Every finding on record at Sayre Health Care Center

Based on observation and staff interview, it was determined that the facility failed to store food and maintain food service equipment and envrionment in accordance with professional standards for food service safety in the facility's main kitchen. Findings include: Observation of the facility's main kitchen on March 31, 2026, at 10:05 AM revealed the following: A small silver metal open rack shelving unit storing clean bowls, cups and other assorted dishes located next to the tray line that had a buildup of dust between the metal wires. The two-door oven had a buildup of brown stains on the bottom of the oven and on the glass of the oven doors. A large amount of food debris was observed on the floor under the oven and stove with black buildup also noted on the tile grout in the corner by the oven. A large metal open wire rack storage shelving unit was observed with clean dishes stored on it. The lowest shelf was observed 10 inches from the floor with no solid barrier between the shelf and the floor to prevent the potential contamination of the dishes from mop water splash or sweeping of the floor debris. The dishwasher room floor under the equipment appeared wet and was dark brown in color. A white pipe that ran under the unit was coated in a brown substance where it ran along the floor under the dishwasher. Two coffee mugs were noted to be in the corner under the dishwashing machine. The floors in the adjoining walk-in freezer and refrigerator had food debris under the shelving units. A dark brown liquid was noted at the threshold of the freezer doors, measuring eight inches long and spreading into the adjoining walk-in refrigerator. The corners of the flooring in the walk-in refrigerator had black buildup in the tile grout. The floor under the ice machine had a white build up, and a cup was noted underneath. The edges of the floor around the wall next to the ice machine were noted with a large amount of brown build up in the grout of the tile floors. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on April 1, 2026, at 2:30 PM. 483.60(i)(2) Store food safe and sanitaryPreviously cited 3/7/25 28 Pa. Code 201.14(a) Responsibility of licensee

Based on a review of select facility policies and procedures, observation, clinical record review, and staff interview, it was determined that the facility failed to assess potential entrapment risks from the use of side rails for four of four residents reviewed for accident hazards (Residents 5, 42, 6, and 70). Findings include: The FDA (The United States Food and Drug Administration) Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, is guidance that identifies key parts of the body at risk for entrapment, describes potential entrapment areas or zones, and recommends maximum and minimum dimensional limits of gaps or openings in hospital bed systems. Three key body parts at risk for life-threatening entrapment in the seven zones of a hospital bed system discussed in this guidance are the head, neck, and chest. To reduce the risk of head entrapment, openings in the bed system should not allow the widest part of a small head (head breadth measured across the face from ear to ear) to be trapped. The FDA is using a head breadth dimension of 120 mm (4.75 inches) as the basis for its dimensional limit recommendations. To reduce the risk of neck entrapment, openings in the bed system should not allow a small neck to become trapped. FDA is recommending 60 mm (two and three-eighths inches) as an appropriate dimension for neck diameter. The openings in a bed system should be wide enough not to trap a large chest through the opening between split rails. The FDA concurs with the dimension of 318 mm (12.5 inches) to represent chest depth for the population vulnerable to entrapment and has used this dimension as the basis for its recommended dimensional limits. This guidance describes seven zones in the hospital bed system where there is potential for patient entrapment. Zone six is the space between the end of the rail and the side edge of the headboard or footboard. This space may present a risk of either neck entrapment or chest entrapment. The facility policy entitled, Side Rail Policy and Procedure, last reviewed without changes on June 3, 2025, revealed that when side rail usage is deemed appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment; however, the facility did not identify that the space between the side rails and a headboard or footboard may also present a risk for entrapment. Observation of Resident 5 on March 31, 2026, at 1:54 PM revealed him to be in his bed which was equipped with siderails bilaterally at the head of his bed, a headboard, and a footboard. Clinical record review for Resident 5 revealed a Side Rail Entrapment Assessment (document used by the facility to indicate an assessment of the seven zones of potential entrapment risks) dated January 2, 2026, that Employee 1 (physical therapist) documented zone six was, N/A (not applicable), for Resident 5. The document questioned if an angle at the end of the rail and side of the headboard was greater than 60 degrees. The document did not question if the gap between the end of the rail and the side edge of the headboard/footboard presented a risk of entrapment (e.g., a size that could trap a head, neck, or chest). The surveyor reviewed the above concern regarding Resident 5's side rail entrapment assessment during an interview with the Nursing Home Administrator and the Director of Nursing on April 2, 2026, at 2:40 PM. Observation of Resident 5's bed system with Employee 1 and the Nursing Home Administrator on April 2, 2026, at 3:00 PM confirmed that Resident 5's bed was equipped with a side rail on each side of his bed, a headboard, and a footboard. Employee 1 measured the gap between the end of the side rail and the headboard to be approximately two inches. The surveyor reviewed with Employee 1 and the Nursing Home Administrator that given Resident 5's bed system created a gap between the end of the rail and the headboard, the assessment of zone 6 should have determined that no entrapment risks existed, not that the assessment was not applicable. Observation of Resident 42's bed system on March 31, 2026, at 2:22 PM revealed that her bed was equipped with side rails bilaterally at the head of her bed, a footboard, and a headboard. Clinical record review for Resident 42 revealed a Side Rail Entrapment Assessment completed by Employee 1 on February 2, 2026, that assessed zone 6 as not applicable. The surveyor reviewed Resident 42's bed system created a gap between the end of the rail and the headboard, the assessment of zone six as not applicable would be an error, and that the facility should have determined that no entrapment risks existed in that zone during an interview with the Director of Nursing and the Nursing Home Administrator on April 2, 2026, at 2:00 PM. Observation of Resident 6 on March 31, 2026, at 12:21 PM revealed them to be in their bed which was equipped with siderails bilaterally at the head of their bed, and a headboard. Clinical record review for Resident 6 revealed a Side Rail Entrapment Assessment completed by Employee 1 on March 13, 2026, that assessed zone 6 as not applicable. Observation of Resident 70 on March 31, 2026, at 12:39 PM revealed them to be in their bed which was equipped with a grab bar to the resident's left side while they are in bed, and a headboard. Clinical record review for Resident 70 revealed a Side Rail Entrapment Assessment completed by Employee 1 on March 12, 2026, that assessed zone 6 as not applicable. During an interview with the Nursing Home Administrator and the Director of Nursing on April 2, 2026, at 2:00 PM, the surveyor reviewed that Resident 6's and Resident 70's bed system created a gap between the end of each rail and the headboard, and that the assessment of zone 6 should have determined that no entrapment risks existed, not that the assessment was not applicable. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure a medication error rate less than five percent (Residents 10 and 59).Findings include:The facility's medication error rate was 7.41 percent based on 27 medication opportunities with two medication errors.Observation of a medication administration pass on April 1, 2026, at 8:09 AM revealed Employee 4 (licensed practical nurse) administer Sucralfate (anti-ulcer medication, adheres to the stomach lining to protect it from acids and enzymes) 1 gm (gram) to Resident 59. The packaging of the Sucralfate medication included instructions to administer the medication on an empty stomach. Resident 59 had their breakfast tray in front of them on their bedside table and had already eaten half of a pancake when their medications were administered. The medication reference Drugs.com (a comprehensive and widely visited website that provides free, peer-reviewed, accurate, and independent drug information) instructions regarding the administration of sucralfate note, Take sucralfate on an empty stomach.Continued observation of a medication administration pass on April 1, 2026, at 8:27 AM revealed Employee 4 administered Bethanechol Tablet 25 MG (milligram) (a medication used to treat bladder spasms and urinary retention). The packaging of the bethanechol medication included instructions to administer the medication on an empty stomach. Resident 10 had their breakfast tray in front of them on their bedside table and had eaten all their breakfast when their medications were administered.The medication reference Drugs.com instructions regarding the administration of bethanechol note, Take bethanechol on an empty stomach, at least 1 hour before or 2 hours after a meal.Interview with Employee 4 on April 1, 2026, at 8:36 AM indicated that she was not aware of the special instruction packaging instructions listed for the medications for Resident 59 and Resident 10.The surveyor reviewed the above two medication error concerns during an interview with the Nursing Home Administrator and the Director of Nursing on April 1, 2026, at 12:30 PM. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate clinical documentation for 1 of 18 residents reviewed (Resident 4).Findings include: Review of Resident 4's medical history revealed a diagnosis list that included the following: heart failure, iron deficiency anemia, vitamin d deficiency, and gastrointestinal hemorrhage (bleeding). The current care plan for Resident 4 revealed the resident is at nutritional risk due to medical history, fluctuating weights, and variable intakes. An intervention included weigh per physician order for close monitoring. Review of the current physician orders for Resident 4 revealed no physician order for weight assessment as noted in the care plan. Dietary documentation for Resident 4 dated February 18, 2026, at 11:34 AM revealed that a reweight was completed with weight gain now noted (significant for 90 and 180 days). The documentation noted to follow with request for weekly weights for close monitoring. Facility documentation titled, Provider Notification Form, dated February 18, 2026, for Resident 4 revealed that resident had a weight gain and dietitian recommends weekly weights. The medical provider wrote a response of, Ok! which was dated February 19, 2026.A review of the recent weights in the electronic health record (EHR) for Resident 4 revealed that the facility staff documented that the resident was weighed on February 14, 2026, February 17, 2026, March 12, 2026, and April 2, 2026. There was no evidence in Resident 4's clinical record that weekly weights were completed as noted as indicated in the dietary documentation on February 18, 2026, and provider's approval on February 19, 2026. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on April 1, 2026, at 2:00 PM. Facility staff provided documentation for Resident 4 titled, Weekly Weights, after it was brought to facility staff's attention as noted above. The documentation was a sheet of paper that included Resident 4 as well as 15 additional residents that were to have weekly weights and not part of any clinical record. The documentation noted that Resident 4 was weighed the weeks of February 24, 2026, March 3, 2026, March 10, 2026, March 17, 2026, March 24, 2026, and March 31, 2026. An interview with the facility on April 2, 2026, at 2:00 PM revealed that the Weekly Weights form containing multiple residents is handed into the Director of Nursing (DON) to review and then the DON passes the information onto the dietary staff. The form is not part of the clinical record. The weights are to be transcribed to the resident's clinical record and were not per the DON. 28 Pa. Code 211.5(f) Medical records

Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to provide the highest practical care regarding a physician ordered fluid restriction for one of 18 residents reviewed (Resident 43).Findings include: A review of the diagnosis list for Resident 43 revealed a medical history that included the following: acute kidney failure and chronic combined systolic and diastolic heart failure (a chronic condition where the heart is unable to meet the needs of body and can lead to symptoms such as fluid buildup in the lungs and legs). A review of the current physician orders for Resident 43 revealed an order dated August 24, 2025, for a 1200 cc (cubic centimeter) fluid restriction; 120 with AM (morning) med pass and 120 cc with HS (bedtime) med pass. A review of the current care plan for Resident 43 revealed the resident has an altered cardiovascular status and chest pain related to the medical history, is at an increased nutritional risk, and has a 1200 ml (milliliter) fluid restriction. An intervention also included the 1200 ml fluid restriction (fluid restrictions included breakfast 300 ml, lunch 300 ml, dinner 300 ml, and nursing total for all medication passes 300 ml). A review of fluid intake for the past 30 days on Resident 43's task list (located in the electronic health record where staff document specific care related events for a resident) revealed the following days where staff had documented the resident's fluid intake which exceeded the 1200 ml fluid restriction: March 6, 2026: 1460 mlMarch 7, 2026: 1600 mlMarch 8, 2026: 1780 mlMarch 9, 2026: 1260 mlMarch 10, 2026: 1650 mlMarch 13, 2026: 1700 mlMarch 14, 2026: 2520 mlMarch 19, 2026: 1500 mlMarch 20, 2026: 1320 mlMarch 22, 2026: 1420 mlMarch 23, 2026: 2380 mlMarch 24, 2026: 1320 mlMarch 28, 2026: 1560 mlMarch 29, 2026: 1760 mlMarch 30, 2026: 1250 mlApril 1, 2026: 1240 mlApril 2, 2026: 1540 ml There was no documentation for Resident 43 that indicated the resident refused to adhere to the ordered and care planned fluid restriction. There was no documentation that indicated the physician was made aware that the resident had exceeded the ordered 1200 ml fluid restriction on the above dates. The Nursing Home Administrator confirmed during a meeting on April 3, 2026, at 1:19 PM that there was no further documentation found for Resident 43 that the resident had refused to adhere to the ordered and care planned fluid restriction or the resident's physician was made aware that the ordered fluid restriction was exceeded. 483.25 Quality of CarePreviously Cited 3/7/25 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff and resident interview, it was determined that the facility failed to ensure assessments accurately reflected residents' status for three of 24 residents reviewed (Residents 5, 30, and 55).Findings include: Clinical record review for Resident 55 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated January 9, 2026, in which facility staff assessed the resident as taking an antibiotic. Further clinical record review revealed no evidence that Resident 55 was on an antibiotic at that time. An interview with Employee 2, registered nurse, on April 3, 2026, at 1:01 PM confirmed that Resident 55 was not on an antibiotic during the assessment period and this was marked in error on the MDS. The Nursing Home Administrator was informed of the above findings for Resident 55 during a meeting on April 3, 2026, at 1:17 PM. Interview with Resident 30 on April 1, 2026, at 10:12 AM revealed that he was waiting for an outside provider to evaluate him and provide him with prosthetics for his legs as he was a bilateral leg amputee (right above the knee, left below the knee). Review of Resident 30's diagnoses list substantiated that his left leg was amputated below the knee joint and his right leg was amputated above the knee joint. His diagnoses also included that he had abnormalities of gait and mobility and reduced mobility since January 3, 2024. An annual MDS dated [DATE], indicated that Resident 30 had no range of motion impairments of either his upper or lower extremities. A quarterly MDS dated [DATE], indicated that Resident 30 had lower extremity range of motion impairment on only one side. The Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual (guidance how to complete and use the MDS assessments) instructions to complete the range of motion section of the MDS assessment noted that if a resident with an amputation does indeed have difficulty completing ADLs (activities of daily living) and is at risk for injury, the facility should code this item as appropriate. This item is coded in terms of function and risk of injury, not by diagnosis or lack of a limb or digit. The annual MDS dated [DATE], and the quarterly MDS dated [DATE], assessed that Resident 30 required substantial/maximal assistance for toileting and standing from sitting position and chair-to-bed-to-chair transfers and partial/moderate assistance for rolling left and right in bed and sitting to lying in bed. Ambulation was not assessed on either assessment and noted as, not applicable. A plan of care initiated by the facility on January 3, 2024, to address Resident 30's risk for falls noted that Resident 30 was a bilateral amputee. The plan of care errantly included that Resident 30 should have appropriate footwear when ambulating or mobilizing in his wheelchair. The plan of care also included that Resident 30 should have non-skid socks on when he was in bed. Interview with the Director of Nursing and the Nursing Home Administrator on April 2, 2026, at 2:12 PM confirmed that the MDS coding related to Resident 30's range of motion failed to capture his range of motion impairments that affected his activities of daily living and safety. Clinical record review for Resident 5 revealed a quarterly MDS dated [DATE], that assessed him as having a wound infection. Review of, Skin and Wound Note, progress notes dated January 8, 2026, and nursing documentation dated January 9, 2026, at 5:29 AM, revealed that Resident 5 had skin impairments, however, neither entry indicated that he had a wound infection. Nursing documentation dated January 14, 2026, at 6:43 AM indicated that Resident 5 required an antibiotic for a urinary tract infection. The surveyor did not identify evidence to support that Resident 5 had a wound infection at the time of the completion of the January 13, 2026, MDS assessment. Interview with the Nursing Home Administrator on April 3, 2026, at 11:45 AM confirmed that the facility determined that Resident 5's coding on the MDS assessment for a wound infection was an error. