Every finding on record at River's Edge Rehabilitation & Healthcare Center

Based on review of clinical records and interviews with staff, it was determined that the facility failed to ensure the resident's wishes related to advance directives was accurately reflected in the clinical record for one of two residents reviewed (Resident R1).Findings Include: Review of facility policy on Advance Directives revealed it is the policy of the facility to establish, implement and maintain written policies and procedures for advanced directives. The resident has the right, and the facility will assist the resident to formulate an advance directive at their option. The facility will inform and provide resident with a written description of the facility's policy to implement advance directives. Resident has the right to accept, request, refuse and or discontinue medical or surgical treatment and to participate in or refuse to participate in experimental research. Per facility procedure, upon admission, identify if the resident has an advance directive and if not, determine if the resident wishes to formulate an advanced directive. A resident has the option to execute an advance directive but will not be required to do so. All advance directive document copies will be obtained and located in the residence chart. Resident wishes will be communicated to the staff via the care plan (identify facility protocol for communication advanced directives either in written or oral format close) And to the resident physician. Review of resident R1's clinical record revealed that resident R1 was admitted to the facility on [DATE], with diagnosis of but not limited to Atrial Fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), Atherosclerotic Heart Disease (arteries become narrowed due to build up of plaque), and End Stage Renal Disease. Review of Resident R 1's physician's orders revealed an order for a Full Code (The medical team will use all lifesaving methods to save a patient if their heart or breathing stops) with an order date of [DATE], and was discontinued [DATE]. Review of Resident R1's care plan revealed a care plan for: Resident R1 requested that CPR measures ARE to be performed (FULLCODE STATUS) Date Initiated: [DATE]. Further, the Full Code care plan was discontinued on [DATE]. Review of Resident R1's POLST form (physician's orders for life sustaining treatments-a medical form that translates a seriously ill person's end-of-life care wishes into actionable medical orders. It instructs emergency renders on specific interventions like CPR- cardiopulmonary resuscitation) dated [DATE], revealed the Resident R1 opted for Do not attempt resuscitation DNR (do not resuscitate-a legal medical instruction telling healthcare providers not to perform CPR if a patient's breathing or heartbeat stops). Interview with the Director of Nursing Employee E2, conducted on [DATE], confirmed Resident R1 had a physician order and care plan for a full code from [DATE], until [DATE], when the physician order was changed to a DNR. Further interview with Employee E2 confirmed that on [DATE], Resident R1 filled out a POLST which indicated that Resident R1 wanted to be a DNR. Further, Employee E2 also confirmed that Resident R1's code status was not timely changed from a full code to DNR until [DATE]. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on review of clinical records, facility documentation, and staff interviews, it was determined that the facility failed to ensure one resident was allowed to exercise their right to make choices regarding daily activities for one of four residents reviewed. (Resident R1)Findings include: Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE] with a diagnoses that included primary osteoarthritis (condition where the cartilage in your joints slowly wears down over time without a specific injury or known cause, leading to pain, stiffness, and reduced movement), low back pain, and major depressive disorder. Review of Resident R1's Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated March 20, 2026, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident is cognitively intact. Interview with Resident R1 on April 15, 2026, at 9:45 a.m. revealed the resident was placed in a chair by staff and requested to be returned to their room. The resident stated staff did not comply with the request, and as a result, the resident contacted the police for assistance. Review of Employee E1, Unit Clerk, witness statement, revealed on April 3, 2026 I put (Resident R1) in dayroom to have breakfast and that was at 8:00 a.m. (Resident R1's daughter) called and I was on the phone with her and she asked me where was her mom because she called her and I said in the day room and I informed her that I am going to put her back in the bed but before the daughter hung up the police were here. Review of Employee E1, Nurse Aide, witness statement, revealed I provided morning care to (Resident R1) at 7:30 a.m. We assisted (Resident R1) out of bed in preparation for scheduled therapy. After getting her ready we escorted her to the dayroom so they could wait comfortably for their therapy session. While in the dayroom the resident became verbally agitated and repeatedly shouted that they wanted to go to their room. Staff attempted to redirect and reassure the resident, explaining that therapy was scheduled and that they would be assisted accordingly. Despite these efforts she continued to yell and became increasingly distressed. She then proceeded to call the police stating that she was being forced to be in the day room. Staff remained calm and continued to monitor the resident to ensure their safety, while also attempting de-escalation techniques. Resident was taken back to the room to calm her down when police arrived. Review of Employee E2, Unit Manager, witness statement, revealed that during the morning clinical meeting, staff discussed getting the resident out of bed and into a Geri-chair for therapy. Employee E2 reported that upon responding to the front area, a police officer was present due to a call from the resident stating they were not being allowed to return to bed. The resident was observed seated in a Geri-chair and continued to request to return to bed. Interview with Employee E1, Nurse Aide, on April 15, 2026, at 1:19 p.m. revealed the resident requested to return to their room approximately four times after breakfast. Staff reassured the resident that therapy would be arriving shortly and did not immediately comply with the request. The Nurse Aide stated approximately 30-40 minutes elapsed between the resident's initial request and when the resident was returned to their room, which occurred once police arrived. Interview with Employee E4, Director of Nursing, on April 15, 2026 at 12:45 p.m. revealed Resident R1 prefers to have therapy in his/her room; however staff encouraged the resident to remain out of bed to attend therapy. Further interview confirmed Resident R1 requested to go to her room several times but was not taken back immediately due to staff wanting the resident to attend therapy. 28 Pa. Code 211.12 (a)(c)(d)(4)(5) Nursing Services 28 Pa. Code 201.29 (j) Resident Rights

