Every finding on record at Saunders Nursing and Rehabilitation Center

Based on a review of facility policy, review of clinical records and interviews with staff, it was determined that the facility failed to follow physician's orders related to medication administration for two of thirteen residents reviewed (Residents R1 and R2).Findings include: Review of the facility policy titled, Medication Administration/Disposition, revised May 8, 2025, revealed medications shall be administered in a safe and timely manner. Medications must be administered within one hour of their prescribed time, unless otherwise specified. Interview with Resident R1 on August 17, 2026, at 11:20 a.m. revealed that the resident had waited hours for his/her medication on Saturday, August 15, 2026. Resident R1 said that the nurse did not come to work and it wasn't until later that they got another nurse to come in. Resident R1 said that he/she needs his/her antidepressant medication on time to keep Resident R1's mood stable. Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnosis of, but not limited to, major depressive disorder (mood disorder characterized by low mood, a feeling of sadness, and a general loss of interest in things). Review of Resident R1's Medication Administration Audit Report for Saturday, August 15, 2026, revealed the following medications were scheduled for administration on at 8:00 a.m. and were administered at the following times: Duloxetine HCL oral capsule delayed release particles 60 MG, give one capsule by mouth in the morning. Given at 9:57 a.m.Duloxetine HCL oral capsule delayed release particles 30 MG, give one capsule by mouth in the morning. Given at 9:57 a.m.Lisinopril Oral Tablet 40 MG give one tablet by mouth one time a day for hypertension. Given at 9:57 a.m.Fluticasone Propionate nasal suspension 50 MCG/ACT one spray in both nostrils in the morning for allergies. Given at 9:57 a.m. Interview with Resident R2 on August 17, 2026, at 11:35 a.m. revealed that the resident had waited hours for his/her medication on Saturday, August 15, 2026. Resident R2 said that Saturday morning was a mess when the nurse did not come in and the supervisor was trying to help after trying to get another nurse to come in, which happened later that morning. Resident R2 said that he/she has a lot of pain, especially in the left shoulder. Resident R2 said that he/she waited for hours for pain medications on Saturday August 15, 2026. Review of Resident R2's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis of, but not limited to, chronic pain and cerebral infarction (damage to the brain) affecting non-dominant left side. Review of Resident R2's Medication Admin Audit Report, for Saturday, August 15, 2026, revealed the following medications were scheduled for administration at 9:00 a.m. and were administered at the following times: Morphine Sulfate ER oral tablet extended-release 15 MG give 1 tablet by mouth every 12 hours for pain. Given at 12:10 p.m.Pregabalin oral capsule 200 MG give one capsule by mouth two times a day for pain, please give with Morphine 15 MG ER and Oxycodone 5 MG or 10 MG PRN. Given at 12:10 p.m.Eliquis oral tablet 5 MG give one tablet by mouth two times a day related to unspecified sequalae of cerebral infarction. Given at 12:04 pmAcyclovir oral tablet 400 MG give one tablet by mouth every 12 hours for prophylaxis. Given at 12:04 p.m.Lisinopril Oral Tablet 2.5 MG give one tablet by mouth one time a day for essential hypertension, hold for SBP less than 100. Given at 12:04 p.m.Lenalidomide oral capsule 5 MG give one capsule by mouth in the morning 21 days on and 7 days off relating to Multiple Myeloma not having achieved remission. Given at 12:04 p.m. Interview on August 18, 2026, at 1:55 p.m. with the Director of Nursing (DON) confirmed that there was a nurse scheduled for 7:00 a.m. to 3:00 p.m. who was a no show, therefore some medications were delayed on August 15, 2026. Further discussion about these medications being delayed for two to three hours, the DON confirmed that this was not acceptable. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.18 (b)(3) Management 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 211.12 (c) Nursing services 28 Pa. Code 211.12 (d)(3) Nursing services 28 Pa. Code 211.12 (d)(5) Nursing services

Based on review of facility documentation and interviews with staff, it was determined that the facility did not ensure one member of the nursing staff was appropriately licensed while providing care to residents on one of seven days reviewed ([DATE]).Findings include:Review of facility documentation revealed that licensed nurse, Employee E3, had worked as a nursing supervisor from 7:00 a.m. until 12:00 a.m. on [DATE]. Further review revealed that the nursing license for Employee E3 had expired on [DATE]. Interview with Employee E2, the Director of Nursing on [DATE], at 12:30 p.m. confirmed that Employee E3 had worked without a valid nursing license on [DATE]. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.19(3) Personnel records.

Based on observations, review of policy and review of facility provided documentation, it was determined that facility did not ensure to provide clean, homelike environment for multiple residents on four units (1st floor unit, 2nd floor unit, 3rd floor unit, 4th floor unit)Findings include:On Monday, April 27, 2026, at 10:00 am, 1st floor unit, observations in common shower room revealed used towels and used paper towels on the shower gurney; floors not cleaned to an acceptable sanitary standard.In room [ROOM NUMBER], bed side table and floor were not cleaned to an acceptable sanitary standard.In room [ROOM NUMBER], bedside table and floor were not cleaned to an acceptable sanitary standard.In room [ROOM NUMBER], foul odor was noted and floor was not cleaned to an acceptable sanitary standard.Observations of 1st floor unit hallways revealed visible debris on the floor; food particles, trash, and dust accumulation.Interview with Resident R42, on April 27, 2026, at 11:30 am, revealed concerns related to unsanitary common shower room and unclean dining tables often left dirty overnight.Review of resident council meeting minutes for month of March, 2026, revealed that residents reported dining room floor not clean - food on floor, chairs not being put back in correct places after cleaning.Review of grievance reports revealed concern was reported by Resident R165 on April 6, 2026, regarding cleanliness of room.Further review of grievance reports revealed a concern was reported by resident R83's representative on February 16, 2026, regarding cleanliness of room and bathroom.Further review of grievance reports revealed a concern reported by Resident R166's representative on January 19, 2026, regarding room not clean regularly, dusty.Further review of grievance reports revealed a concern reported by Resident R205 representative on January 19, 2026, regarding room not cleaned, stating sometimes we don't have a housekeeper on that side. I will do the trash but not the floor.Further review of grievance reports revealed a concern reported by Resident R8 on April 7, 2026, regarding room and shower the shower is dirty and falling apart.Interview with regional housekeeping director on Monday, April 27, 2026 at 12:00 pm, revealed that two housekeepers are assigned to clean one unit during day shift; eight housekeepers in total for four units.Review of facility provided 'housekeeping coverage' for dates of April 19, 2026 through May 2, 2026 revealed facility did not have sufficient amount of housekeepers on following dates: April 19, 2026 - five housekeepers, April 25, 2026 - five housekeepers, April 26, 2026 - five housekeepers.28 Pa Code 201.14(a) responsibility of licensee

Based on observations, resident and staff interviews, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures for nine of thirty-four residents reviewed (Residents R91, R202, R61, R137, R197, R200, R65, R157 and R13).Findings include: Review of the Food and Nutrition Services test tray accuracy and evaluation form, revised January 3, 2024, revealed that the minimum acceptable temperature for entree and starch was 135 degrees and the maximum acceptable temperature for dessert was 45 degrees. Interview with Resident R91 on April 27, 2026, at 10:47 a.m. revealed that he had a problem with the food saying that it is not enough to eat and it is always served cold. Interview with Resident R202 on April 27, 2026, at 10:51 a.m. revealed that she was not happy about the food, it is not any good, and I would know I worked in food service, they just don't know what they are doing down there. Interview with Resident R61 on April 27, 2026, at 10:55 a.m. revealed that she did not think that the food tasted good and it was affecting her appetite. Interview with Resident R137 on April 27, 2026, at 11:00 a.m. revealed that she did not like the food, it was cold, and she did not get what she wanted, like a banana at breakfast. Interview with Resident R197 on April 27, 2026, at 11:26 a.m. revealed that she did not like the food, compared it to dog food, and it was small portions. She said that they would ask what she wanted and then send something else, and if it wasen't for her son she would starve. Interview with Resident R200 on April 27, 2026, at 11:29 a.m. revealed that she did not like the food, it was not appetizing and she just could not eat it, but that she was lucky that her cousin brought her meals to her from home. Interview with Resident R65 on April 27, 2026, at 11:33 a.m. revealed that he had wished the food was better, that he was diabetic and needed to have good nutrition. Interview with Resident R157 on April 27, 2026, at 11:37 a.m. revealed that she felt that the food was not warm enough, especially the coffee. Interview with Resident R13 on April 27, 2026, at 11:42 a.m. revealed that he did not have an appetite and could not eat the food, and he felt that he was losing weight because he was not eating well. Observations during a test tray conducted with the Food Service Director, (FSD) Employee E4, on April 29, 2026, at 12:20 p.m. revealed that the cranberry juice was frozen, Roast Beef was 121 degrees, Peas 129 degrees and Pineapple Tidbits 55 degrees. Could not drink the juice as it was frozen, the peas were dark green and tasted overcooked and were very soft, the baked potato tasted old like it was cooked hours ago and held too long, the roast beef was dry and a little tough to chew and the pineapple tidbits were warm and not appetizing. Interview with the FSD on April 29, 2026, at 12:20 p.m. confirmed the above findings and stated that the baked potatoes were cooked at 10:30 a.m. that morning, and that these food items were outside the acceptable temperature range and therefore not palatable. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

