Every finding on record at Quality Life Services - Chicora

Based on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for nine of sixteen residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, and R9).Findings Include: Interview on 6/26/26, at approximately 12:00 p.m. the Director of Nursing indicated the facility did not have a policy specific to safe, clean, and homelike. During an observation on 6/26/26, at 10:45 a.m. Resident R1's former room had large patches of paint missing with exposed drywall. The floor around the commode in the in-room restroom was damaged with the subfloor visible in spots, potentially causing a fall risk and infection control risk. During an observation on 6/26/26, at 10:49 a.m., the room assigned to Resident R2, R3, R4, and R5 revealed numerous gouges in the floor. Additionally, a wooden closet door had a hole in it, approximately four inches across, with jagged wood present. During an observation on 6/26/26, at 10:49 a.m., the room assigned to Resident R6 and R7 revealed a large section of peeling paint in the restroom and the wall behind the bed had gouges. During an observation on 6/26/26, at 10:51 a.m., the room assigned to Resident R8 and R9 revealed exposed sheetrock and the radiator cover unattached. During an interview on 6/26/26, at approximately 1:30 p.m. the Nursing Home Administrator confirmed the facility failed to provide a clean, safe, comfortable, and homelike environment for nine of sixteen residents. 28 Pa. code: 201.14 (b) Responsibility of licensee.28 Pa Code: 201.18 (e)(1)(2) Management.28 Pa Code: 201.29 (a)(c) Resident Rights.

Based on review of facility documents, facility policy, clinical records, observation, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of ten residents identified to be elopement risks not who did not reside on a secured unit (Resident R10). This was identified as past non-compliance.Findings include: Based on facility policy Elopement Prevention dated 12/1/25, indicated the facility will properly assess residents and plan their care to prevent accidents related to wandering behavior or elopement. Upon admission, readmission, quarterly and as necessary, nurses will complete a Wandering Risk Assessment. Should the resident's behavior warrant elopement prevention measures, a comprehensive elopement prevention plan will be documented as part of the care plan. Staff observations will be noted during the residents' stay and modifications will be made to the care plan and prevention techniques. 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 3/5/26, included diagnoses of paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease) and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of the Wandering / Elopement Risk Evaluation dated 4/9/26, indicated, Noted increased confusion and does wander throughout the facility and will go outside with electric w/c (wheelchair) propelling self. Review of Resident R10's plan of care for elopement risk / wandering initiated 4/9/26, indicated Resident R10 exhibited aimless wandering and included the intervention (dated 5/4/26) of, Monitor for entering restricted areas unattended or statements about going outside with IDT (interdisciplinary team) review for modifications if need warranted. Review of a facility submitted information dated 5/13/26, indicated that on 5/12/26, PT (Physical Therapy) Manager informed DON (Director of Nursing) on 5/12/2026 that she had been notified resident was reportedly found within enclosed secure courtyard residential area the previous evening by another staff member. Information was immediately escalated to RN (Registered Nurse) Supervisor, CRNP (Certified Registered Nurse Practitioner), and DON. Follow-up staff interviews initiated with all scheduled staff from evening 5/11/2026. CNA (Nurse Aide) from previous shift questioned and confirmed resident had been found present within enclosed secure courtyard residential area. Two witness statements obtained reporting consistent findings. RN Supervisor and licensed nurses on unit reported they had not been notified of resident presence in courtyard area at time of occurrence and were unaware resident had accessed courtyard area. Review of facility investigation information indicated that Resident R10 was not accounted for approximately 15 minutes last seen in common area near nurse's station. Review of an employee statement dated 5/12/26, Nurse Aide Employee E1 stated, On Monday May 11th on 6p-6a (6:00 p.m. to 6:00 a.m.), I found [Resident R10] in the courtyard stuck behind the door and in a chair. I told the aid [NA Employee E2] who I was working with and we notified the nurse on our floor [Registered Nurse Employee E3]. Review of an employee statement dated 5/22/26, Nurse Aide Employee E2 stated, [Employee E4] asked [Employee E1] and I to keep an eye on [Resident R1]. After a few minutes [Employee E1] and I came up to hall and [Resident R1] was outside the doors at the courtyard. His wheelchair was stuck on the cement. [Employee E1] and I assisted him back to his room. On 5/12/26, the facility initiated a plan of correction that included:-Resident placed on one-to-one observation.- Flow Sheet for mentation and wheelchair mobility initiated.-Immediate placement of two door alarms to courtyard access doors to alert staff of entry into eh courtyard area.-Vendor contacted on 5/13/26, regarding implementation of keypad locking mechanisms and additional environmental safety measures needed.-Installation of interior exit buttons-Staff education initiated regarding immediate escalation of impaired safety awareness concerns, resident supervision expectations, and chain of command notification requirements.-A resident headcount was conducted, and all residents were accounted for.-Plans of care were updated as appropriate.-Audits of exit doors completed.-Incident reviewed with the Safety Committee. The facility demonstrated compliance by 5/13/26. During an observation on 6/26/26, at approximately 12:00 p.m. the outdoor courtyard was noted to have numeric keypad locks to enter the courtyard. During an interview on 6/26/26, at approximately 1:30 p.m. the Nursing Home Administrator and DON confirmed that the facility failed to make certain each resident received adequate supervision that resulted in an elopement for one of ten residents identified to be elopement risks not who did not reside on a secured unit. This was identified as past non-compliance. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment by not securing maintenance equipment behind a secured door as required (Dining room outside of the kitchen).Findings Include: Interview on 3/9/26, at 2:00 p.m. the Director of Nursing indicated the facility did not have a policy specific to safe, clean, and homelike. During a facility tour on 3/9/26, at 11:00 a.m. the Resident Dining Room directly outside of the facility kitchen, revealed the following equipment being stored: maintenance equipment and carts, resident hand railings (not attached to the wall), a nail gun, a drill with bits, a case of metal ratchets and pieces, scraping tools, shop vacuum, fans amongst other repair tools. The doors to the dining area were not secured with a lock at the front or side entrances of the room. A sign on the doors to the dining room indicated the room was closed and to keep doors closed when not in use. Interview on 3/9/26, at 1:19 p.m. Project Manager Employee E3 indicated the facility has an on-going project to renovate and paint certain areas of the facility. The vendor comes on site at night to not disrupt residents and their activities. Indicated this has been going on for approximately three to four weeks to give the facility a makeover. Further interview on 3/9/26, at 1:20 p.m. Project Manager Employee E3 confirmed the facility failed to provide a clean, safe, comfortable, and homelike environment by not securing maintenance equipment behind a secured door as required (Dining room outside of the kitchen). 28 Pa. code: 201.14 (b) Responsibility of licensee.28 Pa Code: 201.18 (e)(1)(2) Management.28 Pa Code: 201.29 (a)(c) Resident Rights.