Based on observation and interview with staff, it was determined the facility failed to ensure the dish machine was maintained in safe and functional operating condition.Findings include:Observation on April 15, 2026 at approximately 9:15 a.m. of the dish machine revealed the conveyor belt was broken, requiring staff to manually push dishware through the machine to start the wash cycle. Interview with Director of Dietary, Employee E5, confirmed the dish machine was not functioning properly and required manual operation. Further interview revealed there was missing curtains and caps on jets for the dish machine. Review of email communication between Director of Dietary, Employee E5, and Administrator, Employee E6, dated March 12, 2026, revealed the Director of Dietary, Employee E5, had requested repair of the dish machine, stating, please approve asap (as soon as possible), dish machine needs to be fixed asap. Further review of email communication revealed the Administrator, Employee E6, approved the dish machine repair on March 12, 2026 and did not receive quote from repair company until April 02, 2026. Email communication on April 13, 2026 revealed a new quote was submitted for a new dish machine. Interview on April 15, 2026 at approximately 12:45 p.m. with Administrator, Employee E6, revealed the facility is currently in the process of getting a new dish machine. 28 PA. Code 201.14(a) Responsibility of licensee 28 PA. Code 201.18(b)(3) Management

Based on a review of the clinical record, facility documentation, observations, and interviews with staff and residents, it was determined that the facility failed to provide Activities of Daily Living (ADL) assistance for one of the two residents reviewed (Resident R9). Findings include: Clinical record review revealed that Resident R9 was admitted to the facility on [DATE], with diagnoses including hemiparesis (weakness on one side of the body) following a cerebral infarction affecting the right dominant side (stroke) and muscle wasting and atrophy. A review of the physician orders dated October 26, 2025, indicated: Showers (Monday/Thursday on 3-11). Document if the patient/resident refuses shower in Health Status Note. A review of Resident R9's quarterly Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 15, reflecting cognitive intact. The functional abilities section of the MDS indicated that Resident R9 requires partial/moderate assistance with showering tasks. A review of the comprehensive care plan dated September 17, 2024, indicated: Resident R9 has an ADLs self-care performance deficit related to limited mobility and left-side weakness related to CVA (stroke). Observation and interview conducted on March 23, 2026, at 7:36 p.m. revealed that Resident R9 had greasy hair and facial hair. When asked when they last received a shower and shave, Resident R9 responded a couple of weeks ago. Resident R9 prefers bed baths and stated a desire to be shaved daily and have their hair washed. This information was communicated within a few minutes to Licensed Nurse Employee E5, who responded, Yes, we'll give him/her a shower. On March 25, 2026, at 9:59 a.m., an observation was conducted with the Director of Nursing, Employee E2, who confirmed that Resident R9 still had greasy hair and required a facial shave. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code: 211.12(d)(1)(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 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 the resident for one of one residents sampled for post-traumatic stress disorder (PTSD). (Resident R14).Findings include: Review of Resident R14's clinical record revealed the resident was admitted to the facility on [DATE] with a diagnosis of parkinsonism (group of movement symptoms found in several conditions, including Parkinson's disease), post-traumatic stress disorder (PTSD- a mental health condition that develops after experiencing or witnessing a traumatic event, such as a natural disaster, war, violent crime, or personal loss), and anxiety disorder. Resident R14's care plan, dated February 15, 2026, revealed Resident R14 has a mood problem related to disease processes past medical history of obsessive-compulsive disorder and PTSD. Further review of the care plan did not address possible triggers that may cause re-traumatization. Interview with the Director of Nursing, Employee E2, on March 25, 2026, at 12:45 p.m. confirmed that Resident R14's care plan did not include possible triggers that may cause re-traumatization. 28 Pa. Code 211.12(c)(d)(3)(5) Nursing services

Based on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure residents' advance directives and physician orders for Life-Sustaining Treatment (POLST) were followed according to the residents' expressed wishes for 2 of 24 residents reviewed (Resident R5 and R13). Findings include: Review of the facility policy titled Advance Directives Policy and procedure reviewed January 2026, revealed It is the policy of the facility to establish, implement and maintain written policies and procedures for advance directive. The resident has the right and the facility will assist the resident to formulate an advance directive at their option. The facility will inform and provide resident with a written description of the facility's policy to implement advance directives. Resident has the right to accept, request, refuse and/or discontinue medical or surgical treatment and to participate in or refuse to participate in experimental research. Further review revealed Resident wishes will be communicated to the staff via the care plan (identify facility protocol for communication of advance directives either in written or oral format) and to the resident physician. Review of the Pennsylvania POLST (Physician Orders for Life-Sustaining Treatment) is a medical order designed to ensure that a patient's treatment preferences, including life-sustaining interventions and comfort measures, are clearly documented and followed across healthcare settings. At the time the POLST is completed, any existing advance directives must be reviewed. The form must be signed by a physician and the patient or authorized surrogate, though verbal physician orders are acceptable if followed by a physician signature per facility policy. If the patient's condition changes, the patient or surrogate must be contacted to update the POLST. Oral fluids and nutrition should be offered when medically feasible, and comfort measures must be provided in an appropriate setting. Patients or authorized surrogates may revoke or modify any part of the POLST at any time, including withholding or withdrawing life-sustaining treatment. The POLST should be reviewed periodically, and if it becomes invalid or is replaced, the previous form must be voided by marking through sections AE and writing VOID across the form. If any section is incomplete, providers should follow other appropriate methods to determine treatment preferences. Review of Resident R5's clinical record revealed resident admitted to the facility on [DATE], with the diagnosis of Cerebral infarction (clot blocks a blood vessel that feeds the brain), and Dementia (loss of memory). Review of Resident R5's MDS (Minimum Data Set) dated June 26, 2025, revealed that resident's BIMS (Brief interview for mental status) score was 0, indicating severely cognitively impaired. Review of Resident R5's POLST (Physician Orders for Life-Sustaining treatment), dated May 15, 2025, revealed that resident's responsible party elected the following: Part A- Cardiopulmonary Resuscitation (CPR), person has no pulse and is not breathing: DNR (Do Not Resuscitate)/ Do not attempt resuscitation (allow natural death). Part B- Medical Interventions: Person has pulse and/or is breathing Comfort measures only, use medication by any route, positioning, wound care and other measures to relieve pain and suffering, Use oxygen, oral suction and manual treatment of airway obstruction as needed for comfort. Do not transfer to hospital for life-sustaining treatment. Transfer if comfort needs cannot be met in current location. Part C- Antibiotics: No antibiotics. Use other measures to relieve symptoms. Part D- Artificially administered hydration/ nutrition, always offer food and liquids by mouth if feasible: No hydration and artificial nutrition by tube. The POLST form was signed by the physician and Resident R5's responsible party on May 15, 2025, acknowledging that the orders reflect the resident's known desires and best interests. Review of Resident R5's comprehensive care plan revealed focus initiated on June 22, 2025, I have requested that CPR measures are to be performed (Full code status). Review of Resident R5's face sheet revealed Code status: Full Code. Review of Resident R5's physician order, revised on June 21, 2025, for Full code. Interview with Employee E10, Unit Manager on March 24, 2026 at 9:48 a.m. confirmed Resident POLST indicated that the resident is a DNR (do not resuscitate) code, however care plan, orders and face sheet did not reflect this. Interview with Employee E2, Director of Nursing on March 24, 2026 at 10:00 a.m. confirmed Resident's Son (responsible party) does not wish to change anything about the resident's code status from what the POLST indicates (DNR/ comfort measures only). Confirmed Resident R5's care plan, orders and face sheet were not updated to indicate the resident's advance directive. Review of Resident R13's clinical record revealed resident was admitted to the facility on [DATE], with diagnosis of Chronic Obstructive Pulmonary Disease (disease process that causes decreased ability of the lungs to perform) and Heart failure. Review of Resident R13's MDS (Minimum Data Set) dated February 4, 2026, revealed that resident's BIMS (Brief interview for mental status) score was 9, indicating moderately cognitively impaired. Review of Resident R13's POLST (Physician Orders for Life-Sustaining treatment), dated March 10, 2025, revealed that resident elected the following: Part A- Cardiopulmonary Resuscitation (CPR), person has no pulse and is not breathing : DNR (Do Not Resuscitate)/ Do not attempt resuscitation (allow natural death). Part B- Medical Interventions: Person has pulse and/or is breathing: Limited additional interventions- includes care described above. Use medical treatment, IV fluids and cardiac monitor as indicated. Do not use intubation, advanced airway interventions, or mechanical ventilation. Transfer to hospital if indicated. Avoid intensive care if possible. Part C- Antibiotics: Determine use or limitation of antibiotics when infection occurs, with comfort as goal. Part D- Artificially administered hydration/ nutrition, always offer food and liquids by mouth if feasible: No hydration and artificial nutrition by tube. The POLST form was signed by the physician and Resident R13 on March 10, 2025, acknowledging that the orders reflect the resident's known desires and best interests. Review of Resident R13's comprehensive care plan revealed no documented evidence of code status. Review of Resident R13's face sheet revealed DNI- do not intubate. No documented evidence of requested CPR interventions. Review of Resident R5's physician order, revised on March 10, 2025, for DNI- do not intubate. No documented evidence of order for requested CPR interventions. Interview with Employee E10, Unit Manager on March 25, 2026, at 12:35 p.m. confirmed Resident POLST indicates that resident is a DNR (do not resuscitate) code, however care plan, physician orders and face sheet do not reflect this. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29 (a) Resident Rights 28 Pa Code 211.2 (d)(7) Medical Director 28 Pa. Code 211.12 (d)(5) Nursing Services