Based on clinical record reviews, resident and staff interviews, it was determined that the facility failed to provide appropriate ADL care including shaving, and a haircut for one resident and morning care and dressing for another, for a total of two of 34 residents reviewed (Resident R21 and R36) who were unable to carryout ADL care independently.Findings include: Review of Resident R21's care plan revealed an intervention dated December 20, 2024, for personal care which required the assistance of one staff member. Interview with Resident R21 during the initial tour of the facility on April 27, 2026, at 11:00 a.m. revealed that the resident wanted to know if he could get a free hair cut, and that he liked his hair buzzed real short and he also wanted to be shaved. Observation of the resident revealed that his hair was longer and sticking up on top and his face and neck had a heavy growth of facial hair. Interview with Nurse Aide, Employee E8, on April 27, 2026, at 11:21 a.m. confirmed that Resident R21 needed a shave and she was not sure about a haircut. Review of Resident R36's care plan revealed an intervention dated October 17, 2024, which stated that the resident needed assistance for his AM care routine which included personal hygiene, oral care and dressing. Interview with Resident R36 during the initial tour of the facility on April 27, 2026, at 11:10 a.m. revealed that the resident was upset that he was still waiting for morning care and to get up and dressed. Observation of the resident revealed that he was still laying in bed in a hospital style gown. Interview with Nurse Aide, Employee E8, on April 27, 2026, at 11:21 a.m. confirmed that Resident R36 was still waiting for morning care, and that he required a mechanical lift to get him out of bed and she was waiting for another aid to assist and she did not want to start his care until she had help to finish everything at the same time. Interview with the Director of Nursing on April 27, 2026, at 2:20 p.m. confirmed that she would ensure that Resident R21 would get a shave and make sure he would be seen by the barber on their next visit. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review, facility policy, and interview with staff, it was determined the facility failed to ensure pain medication was administered in accordance with the physician's order for one of eight residents reviewed for pain management (Resident R 134). Findings Include: Review of Resident R134 's clinical record revealed Resident R134 was admitted to the facility on [DATE]with a diagnosis of senile degeneration of brain (brain slowly worsening), carcinoma in situ of prostate (D07.5) (early prostate cancer), major depressive disorder (feeling sad daily). Review of Resident R134's clinical record revealed physician's order, dated November 26, 2025, for Oxycodone HCl 10 mg to be given every 4 hours as needed for severe pain Review of Resident R134's April 2026 Medication Administration Record (MAR) revealed that the as needed pain medication Oxycodone HCl 10mg was administered out of the parameter ordered by the physician as follows: April 4, 2026, - Pain level 0April 5, 2026, - Pain level 0April 8, 2026, -Pain level 0April 14, 2026, Pain level 0 Interview on April 29, 2026, at 12:10 p.m. with Director of Nursing, Employee E2, confirmed Resident R134's pain medication was not administered in accordance with physician's order. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of policy, review of clinical records and review of facility provided documentation, it was determined that facility did not ensure that a resident who requires dialysis received services according to professional standards of practice for one of 34 residents reviewed (Resident R82)Findings include:Review of facility policy titled Dialysis Management (Hemodialysis), revised on March 28, 2024, indicates that if dialysis is provided at off-site dialysis center: facility is to complete pre-dialysis information on the communication form and send with resident to dialysis on treatment days, to ensure communication of resident information and coordinate care between dialysis center and facility.Review of Resident R82 clinical record revealed medical diagnosis of end stage renal disease, dependance on renal dialysis, thrombocytopenia, anemia in chronic kidney disease.Review of Resident R82 care plan revealedReview of Resident R82 electronic medication administration record (e-MAR) revealed a physician order to record prior-dialysis weight in chart before dialysis one time a day every Tuesday, Thursday, Saturday for Hemodialysis (HD).Further review of Resident R82 e-MAR revealed missing weights on following dates: 04/09/2026, 04/11/2026, 04/14/2026, 04/18/2026, 04/21/2026, 04/28/2026.Further review of e-MAR revealed a physician order to record post-dialysis dry weight from dialysis in chart upon return from dialysis every evening shift every Tuesday, Thursday, Saturday.Further review of e-MAR revealed missing post dialysis weights for Resident R82 on following dates: 04/09/2026, 04/11/2026, 04/16/2026, 04/18/2026, 04/21/2026, 04/25/2026.Review of Resident R82 dialysis center communication record, dated April 28,2026, revealed missing information regarding which medications were given six hours prior to sending resident to dialysis.Further review of Resident R82 dialysis center communication record, dated March 12, 2026, revealed missing information related to vital signs, medications, time of last meal/diet, facility nurse signature/date/time.Further review of dialysis center communication record, dated April 14, 2026, revealed missing information related to vital signs, medications, time of last meal/diet, facility nurse signature/date/time.28 Pa Code 211.12(c)(3) nursing services28 Pa Code 211.12 (c)(5) nursing services28 Pa Code 211.10(a) resident care policies

Based on observations and interviews with staff it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.Findings include: An initial tour of the Food Service Department was conducted on April 27, 2026, at 9:45 a.m. with Employee E4, Food Service Director, (FSD) which revealed the following: Observation of receiving area revealed white pasty gobs of food spilled on the side of the dumpster including rice and pasta and spilling onto the ground in a big heaping pile. Observation in the kitchen near the tray line revealed a heavy build-up of dirt, grease and dust on the ceiling vents. Observation in the kitchen revealed broken and missing white subway style tiles on the corner of the wall and the broken white tiles laying on the floor. Observation in the kitchen near the tray line revealed coffee urns with a build-up of dark coffee colored stains and coffee grounds around the top of the urn. Observation in the kitchen revealed five reach-in refrigerators which had no independent internal thermometers inside the units, with several of these refrigerators having torn door gaskets which were also stained and dirty. Observation of the convection ovens in the kitchen production area revealed a heavy build-up of black baked on food spillage on the bottom of both the top and bottom ovens. Observation in the kitchen under the flat-top griddle revealed a cabinet with a large accumulation of grease on the door an inside the cabinet. Observation of the stove and cook top revealed an accumulation of grease and food spatters on the gas line and side of the unit. Interview with the FSD on April 27, 2026, at 9:45 a.m. confirmed the above findings. 28 PA Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management

Based on review of facility assessment and staff interview, it was determined that the facility failed to ensure the direct care staff and input from residents, resident representatives, and/or family members was included when conducting the facility assessment. Findings include: Review of the facility's facility assessment, dated January2026, revealed there was no indication that the facility involved direct care staff, input from residents, resident representatives, and/or family members. Interview with Employee E1, Administrator, on April 29, 2026, at approximately 1:03 pm, confirmed there was no direct care staff, resident representatives, and/ or family members included in the facility assessment. 28 Pa. Code 201.18(b)(3) Management28 Pa. Code 211.12(c)(d)(1) Nursing services

Based on staff interviews, review of clinical records, and facility documentation, it was determined the facility failed to ensure the safe handling of meal carts for one of one resident reviewed (Resident R1). This failure resulted in actual harm to Resident R1 when the meal cart rolled over resident's foot resulting in a fracture of the right distal 3rd metatarsal. This deficiency was identified as past non compliance.Findings include: Review of Resident R1's April 2026 physician orders revealed the diagnoses of Hypertension (high blood pressure); Peripheral Vascular Disease (poor circulation of the extremities); Congestive Heart Failure (excessive body/lung fluid caused by a weakened heart muscle), and Alzheimer's disease (progressive degenerative disease of the brain). Review of documentation submitted to the State Survey Agency on March 26, 2026, revealed a dietary staff member (Employee E3) ran over a resident's foot (Resident R1) during meal service. Further review of the description of the event revealed, Per the aide, as he passed room [ROOM NUMBER], he heard the resident state ouch, you ran over my foot. Per the aide, (resident) was not visible in the hallway. She was sitting in her wheelchair inside the doorframe of her room; however, she had her legs extended out into the hallway. The aide states he did not see (resident)'s feet as he passed. Continued review of the submitted incident details revealed the resident was assessed after the incident, complained of pain to (her/his) right foot, and that there was a laceration noted to the bottom of (her/his) right foot. An x-ray was ordered of the resident's right foot which revealed a nondisplaced fracture of the distal 3rd metatarsal (fracture of the long bone of the 3rd toe). The physician was notified and ordered for the resident to be follow with the podiatrist at the facility and to be no weight bearing on the right foot. Review of written statement dated March 26, 2026, with the dietary aide, (Employee E3) noted that the dietary aide (Employee E3) was pushing the cart down the hall to deliver the cart. Dietary aide (Employee E3) reported that prior to the incident he was walking the cart down the back hall. Dietary aide (Employee E3) reported that he did not see the resident, did not see (resident) feet, but stated the way that the resident was sitting, only the resident's feet were in the hallway and the resident's body was positioned inside the door frame. Employee E3 reported in his statement that there was nothing that obstructed his line of sight, but the hall had mediation carts so that he had to maneuver, in addition to residents who were in the hall. Dietary aide (Employee E3) reported that he did not announce his presence to let anyone know that he was coming through the hallway. Dietary aide, (Employee E3) reported that when he hit the resident's foot with the cart, the resident said, ouch the cart hit me. Dietary aide, (Employee E3) reported in his statement that he notified nursing staff of what occurred. During an interview with the Dietary aide, (Employee E3) on April 24, 2026, at 10:26 a.m. he acknowledged that the incident occurred and reported that he could only see the resident's feet hanging out. Dietary aide (Employee E3) revealed he was not looking down at the floor and that when pushing a cart, he was instructed to look forward and to the side. Dietary aide revealed he could see over the cart. He was pushing the food cart but had to move around the medication carts and the hampers that were on the floor. This caused him to go to the side of where the resident was sitting in (her/his) doorway. During the interview, the Dietary aide, (Employee E3) reported he did not know that he went over the resident's feet. Dietary aide, Employee E3 reported that the nurses heard the resident's yell, and they came immediately. Review of written interview dated March 25, 2026, between Licensed nurse (Employee E4), and facility personnel, revealed Licensed nurse reported she heard the resident screaming as she was at the nursing station. Licensed nurse, (Employee E4) indicated she observed the resident sitting in the doorway of her room in her wheelchair with one of her feet under the food cart. During an interview with the Licensed nurse, Employee E4 on April 10, 2026 at 11:03 a.m. the licensed nurse revealed she heard the resident scream, my foot, my foot, and observed the resident sitting in the doorway of her room on the 1st floor with her foot under the food truck the dietary aide was pushing. Licensed nurse, Employee E4 revealed the resident's toe was eventually found to be fractured and reported that the dietary aide was maneuvering his dietary cart around medication carts, etc. that were in the hallway. The facility failed to ensure that a meal cart was handle in a safe manner. This failure resulted in actual harm to Resident R1 when the meal cart rolled over the resident's foot resulting in a fracture of the right distal 3rd metatarsal (bone in toe). On April 7, 20206, the Nursing Home Administrator presented documentation, indicating that the facility initiated a plan of correction on March 25, 2026, to address safe transportation of meals. Facility plan of correction included the following: The resident involved in the incident was immediately assessed by nursing staff.-Physician and responsible party were notified- 3/25/26-pain assessment and skin assessment were completed - 3/25/26-X-ray ordered and completed revealing a non-displaced fracture of the tip of the right metatarsal- 3/25/26The staff member (Employee E3), Dietary aide was:-Immediately removed from cart handling duties pending review- 3/25/26-Re-educated on safe meal cart handling and resident awareness- 3/26/26-Completed competency validation prior to returning to full duties- 3/26/26Staff Education & Competency-All dietary staff will receive mandatory in-service on safe meal cart handling and resident awareness- Completed 100% on 3/26/26The facility will implement the following monitoring plan:-5 random observations per week for 4 weeks, then monthly x 2 months to be conducted by dietary manager/designee, any observation unsafe practices will result in immediate corrective action.-Findings will be review in QAPI meetings. Trends will be analyzed and additional interventions implemented as needed. Review of facility documentation revealed that trainings and audits with the dietary staff on Safe Meal Cart Handling & Resident Safety were conducted. The training included for dietary staff to maintain clear line of sight at all times; move carts at a slow controlled speed; be aware of resident feet and mobility devices; use caution at corners and in crowded hallways; stop immediately if unsure of surrounds and report hazards or equipment issues immediately. It was determined that the plan of correction was implemented and the deficiency was identified as past non-compliance. 28 Pa. Code 201.18(b)(3)(e)(1) Management 28 Pa Code 211.10(d) Resident care policies

