Every finding on record at Saint Anne Home

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food under sanitary conditions. Findings include:The facility's policy for food storage, dated May 29, 2026, revealed that all opened and partially used foods shall be dated, labeled and sealed before being returned to the storage area. The head cook or designee shall be responsible for checking the refrigerator daily for food items that are expiring and shall discard accordingly. The dining service department along with housekeeping is assigned responsibility for monitoring the designated refrigerator and discarding outdated foods daily. Other staff may also monitor and discard food as appropriate.The facility's policy for dietary employee personal hygiene dated May 29, 2026, revealed that all dietary staff must wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting food.Observations in the kitchen dry storage on July 27, 2026, at 09:19 a.m. revealed that there was a quarter bottle of olive oil opened and undated with no lid and covered with an unsecured piece of plastic wrap, a half full gallon of Worcestershire sauce that was opened and undated, and a 3/4 full gallon of cooking [NAME] that was opened and undated.Observations in the kitchenette on [NAME] Garden on July 27, 2026, at 12:07 p.m. revealed a half full half gallon of almond milk opened and undated, a bag of unidentifiable leftover food in to-go containers with an expiration date of July 9, 2026.Observations in the kitchenette on [NAME] Courtyard on July 27, 2026, at 12:19 p.m. revealed six peanut butter and jelly sandwiches and two tuna fish sandwiches with a use by date of July 22, 2026, two containers of applesauce with a use by date of July 22, 2026, a yogurt with a use by date of July 25, 2026, a quart of skim milk 3/4 full opened and undated, and a quart of 2% milk half full opened and undated.Observations in the main kitchen on July 28, 2026, at 12:49 p.m. of Kitchen Staff 5 chopping green peppers and not wearing a beard guard with a fully exposed beard approximately one inch long; Kitchen Staff 6 plating food and not wearing a beard guard, with a fully exposed beard that was approximately four inches long; Kitchen Staff 7 preparing food and not wearing a hair guard with a fully exposed moustache; Kitchen Staff 8 who not wearing a beard guard, with a fully exposed beard approximately one inch long; and observations in the kitchen on July 29, 2026 at 11:49 a.m. revealed Kitchen Staff 9 with a hairnet that only covered her ponytail, leaving approximately four inches of bangs exposed in the front.Interview with the Culinary Director on July 28, 2026, at 12:56 p.m. and July 29, 2026, at 12:10 p.m. confirmed that food items should be labeled and dated properly, expired items should be thrown out, and staff should be wearing beard guards and hairnets properly. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of facility policies, observations, and resident and staff interviews, it was determined that the facility failed to serve food that was palatable and at safe and appetizing temperatures.Findings include: The facility's policy regarding food temperatures, dated May 29, 2026, indicated that all hot foods were to be cooked to appropriate internal temperatures, held, and served at an appropriate temperature.Interview with Resident 2 on July 27, 2026, at 2:39 p.m. revealed that the food is garbage, the vegetables are mush and meat is tough. Observations in [NAME] Courtyard unit for the lunch meal service on July 29, 2026, at 11:47 a.m., revealed the lunch meal consisted of a turkey cutlet or beef tips, a baked sweet potato, and tomato bisque. The last resident to be served in the dining room was at 12:22 p.m. The test tray on July 29, 2026, at 12:33 p.m. revealed that the temperature of the turkey cutlet was 124.5 degrees (F), beef tips were 124.6 degrees (F) baked sweet potato was 142.0 degrees (F) and the tomato bisque was 123.5 degree (F). The tomato bisque and beef tips were not served at the appropriate temperature, and the beef tips were tough to chew and unpalatable.Interview with Culinary Director on July 27, 2026, at 12:57 p.m. confirmed that the tomato bisque was cold and beef tips were cold and difficult to chew. 28 Pa. Code 211.6(f) Dietary Services.

Based on a review facility policies, employee education records, as well as staff interviews, it was determined that the facility failed to ensure that nurse aides completed the required annual education for three of three nurse aides reviewed (Nurse Aides 10, 11, 12). Findings include:The facility's policy regarding continuing education, dated May 29, 2026, indicated that compliance with the facility's standards, policies, and procedures is a condition of employment. This includes compliance with the policies and procedures of this facility's training programs.Review of the employee education file for Nurse Aide 10 revealed that there was no documented evidence of twelve hours of required education completed between 2025-2026.Review of the employee education file for Nurse Aide 11 revealed that there was no documented evidence of twelve hours of required education completed between 2025-2026.Review of the employee education file for Nurse Aide 12 revealed that there was no documented evidence of twelve hours of required education completed between 2025-2026.Interview with the Director of Nursing on July 29, 2026, at 10:34 a.m. confirmed that there was no documented evidence that Nurse Aides 10, 11, and 12 completed the 12 hours of annual training as required.28 Pa. Code 201.18 (b)(3)(e)(1) Management.

Based on review of facility policy and clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 38 residents reviewed (Resident 19).Based on review of facility policy and clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 38 residents reviewed (Resident 19).Findings include: Facility policy for documentation in the medical record dated May 29, 2026, indicated that each residents' medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with the state law and facility policy. Documentation shall be factual, objective and resident centered. False information shall not be documented. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated May 8, 2026, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, had no behaviors, and had diagnoses that included left sided hemiplegia (complete or partial loss of function on one side of the body) following a stroke. Physician's orders for Resident 19 dated July 17, 2026, indicated that the resident was to get out of bed every other day for two hours per day. Review of the Treatment Administration Record (TAR) for Resident 19 dated July 2026 revealed that the resident was out of bed for two hours on July 17, 19, 21, 23, 25, and 27. Review of nurse aide documentation for Resident 19 dated July 2026 revealed that on July 17, 18, 19, 23, 24, and 28, his chair/bed-to-chair transfer ability was documented as not applicable. On July 20, 21, 22, 25, 26, and 27, his chair/bed-to-chair transfer ability was documented as resident refused. An interview with Resident 19 on July 29, 2026, at 1:52 p.m. revealed that staff do not offer to get him out of bed, and he does not believe he has been out of bed in over a month. Interview with the Director of Nursing on July 30, 2026, at 3:15 p.m. confirmed that Resident 19 has not been getting out of bed because he refuses, and that the documentation in Resident 19's TAR indicating that he was out of bed on the above-mentioned dates was inaccurate. 28 Pa Code 211.5(f) Clinical records28 Pa. Code 211.12(d)(5) Nursing services

Based on review of residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident received pneumococcal immunizations for one of 38 residents reviewed (Resident 83) and failed to ensure each resident received the influenza vaccine for one of 38 residents reviewed (Resident 6).Findings include: The facility's pneumococcal vaccine policy, dated May 29, 2026, indicated that all residents will receive immunizations and/or vaccinations that aid in preventing infectious disease unless medically contraindicated or the resident refuses.A quarterly Minimum Data Set (MDS) assessments (a mandated assessment of a resident's abilities and care needs) for Resident 83, dated June 18, 2026, revealed the resident was cognitively intact, required assistance from staff for daily care needs, and his pneumococcal vaccination was not up to date, and it was not offered. Pneumococcal Pneumonia Immunization Consent Form for Resident 83 dated March 20, 2026, revealed education was provided to the resident and authorization to administer the pneumococcal vaccine was obtained. Review of clinical records revealed no documented evidence that the pneumococcal vaccine was administered or contraindicated.Interview with the Director of Nursing on July 29, 2026, at 12:15 p.m. confirmed that Resident 83's signed consent for the pneumococcal vaccine on March 20, 2026, however, as of July 29, 2026, there was no documented evidence that it was administered. An annual MDS assessments for Resident 6, dated February 13, 2026, revealed that resident was cognitively intact, required assistance from staff for daily care needs, and that the resident did not receive the influenza vaccine in the facility for that year's influenza vaccination season because it was offered and refused. There was no documented evidence available that the resident was offered the influenza vaccine during the 2025-2026 flu season and/or she refused it.Interview with the Director of Nursing on July 230, 2026, at 3:15 p.m. confirmed that there was no documented evidence that Resident 6 was offered the influenza vaccine and refused it. 28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include:The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending June 26, 2026, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending July 30, 2026, identified repeated deficiencies related to a failure to assure medications were stored/labeled in a proper manner, failed to provide food that was palatable and at appropriate temperatures, failed to date food items as required and failed to wear hair coverings in the kitchen as per policy.The facility's plan of corrections for deficiencies regarding storage/labeling cited during the survey ending June 26, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with the labeling/storage of medications.The facility's plan of corrections for deficiencies regarding providing palatable food at appropriate temperatures, cited during the survey ending June 26, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F804, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that food was palatable and at appropriate temperatures.The facility's plan of corrections for deficiencies regarding the wearing of appropriate hair coverings in the kitchen, cited during the survey ending June 26, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F812, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure the wearing of appropriate hair coverings in the kitchen. Refer to F761, 804, 81228 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(e)(1) Management.

