Every finding on record at Sapphire Care and Rehab Center

Based on select facility policy, a review of clinical records, and staff interviews, it was determined that the facility failed to notify the physician of the resident's consecutive refusal of medication and treatment, for one of 17 sampled residents (Resident CR1).Findings include: According to the facility policy entitled, Change in Resident's Condition or Status last reviewed February 25, 2026, the facility will notify the resident, physician, and resident representative of changes in the resident's medical or mental condition or status. The policy states the nurse will notify the residents' attending physician or physician on call when there is a refusal of treatment or medications two or more consecutive times. A clinical record review revealed Resident CR1 was admitted to the facility on [DATE], with diagnoses which included metabolic encephalopathy (altered brain function caused by a chemical imbalance ). Resident CR1 was discharged from the facility to the hospital on January 26, 2026. A review of Resident CR1's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 8, 2025, revealed that Resident CR1 was moderately cognitively impaired with a BIMS score of 9 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 means moderate impairment ). Nursing documentation dated December 23, 2025, noted Resident CR1's daughter was visiting and expressed concerns about Resident CR1. The documentation did not reveal any additional information or assessment. According to the nursing documentation, the physician was contacted and ordered Resident CR1 to receive intravenous fluids (IV, administered directly into the vein), laboratory work including a urine sample to rule out urinary tract infection, and diagnostic test including a nasal swab to identify if Resident CR1 had the flu and an abdominal Xray. Nursing documentation dated December 24, 2025, reveals Resident CR1 demonstrated a change in mental status and was refusing to eat and accept medication. The nurse practitioner was made aware and again ordered intravenous fluids, urinary analysis and culture and sensitivity (analyzing the urine to see if there are any bacteria or other substances), and a chest Xray. When Resident CR1's daughter was contacted, the daughter requested Resident CR1 be sent to the hospital for evaluation. A clinical record review revealed a late entry note dated December 25, 2026 by the nurse practitioner describing an evaluation of Resident CR1 while in the facility on December 24, 2026, at 2:07 PM. According to the nurse practitioner documentation, Resident CR1 was assessed on December 24, 2026, in the facility due to reports of nausea, vomiting, and abdominal pain on December 23, 2026. The nurse practitioner described Resident CR1 as being agitated and confused and had suprapubic tenderness (soreness or pain in the lower belly, just above the area where your pelvis meets). The nurse practitioner documented the intent for treatment was to continue in the facility but upon family request, Resident CR1 was transferred to the hospital on December 24, 2026, at 11:20 AM. Resident CR1 returned to the facility on December 25, 2025, at 01:49 AM. According to the hospital Discharge summary dated [DATE], Resident CR1 received an IV antibiotic mixed in a sugar-water solution, a small dose of Midazolam (a calming medicine) by injection, and one liter of IV fluids before returning to the facility. Resident CR1 was to begin taking Cephalexin (antibiotic) upon return to the facility according to the discharge instructions. Review of physician orders dated December 25, 2025, included an order for Cephalexin 500 milligrams (mg) twice a day for a urinary tract infection for a total of five days. Review of the electronic medication administration record (eMAR) revealed on December 25, 2026, the resident refused Trimethoprim Oral Tablet 100 mg (milligram) (an antibiotic to ordered to help prevent infections of the urinary tract). On December 26, 2025, Resident CR1 refused both doses of Cephalexin 500 mg and the Trimethoprim Oral Tablet 100 mg for her urinary tract infection. Additional review revealed the resident refused five other medications, two nutritional supplements, and treatments to a skin injury. The medical record lacked evidence the physician was notified Resident CR1 had not received the prescribed antibiotics necessary to treat a urinary tract information in addition to all medications on December 26, 2025 and wound treatments. An interview with the Nursing Home Administration (NHA) and the Director of Nursing (DON) on August 19, 2026, at 1:30 PM confirmed the facility failed to notify the physician of consecutive refusals of medications and treatments as required by the facility policy. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to consistently provide necessary services to meet the behavioral health needs for two of 27 residents reviewed (Residents 8 and 61).Findings include: A review of the facility's Behavioral Health Services policy, last reviewed April 30, 2026, indicated it is the policy of the facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning. A review of the clinical record revealed that Resident 8 was admitted to the facility on [DATE], with diagnoses that included anxiety disorder (a condition in which excessive worry causes clinically significant distress or impairment in social, occupational, or other areas of functioning), bipolar disorder (a mental health disorder that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and major depressive disorder (a mental health disorder characterized by a persistently low or depressed mood, decreased interest in pleasurable activities, feelings of worthlessness, lack of energy, poor concentration, appetite changes, sleep disturbances, or suicidal thoughts). A review of Resident 8's Quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 5, 2026, revealed that Resident 8 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact). A review of Resident 8's comprehensive care plan, initiated September 30, 2025, revealed the resident was at risk of changes in their mood related to their diagnoses of major depressive disorder, anxiety, and adjustment disorder, and interventions included psychiatric consult and treatment as ordered. A review of a psychiatric services consultant note dated March 23, 2026, revealed the consultant recommended therapy services for treatment of anxiety and depression, with follow-up to occur within 45 to 60 days. A review of a progress note from a Licensed Professional Counselor (LPC) dated April 22, 2026, revealed the resident was seen at their bedside to conduct a follow-up session for talk therapy and assessment for elevated behaviors and recommended follow-up on May 21, 2026. However, there was no documented evidence that Resident 8 received follow-up psychiatric or psychological services as of the survey ending June 30, 2026. A review of the clinical record revealed that Resident 61 was admitted to the facility on [DATE], with diagnoses that included anxiety disorder and depression (a mental health condition characterized by low mood or loss of pleasure or interest in activities for long periods of time). A review of Resident 61's Quarterly MDS dated [DATE], revealed that Resident 61 had moderately impaired cognition with a BIMS score of 9 (a score of 8 through 12 indicates moderate cognitive impairment). A review of Resident 61's comprehensive care plan, initiated January 19, 2024, revealed the resident was at risk of changes in their mood related to their diagnosis of depression and experienced episodes of anxiety, and interventions included psychological consultation and treatment and LPC consultation as needed. A review of a psychiatric services consultant note dated April 14, 2026, revealed the consultant recommended therapy services for treatment of anxiety, depression, insomnia (a sleep disorder), and dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) with follow-up to occur within 14 to 21 days. A review of a progress note from an LPC dated April 20, 2026, revealed the resident was seen at their bedside to conduct a follow-up session for talk therapy and assessment for elevated behaviors and recommended follow-up on May 20, 2026. However, there was no documented evidence that Resident 61 received follow-up psychiatric or psychological services as of the survey ending June 30, 2026. During an interview with the Director of Nursing on June 30, 2026, at 11:00 AM, it was confirmed that Resident 8 and Resident 61 did not receive the recommended follow-up psychiatric and psychological services. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, review of the facility's infection control tracking logs, facility policy, and staff interviews, it was determined the facility failed to maintain a comprehensive infection control program to monitor the development and spread of infections within the facility, including tracking of infections for three out of 27 residents reviewed (Residents 50, 122, and 140).Findings include: Review of the facility's Infection Prevention and Infection Control Plan, indicated as last reviewed by the facility on April 30, 2026, revealed facility leadership is committed to resident safety, providing quality healthcare services, and preventing disease transmission for those that provide support or receive services at the facility. The policy indicated the infection preventionist will provide ongoing, facility-wide outcome and process surveillance of healthcare-associated infections. The policy defined outcome surveillance as a systemic method of collecting, consolidating, and analyzing data concerning a disease or event, followed by dissemination of the information with a goal of improving outcomes. Healthcare-associated infection outcome surveillance incorporates several approaches to minimize risks and control the spread of infections. A review of the facility's infection control data conducted during the survey ending June 30, 2026, revealed the facility's infection control tracking did not reflect evidence of a functional tracking system to monitor and investigate causes of infection and manner of spread. There was no documented evidence of a functional system, which enabled the facility to analyze clusters, changes in prevalent organisms, or increases in the rate of infection in a timely manner. Clinical record review revealed Resident 140 tested positive for SARS-CoV-2 (the virus that causes COVID-19, a contagious respiratory illness) on December 19, 2025. Resident 50 tested positive for SARS-CoV-2 (the virus that causes COVID-19) on January 15, 2026. Resident 122 tested positive for SARS-CoV-2 (the virus that causes COVID-19) on March 3, 2026. During an interview on June 30, 2026, at 9:35 AM, the infection preventionist (IP) was unable to provide any documented evidence of facility tracking or analysis of healthcare-associated infections from November 1, 2025, through March 16, 2026. The IP was unable to provide documented evidence of HAI surveillance, including tracking and monitoring of Residents 50, 122, or 140's SARS-COVID-19 infections. There was no documented evidence of detailed data collection that could be used by the facility to track infections and to identify any potential trends contained in the tracking data from November 1, 2025, through March 16, 2026. There was no documented evidence at the time of the survey that, based on the available tracking data, the facility had identified any possible trends to implement specific interventions to prevent the spread of any of the infections during the above date range. There was no documented evidence from November 1, 2025, through March 16, 2026, that the facility was compiling data and evaluating the data to determine what could be done to prevent the spread or recurrence of infection. The facility failed to include the necessary details to conduct routine, ongoing, and systematic collection, analysis, interpretation, and dissemination of surveillance data to identify infections (i.e., healthcare-associated infections (HAIs) and community-acquired), infection risks, and communicable disease outbreaks and to maintain or improve resident health status and to track staff for adherence to infection control policies and procedures and the potential need for corrective action. During an interview on June 30, 2026, at 10:30 AM, the above information was reviewed with the nursing home administrator (NHA). The NHA was unable to provide documented evidence of healthcare-associated infection tracking, trending, or data analysis records from November 1, 2025, through March 16, 2026. The facility failed to maintain a comprehensive program to monitor the development and spread of infections within the facility, including tracking of infections for residents 50, 122, and 140.28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services.

