Every finding on record at Sena Kean Nursing and Rehabilitation

Based on review of facility policy, Resident Council minutes, and resident interviews, it was determined that the facility failed to ensure that residents were updated in a timely manner regarding Resident Council concerns, and the facility failed to correct Resident Council concerns for a period of four months (January 2026, through April 2026). Findings include: A facility policy Resident Council dated 1/12/26, revealed the facility supports residents' rights to organize and participate in the resident council. The purpose of the resident council is to provide a forum for a) residents, families and resident representatives to have input in the operation of the facility; b) discussion of concerns and suggestions for improvement; c) consensus building and communication between residents and facility staff; and d) disseminating information and gathering feedback from interested residents. A Resident Council Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the item(s) of concern. The quality assurance and performance improvement (QAPI) committee will review information and feedback from the resident council as part of their quality review. Issues documented on council response forms may be referred to the QAPI committee, if applicable. Review of the Resident Council minutes over the past three months, February 2026, through April 2026, revealed a pattern/trend with issues regarding staff shutting call lights off without meeting resident's needs, failure to follow the facility smoking plan to assist residents who desire to smoke, and dietary trays not being passed by nursing staff timely resulting in cold food for residents. During a Resident Council meeting on 4/20/26, at 10:00 a.m. interviews with Residents R72, Resident R89, Resident R90, Resident 95, and Resident R86, who all attend Resident Council meetings regularly indicated that the concerns noted above have been voiced in several past monthly meetings with no resolution. The residents further indicated awaiting until the next monthly Resident Council meeting was not a timely response to learn of facility resolutions. No evidence was provided to ensure the residents' concerns voiced and further stated in the Resident Council minutes for the past three months reviewed were noted of timely corrective actions, in addition to the residents being updated in a timely manner of those actions. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (e)(1)(4) Management 28 Pa. Code 201.29(a) Resident rights

Based on review of facility policy, clinical records, observations, and staff interviews it was determined that the facility failed to appropriately maintain supplemental oxygen equipment for four of 23 residents reviewed for respiratory services (Residents R54, R38, R92, and R60).Findings include: A facility policy entitled Oxygen dated 1/12/26, indicated that any tubing not in use will be placed in a bag to ensure tubing remains clean and dry.Observations on 4/19/26, revealed:-At 3:20 p.m. Resident R38's oxygen tubing hanging on the portable oxygen tank attached to the back of his/her wheelchair and the tubing not in a bag, and the tubing for his/her respiratory nebulizer machine lying on the floor.-At 3:25 p.m. Resident R54's oxygen tubing lying next to his/her bed on the floor and not in a bag. -At 3:33 p.m. Licensed Practical Nurse (LPN) Employee E3 picked Resident R38's respiratory nebulizer tubing up from the floor then attached the tubing to Resident R38's nebulizer mask and was going to administer an as needed medicated nebulizer treatment. During an interview at that time Registered Nurse (RN) Employee E2 confirmed that Resident R38's oxygen and nebulizer tubing should be stored in a bag and should be discarded.During an interview at 3:35 p.m. RN Employee E2 confirmed that Resident R54's oxygen tubing should be stored in a plastic bag to prevent contamination. Observations on 4/20/26, revealed:-At 9:40 a.m. Resident R92 with a clear bag hanging on his/her concentrator [medical device that pulls oxygen in, filters it, and delivers purified oxygen to patients], and his/her oxygen tubing for the portable tank attached to the back of his/her wheelchair hanging over the top of the portable tank on the back of the wheelchair.-At 9:45 a.m. Resident R60's supplemental oxygen tubing for the portable tank wrapped around the right wheel of his/her wheelchair and required cutting to release it.-During an interview at that time, LPN Employee E4 confirmed the above-mentioned observations and cut Resident R60's oxygen tubing from the wheel of his/her wheelchair. Observations on 4/21/26, revealed:-At 10:38 a.m. Resident R38's oxygen tubing for the portable tank attached to the back of his/her wheelchair hanging over the top of the portable tank on the back of the wheelchair.-At 10:41 a.m. Resident R54's oxygen tubing for the portable tank attached to the back of his/her wheelchair hanging over the top of the portable tank on the back of the wheelchair.During an interview at 10:45 a.m. RN Employee E5 confirmed the above-mentioned observations and that the oxygen tubing should be stored in a bag to prevent contamination. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and resident observations, and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for seven of 23 residents (Residents R15, R23, R28, R38, R54, R82, and R83).Findings include:A facility policy entitled Cleaning of Wheelchairs and Geri-chairs dated 1/12/26, indicated that wheelchairs are cleaned according to the resident's shower schedule on the 11:00 p.m. - 7:00 a.m. shift prior to the shower day.Observations on 4/19/26, between 2:00 p.m. and 4:30 p.m. and 4/20/26, between 9:00 a.m. and 2:30 p.m. revealed that Residents R15, R23, R28, R38, R54, R82, and R83's wheelchairs with copious amounts of dried food particles, dried liquids, accumulation of dust and dirt, and debris on frames, wheels, arm rests, seats, seat cushions, and leg rests.During an interview on 4/21/26, at 10:41 a.m. Registered Nurse RN Employee E6 confirmed the condition of the above wheelchairs were as stated. During an interview on 4/22/26, at 9:41 a.m. the Nursing Home Administrator confirmed that the wheelchairs were to be cleaned on the overnight shift by nursing staff, and that they frequently failed to maintain adequate staff on that shift, and that could have contributed to failure to clean the wheelchairs. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3) Management28 Pa. Code 211.12(d)(1)(5)(f.1)(3) Nursing services

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to maintain privacy of confidential information during medication administration for two of five medication carts (West A Cart and East A Cart).Findings include:A facility policy entitled Computer Terminals/Workstations dated 1/12/26, indicated in so far as practical/feasible, computer terminals/workstations will be positioned or shielded so that screen are not visible to the public or to unauthorized staff; only authorized users are granted access to resident and facility information; and a user may not leave his/her workstations or terminal unattended unless the terminal screen is cleared and the user if logged off.Observation on 4/19/26, at 3:55 p.m. revealed the [NAME] A medication cart was parked in [NAME] A hallway and was unattended with the computer screen containing resident information visible to anyone passing by in the corridor. During an interview at the time of the observation, Licensed Practical Nurse (LPN) Employee E1 acknowledged the lack of privacy with resident information on the computer screen.Observation on 4/20/26, at 8:35 a.m. revealed the East A medication cart was parked in East A hallway and was unattended with the computer screen containing resident information visible to anyone passing by in the corridor. During an interview at the time of the observation, LPN Employee E5 acknowledged the lack of privacy with resident information on the computer screen. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to prevent the opportunity for potential unauthorized access of medications on two of five medication carts (East A Cart and [NAME] B Cart).Findings include:A facility policy entitled Medication Labeling and Storage dated 1/12/26, indicated that compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.Observation on 4/19/26, at 3:51 p.m. revealed the [NAME] B Medication Cart was parked in the [NAME] B hallway unlocked and unattended. During an interview at 3:55 p.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that the medication cart should have been locked.Observation on 4/20/26, at 8:35 a.m. revealed the East A Medication Cart was parked in the East A hallway unlocked and unattended.During an interview at that time, LPN Employee E5 verified the cart was not secured while he/she left the cart to attend to a resident. 