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to properly label and date eye drops in one of four medication carts reviewed ( [NAME] courtyard) and failed to store and maintain medications in two of four medication carts reviewed ([NAME] courtyard and [NAME] courtyard).Findings include:The facility's policy regarding medication storage and labeling dated May 29, 2026, revealed that the facility would ensure that multi-dose medications that have been opened or accessed are to be labeled with the date they opened considering the manufacturers' specifications and all medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration.Observations in the [NAME] courtyard medication cart on July 28, 2026, at 11:49 am. revealed that there were 12 loose pills throughout the bottom of the first medication drawer. The pills were as follows; one blue/green capsule, one orange small round tablet, one yellow oblong tablet, two large white round tablets, one small round white tablet, one medium round tan tablet, two small round off white tablets, one tiny white oblong tablet, two half oblong white tablets.Interview with Licensed Practical Nurse 3 on July 28, 2026, at 11:58 a.m. confirmed that the medication cart should not have 12 loose pills in the medication drawer.Interview with the Director of Nursing on July 29, 2026, at 3:33 p.m. confirmed that the [NAME] courtyard medication cart should not have 12 loose pills in the bottom of the drawer. He indicated that the medication cart was on record as being cleaned the previous weekend.Observations in the [NAME] courtyard medication cart on July 29, 2026, at 10:10 am. revealed that there was one bottle of Latanoprost Ophthalmic Solution .005 percent eye drops (used to lower the pressure in the eye) that was opened and not labeled with the date it was opened and 8 loose pills throughout the bottom of the first and second medication drawer. The pills were as follows; one orange small round tablet, one large white round tablet, one large round tan tablet, four small round white tablets, one oblong blue tablet.Interview with Licensed Practical Nurse 4 on July 29, 2026, at 10:12 a.m. confirmed that the bottle of Latanoprost Ophthalmic Solution .005 percent eye drops should have been labeled with the date it was opened and the medication cart should not have 8 loose pills in the bottom of the drawers.Interview with the Director of Nursing on July 29, 2026, at 11:30 a.m. confirmed that the bottle of eye drops should have been labeled with the date it was opened and there should not be 8 loose pills in the bottom of the drawers in the [NAME] courtyard medication cart. 28 Pa. Code 211.9(a)(1) Pharmacy services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to respond to a pharmacy recommendation for two of 38 residents reviewed (Resident 4, 5).Findings include:A facility policy related to medication regimen review, dated May 29, 2026, indicated that the consultant pharmacist will conduct medication regimen reviews (MRRs) and will make recommendations based on the information made available in the residents' health record. The consultant pharmacist will provide the residents' MRRs to the facility identified personnel who will ensure that the attending physician, medical director, and other necessary facility staff receive the recommendations.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated June 13, 2026, revealed that the resident was cognitively impaired, required maximum assistance with care needs, received insulin, and had diagnoses of hypertension (high blood pressure), heart failure, kidney failure, and diabetes.A pharmacy medication regimen review fax for Resident 4, dated April 27, 2026, indicated that irregularities/recommendations were noted, and that a physician's order for ergocalciferol 200 micrograms/milliliter and to give 2 drop by mouth and bedtime was to be clarified to reflect the dose as 2 dropperful= 2 milliliter = 400 micrograms. There was no documented evidence in the residents' clinical record that the order was clarified.A comprehensive MDS for Resident 5, dated June 29, 2021, revealed that the resident was cognitively impaired, was usually understood and could usually understand, had medical diagnoses of high blood pressure, heart failure, kidney failure, and diabetes, and received antipsychotic medications.A review of the clinical record for Resident 5 revealed that the resident was on a pureed or mechanical soft diet, and pills were to be crushed in applesauce for administration.A pharmacy medication regimen review for Resident 5, dated January 29, 2026, revealed that do not crush was to be added to medication orders for 125 milligram (mg) divalproex DR (a delayed release medication to treat seizures), 20 mg Protonix a medication used to gastro-esophageal reflux disease (a chronic condition where stomach acid frequently flows back into the esophagus, irritating its lining), 50mg metoprolol ER (an extended release medication used to treat high blood pressure), and tamsulosin (a medication used to treat an enlarged prostate). There was no documented evidence in the resident's clinical record that do not crush was added to the above orders.Interview with Licensed Practical Nurse 2 on July 30, 2026, at 8:43 a.m. revealed that all medication for Resident 5 is to be crushed, and that they are crushed because there is not a do not crush order in place.A pharmacy medication regimen review for Resident 5, dated March 27, 2026, revealed that the resident needed to have an Abnormal Involuntary Movement Scale (AIMS) (a 12-item, clinician-rated medical exam used to detect and measure the severity of involuntary muscle movements related to long-term anti-psychotic use) completed. There was no documented evidence that an AIMS was completed until April 27, 2026.An interview with the Director of Nursing on July 30, 2026, at 8:43 a.m. confirmed that the recommendation was not appropriately addressed for the above residents. 28 Pa. Code 211.10(c) 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 that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD) (a mental and behavioral disorder that develops related to a terrifying event) for one of 38 residents reviewed (Resident 2).Findings include: A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 27, 2026, indicated that the resident was cognitively intact, was dependent on staff for daily care needs, and had diagnoses that included PTSD. A review of Resident 2's care plan, dated October 17, 2025, indicated that the resident had PTSD related to laying on the floor for days. There was no documented evidence the facility identified Resident 2's specific triggers that could re-traumatize the resident or implement measures as to how facility staff could prevent or minimize triggers from occurring. Interview with the Director of Nursing on July 29, 2026, at 3:39 p.m. revealed that the resident was seen by a psychiatrist at the facility and had a new diagnosis of PTSD and the assessment for triggers should have been completed at that time. 28 Pa Code 201.24(e)(4) admission Policy. 28 Pa Code 211.12(a)(d)(3)(5) Nursing Services. 28 Pa. Code 211.16(a) Social Services.