Based on review of facility policy, clinical record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to ensure a safe environment resulting in a burn for one of three residents (Resident R1).Findings include:Review of facility policy Accidents and Incidents dated 12/1/25, indicated a safe environment will be provided for all residents. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/8/26, indicated diagnoses of high blood pressure, muscle weakness, and need for assistance with personal care.Review of a change in status note dated 2/16/26, stated, Resident served dinner tray and took her tea to drink and dropped it on herself. Burns noted to Right thigh 27x40 cm (centimeters), left inner thigh 4x3 cm, left outer thigh 12x4.5, r/l (right and left) lower quadrant (abdomen) 19x9 cm, upper abdominal quadrant r/l 12.0x3.5 cm, superior (above) to upper quadrant 0.5x1.0 raise flesh color.Review of an Emergency Department Note dated 2/16/26, stated, The patient presents for evaluation of a burn. A staff member at the nursing home accidentally dropped hot water for tea on the patient. She has a superficial (a first-degree burn, involve the top layer of skin. These may present as red and painful to touch, and the skin will show mild swelling) burn to the upper abdomen and the right thigh. The burn area is very minimal. There is no blistering. We applied topical antibiotic ointment to the burn area. Instructions given on discharge papers for nursing home staff to apply this twice daily for the burns. Review of a witness statement dated 2/16/26, completed by Dietary Aide Employee E1 stated, My normal routine, the pitchers of coffee and hot water came down to the dining room at 5:10 p.m. I went around and poured coffee and the hot water for tea and hot cocoa. I was on the other side at the TV end of the dining room with my back towards where Resident R1 was sitting. I heard Resident R1 crying out, I went over and she had spilled her tea water into her lap. This was around 5:25 p.m. I immediately got one of the aides and they took her back to Fairgrounds (nursing unit).Review of a witness statement dated 2/17/26, completed by Dietary Aide Employee E2 stated, I had Dietary Aide Employee E1 pour coffee and teas around 5 - 5:15 p.m. I did not see or hear Resident R1 drop her tea until after service. I was busy getting ready to serve dinner to the residents. We did not check temps of coffee/tea water. Review of an undated and unsigned witness statement indicated, This writer spoke to Resident R1's tablemate concerning incident of Resident R1 getting burned. I asked her if she could tell me what happened. She stated that a kitchen staff member was pouring beverages in dining room. He poured hot water into Resident R1's tea cup and moved on. She said she was eating when she heard Resident R1 screaming and looked up to see her cup tipped over on the table. She said the gentleman ran over to see what happened and then went to get help. I asked her where the staff member was at the time of the incident and she stated he was on the other side of the dining room pouring beverages for other residents.During an interview on 3/4/26, at 10:32 a.m. the Nursing Home Administrator (NHA) stated, The kitchen did not temp the water prior to it being served to residents. Two dietary members were in the dining room at the time of the incident. The assigned Nurse Aide was bringing another resident to the dining room when the incident occurred. During an interview on 3/4/26, at 10:32 a.m. the NHA confirmed that the facility failed to provide adequate supervision to ensure a safe environment resulting in a burn for one of three residents (Resident R1). 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 facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to follow droplet precautions for one of four residents in isolation precautions (Resident R2).Findings include: Review of facility provided document Covid Positive Steps dated 12/1/25, indicated the positive resident must have:-An appropriate sign on their door,-The door should remain closed-Vitals every shift while in isolation-Remains in isolation for 10 days-Appropriate PPE (personal protective equipment) stationed by their room for staff to utilize. Review of the admission record indicated Resident R2 admitted to the facility on [DATE]. Review of the Minimum Data Base (MDS - a periodic assessment of care needs) dated 12/22/25, indicated the diagnoses of high blood pressure, chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe), and depression. Review of facility provided documentation dated 3/6/26, indicated Resident R2 tested positive for covid-19 (respiratory infection). Review of Resident R2's physician orders dated 3/6/26, indicated droplet precautions every shift. Review of Resident R2's care plan dated 3/6/26, indicated maintain droplet precautions as ordered. Observation on 3/9/26, at 11:59 a.m. Resident R2's door had signage for droplet precautions on the door. The door stood in a wide-open position to the outer hallway. Interview on 3/9/26, at 12:00 p.m. Registered Nurse (RN) Employee E4 indicated that Resident R2 was positive for covid-19, was in droplet precautions and the door should remain closed at all times to prevent cross contamination potential. Observation on 3/9/26, at 1:17 p.m. Resident R2's door had signage for droplet precautions on the door. The door remained in a wide-open position to the outer hallway. Interview on 3/9/26, at 1:20 p.m. the Director of Nursing confirmed the facility failed to follow droplet precautions for one of four residents in isolation precautions (Resident R2). 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 observations, facility policy, and staff interview, it was determined that the facility failed to ensure comfortable air temperature levels were provided for one of 34 resident rooms (room [ROOM NUMBER]) and two of three resident areas (Millers Common Room and Dining Room).Findings Include:Review of the facility policy Extreme Weather dated 12/1/25, indicated excessive cold for lengthy periods of time can negatively impact center operations. Excessive cold poses a severe potential harm to confused exit-seeking residents. Geriatric residents have a greater risk of suffering hypothermia because their bodies do no effectively regulate internal temperatures.During an interview on 1/28/26, at 9:30 a.m. the Nursing Home Administrator (NHA) revealed that on 1/25/26, the boiler (form of heat source) needed reset.Observations conducted on 1/28/26, from 12:15 p.m. to 12:45 p.m. with the Maintenance Director, Employee E2 revealed the following air temperatures:[NAME] Lane Nursing Floor-room [ROOM NUMBER]-68 of degrees FahrenheitMiller Common Room-Common Room - 67.3 degrees Fahrenheit-[NAME] Dining Room - 70.5 degrees FahrenheitDuring an interview on 1/28/26, at 3:00 p.m. the Nursing Home Administrator confirmed the facility failed to ensure comfortable air temperature levels were provided for one of 34 resident rooms (room [ROOM NUMBER]) and two of three resident areas (Millers Common Room and Dining Room).28 Pa. Code: 201.18(b)(3) Management

Based on review of facility documents, facility policy, clinical records, observation, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of 17 residents (Resident R1). Findings include:Based on facility policy Elopement Prevention dated 12/1/25, indicated the facility will properly assess residents and plan their care to prevent accidents related to wandering behavior or elopement. Upon admission, readmission, quarterly and as necessary, nurses will complete a Wandering Risk Assessment. Should the resident's behavior warrant elopement prevention measures, a comprehensive elopement prevention plan will be documented as part of the care plan. Staff observations will be noted during the residents' stay and modifications will be made to the care plan and prevention techniques.Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE].Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/9/25, indicated diagnoses of depression, dementia (a group of symptoms that affect memory, thinking and interferes with daily life), and anxiety.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 intact8-12: moderately impaired0-7: severe impairmentReview of Resident R1's MDS assessment dated [DATE], Section C0100 screening indicated a score of 0 revealing that Resident R1 is rarely/never understood and the BIMS screening test was not completed. Review of Resident R1's care plan dated 5/22/24, indicated Resident R1 was an elopement risk/wanderer as evidence by a history of attempts to leave home unattended prior to admission. Care plan included identifying any patterns of wandering that I exhibit: purposeful wandering, aimless, or attempting to escape. Monitor my frequent location.Review of documentation provided by facility dated 1/22/26, at 1:40 p.m. revealed, Resident R1 was observed ambulating outside of the locked memory lane unit, on another resident hallway. Resident R1 was observed in the hallway next to memory lane unit and approximately 36 feet away from memory lane unit.Review of an interview conducted by NHA on 1/23/26, at 2:00 p.m. revealed that Resident R1's husband had visited on 1/22/26, and felt that the resident was far enough from locked door when he exited and left the unit. Residents' husband was in a hurry to get to the pharmacy and failed to look behind him upon leaving the unit.Review of witness statement dated 1/23/26, at 4:15 p.m. revealed that Licensed Practical Nurse Employee E1 indicated the Resident R1 followed her husband out of the unit and staff noticed resident in the hallway and returned resident to locked memory unit.During a review of progress notes dated 6/1/2025, through 1/28/26, revealed that Resident R1 had documented behaviors but none were exit seeking.During an interview on 1/28/26, at 2:08 p.m. the Director of Nursing (DON) stated that when she worked in the locked memory unit that Resident R1's husband would come and go since he knew the code to the doors.During an interview on 1/28/26, at 2:45 p.m. the Nursing Home Administrator (NHA) and DON confirmed that the facility failed to make certain each resident received adequate supervision that resulted in an elopement for one of 17 residents (Resident R1).28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observations and staff interview, it was determined that the facility failed to properly maintain sanitary conditions in the walk-in cooler which created the potential for cross contamination in the designated main kitchen. Findings include: During an observation of the main designated kitchen on 12/1/25, at 10:30 a.m. the following was observed: -(2) fans in walk-in cooler- brown debris -ceiling in walk-in cooler-brown debris During an interview on 12/1/25 at 1:30 p.m. Dietary Director Employee E11 confirmed the brown debris in the walk-in cooler. During an interview on 12/2/25 at 10:00 a.m., Dietary Manager Employee E11 confirmed that the facility failed to maintain sanitary conditions which created the potential for cross contamination. 28 Pa. Code: 201.18(b)(1) Management.28 Pa. Code: 211.6(c) Dietary services.28 Pa. Code: 201.14(a) Responsibility of licensee.

