Every finding on record at Rehab & Nursing CTR Greater Pittsburgh

Based on clinical record review, facility policy, facility documentation, and resident and staff interviews, it was determined the facility failed to ensure residents were free from abuse for one of three residents reviewed (Resident R1). This was identified as harm and past non-compliance.Findings include: During the survey conducted on 8/4/26 in response to a facility reported event, it was identified and reported that Resident R1 was included in a social media post. Onsite review of the video recording by the surveyor on 8/4/26, that was originally posted online on 7/22/26, revealed Resident R1 was video recorded, sitting on the floor, with a clear view of her face and arms, partially exposing a portion of her lower legs, and wearing a blue outfit that covered her upper torso and thigh area. The image also contained a verbal comment from this resident asking to go out for breakfast. A reasonable person in Resident R1's position would likely feel humiliated by having such a video taken and posted on social media without consent. Review of Pennsylvania Statute S 2713.1. Abuse of care dependent person defines when a caretaker can be prosecuted for abusing a care dependent person, including physical, verbal, and digital conduct.(a) Offense defined. A caretaker is guilty of abuse of a care-dependent person if the caretaker:Section (3) With the intent to ridicule or demean a care-dependent person, uses any audio, video or still image of the care-dependent person in any format or medium on or through any electronic service, wireless communication or any form of electronic service or wireless communication as pertaining to communication. Review of the facility policy titled, Resident Rights reviewed on 1/15/2026. The policy indicates federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence, be treated with respect, kindness, and dignity, be free from abuse, neglect, misappropriation of property, and exploitation. Review of the facility policy titled, Identifying Types of Abuse reviewed on 1/15/2026. The policy indicates abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Mental abuse includes abuse facilitated or enabled through the use of technology, such as smartphones and other personal electronic devices. This would include keeping and/or distributing demeaning or humiliating photographs and recordings through social media or multimedia messaging. This may include but is not limited to photographs and recordings of residents. Review of the facility policy titled, Email, Internet, and Social Media Use reviewed on 1/15/2026. The policy indicates that social media platforms are used only within legal, ethical, and professional boundaries established by state and federal privacy laws, professional standards of practice and facility policy. Email and internet may not be used for posting or sharing any information about or unauthorized images of the facility, residents, family, or events on social media or a public forum or using language or conveying information on social media or a public forum that violate the privacy or dignity of any resident or patient. Review of the facility policy titled, HIPAA Breach Notification reviewed on 1/15/2026. Health Insurance Portability and Accountability Act (HIPAA) that includes the Health Information Technology for Economic and Clinical Health Act (HITECH). The policy indicates the organization is committed to protecting the privacy of patients in accordance with state and federal law and reporting of a breach. Confidentiality of protected health information, (PHI) means health information transmitted or maintained in any format that Identifies the individual. Review of the admission record indicated that Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/21/26, indicated a diagnoses of cerebral infarct (stroke), hemiplegia left non-dominant side (paralysis left side of body), Alzheimer's disease (destruction of memory and thinking skills), and anxiety disorder (intense, excessive, persistent worry or fear ). Section C0500 indicated a Brief Interview for Mental Status (BIMS- is a screening test that aids in detecting cognitive impairment) score of 3 - severely impaired cognition. Review of Resident R1's care plan initiated 7/22/26, indicated the resident, wanders related to significant cognitive deficits. The resident has a high risk for falls with poor safety awareness and judgment. Requires supervision and support. Review of the facility documentation submitted 7/22/26, revealed on 7/22/26 at approximately 1:20 a.m. the facility was made aware certified nurse aide (CNA), Employee E1, posted an image of a resident on social media that was circulated to Employees Registered Nurse (RN) E2, Licensed Practical Nurse (LPN) E3 and E4, E5, CNA E6, CNA E7, LPN E8, LPN E9, and CNA E10. CNA Employee E1 was suspended, and the facility investigation was initiated with CNA Employee E1 being terminated on 7/28/26. Review of the facility investigation revealed on 7/21/26, the alleged perpetrator, CNA Employee E1, was scheduled to work the 7:00 p.m. to 7:00 a.m. shift. On 7/22/26, RN Employee E2, notified the Nursing Home Administrator (NHA) and the Director of Nursing (DON) of this event. Written statements from employees in the building on the night shift CNA EmployeeE9, RN Employee E11, and CNA Employee E12 indicated they did not observe CNA EmployeeE1 recording the resident. On 7/22/26 the facility notified the resident's physician, Resident's Representative, Department of Health (DOH), State Police, Area Agency on Aging, Adult Protective Services and Pennsylvania Department of Aging. Resident R1 was assessed; there were no negative outcomes, as Resident R1 was unaware the video was taken and remained at her baseline. On 7/22/26 the facility substantiated the allegation of abuse related to the social media posted video of Resident R1. Review of the written statement dated 7/22/26 by the CNA Employee E1, who was named as the alleged perpetrator, included the following: Upon the resident sitting on the floor yelling at 1 am, we had become very frustrated with the fact that we couldn't redirect her, she needs proper night medication to be able to sleep. I know I am in the wrong for my actions next. I took a video of the resident screaming loudly on the floor. I had shown the video to other staff that work with me. I know what I did was wrong, and I am sorry for it. I know I will probably lose my job. I am sorry to the resident and their family. I am sorry to my workplace. I am sorry to myself. On 7/22/26, the facility-initiated education for all staff clinical and non-clinical topics included objectives understanding the importance of the following. -Cell phonesStaff are prohibited from using personal cell phones in patient care areas or any location near residents. Cell phones must be used only in designated staff areas. -Social Media-HIPPA-Resident Rights -Identifying Types of abuse-Abuse neglect exploitation and misappropriation prevention This plan includes the following:-Immediate suspension of CNA Employee E1 on 7/22/26 with subsequent termination on 7/28/26. -Facility completed a full house audit on 7/24/26 to identify if other residents had experienced similar or were aware of similar events. -Ongoing staff audits will be completed with 10 observations weekly times, three weeks and monthly times, two months to ensure staff are not using cell phones or ear buds on the units. Standard: staff should not be using cell phones or ear buds in the resident areas. Should not take pictures and or video tapes of residents without resident or responsible party consent. A series of 11 observation tasks and questions are completed during the Quality Improvement data collection. First data collection and review were completed 7/31/26. -Education was completed on 7/31/26, for all staff, topics include:Cell phones, social media, HIPPA, Resident Rights, Identifying Types of, abuse neglect exploitation and misappropriation prevention. -Audits and education were reviewed with the Quality Assurance and Performance Improvement Committee for trends and outcomes. During observations on 8/4/2026 from 9:30 am to 2:00 p.m. no employees were observed with their cell phones or ear buds in view. During interviews on 8/4/26 from 10:00 a.m. to 2:00 p.m., the following was revealed:LPN's Employees E13 and E15 confirmed they had recently completed education within the past 10 days on the topics listed in the plan related to confidentiality, HIPAA, resident rights, social media, and abuse. Employees verbalized an understanding of the reporting process. CNA's Employee E22 and E23 confirmed they had recently completed education within the past 10 days on the topics listed in the plan related to confidentiality, HIPAA, resident rights, social media, and abuse. Employees verbalized an understanding of the reporting process. Rehabilitation therapy Employees E14, E24, and E26 (PT, OT and Speech), confirmed they had recently completed education within the past 10 days on the topics listed in the plan related to confidentiality, HIPAA, resident rights, social media, and abuse. Employees verbalized an understanding of the reporting process. Activities Department Employees E16, E17, and 25, confirmed they had recently completed education within the past 10 days on the topics listed in the plan related to confidentiality, HIPAA, resident rights, social media, and abuse. Employees verbalized an understanding of the reporting process. Clinical Liaison Employee E18 confirmed they had recently completed education within the past 10 days on the topics listed in the plan related to confidentiality, HIPAA, resident rights, social media, and abuse. This employee verbalized an understanding of the reporting process. Housekeeping Employee E20 confirmed they had recently completed education within the past 10 days on the topics listed in the plan related to confidentiality, HIPAA, resident rights, social media, and abuse. This employee verbalized an understanding of the reporting process. Culinary Services Employee E19 confirmed they had recently completed education within the past 10 days on the topics listed in the plan related to confidentiality, HIPAA, resident rights, social media, and abuse. This employee verbalized an understanding of the reporting process. Interview and observation conducted on 08/4/2026 at approximately 9:30 a.m., revealed Resident R1 sitting in a wheelchair in front of the nursing station having coffee. Resident R1 appeared well groomed and pleasant during the interview. The resident could not provide specific helpful answers, instead replying I have to think about that, I don't recall, I don't remember to questions. During an interview on 8/4/26 at 10:45 a.m. with the resident's daughter in the resident's room, the daughter detailed the events aligned with the facility reporting. The resident's daughter spoke with the investigating State Trooper, and she has the understanding charges will be filed and confirmed with the Trooper that she wants to proceed and will attend the hearing. The daughter confirmed that her mother does not seem to have any change in her mood or behavior due to her medical and cognitive condition. The daughter has seen the video and is aware of the contents. The daughter commented on the staff and the care is great here, it's one employee who's has a behavior like this that creates the problem. During an interview on 8/4/26 at 2:00 p.m. with the Nursing Home Administrator confirmed the facility failed to ensure Resident R1 was free from mental abuse when a staff member posted on a public social media platform an identifiable video of the resident, including a verbal comment from the resident, while the resident was sitting on the floor in the nursing facility, causing harm to Resident R1 as a reasonable person would not consent to such social media posts. During an interview on 8/4/26, at 2:15 p.m. with the Nursing Home Administrator and review of the facility's immediate actions, education, and review of the QAPI monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction and achieved compliance for the prevention of resident abuse. This incident was identified as past noncompliance. The facility has demonstrated compliance with the regulations since 7/31/26. 28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(b)(1) Management.