Based on review of facility policy, clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician orders were obtained for intravenous (IV) therapy and orders to flush IV catheters (small tube inserted into a vein to deliver fluids or medication) were not obtained for two of 38 residents reviewed (Resident 17, 76).Findings include:The facility's policy regarding IV therapy, dated May 29, 2026, revealed that physician orders are obtained before starting IV therapy and flushing is performed by attaching a 10 milliliter (ml) syringe of normal saline to confirm patency of vascular access device before and after medication administration.A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of the resident's abilities and care needs) for Resident 17, dated June 30, 2026, revealed that the resident was cognitively intact and had a midline intravenous catheter (a soft, medium-length tube inserted into a vein in the upper arm, generally used for one to four weeks) to treat osteomyelitis (infection of the bone).Physician's orders for Resident 17, dated July 13, 2026, included orders to administer 2 grams (gm) of Meropenem (an antibiotic) twice a day day thru July 28, 2026. Review of Resident 17's Medication Administration Records (MAR's) for July 2026, revealed that there was no documented evidence of an order to flush the midline and no evidence that staff flushed the midline IV catheter before and after the medication administration.A quarterly MDS assessment for Resident 76, dated June 30, 2026, revealed that the resident was cognitively intact and was required assistance for daily care needs. Observations on July 28, 2026, at 11:14 a.m. revealed that Resident 76 had an IV site in her right forearm.A nursing note for Resident 76, dated July 25, 2026 7:07 p.m. revealed that an IV heparin lock (an IV catheter that is capped off with a port) 22 gauge was inserted into her right forearm. Review of Resident 76's Medication Administration Records (MAR's) for July 2026 revealed no documented evidence that a physician order was obtained for IV therapy and flush orders were not obtained.Interview with the Director of Nursing on July 29, 2026, at 8:45 a.m. confirmed that physician orders should have been obtained for Resident 17 and 76 before starting IV therapy and flush orders should have been obtained.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure a safe environment for three of 38 residents reviewed (Residents 4, 13, 100).Findings include:A comprehensive minimum data set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 4, dated January 18, 2026, revealed that the resident was cognitively intact, was occasionally incontinent of urine, used a manual wheelchair, and required partial assistance to transfer from the bed to a chair. The resident's care plan, updated April 9, 2026, revealed that the resident had actual falls and required her wheelchair to be placed at her bedside facing the bed with brakes locked when the resident is in bed.A nursing note for resident 4 following a fall, dated April 10, 2026, at 9:54 a.m. revealed that the new intervention for fall prevention is to place the resident's wheelchair at bedside facing her bed with brakes locked when the resident is in bed.A nursing note for resident 4 following a fall, dated April 17, 2026, at 12:00 p.m. indicated that Resident 4 was observed lying on the floor beside her bed on her right side. A bruise was observed to her right cheek, and staff were educated to keep the wheelchair at bedside locked when the resident was resting while in bed.A nursing note for Resident 4 dated April 17, 2026, at 1:23 p.m. the resident had complaints of knee pain in both the right and left knees, and new orders were received for X-rays for both legs.A nursing note for Resident 4 dated April 17, 2026, at 5:44 p.m. the resident was complaining of right leg pain and new orders were received for an X-ray of the right hip.A nursing note for Resident 4 dated April 20, 2026, at 12:34 p.m. revealed that the medical director was in to see the resident and review laboratory results. The resident was non-verbal and not acting herself. The resident was sent to the emergency room for evaluation.A nursing note for Resident 4 dated April 20, 2026, at 4:23 p.m. revealed that the resident was admitted to the hospital with a diagnosis of fall and altered mental status, and fractured pelvis.An interview with the Assistant Director of Nursing and Director of Nursing on July 30, 2026, at 9:33 a.m. revealed that the care plan should not have been updated on April 9, 2026, to reflect that her intervention was to place the wheelchair by her bed after the residents fall; however, there was no documented evidence the intervention was in error and no documented evidence of another fall intervention put in place.A quarterly MDS assessment for Resident 13, dated June 26, 2026, revealed that the resident was severely cognitively impaired and needed extensive assistance for all of his care, and had diagnoses that included cerebral palsy with profound intellectual disorders. The resident's care plan, revised on July 1, 2026, revealed that the resident was at risk for falls and was to have dycem (a rubber-like material used to prevent slipping) above and below the seat cushion on his wheelchair. Physician's orders for Resident 13, dated July 1, 2026, included an order to have dycem above and below the residents wheel chair seat cushion.Observations on July 28, 2026, at 2:41 p.m. and July 29, 2026, at 9:53 p.m. revealed that Resident 13's wheel chair had dycem above his seat cushion, but none below as ordered.An interview with Licensed Practical Nurse 1 on July 29, 2026, at 1:56 p.m. revealed that there was no dycem below the residents wheelchair seat cushion, and there should have been.An interview with the Nursing Home Administrator on July 29, 2026, at 3:23 p.m. confirmed that Resident 13 should have had dycem above and below his seat cushion as ordered and care planned, and he did not.A quarterly MDS assessment for Resident 100, dated April 29, 2026, revealed that the resident was cognitively impaired, and was dependent on staff for daily care needs. A care plan dated October 21, 2025, revealed that the resident was at risk for pressure injuries related to decreased mobility.Physician's orders for Resident 100 dated July 14, 2026, included an order for an air mattress to be in place on her bed.Review of Resident 100's clinical record revealed that here was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to the air mattress being placed on Resident 100's bed.An interview with the Director of Nursing on July 30, 2026, at 10:34 confirmed that Resident 100 did not have an assessment completed regarding potential safety hazards prior to the air mattress being placed on her bed. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for one of 38 residents reviewed (Resident 6).Findings include: Review of the facility policy for Restorative Nursing Programs dated May 29, 2026, revealed that it is the policy of the facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical , mental, and psychosocial functioning. The interdisciplinary team, with the support of and guidance from the physician, will assure the ongoing review, evaluation, and decision making regarding the services needed to maintain or improve resident's abilities in accordance with the resident's comprehensive assessment goals and preferences. Review of the Facility Assessment (comprehensive, documented evaluation that a facility must conduct to determine the resources needed to competently care for its residents during day-to-day operations and emergencies ) dated April 25, 2026, indicated that the type of care that the resident population required and that the facility provided for the resident population included transfers, ambulation, restorative nursing and contracture prevention/care. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated May 16, 2026, indicated that the resident was cognitively intact, required supervision or touching assistance with transfers and ambulation, and had diagnoses that included heart failure. Physician's orders for Resident 6 dated November 14, 2026, included for the resident to be discharged from physical therapy services and to refer to restorative nursing program for ambulation with a wheeled walker. Care plan for Resident 6 dated October 24, 2025, indicated that the resident had the potential for decline in range of motion (how far you can move or stretch a part of your body) due to low back pain and that active range of motion (a structured set of exercises where a patient moves their joints independently using their own muscle strength without any external help) was to be provided to all extremities twice a day, six to seven days a week for at least 15 minutes. The resident was to ambulate up to 100 feet with a front wheeled walker and contact guard assist. Staff were to report any significant decline in ambulation to the Restorative Coordinator and reassess quarterly and as needed. Review of nurse aid documentation and Treatment Administration Records for Resident 6 dated April 2026 through July 2026, revealed no documented evidence that the resident was provided active range of motion or assistance with ambulation. Interview with Resident 6 on July 27, 2026, at approximately 10:30 a.m. revealed that she sometimes takes a walk in the hall with her walker, it depends on what staff are available to help her. Interview with the Occupational Therapist on July 30, 2026, at 1:55 p.m. revealed that the facility previously had an active restorative nursing program, however it does not currently have a restorative nursing program in place. No active range of motion or ambulation orders where put into place for Resident 6 because there is no restorative nursing program. Staff are verbally educated on the functional level of the resident upon discharge from therapy services and therapy relies heavily on staff reporting any decline with the resident to therapy so they can be reevaluated. Interview with the Director of Nursing on July 30, 2026, at 3:22 p.m. revealed that the facility does not currently have a restorative nursing program in place, however there should be an active restorative nursing program in place. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for two of 38 residents reviewed (Resident 4, 76 ).Findings include:A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated May 2, 2026, revealed that the resident was cognitively impaired and required assistance from staff for all daily care needs, and had medical diagnoses that included diabetes. A care plan for Resident 4 dated January 8, 2026, revealed that diabetes medication was to be administered per the physician's orders.A physician's note for Resident 4, dated June 20, 2026, at 9:21 p.m. revealed that the resident's blood sugar check is to be completed later between 8:00 p.m. and 9:00 p.m. due to the belief that the blood sugars are not accurate, and are indicative of a post meal blood sugar and not a true bedtime blood sugar resulting in the resident receiving an inaccurate dose of insulin.Physician's orders for Resident 4, dated June 20, 2026, revealed that the resident was to receive NovoLog insulin injection solution 100 unit/milliliter and inject as per sliding scale: if blood glucose read 0-60 give glucose substitute and recheck, 61-200 = 0 units, 201-250 = 2 units, 251-300 4 units, 301-350 = 6 units, 351-400 = 8 units, 401-501 = 10 units, 451+= 10 units recheck in 2 hours subcutaneously before meals and at bedtime. Bedtime blood glucose monitoring to be completed between 8:00 p.m. and 9:00 p.m.Review of the clinical records for Resident 4 revealed that the blood glucose monitoring was completed on June 22, 2026, at 7:27 p.m., July 3, 2026, at 7:57 p.m., on July 5, 2026, at 7:29 p.m., on July 6, 2026, at 7:29 p.m., on July 7, 2026, at 7:25 p.m., on July 10, 2026, at 7:48 p.m., on July 11, 2026, at 7:15 p.m., on July 16, 2026, at 7:11 p.m., on July 17, 2026, at 7:19 p.m., on July 21, 2026, at 7:40 p.m., on July 22, 2026, at 7:21 p.m., on July 24, 2026, at 7:28 p.m., on July 25, 2026, at 7:18 p.m., on July 27, 2026, at 7:06 p.m., on July 28, 2026, at 7:44 p.m.Interview with the Director of Nursing on July 29, 2026 at 9:44 a.m. confirmed that the blood glucose monitoring was completed early and not per physician's orders on the above dates and times.A quarterly MDS assessment for Resident 76, dated June 30, 2026, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included congestive heart failure (a condition where the heart can not pump blood efficiently). Physician's orders for Resident 76, dated October 21, 2025, included an order for the resident to be weighed daily via chair scale. Review of Resident 76's clinical record revealed that there was no documented evidence that Resident 76's weight was obtained on June 6, 11, 13, 21 and 26, 2026. Interview with the Director of Nursing on July 28, 2026 at 12:15 p.m. confirmed that Resident 76's weights were to obtained per physician's orders on the above dates and they should have been. 28 Pa. Code 211.12(d)(3) Nursing services.