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview it was determined that the facility failed to implement interventions to prevent a resident fall for one of seven residents reviewed for falls (Resident 2).Findings include: Clinical record review for Resident 2 revealed a Fall Report (assessment performed that identified the resident's fall risk level based on score: one to four, low fall risk; five to nine, moderate fall risk; and 10 or greater, high fall risk) dated December 2, 2025, that assessed her score as 14 (high risk). Review of a plan of care initiated by the facility (November 5, 2024) to address Resident 2's fall risk revealed interventions that included: Chair alarm (initiated November 11, 2025)Encourage resident to use handrails or assistive devices properly (initiated November 5, 2024) Review of an annual MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated November 14, 2025, revealed that staff assessed Resident 2 as requiring the supervision or touching assistance of staff to sit from a lying position, stand from a seated position, transfer to and from a bed to a chair, and to walk 10 to 150 feet. The assessment did not indicate that Resident 2 utilized a wheelchair. The assessment indicated that Resident 2 utilized a walker. Nursing documentation dated December 20, 2025, at 2:50 PM revealed that the registered nurse heard Resident 2 yelling, help me, I fell. Staff observed Resident 2 lying on her left side in front of her wheelchair in front of a resident room on the 700 hallway (Resident 2 resided on the 600 hallway). The documentation indicated that staff, Assisted from the floor into wheelchair with two assist. Review of the facility's investigation of the incident dated December 20, 2025, revealed that staff identified Resident 2, was in a different wheelchair without alarm. Interventions implemented to attempt to prevent future falls for Resident 2 included to educate staff regarding the importance of ensuring the resident is in the assigned wheelchair. Review of Resident 2's care plans revealed that the facility revised her fall risk care plan on December 20, 2025, to include the intervention for staff to ensure Resident 2 was always seated in her assigned wheelchair to promote proper fit and stability and ensure chair alarm is in place and activated. The facility failed to implement all fall prevention interventions for Resident 2 on December 20, 2025, that contributed to her fall. The surveyor reviewed the above concerns regarding Resident 2's fall on December 20, 2025, with the Nursing Home Administrator and the Director of Nursing on April 3, 2026, at 10:45 AM. 28 Pa. Code 211.10(d) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to provide respiratory care for a BiPAP (bilevel positive airway pressure)/CPAP (continuous positive airway pressure) device consistent with professional standards of practice one of one resident reviewed for respiratory concerns (Resident 29).Findings include: Clinical record review for Resident 29 revealed a diagnosis list that included obstructive sleep apnea (periods of breathing cessation during sleep). Review of Resident 29's care plan revealed the resident uses oxygen therapy and has an altered respiratory status related to the medical history. The interventions included: BiPAP cleaning per facility policy and BiPAP on at bedtime with settings as ordered. A review of the current physician orders for Resident 29 revealed no order for BiPAP, CPAP, or related. Medical provider documentation for Resident 29 dated December 29, 2025, at 8:22 AM revealed a history of obstructive sleep apnea. The documentation noted, Staff to assist with BiPAP at bedtime. Observation of Resident 29's room on April 1, 2026, at 11:48 AM revealed a BiPAP/CPAP device on the resident's dresser next to the bed. It was not in use. A follow-up observation and concurrent interview for Resident 29 on April 3, 2026, at 10:30 AM revealed that the resident was in bed. The BiPAP/CPAP device remained on the dresser and was not in use. The resident stated she used the device at home but was unable to state if she used it in the facility. An interview with Employee 3, licensed practical nurse, on April 3, 2026, at 10:34 AM revealed that the resident utilizes the device overnight. An interview and concurrent observation of Resident 29's room on April 3, 2026, at 10:45 AM confirmed the device was used for BiPAP and/or CPAP and had an attached mask that was in a plastic bag and distilled water next to the device. The Director of Nursing would have to review the resident's chart to confirm further if the resident was to use the device or not. A follow-up interview with the Director of Nursing on April 3, 2026, at 1:37 PM revealed that the resident does not use the device and it was not removed from the care plan. The facility provided no further documentation on the device. 483.25(i) Respiratory/tracheostomy Care and SuctioningPreviously cited deficiency 3/7/25 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and resident and staff interview, it was determined that the facility failed to develop a trauma-informed plan of care for one of one resident reviewed for behavioral-emotional concerns (Resident 11).Findings include: Clinical record review for Resident 11 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated September 4, 2025, that identified Resident 11 had a Post Traumatic Stress Disorder (PTSD, intrusive thoughts related to a traumatic event, can manifest as flashbacks where the person feels as though they are reliving the trauma). Review of Resident 11's diagnoses list revealed that the facility included Resident 11's PTSD diagnosis since November 25, 2024. Interview with Resident 11 on April 2, 2026, at 1:15 PM revealed that trauma experienced in her past included that she was, raped by five men when (she) was a girl, and her father, .was a drunk and beat (her), and she, .married young in Alabama and (her husband) beat , her. The traumatic events described by Resident 11 all related to male relationships and treatment by males. Resident 11 stated that she performed all her personal hygiene, bathing, and toileting needs independently; and could not accept care assistance in those areas by a male caregiver. Review of a plan of care initiated November 28, 2024, to address that Resident 11, was admitted for a dx (diagnosis) of PTSD, revealed that the facility noted that her PTSD was caused from recent events and did not include any reference to the traumatic events reported to the surveyor by Resident 11. Interventions included in the plan of care did not include the use of outside psychological resources, the restriction of male caregivers for personal care, or the use of medications to treat the symptoms of her PTSD diagnosis. Progress note documentation from the facility's consulting psychological provider dated November 25, 2025, noted that Resident 11's use of Sertraline (antidepressant medication) and Clonazepam (antianxiety medication) were for her PTSD diagnosis, however, the documentation did not note the traumatic events that supported the PTSD diagnosis, potential triggers that could cause Resident 11 to relive the trauma, or non-medicinal interventions necessary to prevent those triggers. Progress note documentation by the facility's consulting psychological provider dated January 8, 2026, March 12, 2026, and March 26, 2026, no longer included Resident 11's PTSD diagnosis, however, continued to include the Sertraline and Clonazepam medications in her medication list. The surveyor reviewed concerns that Resident 11's plan of care and outside psychological treatment did not address her reported trauma and care preferences during an interview with the Director of Nursing and the Nursing Home Administrator on April 2, 2026, at 2:00 PM. The facility failed to account for Resident 11's experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization for her. 28 Pa. Code 211.10(d) Resident care plan 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to ensure the accurate acquiring and administration of medications to meet the needs of one of 18 residents reviewed (Resident 29).Findings include: Review of physician orders for Resident 29 revealed an order dated December 26, 2025, for Potassium Chloride extended release (ER) 20 milliequivalents (MEQ); give one tablet by mouth two times a day for low potassium. A review of the Medication Administration Record (MAR) for Resident 29 revealed that the resident's potassium was not documented as administered per the physician order and the associated MAR notes revealed that staff had documented the following: January 3, 2026, at 9:58 AM: on orderJanuary 5, 2026, at 9:16 AM: awaiting pharmacyJanuary 7, 2026, at 7:29 PM: awaiting pharmacyJanuary 12, 2026, at 9:29 AM: awaiting pharmacyJanuary 13, 2026, at 10:05 AM: Awaiting pharmacy. Unable to pull from pharmacy.January 13, 2026, at 7:13 PM: awaiting pharmacyJanuary 15, 2026, at 9:39 AM: Awaiting pharmacy. Not available in cubex. January 16, 2026, at 11:21 AM: awaiting pharmacyJanuary 19, 2026, at 9:09 AM: not in pack, not available in cubexJanuary 20, 2026, at 10:06 AM: awaiting pharmacy, not available in cubex Facility documentation for Resident 29 titled, Provider Notification Form, dated January 14, 2026, revealed a nurse issue that on January 12-13, 2026, the resident had missed doses of potassium chloride tablets while awaiting pharmacy arrival. The physician response noted that it was ok to administer when received from pharmacy. Another Provider Notification Form for Resident 29 dated January 17, 2026, revealed that on January 15-16, 2026, potassium chloride 20 MEQ was not available in the cubex and awaiting refill and the doses were missed. The physician response noted that it was ok to administer when received from pharmacy. Another Provider Notification Form for Resident 29 dated January 20, 2026, revealed that potassium chloride oral packet 20 MEQ was unavailable in the cubex and awaiting refill / pharmacy. It documentation noted missed doses on January 18-19. The physician response noted that it was ok to administer when received from pharmacy. An interview with Employee 2, registered nurse, on April 2, 2026, at 2:22 PM revealed that facility staff had pulled out the available potassium chloride from the cubex and pharmacy was notified of this. The facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of Resident 29. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on April 1, 2026, at 2:00 PM. 28 Pa. Code 211.9 (k) Pharmacy services 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure the consultant pharmacist reported potential medication irregularities to the attending physician and that the physician provided an appropriate timely response for one of five residents reviewed for medication regimen review (Resident 5).Findings include: The facility policy entitled, Medication Regimen Review, last reviewed without changes on June 3, 2025, revealed that the medication regimen of each resident is reviewed by a licensed pharmacist according to federal, state, and local regulations as well as current standards of practice. The pharmacist must report any irregularities to the attending physician, the facility's medical director, and the Director of Nursing, and these reports must be acted upon in a manner that meets the needs of the residents. If no irregularities are identified, the consultant pharmacist will document, No Irregularities, in the designated location within the Electronic Health Record (EHR). A written report of all irregularities and recommendations resulting from the medication regimen review are provided to a facility designee for the attending physician, Director of Nursing, and medical director. The report will be submitted within 72 hours of the actual review. For non-urgent recommendations, the facility and attending physician must address the recommendation(s) in a timely manner that meets the needs of the resident, but no later than their next routine visit to assess the resident. Clinical record review for Resident 5 revealed a progress note from the facility's contracted pharmacist dated May 15, 2025, at 8:23 AM that the MRR (medication regimen review) was complete and to see a, nursing/physician report for any irregularities and/or action items. The documentation did not stipulate if the potential irregularity was reported to the nurse, or the physician, or to both. Interview with the Nursing Home Administrator and the Director of Nursing on April 3, 2026, at 10:45 AM revealed that the facility had no consultant reports to provide for Resident 5's May 15, 2025, recommendation to the physician. A report provided by the Director of Nursing on April 3, 2026, at 12:59 PM revealed that the consultant pharmacist identified a potential medication irregularity on May 15, 2025, that Resident 5 had multiple orders for the same PRN (as needed) indication; the same dose, frequency, and PRN indicator for Tylenol (Acetaminophen, over-the-counter analgesic) Extra Strength. The recommendation questioned whether one of the orders could be discontinued. A progress note dated May 26, 2025, indicated that Resident 5's physician made a routine visit. A progress note dated June 11, 2025, indicated that Resident 5's physician assessed Resident 5 in response to a fall. A progress note dated June 19, 2025, indicated that Resident 5's physician made a routine visit. The physician did not respond to the consultant pharmacist's identified medication irregularity of May 15, 2025, until July 3, 2025. The physician discontinued one of the PRN Tylenol orders for Resident 5. Progress note documentation by the consultant pharmacist dated June 17, 2025, at 9:56 AM indicated that the MRR was complete and to see a, nursing/physician report for any irregularities and/or action items. The documentation did not stipulate if the potential irregularity was reported to the nurse, or the physician, or to both. A review of the binder reported by the facility to contain all consultant pharmacist review reports with the Director of Nursing on April 3, 2026, at 12:25 PM revealed that there was no report for Resident 5's June 17, 2025, MRR. Progress note documentation by the consultant pharmacist dated September 16, 2025, at 3:02 PM revealed that the MRR was complete and to see a, nursing/physician report for any irregularities and/or action items. The documentation did not stipulate if the potential irregularity was reported to the nurse, or the physician, or to both. A, Note to Nursing, dated September 16, 2025, requested that the facility add parameters to separate the administration of two eye drop medications by three to five minutes because Resident 5 was receiving the eye drops at the same administration time. Information provided by the facility did not include a report to Resident 5's physician in response to the September 2025 MRR. Psychotropic and Sedative/Hypnotic Utilization by Resident review for records updated between September 1 and 17, 2025, by the consulting pharmacist, indicated that Resident 5's use of Escitalopram Oxalate (Lexapro, an antidepressant medication) and Mirtazapine (Remeron, an antidepressant medication) were recommended for a formal assessment of their particular orders in October 2025. This directive was not forwarded to Resident 5's physician via a separate report. Interview with the Director of Nursing on April 3, 2026, at 12:59 PM confirmed that the physician did not respond timely to the MRR recommendation in May 2025. The interview also confirmed that the facility had no MRR report from the pharmacist to the physician for the June and September 2025 MRRs. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of facility documentation and staff interview, it was determined that the facility failed to maintain the posted daily nurse staffing data for a minimum of 18 months for three of three months reviewed (January, February, and March 2026).Findings include: A review of the facility's binder that contained daily nurse staffing postings for January, February, and March 2026, revealed that the facility did not have postings for the following dates and/or shifts: January 1, 3, 9, 10, 11, 17, 18, 23, and 25, 2026February 5, 13 (third shift), 14, 15, 23, 27 (second and third shift), and 28 (third shift), 2026March 6 (second and third shifts), 7, 8, 13 (second and third shifts), 14, 15 (second and third shifts), 20 (second and third shifts), 28, and 29, 2026 Interview with the Nursing Home Administrator and the Director of Nursing on April 2, 2026, at 10:45 AM confirmed that the facility could not produce the documentation to confirm that 18 months of postings were maintained. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18 (b)(3)(e)(1) Management

Based on clinical record review and staff interview it was determined that the facility failed to ensure that the notice of transfer or discharge included the required contents for three of six residents reviewed for hospitalization concerns (Residents 2, 6, and 10). Findings include: Clinical record review for Resident 2 revealed nursing documentation dated March 5, 2026, at 7:45 PM that revealed that the registered nurse assessed Resident 2's pain and arranged for her transport to the hospital via emergency medical services. Nursing documentation dated March 6, 2026, at 2:56 AM revealed that Resident 2's responsible party (daughter) informed the facility that Resident 2 had a hip fracture and was admitted to the hospital. Review of a Discharge/Transfer Notice dated March 6, 2026, for Resident 2 revealed that the notice did not include a statement of the resident's appeal rights that included the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form, and assistance in completing the form, and submitting the appeal hearing request. The notice also did not correctly note the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman. The notice errantly included the local county Ombudsman information in the paragraph stipulated to include the representative of the Office of the State Long-Term Care Ombudsman. The surveyor reviewed the above concerns regarding Resident 2's notice during an interview with the Nursing Home Administrator on April 3, 2026, at 11:45 AM. Clinical record review for Resident 6 revealed the resident was sent to the hospital on January 21, 2026, for a change in condition and returned later that day. There was no evidence that facility staff provided Resident 6, who was alert and oriented, with a copy of the written notice of transfer and bed-hold information as soon as practicable after the transfer only that the information was sent to the resident's responsible party. Clinical record review for Resident 10 revealed the resident was sent to the hospital on December 16, 2025, for a change in condition and was admitted . There was no evidence that facility staff provided the resident's responsible party with a copy of the written notice of transfer and bed-hold information as soon as practicable after the transfer, only that the information was signed by the resident. The facility was unable to provide any documentation for Resident 6 or Resident 10 that they notified both the resident and the resident's representative(s) of the above transfers. Further review of the Discharge/Transfer Notice dated January 21, 2026, for Resident 6, and December 16, 2025, for Resident 10, revealed that the notices did not include a statement of the resident's appeal rights that included the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form, and assistance in completing the form, and submitting the appeal hearing request. The notice also did not correctly note the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman. The notice errantly included the local county Ombudsman information in the paragraph stipulated to include the representative of the Office of the State Long-Term Care Ombudsman. The above concerns related to Resident 6 and Resident 10 Discharge/Transfer Notice were reviewed with the Director of Nursing on April 3, 2026, at 11:45 AM. 483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2)(i)-(iii) Discharge ProcessPreviously cited deficiency 10/8/25 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights

Based on closed clinical record review, review of facility documents, and staff interview, it was determined the facility failed to provide a written notice of transfer before discharge to a resident's responsible party for a facility-initiated discharge for one of one resident reviewed for a facility- initiated discharge (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed the resident was admitted to the facility on [DATE], and was discharged to another skilled nursing facility on September 30, 2025. Review of facility documents dated October 7, 2025, (after the resident's discharge) revealed facility staff conducted meetings on September 23, 2025, and September 26, 2025, with Resident CR1's responsible party to review resident behaviors in the facility including multiple elopement (leave the facility unattended) attempts, falls, wandering into other resident rooms, touching staff and other residents, removing clothing in common areas, and a sexual incident with another resident. It was noted in the documents that the facility could not meet the needs of the residents and a recommendation was made to transfer the resident to another facility. Review of email communication between the Nursing Home Administrator and administration of the receiving facility dated September 26, 2025, indicated a transfer of the resident was planned for September 30, 2025. There was no evidence Resident CR1's responsible party was provided a written notice of transfer as soon as practicable prior to a scheduled facility-initiated transfer that was known four days prior to discharge to include the following: the reason for the dischargethe effective date of dischargethe location to which the resident is to be discharged toa statement of the resident's appeal rights including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request.the name, address (mailing and email) and telephone number of the State Long-Term Care Ombudsman The above information was reviewed with the Nursing Home Administrator and Director of Nursing in a telephone interview on October 9, 2025, at 10:30 AM. 28 Pa. Code 201.14(a) Responsibility of license28 Pa. Code 201.29(a) Resident rights

Based on closed clinical record review, review of facility documents, and staff interview, it was determined the facility failed to ensure the necessary resident information was documented by the physician to facilitate a facility-initiated transfer of a resident to another facility for one of one resident reviewed for a facility-initiated transfer (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed the resident was admitted to the facility on [DATE], with a diagnosis of dementia (memory loss), and was discharged to another skilled nursing facility on September 30, 2025, due to the facility documentation indicating the resident needs could not be met at the facility. Review of facility documents dated October 7, 2025, (after the resident was discharged ) completed by the Director of Nursing, noted that on September 23, 2025, the resident's responsible party was present for a care plan meeting with social services, and the resident care coordinator and the resident's behaviors such as attempting to elope (leave) the facility, pulling the facility fire alarms, threatening to let all the residents out of the building, inappropriate touching of other resident, entering resident rooms and taking items, and frequent falls after interventions implemented. It was discussed the facility is not able to meet the needs of the resident and it is in the best interest of the resident to be transferred to a facility that is able to provide the care and safety she desperately needs. It noted the responsible party was very angry regarding the information. A follow up meeting was requested by the responsible party and was scheduled for September 26, 2025, at 1:00 PM on the same document. Review of Review of the same documents noted above dated October 7, 2025, revealed further documentation by the Director of Nursing that a meeting was held on September 26, 2025, with the inter-disciplinary team, nurse practitioner, and the resident's responsible party, son, and granddaughter to review the resident's behaviors and need to transfer the resident to another facility as the facility could not meet the resident needs and the other facility had a secured unit. Review of email communication between the Nursing Home Administrator and administration of the receiving facility dated September 26, 2025, indicated a transfer of the resident was planned for September 30, 2025. There was no evidence in Resident CR1s clinical record of physician documentation prior to discharge to indicate a transfer of the resident to another facility was necessary for the resident's welfare and the facility could not meet the resident's needs to include the following information as required: The basis for the transfer.The specific resident needs that could not be met in the facility.The facility's attempts to meet the resident's needs.The services available at the receiving facility to meet the needs of the resident. The above information was reviewed with the Nursing Home Administrator and Director of Nursing in a telephone interview on October 9, 2025, at 10:30 AM. 28 Pa. Code 201.29 (a) Resident rights 28 Pa. Code 201.18 (3)(e)(1) Management

Based on observation and staff interview, it was determined that the facility failed to store, prepare, and serve food in a manner to prevent the potential spread of foodborne illness in the main kitchen and the facility's pantry for one of two nursing units (Unit 1 Nursing Unit). Findings include: According to HACCP (Hazard Analysis and Critical Control Points) to avoid the potential for food borne illness, food must be cooled from 135 degrees Fahrenheit to 70 degrees Fahrenheit within two hours, and from 70 degrees Fahrenheit to 41 degrees Fahrenheit or lower in the next four hours. Before cooling food, reduce the quantity or size of the food you are cooling by dividing large food items into smaller portions. Observation and review of the facility's cool down logs with Employee 4, certified dietary manager, on March 4, 2025, at 10:39 AM revealed that facility staff documented the following on February 28, 2025: At 9:45 AM staff cooked four beef rounds and initiated cooling them down for food service at a later date. The beef rounds temperatures were documented as 178 degrees Fahrenheit, 202 degrees Fahrenheit, 199 degrees Fahrenheit, and 172 degrees Fahrenheit respectively. At 10:30 AM (45 minutes later) staff completed four beef round temperatures that were documented as 146 degrees Fahrenheit, 140 degrees Fahrenheit, 137 degrees Fahrenheit, and 147 degrees Fahrenheit respectively. At 11:30 AM (1 hour and 45 minutes later) staff completed four beef round temperatures that were documented as 100 degrees Fahrenheit, 85 degrees Fahrenheit, 76 degrees Fahrenheit, and 89 degrees Fahrenheit respectively. At 12:30 AM (2 hours and 45 minutes later) staff completed four beef round temperatures that were documented as 69 degrees Fahrenheit, 61 degrees Fahrenheit, 66 degrees Fahrenheit, and 64 degrees Fahrenheit respectively. There was no other documentation that indicated staff completed any further cool down temperatures on the four beef rounds. There was no documentation that the four beef rounds reached 40 degrees Fahrenheit, a safe food holding temperature, within a total of four hours after reaching 70 degrees Fahrenheit and within a total of six hours after the potentially hazardous food cool down was initiated. Review of the facility's food service temperature logs dated March 2, 2025, revealed that the facility served the above noted beef rounds as roast beef to residents. Concurrent interview with Employee 4 acknowledged the beef round cool down temperature documentation and subsequent usage. Observation of the Unit 1 Nursing pantry on March 5, 2025, at 9:35 AM revealed that the microwave had dried, stuck-on food on the walls and ceiling. In a lower cabinet to the left of the refrigerator, there were 12 cartons of vanilla Glucerna (a food supplement) with a use by date of February 1, 2025, that were available for resident use. Interview and observation of the Unit 1 Nursing pantry with Employee 4 on March 5, 2025, at 9:41 AM confirmed the above information. The above concerns were reviewed with the Nursing Home Administrator during an interview on March 5, 2025, at 2:15 PM. 483.60(i)(1)(2) Food Procurement. store/prepare/serve Sanitary Previously cited 4/19/24 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on review of the facility policy, employee personnel records, and staff interview, it was determined that the facility failed to develop and implement an abuse prohibition policy that required a thorough investigation of prospective employee's employment history for one of five newly hired employees reviewed (Employee 7). Findings include: The policy entitled Abuse Policy and Procedure last reviewed without changes on June 13, 2024, revealed that the facility will protect the residents from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility will not apply and employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law. All potential employees are screened for a history of abuse, neglect, and misappropriation of property by completing a state criminal background on all prospective employees and if not a resident of the state (where the facility was located) for two consecutive years, an FBI (Federal Bureau of Investigation) check will be conducted. Review of Employee 7's, cook, personnel record on March 7, 2025, revealed that the facility hired them on October 29, 2024, (129 days prior). Employee 7's personnel record revealed that she did not live in the same state as the facility location for more than two years. Further review of Employee 7's record did not reveal any evidence that the facility attempted to obtain or complete an FBI background check to determine criminal history for Employee 7. Interview with Employee 8, human resources, on March 7, 2025, at 10:45 AM and the Nursing Home Administrator on March 7, 2025, at 11:05 AM, revealed that the facility failed to complete the FBI background check within 90 days of employment and confirmed that Employee 7 provided services and access to residents since employed. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.19 Personnel policies and procedures 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to provide a clean, comfortable, and homelike environment on one of two nursing units reviewed (Nursing Unit 2; Residents 24, 50, and 54). Findings include: Observation of Resident 24's room on March 4, 2025, at 12:54 PM; and March 7, 2025, at 12:45 PM revealed a six-foot section of wall located under the resident's window that had a large, black colored linear stain and marring in various areas. Observation with the Nursing Home Administrator (NHA) of an egress area leading outside to the laundry building on March 6, 2025, at 11:17 AM revealed multiple partially smoked cigarette butts discarded on the ground. A concurrent interview with the NHA revealed it was unclear who the cigarette butts belonged to since the facility is non-smoking. The above information for Resident 24's room and the egress area was reviewed in a meeting with the Nursing Home Administrator on March 7, 2025, at 12:38 PM. Observation of the Unit 2 Nursing Unit on the following dates and times revealed: On March 4, 2025, at 11:53 AM the drywall was marred on the lower corner of the wall to the left of Resident 50's bathroom. On March 4, 2025, at 12:30 PM the drywall was warred and gouged on the lower corner of the wall to the left of Resident 54's bathroom. On March 5, 2025, at 9:05 AM there were two fake leather love seats in the lounge near Unit 2 entrance. Both love seat's fake leather was significantly peeling on the seat cushions and arm rests with cloth showing underneath. On March 5, 2025, at 9:25 AM the drywall of Unit 2's dining room walls near the hallway and the door to the courtyard were gouged at both foot and table height. The above information was reviewed during an interview with the Nursing Home Administrator on March 5, 2025, at 2:15 PM. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management

Based on clinical record review and staff interview, it was determined that the facility failed to provide the required notification to a resident whose payment coverage changed for one of three residents reviewed (Resident 2). Findings include: A review of the form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, (a notice that informs the recipient when care received from the skilled nursing facility is ending; and how to contact a Quality Improvement Organization (QIO) to appeal) revealed instructions that a Medicare provider must ensure that the notice is delivered at least two calendar days before Medicare covered services end. A review of the Form Instructions Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055 revealed that examples of the common reasons why an extended care stay, or services may not be covered under Medicare might include the beneficiary no longer requires daily skilled care for a medical condition but wants to continue residing in the skilled nursing facility (SNF). The SNF enters a good faith estimate of the cost of the corresponding care that may not be covered by Medicare. In the blank that follows Beginning on ., the skilled nursing facility enters the date on which the beneficiary may be responsible for paying for care that Medicare is not expected to cover. The beneficiary selects an option box to indicate a desire to continue to receive the care or not to continue to receive the care and if there is a desire to have the bill submitted to Medicare for consideration. The beneficiary or their authorized representative must sign the signature box to acknowledge that they read and understood the notice. The SNF must issue this notice when there is a termination of all Medicare Part A services for coverage reasons. If after issuing the NOMNC, the SNF expects the beneficiary to remain in the facility in a non-covered stay, the SNFABN must be issued to inform the beneficiary of potential liability for the non-covered stay. Clinical record review for Resident 2 revealed census information that Medicare payment for care ended July 26, 2024. Resident 2 remained in the facility. Review of a CMS-10123 form for Resident 2 confirmed that the last covered day of Medicare payment was July 26, 2024. There was no evidence that the facility provided a CMS-10055 form to Resident 2. Interview with the Nursing Home Administrator on March 7, 2025, at 12:00 PM confirmed that there was no additional evidence that Resident 2 received the CMS-10055 form after Medicare payment for her care stopped, but she remained in the facility. 483.10(g)(17)(18)(i)-(v) Medicaid/medicare Coverage/liability Notice Previously cited deficiency 4/19/24 28 Pa. Code 201.18(b)(2)(e)(1) Management 28 Pa. Code 201.29(a) Resident rights

Based on clinical record review and staff interview, it was determined that the facility failed to honor advance directive choices for one of 24 residents reviewed (Resident 175). Findings include: Clinical record review for Resident 175 revealed that on [DATE], the resident's responsible party indicated that the resident was a full code (staff was to start CPR [Cardiopulmonary Resuscitation]). On February 27, 2025, Resident 175's responsible party completed a POLST (Physician Orders for Life-Sustaining Treatment, a form directing medical staff to complete life-sustaining treatment or allow a natural death) form and a facility code status form (a form directing life-sustaining care) both which indicated Do Not Resuscitate (DNR) for Resident 175. Resident 175's code status form was also signed by the physician on February 27, 2025. There was no documentation that the facility changed Resident 175's code status order from full code to DNR until [DATE]. The above information was reviewed during an interview on [DATE], at 3:39 PM with the Nursing Home Administrator. 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate and implement interventions to prevent resident accidents for one of six residents reviewed for falls (Resident 29) and failed to implement interventions to prevent an accident with serious injury resulting in harm for one of six residents reviewed for falls who sustained a subarachnoid hemorrhage (Resident 51). Findings include: The facility policy entitled, Incident/Accident-Reporting, Investigating, and Implementing Corrective Actions, last reviewed without changes on (MONTH) 24, 2019, revealed that it is the policy of the facility to promptly report and investigate an incident or accident and initiate measures to prevent a recurrence. The non-licensed person (e.g. nurse aide) will report the occurrence to the charge nurse and complete a written summary of what was observed or discovered on the facility's incident/accident form via a witness statement. The licensed nurse will report the occurrence to the registered nurse supervisor and initiate the facility incident/accident form. Investigation of the occurrence will be initiated with a statement from staff, residents, and visitors if possible. Immediate interventions will be initiated to prevent recurrence of the incident and ensure resident safety. The event and interventions will be added to the resident's plan of care. The Administrator or designee will be responsible for reporting the incident or accident to the appropriate agencies or authorities, according to local, state, and federal regulations and statutes. The charge nurse and/or the nursing supervisor will initiate any plan of care change that is professionally warranted to ensure resident welfare and safety prior to the end of the shift. The Director of Nursing or designee will check the incident/accident form for completeness, report the incident/accident as necessary to comply with local, state, and federal regulations, and ensure that immediate corrective action/intervention, as warranted, has been initiated and entered into the plan of care. Clinical record review for Resident 29 revealed quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessments dated (MONTH) 13, 2019, and (MONTH) 13, 2019, that assessed Resident 29 as needing the extensive physical assistance of two staff for bed mobility and transferring between two surfaces (to or from bed, chair, wheelchair). Nursing documentation dated (MONTH) 3, 2019, at 8:49 AM indicated that the writer was called to the nursing unit to see the resident. The documentation indicated that staff were transferring Resident 29 with a Hoyer (mechanical device used to lift and transfer a resident with minimum physical effort) when it slipped and hit him in the left cheek bone. Staff assessed a bruise and applied ice. Review of the facility's investigation into this incident dated (MONTH) 3, 2019, at 8:35 AM noted that while using the Hoyer lift with Resident 29, legs caught on the wheelchair and the top bracket came forward and hit Resident 29 in his left cheek resulting in an injury measuring 2 centimeters (cm) on his left cheek bone. The investigation listed only one witness (despite Resident 29 requiring the physical assistance of two staff for all transfers). Review of the facility's investigation into an incident dated (MONTH) 24, 2019, at 1:45 PM, revealed that nurse aides reported that Resident 29 sustained a skin tear while providing his care; the injury occurred while staff was turning Resident 29. The form noted the measurements