Every finding on record at Quality Life Services - Markleysburg

Based on review of the clinical records and facility documents, resident and staff interviews, and observations it was determined that the facility failed to properly temperature the hot water prior to giving it to a resident (Resident R11) which resulted in actual harm of second-degree burn (a burn marked by pain, blistering, and damage to the outer layer of skin with redness and swelling of the tissues beneath the burn) to abdomen, and pelvic area. Findings include: Review of the facility policy Safe Provision of Hot Beverages to Residents - Activities last reviewed 5/1/26, indicated its purpose was to ensure the safe preparation, handling, and distribution of hot beverages to residents in order to prevent burns and other avoidable injuries, while supporting resident comfort, dignity, and choice. Beverages are to be served below scalding temperature. DO NOT serve hot liquids greater than 150 F (Fahrenheit). Hot beverage(s) is to sit for at least 15 minutes with the lid off before served to the resident. After 15 minutes have lapsed, temperature should be taken using a food grade thermometer. If temperature is 105 F or below, the lid can be placed on the cup and given to the resident. Do not leave the resident unattended with the hot beverage. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2025, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggest the following distributions: 13 - 15: cognitively intact8 - 12: moderately impaired0 - 7: severe impairment Review of the clinical record indicated Resident R11 was admitted to the facility on [DATE], with diagnoses that included unsteadiness on feet, difficulty in walking, generalized muscle weakness, and schizoaffective disorder (mental illness where person experiences psychotic [thinking, seeing, or believing things that aren't real], and mood [extreme mania or depression] symptoms at the same time or in cycles). Review of the Minimum Data Set (MDS - standardized assessment tool for all residents of long-term care facilities) dated 6/9/26, indicated the diagnoses remain current. Review of Section C: Cognitive Patterns; C0500: BIMS Summary Score, indicated a BIMS score of 09. Further review of the MDS, Section GG - Functional Abilities Question G0130 Self-Care; A. Eating indicated Resident R11 required set up or clean up assistance from staff. Review of the facility documents dated 5/5/26, at 10:00 p.m. revealed Resident R11 notified staff that he burnt himself with hot water. He asked for hot water for coffee, was in bed with the hot water, and spilled it on himself. Multiple burns marks were noted on Resident R11's abdomen (stomach) described as large pink/red, dull appearance, approximately four large burn areas and two deeper angry red marks on mid-pelvic area which were smaller and linear (a line), skin still intact. Review of a progress note dated 5/6/26, at 8:17 a.m. wound documentation revealed the wound area measured 20 cm (centimeters) wide by 32 cm deep. Review of a progress note dated 5/6/26, at 9:36 a.m. indicated Resident R11 identified Nurse Aid (NA) Employee E4 as the person who gave him the hot water on 5/5/26. NA Employee E4 gave him hot water with the lid on, but he took it off. As he took the lid off, the hot water spilled on him causing mild first and second-degree burns. Review of a Body Check assessment completed on 5/5/26, at 10:15 p.m. indicated Resident R11 had a burn on his abdomen and groin, and a blister on the left hip. It was noted series of burns, approximately six. Four large burns traversing across abdomen from right to left, one large blister left lower abdomen. Review of wound documentation dated 5/6/26, indicated the burn area measured 20 cm (centimeters) wide by 32 cm long. The facility failed to provide measurements of individual wounds or blisters Review of the physician orders revealed the following:-On 8/27/25, All hot liquids to be served in a cup with a lid.-On 3/19/26, supervision for bed mobility-On 5/5/26, all fluids in a straw cup only.-On 5/5/26, may apply cool compresses to burns on abdomen if complaints of discomfort or may administer Tylenol (acetaminophen - mild pain reliever) every two hours as needed until healed This is the verbiage from the exact order. -On 5/5/26, Silvadene external cream 1% (silver sulfadiazine - topical antibiotic cream used to prevent infections in second- and third-degree burns). Apply to abdomen burns topically three times a day for burn to skin, cleanse with cold water and mild soap for seven days, apply cream and cover with ABD (thick gauze pad) three times a day until healed. Review of the eMAR for May 2026, revealed treatment was provided to Resident R11's burns from 5/6/26 to 5/13/26, and 5/16/26 to 5/19/26. Review of the care plan initiated 10/28/24, indicated the following interventions:-Monitor and document the location, size, and treatment of any skin impairment-initiated on 3/5/26 and revised 6/11/26, All hot liquids in a cup with a lid. (resident will take lid off of cup by myself regardless of safety and re-education by staff.) During an interview on 6/4/25, at 9:00 a.m. the Nursing Home Administrator (NHA) stated facility staff (Not all staff were educated, the NA that gave the water never signed it) was provided education on Safe Provision of Hot Beverages to Residents - Activities between 5/6/26 and 5/9/26. During an interview on 6/4/26, at 12:30 a.m. Licensed Practical Nurse (LPN) Employee E2 stated they thought the hot fluid temperature was less than 100 degrees Fahrenheit (100 F) or less. LPN Employee E2 was re-educated on hot water temps on 5/7/26. During an interview on 6/4/26, at 12:33 a.m. Activities Director Employee E8 stated the hot fluids had to be less than 150 F. They were able to show temperature logs for coffee temperatures taken prior to giving the resident the cup. During an interview on 6/4/26, at 12:36 p.m. LPN Employee E9 stated they thought the temperature for hot liquids was approximately 112 F but stated they do not provide hot liquids to the residents. That comes from the nourishment room (kitchen) or activities staff. LPN Employee E9 did not receive re-education on hot water temperatures. During an interview on 6/4/26, at 12:40 p.m. NA Employee E10 stated they did not know what temperature the hot liquids needed to be before given to a resident. NA Employee E10 did not receive re-education on hot water temperatures. During an interview on 6/4/26, at 12:45 p.m. Registered Nurse (RN) Employee E1 stated the water temperature should be 98 F or less. RN Employee E1 received re-education on hot water temperature on 5/6/26. During an interview on 6/4/26, at 12:47 p.m. LPN Employee E12 stated hot water should be between 150 F and 175 F or less. They did not receive re-education on hot water temperatures. During an interview on 6/4/26, at 12:49 p.m. LPN Employee E11 stated hot water needed to be 105 F or less. LPN Employee E11 received re-education on hot water temperature on 5/6/26. During an interview on 6/4/26, at 12:50 p.m. NA Employee E13 stated hot water needed to be 105 F or less. They did not receive re-education on hot water temperatures. During an interview on 6/4/26, at 12:50 p.m. NA Employee E14 stated they could not recall the correct temperature for hot liquids before giving to a resident. They did not receive re-education on hot water temperatures. During an interview on 6/4/26, at 12:52 p.m. NA Employee E15 stated hot water temperature needed to be less that 150 F before handed to a resident. NA Employee E15 received re-education on hot water temperatures on 5/6/26. During an interview on 6/25/26, at 8:40 a.m. Resident R11 stated the staff should have taken the temperature of the water, he stated the burn hurt bad and he has a scar about the size of a half dollar on his left side/hip area. During an interview on 6/25/26, at 10:10 a.m. NA Employee E4 stated at approximately 7:15 p.m. Resident R11 was following her around asking for hot water for coffee, so she went into the kitchen and got water from the hot water spout on the coffee machine, put a lid on the cup and handed it to Resident R11. Her shift was over at 7:30 p.m., she was unable to recall if she told the next shift about the water before her shift was done. She confirmed she did not take the temperature of the hot water before handing it to the resident. She stated that she assumed, since it came from the kitchen, that it would be at the correct temperature for the residents. During an interview on 6/22/26, at 12:40 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide hot water at a safe temperature that resulted in actual harm of Resident R45 (second degree burn to abdomen and pelvic area). 201.14(a)Responsibility of Licensee201.18(b)(1)(e)(2)Management201.20(a)(b)(c)(d)Staff Development201.29(j)Resident Rights211.10(c)(d)Resident Care Policies211.12(d)(1)(2)(3)(5)Nursing Services

Based on review of facility policy, resident records, observation, and staff interview it was determined that the facility failed to uphold the resident's rights to voice grievances without fear of retaliation for ten residents reviewed (Resident R800, R801, R802, R803, R804, R805, R806, R807, R808, and R809).Findings include: Review of the facility policy Resident Rights last reviewed 5/1/26, indicated a resident has the right to file complaints with any individual or agency and recommend changes in policies, home rules and services of the home without intimidation, retaliation or threat of discharge. During a group meeting on 6/23/26 from 1:30 p.m. to 2:15 p.m., Resident R804 did not want to be interviewed until they confirmed that their name was not going to be mentioned when the state surveyor discussed issues with the facility. They stated they are afraid to speak up against the facility staff in fear of retaliation. Resident R802 stated we don't want to bite the hand that feeds us. Residents R805, R807, R803, and R806 stated they did not want the staff to come back and not take care of them. Resident R809 had concerns that their call bell would be ignored, resident care not given, or staff being mean to them. They also stated they did not want get staff in trouble. These residents requested to remain anonymous. During an interview on 6/25/26, at 12:30 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to ensure resident's do not feel retaliated against when voicing complaints or grievances. 28 Pa Code: 201.29 (i) Resident rights.