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and assistance for bed mobility to prevent accidents which resulted in actual harm of a head bleed for one of three residents (Resident R1).Findings Include: Review of facility Falls and Fall Risk, Managing policy dated 1/15/26, indicated that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Review of the admission record indicated that Resident R1 was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses of muscle weakness, spinal stenosis, and depression. Review of Resident R1's physician order dated 7/12/25, indicated to administer 2.5 milligram (mg) Eliquis (blood thinning medication), one tablet, by mouth, two times a day. Review of Resident R1's physician order dated 7/15/25, revealed the resident requires a minimum of an assist of two persons for transfers. Review of Resident R1's Fall Risk Evaluation dated 1/3/26, indicated a score of 17 - high risk. Review of Resident R1's care plan dated 1/5/26, revealed the plan of care has been updated to reflect patient/caregiver education for staff assistance has been increased to assist of two persons with bed mobility as therapy has reported to staff, she tends to make quick movements increasing her risk for falls. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/14/26, indicated diagnoses were current. Section GG - Functional Abilities - Question GG0170 indicated the resident was coded at a 03 partial/moderate assistance for the ability to roll from lying on back to left and right side, and return to lying. Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. Review of Resident R1's clinical record nursing progress note dated 5/2/26, at 3:30 p.m., indicated revealed the writer was called to the resident's room and observed the resident on the floor next to the bed. Laceration noted to the left forehead and hematoma noted to the center forehead. The resident was bleeding from the laceration to her left side of her for head. The doctor was notified and orders were received to transport resident to the hospital for additional evaluation and treatment. The resident's family was notified. Review of facility provided report dated 5/2/26, indicated at approximately 3:30 p.m. a Registered Nurse was called to the Resident R1's room and observed the resident on the floor next to her bed. A laceration was noted to the left side of forehead and a hematoma noted to center. Laceration was bleeding, pressure applied. Physician and family were notified of fall with head injury and a new order to transfer the resident to hospital was obtained. Resident was admitted with brain bleed. The nurse aide reported he rolled her onto her right side (away from caregiver), with her left leg over her right, and she was holding onto the bed as he tucked the sheet under her when he went to move onto the other side of the bed the resident started to fall out of bed and he could not prevent the fall. Review of Resident R1's clinical record nursing progress note dated 5/2/26, revealed the resident was being admitte3d to the Intensive Care Unit (ICU) for an acute subarachnoid bleed, and the resident's head laceration were sutured. Resident received anticoagulation reversal. Review of Nurse Aide, Employee E1's witness statement dated 5/2/26, revealed NA, Employee E1 was in process of changing Resident R1's brief and noticed her sheet needed changed. A brief was put under the resident and NA, Employee E1 rolled her on her right side (away from caregiver). NA, Employee E1 went to tuck the draw sheet and fitted sheet under the resident while she was on her side. The resident started to roll off the bed as the nurse aide tried to reach and roll her onto her back, but the resident rolled off the bed. The resident's head was bleeding. Review of Licensed Practical Nurse (LPN), Employee E2's witness statement dated 5/2/26, revealed the resident fell out of bed while getting changed. LPN, Employee E2 was in an other resident's room when a nurse aide notified her the supervisor needed her for an emergency. When LPN, Employee E2 entered into Resident R1's room the RN, Supervisor was holding pressure to the resident's head. Resident was lying on her back on the floor bedside her bed close to the door. LPN, Employee E2 took over holding pressure while the RN, Supervisor notified a doctor and family, and prepared to send resident to hospital. The nurse aide stated the resident rolled out of bed while he was changing her. Review of Resident R1's Kardex dated 5/3/26, revealed the resident requires an assist of two persons for bed mobility. Review of Resident R1's clinical record nursing progress note dated 5/5/26, revealed during interdisciplinary team meeting held on 5/4/26, review of current fall on 5/2/26, interventions, and care plan completed. On 5/2/26 at approximately 3:30 p.m., staff were called to the resident's room. The registered nurse observed resident on the floor next to her bed. A laceration was noted to the left side of forehead and a hematoma noted to the center. Laceration was bleeding, pressure applied, vital signs stable. Resident was noted with baseline confusion. Resident was transferred to hospital and was admitted with a brain bleed. Resident weighs only 143 pounds and per last MDS on 4/15/26, and is partial/mod assist with mobility rolling left to right. Statement obtained from nurse aide who was assisting resident while in bed, resident was changed for an incontinent episode, during the change the nurse aide noticed the sheet was wet and also required changed. The nurse aide reported he rolled her onto her right side, with her left leg over her right, and she was holding onto the bed as he had tucked the sheet under her when he went to move onto the other side of the bed the resident started to fall out of bed and he could not prevent the fall. Review of Resident R1's Hospital After Visit Summary dated 5/8/26, revealed the resident was admitted to the hospital for a subarachnoid hemorrhage and facial laceration. It was indicated for the resident to pause taking 2.5 mg Eliquis until doctor or other care provider tells you to start again. During a phone interview on 5/28/26, at 9:49 a.m. NA, Employee E1 stated he entered into Resident R1's room on 5/2/26, to conduct rounds and placed the resident's bed up to waist height. As NA, Employee E1 went to roll Resident R1, he didn't realize how far she was on side of bed. The nurse aide had his hand on her, to try to make sure she didn't fall, however as he went to the corner of the bed she started to roll the opposite direction, and started falling head first and her head hit the foot of the bed. Once she was rolled off the bed frame, we noticed blood coming from her head. NA, Employee E1 confirmed he failed to use the correct level of assistance for Resident R1's bed mobility and rolled the resident away from himself. During an interview on 5/28/26, at 10:20 a.m. LPN, Employee E2 stated staff can check a resident's transfer status and bed mobility in their plan of care. It was indicated staff should always roll residents towards them and not away to prevent them from falling off bed. LPN, Employee E2 confirmed Resident R1 was on blood thinners at time of incident and there was a good bit of blood. Interviews with direct care staff to include Registered Nurses (RN). Licensed Practical Nurses (LPN), and Nurse Aides (NA), indicated that when providing care to always roll the residents toward your person. Only this staff had received re-education on proper bed mobility and assistance. During an interview on 5/28/26, at 10:28 a.m. Resident R1 was observed lying in bed with a scabbed area located on the resident's left side of her head. During an interview on 5/28/26, at 10:34 a.m. Director of Therapy revealed Resident R1 was a moderate assist of two person at the time on the fall that occurred on 5/2/26. The Director of Therapy confirmed therapy staff is considered direct care staff, and confirmed the therapy department has not been educated since Resident R1's incident. Interview on 5/28/26, at 12:03 p.m. with the Nursing Home Administrator confirmed the facility failed to make certain each resident received adequate supervision and assistance for bed mobility to prevent accidents which resulted in actual harm of a head bleed for one of three residents (Resident R1). 28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 201.29(a)(c) Resident Rights28 Pa. Code 211.10(c)(d) Resident Care Policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical records, documentation provided by the facility, facility investigation, resident interview, and staff interviews, it was determined that the facility failed to ensure that a resident was free from neglect by failing to provide adequate assistance and interventions to prevent fall with injury, which resulted in actual harm of a scalp laceration, brain bleed and hospital admission to reverse anticoagulation for one of three residents (Resident R1). Findings Include: Review of the facility policy Abuse, Neglect, Misappropriation Prevention Program last reviewed on 1/16/26, indicated that the residents of the facility have a right to be free from abuse, neglect, exploitation and misappropriation of property. The facility will develop and implement policies to prevent and identify such concerns.Review of the facility policy Identifying Neglect last reviewed on 1/16/26, indicated that neglect is the failure of the facility to provide goods and services to a resident that are necessary to avoid or may result in physical harm - is identified as neglect. The facility is aware or should have been aware of goods or services that a resident requires but the facility fails to provide them and this has resulted in (or may result in) actual physical harm, pain, mental anguish or emotional distress. Review of the facility policy Safe Patient/Resident Handling Policy and Procedure, last reviewed on 1/16/26, indicated that staff are trained to utilize safe resident handling equipment and moving techniques to decrease the number of injuries to them and to the residents. The requirements include avoiding unassisted handling of residents and/or identifying potential high-risk residents to avoid potential injuries. Review of the admission record indicated that Resident R1 was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses of muscle weakness, spinal stenosis, and depression. Review of Resident R1's physician order dated 7/12/25, indicated to administer 2.5 milligram (mg) Eliquis (blood thinning medication), one tablet, by mouth, two times a day. Review of Resident R1's physician order dated 7/15/25, revealed the resident requires a minimum of an assist of two persons for transfers. Review of Resident R1's Fall Risk Evaluation dated 1/3/26, indicated a score of 17 - high risk. Review of Resident R1's care plan dated 1/5/26, revealed the plan of care has been updated to reflect patient/caregiver education for staff assistance has been increased to assist of two persons with bed mobility as therapy has reported to staff, she tends to make quick movements increasing her risk for falls. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/14/26, indicated diagnoses were current. Section GG - Functional Abilities - Question GG0170 indicated the resident was coded at a 03 partial/moderate assistance for the ability to roll from lying on back to left and right side, and return to lying. Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. Review of Resident R1's clinical record nursing progress note dated 5/2/26, at 3:30 p.m., indicated revealed the writer was called to the resident's room and observed the resident on the floor next to the bed. Laceration noted to the left forehead and hematoma noted to the center forehead. The resident was bleeding from the laceration to her left side of her for head. The doctor was notified and orders were received to transport resident to the hospital for additional evaluation and treatment. The resident's family was notified. Review of facility provided report dated 5/2/26, indicated at approximately 3:30 p.m. a Registered Nurse was called to the Resident R1's room and observed the resident on the floor next to her bed. A laceration was noted to the left side of forehead and a hematoma noted to center. Laceration was bleeding, pressure applied. Physician and family were notified of fall with head injury and a new order to transfer the resident to hospital was obtained. Resident was admitted with brain bleed. The nurse aide reported he rolled her onto her right side (away from caregiver), with her left leg over her right, and she was holding onto the bed as he tucked the sheet under her when he went to move onto the other side of the bed the resident started to fall out of bed and he could not prevent the fall. Nurse Aide provided this level of care independently when the resident required an assistance level of two. Review of Resident R1's clinical record nursing progress note dated 5/2/26, revealed the resident was being admitted to the Intensive Care Unit (ICU) for an acute subarachnoid bleed, and the resident's head laceration were sutured. Resident received anticoagulation reversal. Review of Nurse Aide, Employee E1's witness statement dated 5/2/26, revealed NA, Employee E1 was in process of changing Resident R1's brief and noticed her sheet needed changed. A brief was put under the resident and NA, Employee E1 rolled her on her right side (away from caregiver). NA, Employee E1 went to tuck the draw sheet and fitted sheet under the resident while she was on her side. The resident started to roll off the bed as the nurse aide tried to reach and roll her onto her back, but the resident rolled off the bed. The resident's head was bleeding. Review of Licensed Practical Nurse (LPN), Employee E2's witness statement dated 5/2/26, revealed the resident fell out of bed while getting changed. LPN, Employee E2 was in an other resident's room when a nurse aide notified her the supervisor needed her for an emergency. When LPN, Employee E2 entered into Resident R1's room the RN, Supervisor was holding pressure to the resident's head. Resident was lying on her back on the floor bedside her bed close to the door. LPN, Employee E2 took over holding pressure while the RN, Supervisor notified a doctor and family, and prepared to send resident to hospital. The nurse aide stated the resident rolled out of bed while he was changing her. Review of Resident R1's Kardex dated 5/3/26, revealed the resident requires an assist of two persons for bed mobility. Review of Resident R1's clinical record nursing progress note dated 5/5/26, revealed during interdisciplinary team meeting held on 5/4/26, review of current fall on 5/2/26, interventions, and care plan completed. On 5/2/26 at approximately 3:30 p.m., staff were called to the resident's room. The registered nurse observed resident on the floor next to her bed. A laceration was noted to the left side of forehead and a hematoma noted to the center. Laceration was bleeding, pressure applied, vital signs stable. Resident was noted with baseline confusion. Resident was transferred to hospital and was admitted with a brain bleed. Resident weighs only 143 pounds and per last MDS on 4/15/26, and is partial/mod assist with mobility rolling left to right. Statement obtained from nurse aide who was assisting resident while in bed, resident was changed for an incontinent episode, during the change the nurse aide noticed the sheet was wet and also required changed. The nurse aide reported he rolled her onto her right side, with her left leg over her right, and she was holding onto the bed as he had tucked the sheet under her when he went to move onto the other side of the bed the resident started to fall out of bed and he could not prevent the fall. Review of Resident R1's Hospital After Visit Summary dated 5/8/26, revealed the resident was admitted to the hospital for a subarachnoid hemorrhage and facial laceration. It was indicated for the resident to pause taking 2.5 mg Eliquis until doctor or other care provider tells you to start again. During a phone interview on 5/28/26, at 9:49 a.m. NA, Employee E1 stated he entered into Resident R1's room on 5/2/26, to conduct rounds and placed the resident's bed up to waist height. As NA, Employee E1 went to roll Resident R1, he didn't realize how far she was on side of bed. The nurse aide had his hand on her, to try to make sure she didn't fall, however as he went to the corner of the bed she started to roll the opposite direction, and started falling head first and her head hit the foot of the bed. Once she was rolled off the bed frame, we noticed blood coming from her head. NA, Employee E1 confirmed he failed to use the correct level of assistance for Resident R1's bed mobility and rolled the resident away from himself. During an interview on 5/28/26, at 10:20 a.m. LPN, Employee E2 stated staff can check a resident's transfer status and bed mobility in their plan of care. It was indicated staff should always roll residents towards them and not away to prevent them from falling off bed. LPN, Employee E2 confirmed Resident R1 was on blood thinners at time of incident and there was a good bit of blood. Interviews with direct care staff to include Registered Nurses (RN). Licensed Practical Nurses (LPN), and Nurse Aides (NA), indicated that when providing care to check the Kardex for appropriate assistance levels and to always roll the residents toward your person. Only this staff had received re-education on proper bed mobility and assistance and Kardex usage. During an interview on 5/28/26, at 10:28 a.m. Resident R1 was observed lying in bed with a scabbed area located on the resident's left side of her head. During an interview on 5/28/26, at 10:34 a.m. Director of Therapy revealed Resident R1 was a moderate assist of two person at the time on the fall that occurred on 5/2/26. The Director of Therapy confirmed therapy staff is considered direct care staff, and confirmed the therapy department has not been educated since Resident R1's incident. Interview on 5/28/26, at 12:03 p.m. with the Nursing Home Administrator confirmed the facility failed to make certain Resident R1 was free from neglect by failing to provide the correct level of assistance and interventions to prevent a fall with injury resulting in actual harm of a laceration, head injury and admission to the hospital for anticoagulation reversal for Resident R1. 28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 201.29(a)(c) Resident Rights28 Pa. Code 211.10(c)(d) Resident Care Policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of nine residents (Resident R1). This was identified as past non-compliance.Findings include:Review of the facility policy Safety and Supervision of Residents dated 1/15/26, indicated the facility will provide a safe environment for all residents.Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE].Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 1/3/26, included diagnoses of dementia (a decline in mental ability severe enough to interfere with daily life, cause by physical changes in the brain) and a psychotic disorder with delusions. Review of an Elopement Risk Evaluation completed on 5/25/24, indicated Resident R1 was at risk for elopement.Review of Resident R1's plan of care for Risk for Elopement initiated 6/5/25, indicated Resident R1 is at risk for elopement due to a history of wandering and verbalized wanting to leave the facility.Review of a progress note dated 7/7/25, at 8:43 a.m. indicated Resident R1 was testing door handles and keypads. When lobby door is open, she will start to run for the door.Review of facility incident report dated 2/5/26 at 10:25 pm, indicated Nurse was assisting other resident with a fall and EMS (emergency medical services). EMS reported resident was outside in wheelchair attempting to go into ambulance. LPN (licensed practical nurse) and RN (registered nurse) brought resident back in wheelchair.Review of a progress note dated 2/5/26, at 11:10 p.m. indicated Resident was reported outside by EMS ambulance when they were attempting to load other resident. LPN and RN saw resident in wheelchair outside and immediately brought indoors and wrapped in blankets. RN and LPN were with another resident on 100 [unit] who fell. LPN on floor said the last time she saw resident was [on] 400.Review of facility submitted information dated 2/6/26, indicated that on 2/5/26, At 10:25pm, LPN had visualized resident at 2200 sitting in wheelchair on his unit at the nurse's station. EMS crew arrived at facility at 2208. EMS rings buzzer to gain access to the facility. Staff remotely opens the coded mag lock door once they see who is trying to enter. Per reenactment, resident had to have been close enough to the door to prop it open with his foot or his arm when EMS entered. Door closes in less than 4 seconds. Per investigation findings, resident propelled through the door [and] through the 25' corridor to the outside door. This door is not alarmed, and resident pushed it open to the outside [and] propelled outside undetected by staff. EMS crew found resident at 2225- 17 minutes after they entered the building.On 1/6/26, the facility initiated a plan of correction that included:-Immediate count of all facility residents.-Elopement assessment completed.-Update to Resident R1's baseline care plan.-Audit of all facility residents for elopement risk.-Update of elopement binders located at the front desk and the first and second floor nurses' stations.-Education for all staff on the facility elopement policy and elopement prevention.-Ad hoc QAPI (Quality Assurance and Performance Improvement) meeting, with resolutions to purchase/install concave mirrors and complete audits.-Audits of admissions to be completed by Director of Nursing or designee five times per week for four weeks, to be reviewed at next QAPI meeting.The facility was incompliance as of that date.Review of Resident R1's clinical record completed on 3/2/26, revealed the elopement assessment and care plan had been updated to include information on his elopement, risk for further elopement, and interventions.During interviews on 3/2/26, staff confirmed they received education on elopement prevention and procedures if an elopement occurs.During an interview on 3/2/26, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide adequate supervision to prevent elopement for one of nine residents.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(e)(1) Management.28 Pa. Code 201.20(b)(1) Staff Development.28 Pa. Code 201.29(a) Resident rights.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.11(d) Resident care plan.28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to properly store food products in the walk-in cooler and freezer which created the potential for cross contamination (Main Kitchen). Findings include: Review of facility policy Food Receiving and Storage dated 1/16/25, indicated foods shall be received and stored in a manner that complies with safe food handling practices. All foods stored in the refrigerator or freezer are covered, labeled and dated. Refrigerated foods are stored in a way which allows for adequate air circulation around food containers. During an observation of the main kitchen on 11/24/25, at 9:50 a.m., the following was observed: Walk in cooler:-one jar of grape jelly was opened undated. Freezer - boxes of multiple types of food items stored to ceiling on top shelves of whole freezer and under fans. During an interview on 11/24/25, at 10:00 a.m., Dietary Manager Employee E1 confirmed that the facility failed to properly store food products and maintain sanitary conditions which created the potential for food borne illness and cross contamination in the Main Kitchen. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(3) Management.

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 decreased Capillary Blood Glucose (CBG) levels for three of seven residents reviewed (Residents R6, R86, and R100).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 isn't 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 the facility policy Management of Hypoglycemia reviewed 1/16/25, indicated the facility provided guidelines for managing hypoglycemia secondary to insulin therapy, or oral hypoglycemic agents. The facility classification/implement protocol of hypoglycemia is as follows:- Level 1: Blood glucose is less than 70mg/dl but greater than 54 mg/dl. Protocol: give oral form of glucose, notify provider immediately, remain with resident, recheck blood glucose in 15 minutes, provide resident meal or snack.- Level 2: Blood glucose is less than 54 mg/dl. Protocol: administer glucagon (rapid form of glucose), notify provider immediately, remain with the resident, place resident in a comfortable and safe place, monitor vital signs, and recheck blood glucose in 15 minutes.- Level 3: Altered mental and/or physical status requiring assistance for treatment of hypoglycemia. Protocol: call 911, administer glucagon or intravenous (IV) 50% glucose, if IV access. Review of the facility policy Change in Resident's Condition or Status reviewed 1/16/25, indicated the nurse will notify the resident's attending physician or physician on call when there has been a need to alter the resident's medical treatment significantly. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the clinical record revealed Resident R6 was admitted to the facility on [DATE], with diagnoses that included congestive heart failure (progressive heart disease that affects pumping action of the heart muscles), diabetes, and high blood pressure. Review of Resident R6 physician's order revealed the following orders:- On 10/3/25, Hypoglycemic protocol - for blood sugar less than 80 if symptomatic or blood sugar less than 70 with or without symptoms present (1) Administer approximately 15 grams of glucose by mouth or carbohydrates found in any of the following: 1/2 cup juice, 1/2 cup applesauce, one cup milk, one tube glucose gel, three glucose tablets AND (2) Wait 15 minutes AND (3) Recheck blood sugar levels, if level still below target give another 15 grams of glucose or meal/snack within one hour. Review of the clinical record, and electronic Medication Administration Record (eMAR) revealed the CBG's were as follows: - On 10/4/25, at 7:01 p.m. CBG was noted to be 49.- On 10/17/25, at 8:04 a.m. CBG was noted to be 65.- On 11/22/25, at 4:21 p.m. CBG was noted to be 61. Review of Resident R6 eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician order was not followed for hypoglycemic protocol. Review of Resident R6 care plan revised on 11/18/25, failed to reveal interventions for diabetes management, including hypo-/hyperglycemia. Review of a clinical record indicated Resident R86 was admitted to the facility on [DATE], with diagnoses that included diabetes, anxiety, and generalized muscle weakness. Review of Resident R86 physician's orders on 11/24/25, failed to reveal orders for hypoglycemic protocol. Review of the clinical record and eMAR revealed the CBG's were as follows: - On 10/24/25, at 12:07 p.m. CBG was noted to be 58. Review of the care plan dated 10/2/25 and 10/13/25, indicated the following interventions:- Administer medications per physician order.- Obtain glucometer readings and report abnormalities as ordered.- Report symptoms of hyperglycemia.- Report symptoms of hypoglycemia. Review of Resident R86's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed dates. Review of the clinical record indicated Resident R100 was re-admitted to the facility on [DATE], with diagnoses that included diabetes, generalized muscle weakness, and high blood pressure. Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 10/1/25, indicated the diagnoses remain current. Review of Resident R100 physician's order revealed the following orders:- On 7/1/25, Hypoglycemic protocol - for blood sugar less than 80 if symptomatic or blood sugar less than 70 with or without symptoms present (1) Administer approximately 15 grams of glucose by mouth or carbohydrates found in any of the following: 1/2 cup juice, 1/2 cup applesauce, one cup milk, one tube glucose gel, three glucose tablets.- On 8/30/25, Check blood sugar at bedtime, notify MD (doctor) if blood sugar is less than 70 or greater than 400. Document in progress notes MD notification. Review of the clinical record and eMAR revealed the CBG's were as follows:- On 10/19/25, at 8:20 a.m. CBG was noted to be 63.- On 11/8/25, at 7:45 a.m. CBG was noted to be 61.- On 11/8/25, at 4:31 p.m. CBG was noted to be 69.- On 11/9/25, at 8:02 a.m. CBG was noted to be 65.- On 11/13/25, at 7:41 a.m. CBG was noted to be 63. Review of the care plan dated 5/14/25 and 5/15/25, indicated the following interventions:- Administer medications per physician order.- Obtain glucometer readings and report abnormalities as ordered.- Report symptoms of hyperglycemia.- Report symptoms of hypoglycemia. Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed date. During an interview on 11/25/25, 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 physicians orders for Residents R6, R86, and R100.