Based on a review of clinical records, facility policy, and staff interviews, it was determined that the facility failed to ensure that the physician documented either a 14-day stop date or a clinical justification for the continued use of PRN (as needed) psychotropic (alters mood, perception, and behavior) medication for two of four residents reviewed (Residents R7 and R5).Findings include: Review of facility policy Psychotropic Medication, dated 2026, revealed Resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used:a. In excessive dose (including duplicate drug therapy); orb. For excessive duration; orc. Without adequate monitoring; ord. Without adequate indications for its use; ore. In the presence of adverse consequences which indicate the dose should be reduced or discontinued; [NAME]. Any combination of the reasons. Further review of facility policy revealed PRN (as needed) orders for psychotropic drugs are limited to 14 days, except as provided if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days. He or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. Review of Resident R7's clinical record revealed Resident R7 was admitted to the facility on [DATE] with a diagnosis of dementia (decline in cognitive function that interferes with daily life), traumatic subdural hemorrhage (bleeding between the brain and it's outer protective covering, often resulting from head injuries), and severe protein-calorie malnutrition (insufficient intake of both protein and calories). Review of Resident R7's clinical record revealed a physician's order, dated February 04, 2026, for Ativan 1 milligram to be given by mouth every 24 hours as needed for anxiety. Further review of the physician's order revealed there was no documented stop date or clinical justification for continued use of the psychotropic medication beyond 14 days. Interview on March 25, 2026 at 10:45 a.m. with Director of Nursing, Employee E2, confirmed that Resident R4 lacked the required stop date within 14 days and a rationale for continued use beyond 14 days. 28 Pa. Code 211.2(d)(3) Medical director 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of clinical records, review of facility policy and interview with residents and staff, it was determined that the facility failed to develop a person-centered resident care plan for two of twenty-four residents reviewed (Resident R5 and Resident R25).Findings Include: Review of facility policy titled Care plan dated September 2024. Under policy states It is the policy of the facility to participate in an individual, interdisciplinary plan of care for all residents. Under procedure states the plan of care shall be individualized to and based upon the assessment and diagnosis of a resident, To provide a comprehensive health care environment, all staff members should consider interdisciplinary collaboration to establish goals and appropriate interventions, and ongoing evaluations and revisions to resident care. Review of Resident R5's clinical record revealed resident admitted to the facility on [DATE], with the diagnosis of Cerebral infarction (clot blocks a blood vessel that feeds the brain), Dementia (loss of memory). Review of Resident R5's MDS (Minimum Data Set) dated June 26, 2025, revealed that resident's BIMS (Brief interview for mental status) score was 0, indicating severely cognitively impaired. Further review of Resident R5's clinical record revealed that there was no care plan developed to address Resident R5's activities. Interview with Resident R5's responsible party on March 24, 2026, at 11:45 p.m. revealed concerns related to sleeping too much during the day, not engaging in activities. Review of Resident R5's clinical tasks, titled activities indicated no data found for last 30 days. Interview with Employee E12, Activities Director on March 26, 2026, at approximately 12:00 p.m. revealed resident gets visited by activities staff 3 times a week for about 15 minutes. Resident isn't always interested in activities and spends a lot of time in his room. Interview with Employee E2, Director of Nursing on March 26, 2026, at approximately 11:00 p.m. confirmed no care plan in place and no documentation under activities task. Review of Resident R25's clinical record revealed resident admitted to the facility on [DATE], with diagnosis of Cerebral infarction (clot blocking blood flow to brain), dementia (loss of memory). Review of Resident R25's MDS (Minimum Data Set) dated February 2, 2026, revealed that resident's BIMS (Brief interview for mental status) score was 9, indicating moderately cognitively impaired. Further review of Resident R25's clinical record revealed that there was no care plan developed to address Resident 5's dementia care. Interview with Employee E2, Director of Nursing on March 26, 2026, at approximately 11:00 p.m. confirmed no care plan in place for dementia care. 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on direct observation, clinical record review, and interviews with staff, it was determined that the facility failed to ensure enteral feedings were administered and monitored according to professional standards of practice, specifically related to labeling, for one of two resident's reviewed fed via enteral feeding (Resident R6).Findings include: Review of the facility's policy titled Enteral Feeding , last revised on 9/2025 under procedures, documentation bullet #16 stated Document administration of feeding on Medication Administration Record (MAR) including: Date, Formula, Rate, Continuous bolus. A review of the clinical record for Resident R6 indicated that the resident was admitted to the facility on [DATE], with diagnoses including, muscle wasting and atrophy, protein calorie malnutrition, cerebrovascular disease (long term weakness with speech and movement after a stroke), and immunodeficiency (immune system is weak). A review of the physician's order for Resident R6, dated March 20, 2026, indicated an enteral feeding order as follows: Jevity 1.5 at a rate of 65 mL/hour x16 hours. TV (total volume)= 1040 ml. Up at 2 pm and down at 6am or until TV is infused. And every shift monitoring- sign to confirm that feeding is infusing as ordered. On March 25, 2026, at 8:39 p.m., an observation was conducted with Licensed Nurse, Employee E5. revealed that Resident R6 was in bed receiving enteral feeding. The feeding bag was not labeled with no information. Employee E6 reported your right it's not labeled, and it should have a labeled on both internal feed bag and flushes. 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(3)(5) Nursing services