Based on review of facility policies, clinical records, and shower schedules, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for one of 38 residents reviewed (Resident 19).Findings include:The facility policy for showering/bathing dated May 29, 2026, indicated that it is facility policy to safely shower/whirlpool tub bath residents and provide comfort and cleanliness. If it is identified that a resident is unable to shower/bath, the resident refuses the shower/bath or requests another time for a shower/bath notify the unit supervisor. The unit supervisor will discuss the bath/shower with the resident and/or make another arrangement for the shower/whirlpool for the resident. Documentation will be entered into the electronic medical record for the reason a bath/shower was not given or other arrangements/preferences that have been made. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated May 8, 2026, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, had no behaviors, and had diagnoses that included left sided hemiplegia (complete or partial loss of function on one side of the body) following a stroke. Care plan for Resident 19 dated May 5, 2026, indicated that the resident had a bathing preference for showers. A review of the nurse aide bathing documentation for Resident 19 dated April 2025, May 2025, June 2025, and July 2025 revealed that the resident was to receive a shower every Saturday. Nurse aide documentation revealed that the resident received a bed bath on April 25, May 2, 9, 15, 30, June 6, 27, and July 25. He received a sponge bath on July 4 . There was no evidence that the resident was offered or refused a shower on these dates or any alternative dates. Review of the bathing documentation also revealed that on April 11 and July 11, the shower was documented as not applicable. There was no evidence that the resident was offered, provided or refused a shower on these dates or any alternative dates. An interview with Resident 19 on July 29, 2026, at 1:52 p.m. revealed that the resident cannot remember when he was last offered a shower because they don't get him out of bed, however if they did offer him a shower, he would reluctantly agree to get a shower. Interview with the Director of Nursing on July 30, 2026, at 1:36 p.m. revealed there was no documented evidence that Resident 19 was offered or refused showers according to his care schedule during the above-mentioned dates, or any alternative dates. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on observations and staff interviews, it was determined that the facility failed to provide a clean and home-like environment. Findings include: The facility's cleaning policy, dated May 29, 2026, indicated that all resident rooms including floors and common areas including the dining area are to be swept daily. Observations of the [NAME] courtyard common area on July 27, at 12:30 p.m. and 2:30 p.m.; July 28, 2026, at 12:32 p.m. and 2:45 p.m. revealed that there was a moderate to large amount of dust, dirt, crumbs and debris located around the perimeter floor/wall of the common area and outside room C108. A plastic spoon was located under a chair on the floor in the common area. In addition, on July 28, 2026, at 10:00 a.m. and 2:45 p.m. there were observations under the dining table of approximately 3 quarter sized pieces of yellow eggs. Interview with Housekeeper 1 on July 28, 2026, at 3:02 p.m. confirmed that there was a large amount of dust, dirt and debris along with a plastic spoon under the chair, and eggs under the table that should not be on the floor in the [NAME] courtyard common area. She indicated that they have four staff in the facility today for eight nursing units, and that her priority is the resident rooms. That she cleaned up to 75 resident rooms in one day and that when she started at the facility two years ago, there were 7 staff for eight units. She further indicated that she is working as fast as she can to keep her nursing units clean, and that the staff on the units also contribute to her workload by not picking up after themselves. Observations of Resident 163 room on July 27, 2026, at 1:36 p.m. and July 28, 2026, at 8:09 a.m. revealed that the resident was seated in his wheelchair and there were potato chip crumbs and a piece of chocolate on the floor on both occasions. Interview with Housekeeper 1 on July 28, 2026, at 11:26 a.m. revealed that she is aware she is not cleaning like she should be and she is missing things due to the fact they are short staffed. She has two and a half units to clean herself, and can't keep up with the job. She confirmed that the floor of Resident 163's room was dirty and should have been cleaned. Interview with the Maintenance/Housekeeping Supervisor on July 29, 2026, at 8:13 a.m. confirmed that the facility should be clean and it was not. He indicated that each staff currently has two units to clean and that they had one staff member leave two weeks ago, and that he has added a weekend shift to help. 28 Pa. Code 201.29(j) Resident Rights. 28 Pa. Code 207.2(a) Administrator's Response .

Based on review of facility policy, resident clinical record, and staff interviews it was determined that the facility failed to report an allegation of abuse for one of 38 residents reviewed (Resident 4). Findings include:Review of facility policy for Protection and Prevention Against Resident Abuse, Neglect, and Exploitation dated May 29, 2026, indicated that residents have the right to be free from any verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, exploitation and misappropriation of resident property. Residents must not be subjected to abuse by anyone including, but not limited to facility staff, other residents, consultants, or volunteers, staff or other agencies serving the individual, family members or legal guardians, friends or other individuals. All staff shall report any systeped residenr abuse, neglect, exploitation, mistreatment or misappropriation of resident property to their supervisor, the director of nursing, the administrator, the corporate compliance officer of via the compliance hot line.A Significant Change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated May 2, 2026, revealed that the resident was cognitively impaired, was sometimes understood and could sometimes understand others, was dependent on staff for daily care needs, and had diagnosis that included dementia.A nursing note for Resident 4 dated May 23, 226 at 1:00 p.m. revealed that the resident was slapped by another resident while sitting in the dining area, and she became weepy.A review of the clinical records revealed that there was no documented evidence that the incident was reported to their immediate supervisor, the director of nursing, the administrator, or the corporate compliance officer.Interview with the director of nursing on July 29, 2026, at 9:44 a.m. revealed that he was not made aware of the above incident, and that staff should have reported the incident per policy so that an investigation could have been conducted. 28 Pa Code: 201.14 (a) (c) Responsibility of management 28 Pa Code: 201.18 (b)(1) Management. Findings include:Review of facility policy for Protection and Prevention Against Resident Abuse, Neglect, and Exploitation dated May 29, 2026, indicated that residents have the right to be free from any verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, exploitation and misappropriation of resident property. Residents must not be subjected to abuse by anyone including, but not limited to facility staff, other residents, consultants, or volunteers, staff or other agencies serving the individual, family members or legal guardians, friends or other individuals. All staff shall report any systeped residenr abuse, neglect, exploitation, mistreatment or misappropriation of resident property to their supervisor, the director of nursing, the administrator, the corporate compliance officer of via the compliance hot line.A Significant Change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated May 2, 2026, revealed that the resident was cognitively impaired, was sometimes understood and could sometimes understand others, was dependent on staff for daily care needs, and had diagnosis that included dementia.A nursing note for Resident 4 dated May 23, 226 at 1:00 p.m. revealed that the resident was slapped by another resident while sitting in the dining area, and she became weepy.A review of the clinical records revealed that there was no documented evidence that the incident was reported to their immediate supervisor, the director of nursing, the administrator, or the corporate compliance officer.Interview with the director of nursing on July 29, 2026, at 9:44 a.m. revealed that he was not made aware of the above incident, and that staff should have reported the incident per policy so that an investigation could have been conducted. 28 Pa Code: 201.14 (a) (c) Responsibility of management 28 Pa Code: 201.18 (b)(1) Management.