Based on a review of clinical records, select facility policies, weight records, and staff and resident representative interviews, it was determined the facility failed to ensure residents maintain acceptable parameters of nutritional status to the extent possible for three of 27 residents reviewed (Residents 13, 106, and 9). Findings include: Review of the facility weight policy last reviewed on April 30, 2026, indicated that resident weights are obtained routinely to monitor parameters of nutrition. Each individual's weight will be determined upon admission or readmission to the facility, weekly for the first four weeks after admission or readmission, and monthly, or as needed. If there is a weight loss or weight gain of 5 or more pounds, a reweight will be obtained. If the weight change is accurate after the reweight, the physician, registered dietitian, and the resident's responsible party (or the resident if appropriate) will be notified. The resident's weight loss will be reviewed the following day in the clinical meeting with the interdisciplinary team. Review of a facility policy entitled Nutritional Assessment, last reviewed by the facility on April 30, 2026, revealed it is the facility's policy to conduct a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, for each resident. The registered dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition. As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. The policy indicated individualized care plans will be developed that address or minimize to the extent possible the resident's risk of nutritional complications. Review of Resident 13's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included dysphagia (difficulty swallowing) and hypertension (blood pressure that is higher than normal). Review of Resident 13's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 5, 2026, revealed that Resident 13 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates no cognitive impairment). Review of the resident's weight record revealed that on May 26, 2026, the resident weighed 131 pounds; on June 7, 2026, the resident weighed 130 pounds; and on June 10, 2026, the resident weighed 107.8 pounds. A weight warning note by the registered dietician dated June 13, 2026, recorded the last available weight as 107.8 pounds on June 10, 2026, and documented that the resident may have lost 22.2 pounds (17.1 percent) in three days. The note further indicated that the resident was consuming more than 50 percent of meals and taking Ensure (nutritional beverage supplement) twice daily, making it unlikely that the resident had lost such a large amount of weight in that short period. The registered dietitian recommended that nursing staff obtain a reweight. Clinical record review revealed no documented evidence that a reweight was obtained as recommended by the registered dietitian for Resident 13. Following surveyor inquiry, the resident was reweighed on June 28, 2026, and weighed 108 pounds. Further review of the clinical record revealed no documented evidence that the physician or resident was notified of the possible weight loss. Review of findings with the registered dietitian on June 29, 2026, at 1:30 PM confirmed that Resident 13's weight monitoring was not carried out according to the facility's Weight Policy. Clinical record review revealed Resident 106 was admitted to the facility on [DATE], with diagnoses including Parkinsonism (a term for a group of neurological disorders that cause movement-related problems, primarily slowed movements, muscle stiffness, and tremors), dementia (a decline in mental abilities, such as memory, reasoning, and communication, that is severe enough to interfere with daily life), and dysphagia (difficulty swallowing). Review of Resident 106's quarterly MDS dated [DATE], revealed Resident 106 was severely cognitively impaired with a BIMS score of 7 (a score of 0 through 7 indicates severe cognitive impairment). Review of Resident 106's care plan dated October 14, 2025, identified the resident was at risk for altered nutritional status. The care plan goal was for the resident to consume adequate nutritional intakes to maintain nutritional status without significant weight change. Planned interventions included monitoring, documenting, and reporting any signs or symptoms of dysphagia; providing adaptive equipment as ordered; providing a fortified mechanical soft chopped diet and nectar thickened liquids; providing oral nutrition supplementation as ordered; obtaining weights as ordered; and having the registered dietitian make recommendations as needed. During an interview on June 27, 2026, at 11:10 AM, Resident 106's spouse expressed concern regarding the resident's declining meal intake, stating, I noticed he's not eating as much, and it really concerns me. Review of Resident 106's weight record revealed the following: May 1, 2026: 168.2 poundsJune 1, 2026: 161.0 poundsJune 2, 2026: 161.0 pounds (re-weight, confirming a 7.2-pound weight loss in one month) According to facility policy, the confirmed weight loss of 5 or more pounds requires physician, registered dietitian, and responsible party notification as well as interdisciplinary team review. However, review of the clinical records revealed no documented evidence the facility notified the physician, registered dietitian, or Resident 106's responsible party of the confirmed 7.2-pound weight loss. There was also no documented evidence that the interdisciplinary team reviewed the resident's significant weight loss or evaluated the need for additional nutritional interventions. During an interview on June 30, 2026, at 9:24 AM, the registered dietitian confirmed the facility failed to identify Resident 106's significant weight loss. At the surveyor's request, staff obtained another weight on June 30, 2026, at 10:40 AM, which documented the resident's weight as 150.4 pounds, representing an additional 10.6-pound weight loss since the June 2, 2026, confirmed weight. There was no documented evidence that the facility recognized or acted upon Resident 106's weight loss identified on June 1, 2026, and confirmed by reweighing on June 2, 2026. There was no documented assessment to determine the cause of the continued weight loss, no evidence additional nutritional support or interventions were implemented to prevent further decline, and no evidence the physician, registered dietitian, and resident representative were informed as required by facility policy. Additionally, the facility failed to demonstrate ongoing monitoring of the resident's nutritional status and weight in accordance with its policies despite the resident's progressive neurological condition and known risk factors for nutritional decline. As a result, Resident 106 experienced continued significant weight loss from 168.2 pounds on May 1, 2026, to 150.4 pounds on June 30, 2026, a total loss of 17.8 pounds without documented timely evaluation or intervention. Clinical record review revealed Resident 9 was admitted to the facility on [DATE], with diagnoses that included severe protein malnutrition (a condition caused by a severe, prolonged deficiency of nutrients, primarily protein and calories) and dementia. Review of Resident 9's admission Minimum Data Set assessment (MDS,) dated May 21, 2026, revealed that Resident 9 had a BIMS score of 99 (a score of 99 indicates that the resident was unable to provide or did not provide answers to complete this section). The assessment indicated Resident 9 had short-term and long-term memory problem, and the ability to make decisions about tasks of daily life was severely impaired. Clinical record review revealed a care plan indicating Resident 9 was at risk for altered nutritional status initiated on May 19, 2026. Interventions implemented to ensure Resident 9 consumed adequate nutritional intakes to maintain nutritional status include providing a diet as ordered (fortified meals) and weighing the resident as ordered, initiated on May 19, 2026. Clinical record review of Resident 9's weights revealed the following: May 16, 2026: 98.0 poundsMay 30, 2026: 94.2 poundsJune 6, 2026: 94.2 pounds A progress note dated June 13, 2026, at 3:17 PM indicated Resident 9 refused weekly weight on this date. During an interview on June 28, 2026, at 1:30 PM, the Registered Dietician (RD) was unable to provide documented evidence that Resident 9 was weighed weekly in accordance with facility policy. The RD confirmed that Resident 9 was at risk for malnutrition and continued weight loss since admission. Clinical record review revealed, following inquiries made during the survey, Resident 9 was reweighed. Resident 9 weighed 98.0 pounds on May 16, 2026, and weighed 90.6 pounds on June 28, 2026, indicating a 7.4-pound, or 7.5%, significant weight loss in 43 days. Nutritional note dated June 29, 2026, at 10:44 AM revealed the resident had a body mass index (value derived from weight and height to screen for underweight. overweight or obesity) of 18.3 (underweight optimum range 18.5-24.9) and had significant weight loss over 30 days. New recommendations indicated to monitor weights weekly. Following inquiries made during the survey, physician's orders for Resident 9 to receive 4.0 ounce health shakes at meals were initiated on June 29, 2026. The facility failed to demonstrate ongoing monitoring of Resident 9's nutritional status and weight in accordance with its policies despite the resident's known risk factors for nutritional decline. As a result, Resident 9 experienced continued weight loss from 98.0 pounds on May 16, 2026, to 94.2 pounds on May 30, 2026, and to 90.6 pounds on June 28, 2026, a total loss of 7.4 pounds without documented timely evaluation or intervention. During an interview on June 30, 2026, at 10:30 AM, the above information was reviewed with the Nursing Home Administrator (NHA). The facility failed to ensure residents maintained acceptable parameters of nutritional status to the extent possible for residents 9, 13, and 106. The facility failed to timely identify, evaluate, and implement interventions for significant weight loss for Residents 9 and 106, resulting in continued weight loss without documented assessment or intervention. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to consistently provide restorative nursing services as planned to maintain mobility for one resident out of 27 residents reviewed (Resident 115).Findings include: Review of the facility's Restorative Nursing Programs Policy, last reviewed April 30, 2026, revealed that the facility will provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practical level. Further review of the policy revealed that all residents will receive maintenance nursing services as needed by certified nursing assistants. A review of the clinical record for Resident 115 revealed the resident was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (brain damage that results from a lack of blood) and hemiplegia (severe weakness or paralysis) and hemiparesis (loss of muscle function on one side of the body). A review of Resident 115's Quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated April 9, 2026, revealed the resident was severely cognitively impaired with a BIMS score of 02 (Brief Interview for Mental Status, a tool to assess the residents' attention, orientation, and ability to register and recall new information; a score of 0 through 7 indicates severe cognitive impairment). A review of the clinical record indicated that physical therapy services were provided to Resident 115 from March 22, 2025, through April 18, 2025. A review of the physical therapy Discharge summary dated [DATE], revealed physical therapy discharged the resident from skilled therapy services and recommended referral to the facility's Restorative Nursing Program (RNP) to maintain the resident's functional abilities. The discharge summary directed staff to provide range-of-motion exercises through all planes of movement, 10 repetitions for two sets, for approximately 15 minutes daily. A review of a physician's order dated September 29, 2025, directed staff to provide active-assisted (resident performs the movement with assistance from another person ) to passive range-of-motion (the movement is performed entirely by another person without assistance from the resident).exercises through all planes of movement, 10 repetitions for two sets, for approximately 15 minutes daily. A review of Resident 115's electronic task report (a summary of scheduled and completed resident-centered care tasks), Documentation Survey Report v2, and Medication Administration Record revealed no documented evidence that the restorative ambulation program had been implemented. An interview with the Director of Nursing on June 30, 2026, at 11:30 AM, confirmed the facility failed to consistently implement the planned restorative nursing program for Resident 115 as recommended by physical therapy to maintain the resident's functional abilities and deter declines to the extent possible and to ensure the resident's goals for ambulation were met. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa Code 211.12(c)(d)(5) Nursing services.

Based on a review of clinical records, select facility policy, payor source data, and resident and staff interviews, it was determined the facility failed to ensure timely and necessary dental services for one resident who is a Medicaid recipient (Resident 13) out of 27 residents reviewed.Findings include: Review of the facility's Dental Services policy, last reviewed April 30, 2026, indicated it is the policy of the facility to assist residents in obtaining routine and emergency ancillary services as needed. The policy defined routine dental services as annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs (x-ray) as needed, dental cleaning, and limited prosthodontic procedures such as taking impressions for dentures and fitting dentures. A review of Resident 13's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included dysphagia (difficulty swallowing) and hypertension (blood pressure that is higher than normal), and the resident's current payor source was Medicaid. A review of Resident 13's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 5, 2026, revealed that Resident 13 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates no cognitive impairment). During an interview on June 29, 2026, at 9:00 AM, the resident stated she has been waiting to receive dentures and did the impressions for them quite a while ago but has not heard any information about when she would receive her dentures and has not seen the dentist recently. Review of Resident 13's Dental Consult Sheet dated January 30, 2026, revealed the resident was seen by the dentist for a comprehensive exam, full mouth x-rays and took impressions and bite registration for complete upper and lower dentures. Review of Resident 13's Dental Consult Sheet dated March 30, 2026, revealed the resident was not seen because the resident was out of the facility in the hospital. Review of the clinical record revealed no further communication with the dentist regarding obtaining Resident 13's dentures, and the resident has not been seen by the dentist since impressions were obtained to receive dentures in January 2026. During an interview with the Director of Nursing on June 29, 2026, at 1:15 PM, the above findings were reviewed regarding the facility's failure to provide prompt dental services, as indicated in the facility policy. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa Code 211.12 (c)(d)(3)(5) Nursing services.

Based on a review of clinical records, facility policies, observations, and resident and staff interviews, it was determined the facility failed to consistently implement and enforce its smoking policy for one of three residents who smoked (Resident 88).Findings include: A review of the facility's smoking policy, reviewed April 30, 2026, revealed that the facility does not allow smoking on the premises. Residents who are alert and oriented and able to leave the facility independently may smoke only while off the property on an approved leave of absence. The policy required that cigarettes, lighters, and other smoking materials be maintained by facility staff. Residents were not permitted to keep smoking materials on their person or in their rooms. Review of an Out on Pass/Going off Grounds document acknowledged by the resident on June 1, 2026, indicated that the Out on Pass leave of absence were permitted between 5:00 AM and 9:00 PM. A review of the clinical record revealed Resident 88 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD a chronic lung disease that restricts airflow and makes breathing difficult). A review of Resident 88's significant change Minimum Data Set assessment (MDS), a federally mandated standardized assessment process conducted periodically to plan resident care, dated May 3, 2026, revealed that Resident 88 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates intact cognition). A review of the clinical record revealed a physician's order dated May 28, 2026, authorizing Resident 88 to leave the facility independently on a leave of absence. Documentation revealed the resident signed the Out on Pass/Going Off Grounds acknowledgment on June 1, 2026. During an interview on June 28, 2026, at 11:00 AM, Resident 88 stated that after receiving the physician's order dated May 28, 2026, authorizing independent leaves of absence to smoke off the facility premises, and before signing the Out on Pass/Going Off Grounds acknowledgment on June 1, 2026, he routinely retained smoking materials, including a pack of cigarettes and a lighter, on his person while inside the facility. The resident stated staff did not request that he surrender the smoking materials, despite the facility's smoking policy requiring staff to retain residents' cigarettes and lighters. The resident further stated he was able to leave the facility to smoke without staff consistently enforcing the facility's established leave-of-absence hours. During an interview and observation on June 29, 2026, at 11:00 AM, Resident 88 showed the surveyor a pack of cigarettes and a lighter stored beneath the seat of his walker. The resident stated that upon returning to the facility from a leave of absence the previous evening, no staff member was present at the reception desk to receive his smoking materials; therefore, he placed the cigarettes on the desk with his name attached. The resident stated the facility did not establish designated hours for independent leaves of absence until June 1, 2026, and that staff did not explain the reason for the change. The resident further stated staff had recently begun requesting that smoking materials be surrendered; however, prior to that time, staff had not consistently requested that he turn in his cigarettes and lighter or asked whether he possessed smoking materials when leaving or returning to the facility. The resident stated the requirement to surrender smoking materials had not been consistently enforced. During an interview on June 30, 2026, the Nursing Home Administrator was unable to provide evidence demonstrating that staff consistently implemented the facility's smoking policy by collecting residents' smoking materials, ensuring residents did not retain cigarettes or lighters while inside the facility, or consistently enforcing the established leave-of-absence procedures for residents who smoked. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services