Based on review of policies and employee files, and staff interviews, it was determined that the facility failed to ensure that Pennsylvania Nurse Aide Registry checks were obtained prior to hire for one of four nurse aides reviewed (Employee E3).Findings Include: The facility's policy titled Criminal Background Checks/Verification of License and Certifications Thru Nurse Aid Registry last revised July 7, 2023 states, Policy- All offers of employment at the facility are contingent upon results of a thorough criminal background check. In addition, for professionals or nurse aides who are required to have a license or certification issued by the respective state they are currently applying for employment, must have a current verification that their license or certification is active and in good standings. Review of facility documentation submitted to the State Survey Agency on March revealed On March 3, 2026, [NAME] Nursing and Rehab Center was notified by the Pennsylvania Attorney General's Office that agency nurse aide [Employee E3] did not possess a valid nurse aide certification during the time she provided services at the facility. Interview held with the Director of Nursing, Employee E2 and the Nursing Home Administrator on March 11, 2026 at 10:03 a.m. it was confirmed that the facility did previously rely on the staffing agency to obtain credentials. The Director of Nursing, Employee E2 stated that the facility was not made aware by the Attorney General's office of the unlicensed employee until March 4, 2026. Review of the facility investigation file included an email from the staffing agency stating, During the investigation, it was found that she pulled a license from a website, and did a very good photoshopping of the name. Looking at it you would never know, however, under close scrutiny, it was apparent that the font on her name was slightly different from the other legit licenses we reviewed. Upon questioning our onboarding team, it was found that they were accepting a license that was uploaded by a clinician from the versification website and not running the verifications themselves. Further review of the facility investigation file revealed nurse aide Employee E3 worked at the facility on the following dates: July 27, August 3, August 23, August 26, August 27, September 2, September 5, September 7. Employee E3 was an agency staff member who provided credentialing documentation to the staffing agency that has since been determined to be false. Employee E3 was removed from the facility schedule in September 2025 and has not worked in the building since that time. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on review of resident records, facility policy, and staff interviews, it was determined that the facility failed to provide discharge instructions and prescription medication upon discharge (Resident R1). Findings:Review of the Facility's Policy titled Discharge Transition Packet Instruction, last revised 6/2025 revealed, The facility will complete discharge transition instruction when the resident/patient is anticipating discharge to a private residence, or personal care/assisted living. The instruction will assist the resident/patient to adjust to returning to his/her previous living environment safely or to a new living environment in a safe manner.A review of the clinical record for Resident R1 revealed a admission date October 14, 2025, with diagnosis of cervical disc degeneration, radiculopathy lumbar, hemiplegia, end stage renal disease, muscle wasting atrophy, difficulty in walking, need for assistance with personal care, chronic diastolic, thrombocytopenia, A review of Resident R1's admission Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 15, reflecting cognitive intact. A clinical progress note dated January 29, 2026, stated that on January 27, 2026, and January 29, 2026, the social worker contacted the resident's family members via email to clarify prior communication and provide follow-up regarding referrals initiated by social services for potential facility-to-facility transfers to other rehabilitation facilities. At that time, Resident R1 had not been accepted for transfer to another facility. Due to the exhaustion of Resident R1's Medicare benefits as of January 29, 2026, and because provisions for an extended stay had not been secured, the facility planned to proceed with discharge on [DATE]. Referrals were initiated for skilled home care services, including physical therapy, occupational therapy, and nursing services. Referrals for custodial home care services could also be made upon request. A post-discharge appointment with Resident R1's primary care provider was to be scheduled. Transportation was arranged for 10:00 a.m. on January 30, 2026.A separate clinical progress note dated January 29, 2026, at 1:42 p.m. revealed that a resident's family member responded that the family had already submitted medical necessity forms on behalf of the resident and that a durable medical equipment (DME) referral from [NAME] was not needed at that time.Another clinical progress note dated January 30, 2026, was written by Licensed Nurse Employee E6, stating that the resident was discharged to home at 9:35 a.m., first going to dialysis and then transferring home. All personal belongings remained at the facility, awaiting family pickup and receipt of discharge instructions and prescriptions.Further review of the clinical file revealed a copy of the discharge summary signed by Registered Nurse Employee E4 on January 30, 2026. The medication section of the discharge summary indicated the following:Glucosamine-Chondroitin oral tablet: 1 tablet by mouth every 8 hours. The last dose was administered on January 30, 2026, at 6:00 a.m., with the next dose due at 2:00 p.m.Auryxia oral tablet 1 g/210 mg (Fe): 1 tablet by mouth three times daily. The last dose was administered on January 30, 2026, at 9:00 a.m., with the next dose due at 2:00 p.m.Gabapentin oral tablet 100 mg: 1 tablet by mouth twice daily. The last dose was administered on January 30, 2026, at 9:00 a.m., with the next dose due at 5:00 p.m.Dorzolamide HCl-Timolol Maleate 2%-0.5% ophthalmic solution: 1 drop in the right eye twice daily. The last dose was administered on January 30, 2026, at 9:00 a.m., with the next dose due at 5:00 p.m.Prednisolone acetate ophthalmic suspension 1%: 1 drop in the right eye every 8 hours. The last dose was administered on January 30, 2026, at 6:00 a.m., with the next dose due at 2:00 p.m.On February 4, 2026, at 12:52 p.m., Registered Nurse Employee E4 was interviewed and confirmed that the resident was discharged on January 30, 2026, at 9:35 a.m., but she did not sign the discharge packet until approximately 9:00 p.m. during her night shift, which was after the resident had already left the facility. Employee E4 stated that she was unable to provide the discharge packet to the resident because the resident was no longer at the facility.Employee E4 explained that the facility typically discharges residents even when they have scheduled appointments prior to going home. She stated that when a resident has an appointment, as Resident R1 did with a scheduled dialysis appointment, the discharge should normally be completed before the appointment, and the resident's discharge instructions, prescriptions, and belongings should be made available for the resident to take with him before leaving the facility. In this case, however, Resident R1 left the facility without receiving discharge instructions, prescriptions, or personal belongings.There was no documentation indicating that the resident refused to sign or receive the discharge instructions or prescriptions. Additionally, it was determined that the nurse responsible for the discharge is expected to review discharge instructions with the resident to ensure understanding and to provide prescriptions. Employee E4 confirmed that she was not the nurse who discharged the resident, and that the discharge instructions were not provided to Resident R1 at the time of discharge.As a result, Resident R1 was discharged without receiving required discharge instructions, medications, or personal belongings, indicating a breakdown in the facility's discharge process and a failure to ensure a safe and complete transition from the facility to home.On February 4, 2026, at 2:06 p.m., an interview was conducted with the Administrator, who confirmed that the resident was alert and oriented and should have received discharge instructions and prescription medication upon discharge on [DATE], at 9:35 a.m. There was no documentation in the clinical file indicating that the facility offered the discharge summary with prescription medication instructions. The clinical file also lacked documentation showing that the resident was offered the information and refused to sign or receive a copy of the discharge summary.The resident's representative arrived to pick up the resident's discharge instructions and prescription documentation on January 30, 2026, at approximately 9:00 p.m., which indicates that the resident was inappropriately discharged without discharge instructions, prescription medication.28 PA. Code 201.14(a)(b) Responsibility of licensee28 PA. Code 201.29(c.3) Resident rights28 PA. Code 211.12(d)(1) Nursing services

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure that all residents had access to a call bell for assistance from staff for 6 of 10 residents observed. (Resident R3, R4, R5, R6, R8, R10).Findings Include:On February 4, 2026, at 10:39 a.m., an observation was conducted with the Director of Nursing, Employee E2, regarding the following residents:Resident R8's call bell was located behind her nightstand dresser, covered with a pillow, and was not accessible to resident.Resident R3's call bell was observed on the dresser and was not within reach.Resident R7's call bell was behind the bed and not accessible to the resident.Residents R5 and R6's call bells were hanging down and out of reach. A family member sitting next to Resident R6 reported that her call bell is often found on the floor and not accessible.Resident R10's call bell was wrapped behind her bed and not accessible to resident. These observations indicate that multiple residents did not have call bell that was accessible to them to request assistance.28 Pa. Code 201.14 (a) Responsibility of licensee28 Pa. Code 201.18 (b)(1) Management

Based on review of facility documentation, observations, and resident and staff interviews, it was determined that the facility failed to serve food at the proper temperature.Findings Include:A review of the facility's policy titled Food Temperatures Policy, revised February 2025, revealed that all hot food items must be cooked to appropriate internal temperatures and held and served at a temperature of at least 135 F. Temperatures must be taken frequently to monitor safe food-holding ranges of at or below 41 F for cold foods and at or above 135 F for hot foods.On December 18, 2025, at 10:39 a.m., an interview was conducted with Resident R1, who reported that the breakfast received that morning included sausages and pancakes that were served cold.On December 18, 2025, at 12:37 p.m., an interview was conducted with alert and oriented Resident R3, who reported a grievance regarding her dinner being served cold on December 13 and December 16, 2025.On December 18, 2025, at 12:27 p.m., a test tray was conducted with the Dietary Director, Employee E4. The following food temperatures were recorded: steamed broccoli at 121.8 F, sweet potatoes at 126 F, honey garlic chicken at 121.3 F, and juice at 46.3 F. Temperatures were taken by the Food Service Director (FSD), Employee E4, who confirmed that these foods were outside the acceptable temperature range for palatability.28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(3) Management

