Every finding on record at Rest Haven-York

Based on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to maintain an effective infection control program related to labeling and storage of medical supplies for one of two residents reviewed with gastrostomy tubes (Resident 14). The facility also failed to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of communicable diseases and infections during two of two meal observations in the Royal Garden Cafe. Findings include: Review of facility policy, titled Care of Enteral Feeding Tube-Position, Cleansing, Observation, Notification, Storage, last reviewed December 16, 2025, line 9 stated, All feeding tube syringes should be stored in a clean area. Reusable supplies should be labeled with the resident's name and date; cleansed with hot water after use; and disposed of after 24 hours. Review of Resident 14's clinical record revealed diagnoses that included dysphagia (difficulty swallowing) and gastrostomy (a surgical opening created through the abdominal wall into the stomach to insert a feeding tube for long-term nutrition, hydration, or medication delivery when oral intake is insufficient or unsafe). Review of Resident 14's current physician orders revealed most medications are administered via the gastrostomy tube. The gastrostomy tube was ordered to be flushed with 60 cc (metric measure 60 cc equals 2 ounces) of water every shift. Orders also said to flush the gastrostomy tube with 30 cc water before and after each med, also flush in between meds given separately. Observation of Resident 14's room on February 2, 2026, at approximately 11:00 AM, revealed the 60 cc piston syringe utilized for flushing the Resident's gastrostomy tube each shift laying on the bedside stand, uncovered and unlabeled; a graduate (measuring containing) was uncovered and unlabeled; and a gallon jug of water 2/3's full was not dated when placed into use. The bedside table was cluttered with many other personal items that included a comb, papers, and Kleenex box. During an interview with Employee 9 (Licensed Practical Nurse) on February 2, 2026, at 11:15 AM, Employee 9 was asked if the piston syringe and graduate should be protected and labeled, and if the gallon of water should be dated when placed into use. Employee 9 replied yes. Employee 9 then picked up the piston syringe and wrote 2/2/2026, on the syringe and placed it in the graduate container. Employee 9 stated he was unsure when the gallon of water was opened and left it sitting there for continued use. Employee 9 added, the syringe is replaced each day. On February 3, 2026, at 8:45 AM, the same 60 cc piston syringe dated 2/2/2026 was laying in the graduate container. The graduate container and water were not labeled with the Resident's name or date. During an interview with the Nursing Home Administrator (NHA) on February 4, 2026, at 10:50 AM, the NHA confirmed the piston syringe, graduate, and water container should be labeled with the Resident's name and dated when placed into use, and the syringe and graduate should be protected from contamination and should be replaced daily. Observation on February 4, 2026, at 12:00 PM, revealed Resident 60 was seated at a table being assisted by a staff member to eat her lunch. At the same table, staff assembled resident meal trays for service. The trays contained a napkin, uncovered silverware, beverages, and a meal ticket. Observation on February 4, 2026, at 12:05 PM, with Employee 5 (Food Service Director), revealed Resident 60 continued to be assisted with her meal at the table where staff assembled meal trays. At that time, Employee 5 revealed residents shouldn't be seated at the table where meal trays were being assembled. Interview with the NHA and Director of Nursing on February 5, 2026, at 10:30 AM, it was revealed to avoid infection control concerns residents shouldn't be seated at the table where meal trays were being assembled. 28 Pa code 211.6(f) - Dietary Services28 Pa. Code 211.12 (d)(5) Nursing services

Based on facility policy review, clinical record review, observations, and staff interview, it was determined that the facility failed to ensure a resident has the right to a dignified existence, including in an environment that promotes maintenance or enhancement of his or her quality of life, for one of 29 residents reviewed (Resident 7).Findings include:Review of facility policy, titled Resident Rights last reviewed December 16, 2025, read, in part, The resident has the right to an environment that promotes maintenance or enhancement of quality-of-life including respect, dignity and privacy.Review of Resident 7's clinical record revealed diagnoses that included urinary tract infection (an infection that takes place throughout your urinary tract), flaccid neuropathic bladder (the inability of the bladder muscles to contract effectively, leading to urinary retention and overflow incontinence), and weakness. Observation of Resident 7 on February 2, 2026, from 1:57 PM to 2:05 PM, revealed she wheeled herself from the dining room back to her room, and her catheter bag was hanging down underneath her chair with urine exposed. Observation of Resident 7 on February 4, 2026, at 11:36 AM, revealed she was sitting at a table in the dining room, and her catheter bag was facing outward underneath her chair with urine exposed. During an interview with the Director of Nursing on February 5, 2026, at 10:33 AM, she revealed she would expect residents to have the right to a dignified existence.28 Pa. Code 201.29(a) Resident rights

Based on observation, policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that the interdisciplinary team determined a resident was safe to self-administer medications for one of the 29 residents reviewed (Resident 10).Findings Include: Review of the facility's policy, titled Medication- Self Administration-Assessment, Review, Care Planning, Documentation, revised April 2022, read, the purpose of the policy is To provide a uniform process through which residents are assessed and reviewed to self-administer medication and care-planning, and documentation is completed. Review of Resident 10's clinical record revealed diagnoses that included Diabetes Mellitus Type II (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar) and Congestive Heart Failure (a chronic, progressive condition where the heart muscle is too weak or stiff to pump blood efficiently, causing fluid to back up into the lungs, liver, and extremities). An observation in Resident 10's room on February 2, 2026, at 10:31 AM, revealed a medication cup with multiple medications placed on the bedside table. An immediate interview with Resident 10 revealed that the Licensed Practical Nurse (Employee 10) leaves the medications there for him to take at his leisure and with his drink of choice. An interview with Employee 10 at 10:42 AM, revealed Resident 10 has not been assessed to self-administer his medications. An interview with the Nursing Home Administrator on February 4, 2026, at 10:44 AM, confirmed Employee 10 should not have left the medications at Resident 10's bedside, and confirmed Resident 10 has not been assessed by the facility to self-administer his medications. 28. Pa. Code 211. 12 (d) (1) (2) (5) Nursing services

Based on facility policy, staff interviews, and clinical record reviews, it was determined that the facility failed to provide an explanation of the risks and benefits of psychotropic medications use and obtain consent prior to administering psychotropic medications for two of three residents reviewed for psychotropic medication use (Residents 15 and 45). Findings included: Review of Facility policy, titled Medications-Psychotropic Drugs - evaluating, monitoring and documenting, revised June 6, 2019, read, in part, if an anti-psychotic is ordered the resident and/or their responsible party will be educated on the risks versus benefits of taking the medication. Review of Resident 15s' clinical record revealed diagnoses that included delusional disorders (a mental health condition characterized by the presence of delusions- false, fixed beliefs about situations that could occur in real life), vascular dementia (a decline in thinking, memory, and behavior caused by conditions that damage brain blood vessels, restricting oxygen), depression (severe feelings of sadness, worthlessness, or hopelessness), and anxiety (feeling of fear, dread, and apprehension about perceived threats or impending misfortune). Resident 15's physician orders included: Haldol (antipsychotic used to treat behavioral issues or agitation, to manage hallucinations and delusions) 1 milligram (mg) once a day, started January 3, 2026; Haldol 0.5 mg twice a day, started January 3, 2026; and Trazadone (antidepressant approved to treat depressive disorder) 25 mg three times a day, started January 20, 2026. Review of psychology consult dated January 24, 2026, documented Haldol .25 mg was started on November 3, 2025, due to failed Geodon (antipsychotic medication) gradual dose reduction. Review of progress note dated November 3, 2025, read, in part, review antipsychotic risk versus benefit with Responsible Party and agrees with the medication. The name of the medication was not documented. Review of progress note dated November 4, 2025, read, in part, Resident admitted with orders for decrease Geodon and start Haldol. Letter sent to Responsible Party with a copy of the risk versus benefit of antipsychotic medications. Review of progress not dated January 20, 2026, read, in part, Trazodone 25 mg three times a day for continued signs of distress. Left message for Responsible Party. Interview with the Director of Nursing on February 5, 2026, at 10:30 AM, it was revealed that the facility should obtain consent and discuss the risks and benefits for use of an anti-psychotropic medication with the resident or resident representative prior to administration of the medication. Review of Resident 45's clinical record revealed diagnoses that included delusional disorder (defined by one or more persistent, fixed, false beliefs [often non-bizarre, such as being followed or poisoned] lasting at least one month) and dementia (a general term for severe mental function loss). Review of Resident 45's physician orders revealed an order for Risperidone (antipsychotic medication) 1 mg, given by mouth, three times daily, starting on August 26, 2025. Review of Resident 45's Care plan revealed a problem of: I have behavioral problems due to vascular dementia with psychotic features; Due to my behaviors I may require antipsychotic medication, with a start date of May 4, 2024. Review of Resident 45's medical record failed to reveal any documented education of the risks and benefits of or consent for Risperidone by Resident 45 or their Representative. Interview with the Nursing Home Administrator on February 3, 2026, at 11:45 AM, revealed that they could not provide any type of documented consent for Resident 45's Risperidone use. 28 Pa. Code:211.10(a) Resident care policies.28 Pa. Code:211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 29 residents reviewed (Residents 45 and 92). Findings Include: Review of Resident 45's clinical record revealed diagnoses that included chronic kidney disease (the long-term, irreversible loss of kidney function) and dementia (a general term for severe mental function loss). Review of Resident 45's Quarterly MDS (Minimum Data Set is part of federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated November 11, 2025, indicated in Section I2300. Urinary Tract Infection (UTI) (LAST 30 DAYS) that Resident 45 had a UTI in the previous 30 days. Review of Resident 45's clinical record failed to reveal any evidence that Resident 45 had a UTI in the 30 days prior to November 11, 2025. Interview with the Nursing Home Administrator (NHA) on February 5, 2026, at 11:45 AM, revealed that Section 2300 was marked in error and a correction was being completed.Review of Resident 92's clinical record revealed diagnoses that included seborrheic dermatitis (a chronic inflammatory skin condition that causes flaky, white-op-yellowish scales, redness and greasy rash) and squamous cell cancer (cancer in outer layer of skin as well as the lining of hollow organs, respiratory tract and digestive tract) of scalp. Observation of Resident 92 on February 2, 2026, at 11:30 AM, revealed there was a large, scabbed area which covered the entire top of her head. Review of Resident 92's Quarterly MDSs dated November 11, 2025; August 12, 2025; and May 15, 2025, failed to document a diagnosis of cancer in Section I. Interview with Employee 8 (Registered Nurse Assessment Coordinator), Director of Nursing, and the NHA on February 5, 2026, at 10:30 AM, revealed the aforementioned MDSs should've documented cancer as an active diagnosis. 28 Pa Code 211.12 (d)(3)(5) Nursing Services.