Based on review of facility policy, clinical records, observations and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for four of five sampled residents (Residents R1, R2, R53, and R98).Findings include: Review of the facility policy Departmental (Respiratory Therapy) - Prevention of Infection last reviewed on 1/16/25, indicated that considerations related to oxygen administration include change the oxygen cannula and tubing every seven days or as needed. Keep the oxygen and tubing used as needed in a plastic bag when not in use. Considerations related to medication nebulizers/continuous aerosol include store the circuit in a plastic bag, marked with date and resident's name, between uses. Discard the administration set up every seven days. Review of Resident R1's admission record indicated she was originally admitted on [DATE]. Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 10/1/25, indicated the diagnoses of pneumonia (lung infection), coronary artery disease (CAD restriction of blood flow to the heart), and heart failure (heart doesn't pump blood as well as it should). Review of Resident R1's current physician orders, indicated resident is on 2 liters per minute of oxygen. Interview and rounds on 11/25/25, at 11:10 a.m. with Licensed Practical Nurse (LPN) Employee E6, Resident R1 was observed in bed and using oxygen. The tubing failed to be labeled as required. Review of Resident R2's admission record indicated she was originally admitted on [DATE]. Review of Resident R2's MDS dated [DATE], indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), heart failure (heart doesn't pump blood as well as it should), and hypertension (high blood pressure). Review of Resident R2's current physician orders, indicated resident is on 2 liters per minute of oxygen and wash filter weekly, label with date. Interview and rounds on 11/25/25, at 11:15 a.m. with Licensed Practical Nurse (LPN) Employee E6, Resident R2 was observed sitting in a chair and using oxygen. The tubing failed to be labeled with an identifiable date. Review of Resident R53's admission record indicated she was originally admitted on [DATE]. Review of Resident R53's MDS dated [DATE], indicated the diagnoses of respiratory failure (not enough oxygen in the body), heart failure (heart doesn't pump blood as well as it should), and hypertension (high blood pressure). Review of Resident R53's current physician orders, indicated resident is on 2 liters per minute of oxygen, change oxygen and nebulizer tubing and wash filter weekly, label with date and initials. Interview and rounds on 11/25/25, at 11:20 a.m. with Licensed Practical Nurse (LPN) Employee E6, Resident R53 was observed sitting in a chair and using oxygen. The tubing failed to be labeled with an identifiable date. Review of Resident R98's admission record indicated she was originally admitted on [DATE]. Review of Resident R98's MDS dated [DATE], indicated the diagnoses of chronic obstructive pulmonary disease (COPD irreversible lung and airway damage), bipolar disorder (extreme mood swings), and diabetes mellitus (high blood sugar). Review of Resident R98's current physician orders, indicated resident is on 2 liters per minute of oxygen and wash filter weekly, label with date. Interview and rounds on 11/25/25, at 11:30 a.m. with Licensed Practical Nurse (LPN) Employee E6, Resident R98 was observed in bed and using oxygen. The tubing failed to be labeled with an identifiable date. During an interview on 11/25/25, at 11:40 a.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for four of five sampled residents (Residents R1, R2, R53, and R98). 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, facility documentation and staff interview, it was determined that the facility failed to protect a resident from neglect and verbal abuse for one of three residents (Resident R114). Findings include:Review of facility policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 1/16/25, indicated residents have a right to be free from abuse, neglect, misappropriation of resident property and exploitation. Review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2024, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. Review of the clinical record indicated Resident R114 was admitted to the facility on [DATE]. Review of Resident R114's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 9/24/25, indicated diagnoses of kidney disease, Chron's disease and diabetes. Question C0500 BIMS Summary Score indicated the resident scored a 15, cognitively intact. Question GG0170 Mobility indicated the resident was coded moderate assist (requiring assist of one staff). Review of a facility grievance document dated 9/24/25, indicated the following: Resident R114 reported that she had not been given an attitude by the nurse aide(NA) (identified as NA Employee E3) when she asked for help to go to the bathroom, but the call bell was not responded to until after she had to take herself to the bathroom as she could not wait any longer and NA Employee E3 responded, it looks like you're already doing it and walked out huffing and puffing.Review of a statement obtained on 9/23/25, from NA Employee E4 indicated that NA Employee E3 had gone in to check on Resident R114 and was told that Employee E3 had slammed Resident R114's door and had been bullying residents all day and swearing and stating that she does not have time for the resident's crap. NA Employee E4 stated that NA Employee E3 is thrown out of resident rooms, and they don't want her in their rooms. Review of a statement obtained on 9/23/25, from NA Employee E5 indicated that when the nurse aides were coming into work, NA Employee E3 was swearing and upset due to staffing being changed. Later when she and NA Employee E3 entered a resident's room, NA Employee E3 stated can you shut the fuck up so he (the resident) can finish talking so he can shut the fuck up and NA Employee E5 stated NA Employee E3 had an attitude and leaving her call bells ringing and did not help pass or pick up trays.During an interview on 11/24/25, at 11:19 a.m., the Director of Nursing confirmed that she did not identify the grievance and statements as potential neglect/ abuse and felt the information was enough of an investigation and took it no further. Confirmed the facility failed to protect one of three residents (Resident R114) from neglect and abuse. 28 Pa. Code: 201.14(a) Responsibility of licensee28 Pa. Code: 201.18(b)(1) Management.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on a review of facility policy, information provided by the facility, clinical records and staff interview, it was determined the facility failed to promptly conduct a thorough investigation to rule out abuse and implement corrective action and submit the results of the completed investigation to the State Survey Agency within five working days of the incident as evidenced by one of three residents reviewed (Resident R114).Findings include:Review of facility policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 1/16/25, indicated residents have a right to be free from abuse, neglect, misappropriation of resident property and exploitation. The policy indicated that the facility will identify and investigate all possible incidents of abuse, neglect, mistreatment or misappropriation of resident property within times frames required by federal requirements.Review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2024, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. Review of the clinical record indicated Resident R114 was admitted to the facility on [DATE]. Review of Resident R114's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 9/24/25, indicated diagnoses of kidney disease, Chron's disease and diabetes. Question C0500 BIMS Summary Score indicated the resident scored a 15, cognitively intact. Question GG0170 Mobility indicated the resident was coded moderate assist (requiring assist of one staff). Review of a facility grievance document dated 9/24/25, indicated the following: Resident R114 reported that she had not been given an attitude by the nurse aide(NA) (identified as NA Employee E3) when she asked for help to go to the bathroom, but the call bell was not responded to until after she had to take herself to the bathroom as she could not wait any longer and NA Employee E3 responded, it looks like you're already doing it and walked out huffing and puffing.Review of a statement obtained on 9/23/25, from NA Employee E4 indicated that NA Employee E3 had gone in to check on Resident R114 and was told that Employee E3 had slammed Resident R114's door and had been bullying residents all day and swearing and stating that she does not have time for the resident's crap. NA Employee E4 stated that NA Employee E3 is thrown out of resident rooms, and they don't want her in their rooms. Review of a statement obtained on 9/23/25, from NA Employee E5 indicated that when the nurse aides were coming into work, NA Employee E3 was swearing and upset due to staffing being changed. Later when she and NA Employee E3 entered a resident's room, NA Employee E3 stated can you shut the f*** up so he (the resident) can finish talking so he can shut the f*** up and NA Employee E5 stated NA Employee E3 had an attitude and leaving her call bells ringing and did not help pass or pick up trays.During an interview on 11/24/25, at 11:19 a.m., the Director of Nursing confirmed that she did not identify the grievance and statements as potential neglect/ abuse and felt the information was enough of an investigation and took it no further. Confirmed the facility failed to identify, thoroughly investigate to rule out abuse and implement corrective action and submit the results of the completed investigation to the State Survey Agency within five working days of the incident as evidenced by one of three residents reviewed (Resident R114). 28 Pa. Code 201.14 (c) Responsibility of licensee.28 Pa. Code 201.18 (b)(1) Management.28 Pa. Code 201.29 (a) Resident rights.28 Pa. Code 211.10(d) Resident care policies.

Based on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to make accessible grievance boxes to residents in three of three locations, 300-lounge, main dining room, and front lobby. Findings include: A review of the facility policy Grievances/Complaints, Filing reviewed 1/16/25, grievances and/or complaints may be submitted orally or in writing and may be filed anonymously. The Centers for Medicare & Medicaid Services (CMS) does not specify exact height requirements for grievance boxes in skilled nursing facilities. However, CMS mandates that grievance procedures be accessible to all residents, including those with disabilities, in compliance with the Americans with Disabilities Act (ADA). In Pennsylvania, the Department of Health incorporates by reference the federal requirements outlined in 42 CFR Part 483, Subpart B, which pertains to long-term care facilities. These regulations emphasize the importance of accessibility but do not provide additional specifications regarding grievance box placement. To ensure accessibility, the ADA Standards for Accessible Design recommend that operable parts, such as slots on grievance boxes, be mounted between 15 and 48 inches above the floor. This range accommodates individuals using wheelchairs and ensures usability for a broad range of residents. During a resident group interview, on 11/24/25 at approximately 1:30 p.m., when asked if they felt they could anonymously file a grievance in the grievance boxes, consensus from the group was no. Residents stated, they are too high to reach, they are not made for people in wheelchairs, and you have to ask someone to help you, so we just ask the staff to do it for us. During rounds on 11/26/25, at 8:15 a.m. the Nursing Home Administrator and surveyor measured the height of the grievance boxes in the 300-lounge, height was 53 inches, main dining room, height was 52 inches, and front lobby, height was 51 inches. Access to the boxes in both the 300 lounge and front lobby were blocked by a table. During an interview on 11/26/25, at 8:30 a.m. the Nursing Home Administrator confirmed the facility failed to make accessible grievance boxes to residents in three of three locations, 300-lounge, main dining room, and front lobby. 28 PA Code: 201.18(e)(4) Management. 28 PA Code: 201.29(a)(b)(c) Resident rights.