Based on staff interviews it was determined that the facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department for 12 of 12 months (July 2025 through June 25, 2026). Findings include:During an interview on 6/23/26, at approximately 10:30 a.m., the Dietary Supervisor Employee E5 stated that she was the manager and was currently working on her Certification to become a CDM.During an interview on 6/24/26, at approximately 8:58 a.m., Registered Dietician (RD) Employee E6 stated that she comes to this facility usually once a week, she goes to a few facilities.During an interview on 6/24/26, at approximately, 9:00 a.m., the Dietary Supervisor Employee E5 and RD Employee E6 confirmed that the facility currently does not have a Certified Dietary Manager and the Registered Dietician is not employed by the facility full time. The facility failed to show evidence that any staff met the qualifications for the position of Food Service Director.Pa Code: 201.18(e)(6) Management.Pa Code: 211.6(c)(d) Dietary Services.

Based on resident council interviews, observation of menus and staff interviews, it was determined that the facility failed to provide food in accordance with resident preferences and provide meals following national guidelines and are periodically updated to mitigate the risk of menu fatigue for the current menu cycle. Findings include: Review of CFR S483.60(c)(1)-(7) Menus must-S483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups;S483.60(c)(5) Be updated periodically;o Menus meet basic nutritional needs by providing meals based on individual nutritional assessment, the individualized plan of care, and established national guidelines and are periodically updated to mitigate the risk of menu fatigue. During the resident council meeting on 6/23/26, at 1:30 p.m., the consensus was identified that the food menu choices repeat and you get same foods over and over. The residents stated that they have food committee and are fearful to tell staff about concerns due to retaliation. Review of the food committee minutes did not include concerns for menu choices. However, the residents had identified concerns that they are fearful of retaliation. During a review of the menus on the Spring/ Summer Menus, week one, identified white rice repeated three times in one week. Week three identified Chicken repeated four times, three times for lunch and one time for dinner. During an interview on 6/24/26, at 9:10 a.m., with the Registered Dietician Employee E6 and the Dietary Supervisor Employee E5 confirmed that the facility menu choices were repeated which had the potential for menu fatigue. 28 Pa. Code: 211.6(a) Dietary services

Based on observation and interview, the facility failed to provide the required 80 square feet of space per resident for 16 of 25 rooms. Findings include:During an observation of the facility floor plan on 6/22/26, at 2:15 p.m. the below room findings were as follows: room [ROOM NUMBER] (2 beds) 72.69 square feet per resident bed.room [ROOM NUMBER] (2 beds) 73.40 square feet per resident bed.room [ROOM NUMBER] (2 beds) 71.37 square feet per resident bed.room [ROOM NUMBER] (4 beds) 69.52 square feet per resident bed.room [ROOM NUMBER] (3 beds) 70.67 square feet per resident bed.room [ROOM NUMBER] (2 beds) 73.70 square feet per resident bed.room [ROOM NUMBER] (2 beds) 74.61 square feet per resident bed.room [ROOM NUMBER] (2 beds) 71.61 square feet per resident bed.room [ROOM NUMBER] (3 beds) 76.52 square feet per resident bed.room [ROOM NUMBER] (4 beds) 77.06 square feet per resident bed.room [ROOM NUMBER] (3 beds) 70.91 square feet per resident bed.room [ROOM NUMBER] (2 beds) 71.90 square feet per resident bed.room [ROOM NUMBER] (2 beds) 66.12 square feet per resident bed.room [ROOM NUMBER] (2 beds) 64.92 square feet per resident bed.room [ROOM NUMBER] (3 beds) 78.40 square feet per resident bed.room [ROOM NUMBER] (3 beds) 71.56 square feet per resident bed. During an interview on 6/25/26, at 12:02 p.m. the Nursing Home Administrator confirmed that the room sizes were less than 80 square feet as required. 28 Pa. Code: 205.20(f) Resident bedrooms

Based on a review of facility policies, documents, observations, and staff interviews it was determined that the facility failed to provide a dignified dining experience on 6/24/26, during the lunch meal service to one of six residents. (Resident R3) in the main dining room.Findings include:A review of facility Resident Rights Policy policy dated 5/1/26, indicated a resident has the right to file complaints with any individual or agency and recommend changes in policies, home rules and services of the home without intimidation, retaliation or threat of discharge. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggest the following distributions:13 - 15: cognitively intact8 - 12: moderately impaired0 - 7: severe impairmentReview of the clinical record indicated Resident R3 was admitted to the facility on [DATE], with diagnoses that included stroke with left side weakness, diabetes, and dementia.Review of the MDS dated [DATE], indicated the diagnoses remain current. Resident R3 has a BIMS of 3 and Section GG: Self Care, GG0130 Eating the resident is dependent on staff for meals.Resident R3's care plan dated 9/18/25, indicated the resident needs assistance with eating.During an observation on 6/24/26, at 11:30 am in the dining room revealed 16 residents seated for lunch. The first meal tray was served at 11:35 a.m. Resident R3 was served her meal tray at 11:45 a.m. At 11:55 a.m., Resident R3 stated Can you help me? At 12:05 p.m. staff assisted resident to eat 20 minutes after her meal was served.During an interview on 6/24/26, at 12:05 p.m. Registered Nurse Supervisor (RNS) Employee E1 confirmed the resident lunch tray was delivered at 11:45 a.m. and the Resident R3 was not assisted to eat until 12:05 p.m.During an interview on 6/24/26, at approximately 1:00 p.m. the Director of Nursing confirmed that the facility failed to provide a dignified dining experience on 6/24/26, during the lunch meal service for Resident R3.Pa Code: 201.29(k) Resident rightsPa Code: 207.2(a) Administrator's responsibility