Based on policy review, observations, and staff interviews, it was determined that the facility failed to provide respiratory services for two of two residents reviewed for respiratory care (Residents 141 and 144). Findings include:Review of facility provided policy, titled Oxygen Therapy- Assessment, Notification, Application, Documentation, last revised April 25, 2018, failed to reveal an expectation for physician's orders for supplemental oxygen. Review of Resident 141's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - a progressive, incurable, but treatable lung disease) and acute kidney failure (a sudden and often temporary loss of kidney function).Observation of Resident 141 on February 5, 2026, at 10:24 AM, revealed Resident 141 sitting in their wheelchair at bedside. Resident 141 was wearing a nasal canula (oxygen delivery device) and receiving supplemental oxygen at 2 liters per minute.Review of Resident 141's care plan revealed a care plan of: I (Resident 141) have COPD, with a start date of January 20, 2026. Further review of the care plan failed to reveal the amount of supplemental oxygen to be delivered to Resident 141 or the oxygen delivery method.Review of current physician orders for Resident 141 revealed an order for, Routine oxygen use- check oxygen saturation every shift- document hours, liters, and source every shift, with a start date of January 21, 2026. Further review failed to reveal any physician's order for the amount of oxygen to be delivered to Resident 141 or the oxygen delivery method to be used.Review of Resident 144's clinical record revealed diagnoses that included COPD and bronchiectasis (a lung condition that causes cough, sputum production, and recurrent respiratory infections).Observation of Resident 144 on February 2, 2026, at 11:22 AM, revealed Resident 144 sitting in their wheelchair at bedside. Resident 141 was wearing a nasal canula and receiving supplemental oxygen at 3 liters per minute.Review of Resident 144's care plan revealed a care plan of: I (Resident 144) have COPD, with a start date of January 29, 2026. Further review of the care plan failed to reveal the amount of supplemental oxygen to be delivered to Resident 144 or the oxygen delivery method.Review of current physician orders for Resident 144 revealed an order for, Routine oxygen use- check oxygen saturation every shift- document hours, liters, and source every shift with a start date of January 12, 2026. Further review failed to reveal any physician's order for the amount of oxygen to be delivered to Resident 144 or the oxygen delivery method to be used.Interview with the Director of Nursing on February 6, 2026, at 10:15 AM, revealed that she is aware of the orders.28 Pa. Code 211.12(d)(1) Nursing services. 28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on facility policy, clinical record review, and resident and staff interviews, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of two residents reviewed that received dialysis services (Resident 12). Findings Include: Review of facility policy, titled Dialysis Care of Resident- transport, communication, observation, documentation, last revised January 2, 2017, read, in part, the facility is to communicate with dialysis facility. Prior to dialysis, pre-dialysis observation will be completed and sent with or faxed to dialysis center. Upon return from dialysis, a post-dialysis observation will be completed, and physician and dialysis center will be notified as needed. Review of Resident 12's clinical record revealed diagnoses that included end stage renal disease (kidneys don't function properly) and dependence on renal dialysis. Review of Resident 12's February 2026 physician orders included: complete pre-dialysis observation once a day on Monday/Wednesday/Friday 2 PM - 4 PM, start October 12, 2025; and complete post-dialysis observation once a day on Monday/Wednesday/Friday 2 PM - 4 PM, start October 3, 2025. No documented physician orders for dialysis. Review of Resident 12's care plan documented a focus area for Resident has hemodialysis due to renal failure, last edited January 15, 2026. Interventions included dialysis treatments Monday/Wednesday/Friday, last edited September 29, 2025; staff to monitor and document vital signs - blood pressure left or right arm, respirations, pulse, pulse oximetry, temperature, and weight, last edited September 29, 2025; dialysis treatments per physician order, last edited September 29, 2025. Review of Resident 12's electronic medical record failed to document complete pre- or post-dialysis assessments on December 5th, 17th, 22nd, 2025; and January 9th, 14th, 23rd, 26th, and 28th, 2026. The facility assessments that were completed didn't include weight monitoring. Interview with Employee 6 (Licensed Practical Nurse [LPN]) on February 2, 2026, at 10:30 AM, revealed the facility doesn't maintain documentation of communication with the dialysis center. The facility completes an assessment pre- and post-dialysis to monitor blood pressure, but not weight. Interview with the Director of Nursing on February 5, 2026, at 10:40 AM, it was revealed facility pre- and post-dialysis assessments should be completed. It was also revealed that communication between the dialysis center and the facility should be available. 28 Pa Code 211.5(f) Clinical records28 Pa. Code 211.12 (d)(1)(3)(5) Nursing service

Based on review of the ice machine equipment manual, observations, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety for one of three pantry refrigerators and one of three ice machines. Findings include: Review of the ice machine manual, section 4- maintenance, read, in part, clean and sanitize the ice machine a minimum of every six months. If the machine requires more frequent cleaning and sanitizing, consult a qualified service company to test the water quality and recommend appropriate water treatment. An extremely dirty ice machine must be taken apart for cleaning and sanitizing. Observation with Employee 1 (Registered Dietitian) on February 2, 2026, at 9:40 AM, of inside the Flowers unit nourishment refrigerator revealed dried yellow and red liquids were noted on the bottom shelf. At that time, Employee 1 revealed the refrigerator needs to be cleaned. Observation with Employee 2 (Licensed Practical Nurse [LPN]) on February 3, 2026, at 9:49 AM, in the ice machine on Lilly Lane revealed pink and black substances on the baffle/deflector that was able to be wiped away with a dry paper towel. The inside top panel of the ice machine, the drip tray, and the bottom rim of the cover in front of the evaporator grid contained a black substance that was able to be wiped with a dry paper towel. At that time, Employee 1 stated that maintenance was in the process of cleaning the machine.Interview with Employee 3 (Maintenance) on February 3, 2026, at 9:55 AM, revealed that someone touched the ice, and he was in the process of emptying the machine and cleaning the inside of the machine.At that time, the surveyor pointed out the concern with the pink and black substance on the drip ledge and the black substance on the inside top panel of the ice machine, the drip tray, and the bottom rim of the cover in front of the evaporator grid. Employee 3 then stated, he uses a chemical to clean the machine; he was not sure what the name of the chemical was.Observation at 10:05 AM, revealed Employee 4 (Director of Operations) was providing instructions to Employee 3 on how to clean the ice machine. At that time, interview with Employee 4 revealed the ice machines are on a 6-month cleaning schedule.Review of Lily Lane ice machine inspection check sheet documented the ice machine was inspection February 2, 2026; and September 2, 2025.Interview with the Nursing Home Administrator on February 5, 2026, at 10:30 AM, revealed the refrigerator and ice machine should be clean. 28 Pa code 211.6(f) - Dietary Services

Based on policy review, observations, clinical record reviews, facility document review, and staff interviews, it was determined that the facility failed to protect the residents' right to privacy for three of three residents reviewed for the use of video/audio monitoring (Residents 16, 27, and 65). Findings include: Review of facility policy, titled Resident Rights, not dated, revealed it stated: 1. The Resident has the right to be informed of their rights and of all rules and regulations governing resident conduct and responsibilities both orally and in writing prior to or upon their admission or as appropriate during their stay. 2. The Resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 3. The Resident has the right to exercise their rights as a Resident of Rest Haven - [NAME] and as a citizen of the United States. 4. If the Resident is not capable of exercising their rights, a court-appointed person or Power of Attorney may exercise their rights. A Resident who has not been adjudged incompetent has the right to designate a representative and the representative may exercise the Resident's rights to the extent provided by the law . 11. The Resident has the right to choose a personal attending physician and to be [NAME] informed by the physician or other professional in advance about the risks and benefits of proposed care and treatment, alternatives to proposed care and treatment, and to participate in planning care and treatment . 24. The Resident has the right to privacy and confidentiality with their written, electronic, and telephone communication and personal visits . 