Every finding on record at Rehab at Shannondell

Based on review of clinical records and interview with staff, it was determined that the facility failed to report an elopement incident to the department of health for one of twelve residents reviewed (Resident R125)Review facility policy on Patient Elopement dated September 2022 revealed that under section Purpose: This policy ensures that patients that leave the facility without staff knowledge or without adequate supervision / safety is managed appropriately. Under section Procedures #3 Patient's Rights with Outings: patients who are not at risk of elopement will have their rights preserved and are free to move throughout the facility and leave the facility with supervision.Review of Resident R125's clinical record revealed that Resident R125 was admitted to facility on March 16, 2026, with diagnoses of but not limited to Intertrochanteric Fracture of the Right Femur, Presence of Right Artificial Hip Joint.Review of the MDS (minimum data set, a federally required resident assessment completed at a specific interval) dated March 26, 2026, revealed section C0500. BIMS (brief interview for mental status) Summary Score was coded14, suggesting that Resident R125 was cognitively intact.Review of progress noted dated April 5, 2026, revealed that at approximately 7:25AM on April 4, 2026, shortly after change of shift nurse entered pt room to check on [Resident R125]. [Resident R125] was not in room. [Resident R125] did not alert nursing that he was leaving. Nurse last seen [Resident R125] in the beginning of shift at approximately 3:45PM. Nurse immediately alerted the aide who began to search the unit for [Resident R125]. Aide did not find resident. 911 was then called. Resident was known to have a visitor whom he was seen leaving the facility at approximately 4:22PM. Officers came and took [Resident R125] and visitors information and sent officers to their homes. Officers did not find anyone to be at either home. Officers later contacted resident's former wife who reported resident's visitor to be very religious. Found both [Resident R125] and visitor at a local church [Resident R125] arrived back on unit at approximately 10:30PM.Interview nurse's aide Employee E6 conducted on April 28, 2026, at 9:43AM confirmed that Employee E6 worked on the second floor, where Resident R125 lived. Further Employee E6 revealed that she left the second-floor unit at around 7pm to work on another unit. Further, Employee E6 revealed that she was not aware that Resident R125 was missing and was only made aware of it when one of the nurses went to her unit to ask if she knew anything about Resident R125 leaving the building.Telephone interview with nurse's aide Employee E7 conducted on April 28, 2026, at 10:20 a.m. confirmed that on April 4, 2026, during the day shift which is from 7am to 7pm, she worked on the second-floor unit where Resident R125 lived.Further interview with Employee E7 revealed that she did not know that Resident R125 left the building but that she heard about it the next day when she came back to work. Further when Employee E7 was asked if she remembered if Resident R125 had a visitor that day, she responded I think so. But did not know what time because she did not pay attention. Interview with the front desk receptionist supervisor, Employee E4 conducted on April 28, 2026, at 12:09 PM revealed that the expectations of the receptionist with checking visitors in and out was that when someone comes in, they have them sign in at the kiosk in the front lobby before going upstairs to the unit. They indicate who they are and where they are going. When asked about visitors taking a resident for a LOA (leave of absence) Employee E4 stated that at the time of arrival, some visitors may sign out the resident also while checking themselves in as a visitor, just to get the process going. While some will wait and sign the resident out when they are downstairs after getting the resident from their room/unit.Further interview with Employee E4 revealed that every situation is different because some residents will come down and sign themselves out and then wait in the lobby for their visitor/ride. When asked what occurs when the resident arrives back from a LOA (leave of absence), Employee E4 stated that when they come back, they then have to sign themselves back in or the visitor must sign them back in on the kiosk in the front lobby. Employee E4 stated that the only situation where the resident do not have to sign out on the kiosk in the front lobby is when they go to the doctors because the nurse already knows about it.Interview with Nursing Home Administrator Employee E1 conducted on April 28, 2026 at 11:25AM confirmed that Resident R125 left the facility together with a friend without the knowledge of the staff. Further, Employee E1 revealed that a concierge who was at the front desk saw the resident leave the building with a visitor.Further interview with the facility administrator revealed that the concierge does not have to inform the staff when residents leave the building. Some residents just leave the building for fresh air and return back to the facility after. The concierge knows the residents so they let the residents go out for fresh air. Further Employee E1 revealed that the concierge treats all residents as if they are in assistive living.Interview with the Director of Nursing, Employee E2 conducted on April 28, 2026, at 9:05 AM revealed that she did not investigate the incident where Resident R125 left the facility without staff knowledge because she did not think that it was an elopement because Resident R125 left the facility to go to church and returned. Further Employee E2 confirmed that no staff or witness statements were taken.Further interview with Employee E2 also revealed that she did not report the incident to the department of health because she did not think it was an elopement 28ode 201.14 Accident prevention and reporting

Based on review of clinical records and interview with staff, it was determined that the facility failed to conduct a timely and thorough investigation of an elopement incident for one of twelve residents reviewed (Resident R125).Review facility policy on Patient Elopement dated September 2022 revealed that under section Purpose: This policy ensures that patients that leave the facility without staff knowledge or without adequate supervision / safety is managed appropriately. Under section Procedures #3 Patient's Rights with Outings: patients who are not at risk of elopement will have their rights preserved and are free to move throughout the facility and leave the facility with supervision.Review of Resident R125's clinical record revealed that Resident R125 was admitted to facility on March 16, 2026, with diagnoses of but not limited to Intertrochanteric Fracture of the Right Femur, Presence of Right Artificial Hip Joint.Review of the MDS (minimum data set, a federally required resident assessment completed at a specific interval) dated March 26, 2026, revealed section C0500. BIMS (brief interview for mental status) Summary Score was coded14, suggesting that Resident R125 was cognitively intact.Review of progress noted dated April 5, 2026, revealed that at approximately 7:25AM on April 4, 2026, shortly after change of shift nurse entered pt room to check on [Resident R125]. [Resident R125] was not in room. [Resident R125] did not alert nursing that he was leaving. Nurse last seen [Resident R125] in the beginning of shift at approximately 3:45PM. Nurse immediately alerted the aide who began to search the unit for [Resident R125]. Aide did not find resident. 911 was then called. Resident was known to have a visitor whom he was seen leaving the facility at approximately 4:22PM. Officers came and took [Resident R125] and visitors information and sent officers to their homes. Officers did not find anyone to be at either home. Officers later contacted resident's former wife who reported resident's visitor to be very religious. Found both [Resident R125] and visitor at a local church [Resident R125] arrived back on unit at approximately 10:30PM.Interview nurse's aide Employee E6 conducted on April 28, 2026, at 9:43AM confirmed that Employee E6 worked on the second floor, where Resident R125 lived. Further Employee E6 revealed that she left the second-floor unit at around 7pm to work on another unit. Further, Employee E6 revealed that she was not aware that Resident R125 was missing and was only made aware of it when one of the nurses went to her unit to ask if she knew anything about Resident R125 leaving the building.Telephone interview with nurse's aide Employee E7 conducted on April 28, 2026, at 10:20 a.m. confirmed that on April 4, 22026, during the day shift which is from 7am to 7pm, she worked on the second-floor unit where Resident R125 lived.Further interview with Employee E7 revealed that she did not know that Resident R125 left the building but that she heard about it the next day when she came back to work. Further when Employee E7 was asked if she remembered if Resident R125 had a visitor that day, she responded I think so. But did not know what time because she did not pay attention. Interview with the front desk receptionist supervisor, Employee E4 conducted on April 28, 2026, at 12:09 PM revealed that the expectations of the receptionist with checking visitors in and out was that when someone comes in, they have them sign in at the kiosk in the front lobby before going upstairs to the unit. They indicate who they are and where they are going. When asked about visitors taking a resident for a LOA (leave of absence) Employee E4 stated that at the time of arrival, some visitors may sign out the resident also while checking themselves in as a visitor, just to get the process going. While some will wait and sign the resident out when they are downstairs after getting the resident from their room/unit.Further interview with Employee E4 revealed that every situation is different because some residents will come down and sign themselves out and then wait in the lobby for their visitor/ride. When asked what occurs when the resident arrives back from a LOA (leave of absence), Employee E4 stated that when they come back, they then have to sign themselves back in or the visitor must sign them back in on the kiosk in the front lobby. Employee E4 stated that the only situation where the resident does not have to sign out on the kiosk in the front lobby is when they go to the doctors because the nurse already knows about it.Interview with Nursing Home Administrator Employee E1 conducted on April 28, 2026, at 11:25AM confirmed that Resident R125 left the facility together with a friend without the knowledge of the staff. Further, Employee E1 revealed that a concierge who was at the front desk saw the resident leave the building with a visitor.Further interview with the facility administrator revealed that the concierge does not have to inform the staff when residents leave the building. Some residents just leave the building for fresh air and return back to the facility after. The concierge knows the residents, so they let the residents go out for fresh air. Further Employee E1 revealed that the concierge treats all residents as if they are in assistive living.Interview with the Director of Nursing, Employee E2 conducted on April 28, 2026, at 9:05 AM revealed that she did not investigate the incident where Resident R125 left the facility without staff knowledge because she did not think that it was an elopement because Resident R125 left the facility to go to church and returned. Further Employee E2 confirmed that no staff or witness statements were taken.Further interview with Employee E2 also revealed that she did not report the incident to the department of health because she did not think it was an elopement. 28 Pa. Code 201.14 Facility responsibility28 Pa. Code 201.18 Management28 Pa. Code 211.12 Administration