Based on review of facility policy, resident clinical records, reports submitted to the State, and staff interview, it was determined that the facility failed to report allegations of neglect for one of two sampled resident records (Resident R46).Findings include: Review of the facility policy Resident Protection from Abuse, Neglect, Mistreatment or Exploitation, dated 5/1/26, indicated that when an incident of abuse, neglect, etc., the facility will notify the PA Department of Health via electronic reporting system (ERS) within 24 hours and complete and online PB22 if directed to do so. During a review of a facility submitted report dated 6/2/26, identified that Resident R40 had alleged neglect by Nurse Aide (NA)Employee E4 and when the facility was investigating the allegation, NA Employee E7's statement and Registered Nurse Supervisor (RNS) Employee E1 identified a second resident had been neglected by NA Employee E4, Resident R46. During an interview on 6/25/26, at approximately 10:50 a.m., RNS Employee E1 stated that Resident R46 was found with his bed soiled in feces, which had been left from NA Employee E4. Review of the facility submitted report dated 6/2/26, identified a PB22 for Resident R40 however, an investigation and submission of a PB22 was not reported for Resident R46. During an interview on 6/25/26, at approximately, 11:34 a.m., the Director of Nursing confirmed that the investigation and PB22 for Resident R46 was not submitted to the Department of Health as required. 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 review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to conduct a thorough investigation involving an allegation of resident neglect for two of three sampled resident records (Resident R40 and R46).Findings include: Review of the facility policy Resident Protection from Abuse, Neglect, Mistreatment or Exploitation, dated 5/1/26, indicated that Neglect is the failure of the facility and or its employees to provide services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Identification of any abuse, neglect, etc., will be identified through complaints of abuse and use of incident reports and will be thoroughly investigated and reported to the Administration and the Department of Health with 24 hours, with PB22's as necessary. During a review of the facility submitted report dated 6/2/26, identified that Resident R40 reported that he does not ask for help from Nurse Aide Employee E4 because she refuses to help him and he holds his urine and bowel movements all day until the next shift because of this. During a review of the statements dated 6/2/26, from NA Employee E7 identified that when he came onto his shift, Resident R40's bed was wet with urine, and Resident R46 bed was soiled with dried stool. During a review of Registered Nurse Supervisor's (RNS) statement identified the same as the NA statement and indicated that Resident R40 sleeps all day and won't ask for help from NA Employee E4 if she's working because she will not help him with the urinal, as per his plan of care. She indicated that Resident R46's bed was not touched all day. During an interview on 6/25/25, at approximately 10:50 a.m., RNS stated that she wrote the statement as she saw and reported it to the Assistant Director of Nursing the next day. Review of the facility submitted report did not include an investigation of Resident R46 not receiving care and did not substantiate the allegation of neglect of either resident. During an interview on 6/23/26, at approximately 9:45 a.m., the Director of Nursing confirmed that the facility failed to thoroughly investigate an allegation of resident neglect for two of three sampled resident records (Resident R40 and R46). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.10 (c)(d) Resident Care policies.28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to assess, document, and notify physicians of increased Capillary Blood Glucose (CBG) levels for one of five residents reviewed (Residents R45).Findings include: The Centers for Disease Control define diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there is not enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it ' s untreated for long periods of time, you can damage your nerves, blood vessels, tissues and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds.Review of facility policy Fingerstick Glucose Measurement reviewed 5/1/26, indicated diabetic residents will have blood glucose levels measured by fingerstick, using a portable blood glucose meter, according to physician ordered schedule. Procedure step 1). Verify physician's order. Step 17). Follow up with insulin administration or physician notification as ordered. Step 18). Document blood glucose level in medical record.Review of facility policy Physician Notification reviewed 5/1/26, indicated upon identification of a resident who has clinical changes, change in condition, or abnormal lab values, a licensed nurse will perform appropriate clinical observations and data collection and report to physician as indicated. Upon identification of a change in condition, the Guidelines for Physician Notification may be used as reference to help determine urgent or routine notification.The facility was unable to provide a policy or procedure for Guidelines for Physician Notification.Review of facility policy Resident Change in Condition or Status reviewed 5/1/26, indicated it is facility policy to promptly address all resident changes in condition and to manage them in compliance with applicable standards of care. Documentation must be provided in the resident record regarding any assessment of the resident and findings, all applicable interventions, and all communications. The licensed nurse will notify the resident's attending physician when there is a need to alter the resident's treatment significantly.Review of the clinical record revealed Resident R45 was admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and depression.Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 4/26/26, indicated the diagnoses remain current.Review of Resident R45 physician's order revealed the following orders: -On 9/9/25, Accucheck (blood glucose monitoring machine) at bedtime with no coverage.-On 9/10/25, Accucheck before meals with coverage.-On 3/23/26, Lispro insulin per sliding scale. If blood sugar is over 400, give 12 units and notify doctor.Review of the clinical record, and electronic Medication Administration Record (eMAR) revealed the CBG's were as follows: -On 5/2/26, at 9:13 p.m. the CBG was noted to be 411.-On 5/5/26, at 11:55 a.m. the CBG was noted to be 482.-On 5/8/26, at 4:12 p.m. the CBG was noted to be 562.-On 5/9/26, at 9:38 a.m. the CBG was noted to be 407.-On 5/10/26, at 9:54 a.m. the CBG was noted to be 404.-On 5/13/26, at 4:29 p.m. the CBG was noted to be 428.-On 5/14/26, at 11:44 a.m. the CBG was noted to be 487.-On 5/18/26, at 8:10 a.m., the CBG was noted to be 401.-On 5/25/26, at 8:22 p.m., the CBG was noted to be 443.-On 5/28/26, at 1:59 p.m., the CBG was noted to be 469.-On 6/5/26, at 8:11 p.m., the CBG was noted to be 420. At 8:19 p.m., a re-check confirmed the results.-On 6/21/26, at 8:06 p.m., the CBG was noted to be 471.Review of Resident R45 eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, and the physician order was not followed for notifications, and documentation was not available for the dates listed above.Review of the care plan dated 9/10/25, revealed the following interventions:-Administer medications as ordered. Monitor for effectiveness and any side effects and report them to the physician.-Check blood sugar levels as ordered.-Monitor for signs and symptoms of hyperglycemia and report to the physician. During an interview on 6/25/26, at 11:40 a.m. Licensed Practical Nurse (LPN) Employee E2 stated for blood sugars less than 70 they would give glucose gel and recheck the blood sugar in 25 minutes. For any blood sugar over the ordered parameter range, they would call the doctor, give ordered insulin, and recheck the blood sugar in 30-60 minutes. They would document in the progress notesDuring an interview on 6/25/26, at 11:45 a.m. LPN Employee E3 stated they would monitor the resident for a blood sugar between 65-70 and give the resident glucose gel. They would notify the doctor for blood sugars noted in the ordered parameters, give the ordered insulin, recheck the resident in 30 minutes, and document in the progress notes and the eMAR.During an interview on 6/25,26, at 11:50 a.m. the Director of Nursing confirmed the facility failed to notify the doctor of a change in condition, failed to document an assessment or interventions used related to blood glucose, and failed to follow the physician's orders for Resident R45 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29(d) Resident Rights 28 Pa. Code 211.10 (c)(d) Resident Care policies 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

Based on a review of select facility policies and procedures, current Centers for Disease Control (CDC) guidelines, clinical record review, and staff interview, it was determined that the facility failed to document each resident was offered an influenza and/or pneumococcal immunization for two of five residents reviewed for influenza and pneumococcal immunizations (Residents R2 and R33).Findings include: A review of facility policy, Influenza and Pneumococcal Disease Prevention, dated 5/1/26, indicated to reduce the disease morbidity and mortality associated with influenza and pneumococcal disease, influenza and pneumococcal vaccines are offered to all residents A review of the clinical record indicated Resident R2 was admitted to the facility on [DATE], with diagnoses that included stroke, hemiplegia (weakness on one side of the body), and seizures. A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 6/19/26, indicated the resident did not receive and was not offered the pneumococcal vaccine. A review of R2's electronic clinical record Immunizations documentation on 6/25/26 at 11:00 a.m., did not include information that the pneumococcal vaccines were offered or declined. A review of the clinical record indicated Resident R33 was admitted to the facility on [DATE], with diagnoses that included stroke, diabetes, and COPD (chronic obstructive pulmonary disease). A review of the MDS dated [DATE], indicated the resident did not receive the influenza and pneumococcal vaccines. A review of R33's electronic clinical record Immunizations documentation on 6/25/26 at 11:00 a.m., did not include information that the influenza and pneumococcal vaccines were offered or declined.During an interview on 6/25/26 at 11:45 a.m., the Director of Nursing confirmed the above findings, and that the facility failed to document each resident was offered an influenza and/or pneumococcal immunization for Residents R2 and R33. 28 Pa. Code 211.5(f)(i)-(xi) Medical records.28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, and review of facility documents it was determined that the facility failed to protect a resident from abuse and neglect for one of two residents reviewed (Resident R1).Findings include:Review of facility policy Resident Protection from Abuse, Neglect, Mistreatment, or Exploitation dated 5/1/26 and 6/9/26, indicated the facility treats 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. 'Abuse' is defined as the willful infliction of harm, unreasonable confinement, intimidation or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. 'Verbal Abuse' is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability. 'Mental Abuse' is defined as humiliation, harassment, threats of punishment or deprivation. '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.The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggest the following distributions:13 - 15: cognitively intact8 - 12: moderately impaired0 - 7: severe impairmentReview of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that include need for assistance with personal care, high blood pressure, and vascular dementia (decline in thinking and memory skills caused by damaged or blocked blood vessels in the brain).Review of Resident R1's MDS dated [DATE], revealed the diagnoses remain current. Further review of the MDS, Section C, Cognitive Patterns; Question C0500 indicated Resident R1 had a BIMS of 04, indicating severe impairment. Section H: Bladder and Bowel, Question H0300 Urinary Continence, indicated Resident R1 was occasionally incontinent (involuntary loss of bladder/bowel control resulting in leakage of urine or stool) of urine; Question H0400 Bowel Continence, indicated Resident R1 was always incontinent.Review of facility documents indicated on 4/13/26, between 7:00 - 9:00 p.m. Resident R1 was talking with a family member on the telephone and had to use the restroom. Resident R1 put the phone down without hanging up. The family member reported Resident R1 was starting to panic because they felt like they were going to have an accident, so they told them to go find a nurse, so they sat the phone down without hanging up. The family member was able to overhear the conversation when Nurse Aid (NA) Employee E1 answered Resident R1's request for assistance to the restroom very rudely and told them to get in the bathroom and he would be in to help. NA Employee E1 was then heard stating very sternly, that he told Resident R1 earlier that they better not get feces on the toilet seat and that they know how to use the bathroom. Resident R1's family member was very upset and called the facility to report it.Review of Resident R1's Kardex Report (quick-reference summary card or file that nurse aids use to see important resident care information, i.e. transfer status, Activities of Daily Living (ADLs) and any assistance needed) dated 4/10/26, indicated for transferring: hand hold staff assistance, Review of the care plan dated 11/3/25, indicated to check on the resident at least every two hours and assist with toileting as needed. Observe for patterns of incontinence and evaluate for toileting schedule if indicated.NA Employee E1 was unavailable for interview.Review of NA Employee E1's employee file indicated they were hired on 5/2/24. They last received Abuse training on 2/27/26, through a company that provides computer training for employees.During an interview on 6/4/26, at 9:00 a.m. the Nursing Home Administrator (NHA) stated NA Employee E1 was suspended from work but quit the next day before their employment could be terminated. The NHA confirmed the facility failed to protect a resident from abuse and neglect for Resident R1.Pa. 28 Code 201.18(b)1)(2)Management