Based on review of clinical records. select facility policy, observations, and staff interviews, it was determined that the facility failed to make reasonable accommodations to meet one resident's assessed need for assistive positioning devices while seated in a wheelchair, for one of 27 residents reviewed (Resident 12). Findings include: Review of the facility policy titled Positioning last reviewed by the facility on April 30, 2026, revealed residents will be screened for positioning needs by Occupational Therapy or Physical Therapy. The policy indicated a positioning evaluation will be completed and included in the medical record. Treatment is to focus on providing necessary equipment and implementing a 24-hour positioning plan. The policy further required documentation of positioning recommendations, the 24-hour positioning plan, and education provided to the resident, family, or caregivers Review of clinical records revealed Resident 12 was admitted to the facility on [DATE], with diagnoses to include adult failure to thrive (a syndrome of physical, cognitive and functional decline affecting older adults with multiple chronic illnesses), bipolar disorder (mental health condition that causes extreme, cyclical shifts in mood, energy, activity levels, and concentration), and post-traumatic stress disorder (a mental health condition that can develop in individuals who have experienced or witnessed a shocking, terrifying, or life-threatening event. These individuals continue to experience severe distress, fear, and stress long after the traumatic event has ended). A review of Resident 12's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 7, 2026, revealed Resident 12 was moderately cognitively impaired with a BIMS score of 9 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8 through 12 indicates moderate cognitive impairment). The assessment also indicated the resident required total staff assistance with transfers. Observation on June 28, 2026, at 12:40 PM revealed Resident 12 seated in a high-back wheelchair (high backrest used for additional support for head, neck and shoulders) with both legs and feet dangling 16-18 inches above the floor without support. Review of the clinical record revealed Resident 12 had a documented height of 55 inches tall (4 feet 5 inches), reflecting the resident's shorter stature. Review of an Occupational Therapy treatment note dated April 22, 2026, revealed Occupational Therapy completed a wheelchair analysis to evaluate the resident's body alignment and functional positioning. The evaluation documented that the resident was provided a new high-back wheelchair with bilateral leg rests with a foot/calf board (a solid, padded panel that attaches to the front of a wheelchair to support the lower legs and feet) to provide increased bilateral lower extremity (leg) support. Review of the Occupational Therapy Discharge summary dated [DATE], indicated Resident 12 achieved the long-term goal of maintaining an upright seated posture for six hours using adaptive equipment and/or devices. However, the discharge summary failed to identify the specific adaptive equipment and positioning devices required to achieve and maintain that goal. A second observation conducted on June 29, 2026, at 1:00 PM revealed Resident 12 sitting in the dining room in the same high-back wheelchair with both legs unsupported and dangling 16-18 inches above the floor. Employee 3 (Certified Occupational Therapy Assistant) observed the resident's positioning and confirmed the wheelchair was missing the legs rests and foot/calf board. Employee 3 also confirmed the positioning devices were not present in the resident's room. During an interview on June 29, 2026, at 1:15 PM the Director of Rehab (DOR) stated Occupational Therapy evaluated Resident 12's seating and positioning needs and provided the resident with a high-back wheelchair, bilateral leg rests, and foot/calf board because the resident's feet were unable to touch the floor. The DOR stated a shorter wheelchair was not trialed because it would prevent the resident from reaching the dining room table during meals. The DOR provided a Staff Education Report dated May 21, 2026, documenting Occupational Therapy educated two staff members regarding Resident 12's positioning needs and use of the high-back wheelchair with leg rests and foot/calf board for optimal positioning. Despite Occupational Therapy identifying the resident's need for the leg rests and foot/calf board and providing staff education regarding their use, the DOR confirmed there was no documented evidence these positioning devices were incorporated into the resident's care plan, physician orders, or Kardex system (a nursing information system used to obtain up-to-date specific care information for each resident) to ensure all staff consistently provided the necessary equipment. The facility failed to communicate and implement the resident's assessed need across disciplines, resulting in staff not consistently accommodating the resident's identified positioning needs while out of bed. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on a review of clinical records, select facility policy, observations, and staff interviews, it was determined the facility failed to consistently implement planned safety interventions for one resident (Resident 61) and failed to prevent unsecured medications from being at bedside, creating a potential accident hazard, for one resident (Resident 115) out of 27 residents reviewed. Findings include: Review of the facility's policy entitled Elopements and Wandering Resident, last reviewed April 30, 2026, revealed it is the policy to ensure that residents who exhibit wandering behavior and are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person centered plan of care addressing the unique factors contributing to wandering or elopement risk. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary team and monitor the implementation of interventions, respond to interventions, and document accordingly. A review of the clinical record revealed that Resident 61 was admitted to the facility on [DATE], with diagnoses that included anxiety disorder (a condition in which excessive worry cause clinically significant distress or impairment in social, occupational, or other areas of functioning) and depression (a mental health condition characterized by low mood or loss of pleasure or interest in activities for long periods of time). A review of Resident 61's Quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 10, 2026, revealed that Resident 61 had moderately impaired cognition with a BIMS score of 9 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8 through 12 indicates moderate cognitive impairment). A review of Resident 61's comprehensive care plan, initiated January 19, 2024, revealed the resident was an elopement risk and wander risk with interventions of a Wander Guard bracelet (an electronic monitoring device used to alert staff when a resident at risk for wandering or elopement approaches an exit) worn on the left ankle. A physician order dated March 4, 2024, directed staff to maintain a Wander Guard bracelet on the resident's left ankle and required staff to verify placement and proper functioning every shift. A review of an elopement risk assessment completed on May 21, 2024, identified Resident 61 as being at moderate risk for elopement. A review of the June 2026 Task Administration Record (TAR) revealed staff consistently documented that Resident 61 was wearing a Wander Guard device on the left ankle. However, direct observation conducted on June 27, 2026, at 11:45 PM revealed no Wander Guard device present on the resident's left ankle or any other extremity. Employee 2, Licensed Practical Nurse (LPN), confirmed the absence of the device during the observation and was unable to locate the Wander Guard within the resident's room. During an interview on June 28, 2026, at 1:30 PM, the Director of Nursing reviewed the above findings and confirmed the facility failed to consistently implement and monitor Resident 61's planned elopement prevention interventions, including maintenance and presence of the Wander guard device. Review of the facility's Medication Storage Policy, last reviewed April 30, 2026, revealed the facility will ensure all medication that are contained on the premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. A review of the clinical record for Resident 115 revealed the resident was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (brain damage that results from a lack of blood) and hemiplegia and hemiparesis (severe weakness or paralysis loss of muscle function) on one side of the body). A review of Resident 115's Quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated April 9, 2026, revealed the resident was severely cognitively impaired with a BIMS score of 02 (Brief Interview for Mental Status, a tool to assess the residents' attention, orientation, and ability to register and recall new information; a score of 0 through 7 indicates severe cognitive impairment). An observation conducted on June 27, 2026, at 11:00 AM revealed a clear plastic disposable drinking cup that had a white paste in it and a disposable spoon, which was present on the nightstand table next to the resident's bed. During an interview on June 27, 2026, at 11:30 AM, Employee 4, Nurse Aide, stated that the cream was a mixture of zinc oxide and A and D ointment (both are topical skin protectants used to prevent and treat minor skin irritation and not for consumption) and was at the bedside for the nurse aides to use as needed during incontinence care. A clinical record review during the survey ending on June 30, 2026, revealed that Resident 115 did not have an order for either cream. During an interview on June 28, 2026, at 1:00 PM, the Director of Nursing was informed of and reviewed the above findings related to nursing staff leaving medicated creams and ointments at residents' bedsides and confirmed that staff should not leave medicated cream at the bedside. 28 Pa. Code 201.18 (b) (1) Management. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d) (1) (3) (5) Nursing services.