Based on review of clinical records and interview with staff, it was determined that the facility failed to ensure that residents are supervised which resulted in a resident leaving the facility without the knowledge of the staff for one on twelve residents reviewed (Resident R125).Review facility policy on Patient Elopement dated September 2022 revealed that under section Purpose: This policy ensures that patients that leave the facility without staff knowledge or without adequate supervision / safety is managed appropriately. Under section Procedures #3 Patient's Rights with Outings: patients who are not at risk of elopement will have their rights preserved and are free to move throughout the facility and leave the facility with supervision.Review of Resident R125's clinical record revealed that Resident R125 was admitted to facility on March 16, 2026, with diagnoses of but not limited to Intertrochanteric Fracture of the Right Femur, Presence of Right Artificial Hip Joint.Review of the MDS (minimum data set, a federally required resident assessment completed at a specific interval) dated March 26, 2026, revealed section C0500. BIMS (brief interview for mental status) Summary Score was coded14, suggesting that Resident R125 was cognitively intact.Review facility policy on Patient Elopement dated September 2022 revealed that under section Purpose: This policy ensures that patients that leave the facility without staff knowledge or without adequate supervision / safety is managed appropriately. Under section Procedures #3 Patient's Rights with Outings: patients who are not at risk of elopement will have their rights preserved and are free to move throughout the facility and leave the facility with supervision.Review of Resident R125's clinical record revealed that Resident R125 was admitted to facility on March 16, 2026, with diagnoses of but not limited to Intertrochanteric Fracture of the Right Femur, Presence of Right Artificial Hip Joint.Review of the MDS (minimum data set, a federally required resident assessment completed at a specific interval) dated March 26, 2026, revealed section C0500. BIMS (brief interview for mental status) Summary Score was coded14, suggesting that Resident R125 was cognitively intact.Review of progress noted dated April 5, 2026, revealed that at approximately 7:25AM on April 4, 2026, shortly after change of shift nurse entered pt room to check on [Resident R125]. [Resident R125] was not in room. [Resident R125] did not alert nursing that he was leaving. Nurse last seen [Resident R125] in the beginning of shift at approximately 3:45PM. Nurse immediately alerted the aide who began to search the unit for [Resident R125]. Aide did not find resident. 911 was then called. Resident was known to have a visitor whom he was seen leaving the facility at approximately 4:22PM. Officers came and took [Resident R125] and visitors information and sent officers to their homes. Officers did not find anyone to be at either home. Officers later contacted resident's former wife who reported resident's visitor to be very religious. Found both [Resident R125] and visitor at a local church [Resident R125] arrived back on unit at approximately 10:30PM.Interview nurse's aide Employee E6 conducted on April 28, 2026, at 9:43AM confirmed that Employee E6 worked on the second floor, where Resident R125 lived. Further Employee E6 revealed that she left the second-floor unit at around 7pm to work on another unit. Further, Employee E6 revealed that she was not aware that Resident R125 was missing and was only made aware of it when one of the nurses went to her unit to ask if she knew anything about Resident R125 leaving the building.Telephone interview with nurse's aide Employee E7 conducted on April 28, 2026, at 10:20 a.m. confirmed that on April 4, 22026, during the day shift which is from 7am to 7pm, she worked on the second-floor unit where Resident R125 lived.Further interview with Employee E7 revealed that she did not know that Resident R125 left the building but that she heard about it the next day when she came back to work. Further when Employee E7 was asked if she remembered if Resident R125 had a visitor that day, she responded I think so. But did not know what time because she did not pay attention. Interview with the front desk receptionist supervisor, Employee E4 conducted on April 28, 2026, at 12:09 PM revealed that the expectations of the receptionist with checking visitors in and out was that when someone comes in, they have them sign in at the kiosk in the front lobby before going upstairs to the unit. They indicate who they are and where they are going. When asked about visitors taking a resident for a LOA (leave of absence) Employee E4 stated that at the time of arrival, some visitors may sign out the resident also while checking themselves in as a visitor, just to get the process going. While some will wait and sign the resident out when they are downstairs after getting the resident from their room/unit.Further interview with Employee E4 revealed that every situation is different because some residents will come down and sign themselves out and then wait in the lobby for their visitor/ride. When asked what occurs when the resident arrives back from a LOA (leave of absence), Employee E4 stated that when they come back, they then have to sign themselves back in or the visitor must sign them back in on the kiosk in the front lobby. Employee E4 stated that the only situation where the resident does not have to sign out on the kiosk in the front lobby is when they go to the doctors because the nurse already knows about it.Interview with Nursing Home Administrator Employee E1 conducted on April 28, 2026, at 11:25AM confirmed that Resident R125 left the facility together with a friend without the knowledge of the staff. Further, Employee E1 revealed that a concierge who was at the front desk saw the resident leave the building with a visitor.Further interview with the facility administrator revealed that the concierge does not have to inform the staff when residents leave the building. Some residents just leave the building for fresh air and return back to the facility after. The concierge knows the residents, so they let the residents go out for fresh air. Further Employee E1 revealed that the concierge treats all residents as if they are in assistive living.Interview with the Director of Nursing, Employee E2 conducted on April 28, 2026, at 9:05 AM revealed that she did not investigate the incident where Resident R125 left the facility without staff knowledge because she did not think that it was an elopement because Resident R125 left the facility to go to church and returned. Further Employee E2 confirmed that no staff or witness statements were taken.Further interview with Employee E2 also revealed that she did not report the incident to the department of health because she did not think it was an elopement. 28 Pa. Code 201.14 Facility responsibility28 Pa. Code 201.18 Management28 Pa. Code 211.12 Administration