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop and/or update person-centered care plans related transfer and bed mobility assistance levels for three of 17 residents (Residents R1, R2, R3) that resulted in the actual harm of a nasal fracture and knee fracture for one of four residents (Resident R1) . This was identified as past noncompliance.Findings include: Review of facility policy Care Plan and Interdisciplinary Care Conferences dated 6/9/25, 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 R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 3/8/26, included diagnoses of quadriplegia (paralysis of all four limbs), history of a stroke, and a seizure disorder. Review of Section GG: Functional Abilities indicated that Resident R1 was totally dependent on staff (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 2/19/26, indicated Resident R1 required an assist of two with a mechanical lift for transfers. Further review of the physicians' orders failed to reveal an order related to bed mobility prior to 3/20/26. Review of Resident R1's plan of care for ADL (activities of daily living) failed to include information regarding bed mobility requirements prior to 3/20/26. Review of Resident R1's Kardex (document that outlines the patients' ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) utilized by nurse aide staff dated 3/14/26, failed to include directions to nurse aide staff regarding bed mobility requirements. Review of Resident R1's physical therapy Discharge summary dated [DATE], indicated that the therapy recommendation for bed mobility was, Total Dependence. During an interview on 4/1/26, at approximately 1:30 p.m. the Director of Nursing confirmed that Resident R1's care plan and Kardex were not updated with the physical therapy recommendation of total dependence and the MDS documentation of dependence for bed mobility. Review of a progress note dated 3/15/26, at 11:26 p.m. indicated, Called to resident's room to find resident laying on floor next to the wall. He was laying prone with face into the floor. His left arm was under his torso. He is alert, asking for help. He yells out when touched or palpated in any way. Resident assisted to supine position (face-up body, lying flat on the back) and assessed. Bloody face cleaned. Laceration noted to left brow, bridge of nose and chin. Review of facility submitted information dated 3/16/26, indicated that on 3/15/26, at 10:00 p.m., Resident R1 was having care provided by [Nurse Aide Employee E1] on 3/15/26 at 10pm. While providing, the care became combative per [NA Employee E1] causing him to fall out of bed. Resident was assessed by RN supervisor and new orders for x-rays to be obtained in the morning from the provider. Resident sustained two fractures: 1. nondisplaced fracture junction of the lateral mid third of the right patella (central portion of the outer side of the kneecap). 2. Nondisplaced, nondepressed nasal bone fracture (fractured nose without movement of the bones out of place). Review of an undated employee statement written by NA Employee E1, indicated, I was not aware of the x2 assist with him. During an interview on 4/1/26, at approximately 1:00 p.m. the Director of Nursing confirmed that the information provided to the nurse aides who provide care did not include Resident R1's bed mobility requirements. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), muscle weakness, and unsteadiness on feet. Review of a physician order dated 1/9/26, indicated Resident R2 required Transfer with assist of 2 staff members. Review of Resident R2's plan of care for ADL (activities of daily living) self-performance deficit indicated, Use a front wheeled walker to transfer with me with staff assistance x1. Further review of the plan of care failed to reveal an update to the care plan related to the physician's order dated 1/9/26, which indicated the need for assistance of two staff members for transfers. Review of Resident R2's Kardex dated 3/17/26, indicated Resident R2 required, Transfer with assist of 2 staff members with FWW (front-wheeled walker). Review of a progress note dated 3/18/26, at 6:52 a.m. indicated, Resident was being transferred to WC (wheelchair), and she did not stand so nurse aid lowered her to the ground. No injury noted, the resident was in care of nurse aid for the entire incident. Review of facility submitted information dated 3/18/26, indicated that on 3/18/26, at 6:40 a.m., indicated, [Resident R2] was being transferred to her WC on the morning of 3/18/26 by GNA (graduate nurse aide) [Employee E2]. She did not stand so nurse aid lowered her to the ground. Per Kardex (task/order) resident is an assist of 2 for transfers. GNA attempted transfer without assistance. Review of a facility incident report dated 3/18/26, indicated, Investigation initiated due to transfer with assist x1. Kardex states should be assist x2.Review of the clinical record indicated Resident R3 was readmitted to the facility on [DATE], after having sustained a left hip fracture at a previous facility. Review of facility census information indicated Resident R3 had resided at this facility since 4/11/14, until discharge on [DATE]. Review of the MDS dated [DATE], included diagnoses of Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking), hip fracture, and history of a stroke. Review of a physician order dated 2/18/26, indicated Resident R3 required Transfers with assist of 2 staff members and FWW WBAT (front-wheeled walker, weight bearing as tolerated). Review of Resident R3's plan of care initiated 2/19/26, failed to include documentation of required transfer assistance until 3/19/26. Review of Resident R3's Kardex dated 2/19/26, through 3/19/26, indicated, Transfer / ambulate with SUP (supervision) and Rollator (four-wheeled walker). Review of Resident R3's clinical record indicated that transfers with supervision and a Rollator was her documented assistance level prior to discharge on [DATE], and subsequent hip fracture, from a prior outside hospital admission requiring these updated levels of assistance. On 3/16/26/24, the facility initiated a plan of correction that included:-Review of all residents' assistance levels by physical therapy staff.-Audit of all residents' transfer and bed mobility assistance levels, and updates where necessary.-Education to all nursing staff to reiterate the need to review the Kardex prior to providing care.-Education to nursing staff responsible for care plan and Kardex updates on verification of needed assistance levels.-New process developed with the clinical team to ensure newly admitted residents and those with a change in required assistance levels are updated timely.-Audits of staff provided care were completed and remain ongoing.-Audit information and education to be reviewed at the Quality Assurance and Performance and Improvement committee. During an electronic interview on 4/2/26/26, at 3:34 p.m. the Director of Nursing confirmed that the facility failed to develop and/or update person-centered care plans related transfer and bed mobility assistance levels for three of 17 residents, this failure resulted in the actual harm of a nasal and knee fracture for Resident R1. This was identified as past noncompliance. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent falls for two of four residents (Resident R1 and R2) that resulted in the actual harm of a nasal fracture and knee fracture for one of four residents (Resident R1).Findings include: Review of the facility policy, Falls: Care During and After dated 6/9/25, indicated, All residents experiencing a fall will receive appropriate care and investigation and interventions will be conducted by the interdisciplinary team. Included in the procedure were the following steps: 5. Remove any causes to fall and implement preventative measures to prevent reoccurrence. 6. Update care plan to reflect new interventions. Review of the American Congress of Rehabilitation Medicine - Caregiver Guide and Instructions for Safe Bed Mobility published 4/28/17, indicated bed mobility refers to activities such as scooting in bed, rolling, side-lying to sitting, and sitting to lying down. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 3/8/26, included diagnoses of quadriplegia (paralysis of all four limbs), history of a stroke, and a seizure disorder. Review of Section GG: Functional Abilities indicated that Resident R1 was totally dependent on staff (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 2/19/26, indicated Resident R1 required an assist of two with a mechanical lift for transfers. Further review of the physicians' orders failed to reveal an order related to bed mobility prior to 3/20/26. Review of Resident R1's plan of care for ADL (activities of daily living) failed to include information regarding bed mobility requirements prior to 3/20/26. Review of Resident R1's Kardex (document that outlines the patients' ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) utilized by nurse aide staff dated 3/14/26, failed to include directions to nurse aide staff regarding bed mobility requirements. Review of Resident R1's physical therapy Discharge summary dated [DATE], indicated that the therapy recommendation for bed mobility was, Total Dependence. Review of a progress note dated 3/15/26, at 11:26 p.m. indicated, Called to resident's room to find resident laying on floor next to the wall. He was laying prone with face into the floor. His left arm was under his torso. He is alert, asking for help. He yells out when touched or palpated in any way. Resident assisted to supine position (face-up body, lying flat on the back) and assessed. Bloody face cleaned. Laceration noted to left brow, bridge of nose and chin. Bleeding stopped. PEARRL (pupillary response test, standing for Pupils Equal, And Round, Regular in Size, Reactive to Light and Accommodation), grips equal and strong. Abrasion noted to LUQ (left upper quadrant), Laceration left great toe. Bilateral knees red. Resident was nude as CNA (nurse aide) providing care was giving him a bed bath. Resident unable to state what happened. He can follow commands such as squeezing fingers or moving arms but is resistant to passive ROM (range of motion). Resident assisted back to bed via lift and assist of five staff.[Medical provider] made aware. Instructed to perform routine Neuro checks (systematic assessments to evaluate brain function, nervous system integrity, and mental status) and obtain x-ray of left shoulder due to resident's complaints of pain. Review of a physician's order dated 2/18/26, indicated Resident R1 was ordered Tramadol (an opiate pain medication) every eight hours as needed for pain. Review of Resident R1's MAR (medication administration record) revealed that prior to the date of the fall from 3/1/26, through 3/14/26, Resident R1 received (2) doses during the entire time frame. Review of Resident R1's MAR (medication administration record) revealed that after the date of the fall from3/15/26, through 3/31/26, Resident R1 received (11) doses during the entire time frame. Review of facility submitted information dated 3/16/26, indicated that on 3/15/26, at 10:00 p.m., Resident R1 was having care provided by [Nurse Aide Employee E1] on 3/15/26 at 10pm. While providing, the care became combative per [NA Employee E1] causing him to fall out of bed. Resident was assessed by RN supervisor and new orders for x-rays to be obtained in the morning from the provider. Resident sustained two fractures: 1. nondisplaced fracture junction of the lateral mid third of the right patella (central portion of the outer side of the kneecap). 2. Nondisplaced, nondepressed nasal bone fracture (fractured nose without movement of the bones out of place). Review of an undated employee statement written by NA Employee E1, indicated, I had went to [Resident R1's] room to wash him up. He had tube feeding on him so I started cleaning him up. We were all done and I rolled him towards me to finish with his linens and brief to pull them out more. After a few seconds of having him rolled he stared yelling and getting combative. He had started coming off the bed because he was upset. I tried to catch him but he was too heavy. So, I tried to lower him the best I could. Soon as he came down onto the ground, I ran and got the nurse and I yelled for everyone to come, it was an emergency. I feel as that his bed was too small. If he had a bigger bed he wouldn't have been able to throw himself off the edge of it. Also, I had no knowledge of him being a x2 assist. I've saw people do them their selves and he doesn't really give me a hard time when I do have him so I was not aware of the x2 assist with him. During an interview on 4/1/26, at approximately 1:00 p.m. the Director of Nursing confirmed that the information provided to the nurse aides who provide care did not include Resident R1's bed mobility requirements. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), muscle weakness, and unsteadiness on feet. Review of a physician order dated 1/9/26, indicated Resident R2 required Transfer with assist of 2 staff members. Review of Resident R2's plan of care for ADL (activities of daily living) self-performance deficit indicated, Use a front wheeled walker to transfer with me with staff assistance x1. Further review of the plan of care failed to reveal an update to the care plan related to the physician's order dated 1/9/26, which indicated the need for assistance of two staff members for transfers. Review of Resident R2's Kardex dated 3/17/26, indicated Resident R2 required, Transfer with assist of 2 staff members with FWW (front-wheeled walker). Review of a progress note dated 3/18/26, at 6:52 a.m. indicated, Resident was being transferred to WC (wheelchair) and she did not stand so nurse aid lowered her to the ground. No injury noted, the resident was in care of nurse aid for the entire incident. Review of facility submitted information dated 3/18/26, indicated that on 3/18/26, at 6:40 a.m., indicated, [Resident R2] was being transferred to her WC on the morning of 3/18/26 by GNA (graduate nurse aide) [Employee E2]. She did not stand so nurse aid lowered her to the ground. Per Kardex (task/order) resident is an assist of 2 for transfers. GNA attempted transfer without assistance. Review of a facility incident report dated 3/18/26, indicated, Investigation initiated due to transfer with assist x1. Kardex states should be assist x2. Review of written documentation as GNA was unavailable for interview, revealed GNA was unaware of transfer status. During an interview on 4/2/26, at 3:34 p.m. the Director of Nursing confirmed the facility failed to provide adequate supervision to prevent falls for two of four residents that resulted in the actual harm of a nasal fracture and knee fracture for one of four residents. 28 Pa. Code: 201.14 (a) Responsibility of Licensee28 Pa. Code: 201.20 (a)(1) Staff Development28 Pa. Code: 211.10 (b)(c)(d) Resident Care Policies28 Pa. Code: 211.12 (d)(2)(3)(5) Nursing Services

