Every finding on record at Rittenhouse Post Acute

Based on review of facility documents, clinical reviews and staff interviews, it was determined that the facility failed to investigation for an allegation of possible staff to resident abuse for one of 12 residents (Resident R41).Findings include: Review of facility policy Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revision dated September 2022, indicated All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/ misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Review of the clinical record indicated Resident R41 was admitted to the facility on [DATE] with diagnoses of Radiculopathy, cervical region (pinched neck nerve); spondylosis without myelopathy or radiculopathy, cervical region (neck arthritis); dysphagia (swallowing difficulty); adjustment disorder with depressed mood (situational depression); need for assistance with personal care (daily care needs); cognitive communication deficit (thinking/communication difficulty); and spondylosis without myelopathy or radiculopathy, lumbar region (lower back arthritis). Review of Resident R41's Minimum Data Set (MDS-a periodic assessment of care needs) dated April 17, 2026, Section C0500, indicated a Brief Interview for Mental Status (BIMS)-a screening test that aids in detecting cognitive impairment) score of 15, indicating cognition intact. A review of the clinical progress note dated April 11, 2026, revealed: Patient is status post (S/P) a C3-C4 and C6-C7 laminectomy with C3-C4 posterior cervical fusion (neck decompression and fusion surgery). The patient is in bed, denies pain or discomfort, is breathing comfortably on room air, and is wearing a neck brace. A surgical scar is noted on the back of the neck. On May 17, 2026, at 1:36 p.m., an interview was conducted with Resident R41, who reported that on April 11, 2026, or around the first week of admission, during the first therapy session, a facility therapist and another staff member (no name given) kneed the resident in the back during a transfer from the bed to a wheelchair. The resident stated, My pain level was 11 and I screamed, and reported that a staff person said, Oh no, we're not going to have a fall. On May 17, 2026, at 3:36 p.m., an interview was conducted with the regional nurses, Employees E3, E4, and E5, to report the allegation. It was confirmed that the facility had not conducted an investigation of the incident and would be conducting an investigation. On May 20, 2026, at 11:36 a.m., an interview was conducted with the Director of Rehabilitation Therapy, Employee E8, who reported that she/he was able to recall when Resident R41 reported to her on the following Monday, April 13, 2026, that she had been kneed in the back by a therapist during a transfer and that the resident had a fall. The therapist was identified as Employee E9, and the incident reportedly occurred during the first week of Resident R41's admission. Employee E8 reported that April 11, 2026, was a Saturday and that Resident R41 was evaluated by Employee E9. Employee E8 reviewed the clinical record and the 24-hour report to determine whether there was any documentation of a fall or incident; however, no documentation was found. Employee E8 then contacted Employee E9 to interview her regarding the allegation. Employee E9 stated, It didn't happen, and that was the extent of the discussion. Employee E8 reported that the allegation was discussed during the morning meeting on April 13, 2026, and that everyone knew about it, meaning the Administrator and Director of Nursing, as both attended the meeting. It was decided during that meeting to pair care for Resident R41 and to deem the allegation unsubstantiated. Employee E8 further reported that, from that time forward, Resident R41 became very untrusting of staff because of the fall in her mind that someone had hurt her, and that Resident R41 would only trust aides to provide in-bed care. A review of the physician order dated April 13, 2026 paired care for all interactions. On May 20, 2026, at 1:36 p.m., an interview was conducted with the regional nurses, Employees E3 and E5, who reported that, according to the interview with the Director of Rehabilitation Therapy, Employee E8, the allegation of abuse was reported to the facility and discussed during the morning meeting on April 13, 2026, and that the facility failed to conduct an investigation. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on clinical record review and staff interviews, it was determined that the facility failed to develop a comprehensive care plan with interventions related to paired care, adaptive utensils, medication refusals, a neck collar, and CPAP machine for two of 12 residents reviewed (Residents R41 and R36).Findings include: Review of the facility policy, Care Plans, Comprehensive Person-Centered, last revised in March 2022, revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Review of the clinical record indicated Resident R41 was admitted to the facility on [DATE] with diagnoses of Radiculopathy, cervical region (pinched neck nerve); spondylosis without myelopathy or radiculopathy, cervical region (neck arthritis); dysphagia (swallowing difficulty); adjustment disorder with depressed mood (situational depression); need for assistance with personal care (daily care needs); cognitive communication deficit (thinking/communication difficulty); and spondylosis without myelopathy or radiculopathy, lumbar region (lower back arthritis). Review of Resident R41's Minimum Data Set (MDS)-a periodic assessment of care needs) dated April 17, 2026, Section C0500, indicated a Brief Interview for Mental Status (BIMS-a screening test that aids in detecting cognitive impairment) score of 15, indicating cognition intact. A review of the clinical progress note dated April 11, 2026, revealed: Patient is status post (S/P) a C3-C4 and C6-C7 laminectomy with C3-C4 posterior cervical fusion (neck decompression and fusion surgery). The patient is in bed, denies pain or discomfort, is breathing comfortably on room air, and is wearing a neck brace. A surgical scar is noted on the back of the neck. Further review of the clinical progress note dated April 12, 2026, revealed: Patient has degenerative spine disease (spondylosis) and is status post cervical spine fusion surgery. Their condition is currently stable. They should continue wearing the cervical collar at all times, and the surgical site should be monitored for any signs or symptoms of infection. Further review of the clinical progress note dated April 12, 2026, revealed: Patient refused morning care and 6:00 a.m. routine medications this morning and stated that (she/he) believes everyone who works here is 'evil' and that the only medication she will be taking is her PRN (as needed) Oxy. Further review of the clinical progress note dated April 27, 2026, revealed: Patient refused routine nighttime medications this shift. Further review of the social services progress notes dated April 29, 2026, revealed: Family meeting was held at bedside with patient. Patient's son was in attendance via phone, and DON (Directo of Nursing), DOR, and SW (Social Worker) were present as well. Patient was educated several times on the importance of participating in PT/OT and not refusing consecutively. A review of the physician order dated April 13, 2026 paired care for all interactions . On May 17, 2026, at 1:36 p.m., an interview was conducted with Resident R41, who reported that (she/he) had cervical spine surgery and was observed wearing a neck collar, and adaptive utensils were observed on the tray next to her lunch tray. Resident R41 also reported that (she/he) has been refusing therapy because (she/he) has not been feeling well. On May 17, 2026, at 2:30 p.m., an observation was conducted with the regional nurses, Employees E3 and E5, and Resident R41, who confirmed that Resident R41 has a neck collar, has adaptive utensils at the bedside, and has a history of refusing medications and treatments. It was also confirmed that a comprehensive care plan dated April 11, 2026, was not developed to address the neck collar, medication refusals, or paired care for all interactions. Review of Resident R36's clinical record, revealed resident admitted to the facility on [DATE], with diagnosis of Obstructive Sleep Apnea (a common sleep disorder characterized by repeated interruptions in breathing during sleep due to the relaxation of throat muscles, leading to airway blockage). Review of Resident R36's physician orders, revealed order dated May 14, 2026, for the continued use of CPAP (continuous positive airway pressure setting on a mechanical ventilator) at bedtime every shift. Review of Resident R36's comprehensive care plan revealed no documented evidence of care plan in place for obstructive sleep apnea. Interview with Employee E3, Regional Director of Nursing on May 18, 2026, at approximately 12:00 p.m., confirmed no care plan in place for obstructive sleep apnea. 28 Pa Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on surveyor observation, clinical record review, and interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards related to medication administration for two of 12 residents reviewed (Resident R41, R65).Findings Include: Review of the clinical record indicated Resident R41 was admitted to the facility on [DATE] with diagnoses of Radiculopathy, cervical region (pinched neck nerve); spondylosis without myelopathy or radiculopathy, cervical region (neck arthritis); dysphagia (swallowing difficulty); atelectasis (partial lung collapse); adjustment disorder with depressed mood (situational depression); need for assistance with personal care (daily care needs); cognitive communication deficit (thinking/communication difficulty); spinal stenosis with neurogenic claudication (narrowed spinal canal); and spondylosis without myelopathy or radiculopathy, lumbar region (lower back arthritis). Review of Resident R41's Minimum Data Set (MDS-a periodic assessment of care needs) dated April 17, 2026, Section C0500, indicated a Brief Interview for Mental Status (BIMS-a screening test that aids in detecting cognitive impairment) score of 15, indicating cognition intact. A review of the progress note dated May 13, 2026, written by licensed nurse Employee E11, indicated: During evening medication pass, this nurse attempted to administer medications, and the patient told me to set them on her table and (she/he) would take them. The patient appeared very sleepy but was awake to answer my questions when asked. I left (her/his) room and came back 20 minutes later, and the patient still had not taken (her/his) medications. The patient was asleep. I awakened the patient, and (she/he) answered but did not take the medication, so I removed the pills from the patient's table. The patient did not take morning medication. The patient stated that (she/he) felt nausea. The patient was educated and will be passed on to the oncoming nurse. On May 17, 2026, at 1:36 p.m., an observation was conducted with Resident R41. The surveyor observed two large pills located on the bedside table and one on the tray table. Resident R41 reported that nursing staff leave large pills at (her/his) tray table. On May 17, 2026, at 2:30 p.m., an observation was conducted with the regional nurses, Employees E3 and E5, and Resident R41, who confirmed that Resident R41 had two large pills on the bedside table and tray table. It was confirmed that the medications were Atorvastatin Calcium 80 mg tablet and Gabapentin oral tablet 800 mg. It was further confirmed that the licensed nurse, Employee E11, did not observe Resident R41 swallow the medications and left them at the bedside. Review of the clinical record indicated Resident R65 was admitted to the facility on [DATE] and discharge on [DATE] with diagnoses of aftercare following join replacement surgery, presence of left artificial knee joint, muscle weakness, and lack of coordination. Review of Resident R65's Minimum Data Set (MDS-a periodic assessment of care needs) dated January 12, 2026, Section C0500, indicated a Brief Interview for Mental Status (BIMS-a screening test that aids in detecting cognitive impairment) score of 15, indicating cognition intact. A review of the grievance report dated January 19, 2026, revealed that Resident R65 reported to (her/his) daughter that (she/he) had been repeatedly offered melatonin by a nurse despite not having an order for the medication and despite informing staff that (she/he) could not take it due to (her/his) cardiac history. The complainant reported that the resident appeared excessively sleepy, nearly fell while recovering from knee replacement surgery, and expressed concerns regarding medication administration practices, including medications not being identified in front of the resident and the absence of an identification bracelet. The complainant further alleged that staff may have been administering melatonin to residents to keep them asleep during the night. The facility investigated the allegation and interviewed the resident and the nurse involved. The investigation determined that on one occasion, the nurse accidentally placed a melatonin tablet intended for another resident into Resident R65's medication cup. The error was recognized, the medication was removed before administration, and Resident R65 did not receive any medication that was not prescribed for her. A review of the facility written statement dated January 19, 2026, revealed that the licensed nurse involved in the incident, Employee E12, documented the following: I entered [Resident R65's] room on January 18, 2026, at 8:45 p.m. to administer (her/his) evening medications. The resident was sitting on the side of (her/his) bed. I was asked which medications I had to administer. I stated, 'Guaifenesin, Lyrica.' I had a second cup which contained '2 Tylenol and 1 Melatonin.' I had pulled the Melatonin for my next patient. The resident responded that (she/he) does not want or use Melatonin. I told (her/him) that I would withhold it. The resident was administered 1 Guaifenesin, 1 Lyrica, and 2 Tylenol. I did not administer any Melatonin; (she/he) received 4 pills from me. I make it a point to introduce myself to our patients each time I enter their room to foster responsibility and [NAME]. We work as a team and treat each patient with respect and courtesy. I regret taking the Melatonin into the room with me. We value and aspire to maintain the confidence of our patients in all aspects of nursing care. On April 15, 2026, at 1:05 p.m., a telephone interview was conducted with licensed nurse, Employee E12, who confirmed, I misspoke. To be honest, it was a matter of expedience for me to have two medication cups for separate residents. I thought I would be offering (her/his) medications, and I was going to two residents in another room to administer medications, one cup for each resident. I had just pulled medications for another resident and misspoke. It was my fault because I misspoke. She told me that she doesn't take Melatonin. I rechecked the computer, and the resident was correct. On April 15, 2026, at 2:30 p.m., an interview was conducted with the Director of Nursing, Employee E2, who confirmed the allegation and reported that they retrained the licensed nurse who attempted to administer the wrong medication. Based on review of the Medication Administration Record (MAR) for January 2026, Resident R65 did not have a melatonin prescription. 28 Pa. Code 201.18 (b) (1) Management 28 Pa. Code 211.12 (d) (1) (2) (5) Nursing services