31. The Resident has the right to an environment that promotes maintenance or enhancement of quality of life including respect, dignity, and privacy during personal care . Review of Resident 27's clinical record on January 29, 2025, revealed diagnoses that included chronic kidney disease stage three (moderately decreased ability of the kidneys to filter toxins from the blood) and history of cerebral infarction (stroke - sudden loss of blood, or bleeding in the brain that causes damage to the brain cells, which can result in physical and mental deficits and/or death). During observations on January 29, 2025, at approximately 9:30 AM, it was observed that a device resembling a camera was observed on the bedside dresser of Resident 27. During a staff interview at approximately 9:36 AM, Employee 9 stated that it was a monitor for Resident 27 to monitor Resident 27 at night due to Resident 27 having a history of attempting to get out of bed and falling. At the time of the observation Resident 27 was not in bed, nor in the room. Observation of the nurses' station adjacent to the unit Resident 27 resided, revealed two small monitor screens. Both screens were in direct line of sight from the hallway. During the observation, no staff were sitting at the nurses' station. It was observed that both monitors were on at that time. Review of Resident 27's physician's orders revealed an order dated January 13, 2025, for, Safety measures: encourage grip socks in bed, offer [out of bed] to nurses station in restless, camera monitor at bedside, low BED. Review of Resident 27's comprehensive plan of care revealed that it did not include the use of a video/audio monitoring system. Observation of the second monitor revealed it displayed Resident 16 who was laying in bed, facing the camera. It was also observed that audio from Resident 16's room was audible from the monitor, which also included light indicators of the audio transmission. Review of Resident 16's clinical record, revealed diagnoses that included peripheral vascular disease (disease of the cardiovascular system that results in decreased blood flow to the extremities) and type II diabetes mellitus (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment). Review of Resident 16's physician orders revealed they did not include an order for the video/audio monitoring device. Review of Resident 16's comprehensive plan of care revealed that the use of a video/audio monitor was not included in the comprehensive plan of care. Review of Resident 65's clinical record on January 30, 2025, revealed diagnoses that included epilepsy (neurological condition characterized by seizures caused by abnormal brain activity) and dementia (irreversible, progressive degenerative brain disease that results in decreased ability to perform activities of daily living and decreased contact with reality). Review of Resident 65's physician orders revealed an order dated November 27, 2024, for Safety measures: redirect/reorient/reassure [as-needed] if resident is seeking to get up to go home, camera monitor, [bilateral] crash mat. Review of Resident 65's comprehensive plan of care revealed it did not include the use of a video/audio monitor. During a staff interview on January 30, 2025, Nursing Home Administrator (NHA) provided a list that revealed seven total residents had video/audio monitoring. Review of the resident list revealed the start date of the monitors were as follows: Resident 16's monitoring device was started on October 1, 2024. Resident 27's monitoring device was started on January 13, 2025. Resident 65's monitoring device was started on November 27, 2024. During a staff interview on January 30, 2025, at approximately 10:15 AM, NHA characterized the video/audio devices as baby monitors. The NHA stated that the use of the monitors is decided during a residents' care plan meeting and that the monitors should be included in the care plan. The NHA further revealed that the facility did not have a policy or procedure for to the protection of Resident(s) privacy with the use of a video/audio monitor. When asked if the facility obtained consent from the resident/resident representative, or the consent of the resident/resident representative of the roommate, the NHA stated that there was no consent obtained. During the staff interview, the NHA revealed that she was not aware that Resident 16's video/audio monitor was transmitting both video and audio. 28 Pa code 201.18(b)(1)(2)(3)(d) Management 28 Pa code 201.29(a) Resident rights 28 Pa code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, observation, review of select facility documentation, and staff interviews, it was determined that the facility failed to utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen. Findings include: Review of facility policy, titled Machine Warewashing, last revised December 1, 2007, read, in part, Purpose: To ensure that the dishwashing machine is operating in accordance with facility guidelines, department policy, manufacturers specifications and regulatory guidelines. Policy: The dish washing machine is serviced on a regular basis. Wash and rinse temperatures of the dish machine are monitored during each major use (3 times daily). Acceptable temperature ranges are: wash- minimum 150 degrees. If the machine operating temperatures are lower than the specified minimum temperature staff members will suspend the machine washing and notify the Dietary Supervisor, and/or the Food Service Director, and/or the Assistant Food Service Director and maintenance personnel. The following process will be used to assess machine operation: The holding tank temperature will be confirmed with a pocket thermometer. The booster heater will be checked to confirm that it is switched on. The holding tank may be emptied and reloaded with fresh water. Temperatures will be rechecked. If the temperature of the dish machine falls below 150 degrees, the bleaching system should be hooked up and booster heater turned off to utilize the low heat option. Observation of the January 2025 dish machine temperature log in the main kitchen on January 27, 2025, at 9:43 AM, revealed the wash temperature was below the minimum safe temperature of 150 degrees on January 9-12 during breakfast; January 9-14 during lunch; and January 8, 16, 21 and 22 during dinner. No corrective action was noted. Interview with Employee 2 (Food Service Director) on January 27, 2025, at 9:44 AM, revealed staff had not made her aware of the low temperatures in January 2025. Review of the dish machine temperature logs from May 2024 through January 2025, revealed If minimum temperature is not met- Please contact maintenance. Review of the May 2024 dish machine temperature log revealed the wash temperature was below the minimum safe temperature of 150 degrees on May 7-9, 11, 12, 14-17, 20, 23, 25-28, and 30 at breakfast; May 8, 9, 11, 12, 14-17, 20, 23, 25-28, and 30 at lunch; and May 10, 14, 16, 17, 20-24 at dinner. Further review failed to reveal notation of corrective action taken. Review of the June 2024 dish machine temperature log revealed the wash temperature was below the minimum safe temperature of 150 degrees on June 5-11, 13, 25, 27, 28, and 30 at breakfast; June 2, 3, 5-11, 13, 14, 17, 18, 22-24, 27, 28, and 30 at lunch; and June 4, 5, 12, 13, 19, and 25 at dinner. Further review failed to reveal notation of corrective action taken. Review of the July 2024 dish machine temperature log revealed the wash temperature was below the minimum safe temperature of 150 degrees on July 3-11, 15-21, 23, 25, and 29-31 at breakfast; July 2-11, 16-23, 26, 30 and 31 at lunch; and July 3 and 26 at dinner. Further review failed to reveal notation of corrective action taken. Review of the August 2024 dish machine temperature log revealed the wash temperature was below the minimum safe temperature of 150 degrees on August 1, 3-5, 7, 8, 12-15, 17, 18, 22-24, 26-29, and 31 at breakfast; August 1, 3-5, 7, 8, 10, 12, 13, 15, 17, 18, 20, 22-24, 26-29 and 31 at lunch; and August 1, 3, 15, and 30 at dinner. Further review failed to reveal notation of corrective action taken. Review of the September 2024 dish machine temperature log revealed the wash temperature was below the minimum safe temperature of 150 degrees on September 1, 4, 5, 7, 10-12, 14, 15, 19, 22, 23, 25, 28, and 29 at breakfast; September 1, 4-7, 10-15, 19-23, 25, 28 and 29 at lunch; and September 2, 12, and 21 at dinner. Further review failed to reveal notation of corrective action taken. Review of the October 2024 dish machine temperature log revealed the wash temperature was below the minimum safe temperature of 150 degrees on October 1, 8, 11-13, 17, 19-23, 26, 27, and 29-31 at breakfast; and October 8, 10-13, 17, 19-23, 26, 27, 30 and 31 at lunch. Further review failed to reveal notation of corrective action taken. Review of the November 2024 dish machine temperature log revealed the wash temperature was below the minimum safe temperature of 150 degrees on November 5-11, 15-24 and 26-30 at breakfast; and November 1, 5-12, 18-24, and 27-30 at lunch. Further review failed to reveal notation of corrective action taken. Review of the December 2024 dish machine temperature log revealed the wash temperature was below the minimum safe temperature of 150 degrees on December 1-13 and 20-25 at breakfast; December 1-9, 11-17, and 21-25 at lunch; and December 1 and 3 at dinner. Further review failed to reveal notation of corrective action taken. Interview with the Nursing Home Administrator on January 29, 2025, at 11:13 AM, revealed she was unable to provide information if the facility process was followed when the dish machine was running below the minimum acceptable wash temperature, and it is the facility's expectation that kitchen equipment is utilized in accordance with professional standards. 28 Pa. Code 201.18(b)(1) Management