Based on a review of facility documentation, cited deficiencies from a previous survey, review of plans of correction documentation, and staff interview, it was determined that the facility's Quality Assurance and Performance Improvement (QAPI) program failed to correct previously cited deficiencies.Findings include: Review of the facility policy, Quality Assurance and Performance Improvement (QAPI)Plan dated 6/9/25, indicated it provides an ongoing, systematic evaluation and improvement process to help ensure that each of the nursing homes and other operational are meeting the organization's quality standards. The facility's deficiencies and plan of correction for the State Survey and Certification (Department of Health) for the following surveys, revealed the facility developed a plan of correction that included quality assurance systems to ensure the facility-maintained compliance with cited nursing home regulations. Review of the facility's deficiencies and plan of corrections for the State Survey and Certification (Department of Health) survey ending 12/18/25, revealed the facility developed a plan of correction that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. Review of the plan of correction for survey ending 12/18/25, revealed the following: Employee E3 was suspended pending investigation for possible neglect due to resident R1 injury.Resident R1's bed mobility status was changed in the Kardex to reflect assistance of 2 staff for care.Director of nursing reviewed all other residents bed mobility statuses to ensure proper assistance is being provided. Any updates noted were updated in the Kardex at this time.Resident's bed mobility will be reviewed weekly during the weekly RISK Meetings by the IDT.Education provided to staff by director of nursing on reviewing their residents's assignments Kardex at the beginning of their shift to ensure they are providing safe/appropriate care and following the resident's plan of care.Audits of staff reviewing the Kardex at the beginning of their shift will be completed by director of nursing or designee as follows:5 employees a day x 5 days x one week,5 employees a day x 4 days x one week,5 employees a day x 3 days x one week,5 employees a day x 2 days x one week to ensure compliance for resident safety and decrease risk for accidents.The results of the audits will be reviewed and recorded in monthly QAPI meeting. During the survey process the following was revealed: -Resident R1's Kardex and care plan were not updated with documented therapy recommendations and Minimum Data Set results. This failure caused Nurse Aide Employee E1 to unknowingly provide care alone, rather than the recommended two-person assist, with the result of Resident R1 sustaining knee and nasal fractures. -Resident R2's Kardex and care plan were not updated with the physician's order requiring two staff members for resident transfers. This failure caused Nurse Aide Employee E2 to unknowingly attempt to transfer Resident R2 alone, rather than the recommended two-person assist, with the result of Resident R2 being required to be lowered to the floor. During an interview on 4/2/26, at 3:34 p.m. the Director of Nursing confirmed that facility failed to correct quality deficiencies and make certain that plans to improve the delivery of care and services effectively addressed concerns identified. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management