Based on a review of clinical records, and interviews with residents, and staff, it was determined that the facility failed to provide the necessary assistance with activities of daily living (ADLs) to maintain proper grooming, nail and shaving for two of the 12 residents reviewed. (Residents R41 and R40)Findings include: Review of the clinical record indicated Resident R41 was admitted to the facility on [DATE] with diagnoses of Radiculopathy, cervical region (pinched neck nerve); spondylosis without myelopathy or radiculopathy, cervical region (neck arthritis); dysphagia (swallowing difficulty); atelectasis (partial lung collapse); adjustment disorder with depressed mood (situational depression); need for assistance with personal care (daily care needs); cognitive communication deficit (thinking/communication difficulty); spinal stenosis with neurogenic claudication (narrowed spinal canal); and spondylosis without myelopathy or radiculopathy, lumbar region (lower back arthritis). Review of Resident R41's Minimum Data Set (MDS-a periodic assessment of care needs) dated April 17, 2026, Section C0500, indicated a Brief Interview for Mental Status (BIMS-a screening test that aids in detecting cognitive impairment) score of 15, indicating cognition intact. A comprehensive care plan dated May 10, 2026, indicated an Activity of Daily Living (ADL) goal for bathing requiring two-staff assistance with bathing/showering. A comprehensive care plan dated April 11, 2026, for oral care stated, I require supervision/setup assistance with oral care. On May 17, 2026, at 1:36 p.m., an interview was conducted with Resident R41, who reported that (she/he) had cervical spine surgery and was observed with dirty nails, dirty hair, and mouth odor. Resident R41 reported that (she/he) is unable to brush her teeth and requires assistance with oral care. Resident R41 was not able to recall when (her/his) teeth were last brushed, and Resident R41 complained of mouth sores. Review of the clinical record indicated Resident R40 was admitted to the facility on [DATE], with diagnoses of wedge compression fracture of the T7-T8 vertebra, subsequent fracture of one rib on the left side, and need for assistance with personal care. A comprehensive care plan dated May 6, 2026, indicated an Activity of Daily Living (ADL) goal for bathing requiring one-staff assistance with bathing/showering. On May 18, 2026, at 11:34 a.m., an interview was conducted with Resident R40, who was observed with long nails and facial hair. Resident R40 also reported that (his/her) nails need to be cut because they are sharp as a razor, and stated that when (he/she) takes (his/her) socks off, (he/she) has already cut (his/her) skin near the ankle. Observation with the Social Worker, Employee E10 who came to see Resident R40, confirmed that Resident R40 uses the nails on (his/her) right hand to remove (his/her) left sock, and there were three cuts on (his/her) ankle. It was also confirmed that Resident R40 has facial hair and wants a shave. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of the facility's nursing staff competencies and skills required to provide resident care, the facility failed to ensure complete competency documentation for two of the two nursing staff reviewed. (Employees E13 and E14) Findings Included: Review of Facility nursing staff competency records revealed that Employee E13, Registered Nurse was hired on July 9, 2025. No documented evidence of competencies related to Medication Administration, Catheter care or pain assessments. Review of Facility nursing staff competency records revealed that Employee E14, Registered Nurse was hired on December 23, 2025. No documented evidence of competencies related to Medication Administration, Catheter care or pain assessments. Interview with Employee E3, Regional Director of Nursing on May 20, 2026, at 12:00 p.m., confirmed that no documented evidence of competency for Employees E13 or E14, indicating that validation of the competencies could not be verified. Due to the absence of documented determinations for these competency items, the facility was unable to demonstrate that the identified staff had successfully met the required competencies necessary to perform their assigned duties. 28 Pa. Code 201.20 (6)(b) Staff Development.