Based on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for three of three residents (Residents R24, R41, and R81).Findings include: Review of facility job description Social Worker, indicated that the Social Worker will carry out social evaluations and plan interventions based on evaluation findings, and counsel residents/family/caregivers as needed in relationship to stress and other identified coping difficulties. Ensure compliance with all Federal, State, and local regulations. Review of the admission record indicated Resident R24 admitted to the facility on [DATE]. Review of Resident R24's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/28/25, indicated the diagnoses of post-traumatic stress disorder (PTSD - a psychiatric disorder that may occur in persons that have witnessed a traumatic event causing intense, disturbing thoughts and feelings related to the experience), anemia (the blood doesn't have enough healthy red blood cells), and paranoid schizophrenia (delusions and hallucinations that blur the line between what is real and what isn't). Review of Resident R24's current care plan indicated the resident has delirium (a sudden severe state of confusion and altered awareness, not a disease but symptom of an underlying medical problem). Resident will be free of the signs and symptoms of delirium such as the following: exhibiting a change in behavior, mood, cognitive function, communication, level of consciousness, or restlessness through the next review date. During an interview on 12/4/25, at 11:34 a.m. Social Worker Employee E4 confirmed that Resident R24 did not have a traumatic informed care plan addressing the PTSD or identifying potential triggers and prevention for re-traumatization. Review of the clinical record revealed Resident R41 was admitted to the facility on [DATE] with diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), PTSD, and muscle weakness. Review of the resident's Social Services assessment dated [DATE], revealed the facility documented the resident does not have a history of trauma/Post-Traumatic Stress Disorder. Review of the resident's Social Services assessment dated [DATE], revealed the facility documented the resident does not have a history of trauma/Post-Traumatic Stress Disorder. Review of the resident's Social Services assessment dated [DATE], revealed the facility documented the resident does not have a history of trauma/Post-Traumatic Stress Disorder. Review of the resident's Social Services assessment dated [DATE]/25, revealed the facility documented the resident does not have a history of trauma/Post-Traumatic Stress Disorder. Review of Resident R41's care plan on 12/1/25, failed to address PTSD by identifying any triggers or how to avoid them. During an interview on 12/4/24, at 11:34 a.m. Social Worker Employee E4 stated Resident R41's Social Service assessments should be documented to reflect the resident does have a history of trauma/Post-Traumatic Stress Disorder and confirmed Resident R41's care plan failed to address PTSD by identifying any triggers or how to avoid them. Review of the admission record indicated Resident R81 admitted to the facility on [DATE]. Review of Resident R81's MDS dated [DATE], indicated the diagnoses of anemia, PTSD, and renal insufficiency (a condition in which the kidneys lose the ability to remove waste and balance fluids). Review of Resident R81's current care plan indicated trauma informed care: resident has a history of actual trauma : PTSD related to Vietnam War. Resident will feel safe and comfortable in the home environment and will express any concerns or fears to the staff. During an interview on 12/4/25, at 11:34 a.m. Social Worker Employee E4 confirmed that Resident R81 did not have a traumatic informed care plan addressing the PTSD in identifying potential triggers and prevention for re-traumatization. Interview on 12/5/25, at 12:30 p.m. the Director of Nursing confirmed the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for three of three residents (Resident R24, R41, and R81). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1) Management.

Based on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to prevent cross contamination during a dressing change for one of three residents (Resident R5), failed to ensure that contact precautions were ordered for two of five residents (Residents R36 and R82) and failed to ensure that contact precautions were care planned for one of five residents (Resident R82) Findings include: Review of facility policy Wound Dressing Change dated 10/13/25, indicated all wound care will be performed using medical aseptic (free from contamination) technique, unless otherwise ordered by physician. The purpose is to prevent contamination of the wound bed. Each area must be treated separately. Review of the facility policy Pediculosis (Lice) Care dated 10/13/25, indicated pediculosis is an infestation of the scalp, the hairy parts of the body, or clothing with adult lice, larvae, or nits. It is transmitted by direct contact with an infested person and indirectly by contact with their personal belongings (clothes, bedding, brush and comb, etc.). Precautions for employees consist of wearing gloves and/or gown if in close contact with infested person or things. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/12/25, indicated diagnoses of anemia (too little iron in the blood), paraplegia (paralysis of the legs and lower body), and hyperlipidemia (high level of fat in the blood). Review of a physician order dated 10/8/25, indicated wound care: coccyx (tailbone), left ischium (the lower and back part of the hip bone), right ischium: cleanse all wounds with Dakins (an antiseptic wound cleanser) solution. Loosely pack with Dakins soaked gauze, use Optilock (an absorbent dressing) as needed for excess drainage. Cover with ABD pads (a highly absorbent dressing). Skin prep (a liquid that forms a protective barrier) to periwound (tissue surrounding a wound) for protection. Change BID (twice a day) or PRN (as needed) for soilage/displacement. Notify provider or wound nurse with any changes.During a dressing change observation on 12/4/25, from 10:03 a.m. to 10:25 a.m. Licensed Practical Nurse (LPN) Employee E3 cleansed the right ischium wound with Dakins-soaked gauze and used the same piece of gauze to cleanse the coccyx wound. During an interview on 12/4/25/25, at 10:30 a.m. LPN Employee E3 confirmed the above observations and that the facility failed to implement infection control practices to prevent cross contamination during a dressing change. Review of Resident R36's clinical record indicated admission to the facility on 7/15/25. Review of Resident R36's MDS dated [DATE]/25, indicated the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), high blood pressure, and depression. Review of facility provided documentation dated 8/24/25, indicated that Resident R36 was found to have bugs that were later identified as lice in the hair. Review of Resident R36's physician orders failed to include orders for contact isolation as required. Review of Resident R36's care plan indicated contact precautions for head lice. Review of Resident R82's clinical record indicated admission to the facility on [DATE]. Review of Resident R82's MDS dated [DATE], indicated the diagnoses of Parkinson's Disease (disorder of the nervous system that results in tremors), dementia, and high blood pressure. Review of facility provided documentation dated 5/10/25, indicated Resident R82 was discovered to have head lice found in the beard of the face. Treatment orders obtained from on call provider and resident was placed on contact precautions per facility infection control policy. Review of Resident R82's physician orders failed to include orders for contact isolation as required. Review of Resident R82's care plan failed to include interventions and identification of contact precautions. Interview on 12/4/25, at 10:11 a.m. the Director of Nursing confirmed that the facility failed to prevent cross contamination during a dressing change for one of three residents (Resident R5) and failed to ensure that contact precautions were ordered for two of five residents (Residents R36 and R82) and failed to ensure that contact precautions were care planned for one of five residents (Resident R82) 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 Quality Assurance attendance records and staff interview it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required members for three of three quarters (Quarter one, two, three of 2025).Findings: Review of Quality Assessment and Assurance minutes sign in sheets and attendance records for Quarter One, Two and Three of 2025, failed to reveal the Infection Preventionist was in attendance. During an interview 12/4/25, at 1:30 p.m. Clinical Services Specialist Employee E5 confirmed that the facility failed to conduct Quality Assurance and Performance Improvement (QAPI) meetings at least quarterly with all the required committee members for three of three quarterly meetings (Quarter one, two, three of 2025), as required. 28 Pa. Code 201.18 (e)(1)(2)(3)(4) Management.