Based on review of facility policy, review of clinical records, and staff interviews it was determined the facility failed to ensure that residents were free from neglect for one of five residents reviewed. (Resident R1)Findings include: Review of policy titled Abuse Policy -Prevention and Management, last revised August 2025, revealed The Facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation/exploitation of resident/patient property by anyone including staff, family, friends, visitors, etc. The Facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation/exploitation of property. The facility must provide a safe resident environment and protect residents from abuse. This includes but is not limited to freedom from corporal punishment and involuntary seclusion. A review of Resident R1's clinical record revealed an admission date of March 11, 2020, with diagnosis of muscle weakness, contracture of multiple sites, chronic fatigue, and multiple sclerosis (autoimmune disorder that affect the central nervous system). Review of Resident R1's annual Minimum Data Set (MDS- assessment of resident care needs) dated September 25, 2025, revealed Resident R1 had a BIMS (Brief interview of Mental Status) of 15 which indicated the resident's cognitive intact. Continued review of the MDS assessment revealed the resident was dependent for bed mobility and was dependent on staff for transfers to and from bed to chair. MDS assessment also revealed, dependent status coding indicates Helper does all of the effort. Residents do none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Review of Resident R1's care plan dated October 6, 2025, revealed Resident R1 required functional level of assist is max assist for bed mobility and use of Hoyer lift for transfers in/out of bed to power wheelchair . resident is to have 2 people with care/bed mobility and transfers. Review of documentation submitted to the State Survey Agency on December 10, 2025, revealing On 12//8/2025, during the evening shift, Resident R1 fell from bed while receiving care. Resident R1 was turning to her side with the assistance of the certified nurse, [Employee E10]. As she turned on her side she slid from the side of the bed onto her knees and onto the floor. Upon immediate assessment, [Resident R1] sustained no obvious injuries, bruises or swellings, however she did complain of bilateral knee pain. Physician was notified and new order noted for x-ray of bilateral knees to rule out fractures. An investigation was started to rule out abuse and neglect, which revealed that agency staff, [Employee E10], failed to follow the plan of care for [Resident R1] by performing bed mobility without a 2-person present and was using her personal cellphone and wearing ear buds in the resident care area at the time of the incident. [Resident R1] is AAOx3 (person, time and place) with BIMS 15, is bed bound, she requires a total lift for transfers and 2 people for care/bed mobility. Resident R1 was interviewed and stated that while she was receiving care, the aid was alone, on her phone and wearing ear buds. The facility made [Employee E10] a do not return to the facility and reported her to her agency. The facility immediately began to re-educate all license and certified nursing staff on following the plan of care with regards to bed mobility and performing care and on the facility's no tolerance policy for cell phone use/earbuds in the resident care areas. Facility has substantiated the allegation of neglect regarding [Employee E10]. On December 18, 2025, at 10:39 a.m., an interview was conducted with Resident R1, who reported that she experienced a fall on December 8, 2025, during the evening shift and received care from only one nursing aide, Employee E10, who was on her cell phone and wearing earbuds. Resident R1 reported that she did not sustain any injuries and experienced only minor pain after the fall. She also stated that nursing staff did not come to assess her on the night of the fall. A review of the facility's internal investigation revealed statement from the nurse aide, Employee E10 which revealed the following I was changing [Resident R1] and as I went to turn her she wasn't holding on to the rail and her feet was handing off the bed a little so I went over to try and put back up but couldn't so I just slid her down to the floor and went and got help to put her back on the bed I got done changing her asked if she was okay and she said yes I asked her if anything hurt she said her knee was hurting a little I don't think it was from that because she didn't hit the floor. Review of nursing note dated December 9, 2025, written by licensed nurse Employee E9, revealed: The resident mentioned to the aide that during PM care the previous night, she bumped her knees during a transfer. Neurological checks were initiated, and vital signs were obtained; all were within normal limits. The resident was offered Tylenol but denied any pain or discomfort. No signs of distress were noted. An X-ray was ordered. The physician and POA were notified. On December 18, 2025, at 2:05, an interview with the Director of Nursing, Employee E2, confirmed that the facility substantiated neglect involving Resident R1. The nursing aide, Employee E10, had their agency notified of the substantiated neglect and was placed on the do-not-return list. X-ray results of both knees were ordered and were negative for any fractures. 28 Pa. Code 201.18(b)(1) Management 28 Pa Code 211.12.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility did not ensure that all allegations of neglect were reported immediately to the Pennsylvania Department of Health for one of 5 residents reviewed. (Resident R1).Findings Include:A review of the facility policy titled Incident Reporting and investigation of accident hazards, supervision, assistive device, last updated October 2025, revealed It is the policy of the Facility to monitor and evaluate any adverse occurrence which is not consistent with the routine operation of the Facility or care of a resident(s). All accidents/incidents where there is mistreatment, neglect, abuse or injuries of unknown origin will be reported to the Director of Nursing (DON) and Administrator (NHA) immediately for further review and reporting based on State and Federal regulations. A review of Resident R1's nursing notes revealed admission date of March 11, 2020, with diagnosis of muscle weakness, contracture of multiple sites, chronic fatigue, and multiple sclerosis. Review of Resident R1's annual Minimum Data Set (MDS- assessment of resident care needs) dated September 25, 2025, revealed Resident R1 had a BIMS (Brief interview of Mental Status) of 15 which indicated the resident's cognitive intact. Continued review of the MDS assessment revealed the resident was dependent for bed mobility and was dependent on staff for transfers to and from bed to chair. MDS assessment also revealed, dependent status coding indicates Helper does all of the effort. Residents do none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Review of Resident R1's care plan dated October 6, 2025, revealed Resident R1 required functional level of assist is max assist for bed mobility and use of Hoyer lift for transfers in/out of bed to power wheelchair . resident is to have 2 people with care/bed mobility and transfers. Review of the documentation submitted to the State Survey Agency on December 10, 2025, revealing On 12//8/2025, during the evening shift, [Resident R1] fell from bed while receiving care. [Resident R1] was turning to her side with the assistance of the certified nurse, [Employee E10]. As she turned on her side she slid from the side of the bed onto her knees and onto the floor. Upon immediate assessment, [Resident R1] sustained no obvious injuries, bruises or swellings, however she did complain of bilateral [NAME] pain. Physician was notified and new order noted for x-ray of bilateral knees to rule out fractures. An investigation was started to rule out abuse and neglect, which revealed that agency staff, [Employee E10], failed to follow the plan of care for [Resident R1] by performing bed mobility without a 2-person present and was using her personal cellphone and wearing ear buds in the resident care area at the time of the incident. [Resident R1] is AAOx3 (alert and oriented to people, places and time) with BIMS 15, is bed bound, she requires a total lift for transfers and 2 people for care/bed mobility. Resident R1 was interviewed and stated that while she was receiving care, the aid was alone, on her phone and wearing ear buds. The facility made Employee E10 a do not return to the facility and reported her to her agency. The facility immediately began to re-educate all license and certified nursing staff on following the plan of care with regards to bed mobility and performing care and on the facility's no tolerance policy for cell phone use/earbuds in the resident care areas. Facility has substantiated the allegation of neglect regarding Employee E10. On December 18, 2025, at 10:39 a.m., an interview was conducted with Resident R1, who reported that she experienced a fall on December 8, 2025, during the evening shift and received care from only one nursing aide, Employee E10, who was on her cell phone and wearing earbuds. Resident R1 reported that she did not sustain any injuries and experienced only minor pain after the fall. She also stated that nursing staff did not come to assess her on the night of the fall. A review of the facility's internal investigation revealed a statement from Resident R1 which was facilitated by the social worker, Employee E11 and revealed that Resident R1 reported that I fell to the floor and then the girl on the phone went and got another CNA (nurse aide). They put me back in bed, No one elver came back to my room on that shift. Once the 11-7 nurse came in my room I said my knee hurts because I feel. A review of the facility's internal investigation revealed statement from the nurse aide, Employee E10 which revealed the following I was changing [Resident R1] and as I went to turn her she wasn't holding on to the rail and her feet was handing off the bed a little so I went over to try and put back up but couldn't so I just slid her down to the floor and went and got help to put her back on the bed I got done changing her asked if she was okay and she said yes I asked her if anything hurt she said her knee was hurting a little I don't think it was from that because she didn't hit the floor. Review of nursing notes dated December 9, 2025, written by licensed nurse Employee E9, revealed: The resident mentioned to the aide that during PM care the previous night, she bumped her knees during a transfer. Neurological checks were initiated, and vital signs were obtained; all were within normal limits. The resident was offered Tylenol but denied any pain or discomfort. No signs of distress were noted. An X-ray was ordered. The physician and POA (power of attorney) were notified. An interview with the Director of Nursing, Employee E2, confirmed that the certified nursing assistant, Employee E10, did not report the fall to the nursing staff on December 8, 2025, during the 3:00 p.m. to 11:00 p.m. shift. Based on the nursing progress note dated December 9, 2025, written by licensed nurse Employee E9, this was the first time the facility became aware of the fall, when Resident R1 reported it to Employee E9 on December 9, 2025. The Director of Nursing confirmed that staff failed to notify the nursing staff during both the 3:00 p.m. to 11:00 p.m. shift and the 11:00 p.m. to 7:00 a.m. shift on December 8, 2025. 28 Pa. Code: 201.14(a)(c) Responsibility of licensee28 Pa. Code: 201.18(b)(1)(e)(1) Management28 Pa. Code 211.12(c)(d) Nursing services

Based on review of facility policy, review of clinical record, review of facility provided documentation and interview with resident and staff, it was determined that facility did not ensure a resident received treatment and care in accordance with professional standards of practice related to heat therapy for one of five residents reviewed. (Resident R1)Findings include:Review of facility policy 'Hydrocollator - therapy,' revised November 7, 2022, indicates that hydrocollator temperature should be checked daily (therapeutic temperature range is 150-170 degrees Fahrenheit. This is the responsibility of therapy department.Further review of policy indicates the following: 10. Place hot pack in cover holder/envelope.11. wrap the hot pack in layers of toweling and place on the resident /patient's affected area.12. check the resident/patient's skin as indicated after application to ensure skin integrity.13. if skin presents with redness or is hot to the touch add another 2 layers of toweling for safety.14. skin should be routinely checked.17. report any injury or excessive redness to nursing immediately and fill out an incident report if indicated.18. document the patient's response to treatment and the need for continued skilled intervention.Review of Resident R1's clinical record revealed that R1, a [AGE] year old male resident was found to have a left shoulder blister on September 5, 2025, measuring 3.5cm length by 2.0cm in width; the resident explained that that it happened during a prior physical therapy session where a heating pad was put on it after he complained of left shoulder pain.Review of facility provided documentation revealed that on September 5, 2025, the facility became aware that Resident R1 sustained a blister on the left shoulder after using a heating pad from the hydrocollator. Resident R1 was noted to receive heat therapy to the left shoulder on September 2, 2025. Per therapist and resident statements, all the time of usage on September 2, 2025, there was no evidence of injury .Interview with physical therapy associate, Employee E3, on September 15, 2025 at 12:45 pm, revealed that redness was noted on resident's left shoulder after heat therapy treatment on September 2, 2025. No complaint of pain or discomfort voiced by resident post treatment.Further interview with physical therapy associate, Employee E3 revealed that while administering heat therapy to Resident R1 on September 2, 2025 - heat pack was placed in envelope, wrapped in two layers of towels, placed on resident's left shoulder and skin was checked after treatment - not after initial application, and not checked routinely as per facility's policy/ protocol.Review of facility provided statement from Resident R1 on September 5, 2025, indicated that he did not experience any pain post treatment on September 2, 2025, until Friday, September 5, 2025, while getting dressed - he had pain in left shoulder.Interview with Nurse aide, Employee E5, on September 15, 2025, at 1:55 pm, revealed no indication that skin concerns were noted during Resident R1's scheduled bath/shower time on Wednesday, September 3, 2025, evening shift.Further review of facility provided documentation revealed that temperature in the hydrocollator was not checked daily as per their policy, on the following dates: September 1, 2025 through September 4, 2025, August 2, 2025, August 3, 2025, August 9, 2025, August 10, 2025, August 16, 2025, through August 31 2025.Facility did not ensure to complete daily hydrocollator temperature checks and did not ensure to accurately assess and report skin changes as per policy. 28 Pa Code 211.12(d)(1)(2)(3)(5) Nursing services28 Pa Code 211.10(a)(d) Resident care policies