Based on clinical records and select policy reviews, observations, and staff interviews, it was determined the facility failed to provide oxygen equipment in accordance with physician orders for one of 27 sampled residents (Resident 7).Findings include: Review of the facility's oxygen administration and tracheostomy care policies, reviewed April 30, 2026, revealed that oxygen will be administered under the orders of a physician. The facility will provide necessary respiratory care and services, such as oxygen therapy, treatments, mechanical ventilation, tracheostomy care, and suctioning. Based on resident assessment, attending physician orders, and professional standards of practice, the facility, in collaboration with the resident or resident's representatives, will develop a care plan that includes appropriate interventions for respiratory care. Clinical record review revealed that Resident 7 had diagnoses that included respiratory failure and tracheostomy (a surgically created opening in the front of the neck into the windpipe to create an airway with a tube placed in this opening to keep it open for breathing). A review of Resident 7's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 8, 2026, revealed that Resident 7 had moderate cognitive impairment with a BIMS score of 12 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8 through 12 indicates moderate cognitive impairment). Review of current physician orders revealed the resident required supplemental oxygen at 6 liters per minute and that the amount of oxygen was to be titrated (increased or decreased) to maintain oxygen saturations (the percentage of red blood cells in the blood carrying oxygen, with normal levels for healthy individuals being 95 to 100%) greater than 92%. This was to be measured in the facility utilizing a pulse oximeter (a device that can be attached to the finger or toe to measure the percentage of blood saturation). Observation of the resident's oxygen administration device on June 28, 2026, at 10:30 AM and June 29, 2026, at 11:00 AM revealed the facility's current oxygen setup was not designed so that the resident's oxygen could be titrated, as it required a fixed oxygen flow rate. Closer inspection of the fixed rate of the oxygen device indicated that a flow rate of 8 liters per minute was to be utilized with this device; however, the oxygen flow rate set by the facility was at 6 liters per minute and did not correlate with the appliance chosen. It was not until surveyor notification that the physician was contacted and adjustments were implemented so the oxygen device correlated with physician orders and resident needs. An interview with the Nursing Home Administrator on June 30, 2026, at 9:00 AM revealed that the facility contacted the physician and consulted with a respiratory therapist to modify the oxygen setup to correlate with physician orders. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records, facility policy, and resident and staff interviews, it was determined the facility failed to comprehensively monitor and implement appropriate interventions for new onset and worsening pain in accordance with physician orders and facility policy for one of 27 residents reviewed (Resident 105).Findings include: Review of the facility's Pain Assessment and Management policy, last reviewed April 30, 2026, revealed the purpose of the policy is to ensure that pain management is provided to residents who require such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The policy indicated the facility will reassess residents' pain management at established intervals for effectiveness. If re-assessment findings indicate pain is not adequately controlled, the pain management regimen and plan of care will be revised as indicated. Clinical record review revealed Resident 105 was admitted to the facility on [DATE], with diagnoses that included acute respiratory failure (a condition where the lungs fail to adequately oxygenate the blood or remove carbon dioxide, leading to insufficient oxygen to meet the body's needs) and chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe). Review of Resident 105's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 3, 2026, revealed that Resident 105 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact). A physician's order for acetaminophen 325 milligram (mg) tablets, initiated on June 2, 2026, directed staff to administer 650 mg by mouth every six hours as needed for a pain level of 1 through 5, based on a standard 0 to 10 pain rating scale, where 0 indicates no pain and 10 indicates the worst pain imaginable. A nursing progress note dated June 10, 2026, revealed that at approximately 4:30 AM the resident activated the call bell and was observed halfway off the bed while attempting to transfer to a wheelchair. The resident stated she struck her ankle on the wheelchair while attempting to go to the bathroom. The resident was able to move the foot and ankle and wiggle the toes. The resident reported pain rated as 10 out of 10 on the standard pain scale, indicating the worst pain imaginable. Staff applied ice, elevated the foot, and notified the nursing supervisor. At 5:40 AM, the resident reported the pain continued and radiated (spread) up the leg and requested acetaminophen. Review of a medication administration record (MAR) dated June 2026 revealed Resident 105 was administered acetaminophen 650 mg for a pain level 10 on June 10, 2026. The MAR indicated on June 10, 2026, at 5:26 AM that the acetaminophen 650 mg was ineffective for treating Resident 105's pain. Review of Resident 105's vital signs in the electronic health record pain level tab revealed the following recordings of pain on June 10, 2026: 4:30 AM 8 out of 105:26 AM 10 out of 106:50 AM 10 out of 10 A late-entry progress note dated June 10, 2026, at 9:00 AM (entered into the clinical record on June 14, 2026, at 2:54 AM) documented that Resident 105 was assessed at the bedside for complaints of left ankle pain. The note documented that the resident reported pain and difficulty walking on the left ankle. The assessment identified bruising and swelling of the left ankle. The assessment and plan documented left ankle pain and included orders for a left ankle X-ray, physical therapy and occupational therapy as needed, orthopedic follow-up as needed, acetaminophen, baclofen (a medication used to relieve muscle spasms), and continued monitoring. A physician's order dated June 10, 2026, at 9:30 AM directed staff to obtain an X-ray of Resident 105's left ankle for complaints of pain. A review of the Pain Evaluation assessment dated [DATE], at 9:33 AM (entered into the clinical record on June 12, 2026, at 12:35 PM) documented that Resident 105 rated the left ankle pain as 8 out of 10 on a standard pain scale. The assessment documented that the resident reported the pain hurts even more and identified ice, elevation, and acetaminophen as measures that relieved the pain. A review of the mobile radiology report revealed that Resident 105 underwent a left ankle X-ray on June 10, 2026, at 4:51 PM. The report, issued on June 10, 2026, at 7:06 PM identified an acute nondisplaced [NAME] Type C fracture (a recent ankle fracture located above the ligaments that stabilize the two lower leg bones, with the broken bone remaining in its normal position). A nursing progress note dated June 10, 2026, at 11:46 PM documented that three emergency medical services personnel transferred Resident 105 to the local emergency department for evaluation and treatment of the left ankle fracture. The note further documented that, at the time of transfer, the resident continued to report left ankle pain rated as 8 out of 10. A review of the emergency department after-visit summary dated June 10, 2026, documented that the resident sustained a closed fracture of the left fibula (the smaller bone of the lower leg). The emergency department applied a splint and administered hydrocodone-acetaminophen 5 mg/325 mg (a combination opioid and non-opioid pain medication). During a telephone interview conducted by the surveyor on June 29, 2026, at 12:30 PM Resident 105 stated that she fell while walking to the bathroom at approximately 4:30 AM on June 10, 2026. The resident stated that she struck her ankle against a wheelchair, fell to the floor, and staff assisted her back to bed and administered acetaminophen. The resident stated that she remained in severe pain until she was transferred to the hospital at approximately 11:30 PM. The resident further stated she was frustrated because she believed her pain was not adequately addressed while she waited for the X-ray results and transfer to the hospital. During an interview on June 29, 2026, at 1:55 PM, Employee 1, Registered Nurse Supervisor (RNS), stated that at approximately 11:00 PM on June 10, 2026, she contacted the mobile radiology provider to obtain the results of Resident 105's ankle X-ray. Employee 1 stated that the radiology provider acknowledged a delay in reporting the results. Employee 1 stated that, after receiving the report confirming a fracture, she notified the on-call physician, informed the resident of the results, and initiated transfer to the emergency department. During an interview on June 30, 2026, at 10:30 a.m., the above findings were reviewed with the Nursing Home Administrator (NHA). The NHA was unable to provide documented evidence demonstrating that the facility performed ongoing assessments of Resident 105's pain or implemented additional pain management interventions between the resident's injury at approximately 4:30 AM on June 10, 2026, and the transfer to the emergency department at approximately 11:46 PM that same day, after the fracture was confirmed. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on review of clinical records, select facility policy review, and staff interview, it was determined the facility failed to ensure a resident was free from a chemical restraint and failed to ensure non-pharmacological interventions were attempted and documented prior to administration of a psychotropic medication for one of 10 residents reviewed (Resident CR1). Findings include: A review of the facility policy titled Use of Psychotropic Medication, last reviewed by the facility on February 24, 2026, revealed it is the facility policy to ensure residents do not receive psychotropic medication (medications that affect the chemical makeup of the brain and nervous system, altering mood, cognition, and perception) that are not clinically indicated and necessary to treat a specific condition documented in the medical record. The policy also indicated that behavioral and other non-pharmacological approaches (non-medication approaches used to manage symptoms or behaviors, such as environmental, behavioral, or comfort measures) are used to minimize or eradicate the need for medications, permit the lowest possible dose if indicated, and support efforts at gradual dose reduction. The policy indicated psychotropic medication may be considered appropriate when non-pharmacological approaches have been attempted and documented as ineffective in relieving symptoms causing significant distress or presenting safety concerns. The clinical record review revealed Resident CR1 was admitted to the facility on [DATE], with diagnoses to include Alzheimer's disease (a progressive, fatal neurological disorder and the most common cause of dementia, characterized by memory loss, cognitive decline, and behavioral changes due to brain cell death) and dementia (a progressive syndrome caused by abnormal brain changes that damage cells and impair memory, thinking, behavior, and daily functioning). A review of Resident CR1's Medicare 5 day Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 20, 2026, revealed that Resident CR1 was moderately cognitively impaired with a BIMS score of 08 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 08 to 12 indicates moderate cognitive impairment). Review of the comprehensive care plan revealed a focus area identifying Resident CR1 as being at high risk for elopement (leaving the facility unsafely or without staff knowledge) related to exit-seeking behaviors. Interventions included reorientation to surroundings, frequent monitoring of the resident's location, encouraging participation in structured activities, providing diversion activities, redirecting the resident away from exits, and providing the resident with diversional activities to reduce exit seeking behaviors. A review of physician orders revealed Resident CR1 prescribed the following medications on the resident's date of admission March 14, 2026: Divalproex 125mg capsules (a medication affecting brain chemistry sometimes used off label to manage behavioral symptoms associated with dementia). Ordered dose: 250 mg by mouth every morning and at bedtime related to dementia with other behavioral disturbance. Donepezil 10mg tablets (a medication used to treat symptoms of dementia by supporting cognitive function). Ordered dose: one tablet by mouth at bedtime. Memantine 10mg tablets (a medication used to treat moderate to severe dementia by regulating brain signaling). Ordered dose: one tablet by mouth every 12 hours. A review of CR1's progress notes revealed a physician progress note dated March 16, 2026, at 1:40 PM indicating resident CR1 was adjusting well since admission with no acute issues identified. Review of physician orders dated March 16, 2026, at 12:15 PM revealed an order for Quetiapine Fumarate 25 mg tablets (an antipsychotic medication used to affect mood and behavior), to be administered every 12 hours as needed (PRN, administered when symptoms occur rather than on a routine schedule) for agitation. Review of the March 2026 Medication Administration Record (MAR) revealed Resident CR1 received PRN quetiapine on March 16, 2026, at 8:09 PM. The clinical record failed to document symptoms of agitation requiring medication use and did not include documentation of non-pharmacological interventions attempted prior to administration. Progress notes revealed the following:On March 17, 2026, at 2:48 PM, Resident CR1 was documented attempting to open the facility front door. Family was contacted, and the resident was moved to another unit in an attempt to reduce elopement risk. On March 18, 2026, at 6:51 AM, Resident CR1 was documented as awake all night with agitation and exit-seeking behaviors. Documentation indicated redirection (guiding the resident away from exits or concerning behavior using verbal reassurance or engagement) was effective. On March 19, 2026, at 1:19 PM, Resident CR1 was documented attempting to open a dining room window and expressing a desire to go home with her husband. Documentation indicated staff contacted the resident's husband, after speaking with her husband, the resident became calmer and consumed lunch. On March 20, 2026, at 2:03 PM, Resident CR1 was administered PRN quetiapine after documentation indicated the resident was upset, refusing lunch, searching for her husband, and attempting to pull the fire alarm. Documentation indicated redirection was not effective prior to administration. On March 20, 2026, at 2:54 PM, follow-up documentation indicated the resident was resting quietly in her wheelchair and appeared calm and relaxed. On March 22, 2026, at 8:54 PM, documentation indicated Resident CR1 slept most of the shift, did not eat dinner, and was difficult to arouse. When the nurse aide attempted to wake the resident, CR1 would open 1 eye and roll over back to sleep. The note indicated the resident had been awake most of the previous night and crashed during the day. The note documented the resident's dinner tray would be held for later. On March 23, 2026, at 10:38 AM, Resident CR1 received PRN quetiapine for anxiety and agitation related to searching for her husband and attempting to leave the unit to find him. Documentation did not include evidence of non-pharmacological interventions attempted prior to administration. A physician progress note on March 23, 2026, at 7:25 PM documented CR1 was evaluated for dementia. The note documented that resident CR1 was recently agitated and searching for her husband. The note indicated the resident was exhibiting restlessness and confusion, but no aggressive behaviors were reported. The note documented the resident remained redirectable with staff support. The note documented physician recommendations to continue non-pharmacological interventions such as reorientation, reassurance, structured routine, and to provide a calm environment for CR1 and provide redirection as needed. The note documented to monitor resident CR1 for escalation of agitation or safety concerns and to notify the provider immediately of any increase or change in behavior. A progress note on March 24, 2026, at 10:02AM documented that Resident CR1 received PRN quetiapine; however, the clinical record did not document behaviors requiring medication, non-pharmacological interventions attempted, or clinical justification for administration. Review of the clinical record failed to demonstrate the facility defined Resident CR1's behavioral expressions of anxiety, agitation, or aggression in observable and measurable terms to guide staff in determining when administration of quetiapine was clinically indicated. Without clearly defined parameters, staff lacked objective criteria to support consistent and appropriate decision-making regarding PRN psychotropic medication used to ensure the medication was administered appropriately and consistently. Review of Resident CR1's clinical record revealed no documented evidence non-pharmacological interventions were attempted and found ineffective prior to administration of quetiapine for two of four administrations reviewed. During an interview conducted April 15, 2026, at 11:50 AM, the above findings were reviewed with the Director of Nursing. The Director of Nursing was unable to provide documented evidence demonstrating non-pharmacological interventions were consistently attempted prior to administration of PRN quetiapine for 50 percent of administrations reviewed. The Director of Nursing was also unable to provide documentation demonstrating the facility defined Resident CR1's specific behavioral symptoms in measurable terms to guide staff in determining when administration of quetiapine was clinically indicated. During an interview conducted April 15, 2026, at 11:50 AM, the above findings were reviewed with the Director of Nursing. The facility did not provide documentation showing that non-pharmacological interventions were attempted prior to two of four administrations of PRN quetiapine and did not provide documentation identifying the specific behaviors indicating when use of the medication was appropriate. The clinical record did not demonstrate consistent implementation of individualized non-pharmacological interventions or sufficient documentation supporting the clinical need for each PRN administration of the antipsychotic medication. 28 Pa. Code 211.2(3) Medical director. 28 Pa. Code 211.5(ii)(xi) Clinical records. 28 Pa. Code 211.8(e) Use of restraints. 28 Pa. Code 211.9(1) Pharmacy services. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(5) Nursing services.

Based on a review of select facility policies, clinical record review, and staff and resident interviews, it was determined that the facility failed to promptly notify a resident's designated representative and power of attorney of a significant change in the resident's condition and new treatment orders, for one resident out of eight sampled (Resident 1). Findings include: A review of the facility's policy Change in a Resident's Condition or Status last reviewed by the facility July 2025, indicated the facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and /or status. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status. Except in emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD, an ongoing lung condition caused by damage to the lungs that results in swelling and irritation, also called inflammation, inside the airways that limit airflow into and out of the lungs, making it difficult to breathe) and acute bronchitis (also known as a chest cold, is short-term inflammation of the bronchi (large and medium-sized airways) of the lungs and the most common symptom is a cough). The resident's clinical record identified a POA (power of attorney, a legal authorization that allows someone to make decisions or take actions on behalf of another person in financial, legal, or medical matters) and designated representative for emergency contact. A review of a quarterly Minimum Data Set assessment (MDS, a standardized assessment completed at specific intervals to plan care) dated October 17, 2025, indicated the resident had a BIMS score of 15 (Brief Interview for Mental Status, a tool used to assess the resident's attention, orientation, and the ability to register and recall new information. A score of 13-15 indications intact cognition). A review of the resident's clinical record revealed a physician/CRNP note completed by the facility's certified nurse practitioner on November 17, 2025, at 1:43 PM, documented an evaluation was completed due to Resident 1 coughing for two days and looked very tired. The documentation indicated a negative COVID-19 test and recorded vital signs, including oxygen saturation of 91 percent on room air. The assessment included acute cough with hypoxia (lower than normal oxygen levels in the blood), and new treatment orders were initiated, including a chest x-ray, supplemental oxygen via nasal cannula at two liters for oxygen saturation less than 93 percent, Mucinex 600 mg by mouth twice daily for seven days, albuterol as needed, and continued monitoring with instructions to notify the provider if symptoms worsened. The care plan was noted as discussed with nursing staff. Further review of Resident 1's clinical record failed to reveal documentation that the resident's responsible party or POA was notified of the resident's change in condition and the newly initiated treatment orders related to respiratory status. During an interview with Resident A1 on December 29, 2025, at 10:55 AM, the resident stated that his daughter was his responsible party and power of attorney and expressed that he wanted the facility to notify her of changes to his care. During an interview with the Nursing Home Administrator on December 29, 2025, at 11:02 AM, the above findings were reviewed. The Nursing Home Administrator confirmed that the facility was unable to provide documented evidence that Resident 1's responsible party or power of attorney was notified of the resident's change in condition and corresponding changes to the care plan, as required by facility policy. 28 Pa Code 211.10 (c) Resident care policies 28 Pa Code 211.12 (c)(d)(3)(5) Nursing services