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the resident and the resident's representative, in writing regarding the reason for transfer to the hospital, and to ensure that the ombudsman was notified of the transfer to the hospital, for seven of 38 residents reviewed (Residents 1, 4, 7, 12, 76, 100, 144). Findings include: The facility's policy regarding ombudsman notification, dated May 29, 2026, indicated that the ombudsman would be notified on a monthly basis of any emergent facility initiated discharge or transfer. The facility did not provide a policy regarding providing a written notice to the resident and the resident's representative upon transfer to the hospital.A quarterly MDS assessment for Resident 1, dated May 21, 2026, indicated that the resident was cognitively intact, required assistance from staff for all daily care needs, and had a diagnoses that included malignant neoplasm of the bladder.Nursing notes for Resident 1, dated May 2, 2026, at 4:37 p.m., revealed that the resident presented with an altered mental status and blood in his urine, he was transferred to the hospital and was admitted A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4 dated February 14, 2026, revealed that the resident was cognitively intact, required partial assistance from staff for daily care needs and had medical diagnoses that included dementia.A nursing note for Resident 4 dated April 2026, at 12:24 pm revealed that the resident was nonverbal and lethargic, and she was sent to the emergency room for evaluation.Review of Resident 4's clinical record revealed that there was no documented evidence that the ombudsman, and resident and/or resident representative were notified in writing of the purpose for the resident's transfer regarding her hospitalization on April 20, 2026. A quarterly MDS for Resident 7 dated January 6, 2026, revealed that the resident was cognitively intact and required assistance from staff for daily care needs.A nursing note for Resident 7 dated March 5, 2026, at 3:13 p.m. revealed the resident had an unwitnessed fall, was sent to the hospital for evaluation and was admitted .Review of Resident 7's clinical record revealed that there was no documented evidence that the ombudsman, and resident and/or resident representative were notified in writing of the purpose for the resident's transfer regarding her hospitalization on March 5, 2026.An admission MDS for Resident 12 dated June 29, 2026, revealed that the resident was cognitively intact and required assistance from staff for daily care needs.A nursing note for Resident 12 dated July 27, 2026, at 12:27 p.m. revealed the resident had a change in condition, was sent to the hospital for evaluation and was admitted .Review of Resident 12's clinical record revealed that there was no documented evidence that the ombudsman, and resident and/or resident representative were notified in writing of the purpose for the resident's transfer regarding his hospitalization on July 27, 2026.A quarterly MDS for Resident 76 dated June 30, 2026, revealed that the resident was cognitively intact and required assistance from staff for daily care needs.A nursing note for Resident 76 dated July 12, 2026, at 1:30 p.m. revealed the resident had difficulty swallowing, was sent to the hospital for evaluation and was admitted .A nursing note for Resident 76 dated July 17, 2026, at 4:29 p.m. revealed the resident continued to have difficulty swallowing, was sent to the hospital for evaluation and was admitted .Review of Resident 76's clinical record revealed that there was no documented evidence that the ombudsman, and resident and/or resident representative were notified in writing of the purpose for the resident's transfer regarding her hospitalization on July 12, 17, 2026.A quarterly MDS for Resident 100 dated April 29, 2026, revealed that the resident was cognitively impaired and was dependent on staff for daily care needs.A nursing note for Resident 100 dated April 22, 2026, at 9:58 a.m. revealed the resident had difficulty breathing, was sent to the hospital for evaluation and was admitted .A nursing note for Resident 100 dated October 26, 2026, at 11:39 p.m. revealed the resident had a choking episode, was sent to the hospital for evaluation and was admitted .Review of Resident 100's clinical record revealed that there was no documented evidence that the ombudsman, and resident and/or resident representative were notified in writing of the purpose for the resident's transfer regarding her hospitalizations on April 22 and October 26, 2026.A quarterly MDS for Resident 144 dated April 1, 2026, revealed that the resident was cognitively intact, was dependent on staff for daily care needs.A nursing note for Resident 144 dated May 23, 2026, at 5:03 a.m. revealed the resident had a large amount of blood in her brief and was being sent to the emergency room for evaluation.Interview with the Director of Nursing on July 29, 2026, at 2:12 p.m. confirmed that for Residents 1, 4, 7, 12, 76, 100, 144, there was no written notification of hospital transfer provided to them or their representatives, and that the ombudsman was not notified of the transfer to the hospital as required. 28 Pa. Code 201.29(j) Resident Rights.

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that each resident received assistance devices to prevent accidents for one of three residents reviewed (Resident 1).Findings include:A wheelchair transport policy dated January 8, 2026, revealed that footrests must be used when staff, family, volunteers and healthcare partners (vendors) are assisting residents who are transported by wheelchair, Broda chair or any other chair with attachable footrests to prevent accident/injury. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated February 13, 2026, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included dementia.An incident investigation dated December 20, 2025, at 10:40 p.m. revealed that Nurse Aide 1 was pushing Resident 1 in her wheelchair to her room without leg rests. The resident leaned forward and fell onto the floor. She sustained a 1.5 by 1.5-centimeter abrasion to the left side of her forehead, a 0.5 by 0.5-centimeter abrasion to left eyebrow and a 3 centimeter by 3-centimeter bruise to the left side of her forehead.A witness statement from Nurse Aide 1, dated December 20, 2025, at 9:14 p.m. revealed that she was pushing Resident 1 in her wheelchair and she leaned forward and fell out of the wheelchair and confirmed that resident did not have leg rests on when she was pushing her.Interview with the Nursing Home Administrator on March 5, 2065, at 3:12 p.m. confirmed that leg rests should have been in place when transporting Resident 1.28 Pa. Code 211.10(c)(d) Resident Care Policies.28 Pa. Code 211.12(d)(5) Nursing Services.

Based on clinical record reviews as well as observations and resident and staff interviews, it was determined that the facility failed to develop an individualized care plan for three of three residents reviewed (Residents 1, 2, 3).Findings include:A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 30, 2025, indicated that the resident was confused, had diagnoses that included a hip fracture and dementia, and required assistance from staff for his daily care needs, including bed mobility. Resident 1's care plan, dated November 30, 2025, revealed that it did not include that the resident's bed was against the wall.Observations of Resident 1's room on December 16, 2025 at 8:36 a.m. revealed that his bed was against the wall in his room.A quarterly MDS assessment for Resident 2, dated November 4, 2025, revealed that the resident was alert with some confusion, had diagnoses that included dementia, and required some assistance from staff for daily care needs, including bed mobility.Resident 2's care plan, dated October 22, 2025, revealed that it did not include the resident's preference to keep her bed up against the wall. A comprehensive MDS assessment for Resident 3, dated November 2, 2025, revealed that the resident was alert and oriented, had diagnoses that included schizoaffective disorder, and required some assistance from staff for daily care needs, including bed mobility.Resident 2's care plan, dated November 4, 2025, revealed that it did not include the resident's preference to keep her bed up against the wall. An interview with the Director of Nursing on December 16, 2025 at 11:13 a.m. confirmed that Residents 1, 2, and 3's care plans did not include anything regarding their beds against the wall and that they should have.28 Pa. Code 211.11(d) Resident care plans.

Based on review of policies, as well as observations and interviews with residents and staff, it was determined that the facility failed to serve food that was palatable and at proper temperatures. Findings include: The facility's policy regarding food preparation and service, dated October 10, 2024, revealed that food was to be prepared by methods which ensure retention of flavor, appearance, and nutrients. Food was to be maintained at proper temperatures during service and transported in a sanitary manner. Standardized recipes, adjusted to the proper yield for the facility, would be available and used in food preparation. Each type of food was to be served at an acceptable temperature. When holding food temporarily before serving, keep hot foods at 140 degrees Fahrenheit (F) or above and cold foods at 40 degrees F or below. Interview with Resident 63 on June 23, 2025, at 11:04 a.m. revealed that the food was not always warm and she even eats in the dining room. Interview with Resident 93 on June 23, 2025, at 11:10 a.m. revealed that the food was terrible, tasted bad, it was covered with slop, and the temperature varied. A test tray for the lunch meal on the Villa [NAME] nursing unit on June 25, 2025, revealed that the cart left the kitchen at 12:19 p.m., arrived on the nursing unit at 12:21 p.m., and the last resident was served at 12:36 p.m. The test tray was tasted at 12:36 p.m. and the oven roasted potatoes were 104.1 degrees F and the brussel sprouts were 106.2 degrees F. The potato chip chicken was tasted and it was bland and had no flavor. Interview with the Chef Manager on June 25, 2025, at 12:36 p.m. confirmed that the temperatures of the oven roasted potatoes and brussel sprouts was low and the potato chip chicken was prepared without using any seasoning. 28 Pa. Code 211.6(b) Dietary Services.