Based on review of facility policy, review of facility documentation, and staff and resident interviews, it was determined that the facility failed to ensure residents were kept free from abuse and neglect for two of three residents reviewed (Resident R1 and R3). Findings Include: Review of facility policy Abuse Policy - Prevention and Management reviewed August 2024, revealed the facility prohibits the mistreatment, neglect, and abuse of residents. The facility must provide a safe resident environment and protect residents from abuse. Review of Resident R1's clinical record revealed a quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated May 3, 2025, which indicated the resident was cognitively intact, determined by a Brief Interview for Mental Status (BIMS) score of 15. Continued review of Resident R1's quarterly MDS dated [DATE], revealed the resident had diagnoses of anxiety (feeling of worry, fear, nervousness) and depression (persistent feeling of sadness and loss of interest). Review of facility documentation originally submitted to the State Survey Agency on May 25, 2025, revealed Resident R1 alleged on May 24, 2025, the nurse aide, Employee E3, hit Resident R1's foot with a linen cart and was verbally abusive toward the resident. Review of statement by Registered Nurse (RN), Employee E4, dated May 24, 2025, revealed on 5/24/2025 at approximately 5:15 p.m. Resident R1 called for the nurse and subsequently reported to the RN, Employee E4, that nurse aide, Employee E3, purposely hit the resident's foot with a cart. Nurse aide, Employee E3, overheard Resident R1 speaking with Registered Nurse, Employee E4, and came out of a room and began yelling at the resident. Further review of the statement by Registered Nurse, Employee E4, revealed the nurse aide, Employee E3, began verbally attacking the resident saying, I should throw you out of that chair, then you'll see . if my people were up here then you would find out!. As the Registered Nurse, Employee E4, was escorting nurse aide, Employee E3, off the nursing unit they passed Resident R1's room and the nurse aide, Employee E3, stopped at the resident's room yelling You are a lucky b*!~ because my family isn't here. Continued review of the statement by Registered Nurse, Employee E4, revealed 911 (Emergency Medical Services) was promptly called and when police arrived the nurse aide, Employee E3, was escorted out of the building and trespassed from the property. Interview with the Nursing Home Administrator on 6/17/2025 at 10:00 a.m. revealed that nurse aide, Employee E3, was an agency employee and the staffing agency was notified that the employee was no longer allowed to return to the building to work. Based on staff witness statements and staff interview, it was confirmed that nurse aide, Employee E3, was verbally abusive, loud, and threatening toward Resident R1. Review of Resident R3's clinical record revealed a quarterly MDS dated [DATE], which indicated that the resident was cognitively intact, determined by a BIMS score of 15. Continued review of Resident R3's clinical record revealed the resident had diagnoses of depression, muscle weakness, and need for assistance with personal care. Review of facility documentation submitted to the State Survey Agency revealed on May 14, 2025, on the 7:00 a.m. to 3:00 p.m. shift, Resident R3 reported to nurse aide, Employee E7, that on the previous shift (May 13, 2025, 11:00 p.m. to 7:00 a.m.) the resident needed to be changed but was afraid to put the call bell on to ask for assistance. Resident R3 reportedly overheard his/her assigned nurse aide, Employee E8, in the hallway saying, why does [he/she] keep putting the call light on I already went in there twice and gave water. Resident R3 reported feeling intimated and did not want to report in fear of retaliation. Review of statement by nurse aide, Employee E8, dated May 15, 2025, revealed the employee indicated that on May 13, 2025, during the 11:00 p.m. to 7:00 a.m. shift Resident R3 was dry during rounds at 12:00 a.m., was given water but not changed at 4:00 a.m., and subsequently Resident R3 was given care and changed at 6:00 a.m. with the assistance of the charge nurse, Employee E9. Review of facility documentation dated May 19, 2025, revealed licensed nurse, Employee E9, was interviewed and was unable to support the claims that he/she was present for care at 6:00 a.m. per nurse aide, Employee E8's statement. Review of statement dated May 19, 2025, by Nurse aide, Employee E7, revealed on May 14, 2025, around 7:45 a.m. [Resident R3] stated to me that [he/she] had on the same brief from yesterday [May 13, 2025] that I put on at 10:00 p.m. Resident R3 reported to nurse aide, Employee E7, that he/she did not get changed at all by assigned nurse aide, Employee E8, through the May 13, 2025, 11:00 p.m. to 7:00 a.m. shift. Further review of statement by nurse aide, Employee E7, revealed Resident R3's bed was soaked, and the whole bed had to be changed. Nurse aide, Employee E7, indicated that the bed needed to be cleaned with bleach due to the strong urine odor. Continued review of facility documentation revealed the facility expanded the investigation and interviewed similar residents who were under the care of nurse aide, Employee E8, during May 13, 2025, 11:00 p.m. to 7:00 a.m. shift. Review of facility documentation revealed Resident R4 was interviewed who reported nurse aide, Employee E8, makes the resident feel uncomfortable by saying mean things such as you have to wait, with a nasty disposition. Resident R4 reported that nurse aide, Employee E8, started the shift with an attitude and is very inpatient. Based on staff statements and interviews the facility subsequently substantiated allegation of mental abuse and neglect. Nurse aide, Employee E8, was terminated as an employee of the facility as of May 20, 2025. 28 Pa. Code 201.29 (c) Resident rights.