Based on review of personnel records and staff interview, it was determined that the facility failed to complete annual performance evaluation at least once every 12 months for four of four nurse aide (NA) personnel records (NA Employees E12, E13, E14, and E15). Findings include:Review of NA Employee E12's personnel record indicated a hire date of 7/6/10. Review of NA Employee E12's personnel record failed to include an annual performance evaluation at least once every 12 months as required.Review of NA Employee E13's personnel record indicated a hire date of 2/3/12. Review of NA Employee E13's personnel record failed to include an annual performance evaluation at least once every 12 months as required.Review of NA Employee E14's personnel record indicated a hire date of 3/6/25. Review of NA Employee E14's personnel record failed to include an annual performance evaluation at least once every 12 months as required.Review of NA Employee E15's personnel record indicated a hire date of 1/6/23. Review of NA Employee E15's personnel record failed to include an annual performance evaluation at least once every 12 months as required.Interview on 12/3/25, at 12:47 p.m. the Corporate Human Resources Employee E7 confirmed that the facility failed to complete annual performance evaluation at least every 12 months for four of four nurse aide (NA) personnel records (NA Employees E12, E13, E14, and E15). 28 Pa Code: 201.14 (b) Responsibility of licensee28 Pa Code: 201.18 (b)(1)(3) Management

Based on observations, review of facility policy, clinical record review, 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 three residents (Residents R1, R63, and R92).Findings include: Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/10/25, indicated diagnoses of high blood pressure, muscle weakness, and need for assistance with personal care. During an observation on 12/1/25, at 9:58 a.m. bilateral (both sides) side rails were observed on the top of Resident R1's bed. Review of Resident R1's comprehensive care plan failed to include measurable objectives and timetables with specific interventions/services for use of bed rails. Review of the clinical record indicated Resident R63 was admitted to the facility on [DATE].Review of Resident R63's MDS dated [DATE], indicated diagnoses of anemia (too little iron in the blood), Parkinson's Disease (neuromuscular disorder causing tremors and difficulty walking), and depression. During an observation on 12/1/25, at 10:05 a.m. bilateral side rails were observed on the top of Resident R63's bed. Review of Resident R63's care plan dated 12/24/22, indicated the resident uses assist fails for bed mobility: bilateral 1/2 rails for mobility, repositioning and promote independence. Review of Resident R63's clinical record failed to reveal an ongoing accurate assessment for the resident's side rail usage. Review of the clinical record indicated Resident R92 was admitted to the facility on [DATE]. Review of Resident R92's MDS dated [DATE], indicated diagnoses of high blood pressure, diabetes mellitus (DM, a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and End-Stage Renal Disease (ESRD, an inability of the kidneys to filter the blood).During an observation on 12/1/25, at 10:06 a.m. bilateral enabler bars were observed on the top of Resident R92's bed.Review of Resident R92's clinical record failed to reveal an ongoing accurate assessment for the resident's bilateral enabler bar usage. Review of Resident R92's comprehensive care plan failed to include measurable objectives and timetables with specific interventions/services for use of enabler bars. During an interview on 12/3/25, at 1:08 p.m. Registered Nurse Assessment Coordinator (RNAC) Employee E1 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 three residents (Residents R1, R63, and R92). 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, clinical and facility record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision for one resident resulting in elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge) for one of three residents (Resident R94) and failed to provide adequate supervision to ensure a safe environment resulting in a burn for one of three resident's (Resident R35).Review of the facility policy Accidents and Incidents dated 10/13/25, indicated a safe environment will be promoted for all residents. Review of Resident R35's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R35's Minimum Data Set (MDS-periodic assessment of a resident's abilities and care needs) dated 10/21/25, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), depressive disorder and hypertension. Review of Resident R35's physician's orders dated 11/3/25, indicated restorative dining. Review of a progress note dated 11/7/25, at 1:02 p.m. indicated Nurse was informed by CNA that resident was in the dining area for activities and had coffee spilled in her lap and it was red and blistered. Resident assessed and RN supervisor notified. Daughter was notified of incident. Review of facility provided documents indicated Coffee was provided by the Activities department and not dietary. The temperature of the coffee was not taken prior to serving the resident's. During an interview on 12/3/25, at 2:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide adequate supervision for one of three residents, which resulted in a burn. Review of the facility policy Elopement Prevention dated 10/13/25, indicated the facility properly assesses residents and plans their care to prevent accidents related to wandering behavior or elopement. The admitting nurse will perform an initial assessment. A care plan will be developed that reflects the potential for elopement and preventative measures. Review of the admission Record indicated Resident R94 was admitted to the facility on [DATE], with the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), renal insufficiency (a condition in which the kidneys lose the ability to remove waste and balance fluids), and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). Review of the Nursing Review V-12 form dated 10/3/25, at 1:46 p.m. indicated family brought resident to the facility due to living alone and having severe dementia. Resident is walking independently. Resident is alert to person only and sometimes understands others. Resident has a known history of wandering. Does not understand surroundings. Resident photo will be added to those at risk. Review of Resident R94's baseline care plan on 12/1/25, failed to include interventions for supervision and resident centered interventions to prevent elopement. Review of Resident R94's progress notes indicated the following:-10/4/25, at 9:42 a.m. indicated Resident R94 was asking Where is the door so I can leave?. Wander guard placed on resident's right wrist. Resident refused to have it placed on the ankle.-10/4/25, at 5:42 p.m. indicated staff took resident dinner tray to the room, on the tray table was the wander guard that was placed that morning on the wrist. Resident removed the wander guard. Staff immediately began searching for the resident. Personal care staff notified the skilled nursing side that resident was in the personal care unit. Resident stated they were looking for their sister.-10/4/25, at 9:50 p.m. indicated safety checks began every 15 minutes.-10/5/25, at 4:42 p.m. indicated Resident was sitting in the lounge, got up quickly and stated I am getting out of here. My sister's blue Subaru just pulled up to pick me up. Writer attempted to show resident that no cars had pulled up outside, when resident pushed past writer stating, She is out there. continues to pace in front of the window looking for the blue Subaru.-10/5/25, at 5:19 p.m. indicated Resident was pacing back and forth in front of the window watching for the sister's car. Writer walked around the corner to the printer and heard the wander guard alarm. Writer immediately returned to where resident was last seen, and they were no longer there. Writer ran to the front door and resident was standing outside the front doors with another resident's family standing with resident and asking resident where they were going. Resident indicated I'm looking for my sister's blue Subaru; there is a Subaru right there (pointing at cars in the parking lot). Review of Personal Care Employee E10's undated witness statement indicated on 10/4/25, while working on the personal care unit, they heard the door alarm sound. Staff went to the door to see who it was, and an elderly man was through the door. Staff asked resident if they needed something as they kept walking down the hall. Resident said that they were looking for their sister. When staff reached the personal care unit's lobby, they had the resident sit down to take a break on the couch. Staff then called over to the skilled nursing side and told them Resident R94 was on the personal care unit. Interview on 12/3/25, at 11:15 a.m. the Director of Nursing confirmed the facility failed to ensure proper supervision and failed to implement patient centered interventions for a resident identified as an elopement risk, which resulted in an elopement to personal care on 10/4/25, and elopement out the front doors of the facility on 10/5/25. 28 Pa. Code 201.14 Responsibility of Licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 201.29 Responsibility of Licensee.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.28 Pa. Code 211.10(d) Resident care policies.