Based on staff interviews it was determined that the facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department for 12 of 12 months (May 2025 through May 20, 2026).Findings include: An interview conducted on May 19, 2026, at 1:04 p.m. with Dietary Director, Employee E6, confirmed that he/she is the Director of Food and Nutrition Services; however, he/she does not hold a Certified Dietary Manager (CDM) credential, Certified Food Service Manager certification, or similar nationally recognized food service management and safety certification from a national certifying body, and is not currently working toward CDM certification. An interview with the NHA, Employee E1, and DON, Employee E2, on May 20, 2026, at 2:30 p.m., confirmed that the facility is utilizing a regional dietitian, Employee E7. Upon request to verify full-time status, only 17.33 hours were documented from May 13, 2026, to May 19, 2026. It was confirmed that the facility did not have a full-time dietitian, and it could not be verified that Employee E7 provided services to residents residing in this specific facility during the identified time period. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.6(c) Dietary Services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a plan of care was related to the diagnosis of seizure for one of two residents reviewed. (Resident R1)Findings include:Review of Resident R1's August 2025 physician orders included the diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest); back pain; convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement that can happen during of without seizures) and cerebral infarction (a stroke). Continued review of the resident's physician's orders indicated that the resident also was being prescribed medication for the treatment of seizures (a sudden burst of electrical activity in the brain. It can cause changes in behavior, movements, feelings and levels of conscious).Review of the resident's person-centered plan of care did not include a plan of care for the resident's seizure diagnosis to ensure that appropriate goals and interventions are included and in place for this care area.During an interview with the Director of Nursing (DON) on August 19, 2025, at 1:46 p.m. the DON confirmed during the interview that the resident did not have a car plan in place for seizures.28 Pa Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c(1) )Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of clinical records, review of facility policy and staff interview, it was determined that the facility failed to ensure that medication was deliver timely from the pharmacy to be administer to the resident as ordered by the physician for 1 out of 2 residents reviewed (Resident R1). Findings include: Review of the facility policy, Policy Services Overview, with a revision date of April 2019 indicated that the facility shall contract with a licensed consultant pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements. The policy also indicated that pharmacy services are available to residents 24 hours a day, seven days a week and indicated that residents will have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner.Review of the Resident R1's August 2025 physician orders included a physician's order with a start date of August 10, 2025. at 9:00 a.m., for the resident to be administered 1-100 milligram tablet of the medication, Lamotrigine, once a day (9:00 a.m.) by mouth. The physician orders indicated that the medication was being prescribed for the treatment of the resident's seizure diagnosis. Review of Resident R1's August 2025 physician orders included an order with a start date of August 9, 2025, at 9:00 p.m. for the resident to administer 1-125 milligram tablet of the medication, Lamotrigine, by mouth at bedtime (9:00 p.m.). The physician orders indicated that medication was being prescribed for the treatment of the resident's seizure diagnosis. Lamotrigine Oral Tablet (Lamotrigine)Give 125 mg by mouth at bedtime for seizures.Continued review of the August 2025 physician orders included a physician's order, with a start date of August 9, 2025, at 9:00 p.m. for the resident to be administered 1-50 milligram tablet of the medication, Lacosamide, by mouth every morning (9:00 a.m.) and at bedtime (9:00 p.m.) for seizure disorder: Vimpat Oral Tablet 50 MG (Lacosamide) Give 1 tablet by mouth every morning and at bedtime for Seizure Disorder.Review of the Medication Administration Record (MAR) indicated that on August 9, 2025, the resident was not administered her 9:00 p.m. dose of the medication, Lacosamide. Continued review of the MAR indicated that the resident was also not administered her 9:00 p.m. dose of the medication, Lamotrigine on August 9, 2025. Review of a nursing note dated August 10, 2025 at 6:03 a.m. by nursing staff documented that the resident did not receive her seizure 9:00 p.m. seizure medications during the 7:00 p.m. through the 7:00 a.m. nursing shift. Patient did not receive Seizure medications this shift. Doctor . made aware.During an interview with the Director of Nursing (DON) on August 19, 2025, at 11:45 a.m. the DON confirmed that the resident was not administered the above referenced seizure medications, as ordered by the physician, because they were not delivered by the facility's pharmacy. 28 Pa Code 211.9 (d) Pharmacy services28 Pa Code 211.9 (l)(1) Pharmacy services28 Pa Code 211.9 (l)(2) Pharmacy services