Based on review of clinical records and interview with staff, it was determined that the facility failed to ensure pain medication was administered in accordance with the physician's order for one of four residents reviewed for pain management (Resident R33).Findings Include: Review of Resident R33's clinical record revealed Resident R33 was admitted to the facility on [DATE] with a diagnosis of local infection of the skin and subcutaneous tissue, polyneuropathy (condition that damages multiple peripheral nerves in the body), and anxiety disorder. Review of Resident R33's clinical record revealed physician's order, dated February 16, 2026, for Oxycodone 5 milligrams give 5 mg by mouth every 4 hours as needed for pain 6-10. Review of Resident R33's March 2026 Medication Administration Record (MAR) revealed that the as needed pain medication Oxycodone 5 milligrams was administered out of the parameter ordered by the physician as follows: March 1, 2026- Pain level 5March 2, 2026 at 8:38 a.m.- Pain level 5March 2, 2026 at 9:01 p.m.- Pain level 4March 7, 2026- Pain level 4March 8, 2026- Pain level 5March 10, 2026 at 8:47 p.m.- Pain level 5 March 10, 2026 at 7:58 p.m.- Pain level 4March 12, 2026- Pain level 0March 16, 2026- Pain level 5March 18, 2026- Pain level 5March 20, 2026- Pain level 4March 22, 2026- Pain level 3March 23, 2026- Pain level 4 Interview on March 25, 2026, at 12:45 p.m. with Director of Nursing, Employee E2, confirmed Resident R33's pain medication was not administered in accordance with the physician's order.28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services

Based on observations, and staff interview, it was determined that the facility failed to ensure that the grievance forms were available and that residents had the right to file an anonymous grievance for two of two nursing units (first and second floor).Findings include: On March 24, 2026, at 11:38 a.m., observations were conducted with the Administrator, Employee E1 confirmed that grievance forms were only available at the front desk, and residents would need to request a form in order to receive one. No method had been established for residents to file anonymous grievances. Observation of the second floor revealed that no forms were readily available to residents; forms could only be obtained upon request and were located in the filing cabinet behind the nursing stations. 28 Pa. Code 201.18 (b)(1)(3) Management 28 Pa. Code 201.29 (a) Resident Rights

