Every finding on record at Seneca Place

Based on review of clinical records and staff interviews, it was determined that the facility failed to obtain physician orders for management of hypoglycemia (low blood sugar) for one of two residents (Resident R173) failed to obtain physician orders for hypoglycemia and hyperglycemia (high blood sugar) for one of two residents (Resident R15) failed to notify a physician's of a resident with a hypoglycemic episode (low blood sugar) for one of two residents (Resident R173) and failed to obtain orders for a urinary condom catheter (non-invasive external urinary catheter worn like a condom it collects urine as it drains from the bladder and sends it to a collection bag) for one of three residents (Resident R185).Findings include: Review of the facility policy External Male Catheter-Condom Catheter last reviewed 5/21/26, indicated the purpose of this procedure is to prevent urinary tract infection and skin breakdown in an incontinent resident. Verify that there is a physician's order for this procedure. Review of the facility policy Diabetes Clinical Protocol last reviewed 5/21/26, indicated the physician will order desired parameters for monitoring and reporting information related to blood sugar management. The staff will incorporate such parameters into the Medication Administration Record and care plan. Review of Resident R185's clinical record indicated re-admission date of 6/16/26, with diagnosis of hypertension (high blood pressure), Benign Prostate Hyperplasia (BPH- the prostrate grows and affects the urinary system in men) and anxiety. During an observation completed on 6/22/26, at 9:57 a.m. Resident R185 was in bed a urinary catheter bag was viewed hanging on the bedframe. During an interview completed on 6/22/26, at 9:58 a.m. Registered Nurse (RN) Employee E10 confirmed the urinary bag was on the bedframe. Review of Resident R185's clinical admission notes completed on 6/16/26, at 1:20 p.m. revealed: Genitourinary: Resident continent of bladder. Urine is clear yellow. Denies urinary complaints. Genitourinary Note: condom catheter. Review of Resident R185's clinical record failed to include orders for a urinary condom catheter. During an interview completed on 6/24/26, at 9:40 a.m. upon asking Registered Nurse (RN) Employee E9 concerning a urinary catheter for Resident R185 replied when he re-admitted I saw that he had it, it was left on by the staff and confirmed that there were not any physician orders for Resident R185's urinary condom catheter and that the facility failed to obtain orders for a urinary condom catheter for one of three residents (Resident R185). Review of Resident R173's clinical record indicated an admission date of 6/12/26, with the diagnosis of Diabetes (high sugar in the blood) hypertension (high blood pressure) and hyperlipemia (high fat in the blood). During an interview completed on 6/22/26, at 10:22 a.m. upon asking Resident R173 concerning her diabetic care responded I'm a diabetic that is one of the reasons why I am here. I'm going to see the nutritionist later today they are wonderful that work with me. Review of Resident R173's physician orders dated 6/12/26, revealed: Insulin Lispro Injection Solution 100 UNIT/milliliter (ML) Insulin Lispro inject as per sliding scale: if 70 - 140 = 0 units; 141 - 180 = 2 units; 181 - 220 = 4 units; 221 - 260 = 6 units; 261 - 300 = 8 units; 301 - 340 = 10 units, subcutaneously before meals for DM greater (<) 340=12 units and call MD. The orders failed to include parameters for hypoglycemia (low blood sugar levels). Review of Resident R173 nursing progress notes dated 6/22/26, at 5:45 a.m. revealed resident was seen sweating profusely at around 4:00 a.m. Her blood sugar was checked and was 65. Hypoglycemic protocol initiated, sugar went to 109. She is currently sleeping in no acute distress. The note failed to reveal that the physician was notified concerning Resident R173's blood sugar reading of 65. During an interview completed on 6/24/26, at 12:29 p.m. upon asking RN Employee E9 concerning residents that experience hypoglycemia replied they should notify the supervisor if having hypoglycemia, I would like to see the parameters in the order such as if less than 70 notify the physician and confirmed that Resident R173's physician orders failed to include parameters for hypoglycemia and that the physician was not notified of Resident R173's hypoglycemic (low blood sugar) episode that occurred on 6/22/26. Review of the clinical record revealed Resident R15 was admitted to the facility on [DATE]. Review of Resident R15's MDS dated [DATE], indicated the diagnosis of hypertension (high blood sugar) diabetes (high sugar in the blood) and depression. Review of Resident R15's physician orders dated 6/14/26, revealed:Insulin Lispro 100 UNIT/ML Solution pen-injector: Inject as per sliding scale: 0 - 249 = 0; 250 - 300 = 2 units; 301 - 350 = 4 units; 351 - 400 = 6 units; 401 - 450 = 8 units, subcutaneously before meals and at bedtime for diabetes. The orders failed to include parameters for hypoglycemia and hyperglycemia. During an interview completed on 6/24/26, at 1:19 p.m. RN Employee E9 confirmed that Resident R15's physician orders failed to include parameters for hypoglycemia and hyperglycemia. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.10 (c)(d) Resident Care policies.28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications in one of three medication storage rooms (4th Floor Medication Room) and four of five medication carts (2 East Medication Cart, 2 [NAME] Medication Cart, 3 [NAME] Medication Cart, and 4 [NAME] Medication Cart). Findings include: Review of the facility policy Labeling of Medication Containers dated 5/21/26, indicated all medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations. Labels for individual medications include all necessary information including the expiration date when applicable. Observation completed on 06/22/26, at 12:46 p.m. the 4 [NAME] Medication Cart contained: 1 Fluticasone Propionate inhaler (prevents symptoms of asthma attack) opened and not labeled with a date as required 3 Albuterol inhalers (relaxes airway muscles) opened and not labeled with a date as required 1 bottle of Optase hylo night eye drops (eye lubricant) opened and not labeled with a date as required 1 tube of Systane eye ointment (lubricates eyes while you sleep) opened and not labeled with a date as required. 1 bottle of Lantsopropt eye drops (medication that reduces pressure in the eye) opened and not labeled with a date as required. 1 Lispro (fast acting) insulin pen opened and not labeled with a date as required. 1 Lantus (long acting) insulin pen opened and not labeled with a date as required. 1 Insulin Glargine (long acting) pen opened and not labeled with a date as required. 1 Insulin Glargine pen not stored in a bag as required. 1 bottle of Ibuprofen liquid (treats pain, fever and inflammation) opened and not labeled with a date as required. 1 bottle of Peridex rinse (used to treat red, swollen gums) opened and not labeled with a date as required. 1 bottle of Bismuth (used for digestive comfort) opened and not labeled with a date as required. 1 bottle of Tylenol (reduces pain and fever) liquid opened and not labeled with a date as required. 1 tube of Voltaren gel (topical pain relief) opened and not labeled with a date as required and stored with oral medication. 2 boxes of Ipratropium Bromide (medication to open airways) opened and not labeled with a date as required. 1 tube of tacrolimus ointment (topical medication used to treat skin rash) opened not labeled with a date as required and stored with oral medications. 1 Ventolin inhaler (relaxes airway muscles) opened and not labeled with a date as required opened stored in a cup. During an interview completed on 6/22/26, at 1:07 p.m. Registered Nurse (RN) Employee E11 confirmed the above observations and that the facility failed to properly store medications in the 4 [NAME] Medication Cart. Observation on 6/22/26, at 1:11 p.m. of the 2 [NAME] Medication Cart indicated the following medications not labeled with a date of expiration: Budesonide (medication that reduces inflammation). Latanoprost (medication that reduces pressure in the eye). Timolol (medication that reduces pressure in the eye). Interview on 6/22/26, at 1:11 p.m. Licensed Practical Nurse (LPN) Employee E8 confirmed the above medications failed to include a label with the date of expiration. Observation on 6/22/26, at 1:29 p.m. of the 3 [NAME] Medication Cart indicated the following medications not labeled with a date of expiration, and one medication unopened that required refrigeration: Ipratropium nebulizer solution (medication to open airways). Lantus insulin vial (long-acting insulin to manage high blood sugar) was unopened and affixed with a label that indicated refrigerate. The vial failed to include a label with the date of expiration. Interview on 6/22/26, at 1:29 p.m. LPN Employee E1 confirmed the above medications failed to include a label with the date of expiration. Observation on 6/24/26, at 9:33 a.m. The 4th floor medication room refrigerator contained the following: One bottle of Tubersol solution opened and not labeled with a date as required. Interview completed on 6/24/26, at 9:38 a.m. Registered Nurse (RN) Employee E9 confirmed the above observations and that the facility failed to properly store medications in the 4th Floor Medication room. Observation on 6/24/26, at 10:35 a.m. of the 2 East Medication Cart indicated the following medication not labeled with a date of expiration: albuterol nebulizer solution (medication that opens airways quickly). Interview on 6/24/26, at 10:35 a.m. LPN Employee E7 confirmed the above medication failed to include a label with the date of expiration. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa. Code: 211.12(d)(2)(3) Nursing services.