Based on a review of facility policies, clinical records, and investigation reports, as well as observations and staff interviews, it was determined that the facility failed to ensure that the environment was free of accident hazards by failing to ensure that hot liquids were served at appropriate temperatures for two of five residents reviewed (Residents 2, 5) resulting in burns to the residents, and failed to ensure that temperatures of hot liquids were taken, per facility policy, prior to serving the hot liquids to the residents. The facility's failure also placed the current residents who will receive hot liquids in Immediate Jeopardy of the likelihood of serious bodily injury, harm, or death. Findings include: The facility policy regarding serving hot liquids, dated October 10, 2024, indicated that dining services will follow the tray assessment schedule and monitor random meals for the temperature of hot liquids prior to delivery to the resident. Temperatures upon delivery to the resident will not exceed 155 degrees Fahrenheit (F). For dining in the remote dining areas, the temperature of hot beverages and soups will be recorded by the dining room server at time of meal service. The temperature of hot liquids will not exceed 155 degrees F at time of delivery to the resident. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated August 31, 2024, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that include dementia, anxiety, and depression. A care plan for the resident, dated August 11, 2024, revealed that the resident required extensive assistance with her Activities of Daily Living (ADL's - they include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) related to impaired mobility. A nursing note for Resident 2, dated November 13, 2024, revealed that the writer was called to the unit at 7:45 a.m. and that the resident had spilled hot coffee on herself. The resident was assessed, and redness was observed to her left upper thigh. No blistering was present, slight discomfort but no extreme pain. A cool compress was applied. When staff give Resident 2 hot liquids, the hot liquids are to be placed in a sippy cup with a lid. A facility incident report for Resident 2, dated November 13, 2024, revealed that the writer was called to the unit at 7:45 a.m. because the resident had spilled hot coffee on herself. The resident was assessed, and redness was observed to her left upper thigh. No blistering was present. When the resident was interviewed, she stated ,I spilled my hot coffee. The hot water temperature was 149 degrees F when checked. However, there was no documented evidence that the temperature of Resident 2's hot coffee was checked prior to being served to her. Interview with the Assistant Nursing Home Administrator on November 21, 2024, at 4:25 p.m. confirmed that there was no documented evidence that the hot coffee was temped prior to the resident receiving it and there should have been. Observations in the [NAME] Courtyard dining room on November 21, 2024, at 11:55 a.m. revealed that Resident 2 was sitting at the dining room table. The Chef Manager came to the kitchen on the unit to temp the hot coffee, which was 171 degrees F. Nurse Aide 1 served the coffee to Resident 2 after it was temped at 171 degrees F, and Resident 2 was observed consuming the hot coffee out of her sippy cup. Interview with Dietary Manager on November 21, 2024, at 1:06 p.m., revealed that the acceptable range to serve coffee is between 145 and 155 degrees F. The Dietary Manager stated that the coffee machine that was currently in the [NAME] Courtyard kitchen and used during lunch was not the facility's coffee machine but one that staff had brought in on an unknown date. She stated that no temperature logs were being completed prior to serving the residents. A quarterly MDS assessment for Resident 5, dated August 19, 2024, revealed that the resident was understood and could understand others. A care plan for the resident, dated August 15, 2024, revealed that the resident required extensive assistance with her ADL's related to impaired mobility. A nursing note for Resident 5, dated August 30, 2024, revealed that the writer was called to the unit at 3:20 p.m. and that the resident was observed lying in bed and a red area was observed to her left upper thigh. The area measured nine centimeters (cm) by 20 cm. The resident stated, I was getting a drink of my hot tea and knocked the cup over. A cool compress was applied. When staff gives the resident hot liquids, they are to be placed in a cup with a lid. The resident was reassessed at 9:20 p.m. and she was resting in bed and had intact blisters observed to left upper thigh. A facility investigation report for Resident 5, dated August 30, 2024, revealed that the writer was called to the unit at 3:20 p.m. The resident was observed lying in bed and a red area was observed to her left upper thigh. The area measured nine centimeters (cm) by 20 cm. When the resident was reassessed, the resident had blisters. When the resident was interviewed, she stated, I was getting a drink of my hot tea and knocked the cup over. The hot water temperature was 185.1 degrees F when checked; however, there was no documented evidence that the temperature of Resident 5's hot tea was checked prior to being served to her. A wound physician's note for Resident 5, dated September 4, 2024, revealed that this was the initial wound encounter with the resident. Measurements of the resident's wound was 6.2 cm by 11.3 cm with no measurable depth. The wound was irregular shaped, full thickness, with mixed second-degree (involve the outer and middle layers of skin) and third degree (a serious wound that damages all three layers of your skin) burns of the resident's left thigh as a result from a coffee spill. Interview with the Assistant Nursing Home Administrator on November 21, 2024, at 4:25 p.m. revealed that she spoke with the nurse who completed the investigation on Resident 5's coffee spill and said that she confirmed that temperature of the hot liquid was taken from the same machine that the resident's hot liquid was obtained from. Interview with the Nursing Home Administrator and the Assistant Nursing Home Administrator on November 21, 2024, at 6:35 p.m. revealed that Resident 5 must have been served the hot tea by nursing staff and that there was no documented evidence that the temperature was obtained prior to the resident receiving the hot tea. On November 21, 2024, at 4:30 p.m. the Nursing Home Administrator was given the Immediate Jeopardy template and informed that the health and safety of current residents were placed in Immediate Jeopardy due to the facility's failure of not obtaining hot liquid temperatures prior to serving to the residents. An immediate action plan was submitted and contained the following: The facility submitted and implemented an immediate action plan that included the facility will immediately review all daily temperature logs for the current dinner meal being served to ensure the temperature falls within current policy guidelines with all staff currently working. The facility will educate all Dining Service staff that the requirement of taking temperatures of hot beverages in the serving container prior to serving these beverages to the residents must be done prior to every meal and documented on the Daily Temperature Log. If the temperature of a hot beverage falls outside the range of 145 degrees Fahrenheit to 155 degrees Fahrenheit, do not serve the beverage until it cools down and is in these parameters. Daily monitoring of Daily Temperature Logs will be done by the Director of Dining Services or designee. The Director of Dining Services or designee will audit weekly for four weeks, then once a month for two months for any allegations of abuse or neglect emphasizing to all employees zero tolerance. Audits will include assessing whether the unit report sheets are up to date and that staff are utilizing these quick reference guides prior to initiating care. All findings will be reported to the Quality Assurance Performance Improvement Committee. If deficient practices are identified, additional corrective action will be taken. The Immediate Jeopardy was lifted on November 21, 2024, at 6:50 p.m. when it was confirmed that the facility had completed education for the current staff working in house and audits of the dinner meal hot coffee temperatures being within policy guidelines. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies, clinical records, and investigation documents, as well as staff and resident interviews, it was determined that the facility failed to ensure that residents were free from abuse and neglect for one of seven residents reviewed (Resident 1) who was transferred incorrectly, resulting in a fracture. Findings include: The facility's abuse policy, dated October 13, 2023, indicated that residents have the right to be free from any verbal, sexual, physical, and mental abuse; corporal punishment; involuntary seclusion; exploitation; and misappropriation of resident property. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff or other agencies serving the individual, family members or legal guardians, friends or other individuals. The intent of the policy is to develop and maintain a proactive process of detection and prevention of resident mistreatment, neglect, abuse, and misappropriation of property. Any staff member found guilty of abusing, neglecting or mistreating residents will be discharged immediately. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated July 9, 2024, revealed that the resident was cognitively impaired, required assistance with care needs, was dependent for transfers, and had diagnoses that included Alzheimer's disease and osteoporosis (condition that weakens the bones and increases risk for fracture). The current activities of daily living care plan for Resident 1 indicated that the resident required the use of a mechanical lift for transfers. A facility investigation document, dated August 6, 2024, revealed that Nurse Aide 1 (an agency nurse aide) called the facility on August 6, 2024, and reported to Registered Nurse 3 that a fall occurred on August 5, 2024, involving Resident 1. Nurse Aide 1 reported that she went into Resident 1's room on August 5, 2024, and saw her on the floor and Nurse Aide 2 (an agency nurse) was in the resident's room. Nurse Aide 1 stated that Nurse Aide 2 asked her to help pick the resident up. They picked the resident up off the floor and put her in her wheelchair and did not report it to the licensed practical nurse or the registered nurse. The resident was assessed following the report of the incident on August 6, 2024, and she was complaining of severe pain to her left leg with transfers and movement. Her left leg was swollen. The physician was notified, and an x-ray was ordered of the resident's left hip and knee. The x-ray results revealed a minimally impacted supracondylar fracture of the distal left femur. The physician was notified, and the resident was sent to the hospital. A written statement from Registered Nurse 3, dated August 6, 2024, revealed that on August 6, 2024, she received a phone call from Nurse Aide 1, indicating that she had to report an incident that occurred August 5, 2024. She indicated that before breakfast, between 7:00 a.m. and 8:00 a.m., she heard yelling and went into Resident 1's room and found Nurse Aide 2 in the room and Resident 1 was on the floor. Nurse Aide 1 stated that Nurse Aide 2 said the resident did not fall and asked her to help her get the resident up. They both assisted the resident off the floor and into her wheelchair. Neither nurse aide reported the incident to the licensed practical nurse on the unit or the registered nurse supervisor. Registered Nurse 3 assessed the resident after the call indicating that the resident was lying in bed and comfortable at rest but had pain with movement and transfers. She noted the resident's left leg was slightly more swollen than the right leg, and the resident was unable to explain what happened due to her diagnosis of Alzheimer's dementia. She indicated that the medical director was notified, x-rays were ordered to the left knee and leg, the daughter was called and updated, and the Director of Nursing was notified. Human resources contacted the staffing agency and informed them that Nurse Aide 2 was not to return to the facility. Registered Nurse 3 stated that she called Licensed Practical Nurse 4, who revealed that she was not informed of any incident on August 5, 2024. Licensed Practical Nurse 4 also indicated the Resident 1 did not have a hoyer lift pad underneath her at breakfast. Registered Nurse 3 indicated that she was the registered nurse on duty on August 5, 2024, and no nurse aide reported that the resident was on the floor. Registered Nurse 3 indicated that the x-rays were obtained showing a minimally impacted supracondylar fracture of the distal left femur, the medical director was notified, the daughter and Director of Nursing was notified, and the resident was sent to the hospital. Registered Nurse 3 indicated that she called and made a report to the after-hours Area Agency on Aging (AAA). A written statement from Nurse Aide 1, dated August 6, 2024, at 1:41 p.m., revealed that on August 5, 2024, between 7:00 a.m. and 8:00 a.m., while she was trying to find someone to give her report, she heard yelling from a room. She went into Resident 1's room and found Nurse Aide 2 in the resident's room and the resident was on the floor. A written statement from Nurse Aide 2, dated August 7, 2024, at 3:50 p.m., indicated that she started her shift at 6:30 a.m. on August 5, 2024, and when she got there, she went to the Director of Nursing's office, and they told her to go to a certain floor and the night shift came up to the office were she and another nurse aide were waiting to get report. She indicated that she did not get report and it was starting to get late and breakfast was coming, so she started with Resident 1 and went into her room and asked her if she was ready to get up and she said yes. She got her dressed, set her up at the edge of the bed, got her fully dressed, and got the chair close to her bed where she got her up to stand and pivot. She indicated that she did not see Resident 1's hoyer sling in the room at all and did not know she was a hoyer lift, so she helped her stand up and when she did, she fumbled to the floor. She indicated that she helped the resident to the floor and put a pillow behind her, and before she could put the pillow behind her, Nurse Aide 1 came in. Nurse Aide 2 indicated she needed help. Nurse Aide 2 grabbed the resident's arms and she grabbed her legs and lifted her to her wheelchair. She indicated that they both went to tell the nurse and report it to her, and she said she will report it once they got the rest of the people done for breakfast. She indicated that hours later, Nurse Aide 1 went to her and said that Resident 1 was a hoyer lift and she never knew. Description of follow up-action, (as documented on the event report) for Resident 1, dated August 7, 2024, revealed that Nurse Aide 2 was interviewed and indicated that she reported Resident 1's fall to the unit nurse; however, the unit nurse denied being notified. Nurse Aide 1, who was Nurse Aide 2's partner, reported the incident the next day indicating that she thought Nurse Aide 2 had not reported it. Failure to notify the licensed practical nurse who was assigned to Resident 1 was verified. Failure to follow the care plan for Resident 1 to transfer with assist of two or hoyer lift was verified. Review of investigation documentation revealed that Nurse Aide 2 received abuse and neglect training on March 19, 2024. An interview with the Director of Nursing on August 28, 2024, at 5:00 p.m. revealed that Nurse Aide 1 reported Resident 1's fall on August 6, 2024, because she did not believe Nurse Aide 2 reported it. Nurse Aide 2 was not permitted back to the facility. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 201.29(a)(j) Resident Rights. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of established infection control guidelines, the facility's policies and documents, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable infections, by failing to follow infection control guidelines from the Centers for Disease Control (CDC) and the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections and prevent cross-contamination during the COVID-19 pandemic for 8 of 56 residents reviewed (Residents 5, 18, 44, 68, 72, 94, 112, 137). The facility's failure created a situation in which four of these residents (Residents 5, 44, 68, 72) were placed in Immediate Jeopardy related to a lack of proper infection control procedures for cohorting residents and failure to follow infection control standards and DOH guidelines to reduce the spread of infections and prevent cross-contamination during the COVID-19 pandemic. Findings include: Pennsylvania Health Alert Network (PAHAN) - 626, Core Infection Prevention and Control Measures for Long-term Care Facilities, dated February 15, 2022, revealed that the facility should identify a COVID-19 care unit dedicated to monitor and care for for residents with confirmed with the [CONDITION(S)]-CoV-2 infection. The facility should determine the location of the COVID Care Unit and create a staffing plan. By doing this before residents or Healthcare Professional (HCP) with [CONDITION(S)]-CoV-2 infection are identified in the facility will allow time for residents to be relocated to create space for the unit and to identify HCP to work on this unit. Facilities that have already identified cases of [CONDITION(S)]-CoV-2 infection among residents but have not developed a COVID Care Unit should work to create one unless the proportion of residents with [CONDITION(S)]-CoV-2 infection makes this impossible (e.g., the majority of residents in the facility are already infected). The location of the COVID Care Unit should ideally be physically separated from other rooms or units housing residents without confirmed [CONDITION(S)]-CoV-2 infection. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with [CONDITION(S)]-CoV-2 infection. The COVID Care Unit should have dedicated entrance and exit points such that HCP not working in that unit do not need to pass through. HCP working on the COVID Care Unit should have access to a restroom, break room, and work area that are separate from HCP working in other areas of the facility. Ensure HCP practice source control measures and physical distancing in the break room and other common areas (i.e., other than while eating, HCP wear a respirator or source control and sit at least 6 feet apart while on break). Ensure that high-touch surfaces in staff break rooms and work areas are frequently cleaned and disinfected (e.g., each shift). PAHAN - 627, regarding Response to an Outbreak and Residents with Exposure to COVID-19 for Long-term Care Facilities (LTCF), dated February 15, 2022, revealed that residents with confirmed COVID-19 infection should be placed in the COVID Care Unit (Red zone) under isolation as described in PA-HAN-624 or its successor. PAHAN - 624, regarding Interim Infection Prevention and Control Recommendations for Healthcare Settings during the COVID-19 Pandemic, dated February 8, 2022, revealed that quarantined patients and those with suspected infection should NOT be cohorted with patients with confirmed [CONDITION(S)]-CoV-2 infection unless they are confirmed to have [CONDITION(S)]-CoV-2 infection through testing. Place a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). The patient should have a dedicated bathroom. Facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with [CONDITION(S)]-CoV-2 infection. Dedicated means that HCP are assigned to care only for these patients during their shifts. Only patients with the same respiratory pathogen should be housed in the same room. Limit transport and movement of the patient outside of the room to medically essential purposes. Communicate information about patients with suspected or confirmed [CONDITION(S)]-CoV-2 infection to appropriate personnel before transferring them to other departments in the facility (e.g., radiology) and to other healthcare facilities. Personal Protective Equipment - Health Care Personal (HCP) who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). This is also known as