Based on review of clinical records, facility policy, facility investigative reports, and interview with staff, it was determined the facility failed to ensure hospice staff implemented care-planned interventions for one of 34 residents reviewed, who was identified as a fall risk. This failure resulted in actual harm to Resident R24 who sustained a fall out of bed during care, required transfer to the hospital via emergency medical services and sustained four sutures to left forehead/eyebrow and back of the head. (Resident R24) Findings include: Review of facility policy titled, Fall Prevention and Management revised January 1, 2023, revealed the interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. Review of subsection titled, Procedure revealed 1. Assess and review resident risk factors for falls and injuries upon admission, re-admission, quarterly, annually a significant change and/or after a fall. Review the completed Fall Risk Assessment/ Evaluation. Review other interdisciplinary Team (IDT) assessments as they related to fall risks. 2. Implement goals and interventions with input from resident/family if able for inclusion in Interdisciplinary Plan of Care based on individual needs after attempting to determine possible causes. 3. Communicate interventions to the care giving teams and family responsible party. Review of facility policy titled, Incident Reporting and Investigation of Accident Hazards, Supervision, Assistive Devices, revised October 30, 2024, revealed assistance Devices or Assistive Device refers to any item (e.g. fixtures such as handrails, grab bars, and mechanical devices/equipment such as stand- alone or overhead transfer lifts, cane, wheelchairs, and walkers) that is used by, or in the care of a resident to promote, supplement, or enhance the resident's function or safety . Environment refers to any environment in the facility that is frequent by or accessible to resident including (but not limited to) the resident 's rooms, bathrooms, hallway, dining areas, lobby, outdoor patios, therapy areas and activity areas. Review of facility policy titled Care Planning Process and Care Conference, revised March 19, 2025, revealed the purpose of policy is to assure that all services, as outlined by the comprehensive care plan being provided, meet professional standards of quality, including activities of daily living (ADL's), falls, skin tears, risk for skin breakdown, nutritional status, behaviors . Review of Resident R24's clinical record revealed the resident's diagnoses of Dementia (progressive decline in mental ability), Parkinson's disease (disorder of central nervous system that affects movement), and Anxiety (mental health condition characterized by excessive fear or anxiety that interferes with daily activities) Review of R24's quarterly Minimum Data Set (MDS- assessment of resident's care needs) completed on August 14, 2024, revealed BIMS score of 2 which indicated the resident had severe cognitive impairment. Continued review of the MDS assessment revealed the resident was determined to require extensive assistance of one person physical assist for bed mobility. Review of Resident R24's physician orders revealed an order initiated April 16, 2024, for ¼ side rail enablers to bed bilaterally to assist with bed mobility and increase functional independence. Review of Resident R24's care plan initiated November 18, 2024, revealed the care plan included the use of 1/4 siderail enablers to bed bilaterally to assist with bed mobility and increase functional dependance. Intervention listed ensure enablers are up at all times while resident is in bed. Review of information dated September 3, 2024 submitted by the facility to the Department of Health revealed, On 9/3/2024 while performing personal care, the aide from [hospice provider] turned [resident] toward her in the bed to assist (resident) with pulling up (his/her) pants. The aide was attempting to walk to the other side of the bed to finish up, and did not realize that [resident] was holding on to her (aide) pocket. [Resident R24] fell from the bed to the floor. [Resident R24] sustained a laceration to (his/her) left eyebrow and the left back side of (his/her) head. First aid was applied to the area and 911 was called. [Resident R24]'s daughter was notified regarding the fall. [Resident] was taken to [area hospital] where (he/she) received 4 sutures to (his/her) left eyebrow and 4 staples to the left back side of (his/her) head. [Resident] returned to the facility around 2028. Care plan reviewed and updated. New intervention noted for 2-person assist with bed mobility noted. Review of nursing documentation dated September 3, 2024, at 11:45 a.m. revealed the hospice nurse aide called nurse on duty for help, upon arrival resident was on the floor in supine (lying on one's back with face upward) position. Resident had two lacerations on the head, one above (his/her) left eyebrow and the left side of the head. Injury site was cleansed with normal saline, gaze applied, Bright blood noted pressure applied to the area . on O2 (oxygen) @ 2L (liters). 911 (emergency medical services) called to transfer resident to [local hospital]. Continued review of nursing notes dated September 4, 2024, revealed Resident did return with 4 sutures in left forehead/eyebrow, 4 stapes left side of head. Review of facility investigation report, completed on September 4, 2024, revealed on September 3, 2024, while receiving care from hospice nurse aide, Employee E3, at approximately 11:45 a.m., Resident R24 had a witnessed fall that resulted in a transfer to hospital where [he/she] received four sutures to [his/her] left eyebrow and four staples to the left back side of [his/her] head. Further review of same report revealed the hospice nurse aide, Employee E3 turned Resident R24 toward her in bed to assist him/her with pulling up his/her pants; the aide was attempting to walk to the other side of the bed to finish up, and did not realize Resident R24 was holding onto aide's pocket. Resident R24 fell from bed to the floor. The resident sustained two lacerations on the head. Further review of Resident R24's fall incident/accident investigation report, completed on September 3, 2024, at 11:45 a.m., revealed one of the question on the report was were proper tools/equipment being used? for which the answer was marked as no, without further description. Review of hospice nurse aide, Employee E3's statement failed to reveal evidence bilateral 1/4 side rail enablers were utilized at the time. Interview with hospice nurse aide, Employee E3 on Friday, May 9, 2025, at 10:40 a.m., revealed Employee E3 was not aware the resident's care plan and physician's order indicated the need for bilateral ¼ side rails as mobility enablers. The facility failed to ensure hospice staff were aware of Resident R24's care plan interventions related to the use of 1/4 side rails while in bed for safety. This failure resulted in actual harm to Resident R24 who was holding onto nurse aide, Employee E3's pocket while in bed, fell out of bed when Employee E3 moved away from resident, sustaining four sutures to left forehead/eyebrow and four sutures to the back of the head. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1)(e)(1) Management 28 Pa Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of facility policy, resident clinical records, and staff interviews, it was determined that the facility failed to obtain a physician order and develop a comprehensive care plan for for hospice services for one of eight residents reviewed (Resident R8). Findings include : Facility policy titled Clinical Manual/Social Services Manual last reviewed April 2025 revealed It is the policy of this facility to participate in hospice care as an approach to caring for terminally ill residents that require palliative care as opposed to providing curative care. Based on Federal guidelines, the Facility has the following options as it relates to Hospice Care: i. Arrange for the provision of hospice services through an agreement with one or more Medicare-certified. It further revealed under iii D (f). Obtaining the following information from the hospice: The most recent hospice plan of care specific to each resident (f) Hospice physician and attending physician (if any) orders specific to each patient. v. The facility must ensure that each resident's written plan of care includes both the most recent hospice. Interview conducted on June 11, 2025, at 10:43 a.m., with Licensed nurse, Employee E4, who reported that Resident R8 was a resident receiving hospice services (supportive services for end-stage terminal illness). It was further reported that hospice aide, Employee E6 had offered morning care, but Resident R8 refused. Employee E6 stated they would return in an hour to attempt to offer morning care again. Review of Resident R8's clinical record revealed that the resident was admitted to the facility on [DATE]. Review of Resident R8's physician orders did not include a physician's order for hospice care. On June 11, 2025, at 11:43 a.m., an interview was conducted with the Director of Rehabilitation, Employee E7, who confirmed that Resident R8 has half railings on her bed. According to her last physical therapy discharge evaluation, which occurred on March 23, 2025, Resident R8 could benefit from the use of the railings. Resident R8 is able to perform some movements with her upper extremities and would therefore benefit from the use of enablers during morning care. Review of Resident R8's clinical record revealed that there was no comprehensive care plan developed by the facility for hospice services and the coordination of services with the contracted hospice provider or for the use of enablers to support the resident's independence during morning care. Interview conducted on June 11, 2025, at 10:49 a.m., with licensed nurse, Employee E5, who provided a hospice communication binder. The binder reflected that Resident R8 had been on hospice since May 31, 2025, and that a hospice contractor's care plan was created on the same date. It was further revealed that the hospice care plan did not include any instructions regarding the resident's use of enablers. The last documented hospice service that was received and documented in the binder was June 9, 2025. This was confirmed by Employee E5. On June 11, 2025, at 10:59 a.m., an interview was conducted with charge nurse Employee E4, who confirmed that Resident R8 had no physician order for hospice and no comprehensive care plan for hospice services or the use of enablers. Based on the clinical record and her knowledge, it was unknown how often Resident R8 received hospice services at the facility. Employee E4 further stated, 'I don't know who is responsible for entering the physician order and comprehensive care plan. On June 11, 2025, at 11:01 a.m., an email was sent to the Director of Nursing notifying them that the clinical record did not include documentation of hospice services for Resident R8. Shortly thereafter, a physician order and comprehensive care plan were entered into Resident R8's clinical file. On June 11, 2025, at 11:07 a.m., an interview was held with hospice contractor aide, Employee E6, who reported that this was her first time providing hospice services to Resident R8. Employee E6 was unsure whether Resident R8 was permitted to use enablers. When asked to describe the morning care order, she did not provide any information regarding enablers. She further reported that she follows the hospice contractor's care plan specifically designed, which she could not recall. Then access her phone to view the specific care plan for Resident R8, it was found that the care plan did not include any reference to enablers. It was also confirmed that hospice contractor aides do not have access to the facility's electronic comprehensive care plan. On June 11, 2025, at 12:33 p.m., a meeting was held with the Administrator (Employee E1), Director of Nursing (Employee E2), and Regional Nurse (Employee E10) confirmed hospice aides do not have access to residents' electronic care plans. 28 Pa. Code: 201.14 (a) Responsibilities of licensee. 28 Pa. Code: 201.18 (b)(1)(3) Management. 28 Pa. Code: 201.20(a) Staff development. 28 Pa. Code: 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed monitor and serve hot beverages at a safe temperature. This failure resulted in Immediate Jeopardy situation to Resident R371 who spilled a hot beverage and sustained a second degree on the right thigh for one of four residents reviewed. (Resident R371) Findings include: Review of facility policy Hot Liquid Safety last revised February 24, 2023, the intention of the policy was to minimize the risk for potential injury related to burns caused by hot liquids. Continued review of the facility policy revealed that residents will be evaluated on admission, readmission, quarterly and change on condition to ensure appropriate precautions will be implemented. If the resident triggers for any risk factors such as: weakened strength, impaired cognition, contractures of upper extremities, vision impairment, balance issues and nerve of muscular conditions (termers, cerebral palsy, multiple sclerosis, Parkinson disease, cerebrovascular accident, Huntington's disease, and traumatic brain injury). Further eval should be completed by occupational therapy physical therapy and or speech therapy. Continued review of the facility policy of hot liquid safety revealed that it is the facility staff responsibility to implement interventions such as serving temperatures at point of service no greater than 140 degrees Fahrenheit, serving hot beverages in a cup with a lid, providing protective lap covering, staff supervision or assistance. Review of Resident R371's Significant Change Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 18, 2024, revealed the resident was cognitively impaired with a BIMS (brief interview of mental status) score of 4 which indicated that the resident was cognitively impaired. Further review of the MDS indicated that Resident R371 had impairment in range of motion to upper extremity on one side. The MDS revealed the resident had diagnoses including Parkinson's disease (progressive disease of the central nervous system characterized by tremors, muscle weakness and unsteady gait), Arthritis (joint inflammation), and malnutrition. Continued review of Resident R371's MDS revealed the MDS section G0130 A. Eating - how resident eats and drinks, regardless of skill was coded as Substantial, Maximal assistance -the resident is minimally involved in the activity, the helper does more than half the work. Review of Hot Liquid Safety Evaluation dated February 1, 2024, revealed that Resident R371 was determined to be visually impaired, cognition impaired, altered level of consciousness, weakened upper extremity strength, tremors, demonstrated difficulty handling eating equipment, had contractures, and balance issues. Review of Physical Therapy Evaluation dated January 15, 2024, Resident R371 was refereed to pt (physical therapy) due to exasperation of decrease in strength, decrease in functional mobility, decrease in transfers, reduced ability to ambulate, decreased judgement, increased need for assistance from other and reduced ADLs (activities of daily living). Continued review of this physical therapy evaluation revealed that Resident R371 was identified to have Hypotonic (weak) muscle tone, kyphotic posture /gross motor coordination impaired. The resident required total dependence for mobility and transfers. Review of Occupational Therapy evaluation dated February 2, 2024, revealed Resident R371 was assessed with impaired range of motion, his shoulders were very limited, and his fine motor coordination was impaired. Review of facility documentation provided to the State Survey Agency on February 1, 2024, revealed Resident R371 was dining in the common room and dropped a cup of hot water on his right thigh. Upon further investigation, it was determined that, Licensed Nurse, Employee E10 provided Resident R371 with a cup of hot water from the kitchen lunch trucks and prepared hot tea for the resident. It was further identified that the temperature of the beverage may not have been temped. Review of Resident R371's progress nurses note dated February 1, 2024, revealed that the resident presented with a 7.9 centimeter (cm) x 7.8 cm x 0.1 cm area flat fluid filled blister. Review of Resident R371's physician orders revealed a physician order dated February 2, 2024, to apply Silvadene External Cream 1% (topical antibiotic cream used to treat burns and prevent infection) daily for burn. Review of facility investigation into the incident revealed a written statement dated February 1, 2024, by Licensed nurse, Employee E10 this nurse gave [Resident 371] tea with hot water at lunchtime, I was not aware the water was so hot. No, I did not heat the water up and no family was present. Interview with Licensed nurse, Employee E10 on July 17, 2024 at 12:40 p.m. confirmed that she handed the cup of hot water to Resident R1, she placed it on his lunch tray. He picked it up and spilled it. Licensed nurse, Employee E10 immediately brought Resident R371 to his room, undressed him and applied cool compress. Unit manager, Licensed nurse Employee E7 was presented during the above interview. Review of facility documentation revealed a written statement dated February 1, 2024, by nurse aide, Employee E55, stated Today at lunchtime [Resident R371] stopped me as I was collecting trays. He asked if I could help him. I answered yes, how can I help? [Resident R371] explained that he had dropped his tea and that he had spilled it on himself. I checked and then contacted the nurse on the floor to explain what [Resident R371] had told me and what I have seen. The nurse verified what she was told and asked me to get a cold compress and the nurse placed it on his leg and I went back on the floor and provided care and collect the remaining trays. An interview with nurse aide, Employee E55 was attempted but unsuccessful. Observations conducted on July 17, 2024, during the lunch meal on the common area on the Fourth floor (dementia unit) revealed that residents were served hot coffee and hot tea. The steam coming from the top the cups was spotted. The Dietary Director, Employee E43 tested the tempeture of the cart carafe, the temperature was reported as 152 degrees Fahrenheit. Review of facility documentation Food Temperature Log for July 1-15, 2024 noted that the hot beverage temperature should not exceed 140 degrees. Fill temps log out for every truck. Temps should be recorded from the carafe. Review of the Food Temperature Log sheets revealed hot beverages were not temped on the following days and meals: 7/3/24 dinner, 7/4/24 lunch and dinner; 7/5/24 dinner,7/9/24 dinner, and 7/10/24 breakfast, lunch and dinner. The completed logs for these dates indicated that the temperatures for each carafe was measured as 140 degrees Fahrenheit in the kitchen and temperatures on the floor ranged from 130 -139 degrees Fahrenheit. Interview with Dietary Director, E43 revealed that the kitchen staff has not been taking any temperatures since he began his position two weeks prior. Dietary Director, Employee E43 confirmed that the recent tempeture logs were inaccurate. Review of tempeture logs revealed on February 1, 2024, the day Resident R371 sustained a Second degree burn on his thigh, the temperatures of the hot beverage ranged from 140 degrees Fahrenheit in the kitchen to 135 degrees Fahrenheit at point of service. The lunch temperatures were signed by Dietary staff, Employee E50. Interview with Dietary staff, Employee E50 on July 17, 2024, at 11:35 a.m. revealed coffee maker was not working that day the heater element was broke he further stated the hot water and coffee dispensed from the machine was not hot. Employee stated the temps reported in the tempeture log were inaccurate. Interview with Nursing Home Administrator, Employee E1 confirmed service was completed on February 1, 2024, for the coffee/hot water machine. Employee E1 provided a service invoice for the repair of the coffee/ hot water machine. Interview with technician of the coffee service company on July 18, 2024, at 12:14 p.m. confirmed that on February 1, 2024, the company sent a service technician to the facility to repair the coffee machine. The service technician indicated the water before the machine was fixed the temp was reported at 90 degrees Fahrenheit thermostat was replaced at set at tempeture of 140 degrees Fahrenheit. An Immediate Jeopardy situation was identified to the Nursing Home Administrator, Employee E1 on July 18, 2024, at 12:24 p.m. for the facility's failure to ensure that hot beverages were served at safe temperatures and failure to provide appropriate supervision during meal service, resulting in Resident R1 sustaining a Second degree burn on his right thigh from hot water. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator and Director of Nursing on July 18, 2024, at 12:24 p.m. The following action plan was received and accepted on July 18, 2024, at 4:45 p.m. -Licensed staff conducted a hot liquid safety evaluation for all residents in the facility. Any resident that triggers at risk will be evaluated further by occupational therapy to determined the resident requires assistance during meals or adaptive equipment. -All staff will be educated on the results of hot liquid safety assessment an intervention will be included in the resident care plan. -To ensure that tempeture of hot liquids is accurate, the facility developed a protocol and educated all staff on July 18, 2024 -Prior to hot liquids leaving dietary, a temperature will be taken by two staff members in Dietary. One staff member will take the temperature and the supervisor/designee will verify the accuracy of the temperature. The temperature will be documented on the hot beverage from along with both staff members signing off on this form. -Tempeture on the unit should not exceed 140 degrees Fahrenheit. -Any hot beverage temps over 140 degrees will be sent back to the dietary department for a replacement. -The hot beverage monitoring form will be submitted daily the NHA/designee for review to assure compliance. The Hot Liquid tools will be submitted to the Quality Assurance Committee for review. Interviews with 52 staff members from all departments were conducted on July 19, 2024. Review of Food Temperature Log sheets revealed hot beverage temperatures were monitored and documented for meals at dinner on July 18, 2024, dinner and July 19, 2024, breakfast and lunch. Observation of the Forth floor lunch meal confirmed that facility was obtaining and accurately recording the temperature of hot beverages. All staff members reported that they received education regarding the facilities updated Hot Liquid policy which included the hot beverage temps will be taken and verified by a second staff member, the resident have been evaluated to determine if more assistance is need for them. Hot liquids evaluations were conducted on 38 of 38 resident records reviewed. The Immediate Jeopardy was lifted on July 19, 2024, at 4:53 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.6(c)(d) Dietary Services

Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to developed interventions in Resident R108's baseline care plan, who was identified at high risk for falls. This failure resulted in actual harm to Resident 108 who sustained a fall and a left [CONDITION(S)]. The facility failed to develop baseline care plans within 48 hours of admission related to falls, [CONDITION(S)] medications, transmission based precautions, diabetes and cardiac conditions for six of 37 residents reviewed (Residents R108, R97, R270, R271, R273 and R83). Findings include: Review of facility policy, Baseline Care Plan - Guidelines undated, revealed that, Baseline Care Plan must be completed within 48 hours of admission to the facility. Continued review revealed, Until the Comprehensive Care Plan is completed, the Baseline Care Plan needs to be updated when addressing changes or needs. Review of Resident R108's hospital record revealed that the resident was admitted there on October 20, 2021, after experiencing multiple falls. The hospital record further indicated that the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record review for Resident R108 revealed that the resident was admitted to the facility on [DATE], at 9:28 p.m. with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of Resident R108's clinical record indicated that nursing staff had assessed Resident R108 upon admission and had identified the resident as being at high risk for falls. The clinical record further indicated that Resident R108 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician examined Resident R108 on October 28, 2021. The exam revealed that this resident was awake alert pleasant but cognitively impaired. Review of physical therapist documented on October 28, 2021 revealed that Resident R108 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident exhibited forward lean of trunk, inadequate hip extension, inadequate knee extension/flexion. and inadequate toe clearance associated with muscle weakness. Review of occupational therapist documentation dated October 28, 2021 revealed that Resident 108 needed assistance with personal care. Her limiting factors include decrease strength, balance and pain in left hip. Review of nursing notes dated October 30, 2021 at 7:21 a.m. indicated that Resident R108 experienced an unwitnessed fall. The resident complained of pain in the left lower extremity. Continued review of nursing notes on October 30, 2021 at 12:19 p.m. revealed that the physician gave orders at approximately 7:30 a.m. to x-ray resident's left hip related to status post [MEDICAL RECORD OR PHYSICIAN ORDER] Review of nursing documentation on October 30, 2021 at 12:31 p.m. revealed the results of the x-ray was a non displaced fracture in the greater trochanter (is a tubercle of the femur near its joint with the hip bone) of the left femur (thigh bone). The physician then gave orders to transfer Resident R108 to the hospital for this injury. Review of the facility investigation into the fall revealed that the resident was found lying on the left side, on the floor in her bathroom. Nursing Assistant, Employee E19, responsible for the care of Resident R108 on October 30, 2021 documented that she observed the resident in bed asleep three hours before the fall on October 30, 2021 at 1:00 a.m. and that she found the resident on October 30, 202 at 11:30 a.m. lying on the floor in the bathroom. Review of resident baseline care plan developed October 27, 2021 revealed that Resident R108 requiring one person physical assist for toileting (how a resident uses the toilet room, commode, bedpan or urinal; transfers on/off toilet; cleanses self after elimination) and bed mobility (how a resident moves to and from lying position, turns side to side and positions body while in bed) and a two person physical assist for transfers. The nursing staff indicated that Resident R108 was occasionally incontinent of bladder and bowel. Further review of Resident R108's baseline care plan dated October 27, 2021 under section title Safety Risk revealed that the resident was identified for falls and that the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no interventions or measures developed for the care of Resident R108, who was identified at high risk for fall. It was confirmed through interview with the Nursing Home Administrator, on December 2, 2021 at 1:00 p.m. that there was no documentation to indicate that the facility developed and implemented a care plan for safety precautions for Resident R108 as part of the baseline care plan. The facility failed to develop interventions to prevent falls in Resident 108's baseline care plan resulting in actual harm to Resident 108 who sustained a fall and a left [CONDITION(S)]. Review of Resident R97's Annual MDS (Minimum Data Set - a mandatory periodic resident assessment tool) dated August 2, 2021, revealed that the resident was admitted to the facility October 15, 2020, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Clinical record review for Resident R97 revealed a Fall Risk Evaluation, dated October 15, 2020, which indicated that the resident was identified as being at risk for falls related to confusion, chair bound status, use of assistive devices, medications and predisposing disease conditions. Review of Resident R97's baseline care plan, dated as completed October 17, 2020, revealed that there was no documentation on the baseline care plan that the resident was identified by the facility as being at risk for falls or any interventions/measures for fall prevention. Review of Resident R83's Admission MDS assessment, dated July 16, 2020, revealed that the resident was admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R83's Medication Administration Records (MARs) for July 2020, revealed that the resident received Lorazepam 0.5 mg (milligrams) twice a day for anxiety and [MEDICATION(S)] 50 mg daily for depression. Both medications were started on July 4, 2020. Review of a psychiatric (mental health) evaluation dated July 6, 2020, revealed that Resident R83's orders for Lorazepam and [MEDICATION(S)] were reviewed by the mental health provider and that the resident would continue to benefit from the use of these medications to manage his mood and behavior, to prevent regression and recommended that no medication adjustments were advised at that time. Review of Resident R83's baseline care plan, dated as completed July 6, 2020, revealed that there was no indication on the care plan that the resident received antianxiety and antidepressant medications. Interview on December 2, 2021, at 10:39 a.m. with licensed nurse Employee E14, revealed that she was unable to explain why Resident R83's baseline care plan did not include the resident's antianxiety or antidepressant medications. Review of Resident R270's clinical record revealed an admitted [DATE] diagnosed with [CONDITION(S)] and collapse ([CONDITION(S)]) Diabetes Mellitus (the body's inability to produce insulin), Congestive heart failure (the heard doesn't pump blood efficiently) and [CONDITION(S)] heart disease (disorder of the heart and blood vessels). Review of Resident 270's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident 270's baseline care plan revealed the facility failed to care plan the resident with goals and interventions related to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R271's Clinical Admission Evaluation dated November 27, 2021 indicated on admission the resident was diagnosed with C-diff. (Clostridioides difficile is a bacterium infection in the large intestines). Continue review of the Clinical Admission Evaluation further stated, Continues with contact precautions related to C-diff. Review of Resident R271's baseline care plan, completed on November 28, 2020, revealed no indication the resident was on contact precautions related to C-diff and interventions for the care of Resident 271 related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident R273's November 2021 physician order's revealed an admitted [DATE] diagnosed with Extended Spectrum Beta Lactamase (ESBL) resistant ( an infectious disease where it's enzyme makes it harder to kill bacteria with most antibiotics) and Type II Diabetes. Further review of the orders revealed on November 10, 2021 orders for [MEDICATION(S)] Sodium (antibiotic) 500 mg given intravenously for 2 days for ESBL and Glucose (sugar) reading, done before meals and at bedtime, including 10 units of Novolog insulin given subcutaneously before meals and 14 units of Insulin [MEDICATION(S)] subcutaneously at bedtime for controlling the diabetes. Review of Resident R273's baseline care plan revealed no interventions and instructions for the care of Resident 273 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.11(b) Resident care plan 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to properly supervised a resident who was identified at high risk for falls (Resident R108). This failure resulted in actual harm to Resident 108 who sustained a fall and a left [CONDITION(S)]. The facility failed to ensure the proper transfer for a resident from bed to chair (Resident R83) for two of 37 residents reviewed (Resident R108 and Residents R83). Findings include: Review of an undated facility policy titled, Skills Check List for Mechanical Lifts revealed that two persons are always needed to utilize the lifts. Review of Resident R108's hospital record revealed that the resident was admitted to the hospital on October 20, 2021, after experiencing multiple falls. The hospital record further indicated that the resident had a diagnosis of dementia (a type of brain disorder that causes problems with memory, thinking and behavior). Review of the clinical record review for Resident R108 revealed that the resident was admitted to the facility on [DATE], at 9:28 p.m. with diagnoses including high blood pressure, muscle weakness and a history of falling. Continued review of Resident R108's clinical record indicated that nursing staff had assessed Resident R108 upon admission and had identified the resident as being at high risk for falls. The clinical record further indicated that Resident R108 had a history of one to two falls in the past three months. The physician examined Resident R108 on October 28, 2021. The exam revealed that this resident was awake alert pleasant but cognitively impaired. Review of physical therapist documented on October 28, 2021 revealed that Resident R108 had a history of falls, muscle weakness. The physical therapy staff assessed Resident R108 as requiring moderate assist for transfers using a contact guard (or one person assist) and poor standing balance. The resident exhibited forward lean of trunk, inadequate hip extension, inadequate knee extension/flexion. and inadequate toe clearance associated with muscle weakness. Review of occupational therapist documentation dated October 28, 2021 revealed that Resident 108 needed assistance with personal care. Her limiting factors include decrease strength, balance and pain in left hip. Review of nursing notes dated October 30, 2021 at 7:21 a.m. indicated that Resident R108 experienced an unwitnessed fall. The resident complained of pain in the left lower extremity. Continued review of nursing notes on October 30, 2021 at 12:19 p.m. revealed that the physician gave orders at approximately 7:30 a.m. to x-ray resident's left hip related to status post fall. Review of nursing documentation on October 30, 2021 at 12:31 p.m. revealed the results of the x-ray was a non displaced fracture in the greater trochanter (is a tubercle of the femur near its joint with the hip bone) of the left femur (thigh bone). The physician then gave orders to transfer Resident R108 to the hospital for this injury. Review of the facility investigation into the fall revealed that the resident was found lying on the left side, on the floor in her bathroom. Nursing Assistant, Employee E19, responsible for the care of Resident R108 on October 30, 2021 documented that she observed the resident in bed asleep three hours before the fall that occured on October 30, 2021 at 1:00 a.m. and found the resident lying on the floor in the bathroom. Review of resident baseline care plan developed October 27, 2021 revealed that Resident R108 requiring one person physical assist for toileting (how a resident uses the toilet room, commode, bedpan or urinal; transfers on/off toilet; cleanses self after elimination) and bed mobility (how a resident moves to and from lying position, turns side to side and positions body while in bed) and a two person physical assist for transfers. The nursing staff indicated that Resident R108 was occasionally incontinent of bladder and bowel. Further review of Resident R108's baseline care plan dated October 27, 2021 under section title Safety Risk revealed that the resident was identified for falls and that the resident sustained a fall in the last month prior to admission. There was no interventions or measures developed for the care of Resident R108, who was identified at high risk for fall. The facility failed to ensure the proper supervision of Resident R108 with a history of falls prior to admission. This failure resulted in actual harm to Resident R108 sustained a fall and left hip fracuture. Review of Resident R83's Admission Minimum Data Set (MDS-assessment of care needs) dated July 16, 2020, revealed that the resident was admitted to the facility on [DATE], with diagnoses including: dementia (progressive [CONDITION(S)] brain disorder causing confusion, impaired cognition and memory loss) and depression. Continued review of the MDS revealed that the resident was identifed care needs related to falls. Review of Resident R83's Quarterly MDS dated [DATE], revealed that the resident required extensive assistance from two or more staff persons for transfers (moving from one place to another). Review of Resident R83's care plan dated initiated July 17, 2020, and continuing to present, revealed that the resident was identifed as at risk for falls due to confusion, deconditioning and problems with his gait/balance. The care plan further reflected that nursing interventions, dated initiated December 31, 2020, indicated that the resident required maximum assistance with all transfers using a sit to stand lift and two person assist. Continued review of the care plan revealed that the resident had a fall where he was lowered to the floor on August 10, 2021. Review of Resident R83's clinical record revealed a nurse's note dated August 10, 2021, which indicated that the nurse was called to resident room . when resident was observed in a sitting position against the bed being held up by nursing assistant. When asked what happened, per staff, he was transfer resident from bed but had lowered him to the floor. Review of facility documentation related to the incident for Resident R83 revealed a witness statement from the nurse aide who had transferred the resident. The statement indicated, I sat him on the side of his bed and he slid his body down. I lowered him to the floor right before the nurse walked in. Review of facility documentation, Resident Incident Investigation for Resident R83, dated August 17, 2021, revealed that the investigation concluded that, Resident was being transferred from bed to chair when resident was slid to the floor mat. Interview with the Director of Nursing (DON) on December 1, 2021, at 3:15 p.m., revealed that the DON was unable to explain why Resident R83 was sat up on the side of the bed by the nurse aide without the assistance of another staff person. Further, the DON was unable to explain why the resident was not transferred using a sit to stand lift device. Interview with Employee E11, Therapy Director, on December 2, 2021, at 9:42 a.m., confirmed that Resident R83 required the use of a sit to stand mechanical lift for all transfers. 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.11(b) Resident care plan 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on clinical record review, review of facility documentation, review of facility policies and interviews with staff, it was determined that the facility failed to use the appropriate assistive device during a resident transfer, which resulted in actual harm to one of 41 residents reviewed (Resident R84) who sustained a fractured ankle as a result. Findings include: Review of an undated facility policy, Hoyer Lift (a mechanical lift used to transfer residents), revealed that, All mechanical lifts are a two person procedure. Residents are not to be lifted manually. Review of Resident R84's clinical record revealed an annual Minimum Data Set (MDS- a mandatory periodic resident assessment tool) dated (MONTH) 28, (YEAR), which indicated that the resident was severely cognitively impaired and required the physical assistance from two or more staff members for bed mobility, transfers and toileting. Continued review of Resident R84's clinical record revealed a physician order [REDACTED]. Review of Resident R84's care plan, dated initiated (MONTH) 30, (YEAR), revealed that the resident has a self-care deficit due to dementia. The care plan further indicated that the resident had limited mobility and listed interventions including the use of a Hoyer lift for transfers. Review of facility documentation dated (MONTH) 5, (YEAR) and completed by Employee E9, registered nurse, revealed that on Sunday, (MONTH) 4, (YEAR), during care Resident R84 was observed crying out in pain when her right foot/ankle was touched and that swelling was noted to her right ankle. At that time the physician was notified and an order for [REDACTED].>Review of the Radiology report, dated (MONTH) 4, (YEAR), of Resident R84's right ankle revealed generalized soft tissue swelling and likely acute fractures of the distal tibia and fibula (bones of the lower leg-ankle) with mild displacement. Resident R84 was subsequently sent to the hospital for treatment. Review of information submitted by the facility on (MONTH) 16, (YEAR), revealed that a nurse aide (Employee E6) transferred Resident R84 from the bed to the chair by himself, without using a Hoyer lift. Later that evening Resident R84 screamed out in pain and it was discovered through an xray that the resident had a fracture to her right ankle. Review of a written statement by Employee E6, nurse aide, dated (MONTH) 6, (YEAR), indicated that he provided care to Resident R84 on Friday, (MONTH) 2, (YEAR), and that he transferred the resident from the bed to the chair. During an interview conducted by the DON on (MONTH) 6, (YEAR), with Employee E6, it was noted that when the DON asked Employee E6 how he transferred Resident R84, he stated that he picked up the resident and placed her in the chair and that he did it by himself without any help. The facility failed to ensure that staff utilized the appropriate assistive devices during resident transfers, which resulted in actual harm to Resident R84 who sustained a fractured ankle as a result. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 11/15/2018, 1/20/19 28 Pa. Code 201.18(b)(1) Management Previously cited 11/15/2018 28 Pa. Code 201.18(b)(3) Management Previously cited 11/15/2018 28 Pa. Code 211.12(5) Nursing services Previously cited 11/15/2018, 9/3/19

