Every finding on record at Robert Packer Hospital Skilled Care and Rehabilit

Based on staff interview it was determined that the facility failed to maintain documentation of staff COVID-19 vaccination status, and provide evidence that staff were offered the COVID-19 vaccine or information on obtaining the COVID-19 vaccine for two of two staff reviewed. (Employees 1 and 10)Findings include: Interview with Employee 4, Infection preventionist on January 13, 2026, at 12:00 PM revealed that she educated staff regarding COVID-19 vaccine recommendations on December 15, 2025, but that she did not offer the vaccine or provide the staff with information on where to get the vaccine. She also indicated that she is unable to provide evidence that she maintained staff documentation of screening, education, offering of COVID-19 vaccinations, and their current COVID-19 vaccination status. Interview of Employee 10 nurse aide, on January 13, 2026, at 1:22 PM revealed that she has not been offered COVID-19 vaccine or provided with information on where to obtain the COVID-19 vaccine, since 2021 when COVID first started. Interview of Employee 1, licensed practical nurse, on January 13, 2026, at 1:24 PM revealed that she has not been offered COVID-19 vaccine or provided with information where to obtain one since she was hired three years ago. The facility failed to offer staff the COVID-19 vaccine or provide them with information on where to obtain the vaccine, and failed to maintained staff documentation of screening, education, offering of COVID-19 vaccinations, and their current COVID-19 vaccination status. The surveyor reviewed the above noted findings with the Nursing Home Administrator on January 13, 2026, at 1:45 PM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of select facility policies and procedures, clinical record review, observation, and staff interview it was determined that the facility failed to provide the highest practicable care for a central venous catheter for one of two residents reviewed for central venous catheter concerns (Resident 41).Findings include: Observation of Resident 41 on January 10, 2026, at 2:35 PM revealed an intravenous access site covered by a dressing on his left arm. Observation of Resident 41 and Resident 41's room revealed no signage that indicated there were any restrictions to using his left arm for blood pressure assessments or for venipuncture for blood draws for laboratory testing. There was no emergency kit (e.g. compression dressing supplies) visible in Resident 41's room. Due to cognitive deficits, Resident 41 was unable to provide information regarding his left arm intravenous site. Resource information available from the Mayo Clinic (https://www.mayoclinic.org; Peripherally inserted central catheter (PICC) line - Mayo Clinic) listed risks of peripherally inserted central catheter (PICC, thin, soft, flexible tube inserted through a vein the arm and passed through to the larger veins near the heart for the administration of fluids or medication) line use which can include bleeding, damage to veins in the arm, blood clots, or a blocked or broken PICC line. PICC line protection measures included avoiding getting the PICC line wet and no blood pressure readings taken on the affected arm. The surveyor requested any facility policy or procedure related to the planning of care for a resident with a central line intravenous access device during an interview with the Nursing Home Administrator and the Director of Nursing on January 12, 2026, at 2:00 PM. Review of the facility policy entitled, SNF Central Venous Catheter Policy, revealed that the policy was dated January 12, 2026. The policy stipulated that staff will not take blood pressure assessments or draw blood from the affected arm. The policy did not indicate the procedure to ensure all providers of care were informed of any limb restrictions during the use of a PICC line (e.g. disposable bracelets, signage, care plan, physician order, etc.). The policy did not include immediate care necessary for the potential complications of breaks in the line or bleeding (e.g., emergency kit at bedside). The policy indicated that the facility utilized the Lippincott procedure resource to develop their policy. Email communication with the Nursing Home Administrator on January 13, 2026, at 1:22 PM indicated that the facility did not have a policy or procedure regarding the care and services of a PICC line before the surveyor's questioning. Review of the facility policy entitled, Blood Pressure Measurement, last revised February 24, 2025, stipulated staff should not apply a blood pressure cuff over a PICC or midline catheter (intravenous access inserted into a peripheral vein in the upper arm, the catheter tip is positioned at or near the level of the armpit). The policy stipulated that the staff could use a blood pressure cuff distal to the PICC insertion site. The policy listed 37 references used to develop the policy. The surveyor requested the references that related to PICC care and services used to develop facility policies during an interview with the Director of Nursing on January 13, 2026, at 11:24 AM. The facility did not provide the references during the onsite survey. Clinical record review for Resident 41 revealed nursing documentation dated January 5, 2026, at 7:50 PM that Resident 41 was scheduled for an appointment with interventional radiology for a PICC line insertion. Nursing documentation dated January 6, 2026, at 5:19 PM revealed that Resident 41 had new orders to place a PICC line and begin Daptomycin (antibiotic used to treat complicated bacterial infections) intravenously every day for 14 days and Ertapenem (antibiotic used to treat severe infections) intravenously every day for 14 days. A physician's order dated January 7, 2026, instructed staff to perform a heparin lock flush injection (an anticoagulant medication that prevents clotting) daily when the intravenous line is capped (not in use). Review of Resident 41's plans of care available in his medical record did not indicate that staff initiated a plan of care that related to his PICC line. Observation of Resident 41's room on January 12, 2026, at 10:52 AM with Employee 1 (licensed practical nurse) and Employee 2 (nurse aide) verified that there were no measures readily visible to prevent staff from utilizing Resident 41's left arm for blood pressure assessments or venipuncture. There were no medical supplies readily visible to use in the event of an emergency complication, such as bleeding or line breakage. Employees 1 and 2 indicated that they believed Resident 41's room should have a sign for staff to not use his left arm; and that a bag containing emergency medical supplies should be taped on the wall near his bed. The surveyor reviewed the above concerns regarding Resident 41's PICC line care and services during an interview with the Nursing Home Administrator and the Director of Nursing on January 12, 2026, at 2:00 PM. Interview with the Director of Nursing and Employee 4 (infection control/staff educator) on January 13, 2026, at 11:24 AM again reviewed the surveyor's concerns that routine prevention measures and emergency care procedures are not part of Resident 41's care plan, facility policies, or staff education materials. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to obtain routine vision services for one of three residents reviewed for vision concerns (Resident 5).Findings include: Observation of Resident 5 on January 11, 2026, at 10:54 AM revealed her to wear glasses. During an interview with Resident 5 on the date and time of the observation she stated that she, probably could use an exam to see if they need updating. Resident 5 stated that she did not believe that she received professional eye services in the past year. Clinical record review for Resident 5 revealed that the facility admitted her on May 15, 2024. Diagnoses listed for Resident 5 included: Diabetes mellitus (dated August 29, 2023, high blood sugar levels that can damage the tiny blood vessels in the eye) Hypertension (dated February 12, 2008, high blood pressure that can damage the blood vessels in the eye)Exudative age-related macular degeneration, left eye, with active choroidal neovascularization (dated July 26, 2019, wet AMD, membranes develop under the eye's retina that can leak fluid and blood and, if left untreated, can cause a blinding scar) A physician's order dated September 5, 2025, instructed staff to consult the facility's contracted provider that provides dental, eye, and podiatry services. Comments included in the order instructed staff to, Include the results of the evaluation, testing and/or treatment in the patient's medical record at the location for review. The surveyor requested evidence of professional eye care services provided for Resident 5 in the past year during an interview with the Director of Nursing and the Nursing Home Administrator on January 11, 2026, at 2:00 PM. Interview with the Director of Nursing on January 13, 2026, at 12:05 PM confirmed that Resident 5 consented to services from the facility's contracted provider for vision services on August 27, 2025. Resident 5 became eligible for Medicaid-provided services on September 25, 2025. The facility had no evidence that the contracted provider provided services since Resident 5's admission to the facility. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to implement an intervention to heal pressure ulcers for one of two residents reviewed for pressure ulcer concerns (Resident 41).Findings include: Observation of Resident 41 on January 10, 2026, at 2:37 PM revealed him to be in his bed. An Air Element pump unit (medical device that controls the settings of a specialty mattress to permit the mattress to stay fully inflated or alternate the air pressure in air cells to partially deflate and inflate, avoiding prolonged pressure on any single point beneath the resident to help prevent pressure ulcers; with static pressure mode, all of the air cells are equally inflated) that hung from a footboard at the base of his bed included a lit button that indicated the mattress was set to Static. Clinical record review for Resident 41 revealed nursing documentation dated August 30, 2025, at 7:31 PM that Resident 41's deep tissue pressure injury (tissue necrosis/death that develops when soft tissue is compressed between a bony prominence and an external surface for an extended period) on his left outer heel measured 3.3 centimeters (cm) by 1.8 cm; and was red, purple, boggy, and painful to touch. Resident 41 stated that it had been painful for at least a week. Nursing documentation dated September 23, 2025, at 11:14 AM indicated that staff obtained a new physician's order for an air mattress. A physician's order dated September 23, 2025, at 11:20 AM instructed that Resident 41 was to have an alternating air mattress; and that staff were to check the inflation every shift. Nursing documentation dated October 15, 2025, at 12:26 PM indicated that staff assessed Resident 41's left heel; that the scab (unhealthy leathery wound surface) was off the heel, that the wound was larger, and that staff made an appointment for the facility's contracted wound consultants. Nursing documentation dated October 16, 2025, at 10:51 AM revealed that Resident 41's left heel was, .very sore with dark area and open area to heel and surrounding tissue red and painful to touch. Purulent (yellow or discolored drainage from a wound that is usually indicative of infection) drainage noted. The physician ordered staff to culture the wound for infection. Nursing documentation dated October 20, 2025, at 12:43 PM revealed that Resident 41's wound culture results indicated an infection with MRSA (Methicillin-resistant Staphylococcus aureus, bacteria that are genetically distinct from other strains of Staphylococcus aureus; is responsible for several difficult-to-treat infections in humans because the bacteria is resistant to, and cannot be treated with, commonly used antibiotics). Nursing documentation dated December 31, 2025, at 3:49 PM revealed that Resident 41 returned from his appointments with the infectious disease and wound care consultant providers and would have a wound culture. Nursing documentation dated January 2, 2026, at 10:09 AM revealed that the tissue exam done on December 31, 2025, was positive for bacteria that included staphylococcus aureus. Clinical record review for Resident 41 revealed nursing documentation dated January 5, 2026, at 7:50 PM that Resident 41 was scheduled for an appointment with interventional radiology for a PICC line (PICC, thin, soft, flexible tube inserted through a vein the arm and passed through to the larger veins near the heart for the administration of fluids or medication) insertion. Nursing documentation dated January 6, 2026, at 5:19 PM revealed that Resident 41 had new orders to place a PICC line and begin Daptomycin (antibiotic used to treat complicated bacterial infections) intravenously every day for 14 days and Ertapenem (antibiotic used to treat severe infections) intravenously every day for 14 days. Review of an active plan of care developed by the facility on March 3, 2025, to address Resident 41's risk for skin breakdown listed interventions that included: Provide pressure-relief mattress, started March 3, 2025Bed foot board removed for pressure relief, started August 21, 2025 The plan of care was not updated to reflect the implementation of an alternating air mattress that included the device pump (hanging from the bed's footboard); or the appropriate settings necessary to ensure staff maintained the mattress on the alternating pressure (not static) settings. Observation of Resident 41's left heel wound care on January 12, 2026, at 10:52 AM with Employee 1 (licensed practical nurse) and Employee 2 (nurse aide) indicated that neither staff were knowledgeable regarding the appropriate settings necessary on the Air Element pump to implement an alternating pressure surface when Resident 41 was in bed. Clinical record review with Employee 1 on January 12, 2026, at 10:58 AM confirmed that Resident 41's physician orders required that staff implement an alternating air mattress; and that staff were to check the inflation every shift. Interview with Employee 9 (licensed practical nurse) with Employee 1 on January 12, 2026, at 11:10 AM indicated that if the Static button on Resident 41's mattress pump is engaged (lit) it means that the mattress is not in alternating pressure mode. The interview indicated that Employee 3 (licensed practical nurse) was the nurse assigned to Resident 41's care on this shift. Interview with Employee 3 on January 12, 2026, at 11:20 AM revealed that she was not knowledgeable regarding the appropriate settings necessary on the Air Element pump to implement an alternating pressure surface when Resident 41 was in bed; that she, .would have to look it up. Employee 3 stated that she checks the inflation of the mattress (per the physician's order) by pressing on the surface of the mattress to ensure that it is inflated. She does not review the settings on the pump to ensure any particular setting (e.g., if the Static button is engaged). Review of Resident 41's treatment administration record revealed that Employee 3 signed for the assessment of the mattress inflation on the following dates and times during the last 30 days: December 20, 2025, at 1:27 PMDecember 27, 2025, at 1:27 PMDecember 29, 2025, at 2:06 PMJanuary 2, 2026, at 9:12 PMJanuary 3, 2026, at 1:50 PMJanuary 10, 2026, at 1:45 PM Review of the Air Element manufacturer's manual confirmed that the Static Mode on the mattress is used to pause alternation when sitting, transferring, or during the mattress setup. Employee 1 revised Resident 41's physician order regarding the alternating air mattress on January 12, 2026, at 12:20 PM (following the surveyor's questioning) to include instructions for staff to check that the static button is always in the off position to ensure that the air alternating mode is on. The surveyor reviewed the above concerns regarding the appropriate implementation and staff knowledge regarding the appropriate settings of the alternating air mattress for Resident 41 during an interview with the Director of Nursing and the Nursing Home Administrator on January 12, 2026, at 2:00 PM. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure preventative fall interventions were implemented for one of two residents reviewed for falls (Resident 39). Findings include: This deficiency is cited as past non-compliance. Clinical record review for Resident 39 revealed a fall risk assessment dated [DATE], that indicated she was a high fall risk. Review of Resident 39's care plan entitled Potential for Falls secondary to needing walker to ambulate, decreased vision, and occasional incontinence, dated November 23, 2025, revealed that she was to have a chair alarm and her call bell in reach. Review of a facility reported incident revealed that on November 24, 2025, at 3:30 PM Resident 39 was not present in her room during room rounds at change of shift by the licensed practical nurse. It was reported the nurse walked around the unit looking for Resident 39 when she heard help me coming from the shower room. She entered the shower room and found Resident 39 naked in the shower chair under the running water, shivering. The water temperature was noted to be 96 degrees. Resident was dried, dressed, and assessed and was noted to have no injury or ill effects. The director of nursing interviewed Employee 7, nurse aide, on November 24, 2025. Review of the interview notes revealed that Employee 7 indicated that she did leave Resident 39 in the shower but made arrangements for Employee 8, nurse aide, to finish the shower. Review of Employee 8's statement dated November 24, 2025, indicated that she told Employee 7 that she could not do it because she had a hall to herself and would not be able to leave that hall to go do the shower which was in a different hall. Interview of Resident 39 related to the event on November 24, 2025, on January 12, 2026, at 3:15 PM revealed that the nurse aide, Employee 7 assisted her in the shower and helped her wash her hair and body and then stated it was time for her to go home and that someone else would be into finish the shower. She said that Employee 7 then left. She said that she got cold and upset. She said it really stressed her out. She said she did not have any bell to ring so all she could do was yell for help and eventually another staff member came to help her. She estimated she was in the shower at least an hour or more. Surveyor inquired about her chair alarm and walker, and she indicated the alarm was not on her because she was in the shower and she did not know where her walker was. Interview with the Nursing Home Administrator on January 12, 2026, at 8:45 AM revealed that Resident 39 was to have one person with her in the shower and she was to have a chair alarm at all times because she was a fall risk. She confirmed that Resident 39 was left alone in the shower by Employee 7, with no call bell in reach, her walker was not present, and she did not have a chair alarm on. Review of the facility's investigation into Resident 39's event revealed that Employee 7 was suspended during the investigation and her employment was terminated on December 25, 2025. The facility educated all nursing staff on November 24-25, 2025, on not letting resident's unattended in the shower room and bathing/shower safety related to fall prevention. The facility failed to implement care planned fall preventative measures for Resident 39. 28 Pa. Code 201.18(e)(1) Management28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure appropriate labeling of medication and implement measures for controlled substance accountability during medication administration for four of eight residents observed for medication administration (Residents 7, 8, 28, and 34).Findings include: The current facility policy entitled, Medication Administration, Procedures for Medication Administration, General Procedures to Follow for all Medications, revealed that the staff are to read the medication label three times before pouring the medication. After administration, staff are to return to the medication cart and document the administration in the Medication Administration Record (MAR). Observation of a medication administration pass on January 10, 2026, at 11:53 AM revealed Employee 5 (licensed practical nurse) prepared Carboxymethylcellulose Sodium ophthalmic solution (Refresh Plus, lubricant used to relieve burning, irritation, and discomfort caused by dry eyes) eye drops for Resident 34. The label on the box of medication did not include which (or both) eye(s) staff were to administer the medication. Employee 5 entered Resident 34's room to administer the medication; however, Resident 34 was in her bathroom. Employee 5 returned to the medication cart without administering the medication on January 10, 2026, at 12:02 PM. Clinical record review for Resident 34 revealed that the physician order dated May 27, 2025, instructed staff to administer one drop of the Refresh Plus medication four times a day; however, the order did not include instructions if the medication was ordered for one or both eyes. The order included that the associated diagnoses for the medication was for a macula scar of the posterior pole of the right eye (abnormality of the internal structures of the eye that affects vision). Review of Resident 34's medication administration record indicated that Employee 5 