Based on review of facility policies and documentation, clinical records, and interviews with staff, it was determined the facility failed to ensure Resident R65 who required supervision/assistance with ambulation was accompanied by an escort during a medical appointment outside of the facility. This failure resulted in actual harm to Resident R65 who sustained a fall and fracture of nasal bone for one of four residents reviewed. (Resident R65) Findings include: Review of facility policy titled Transportation, Diagnostic Services dated December 2008, revealed under section Policy Statement indicated, Our facility will assist residents in arranging transportation to/from diagnostic appointments when necessary. Additional review of facility policy revealed under section Policy Interpretation and Implementation revealed the following: #1. Should it become necessary to transport a resident to a diagnostic service outside the facility, the social service designee or charge nurse shall notify the resident's representative (sponsor) and inform them of the appointment. #2. The resident's representative (sponsor) will be responsible for transporting the resident to his or her lab appointment. # 4. A member of the nursing staff, or social services, will accompany the resident to the diagnostic center when the resident's family is not available. Review of facility policy titled Safety and Supervision of Residents dated December July 2017, under section titled, Policy Statement revealed Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Additional review of facility policy indicated under section Policy Interpretation and Implementation, subsection Facility-Oriented Approach to Safety revealed the following, #1. Our facility-oriented approach to safety addresses risks for groups of residents. #2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI (Quality Assessment Improvement Program) reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization. # 4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. Further review of same facility policy, under subsection titled, Individualized, Resident-Centered Approach to Safety revealed the following: #1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. #2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. #3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Providing training, as necessary d. Ensuring that interventions are implemented. Review of facility policy titled Falls - Clinical Protocol dated September 2012, under section titled Assessment and Recognition revealed the following; #1. As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling. #c. While many falls are isolated individual incidents, a significant proportion occur among a few residents/patients. Those individuals may have a treatable medical disorder or functional disturbance as the underlying cause. #2. In addition, the nurse shall assess and document/report the following: c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc. #3. The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk. #a. Risk factors for subsequent falling include lightheadedness or dizziness, multiple medications, musculoskeletal abnormalities, peripheral neuropathy, gait and balance disorders, cognitive impairment, weakness, environmental hazards, confusion, visual impairment, and illnesses affecting the central nervous system and blood pressure. Review of Resident R65's clinical record revealed, Resident R65 was admitted to the facility on [DATE], with diagnoses including Obstructive Pulmonary Disease (lung and airway disease that restricts breathing), Muscle Weakness, Unspecified Abnormalities of Gait and Mobility. Review of Resident R65's admission MDS (Minimum Data Set- federally required resident assessment completed at specific intervals) dated December 19, 2024, subsection GG0115 revealed Functional Limitation in Range of Motion (Code for limitation that interfered with daily functions or placed resident at risk of injury in the last 7 days), A. Upper extremity (shoulder, elbow, wrist, hand) was coded 1- (Impairment on one side), section GG - Functional Abilities, D. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed was coded 04(Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.), E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair) was coded 04, I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space, J. Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns and K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space were all coded 04. Further section L. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. And M. 1 step (curb): The ability to go up and down a curb and/or up and down one step, were coded 88 (Not attempted due to medical condition or safety concerns). Review of Resident R65's care plan initiated December 13, 2024 revealed I have an ADL (Activities of Daily Living) Self Care Performance Deficit r/t (related to) Muscle wasting, Atrophy. Care plan interventions/tasks include the following: ambulation: I require supervision with ambulation. Transfers: I require supervision/setup with transfers. Review of the Resident R65's Physical Therapy Evaluation and Treatment Plan, under section Functional Mobility assessment dated [DATE], revealed the following: Transfers, Resident R65 requires SBA (standby assist- someone must be always be standing behind the resident to provide physical assistance in case resident loses balance or to provide physical support as needed ), Gait on level surfaces, Resident R65 requires SBA, Distance on Level Surfaces, can walk up to a distance of 150 feet, Assistive Device: 2 wheeled walker. Further review of Resident R65's Physical Therapy Evaluation and Treatment Plan, revealed for uneven surfaces indicated DNT (did not test- resident has not been evaluated on his ability to ambulate safely on uneven surfaces), Stairs was indicated DNT, number of stairs- 0 steps, Negotiated stairs-DNT ([Resident R65] has not been evaluated on his/her ability to safely go up and down stairs and to navigate stairs, Community Ambulation (ambulating outside of the facility) = SBA Further, under section Sensation/Sensory =IMPAIRED (impaired-not functioning normally), Touch Pressure=IMPAIRED (history of mild neuropathy bilateral feet). Review of Resident R65's Physical Therapy Assessment Summary dated December 13, 2024, revealed Resident R65 presented with deficits in cardiovascular endurance, dynamic balance (ability to maintain control of one's center of mass while the body is in motion or experiencing external forces. It involves adjusting and controlling the body's position in space while moving, walking, and other activities that require balance), functional strength, and activity tolerance limiting participation in functional mobility. Further, Resident R65 was below baseline levels. Resident R65 required SBA (standby assist) for functional transfers, with picking up object from ground and to ambulate 150 feet with rolling walker. Further additional functional mobility was not assessed due to increased fatigue. Review of Resident R65's physical therapy treatment encounter dated December 17, 2024 revealed skilled intervention focused on outdoor mobility training, and ambulation over uneven surfaces: 1. Gait training over uneven surfaces, carpets, change in surfaces, navigating through elevators, 500 feet with rolling walker and supervision for balance and rolling walker management with one episode of minimal assist for mild LOB (loss of balance) when navigating over carpet stuck on rolling walker, 3. Outdoor gait training over inclined and declined surfaces and uneven sidewalks 500 feet without assistive device and Sup (supervision) (close supervision -resident within arm's length for safety in case resident loses balance) for balance due to mild increased sway, seated rest breaks required between trials to manage increased fatigue. Review of Resident R65's physician's order with start date of December 19, 2024 revealed an order for: Follow up with plastic surgery and reconstructive surgery on December 19, 2024 at 2:00 pm. Further review of Resident R65's clinical record failed to reveal physician order for LOAs (leave of absences) to go to medical appointment or instructions during LOA. Review of Resident R65's nursing notes dated December 13, 2024, December 15, 2024, December 18, 2024, and December 19, 2024 (time stamped 4:02AM), revealed ADLs/Functional Status: Exhibits Unsteady gait weakness. Review of Resident R65's nursing notes dated December 19, 2024 (1:16 p.m.), revealed Resident R65 left facility to attend a doctor's appointment using a rolling walker. Resident R65 was picked up by an ambulance transportation. Review of Resident R65's progress notes dated December 19, 2024, at 8:50 p.m., revealed Resident R65 returned to the facility from local hospital with a fractured nose. Continued review of Resident R65's nursing note dated December 20, 2024, revealed the following: Resident R65 was alert and oriented x 4 (oriented to people, places, and time) with a BIMS (Brief Interview of Mental Status) of 15 (indicating full cognitive functioning), went LOA to an appointment via ambulance transport around 1 p.m. on December 19, 2024 at 4:30 p.m. Charge nurse called to check in on patient status and nurse was informed that patient was at a local hospital following a fall that occurred while out on appointment. Hospital's nurse informed Charge Nurse that Resident R65 will be transported back to the facility with paperwork. When asked [he/she] tripped while ambulating in the lobby of appointment building. Patient returned to facility with a Dx (diagnosis) of nasal fracture and sinus precautions. Review of facility document titled, Full QA (Quality Assurance) report signed by Director of Nursing, Employee E2 on December 20, 2024, revealed a statement from Resident R65 indicating; When I was walking past the lobby, there were a thick mats where my walker got caught up which made me trip and fall forward. Interview with Rehabilitation Department staff, Employee E8 conducted on May 15, 2025, at 12:05 p.m. confirmed that before Resident R65 fall incident on December 19, 2024, Resident R65 was still unsteady and required standby assist for ambulation (walking). Further interview with Employee E8 revealed that standby assist during ambulation means that someone must be always standing behind Resident R65 while the resident is ambulating, to provide resident with verbal cueing and or physical help or physical support if needed in order to prevent falling in case of a loss of balance. Interview with Director of Nursing (DON), Employee E2 conducted on May 15, 2025, at 12:30 p.m. confirmed the facility allowed Resident R65 to go out to a doctor's appointment without an escort. Further, Employee E2 revealed that the plan was for Resident R65's family to meet Resident R65 inside the doctor's office. Continued interview on May 15, 2025 with Director of Nursing, Employee E2, revealed Resident R65 was transported via ambulance from the facility to the building where the doctor's office was located. Resident R65 was dropped off by the ambulance in front of the building and Resident R65 proceeded to walk with a rolling walker into the building unassisted and without supervision, where the resident subsequently fell in the lobby resulting in a fracture of the nasal bone. The facility failed to ensure Resident R65, who required supervision/assistance with ambulation was provided with an escort to supervise the resident during a medical appointment which resulted in actual harm to Resident R65 after sustaining a fall and fracture to the nasal bone. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of documentation and staff interview, it was determined the facility failed to ensure residents were provided a Notification of Medicare Non-Coverage (NOMNC) for one of three residents reviewed (Resident R66). Findings include: Review of facility documentation revealed no evidence that the Notification of Medicare Non-coverage was provided to Resident R66. Interview with Director of Social Services, Employee E3 conducted on May 14, 2025, at 11:05 a.m. confirmed that she was responsible for sending the Notice of Medicare Non-Coverage to residents who were discharged from Medication Part A with remaining Medicare days. Continued interview with Social Services, Employee E3 revealed that Resident R66 was scheduled to leave at a planned date of September 27, 2024, but requested to leave on September 25, 2025. Further, Employee E3 also revealed that Resident R66 informed Employee E3 of his wishes to go home earlier a few days before September 25, 2025. Further, Employee E3 also revealed that she informed Rehab about Resident R66 wishing to leave earlier, and that rehab cleared the resident to go home. Employee E3 confirmed that she did not provide Resident R66 with a Notification of Medicare Non-coverage. Further Employee E3 also confirmed that should have been provided to Resident R66 with a Notification of Medicare Non-coverage. 28 Pa. Code 201.18(b)(1) Management

Based on observations, review of facility policy, review of clinical records, and staff in our view, it was determined that the facility failed to develop and implement a person center and comprehensive care plan related to resident's nutritional needs and weight loss for one resident. (Resident R1) Findings include: Review of facility policy titled Care Plans, Comprehensive Person Centered dated March 2022, revealed that a comprehensive person center care plan includes measurable objectives and timetables to meet all resident's physical, psychosocial and functional needs. The care plan includes the resident's goals upon admission, reflects currently recognized standards of practice for problem areas and conditions. When possible, the care plan interventions address the underlying source of the problem areas. Assessments of the residents are ongoing, and care plans are reassessed as information about the resident and the residents' conditions change. The interdisciplinary team reviews and updates the care plan when there has been a significant change in the residents' condition. Review of policy titled Weight Assessment and Intervention dated March 2022, revealed that resident weights are monitored for undesirable or unintended weight loss or gains. Undesirable weight change is evaluated, this evaluation includes recent target weight range, resident's calorie protein and other nutrient needs compared to the resident's current intake, the relationship between current medical condition or clinical situation and recent fluctuations in weight and whether and to what extent weight stabilizing or improvement can be anticipated. Care planning for weight loss or impaired nutrition is a multi-disciplinary effort and includes the physician nursing staff, the dietitian, the consultant pharmacist, and the resident or resident's legal surrogate. Individualized care plan shall address, to extent possible the identified cause of weight loss, goals and benchmarks for improvement, and time frames and perimeters for modern monitoring and reassessment. Interventions for undesirable weight loss are based on careful consideration of the following; resident choice preferences, common nutrition, functional factors that may inhibit independent eating, environmental factors that may inhibit appetite, chewing and swallowing abnormalities, medications that may interfere with appetite, the use of supplementation or feeding tubes and end of life directives. Review of Review of resident R 1's admission minimum data set (MDS- a federal mandated assessment tool for all residents) dated December April 23, 2025, revealed that resident R1 was admitted into the facility April 16, 2025, 2024 with diagnosis' including Coronary artery disease( a heart disease that happens when coronary arteries cannot supply the heart with enough blood, oxygen and nutrients), hypertension(high blood pressure-a condition where the force of blood in the heart is consistently too high), diabetes(the body does not produce enough insulin or cannot properly use insulin, leading to high blood sugar levels), aphasia(inability to swallow ), malnutrition(Lack of proper nutrition ), and depression(persistent feeling of sadness and changes of how you think, sleep, eat , and act). Resident assessment with a cognitive BIMS (brief interview for mental status) score of 11, indicating the resident is moderate cognitive impairment. Review of resident's weight summary dated April 16th, 2025, resident was recorded as being 118.0 pounds admission, April 23rd, 2025, resident reported being 107.6, indicating a 10.4-pound weight loss. After two weeks the resident was weighted again and was documented as 102.8 pounds, indicating a 4.8-pound weight loss. Review of resident R1's care plan revealed that Resident is at risk for malnutrition related to muscle fat wasting on NFPE (nutrition focused physical exam), need for modified food texture food, need for an ONS (oral nutrition supplements), altered nutrition related labs, increased metabolic needs and chronic medical diagnosis which was initiated April 22, 2025. The intervention for this focus was to provide a regular, thin liquid diet that noted I prefer the following foods: pescatarian diet A diet that is free of meat and chicken, primarily a plant-based diet with fish consumption. Further review of resident R1's care plan revealed no focus or intervention and goals of resident 's documented weight loss. Continued review of resident R1's care plan revealed there was no interventions of resident's preference of pescatarian diet and supplemental needs that accompany this diet. Interview with dietitian, employee E5, conducted on May 14, 2025, at 10:53 AM confirmed that the resident has documented weight loss which has not been included in the resident care plan. Employee E5 stated that she has worked with the kitchen staff to develop a pescatarian diet for resident R1. There is no indication that the facility has any documented menu choices for pescatarian residents' preferences. 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(5) Nursing service