Based on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement enhanced barrier precautions for three residents reviewed who had a indwelling Foley catheter, wound and internal feeding tube. (Residents R6, R91, and R108).Based on a review of the facility's Infection Control requirements Influenza Vaccine for Unvaccinated Healthcare workers to be wearing a mask, the facility failed to ensure that unvaccinated healthcare workers are wearing a mask. Specifically, vaccinated record for one Licensed Practical Nurse, who refused the Influenza Vaccine was not wearing a mask. Findings Include: According to the facility policy titled Influenza Vaccine (reviewed December,2025) number 11, the use of source control for unvaccinated health care workers will be based on state guidelines or outbreak status. On the Mask Acknowledgement form, it states that during influenza season a surgical mask will be worn during direct resident contact, in common areas of the facility, and Flu season October to May. A review of the facility policy titled, Enhanced Barrier Precaution Policy and Procedure last revised 11/2024, revealed enhance Barrier Precautions are to be implemented for all residents with any of the following during high-contact resident care activities: Infection or colonization with an MDRO when Contact precautions do not apply. Wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ Ventilator) regardless of MDRO colonization status. A review of the facility's healthcare workers vaccine records revealed that a Licensed Practical Nurse, Employee 4 refused the Influenza Vaccine on November 3, 2025. Observations conducted on March 25, 2026 at 9:22 a.m. revealed that Licensed nurse, Employee E4 was not wearing a mask during medication pass. On March 25, 2026, during an interview with the Infection Preventionist, Employee 3 confirmed that all healthcare workers who refuse the Influenza vaccine must wear a mask during flu season. This was also confirmed by the Director of Nursing Employee 2 on March 25, 2026 approximately 1:00 p.m. A review of the clinical record for Resident R6 indicated that the resident was admitted to the facility on [DATE], with diagnoses including muscle wasting and atrophy, protein calorie malnutrition, cerebrovascular disease (long term weakness with speech and movement after a stroke), and immunodeficiency (immune system is weak). A review of the physician's order for Resident R6, dated March 20, 2026, indicated an enteral feeding order as follows: Jevity 1.5 at a rate of 65 mL/hour x16 hours. TV (total volume) = 1040 ml. Up at 2 pm and down at 6am or until TV is infused. And every shift monitoring- sign to confirm that feeding is infusing as ordered. On March 23, 2026, at 8:11 p.m., Nursing Aide, Employee E7 provided direct care to Resident R6 while only wearing gloves. When asked if Resident R6 was on enhanced barrier precautions, as indicated by the sign outside the door, Employee E7 responded, No, [Resident R6] is not on enhanced barrier precautions. A review of the clinical record for Resident R108 indicated that the resident was admitted to the facility on [DATE], with diagnoses including dysphagia (difficulty swallowing), chronic respiratory failure with hypoxia (lungs unable to supply enough oxygen), Alzheimer's disease (memory loss), and nutritional deficiencies. Resident R108's physician order dated November 21, 2025 indicated Enhanced Barrier Precautions related to wounds. On March 24, 2026, at 9:32 a.m., Nurse Aide, Employee E8 provided direct care to Resident R108 while only wearing gloves. When Resident R108 needed to be transferred using a two-person mechanical, Employee E8 confirmed in the hallway that they were not wearing the appropriate personal protective equipment (PPE), even though a sign outside Resident R108's door indicated that the resident was on enhanced precautions. A review of the clinical record for Resident R91 indicated that the resident was admitted to the facility on [DATE]. Review of Resident R91's care plan dated December 12, 2025, revealed [Resident R91[ receives care with Enhanced Barrier Precautions R/T (related to) indwelling catheter. On March 23, 2026, at 8:31 p.m., Licensed Nurse, Employee E5 provided catheter care while only wearing gloves. Assisting Director of Nursing Employee E9 confirmed that Resident R91 was on enhanced barrier precautions, and Employee E5 was not wearing the required PPE. 28 Pa. Code 211.10 (d) Resident care policies 28 Pa. Code 211.12 (d)(5) Nursing services

Based on a review of clinical records, facility documents, and staff interview, it was determined that the facility failed to ensure residents had the capacity to understand the terms of a binding arbitration agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not) for three of five residents reviewed (Resident R135, R126, R7). Findings include: Review of Resident R135 revealed the resident was admitted to the facility on [DATE] with a diagnosis of disorder of kidney and ureter ( kidneys or the tubes that carry urine from the kidneys to the bladder are not working properly, which can affect how the body filters waste and removes urine), cerebrovascular disease (condition that affects the blood vessels in the brain, reducing blood flow and potentially causing brain damage, such as a stroke), and anxiety disorder. Review of Resident R135's Brief Interview for Mental Status (BIMS), dated March 18, 2026, revealed a BIMS summary score of 7, indicating severe cognitive impairment. Review of Resident R135's admission paperwork revealed Resident R135 signed an Arbitration Agreement on March 17, 2026. Review of Resident R126 revealed the resident was admitted to the facility on [DATE] with a diagnosis cerebral infarction (when part of the brain is damaged because blood flow to that area is blocked, often resulting in a stroke), Alzheimer's disease (condition that slowly damages the brain, causing memory loss, confusion, and difficulty thinking and making decisions), and encephalopathy (condition in which the brain does not function properly, leading to confusion, memory problems, or changes in behavior). Review of Resident R126's Brief Interview for Mental Status (BIMS), dated March 13, 2026, revealed a BIMS summary score of 0, indicating severe cognitive impairment. Review of Resident R126's admission paperwork revealed Resident R126 signed an Arbitration Agreement on March 13, 2026. Review of Resident R7 revealed the resident was admitted to the facility on [DATE] with a dementia (decline in memory and thinking skills severe enough to affect a person's daily life and ability to function), traumatic subdural hemorrhage (bleeding between the brain and its outer covering caused by a head injury, which can put pressure on the brain and affect how it works), and severe protein-calorie malnutrition (serious condition where the body does not get enough protein and calories, leading to extreme weight loss, weakness, and poor overall health). Review of Resident R7's Brief Interview for Mental Status (BIMS), dated February 03, 2026, revealed a BIMS summary score of 7, indicating severe cognitive impairment. Review of Resident R7's admission paperwork revealed Resident R7 signed an Arbitration Agreement on February 02, 2026. Interview with the admission Director, Employee E13, on March 25, 2026, at 10:45 a.m. confirmed Resident R135, R126, and R7 had severe cognitive impairment based on their BIMS score, indicating the residents did not have the capacity to understand the terms of a binding arbitration agreement. 28 Pa Code: 201.18(b)(1)(3) Management. 28 Pa Code: 201.24(a) admission policy.

Based on review of facility assessment and staff interview, it was determined that the facility failed to ensure the direct care staff and input from residents, resident representatives, and/or family members was included when conducting the facility assessment.Findings include: Review of the facility's facility assessment, dated January 29, 2026, revealed there was no indication that the facility involved direct care staff, input from residents, resident representatives, and/or family members. Interview with the Administrator, Employee E1, on March 25, 2026, at 12:00 p.m., confirmed there was no direct care staff, resident representatives, and/ or family members included in the facility assessment. 28 Pa. Code 201.18(b)(3) Management28 Pa. Code 211.12(c)(d)(1) Nursing services