documented the administration of the eye drop medication on January 10, 2026, at 11:54 AM; however, Employee 5 did not administer the medication at that time due to the Resident's unavailability while she was in the bathroom. Interview with Employee 5 on January 11, 2026, at 10:00 AM indicated that she administered Resident 34's eye drop medication in both eyes (after the surveyor's medication administration observations). Employee 5 confirmed that the MAR, the medication label, and the physician order for the medication did not specify the eye(s) that required the treatment. Employee 5 indicated that it may have been an error that she documented the administration at the time the resident was in the bathroom. The current facility policy entitled, Medication Administration, Preparation and General Guidelines, Controlled Medications, revealed that when a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record:Date and time of administrationAmount administeredSignature of the nurse administering the dose, completed after the medication is actually administered Observation of a medication administration pass on January 10, 2026, at 11:56 AM revealed Employee 5 accessed the locked controlled substance drawer in the medication cart to obtain Hydrocodone-APAP (combination medication that includes hydrocodone, opioid pain reliever, and acetaminophen, a non-opioid pain reliever) 5/325 milligrams (mg) for Resident 8. Employee 5 removed the medication from the supply and secured the narcotic box, crushed the medication, and left the medication cart to administer the medication to Resident 8 while he was in the common dining area on January 10, 2026, at 11:59 AM. Employee 5 did not record the administration on the controlled substance accountability record. Interview with Employee 5 on January 10, 2026, at 1:51 PM (approximately two hours after the observed administration) confirmed that she did not record Resident 8's Hydrocodone-APAP medication use at the time of the administration. Employee 5 updated the supply count on the document at the time of the interview. Observation of a medication administration pass on January 10, 2026, at 1:14 PM revealed Employee 5 accessed the locked controlled substance drawer in the medication cart to obtain Clonazepam 0.5 mg (benzodiazepine medication used to treat seizures and panic disorders) for Resident 28. Employee 5 removed the medication from the supply and secured the narcotic box, crushed the medication, and left the medication cart to administer the medication to Resident 28. Employee 5 did not record the administration on the controlled substance accountability record. Interview with Employee 5 on January 10, 2026, at 1:52 PM confirmed that she did not record Resident 28's Clonazepam medication use at the time of the administration. Employee 5 updated the supply count on the document at the time of the interview. Observation of a medication administration pass on January 10, 2026, at 1:37 PM revealed Employee 5 accessed the locked controlled substance drawer in the medication cart to obtain Tramadol HCL (narcotic analgesic) 50 mg for Resident 7. Employee 5 removed the medication from the supply, secured the narcotic box, and left the medication cart to administer the medication to Resident 7 who was in the common activity room. Employee 5 did not record the administration on the controlled substance accountability record. Interview with Employee 5 on January 10, 2026, at 1:53 PM confirmed that she did not record Resident 7's Tramadol HCL medication use at the time of the administration. Employee 5 updated the supply count on the document at the time of the interview. The surveyor reviewed the above concerns regarding medication labeling and controlled substance accountability procedures during an interview with the Nursing Home Administrator and the Director of Nursing on January 11, 2026, at 2:00 PM. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to provide dental care services for one of six residents reviewed for dental concerns (Resident 5).Findings include: Observation of Resident 5 on January 11, 2026, at 10:54 AM revealed her to have natural teeth. During an interview with Resident 5 on the date and time of the observation she stated that she, .cracked them (teeth), don't know how, a couple of them were pulled. Resident 5 stated that she did not believe that she received professional dental services in the facility since her admission. Clinical record review for Resident 5 revealed that the facility admitted her on May 15, 2024. A physician's order dated September 5, 2025, instructed staff to consult the facility's contracted provider that provides dental, eye, and podiatry services. Comments included in the order instructed staff to, Include the results of the evaluation, testing and/or treatment in the patient's medical record at the location for review. The surveyor requested evidence of professional dental care services provided for Resident 5 in the past year during an interview with the Director of Nursing and the Nursing Home Administrator on January 11, 2026, at 2:00 PM. Interview with the Director of Nursing on January 13, 2026, at 12:05 PM confirmed that Resident 5 consented to services from the facility's contracted provider for dental services on August 27, 2025. Resident 5 became eligible for Medicaid-provided services on September 25, 2025. The facility had no evidence that the contracted provider provided services since Resident 5's admission to the facility. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of select facility policies and procedures, clinical record review, observation, and family and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection related to enhanced barrier precautions for one of one resident reviewed for indwelling urinary catheter concerns (Resident 1) and handwashing for three of eight residents reviewed for medication administration (Residents 7, 28, and 34).Findings include: The facility policy entitled, Enhanced Barrier Precautions (EBP), dated June 3, 2025, revealed that resident care facilities adhere to enhanced barrier precautions (EBP) based on the recommendations provided by the Centers for Disease Control and Prevention (CDC). EBP refers to an infection control intervention designed to reduce transmission of MDROs (multi-drug-resistant organisms) that employ targeted gown and glove use during high-contact resident care activities, especially for those at increased risk of acquiring or spreading an MDRO. EBP are used in conjunction with standard precautions and expand the use of PPE (personal protective equipment such as gowns, gloves, and eye protection) to donning a gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with an indwelling medical device. Examples of an indwelling medical device include urinary catheters. High-contact resident care activities include urinary catheter device care. Clinical record review for Resident 1 revealed a physician's order dated February 6, 2025, for staff to change his Foley catheter (flexible tubing inserted through the penis to the bladder to drain urine) every 30 days. Review of a plan of care started by the facility on January 8, 2026, to address enhanced barrier precautions due to an indwelling urinary catheter indicated that signage, PPE, and trash receptacles would be in Resident 1's room. A gown and gloves would be worn for all high-contact activities such as personal care and any contact with invasive devices such as an indwelling catheter. Observation of Resident 1 on January 10, 2026, at 2:56 PM revealed no visible urinary collection bag or tubing. Interview with Employee 3 (licensed practical nurse) on January 10, 2026, at 3:04 PM revealed that Resident 1 does not typically allow staff to discontinue the smaller urinary collection bag secured on his leg to connect a larger urinary collection bag. Interview with Resident 1's wife on January 11, 2026, at 11:33 AM revealed that Resident 1 required urinary catheterization before his admission to the facility. Resident 1's wife confirmed that Resident 1 preferred the smaller urinary collection bag that is secured to his leg rather than have tubing exposed that can catch on objects in his environment. Observation of Resident 1 on January 11, 2026, at 11:50 AM revealed Employee 6 propelled him in his wheelchair from the hallway into his bathroom. Employee 6 did not obtain PPE from the organizer on Resident 1's room door. Continued observation on January 11, 2026, at 11:55 AM revealed Employee 6 exited Resident 1's bathroom with Resident 1 without visible PPE. Interview with Employee 6 on January 11, 2026, at 11:56 AM confirmed that she did not use PPE during her interaction with Resident 1; however, she took him into the bathroom to empty the urine from his urinary collection bag. The surveyor reviewed the above concerns regarding EBP not utilized for Resident 1's care during an interview with the Director of Nursing and the Nursing Home Administrator on January 12, 2026, at 2:00 PM. Observation of a medication administration pass for Resident 28 on January 10, 2026, at 1:18 PM revealed Employee 5 (licensed practical nurse) donned gloves to prepare and administer medications to Resident 28. Employee 5 removed the gloves after the medication administration and returned to the medication cart where she touched the medication cart surfaces, the mouse connected to the computer on the medication cart, and the medication cart keys without performing hand hygiene. Continued observation of the medication administration pass on January 10, 2026, at 1:34 PM revealed Employee 5 wore gloves to administer medications to Resident 7 while she was in the common activity room. Employee 5 removed her gloves and entered the staff bathroom to wash her hands. Employee 5 utilized her clean, but wet, hand to turn off the faucet before obtaining a disposable towel to dry her hands. Employee 5 returned to the medication cart, donned new gloves, and prepared additional medication to administer to Resident 7. Employee 5 wore the gloves to administer the medication to Resident 7 while she continued to sit in the common activity room. After administering the medication to Resident 7, Employee 5 wore the gloves until she returned to the medication cart, used her gloved hand to use a pen to document paperwork on the medication cart, then removed her gloves. Without performing hand hygiene, Employee 5 used the mouse connected to the medication cart computer. Continued observation of the medication administration pass on January 10, 2026, at 1:41 PM revealed Employee 5 donned gloves to prepare medications for Resident 34. Employee 5 left the medication cart with gloved hands to administer medications in Resident 34's room and until she returned to the medication cart. Employee 5 removed the gloves and used the mouse connected to the medication cart computer before utilizing alcohol sanitizer and applying new gloves. Interview with Employee 5 on January 10, 2026, at 1:49 PM confirmed that it is the facility's policy to immediately perform hand hygiene (with soap and water or alcohol hand sanitizer) when gloves are removed. Employee 5 also confirmed that it is the expectation that staff do not touch the potentially contaminated surfaces of the sink faucet after washing hands without obtaining a disposable towel to do so. Employee 5 confirmed that she did not perform appropriate hand hygiene during the medication administration pass observed. The surveyor reviewed the above infection control concerns during an interview with the Nursing Home Administrator and the Director of Nursing on January 11, 2026, at 2:00 PM. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to store food and maintain food service equipment in accordance with professional standards for food service safety in the facility's main kitchen. Findings include: Observation of the facility's main kitchen on February 9, 2025, at 10:15 AM with Employee 1, dietary supervisor, revealed the following: The lower shelf of the food preparation table beside the steamer was observed with a large clear plastic container with a white powdery substance filling half of the container. The exterior of the contained had dried food on it, was dusty, and sticky to touch. The container was labeled with a sticker indicating flour was in the bin, and dated August 4, 2024, with a use by date of January 4, 2025. An additional large clear plastic container beside the flour also with a dirty exterior on the sides and lid of the container with dried food, and dust, partially filled with rice labeled with a May 21, 2024, as to when it was placed in the bin, with a use by date of November 4, 2024. The exterior side of the steamer was observed with dried food splatter. A white plastic pipe extending from behind the ice machine along the wall behind a preparation table was dirty and dusty and dried food debris was observed collected between the pipe and the wall. The open area behind the steamers, oven, and stove, was observed with dust and debris buildup. A large metal rack was observed hanging from the ceiling over a food preparation table. Multiple pans, ladles, spoons and whisks were observed hanging from the rack with food contact surfaces stored open to air, with no cover. The ceiling tiles directly above the rack contained dried food splatter. The exterior base of the food warmer contained a buildup of dried food particles and dust. Two white potholders were observed on a preparation table significantly stained and blackened. A small upright cooler by the food service tray line contained dried food and liquid on the exterior. The lower shelves in the walk-in cooler were soiled with debris and dried food and liquid spots. Review of the main kitchen's temperature monitoring log for the walk-in freezer, walk-in cooler salad refrigerator, line refrigerator, cooks' refrigerator, and juice refrigerator, revealed no documented temperature monitoring for February 6, 7, 8, or as of the time of observation on February 9, 2025. The last documented temperatures for the items were listed as February 5, 2025. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on February 11, 2025, at 2:10 PM. 28 Pa. Code 201.14 (a) Responsibility of Licensee

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by one of three residents reviewed (Resident 61). Findings include: Clinical record review for Resident 61 revealed the facility admitted her on January 2, 2025, with diagnosis of Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 61's admission Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated January 8, 2025, indicated that the facility assessed Resident 61 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 61's care plan entitled, psychosocial needs initiated January 4, 2025, revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. Resident 61's clinical record also had a care plan entitled, Anxiety-Cognitive, initiated on January10, 2025, that failed to address individualized person-centered approaches to address Resident 61's dementia and cognitive loss. The findings were reviewed with the Nursing Home Administrator on February 12, 2025, at 12:10 PM and she confirmed that Resident 61 did not have an individualized care plan for dementia and cognitive loss. 483.40(b)(3) Dementia Treatment and Services Previously cited 3/8/2024

Based on closed clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care for a resident's change in condition that resulted in hospitalization and death for one of three residents reviewed causing actual harm (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed that the facility admitted her on [DATE]. A physician's order dated [DATE], instructed staff to administer Lactulose (laxative used to treat chronic constipation and brain abnormalities due to liver failure) three times a day and hold for loose stools. A review of bowel movement history documentation (electronic documentation completed by nurse aide staff of residents' bowel movements) revealed that Resident CR1 was continent of bowel movements on [DATE] and 30, 2024; and [DATE]. Staff documented that these bowel movements were soft or formed. Documentation on [DATE], at 11:32 AM noted that Resident CR1 had two occurrences of incontinence of a large amount of loose stool. Nurse aide staff documented on [DATE], at 2:12 PM, 7:12 PM, and 11:30 PM, an additional seven occurrences of loose stool. Review of Resident CR1's medication administration record (MAR, electronic documentation by licensed nursing staff of the administration of medications) revealed that licensed staff documented the administration of the Lactulose medication on [DATE], at 2:00 PM and 10:00 PM (despite Resident CR1's loose stools). Nurse aide staff continued to document on [DATE], at 1:30 AM, 3:51 AM, 2:10 PM, and 6:28 PM, that Resident CR1 had a total of 10 incontinent episodes of stool with mucous present. The staff documented specifically that the stool was loose on two of the occasions. The staff did not include an assessment of the stool consistency for the other eight occurrences. Review of Resident CR1's MAR indicated that licensed staff documented the administration of the Lactulose medication on [DATE], at 8:00 AM, 2:00 PM, and 8:00 PM (despite Resident CR1's loose stools). Nurse aide staff documented that Resident CR1 had five incontinent episodes of yellow stool on [DATE], at 6:14 AM. The staff did not document the consistency of the stool for those five episodes. Nurse aide staff documented an additional three occurrences of watery stool with mucous present on [DATE], at 1:34 PM. Review of Resident CR1's MAR indicated that licensed staff documented the administration of the Lactulose medication on [DATE], at 8:00 AM and 2:00 PM (despite Resident CR1's eight episodes of bowel incontinence on this date). A physician's progress note dated [DATE], at 6:05 PM documented that Resident CR1 was negative for constipation, diarrhea, and nausea. There was no evidence in Resident CR1's clinical record that nurse aide staff informed licensed staff of Resident CR1's numerous loose stools or that licensed staff notified the physician of this change in Resident CR1's condition. There was no evidence that licensed staff reviewed the nurse aide documentation regarding the loose stools prior to administering the lactulose. Nurse aide staff continued to document a total of seven incontinent episodes of loose stools with mucous present on [DATE], at 9:44 PM and 11:46 PM and [DATE], at 5:16 AM. Licensed staff documented the administration of the Lactulose medication on [DATE], at 8:00 PM and [DATE], at 8:00 AM, 2:00 PM, and 8:00 PM. Nurse aide staff documented a total of 11 occurrences of incontinent loose or watery stools from [DATE], at 1:34 PM, to [DATE], at 2:21 PM. Licensed staff documented the administration of the Lactulose medication three times daily from [DATE], at 8:00 AM, through [DATE], at 2:00 PM. Nursing documentation dated [DATE], at 6:15 PM revealed that Resident CR1 had increased lethargy (decrease in consciousness and altered mental abilities) and confusion. Previous assessment, resident was alert and able to answer questions. Resident CR1 had significant abdominal distention and increased swelling to her lower extremities. The documentation noted that, Resident moving bowels; however, did not note the numerous episodes of loose stools over the previous seven days. Staff contacted emergency medical services to send Resident CR1 to the hospital emergency room . A laboratory report dated [DATE], at 11:26 PM indicated Resident CR1's stool specimen was positive for C. difficile toxin (bacterial infection of the colon that produces toxins that damage the cells of the intestinal lining causing inflammation (colitis) and causes symptoms that range from diarrhea to life-threatening damage to the colon). Hospital emergency department physician documentation dated [DATE], noted that laboratory testing of Resident CR1's stool was positive for C. difficile toxin, that she had a severely elevated white blood cell count (the immune system is stimulated by conditions such as infection, inflammation, or injury), and that her abdominal CT (medical scan that uses x-rays to create images of the abdominal organs) showed extensive colitis (intestinal inflammation). The final impression documented by the provider was, C. difficile colitis. Clinical impressions included C. difficile colitis and sepsis (infection detected in the bloodstream) with acute organ dysfunction (severe injury to an organ) without septic shock (most severe stage of sepsis that often includes multiple organ failure). A history and physical assessment by the hospital physician dated [DATE], at 1:20 PM documented Resident CR1's diagnoses as toxic megacolon (serious complication of severe colitis that is characterized by a very dilated colon) secondary to C. difficile colitis and acute metabolic encephalopathy (brain dysfunction caused by an underlying condition) secondary to the previous (toxic megacolon secondary to C. difficile colitis) and decompensated cirrhosis (liver damage). Death report documentation by the hospital physician certified that Resident CR1 died on [DATE], at 2:13 PM due to cardiopulmonary arrest (the stopping of effective breathing and blood circulation) as a consequence of septic shock because of colitis. The surveyor reviewed concerns that nurse aide staff did not inform licensed nursing staff of Resident CR1's change in condition (numerous loose stools) during interviews with the Nursing Home Administrator on [DATE], at 2:40 PM and 3:13 PM. The interview also reported the surveyor's concerns that there was no evidence that nursing staff notified Resident CR1's physician of the change in Resident CR1's condition. Interview with the Nursing Home Administrator and the Director of Nursing on [DATE], at 3:33 PM confirmed the above findings for Resident CR1. 