28. Pa. Code 201.18(b)(1) Management28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policies, facility documentation, and clinical records, and staff interviews, it was determined that the facility failed to ensure that two of three residents reviewed were free of neglect during care which resulted in actual harm of left femur fracture for one resident (Resident R1) and actual harm of a laceration of the right eyebrow and forehead for one resident (Resident R2).Findings include: Facility policy entitled Abuse Investigation and Reporting dated 1/22/25, revealed The Administrator or designee will monitor that any further potential abuse, neglect, exploitation, or mistreatment is prevented while the investigation is in progress. Facility policy entitled Abuse Prevention Program dated 1/22/25, revealed Our residents have the right to be free from abuse, neglect, misappropriation of residents properly and exploitation. Facility policy entitled Safe Resident Handling and Movement Policies' dated 1/22/25, revealed Subject to Care Plan team determinations regarding rehabilitation, restoration or maintenance of functional abilities, medical contraindications, emergencies, or other exceptional circumstances, staff is expected to follow the individual resident's plan of care as written. And Transfer assistance, mobility assistance and other resident handling and movement tasks are to be carried out in accordance with the individual resident's care plan. Facility investigation refers to the regulatory definition of Neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Resident R1's physician's orders revealed an order dated 9/12/25, to transfer with staff assist of two with wheeled walker, stand up lift as needed. Resident R1's admission MDS dated [DATE], under Section GG 0170 Mobility for Sit to Stand. The ability to come to a standing position from sitting in a chair, wheelchair, or the side of the bed was coded as Dependent indicating Helper does ALL the effort. Resident does 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. Resident R1's clinical record revealed a nursing note written by Registered Nurse (RN) Employee E13, dated 9/19/25, at 8:55 p.m. This writer called to [NAME] Wing shower room by Licensed Practical Nurse [LPN] due to Resident was on the floor. Upon entering room, note Resident lying supine [on back] on floor to left of the room with head toward the left side of room and legs stretched out with exception of left low extremity [LLE] which was slightly bent and externally rotated. Resident assessed. Skin pink, warm and dry. Respiration easy and regular with occasional dry cough noted. Skin assessed - Resident has old, scabbed abrasion to L knee noted. LLE noted to be slightly bent and externally rotated. Resident unable to participate in passive or active range of motion [ROM - how far you can move or stretch a part of your body such as a joint or muscle] in this leg. Resident indicated pain 9/10 across mid/posterior thigh. Denies hitting head. Note towels on the floor, Resident and Certified Nursing Assistant [CNA] explained that this was to keep him from slipping, however Resident stated that he stepped off of the towels and slipped. Resident was being assisted by CNA to wheelchair and was lowered to the ground. Certified Registered Nurse Practitioner [CRNP] was notified and resident sent to the ER. Resident R1's clinical record revealed a nurse's progress note dated 9/20/25, that identified the resident was sent from a local hospital ER to another medical center in another city due to Left hip/femur fracture due to this evening's fall. Daughter and CRNP notified. Documentation submitted by the facility dated 9/20/25, revealed that the facility initiated an investigation which revealed CNA Employee E9 provided a written statement with an incident date of 9/19/25, which revealed, When transferring from shower chair to wheelchair, towels were placed under feet to keep bottom of feet dry, he placed heel of foot at the top of towel and went to stand even with shower chair locked, he slid on towel and on the edge of shower chair. Employee E9, was able to catch his top half of body and carefully put him on the floor so that he didn't hit his head, but his bottom half had fallen onto the floor. He stated he had throbbing pain in hip and Nurse and RN were notified. The facility investigation revealed that LPN Employee E7 provided a written statement with an incident date of 9/19/25, which revealed at the beginning of the shift between 1600 and 1700, CNA E9 and 2 other CNA's approached LPN E7 asking if Resident R1 was able to be put on the toilet. LPN E7 replied, yes, he/she can transfer with two assist and walker. Around 2000 that evening, CNA Employee E9 came and said, I have an emergency. He is on the floor. LPN employee E7 followed CNA Employee E9 to the shower room and saw Resident R1 laying on his back in the shower stall. His left leg was bent up with the knee going outward and towards the ground. He said they couldn't move his leg and had fallen directly on the left hip that he had previously repaired. During an interview on 10/22/25, at 12:00 p.m. the Director of Nursing (DON) confirmed that CNA Employee E9 had transferred Resident R1 on 9/19/25 without the assistance of a second staff member and did not follow orders which identified that Resident R1 required two staff for transfers. The facility failed to ensure that Resident R1 was free of an accident that resulted in actual harm of a left femur fracture from an improper transfer done with assistance of one staff and not with the required two-person assistance. Resident R2's clinical record revealed an admission date of 7/5/19, with diagnoses that included Alzheimer's (a brain disorder that destroys memory and thinking skills), Benign Prostatic Hyperplasia (BPH - a noncancerous enlargement of the prostate gland, which can result in frequent urination, difficulty starting or stopping urination and a weak urine stream) and Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing). Resident R2's quarterly Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care) dated 9/23/25, under Section C Cognitive Pattern Subsection C0100 Should Brief Interview for Mental Status Be Conducted was coded as No (resident is rarely/never understood) Resident R2's quarterly MDS dated [DATE], under Section GG 0170 Mobility for Roll left to right. The ability to roll from lying on back to left and right side and return to lying on back on the bed was coded as Dependent indicating Helper does ALL the effort. Resident does 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. Resident R2's ADL (Activities of Daily Living) Self Care Performance Deficit care plan revealed an intervention effective 12/31/24, indicating that Resident R2 was Dependent on 2 staff for bed mobility. Resident R2's Kardex (a documentation system used to organize and reference key resident information) revealed under the section titled Bed Mobility, ADL - Bed Mobility (Assist of 2 staff) and Bed Mobility - Resident R2 is dependent on 2 staff for bed mobility. Resident R2's task (a program used by nursing staff to verify resident bed mobility assist orders) revealed ADL - Bed Mobility (assist of 2 staff). Resident R2's clinical record revealed a progress note written by Registered Nurse (RN) Employee E10 dated 10/16/25, at 6:41 a.m. Called to resident's room for a roll off the bed by the CNA [Certified Nursing Assistant]. Arrived to find the resident on the floor by his bed laying on his right-side bleeding from a laceration. The resident was moaning in pain and there was about 40 milliliters [ml] of blood on the phone. Apparently the CNA went to roll the resident on his side and rolled him onto the floor. The height of the bed was approximately 18 inches above the floor. The resident was transferred back to bed, the laceration was cleaned and dressing. Resident R2's clinical record revealed a progress note written by Certified Registered Nurse Practitioner (CRNP) Employee E11, dated 10/16/25, at 6:34 p.m. for earlier incident revealing Phone call from RN at this time. Resident was accidentally rolled out of bed while aide was performing a.m. care. He sustained a right eyebrow laceration. Upon assessment, laceration will require sutures and he should have a head CT also. Orders given to clean site, apply pressure dressing, and send to ED [Emergency Department] for eval and treat. Resident R2's clinical record revealed a progress note written by RN Employee E12 dated 10/16/25, at 10:20 a.m. that indicated an RN from local hospital called report to this writer on resident s/p (status post) fall this AM. Resident has 10 stitches to laceration above R (right) eye, stitches are absorbable but can be removed after 10 days if provider prefers. Bacitracin ointment and kerlix over stitched area. VSS (vital signs stable). Resident's family at bedside, leaving ER estimated 1040. Unit RN Supervisor notified via telephone. Review of Resident R2's incident investigation revealed that CNA Employee E2 revealed he/she was performing morning care on Resident R2 and when he rolled Resident R2 over he started to roll too far and then rolled out of bed onto the floor. The facility failed to ensure that Resident R2 was free from neglect resulting in actual harm of a laceration of the right eyebrow and forehead. During an interview on 10/22/25, at approximately 3:10 p.m. the Nursing Home Administrator and DON confirmed that CNA Employee E2 did not follow the task orders, Kardex information, or the care plan, which identified that Resident R2 required two staff for bed mobility / rolling side to side and attempted to roll Resident R2 independently that caused harm to Resident R2. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, facility documentation and clinical record, and staff interviews, it was determined that the facility failed to appropriately transfer a resident in accordance to facility policy which resulted in actual harm of a left hip and femur (upper leg) fracture for one of three residents reviewed (Resident R1). This deficiency is cited as past non-compliance.Findings include: Facility policy entitled Safe Resident Handling and Movement Policies, dated 1/22/25, revealed, staff is expected to follow the individual resident's plan of care as written. Residents identified using the Minimum Data Set Assessment as Totally Dependent or requiring Extensive Assistance for Transfer and/or Mobility will be handled by means of mechanical lift equipment and/or other resident assist devices; A total dependent transfer requiring a mechanical lift will require two staff for bed mobility; transfer assistance, mobility assistance and other resident handling and movement tasks are to be carried out in accordance with the individual resident's care plan; and individual employees shall not deviate from the individual resident's care plan. Resident R1's clinical record revealed an admission date of 8/8/25, with diagnoses that included fracture of left femur (upper leg), difficulty in walking, Atrial Fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications), and asthma. Resident R1's physician's orders revealed an order dated 9/12/25, to transfer with staff assist of two with wheeled walker, stand up lift as needed. Resident R1's admission MDS dated [DATE], under Section GG 0170 Mobility for Sit to Stand. The ability to come to a standing position from sitting in a chair, wheelchair, or the side of the bed was coded as Dependent indicating Helper does ALL the effort. Resident does 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. Resident R1's clinical record revealed a nursing note written by Registered Nurse (RN) Employee E13, dated 9/19/25, at 8:55 p.m. This writer called to [NAME] Wing shower room by Licensed Practical Nurse [LPN] due to Resident was on the floor. Upon entering room, note Resident lying supine [on back] on floor to left of the room with head toward the left side of room and legs stretched out with exception of left low extremity [LLE] which was slightly bent and externally rotated. Resident assessed. Skin pink, warm and dry. Respiration easy and regular with occasional dry cough noted. Skin assessed - Resident has old, scabbed abrasion to L knee noted. LLE noted to be slightly bent and externally rotated. Resident unable to participate in passive or active range of motion [ROM - how far you can move or stretch a part of your body such as a joint or muscle] in this leg. Resident indicated pain 9/10 across mid/posterior thigh. Denies hitting head. Note towels on the floor, Resident and Certified Nursing Assistant [CNA] explained that this was to keep him from slipping, however Resident stated that he stepped off of the towels and slipped. Resident was being assisted by CNA to wheelchair and was lowered to the ground. Certified Registered Nurse Practitioner [CRNP] was notified and resident sent to the ER. Resident R1's clinical record revealed a nurse's progress note dated 9/20/25, that identified the resident was sent from a local hospital ER to another medical center in another city due to Left hip/femur fracture due to this evening's fall. Daughter and CRNP notified. Documentation submitted by the facility dated 9/20/25, revealed that the facility initiated an investigation which revealed CNA Employee E9 provided a written statement with an incident date of 9/19/25, which revealed, When transferring from shower chair to wheelchair, towels were placed under feet to keep bottom of feet dry, he placed heel of foot at the top of towel and went to stand even with shower chair locked, he slid on towel and on the edge of shower chair. Employee E9, was able to catch his top half of body and carefully put him on the floor so that he didn't hit his head, but his bottom half had fallen onto the floor. He stated he had throbbing pain in hip and Nurse and RN were notified. The facility investigation revealed that LPN Employee E7 provided a written statement with an incident date of 9/19/25, which revealed at the beginning of the shift between 1600 and 1700, CNA E9 and 2 other CNA's approached LPN E7 asking if Resident R1 was able to be put on the toilet. LPN E7 replied, yes, he/she can transfer with two assist and walker. Around 2000 that evening, CNA Employee E9 came and said, I have an emergency. He is on the floor. LPN employee E7 followed CNA Employee E9 to the shower room and saw Resident R1 laying on his back in the shower stall. His left leg was bent up with the knee going outward and towards the ground. He said they couldn't move his leg and had fallen directly on the left hip that he had previously repaired. During an interview on 10/22/25, at 12:00 p.m. the Director of Nursing confirmed that CNA Employee E9 had transferred Resident R1 on 9/19/25 without the assistance of a second staff member and did not follow orders which identified that Resident R1 required two staff for transfers. The facility failed to ensure that Resident R1 was free of an accident that resulted in actual harm of a left femur fracture from an improper transfer done with assistance of one staff and not with the required two-person assistance. This deficiency is cited as past non-compliance. On 9/20/25, the facility concluded the investigation of Resident R1's fall and initiated the following actions: Facility immediately suspended agency CNA Employee E9 and at conclusion of investigation made CNA Employee E9 a Do Not Return. Review of all resident transfer orders, Kardex (a nursing tool for resident information) transfer status and care plan transfer status were completed and updated by the DON on 9/20/25. All nursing staff were re-educated by the Assistant Director of Nursing (ADON) regarding how to locate resident's transfer status, two person assists and definition of neglect. Interviews with NA Employees E1, E2, E3, E4, E6, and LPN Employee E5 on 10/22/25, confirmed that they were re-educated a few weeks ago on where to find information regarding a resident's transfer status, two person assists, and the definition of neglect. Audits were conducted to ensure residents are transferred per their care plans, Kardex, and orders, which occurred from 9/24/25, through 10/21/25 with all transfers performed appropriately. The facility has demonstrated compliance with using correct transfer status for residents since 10/21/25. During an interview with the NHA and the DON on 10/22/25, at approximately 3:10 p.m. and review of the facility's immediate actions, education, competencies, and audits, it was verified that the facility had implemented a plan of correction to ensure residents are free from harm/injury regarding transfer status and had achieved substantial compliance. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policies and documents, and clinical records, and resident and staff interviews, it was determined that the facility failed to provide written notification to the resident, family and/or the resident's representative, prior to a facility-initiated room change, including the reason for the change for one of 25 residents reviewed (Resident R53). Findings include: A facility policy entitled Bed Hold Notification dated 1/22/25, indicated that if the resident is covered by Medicaid and admitted to the hospital, the bed will be held automatically for 15 days by the Medicaid Provider regulations. A facility policy entitled Bed Holds and Returns dated 1/22/25, indicated that residents who seek to return to the facility within the bed hold period defined in the state plan are allowed to return to their previous room, if available. A facility policy entitled Room Assignment/Change Policy dated 1/22/25, indicated: when a room change is necessary, the resident and family will be consulted and reasons for the move will be explained by the Social Services Department/designee; each resident will be given reasonable, advance notice prior to transfer within the facility, notice will provided both verbally and in writing; Social Services will generate an in-house transfer notice to inform staff of the location and date of transfer within the facility, and that the transfer will also be documented on the resident's clinical record. Resident R53's clinical record revealed an admitted [DATE], with diagnoses that included morbid obesity, lymphedema (chronic condition causing swelling, usually in an arm or leg, due to a buildup of lymph fluid), and ongoing blood clots in the right leg. Review of a resident census document indicated he/she was enrolled in Medicaid and was coded as a Paid Hospital Leave dated 4/22/25, and coded as Active on 4/25/25, to a different room. There was no evidence that the facility provided written notification with the reason for the change prior to the facility-initiated room change. Review of the facility Daily Census report provided by the facility on 4/30/25, revealed that Resident R53's previous room was not occupied by another resident during his/her hospital stay between 4/22/25, and 4/25/25, or since his/her return to the facility on [DATE]. Review of a Bed Hold Policy notification provided to Resident R53 on 4/22/25, revealed that he/she was notified that his/her bed will be held for 15 days while he/she is admitted to the hospital. During an interview on 4/28/25, at 2:02 p.m. Resident R53 confirmed that he/she was not permitted to return to his/her previous room upon return from the hospital, and that he/she wanted to return to their previous room and not stay in his/her current room. During an interview on 4/29/25, at 1:24 p.m. the Nursing Home Administrator confirmed the facility failed to provide a written notice of facility-initiated room change to Resident R53. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(a) Resident rights

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure physician orders and resident's Physician Order for Life Sustaining Treatment (POLST- a legal document specifying the resident/responsible party choices regarding life-sustaining treatments) were consistent for one of 25 residents reviewed (Resident R97). Findings include: The facility policy entitled Advance Directives dated [DATE], revealed The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive .the interdisciplinary team will be informed of changes and/or revocations so that appropriate changes can be made in the resident medical record and care plan. Resident R97's clinical record revealed an admitted [DATE], with diagnoses that included dementia (thinking and social symptoms that interfere with daily living and functioning), hypertension (high blood pressure), and heart disease. Resident R97's physician's orders dated [DATE], revealed an order for Do Not Resuscitate-Allow Natural Death (DNR). Resident R97's clinical record revealed a POLST dated [DATE], for cardiopulmonary resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest). During an interview on [DATE], at approximately 9:51 a.m. Registered Nurse Supervisor Employee E3, confirmed Resident R97's physician's orders and POLST were not consistent with each other. 28 Pa. Code 201.18 (b)(1)(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.5(f)(i)(iv) Medical records 28 Pa. Code 211.10(c) Resident care policies