Based on review of facility policy, review of clinical record, observations, and interview with staff it was determined that the facility failed to administer intravenous (IV) medications in accordance with professional standards of practice for one of twelve residents reviewed (Resident R8). Findings include:Review of facility policy Central Venous Catheter Dressing Change (allows delivery of medications directly into the blood stream) dated May 2011, revealed the Registered Nurse will measure external portion of catheter (ensures that the catheter is properly positioned within the vein) and document in residents electronic medical record and further ensure external measurement is what is documented on the IV insertion records and notify physician of any discrepancies.Review of Resident R8's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated April 15, 2026, revealed the resident was admitted to the facility on [DATE], and had diagnoses of wound infection and bacteremia (presence of bacteria in the bloodstream).Further review of Resident R8's MDS dated [DATE], revealed the resident received intravenous (IV) therapy for antibiotic medications while a resident of the facility.Review of Resident R8's clinical record revealed a physician order dated April 9, 2026, for vancomycin (antibiotic) 200 milliliters by intravenous route every 12 hours for 21 days.Continued review of Resident R8's clinical record revealed a physician order start date April 13, 2026, to measure external catheter length with each dressing change weekly.Review of Resident R8's comprehensive care plan dated April 10, 2026, revealed the resident was at risk for complications related to mid-line (a type of intravenous tube) and interventions included to measure and document length of external catheter during dressing changes. The external length on admission was left blank in the care plan.Observations and interview on April 27, 2026, at approximately 10:15 a.m. with Resident R8 confirmed he/she had IV access for administration of an antibiotic.Review of Resident R8's clinical record revealed no documented evidence the facility measured and documented the external catheter length on admission, or thereafter with dressing changes.Interview on April 28, 2026, at 1:55 p.m. with the Director of Nursing, Employee E2, confirmed the facility did not document Resident R8's external catheter length and the facility did not have a copy of what the documented external catheter length was at the time of insertion from the hospital.28 Pa. Code 201.14 (a) Responsibility of licensee.28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of facility policy, review of clinical documents, observation, and interviews with staff, it has was determined that the facility did not ensure that oxygen therapy was provided in accordance with professional standards of practice related to physician orders and documentation for two out of ten residents reviewed (R1, R12) Findings include:Review of facility policy titled Oxygen Utilization/Storage, last updated July 2021, revealed that Oxygen is prescribed by the physician and must include .device (e.g., nasal cannula, simple mask), flow rate .duration (continuous, exertion, sleep, PRN with clear parameters).Review of clinical records for resident R1 revealed that he was admitted on [DATE], with diagnoses including, but not limited to, acute and chronic respiratory failure, pneumonia, congestive heart failure (CHF, a condition where the heart is too weak or stiff to pump blood effectively, causing fluid buildup in the lungs or body. This can cause shortness of breath, fatigue, and swelling), and chronic obstructive pulmonary disorder (COPD, a progressive, generally irreversible lung disease, which causes persistent breathing difficulties). Observation of resident R1 on April 27, 2026, at 11:18 a.m. revealed the resident was receiving oxygen therapy through a nasal cannula at three liters per minute flow rate. Further review revealed a physician order, dated March 24, 2026, which stated Oxygen via nasal cannula to keep pulse ox >92% may titrate or wean as tolerated. No specification of flow rate or delivery device was noted. Review of the resident's care plan revealed a plan for risk of alteration in breathing patterns related to COPD, oxygen use, pneumonia, acute and chronic respiratory failure initiated on March 24, 2026, with an intervention of oxygen as ordered. No further instructions for the use of oxygen therapy were noted. Review of clinical records for resident R12 revealed that the resident was admitted to the facility on [DATE], with diagnoses including, but not limited to, pulmonary embolism (PE) with cor pulmonale (a blood clot in the lungs which lead to enlargement and failure of the right side of the heart), pleural effusion (a buildup of fluid in the lining around the lungs, which can make it more difficult to breathe), asthma, and acute and chronic respiratory failure. Observation of resident R12 on April 27, 2026, at 11:30 a.m. revealed the resident was receiving oxygen therapy through a nasal cannula at six liters per minute flow rate. Further review revealed a physician order, dated November 4, 2025, which stated Oxygen via nasal cannula to keep pulse ox >92% may titrate or wean as tolerated. No specification of flow rate or delivery device was noted. Review of the resident's care plan revealed a plan for risk of alteration in breathing patterns related to acute and chronic respiratory failure, asthma, COPD, oxygen use, pleural effusion, PE initiated on October 30, 2025, with an intervention of oxygen as ordered. No further instructions for the use of oxygen therapy were noted. In an email to employee E2, the Director of Nursing (DON), dated April 28, 2026, at 12:41 p.m., the surveyor notified employee E2 that complete oxygen orders could not be found for residents R1 and R12. In a reply at 1:38 p.m., she confirmed that the oxygen orders for residents R1 and R12 were not clear and needed to be updated.

Based on clinical record, hospital record and policy and procedure review and interviews with staff, it was determined that the facility failed to immediately inform the physician of an accident that resulted in injury for one of five residents reviewed. (Resident R1)Findings include:A review of the policy titled physician notification dated November, 2019 revealed that it was the responsibility of the facility to notify the resident's attending physician of changes in the resident's medical condition or status. The policy indicated that the charge nurse was responsible to notify the resident's attending physician when there had been an accident or incident involving the resident. The nurse was also responsible for documenting the details and observations pertinent for the physician notification. The nurse was responsible for recording any instructions given to the nurse by the physician related to the incident or accident. Clinical record review revealed that Resident R1 had fallen at 5:00 a.m., on April 28, 2025. The nursing note at 7: 39 a.m., on April 28, 2025 indicated that the licensed nurse, Employee E5, went into Resident R1's room during morning rounds and found Resident R1 in bed, eyes closed. Resident R1 was awakened with verbal stimuli and reported to the licensed nurse, Employee E5 that she fell while ambulating to the bathroom at about 5:00 a.m., on April 28, 2025. The licensed nurse, Employee E5, called the nurse aide and requested information about Resident R1's care during the time he was responsible for the resident on the overnight shift. The nurse aide, Employee E7, confirmed that the resident fell at 5:00 a.m., on the 11:00 pm to 7:00 am shift. Nurse aide, Employee E5 said that he picked the resident up off the floor and placed her in the wheelchair and took her to the bathroom, then returned the resident to the bed. The nursing aide, Employee E7, reported that he did not notify anyone of the fall for Resident R1, that occurred at 5:00 a.m., during the 11:00 pm to 7:00 am shift. Review of physician's notes dated April 28, 2025 revealed that the reason for the visit was that the resident had a fall over night and the resident was complaining of pain of the left elbow, hip and knee. The resident stated that she fell over her walker and landed on the left side. She reported to the physician that she also hit her head. The physician ordered x-rays of the left elbow, hip and knee and pain medication as needed. The physician noted that the Resident had a left shin skin tear. The physician also ordered treatment for Resident R1's skin alteration. Interview with the Director of Nursing, Employee E2, at 10:30 a.m., on June 30, 2025 confirmed that Employee E7, nurse aide, failed to immediately report to nursing staff the fall incident that took place at 5:00 a.m., on April 28, 2025 for Resident R1. The Director of Nursing also confirmed that Resident R1 self reported the incident (fall) to the licensed nurse during the 7:00 am to 3:00 pm nursing shift on April 28, 2025.28 PA. Code 211.10(c)(d) Resident care policies28 PA. Code 211.12(d)(1) Nursing services