of the skin tear as 2 cm by 0.5 cm to his left outer arm. The investigation identified only one witness (despite Resident 29 requiring the physical assistance of two staff for bed mobility). Nursing documentation dated (MONTH) 4, 2019, at 4:20 PM revealed that staff called the writer to Resident 29's room where he was found with the upper part of his body in the bed and his legs were out of bed on a mat. Review of the facility's investigation dated (MONTH) 4, 2019, at 4:20 PM, revealed that the facility did not implement any new interventions to prevent fall recurrence; the only intervention listed was a mat (already in place at the time of the fall per the nursing documentation). Nursing documentation dated (MONTH) 9, 2019, at 5:00 AM indicated that staff heard Resident 29 screaming, help. Staff went to Resident 29's room and found him to have the lower half of his body out of bed (he was on his knees). Review of the incident report dated (MONTH) 9, 2019, revealed that the facility had no new interventions added after the fall to prevent recurrence. Interview with Employee 3 (certified dietary manager) on (MONTH) 27, 2019, at 12:31 PM confirmed that Resident 29 had two falls from his bed without a new intervention to prevent recurrence. The interview also confirmed that investigations regarding injuries sustained during care failed to obtain a witness statement from all staff with pertinent information regarding the incidents. Although Resident 29 required the physical assistance of two staff, the facility failed to identify, and obtain information from, the two staff present for care. Clinical record review for Resident 51 revealed nursing documentation dated (MONTH) 10, 2019, at 1:00 AM indicating that the registered nurse, the licensed practical nurse, and two nurse aides were charting in the nurse's station when staff heard a very faint call for help from a female resident. Upon checking a camera monitor, staff noticed Resident 51 lying on the floor in the hallway, on her left side, with her head resting on the floor. The initial assessment revealed that Resident 51 continuously stated, .my leg, my leg, it hurts. I can't move my leg; and pointed to her left leg. Resident 51 stated, The pain in my leg is going all the way down my leg and up into my back. Upon light palpation, the resident stated the pain was located directly at the hip joint. Resident 51 stated, The pain hurts so bad. I think I might pass out. The registered nurse identified that Resident 51 presented with a large, raised, hematoma (collection of blood under the skin that presents as a raised, bruised, area) located on the back left side of Resident 51's head that was tender on palpation. Emergency medical personnel arrived at the facility and transported Resident 51 to the emergency department for further evaluation of hip and head injuries. Clinical record review for Resident 51 revealed nursing documentation dated (MONTH) 10, 2019, at 5:00 AM that the nursing staff contacted the emergency department to obtain a status report of Resident 51. The emergency department staff informed the facility staff that Resident 51 had sustained multiple pubic rami (bones that make up the front of the pelvis) fractures. The documentation indicated that the facility staff contacted Resident 51's daughter to inform her that Resident 51 could be found in the intensive care unit and that she had sustained [MEDICAL CONDITION] during her fall. Review of the facility's investigation dated (MONTH) 10, 2019, at 1:00 AM confirmed that Resident 51 sustained an unwitnessed fall; and that the facility implemented chair and bed alarms as a new intervention to prevent fall recurrence. Review of a plan of care developed by the facility on (MONTH) 10, 2019, to address Resident 51's risk for falls characterized by her history of falls and injury listed interventions that included the facility initiated bed and chair alarms on (MONTH) 14, 2019. Nursing documentation dated (MONTH) 20, 2019, at 9:25 AM revealed that the writer was working on a computer when the writer heard a nurse aide yell, .oh my God! The writer noted that staff saw Resident 51 on the floor, on her abdomen. Staff summoned the registered nurse to the unit. Staff noted blood coming from Resident 51's forehead. Resident 51 left the facility enroute to the emergency room at 9:40 AM. Nursing documentation dated (MONTH) 20, 2019, at 9:30 AM revealed that Resident 51 fell on the floor in the dining room. Staff found Resident 51 on the floor, face down, with a cut on her head measuring one inch and bleeding. Staff called an ambulance service to take Resident 51 to the emergency room for evaluation. Nursing documentation dated (MONTH) 20, 2019, at 4:07 PM revealed the writer contacted the emergency room regarding Resident 51's status. The emergency room informed the writer that Resident 51 was admitted to the hospital with [REDACTED]. Review of the facility's investigation dated (MONTH) 20, 2019, at 9:15 AM confirmed that because staff heard the nurse aide yell, staff responded to the dining room to find Resident 51 had fallen out of her chair onto the floor. The incident investigation stipulated that Resident (51) had no alarm. The witness statement from the nurse aide identified as the witness who found the resident attested that Resident 51 did not have an alarm on. Witness statements from a second nurse aide and a licensed practical nurse both stipulated no chair alarm was present. Review of an electronic adverse event report dated (MONTH) 20, 2019, provided the local field office information that Resident 51 sustained a fall, was transferred to the emergency room , and was diagnosed with [REDACTED]., environment was free of clutter, bed alarm in place, call bell within reach, and bed maintained in low position. Neglect was ruled out in course of investigation. The event report failed to list a chair alarm as a care plan intervention in place prior to the event. The event failed to report that the plan of care included a chair alarm; and that it was not in place at the time of Resident 51's fall. The event indicated that the facility ruled out neglect; however, failed to thoroughly investigate the potential failure of staff to implement the necessary intervention. The facility's investigation of Resident 51's fall on (MONTH) 20, 2019, failed to thoroughly investigate the absence of the necessary care plan intervention (chair alarm), identify the staff member who potentially failed to implement the necessary intervention (potential neglect), and failed to notify the local Department of Health of the potential neglect. The surveyor reviewed the above findings during an interview with Employee 3 (certified dietary manager) and the Nursing Home Administrator on (MONTH) 27, 2019, at 11:10 AM. The interview confirmed that Resident 51 fell on (MONTH) 10, 2019, and the facility implemented the new intervention of bed and chair alarms to prevent future falls. There was no indication that staff implemented the chair alarm before her fall on (MONTH) 20, 2019, when Resident 51 fell from her chair, struck her head on the floor, and sustained a brain hemorrhage. The interview confirmed that this information was not fully disclosed to the local field office of the Department of Health via the electronic event report. 483.25(d) Free of Accident Hazards/Supervision/Devices Previously cited deficiency 9/4/19 28 Pa. Code 211.11(d) Resident care plan Previously cited 10/5/18 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 9/4/19, 11/27/18, and 10/5/18

Based on review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure an environment free from potential accident hazards, and prevent resident accidents with injury, for one of 10 sampled residents (Resident 8). Findings include: The facility policy entitled, "Falls," last reviewed April 1, 2014, revealed that it is the policy of the facility to make sure that all residents are assessed for fall risk. Those determined to be at risk will receive appropriate intervention to reduce the risk and minimize the potential to fall. The facility will develop an individualized plan of care considering factors such as environmental modifications. Although the policy did not provide instructions regarding completing a thorough investigation of a resident's fall, the, "Fall Prevention Tracking/Investigative Form," included in the policy, instructs staff to fill out the front and back of the form as accurate information about each fall will give valid and useful feedback about causes of falls. The information can be used to focus on improvement efforts to prevent future falls. Review of Resident 8's plan of care interventions to address her fall risk included alarms to her bed and chair to alert staff of attempts of self-transferring. Clinical record review for Resident 8 revealed nursing documentation dated December 29, 2013, at 7:09 PM indicating that staff heard a chair alarm sounding and found Resident 8 on the floor in the therapy room. Review of the facility's completed Incident/Accident Report (form the facility utilizes to begin documentation of the details of incidents such as falls) dated December 29, 2013, at 6:50 PM, regarding the incident in the therapy room, revealed that staff failed to complete the section stipulating if the person (Resident 8) was authorized to be at the location of the incident/accident. The investigation did not include how Resident 8 was able to enter the therapy room (that staff is to lock when unsupervised) at 6:50 PM, on a Sunday evening, when it is not likely that therapy staff are in the facility. The investigation did not include any witness statements from therapy staff. Interview with Employee 8, therapy department director, on October 3, 2014, at 9:40 AM revealed that she was unaware of the incident on December 29, 2013; and stated that it was not