Based on review facility policy and clinical records, observation, and staff interview, it was determined that the facility failed to provide appropriate suprapubic urinary catheter (tubing inserted directly into the bladder through a small incision in the lower abdomen and above the pubic bone to drain urine into a bag) care for one of three residents reviewed for catheters (Resident R51). Findings include: Review of facility policy entitled Catheter Care, Urinary dated 1/22/25, revealed Be sure the catheter tubing and drainage bag are kept off the floor. Review of Resident R51's clinical record revealed an admitted [DATE], with diagnoses that included cerebral infarction (stroke), neuromuscular dysfunction of the bladder (a communication breakdown in the body that controls bladder function), and muscle weakness. Review of Resident R51's clinical record revealed a physician's order dated 12/26/24, for a suprapubic catheter related to neuromuscular dysfunction of the bladder. Observations on 4/29/25, at approximately 9:25 a.m. revealed that the bottom of Resident R51's urinary drainage bag was on the floor and there was not a privacy cover on the urinary drainage bag. During an interview on 4/29/25, at approximately 9:27 a.m. the Assistant Director of Nursing confirmed that Resident R51's urinary catheter bag should not be on the floor and a privacy cover should in place. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of clinical records, observations, and resident and staff interviews, it was determined that the facility failed to provide oxygen according to physician's orders and failed to promote cleanliness and help prevent the spread of infection for two of 25 residents reviewed (Residents R21 and R59). Findings include: No facility policy was provided regarding management of oxygen therapy. Resident R21's clinical record revealed an admitted [DATE], with diagnoses that included respiratory failure with hypoxia (a condition where the lungs cannot provide enough oxygen throughout the body), chronic obstructive pulmonary disease (COPD - a group of lung disease that block airflow and make it difficult to breathe) , diabetes mellitus (a group of diseases that result in too much sugar in the blood), and morbid obesity with alveolar hypoventilation (a breathing disorder that could affect a person who is overweight). Resident R21's clinical record revealed a physician's order dated 1/23/25, for O2 [oxygen]: therapy at 8 lpm (liters per minute) via nasal cannula [device that delivers extra oxygen through a tube and into your nose]. Pad tubing/humidify every shift for oxygen. Observations on 4/27/25, at 2:15 p.m. revealed Resident R21 sitting in his/her wheelchair with oxygen being delivered via nasal cannula at 8 lpm. The concentrator filter on the right side of the concentrator was observed covered with a dusty gray substance. During an interview with Resident R21 on 4/27/25, at 2:15 p.m. he/she indicated that the oxygen concentrator filter on the right side of the concentrator has never been cleaned and/or changed. During an interview on 4/27/25, at 2:20 p.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that Resident R21's concentrator filter was dirty and covered with a dusty gray substance and did not appear to be cleaned weekly. The Director of Nursing (DON) confirmed on 4/29/25, at 1:53 p.m. that Resident R21's oxygen concentrator's filters should be checked and cleaned weekly. Resident R59's clinical record revealed an admitted [DATE], with diagnoses that included irregular heartbeat, chronic obstructive pulmonary disease (COPD- a common lung disease causing restricted airflow and breathing problems), heart failure, and high blood pressure. Further review of Resident R59's clinical record revealed a physician's order dated 3/06/23, for O2 therapy at 2 lpm as needed (PRN) via nasal cannula. There was a lack of evidence for a physician's order for maintaining/cleaning the oxygen equipment and lack of evidence that staff documented/recorded Resident R59's use of oxygen therapy on his/her medication administration record (MAR)/treatment administration record(TAR), and lack of evidence that staff performed respiratory assessments related to the use of supplemental oxygen. Observation on 4/27/25, at 3:16 p.m. revealed Resident R59 sitting up in bed with supplemental O2 in place via nasal cannula, and the oxygen concentrator filter was covered with a thick layer of gray fluffy substance. During an interview at that time, Resident R59 confirmed that he/she wears oxygen 24/7 (24 hours a day/seven days a week). Continued observations on 4/28/25, and 4/29/25, between 8:00 a.m. and 3:00 p.m. revealed Resident R59 with his/her supplemental O2 in place. During an interview on 4/27/25, at 4:28 p.m. the DON confirmed that the oxygen concentrator filter was covered in thick layer of gray fluffy substance. During an interview on 4/28/25, at 10:28 a.m. the Assistant DON confirmed there was no order for cleaning the concentrator filter. During an interview on 4/29/25, at 12:05 p.m. LPN Employee E2 confirmed that Resident R59 had his/her O2 on for the last three days and that he/she has it on all the time; there was no evidence of documentation in MAR/TAR that he/she has been receiving the O2; and no documentation that staff completed respiratory assessments related to O2 use. During an interview on 4/29/25, at 12:23 p.m. the DON confirmed there was no evidence that staff monitored Resident R59's use of O2. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in two of two unit refrigerators reviewed (West Unit and East Unit). Findings include: A facility policy entitled, Pantries and Pantry Refrigerators and Freezers dated 1/22/25, revealed, The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation Observation on 4/30/25, at approximately 9:27 a.m. of the [NAME] Unit freezer revealed several ice packs that are used for treatments on resident's bodies stored next to popsicles, candy bars, and several other food items. During an interview at the time of observation of the [NAME] Unit freezer with Social Services employee, he/she confirmed that ice packs that are used on resident's bodies should not be stored in the resident freezer with food. Observation on 4/30/25, at approximately 9:31 a.m. of the East Unit freezer revealed several ice packs that are used for treatments on resident's bodies stored next to several food items. During an interview at the time of observation of the East Unit freezer with Social Services employee, he/she confirmed that the ice packs that are used on resident's bodies should not be stored in the resident freezer with food. 28 Pa. Code 201.18 (e)(2.1) Management

Based on review of clinical record and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of six residents reviewed for catheters (Resident R1). Findings include: Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), urinary retention (inability to release urine from the bladder) and bladder infections. Resident R20's physician's orders revealed an order dated 9/26/24, that directed facility staff not to change the suprapubic catheter (a tube inserted into the bladder to drain the urine). A nurse's note dated 10/21/24, at 2:41 a.m. revealed that a nurse attempted to change Resident R1's suprapubic catheter against physician's orders by removing the suprapubic catheter and attempting to replace it, but was unable to insert a new catheter. During interview on 11/09/24, at approximately 12:40 p.m., the Nursing Home Administrator and Director of Nursing confirmed that a nurse did attempt to change Resident R1's suprapubic catheter and did not follow physician's orders. 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to follow acceptable infection control practices regarding enhanced barrier precautions during observation of care of a gastric tube for one of 25 residents reviewed (Resident R2). Findings include: Review of the facility policy entitled Administering Medications with a policy review date of 1/17/24, revealed that staff follows established infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Review of the facility policy entitled Enhanced Barrier Precautions implemented in April 2024, revealed Standard Precautions continue to apply to the care of all residents, regardless of suspected of confirmed infection or colonization status. Enhanced Barrier Precautions (EBP) employs targeted gown and glove use during high-contact resident care activities in which there is opportunity for transfer of Multi-Drug Resistant Organisms (MDRO) to staff hands and clothing. EBP are indicated for residents with any of the following wherever they reside in the facility: Infection or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply; or wounds and/or indwelling medical devices, regardless of MDRO infection of colonization status. Indwelling medical devices include, but not limited to central lines or PICC lines, urinary catheters, feeding tubes, tracheostomies and ventilators, and dialysis catheters. Appropriate notification/signage is placed at the room entrance indicating the type of precaution and instructions for Personal Protective Equipment (PPE) use. PPE will be available to staff for donning (put on) prior to entering the resident's room. Doffing (take off) to occur before leaving the residents room Observation of a tube feeding administration for Resident R2 on 5/29/24, at 1:44 p.m. revealed that Licensed Practical Nurse (LPN) Employee E3 washed hands, donned gloves, entered Resident R2's room, and positioned Resident R2 for administration of the enteral tube feeding. LPN Employee E2 proceeded to check placement of Resident R2's enteral feeding tube and administer the enteral feeding. LPN Employee E2 then repositioned the resident in bed for comfort, doffed gloves and washed hands. During an interview with LPN Employee E2 on 5/29/24, at approximately 1:55 p.m. it was confirmed that gloves and a gown should have been worn during administration with an enteral feeding tube due to EBP. Observation of Resident R2's room revealed that there was no signage alerting persons of EBP for infection control and no PPE available outside of the room for use. During an interview on 5/29/24, at approximately 1:58 p.m. the Infection Preventionist confirmed that EBP were not in place and employees should be wearing gloves and gowns when working with enteral feeding tubes. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide a resident and/or his/her representative with a summary of the baseline care plan for three of five residents reviewed for baseline care plans (Resident R31, R103 and R105). Findings include: Review of facility policy entitled, Care Plans Baseline dated 1/17/24, revealed The resident and/or representative are provided a written summary of the baseline care plan that includes, but is not limited to the following .Goals and objectives, summary of medications, dietary instructions, and treatments. Review of Resident R31's clinical record revealed an admitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (condition when your lungs do not have adequate air flow), hypertension (high blood pressure), and heart failure (a condition where the heart cannot supply the body with enough blood). Review of Resident R31's clinical record revealed an assessment dated [DATE], Baseline care plan which revealed a question Were the baseline care plans shared with the resident and/or resident representative? The question revealed the answer no. Further review of Resident R31's clinical record lacked evidence that a summary of the care plan that included goals and objectives, a summary of medications, dietary instructions and treatments was provided to Resident R31 and/or his/her representative. Review of Resident R103's clinical record revealed an admitted [DATE], with diagnoses that included hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones), hypertension, and hyperlipidemia (high cholesterol). Review of Resident R103's clinical record revealed an assessment dated [DATE], Baseline care plan which revealed a question Were the baseline care plans shared with the resident and/or resident representative? The question revealed the answer no. Further review of Resident R103's clinical record lacked evidence that a summary of the care plan that included goals and objectives, a summary of medications, dietary instructions and treatments was provided to Resident R103 and/or his/her representative. Review of Resident R105's clinical record revealed an admitted [DATE], with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), hypertension, and dysphagia (difficulty swallowing). Review of Resident R105's clinical record revealed an assessment dated [DATE], Baseline care plan which revealed a question Were the baseline care plans shared with the resident and/or resident representative? The question revealed no answer. Further review of Resident R105's clinical record lacked evidence that a summary of the care plan that included goals and objectives, a summary of medications, dietary instructions and treatments was provided to Resident R105 and/or his/her representative. During an interview on 5/30/24, at 1:57 p.m. the Regional Nurse Consultant confirmed that there was no evidence that Residents R31, R103 and R105 and/or their representatives were provided a summary of the care plan that included goals and objectives, a summary of medications, dietary instructions, and treatments. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of facility policy and clinical record, observation, and staff interviews, it was determined that the facility failed to ensure medications were consumed for one of seven residents reviewed during medication administration review (Resident R55). Findings include: Review of facility policy entitled Administering Medications dated 1/17/24, revealed Medications are administered in a safe and timely manner . Review of facility education/training entitled Checklist for oral medication administration revealed Remain with the resident until each medication is swallowed. Never leave medication at the resident's bedside. And Review of facilities audit tool entitled Medication Administration Observation Audit, revealed Resident is observed until all meds are ingested. Review of Resident R55's clinical record revealed an admitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (condition when your lungs do not have adequate air flow), chronic kidney disease (a disease that affects the kidney's ability to filter waste products and extra fluid from the body), and disorientation (an altered mental state where a person does not know their location, identity, or time). Observation on 5/29/24 at 9:42 a.m. revealed a medication cup filled with multiple unknown medications sitting on the resident's bedside tray table. Resident R55 was sitting in his/her wheelchair in front of his/her bedside table. Resident R55 stated staff doesn't wait for me to take my pills because it takes me a while. He/she also stated, there is a pill on the floor. A small white unknown medication was observed laying on the floor in front of Resident R55's bedside tray table. Further observations revealed the Licensed Practical Nurse (LPN) was down the hallway assisting other residents. During an interview on 5/29/24, at 9:49 a.m. Registered Nurse Employee E1 confirmed that there was a cup filled with unknown medications sitting on Resident R55's bedside table without staff present. He/she also confirmed that medications should never be left at bedside and the nurse administering medications should stay with the resident until the resident ingested the medications. 28 Pa. Code 211.9(a)(1)(c) Pharmacy Services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, observations, and staff interviews it was determined that the facility failed to appropriately discard outdated medications for one of three medication carts reviewed (West A Hall medication cart). Findings include: Review of facility policy entitled Administering Medications with a policy review date of 1/17/24, indicated The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. Review of Novolog Insulin manufacturer's guidelines revealed after initial use a vial may be kept at temperatures below 30 degrees Celsius (86 degrees Fahrenheit) for up to 28 days, but should not be exposed to excessive heat or sunlight. Observation of drug storage on 5/30/24, at 10:58 a.m. of the [NAME] A Hall medication cart revealed a vial of Novolog Insulin with an open date of 4/10/24, which was beyond the expiration date of 28 days after opening. During an interview at the time of the observation, Licensed Practical Nurse (LPN) Employee E2 confirmed that the Novolog Insulin vial should have been discarded and not remaining in the medication cart for resident use as it was beyond the 28 days after opening. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that known medication allergies were verified prior to the administration of a medication for one of six residents reviewed (Resident R1). Findings include: Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included depression, schizophrenia (a disorder that affects the ability to think, feel and behave clearly), abnormal involuntary moments, convulsions/seizures and delusional disorders. A nurse's note dated 1/15/24, at 10:00 a.m. documented a decline in Resident R1's condition and a physician's order to administer a one time dose of Haldol (an antipsychotic medication used to treat mental disorders including schizophrenia) 2.5 milligrams (mg). The medication administration record revealed that the Haldol 2.5 mg IM (intramuscular injection) was administered at 11:30 a.m. on 1/15/24, as physician ordered. Review of a nurse's note dated 1/15/24, at 12:25 p.m. identified the discovery that Haldol was listed under Resident R1's allergies. A review of Resident R1's clinical record revealed that Haldol was listed as an allergy. During interview on 1/30/24, at 1:50 p.m. Registered Nurse Employee E1 confirmed that Resident R1's allergy list was not checked prior to the administration of Haldol. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and resident council minutes, and resident and staff interviews, it was determined that the facility failed to respond to resident concerns and grievances identified during resident council minutes for three of three months (October, November, December 2023). Findings include: Review of a facility policy entitled, Resident Council indicated that a Resident Council Response Form will be utilized to track issues and their resolution; and the facility department related to any issues will be responsible for addressing the item(s) of concern. Review of a facility policy entitled, Grievance Policy indicated: that all concerns and questions may be presented to the facility administrator (NHA), director of nursing (DON), the registered nurse supervisor (RN Supervisor), or any department head, this may be done either orally or in writing; any new grievance shall be brought to the morning meeting to ensure that they have been entered into the grievance log and assigned for follow up; upon completion of the facility investigation, the NHA will ensure that the investigation results and resolution steps are communicated to the individual who originally submitted the grievance, complaint and/or suggestion; and resolution of the concern is desired within five working days from the date the concern was filed. Review of the October 2023 Resident Council Meeting Minutes revealed; lack of evidence that previous Resident Council concerns were discussed with the Resident Council; new concerns included with staff being on their cell phones while giving care, call bell response times, staff leaving residents in the bathroom unattended. There was no evidence that the concerns were assigned to a department responsible for investigation. Review of the November 2023 Resident Council Meeting Minutes revealed; lack of evidence that previous Resident Council concerns were discussed with the Resident Council; new concerns included wraps not being done on a resident's legs on 11/11/23, and 11/12/23, staff turning off call bells and not returning to provide care, 3-11 shift staff on their cell phones while feeding residents, staff eating off resident meal trays, late smoke breaks, staff yelling at residents, a Nurse Aid being too big to toilet a resident in their room, supper being late, dietary running out of supplies, unit pantries not being stocked with snacks, and residents requesting meal of the month being implemented. There was no evidence that the concerns were assigned to a department responsible for investigation. Review of the December 2023 Resident Council Meeting Minutes revealed; that follow-up discussion from the previous meeting included that the smoke break time was better, and lacked evidence that other concerns from the previous meeting were discussed with the Resident Council; new concerns included call bells not being answered timely, staff sitting in chairs on the halls, staff on cell phones while providing care, combative residents, female resident requesting to have no male nurse aids, [NAME] pantry not stocked (out of tea bags and crackers), and meal of the month to return in January. There was no evidence that the concerns were assigned to a department responsible for investigation. Review of facility Concern Logs revealed: Dated 10/02/23, Resident Council concerns were documented and that a written notice of resolution was provided to the Resident Council on 10/09/23. Dated 11/13/23, Resident Council concerns were documented and that a written notice of resolution was provided to the Resident Council on 11/20/23, regarding care/treatment and dietary concern types. Dated 12/05/23, Resident Council concerns were documented and that a written notice of resolution was provided to the Resident Council on 12/05/23. Dated 12/13/23, Resident Council concerns were documented and that a written notice of resolution was provided to the Resident Council on 12/20/23. Review of an investigation/staff education dated 10/02/23, revealed that the Assistant Director of Nursing (ADON) educated staff on call bell response, leaving residents alone in the bathroom, and re-educated staff on the facility cell phone policy. There was a lack of evidence indicating that the issues were resolved and confirmation of the Resident Council's satisfaction with the outcome. Review of an investigation/staff education dated 11/13/23, revealed that the ADON educated staff on completing resident treatments, call bell response, leaving residents alone in the bathroom, and re-educated staff on the facility cell phone policy, staff eating off resident meal trays, smoke break, toileting residents, and staff yelling at residents There was a lack of evidence indicating that the issues were resolved and confirmation of the Resident Council's satisfaction with the outcome. Review of an investigation/staff education dated 11/13/23, revealed the Dietary Department was working on training staff, education regarding time management and stocking, and discussing bringing back the meal of the month. There was a lack of evidence indicating that the issues were resolved and confirmation of the Resident Council's satisfaction with the outcome. Review of an investigation/staff education dated 12/13/23, revealed staff was educated on donning (putting on)appropriate personal protective equipment in the isolation hall, relocation of residents was disorganized, call bell response, staff using vulgar language while feeding residents. Corrective actions were documented, and there was no evidence of the responsible staff member, resolution of the issues and confirmation of the Resident Council's satisfaction with the outcome. During interviews on 1/11/24, between 10:30 a.m. and 2:00 p.m. Resident Council members (Residents R1, R2, R3, R4, and R8) confirmed that previous concerns are not discussed at Resident Council Meetings and they confirmed that staff continue to turn off call bells, sit in resident rooms on their cell phones in the evening, and were told there are no snacks in the pantry. During an interview on 1/11/24, at 2:30 p.m. the ADON confirmed that staff has been re-educated repeatedly on certain reported issues. During an interview on 1/11/24, at 2:30 p.m. the Director of Nursing and Nursing Home Administrator confirmed that there was lack of evidence that the repeated education was effective, there was a lack of developing an alternative method of resolution to the repeated concerns, and also there was a lack of evidence that the Resident Council was informed of the outcome and was satisfied with the outcomes by the facility. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1)(4) Management

Based on review of the Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care) and the October 2019 Resident Assessment Instrument User's Manual (instruction manual for completing the MDS assessments), clinical records, and staff interviews, it was determined that the facility failed to ensure that the MDS assessment accurately reflected the status for two of 24 residents reviewed (Residents R46 and R84). Findings include: Review of RAI instructions for MDS Section O0100C Special Treatments, Procedures, and Programs - Oxygen Therapy indicated to check if the treatments, procedures, and programs were performed during the last fourteen days. Review of RAI instructions for MDS Section O0100J Special Treatments, Procedures, and Programs - Dialysis indicated to check if the treatments, procedures, and programs were performed during the last fourteen days. Resident R46's clinical record revealed an admitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (a lung disease that obstructs airflow to the lungs resulting in difficulty breathing), high blood pressure, and anxiety. Resident R46's clinical record revealed a physician's order dated 8/15/22, for oxygen therapy at four liters per minute via nasal cannula (a tube that delivers oxygen to your nose through soft prongs) continuously for difficulty breathing. Staff signage on the treatment record identified the usage of oxygen at four liters per minute by way of nasal cannula for the entire fourteen-day look-back period for Resident R46. Review of Resident R46's quarterly MDS with an Assessment Reference Date (ARD) of 5/23/23, did not indicate the use of oxygen while a resident in the facility. Resident R84's clinical record revealed an admitted [DATE], with diagnoses that included end stage renal disease (loss of kidney function), pneumonia, diabetes, and anxiety. Resident R84's clinical record revealed a physician's order dated 12/12/22, for the resident to attend dialysis (mechanical treatment to remove toxins from the body) three times a week. Review of progress notes documented in the clinical record that Resident R84 had been taken to dialysis during the fourteen-day look-back period. Review of Resident R84's quarterly MDS with an ARD of 6/21/23, did not identify dialysis while a resident in the facility. During an interview on 7/27/23, at 4:45 p.m. Registered Nurse Assessment Coordinator confirmed that the 5/23/23, MDS for Resident R46 was coded incorrectly regarding oxygen and the 6/21/23, MDS for Resident R84 was coded incorrectly regarding dialysis. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f) Clinical Records