Based on clinical record review, review of facility policy, and staff interviews, it was determined that the facility failed to follow its own policies and procedures for monitoring nutritional status, obtaining weights, completing reweights, and ensuring timely notification of significant weight changes for six of ten sampled residents (Residents 16, 18, 21, 97, 107, and 119). Findings include: A review of the facility's Nutritional Assessment Policy last reviewed August 7, 2025, indicated that as part of the comprehensive assessment, a nutritional assessment, including nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by change in condition that place the resident at risk for impaired nutrition. The nutritional assessment will be conducted by the interdisciplinary team and identify components which include Nursing: current height and weight, a description of the resident's usual intake and appetite, a history of reduced appetite or progressive weight loss or gain prior to admission, a description of the resident's overall appearance, Physician: current clinical conditions and recent events that may have affected a resident's nutritional status and risk factors, current laboratory results related to fluid and electrolyte status, and the presence of chewing or swallowing abnormalities, and Dietitian: an estimate of calorie, protein, and fluid needs, whether the resident's current intake is adequate to meet his or her nutritional needs, and special food formulations. A review of the facility Weight Policy last reviewed August 7, 2025, indicated the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for residents. Nursing staff will measure resident weights on admission and the next day, weekly for four weeks then monthly thereafter. Obtain weights as needed based on acuity. Weights will be recorded in the resident's medical record. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian. The dietitian will review individual weight trends over time. Negative trends will be evaluated by the treatment team whether the criteria for significant weight change have been met. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: 1 month 5% weight loss is significant; 3 months 7.5% weight loss is significant; 6 months 10% weight loss is significant. Clinical record review noted Resident 16 was admitted to the facility on [DATE], with diagnoses which included but not limited to Alzheimer's disease, unspecified (a condition that slowly affects how a person thinks, remembers, and acts), Muscle wasting and atrophy (muscles become smaller and weaker over time). Clinical record review of the nutrition notes dated March 11, 2025, reported a weight of 113 lbs. and confirmed Resident 16 experienced a significant loss of 9.0 lbs. (7.4%) in 30 days, significant loss of 12.0 lbs. (9.6%) in 90 days, and a non-significant loss of 5.0 lbs. (4.2%) in 180 days. Ensure (commercially prepared nutritional beverage) was then recommended on March 11, 2025, to address the weight loss. There was no documented evidence that Resident 16's resident representative and provider was notified. Further review of the nutrition note, dated April 25, 2025, documented the resident's weight as 109 pounds and confirmed that the resident continued to experience weight loss of 6.2% in approximately 50 days and 7.5% in 90 days. There was no documented evidence in the clinical record that further nutritional interventions were initiated at that time, or that the resident's physician or resident representative was notified of the changes. A progress note dated May 9, 2025, documented a change in nutritional supplements, discontinuing Ensure (a commercially prepared nutritional beverage) and substituting double desserts, citing the resident's lack of tolerance and acceptance of Ensure. The clinical record contained no documented evidence that the resident's weight trend or response to this intervention was evaluated in accordance with facility policy. Review of the nutrition note, dated June 20, 2025, documented the resident's weight at 108.2 pounds and showed a cumulative weight loss of 16.8 pounds (13.4%) in 180 days. There was no documented evidence that the resident's physician or representative was notified of this significant weight loss, nor was there evidence that the required reweight was obtained to confirm accuracy or prompt reassessment of nutritional interventions. Clinical record review revealed that Resident 18 was admitted to the facility on [DATE], with diagnoses to include hemiplegia (paralysis on one side of the body) and muscle wasting and atrophy (thinning of muscle mass) and was dependent on tube feedings for nutrition. The resident was weighed on admission and the following day; however, no weekly weights were obtained for the next four weeks as required by facility policy. Records showed that the last documented weight was July 4, 2025, with no further weights until August 13, 2025, after surveyor inquiry. Resident 18 was weighed on August 13, 2025, and weighed 138 lbs. Interview with the registered dietitian on August 14, 2025, at 10:00 AM confirmed that Resident 18's weight monitoring was not completed as per facility policy. Clinical record review revealed that Resident 21 was admitted to the facility on [DATE], with diagnoses including dementia (a condition marked by loss of memory, reasoning, and thinking severe enough to interfere with daily life). On admission, the resident's weight was documented at 123 pounds.Review of the resident's weight record showed no documented evidence that weekly weights were obtained for four weeks following admission, as required by the facility's Weight Policy. Further review of the clinical record revealed that the resident was transferred to the hospital on July 17, 2025, and readmitted to the facility on [DATE]. A subsequent weight, documented on July 29, 2025 (six days after readmission), showed the resident weighed 107 pounds. This represented a 16-pound (13%) weight loss since June 13, 2025, which meets the facility's definition of significant weight loss. There was no documented evidence that a required reweight was obtained to confirm this loss. As of surveyor review on August 14, 2025, there was no documented evidence that further weights were obtained, despite the documented weight loss and facility policy requiring weekly weights for four weeks upon admission or readmission. A dietitian note dated July 24, 2025, recorded the last available weight as 123 pounds and recommended that nursing staff obtain a current weight. A dietitian weight warning note dated August 1, 2025, documented that the resident may have lost 16 pounds (13%) in approximately 45 days. The note further indicated the resident was consuming more than 75% of meals and taking Ensure (nutritional beverage supplement) twice daily with fair acceptance, making it unlikely that the resident had lost such a large amount of weight in that short period. The note directed staff to obtain a reweight and provide additional dessert as an intervention. Further review of the clinical record revealed no documented evidence that the physician or resident representative was notified of the possible weight loss, and no documented evidence that the recommended reweight was obtained as directed by the dietitian. Review of findings with the registered dietitian on August 14, 2025, confirmed that Resident 21's weight monitoring was not carried out according to the facility's Weight Policy. Clinical record review revealed that Resident 97 was admitted to the facility on [DATE], with diagnoses including moderate protein-calorie malnutrition (an imbalance between the nutrients needed by the body and the nutrients actually consumed). Further review of the resident's weight record showed that the resident weighed 118 pounds on June 6, 2025, and 110 pounds on July 2, 2025, reflecting an 8 pound loss (6.7%) in 30 days. An unplanned weight loss greater than 5% in 30 days meets the facility's definition of significant weight loss. A dietitian weight warning note dated July 3, 2025, acknowledged the 8 pound (6.7%) weight loss in approximately 30 days. The note further documented that the resident was consuming more than 75% of meals with a fair intake of Ensure (a commercially prepared nutritional beverage) and health shakes twice daily. The dietitian recorded that it was unlikely the resident had lost such a large amount of weight in that short timeframe and suggested that the June weight was likely an error. The note recommended continued monitoring of weights and laboratory values. Despite this recommendation, there was no documented evidence that weekly weights were obtained for four weeks as required by the facility's Weight Policy. Further review of the clinical record revealed no documented evidence that the resident's physician or representative was notified of the significant weight loss, as required by facility policy. Clinical record review revealed that Resident 107 was admitted to the facility on [DATE], with diagnoses including diabetes and dysphagia (difficulty swallowing). A nutritional assessment dated [DATE], documented that the resident's hospital weight prior to admission was 157 pounds. The assessment also recorded a history of significant weight loss of 13 pounds, or 7.6%, in three months as noted in the hospital record. Review of the resident's weight record revealed that on August 13, 2025, fourteen days after admission, the resident's weight was documented as 150 pounds. This represented a continued weight loss. There was no documented evidence that weights were obtained in a timely manner following admission, as required by the facility's Weight Policy. Review of findings with the registered dietitian on August 14, 2025, confirmed that Resident 107's weight monitoring was not completed in accordance with facility policy. Clinical record review revealed that Resident 119 was admitted to the facility on [DATE], with diagnoses including cerebral infarction (brain damage caused by lack of blood supply to the brain) and dependence on tube feedings for nutrition. Review of the resident's weight record showed that on May 16, 2025, the resident weighed 302.4 pounds. A nutrition progress note completed by the registered dietitian on July 3, 2025, documented the most recent weight as 302.4 pounds, with the note indicating that the resident's weight reflected stability. There was no documented evidence that monthly weights were obtained after May 16, 2025, as required by the facility's Weight Policy. A subsequent nutrition progress note dated July 22, 2025, again documented the most recent weight as 302.4 pounds from May 16, 2025, and reflected stability, despite no monthly weights being documented in the record as required. The weight record then showed that on July 29, 2025, the resident weighed 257 pounds, representing a potential 45.4 pound (15.0%) weight loss in approximately 70 days. A nutrition progress note dated August 1, 2025, documented that the July 29, 2025, weight was likely an error and recommended a reweight to confirm accuracy. The note further directed that, if the weight loss was confirmed, consideration for nutritional interventions would be assessed. Further review of the clinical record revealed no documented evidence that a reweight was obtained, as requested by the dietitian. There was also no documented evidence that the resident's physician or representative was notified of the potential significant weight loss. Review of findings with the registered dietitian on August 14, 2025, at 10:00 AM, confirmed that Resident 119's weight monitoring was not completed in accordance with facility policy. Review of findings with the nursing home administrator on August 15, 2025, confirmed that weight monitoring for the above-mentioned residents had not been consistently completed as required by policy to ensure accurate assessment of nutritional status and timely planning of nutritional support. 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa Code 211.12 (c)(d)(3)(5) Nursing services.

Based on observation and staff interview, it was determined that the facility failed to ensure the availability of a functioning bed for all current licensed and certified resident beds on two of three resident care units, (first floor and second floor).Findings include: The facility is licensed and certified by the State and the Centers for Medicare & Medicaid Services (CMS) for a specific number of resident beds. The facility must provide residents with bedrooms that are appropriately furnished with a bed, mattress, and related equipment in accordance with the facility's license and certification. Licensed capacity, in plain terms, is the maximum number of residents the facility is legally permitted and expected to be accommodated at any given time. Beds must be physically present to demonstrate that the facility is able to provide immediate, safe, and appropriate accommodations for its licensed capacity, and not merely maintain bed space on paper. Observations made during an environmental tour August 14, 2025, at 11:30 A.M., multiple missing resident beds were observed on the first and second floor units, as follows: Resident room [ROOM NUMBER], licensed as a triple room, contained no bed for 104B.Resident room [ROOM NUMBER], licensed as a triple room, contained no bed for 106B.Resident room [ROOM NUMBER], licensed as a double room, contained no bed for 113B.Resident room [ROOM NUMBER], licensed as a double room, contained no bed for 116B.Resident room [ROOM NUMBER], licensed as a double room, contained no bed for 217B. These observations confirmed that the facility did not maintain the full complement of licensed and certified beds, as several licensed resident spaces were without a functioning bed and mattress. The missing beds were not stored elsewhere in the facility and therefore were not available for immediate use. A review of the findings with the Nursing Home Administrator on August 14, 2025, at approximately 12:00 p.m. was conducted and confirmed. 28 Pa Code 201.18(b)(1) Management. 28 Pa Code 205.20 Resident rooms.

Based on clinical record review, select facility policy, and staff interviews, it was determined the facility failed to provide professional standards of practice for diabetes management for one resident out of 29 sampled (Resident 119). Findings include: A review of facility policy entitled Administering Medications, last reviewed on August 7, 2025, revealed that medications must be administered in accordance with the physician's orders and if the dosage is believed to be inappropriate or excessive for a resident or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's attending physician or the facility's medical director to discuss the concerns. A review of Resident 119's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (brain damage that results from a lack of blood) and diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin {a hormone that helps regulate blood sugar levels} or when the body cannot effectively use the insulin it produces). A review of a quarterly Minimum Data Set assessment (MDS a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 22, 2025, revealed that Resident 119 had moderately impaired cognition with a BIMS score of 9 (Brief Interview for Mental Status a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates cognition is moderately impaired). A clinical record review for Resident 119 revealed physician orders, dated June 10, 2025, for insulin aspart 5 units subcutaneous (under the skin) injection four times a day. A review of Resident 119's Medication Administration Record (MAR) for July 2025 revealed the following:Insulin aspart was held on July 20, 2025, at 11:00 PM administration with a documented blood glucose of 94 mg/dL.Insulin aspart was held on July 29, 2025, at the 5:00 PM administration with a documented blood glucose of 103 mg/dL.Insulin aspart was held on July 29, 2025, at the 11:00 PM administration with a documented blood glucose of 118 mg/dL. Further review of Resident 119's MAR for August 2025 revealed the following:Insulin aspart was held on August 2, 2025, at the 5:00 PM administration with no blood glucose documented.Insulin aspart was held on August 2, 2025, at the 11:00 PM administration with a documented blood glucose of 101 mg/dL.Insulin aspart was held on August 7, 2025, at the 2:00 PM administration with a documented blood glucose of 99 mg/dL. A review of Resident 119's clinical record revealed no physician orders indicating parameters for holding insulin aspart. Additionally, there was no documented evidence that the physician was notified that insulin doses had been withheld on the above dates. During an interview with the Nursing Home Administrator on August 15, 2025, at approximately 10:30 AM, the aforementioned information regarding the administration of the insulin aspart was reviewed. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services. 28 Pa Code 211.10 (c)(d) Resident care policies.

Based on observations and staff interviews, it was determined that the facility failed to demonstrate an effective maintenance program of inspection of all bed frames with bed extenders to assure the limiting of entrapment zones and promote resident safety for two residents out of 29 sampled (Resident 1 and Resident 7) and in three resident rooms observed.Findings included: Entrapment is a situation in which a resident's head, neck, chest, or limbs can become trapped between parts of a hospital bed system such as the mattress, bed frame, side rails, or footboard. The U.S. Food and Drug Administration (FDA) and the Centers for Medicare & Medicaid Services (CMS) according to Guidance for Industry and FDA Staff: Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment issued March 10, 20026 identify seven potential entrapment zones, including the space between the mattress and the footboard of the bed (Zone 6). Zone 7 Between the Head or Foot Board and the End of the Mattress When there is too large of a space between the inside surface of the headboard or footboard and the end of the mattress, the risk of head entrapment increases. Such gaps can result in serious injury or death if a resident becomes caught in them. Facilities are expected to inspect and maintain bed systems to minimize or eliminate entrapment hazards. Observations made during an interview with Resident 7 on August 13, 2025, at approximately 9:00 A.M., revealed a bed frame with a bed extender being utilized due to the resident's height that had an approximately 4 inches to 6 inch gap from the bottom of the mattress to the footboard of the bed. Observations made of Resident 1 on August 13, 2025, at approximately 9:30 A.M., revealed a bed frame with a bed extender that had a gap from the bottom of the mattress to the footboard that was filled in with wedges that are normally used for repositioning. Observations made during a tour of the facility of the second floor on August 13, 2025, at approximately 9:35 A.M., revealed a bed frame with a bed extender that had a gap from the bottom of the mattress to the footboard in rooms 205-B and 210-B. An interview on August 15, 2025, at approximately 10:00 A.M., with the physical therapy director, revealed that when a bed extender is used, it was the facility's practice to place a wedge in the gap created by the extender. The director acknowledged that wedges commonly used for repositioning were being applied in these circumstances. The information regarding bed extenders and maintenance of bed gaps was reviewed with the Nursing Home Administrator on August 15, 2025, at approximately 10:15 A.M. 28 Pa. Code 201.18 (e) (2.1) Management.