Based on a review of facility provided documents and staff interview, it was determined the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections during the periods of 10/4/25, through 10/13/25, and 11/16/25, to present.Findings included:During an interview on 12/5/25, at 1:25 p.m. the Director of Nursing (DON) stated, I was the Infection Preventionist and Assistant Director of Nursing for the period of 10/13/25, - 11/16/25, when I became the Interim DON. Prior to my tenure IP Employee E16's last day of work was on 10/4/25.During an interview on 12/5/25, at 12:30 p.m. the DON confirmed that the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections during the periods of 10/4/25, through 10/13/25, and 11/16/25, to present.28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(1) Management.28 Pa. Code: 201.19(3) Personnel records.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly store medications in one of three medication rooms (Memory Lane Medication Room).Findings include:Review of facility policy Storage of Medications dated 10/13/25, indicated certain medications such as multiple dose injectable vials require an expiration date shorter than the manufacturer's expiration date to ensure medication purity and potency. During an observation on 12/4/25, at 9:14 a.m. of the Memory Lane Medication Room Refrigerator revealed two tuberculin multiple dose vial (a substance used in the tuberculin skin test (TST) to diagnose tuberculosis infection) that was opened and not labeled with the date opened as required.During an interview on 12/4/25, at 9:14 a.m. Licensed Practical Nurse (LPN) Employee E16 confirmed the above observation and that the facility failed to properly store medication in one of three medication rooms (Memory Lane Medication Room).28 Pa. Code: 201(a) Responsibility of licensee.28 Pa. Code: 211.9(a)(1)(k) Pharmacy services.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of resident clinical records, facility policy and staff interview it was determined the facility failed to provide consistent and complete communication with the dialysis (a machine that filters wastes, salts, and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for two of two residents (Residents R13 and R92).Findings include: Review of the clinical record indicated Resident R92 was admitted to the facility on [DATE]. Review of Resident R92's MDS dated [DATE], indicated diagnoses of high blood pressure, diabetes mellitus (DM, a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and End-Stage Renal Disease (ESRD, an inability of the kidneys to filter the blood).Review of a physician order dated 11/5/25, indicated Resident R92 receives dialysis treatment at an outside facility every Monday, Wednesday, and Friday. Review of Resident R92s clinical record did not include complete communication forms for four days during the period of 11/1/25, through 11/30/25. The incomplete forms were on the following dates: 11/19/25, 11/21/25, and 11/25/25. No communication form was located for 11/5/25.During an interview on 12/3/25, at 2:20 p.m. Licensed Practical Nurse (LPN) Employee E2 confirmed the above dates did not include complete dialysis communication forms and that the facility failed to provide consistent and complete communication with the dialysis center for Resident R92. Review of the clinical record indicated that Resident R13 was admitted to the facility on [DATE]. Review of Resident R13's Minimum Data Set (MDS- a periodic assessment of care needs) dated 10/11/25, indicated with the diagnoses of end stage kidney disease (a condition where the kidney reaches advanced state of loss of function), dependance on renal dialysis and anxiety disorder. Review of R13's physician order dated 11/19/25, indicated the resident has dialysis one time a day every Tuesday, Thursday and Saturday. Review of Resident R13's Dialysis Communication Records indicated no completed communication records. Interview on 12/3/25 at 11:015 a.m. the Director of Nursing confirmed the facility failed to provide consistent and complete communication with the dialysis center for two of two residents reviewed (Residents R92, R13). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(c) Resident care policies.28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident care needs for one of five residents (Resident R92).Findings include: Review of facility policy Care Plan and Interdisciplinary Care Conferences dated 10/13/25, indicated the care plan is a working tool that is reviewed and revised at specific intervals and as needed to reflect response to care and changing needs and goals. Review of the clinical record indicated Resident R92 was admitted to the facility on [DATE]. Review of Resident R92's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/23/25, indicated diagnoses of high blood pressure, diabetes mellitus (DM, a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and End-Stage Renal Disease (ESRD, an inability of the kidneys to filter the blood). Review of a physician order dated 5/6/25, indicated to apply Dexcom G7 Sensor (a wearable continuous blood glucose monitor) transdermally (to the skin) every evening shift every 10 days for DM. Review of Resident R92's current care plan failed to include the development of goals and interventions related to the resident's wearable continuous blood glucose sensor. During an interview on 12/3/25, at 1:11 p.m. Registered Nurse Assessment Coordinator (RNAC) Employee E1 confirmed that the facility failed to develop a comprehensive care plan to meet resident care needs for Resident R92. 28 Pa Code: 201.14(a) Responsibility of licensee.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policies, clinical records, facility documents, and staff interviews it was determined that the facility failed to identify a scoop mattress (a specialty medical mattress with soft raised foam edges) as a possible restraint, and failed to assess the functional status of the individual resident to determine if the use of a scoop mattress is a restraint for one of three residents (Resident R63).Findings include: Review of facility policy Physical Restraint Policy and Procedure dated 10/13/25, indicated physical restraints are defined as any manual method of physical or mechanical device, material or equipment attached or adjacent to the elder's body that the individual cannot remove easily which restrict freedom of movement or normal access to one's body. Review of the clinical record indicated Resident R63 was admitted to the facility on [DATE].Review of Resident R63's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/12/25, indicated diagnoses of anemia (too little iron in the blood), Parkinson's Disease (neuromuscular disorder causing tremors and difficulty walking), and depression. Section GG - Functional Abilities, Question GG0170A: Roll left and right, indicated the resident was coded 1 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 a physician order dated 10/21/24, indicated resident provided a scoop mattress for positioning/comfort and safety while in bed. During an observation on 12/1/25, at 10:05 a.m. Resident R63's mattress was observed with bilateral (both sides) raised edges on the top and bottom portions. Review of Resident R63's clinical record failed to identify any assessments or ongoing evaluations for the usage of the scoop mattress. During an interview on 12/3/25, at 1:08 p.m. Registered Nurse Assessment Coordinator (RNAC) Employee E1 confirmed that the facility failed to identify a scoop mattress as a possible restraint and failed to assess the functional status of the individual to determine if the use of a scoop mattress is a restraint for Resident R63. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.8(e) Use of restraints.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, review of clinical records, observations and staff interview, it was determined that the facility failed to determine whether it was safe to self-administer medications for one of six residents (Resident R25). Findings include: Review of the facility policy Self-Administration of Medications dated 10/13/25, indicated in order to maintain the residents' high level of independence, resident's who desire to self-administer medications are permitted to do so if the facility 's interdisciplinary team has determined the practice would be safe for the resident and other resident's of the facility and there is a prescriber's order to self-administer. Review of the admission record indicated Resident R25 was admitted to the facility on [DATE]. Review of Resident R25's Minimum Data Set (MDS- a periodic assessment of care needs) dated 11/17/25, indicated the diagnoses of malignant neoplasm of upper lobe, right bronchus or lung, respiratory failure and chronic kidney disease. Observation on 12/1/25, at 10:30 a.m. of Resident R25's room indicated a two medicine cup's at the bedside table, one with liquid and the other with three pills. Interview with Registered Nurse (RN) Employee E9 confirmed the cup with three pills were fish oil, zoloft and movantik and the liquid was MiraLax and confirmed she left the pills and liquid at the bedside unattended. Review of Resident R25's clinical record failed to have a physician order, assessment, or plan of care addressing self-administration of medications. Interview on 12/1/25, at 10:45 a.m. RN Employee E9 confirmed the medications were stored in the resident room inappropriately and that Resident R25 failed to have an assessment, physician order, or plan of care for self-administration of medications. 28 Pa code: 211.12(d)(1)(5) Nursing services.