Based on observations, review of facility policy and clinical records, staff interviews, it was determined that the facility failed to follow accepted professional standards and principles for administering medications which jeopardized resident's health and safety for one of five residents reviewed for medication administration (Closed Record Resident CR1). This deficiency is cited as past non-compliance. Findings include: Review of the facility policy entitled, Administering Medications revised April 2019, revealed that the director of nursing services supervises and directs all personell who administer medication and/or have related functions; medications are administered in accordance with prescribers orders, including any required time frame; the individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right route of administration before giving the medication; as required or indicated, the individual administering the medication records in the resident's medical record the date and time, the dosage, route, and signature and title of person administering the drug. Review of Resident CR1's clinical record revealed an admitted [DATE], with diagnoses that included congestive heart failure (heart condition where the heart doesn't pump blood as well as it should), kidney disease, Type 2 Diabetes (condition that affects how the body uses glucose [sugar]), pneumonia (infection of the lung), chronic obstructive pulmonary disease (COPD- group of diseases that cause airflow blockage and breathing-related problems), and shortness of breath. Review of physician's orders revealed that on 10/28/22, Resident CR1 was ordered a loading dose of Digoxin (medication used to control the rate and rhythm of the heartbeat) 250 micrograms (mcg) every six hours by mouth for one day (four doses), then 125 mcg of Digoxin by mouth daily. Review of Resident CR1's medication administration record revealed that staff initials indicated the following: -on 10/29/22, he/she was administered four doses of 250 mcg of Digoxin (correct dosage) -on 10/30/22, and 10/31/22, he/she was administered four doses of 250 mcg of Digoxin and one dose of 125 mcg of Digoxin (four extra doses of 250 mcg) each day -and on 11/01/22, he/she was administered three doses of 250 mcg of Digoxin (three extra doses of 250 mcg) and one dose of 125 mcg of Digoxin Review of pharmacy delivery packing slips revealed: -on 10/29/22, the facility received four doses of 250 mcg of Digoxin and three doses of 125 mcg of Digoxin for Resident CR1 (completed) -and on 10/31/22 the facility received two cards containing a total of 28 doses of 125 mcg of Digoxin for Resident CR1 (20 of 28 doses remaining) Review of Resident CR1's clinical record revealed progress notes that indicated: -on 10/24/22, he/she experienced shortness of breath, abnormal lung sounds, swelling in both ankles and feet -on 10/25/22, he/she experienced shortness of breath, moist cough, abnormal lung sounds -on 10/27/22, he/she experienced increased respiratory effort, abnormal lung sounds, low oxygen saturation on room air, falling asleep at physical therapy -on 10/27/22, physician notified of tiredness, falling asleep at therapy, cough, abnormal lung sounds, and lab work and chest x-ray ordered -10/28/22, at 11:51 a.m. chest x-ray results pulmonary vascular congestion (engorged blood vessels in the lungs caused by a back-up of blood not getting effectively pumped out of the heart) -on 10/28/22, at 4:32 p.m. physician ordered Digoxin 250 mcg every six hours by mouth for one day (four doses) and then 125 mcg daily by mouth, and the electronic health system identified that the order for Digoxin 250 mcg every six hours by mouth for heart failure was outside of the recommended dose -on 10/28/22, at 5:35 p.m. the pharmacist questioned the ordered dose of Digoxin and was advised by facility staff that the 250 mcg of Digoxin was to be given as a loading dose and that the dose would decrease to 125 mcg daily after the first four doses -on 10/31/22, at 1:35 p.m. noted resident was coughing less, feels better, and swelling in ankles and feet decreased -on 11/01/22, at 8:06 p.m. son notified of order to discontinue Digoxin -on 11/02/22, 8:24 a.m. progress note indicated resident with low pulse, low oxygen saturation with oxygen on, refusal of breakfast, reported nausea, swelling in both legs, loose bowel movement, and refusal of dinner the previous night due to reported upset stomach. -on 11/02/22, 10:06 a.m. physician notified of resident condition and order received for anti-nausea medication -on 11/03/22, 9:28 a.m. increased confusion, removing oxygen, oxygen saturation 65, pulse 48, purse lip breathing, oxygen re-applied- saturation up to 79, increased respiratory effort -on 11/03/22, at 9:33 a.m. noted to be excessively sleepy, abnormal lung sounds, fingers dusky (grey), oxygen saturation 79 with oxygen, oxygen increased, pulse 48, swelling, decreased appetite for breakfast, son notified, physician order at 9:55 a.m. to send to the hospital -on 11/03/22, at 10:39 a.m. transferred to the hospital -on 11/03/22, the facility was notified that the resident was life flighted to another hospital for digoxin toxicity ([digoxin level greater than two ng/ml (nanograms per milliliter - is the most commonly used unit of measure to express drug testing cut-off levels and quantitative test results]), the hospital reported that resident's digoxin level was 6.26 ng/ml. -on 11/07/22, 12:51 p.m. physician notified that resident ceased to breathe at the hospital on 11/06/22. Review of hospital records for Resident CR1 revealed that on 11/03/22, at 8:45 p.m. his/her Digoxin level was 8.08 ng/ml, and on 11/04/22, at 6:48 a.m. his/her Digoxin level was greater than 10 ng/ml. The Administrator and Director of Nursing were made aware of the Immediate Jeopardy situation on 11/21/22, at 3:50 p.m. The immediate jeopardy template was given to the Nursing Home Administrator and an immediate action plan was requested. The immediate action plan was provided by the NHA and DON on 11/21/22, which was accepted at 5:40 p.m. This deficiency is cited as past non-compliance. The facility implemented their corrective action plan on 11/10/22, which included the following interventions: 1. On 11/09/22, Registered Nurses (RNs) were re-educated on transcribing physician's orders and a validation was completed. 2. On 11/10/22, Licensed Practical Nurses (LPNs) were re-educated on the rights of medication administration. 3. On 11/08/22, LPNs were re-educated on the 24-hour chart check policy. 4. On 11/10/22, Residents prescribed cardiac medications for treatment of Congestive Heart Failure (occurs when the heart muscle doesn't pump blood as well as it should) were identified. 5. On 11/08/22, the Director of Nursing (DON) or designee began auditing five new physician's orders per week to ensure each order was transcribed correctly for four weeks, this will continue monthly for three months. 6. On 11/08/22, the DON or designee began completing audits of two nurses per day for five days and will continue to audit two nurses per week for three weeks to ensure the rights of medication administration was followed. 7. The pharmacy or designee will complete monthly medication administration competencies for licensed nurses. Scheduled to be complete prior to end of November 2022. The facility corrective action plan to mitigate the risk of additional transcription and medication errors was implemented on 11/08/22, and finalized on 11/10/22, as evidenced by the action steps above. Observations on 11/21/22, between 4:22 p.m. and 4:55 p.m. of medication administration to four residents (Residents R2, R3, R4, and R5), revealed that LPN Employees E1, E4, and E5, administered medications using the appropriate six step process (right patient, right medication, right dose, right route, right time, right documentation) of safe medication administration. Observations included the administration of 150 milligrams of Seroquel (antipsychotic- works by changing the actions of chemicals in the brain) by mouth. This administration required LPN Employee E4 to combine one 100 milligram tablet and two 25 milligram tablets to equal the correct dose. Observations also included the administration of one milligram of Haldol (antipsychotic) by intramuscular injection. This administration required LPN Employee E5 to use a syringe to withdraw the correct dose from a multi-dose vial containing two milligrams of medication per one milliliter of liquid. The LPN successfully withdrew the appropriate 0.5 milliliter of liquid from the vial to administer the correct dose of one milligram. Interviews on 11/21/22, between 4:22 p.m. and 4:55 p.m. LPN Employees E1, E4, and E5, and RN Employees E2, and E3 confirmed that they received education regarding the correct process of transcribing physician orders to the resident's medical records, and the six rights of safe medication administration. Observations, staff interviews, and review of the facility's corrective actions on 11/21/22, between 4:22 p.m. and 5:40 p.m. revealed the facility had implemented the previously stated corrective actions. On November 21, 2022, at 5:40 p.m. the Immediate Jeopardy was removed on 11/21/22, at 5:40 p.m. after ensuring the immediate corrective action plan had been implemented and compliance achieved. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12 (d) (5) Nursing Services

Based on observation, review of facility policies and documentation, and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program by failing to follow infection control guidelines from the Centers for Disease Control and Prevention (CDC) and the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections and prevent cross-contamination during the COVID-19 pandemic. This failure placed the facility in an Immediate Jeopardy situation for six of 18 residents reviewed (Residents R1, R6, R7, R13, R14, and R15) Findings include: Pennsylvania Health Alert Network (PA-HAN) 530, regarding Long-Term Care Facility Guidance for Testing and Cohorting (for outbreaks and exposure to COVID-19 - a contagious [MEDICAL CONDITION] disease that can cause a variety of symptoms, including breathing problems, fever, and cough), dated October 7, 2020, indicated that residents needed to be cohorted (grouped together) to separate units in three zones, based on test results: - COVID-19 positive residents (Red Zone): residents with a positive test and still within the parameters for transmission-based precautions. - Potentially exposed residents (Yellow Zone): residents with a negative COVID-19 test who remain asymptomatic but were within 14-days of possible exposure to COVID-19. - Unexposed (Green Zone): any residents in the facility who were not tested and were thought to be unexposed to COVID-19. - Zones were to be clearly marked with limited access signs or temporary barriers to prevent unnecessary foot traffic to the area. Review of CDC guidance Responding to Coronavirus (COVID-19) in Nursing Homes, dated 4/30/2020, indicated that Residents of nursing homes who have a confirmed COVID-19 infection, regardless of symptoms, should be transferred to a designated COVID-19 care unit. Roommates of residents with COVID-19 should be considered exposed and potentially infected, and if at all