Based on observations and a staff interview, it was determined the facility failed to post contact information, Adult Protective Services (APS), Medicaid Fraud Unit, and a statement the resident may file a complaint with the State Agency as required, in the building. Findings include: The facility must post, in a form and manner accessible and understandable to residents, resident representatives; a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit. Observations conducted on 11/25/25, at approximately 11:30 a.m., on the nursing units, revealed the facility did not have the required elements (agency name, address, email address, and phone number) of Adult Protective Services (APS), Medicaid Fraud Unit, and a statement the residents may file a complaint with the State Agency posted or accessible to residents or resident representatives. During rounds and an interview with the Nursing Home Administrator (NHA) on 11/26/25, at 8:15 a.m., the NHA confirmed the facility failed to post required information for Adult Protective Services (APS), Medicaid Fraud Unit, and a statement the residents may file a complaint with the State Agency as required, in the building. 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 201.18(e) Management

Based on observation and staff interviews, it was determined that the facility failed to ensure that current and accurate nurse staffing information was posted in the facility at the beginning of each shift. Findings include: Observation conducted on 11/24/25, at approximately 9:00 a.m., revealed that nurse staffing information was posted in the main lobby on the reception desk. At that time, the nurse staffing information had the date of (11/7/25), resident census, and the staffing hours did not accurately reflect the current total number of hours worked for licensed and unlicensed nursing staff directly responsible for resident care per shift for the current date. During an interview on 11/24/25, at 9:05 a.m., Employee E2 receptionist stated that the posting for staffing isn't up to date. During an interview with the Nursing Home Administrator (NHA) on 11/24/25, at approximately 9:50 a.m., the NHA confirmed the facility failed to post the required current facility information for staffing hours and the census for 11/24/25. 201.18(b)(3) Management.

Based on review of facility policy, clinical records, facility documentation, and staff interviews, it was determined that the facility failed to provide adequate assistance and interventions to prevent fall with injury, that resulted in actual harm causing a subarachnoid hemorrhage, six sutures to the scalp, and a C4 (fourth cervical vertebrae) fracture for one of three residents (Resident R1) Findings include: Review of the facility policy Safe Patient/Resident Handling Policy and Procedure, last reviewed on 1/16/25, indicated that staff are trained to utilize safe resident handling equipment and moving techniques to decrease the number of injuries to them and to the residents. The requirements include avoiding unassisted handling of residents and/or identifying potential high risk residents to avoid potential injuries. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses which included anemia, gastrointestinal bleed, diabetes, a stroke, sacroilitis(inflammation of the pelvic joint), anxiety, difficulty walking, abnormal posture, and Stage 5 kidney disease, the resident refuses dialysis and will return home with Hospice. A Minimum Data Set (MDS - a periodic assessment of resident care needs) dated 3/12/25, indicated the diagnoses remained current, Section GG 0115 Functional Limitation/Range of Motion identified Resident R1 having bilateral upper extremity impairments. Section GG 0170 Mobility identified Resident R1 as partial/ moderate assist (which required one staff that does less than half the effort ) for bed mobility. Additionally, Resident R1's BIMS was 15. This indicated cognition was intact. Review of Resident R1's Resident Evaluation dated 3/12/25, indicated the use of bed rails. Review of Resident R1's plan of care dated 2/25/25, indicated Resident R1 was at risk for falls due to impaired balance/poor coordination and to minimize risk for falls or injuries related to falls Resident R1 was to be encouraged to change positions slowly and use assistive devices as needed and staff were to provide assistance to transfer and ambulate as needed. Resident R1 was also identified as having an ADL (assistance of daily living) deficit related to physical limitations and as to receive necessary assistance to meet her ADL needs with use of bedrails. Review of an incident report dated 4/1/25, at 11:40 p.m., indicated that Resident R1 was being provided incontinence care by Nurse Aide (NA) Employee E1. Resident R1 had loose stools and had not been changed at the hospital. NA Employee E1 turned Resident R1 away from her and then took hands off the resident and reached away to get cleansing spray from the nightstand; NA Employee E1 stated she heard a thud, and the resident had rolled out of bed resulting in the subarachnoid hemorrhage, scalp laceration, and C4 fracture. Bed rails were not on the bed a the time of the incident. Review of the statement that was attached to the investigation undated but signed by NA Employee E1 stated that I rolled Resident R1 to the right side to left side several times to remove linens, blankets and sheets from her bed and in doing that I went from left side to right side several times. Resident R1 asked me to change her brief since it had not been done at the hospital all day. I opened the brief and she was saturated with bowel. I wiped and sprayed the front then put her on her side and wiped the back, took the brief off and liquid bowel sprayed across the sheet. Now I had no wipes left so I put Resident R1 on her back, went to the bathroom to get new pack of wipes then put Resident R1 on her side and turned to get spray from stand. I heard a thud, Resident R1 rolled out of bed. During an attempted phone interview, on 4/22/25, at 11:48 a.m., NA Employee E1 was not available for comment. During an interview on 4/22/25, at 1:07 p.m., NA Employees E2 and E3, indicated that while providing incontinence care, the kardex is used and if siderails are in place and the resident is an assist of one, then they may use siderails if the resident is able to hold on. If no siderails are on and the resident is identified as requiring one assist, then always turn them towards you and go on each side or get a second staff person to help. During an interview on 4/22/25, at 1:17 p.m., NA Employee E4 stated that she will utilize the siderail if in place or turn the resident towards her to avoid the possibility of a fall. During an interview on 4/22/25, at 12:45 p.m., the DON confirmed that Resident R1 did not have siderails on her bed when the fall occurred. During an interview on 4/22/25, at 2:15 p.m., the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide adequate assistance and interventions to prevent fall with that resulted in actual harm causing a subarachnoid hemorrhage, six sutures to the scalp, and a C4 fracture for Resident R1. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.29(a)(c)(d)(j) Resident rights.