Based on review of facility policies, clinical records, incident reports, and staff interview, it was determined that the facility failed to prevent residents from injury while providing care for one of three residents (Resident R1).Findings include:Review of the facility policy Resident Protection from Abuse, Neglect, Mistreatment, or Exploitation, defines neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods and services that a resident requires but the facility failed to provide them to the resident, that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress.The facility was unable to provide a policy regarding Activities of Daily Living (ADLs).The facility was unable to provide a policy regarding Resident Transfers.The facility was unable to provide a policy regarding Resident Bed Mobility.The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggest the following distributions:13 - 15: cognitively intact8 - 12: moderately impaired0 - 7: severe impairmentReview of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included need for assistance with personal care, mixed receptive-expressive language disorder (people struggle with both understanding and using language to express themselves), and anxiety.Review of the Minimum Data Set (MDS - standardized assessment tool for all residents of long-term care facilities) dated 9/15/25, indicated the diagnoses remain current. Further review of the MDS dated [DATE], Section C: Cognitive Patterns, Question C0500 indicated Resident R1 had a BIMS of 03. Section GG: Functional Abilities; G0170: Mobility: A - Roll left and right, indicated Resident R1 required substantial/maximum assistance. Review of the MDS coding instructions for Section GG indicated the following:- 02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.- 01. 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 2/5/25, indicated bilateral assist rails at top of the bed for bed mobility. Review of a physician order dated 3/26/25, indicated transfer with mechanical lift with assistance of two. Review of the care plan dated 6/15/22, indicated to use caution during transfers and when turning and repositioning me in bed to prevent striking my arms, legs, or hands against any sharp or hard surfaces. On 8/7/25, the care plan indicated ADLs and functional mobility self-performance and staff support may fluctuate at times related to my behaviors, diagnosis and/or acute illness. Review of the Kardex dated 11/27/25, failed to indicate bed mobility status. Review of facility documents dated 11/28/25, at 5:25 a.m. indicated Nurse Aid (NA) Employee E3 provided care to Resident R1 when she was being rolled onto her right side using the bed pads, Resident R1 started to push against NA Employee E1. NA Employee E3 stated he felt and heard a pop in her hip/leg and started to scream in pain. Review of NA Employee E3 undated witness statement indicated I rolled the resident onto her side using a standard technique with one hand a few inches below the hip and one hand on the knee to assist with the turn. During the roll, Resident R1's body weight shifted back towards me creating additional resistance. As I applied pressure to counter the additional resistance and complete the turn I heard an audible snap sound from the resident's leg area. I also want to be clear, the additional resistance was caused by the resident pushing the handrail.Resident R3 was suspended pending facility investigation.Review of the Documentation V2 report for September 2025, Resident R1 required assistance of two staff for bed mobility on 22 of 30 days. Review of the Documentation V2 report for October 2025, Resident R1 required assistance of two staff for bed mobility on 26 of 31 days. Review of the Documentation V2 report for November 2025, Resident R1 required assistance of two staff for bed mobility on 24 of 26 daysReview of x-ray results dated 11/28/25, indicated Resident R1 sustained an acute spiral oblique subtrochanteric fracture of the proximal left femur (fracture that usually requires surgical intervention to ensure proper alignment and healing), with modest age-related degenerative changes seen throughout remaining pelvis and hips.During an interview on 12/18/25, at 10:25 a.m. Occupational Therapist (OT) Employee E4 stated therapy only fills out the GG section of the MDS for 'skilled residents, the RNAC (Registered Nurse Assessment Coordinator) fill out the rest of the residents. When therapy fills out the MDS section GG, it depends on the resident, substantial/maximum assistance doesn't always mean the resident needs assistance of two staff. We leave it up to the staff to decide how much assistance is needed. Therapy does not fill out the bed mobility assistance needed; they only write orders for resident transfer status.During a telephone interview on 11/28/25, at 11:00 a.m. RNAC Interim Employee E5 stated that GG section is completed using the NA and therapy documentation. If the resident is not receiving therapy, then only the NA tasks are used as look back. During an interview on 12/18/25, at 11:43 a.m. NA Employee E6 stated she would look on the point of care charting in the computer for ADL/bed mobility/transfer status of a resident.During an interview on 12/18/25, at 11:58 a.m. NA Employee E7 stated she would look on the computer POC (point of care) charting or would ask a nurse or therapy the ADL/bed mobility/transfer status of the residents.NA Employee E3 was unavailable for interview.During an interview on 12/18/25, at 12:05 p.m. Assistant Director of Nursing (ADON) Employee E2 stated she was a nurse aid before becoming a nurse and felt NA Employee E3 used proper hand placement techniques to assist Resident R1 with bed mobility.During an interview on 12/18/25, at 12:10 p.m. the Nursing Home Administrator confirmed the facility failed to prevent residents from injury while providing care for Resident R1.28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (e)(1) Management.28 Pa Code: 211.10 (c)(d) Resident care policies.28 Pa Code: 211.11 Resident care plan.

Based on facility policy review, observations and staff interviews, it was determined that the facility failed to properly date insulin medication vials upon opening, failed to dispose of expired insulin medication vials, and failed to store medications in a safe and sanitary manner in one of two medication carts reviewed (Blue cart).Findings include:Review of facility policy Insulin Vial Use indicated once an insulin vial is removed from the refrigerator and/or opened for use, they will be marked with the resident's name, the date they are opened, and dated for expiration as follows:-Levemir/Lantus (long-acting insulin that works slowly, over about 24 hours) - 42 days-Novolog/Aspart (fast acting insulin that starts to work about 15 minutes after injection, peaks in about one hour, and keeps working for two to four hours) - 28 days-Novolog Mix 70/30 (starts working in two to four hours, peaks in four to ten hours, and keeps working for 12 - 18 hours) - 14 daysReview of facility provided Storage and Disposal of Medications and Medical Supplies pages 116 and 117, indicated prescription medications, over-the-counter medications (OTC), Complimentary and Alternative Medication (CAM), and syringes shall be kept in an area or container that is locked. Prescription medications, OTC, and CAM shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture, and light and in accordance with manufacturer's instructions. Prescription medications, OTC, and CAM that are discontinued, expired, or for residents who are no longer in the facility shall be destroyed in a safe manner according to federal and state regulations.During an observation on [DATE], at 11:50 a.m. Blue Cart was unattended in a resident lounge with the following medications left on top of the cart, assessable to residents, guests, and visitors:-one Aspart insulin vial with open date of [DATE], expiration date [DATE].-two Apart insulin vials with open date [DATE]. No expiration date noted (would be [DATE] according to facility policy).-one Lantus insulin vial opened, not dated.-one Aspart insulin vial with expiration date of [DATE].-three Lantus flex pens opened, not dated and not stored in individual bags, causing risk of cross-contamination.During an interview on [DATE], at 11:52 a.m. LPN Employee E1 confirmed the above observations.During an interview on [DATE], at 12:05 p.m. the Assistant Director of Nursing (ADON) Employee E2 confirmed that the medication vials and insulin pens were not stored in a manner to prevent cross-contamination and medication vials were not dated upon opening or disposed of on the expiration dates in the Blue medication cart.28 Pa. Code: 211.9 (a) (1) (2) (h) Pharmacy services.28 Pa. Code: 211.12 (d) (1) (2) (3) (5) Nursing services.