Based on review of facility policy, clinical record reviews and staff interviews, it was determined that the facility failed to monitor, implement and modify interventions consistent with the resident's assessed needs to maintain acceptable parameters of nutrition for two of sixteen resident records reviewed. (Residents R61 and Resident R1) Findings include: Review of facility policy on Weight Assessment and Intervention dated March 2022, section Policy Statement Resident weights are monitored for undesirable or unintended weight loss or gain. Section Policy Interpretation and Implementation Weight Assessment #1. Residents are weighed upon admission and at intervals established by the interdisciplinary team. #2. Weights are recorded in each unit's weight record chart and in the individual's medical record. #3. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. a. If the weight is verified, nursing will immediately notify the dietitian in writing. #4. Unless notified of significant weight change, the dietitian will review the unit weight record monthly to follow individual weight trends over time. #5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight - actual weight)/(usual weight) x 100]: a. 1 month - 5% weight loss is significant; greater than 5% is severe. Section Evaluation #1. Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. The evaluation includes a. the resident's target weight range (including rationale if different from ideal body weight); b. the resident's calorie, protein, and other nutrient needs compared with the resident's current intake; c. the relationship between current medical condition or clinical situation and recent fluctuations in weight; and d. whether and to what extent weight stabilization or improvement can be anticipated. Review of Resident R61's clinical record revealed that Resident R61 was admitted to the facility on [DATE], with diagnoses of Fracture of Lumbosacral spine ad pelvis. Review of resident R61's weight record revealed the following: On May 3, 2025, Resident R61's weight was 179.0 lbs. (pounds), On May 6, 2025, Resident R61's weight was 171.8 lbs., On May 13, 2025, Resident R61's weight was 169.8 lbs. Further review of Resident R61's clinical record revealed that there were no dietary notes until May 14, 2025. Review of Dietary note dated May 14, 2025, revealed a Weight Change Note as follow: WEIGHT CHANGE: Value: 169.8 -5.0% change [ 5.1%, 9.2] reweigh pending. Further review of Resident R61's weight record revealed that no reweight was done. Last recorded weight was on May 13, 2025, at 169.8 lbs. Further, review of Resident R61's clinical record revealed that there was no documented evidence that the weight loss was addressed by the dietician Employee E5 or by staff at the facility. Review of the nutrition care plan revealed that Resident R61 was at risk for malnutrition related to muscle/fat wasting, need for therapeutic diet, altered nutrition-related labs, increased metabolic needs, and chronic medical Dx. Date Initiated: 05/05/2025 Further review of Resident R61's care plan revealed that the care plan was not updated to address the significant weight loss observed on May 3, 2025, May 6, 2025, and May 13, 2025. Interview with Dietician Employee E5 conducted on May 14, 2025, at 10:53 AM confirmed that Resident R61 had a 9.2 lbs. weight loss or 5.14% weight loss from May 3, 2025, to May 13, 2025, a 5.14%weight loss in 10 days. Further Employee E5 confirmed that she has not seen Resident R61 until May 14, 2025. Review of Review of resident R 1's admission minimum data set (MDS- a federal mandated assessment tool for all residents) dated December April 23, 2025, revealed that resident R1 was admitted into the facility April 16, 2025, 2024 with diagnosis' including Coronary artery disease( a heart disease that happens when coronary arteries cannot supply the heart with enough blood, oxygen and nutrients), hypertension(high blood pressure-a condition where the force of blood in the heart is consistently too high), diabetes(the body does not produce enough insulin or cannot properly use insulin, leading to high blood sugar levels), aphagia(inability to swallow ), malnutrition(Lack of proper nutrition ), and depression(persistent feeling of sadness and changes of how you think, sleep, eat , and act). Resident assessment with a cognitive BIMS (brief interview for mental status) score of 11, indicating the resident is moderate cognitive impairment. Review of resident R1's hospital record prior to entering the facility, dated April 15, 2025, revealed resident presented to the emergency roiagnom on [DATE], following a fall with progressively worsening lower back pain., she was treated conservatively with pain control and early mobilization and was discharged on [DATE]th to a skilled nursing facility. This document included resident's current weight as 53.5 kilograms,118 pounds dated April 15, 2025. Review of resident nutritional risk assessment dated [DATE]st, 2025, revealed resident is at risk for malnutrition with a score of 11.0. The resident's BMI (body mass index-measure of body fat based on height and weight) was 23.8(indicating resident is within normal body weight). Resident's most recent weight documented as 118 pounds on the admission April 16th, 2025. The resident estimated calories are 1501 to 1770. Resident R1's documented food intake revealed that intake meals 51 to 75% of estimated needs. The resident report she is pescatarian RD (registered dietician) will update diet preferences via food service director. Continue review of this assessment document revealed that this resident is at risk for malnutrition she presents a need for modified food texture, need for ONS(oral nutritional supplement), altered nutrition related to labs, increased metabolic needs, and chronic medical diagnosis with a plan to offer ensure plus 8 ounce via PO twice a day for low protein and albumin provides 350K Cal and 20 grams of protein. Review of resident recorded weights revealed on April 16, 2025(admission resident weight recorded as 118.0, April 23, 2025, resident's weight recorded as 107.6 pounds, May 7, 2025, resident's weight recorded as 102.8 pounds. Review of resident clinical record dietary notes revealed that on April 30, 2025, resident R1 triggered for weight warning indication that resident R 1 has sustained a weight loss of 10.4 pounds 8.8% change. REWEIGHT PENDING. There was no indication that resident R1 was reweighed. Further review of resident R 1 clinical record dietary notes dated May 7, 2025, revealed that resident R 1 triggered weight warning indicating resident now recorded weight of 102.8, 12.7 % one-month weight loss. The RD met with resident to address recent significant weight change. Residents reported that occasionally her family provides her own food. RD offered Ensure clear once a day. Full comprehensive assessment to follow. Further review of resident R 1 clinical record dietary notes dated May 14, 2025, revealed Note Text: WEIGHT CHANGE: Value: 102.9Vital Date: 2025-05-13 14:13:00.0MDS: -5.0% change over 30 day(s) [ 12.7%, 15.0]-5.0% change [ 12.8% , 15.1 ]-7.5% change [ 12.8% , 15.1 ]-10.0% change [ 12.8% , 15.1 ]reweight pending. No indication that resident R 1 was reweighed. Interview with resident R 1 on May 13, 2025, at 10:48 a.m. revealed that this resident has concerns of diet and weight loss. Resident R1 stated that she has not been provided her dietary preference of a pescatarian diet. Interview with Resident R 1 on May 15, 2025, revealed that this resident was served a plate of French fries the previous evening for dinner. Interview with dietitian employee E5 conducted on May 14, 2025, at 10:53 AM revealed that she is aware of resident R1's recent weight loss, she believed the weight loss has been attributed to healing process, and the initial weight recorded may have been inaccurate. This employee was unable to provide any meal tracking or nutritional requirements for this resident. Employee E5 and has confirmed that a full comprehensive assessment addressing the residents weight loss, or any documented interdisciplinary team notification has not been completed. 28 Pa. Code 211.12(c) Resident care policies 28 Pa. Code: 211.12(c)(d)(1)(2)(3)(5) Nursing services