Based on review of clinical record, review of policy and procedures, interviews with staff, and review of hospital records, it was determined that the nursing staff failed to properly supervise one of five residents reviewed during transfer and ambulation. (Resident R1) Findings include:A review of the facility policy titled fall management dated February, 2023 revealed that it was the responsibility of the facility staff to assess residents who were at risk for falls and identify the reason for the fall to prepare a care plan to reduce the potential for future falls. This policy indicated that a plan of care would be developed and initiated to address fall risk factors and measures to prevent falls. A facility incident report will be completed post fall and witness statements/information would be documented and used to develop care plan approaches to prevent falls.A review of the facility's policy titled incident and accident investigation dated January, 2022 revealed that the purpose of the investigation of an incident was to complete a prompt and thorough review and report of all falls to promote resident safety and quality of care. The policy indicated that the registered nurse (ADON- Assistant Director of Nursing) was responsible for the investigation and obtaining employee statements of the circumstances surrounding the fall. The ADON was also responsible for determining new interventions that would be effective to prevent falls. The ADON was also responsible for conducting interviews with the resident involved in the fall. The ADON was responsible for training of tasks to staff to prevent further falls. The ADON was responsible for providing a summary of the investigation into the fall/incident. Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE] with the diagnosis of Anemia, Atrial Fibrillation (irregular heart beat) and generalized weakness. Review of physical therapist's assessment dated [DATE] indicated Resident R1 had a diagnosis of BPPV (vertigo or sudden onset of asensation of spinning or moving). The therapist's assessment also indicated that Resident R1 had kyphosis (an excessive forward curve of the spine) and inadequate hip extension, unsteadiness on the feet and inadequate toe clearance; which was associated with muscle weakness in the resident's gait. The therapist assessed Resident R1 to be at risk for falls; because of the resident reduced balance. The physical therapy care plan for Resident R1 was to provide Resident R1 with partial/moderate assistance with walking to prevent falls. Review of the occupational therapist assessment dated [DATE] indicated Resident R1 required care giver assist to walk with cues from staff to perform proper/safe walking techniques for a distance of 15 feet with a roller walker. The occupational therapist indicated that Resident R1 required the support of a staff member to stand from a seated position.Clinical record review revealed a physicial therapy progress note dated April 24, 2025 that indicated Resident R1 had decreased cadence (balance or movement), decreased step/stride length and decreased toe clearance and flexed posture. The progress indicated that Resident R1 was ambulating with a roller walker and care giver assist with a wheelchair following. Review of Resident R1's admission comprehensive assessment (MDS-an assessment of care needs) dated April 28, 2025 indicated that this resident was cognitively intact. Resident R1 was assessed with bilateral lower extremity impairments on both sides of the body. The assessment indicated for toileting hygiene Resident R1 required supervision or touching assistance in which the staff provides verbal cues and/or touching and/or contact guard assistance as resident completes the activity. The resident had functional mobility impairments from chair/bed to chair transfers; required supervision or touching assistance provided by staff. Resident R1 required partial/moderate assistance from staff for ambulation. The staff member was required to lifted, hold or support the trunk or limbs of the resident for ambulation or transfers. The resident was dependent for walking 50 feet with assist of two for ambulation 50 feet. The comprehensive assessment identified Resident R1 as occasionally incontinent of urine. Review of Resident R1's care plan dated April 22, 2025 revealed that the resident was care planned for falls. Interventions included to assist with transfers as needed and resident is supervision.Review for Resident R1's nursing notes dated April 24, 2025 at 10:25 a.m. indicated This nurse was called by therapy and was notified that this patient had fallen with therapy out of the balcony. This nurse went to the balcony right away. The patient was found lying face down with her head towards the ceiling. She was immediately assessed for injuries by this nurse .This nurse notice bleeding form her right hand and right knee .CRNP noticed. Continued review of nursing notes dated April 24, 2025 at 11:04 a.m. revealed that the resident reported discomfort of bilateral knees and left side.Nursing note dated April 25, 2025 indicated that continued care from the occupational and physical therapy departments were necessary for gait training, transfer training and dynamic balance to help prevent further falls for Resident R1.Interview with the physical therapist, Employee E6, at 1:00 p.m., on June 30, 2025 confirmed that in order to promote safe transfers and ambulation, Resident R1 required moderate supervised assistance of a staff member to use a rolling walker for transfers as demonstrated for 15 feet. The physical therapist also confirmed that Resident R1 required cueing and physical support from staff to go from a seated position to standing position and standing position to seated position for safety reasons. Review of nursing note dated April 26, 2025 indicated Resident R1 required assist of one staff member for transfers. The nursing note also indicated that this resident required assist of one staff person to use a rolling walker for ambulation. Review of nursing note dated April 28, 2025 revealed that the resident self reported to a licensed nurse, Employee E5, that she had a fall at 5:00 a.m., while standing to walk to the bathroom. The nursing assistant, Employee E7, responsible for the care of Resident R1 at 5:00 a.m., was contacted and reported that walker was placed in front of Resident R1. The nursing assistant, Employee E7 reported that during this transfer with Resident R1, he turned away from the resident to grab her trash to empty it, as it was full. The nursing assistant, Employee E7, reported that Resident R1 fell, when he turned away from her to empty the trash, as it was full. Clinical record review for April 28, 2025 indicated that Resident R1 was found to have a weeping open area on the left shin, that required treatment as ordered by the physician.Interview with the Director of Nursing, Employee E2, on June 30, 2025 at 10:45 a.m., confirmed that there was no documentation to indicate a written statement had been obtained from the nursing assistant, Employee E7 that indicated he turned his head for a split second to empty her trash can, on April 28, 2025. Review of the incident documentation indicated that Resident R1 was walking to the bathroom with her walker when she fell. There was no documentation to indicate that the nursing assistant provided contact guard, moderate supervised assistance and cueing to keep both hands on the walker as required for safe transfers for Resident R1 at 5:00 a.m., on April 28, 2025.28 PA. Code 211.10(d) Resident care policies28 PA. Code 211.12(d)(1) Nursing services