likely that any therapy staff were in the building at that time. Employee 8 confirmed that the therapy department door is to remain locked at all times when unsupervised, as there are potential accident hazards, such as a hydrocollator (machine containing gel packs in water maintained at approximately 160 degrees Fahrenheit) in the room. Interview with the Nursing Home Administrator and Director of Nursing on October 2, 2014, at 1:15 PM confirmed that the facility did not investigate the December 29, 2013, incident to determine how Resident 8 gained access to an unsupervised therapy department. Nursing documentation dated January 4, 2014, at 10:42 AM, read, "Resident up in wheelchair by nsg. (nursing) station after falling upon self transferring; fell in bathroom..." Review of the facility's Incident/Accident Report (incorrectly) dated February 1, 2014, at 9:15 AM included a witness statement from the charge nurse that staff heard Resident 8 saying, "Help," and found her on the floor in the bathroom. The witness statement did not indicate that any alarms sounded to alert staff that Resident 8 was attempting to self-transfer. The Fall Prevention Tracking/Investigative Form, completed by staff that did not provide a witness statement, noted that staff did not hear Resident 8's alarm because she shut the bathroom door. No witness statements contained in the investigation indicated that anyone heard an alarm either before or after finding the resident on the floor. Interview with the Nursing Home Administrator and Director of Nursing on October 3, 2014, at 9:40 AM, confirmed that staff incorrectly dated the Incident/Accident Report. The facility could not identify any staff that provided a statement to confirm that Resident 8's alarm sounded at the time of the January 4, 2014, fall. Nursing documentation dated February 27, 2014, at 3:45 PM revealed that at 3:25 PM, Resident 8 self-transferred and fell in the bathroom. The documentation indicated that physical therapy witnessed the fall. There was no indication in the documentation that staff heard an alarm at the time of the fall. Review of the witness statement provided by the physical therapist dated February 27, 2014, revealed that she saw Resident 8 near the bathroom while she was assisting another resident ambulating in the hallway. The physical therapist indicated that, "...by the time (the resident she was ambulating) sat down, heard (Resident 8) cry out most likely as she was falling." There was no indication from the witness statement that the physical therapist witnessed the fall or heard an alarm before the resident fell . A witness statement provided by the licensed practical nurse dated February 27, 2014, revealed that the fall "Was not witnessed. Heard someone screaming from resident room...Ran into room to find resident on bathroom floor." The witness statement did not suggest that an alarm sounded at the time of the fall. Review of the Fall Prevention Tracking/Investigative form dated February 27, 2014, at 3:25 PM, revealed that staff did not complete the section indicating the use of any sensor devices. Nursing documentation on the following dates and times noted that Resident 8 complained of pain: February 28, 2014, at 2:17 AM and 12:04 PM. March 1, 2014, at 2:10 PM. March 4, 2014, at 9:00 AM. March 6, 2014, at 2:48 PM. March 7, 2014, at 11:58 AM. March 8, 2014, at 3:45 AM. Nursing documentation dated March 9, 2014, at 7:54 AM revealed that Resident 8 could not bear weight on her left leg, complained of left pelvic, hip, and knee pain, and that the left leg appeared swollen. Staff obtained a physician's orders [REDACTED]. Nursing documentation dated March 9, 2014, at 12:15 PM revealed that the hospital admitted Resident 8 for a broken left hip. Review of a CT (computerized tomography, x-ray) scan signed by a physician on March 7, 2014, at 5:16 PM revealed that Resident 8 had an impacted fracture of the neck of the left femur. Interview with the Nursing Home Administrator and Director of Nursing on October 2, 2014, at 1:15 PM, and October 3, 2014, at 9:40 AM, confirmed the above findings regarding Resident 8's fall on February 27, 2014. Review of an Incident/Accident Report dated September 6, 2014, at 7:00 AM revealed that Resident 8 slid off the edge of her bed to the mat on the floor while trying to get out of bed. The documentation did not indicate that the facility evaluated Resident 8's bedroom environment (i.e. type of mattress) in an effort to reduce the risk of Resident 8 sliding off the edge of her bed in the future. Interview with the Nursing Home Administrator and Director of Nursing on October 3, 2014, at 9:40 AM, confirmed the above details of Resident 8's fall on September 6, 2014. Observation of Resident 8 on October 3, 2014, at 11:20 AM revealed that Employee 9, nurse aide, removed Resident 8's alarming seatbelt, transferred her to the toilet in the bathroom, instructed the resident to ring the bell when she was ready, and placed her wheelchair outside the bathroom, while leaving Resident 8 in the bathroom unattended. Interview with Employee 9 on October 3, 2014, at 11:35 AM (while Resident 8 remained in the bathroom), revealed that it is her practice to remove the wheelchair from the bathroom to prevent Resident 8 from attempts at self-transfers; however, Employee 9 confirmed that staff would have no way of knowing if Resident 8 attempted to stand and walk outside the bathroom to her wheelchair. Employee 9 confirmed that Resident 8 had no alarms engaged to alert staff of attempts to self-transfer. Interview with the Nursing Home Administrator on October 3, 2014, at 1:45 PM, revealed that the facility would now implement instructions for staff to remain with residents who are at risk for falls when in the bathroom. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.11 (d) Resident care plan. 28 Pa. Code 211.12 (d)(1)(5) Nursing services. Previously cited 10/10/13.

Based on clinical record review, review of select facility policies, and staff interview, it was determined that the facility failed to ensure sufficient fluid intake to maintain proper hydration for one of 11 sampled residents (Resident 4). Findings include: The "Hydration Policy," last reviewed and revised May 2011, revealed that the facility would provide sufficient fluid intake to maintain proper hydration and health. The amount of hydration needed is specific for each resident, and fluctuates as the resident's condition fluctuates. The certified dietary manager (CDM) and/or registered dietitian will determine and document Resident fluid requirements upon admission and after a significant change in condition. Interview with the Director of Nursing on July 15, 2011, at 11:40 AM, revealed that the facility does not have a policy for fluid intake and output monitoring. Clinical record review revealed that Resident 4 was admitted to the hospital from June 7 to 10, 2011, with complaints of altered mental status. Resident 4's assessment revealed that she has a history of recurrent urinary tract infections. Interview with Employee 5, CDM, on July 15, 2011, at 9:30 AM, revealed that she considers Resident 4 a high risk for fluid imbalance based on her history of recurrent urinary tract infections. Review of Resident 4's plan of care for her urinary tract infections revealed that all staff should encourage adequate fluid intake and provide fluids per preference and estimated needs. Staff should monitor her intake and output per the facility policy. Resident 4's dietary notes revealed a Significant Change Nutrition assessment dated [DATE], that indicated the registered dietitian assessed Resident 4's fluid needs as 1650-1925 cc (cubic centimeters) of fluid each day. Interview with Employee 5 on July 15, 2011, at 9:30 AM, revealed that Resident 4 was on fluid intake and output monitoring after her return from the hospital from June 11 to June 22, 2011. Review of the Fluid Intake Monitoring from June 11 to 22, 2011, revealed that Resident 4 did not meet her fluid needs on three of 12 days (June 11, 12, and 20, 2011). There were also three of the 12 days that the facility did not determine if she met her fluid needs (June 16, 17, and 18, 2011). Resident 4 did not meet her needs based on her fluid intake on those dates and nobody calculated the amount of fluid she received in her food to determine if she met her total estimated needs. Nursing documentation dated July 9, 2011, revealed that nursing staff found Resident 4 on the floor and she was unconscious. When she woke up, Resident 4 was staring blankly with no pupil reaction to light. The facility sent Resident 4 to the emergency room . Review of Resident 4's clinical record revealed that the hospital admitted her with a [DIAGNOSES REDACTED]. At the time of the hospital admission, Resident 4 had acute kidney injury with a Creatinine level of 1.6 milligram/deciliter (normal 0.6-1.3 mg/dl, if elevated could be an indication of dehydration). The hospital staff initiated intravenous fluids for Resident 4. On July 10, 2011, Resident 4's Creatinine level was 1.0 mg/dl, which is her baseline. Interview with Employee 5 on July 15, 2011, at 9:30 AM revealed that Resident 4 was not on fluid intake and output monitoring prior to her hospitalization on [DATE]. The last day the facility monitored Resident 4's fluid intake was June 22, 2011. Employee 5 indicated that the facility had no documentation to support that Resident 4 was meeting her daily fluid needs. The facility failed to ensure sufficient fluid intake for Resident 4 to maintain proper hydration and health. 483.25 (j) Sufficient Fluid to Maintain Hydration Previously cited deficiency 8/31/10 28 Pa. Code 201.18(b)(1) Management. Previously cited 8/31/10 28 Pa. Code 211.10 (d) Resident care policies. Previously cited 8/31/10 28 Pa. Code 211.12 (d)(1)(5) Nursing services. Previously cited 8/31/10