Based on review of state laws, facility policy and facility documents, and staff interviews, it was determined the facility failed to identify and timely report criminal allegations of abuse/neglect to local law enforcement and required agencies to protect residents for one of five staff members Licensed Practical Nurse (LPN, Employee E1). This failure created an immediate jeopardy situation. Findings include: Review of the Older Adult Protective Services Act of 11/6/87, amended by Act 1997-13, Chapter 7, Section 701, requires any employee or administrator of a facility who suspects abuse is mandated to report the abuse. All reports of abuse should be reported to the local area agency on aging and licensing agencies. If the suspected abuse is sexual abuse, serious bodily injury, or suspicious death, the law requires additional reporting to the Department of Aging and local law enforcement. Review of the State Operations Manual, Appendix PP revised 7/23/25, revealed the facility must develop and implement written policies and procedures that ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.(i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual's obligation to comply with the following reporting requirements.(A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility.(B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. Review of the facility policy titled, Resident Protection from Abuse, Neglect, Mistreatment or Exploitation review date 5/19/25, indicated it is the policy of the facility to identify abuse/neglect through various methods such as reports from employed or contracted staff, utilization of resident incident reports, review prior incidents and any patterns of staff behaviors. Allegations involving residents, visitors, employees, or any other person must be reported to the Administrator or Director of Nursing (DON) immediately. The Administrator or DON will notify the Department of Health via electronic reporting system within 24 hours of the incident and complete an on-line PB-22 if directed to do. The County Area Agency on Aging will be contacted and a verbal report of allegation of abuse will be submitted within 24 hours of the event. All written reports shall include, at a minimum, the name and age of the resident, address of resident representative, address of the home, nature of the alleged offense, and any specific comments or observations that are directly related to the alleged incident and individuals involved. All investigation will be conducted thoroughly and will attempt to gather as much factual information as possible. The Elder Justice Care Act requires each owner, operator, employee, manager, agency, or contractor of a nursing home facility (a covered individual) to report any responsible suspicion of a crime no later than (2) hours after forming the suspicion. In addition to reporting all obligations described above, covered individuals must report any reasonable suspicion of a crime to the Department of Health and to the local police serving the community where the resident is receiving care. Review of facility investigation documentation including witness statement dated 10/31/25, revealed Housekeeper, Employee E6 has worked at the facility for 13 years and since LPN, Employee E1 started on the memory impaired unit she has never seen so many die at one time. Housekeeper, Employee E6 stated I think they are given something they shouldn't be. It raises flags, and stated residents seem sedated. Review of Licensed Practical Nurse (LPN), Employee E4's witness statement dated 10/31/25, revealed about a month ago, LPN, Employee E4 was receiving report from LPN, Employee E1 on 9/28/25, when it was reported Resident R1 was hypothermic and when asked if the resident's temperature was rechecked or a nurse was notified, LPN, Employee E1 stated a RN wasn't informed. During report LPN, Employee E1 also stated everyone gets melatonin and made references to administering everyone Tylenol. Resident R1 was found to have an abnormally low rectal temperature upon follow up. Residents also were more sedated than usual and lethargic. Residents were not fully awake or unable to eat a meal until supper time. This was the residents' daily behavior for the whole weekend. Also, NA, Employee E5 came to me stating that LPN, Employee E1 gave everyone Tylenol and melatonin. I told aide to do the right thing and report this to the DON and Nursing Home Administrator. Review of the facility's investigation revealed an undated document titled by Nurse Aide (NA), Employee E5's name revealed, I have concerns with LPN, Employee E1. She keeps people snowed and gives Tylenol/Melatonin even if not ordered. I can tell a difference when LPN, Employee E1 works from when another nurse works in the resident's behaviors. They just want to sleep. It was revealed on normal days without LPN, Employee E1, Resident R5 yells out and when LPN, Employee E1 is there the resident does not. Review of facility documentation submitted on 11/3/25, revealed approached by staff that they had suspicions that a staff member was allegedly giving medication Melatonin to all residents whether they had an order from a provider or not. Facility failed to report criminal allegations of residents being sedated, unable to consume meals during the day, and increase in deaths on the memory impaired unit. During an interview on 11/5/25, at 10:01 a.m. Housekeeper, Employee E6 stated LPN, Employee E1 made the comment Monday, that she was giving everyone melatonin. Housekeeper, Employee E6 stated the weekend Resident R1 was sent out to the hospital for a change in condition, all day Saturday and Sunday residents couldn't open their eyes, eat, talk to us or anything. Housekeeper, Employee E6 stated I think something was given overnight and expressed concerns related to the increase in deaths on the memory impaired unit. I had nine people pass away just in October. Every time LPN, Employee E1 works, residents are much more tired. During an interview on 11/5/25, 10:15 a.m. LPN, Employee E7 stated I see a decline in residents where LPN, Employee E1 is working, but they have been here for years. A lot of them decline faster than I thought they would have. During an interview on 11/5/25, at 11:14 a.m. NA, Employee E8 stated sometimes LPN, Employee E1 says she is going to give them their medication, so she has a good night. They were kind of hard to wake up the next day, some wouldn't wake up, go through breakfast lunch, did get them up for supper. NA, Employee E8 stated. I worked with her twice a week and only noticed resident druggy, overly sleeping when she works the day before. During an interview on 11/5/25, at 11:24 a.m. NA, Employee E9 11/5/25, stated they have concerns with LPN, Employee E1. It was revealed LPN, Employee E1 makes the comment, we are going to have a good night, they are going to go to bed and rest. NA, Employee E6 stated residents were sleeping the next morning until 6 p.m., couldn't eat, couldn't get out of bed, it's been ongoing since LPN, Employee E1 has been working back there. During a phone interview on 11/6/25 at 9:12 a.m. NA, Employee E5 was unavailable for interview. During an interview on 11/6/25, at 11:05 a.m. the Nursing Home Administrator and Director of Nursing were asked for evidence the facility reported allegations of abuse/neglect to Area Agency on Aging (AAA). Review of facility documentation revealed the Area Agency on Aging was notified on 11/6/25, at 12:40 p.m. a total of 10 days since the facility was made aware of abuse/neglect allegations. During an interview on 11/6/25, at 2:03 p.m. the Director of Nursing confirmed they were made aware of allegations involving LPN, Employee E1 on 10/27/25. The DON and NHA confirmed the facility failed to timely initiate an investigation, report to appropriate agencies. NHA and DON confirmed the facility had not reported the allegations to police when it was made aware on 10/27/25, a total of 10 days later. The DON stated it was Hearsay and gossip when asked why the facility failed to report the allegations. During a second attempted phone interview on 11/7/25 at 9:32 a.m. NA, Employee E5 was unavailable for interview. On 11/7/25, at 12:41 p.m., the NHA and DON were made aware that Immediate Jeopardy (IJ) existed. The NHA was provided with the IJ Template, the facility failed to identify and timely report serious abuse/neglect allegations to local law enforcement and required agencies. This failure created an immediate jeopardy situation. A corrective action plan was requested. During an interview on 11/7/25, at 1:32 p.m. the Chief Nursing Officer (CNO), Employee E10 stated I was told this Friday, and I know the DON knew. I was at another facility, and I immediately came here and started the investigation. On 11/7/25, at 2:38 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action: -Review of current residents' medical records will be reviewed for signs of abuse/neglect within the last 30 days by the DON and/or designee. All interviewable residents will be interviewed for any signs and/or symptoms of abuse and/or neglect. If any allegations of abuse/neglect are found, abuse policy will be followed, and an investigation and reporting will begin immediately. This will be completed by Monday, 11-10-25. -Staff will be interviewed for review of abuse/neglect allegations that have not been reported to the DON and/or designee. If any allegations are identified, investigation and reporting will begin immediately. This will be completed by Saturday, 11-8-25. -Review of Electronic event report for neglect allegation will be updated by the DON/designee to accurately reflect concern for Nurse giving Tylenol and Melatonin to all residents on the memory unit whether there is an order or not thus causing potential harm. This will be completed by 11-7-25. -Area of aging was notified on 11-6-25. State Police were notified on 11-6-25. -NHA and/or designee will review Abuse/Neglect Policy, Incidents and Accidents Policy, and reporting criteria and will update if needed. This will be completed by 11-7-25. -All house staff and agency staff will be educated on the abuse/neglect policy and reporting abuse by the DON and/or designee prior to their next shift worked. This will be completed by Monday, 11-10-25. -All residents who have had an allegation of abuse/neglect in the last 30 days will be audited by the DON and/or designee to ensure that it was reported appropriately and timely. This will be completed by 11-8-25. -All audits and policy changes related to IJ 609 will be reviewed at an Ad hoc Quality meeting by Monday, 11-10-25. Review of 95 of 95 resident clinical records for incidents or allegations of abuse or neglect was conducted for evidence of abuse or neglect. 3/95 had concerns for abuse/neglect, 1 of the 3 were already reported and an investigation for the other two were immediately initiated. 31/95 Residents were interviewed to see if any concerns about abuse were present. No residents indicated concerns of abuse when interviewed. An audit of resident's Medication Administration Record and Treatment Administration Record revealed 95/95 residents were reviewed, which identified 84/95 residents had concerns related to failing to sign off orders. Failing to sign off physician orders on Mar/TAR was added to abuse training and education was provided for all staff. On 11/9/25, the facility resubmitted the ERS report to include the concern for LPN, Employee E1 giving medications without an order and the allegation of increased deaths on the memory impaired unit. Area of Aging and the State Police were notified on 11/6/25. A review of facility documentation revealed a trooper arrived on-site at the facility on 11/7/25, at 5:00 p.m. Abuse/Neglect Policy was reviewed on 11/7/25, no revisions were made. Reportable Events Notification Policy was reviewed with no revision made on 11/7/25. 106/130 in-house staff were educated on abuse/neglect policy and reporting. 54/63 agency staff members were educated on abuse/neglect and reporting. During in person interviews completed on 11/9/25, at 12:23 p.m. 14/14 interdisciplinary staff members confirmed they were educated on types of abuse/neglect, to report immediately, and who to report to. During phone interviews completed on 11/9/25, at 2:00 p.m. 14/14 staff confirmed education on types of abuse, when to report, and who to report to. All staff are required to verify education prior to the start of their next shift. Facility completed review of clinical records and facility incidents for the past 30 days to audit all allegations of abuse/neglect to ensure accurate reporting was completed. Facility identified 2 allegations of abuse/neglect during audit and reported them to Department of Health and initiated an investigation. Ad Hoc Meeting was conducted on 11/8/25, no changes were made related to abuse and reporting policy. Audits of clinical records revealed two incidents of abuse/neglect which were reported. The Immediate Jeopardy was lifted on 11/9/25, at 2:41 p.m. when the action plan implementation was verified. During an interview on 11/10/25, at 12:05 p.m. the NHA, Chief Nursing Officer, Employee E10, Clinical Operations Specialist, Employee E11 confirmed that the facility failed to identify and timely report criminal allegations of abuse/neglect to local law enforcement and required agencies for one of five staff members (Licensed Practical Nurse (LPN), Employee E1). This failure created an immediate jeopardy situation. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 201.18 (b) (1) (e) (1) Management. 28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.