possible should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for COVID-19 fourteen days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). Exposed residents may be permitted to room share with other exposed residents, if space is not available for them to remain in a single room. Review of facility document entitled Interim Additional Guidance for Infection Prevent and Control for Patients with Suspected or Confirmed COVID-19 in Nursing Homes indicated that facility will Dedicate space in the facility to care for residents with suspected or confirmed COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19. Observation on 1/19/2021, at 11:00 a.m. and again on 1/23/2020, at 9:00 p.m. revealed all residents residing in the facility were positive for COVID and were in the red zone. Review of room assignments and review of facility line listing for residents indicated that exposed / negative residents remained in the room with diagnosed positive residents. The facility employs the [MEDICATION NAME] testing which confirms positive or negative results within 15-minutes. The facility also routinely utilized additional testing through an outside laboratory company. Resident R2 was swabbed on 12/20/2020, was moved from West C 41 to East B 16 on 12/22/2020, with positive results being received 12/23/2020, and remained in the same room as Resident R1 who was swabbed on 12/27/2020, via [MEDICATION NAME] testing and was negative and was swabbed again on 1/3/2021, with positive results being received 1/6/2021. Resident R5 was swabbed on 12/27/2020, was moved from West A8 to West B 23 on 12/29/2020, with positive results being received 12/31/2020, and remained in the same room as Resident R6 who was swabbed on 12/27/2020, and was negative and swabbed again on 1/3/2021, with positive results being received 1/6/2021. Resident R8 was swabbed on 12/20/2020, with positive results being received 12/23/2020, and remained in the same room as Resident R7 who was swabbed on 12/27/2020, with positive results being received on 12/31/2020 until 12/27/2020 when Resident R8 was admitted to the hospital. Resident R16 was swabbed on 12/20/2020, with positive results being received 12/23/2020, and remained in the same room as Resident R13 who was swabbed on 1/3/2021, with positive results being received 1/6/ Resident R17 was swabbed on 12/20/2020, with positive results being received 12/23/2020, and remained in the same room as Resident R14 who was swabbed on 12/27/2020, with positive results being received 12/31/2020. Resident R18 was swabbed on 12/23/2020, with positive results being received 12/27/2020, and remained in the same room as Resident R15 who was swabbed on 1/3/2021, with positive results being received on 1/6/2021. During an interview on 1/23/2021, at 11:30 a.m. the Director of Nursing (DON) confirmed that cohorting COVID positive residents with COVID exposed / negative roommates was a result of the directions received from Regional Response Health Collaboration Program (RRHCP) consultant on 12/23/2020. During an interview on 1/23/2021, at 1:50 p.m. the representative from RRHCP stated they did not direct the facility to leave positive COVID residents with COVID exposed /negative roommates and facility should have cohorted residents based on zone guidelines. The DON was made aware that Immediate Jeopardy existed for six of 18 Residents in the facility on 1/23/2021, at 5:58 p.m. and that a corrective action plan was required. On 1/23/2021, at 8:40 p.m. an acceptable corrective action plan was approved which included the following interventions: 1. Immediately started education with staff by reviewing PA-HANS 530 with special focus on setting up zones, cohorting residents and testing. For employees not on duty notices posted to report to RN Supervisor prior to the start of their shift to receive education. 2. As of 1/8/2021, all residents were COVID-19 positive. Effective 1/24/2021, all Residents except five will have completed their quarantine and will be placed in a green zone. The remaining five will be placed in designated red zone for the remainder of their quarantine time and then will be moved to a green zone. 3. Facility dedicated West B-Hall, West C-Hall, East A-Hall, and East B-Hall as their green zones. 4. Facility dedicated East C-Hall rooms 28-31 and 38-41 as their yellow zone. 5. Facility dedicated East C-Hall rooms 32 A and B, 35 A and B, and 36 A and B as their red zone. 6. If facility needs additional red zone rooms, they will include more rooms on East C-Hall and if needed move their yellow zone to a different hall. 7. Currently West A-Hall is unoccupied but will be designated as a green zone. 8. If a Resident shows signs and symptoms they will have a POC test at the facility followed by a PCR test done through Aegis Lab. If the POC test is positive the resident will immediately be moved to the designated red zone. If the POC test is negative the resident will immediately be moved to the designated yellow zone until the PCR test results are received and then additional moves will occur based on those results. 9. If a resident is COVID-19 positive their roommate will be moved to the yellow zone due to exposure. Observation on 1/23/2021, at 9:30 p.m. revealed the facility put their plan into place and staff who were onsite were educated by reviewing PA-HAN 530. Notices were posted for staff not on duty at that time to report to the RN Supervisor prior to the start of their shift. There were no negative residents in the facility that required moving and facility is not currently accepting new admissions. The Immediate Jeopardy was removed on 1/23/ , at 9:40 p.m. when the action plan implementation was verified. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on facility policy, review of clinical records and facility investigation reports and staff interviews, it was determined that the facility failed to make certain that a resident was free from neglect by not being turned and repositioned every two hours as ordered and left overnight that resulted in harm of a new Stage II (partial thickness loss of dermis [skin] presenting as a shallow open ulcer with a red or pink wound bed) pressure ulcer for one of eight residents reviewed (Resident R1). This deficiency was cited as past non-compliance. Findings include: The facility policy entitled, Resident Abuse & Neglect Prevention Program, dated 1/1/20, indicated that each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation as defined in the regulation. Resident R1's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R1's skin care plan indicated to follow facility policies and procedures for the prevention / treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nurse's Note dated 9/18/20, written by Assistant Director of Nursing Employee E1 revealed that Resident R1 was found to be lying in bed at approximately 7:00 a.m. with a Hoyer (type of mechanical lift) lift pad and two soaker pads (padding underneath the resident for urinary incontinence episodes) and a brief (incontinence care product) underneath the resident. Resident was noted to have several indentations on posterior trunk and back of legs. Right buttocks were also noted to have open areas with scant amount of bloody drainage. Skin assessment was completed and Resident R1 noted to have a new Stage II pressure ulcer area to right buttocks. Right superior buttock wound measured 2.4 centimeters (cm) in length by 1.0 cm in width with sero-sanguineouis (bloody) drainage. Second open area on right buttock inferior to first area also open Stage II wound measuring 0.4 cm x 1.0 cm with same drainage as first wound area cleansed and dressing applied. An Open Lesion initial report dated 9/18/20, indicated right buttock pressure ulcer is 2.4 cm x 1.0 cm Stage II in house acquired. There was no evidence of documentation regarding second open area on this report. A facility investigation report dated 9/18/20, submitted to the Department of Health revealed that an event that had occurred on 9/18/20, at 7:00 a.m. The report revealed that Nurse Aide (NA), Employee E2, was willfully negligent in the care of Resident R1 and failed to review or follow the resident's plan of care to follow policy for skin care / protection. An investigation report revealed that NA Employee E2 failed to turn and reposition Resident R1 every two hours as ordered and to check if resident was on an air overlay, not noting that the resident had a hoyer lift pad, two soaker pads and a brief underneath the resident resulting in the development a new Stage II pressure ulcer the the right buttocks. During an interview on 11/10/20, at 10:30 a.m. the Director of Nursing confirmed that on 9/18/20, Resident R1 was left overnight on a hoyer lift pad, two soaker pads and not turned and repositioned every two hours as ordered that resulted in a pressure injury (Stage II) and that NA Employee E2 was negligent providing care for Resident R1. The facility failed to make certain that a resident was free from neglect for one resident (Resident R1) that resulted in harm of newly developed an Stage II pressure ulcer to the right buttock due to being left on a hoyer lift pad, two soaker pads and not being turned and repositioned every two hours around the clock as ordered by the physician. Following the incident on 9/18/20, the facility implemented a corrective action plan that included immediate staff education, conducting an internal investigation, whole house education on abuse/neglect, presenting information to the Quality Assurance/Performance Improvement committee for discussion of steps to correct the facility identified non-compliance and was in substantial compliance prior to the survey of 11/13/20. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.109(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services