9 independently were interviewed and reported that they had all been retrained to measure temperatures to ensure hot foods are at 140 F or below before being placed on residents' trays. An interview with the Administrator, Employee E1 on January 16, 2025, at 12:03 p.m. confirmed the Dietary aide Employee E5 did not check the hot water temperature to verify if it was at a safe temperature, which resulted in Resident R1 receiving a burn. The facility failed to check the temperature of the hot water provided to the Resident R1 which resulted in actual harm to Resident R1, spilling a hot water cup on her/his left upper and outer thigh, and developing a blister on the left thigh measuring and deep redness on the outer thigh. 28 Pa. Code 211.10(c)(d) Resident Care Policies 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on observation, review of clinical record and facility documentation and staff interview, it was determined that the facility failed to adequately assess, monitor and develop appropriate interventions to prevent decline in skin integrity, for one of 15 residents reviewed, resulting in actual harm (Resident R33). Findings include: Review of Resident R33's clinical record revealed that the resident had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An annual Minimum Data Set assesment (MDS-a periodic assessment of resident care needs) dated February 5, 2014, indicated that the resident was physically impaired in both legs, was non-ambulatory (unable to walk), and required extensive assistance from one or more staff for transferring (act of moving from one area to another), dressing, personal hygiene and bathing. The MDS reflected that the resident had been identified with care needs in the area of pressure ulcers. At the time of the assessment, the resident's skin was noted as intact. A plan of care for Resident R33, dated September 12, 2012, indicated that the resident had limited physical mobility. The care plan further noted that the resident was at risk for the development of skin breakdown due to bowel and bladder incontinence. The care plan listed specific nursing interventions to reduce the risk of injury to the resident which included diet, the use of assistive devices and a turning and repositioning schedule. physician's orders [REDACTED].T. (Physical Therapy) evaluation for bilateral (both sides) Multipodus boots (splint used to prevent foot drop and maintain proper leg alignment) ... ". Physical therapy documentation reflected that the resident had been evaluated by Employee E3, physical therapist, on February 21, 2014, for the use of the Multipodus boots. Additional physical therapy documentation indicated that the resident had been seen on March 3, 2014, at which time Employee E3 had applied the Multipodus boots to the resident. A review of nursing documentation dated March 4, 2014, indicated the presence of a blister noted to the resident's left calf. Further review of nursing notes revealed no nursing documentation present from February 20, 2014, until the blister was found on March 4, 2014. Review of facility documentation dated March 4, 2014, at 4:00 p.m., confirmed the presence of a bruise to the resident's right calf and a partial thickness wound measuring five centimeters long by three centimeters wide to the resident's left calf. Further review of the documentation indicated that the skin breakdown had been noted when the Multipodus boots had been removed. Interview with Employee E4, rehabilitation program manager, on July 23, 2014, at 1:40 p.m., confirmed that Employee E3 had applied the Multipodus boots to Resident R33 on March 3, 2014. Further interview with Employee E4 on July 24, 2014, at 9:00 a.m., confirmed that the Employee E3 had not developed any formal wearing schedule for the Multipodus boots nor had the therapist informed the charge nurse of the application of the boots to Resident R33. Observation of wound care to Resident R33 on July 23, 2014, at 9:00 a.m., confirmed the presence of two ulcers to the resident's left calf. Further observation of the resident's wounds on July 23, 2014, revealed that the upper wound measured approximately nine centimeters long by four centimeters wide and contained exposed tendon. The lower ulcer was approximately ten centimeters long, three centimeters wide and 0.8 centimeters deep. A moderate amount of tan blood tinged drainage was noted from both wounds. A faint odor was detected when the dressings were removed from the resident's wounds. Interview with Employee E2, on July 22, 2014, at 3:45 p.m., confirmed that Resident R33 had developed two pressure ulcers to the left calf following the application of a Multipodus boot to the resident's lower legs. Further interview with Employee E2 revealed that the resident's wounds have worsened since their onset and that the resident has been referred to an outside wound care center for treatment. In addition, interview with Employee E2 confirmed that nursing staff had been unaware that physical therapy had applied the Multipodus boots to Resident R33's lower legs and that nursing staff had not removed the Multipodus boots or inspected the resident's skin until the blisters were discovered on March 4, 2014. The facility failed to assess and monitor the skin integrity of one resident identified as at risk for the development of pressure ulcers resulting in actual harm to the resident. 28 Pa Code: 201.18(a)(1) Management. 28 Pa Code: 211.12(c)(1) Nursing services. Previously cited 7/25/12. 28 Pa Code: 211.10(d) Resident care policies. Previously cited 7/25/12.

Based on review of clinical records and facility documentation and interviews with staff, it was determined that the facility failed to maintain a safe environment related to the serving temperatures of hot beverages resulting in actual harm to one of 15 residents reviewed (Resident R60). Findings include: Review of the clinical record for Resident R60 revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An annual Minimum Data Set assessment (MDS-a periodic assessment of resident care needs) dated May 16, 2014, indicated that the resident had impaired cognition and had been identified with care needs in the areas of activities of daily living (ADL-routine daily tasks such as dressing, eating and walking). A review of facility documentation dated June 30, 2014, at 9:15 a.m., indicated that the resident had sustained a burn to the right forearm, after a coffee spill during the breakfast meal. The burn was pink in color and measured 16 centimeters long by three and one half centimeters wide. Review of facility documentation dated July 17, 2014, indicated that the resident had sustained a second degree burn to the right forearm. The resident required daily wound care with Silvadene cream (an anti-infective cream used to treat burns) and was covered with xerofoam (non-adherent type bandage used for open wounds) dressing. In addition, the resident received Tylenol 650 milligrams (mgs) through July 5, 2014, for treatment of [REDACTED]. Review of the facility "Hot Beverage Temperature Log" for June 30, 2014, on the second floor pantry revealed a recorded temperature of 176 degrees Fahrenheit. The temperature range listed on the log indicated that the acceptable serving temperature for hot liquids was 145-155 degrees Fahrenheit. Interview with Employee E5, Dietary Director, on July 23, 2014, at 10:00 a.m., confirmed that the temperature of the coffee beverage served on June 30, 2014, to Resident R60, exceeded the facility's acceptable parameters. The facility failed to ensure that hot beverages were served within acceptable temperature ranges resulting in actual harm to one resident. 28 Pa Code:211.6(c) Dietary services. 28 Pa Code: 201.18(b)(1) Management. Previously cited July 25, 2012.