Based on policy, employee files, facility documents, staff interviews, it was determined that the facility failed to ensure all nursing staff were educated on abuse/neglect before working in the facility for one of five staff members (LPN, Employee E1) and two of five staff members (LPN, Employee E2 and Registered Nurse, Employee E3) annually. The facility failed to identify incidents of abuse/neglect, and timely report and investigate allegations of abuse/neglect. The facility put other residents at risk for abuse/neglect from Licensed Practical Nurse (LPN), Employee E1 by allowing the staff member to continue to work after abuse/neglect allegations were made. This failure created an immediate jeopardy situation.Findings include: Review of the facility's policy titled Resident Protection from Abuse, Neglect, Mistreatment or Exploitation review date of 5/19/25, indicated it is the policy of the facility that each of its own and operated homes treat all residents with kindness, respect and in a manner that is at all times free from any form of abuse, neglect, misappropriation of property, exploitation, or mistreatment. To protect our residents, each of our homes will implement procedures in the areas of screening, training, prevention, identification, investigation, protection, reporting/response and corrective action. The facility has developed and implemented personnel and other policies to ensure that all staff are qualified and meet all regulatory standards for hire. In addition, we screen our employed contracted prior to employment, Employed staff, upon hire and at least annually through in-service education will receive training on issues related to abuse prohibition and prevention. We provided adequate supervision of our staff to identify inappropriate behaviors and to ensure that care/services are provided safely and as needed. We provide appropriate information to our staff of those residents with potential for aggressive behavior. Abuse and neglect will be identified through various methods such as reports from employed or contracted staff, utilization of resident incident reports, review prior incidents and any patterns of staff behaviors. Allegations involving residents, visitors, employees, or any other person must be reported to the Administrator or Director of Nursing (DON) immediately. The Administrator or DON will notify the Department of Health via electronic reporting system within 24 hours of the incident and complete an on-line PB-22 if directed to do. The County Area Agency on Aging will be contacted and a verbal report of allegation of abuse will be submitted within 24 hours of the event. All written reports shall include, at a minimum, the name and age of the resident, address of resident representative, address of the home, nature of the alleged offense, and any specific comments or observations that are directly related to the alleged incident and individuals involved. All investigation will be conducted thoroughly and will attempt to gather as much factual information as possible. If a specific employee is suspected of abuse of a resident, the home shall immediately implement a plan of supervision or, where appropriate, reassignment, suspension or where appropriate, reassignment, suspension or termination of employment of the employee. The Elder Justice Care Act requires each owner, operator, employee, manager, agency, or contractor of a nursing home facility (a covered individual) to report any responsible suspicion of a crime no later than (2) hours after forming the suspicion. In addition to reporting all obligation described above, covered individuals must report any reasonable suspicion of a crime to the Department of Health and to the local police serving the community where the resident is receiving care. Review of witness statement dated 10/31/25, revealed Housekeeper, Employee E6 has worked at the facility for 13 years and since LPN, Employee E1 started on the memory impaired unit she has never seen so many die at one time. Housekeeper, Employee E6 stated I think they are given something they shouldn't be. It raises flags, and stated residents seem sedated. Review of Nurse Aide (NA), Employee E5's undated witness statement revealed, I have concerns with LPN, Employee E1, keeps people snowed. and gives melatonin and Tylenol even if not ordered. Review of LPN, Employee E4's witness statement dated 10/31/25, revealed about a month ago, LPN, Employee E4 was receiving report from LPN, Employee E1 when it was reported Resident R1 was hypothermic and when asked if the resident's temperature was rechecked or a nurse was notified, LPN, Employee E1 stated a RN wasn't informed. During report LPN, Employee E1 also stated everyone gets melatonin and made references to administering everyone Tylenol. Resident R1 was found to have an abnormally low rectal temperature upon follow up. Residents were also more sedated than usual and lethargic. Residents were not fully awake or unable to eat a meal until supper time. This was the resident's daily for the whole weekend. Also, NA, Employee E5 came to me stating that LPN, Employee E1 gave everyone Tylenol and melatonin. I told aide to do the right thing and report this to the DON and Nursing Home Administrator. Review of facility documentation submitted on 11/3/25, revealed the DON was approached by staff that they had suspicions that a staff member was allegedly giving medication to all residents whether they had an order from a provider or not. Further review failed to reveal allegations of residents being sedated, unable to consume meals during the day, or increase in deaths on the memory impaired unit. During an interview on 11/5/25, at 9:56 a.m. LPN, Employee E4 revealed while receiving report from LPN, Employee E1 about a month ago, during the weekend of 9/28/25, LPN, Employee E1 instructed everyone gets melatonin. and made references to administering everyone Tylenol. LPN, Employee E4 stated residents were also more sedated than usual and lethargic, residents were not fully awake or able to eat a meal until suppertime. This was the residents condition for the whole weekend. LPN, Employee E4 stated NA, Employee E5 came to me stating LPN, Employee E1 gave everyone Tylenol and melatonin. I told the aide to do the right thing and report it. Facility nursing staff failed to report an allegation of abuse/neglect during the weekend of 9/28/25, when LPN, Employee E4 was made aware of abuse allegations. Interview conducted on 11/5/25, at 10:01 a.m. Housekeeper, Employee E6 indicated LPN, Employee E1 made the comment Monday, that she was giving everyone melatonin. Housekeeper, Employee E6 stated the weekend Resident R1 was sent out to the hospital for a change in condition, all day Saturday and Sunday residents couldn't open their eyes, eat, talk to us or anything. Housekeeper, Employee E6 stated I think something was given overnight and expressed concerns related to the increase in deaths on the memory impaired unit. I had nine people pass away just in October. Every time LPN, Employee E1 works, residents are much more tired. Interview conducted on 11/5/25, 10:15 a.m. LPN, Employee E7 stated I see a decline in residents where LPN, Employee E1 is working, but they have been here for years. A lot of them decline faster than I thought they would have. Interview conducted on 11/5/25, at 11:14 a.m. NA, Employee E8 stated sometimes LPN, Employee E1 says she is going to give them their medication, so she has a good night. They were kind of hard to wake up the next day, some wouldn't wake up, go through breakfast lunch, did get them up for supper. NA, Employee E8 stated. I worked with her twice a week and only noticed resident druggy, overly sleeping when she works the day before. During an interview on 11/5/25, at 11:24 a.m. NA, Employee E9 stated they have concerns with LPN, Employee E1. NA, Employee E9 stated, LPN, Employee E1 makes the comment, we are going to have a good night, they are going to go to bed and rest. NA, Employee E6 stated residents were sleeping the next morning, couldn't eat, couldn't get out of bed, it's been ongoing since LPN, Employee E1 has been working back there. Nursing floor staff failed to identify, correct, and intervene in situations in which allegations of abuse and neglect were reported on the Memory impaired unit since 9/28/25. During an interview on 11/6/25, at 10:19 a.m. LPN, Employee E1 was asked if they have been trained on dementia training and stated I am unsure if dementia training was completed. I am very used to working with them, worked as an aide years ago. I want them comfortable; I don't want them in pain. That's my goal. On 11/6/25, a review of LPN, Employee E1's agency RN/LPN Skills List dated 5/16/25, was not signed by a clinical staff member. A review of the personnel file for Licensed Practical Nurse (LPN), Employee E1 revealed LPN, Employee E1 worked at the facility through agency from 7/23/25, to 8/17/25. There was no evidence that LPN, Employee E1 was educated on abuse prior to starting on 7/23/25. LPN, Employee E1 was hired as in-house staff on 8/26/25. During