Based on observations, resident and staff interviews, and a review of facility documentation, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures for six of 24 residents reviewed (Residents R3, R8, R12, R44, R80, and R112).Findings include: A review of facility policy titled food temperatures, undated, revealed foods will be served at the proper temperature to ensure food safety, Acceptable serving temperatures are: Meat, entrees- greater than 135 degrees but preferably 160 degrees to 175 degrees; potatoes greater than 135 degrees; vegetables greater than 135 degrees. Interview with Resident R112 on March 23, 2025, at 7:45 p.m. revealed food is always cold when it is served, it sits on the carts too long and it just doesn't stay hot. Observations during a test tray conducted on March 24, 2025, at 12:45 p.m. revealed that the last tray was passed at 12:45 p.m. Temperatures were taken by the Food Service Director (FSD), Employee E11, which revealed that the hamburger served was only 130 degrees Fahrenheit (F), broccoli was only 119 degrees F., and the potatoes were only 124 degrees F., all outside the acceptable temperature range for palatability. An interview with the Food Service Director (FSD), Employee E11, on March 24, 2025, at 12:55 p.m. confirmed that these food items were outside the acceptable temperature range and therefore not palatable. Further confirmed kitchen was short on heat plates and covers during observed service on March 24, 2025, so resident meals were delivered wrapped in plastic wrap. On March 25, 2026, at 8:58 a.m., an interview was conducted with Resident R80 and a family member who visits daily. They reported that the facility's meals include too many carbohydrates; for example, a slice of pizza is served with mashed potatoes. During interview with Resident R3 conducted on March 23, 2026, at approximately 7:00 p.m., the resident stated that the food does not taste good. During interview with Resident R12 conducted on March 23, 2026, at approximately 1910 with Resident R12, revealed food does not taste good and needs improvement. Interview conducted on March 23, 2026, at approximately 7:20 p.m. with Resident R44 revealed food does not taste good and does not match the menu. Interview conducted on March 23, 2026, at approximately 7:30 p.m. with resident R8 revealed food does not taste good, the food is cold and does not match the menu. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.14(a) Responsibility of licensee

Based on observations and an interview with staff it was determined that the facility did not ensure that garbage and refuse was disposed of properly. Findings include: A tour of the main kitchen was conducted with the Food Service Director (FSD), Employee E6, on March 25, 2025, at 10:05 a.m. revealed the following: Observations of the receiving area and loading dock, that are used by the facility to transport clean food, revealed hundreds of cigarette buds. Further observations revealed the garbage was not covered. Interview with Food Service Director, Employee E6 along duration of the tour confirmed observations of the receiving and dumpster area. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 207.2(a) Administrator's responsibility

Based on observations, interviews with staff, and a review of facility procedures, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Findings include: Review of facility policy, Food Storage undated, revealed, Food items will be stored, thawed, and prepared in accordance with good sanitary practice. Continued review revealed, All products shall be dated upon receipt or when they are prepared. Use Date shall be marked on all food containers . and all cooked meat shall be used within 3-4 days. A tour of the main kitchen was conducted with the Food Service Director (FSD), Employee E6, on March 25, 2025, at 10:05 a.m. Observations in the main refrigerator revealed two 10-pound ground beef links were unlabeled and undated; opened ham deli meat was dated March 10, 2025; two 10-pound ready to eat roast beef labeled with a received date March 17, 2025; and opened mozzarella cheese labeled with a recieved date December 10, 2024. Observations of the three-compartment sink revealed Dietary Aid, Employee E7, was manually washing pots and pans. Upon pH test of the sanitation solution (pH test determines how acidic or basic substance is) at approximately 10:15 a.m. revealed no change in pH test strip, indicating the sanitizer being tested was outside the pH range. Follow-up interview with the FSD confirmed this finding. Interview with the FSD during the kitchen tour confirmed the above-mentioned findings. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management

Based on staff interview and review of clinical records, it was determined that the facility failed to ensure that care plan meetings were held for one of 24 residents reviewed. (Resident R55) Findings include: Review of Resident R55's person-centered plan of care indicated that the resident exhibited a decline in communication due to hearing deficit and impaired cognition and thought process related to diagnoses of dementia. Review of Resident R55's clinical records revealed a nursing note dated June 3, 2024, which indicated, care conference meeting was held and that the resident's daughter in law attended via phone. Further review failed no documented evidence of care conference meetings occurred after June 2024. Interview with the facility Administrator and Social Worker, Employee E8, conducted on March 27, 2025, at 10:55 a.m. confirmed that the last care conference was conducted in June 2024 with resident and their representative. Further interview confirmed that the facility failed to conduct a care conference meeting with Resident R55 and their representative in September 2024 and December 2024. 28 Pa. Code 201.29(c.3)(1) Resident rights 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 select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to implement treatment and services for incontinence management for one of 24 residents reviewed.(Resident R11). Findings include: Review of physician order for Resident R11, dated March 24, 2025, indicated an order to change unrinary Foley Catheter with size 16fr/10ml; change monthly, and as needed, based on clinical indications such as infection, obstruction, or when the closed system is compromised, every night shift, every 4 weeks on Tuesdays, and as needed. On March 27, 2025, at 1:00 p.m., it was observed that Resident R11 had a Foley Catheter of 16fr/5ml Balloon, instead of the physician ordered size of 16fr/10ml Balloon. At the time of the finding, confirmed the same with a Licensed Nurse, Employee E5. 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on the review of clinical records and interview with staff, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer to the hospital and the reasons for the transfer to the hospital in a timely manner, in writing and in a language and manner they understood for two of 24 residents reviewed for hospitalizations (Residents R31 and R102). Findings Include: Review of nursing notes for Resident R31 dated November 20, 2024, at 11 p.m. revealed that the resident was admitted to the hospital with diagnosis of hematoma of the left kidney and abdominal pain. Further review revealed a note, dated on October 25, 2024, at 2:42 p.m. revealed that Resident R31 was discharged home. Review of nursing notes for Residents R102 dated March 20, 2025, at 4:35 p.m. revealed that resident was transfer to hospital for evaluation of gastro intestinal bleed. Review of clinical record revealed no evidence that Residents R31, R102, R27 and R99 representatives were notified of the transfer to the hospital and the reasons for the transfer in writing, and in a language and manner they understood. Interview with the Nursing Home Administrator, Director of Nursing, on March 26, 2025, at 10:30 a.m. confirmed that the residents' representatives were not notified of the hospital transfers and the reasons for the transfers in writing, and in a language and manner they understood. Further interview confirmed that there was no system in place regarding notifying the residents representatives, in writing, including the reasons, prior to resident transfer or discharge. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights

Based on review of facility policy, review of clinical records, review of facility documentation and resident interview, it was determined that the facility failed to ensure that Resident R12 was free from resident abuse, which resulted in physical and psychosocial harm to Resident R12 who sustained bruise to right posterior upper extremity and emotional anguish for one of 12 residents reviewed. (Resident R12) Findings include: Review of facility policy title Abuse, Neglect and Exploitation last reviewed January 2023 revealed that abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Verbal abuse means the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Under 'Resident protection after alleged abuse, neglect, and exploitation' - facility is to make efforts to protect all residents after alleged abuse as well as protection of staff and/or residents from retaliation. Review of R12's clinical record revealed the diagnoses of cerebral infarction (stroke), dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, major depressive disorder (mental disorder characterized by low moods and loss in pleasurable activities), unsteadiness on feet, muscle wasting and atrophy, encephalopathy (disease of brain that alters function and structure). Review of nursing notes from February 25, 2023 at 4:15 pm, revealed resident was observed to have a bruise on right upper extremity (RUE) which was reported by Resident R12's husband to nursing assistant. Upon assessment resident stated, I asked the CNA (nurse aide) to change my diaper .she was upset with me because I wet the bed .the CNA threw me around in the bed and locked me in the bathroom for an hour. PRN (as needed) Tylenol administered to patient for complaint of pain to RUE. Upon full body assessment, this nurse noted two scratches (2cm L (length) x 0.5 cm W (width)) to right shoulder, a yellow bruise to left posterior LUE (2cm L x 3 cm), and fresh red bruise to right Posterior UE (8 cm L x 9 cm W). + AROM (active range of motion). Review of R12's 'weekly skin checks' from February 25, 2023, at 4:48 pm revealed fresh red bruise to right Posterior UE (upper extremity) (8 cm L x 9 cm W). Review of Resident R12's psychological evaluation on February 28, 2023, revealed that resident was seen for follow up supportive/life review therapy/behavioral management session per facility request due to resident making allegations of verbal abuse by a nursing staff member. Patient was alert, recognized clinician, and engaged well in interview process. She became tearful as she relayed details of incident with what she described as a nurse, African-American, with blonde braids. She reported that the staff member called her, a pig and a slob,because she had wet her bed, and threw me around in bed, and locked me in the bathroom. when asked how a staff member could lock her in the bathroom, which has no locks she stated, I don't know. I just know I couldn't get the door open.Patient currently presents with mild, ongoing depression and tearfulness. Patient's allegations discussed with DON (Director of Nursing) who reported the aide was from an agency, she has already been reported, and is not allowed to return to this facility. Patient reports ongoing symptoms of depression, primarily associated with loss of two of her children. Will follow up next week to assess capacity to retain information across sessions. Interview with Resident R12 on March 27, 2023, at 10:47 a.m. revealed I wet the bed, I was locked in bathroom for an hour, my wheelchair got stuck and she wouldn't help me out of bathroom she stripped my bed and threw me around in bed, she was abusive, mean, cruel. When asked if resident has been having any concerns regarding treatment from staff since incident on February 25, 2023, resident stated, I wouldn't name any names, I don't feel safe, I need assistance with toileting and I am scared they won't take me to the bathroom anymore, I am scared I will get locked in bathroom again. Resident was tearful during interview. Review of facility's investigation report completed on February 27, 2023, revealed that on February 25, 2023, at 8:30 a.m., assigned nursing assistant, Employee E12 to R12 was verbally abusive to the resident by stating I will smack you in your *F** face with that diaper. When addressed by charge nurse, nursing assistant stated, I know what I said, I said what I said. Further review of the facility investigation revealed a written statement provided by nursing assistant on duty who confirmed I heard the CNA who was taking care of [Resident R12] telling her to shut the *F*** up before I smack you in the face with these diapers. Review of the facility investigation submitted to the Department of Health on February 28, 2023, revealed that the facility substantiated that Resident R12 was verbally abused by nursing aide, Employee E12. The facility failed to ensure that Resident R12 was free from resident abuse, which resulted in actual harm to Resident R12, who sustained bruise to right posterior upper extremity and emotional anguish. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of clinical records, hospital records and facility documentation and interviews with staff, it was determined that the facility failed to ensure that one resident identified as a fall risk received adequate supervision which resulted in a fall and caused actual harm to one of three residents reviewed who was hospitalized with a laceration and a [MEDICATION NAME] (upper back) compression fracture (Resident R1). Findings include: Review of Resident R1's hospital records dated (MONTH) 22, (YEAR), through (MONTH) 23, (YEAR), revealed that the resident had been admitted to the hospital with [REDACTED]. The hospital records further indicated that the resident had been hospitalized following an unwitnessed fall down a flight of stairs. The resident sustained [REDACTED]. Review of Resident R1's clinical record revealed that the resident was admitted to the facility on (MONTH) 24, (YEAR), with diagnoses, including but not limited to, history of falling, difficulty walking, [MEDICAL CONDITION] and traumatic subdural hematoma. physician's orders [REDACTED]. A physician's admission assessment dated (MONTH) 25, (YEAR), further noted that the goal of the admission for Resident R1 was fall prevention. Review of a nursing Admission Assessment for Resident R1, dated 10/24/2018, revealed that the resident had a personal history of falling in the past 30 days. Further review of the admission assessment stated that any resident with a history of falling is high risk. Additional review of nursing documentation dated (MONTH) 25, (YEAR), indicated that Resident R1 was confused and had a [DIAGNOSES REDACTED]. The comprehensive Minimum Data Set (MDS- an assessment of resident care needs) dated (MONTH) 7, (YEAR), indicated that the resident was moderately cognitively impaired. A review of the occupational therapist's (person qualified to assess the needs of those recuperating from injuries) assessment dated (MONTH) 25, (YEAR), identified Resident R1 as being at risk for falls due to physical impairments and functional deficits (impairments in balance, dexterity, fine motor coordination, gross motor coordination, mobility, strength and problem solving). Additionally, the occupational therapist identified Resident R1 with poor sitting balance requiring moderate assist/support of staff to attain sitting balance. The therapist also indicated that this resident was dependent on staff for self care and transfers. Review of documentation submitted by the facility revealed that on (MONTH) 8, (YEAR), at approximately 2:00 a.m. Resident R1 was found trying to climb out of bed. The documentation indicated that nursing staff placed the resident into a wheelchair and brought the resident to the nursing station for closer observation. The documentation further indicated that the resident subsequently fell from the wheelchair while at the nurses station. The resident was noted with an open area to her forehead and subsequently sent to the emergency room for further evaluation. Review of Resident R1's hospital History and Physical dated (MONTH) 8, (YEAR), revealed that the resident had sustained a two cm (centimeter) laceration to her right forehead and a T3 (third [MEDICATION NAME] vertebrae) vertebral fracture as a result of the fall at the facility. The resident was subsequently admitted into the hospital for continued monitoring. Continued review of facility documentation dated (MONTH) 8, (YEAR), at 2:10 a.m. revealed that Resident R1's fall from the wheelchair was not witnessed and/or observed by any staff members. The registered nurse responsible for Resident R1 on (MONTH) 8, (YEAR), documented that at 2:25 a.m. Resident R1 had fallen from the wheelchair while at the nurses station. The registered nurse indicated that this fall was not observed. Interview with the Director of Nursing on (MONTH) 8, (YEAR), at approximately 1:00 p.m. confirmed that Resident R1 had been left unattended by staff at the time of her fall on (MONTH) 8, (YEAR). Continued interview with the Director of Nursing confirmed that the facility had no written protocol or guidelines defining what constitutes fall/safety precautions for Resident R1 as ordered by the physician on (MONTH) 24, (YEAR). Additionally, the Director of Nursing confirmed that nursing staff had not developed or implemented any specific interventions to address Resident R1's fall/safety precautions upon admission to the facility. The facility failed to ensure that one resident identified as at risk for falls was provided with the appropriate level of supervision and subsequently fell from her wheelchair. This fall resulted in actual harm to the resident who sustained a laceration and a fractured vertebrae and was hospitalized as a result of the fall. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 09/28/18, 08/17/17, 09/01/16 28 Pa. Code 201.18(a)(d) Management 28 Pa. Code 201.18(b)(1) Management Previously cited 09/28/18, 01/26/18, 08/17/17, 09/01/16 28 Pa. Code 201.18(b)(3) Management Previously cited 09/28/18, 08/17/17 28 Pa. Code 201.18(e)(1) Management Previously cited 09/01/16 28 Pa. Code 211.11(a)(b)(c)(d) Resident care plan 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 09/28/18, 01/26/18, 08/17/17 28 Pa. Code 211.12(d)(2) Nursing services Previously cited 09/01/16 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 01/26/18, 08/17/17