Based on staff interviews, review of faciltiy policy and review of clinical records, it was determined that the facility failed to inform the resident and/or her responsible party of their right to formulate an advanced directive upon admission, and failed to clarify the resident's code status upon admission to ensure that the resident's wishes regarding end of life care would be honored for 1 out of 2 residents reviewed (Resident R1). Findings include: Review of the facility policy, Patient Code Status, with a revision date of [DATE], indicted that the purpose of the policy was to ensure that patients are able to choose their code status and to ensure that all necessary documentation is included in patient's chart. The policy also indicated that social services will verify the patient's code status choice (DNR or Full Code) with their admission assessment within 1 business day of a resident's admission. Continued review of the policy indicated that a physician's order for DNR will be contained in the electronic medical record, and that if a patient is not DNR, the patient is considered to be Full Code, and that if a patient is unable to express these wishes, the social services department will consult with the appropriate decision makers for the resident as part of their admission assessment. Review of the resident's hospital discharge summary indicated that the resident was admitted into the hospital's intensive care unit on [DATE] after a fall in her home, and subsequently transferred to the facility for rehabilitation services on [DATE]. Review of a nursing notes dated [DATE] at 2:00 p.m. by the licensed nurse (Employee E3) who completed the resident's nursing admission assesssment indicated that the resident was admitted into the facility on the referenced date with diagnoses of fall, traumatic, subdural hematoma (bleeding in the brain that can happen after a head injury; subarachnoid hemorrhage (a type of stroke); intraparenchymal Hematoma (a type of stroke that occurs when blood accumulates in the brain tissues), intraventricular Hemorrhage (a type of bleeding that occurs within the ventricles of the brain, which are fluid-filled spaces that help cushion and protect the brain). Continued review of the resident's nursing note indicated that the resident was assessed by Employee E3 as being Alert and Oriented x 2 (a term used in healthcare to describe a patient's mental status, and indicates that the person may be aware of their own identity and current time, but may not be oriented to place or situation). Review of information received by State Survey Agency on [DATE] reported that the resident had a fall on [DATE], and subsequently passed away on the same day. Review of documentation provided by the facility, and completed by the charge nurse who was assigned to Resident R1 on [DATE] from 7:00 a.m. through 7:00 p.m., indicated that the resident had a fall on [DATE]. Review of the documentation indicated that the resident's nurse aide found her on the floor lying on her back in front of the recliner chair where she was last seen sitting. The documentation indicated that the nurse aide alerted Licensed nurse, Employee E4 of the incident, was assesssed by Employee E4 and placed back on bed. Facility documentation reviewed on the event indicated that when assessed after the fall, the resident was awake and conscious, but unable to follow verbal commands, or tell the staff what happened. Continued review of the resident's fall incident documentation also indicated that the nurse practitioner was notified of the fall, and ordered that the resident to be sent out to the emergency room . The resident's husband was also contacted and notified of her fall and the nurse practitioner's order to send the resident out to the hospital Continued review of the documentation provided on the incident revealed that while completing addition assessments on the resident (neurological checks), the resident's blood oxygen level (the amount of blood that an individual has circulating in their blood) began to decrease into the 80's (a blood oxygen level that would require immediate medical attention), and a pulse could not be read for the resident when attempts were made to obtain one. Facility documentation indicated that cardiopulmonary resuscitation (CPR-an emergency life saving procedure when an individual's heart stops breathing) was started at 4:30 p.m. Documentation also indicated that emergency medical technicians arrived and called the resident's son to obtain the resident's code status, and that the son verbalized to the emergency medical technicians that he wanted CPR to continue on his mother. Continued review of he documentation on the incident revealed that CPR continued for 40 minutes, and that the resident was pronounced as deceased at 5:08 p.m. Review of information from the hospital indicated that on [DATE] (date of the resident's hospital admission), the physician reviewed that resident's code status and indicated Code status goals of care discussed: full code. Review of hospital documentation sent over to the facility with the resident's hospital discharge summary by the hospital was a form with Physician Care Manager document that indicated that the resident's code status was DO NOT RESUSITATE/DO NOT INTUBATE (a medical order issued by a physician or other authorized non-physician practitioner that directs healthcare providers not to administer CPR in the event of cardiac or respiratory arrest), in addition to information related to the resident's discharge orders, follow up appointments, and the resident's prescriptions. Review of the resident's clinical record at the facility did not show evidence that upon the resident's admission on [DATE] at approximately 2:00 p.m. that any attempt was made by the facility to determine from the resident and/or her family/responsible party, if the resident had an advanced directive or wanted to develop an advanced directive if she did not have one. Continued review of the clinical record also did not show evidence that upon admission the facility made any attempts to obtain the resident's code status (the level of medical interventions a person wishes to have started if their heart or breathing stops) to ensure that the resident and/or her responsible party's request regarding this decision would be honored by the facility, and that staff would know how to correctly proceed in a medical event involving the resident. During an interview with Employee E4 (licensed nurse) on [DATE] at 12:30 p.m. Employee E4' statement was reviewed and confirmed regarding her account of the incident on [DATE]. Employee E4 reported that the resident was Full Code when a resident is admitted on the weekend. It was verified with her that Resident R1 was admitted on a Friday at or before 2:00 p.m. Employee E4 reported that when the EMT arrived at the facility, they saw where the resident was a DNR, so an EMT called the resident's son and asked if he wanted EMT to continue providing CPR to the resident. During an interview with Employee E3 (licensed nurse) on [DATE] at 1:04 p.m. the nurse reported that the resident came in at approximately 2:00 p.m. and that the resident's family came on [DATE], but after he completed the resident's admission. Employee E3 reported that he obtained the medical report from the sending hospital which included information on her history and physical. Employee E3 reported that there was no information discussed about the resident's code status, and that obtaining the resident's code status is part of the social services assessment. During an interview with Employee E5 (licensed nurse/case manager supervisor to the social workers) Employee E5 reported that she was notified of the incident regarding Resident R1 and assisted staff with providing CPR to the resident. Employee E5 reported that when the EMT'S arrived, one EMT called the resident' son to confirm the resident's code status, and the son instructed the EMT that he can continue CPR on his mother. Employee E5 reported that she remained in the room with the EMT'S, who eventually pronounced the resident dead. Continued interview with Employee E5 confirmed that by default she (Resident R1) was a Full Code when she was admitted into the facility. Employee E5 reported that social workers see new admissions within the next business day after a resident is admitted to confirm the resident's code status, and to complete the social services admission assessment. Employee E5 reported that if the resident is not awake, alert or oriented, the social worker will contact the family for the admission assessment and the code status information. The facility failed to inform Resident R1 and/or her responsible party of their right to formulate an advanced directive, upon admission, and failed to clarify Resident R1's code status upon admission to ensure that the resident's wishes regarding end of life care would be honored. 28 Pa. Code 201.29 (a) Resident Rights

Based on observation, review of clinical records and staff interview, it was determined that the facility failed to implement a system of records of receipt and disposition of all controlled drugs between shifts to enable an accurate reconciliation and accountability for two of three medication carts observed. (Medication Cart 3rd Floor B Front and Medication cart 3rd Floor B Back) Findings: Review of facility narcotic book for Medication Cart 3rd Floor B Front conducted on July 10, 2024, at 8:52 p.m., during medication administration observation with licensed nurse, Employee E5 revealed an entry for July 10, 2024, with time written 1900 (7:00 p.m.). Further, the column for Nurse going off duty for July 10, 2024, with time written for 1900 had a signature. Interview with licensed nurseEmployee E5 conducted at the time of the observation, revealed that licensed nurses work a 12-hour shift and that between shifts, the outgoing and incoming nurses count the narcotics together and that the once they are done counting the controlled substances in the cart, the outgoing nurse signs the outgoing column of the narcotic book for that date and the incoming nurse also signs the incoming column of the narcotic book for that date. Further interview with Employee E5 revealed that licensed nurse Employee E5 was the one who counted the narcotics at the beginning of the day shift on July 10, 2024. Interviewed with Employee E6 conducted at the time of the observation, confirmed that at the beginning of the day shift for July 10, 2024, he pre signed the column for Nurse going off duty for July 10, 2024, for which the time 19:00 was written. Further Employee E6 also revealed that he pre signed it because he was going to be the one to sign it at the end of his shift anyway. Further review of the narcotic book for Medication Cart 3rd Floor B Front revealed that on: June 6, 2024 at 7:00 (1.m.), the column Nurse going off duty did not have a signature. June 22, 2024, at 11:00 p.m., the column Nurse coming on duty did not have a signature. June 23, 2024, at 7:00 a.m., the column Nurse going off duty did not have a signature. June 25, 2024, at 7:00 a.m., the column Nurse going off duty did not have a signature. June 30, 2024, at 5:45 a.m., the column Nurse coming on duty did not have a signature. Further review of the facility narcotic book for Medication Cart 3rd Floor B Back revealed that on: June 6, 2024, at 7:15 a.m., the column Nurse going off duty did not have a signature. June 19, 2024, at 7:00 a.m., the column Nurse going off duty did not have a signature. June 22, 2024, at 5:00 a.m., the column Nurse coming on duty did not have a signature. June 22, 2024, at 7:00 a.m., the column Nurse going off duty did not have a signature. June 29, 2024, at 7:00 p.m., the column Nurse coming on duty did not have a signature. July 4, 2024, at 7:00 p.m., the column Nurse coming on duty did not have a signature. July 10, 2024, at 7:00 a.m., the column Nurse coming on duty did not have a signature. Review of the facility narcotic book for Medication cart 3rd Floor B Back conducted during medication administration on the 3rd floor unit on July 10, 2024, at 9:12 a.m. with Employee E6 and Employee E8 revealed that the on July 10, 2024, at 7:00 a.m. the incoming column did not have a signature. Interview with licensed nurse Employee E8 conducted by Employee E6 at the time of the observation in the presence of the surveyor, confirmed that Employee E8 did not sign the column for Nurse coming on duty at the beginning of her shift for July 10, 2024 28 Pa. Code 201.18(b)(2) Management 29 Pa. Code 211.9(a)(1)(k) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, interviews with staff, review of clinical records and facility policy, it was determined that the facility failed to have a medication error rate less than five percent (Residents R9 and R244). Findings include: Review of the facility's medication policy dated 2/2017 states, All medications are administered safely and appropriately to all residents and to follow 6 Rights of Medication Administration during medication pass (right resident, right medication, right dose, right route, right time, right documentation). The facility's medication error rate was 8 % based on 25 medication opportunities with two medication errors. Review of Resident R9's physician orders instructed to take Cyanocobalamin (Vitamin B-12) 1,000 mcg sublingual route (placed under your tongue to dissolve) once daily. Observation of a medication administration pass on July 11, 2024, at 9:08 a.m. with Registered Nurse, Employee E3 revealed the nurse administered Cyanocobalamin by mouth to Resident R9. Review of Resident R244's physician orders instructed to take Cyanocobalamin 1,000 mcg sublingual route once daily. Observation of a medication administration pass on July 11, 2024, at 9:38 a.m. with Licensed Practical Nurse, Employee E4 revealed the nurse administered the Cyanocobalamin by mouth to Resident R244. Interview with the Director of Nursing on July 11, 2024, at 12:30 p.m. confirmed the nurses did not follow the physician's order for Cyanocobalamin and did not administer the medication sublingually. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, reviewof facility policy, observation, and staff interview, it was determined that the facility failed to ensure that all drugs and biologicals are stored and labeled in accordance with professional standards for one of three medication carts observed (Med cart 3rd B back) and one of two medication rooms observed (Third-floor medication room). Findings include: Review of facility policy for medication administration dated February 2017, revealed that under section Policy: all medications are administered safely and appropriately to all residents. Under section Process: Check medication for expiration date and discard if indicated and check multi dose vials for date when opened and discard if indicated. Observation of med cart 3rd B back conducted during medication administration on the 3rd floor unit on [DATE], at 9:12 a.m. with Licensed nurses, Employee E6 and Employee E8 revealed a Glucagon injection (an emergency medication used to treat severe hypoglycemia (low blood sugar) in diabetes patients) in the top drawer of the medication cart. Further observation revealed that the Glucagon injection had an expiry date of [DATE]. Interview with Licensed nurse, Employee E6 conducted at the time of the observation confirmed that an expired Glucagon injection in the top drawer of the medication cart had an expiration date of [DATE]. Observation of the third-floor medication room conducted on [DATE], at 10:09 a.m. with Licensed nurse, Employee E7 revealed an open vial of Tuberculin PPD 5TU/0.1ml (used in a skin test to help diagnose tuberculosis) in the refrigerator did not have a date opened affixed to the vial or the box. Interview with Licensed nurse, Employee E7 conducted at the time of the observation confirmed that an open vial of tuberculin PPD 5TU/0.1ml in the refrigerator did not have a date opened affixed to the vial or the box. 28 Pa. Code 201.18(b)(l) Management 28 Pa. Code 211.12(d) Nursing services 28 Pa. Code 211.9(i) Pharmacy services