483.25 Quality of Care Previously cited deficiency [DATE] 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, employee personnel records, and family and staff interview, it was determined that the facility failed to thoroughly investigate and report to the appropriate agencies incidents of potential resident neglect for two of four residents reviewed for accident concerns (Residents 4 and 48); and the facility failed to implement its abuse prohibition policy pertaining to newly hired employee training for two of five newly hired employees reviewed (Employees 4 and 5). Findings include: The facility policy entitled, Resident Abuse and Neglect Prevention Program, last reviewed without changes on February 28, 2024, revealed that the facility has a plan in place to assure appropriate steps are taken to protect each resident from mistreatment, neglect, abuse, and misappropriation of property. Every complaint or allegation of resident abuse or neglect shall be promptly reported to the immediate supervisor of the area and the Administrator and/or his/her designee. Each report shall be treated promptly and with discretion with priorities that include the compliance with pertinent laws and regulations. The interpretation of the definition of neglect noted, Neglect refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safe, adequate, and appropriate services, treatment and care, including but not limited to nutrition, medication, therapies, and activities of daily living. The absence of reasonable accommodations of individual needs and preferences may result in resident neglect. Section I, Abuse and Neglect Prevention included that employees are expected to immediately report any event, incident, or other concern that may be related to potential abuse or neglect. Negligence or willful inattention to resident needs or preferences as specified in the plan of care is unacceptable. Immediately upon discovery of an allegation of abuse or situation with the potential for abuse or harm, the facility will take all reasonable measures to separate the alleged perpetrator from access to the alleged victim. Upon receiving a report of abuse or alleged abuse, the registered nurse supervisor, Director or Nursing or assistant director of nursing or Administrator will begin the investigation. Any employee identified as the alleged perpetrator will be placed on immediate automatic suspension pending the outcome of the investigation. The facility will report alleged and substantiated incidents to the Pennsylvania Department of Health, additional state agencies and/or local authorities per federal and state requirements. Any report or allegation of abuse/neglect will be reported initially by the Administrator, Director of Nursing, assistant director of nursing, or delegated supervisor within 24-hours of knowledge of the event through the electronic event reporting system and use of the PB-22 (Provider Bulletin 22, document used to outline a facility's investigation of potential abuse/neglect, appropriate agency notifications, and corrective actions); Area Agency on Aging, and (if required) Protective Services, the local police, and the Pennsylvania Department of Aging. The investigative team's investigation will include interviews/statements from any witnesses to the incident, interview/statements from staff members having contact with the resident during the time of the alleged incident, and a review of all circumstances surrounding the incident. The Administrator or his/her designee will complete the PB-22 within five working days of the incident. The Employee Abuse Prevention and Training procedure included that all new employees are required to attend an orientation program which includes a minimum of two hours of training related to Abuse and Neglect Prevention, Identification/Reporting of Abuse, and Techniques for Care for the Cognitively Impaired Resident. The employee signs a statement of receipt of education once completed, which is then maintained in the employee file. Interview with Resident 4's daughter on March 5, 2024, at 2:12 PM, revealed that her mother was, dropped, by staff during a shower on the Thursday before Christmas while one staff member attempted to provide care. Resident 4's daughter indicated that her mother was to have two staff present for care; however, only one staff was present when they attempted to transfer her. Resident 4's daughter stated that her mother sustained a large skin tear to her arm and that she struck her head which caused bruising and swelling. Clinical record review for Resident 4 revealed physical therapy documentation dated January 21, 2022, that indicated an evaluation of surface transfers for safety. The documentation indicated that Resident 4 required a Hoyer lift (mechanical device used to move a resident from one surface to another via a sling requiring no participation or weight bearing by the resident) for all transfers. The documentation stipulated that Resident 4 could, transfer between surfaces in the big bathroom with the assistance of two staff. Review of a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated July 25, 2023, continued to assess Resident 4 as dependent upon the extensive physical assistance of two staff for transfers and toileting. An annual MDS assessment dated [DATE], assessed Resident 4 as dependent (helper does all of the effort, the resident does none of the effort to complete the activity) for chair/bed-to-chair transfers and toileting hygiene. Tub/shower and toilet transfers were not attempted due to medical condition or safety concerns. A quarterly MDS assessment dated [DATE], assessed Resident 4 as dependent for transfers (toilet transfer, chair/bed-to-chair, tub/shower transfer), toileting hygiene, and shower/bathing. Nursing documentation dated December 21, 2023, at 9:49 AM, revealed that the registered nurse was called to the big bathroom on Resident 4's nursing unit where she noted Resident 4 on the floor in front of her wheelchair. Resident 4 had a hematoma (swelling and discoloration caused by pooling of blood under the skin) to the middle of her forehead and a skin tear to her right forearm that measured 4.5 centimeters (cm) by 2 cm. Nursing documentation dated December 24, 2023, at 7:47 AM, revealed that Resident 4 had moderate pain of her right forearm, which was red, warm, and swollen. The staff notified Resident 4's physician who provided orders for an x-ray and an antibiotic for cellulitis (skin infection) and UTI (urinary tract infection). Nursing documentation dated December 27, 2023, at 1:57 PM, revealed that the physician assessed Resident 4's skin tear and provided new orders to culture the wound drainage (which was described as excessive and with an odor). Review of the facility's Incident/Accident Report and Investigation of Resident 4's fall on December 21, 2023, identified that Resident 4's mobility status per her plan of care prior to the occurrence was, Hoyer/2 (two) assist surface transfer in big BR (bathroom); and that care plan interventions for transfer were not carried out as care planned. The report specifically noted, only 1 (one) staff member assisting. Although the report indicated that Resident 4 was correctly transferred into a chair via a Hoyer lift before a nurse aide transferred her into the bathroom alone, the investigation did not include a statement or interview notes with a second staff person who was present during the Hoyer lift. The statement from the nurse aide present during the fall stipulated that she was assisting Resident 4 to stand to transfer her into her wheelchair from the shower chair when Resident 4 sat back down on the edge of the shower chair and slid off. Interview with the Nursing Home Administrator on March 8, 2024, at 10:20 AM, confirmed that the facility did not identify Resident 4's fall as an incident of potential resident neglect although the required level of staff assistance was not present during the transfer. The facility submitted an event report to the Department and initiated a PB-22 report following the surveyor's questioning. Review of Employee 4's (nurse aide) personnel record revealed that the facility hired her on January 2, 2024. Employee 4's time sheet revealed that she worked January 8, 9, 11, 15, 16, 18, 22, 23, 26, 29, and 31, 2024; and February 1, 2, 5, 6, and 7, 2024. Review of Employee 5's (nurse aide) personnel record revealed that the facility hired her on January 3, 2024. Employee 5's time sheet revealed that she worked January 3, 5, 6, and 9, 2024. Interview with Employee 2 (associate vice president) and Employee 3 (regulatory specialist) on March 7, 2024, at 12:23 PM, revealed that a review of Employee 4's and Employee 5's personnel records provided no evidence that their orientation programs included the training related to abuse and neglect prevention. Interview with the Director of Nursing on March 7, 2024, at 1:05 PM, revealed that Employee 4 completed abuse prevention training on February 7, 2024. The interview also confirmed that Employee 5 did not complete abuse prevention training until January 9, 2024. The interview confirmed that Employees 4 and 5 did not receive their abuse orientation training before their presence on the nursing units. In an interview with Resident 48 and a family member of the resident on March 5, 2024, at 11:49 AM, the family member indicated they had been notified on a few occasions recently that Resident 48 required being lowered to the floor by staff. Clinical record review for Resident 48 revealed a nursing noted dated December 2, 2023, at 6:27 PM noting the resident was being taken to the bathroom assisted by staff, needed to rest, just tried to sit, and staff assisted the resident to the floor. Review of Resident 48's physician's orders revealed an order dated November 29, 2023, which indicated the resident may stand pivot transfer with one assist and rolling walker and was ambulatory with a rolling walker with two assist. This order was active at the time of the December 2, 2023, incident. Review of facility documents investigating Resident 48's incident of being lowered to the floor on December 2, 2023, noted again the resident was walking to the bathroom with staff when she started to sit and the staff member lowered the resident to the floor, and Resident 48's mobility status was two assist with a rolling walker and only one staff member was assisting the resident and the staff member was not aware of the changed status for the