Based on review of clinical records, staff and resident interviews, it was determined that the facility failed to provide culturally competent, trauma informed care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of residents for two of two residents with diagnosis of PTSD (post-traumatic stress disorder). (Resident R60 and Resident R63) Findings include: Review of facility policy on Trauma Informed Care and Culturally Competent Care dated August 2022 revealed that under section Purpose To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice. To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Under section General Guidelines 1. Traumatic events which may affect residents during their lifetime include: a. physical, sexual and emotional abuse; b. neglect; c. interpersonal or community violence; d. serious injury or illness; e. bullying; f. forced displacement; g. racism; h. war; and i. generational or historical trauma. # 2. Trauma-informed care is based on Trauma-Informed and Resilience Oriented ([NAME]), evidence-based and emerging best practices. 3. For trauma survivors, the transition to living in an institutional setting (and the associated loss of independence) can trigger profound re-traumatization. 4. Triggers are highly individualized. Under section Organizational Strategies #1. Evaluate the need for trauma-informed practices as part of the facility assessment. #2. Utilize the facility assessment to identify the cultural characteristics of the resident population, including language, religious or cultural practices, values and preferences. #3. Develop an organizational culture that supports all Trauma-Informed and Resilience Oriented ([NAME]) domains. These include: a. universal and early screening and assessment; b. resident-centered care and services; e. safe and secure environments; g. ongoing performance improvement and evaluation. #7. Establish an environment of physical and emotional safety for residents and staff. Under section Resident Screening #1. Perform universal screening of residents, which includes a brief, non-specialized identification of possible exposure to traumatic events. #2. Utilize screening tools and methods that are facility-approved, competently delivered, culturally relevant and sensitive. #3. Screening may include information such as: a. trauma history, including type, severity and duration; b. depression, trauma-related or dissociative symptoms; c. risk for safety (self or others); d. concerns with sleep or intrusive experiences; e. behavioral, interpersonal or developmental concerns; f. historical mental health diagnosis; g. substance use; h. protective factors and resources available; and i. physical health concerns. 4. Utilize initial screening to identify the need for further assessment and care. [NAME] section Resident Assessment #1. Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers. #2. Utilize licensed and trained clinicians who have been designated by the facility to conduct trauma assessments. #3. Use assessment tools that are facility-approved and specific to the resident population. Review of Resident R60's clinical record revealed that Resident R60 was admitted to the facility on [DATE], with diagnoses of but not limited to PTSD (Post Traumatic Stress Disorder). Review of Resident R60's admission MDS (Minimum Data Set-a federally required resident assessment completed at a specific interval) dated May 7, 2025, Section I - Active Diagnoses, I6100. Post Traumatic Stress Disorder (PTSD) was marked X indicating that resident had a diagnosis of PTSD. Further review of Resident R60's clinical record revealed no documented evidence that an assessment related to PTSD was conducted on Resident R60, Furtherer, there was no documented evidence that Resident R60 received services to address Resident R60's diagnoses of PTSD. Further review of Resident R60's clinical record revealed a psych note dated May 5, 2025. Review of the psych note dated May 5, 2025, revealed that Resident R60 was seen due to psychotropic use while in a rehabilitation setting. Further, there was no mention of Resident R60's diagnoses of PTSD in the psych evaluation. Review of Resident R60's care plans revealed no care plan addressing Resident R60's PTSD diagnoses. Review of Resident R63's clinical record revealed that Resident R63 was admitted to the facility on [DATE], with diagnoses of but not limited to PTSD (Post Traumatic Stress Disorder). Further review of Resident R63's clinical record revealed no documented evidence that an assessment related to PTSD was conducted on Resident R63. Furtherer, there was no documented evidence that Resident R63 received services to address Resident R63's diagnoses of PTSD. Review of resident R63's care plans revealed no care plan addressing Resident R63's PTSD diagnoses. 28 Pa. Code 211.12(c)(d)(3)(5) Nursing services

Based on review of facility policy, review of clinical records, and staff and resident interviews, it was determined that the facility failed to ensure one resident was free from significant medication error for 1 of 3 resident reviewed. (Resident R1) Findings include: Review a facility policy titled Administering Medications dated April 2019, revealed that all medications are administered in accordance with prescriber orders and residents may self-administer their medication only if the attending physician comment in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. Review of the National Institute of Health article titled Magnesium Fact Sheet for health professionals dated June 2, 2022, revealed magnesium is a nutrient that the body needs to stay healthy magnesium is an important for many processes in the body including regulating muscle and nerve function, blood sugar levels, and blood pressure and making protein, bone and DNA. Recommended intakes for magnesium and other nutrients are provided in a dietary reference intakes developed by the Food and Nutrition Board at the Institute of Medicine and the National Academies. Health risks from excessive magnesium too much magnesium from foods does not pose a health risk in healthy individuals because the kidneys eliminate excess amounts in urine however high doses of magnesium from dietary supplements or medications often result in diarrhea and can be accompanied by nausea and abdominal cramping. Very large doses of magnesium containing lads live in and acids providing more than 5000 milligrams a day have been associated with magnesium toxicity including fatal hyper magnesium [NAME]. The risk of magnesium toxicity increases with impaired renal function or kidney failure. Several types of medication that has potential to interact with magnesium supplements or affect the magnesium status. Review of Resident R1's clinical record physician's orders revealed no order for the supplement Magnesium. Observation of licensed nurse employee E6 on May 14, 2025 at 10:05 a.m. revealed licensed nurse employee E 6 administering morning medication to resident R1. During this observation a bottle of magnesium gummy vitamins 84 mg were viewed on the resident's table. Interview with Resident R1 at time of the above observation revealed that they are her vitamins and she takes them twice daily. Interview with licensed nurse employee E6 at time of the above observation confirmed that there was no order for this supplement and this nurse was unaware that resident R1 was consuming this supplement. 28 Pa.Code 211.10(c) Resident Care Policies 28 Pa. Code 211.12(c) Nursing Services