Based on observations, facility policy review, and staff interviews, it was determined that the facility failed to ensure staff implemented infection control policies to prevent the spread of infection by doffing PPE (personal protective equipment) prior to exiting the resident room in two of seven resident care areas observed (100 and 700 hall), and failed to properly disinfect resident areas after one of two dressing changes observed (Resident 12). Findings Include: Review of facility policy with the subject of, PRECAUTIONS, CONTACT - Notification, Initiation, Communication, Prevention, Discontinuation, last revised March 30, 2021, revealed the policy's purpose stated, To provide a uniform process through which facility is notified of potentially harmful microorganisms, contact precautions are initiated, risk is communicated, spread of microorganisms is prevented and contact precautions are discontinued. Review of the aforementioned policy's Procedure section revealed it included, 5. Obtain a container for dirty linens and place inside the resident's room .10. The following personal protective equipment will be used when caring for residents with a potentially harmful microorganism: a. Gloves - required when entering a resident's room, when anticipating direct contact with a resident, [the residents] environment or [the residents] equipment that could result in contamination of the hands; remove gloves and wash hands immediately before leaving the room . Review of Resident 24's clinical record revealed diagnoses that included diabetes (a chronic disease that occurs when the body doesn't produce enough insulin or can't use insulin properly) and peripheral vascular disease (a condition that affects the blood vessels outside the heart and brain). Review of Resident 24's current physician orders revealed an order for enhanced barrier precautions related to a wound, with a start date of November 24, 2024, and no end date. Observation of Employees 7 and 8 on January 27, 2025, at 10:11 AM, revealed them wearing protective gowns while providing care to Resident 24, who is on enhanced barrier precautions. After Employees 7 and 8 completed providing the care, they exited Resident 24's room and entered the hallway, still wearing the protective gowns. Employees 7 and 8 then removed their gowns and disposed of them in the garbage can located in the hallway. Interview with the Nursing Home Administrator (NHA) on January 28, 2025, at 1:15 PM, revealed that the garbage cans are located in the hallway because of a lack of space in the resident rooms, and that her expectation is that the employees would have removed their gowns and gloves before exiting the Resident room and put them in a garbage bag; which they could then place into the garbage can that was located in the hallway. Review of facility policy, Precautions, Enhanced Barrier, last revised November 11, 2024, failed to reveal a location that PPE should be removed and disposed of. Review of Resident 12's clinical record revealed diagnoses that included pressure ulcer (a localized area of skin damage that develops when prolonged pressure is applied to a specific area of the body) and heart failure (a condition where the heart muscle is weakened and cannot pump blood effectively). Observation of a dressing change completed by Employee 6 on January 29, 2025, at 9:31 AM, revealed Employee 6 completed a dressing change on Resident 12's ankle. After completing the dressing change, Employee 6 gathered up the garbage from the supplies used, including the bandage that was removed from Resident 12's ankle and the gauze that was used to clean the pressure ulcer on her ankle, and placed them into a biohazard garbage bag. Employee 6 then sat that garbage bag on Resident 12's bedside table. Employee 6 finished gathering her supplies and exited Resident 12's room and disposed of the garbage in the appropriate receptacle. At no time did Employee 6 cleanse Resident 12's bedside table after sitting the garbage bag filled with biohazard garbage on it. Interview with the NHA on January 29, 2025, at 1:15 PM, revealed that her expectation would be that the Employee would have cleansed the bedside table after it was contaminated. Review of Resident 37's clinical record on January 27, 2025, revealed diagnoses that included stage three pressure ulcer of the sacrum (wound that extends below the tissue of the skin caused by pressure over a bony prominence) and congestive heart failure (decreased ability of the heart to pump blood throughout the body). Further review of Resident 37's clinical record revealed that Resident 37 was on contact precautions due to an infection with a multi-drug resistant organism (MDRO). During wound dressing observations on January 29, 2025, at approximately 10:25 AM, Employee 15 (Licensed Practical Nurse) was observed preparing Resident 37 for the wound dressing change on Resident 37's sacral area. Employee 15 was assisted with repositioning the Resident, including handling Resident 37's foley catheter bag. During the dressing change observation, Employee 15 was observed placing Resident 37's foley catheter bag on the Resident's bed during repositioning. After Resident 37 was repositioned, Employee 19 handled Resident 37's foley catheter bag and hung it on the bed frame. Employee 15 then placed a red biohazard bag onto the Resident's bed in the approximate same location that the foley bag was placed earlier. After the dressing change, Employee 15 and Employee 19 exited the room while wearing gown and gloves (personal protective equipment utilized while providing care to Resident 37). Employee 15 was observed holding the red biohazard bag with her gloved hand. Both Employee 15 and 19 removed the gloves and gowns while in the hallway. Employee 15 was then observed handling the red biohazard bag with her bare hand. Employee 15 was then observed walking through the hall of the [NAME] unit to the nurses' station while holding the red bag. Employee 15 then retrieved a key attached to a piece of metal from the wall at the nurses' station. Employee 15 was then observed opening a utility closet, unlocking a freezer, and placing the red biohazard bag into the freezer, after which Employee 15 exited the room and returned the key to it's hanging apparatus on the wall at the nurses' station. Finally, Employee 15 washed her hands with soap and water at the nurses' station. During a staff interview directly after the observation, Employee 15 was asked if she knew when the key she had utilized was last cleaned. Employee 15 responded that she did not know. When asked if the key is ever cleaned, Employee 15 responded that she did not know. Interview with the NHA on January 29, 2025, at approximately 1:00 PM, the NHA again confirmed that staff should be removing gown and gloves while in the room, placing them in a bag and then exiting the room to dispose of the gown and gloves in the disposal bin outside of the resident room. During a staff interview on January 30, 2025, at approximately 10:15 AM, the NHA agreed that the observation of Employee 15 transporting the red biohazard bag with her bare hand and touching other surfaces during that time was an infection control concern. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like environment for one of 30 resident's reviewed (Resident 106). Findings include: Review of facility policy, titled Resident Rights, not dated, read, in part, The Resident has the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Observation in Resident 106's room on January 27, 2025, at 10:01 AM, revealed her tray table was dirty, and the mat overtop was stained with a red substance. Observation in Resident 106's room on January 28, 2025, at 10:48 AM, revealed her tray table was dirty, and the mat overtop was stained with a red substance, same as the day prior. Observation in Resident 106's room on January 29, 2025, at 10:51 AM, revealed her tray table was dirty, and the mat overtop was stained with a red substance, same as the days prior. During an interview with the Nursing Home Administrator (NHA) on January 29, 2025, at 11:12 AM, the surveyor revealed the concern with the observations of Resident 106's tray table. Follow-up interview with the NHA on January 30, 2025, at 10:11 AM, she revealed house keeping staff does weekly rounds to clean rooms, and it is the responsibility of nursing staff to wipe down tray tables daily and clean them as needed. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(3) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to conduct a Significant Change Minimum Data Set (MDS - standardized assessment tool utilized to identify a resident's physical, mental, and psychosocial needs) for one of four residents reviewed for hospice status (Resident 70). Findings include: Review of Centers for Medicare and Medicaid Services' Resident Assessment Instrument Version 3.0 Manual provides instructions for completing the resident Minimum Data Set assessment. The manual revealed instructions that a Significant Change Minimum Data Set is required to be performed when a terminally ill resident enrolls into a hospice program (end of life program). Review of Resident 70's clinical record revealed diagnoses that included vascular dementia (brain damage caused by multiple strokes that causes memory loss in older adults) and hypertension (elevated blood pressure caused by the force of blood against the artery walls being too high). Review of Resident 70's MDS assessments revealed Resident 70 had an annual MDS completed with an assessment reference date of April 4, 2024. Review of Resident 70's clinical record revealed that Resident 70 was admitted to Hospice services on March 29, 2024. Review of Resident 70's MDS assessments revealed the facility did not conduct a Significant Change MDS after Resident 70 was admitted to Hospice. Instead, the facility conducted an Annual MDS assessment that had an assessment reference date of April 4, 2024. During a staff interview on January 29, 2025, at approximately 11:00 AM, the Nursing Home Administrator revealed that the facility should have conducted a Significant Change MDS because of Resident 70 entering Hospice services. A copy of the modified MDS dated [DATE], changed to a significant change in status assessment was provided on January 29, 2025. 