Based on review of clinical records, facility documentation, hospital records, interviews with facility staff, and a review of facility policies and procedures, it was determined that the facility failed to accurately assess, monitor or obtain services timely for a Resident who had an Indwelling Foley Catheter (Tube inserted directly into the bladder to allow disposal of urine) removed for one of 3 Residents reviewed who had Foley Catheters, resulting in actual harm to Resident CL1. Findings include: A review of the facility policy realted to Catheter: Indwelling Uriary Male/Female, Insertion Maintenace and Removal, dated February 26, 2015 revealed that a Resident should be observed for signs of voiding difficulties. A review of Resident CL1's clinical revealed a History and Physical from the admitting Physician, dated June 14, 2017 that the Resident was admitted with the [DIAGNOSES REDACTED]. Review of Resident CL1's Plan of Care initiated June 16, 2017, revealed that he had a Foley Catheter inserted that was a 16 French (fr) with a 10-cubic centimeter (cc) balloon and that a voiding trial (a trial to see if resident can void on their own) should be done on June 20, 2017. Review of a Nursing Note dated June 20, 2017 revealed that the voiding trial was attempted at 6:00 a.m. and failed, that the Foley Catheter needed to be reinserted by 2:00 p.m. and at 2:00 p.m. there was 300 cc' s' of urine drained from the bladder. The Physician ordered another voiding trial on July 7, 2017 to be attempted. Review of Nursing notes dated July 7, 2017, at 8:30 a.m. revealed that resident CL1's Foley Catheter was removed and that he had one wet heavy attends (incontinent brief). The next note documented on July 7, 2017, was at 8:10 p.m. from the physician stating that the voiding trial had failed, that the Resident was sitting in a chair and anxious to go home. The next nursing note dated July 8, 2017 at 12:30 a.m. revealed that Resident CL1 was sent to the emergency room (ER) related to failing a voiding trial and not being able to reinsert the Foley Catheter, little to no urine on the 3-11 shift due to the Resident's [MEDICAL CONDITION], and that the abdomen was distended and that the Resident was picked up by 911 transport due to transportation not being available. Interview with Facility staff, employee E5 (Licensed Nurse) on January 17, 2018, at 2:30 p.m. revealed that he wrote the Nursing note on July 7, 2017, at 8:30 a.m. and that was the only note that shift but he also stated that he passed on verbally to the oncoming 3-11 shift that Resident CL1 had not voided anything further since 8:30 that morning. Interview with employee E4 the nurse who took over on July 7, 2017, at 3:00 p.m. revealed that she obtained a physician's order to send Resident CL1 to the ER at 4:00 p.m. on July 7, 2017, because he was unable to void. A review on Resident CL1's hospital records on January 26, 2018, revealed Ambulance records which stated that a call was received at 11:24 p.m. from River's Edge of need to transport a Resident to the ER. Resident CL1 was noted as being picked up by 11:44 p.m. and arrived at the ER at 11:58 p.m. This Ambulance record also noted that the reason for the transport was that the Resident was unable to void for the past 12 hours and complained of pelvic pain. Further review of the Hospital records on January 26, 2018, revealed that upon arrival to the ER Resident CL1's bladder was drained of 835 cc's of urine (28 ounces) which the urinalysis identified as having a large amount of blood, two types of bacteria with a large number of white blood cells present. The Resident was subseqently admitted with the [DIAGNOSES REDACTED]. Interviews with facility staff and review of facility documentation failed to produce any evidence that the facility was monitoring, assessing, or evaluating Resident CL1's urine output after 8:30 a.m. on July 7, 2017, or why the Resident CL1 was not transferred to the ER for over fifteen hours after the last time he had voided resulting in actual harm and admission to the hospital for the [DIAGNOSES REDACTED]. 483.25 Quality of Care. Previously cited 8/17/17 28 Pa. Code 211.10(c) Resident care policies Previously cited 8/17/17 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 201.18(b)(1) Management Previously cited 8/17/17, 9/1/16 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 8/17/17