Based on observations and interviews with residents and staff, it was determined that the facility failed to ensure a homelike atmosphere during mealtime for two of two floors (Second and Third floor). Findings include: Observations conducted of Resident R75 revealed that the resident was served lunch in his room on September 5, 2023, at approximately 12:00 p.m. The resident stated,There's no other place to eat. On September 6, 2023, at 11:15 a.m. Resident R3's son stated, Ever since Covid the residents are confined to their rooms for dining. I'd think they would have them opened for social interaction. They say that helps with healing. During the same time Resident R277 stated, I was here five years ago, and you would eat in the dining room next to the courtyard. It's a shame because it's such a beautiful room but we eat in our rooms now. On September 6, 2023 at 1:16 p.m. Resident R60's wife stated, Residents aren't served meals in the dining room they eat in their rooms. I would think they would want the residents to get out of their rooms. It's a holistic (comprehensive) approach to healing. On September 5, 2023, at 2:30 p.m., the Nursing Home Administrator confirmed the facility no longer serves meals in the dining room and all residents are served meals in their room. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on observation, review of facility policy, and interview with residents and staff, it was determined that the facility failed to ensure that grievance/concern forms were available for residents, family or guests for two of two floors (Second and Third floors). Findings include: Review of the facility's Grievance Policy revised on December 2021 states the facility will respond to grievances in a timely manner and seeks resolution that is satisfactory to the resident and prioritizes ongoing communication (phone calls, text messaging, emails, meetings, patient portal) to keep the residents/families informed. Further review of the grievance policy did not indicate nor provide the procedure necessary for submitting an anonymous compliant. September 5, 2023, at approximately 12:00 p.m. Resident R75 indicated he was not aware he could submit an anonymous complaint. September 6. 2023 at 1:16 p.m. Resident R60's wife indicated she was not aware she could submit an anonymous complaint. On September 8, 2023, at 9:30 a.m., the Nursing Home Administrator confirmed the facility failed to ensure methods of submitting an anonymous grievance was obtainable for the residents and/or the process of submission. 28 Pa. Code 201.29(a) Resident Rights

Based on clinical record review, review of faciltiy policy and interviews with the staff, it was determined that the facility failed to develop and implement a baseline care plan for one of 25 residents reviewed (Resident R210). Findings include: Review of the facility's policy titled, Care Plan, revised on March 2023, stated that the resident's care plan shall be used in developing the resident's daily care routine and will be available to staff personnel, who have responsibility for providing care or services to the residents. It is required that a baseline care plan to meet the residents' immediate needs should be developed within forty-eight hours of the residents' admission. Review of the admission record indicated, Resident R210 was admitted to the facility, on September 1, 2023, with the diagnoses of Acute Respiratory Failure (Respiratory Failure is a serious condition that makes it difficult to breathe), Chronic Obstructive Pulmonary Disease (COPD)(COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems), and Malignant Neoplasm of Right Kidney (Cancerous Tumor of Right Kidney). Review of Resident R210's care plan indicated that it was initiated only on September 5, 2023, beyond the forty-eight-hour requirement. Interview on September 7, 2023, at 12:23 p.m., with the charge Nurse of 3 C Unit, Licensed nurse, Employee E10, confirmed that the baseline care plan for Resident R210, was not developed in 48 hours of Resident R210's admission to the facility, to address his immediate care needs. 28 Pa. Code 211.11(a)(b)(c) Resident care plan 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of clinical records and review of facility policy, it was determined the facility failed to ensure a resident's care plan was updated and revised to reflect the resident's specific care needs after a change in condition for one of 25 resident records reviewed (Resident R60). Findings include: Review of the facility's policy titled, Care Plan revised on March 2023 stated the resident's care plan shall be used in developing the resident's daily care routine and will be available to staff personnel who have responsibility for providing care or services to the resident. Review of Resident R60's clinical record revealed the resident was admitted on [DATE], with the diagnoses of heart diseases and atrial fibrillation (abnormal heartbeat). Review of physician note dated August 16, 2023, stated that orthostatic blood pressure (a sudden drop in blood pressure upon standing from a sitting or supine position) and TED stockings (compression stockings) were added to Resident R60's regimen. Review of Resident R60's physician orders dated August 16, 2023, instructed to take orthostatic blood pressures for three days and to notify the physician of a 10 point drop in the resident's blood pressure and to apply [NAME] Stockings to the resident's bilateral lower extremities daily. Review of Resident R60's care plan failed to include his diagnosis of orthostatic blood pressure and the intervention of compression stockings. 28 Pa. Code 211.12(d)(3) Nursing services

Based on a review of facility policy, observation, review of incident report, review of manufacture guidelines, and interview staff , it was determined that the facility failed to ensure that a medication was administered in accordance with profession standards for one of 8 residents reviewed. (Resident R262) Findings include: Review of facility policy titled Medication Administration dated February 2017, revealed the employee administrating the medication must stay with the resident/ patient until the resident is finished taking the medication. Review of manufacture Glenmark Pharmaceuticals Limited guidelines dated October 2022 package insert, revealed that the medication Pravastatin instructed the medication to be taken at the same time each day with or without food. If a dose is missed, take the medication as soon as you can but skip the missed dose if close to time for next dose. Do not take two doses at one time. Observation on the second floor, on September 5, 2023, at 10:05 a.m. revealed that Resident R262's daughter reported that there was a medication found on the resident's tray table. Surveyor observed Llicensed nurse, Employee E13 took the medication from resident's daughter and said she would call the doctor for further instruction. Review of Resident R262's physician orders revealed an order for Pravastatin (a medication used to lower cholesterol) a 40 milligrams (mg) tablet to be given daily at bedtime. Further review of Resident R262's September 2023 Medication Administration Record revealed that the medication Pravastatin was administered to Resident R262 on September 4, 2023, at 8:30 p.m., the evening before the medication was found. Interview with the Director of nursing (DON) on September 6, 2023, revealed that the medication was identified as Pravastatin 40 mg ordered to be given daily at bedtime. The DON stated that the found pill was administered to the resident the previous evening. Review of facility incident report revealed that it is unknown how the pill ended up on the resident's tray. A staff message was sent to all staff reminding them to stay with remain with residents when administering medication to ensure that the medications are swallowed without difficulty and taken as prescribed. Pa Code 211.9(a)(1) Pharmacy Services Pa Code 211.10(c) Resident care policies Pa Code 211.12 (d)(1) Nursing Services