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on facility policy review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain grooming for one of 30 residents reviewed (Resident 7). Findings include: Review of facility policy, titled Shaving Residents- Preparation, Completion, last revised May 23, 2017, read, in part, Policy: It is the policy of this facility to prepare for and shave residents as needed. Purpose: To provide a uniform process, through which staff prepare for and shave residents. Document in electronic health record. Review of Resident 7's clinical record revealed diagnoses that included hypertension (high blood pressure), anxiety disorder (a persistent a feeling of worry, nervousness, or unease), and neuromuscular dysfunction of bladder (occurs when the nerves that control the bladder are damaged or not functioning properly). Observation of Resident 7 on January 27, 2025, at 11:57 AM, revealed a quarter inch of facial hair over her upper lip and on her chin. Interview with Resident 7 on January 27, 2025, at 11:57 AM, revealed she had a shower that morning and she prefers assistance with shaving on shower days. Observation of Resident 7 on January 28, 2025, at 10:53 AM, revealed a quarter inch of facial hair over her upper lip and on her chin. Observation of Resident 7 on January 29, 2025, at 10:47 AM, revealed a quarter inch of facial hair over her upper lip and on her chin. Review of Resident 7's care plan revealed a focus area of ADLs (Activities of Daily Living) Functional Status, last edited December 23, 2024, with an intervention for I need staff to follow my care profile for specific ADL information, last edited January 29, 2024. Review of Resident 7's clinical record revealed documentation on January 27, 2025, at 7:14 AM, that she received a shower and required Physical help in part of bathing with 1 person physical assist, and documentation that stated How did the resident maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands, and was documented that Resident 7 required Partial/Moderate Assistance. Email correspondence with the Nursing Home Administrator (NHA) on January 29, 2025, at 2:29 PM, revealed she did not have any information to provide regarding Resident 7's facial hair. During a follow-up interview with the NHA on January 30, 2025, at 10:13 AM, she revealed her expectation that staff should offer shaving with showers and as desired. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on clinical record review, hospital record review, and staff interviews, it was determined that the facility failed to provide care and services that met professional standards for one of 30 residents reviewed (Resident 240). Findings include: Review of Resident 240's clinical record on January 29, 2025, revealed diagnoses that included stage three chronic kidney disease (moderate impairment of the kidneys to filter toxins from the blood) and anxiety disorder (mental health disorder characterized by excessive worry and fear). Review of Resident 240's clinical record revealed that Resident 240 was admitted to the facility from the hospital on January 27, 2025, at 1:40 PM. Review of hospital discharge records for Resident 240 revealed that the discharge information did not include any wounds identified on Resident 240. Review of Resident 240's electronic health record revealed that on January 27, 2025, Employee 15 (Licensed Practical Nurse) completed the admission document titled, Other Ulcers, Wounds and Skin Problems, provided the descriptive categories for staff to check that included Infection of the foot (e.g., cellulitis, purulent drainage); Diabetic foot ulcer(s); Other open lesion(s) on the foot; Open lesions(s) other than ulcers, rashes, cuts (e.g., cancer lesion); Surgical wound(s); Burn(s) (second or third degree); Skin tear(s); Moisture Associated Skin Damage (MASD) (i.e. incontinence (IAD), perspiration, drainage); None of the above were present. Review of the aforementioned subsection revealed it was marked as, None of the above were present, by Employee 15. Review of the subsection, titled Referrals revealed it provided areas to identify needed referrals to Wound Team [sic], and Wound Clinic and it was marked No Referrals Necessary. Review of paper document, titled Skin Wound Documentation Form, revealed that on January 27, 2025, Employee 15 documented multiple areas, including: wound 1 - wound at the tip of the left great toe that measured 1 centimeters (cm - metric unit of measure) by 0.5 cm; wound 2 - a wound at the top of the right great toe that measured 0.7 cm by 0.7 cm; wound 3 - a wound to the side of the right fifth digit (toe) that measured 0.5 cm by 0.5 cm; and wound 9 - an area at the right chest that measured 0.1 cm by 0.1 cm with the description of open area. Review of the document revealed that each line had a space for staff to document a Skin Code for each wound identified. Review of the Skin/Wound Codes section revealed that the codes indicated the type of wound identified, with an option of O = Other specify. Review of the wounds identified, wound 1, 2, 3, and 9, revealed Employee 15 documented O. Review of available clinical record revealed no further information on wound characteristics or type of wound was documented by Employee 15. Review of clinical records for Resident 240 revealed no assessment by a registered nurse of the wounds identified. Review Resident 240's progress notes revealed no documentation to the physician that Resident 240 was admitted with wounds that were not previously identified prior to admission. Review of the physician Admission History and Physical Visit, dated January 28, 2025, completed by Physician 2, revealed the Physical exam subsection Skin, stated, no lesions noted of exposed skin. Review of the physician assessment failed to reveal that the physician was made aware or identified the area identified as wounds by Employee 15 upon Resident 240's admission. The facility wound nurse (Employee 18) did not assess the Resident's foot for wounds until January 29, 2025, and did not a progress note regarding assessing the areas until January 30, 2025, at 8:47 AM. During a staff interview with Employee 18 on January 30, 2025, Employee 18 revealed that the Resident had scabs (hard dark brown tissue composed of dried blood, platelets, and fibrin) on her feet but no wounds. However, subsequent observations of Resident 240's right great toe revealed an area at the right great toe consistent with a wound that was covered with eschar (dark, hard area similar to a scab but is composed of dead tissue, debris and dried blood). Review of the consultant wound progress note dated January 30, 2025, revealed Resident 240 was diagnosed with a full thickness arterial wound of the right great toe which was covered with eschar. As of January 30, 2025, at 1:00 PM, the facility had no further information to provide regarding why an assessment of a previously unidentified wound(s) for Resident 240 was not performed by a Registered Nurse upon admission. 28 Pa code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and staff interviews, it was determined that the facility failed to ensure residents receive treatment and services consistent with professional standards to promote healing and prevent infection for one of two residents reviewed for pressure ulcers (Resident 37). Findings include: Review of Resident 37's clinical record on January 27, 2025, revealed diagnoses that included stage three pressure ulcer of the sacrum (wound that extends below the tissue of the skin caused by pressure over a bony prominence) and congestive heart failure (decreased ability of the heart to pump blood throughout the body). During wound dressing observations on January 29, 2025, at approximately 10:25 AM, Employee 15 (Licensed Practical Nurse) was observed preparing Resident 37 for the wound dressing change on Resident 37's sacral area. After repositioning Resident 37, Employee 15 observed Resident 37 had a bowel movement. Employee 15 cleaned Resident 37's bowel movement prior to starting the dressing change. During the observation, it was observed that Employee 15's gloves were visibly soiled with feces. After cleaning Resident 37's bowel movement and starting the wound dressing change, Employee 15 did not perform hand hygiene with soap and water. Instead, Employee 15 utilized an alcohol-based hand rub during glove changes between cleaning Resident 37's bowel movement and accessing Resident 37's wound. During the observation, it was observed that the dressing that was present on Resident 37 was not dated. After removing the old dressing and cleansing the wound, Employee 15 was observed retrieving a marker from her pocket with her bare hands. At which time, Employee 15 was observed holding two foam dressings one hand and using the marker to write on the new dressing. Employee 15 was observed returning the marker to her pocket. During a staff interview on January 29, 2025, at approximately 11:00 AM, Employee 15 confirmed that her pocket is not considered a clean area. During a staff interview on January 30, 2025, at approximately 10:15 AM, Nursing Home Administrator along with Employee 5 (Registered Nurse/Quality Assurance) confirmed that Employee 15 should have performed hand hygiene with soap and water between cleaning the bowel movement and starting the dressing change, that Employee 15's pocket was not considered a clean surface, and that facility should be labeling wound dressings when they are applied with date and time, and initials. 28 Pa code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical records review, observations, and resident and staff interviews, it was determined that the facility failed to ensure that the resident environment was free of accident hazards for one of 30 Residents reviewed (Resident 26). Findings include: Review of facility policy, Tobacco/smoking- communication, interventions, guidelines, last revised March 2, 2017, revealed that Rest Haven-[NAME] is a smoke and tobacco-free facility/campus. Review of Resident 26's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (a group of lung diseases that cause ongoing inflammation and narrowing of the airways, leading to difficulty breathing) and normal pressure hydrocephalus (a condition where excess cerebrospinal fluid [CSF] accumulates in the brain's ventricles [fluid-filled spaces] without an increase in intracranial pressure). Observation of Resident 26 on January 28, 2025, at 10:04 AM, revealed Resident 26 sitting in her wheelchair in the facility parking lot, next to Employee 9, smoking a cigarette. Interview with Resident 26 on January 29, 2025, at 9:34 AM, revealed that Resident 26 keeps her cigarettes and lighter in her room and that she has nowhere to lock them up, where they cannot be accessed by other residents. Review of Resident 26's medical record on January 28, 2025, failed to reveal any smoking evaluation for Resident safety. Review of Resident 26's care plan failed to reveal a care plan with a focus area related to safety while smoking. Review facility provided email from Resident 26's Representative dated December 11, 2024, at 12:33 PM, revealed that Resident 26 had a desire to smoke cigarettes, and she would leave the facility to do so. Interview of the Nursing Home Administrator on January 28, 2025, at 1:30 PM, revealed that the facility was aware that the Resident was smoking and that they required her to leave the facility grounds to smoke. She also revealed that facility employees are not permitted to take the Resident out to smoke while clocked in to work. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility investigation, clinical record review, and staff interviews it was determined that the facility displayed past noncompliance, in that they had failed to ensure residents receive treatment and care in accordance with professional standards of practice and physician orders for one of seven residents reviewed (Resident 6 ). Findings Include: Review of Resident 6's clinical record revealed diagnoses that inlcuded Diabetes Mellitus Type II (a problem in the way the body regulates and uses sugar as a fuel) and vascular dementia (Brain damage caused by multiple strokes) Review of Resident 6's physician orders revealed an order that read Ozempic (semaglutide) pen injector; 0.25 mg or 0.5 mg .subcutaneous once a day on Friday. Review of Resident 6's Medication Administration Record (MAR), during the month of March 2024, revealed staff did not administer the medication on March 12, 2024, March 22, 2024 and March 29, 2024. The MAR revealed documentation of the reason the medication was not adminstered as Drug/Item unavailable. Review of Resident 6's MAR, during the month of April 2024, revealed staff did not administer the medication on April 5, 2024, with the reason documented as Drug/Item unavailable. An interview with the Nursing Home Administrator, on May 6, 2024, revealed the facility administrator had not been immediately informed of the medication being unavailable, however, once notified, management initiated an investigation, and a plan to address the missing medication. After the administrator was made aware of the missing medication, the medication was re-ordered and the resident was administered the medication. Review of the April and May MAR revealed that Resident 6 was administered the medication per physcian order. After the identification of the missing medication, the facility initiated a plan of correction. Review of the facility's corrective action information revealed all weight loss, injectable medication pens, will be kept in the Supervisor's office. The Supervisor will be notified and the Supervisor and Licensed Practical Nurse (LPN) will administer the medication together. The Supervisor will keep a log of dates the medication was adminstered and the Supervisor will initial the medication was administered and document the LPN administered the medication. The facility educated staff and performed audits to ensure compliance. Prior to the abbreviated survey the facility failed to ensure Resident 6's medication was administered on four occasions, and inform facility administration and/or management of the medication not being available in order to administer to the resident. The facility immediately began an investigation when made aware, investigated the incident thoroughly, and initiated interventions in an effort to prevent a future incident. During the abbreviated survey audits, staff education, and initiated procedures regarding the process of administering injectable medications were observed and reviewed. Staff interviews revealed that staff were educated, and knowledgeable regarding the implemented procedures. 28 Pa. Code 211.12 (d) (1) (2) (5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident's status for two of 28 residents reviewed (Residents 7 and 8). Findings Include: Review of Resident 7's clinical record revealed diagnoses that included vitamin D deficiency, osteoporosis (a condition that weakens bones and increases the risk of fractures), and chronic pain. Review of Resident 7's quarterly Minimum Data Set (MDS - assessment tool utilized to identify residents' physical, mental and psychosocial needs), with an assessment reference date (ARD - last day of the assessment period) of February 6, 2024, revealed Resident 7 was coded as having had a weight loss of 5% or more in the last month or 10% or more in the last six months. Review of Resident 7's weights since her admitted [DATE], failed to reveal a significant weight loss that should have been coded on the quarterly MDS Assessment with ARD of February 6, 2024. During an interview with the Director of Nursing (DON) on February 28, 2024, at approximately 10:15 AM, the surveyor inquired about Resident 7 being coded for weight loss on her quarterly MDS Assessment. A follow-up interview with the DON on February 29, 2024, at 11:27 AM, revealed Resident 7 did not have a significant weight loss to be captured on the assessment, and she would have expected resident MDS assessments to be coded accurately. Review of Resident 8's clinical record revealed diagnoses that included sepsis (a life-threatening complication from infection, causing the body to have a severe inflammatory response to bacteria) and urinary tract infection (UTI - an infection in any part of your urinary system: kidneys, bladder, ureters, and urethra). Review of Resident 8's clinical record revealed a hospital discharge summary dated January 29, 2024. Further review of the aforementioned document revealed Resident 8 had been hospitalized [DATE] through 29, 2024, and was diagnosed with sepsis related to a UTI. Review of Resident 8's quarterly Minimum Data Set, dated dated dated [DATE], section I2300 urinary tract infections (UTI) (last 30 days) revealed the facility failed to indicate Resident 8 had a UTI in the last 30 days. During an interview with the DON on February 29, 2024, at 11:35 AM, in the presence of the Nursing Home Administrator, the DON stated Resident 8's UTI should have been indicated on the MDS and it is the expectation of the facility for MDS assessments to be accurate. 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for two of 28 residents reviewed (Residents 118 and 128). Findings include: Review of facility policy, titled Interdisciplinary plan of care- development. Review, and update, last revised October 13, 2017, revealed It is the policy of this facility to develop an individualized plan of care for each resident, and review and update the care plan as needed .Care plans will be updated with the quarterly OBRA (Omnibus Budget Reconciliation Act) schedule, as significant changes occur and by the interdisciplinary team as changes arise. Review of Resident 118's clinical record revealed diagnoses that included post-traumatic stress disorder (PTSD - a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event) and generalized anxiety disorder (condition that causes you to feel anxious about a wide range of situations and issues). Review of Resident 118's care plan on February 27, 2024, at 11:17 AM, revealed a care plan focus created March 17, 2023, for I have post-traumatic stress disorder (PTSD) due to, with an intervention of, I need staff to be aware of my triggers to trauma. My triggers include. During a staff interview February 28, 2024, at 10:24 AM, with the Director of Nursing (DON) and Nursing Home Administrator (NHA), the surveyor requested additional information regarding Resident 118's PTSD diagnosis indicators and triggers not being identified on the care plan. During an additional staff interview February 29, 2024, at 12:15 PM, with the NHA, she indicated the facility was unable to determine Resident 118's PTSD triggers due to Resident 118's inability to communicate his triggers and not having any relatives familiar with his diagnosis. The NHA stated that Resident 118's care plan had been updated now, and it was the facility's expectation that the care plan would have been updated timely. Review of Resident 128's clinical record revealed diagnoses that included congestive heart failure (CHF - excessive body/lung fluid caused by a weakened heart muscle), emphysema (a lung disease which results in shortness of breath due to destruction and dilatation of the alveoli), and acute pulmonary edema (a condition where fluid accumulates in lung tissues causing shortness of breath, wheezing, and coughing up blood). Review of Resident 128's physician orders on February 26, 2024, revealed an order for, Diet (Regular) Diet Consistency (regular) Liquid Consistency (Thin) 1200 ml (milliliter- unit of measure) fluid restriction, with a start date of January 9, 2024. Review of Resident 128's clinical record revealed a fax from Resident 128's cardiology appointment on January 29, 2024, with the following recommendations: 2300 mg (milligram- unit of measure) sodium restriction, 1800 ml fluid restriction. Review of Resident 128's clinical record revealed an evaluation note on January 30, 2024, that stated, Fluid restriction updated to 1800, weight changed to three times weekly and fax to HF (heart failure) clinic on Fridays. Review of Resident 128's care plan on February 28, 2024, at 10:00 AM, failed to reveal that Resident 128 is to follow an 1800 ml fluid restriction and sodium restricted diet. During an interview with the DON on February 28, 2024, at 1:22 PM, the surveyor requested information on whether Resident 128's fluid restriction should be 1200 ml or 1800 ml, and whether she was on a sodium restricted diet or not. Email correspondence with the DON on February 29, 2024, at 10:40 AM, revealed that Resident 128 should have had the 1800 ml fluid restriction starting January 30, 2024, and she explained the facility process of following a low sodium diet. During an interview with the DON on February 29, 2024, at 11:29 AM, she revealed Resident 128's care plan should have been updated to reflect the 1800 ml fluid restriction and sodium restriction. 28 Pa. Code 211.12(d)(5)Nursing services