Based on review of resident clinical records, facility policy and staff interview it was determined the facility failed to provide consistent and complete communication with the dialysis (treatment that helps body remove extra fluid and waste products) center for three of three residents (Residents R17, R34, and R86), failed to ensure that monitoring of the residents' access site was accurate and completed for two of three residents (Resident R17 and R86). Findings include: Review of the facility policy Dialysis Communication Documentation Policy dated 5/21/26, indicated all dialysis-related communication- whether incoming or outgoing- must be documented in the resident's Electronic Medical Record (EMR) under the documents section. Staff receiving dialysis-related communication must document the information in the EMR on the same day it is received. Review of facility policy Hemodialysis Catheters - Access and Care of dated 5/21/26, indicated the nurse should document in the resident's medical record every shift location of catheter, condition of dressing (interventions if needed), if dialysis was done during shift, any part of report from dialysis nurse post-dialysis being given, and observations post-dialysis. Review of the clinical record indicated Resident R17 was admitted to the facility on [DATE]. Review of Resident R17's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/21/26, with diagnoses of high blood pressure, End Stage Renal Disease (ESRD, an inability of the kidneys to filter the blood), and muscle weakness. Review of a physician order dated 3/21/26, indicated hemodialysis Monday, Wednesday, and Friday. Review of Resident R17's comprehensive care plan indicate the resident has chronic renal failure related to end stage renal disease requiring dialysis. Interventions include right AV fistula (arteriovenous fistula - surgically created connection between an artery and a vein that provides reliable vascular access for hemodialysis) for dialysis use only, monitor bruit (whooshing or rumbling sound) and thrill (palpable vibration felt over fistula) every shift - report absence of either to physician, and send dialysis communication book. Review of Resident R17s clinical record did not include complete communication forms for six days during the period of 5/1/26 through 6/22/26. The incomplete forms were on the following dates: 5/6/26, 5/11/26, 5/22/26, 5/25/26, 6/1/26, and 6/17/26. During an interview on 6/22/26, at 12:56 p.m. Licensed Practical Nurse (LPN) Employee E1 confirmed the above dates did not include complete dialysis communication forms and that the facility failed to provide consistent and complete communication with the dialysis center for Resident R17. Review of a physician order dated 10/13/25, indicated monitor right AV fistula site for pain, swelling, redness and warmth at the site and monitor resident for fever, chills, and general weakness. Notify physician with any concerns every shift. Review of Resident R17's June 2026 Treatment Administration Record (TAR) revealed the above treatment was not signed off as completed or refused on the following shifts: Review of a physician order dated 5/2/26 indicated left AV fistula - check for bruit every shift. 6/2/26 7 a.m. - 3 p.m. shift 6/3/26 7 a.m. - 3 p.m. shift 6/5/26 7 a.m. - 3 p.m. shift 6/7/26 7 a.m. - 3 p.m. shift 6/9/26 7 a.m. - 3 p.m. shift 6/10/26 7 a.m. - 3 p.m. shift 6/11/26 7 a.m. - 3 p.m. shift 6/15/26 3 p.m. - 11 p.m. shift 6/19/26 7 a.m. - 3 p.m. shift 6/21/26 3 p.m. - 11 p.m. shift Review of Resident R17's June 2026 TAR revealed the above treatment was not signed off as completed or refused on the following shifts: 6/9/26 7 a.m. - 3 p.m. shift 6/11/26 7 a.m. - 3 p.m. shift Review of a physician order dated 5/2/26, indicated left AV fistula - check for thrill every shift - notify physician if not palpated. Review of Resident R17's June 2026 TAR revealed the above treatment was not signed off as completed or refused on the following shifts: 6/2/26 7 a.m. - 3 p.m. shift 6/3/26 7 a.m. - 3 p.m. shift 6/5/26 7 a.m. - 3 p.m. shift 6/9/26 - 7 a.m. - 3 p.m. shift 6/10/26 7 a.m. - 3 p.m. shift 6/11/26 7 a.m. - 3 p.m. shift 6/15/26 3 p.m. - 11 p.m. shift 6/19/26 7 a.m. - 3 p.m. shift 6/21/26 3 p.m. - 11 p.m. shift During an interview on 6/23/26, at 2:03 p.m. the Director of Nursing (DON) stated, We will have to clarify Resident R17's orders, it's confusing having some orders say left AV fistula and some saying right AV fistula. During an interview on 6/23/26, at 2:41 p.m. the DON stated, Resident R17 has a fistula in their left arm, we've updated the orders to be accurate. During this interview, the DON confirmed the facility failed to ensure monitoring of Resident R17's dialysis access site was accurate and complete. Review of the admission record indicated Resident R34 was admitted to the facility on [DATE]. Review of Resident R34's MDS dated [DATE], indicated the diagnoses of atrial fibrillation (irregular heart rhythm), anemia (the blood doesn't have enough healthy red blood cells), End Stage Renal Disease (ESRD -kidneys cease to