Based of a review of facility policies and procedures, observation, review of manufactures' guidelines, interview with staff, it was determined that the facility failed to store and label medication in accordance with acceptable professional standards for one of three medications carts reviewed. (second floor Cart B) Findings include: Review of facility policy titled dated Medication Storage dated July 2021 revealed that medications that require refrigeration will be stored in the medication room refrigerator when not in use or as soon as possible after use. Further review of the facility's policy revealed that all medications with current physician orders will be store in the medication cart that is designated for the unit that the resident is residing. Review of manufacture of Tubersol, Sanofi Pasteur's guidelines, revealed that this drug must be stored at 2 C to 8 C (35 F to 46 F). Do not freeze. Discard product if exposed to freezing. Observation on September 5, 2023, at 11:20 a.m. on the Second-floor nursing station cart B, revealed that there were 2 vials of Tubersol (Tuberculin, purified Derivative used to aid in the diagnosis of tuberculosis infection), were found in the opened an at room temperature. Further observation of Cart B revealed a bubble pack medication card containing five yellow pills. This package of medication was not labeled with prescribing information (US Food and Drug Administration requirement to identify information containing propriety name, the brand name, generic name, dosage, strength, and route of administration. Further observation of the package of medication had a handwritten identifier labeling it Zofran (a medication used to prevent nausea and vomiting). Interview with Licensed nurse, Employee E14 on September 5, 2023, at 11:31a.m. confirmed that the 2 vials of Tubersol should not have been stored in refrigeration. Further interview with Employee E14 revealed that the medication Zofran was not acceptable without labeling information. 28 Pa. Code 211.9(k) Pharmacy services 28 Pa. Code 211.12(c) Nursing services

Based on interviews with staff, review of clinical records, review of admission records and review of facility policies and procedures, it was determined that the facility failed to ensure that residents and/or responsible party were informed of all his or her rights, rules, regulations and responsibilities, prior to and/or upon the resident's admission for one out of five residents reviewed (Resident R1). Findings include: Review of the facility's Admission Agreement, Skilled Nursing and Rehabilitation, with a revision date of September 2021, stated that the purpose of the policy is to ensure that documentation is shared with all admitting patients of their representatives. Review of the Resident R1's nursing notes indicated that the resident has received intermittent rehabilitation services from the facility from July 2022 through November 3, 2022, when the resident was subsequently discharged from the facility, and returned to her home with the continuation of hospice services. Review of the resident's November 2022 physician orders listed the diagnoses of hypertension (high blood pressure); heart failure (when the heart muscle doesn't pump blood as well as it should); Chronic Obstruction Pulmonary Disorder (COPD- a disease that damages your lungs over time, making it difficult to breath); chronic respiratory failure (difficulty breathing), heart failure (and diabetes (disease that causes high blood sugar). Review of Resident R1's nursing notes for October 5, 2022 at 1:37 p.m. stated that the resident was sent out to the hospital for a change in condition, and was admitted into the hospital for hypoxia (low level of oxygen in your blood tissues), and hypertension. Review of a nursing note dated October 19, 2022 dated 12:22 p.m. indicated that the resident was admitted back into the facility from the hospital with an admitting diagnosis of hospice, end stage COPD, and heart failure. Review of the admission records for Resident R1's October 19, 2022 admission provided no evidence that information including, but not limited to the following was reviewed, signed/acknowledge by the resident's and his/or her responsible party prior to and/or upon the resident's admission into the facility: resident rights related to photo release authorization, consent for treatment, facility behold policy information, services provided by the facility, payment for services provided by the facility, information regarding personal funds, the facility's admission agreement. Continued review of the resident's admission records also did not show evidence that any information regarding the payment amount that the resident would be responsible for during her stay at the facility, with the implementation of hospice services, was provided to the resident and/or her responsible party at any time prior to or during her admission into the facility in October 19, 2022. Review of documentation from the facility also indicated that the resident's daily rate that the resident and/or her responsible party would be responsible for paying upon her readmission to the facility with hospice care on October 19, 2022, was $585 a day. This was confirmed by the Nursing Home Administrator (NHA) on March 22, 2023 at 1:13 p.m. Review of the resident's financial statement provided by the facility indicated that the resident still had an unpaid balance of $8,950.00 for her cost of care at the facility. During an interview with the Director of Admission (Employee E3) on March 22, 2023 at 1:58 p.m. it was confirmed that there was no documentation that could be produced to show evidence that the facility provided the resident and/or her responsible party with information related to the resident's admission into the facility, including, but not limited to the cost of care prior to and/or upon her admission into the facility on [DATE] when the resident returned from the hospital with hospice services. 28 Pa. Code 201.29(e) Resident rights

Based on observation, clinical record review, review of facility policy and staff interview, it was determined that the facility did not ensure that the resident privacy regarding medical treatment was protected for three of three residents observed. (Resident R252, Resident R239 and Resident R60) Findings include: Review of facility review of policy and procedure entitled Patient Code Status revealed the following Code Status Procedure: 5. The facility does not obtain a physician order for full code and if a patient does not have an order for DNR, they are considered full code. 6. If a resident is unable to express these wishes, the social services department will consult with the appropriate decisions makers for the resident, in accordance with this policy. 7. In an effort to ensure the nursing and other staff members are aware of the patient ' s decision, the social service department will place a colored arm band on the patient as an additional reminder for nursing staff. 8. Nursing staff should verify code status in the electronic medical record . prior to initiating CPR. Observation of the Unit 2B conducted on [DATE], between 8:30 a.m. and 11:00 a. m. revealed that Resident R252, Resident R239 and Resident R60 were wearing a purple wristband with DNR (DNR- Do Not Resuscitate is a medical order instructing health care providers not to do cardiopulmonary resuscitation if the patient's breathing stops or if the patient's heart stops beating.) written on it. Review of Resident R252's clinical record revealed that Resident R252 was admitted to the facility on [DATE]. Review of Resident R 252's admission MDS (MDS-Minimum Data Set, a federally requires resident assessment completed at a specific interval) assessment dated [DATE], revealed that she had a BIMS (Brief Interview for Mental Status) score of 15 which indicated that Resident R252 was cognitively intact. Further review of Resident R252's clinical record revealed that on [DATE], the Social Worker documented in the progress note that Resident R252 was DNR and review of resident R 252's advance directives confirmed that Resident 252 was DNR. Review for Resident R60's clinical record revealed Resident R60's most recent re-admission to the facility was on [DATE]. Review of Resident R60's most recent Comprehensive MDS assessment dated [DATE], revealed that she had a BIMS score of 15 indicating that Resident R60 was cognitively intact. Further review of Resident R60's clinical record revealed that on [DATE], the Social Worker documented in the progress note that Resident R60 was DNR and review of Resident R60's advance directives revealed that resident 60 was DNR. Review for Resident R239 clinical record revealed Resident R239 was admitted to the facility was on [DATE]. Review of Resident R239's admission MDS assessment dated [DATE], revealed that she had a BIMS score of 15 indicating that Resident R239 was cognitively intact. Further review of Resident R 239's record revealed that on [DATE], the Social Worker documented in the progress note that Resident R239 was DNR and review of Resident R 239's advance directives revealed that Resident R239 was DNR. Interview with Clinical Staff, Employee E3, conducted on [DATE], at 1:40 p.m. revealed that for residents who had chosen to be DNR there was a red dot on the med pass section of the electronic medical record system which identifies if a resident was on DNR and that there was a report paper that has the list of the residents on DNR. Employee E3 also stated that she thought that the purple band on the residents were from the hospital. Interview with Director of Nursing (DON) conducted on [DATE], at 3:00 p.m. revealed that the residents on DNR used an armband with DNR written on it. Interview with Nursing Home Administrator conducted on [DATE], at 3:20 p.m. confirmed that the residents who were DNR wore a wrist band with DNR written on it. 28 Pa. Code 211.29(j) Resident rights