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure that drugs ad biologicals are stored in a safe/secure environment in accordance with professional standards for one of one medication room and for one of sixteen residents observed. (Resident R60) Findings include: Review of facility policy on Medication Labeling and Storage dated February 2023, under section Policy Statement, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Under section Policy Interpretation and Implementation, subsection Medication Storage 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. 5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. 6. Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly. Subsection Medication Labeling #1. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. # 5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Review of Resident R60's clinical record revealed that Resident R60 was admitted to the facility on [DATE], with diagnoses of but not limited to Chronic Obstructive Pulmonary Disease (COPD-lung an dairway disease that restict breathing). Review of Resident R60's physician's orders revealed an order for Fluticasone-Salmeterol 500-50 MCG/ACT Aerosol Powder, breath activated 1 puff inhale orally every 12 hours for COPD Instruct patient to rinse mouth to prevent thrush. -start date-05/01/2025 Observation of Resident R60's environment conducted on May 13, 2025, at 9:26 a.m. during the initial tour of the facility revealed the inhaler Fluticasone with Resident R60's name on it on top of the overbed table. Interview with Resident R60 conducted at the time of the observation revealed that the nurses gave her the Fluticasone. Further interview revealed that Resident R60 did not remember the name of the nurse who gave her the Fluticasone Inhaler. Follow-up observation conducted with Director of Nursing Employee E2 on May 13, 2025, at 10:04 am revealed that the Fluticasone inhaler was still on top of Resident R60's overbed table. Interview with DON (Director of Nnursing) Employee E2 conducted at the time of the observation confirmed that Fluticasone inhaler labelled with Resident R60'd name was on top of Resident R60's overbed table. Observation of the medication refrigerator located in the medication room conducted on May 14, 2025, at 9:57 a.m. with DON, Employee E2 revealed an open vial of tuberculin purified protein derivative. Further observation revealed that the open vial of tuberculin purified protein derivative was not dated. Interview with Employee E2 conducted at the time of the observation confirmed that the vial of tuberculin purified protein derivative was not dated. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of personnel files, review of facility documentation, and staff interview, it was determined that the facility failed to employ a qualified registered dietitian. Findings include: Review of dietitian job description revealed the clinical dietitian assesses the nutritional needs and dietary restrictions of the residents to develop and implement a plan of care to meet nutritional needs and maintain overall quality of life. Job descriptions and responsibilities include to complete assessments, chart reviews, develop an individualized nutrition care plan, nutrition focus physical exams, provide nutrition education counseling and support, review all monthly and weekly weights complete assessment and make modifications to nutrition plan of care as clinically indicated. Further review of the dietitians' responsibilities includes collaborate with inner disciplinary team members, consult with positions, assistant coordination of nutritional care services, monitor food service operations, perform all duties necessary and in accordance with the facility policy, understand and follow CMS guidelines and combines with the Department of health regulations. Requirements needed for the position of registered dietitian includes registered dietitian with the American Dietetic Association maintaining the statuses or requirement of the position. Review of the regional dietitian job description revealed the responsibilities and duties include to provide facility coverage during the absence of a registered dietitian. Interview on May 14, 2025, at 10:53 a.m. with registered dietitian employee E5 confirmed that the dietitian has not completed the mandatory dietary LDN licensure exam. Interview with NHA employee E1 and DON employee E2 on May 15, 2025, confirmed that dietician employee E5 has not completed the LDN licensure exam. Employee E5 has been working under the direct supervision of regional dietician employee E 11. Review of resident records revealed that there was no indication that licensed dietician reviewed or consulted on any clinical documents. Review of Resident R1's clinical record of dietary notes, weight loss notation, nutritional assessment and care plan, revealed that resident dietician employee E5 was the only employee who reviewed and documented any notes pertaining to resident significant weight loss. There is no cosignature or indication that employee E 11 reviewed and or advised on the clinical record. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.6(c) Dietary Services

Based on staff interviews and a review of employee personnel records, it was determined that the facility's activities program was not directed by a qualified professional as required. Findings included: Interview with the nursing home administrator (NHA) and Regional Staff, Employee E3 on August 26, 2024, at 1:00 p.m., stated Employee E8, Social Worker oversaw facility activity program including programs and assessments and tha the facility did not have any other activity staff. Interview with Employee E8, Social Worker on August 26, 2024, at 2:02 p.m., stated she did not possess a license or registration as qualified therapeutic recreation specialist or an activity professional. She stated she did not have 2 years of experience in a social or recreational program within the last 5 years, one of which was full-time in a therapeutic activities program. Employee E8, Social Worker stated she was not a qualified occupational therapist or occupational therapy assistant; or has completed a training course approved by the State. Employee E8, Social Worker confirmed that she did not have qualification as a activity professional or as an activity director and she was not aware of the requirement. 28 Pa. Code 201.18(e)(6) Management

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: Facility policy titled Sanitization (revised 2022), indicated that dishwasher machines are operated according to manufacturer's instructions. General recommendations for heat and chemical sanitation for high temperature dishwasher: wash temperature (,d+[DATE] F) and rinse temperature (180 F). During an observation in the main kitchen dish room area revealed a high temperature dishwasher machine with a wash cycle temperature at 172 Fahrenheit (F) and final rinse cycle temperature at 515 F. Follow up kitchen observation revealed wash cycle temperature at 170 F and final rinse cycle temperature at 210 F. Interview with Employee E4, Dietary Director, confirmed the temperatures and stated the facility is in contact with the manufacture to fix the inaccurate readings noted on the digital thermostat. During an observation in the main kitchen dry storage area on [DATE] at 10:42 am, revealed four boxes of cornbread mix dated June, 2024, one container of molasses dated [DATE], one container of cooking wine dated February 1, 2024, and loafs of bread not dated. Interview on [DATE], at 10:48 am, with Employee E4, Dietary Director, confirmed the facility failed to dispose of expired food products. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 211.6(f) Dietary Services.

51165 Based on review of facility policy, observation, clinical record review, and staff interview, it was determined that the facility failed to establish Enhanced Barrier Precautions for five of six residents reviewed (Resident 62, Resident 63, Resident 65, Resident 112, Resident 116). Findings include: Enhanced Barrier Precautions dated August 2022 revealed that Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is changed before caring for another resident. c. Face protection may be used if there is also a risk of splash or spray. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: d. dressing; e. bathing/showering; f. transferring; g. providing hygiene; h. changing linens; i. changing briefs or assisting with toileting; j. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and k. wound care (any skin opening requiring a dressing). EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. Staff are trained prior to caring for residents on EBPs. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. PPE is available outside of the resident rooms. Residents, families and visitors are notified of the implementation of EBPs throughout the facility. Observation on August 26, 2024, at 11:00 a.m. of resident rooms for Resident R62, R63, and R65 revealed that there were signs for Enhanced Barrier Precaution at the door. Further observation revealed no isolation cart or supplies available near the above resident rooms or that side of the nursing unit. Interview with Resident R65 on August 26, 2024, at 10:30 a.m. stated she did not see any staff wearing any gowns when providing care including incontinence care. Review of clinical record revealed that Resident R65 was admitted to the facility with spinal surgery and open wound on August 14, 2024. Review of physician order for Resident R65 revealed that the Enhanced Barrier Precaution was only ordered on August 26, 2024. Review of clinical record revealed that Resident R63 was admitted to the facility with a urinary catheter on August 23, 2024. Review of physician order for Resident R63 revealed that the Enhanced Barrier Precaution was ordered on August 26, 2024. Review of clinical record revealed that Resident R62 was admitted to the facility with joint replacement surgery and open wound on August 9, 2024. Review of physician order for Resident R65 revealed that the Enhanced Barrier Precaution was ordered on August 26, 2024. Observation on August 26, 2024, at 10:00 a.m. of Resident R112 and R116 rooms revealed that there were signs for Enhanced Barrier Precaution at the door. Further observation revealed no isolation cart or supplies available near the above resident rooms. Clinical record review revealed Resident R112 was admitted to the facility on [DATE] for after care following joint replacement surgery. Resident R112 cultures were positive for group A hemolytic strep (type of bacteria that can cause a variety of infections). Interview with Resident R112 on August 26, 2024, at 10:30 a.m. stated she does not see any staff wearing gowns when providing direct care. Review of physician order for Resident R112 revealed no orders for Enhanced Barrier Precaution. Interview with Licensed nurse, Employee E9 on August 27, 2024 at 10:05 a.m. confirmed Resident R112 should be on Enhanced Barrier Precautions due to recent surgery and positive cultures for Group A hemolytic strep. Clinical record review revealed Resident R116 was admitted [DATE] for surgical aftercare following surgery on the skin and subcutaneous tissue. Observation on August 28, 2024 at 09:20 a.m. revealed nurse aide, Employee E10 providing direct care to Resident R116 without a gown. Review of physican orders for Resident R116 revealed Enhanced Barrier Precaution was only ordered on August 27, 2024. Interview with Licensed nurseEmployee E9 on August 28, 2024 at 9:25 a.m. confirmed gowns should be worn while providing direct care with Resident R116. 28 Pa.Code 211.10(d) Resident care policies 28 Pa.Code 211.12(d)(1) Nursing services

Based on review of facility documentation, clinical record reviews, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers as required for one of one records reviewed related to hospital transfers (Residents R10). Findings include: Review of progress notes for Resident R10 revealed a note, dated May 28, 2024. which indicated that the resident was transferred to a local hospital emergency department due her medical conditions. A request for the evidence of notification of the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers were requested to the administrator and facility administrative staff from previous management, Employee E5. Facility did not submit evidence of notification of the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers as requested. Interview on August 27, 2024, Employee E5 confirmed that the Office of the State Long-Term Care Ombudsman was not notified as required of facility-initiated emergency transfers for Resident R10. Employee E5 also stated facility did not send any notification to the Office of the State Long-Term Care Ombudsman as required for any hospital transfers. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(2) Management