Based on facility policy review, clinical record review, hospital record review, facility incident report, and staff interviews, it was determined that the facility failed to ensure the prevention of a significant medication error, which caused actual harm by compromising the resident's clinical condition and resulted in the resident's transfer to the hospital for medication overdose following the medication error for one of 28 residents reviewed (Resident 359). Findings Include: Review of facility policy, titled Medication Administration- Preparation, Review, Safety, Administration last reviewed in May of 2022, revealed the following: Policy: It is the policy of this facility to prepare, review and safely administer medications. Measures identified in the policy included: 2. Read EMAR and medication label 3 times before administering medication. Review of Resident 359's clinical record revealed diagnoses that included Alzheimer's Disease, anxiety disorder, and dementia with behavioral disturbances. Review of Resident 359's physician's orders revealed an order for lorazepam gel (a topical medication that is applied to the skin to reduce anxiety) 5 milligrams/milliliter give 0.5 milligrams topical every six hours as needed (prn), for combativeness, restlessness, and inability to relax, dated February 18, 2023. Review of Resident 359's Medication Administration Records revealed that a prn (given as needed) dose of lorazepam (ativan) gel was administered on February 24, 2023, at 6:34 PM, for restlessness and anxiety. It further indicated that the medication was effective. Review of Resident 359's clinical record progress notes revealed a nurse's note dated February 24, 2023, at 12:57 PM, that indicated that Resident 359 was pleasant and cooperative with care; took medications crushed without difficulty; vital signs were stable; complained of abdominal pain/discomfort; and had normal bowel sounds. The note further indicated that the Registered Nurse was aware, and that nursing would continue to monitor. Further review of the progress notes revealed that there was no nurse's note corresponding to the ativan administration on February 24, 2023, at 6:34 PM. The next entry in the nurse's notes was dated for February 24, 2023, at 8:49 PM, which indicated, Writer found resident in unresponsive state at 20:05 [8:05 PM]. Resident was sitting at nursing station in wheelchair. Writer noticed resident had head hyperextended and pupils were not reactive to light. Resident did not respond to staff for about 15-20 minutes. Resident was trying to cough, but was unable to clear throat. Abdominal thrust attempted, unsuccessful, gag reflex was absent. Vital Signs: Temperature 98 degrees F, Pulse/ Heart Rate 54, Respirations 18, Blood Pressure 170/71, and Oxygen Saturation was 97% on Room Air. Initial Blood Pressure was 188/88 then came down to 170/71. Resident had no strength or grip to LUE [Left Upper Extremity] or RLE [Right Lower Extremity]. The note further indicated that Resident 359's Power of Attorney was contacted and updated on Resident's status and that the Power of Attorney wanted the Resident sent to the hospital to be evaluated. The physician was then notified of Resident's status and an order was obtained to send Resident 359 to the hospital due to unresponsive episode, loss of consciousness, high blood pressure, and possible aspiration (accidental breathing in of fluid or food into the lungs). A nurse's note dated February 24, 2023, at 11:42 PM, indicated that the emergency department at the hospital was called and was given information on the medications administered earlier in the evening. Review of Resident 359's Hospital History and Physical dated February 25, 2023, at 7:01 AM, indicated the following: 1. Principal problem: altered mental status, unspecified altered mental status type; 2. Active problems: small bowel obstruction; incarcerated hernia; accidental overdose; dementia; and somnolence; 3. At some point was given topical ativan. Apparently, [Resident 359] were given a very large dose by mistake; 4. Was given 5mg on skin instead of half a milligram. This was for some agitation and quite possibly the agitation was probably from abdominal pain; 5. The patient [Resident 359] is protecting their airway, but is very sedated and obviously cannot be discharged at this time; 6. Consideration was given to administering a medication to reverse the sedation, but the physician determined for the sake of bringing [patient] out of this slowly, it is probably reasonable to let it fade off; 7. At this point, we think [patient's] mental status is most likely due to ativan induced somnolence. Patient still able to protect [their] airway; and 8. Suspect [their] mental status is most likely due to the ativan overdose. Plan for hospitalization for monitoring of his mental status. Review of the facility's event/incident report indicated that Resident 359 was given prn (as needed) ativan at 6:34 PM for agitation. The agency (supplemental nursing staff provided by a contracted company) nurse, [Employee 2] gave 1 milliliter of ativan which equaled 5 milligrams rather than the ordered dose of 0.1 milliliter which equaled 0.5 milligrams. Resident was found unresponsive at 8:05 PM, assessed by Registered Nurse immediately, physician notified, and Resident was sent to the ER for evaluation. Medication error was not found until the change of shift when the administering agency nurse was counting controlled medications with the next shift. The report also indicated that the agency that provided the nurse was notified and that this nurse would not return to the facility. During an interview with NHA and Director of Nursing (DON) on March 9, 2023, at approximately 10:36 AM, the DON indicated that she would have expected the agency nurse to properly administer the medication as ordered. 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.9(a)(1) Pharmacy Services

Based on observations, review of clinical records, facility policies and staff interviews, it was determined that the facility failed to ensure an environment free from accident hazards and failed to ensure adequate supervision to prevent accidents for six out of 11 residents reviewed (Residents 3, 7, 13, 14, 16, 17). Findings included: Review of the facility's policy titled, "Medication-Controlled Drugs", revised on June 19, 2013, revealed that when medication is discontinued any remaining medication should be given to the nursing supervisor to place in a locked area until proper disposal occurs. Observations during the initial tour on July 28, 2013, between 9:15 a.m. and 9:35 a.m., on the Orchid Unit, revealed two packets of medication laying on the corner of the nursing station desk with Resident 16 in a wheelchair approximately three feet from the medication. The medication was unsupervised while Licensed Practical Nurse, LPN 1, was in a resident's room. The medication was Lorazepam 0.5 mg (medication used for anxiety) with 20 pills in the packet and acidophilus capsules (used for milk allergies [REDACTED]. An interview with LPN 1 on July 28, 2013, at 9:35 a.m,. confirmed that she left the medication there for the supervisor and that she should have locked them in the medication cart. LPN 1 also stated that Resident 16 is alert and can propel herself in the wheelchair. During an observation on July 28, 2013, at 9:25 a.m., the Boiler Room on the Rehab Unit was unlocked. It was observed to contain a hot water tank that was in operation with a registered temperature reading of 155 degrees, four electrical panels, five boxes of biohazard materials (infectious agents), three sharps containers (units used to hold used needles), and a housekeeping cart with bottles of Purell alcohol based sanitizer and Comet bathroom cleaner. At 9:45 a.m., the Physical Therapy room was unlocked and unattended with a Hydrocollator (unit used to maintian temperature of heat packs) powered on and the water temperature tested at 148 degrees Fahrenheit. A bottle of Oxivir 5 disinfectant was sitting on the counter by the door. During an interview on July 28, 2013, at 9:40 a.m., LPN 2 stated that the doors should not be unlocked and he locked the Boiler Room door. He stated that therapy personnel were not present on the weekends and he would have to call the supervisor for a key to lock the therapy room. At 9:47 a.m., the Supply Closet across from resident room 329 was observed to be unlocked with no staff in the hallway. The room was observed to contain three bottles of multi-vitamins, five bottles of Milk of Magnesia, three bottles of laxative fiber, twelve bottles of Aspirin, and four bottles of Acetaminophen. During an interview on July 28, 2013, at 9:47 a.m., Nursing Assistant, NA 3, stated the door should be locked, and she promptly locked it. During an observation on July 29, 2013, at 9:30 a.m., two blister packs of medication containing Doxycyline (an antibiotic) and Cephalexin (an antibiotic) were observed sitting unattended at the Rehab nurses station. During an interview on July 29, 2013, at 10:30 a.m., Registered Nurse, RN 2, stated that the medications were waiting to be given to a supervisor to return to the pharmacy. She stated the medications for return are kept at the nurses' station, and there are usually staff around the area. During an interview with the Nursing Home Administrator and the Director of Nursing (DON) on July 29, 2013, at 2:30 p.m,. both agreed that the medication should have been locked in the medication cart until the supervisor was able to destroy them. A review of Resident 3's clinical record revealed [DIAGNOSES REDACTED]. Resident 3's care plan, dated June 2, 2013, indicates that she