Based on observation, review of facility documentation, review of facility policy, and interviews with staff, it was determined that the facility did not ensure that effective infection control was maintained during wound treatment for one of one wound treatment observed. (Resident R8) Findings include: Review of facility policy, Wound Care Treatment revealed, wash hands. Don gloves and remove old or soiled wound care treatment. Inspect wound and notify physician of changes prn (as needed). Remove gloves and wash hands. Don clean gloves and cleanse wound as per physician orders. Review of November 2022 physician orders for Resident R8's wound to the right leg revealed to cleanse wound to the leg with normal saline solution. Apply Santyl to wound and cover with a clean, dry dressing once daily. Observation of wound care on November 4, 2022 at 1:30 p.m. for Resident R8 revealed that Licensed Nurse, Employee E8, doffed gloves after removing soiled dressing from right leg, disposed of soiled dressing in plastic bag and proceeded to don a new pair of gloves without using hand sanitizer or washing her hands. Interview on November 4, 2022 at 1:50 p.m. with Licensed Nurse, Employee E8 confirmed that hands were not sanitized or washed after removing gloves and before donning new gloves. 28 Pa. Code S211.12(c) Nursing services 28 Pa. Code S211.12(d)(1) Nursing services 28 Pa. Code S211.12(d)(2) Nursing services 28 Pa. Code S211.12(d)(3) Nursing services 28 Pa. Code S211.12(d)(5) Nursing services

Based on a review of clinical records, facility policies, facility documentation and interviews with staff, it was determined that the facility failed to ensure that residents were free from neglect during the provision of incontinence care, which resulted in actual harm to Resident R1 sustaining a fall, transfer to the hospital and diagnosed with a left humerus fracture, left pelvis fractures, right femoral neck (upper leg bone near hip) fracture, and chronic (longtime) right humerus fracture for one of four residents reviewed. (Resident R1) Findings include: Review of a facility policy revised May 2017, titled, Abuse, Neglect and Exploitation, revealed that Residents must not be subjected to abuse, neglect, mistreatment, involuntary seclusion or misappropriation of their property by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff or other agencies that provide service to the resident, family members or legal guardians, friends, or other individuals. Review of the clinical record for Resident R1 revealed that the resident had been admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review Resident R1 quarterly Minimum Data Set (MDS- assessment of resident care needs) assessment completed on May 28, 2020, revealed a BIMS (Brief Interview of Mental Status-a brief screening tool that aids in detecting cognitive impairment) score of 10, which indicated that the resident had moderate cognitive impairment. The MDS identified the resident as requiring extensive assistance of two person for bed mobility, transfer, toilet use and dressing. Further review of the MDS revealed that the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was also receiving hospice services. Review of the resident's care plan revised September 1, 2020, identified the resident with the following problem areas: limited physical mobility secondary to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's Care Plan Summary dated October 5, 2020, that indicated that Resident R1 required the assistance of two staff for ADL (activities of daily living, like dressing, bathing, eating, etc.) care. An interview with the Director of Nursing (DON) on October 9, 2020, at approximately 12:00 p.m. revealed that the Care Plan Summary was a one page chart listing vital care information which is used by the Nurse Aides to give proper care to the residents on their assignment. Review of facility documentation dated October 5, 2020, revealed that Employee E4, nurse aide, was assigned to the 2C nursing unit during the evening (3-11 p.m.) shift on October 5, 2020 and was responsible to care for Resident R1. Further review revealed that on October 5, 2020, at 10:15 p.m., licensed nursing staff, Employee E8, heard Employee E4, nurse aide, scream for help from Resident R1's room. Upon reaching the resident's room Employee E8 found Resident R1 lying face down next to his bed, which was in the high position due to the resident receiving incontinent care, with blood on the floor surrounding his head. The resident was conscious, but unable to move independently due to his left sided [CONDITION(S)], and he would yelled out with any movement. The Employee E4 communicated to licensed staff, Employee E8 that the resident had rolled out of bed while she was attempting to give him care. The resident was found conscious but unable to move independently due to left side [CONDITION(S)] and pain. The resident vital signs were assessed and oxygen applied due to oxygen saturation level in the 80's. The resident's physician was notified of the incident and the resident was transfer to the hospital via 9-1-1 (Emergency Medical Services) A telephone interview with Employee E4, on October 9, 2020, at approximately 12:50 p.m. revealed that Employee E4 was working on 2C on October 5, 2020, with another caregiver, Employee E5, and that they had discussed who needed to have assistance of two staff before they took their breaks. They discussed waiting until after breaks to care for Resident R1 who required an assist of two staff. Employee E4 stated that she took her break first and Employee E5 went on break when she returned to the floor. During her rounds while Employee E5 was on break she checked on Resident R1 who had had explosive diarrhea, and that it was all over him, and that Employee E4 felt that it was important to clean him up right away. When asked if anyone else was on the floor, she said that Employee E7, the floor nurse, was giving medications, and when she looked out the door for her she saw a light was on in the hall and that she was in with another resident. When Employee E4 was asked by the surveyor if she had ever performed incontinence care on Resident R1 by herself before, she stated that she had done this on more than one occasion, and that was why she was confident that she could do it herself rather than wait for help. When asked again if she knew that the resident required assistance from two staff for care, she said that she was aware of this and had discussed this with Employee E5 before breaks. Employee E4 continued to recount how she instructed the resident to hold on to the side rail while she rolled him on his side to provide care, and that while she was cleaning the resident's bottom she had her head down but noticed that the air mattress was leaning up. She stated that when she lifted her head, she saw the resident's feet and legs sliding over the edge of the bed and that she tried to reach across the bed to grab his legs but could not reach him. She stated that she ran around the bed but that the resident had already fallen to the floor. She said that she was calling the resident's name, but he was not answering her, and she began yelling for help and also turned on the emergency call bell light and waited with the resident until the nurse came. A telephone interview with Employee E5, Physical Therapist, on October 9, 2020, at approximately 1:15 p.m. revealed that she was working the evening shift on 2C as a caregiver on October 5, 2020, with Employee E4, nurse aide. She stated that they were getting the residents ready for bed. She also indicated that they were reviewing the resident list and that Employee E4 indicated that Resident R1 required a two person assist. She said it was getting late and Employee E4 went on break first, and when the Employee E4 returned, she asked if it was ok if she went on break, and Employee E4 said yes for her to go on break. Employee E5 stated that when she returned from her break the ambulance and EMS (Emergency Medical Services) staff were there for Resident R1 and nurses for the other units were also there to help. She said that Resident R1 was still on the floor, and that she had no interaction with him, but rather was caring for all the other residents during all the commotion. A review of Resident R1's hospital records dated October 6, 2020, revealed an entry titled, Trauma Surgery History and Physical, this document revealed that Resident R1 was taken to the Emergency Department (ED) after sustaining a fall from bed while being changed. Further review of hospital records also revealed that he was initially evaluated by the Emergency Department staff and was found to have sustained a left humerus (upper arm bone) fracture, left pelvis (hip) fractures, right femoral neck (upper leg bone near hip) fracture, and chronic (longtime) right humerus fracture as well as pneumonia (inflammation/infection in lung) and hypovolemic shock (dangerous condition that happens when you suddenly lose a lot of blood or fluids). An interview with Employee E1, Nursing Home Administrator, on October 9, 2020, at approximately 1:15 p.m. confirmed that this incident was reported to the Department of Health as neglect, and that he acknowledged that the investigation concluded that Employee E4 did not follow the resident's care plan which required a two person assist for Resident R1's incontinent care. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.5(g) Clinical records 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services