Number of residents sampled: Number of residents cited: Based on the review of professional standards of practice, facility policy, clinical record review and staff interview, it was determined that the facility failed to develop and implement care and services consistent with professional standards of practice to prevent the development of a pressure ulcer that developed into a Stage III pressure ulcer (full thickness skin loss that extends into the subcutaneous or fat layer) to the right lateral ankle and a Stage I pressure ulcer (non-blanchable reddened area) to the right inner and outer aspect of the right knee from a immobilizer brace worn due to a fracture. This resulted in actual harm for one of two residents (Resident R3).Findings include:Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning, and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement, and wound cleansing; using adjunctive therapies; and considering possible surgical repair. According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, standardized pressure ulcer risk assessment, and care planning and implementation to address the areas of risk. Review of the facility policy Preventive Skin Care, dated 6/9/25, with a previous review date of 6/11/24, indicated the facility will provide the highest quality of skin care possible and promote preventive measures for skin integrity. From admission, weekly skin assessments will be completed by the nursing staff and documented in the electronic clinical record. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE], with diagnoses which included respiratory failure, Traumatic Brain Injury with loss of consciousness, bipolar disorder, communication deficit, bilateral cataracts, repeated falls, dizziness, abnormal posture, and a fracture of the right ankle dated 3/15/25. Review of Resident R3's quarterly Minimum Data Set (MDS - a periodic assessment of resident care needs) dated 5/7/25, indicated the diagnoses remained current. Section GG0110(Activities of Daily Living (ADL's) assistance indicated Resident R3 required physical assistance of two staff for bed mobility. Review of Resident R3's clinical record identified that on 3/15/25, Resident R3 had developed a fracture of his right ankle from another resident pushing his wheelchair and his leg getting trapped under the wheelchair causing a fracture which had been identified by the facility and the facility provided the information. On 3/17/25, Resident R3 was assessed by the Orthopedic Physician and a T scope brace (adjustable knee brace to control range of motion) was placed for immobilization of the fracture. Review of a Physician order dated 3/17/25, stated Resident to wear brace to RLE (right lower extremity) at all times, except for hygiene.Review of Resident R3's clinical record did not include documentation of skin checks being completed to the right leg until 4/2/25 due to a skin impairment, 16 days after the T brace was placed.Review of Resident R3's Treatment Administrative Record (TAR) dated 4/1/25, through 4/9/25, identified four of 21 opportunities of missed documented assessments of skin, with no documented issues identified.Review of the clinical record indicated that on 4/9/25, Resident R3 had developed a Stage I pressure ulcer of his right inner aspect of the knee measuring 3 centimeters (cm) x 1 cm x < 0.1 cm area and a 1 cm x 1.5 cm x <0.1cm area of the right outer aspect of the right knee, related to a medical device. A Stage III pressure ulcer was identified of the right lateral ankle measuring 9.5 cm x 3.5 cm x 0.2 cm with 90% of the tissue of the wound being slough (dead tissue). The brace was removed.Review of care plan for Resident R3 on 3/17/25, failed to reveal evidence the facility updated resident's care plan with individualized interventions to address resident's decreased mobility status, need for skin assessments and higher risk for developing pressure ulcers. During an interview on 7/29/25, at 10:00 a.m., Nurse Aide (NA) Employees E22 and E23, stated that skin checks are performed during routine care and findings are to be reported to the nurse.During an interview on 7/29/25, at 11:13 a.m., Registered Nurse (RN) Employee E20 stated that skin assessments are to be documented weekly in the residents TAR and any findings addressed immediately.During an interview on 7/29/25, at 1:48 p.m., the Director of Nursing confirmed that the facility failed to ensure that interventions to prevent pressure ulcers were implemented which resulted in actual harm to Resident R3 who developed Stage I and Stage III pressure ulcers to the right leg from a medical device (T Brace). 28 Pa. Code 211.10(c)(d) Resident care policies28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Number of residents sampled: Number of residents cited: Based on a review of facility policies, clinical records, investigation report and staff interviews, it was determined that the facility failed to ensure that the environment was free of accident hazards for one of two residents (Resident R3) resulting in harm when hot soup spilled onto Resident R3's right upper, inner thigh area causing a second- degree burn measuring 2 cm x 1.5 cm x <0.1 cm blister requiring treatment. Findings include:Review of the facility policy Accidents and Incidents dated 6/9/25, with a previous review date of 6/11/24, indicated that if an accident/incident occurs involving a resident are reported and investigated for corrective actions and quality improvement. The facility policy regarding hot liquid safety was not provided.The facility provided food temperatures identified the soup at 170 degrees Fahrenheit.Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE], with diagnoses which included respiratory failure, Traumatic Brain Injury with loss of consciousness, Bipolar disorder, Communication deficit, bilateral cataracts, repeated falls, dizziness, abnormal posture and anxiety, a fracture of the right ankle dated 3/15/25. Review of Resident R3's quarterly Minimum Data Set (MDS - a periodic assessment of resident care needs) dated 5/7/25, indicated the diagnoses remained current. Section GG0110(Activities of Daily Living (ADL's) assistance indicated Resident R3 required physical assistance of one staff for eating. Review of Resident R3's plan of care prior to the incident indicated Resident R3 required assistance of one staff for eating. Care plan interventions included lids were to be provided with hot items (hot beverages and/or soup, etc.)Review of Resident R3's physician orders dated 5/6/25, indicated Resident R3 required supervision with a divided plate with Dycem (non -slip mat) to prevent it sliding, all drinks to be in sippy cups, all hot liquids to have a plastic lid with straws in all liquids including soups.Review of a restorative nursing progress note dated 6/10/25, indicated Resident R3's need for the divided plate with Dycem under, all liquids in a sippy cup with oversight and cueing and assist of one staff.Review of a progress note dated 7/25/25, at 5:30 p.m., indicated that Resident R3 had yelled out when he spilled soup on his leg, Resident R3 stated it was hot or similar words and when assessed his right upper, inner thigh had a large, reddened area with no blister at that time.Review of facility submitted information dated 7/25/25, indicated that Resident R3 was in the dining room when it was witnessed, he had soup in his hand (resident was seated at the table) and spilled it on his leg (upper thigh area).Review of Licensed Practical Nurse (LPN) Employee E2's statement indicated that Resident R3 had yelled out help, ouch and the LPN Employee E2 saw that Resident R3 had spilled soup in his lap and had cleaned him up and then she notified the RN Supervisor.Review of the facility investigation report dated 7/25/25, indicated that on Saturday 7/26/25, a 2cm x 1,5 cm x <0.1 cm blister had developed and Silvadene (topical antibiotic cream used to prevent and treat infections associated with second and third-degree burns) was ordered. The indicated interventions to prevent re-occurrence were reviewed onsite and appeared to be unchanged from Resident R3's unfollowed previous orders; supervision with meals and lids served with hot liquids.During an interview on 7/29/25, at 9:45 a.m., Dietary Manger Employee E26 indicated that lids on bowls/cups are communicated to dietary and are placed on the resident meal ticket.During an interview on 7/29/25, at 10:00 a.m., Nurse Aide (NA) Employees E22 and E23 stated, the dietary ticket usually has meal aide needs on the ticket and the resident care plans also indicate special or adaptive equipment.During an interview on 7/29/25, at 1:00 p.m., the Director of Nursing (DON) stated, on the submitted event with Resident R3's plan of care with meals would be different from the current, unfollowed interventions. when asked how the current interventions were identified as being an adjustment after the incident occurred. The DON also confirmed that Resident R3 should have had lid on the soup and the resident should have been assisted with meals which resulted in actual harm when hot soup spilled onto Resident R3's right upper, inner thigh area causing a second- degree burn measuring 2 cm x 1.5 cm x <0.1 cm blister requiring treatment. 28 Pa. Code 201.18(b)(1) Management. 28 Pa Code 211.12(d)(5) Nursing Services.

Number of residents sampled: Number of residents cited: Based on clinical record reviews and staff interview, it was determined that the facility failed to ensure proper monitoring and documentation of behaviors for one of three residents (Resident R51).Findings include:Review of the clinical record indicated Resident R51 was admitted to the facility on [DATE], with diagnoses which included a stroke, lung disease, and falls. Review of a progress note dated 7/1/25, indicated Resident R51 touched Resident R41 and when asked he stated he wanted to and that she did not give permission, but he wanted to do it. Review of a facility provided document dated 7/1/25, indicated that Resident R51 had inappropriately touched Resident R41's breast under her clothing. The investigation indicated Resident R51 was asked if he had increased sexual drives and he stated he did not know and was asked to go a Behavioral Health Unit but refused. The facility physician notified and provided medication for hypersexual behaviors.Review of Resident R51's Medication Administration Record (MAR) for July 2025, indicated that Medroxyprogesterone (hormone used to decrease sexual drive in men)10mg was ordered daily for sexual dysfunction. The MAR or Treatment Administration Record (TAR) did not include monitoring of sexual behaviors.Review of the clinical record did include Psychiatrist visit on 7/16/25.Review of Resident R51's clinical record did not include documentation of any behavior monitoring being done by any staff, including nursing, social services, or nursing assistants. Resident R51 was not being monitored of his whereabouts to make certain he could not sexually abuse any other women residents in the building and his room was next to two rooms containing female residents.During an interview on 7/30/25, at 11:25 a.m., the Director of Nursing confirmed that the facility failed to ensure proper monitoring and documentation of behaviors for one of three residents (Resident R51). 28 Pa Code 201.18(b)(2) Management28 Pa Code 211.12(d)(1)(5) Nursing services