is at risk for falls due to medication side effects, cognitive loss, no safety awareness and impulsiveness. Care plan interventions included that the staff were to review her care profile sheet, and have a body alarm in place when in bed and in her wheelchair. Review of an Accident/Incident Report dated July 5, 2013, indicates Resident 3 had a fall from her wheelchair and sustained an abrasion and bruise to her left forehead. The report indicates that the body alarm was not on the wheelchair and that the staff had forgotten to put it on. Review of Resident 14's care plan, dated June 10, 2013, indicates that she is at risk for falls due to medication side effects, cognitive loss, and history of falls. The resident's [DIAGNOSES REDACTED]. Her care plan included that staff were to review her care profile sheet which states that various types of alarms are or were in use since the care plan was developed in June 2013. Review of Resident 14's Accident/Incident Reports revealed the following: Report dated June 29, 2013, indicated that Resident 14 had a fall from her bed and was found lying on her left side on the floor, beside her bed by the staff who heard her yelling out for help. The report indicated that the personal alarm, which was to have been on, did not sound. There was no investigation into why it didn't sound. The resident sustained [REDACTED]. Report dated July 2, 2013, indicated that Resident 14 was found on the floor beside her wheelchair after she had been left unattended and was without the alarm attached. She sustained no injury. Report dated July 3, 2013, indicated that Resident 14 was found on the floor beside her bed with the body alarm not attached to the resident. She sustained no injury. During an interview on July 31, 2013, at 9:50 a.m., the DON stated that she was aware of the aforementioned falls and expects that the staff would put the alarms on the residents according to their care plans, and that, if the alarm was on but didn't sound, an explanation of why the alarm did not sound, would be noted so it could be corrected. Resident 13 was admitted to the facility on [DATE], following a fall with a fracture while at home. Review of the Fall Risk assessment dated [DATE], revealed a total assessment score of 14 which placed her at high risk for falls. Interventions that were supposed to be implemented following admission included non-skid footwear and a bed alarm. Review of the care planning notes dated June 5, 2013, revealed a body alarm was to be put into place. Review of an Accident/Incident Report dated July 11, 2013, revealed that Resident 13 was found on the floor by therapy with no injury noted. The statement by therapy staff indicated they, "went to patients room and unable to locate her in bed, wheelchair or bathroom, walked towards middle of room and located patient on floor between beds with no verbal response or movement." There was no documentation on the report that an alarm was in place or sounding. Review of the care plan revealed interventions of a bed and chair alarm were not added until July 11, 2013. During an interview on July 30, 2013, at 11:35 a.m., the DON stated it was unclear whether the bed alarm was implemented on admission but that it should have been. Resident 17 was readmitted to the facility on [DATE]. Review of the Fall Risk assessment dated [DATE], revealed a total assessment score of 22, with anything above a score of 10 being a high risk Interventions that were checked as implemented included a bed and chair alarm. Review of the care planning notes dated May 13, 2013, revealed a history of falls, and bed and chair alarms in place. Review of an accident report dated May 24, 2013, revealed Resident 17 was found on the floor with alarms sounding. The intervention was to discontinue the bed alarm and replace it with a laser alarm (unit used to detect resident falls) to the right side of the bed, and to request bolster pillows from Hospice (a type of care which focuses on comfort and support). Review of an accident report dated June 12, 2013, revealed that the resident was found on the floor with an abrasion to the forehead. The alarm was found to be upside down and facing the door, and not sounding. Interventions included to change the alarm to a body alarm and to add a horseshoe pillow. Review of an accident report dated June 26, 2013, revealed that the resident was found on the floor, and the nursing notes indicate an abrasion and hematoma (a collection of blood outside a blood vessel) to the left eye. The body alarm was not sounding due to the position of the alarm box on the bed frame. Interventions included to check with Hospice regarding the bolster pillows. Review of nursing notes and Hospice notes revealed no documentation of a request for bolster pillows. During an interview on July 31, 2013, at 9:50 a.m., RN 3 stated the facility does have bolster pillows, but because Resident 17 was on Hospice all of the supplies had to be provided by the Hospice company. Resident 7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Fall Risk assessment dated [DATE], revealed a total assessment score of 16 and interventions implemented included non-skid footwear. Review of an accident report dated June 23, 2013, revealed the resident was found on the floor with an abrasion to the left forearm. The intervention was to place a laser alarm to the left side of the bed and keep the bed in the low position. Review of an accident report dated June 25, 2013, revealed that the resident was found on the floor after last being in his wheelchair. The intervention was to implement a body alarm. Review of an accident report dated June 26, 2013, revealed that the resident was found on the floor on the right side of his bed. Documentation indicates that the resident was wearing black socks, alarms were present but not sounding, and the care plan was not followed. New interventions included to change the alarm to a bed and chair alarm, apply non-skid socks at all times, and provide staff education. The resident was transported to the hospital for the treatment of [REDACTED]. During an interview on July 29, 2013, at 11:00 a.m., the Assistant Director of Nursing stated that a laser alarm was only placed to the left side of his bed because that was the side he was falling from. She stated that the report was documented incorrectly by saying the care plan was not followed. During an interview on July 30, 2013, at 10:00 a.m., the DON stated that the body alarm was just for use in a chair and the laser alarm was for the bed. She stated the nurse who documented the care plan was not followed did so out of error because the nurse thought the laser alarm was care planned to be on both sides of the bed, but it was only planned for the left side. 28 Pa. Code: 201.18 (e) (1) Management. Previously cited 7/7/11, 8/10/12 28 Pa. Code: 201.29 (d) Resident rights. Previously cited 7/7/11 28 Pa. Code: 211.10 (d) Resident care policies. Previously cited 7/7/11, 8/10/12 28 Pa. Code: 211.12 (d) (2) Nursing services. Previously cited 7/7/11 28 Pa. Code: 211.12 (d) (3) (5) Nursing services. Previously cited 7/7/11, 8/10/12

Based on review of clinical records and and interview with staff, it was determined that the facility failed to provide timely and necessary care and services for one of 21 residents (Resident R15) reviewed. Findings include: Review of Resident R15's clinical record and interview with Assistant Director of Nursing on July 1, 2011, at 9:30 a.m., revealed that on April 19, 2011, Psychiatrist 1 recommended discontinuing Resident R15's [MEDICATION NAME] (an antipsychotic) 25 milligrams (mg.) each night at bedtime and that he planned to see the resident again in two months (on or about June 19, 2011). This order was verified by the resident's physician on April 21, 2011 (2 days later). Review of Resident R15's May and June Behavior Intervention Monthly Flow Records revealed that he began to exhibit behavior problems regularly at the end of May and exacerbated between June 9-18, 2011. The ADON revealed that, due to his behavior problems, the facility should have recognized that Resident R15 needed to see Psychiatrist 1 before his planned appointment on or about June 19, 2011, and that staff should have asked Psychiatrist 1 to see Resident R15 on June 7, 2011 when he was in the facility to see residents for whom appointments had already been scheduled. Review of nurses notes revealed that between June 1-18, 2011, the resident had episodes of grabbing and hitting other residents, making threats, making accusations and was delusional. His care plan for behaviors dated April 13, 2011, had no changes made in interventions to deal with the increasing combative behavior or new [MEDICAL CONDITION]. The Shift Reports from May 24-June 21, 2011 were nonspecific regarding the types of behavior he exhibited. There was no evidence that the physician was contacted after June 11, 2011, when he demonstrated increased physical aggression towards other residents nor were these behaviors monitored until June 15, 2011, on the June 2011 Behavior/Intervention Monthly Flow record. Resident R15's physician had not been in to examine him since May 12, 2011 (prior to these episodes). Nurses notes dated June 15, 2011, reported that he threw coffee at staff, was choking/grabbing the shoulders and neck of a female resident, on Jue 16, , he was combative with staff and was hitting a female resident and on June 17, 2011, he was violent to staff and two residents. His aggressiveness through June 21, 2011, when he was seen by Psychiatrist 1 who identified his physical aggression, that he was angry, agitated, verbally hostile, threatening and hallucinating and ordered his transfer to the hospital. Interview with Psychiatrist 1 on July 5, 2011, at 2:08 p.m., confirmed that the facility should have advised him to see Resident R15 on June 7, 2011. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. Previously cited 8/5/10 28 Pa. Code: 211.5 (f)(g) Clinical Records. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing Services.