Based on clinical record review and staff interview, it was determined the facility failed to demonstrate that a resident's discharge from the facility was appropriate and necessary, for one of three sampled residents (Resident 112).Findings include: Clinical record review revealed that Resident 112 was admitted to the facility on [DATE], with diagnoses to include acute kidney failure (an abrupt decrease in kidney function, resulting in the retention of waste products) and unsteadiness on feet. Review of an entry Minimum Data Set Assessment (MDS a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated July 7, 2025, indicated the resident had a BIMS (brief interview mental screener that aids in detecting cognitive impairment) score of 14 indicating she was cognitively intact. A review of Resident 112's hospital discharge history and physical paperwork from July 7, 2025, revealed the resident had been hospitalized in part due to her inability to care for herself. Review of Resident 112's clinical record revealed the resident was discharged home from the facility on July 19, 2025. Information provided from the Area Agency on Aging revealed upon return home the resident had no food in her home that the only item in the refrigerator/freezer was ice cubes. A review of Resident 112's clinical record revealed social service notes dated July 18, 2025, indicating residents discharge planning had been discussed with the resident's family. However, there were no social service notes indicating how the family would assist the resident with acquiring food and other services to assist the resident in the transition to home, given the resident's prior difficulty in caring for herself. During an interview on August 14, 2025, at approximately 11:00 AM, the Director of Social Services (SS) confirmed Resident 112 was to be discharged to her home. The Director of SS was unable to provide documented evidence that Resident 112 would receive the required care and services to ensure a safe discharge to home. A physician discharge note dated July 19, 2025, indicated Resident 112 arrived at the facility after a hospitalization due to increased weakness and inability to care for herself, and was to be discharged home. The facility failed to demonstrate that the discharge was appropriate. During an interview with the Social Service Director on August 14, 2025, at 12:00 PM it was unable to provide documented evidence that Resident 112's discharge was safe and appropriate.28 Pa. Code 201.29(h) Resident rights 28 Pa. Code 201.14(a) Responsibility of Licensee.

Based on a review of clinical records, the Resident Assessment Instrument, and staff interview, it was determined the facility failed to ensure that Minimum Data Set Assessments accurately reflected the status of two residents out of 29 sampled. (Residents 21 and 72).Findings include: According to the Resident Assessment Instrument (RAI) User's Manual (an assessment tool utilized to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan, and the RAI also assists staff to evaluate goal achievement and revise care plans accordingly by enabling the facility to track changes in the resident's status) dated October 2024, Section K0300 Weight Loss the facility is to record loss of 5% or more in the last month or loss of 10% or more in the last 6 months. A clinical record review revealed Resident 21 was admitted to the facility on [DATE]. Resident 21 was transferred to the hospital on July 17, 2025, and readmitted to the facility on [DATE]. A review of a Medicare 5 day Minimum Data Set Assessment (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated July 29, 2025, indicated in Section K0200 that the resident's height was 67 inches and weight was 107 pounds. Review of Section K0300 indicated that Resident 21 did not experience a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Review of Resident 21's Weight Record revealed that on June 13, 2025, the resident weighed 123 pounds. On July 29, 2025, the resident weighed 107 pounds which is indicative of a 13 % significant weight loss in the last month. During an interview on August 14, 2025, at approximately 11:00 AM the Registered Dietitian (RD) confirmed that Resident 21 did experience a 18.6% weight loss between June 13, 2025, and the Medicare 5 day MDS assessment dated [DATE], and that Section K0300 was inaccurate. According to the RAI User's Manual dated October 2024, Section O, Special Treatments, Procedures, and Programs O 0110 J1 Dialysis, indicates facilities will code peritoneal or renal dialysis, which occurs at the nursing home or at another facility, and record treatments of hemofiltration, slow continuous ultrafiltration (SCUF), continuous arteriovenous hemofiltration (CAVH), and continuous ambulatory peritoneal dialysis (CAPD) in this item. Intravenous (IV) medication and blood transfusions administered during dialysis are considered part of the dialysis procedure. A clinical record review revealed Resident 72 was admitted to the facility on [DATE], with diagnoses which included end-stage renal disease (final stage of chronic kidney disease in which the kidneys no longer support the body's needs) with maintenance hemodialysis (a machine filters wastes, salts, and fluid from the blood when the kidneys are no longer healthy enough to function) every Monday, Wednesday, and Friday. A review of an admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) Section O 0110. Special Treatments, Procedures, and Programs, J1, Dialysis completed for Resident 72, dated August 5, 2025, indicated the resident did not receive dialysis treatments while a resident at the facility. Further review of the clinical record revealed that Resident 72 did receive dialysis treatments on August 1 and August 4, 2025. During an interview on August 13, 2025, at approximately 1:00 PM, the Registered Nurse Assessment Coordinator (RNAC) confirmed that Resident 72's was receiving dialysis services. The RNAC confirmed the facility coded Resident 72's MDS assessment dated [DATE], in error as related to dialysis services. 28 Pa. Code 211.5(f)(i) Medical records. 28 Pa. Code 211.12(d)(3) Nursing services.

Based on observation, select facility policy, and resident and staff interviews, it was determined the facility failed to reasonably accommodate residents' need for call bell accommodation for one out of 29 residents sampled (Resident 18).Findings include: A review of a facility policy titled Call Light Policy, last reviewed by the facility on August 7, 2025, revealed that it is the policy to ensure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Further review revealed that each resident will be evaluated for unique needs and preferences to determine any special accommodation that may be needed for the resident to utilize the call system, and any special accommodations will be identified on the resident's person-centered plan of care and provided accordingly, with examples to include touch pads, larger buttons, and bright colors. A review of Resident 18's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include hemiplegia (paralysis on one side of the body) and muscle wasting and atrophy (thinning of muscle mass). A review of an admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 9, 2025, revealed that Resident 18 had moderately impaired cognition with a BIMS score of 12 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates cognition is moderately impaired). Further clinical record review of a skilled nursing progress note, dated July 17, 2025, revealed that Resident 18 was contracted in both upper and lower extremities. Contractures are a permanent shortening of muscles, tendons, or joints, often due to immobility or neurological conditions, which can cause stiffness and limit movement. Observations made during an interview with Resident 18 on August 13, 2025, at approximately 11:00 AM, revealed that the resident had contractures to both hands. During the interview, it was revealed that Resident 18 was unable to use his push-button call bell due to these contractures. Resident 18 stated that he had not been able to use his call bell for assistance at the facility and would like a touch-sensitive call bell system. An interview with Employee 1, Licensed Practical Nurse, conducted on August 13, 2025, at approximately 11:15 AM, confirmed the observation that Resident 18 was unable to utilize the standard push-button call light due to his hand contractures. Following surveyor inquiry, observation at approximately 12:00 PM on August 13, 2025, revealed that the facility did provide a touch-sensitive call light device, which Resident 18 was able to operate. During an interview with the Nursing Home Administrator on August 13, 2025, at approximately 12:30 PM, it was confirmed that Resident 18 had not been provided with a call system compatible with his physical needs prior to the surveyor's inquiry. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing Services. 28 Pa. Code 201.29 (a) Resident Rights.

Based on a review of the facility's abuse prohibition policy, select investigative reports and clinical records, and interview with staff it was determined that the facility neglected to provide the care and services necessary to avoid physical harm and maintain physical health for one resident out of four residents sampled (Resident 2) resulting in serious injuries, a fractured arm and tooth. Findings include: The facility's policy titled Abuse Policy dated as reviewed by the facility on January 25, 2023, revealed that the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A review of the clinical record revealed that Resident 2 was initially admitted to the facility on [DATE], with diagnoses to include ataxia (poor muscle control that causes clumsy voluntary movements) following a cerebral infarction (stroke), end stage renal disease, and muscle weakness. A Quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated September 14, 2023, indicated that the resident required extensive assistance of two staff members for bed mobility. A review of the resident's current plan of care, initially dated March 3, 2022, that the problem/need of an ADL (activities of daily living) self-care performance deficit related to stroke and end stage renal disease with planned interventions for bed mobility included that the resident required two (2) staff participation to reposition and turn the resident in bed. A review of the resident's Kardex (a nursing information system used to obtain specific care information for each resident) dated as of December 1, 2023, revealed that the resident required two (2) staff assist for bed mobility. A nursing progress note dated November 30, 2023, at 9:30 PM indicated that the nurse was paged to assess Resident 2 and found Resident 2 lying on the floor face down in the resident's room. The resident's face was facing toward the bed, with noted facial bleeding, and her right arm was twisted to 90 degrees. The resident was transferred to the hospital at that time. A review of the hospital CT scan report dated November 30, 2023, revealed that the resident had an acute fracture (break) of the right proximal humeral neck (bone located at the top of the arm) and an acute fracture of the dental alveolus (tooth socket) for tooth 8 (front tooth). A review of the facility's investigation report dated December 1, 2023, revealed that Employee 1, a nurse aide, performed care to Resident 2 by herself even though the resident's care plan indicated that the resident required the assistance of two staff members. Resident 2 required the assistance of two staff members during care and only one staff member was present, Employee 1. The resident rolled off the bed as Employee 1 moved to the other side of the bed to perform a care task. Employee 1 did not follow facility protocol and the resident's care plan while providing care to the resident in bed. The facility has suspended Employee 1 pending further investigation. A review of a witness statement from Employee 1 dated November 30, 2023, (no time indicated) revealed that Resident 2 fell out of bed while Employee 1 was in the process of changing the resident. Resident 2 had vomited and, in the process of changing her bed linens, Employee 1 moved the resident to the other side of the bed. While Employee 1 moved to the other side of the bed, Resident 2 reached to grab an item off her dresser and fell out of bed. A review of the PB-22 Report (report form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property) dated December 1, 2023, at 4:45 PM revealed that the facility concluded that, upon investigation, the allegation of neglect is substantiated as staff did not follow the resident's established plan of care, neither did she (Employee 1) follow protocol to check the Kardex before starting the resident's care. The facility's conclusion was that the staff member, Employee 1, will be terminated. An interview with the Nursing Home Administrator on December 28, 2023, at approximately 2:00 PM confirmed the facility failed to ensure that Resident 2 received the services necessary to avoid physical harm. The NHA confirmed that Employee 1 performed the task alone when the care plan and Kardex indicated that the resident required two staff assist resulting in the resident's fall and serious injury during bed mobility. This deficiency is cited as past non-compliance. The facility's corrective action plan included the following: 1. The resident was sent to the hospital and admitted . Upon return will be evaluated by PT/OT. Employee suspended pending investigation. 2. All residents reviewed to ensure bed mobility is documented in the care plan and Kardex with appropriate assist level. 3. Re-education to nursing staff will include abuse policy, where to locate information on how to care for residents on the Kardex. Ensuring care plans are updated with bed mobility. 4. The DON/designee will review all newly admitted residents to ensure bed mobility is documented in the care plan with appropriate assist level and on Kardex weekly x 4 then monthly x 2. Results will be taken through QAPI for further action if necessary. The facility's compliance date was December 4, 2023, and completion of corrective action plan noted above was confirmed during the survey ending December 28, 2023. 28 Pa. Code 201.18 (e)(1)(3) Management 28 Pa. Code 201.29 (a)(c) Resident Rights 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services