Based on a review of the clinical record and facility policy, staff interviews, and a review of hospital records, it was determined that the facility failed to notify the physician of a resident's fall and subsequent change in condition in a timely manner, resulting in actual harm to the resident (Resident R1). Findings include: Review of the facility's policy, "Falls Management Guidelines," revised June 2014, revealed that the attending physician is to be notified about falls and status changes of the residents. Review of the clinical record revealed that Resident R1 was admitted to the facility, from the hospital, on December 10, 2014. A nusing note on this same date revealed that this resident had [DIAGNOSES REDACTED]. A nursing note at 2:25 p.m., on December 19, 2014, indicated that Resident R1 was alert, oriented to person, place, and time, and was able to make his needs known. A social service note on this same date indicated that this resident was cognitively intact. Continued review of the clinical record revealed a late entry nursing note at 12:18 p.m., on December 20, 2014, that indicated the resident was found on the floor beside his wheelchair. When asked if he had hit his head, the resident replied, "maybe." A subsequent nursing note at 11:10 p.m., that same evening indicated that the resident seemed very confused. A nursing note on the following day, December 21, at 10:13 p.m., indicated that the resident was resistive to care and would not stand up. A review of a Resident Incident Report, dated December 20, 2014, revealed that the fall occurred at 11:35 a.m., that morning. Additional information on this report indicated that the physician was not notified until 8:30 a.m., on December 21, 2014, approximately 21 hours after the fall occurred. The clinical record did not indicate what information the physician was provided. Nursing documentation further indicated that the physician who was covering for the primary physician, saw the resident on December 22, 2015, at 8:30 a.m. This physician visit was also documented on the incident report indicating that the physician was notified approximately 45 hours after the fall. Following this visit, the physician ordered a UA (a urinalysis, an array of tests performed on urine) to rule out a UTI (an infection of one or more of the components of the urinary track). The Neurological Assessment Form (a form used to monitor any resident after a fall, who has hit their head or has a change in mental status) monitors the level of consciousness, the blood pressure, the resident's pupil size and reaction among other things. Review of this form for Resident R1 revealed that throughout the day on December 20, 2014, and into the morning of December 21, Resident R1 was drowsy, but responding to verbal stimuli. Documentation on the Neurological Assessment Form on December 21, 2014, noted the resident was confused, restless and combative and not compliant with care at 8:20 a.m., and refused an assessment at 12:20 p.m. and 8:20 p.m. There was no evidence that the physician was notified of this change in the resident's behavior/mental status. Continued review of the Neurological Assessment Form revealed that on December 22, 2014, Resident R1 was noted to be non-responsive at 8:20 a.m. Four hours later, at 12:20 p.m., this resident was again noted to be non-responsive. A nursing note at 3:56 p.m., on this date indicated that the resident was not responsive to either his name or to touch and that his eyes appeared to be fixed. A subsequent nursing note indicated that the resident was transferred to the hospital at 5:30 p.m. Hospital records indicated that on arrival, the resident had global [MEDICAL CONDITION] (loss of the ability to communicate) and had right [MEDICAL CONDITION] neglect (right sided weakness). The resident had two tonic-clonic [MEDICAL CONDITION] (a loss of consciousness and violent muscle contractions) with right dense [MEDICAL CONDITION] (weakness) and a new large acute left subdural (a collection of blood in the brain) requiring decompression surgery (a surgical procedure to relieve pressure). On arrival to the to the intensive care unit, the resident developed convulsive [DIAGNOSES REDACTED] (condition in which epileptic [MEDICAL CONDITION] follow one another without recovery of consciousness between them) requiring intubation (insertion of a tube into the body for air). The resident underwent [REDACTED]. He was extubated (removal of the tube providing air) on January 3, 2015, but required reintubation within 12 hours. After multiple family meetings, the resident underwent [REDACTED]. The facility failed to notify the physician that the resident had fallen and may have hit his head, and failed to notify the physician of the changes in behavior/mental status in a timely manner, resulting in actual harm to the resident. This was confirmed in an interview with the Director of Nursing at 3:00 p.m., on April 8, 2015. 42 CFR 483.25 Provide Care/Services for Highest Well Being. Previously cited 1/30/15, 10/10/14. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 1/30/15. 28 Pa. Code 201.18(b)(1) Management. Previously cited 1/30/15. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(3) Nursing services. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. Previously cited 1/30/15, 10/10/14.

Based on review of a clinical record, facility documentation, facility Policy and Procedure and interviews with facility staff, it was determined that the facility failed to ensure safety measures for one resident identified as high risk for aspiration precautions which resulted in actual harm. Resident: CL 1 Findings include: Clinical record review of Resident CL 1 revealed [DIAGNOSES REDACTED]. The resident assessment dated [DATE], indicated that Resident CL 1 was alert, oriented, required total assistance with activities of daily living and was able to communicate her requests despite her expressive impairment. A June 2012 physician progress notes [REDACTED]. Physician orders [REDACTED]. A review of facility documentation dated August 15, 2012, at 3:30 p.m., indicated that Resident CL 1 had requested and received one and a half soft pretzels at an afternoon social under the recreational staffs' supervision. A review of the undated facility Policy and Procedure for Identification Band Visual Cues noted that the recreational staff should have checked the visual communication mechanism (orange dot )on her wrist identification bracelet to alert the staff of distinguishing fluid/food consistency/special needs. After eating the soft pretzels, the resident started to cough and was returned to the unit where she resided and exhibited increased choking and coughing spells. Emergency procedures were put into place and the resident was transferred by 911 to the hospital for emergency evaluation and treatment and admitted . There was no evidence that adequate communication between activities staff,dietary and nursing departments were in place to maintain safety precautions for this resident with aspiration precautions at all events administering food to residents. A review of the August 2012 care plan for this resident related to dysphagia and aspiration pneumonia had interventions including aspiration precautions, have the resident take small bites and monitor for prolonged swallowing or pocketing food. The facility failed to adequately monitor and supervise this resident to ensure that all food events would offer safe options for this resident with history of aspiration and swallowing deficits, resulting in actual harm. Interview with Employee E1, the administrator, on August 21, 2012, at 3:00 p.m., confirmed that the recreational staff failed to follow the facility Policy and Procedure regarding visual cue guidelines resulting in the resident being transferred to the hospital and currently on a ventilator to maintain her respiratory status. 28 PA Code: 201.18(b)(1) Management

Based on a clinical record review, facility documentation, and staff interview, it was determined that the facility failed to adequately assess and monitor the hydration status of one resident resulting in that resident being hospitalized and resulting in actual harm. ( Resident R1 ) Findings include: A review of nursing admission notes dated June 9, 2011, revealed the resident was admitted with a [DIAGNOSES REDACTED]. ( bone and deep tissue visible ) A review of physician orders [REDACTED]. The resident was receiving no oral intake as per physician order. A laboratory study was done on June 22, 2011 and the BUN ( a sample of elements within the body indicating hydration level ) value was found at 20 milligrams per deciliter. The therapeutic range of this indicator is between 8 and 20 milligrams per deciliter. On July 3, 2011, during the 3-11 shift the resident was found to be short of breath, tachypneic, ( a rapid rate of breathing ) and in respiratory distress. The physician gave an order for [REDACTED]. She was found with a temperature of 103.7, tachypneic, and a worsening mental status. A history and physical report of the resident's admission on July 3, 2011 indicated the resident was found to have profound dehydration with an estimated 4 liters free water deficit within her body. She also was found [MEDICAL CONDITION] syndrome most likely caused by recurrent aspiration pneumonias. The laboratory data completed by the hospital upon the resident's admission indicated a BUN value of 68 mg/dl.,again, the therapeutic range being from 8 to 20 milligrams per deciliter. The report further indicated the resident received 3 liters of intravenous fluid while in the emergency room and another 1 liter over the next 24 hrs. to adequately rehydrate the resident. The facility failed to adequately and timely monitor and assess the resident's hydration needs resulting in the need for hospitalization and emergent intravenous re-hydration and causing actual harm to Resident R1. 28 Pa. Code: 211.12(d)(5) Nursing Services