Based on clinical record review, interviews with staff, review of facility documentation and review of facility policies, it was determined that the facility failed to ensure that a hot beverage was served at a safe temperature for one of seven residents reviewed which resulted in actual harm to Resident R1 who sustained a burn from a hot beverage. (Resident R1) Findings include: Review of the facility's policies entitled Food and Beverage Temperatures-Patient Safety dated October 6, 2016, revealed that the purpose of this policy was to outline practices and accountabilities to ensure that food and beverages are received at a safe temperature and delivered by the appropriate personnel. The policy indicated that a patient would receive food and beverages at safe temperatures and in accordance with applicable legislation, codes and standards of practice. This policy indicated that hot foods and beverages were only to be provided by the Dietary Department. Review of Resident R1's clinical record revealed an occupational therapist assessment dated [DATE], which indicated that Resident R1 had a diagnosis of bilateral carpal tunnel syndrome (the median nerve, which runs from the forearm into the palm of the hand becomes squeezed at the wrist). Review of physician's progress notes dated September 24, 2020, revealed a neurological assessment of mental status which indicated that Resident R1 was alert and oriented to person place and time. Review of Resident R1's nursing notes dated September 22, 2020, revealed that Registered Nurse, Employee E7 assessed Resident R1's skin after hot tea was spilled on Resident R1's abdomen. The resident was assessed by nursing staff and found with an opened blister measuring 1cm (centimeter) x 1cm. Employee E7 indicated that the resident's physician was notified about the incident and an order was obtained for the topical antibiotic treatment [MEDICATION(S)] cream and to leave skin (burn) open to air. Review of physician's progress dated September 22, 2020, revealed that a 1cm x 2 cm open blister was noted by the physician on Resident R1's mid abdomen post spilling hot tea. The resident had minimal tenderness upon examination. The physician indicated to continue to treat with [MEDICATION(S)]. The care planned by the physician was to monitor use of the hot foods and drinks. Further review of Resident R1's clinical record revealed that Resident R1 continued with treatment of [MEDICATION(S)] throughout the stay at the facility. The resident was discharged to home on September 26, 2020, with prescription for continued skin treatment for the burn. Interview with nursing assistant, Employee E6, on September 28, 2020, at 2:30 p.m., revealed that Employee E6 used a styrofoam cup and put water into the cup and placed it into a microwave located on the nursing unit, to prepare hot water for tea for Resident R1. The nursing assistant reported that the temperature of the water was not verified. The nursing assistant reported that the temperature of the water was not tested because there was no thermometer available for use to check the temperature of the heated water, before giving it to Resident R1. During the interview with Employee E6, the nursing assistant explained that after heating the water in the microwave for Resident R1's hot tea, this hot beverage was given to the Registered Nurse, Employee E7 to deliver to the resident. Interview with Registered Nurse, Employee E7 on September 28, 2020, at 2:45 p.m. revealed that this nurse, placed the hot beverage on the meal tray and gave it in the styrofoam cup to Resident R1 during the breakfast meal service on the nursing unit on September 22, 2020. Further interview with Employee E7, on September 28, 2020, at 2:45 p.m., revealed that the nurse was unaware of the facility policy entitled Food and Beverage Temperatures- Patient Safety. Employee E7 confirmed that the temperature of the hot beverage was not tested after being heated in the microwave for Resident R1, on September 22, 2020; because there was no thermometer available for use for this purpose. Employee E7 reported being uninformed that the Dietary Department were to provide the hot food and beverages (hot tea and coffee ) to the residents. Interview with the Director of Nursing at 11:30 a.m., on September 28, 2020, confirmed the incident that happened on September 22, 2020 during the breakfast meal service and meal tray delivery to Resident R1. The Director of Nursing also reported that Resident R1 said that the cup of hot tea missed her mouth; while she was eating breakfast that morning. The resident reported spilling the hot beverage (tea) that was provided in a styrofoam cup onto her abdomen; which caused a burn to her skin. 28 Pa. Code 201.18(b)(1)Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.10(c)Resident care policies 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.6(c)(d) Dietary services

Based on observation, clinical record review, staff interviews and review of facility policy and procedure, it was determined that the facility failed to provide safe hot water temperatures at resident outlets and failed to prevent an accident for one of 11 residents reviewed (Resident CL2). Findings include: Review of Resident CL2's Minimum Data Set assessment (MDS - a periodic assessment of resident care needs) dated July 18, 2016, revealed that the resident was alert and oriented and that the resident had [DIAGNOSES REDACTED]. The MDS indicated that the resident needed extensive assistance with transfers, toileting and hygiene and was independent after being set up for eating. Review of a rehabilitation progress note dated July 6, 2016, revealed that the resident wore a hip abductor brace (its purpose is to provide support and stabilization following a hip replaement) at all times and the brace limits the resident's independence and participation in self-care tasks. The resident received scheduled narcotic pain medication every twelve hours. Review of facility documentation revealed that on July 6, 2016, the nurse aide made a cup of tea for the resident. The nurse aide told the resident to be careful and wait until the tea cooled before drinking it. The nurse aide then left the resident. A few minutes later the resident rang the call bell to say he/she spilled the tea on him/herself. The skin on the right chest was red. The same documentation, dated July 6, 2016, revealed that the resident was educated to handle hot tea while sitting up in the bed or the chair after the incident. A review of nursing documentation revealed that a care plan for hot temperatures was not developed until after the incident with the tea. A nursing progress note on July 7, 2016, revealed that the resident had multiple blisters on the right chest wall and right abdomen. There was no documentation of the size of the burns or if the resident was in a sitting position when given the hot tea. The facility failed to educate a resident with a hot beverage how to handle it correctly resulting in actual harm. Observations during the initial tour of the facility, on October 5, 2015, at 10:00 a.m. with Registered Nurse, Employee E4, revealed that in the common area bathroom, the water temperature was 117.16 degrees Fahrenheit. This temperature reading was confirmed with the Project Manager for the facility, Employee E3, on October 5, 2016, at 10:30 a.m. During the environmental tour with Employee E3 on October 6, 2016, at 1:40 p.m. it was revealed that the mixing valve had been adjusted and was reset to 104 to 108 degrees Fahrenheit. An interview with Employee E3 during the tour, confirmed that the mixing valve was set at 117 degrees Fahrenheit on October 5, 2016, when the water temperature had been measured at 117.16 degrees Fahrenheit. Review of the hot water temperature log revealed that temperatures were taken approximately weekly and that on August 4, 12, 19, 26, 30, 2016, and September 9, 16, 23, 29, 2016, there was no temperature taken at the resident's showers. Review of the temperature log revealed that on September 9, 2016, the temperature at the sink in rooms 402 and 406 was 117 and 115 degrees Fahrenheit, respectively; September 16, 2016, the temperature at the sink in rooms 402 and 421 was 115 degrees Fahrenheit; September 23, 2016, the temperature at the sink in rooms 402 and 421 was 114 and 116 degrees Fahrenheit, respectively; September 29, 2016, the temperature at the sink in room 402 and 406 was 116 degrees Fahrenheit. After the hot water temperature at 117 degrees Fahrenheit was identified at the mixing valve on October 6, 2016, the water temperature at the bathroom sinks and showers in rooms 402, 421, 416, 418 and 420 was recorded as 114 to 116 degrees Fahrenheit. There was no evidence of any action taken by the facility to correct the high temperature readings at the residents' water outlets. An interview with the Nursing Home Administrator on October 7, 2016, at 11:00 a.m. revealed that there was no policy and procedure directing the staff regarding what was to be done when water temperature exceeded 110 degrees Fahrenheit. The facility failed to provide safe hot water temperatures at the residents' water outlets and failed to prevent an accident for one of 11 residents resulting in harm to the resident. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 08/03/16, 11/06/15, 09/04/14 28 Pa. Code 201.18(b)(1) Management Previously cited 11/06/15, 09/04/14 28 Pa. Code 201.18(b)(3) Management Previously cited 09/04/14 28 Pa. Code 205.63(c) Plumbing and piping systems required for existing and new construction 28 Pa. Code 207.2(a) Administrator's responsibility 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 11/06/15, 09/04/14