resident. An attached statement from employee 6, nurse aide, dated December 2, 2023, indicated she was walking the Resident 48 to the bathroom and was going by her paper as to what the resident's status was. The facility document also indicated the staff member was educated for resident changes in status. Further clinical record review for Resident 48 revealed a nurse's note dated January 19, 2024, at 1:10 PM noting while staff was assisting the resident to the bathroom at 7:20 AM the resident's knees buckled and the resident was lowered to the floor in the bathroom. A review of Resident 48's physician's order dated December 29, 2023, for Resident 48's transfer/ambulation status was to utilize a two wheeled walker and two assist. This order was active at the time of the January 19, 2024, incident. Review of facility documents regarding Resident 48's incident on January 19, 2024, revealed staff assisted the resident to and from the bathroom with one assist, and the resident was ordered two assist for transfers/ambulation and noted staff education was completed. An attached statement from employee 7, licensed practical nurse, dated January 19, 2024, noted employee 7 was walking Resident 48 to the restroom when she stated her legs were giving out and she lowered her to a safe seat on the floor. Clinical record review for Resident 48 revealed a nurses note dated February 20, 2024, at 7:42 AM which noted again Resident 48 became weak during transfer and was assisted to the floor. Review of physician orders for Resident 48 revealed an order dated February 3, 2024, for Resident to transfer with a two wheeled walker and two assist. This order was active at the time of the February 20, 2024, incident. Review of Resident 48's care plan revealed the resident had an active plan of care for the potential for falls in which an intervention was added on December 12, 2023, which indicated the resident was to have a gait belt for transfers, and transfers, ambulation with two assist and two wheeled walker with staff education 1/21/24 for fall, noted beside it. Review of a facility document investigating Resident 48's incident on February 20, 2024, occurred at 5:30 AM and revealed the resident was assisted to the floor when she became weak during transfer from her bed to her recliner, and the resident was being transferred with one assist and her mobility plan of care was two assist with two wheeled walker and her transfer plan of care was two assist. An attached statement from employee 8, nurse aide, indicated after assisting Resident 48 to the bathroom the resident sat in the recliner and then decided to go to bed and got weak and slid off the chucks while getting up. Another attached statement from employee 9, licensed practical nurse, noted the resident wanted to go from the bathroom to the recliner, to bed and became weak and we lowered her to the floor, although the facility document indicated staff education was to be completed to prevent reoccurrence as the resident to be assisted by two using a two wheeled walker. There was no other documentation to indicate a second staff member was present. There was no evidence the incidents for Resident 48 that occurred on December 2, 2023, January 19, 2024, and February 20, 2024, all resulting in the resident being lowered to the floor during ambulation/transfer without the ordered/appropriate level of assistance were reported to the Department of Health event reporting system or investigated as alleged neglect for not following the resident's orders/plan of care resulting in falls for the resident. Resident 48 did not sustain any injuries from the incidents. In an interview with the Nursing Home Administrator and Director of Nursing on March 8, 2024, the above findings were reviewed for Resident 48. The Director of Nursing confirmed the incidents were not reviewed or investigated as potential neglect. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.19(6)(8) Personnel policies and procedures 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of resident personal fund accounting, clinical record review, and resident and staff interview, it was determined that the facility failed to provide a resident fund quarterly statement for one of two residents reviewed for personal fund concerns (Resident 40). Findings include: Clinical record review for Resident 40 revealed an MDS assessment (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated January 30, 2024, that assessed Resident 40 as able to make himself understood, had clear comprehension when understanding others, and had a BIMS (Brief Interview for Mental Status, an assessment tool to determine cognitive deficits) score of 15 (indicating no cognitive deficits). Review of a, Resident Trust Fund Authorization Form, (document that the facility utilized to obtain a resident/resident representative authorization to hold money for the resident) signed by Resident 40 on May 26, 2020, revealed that Resident 40 did not designate another person to manage his personal funds. The document stipulated that a, .full and complete separate accounting of all financial transactions made on his/her behalf will be maintained and made available to the Resident and/or Power-of-Attorney/Guardian at least quarterly and upon request. Interview with Resident 40 on March 5, 2024, at 10:20 AM, revealed that he did not receive any financial statements pertaining to his personal fund account. Resident 40 denied that he had any family or individuals who assisted him to manage his finances. Interview with the Director of Nursing and the Nursing Home Administrator on March 7, 2024, at 2:19 PM, confirmed that the facility had no evidence that Resident 40 received a statement of his personal fund account at least quarterly. 483.10(f)(10)(iii) Accounting and Records Previously cited deficiency 4/7/23 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(2)(3)(e)(1)(f) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(3) Nursing services

Based on clinical record review and staff interview it was determined that the facility failed to provide the correct required notification to a resident whose payment coverage changed for two of three residents reviewed (Residents 18 and 60). Findings include: A review of the form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, (a notice that informs the recipient when care received from the skilled nursing facility is ending; and how to contact a Quality Improvement Organization (QIO) to appeal) revealed instructions that a Medicare provider must ensure that the notice is delivered at least two calendar days before Medicare covered services end. A review of the Form Instructions Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055 revealed that examples of the common reasons why an extended care stay, or services may not be covered under Medicare might include the beneficiary no longer requires daily skilled care for a medical condition but wants to continue residing in the skilled nursing facility (SNF). The SNF enters a good faith estimate of the cost of the corresponding care that may not be covered by Medicare. In the blank that follows Beginning on ., the skilled nursing facility enters the date on which the beneficiary may be responsible for paying for care that Medicare is not expected to cover. The beneficiary selects an option box to indicate a desire to continue to receive the care or not to continue to receive the care and if there is a desire to have the bill submitted to Medicare for consideration. The beneficiary or their authorized representative must sign the signature box to acknowledge that they read and understood the notice. The SNF must issue this notice when there is a termination of all Medicare Part A services for coverage reasons. If after issuing the NOMNC, the SNF expects the beneficiary to remain in the facility in a non-covered stay, the SNFABN must be issued to inform the beneficiary of potential liability for the non-covered stay. Clinical record review for Resident 18 revealed ADT (Admit, Discharge, Transfer) Event documentation that indicated Resident 18's care changed from skilled to non-skilled on November 23, 2023. A review of a CMS-10123 form provided by the facility confirmed that Resident 18's last covered day of Medicare A services ended November 22, 2023. The facility did not provide a CMS-10055 form for Resident 18 who remained in the facility for services that would not be covered by Medicare Part A. The facility provided a CMS-R-131 (Advance Beneficiary Notice of Noncoverage (ABN) used to notify beneficiaries of the discontinuation of Medicare Part B services) form which was signed by Resident 18's Power-of-Attorney on November 21, 2023. There were no comments or information provided on the form to indicate a reason that the notice was not given at least two days before a change in Resident 18's payment source. The graph on the CMS website (Beneficiary Notices Initiative) stipulates that the provider types for the CMS-R-131 form use include independent laboratories, home health agencies, hospices, physicians, practitioners, and providers paid under Medicare Part B. The same graph instructs that skilled nursing facilities are to use the CMS-10055 form. Interview with the Nursing Home Administrator on March 8, 2024, at 10:21 AM, confirmed that the facility provided the incorrect Medicare notice to Resident 18's Power-of-Attorney which was dated less than two days from the date the payment source for her care changed. Clinical record review for Resident 60 revealed that the coverage for his skilled nursing care ended December 9, 2023. A review of a CMS-10123 form provided by the facility confirmed that Resident 60's last covered day of Medicare A services ended December 9, 2023. The facility did not provide a CMS-10055 form for Resident 60 who remained in the facility for services that would not be covered by Medicare Part A. The facility provided a CMS-R-131 form which was signed by Resident 60's daughter on December 5, 2023. Interview with the Nursing Home Administrator on March 8, 2024, at 10:21 AM, confirmed that the facility provided the incorrect Medicare notice to Resident 60's representative when the payment source for his care changed. 483.10(g)(17)(18)(i)-(v) Medicaid/medicare Coverage/liability Notice Previously cited deficiency 4/7/23 28 Pa. Code 201.18(b)(2)(e)(1) Management 28 Pa. Code 201.29(a) Resident rights

Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide the highest practicable care related to physician ordered bowel management medications for one of 17 residents reviewed (Resident 26). Findings include: Interview with Resident 26 on March 5, 2024, at 12:08 PM, revealed that she needs MOM (Milk of Magnesia, liquid medication used to stimulate a bowel movement) or a suppository (Bisacodyl/Dulcolax, medication inserted into the rectum to stimulate a bowel movement) occasionally. Resident 26 believed that she had a bowel movement approximately every three days. Clinical record review for Resident 26 revealed the following active physician ordered bowel protocol medications dated as initiated on November 2, 2022: Magnesium Hydroxide 400 mg (milligrams) per 5 ml (milliliters) oral suspension (Milk of Magnesia, MOM) 30 ml daily as needed if no bowel movement every second and third day Bisacodyl 10 mg rectal suppository daily as needed on the fourth day of no bowel movement Fleet enema 7-19 gm (grams) per 118 ml daily as needed if suppository ineffective (liquid medication instilled through the rectum to stimulate a bowel movement) Review of Resident 26's Bowel Movement History documentation (electronic documentation used by staff to record episodes and descriptions of residents' bowel movements) dated January and February 2024 revealed the following: Did not have a bowel movement between January 2, 2024, at 2:51 PM, and January 8, 2024, at 2:26 PM Did not have a bowel movement between January 14, 2024, at 6:57 AM and January 19, 2024, at 7:09 AM. Did not have a bowel movement between January 30, 2024, at 1:40 PM and February 4, 2024, at 10:53 PM. Review of Resident 26's MAR (Medication Administration Record, electronic system used by staff to document the administration of medications) dated January and February 2024 revealed that staff administered the MOM medication on the following dates: January 5, 2024, at 6:46 AM January 8, 2024, at 1:33 AM January 17, 2024, at 9:46 PM February 3, 2024, at 7:21 AM Resident 26's clinical record did not contain evidence that staff attempted to administer the bowel management medications as ordered per the following: MOM medication on January 4, 2024; the Dulcolax on January 6, 2024; or the Fleet enema following an ineffective suppository after January 6, 2024. MOM medication on January 16, 2024, or the Dulcolax on January 18, 2024 MOM medication on February 1 or 2, 2024 The surveyor reviewed the above findings during an interview with the Nursing Home Administrator on March 8, 2024, at 9:35 AM. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to monitor antibiotic use for one of three residents reviewed for antibiotics (Resident 48). Findings include: Clinical record review for Resident 48 revealed a nurse's note dated February 21, 2024, at 1:09 PM noting Resident 48 had a new order for Cipro, (Ciprofloxacin, a medication used to treat bacterial infections in many different parts of the body), 500 milligrams for 10 days, and that a urinalysis with culture and sensitivity was ordered, also noting the resident had thick, tan, purulent urine. Further review of Resident 48's clinical record revealed Resident 48 did have a physician's order to start Ciprofloxacin HCL 500 mg twice a day to start February 21 and end on March 1, 2024, as indicated for a urinary tract infection. Review of Resident 48's lab reports revealed a urine specimen was collected on February 22, 2024, and resulted the same day showing greater than 100,000 CFU/mL, (colony forming unit per milliliter), normal urogenital flora and no further workup was needed. A review of Resident 48's medication administration record revealed the resident was administered the Ciprofloxacin twice a day from February 21 through March 1, 2024, as ordered. There was no evidence Resident 48's physician was contacted to review the use of the antibiotic after the urinalysis revealed no need for a culture and sensitivity workup or any physician documentation indicating an explanation as to why the antibiotic was ordered prior to urinalysis results, or as to why it continued after the urinalysis results were available. In an interview with the Nursing Home Administrator, Director of Nursing, and employee 1, infection control, on March 8, 2024, at 12:49 PM it was confirmed an antibiotic was started on Resident 48 for a urinary tract infection prior to the urinalysis being completed, the antibiotic continued after no culture and sensitivity was indicated, and there was no evidence of communication with the physician regarding the continued antibiotic use or documentation to indicate as to why the antibiotic continued to be administered until March 1, 2024 as ordered. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for one of five residents reviewed (Resident 29). Findings include: Review of Resident 29's clinical record revealed a physician order dated January 15, 2024, for staff to administer Haldol (typical used to treat schizophrenia or Tourette's syndrome) .5 mg (milligrams) every four hours as needed for behaviors. The facility stopped and restarted the same Haldol order on January 25, 2024, February 7, 2024, February 23, 2024, February 29, 2024, and March 8, 2024, making it a continuous as needed order. The most recent physician order for Haldol dated March 8, 2024, continues until April 7, 2024, making it almost a month of as needed usage for Resident 29. There was no documented evidence in Resident 29's clinical record to justify the continued use of the as needed Haldol for almost a four-month period. A pharmacy recommendation dated January 20, 2024, indicated that the pharmacist identified that Resident 29's as needed Haldol order did not have a 14 day stop date. The pharmacist recommended that Resident 29's physician provide the stop date for her Haldol usage. There was no response from Resident 29's physician to indicate a stop date or a rationale for using the Haldol as needed past 14 days. Interview with the Director of Nursing on March 8, 2024, at 12:40 PM, confirmed the above findings for Resident 29. 28 Pa. Code 211.9(k) Pharmacy services 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by one of three residents reviewed (Resident 29). Findings include: Clinical record review for Resident 29 revealed the facility admitted her on May 12, 2023, with diagnosis including Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 29's admission Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated May 18, 2023, indicated that the facility assessed Resident 29 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 29's care plan dated May 25, 2023 revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss, which should reflect family involvement in development. The facility indicated that Resident 29's goal would be for Resident 29 to return to her previous cognitive status which would be impossible. The findings were reviewed with the Administrator and Director of Nursing on March 6, 2024, at 1:15 PM, and confirmed that Resident 29 did not have an individualized care plan for dementia and cognitive loss. 483.40(b)(3) Dementia Treatment and Services Previously cited 4/7/23 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to appropriately implement interventions to maintain skin integrity for two of four residents reviewed for pressure ulcer risk (Residents 17 and 22) and failed to provide the highest practical care to promote pressure ulcer healing for one of four sampled residents (Resident 30). Findings include: A review of the current physician orders for Resident 17 dated March 23, 2023, instructed staff to float (elevate) the resident's heels while in bed and another order to elevate the resident's legs. A review of the current care plan for Resident 17 revealed a problem associated with skin integrity. The care plan indicated the resident has a history of skin tears and moisture associated skin damage (MASD) to the legs and buttocks. The resident remains at risk for further breakdown due to decreased mobility, incontinence, oxygen tubing, an indwelling catheter, age, and a history of chronic disease. Interventions dated March 22, 2023, instructed staff to implement precautions to protect skin integrity and implement measures to reduce friction, skin shear, and tissue load. Interventions dated April 1, 2023, instructed staff to elevate the resident's legs as much as tolerated, and to float the heels when in bed. An observation of Resident 17 on April 4, 2023, at 12:01 PM revealed the resident was in bed and in the semi-fowler's position (head of bed elevated). The resident's legs were not elevated and there was no intervention employed to relieve the pressure on the resident's heels as directed. An observation of Resident 17 on April 5, 2023, at 1:56 PM revealed the resident was supine (lying face up) in bed. The resident's legs were not elevated and there was no intervention employed to relieve the pressure on the resident's heels as directed. An interview with Employee 4, licensed practical nurse, on April 5, 2023, at 1:58 PM confirmed Resident 17's heels or legs were not elevated or being floated and proceeded to place a pillow under the resident's legs. The above findings for Resident 17 were reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on April 5, 2023, at 2:15 PM. A review of the current physician orders for Resident 22 dated March 3, 2023, instructed staff to apply bilateral Prevalon boots (cushioned boots that help to relieve pressure on the heel). A review of the current care plan for Resident 22 revealed a problem with MASD, skin excoriation, and concerns with the resident's heels. The care plan further indicated that the resident is at risk for further skin breakdown due to decreased mobility, an indwelling catheter, diet, and a history of chronic disease. Interventions dated March 2, 2023, included Prevalon boots to the resident's bilateral feet when in bed and to float heels (suspend in the air, usually with pillows) when in the bed. An observation of Resident 22 on April 5, 2023, at 10:15 AM revealed Resident 22 was in bed. The Prevalon boots were not on, and the resident's heels were not elevated. Observation of Resident 22 on April 6, 2023, at 8:50 AM revealed the resident was in bed. The Prevalon boots were not on, and the resident's heels were not elevated. An interview with Employee 4 on April 6, 2023, at 9:08 AM confirmed Resident 22 did not have the bilateral boots on, and the resident's heels were not elevated as directed by the physician order and the care plan. When Employee 4 searched the room, the boots were found in the resident's closet. Employee 4 proceeded to apply Resident 22's boots. The above findings for Resident 22 were reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on April 6, 2023, at 2:30 PM. Interview with Resident 30 on April 5, 2023, at 9:48 AM revealed that she was admitted to the facility with, a spot at the bottom of (her) spine near (her) butt that has a tunnel (an invisible wound tract that extends beyond the visible wound under the skin). Resident 30 indicated that she is receiving services from consulting wound specialists. Clinical record review for Resident 30 