Based on review of facility policy, clinical records, documentation provided by the facility, facility investigation, resident interview, and staff interviews, it was determined that the facility failed to ensure that a resident was free from neglect by failing to provide adequate assistance and interventions to prevent fall with injury, which resulted in actual harm as evidenced by a subarachnoid hemorrhage, six staples to the left side of the scalp, and a C4 (fourth cervical vertebra) fracture which required use of a cervical collar to be worn at all times for one of three residents (Resident R1). Findings include: Review of the facility policy Abuse, Neglect, Misappropriation Prevention Program last reviewed on 1/16/25, indicated that the residents of the facility have a right to be free from abuse, neglect, exploitation and misappropriation of property. The facility will develop and implement policies to prevent and identify such concerns. Review of the facility policy Identifying Neglect last reviewed on 1/16/25, indicated that neglect is the failure of the facility to provide goods and services to a resident that are necessary to avoid or may result in physical harm - is identified as neglect. The facility is aware or should have been aware of goods or services that a resident requires but the facility fails to provide them and this has resulted in (or may result in) actual physical harm, pain, mental anguish or emotional distress. Review of the facility policy Safe Patient/Resident Handling Policy and Procedure, last reviewed on 1/16/25, indicated that staff are trained to utilize safe resident handling equipment and moving techniques to decrease the number of injuries to them and to the residents. The requirements include avoiding unassisted handling of residents and/or identifying potential high risk residents to avoid potential injuries. Review of the facility policy Bed Safety and Bed Rails last reviewed on 1/16/25, indicated that consideration is given to the resident's safety, medical conditions, comfort, and freedom of movement regarding previous sleeping habits and environment. The resident assessment determines the use of bed rails and is prohibited unless the criteria for use is met including the residents medical diagnosis, size and weight and existence of delirium. During an interview on 4/22/25, at 12:45 p.m., the Director of Nursing indicated that the resident must have a Brief Interview of Mental Status (BIMs) level of at least a 9 to be considered for use of siderails. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses which included anemia, gastrointestinal bleed, diabetes, a stroke, sacroilitis(inflammation of the pelvic joint), anxiety, difficulty walking, abnormal posture, and Stage 5 kidney disease, the resident refuses dialysis and will return home with Hospice. A Minimum Data Set (MDS - a periodic assessment of resident care needs) dated 3/12/25, indicated the diagnoses remained current, Section GG 0115 Functional Limitation/Range of Motion identified Resident R1 having bilateral upper extremity impairments. Section GG 0170 Mobility identified Resident R1 as partial/ moderate assist (which required one staff that does less than half the effort ) for bed mobility. Additionally, Resident R1's Brief Interview of Mental Status was 15. This indicated cognition was intact. Review of Resident R1's Resident Evaluation dated 3/12/25, indicated the use of bed rails. Review of Resident R1's plan of care dated 2/25/25, indicated Resident R1 was at risk for falls due to impaired balance/poor coordination and to minimize risk for falls or injuries related to falls Resident R1 was to be encouraged to change positions slowly and use assistive devices as needed and staff were to provide assistance to transfer and ambulate as needed. Resident R1 was also identified as having an Activities of Daily Living (ADL) deficit related to physical limitations and as to receive necessary assistance to meet her ADL needs with use of bedrails. Review of the clinical record indicated that on 3/21/25, Resident R1 began having loose dark stools and dark emesis, which then prompted lab work resulting in a hemoglobin level of 6.5 (normal is 13.8-17.2) requiring a blood transfusion. Resident R1 was sent to the hospital and admitted from 3/22/25, through 3/26/25, with anemia. Review of the clinical record indicated that on 3/27/25, Resident R1 had a nosebleed and on 3/31/25, she again began having dark stools that tested positive for blood. Lab work was drawn again resulting in a Hemoglobin level of 6.6 then 5.5. Resident R1 was to be sent out for another blood transfusion. Review of the clinical record indicated that on 4/1/25, at 1:15 p.m., Resident R1 went to the hospital and had a blood transfusion and returned to the facility on [DATE], at 11:30 p.m. Review of an incident report dated 4/1/25, at 11:40 p.m., indicated that Resident R1 was being provided incontinence care by Nurse Aide (NA) Employee E1. Resident R1 had loose stools and had not been changed at the hospital. NA Employee E1 turned Resident R1 away from her and then took hands off the resident and reached away to get cleansing spray from the nightstand and NA Employee E1 stated she heard a thud, and the resident had rolled out of bed causing a head laceration, resulting in the subarachnoid hemorrhage and C4 fracture. Bed rails were not on the bed at the time of the incident. Review of the statement that was attached to the investigation undated but signed by NA Employee E1 stated that I rolled Resident R1 right side to left side several times to remove linens, blankets and sheets from her bed and in doing that I went from left side to right side several times. Resident R1 asked me to change her brief since it had not been done at the hospital all day. I opened the brief and she was saturated with bowel. I wiped and sprayed the front then put her on her side and wiped the back, took the brief off and liquid bowel sprayed across the sheet. Now I had no wipes left so I put Resident R1 on her back, went to the bathroom to get new pack of wipes then put Resident R1 on her side and turned to get spray from stand. I heard thud, Resident R1 rolled out of bed. During an attempted phone interview, on 4/22/25, at 11:48 a.m., NA Employee E1 was not available for comment. During an interview on 4/22/25, at 1:07 p.m., NA Employees E2 and E3, indicated that while providing incontinence care, the kardex is used and if siderails are in place and the resident is an assist of one, then they may use siderails if the resident is able to hold on. If no siderails are on and the resident is identified as requiring one assist, then always turn them towards you and go on each side or get a second staff person to help. During an interview on 4/22/25, at 1:17 p.m., NA Employee E4 stated that she will utilize the siderail if in place or turn the resident towards her to avoid the possibility of a fall. During an interview on 4/22/25, at 12:45 p.m., the DON confirmed that Resident R1 did not have siderails on her bed when the fall occurred. During an interview on 4/22/25, at 2:15 p.m., the Nursing Home Administrator and the Director of Nursing confirmed NA Employee E1 rolled Resident R1 away to provide care then turned away from Resident R1 during care resulting in neglect by not providing adequate supervision and assistance causing a fall out of bed, which resulted in actual harm for Resident R1 resulting in a subarachnoid hemorrhage, six sutures to the scalp, and a C4 fracture. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.29(a)(c)(d)(j) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3) Nursing services.

Based on review of facility policy, observation and staff interview, it was determined that the facility failed to properly secure medication in one of two medication carts on the 300 hall nursing unit (B cart). Findings include: Review of the facility policy Medication Labeling and Storage last reviewed on 1/18/24, indicated the facility stores medications in locked compartments and only authorized have access to the keys. During an observation on 12/8/24, at 12:10 p.m., the 300 hall B medication cart was left unsecured and unattended and accessible to any passerby. During an interview on 12/8/24, at 12:15 p.m., the Director of Nursing confirmed the facility failed to properly secure medications on one of two medication carts on the 300 hall nursing unit accessible to any passerby. 28 Pa. Code: 211.9(a)(1)(k) Pharmacy services. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of the facility policy and clinical records and staff interviews, it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions such as a living will or durable power of attorney for health care for when the individual is incapacitated) for four of the nine residents reviewed (Resident R24, R29, R57, R71). Findings Include: A review of the facility policy Advanced Directives last reviewed 1/18/24, indicated the facility will comply with the requirements related to maintaining written policies and procedures regarding advance directives, including provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advance directive. A review of the medical record indicated Resident R24 was admitted to the facility on [DATE], with diagnoses that included type II diabetes (long-term condition in which the body has trouble controlling blood sugar and using it for energy), dysphagia (difficulty swallowing), muscle weakness, left below knee amputation. A review of the clinical record failed to reveal and advance directive or documentation that Resident R24 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R29 was admitted to the facility on [DATE], with diagnoses that include type II diabetes, dysphagia, high blood pressure, difficulty walking. A review of the clinical record failed to reveal and advance directive or documentation that Resident R29 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R57 was admitted to the facility on [DATE], with diagnoses that include high blood pressure, history of falling, chronic kidney disease, stage III (moderate level of kidney damage where the kidneys have mild to moderate impairment in filtering waste from the blood). A review of the clinical record failed to reveal and advance directive or documentation that Resident R57 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R71 was admitted to the facility on [DATE], with diagnoses that include multiple sclerosis (the immune system eats away at the protective covering of nerves , this damage disrupts communication between the brain and the body), dysphagia, chronic kidney disease, stage III. A review of the clinical record failed to reveal and advance directive or documentation that Resident R71 was given the opportunity to formulate an Advanced Directive. During an interview on 12/10/24 at 12:45 p.m. the Social Worker and the Director of Nursing (DON) confirmed that the clinical record did not include documentation that Resident R24, R29, R57, R71, were not afforded the opportunity to formulate Advance Directives. 28 Pa. Code: 201.29(b)(d)(j) Resident rights.