Transmission-based Precautions for COVID-19. The facility's policy regarding COVID-19, dated October 13, 2021, revealed that if Coronavirus disease is suspected, the infection preventionist and/or designee will: Mask the resident and move the resident to a private room, if available, with the door closed. Use airborne (N95 mask) and contact (gown, gloves, and goggles) precautions. If a resident is in a semi-private room and a private room is unavailable at the time of outbreak, both residents in the semi-private room will be masked and placed in contact/droplet precautions with the door closed as a result of exposure within six feet. The facility's policy regarding Infection Control for COVID-19, dated October 13, 2021, revealed that the facility will ensure appropriate resident placement (isolation) in a single space/private room if available. If private rooms are unavailable, the interdisciplinary team will make room placement decisions balancing risks to other residents; and by cohorting impacted residents. The primary goal of the facility is to prevent [CONDITION(S)]-CoV-2, the virus that causes COVID-19 from being introduced within the campus. Prevention efforts include: Following standard precautions, which are the minimum infection prevention practices that apply to all resident care, regardless of suspected or confirmed infection status of the resident, in any setting where healthcare is delivered. Standard Precautions include: Hand hygiene and use of personal protective equipment (PPE) (e.g., gloves, gowns, masks, eyewear) when there is an expectation of possible exposure to infectious material. In the event COVID-19 is introduced within the facility, efforts will transition to preventing the COVID-19 from spreading. Prevention efforts will include: Hand hygiene, use of personal protective equipment (PPE) (e.g., gloves, gowns, masks, eyewear) when there is an expectation of possible exposure to infectious material, and following Transmission Based precautions, which is the second tier of basic infection control. Facility personell will use PPE appropriately. Guidance from the Centers for Disease Control (CDC - a national public health agency), dated April 30, 2020, included that residents of nursing homes who have a confirmed COVID-19 infection, regardless of symptoms, should be transferred to a designated COVID-19 care unit. Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for COVID-19 fourteen days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). Exposed residents may be permitted to room share with other exposed residents, if space is not available for them to remain in a single room. A COVID-19 test result for Resident 94, dated July 18, 2022, revealed that the resident was positive, and a COVID-19 test result for Resident 68, dated July 18, 2022, revealed that the resident was negative. Daily census information revealed that Residents 94 and 68 were roommates at the time that Resident 94 had a positive test result on July 18, 2022, and there was no documented evidence that either resident was moved following Resident 94's positive test result. A progress note for Resident 68, dated July 19, 2022, revealed that the resident could not understand why her room was in isolation. It was explained to the resident that her roommate was sick. The resident currently has no COVID symptoms that were apparent throughout the day. During the evening shift nurse aides reported that she did in fact sound sick. The resident was swabbed and was COVID positive. Interviews with Residents 94 and 68 on August 8, 2022, at 3:01 p.m. and 3:02 p.m., respectfully, revealed that neither of them were approached to have their room changed and/or refused to have their room changed. Daily census information, dated July 18, 2022, revealed that the facility had 10 vacant rooms and two of the 10 rooms were private rooms. A COVID-19 test result for Resident 18, dated July 20, 2022, revealed that the resident was positive, and a COVID-19 test result for Resident 44, dated July 20, 2022, revealed that the resident was negative. Daily census information revealed that Residents 18 and 44 were roommates at the time that Resident 18 had a positive test result on July 20, 2022, and there was no documented evidence that either resident was moved following Resident 18's positive test result. A progress note for Resident 44, dated July 27, 2022, revealed that as part of routine outbreak testing the resident was retested for COVID this a.m. The resident's test was positive for COVID at this time. Interview with Resident 44 on August 8, 2022, at 4:33 p.m. revealed that her roommate was really sick and that they have been together here in their room for almost a week since she tested positive for COVID. Daily census information, dated July 20, 2022, revealed that the facility had nine vacant rooms and two of the nine rooms were private rooms. A COVID-19 test result for Resident 137, dated July 23, 2022, revealed that the resident was positive, and a COVID-19 test result for Resident 5, dated July 23, 2022, revealed that the resident was negative. Daily census information revealed that Residents 137 and 5 were roommates at the time that Resident 137 had a positive test result on July 23, 2022, and there was no documented evidence that either resident was moved following Resident 137's positive test result. A progress note for Resident 5, dated July 27, 2022, revealed that the resident was re-swabbed this a.m. for progression of COVID symptoms. The resident's test was positive for COVID at this time. Interview with Resident 137's Family Member 1 on August 8, 2022, at 4:30 p.m. revealed that she does not recall if she was asked about moving her mother's room. Daily census information, dated July 23, 2022, revealed that the facility had 12 vacant rooms and five of the 12 rooms were private rooms. A COVID-19 test result for Resident 112, dated July 29, 2022, revealed that the resident was positive, and a COVID-19 test result for Resident 72, dated July 29, 2022, revealed that the resident was negative. Daily census information revealed that Residents 112 and 72 were roommates at the time that Resident 112 had a positive test result on July 29, 2022, and there was no documented evidence that either resident was moved following Resident 112's positive test result. A COVID-19 test result for Resident 72, dated August 1, 2022, revealed that the resident was positive for COVID. Interview with Resident 72's Family Member 2 on August 8, 2022, at 4:25 p.m. revealed that when someone from the facility called and told her that her mother's roommate tested positive for COVID she had asked about moving her mother. She was told that there were so many residents and no other rooms available and that they would pull the curtain between them. She indicated that she thought to herself, What good is that going to do? Interview with Resident 112's Family Member 3 on August 8, 2022, at 4:34 p.m. revealed that she does not recall being asked about any room changes. Daily census information, dated July 29, 2022, revealed that the facility had 14 vacant rooms and nine of the 14 rooms were private rooms. Interview with the Infection Preventionist on August 8, 2022, at 2:00 p.m. revealed that if she had a resident who tested positive for COVID she would try to move the resident out. However, she was having difficulty moving these residents because they were in a social group on the unit and they all sat across from each other at meal times. They all refused to be moved so she thought they were all exposed any way. She also indicated that she was unable to move residents at that time because she was in a bed lock and had admissions during that time. Observations on the [NAME] Courtyard Unit on August 8, 2022, at 2:45 p.m. revealed that there was a sign prior to entering the unit indicating that the unit was a Red Zone (COVID Care Unit) and the required PPE usage in the Red Zone was a N95 and goggles/face shield at all times. There were also multiple resident rooms indicating that they were a Yellow Zone (potentially exposed to COVID-19) and the required PPE was a N95 and goggles/face shield at all times. Observations on the [NAME] Courtyard Unit resident dining/lounge area on August 8, 2022, at 2:59 p.m. revealed that Housekeeper 1 was working in the area of the resident dining/lounge area of the unit with his N95 mask on down under his chin. There was a resident sitting at a table in the resident dining/lounge area within the area of the housekeeper. Interview with Housekeeper 1 at the time of observation confirmed that he should have had his N95 mask up covering his mouth and nose. Interview with the Infection Preventionist on August 10, 2022, at 1:25 p.m. confirmed that Housekeeper 1 should have had his mask up covering his mouth and nose. She indicated that she does walk throughs and that it did not surprise her that a staff member had their mask down. On August 8, 2022, at 5:57 p.m. the Nursing Home Administrator was informed that the health and safety of residents were in Immediate Jeopardy due to cohorting COVID-19 positive and negative residents in the same room, and for failing to follow established infection control guidelines. The facility submitted and implemented an immediate action plan that included ensuring that each resident was assessed to ensure there were no COVID negative residents residing in the same room with COVID positive residents. The facility developed an infection control education plan for all staff who are responsible for COVID testing of residents and resident placement. The education included not cohorting positive and negative residents in the same room. The Immediate Jeopardy was lifted on August 8, 2022, at 8:55 p.m. when it was confirmed that the facility assessed all residents to ensure that no COVID negative residents were in the same room as COVID positive residents, and educated the Director of Nursing and Infection preventionist and all staff who were responsible for COVID testing, which included all registered nurse supervisors, Assistant Director of Nursing and Inservice Educator. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(d)(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.