revealed nursing documentation dated March 20, 2023, at 11:38 AM that indicated Resident 30 had a wound care appointment that day, and the treatment orders changed. The documentation indicated that staff were to discontinue the wound vac (medical device that provides continuous suctioning over a wound to promote an optimal environment for wound healing), and implement a new treatment for packing the wound with gauze soaked with half-strength betadine (povidone-iodine, used to help prevent infection in wounds) twice daily. Review of the Wound Care Specialist documentation dated March 20, 2023, revealed that the provider documented that nursing staff noted increased green drainage and a strong odor (abnormal wound assessments that often indicate infection) from Resident 30's wound. The practitioner also noted green drainage and a strong odor in the documentation of the wound's examination. The treatment plan documented by the practitioner noted, VAC hold. Irrigate wound with 1/2 (one-half) strength betadine BID (twice daily). Active physician orders in Resident 30's electronic medical record dated March 20, 2023, included a discontinuation of the wound vac and instructions to pack Resident 30's wound with one-half strength betadine soaked gauze twice daily. The physician orders did not include directives regarding irrigating the wound as per the consulting wound specialist's plan. The physician orders included a directive to pack the wound with half-strength betadine gauze although this was not listed in the practitioner's treatment plan. Wound Care Specialist documentation dated April 3, 2023, continued the treatment plan to, Irrigate wound with 1/2 strength betadine BID at all dressing changes. The plan continued to omit any directive to pack the wound. Observation of Resident 30's wound care treatment with Employee 6 (registered nurse) and Employee 3 (licensed practical nurse) on April 6, 2023, at 10:49 AM revealed Employee 3 mixed betadine and sterile water to achieve a one-half strength solution. After removing the soiled dressings from a pressure ulcer at the bottom of Resident 30's spine, Employee 3 utilized a syringe of normal sterile saline (NSS) to irrigate the invisible tract extending proximally from the wound. Employee 3 utilized the one-half strength betadine solution to soak sterile gauze to pack the tract and wound after the irrigation with NSS. The surveyor reviewed the above concerns regarding Resident 30's wound treatment during an interview with the Nursing Home Administrator, the Director of Nursing, and Employee 1 (occupational therapy assistant/infection preventionist) on April 6, 2023, at 2:00 PM. Interview with the Nursing Home Administrator and Employee 3 on April 7, 2023, at 9:30 AM confirmed that the active physician orders for treatment did not reflect the wound specialist's documented treatment plan of March 20, 2023. The interview confirmed that staff did not seek clarification from the wound care specialist practitioner until after the surveyor's questioning. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of select facility policy and procedures, observations, and staff interview, it was determined that the facility failed to ensure confidentiality of personal health information and resident's right to privacy in the main kitchen on one of two nursing units (Kitchen, Short Hall, and Residents 5 and 162). Findings include: A review of the policy titled General Safeguards to Protect PHI (Protected Health Information), last reviewed without changes on February 8, 2023, revealed that the policy establishes guidelines to help safeguard protected health information from being seen by those who are not authorized to see it. A section of the policy titled Computers revealed the following information: computer screens at each workstation should be positioned so that only authorized users at that workstation can read the display. Workstations and applications should be locked or secured when not being actively used. A section of the policy titled Disposal of paper with PHI revealed the following information: Paper documents containing PHI must be shredded when no longer needed. If retained for a commercial shredder, they should be kept in a secure bin. Blue recycle bins are not for PHI. Use only secure LOCKED containers for disposal of PHI. Observation in the facility's main kitchen on April 4, 2023, at 10:00 AM revealed an overflowing knee-high, plastic garbage bin overfilled with papers in the dishwashing area. The bin was easily accessible to anyone passing by. Further review of the bin revealed pieces of paper that included menus and dietary information for residents. The surveyor pulled out a piece of paper that noted a menu for Resident 162 that indicated the resident's full name, the current location in the facility, and a notation that the resident was on a regular diet. A concurrent interview with Employee 5, dietary manager, revealed that the papers are supposed to be placed in the HIPAA (Health Insurance Portability and Accountability Act) bin. The bin was located three feet away. Observation in the Short Hall section of the facility on April 4, 2023, at 1:45 PM revealed a computer on the wall that was logged into Resident 5's medical record. There were no observed staff members around at the time and the resident's PHI was easily viewable by anyone passing in the hallway. Employee 7, nurse aide, was then observed returning to the computer after coming out of a resident's room. It was unknown how long the resident's chart was left unsecured and easily viewable in the hallway. Observation in the Short Hall section of the facility on April 4, 2023, at 2:10 PM revealed a black clipboard that was upside down on a blue canvas cart in the hallway with no staff members around and easily accessible to anyone passing by. Upon further review by the surveyor, the clipboard contained documents for residents in the facility that included multiple instances of protected health information for each resident. An interview on April 4, 2023, at 2:16 PM with Employee 7 revealed the clipboard belonged to another staff member and that it is an assignment sheet. Employee 7 further reported that it was kept in the hallway because there is nowhere to keep it. The main nurse's station for that hallway was located only three rooms away at the end of the hall. Employee 7 further stated the staff were told it was ok because it was upside down. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on April 5, 2023, at 2:22 PM. Regarding the PHI left on the blue canvas cart, the Nursing Home Administrator further revealed that the expectation would be for staff to not leave this information on the cart in a public hallway. 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 211.12(d)(1) Nursing services

Based on clinical record review, review of select policy and procedures, and staff interview, it was determined that the facility failed to ensure that one resident reviewed was free of significant medication errors resulting in an exacerbation of the resident's clinical condition and eventual death (Resident CR1). Findings include: Review of the facility's policy entitled Medication Administration, identified by the Nursing Home Administrator as the most recent, indicated that nursing staff is to administer medications as prescribed in accordance with good nursing principles and practices. Nursing staff is to identify residents before they administer medications. Closed clinical record review for Resident CR1 revealed multiple [DIAGNOSES REDACTED]. Review of a statement signed by Employee 1 (licensed practical nurse) revealed that on [DATE], she was completing a medication pass. She poured Resident 38's medication and was called away to help another resident. When she returned to the medication cart Resident CR1 was sitting there in his wheelchair. Employee 1 administered Resident 38's medications to Resident CR1 in error at 8:45 AM. The medications included: [MEDICATION NAME] (lowers blood pressure) 200 milligrams (mg), [MEDICATION NAME] (lowers blood pressure) ,[DATE] mg, [MEDICATION NAME] (vitamins for eyes), [MEDICATION NAME] (used to treat depression) 12.5 mg, and [MEDICATION NAME] used to treat an enlarged prostrate) 5 mg. Employee 1 reported the medication errors to the registered nurse supervisor who contacted the physician. The physician ordered nursing staff to monitor Resident CR1's blood pressure every hour for 24 hours. If the systolic blood pressure (the first number) was less than 100 mm/Hg (millimeters of mercury) nursing staff was to send him to the emergency room for evaluation. His blood pressure readings were: 9:15 AM ,[DATE] mm/Hg 10:15 AM ,[DATE] mm/Hg 11:15 AM ,[DATE] mm/Hg Nursing documentation dated [DATE], revealed that at 11:15 AM the nursing supervisor assessed Resident CR1 as being very fatigued and weak. She notified his physician and sent him to the emergency room . The examining physician in the emergency room documented that Resident CR1 was at the emergency room for evaluation due to [MEDICAL CONDITION] (low blood pressure) due to receiving [MEDICATION NAME] ([MEDICATION NAME]) 200 mg instead of [MEDICATION NAME] 12.5 mg as ordered and possibly [MEDICATION NAME] as well. The physician considered his condition critical and admitted him to the intensive care unit. Review of the physician's hospital discharge summary included a brief history of the resident indicating that he was legally blind due to Diabetes complications with endstage [MEDICAL CONDITION] who was in his normal state of health until he was given the wrong dosage of a medication of a Beta blocker and possibly another cardiac drug. His hospital course revealed that his renal function continued to decline. The physician attempted to remove extra fluids with medication, which seemed to work initially and then stopped working. His kidney function continued to tank. He had slowly declining function and almost no urine output as apparently his kidneys were damaged even further by the [MEDICAL CONDITION] and [MEDICATION NAME] (a medication that had been used to provide pressure support while in the intensive care unit). The physician tried other medications with no response of his renal function. Resident CR1 experienced confusion due to the [MEDICAL CONDITION]. Resident CR1 remained in the intensive care unit until his return to the facility on [DATE]. His physician placed him on comfort care. Resident CR1 expired on [DATE], at 1:40 AM. An interview with the Nursing Home Administrator on [DATE], at 1:00 PM confirmed the above information. 28 Pa. Code 211.9 (a)(1) Pharmacy services. Previously cited [DATE] 28 Pa. Code 211.10 (c) Resident care policies. Previously cited [DATE] 28 Pa. Code 211.12 (d)(1)(5) Nursing services. Previously cited [DATE].