an interview on 11/6/25, at 11:30 a.m. the DON revealed LPN, Employee E1's agency skills were completed by a reference and confirmed LPN, Employee E1 failed to complete the facility's documentation required for onboarding prior to agency staff working in the facility. A review of the personnel file for LPN, Employee E2 revealed LPN, Employee E3, began working at the facility through agency on 1/18/24. There was no evidence LPN, Employee E2 was educated on abuse annually. A review of the personnel file for Registered Nurse (RN), Employee E3 revealed RN, Employee E2 began working at the facility through agency on 6/15/23. There was no evidence RN, Employee E3 was educated on abuse annually. During an interview on 11/6/25, at 2:02 p.m. the Director of Nursing (DON) stated she was made aware of allegations of abuse/neglect on 10/27/25, by Housekeeper, Employee E6. The DON confirmed the facility did not obtain witness statements until 10/31/25, for a total of 5 days after being notified of allegation of abuse. The Director of Nursing confirmed LPN, Employee E1 continued to work (on 10/29/25, 5:53 p.m. to 6:30 a.m.) after suspicions of abuse/neglect were reported. During an interview on 11/6/25, at 2:04 p.m. the DON and NHA confirmed the facility was made aware of an allegation of neglect involving LPN, Employee E1 on 10/27/25. The DON and NHA confirmed the facility failed to timely initiate an investigation, report to appropriate agencies, and suspend the alleged perpetrator immediately. During an interview on 11/6/25, at 4:08 p.m. the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the facility failed to ensure one of five agency staff members were educated on abuse prior to their start date (LPN, Employee E1), and failed to ensure two of five agency staff members were educated on abuse annually (LPN, Employee E2 and RN, Employee E3). During a second attempted phone interview on 11/7/25 at 9:32 a.m. NA, Employee E5 was unavailable for interview. On 11/7/25, at 12:41 p.m., the NHA and DON were made aware of Immediate Jeopardy (IJ) related to abuse and neglect. The NHA was provided with the IJ Template, the facility failed to ensure all nursing staff were educated on abuse/neglect prior to working in the facility and annually. The facility failed to identify incidents of abuse/neglect, and report and investigate allegations of abuse/neglect timely. The facility put other residents at risk for abuse/neglect from Licensed Practical Nurse (LPN), Employee E1, was allowed to continue to work after allegations were made. A corrective action plan was requested. On 11/7/25, at 3:40 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action: -Current medical records will be reviewed for any signs of abuse/neglect from the last 30 days. All interview able residents will also be interviewed for any signs and/or symptoms of abuse and/or neglect. If any is found abuse policy will be followed and an investigation and reporting will begin immediately. This will be completed by Monday, 11/10/25. -All staff will be interviewed for allegations of abuse/neglect that have not been reported in the last 30 days by the DON and/or designee. If any are identified, investigations and reporting will begin immediately. This will be completed by Saturday 11/8/25. -Education will be completed by the Chief Nursing Officer to the Director of Nursing and Nursing Home Administrator on immediate reporting of any allegation/neglect by 11/7/25. -Education will be completed by the Chief Nursing Officer to the Director of Nursing and Nursing Home Administrator on the immediate suspension of an employee with an allegation of abuse/neglect by 11/7/25. -Education to be completed by the DON/Designee to Licensed Nursing Staff both in house and agency on the appropriate medication administration and following Physician's orders by Monday, 11/10/25, or prior to their next scheduled shift. An audit of each resident's Medication Administration Record (MAR) and Treatment medication Record (TAR) will be completed to ensure medications and treatments have been administered/given as ordered for the last 30 days. -NHA and/or designee will review the Abuse/Neglect Policy and will update if needed. This will be completed by 11/7/25. -All house staff and agency staff will be educated on the abuse/neglect policy and reporting abuse by the DON and/or designee prior to their next shift worked. This will be completed by Monday, 11/10/25. -All audits and policy changes related to immediate jeopardy will be reviewed at an ad hoc Quality meeting by Monday, 11/10/25. Review of 95 of 95 resident clinical records for incidents or allegations of abuse or neglect, 3 of 95 had concerns for abuse/neglect, 1 of the 3 were already reported and an investigation for the other two were immediately initiated. 31/95 Residents were interviewed to see if any concerns about abuse were present. No residents indicated concerns of abuse when interviewed. An audit of resident's Medication Administration Record and Treatment Administration Record revealed 95/95 residents were reviewed, which identified 84/95 residents had concerns related to failing to sign off orders. Failing to sign off physician orders on Mar/TAR was added to abuse training and education was provided for all staff. 54/63 agency staff were interviewed as of 11/9/25 for allegations of abuse/neglect that have not been reported in the last 30 days. 54/54 agency staff members failed to have any concerns. 106/130 in-house staff members were interviewed to see if any incidents of abuse failed to be reported in last 30 days. No new incidents of abuse/neglect were identified through interviews. All staff are required to be interviewed for instances of abuse/neglect that were not reported in last 30 days, prior to the start of their next shift. Any incidents will be reported and investigated timely. Education was completed by Chief Nursing Officer to Director of Nursing and Nursing Home Administrator on 11/7/25, to immediately report any incidents that seriously compromise quality assurance or patient safety. Education was completed by Chief Nursing Officer to Director of Nursing and Nursing Home Administrator on 11/7/25, to immediately suspend an employee with an allegation of abuse/neglect. The NHA and DON signed and dated education. An audit of resident's Medication Administration Record and Treatment Administration Record revealed 95/95 residents were reviewed, which identified 84/95 residents had concerns related to staff failing to document physician orders were completed in the clinical record. Failing to sign off physician orders on MAR/TAR was added to abuse training and education was provided for all staff. 26/32 agency licensed nursing staff and 17/26 licensed nursing staff were educated on MAR/TAR and physician orders. All licensed nursing staff, not educated, must verify education on physician orders and MAR/TARs prior to the start of their next shift. Abuse/Neglect Policy was reviewed on 11/7/25, no revisions were made. Reportable Events Notification Policy and was reviewed with no revision made on 11/7/25. 106/130 in-house staff were educated on abuse/neglect policy and reporting. 54/63 agency staff members were educated on abuse/neglect and reporting. During in person interviews completed on 11/9/25, at 12:23 p.m. 14/14 interdisciplinary staff members confirmed they were educated on types of abuse/neglect, to report immediately, and who to report to. During phone interviews completed on 11/9/25, at 12:51 p.m. 14/14 staff confirmed education on types of abuse, when to report, and who to report to. All staff are required to verify education prior to the start of their next shift. Audits of all 95/95 current residents were conducted on the progress notes for evidence of abuse or neglect. 3/95 had concerns for abuse/neglect, 1 of the 3 were already reported and an investigation for the other two were immediately initiated. 31/95 Residents were interviewed to see if any concerns about abuse were present. No residents indicated concerns of abuse when interviewed. Ad Hoc Meeting was conducted on 11/8/25, no changes were made related to abuse and reporting policy. Audits of clinical records revealed two incidents of abuse/neglect which were reported The Immediate Jeopardy was lifted on 11/9/25, at 2:41 p.m. when the action plan implementation was verified. During an interview on 11/10/25, at 12:05 p.m. the NHA, Chief Nursing Officer, Employee E10, Clinical Operations Specialist, Employee E11 confirmed that the facility failed to ensure all nursing staff were educated on abuse/neglect before working in the facility and annually. The facility failed to identify incidents of abuse/neglect, and timely report and investigate allegations of abuse/neglect. The facility put other residents at risk for abuse/neglect from Licensed Practical Nurse (LPN), Employee E1 by allowing the staff member to continue to work after allegations were made. This failure resulted in an immediate jeopardy situation. 28 Pa. Code 201.14(c) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(5) Nursing services.