Based on a review of the facility's abuse prohibition policy, select investigative reports and clinical records, and interview with staff it was determined that the facility neglected to provide the care and services necessary to avoid physical harm and maintain physical health for one resident out of four residents sampled (Resident 2) resulting in serious injuries, a fractured arm and tooth. Findings include: The facility's policy titled Abuse Policy dated as reviewed by the facility on January 25, 2023, revealed that the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A review of the clinical record revealed that Resident 2 was initially admitted to the facility on [DATE], with diagnoses to include ataxia (poor muscle control that causes clumsy voluntary movements) following a cerebral infarction (stroke), end stage renal disease, and muscle weakness. A Quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated September 14, 2023, indicated that the resident required extensive assistance of two staff members for bed mobility. A review of the resident's current plan of care, initially dated March 3, 2022, that the problem/need of an ADL (activities of daily living) self-care performance deficit related to stroke and end stage renal disease with planned interventions for bed mobility included that the resident required two (2) staff participation to reposition and turn the resident in bed. A review of the resident's [NAME] (a nursing information system used to obtain specific care information for each resident) dated as of December 1, 2023, revealed that the resident required two (2) staff assist for bed mobility. A nursing progress note dated November 30, 2023, at 9:30 PM indicated that the nurse was paged to assess Resident 2 and found Resident 2 lying on the floor face down in the resident's room. The resident's face was facing toward the bed, with noted facial bleeding, and her right arm was twisted to 90 degrees. The resident was transferred to the hospital at that time. A review of the hospital CT scan report dated November 30, 2023, revealed that the resident had an acute fracture (break) of the right proximal humeral neck (bone located at the top of the arm) and an acute fracture of the dental alveolus (tooth socket) for tooth 8 (front tooth). A review of the facility's investigation report dated December 1, 2023, revealed that Employee 1, a nurse aide, performed care to Resident 2 by herself even though the resident's care plan indicated that the resident required the assistance of two staff members. Resident 2 required the assistance of two staff members during care and only one staff member was present, Employee 1. The resident rolled off the bed as Employee 1 moved to the other side of the bed to perform a care task. Employee 1 did not follow facility protocol and the resident's care plan while providing care to the resident in bed. The facility has suspended Employee 1 pending further investigation. A review of a witness statement from Employee 1 dated November 30, 2023, (no time indicated) revealed that Resident 2 fell out of bed while Employee 1 was in the process of changing the resident. Resident 2 had vomited and, in the process of changing her bed linens, Employee 1 moved the resident to the other side of the bed. While Employee 1 moved to the other side of the bed, Resident 2 reached to grab an item off her dresser and fell out of bed. A review of the PB-22 Report (report form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property) dated December 1, 2023, at 4:45 PM revealed that the facility concluded that, upon investigation, the allegation of neglect is substantiated as staff did not follow the resident's established plan of care, neither did she (Employee 1) follow protocol to check the [NAME] before starting the resident's care. The facility's conclusion was that the staff member, Employee 1, will be terminated. An interview with the Nursing Home Administrator on December 28, 2023, at approximately 2:00 PM confirmed the facility failed to ensure that Resident 2 received the services necessary to avoid physical harm. The NHA confirmed that Employee 1 performed the task alone when the care plan and [NAME] indicated that the resident required two staff assist resulting in the resident's fall and serious injury during bed mobility. This deficiency is cited as past non-compliance. The facility's corrective action plan included the following: 1. The resident was sent to the hospital and admitted . Upon return will be evaluated by PT/OT. Employee suspended pending investigation. 2. All residents reviewed to ensure bed mobility is documented in the care plan and [NAME] with appropriate assist level. 3. Re-education to nursing staff will include abuse policy, where to locate information on how to care for residents on the [NAME]. Ensuring care plans are updated with bed mobility. 4. The DON/designee will review all newly admitted residents to ensure bed mobility is documented in the care plan with appropriate assist level and on [NAME] weekly x 4 then monthly x 2. Results will be taken through QAPI for further action if necessary. The facility's compliance date was December 4, 2023, and completion of corrective action plan noted above was confirmed during the survey ending December 28, 2023. 28 Pa. Code 201.18 (e)(1)(3) Management 28 Pa. Code 201.29 (a)(c) Resident Rights 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services

Based on a review of clinical records, select facility investigative reports and abuse policy and staff interview it was revealed that the facility neglected to provide the care necessary to prevent physical harm, a serious injury, a diagnosed fractured elbow, sustained during an avoidable fall, by one of six residents reviewed (Resident 50). Findings include: Review of the facility's policy titled Abuse Protection with a policy review date of January 2021, indicated that each resident has the right to be free of verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. The facility defines neglect as the refusal or failure to fulfill any part of a person's obligations or duties to an elder. Review of Resident 50's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 50's Annual MDS (Minimum Data Set - a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 13, 2021, revealed that the resident had a BIMS score (Brief Interview for Mental Status is a tool used to evaluate cognitive impairment and assist with dementia diagnosis) of 99, which indicated that the resident had severe cognitive impairment. Resident 50 required extensive assistance of two plus persons physical assist to perform bed mobility, transfers, and toilet use (i.e., how the resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts clothes). Review of Resident 50's comprehensive care plan dated October 11, 2020, revealed was at risk for falls due to limited mobility with a goal to be free of falls with significant injury. Interventions identified for the resident were for staff to meet and anticipate the needs of the resident, and to be sure that the resident's call light was within reach and encourage the resident to use it for assistance as needed due to her requiring prompted response to requests for assistance. The resident's care plan also identified the resident with deficits in ADL (activities of daily living) due to [CONDITION(S)] with [CONDITION(S)] and indicated that the resident required assistance of two staff members with transfers. A review of a Pennsylvania Department of Health PB-22 report form for investigation of alleged abuse, neglect and misappropriation of property and information submitted by the facility dated September 15, 2021, at 7:30 PM revealed that on Tuesday, September 7, 2021, at 3:00 PM, Employee 2, a nurse aide, was using a sit to stand lift to transfer Resident 50 and the resident slid out of the sling and fell to his buttocks. Resident 50 hit his right elbow to the floor, but Employee 2 prevented him from his head hitting the floor, and held him in a seated position. Resident 50 was noted to have non-skid socks on his feet. The resident had complaints of discomfort to his right arm and right leg. Ordered pain medication (Tylenol) was administered as ordered and it was noted that there were no injuries visually observed. Resident 50's physician was notified, and orders were received for x-rays of the right arm and right leg, stat (as soon as possible), and neuro checks were initiated. A review of x-ray reports dated September 7, 2021, at 8:11 PM, revealed that Resident 50 had a small avulsion type fracture (when a small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone) noted along the articular aspect of the distal medial condyle humeral (is the long bone in the arm that runs from the shoulder to the elbow). The investigative report noted that Resident 50 required the assist of 2 staff for ADLs (activities of daily living), including for transfers. The resident's family and the county Area Agency on Aging were notified. Employee 2 was suspended pending further investigation. The facility's investigation concluded that Employee 2 provided Resident 50's care independently. The local police and the Pennsylvania Department of Aging were notified of the incident of neglect that resulted in serious bodily injury. The findings of the facility's investigation concluded that Resident 50 was an assist of 2 staff with all ADLs. Employee 2 did not look up the resident's care required in the Kardex or care plan, or ask any other staff to assist with the transfer of Resident 50's. Employee 2 admitted to providing care independently and not following the resident's care plan for safe transfers. Review of Employee 2's witness statement that was dated September 7, 2021, no time indicated, revealed that Employee 2 stated that, at 3:00 PM, I took Resident 50 to his room to put him back to bed. I got the sit-to-stand and placed the sling under his arms and attached it to the machine. I put his legs in place on the machine. As I was using the button to stand him up, I did not realize that his arm slipped out of the sling and Resident 50 started to fall. Employee 6, from maintenance, came in to help me lower Resident 50 to the floor. As Resident 50 was being lowered to the floor, he hit his right side on the floor. Further review of the facility's investigation report revealed that Resident 50 was care planned to be an assist of 2 staff for all ADL's. The initial investigation revealed that Employee 2 was providing care independently. Employee 2 was immediately suspended pending further investigation. Facility documentation revealed that Employee 2 did not work after her suspension and was terminated from employment at the facility on September 9, 2021. During an interview with the nursing home administrator (NHA) on September 15, 2021, at 1:30 PM, the NHA stated that Employee 2 had stated that she knew Resident 50 required assistance of two persons with transfers and didn' t use another person because other nurse aides were busy with other residents and that she wanted to complete her assignment for that shift. The NHA confirmed that Employee 2 neglected to fulfill duties required to safely transfer Resident 50 that resulted in a fall with injury and discomfort as indicated in the facility's Abuse Protection policy. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.18(e)(3) Management Previously cited 11/22/19, 7/21/21 28 Pa. Code 201.29(a) Resident rights Previously cited 11/22/19, 7/21/21 28 Pa. Code 201.29(c) Resident rights Previously cited 11/6/20, 7/21/21 28 Pa. Code 211.12(a)(d)(3)5) Nursing services Previously cited 11/22/19, 8/4/20, 11/6/20, 12/1/20, 1/15/21, 3/19/21, 7/21/21 28 Pa. Code 211.12(c) Nursing services Previously cited 11/22/19, 8/4/20, 11/6/20, 1/15/21, 3/19/21, 7/21/21

Based on a review of clinical records and resident incident/accident reports and staff interview, it was determined that the facility failed to provide adequate staff supervision and effective safety interventions to prevent a fall and serious injury to one of 23 sampled residents (Resident 27). Findings include: A review of the clinical record revealed that Resident 27 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. An admission Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 25, 2015, revealed that the resident was cognitively intact, however, his speech was unclear. The resident required the assistance of one staff member for transfers, toileting and ambulation. Review of the fall assessments of the resident dated August 20, 2015, and January 15, 2016, revealed that Resident 27 was identified as being at high risk for falls on each assessment. A physical therapy evaluation dated August 21, 2015, revealed that the resident had impaired ability to perform transfers and ambulation and required assistance for all transfers and mobility. A review of the resident's care plan dated August 21, 2015, revealed that Resident 27 required toileting and transfer assistance related to self-care and mobility impairments. A revision to the resident's care plan dated September 30, 2015, noted the resident's risk for falls and planned interventions of the use of chair and bed alarms (audible alarms sound to notify staff of the resident's unsafe/unassisted, transfer/ambulation attempts). A physician's orders [REDACTED]. According to a resident incident/accident report and facility documentation submitted on January 19, 2016, at 8:05 AM the staff found the resident in the bathroom of the resident's room on the floor next to his wheelchair. It was documented as an unwitnessed fall. Around 5 PM on that date, the resident complained of pain. The physician ordered an X-ray, that revealed a fracture of the femur (thigh bone). The resident was hospitalized for [REDACTED]. The facility's report of the incident noted that all appropriate interventions were in place prior to fall. Resident 27 stated that he fell , but was unable to communicate what he was doing prior to the fall. Attempts to interview the resident during the survey ending September 16, 2016, were unsuccessful due to the resident's speech impairment. A description of the facility's follow up actions to this fall included that the resident was being evaluated for a toileting schedule. The facility's investigation report dated January 19, 2016, noted that the following occurred, Falls: ambulating without assistance in resident's bathroom, injury: bruise/contusion: back. The facility's investigation into the fall of January 19, 2016, revealed that Employee 1, a Nurse Aide, did not witness the fall, but noted that, I put him on the toilet, and last saw the resident, sitting on the toilet, in the resident's room. Employee 1 documented that she had checked the fall prevention devices at approximately 8:03 AM and the devices were in place. An interview with Employee 1 on September 12, 2016, at 10:58 AM revealed that she assisted Resident 27 onto the toilet in his bathroom and left the room, leaving him unattended in the bathroom. At approximately 8:05 AM she returned to the resident's bathroom and found him on the bathroom floor next to his wheelchair. The facility failed to provide adequate staff supervision and assistance to a resident who was identified at risk for falls, dependent on staff for activities of daily living, including transfers and mobility, resulting in a fall with serious injury, which was confirmed during an interview with the Nursing Home Administrator on September 16, 2016, at approximately 10:40 AM. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices Previously cited 10/6/15 28 Pa. Code 211.12(a)(c)(d)(5) Nursing services Previously cited 8/23/16, 7/6/16, 2/25/16, 1/14/16, 12/3/15, 10/6/15