Based on reviews of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to implement effective safety measures by not supervising use of a cold pack in a manner that promotes safety for one of three residents reviewed (Resident R1), which resulted in actual harm of a superficial frostbite burn (involving the epidermis and dermis layers of the skin that is red blistered swollen and painful). This was identified as harm for one resident (Resident R1). Findings include: A review of the facility policy, Ice/Cold Pack, last reviewed 1/18/24, indicated the facility will provide appropriate toweling between ice pack and area to be treated. The treatment time is 10-20 minutes and should be checked every 10 minutes. The treatment and response to treatment should be documented in medical record. A review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses that included sciatica (pain along sciatic nerve), hyperlipidemia (high levels of fat particle in the blood), polyneuropathy (multiple peripheral nerves become damaged causing pain) and hypertension (blood against the artery walls is too high). Further review indicated the resident had a Brief Interview of Mental Status of 15 which indicated Resident R1 was cognitively intact. Resident R1 was discharged home on 8/11/24. A review of the Physical Therapy (PT) Evaluation & Plan of Treatment dated 7/29/24, indicated that Resident R1 treatment approaches may include a modality (method of treatment, piece of equipment, or interventional strategy) application of hot or cold packs supervised which was electronically signed by the Medical Director. A review of the care plan initiated 7/27/24 for potential for pain related to impaired mobility, failed to include the use of cold packs as an intervention. A review of an incident report dated 7/30/24, indicated Resident R1 stated ice pack was left on direct skin for too long. Redness and blistering were noted behind the right knee. Injury type observed at the time of the incident was a burn to the right inner knee area. Physician and daughter were notified. A review of a physical therapy treatment encounter note dated 7/30/24, indicated Resident R1 was given ice pack by PT initially and declined all other PT services the rest of the day. A review of a wound and vascular progress note dated 8/6/24, indicated Resident R1 admitted to removing cloth from ice pack and placing ice pack directly on her skin. Behind the right knee was noted to have redness and blistering. Encounter diagnosis of superficial frostbite of right knee and lower leg noted. A review of a facility witness statements dated 8/8/24, indicated the following: PT Employee E1 indicated Resident R1 was approached for treatment which she refused due to pain. PT Employee E1 spoke with nurse on the unit regarding pain medication, which were not due at the time. Ice pack was then offered to Resident R1. Nurse confirmed I [PT employee E1] provided with proper toweling. Licensed Practical Nurse (LPN) Employee E2 indicated At no time did I [LPN Employee E2] give an ice pack to anyone on the 200 unit. During an interview on 8/14/24 at 11:58 a.m., PT Employee E1 revealed I went to see Resident R1 sometime before lunch however treatment was refused due to pain. Resident wanted pain medication and ice, so I spoke with the nurse to see if pain medication was due, but it was not. I went to get the ice from the freezer for the nurse and verified with her that ice pack was covered and being given to resident at that time. I went back to attempt treatment a couple hours later, but resident refused again. During an interview on 8/15/24 at 9:42 a.m., with Licensed Practical Nurse (LPN) Employee E2, revealed they were the nurse caring for Resident R1 on the day of the incident. LPN Employee E2 stated I was never shown an ice pack that day. I never saw the resident with an ice pack. I did not provide resident with direct contact care the second half of my shift to notice any burn. Phone calls were placed to Resident R1 on 8/14/24 and 8/15/24, voice mails were left and telephone calls were not returned. The facility provided documentation of the in-service training that was provided to the staff, including Registered Nurses, Licensed Practical Nurses, Occupational Therapist and Physical Therapist, at the facility on 8/6/24, which addressed following the facility policy and procedures for using ice/cold packs. During interviews with nursing staff on 8/15/24 from 9:42 a.m. through 10:34 a.m. revealed LPN Employee E2, Registered Nurse (RN) Supervisor Employee E3, LPN Employee E4, Unit Clerk Employee E5, LPN Employee E6, LPN Employee E7, LPN Employee E8, and LPN Employee E9 confirmed proper procedure for using ice/cold packs. During an interview on 8/15/24, at 11:18 a.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility failed to implement effective safety measures by not providing education and supervision of the use of an ice pack resulting in actual harm of a frostbite burn to 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 review of manufacturer guidelines, observation, and staff interview, it was determined that the facility failed to make certain that medications were properly stored in two of two medication carts (200 B and 200 A). Findings include: Review of the Humalog lispro insulin (injectable medication used to treat high blood sugar) prescribing information revised 02/2020, indicated that for Humalog injection pens Do not use your pen past the expiration date printed on the label or for more than 28 days after you first start using the pen. For Humalog vials of insulin Do not use Insulin Lispro Injection past the expiration date printed on the label or 28 days after you first use it. During an observation of the 200 B medication cart on 11/17/23, at 11:17 a.m. a partially used flex-pen of Humalog was observed, without an open date. During an interview on 11/17/23, at 11:18 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed the above observation. During an observation of the 200 A medication cart on 11/17/23, at 11:21 a.m. two partially used vials of Humalog were observed, without an open date. During an interview on 11/17/23, at 11:22 a.m. LPN Employee E2 confirmed the above observation. During an interview on 11/17/23, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain that medications were properly stored in two of two medication carts. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. 28 Pa. Code: 211.9 (a)(1) Pharmacy services. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services.

Based on a review of facility policy and clinical records, and resident and staff interview, it was determined that the facility failed to provide specialized rehabilitative services for two of four residents (Residents R35 and R61). Findings include: A review of the facility policy Restorative Nursing Services last reviewed 1/20/22, indicated residents will receive restorative nursing care as needed to help promote optimal safety and independence. During resident group meeting two out of seven resident's stated the restorative nurse aide gets pulled to the floor and they do not get restorative nursing. A review of the clinical record revealed that resident R61 was admitted to the facility on [DATE], with diagnoses that included, cerebral palsy (condition marked by impaired muscle coordination, caused by damage to the brain), spastic hemiplegic cerebral palsy and fatty liver. A review of the minimum data set (MDS-periodic assessment of care needs) dated 10/11/22, indicated the diagnoses remain current. Review of Resident R61's medical record included Therapy Communication to Nursing, dated 4/08/22, stated that therapy recommends that nursing follow through with the following: RNP (Restorative Nursing Program) for Ambulation with RW(Rolling Walker). Patient will ambulate 50-75 feet with RW and SBA(stand by assist) with wheel chair follow. A review of the Restorative Bed Mobility Tasks documentation indicated Resident R61 did not receive active rehabilitation on 12/1/22-12/13/22, 12/15/22-12/17/22, 12/29-12/31/22 A review of the clinical record revealed that resident R35 was admitted to the facility on [DATE], with diagnoses that included, muscle weakness, heart disease, and hypertension (a condition impacting blood circulation through the heart related to poor pressure). A review of the minimum data set (MDS-periodic assessment of care needs) dated 9/26/22, indicated the diagnoses remain current. Review of Resident R35's medical record included Therapy Communication to Nursing, dated 1/31/22, stated that therapy recommends that nursing follow through with the following: Transfer supine (lying horizontally with the face and torso facing up) to sit max (maximum) assist (providing 51-75 percent of the work required for the task), sit at edge of bed with assist to place legs flexed under him to sit and use of arms on edge of bed assistance can vary from Min (minimum- providing one to 25 percent of the work required for the task) to Mod (moderate- providing 26-50 percent of the work required for the task) Limit to 5 mins (minutes). A review of the Restorative Bed Mobility Tasks documentation indicated Resident R35 did not receive active rehabilitation on 12/8/22, 12/9/22, 12/14/22, 12/15/22, 12/17/22, 12/20/22, 12/21/22, 12/22/22, 12/24/22, 12/27/22, 12/28/22, 12/30/22, 12/31/22, 1/3/23, and 1/4/23. During an interview on 1/6/23, at 11:30 a.m., Nursing Home Administrator confirmed that the Restorative Aide is pulled to work on the floor as a nurse aide and the facility fails to provide the restorative program. During an interview on 1/6/23, at 1:45 p.m., Restorative Aide Employee E1 stated that she is the only Restorative Aide at the facility and that she is often pulled out of restorative to fill other needs in the building. It was also clarified that she works as a Restorative Aide approximately 15 percent of her working hours and confirmed that the facility failed to provide specialized rehabilitative services as needed to help promote optimal safety and independence. 28 Pa Code: 201.18(e)(1) Management. 28 Pa. Code: 211.10(c)(d) Resident care policies.

Based on facility policy, clinical record reviews and staff interview, it was determined that the facility failed to provide medications per a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: A review of policy Medication Administration, dated 2/21/21, indicated staff will provide safe and accurate medication administration to the residents. During a clinical record review and subsequent review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R243's progress note dated 12/20/21, for the corresponding dates indicated the medication is on order from the pharmacy. During a clinical record review and subsequent review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R243's progress note dated 12/21/21, for the corresponding dates indicated the medication was on order. During a clinical record review and subsequent review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R243's progress note dated 12/22/21, for the corresponding date indicated the medication was on order. During a clinical record review and subsequent review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R245's progress note dated 12/22/21, 12/23/21, for the corresponding dates indicated the medication was not available, waiting for pharmacy to deliver. During a clinical record review and subsequent review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R245's progress note dated 12/23/21, for the corresponding dates indicated the medication was on order. During a clinical record review and subsequent review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R245's progress note dated 12/23/21, for the corresponding dates indicated the medication was on order. During a clinical record review and subsequent review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R246's progress note dated 9/14/21, for the corresponding dates indicated the medication was not available. During a clinical record review and subsequent review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] & 12/19/21 and to see nurses notes. Review of Resident R1's progress note dated 12/18/21 & 12/19/21, for the corresponding dates indicated the medication was not available. During a clinical record review and subsequent review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's progress note dated 12/12/21, for the corresponding dates indicated the medication was not available. During a clinical record review and subsequent review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R250's progress note dated 12/23/21, for the corresponding dates indicated the medication was on order from the pharmacy. During a clinical record review and subsequent review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's progress note dated 12/24/21, 12/25/21, 12/26/21, 12/27/21, for the corresponding dates indicated the medication on order from the pharmacy. During an interview on 1/6/22, at 10:15 a.m. the Director of Nursing confirmed that the medication was not available for these resident's as indicated. 28 Pa. Code: 201.14(a)Responsibility of licensee 28 Pa. Code: 211.9(a)(1)Pharmacy services