Based on observation and interview, the facility failed to provide the required 80 square feet of space per resident for 16 of 25 rooms.During an observation of the facility floor plan on 7/30/25, at 2:15 p.m. the below room findings were as follows: room [ROOM NUMBER] (2 beds) 72.69 square feet per resident bed.room [ROOM NUMBER] (2 beds) 73.40 square feet per resident bed.room [ROOM NUMBER] (2 beds) 71.37 square feet per resident bed.room [ROOM NUMBER] (4 beds) 69.52 square feet per resident bed.room [ROOM NUMBER] (3 beds) 70.67 square feet per resident bed.room [ROOM NUMBER] (2 beds) 73.70 square feet per resident bed.room [ROOM NUMBER] (2 beds) 74.61 square feet per resident bed.room [ROOM NUMBER] (2 beds) 71.61 square feet per resident bed.room [ROOM NUMBER] (3 beds) 76.52 square feet per resident bed.room [ROOM NUMBER] (4 beds) 77.06 square feet per resident bed.room [ROOM NUMBER] (3 beds) 70.91 square feet per resident bed.room [ROOM NUMBER] (2 beds) 71.90 square feet per resident bed.room [ROOM NUMBER] (2 beds) 66.12 square feet per resident bed.room [ROOM NUMBER] (2 beds) 64.92 square feet per resident bed.room [ROOM NUMBER] (3 beds) 78.40 square feet per resident bed.room [ROOM NUMBER] (3 beds) 71.56 square feet per resident bed. During an interview on 7/31/25, at 12:02 p.m. the Nursing Home Administrator confirmed that the room sizes were less than 80 square feet as required. 28 Pa. Code: 205.20(f) Resident bedrooms

Based on review of facility policy, clinical record review, facility incident report, manufacturer guidelines, and staff interviews it was determined that the facility failed to provide adequate supervision and ensure resident environment was free from hazards for one of two residents (Resident R1), which caused a second degree burn (damages the outer layer of your skin and the second layer of your skin) to a resident's lower leg resulting in actual harm. Findings include: Review of the facility policy Preventative Skin Care dated 5/25/22, indicated each resident will receive weekly skin inspections by the nursing assistance on shower or bath day. The Nurse Aide assigned to the resident will perform a visual head to toe inspection while completing the shower or bath. The Nurse Aide will document any abnormalities and report to the licensed nurse of any findings. Review of the facility policy Skin Integrity and Wound Management dated 5/25/22, indicated to identify resident's skin integrity status and need for prevention, intervention, or treatment modalities through review of all appropriate assessment information. Perform skin inspection on admission and weekly by a licensed nurse. Review of the manufacturer's owner's guide for GlenDimplex Electric Baseboard Heater states to maintain at least 12 inches minimum clearance from all objects above and in front of the baseboards, and six inches minimum on both sides. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that include diabetes, neuropathy (condition resulting from damaged or malfunctioning of nerves that causes weakness, numbness and pain in hands and feet), and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). Review of the Minimum Data Set (MDS - standardized assessment tool for all residents of long-term care facilities) dated 1/24/23, indicated the diagnoses remain current. Review of facility documents dated 2/3/23, revealed Resident R1 sustained an unwitnessed injury to his right lower leg, that was determined by the provider to be a burn. The wound was brown and dried when observed, measuring 11.5 cm x 7.5 cm x 0.1 cm; required daily treatment. During an interview on 2/21/23, at 11:52 a.m. Physical Therapy (PT) Director Employee E1 stated that she observed the area on 2/3/23, in the Dining Room. Resident R1 was sitting in his wheelchair with his pant leg slightly raised with the edge of the wound visible. PT Director Employee E1 stated she notified the Nursing Home Administrator(NHA), Director of Nursing (DON), and the Nurse Practitioner (NP) immediately. Resident R1 was assessed, and the burn was determined to be days old. PT Director Employee E1 stated Resident R1 was able to self-propel his wheelchair for short distances. Review of a progress note dated 2/3/23, at 1:50 p.m. Nurse Practitioner Employee E5 stated the cause of Resident R1's injury was identified as the baseboard heater in his room, and diagnosed him with second degree burns. Review of a physician's order dated 2/3/23, instructed to gently cleanse wound to right lower leg with normal saline (an isotonic solution that does not interfere with normal wound repair), pat dry, apply a dry foam dressing (are non-occlusive and are composed of a film coated gel), over opened wound and secure with Kling gauze (an absorbent gauze roll, which stretches and conforms to the body shape and clings to itself as it is wrapped), remove/change for showers and as needed. Review of the clinical record weekly skin progress notes dated 2/1/23, at 11:46 a.m. failed to reveal a full body weekly skin check occurred. Review of the care plan initiated on 1/18/23, indicated for staff to check for any breaks in the skin and promptly address with the doctor, to monitor resident's location frequently, and to check skin weekly for redness, open areas, scratches, cuts, bruises, and report changes to the nurse, the resident required staff assistance for transfers, bathing, and dressing, distract him from wandering, identify patterns of wandering, provide with structured activities, . Further review of the care plan initiated on 1/23/23, indicated the resident has decreased safety awareness and needed one-on-one with staff to maintain safety during activities. Review of care plan on 2/21/23, revealed the facility failed to update the plan of care following the identified burn on Resident R1's leg. Review of a physician's order dated 2/3/23, instructed to gently cleanse wound to right lower leg with normal saline (an isotonic solution that does not interfere with normal wound repair), pat dry, apply a dry foam dressing (are non-occlusive and are composed of a film coated gel), over opened wound and secure with Kling gauze (an absorbent gauze roll, which stretches and conforms to the body shape and clings to itself as it is wrapped), remove/change for showers and as needed. During an interview on 2/21/23, at 12:37 p.m. the Director of Nursing stated Resident R1's room was searched for a heat source, and when the baseboard heater was touched it was very hot, so a nightstand was placed 12 inches in front of it to make it not accessible by wheelchair. The DON stated temperatures were not taken of the surface of the baseboard heaters at any time after the incident occurred. During an interview on 2/21/23, at 3:05 p.m. Nurse Aide (NA) Employee E2 stated she was told in shift report on 1/31/23 about the wound on Resident R1's right lower leg. She stated, I think they said it was reported to a nurse, I did not report it because I thought the previous shift had. During an interview on 2/22/23, at 8:40 a.m. NA Employee E3 stated Resident R1 was showered on 1/25/23, and no wound was noted, on 1/31/23, the wound was already scabbed over, so I thought it was already reported. NA Employee E3 stated the nurses are supposed to do the skin checks on or during shower days. During an interview on 2/22/23, at 9:00 a.m. NA Employee E4 stated she showered Resident R1 on 1/29/23 but was unsure if the wound was present on that day. NA Employee E4 stated she would have notified the nurse if the wound was present. She stated, weekly skin checks are usually done by the nurses, but technically everyone is supposed to do them, and that she has never charted a skin check once its completed and is unsure where to document it at. During an interview on 2/21/23, at 12:45 p.m. Licensed Practical Nurse (LPN) Employee E7 stated she would report a possible new skin concern to the supervisor, fill out an incident report, and take measurements of the wound. During an interview on 2/21/23, at 12:50 p.m. LPN Employee E8 stated she would report a possible new skin concern to the supervisor and apply treatment if needed. During an interview on 2/21/23, at 12:50 p.m. NA Employee E9 stated she would report a possible new skin concern to the supervisor. During an interview on 2/21/23, at 12:52 p.m. NA Employee E10 stated she would report a possible new skin concern to the med nurse and charge nurse and fill out an incident report. During an interview on 2/21/23, at 12:53 p.m. NA Employee E11 stated she would report a possible new skin concern to the nurse. During an interview on 2/21/23, at 12:55 p.m. NA Employee E12 stated she would report a possible new skin concern to the nurse, the Director of Nursing, and the Nursing Home Administrator. During an interview on 2/21/23, at 12:56 p.m. NA Employee E13 stated she would report a possible new skin concerns to the nurse and she would notify someone. During an interview on 2/22/23, at 12:35 p.m. the Director of Nursing confirmed the facility failed to provide adequate supervision and ensure resident environment was free from hazards resulting in actual harm of a second degree burn that required treatment for Resident R1. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (e)(1) Management. 28 Pa. Code: 201.29 (a)(j) Resident rights. 28 Pa. Code: 211.10 (d) Resident care policies. 28 Pa. Code: 211.12 (d)(5) Nursing services.