Based on a review of clinical records and facility documentation and interview with facility staff, it was determined that the facility failed to provide adequate supervision of one resident with identified behavioral symptoms (Resident CR1) to protect others from these intrusive behaviors, which resulted in significant injury to another resident (Resident CR2) out of 24 sampled residents. Findings include: A review of Resident CR1's clinical record revealed that the resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. and had difficulty making decisions in new situations. The resident was assessed to require limited assistance with one person for locomotion on the nursing unit. The MDS also indicated that the resident displayed physical behavioral symptoms directed toward others including (as per MDS critera) hitting, kicking, pushing, scratching and grabbing. A review of nursing documentation dated August 4, 2015, at 9:35 PM indicated that the resident transfers herself independently unsupervised and wanders into other resident rooms. A bed alarm was placed on her bed to alert staff when she would exit the bed independently. Nursing documentation of August 6, 2015, at 9:32 PM indicated that the resident was found wandering into other residents' rooms; she was redirected at times and was confused. Nursing documentation of August 7, 2015, at 1:52 PM and 10:36 PM indicated that the resident was wandering in and out of other residents' rooms. There was no evidence that the facility increased supervision of the resident in response to the resident's display of wandering, intrusive and unwanted behaviors, which were exhibited over the past four days. Nursing documentation dated August 8, 2015, timed at 3:22 PM revealed that the resident was continuously walking throughout hallways and entering other resident bedrooms, going into residents' closets and drawers. Nursing noted that the resident was confused and did not remember where her bedroom was and attempted to sleep in any bedroom, even if a resident was currently asleep in the bed (in that room). Nursing also noted that the resident walked into resident Room 109 and spit mouthwash at the residents in the room and stated she is happy to do so. The entry also indicated that the resident was on every 15 minute watches as of this date. Interview with the director of nursing (DON) on October 5, 2015, at 9:00 AM revealed that the nurse note written at 3:22 PM was in response to the resident's behaviors displayed that had been displayed at 8:30 AM on that date. A review of the every 15 minute watch sheets indicated that the watches were put in place at 8:30 AM on August 8, 2015, after an intrusive episode had occurred. A review of nursing documentation dated August 8, 2015, indicated that 5:10 PM the resident entered resident Room 110 where three residents resided and a visitor present. Resident CR2 (resided in 110B) asked Resident CR1 to leave the room. V1 (a visitor, witness ) wrote a statement describing the event, which indicated that Resident CR1 entered resident room 110 and started yelling at the residents in the room. Resident CR2, who was in the middle bed (110B) was standing next to her bed at this time. According to V1's statement, Resident CR2 told Resident CR1 to get out of her room that she does not belong there. Resident CR1 was heard to yell NO! and then she was observed to pick up her hand (to strike a resident). V1 intervened to prevent Resident CR1 from striking another resident by grabbing Resident CR1's arm and informing her Honey you're in the wrong room. V1's statement indicated that Resident CR1 hit Resident CR2 so hard that Resident CR2's body twisted, her face hit the footboard, knocked her glasses off and (Resident CR2) fell straight down twisting her hip and her leg. The witness statement continued by stating that Resident CR1 called Resident CR2 an expletive and Resident CR1 said that woman (Resident CR2) needed to be locked up. Nursing documentation indicated staff redirected Resident CR1 out of Resident Room 110 and was seated in wheelchair with a chair alarm and placed under visual staff supervision at all times. According to the V1 witness statement and nursing documentation, staff then entered the room to observe Resident CR2 lying on the floor. Resident CR2 was transferred to the hospital on August 8, 2015, at 6:30 PM and diagnosed with [REDACTED]. Resident CR2 did not return to the facility. A review of the every 15 minute checks of Resident CR1 revealed that staff began conducting these checks after Resident CR1 spit mouthwash at residents on the morning of August 8, 2015. The documented checks revealed that the resident was in the hall of the nursing unit where she resided from 4:15 PM until 7:15 PM when she was transferred to hospital for an evaluation in response to the altercation with Resident CR2 and was diagnosed with [REDACTED]. The fifteen minute checks also reflected that Resident CR1 was in the hall before and after the incident on August 8, 2015, that resulted in serious injury to Resident CR2. The every 15 checks of Resident CR1 failed to accurately reflect the resident's whereabouts. There was no evidence that the facility had provided the type and degree of supervision of Resident CR1 necessary to protect other residents in the facility and prevent serious injury to Resident CR2. 483.25 Quality of Care Previously cited state deficiency 9/11/14 28 Pa. Code: 201.18(e)(1) Management Previously cited 9/11/14 28 Pa. Code: 211.12 (a)(c)(d)(1)(5) Nursing services Previously cited 9/11/14, 7/16/15

Based on review of clinical records and select resident Incident Reports, and staff interview, it was determined that the facility failed to provide adequate supervision and implement effective interventions to prevent falls for one resident (Resident 95) and failed to provide supervision and needed assistance with a hot beverage to prevent a burn for one of 24 residents sampled (Resident 104). Findings include: A review of the clinical record of Resident 104 revealed that the resident had [DIAGNOSES REDACTED]. A review of an admission Minimum Data Set Assessment (standardized assessment completed at specific intervals to define resident care needs) dated, March 27, 2012, revealed that the resident was severely cognitively impaired and required staff assistance with activities of daily living to include staff assistance with eating/drinking. A nurses note dated, June 6, 2012, at 2:47 PM, noted that when serving breakfast to the resident a teacup was found in the resident's lap. A bedside table was on the right side of the resident. A reddened area, which measured 9 cm x 4 cm was found on the right upper quadrant of the resident's abdomen. The physician was notified and cold compresses were applied, twenty minutes, on and twenty minutes off, times eight hours. Review of a resident Incident Report dated June 6, 2012, indicated that the incident occurred at 9:25 AM in the dayroom of the Advanced Alzheimer Care Unit. Further review of the facility's investigation revealed no documented evidence that the resident, who required assistance with eating, was provided with the required assistance to drink hot tea from a cup, which was placed on a bedside table on the right side of the resident. The facility's investigation was unable to determine, which staff member placed the hot tea on the table within the reach of the resident, who required assistance and supervision meals. Interview with the director of nursing on September 13, 2012, at 10:00 AM, confirmed that the resident required supervision and staff assistance with eating and drinking. The DON confirmed that the hot tea should not have been left in the resident's reach without adequate supervision /staff assistance to ensure the resident's safety. A review of the facility policy for Falls Management Clinical Guidelines, updated January 20, 2012, revealed that following a resident's fall, appropriate interventions are implemented, the care plan is updated and continue ongoing assessment and documentation by licensed nurse per center practice. A review of the clinical record revealed that Resident 95 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment dated [DATE], revealed Resident 95 was severely, cognitively impaired and required assistance for activities of daily living including ambulation and transfers. A review of nursing documentation dated December 30, 2011, revealed that Resident 95 had a fall with no injury. A review of the resident's care plan for the problem of the resident's risk for falls dated January 13, 2012, revealed that the resident was at risk for falling, had a history of [REDACTED]. A self care deficit care plan dated February 9, 2012, revealed interventions including locomotion assistance of forward wheeled walker and supervision. A physical therapy progress report and discharge summary dated January 11, 2012, revealed " patient can still be ambulatory with rolling walker with supervision." A review of a quarterly interdisciplinary assessment of the resident dated March 24, 2012 revealed no indication that this resident was at risk for falling. A review of a facility investigation report and a nurses note dated June 16, 2012 at 1:34 PM revealed that Resident 95 was found on the floor in the hallway, no injury was noted. New interventions noted at that time included physical therapy to review balance and to update the behavior care plan. A review of facility investigation report and a nurses note dated June 20, 2012 at 1:51 PM revealed Resident 95 was found on the floor, in the hallway. The noted intervention following this fall was to continue the supervision. A review of a Physical Therapy screen dated Thursday, June 21, 2012, completed in response to the two recent falls, revealed that the resident had a new deficit in ambulation and transfers. The Physical Therapist comments revealed a decrease in quality of gait with increased right lower extremity scissoring (crossing the legs while advancing with slow, small steps, causing an unsteady gait), decreased foot clearance, decreased steadiness with change of direction. There was also noted decreased steadiness with immediate standing balance. The Physical Therapist recommended to nursing, that a physicians order be obtained for Physical Therapy services to evaluate and treat the resident. A review of a facility investigation and nurses note dated June 24, 2012 at 7:43 AM revealed that Resident 95 was found sitting on the floor in the dining room. The resident complained of right hip pain. The physician was contacted. The resident was transferred to the hospital and admitted with a right femoral head fracture. The prior intervention to prevent falls included, ambulating with supervision with roller walker. The intervention after this fall was to continue the supervision. A review of a witness statement by Employee 8 (a nurse aide) {no date or time indicated}, revealed "I heard a loud boom sound. I reached the kitchen and saw Resident 95 on the floor. The last I saw Resident 95 was when I toileted her at about 6:50 AM and she came out at 6:55 AM." There was no indication from the investigation that any staff were present when this resident ambulated into the dining room and fell , despite the intervention indicating ambulation with walker and supervision. During an interview on September 13, 2012 at 1:15 PM Employee 7 (Physical Therapist) stated that ambulating with supervision means that a nursing staff member can see the resident while ambulating. She further stated that if nursing sees a decline in ambulation or transfers they will make a referral to PT for a screen. If physical therapy is needed, physical therapy staff notifies nursing to obtain a physicians order for the therapy. When asked whose responsibility it was to implement additional safety measures until nursing gets a response from the physician and treatment can be initiated, Employee 7 (PT) replied that "it was up to nursing." During an interview on September 13, 2012 at 2 PM the Director of Nursing confirmed that the nursing staff did not follow the resident's plan of care for safe ambulation. The fall of June 24, 2012 at 7:00 AM occurred at the change of shift with no nursing staff watching Resident 95 as she ambulated in the dining room. She stated that there was no response from the physician for an order for [REDACTED]. She further confirmed that nursing did not implement any additional interventions to prevent falling after the June 20, 2012, fall despite the results of the physical therapy screen, completed June 21, 2012. 28 Pa. Code 211.12 (a)(d)(3)(5) Nursing services. Previously cited 10/14/11, 11/15/11

Based on review of clinical records and select facility policy and procedures and staff interview, it was determined that the facility failed to implement planned measures and services prescribed to prevent the development of pressure sores for one resident out of six sampled (Resident A3). Findings include: A review of the clinical record revealed that an orthopedic clinic appointment was completed for Resident A3 on May 6, 2011, due to an injury ([MEDICAL CONDITION] lower leg) that the resident sustained [REDACTED]. The orthopedic appointment resulted in a lower leg splint being applied to the left lower leg with instructions for full time wear and no weight bearing. A follow-up orthopedic clinic appointment conducted on May 12, 2011, revealed that the left lower leg splint could be discontinued with orders for a CAM (fracture boot) walker boot to be applied, which can be removed for care. On May 12, 2011, physical therapy services ordered the CAM walker boot for the resident at the facility. Physician orders [REDACTED]. Further physician instructions included that the resident was to be assessed for inadequate circulation, swelling, redness or impaired skin integrity every shift. A review of facility policy dated September 21, 2010 revealed that professional nurses will assure that removal/check schedules are in place to check skin integrity beneath braces, etc. There was no evidence in the resident's clinical record that a removal/check schedule had been in place to assure that the left lower leg splint was removed for a check of skin integrity beneath the splint prior to the availability of the CAM boot and as ordered by the physician. Nursing documentation dated May 19, 2011 at 10:28 PM revealed that the physical therapist had removed the resident's left lower leg splint that same evening. Nursing documentation and a Certified Registered Nurse Practitioner progress note completed at 8:15 PM May 19, 2011, identified that the resident had two areas of bruising on top of the foot over the toes. Three unstageable pressure areas with darkened centers were identified on the resident's left heel and back of the ankle measuring 1.2 centimeters (cm) by 1.4 cm; 1.4 cm by 1.2 cm; and 3.0 cm by 1.6 cm. There was no evidence that the resident's left lower leg splint had been removed for three times daily skin inspections from May 13, 2011 through the evening hours on May 19, 2011 when the CAM walker boot became available and the splint was removed by the physical therapist in order to apply the CAM walker boot. An interview conducted with the Clinical Service Consultant on May 20, 2011 at approximately 2:15 PM verified that the resident's left lower leg splint had not been removed for the skin integrity checks that had been ordered to be conducted on every shift since May 13, 2011. 483.25 Pressure sores Previously cited 11/13/2009, 11/18/2010 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services Previously cited 11/18/2010, 1/20/2011, 3/9/2011 211.12 (a)(d) Resident care policies Previously cited 11/18/2010, 1/20/2011

Based on clinical record and select policy review and resident and staff interview, it was determined that the facility failed to assure that each resident receives and is provided with necessary assistance devices required to prevent accidents, which resulted in serious injury for one resident out of six residents sampled (Resident A3). Findings include: Resident A3 was readmitted to the facility on [DATE]. A Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was moderately impaired cognitively and required an assist of one person to help with transfers and ambulation, along with the use of a walker as an assistive device. A review of the resident's plan of care, initially dated December 22, 2010, identified that the resident required the assist of one person for transfers. The care plan, including the identification that the resident had a potential risk for falls failed to identify that the resident utilized a walker as an assistive device for ambulation. A fall risk assessment completed on February 23, 2011 revealed that the resident was at high risk for potential falls due to poor balance while standing and walking and requires the use of a walker. A review of a physical therapy discharge summary completed on March 18, 2011, revealed that the resident had reached maximum potential in ambulation abilities utilizing assistance from one person and the rolling walker for ambulation of an average of 50 feet. The Physical Therapy discharge summary identified that the resident continued to be a fall risk due to the resident's safety awareness and ataxic-gait like pattern (unsteady, uncontrolled gait and throwing the feet outwards). A review of an accident report dated May 5, 2011 at 8:04 AM revealed that the resident had been ambulating back to bed from the bathroom with a caregiver, the resident's knees buckled and the resident "twisted" the left ankle. There was no documentation indicating that the resident also had use of the rolling walker identified for the resident's use to assist with safety during ambulation. An orthopedic clinic appointment conducted on May 6, 2011, identified a fracture of the left leg and placed the resident on no weight bearing for that leg and a left leg splint to be worn full time with follow-up with the orthopedic on May 12, 2011. During an interview with Resident A3 on May 20, 2011 at approximately 2:00 PM, the resident relayed that that only one person helped walk the resident back from the bathroom and that the walker was not used. The resident relayed that a "trip" caused the resident to lose balance and the leg "twisted." An interview conducted with the Clinical Service Consultant on May 20, 2011, at approximately 2:15 PM verified that the resident's caregiver was questioned on this same date and it was confirmed that the rolling walker had not been used nor was it identified on the resident's plan of care to assure that the resident was provided with the necessary assistance devices identified for safe and steady ambulation. 483.25 (h) Accidents and Supervision Previously cited 11/18/2010, 1/20/2011, 3/9/2011 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services Previously cited 11/18/2010, 1/20/2011, 3/9/2011 28 Pa. Code 211.11 (d) Resident care plan Previously 11/18/2011, 1/20/2011