function on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). Review of Resident R34's physician order dated 6/2/26, indicated send communication binder to dialysis Tuesday, Thursday, and Saturday. Ensure communication sheets are completed upon return every day and evening shift every Tuesday, Thursday, and Saturday. Review of Resident R34's current care plan indicated resident has ESRD with renal failure and is dialysis dependent. Review of Resident R34's communication binder for dialysis indicated that the dialysis communication record on 6/9/26, 6/11/26, and 6/13/26 were incomplete and failed to have correspondence from the dialysis center as required. Interview on 6/22/26, at 1:25 p.m. LPN Employee E16 confirmed Resident R34's dialysis communication record on 6/9/26, 6/11/26, and 6/13/26 were incomplete and failed to have correspondence from the dialysis center as required. Review of admission record indicated Resident R86 was admitted to the facility 9/5/25. Review of Resident R86's MDS dated [DATE], indicated the diagnoses of quadriplegia (paralysis that affects all limbs and body from the neck down), diabetes mellitus (chronic condition that occurs when the body cannot properly use blood sugar (glucose), leading to high blood sugar levels), and dependence on renal dialysis. Section O0100J, Dialysis was coded with an X indicating dialysis was performed within the last 14 days while a resident. Further review of Resident R86's physician order dated 4/17/26, indicated right AV (arteriovenous)fistula (an abnormal connection between an artery and vein, most commonly created surgically in the arm for hemodialysis access) - check Thrill (palpable vibration of fistula) every shift, notify physician if thrill not palpated. Review of Resident R86's TAR for June 2026, failed to reveal documentation of Resident R86's Thrill was signed off or refused for 6/1/26, 6/2/26, 6/3/26, 6/5/26, 6/7/26, 6/9/26, 6/11/26, 6/17/26, 6/19/26, and 6/21/26 on the daylight shift, and failed to reveal documentation on 6/15/26 and 6/21/26, on the evening shift. Further review of Resident R86's physician order dated 4/17/26, indicated right AV fistula - check Bruit (audible whooshing sound from turbulent blood flow) every shift, if Bruit not auscultated - notify physician. Review of Resident R86's TAR for June 2026, failed to reveal documentation of Resident R86's Bruit was signed off or refused for 6/1/26, 6/2/26, 6/3/26, 6/5/26, 6/7/26, 6/9/26, 6/11/26, 6/17/26, 6/19/26, and 6/21/26 on the daylight shift, and failed to reveal documentation on 6/15/26 and 6/21/26, on the evening shift. During an interview on 6/22/26, at 2:06 p.m., the DON confirmed that the facility failed to document dialysis specific care as ordered by the physician for Resident R86. Review of physician order dated 3/1/26, indicated Renal dialysis Monday, Wednesday, and Friday; chair time 11:30 a.m., pickup 9:30 a.m. for Resident R86. Review of Resident R86's physician order dated 9/17/25, indicated send dialysis communication book with resident on dialysis days every day shift Monday, Wednesday, and Friday. Review of current plan of care initiated 1/10/25, indicated Resident R86 needs dialysis - renal dialysis Monday, Wednesday, and Friday; send dialysis communication book. Review of Resident R86's communication binder for dialysis indicated that the dialysis communication record on 6/10/26, 6/15/26, 6/20/26, and 6/22/26 were incomplete and failed to have correspondence from the dialysis center as required. On 6/26/26, at 9:15 a.m., information was disseminated to the DON indicating that Resident R86's dialysis communication book was incomplete by failing to have clinically documented dialysis treatment information available for each treatment. During an interview on 6/26/26, at 1:30 p.m., the Nursing Home Administrator (NHA) and DON confirmed that the facility failed to provide consistent and complete communication with the dialysis center for three of three residents (Residents R17, R34, and R86) and failed to ensure that monitoring of the residents' access site was completed for two of three residents (Resident R17 and R86). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policies, clinical record review, observations, and staff interviews, it was determined that the facility failed to properly monitor resident personal refrigerator temperatures for one of two refrigerators (Resident R98) which created the potential for food borne illness, failed to handle and wash facility linens in a safe an aseptic (free from disease-causing microorganisms) manner during an observation of the main laundry room, failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R10), and failed to implement a comprehensive program for water management to monitor the potential development and spread of Legionella within the facility. Findings include: Review of the facility policy Refrigerators and Freezers dated 5/21/26, indicated monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. Review of the facility policy Departmental (Environmental Services) - Laundry and Linen dated 5/21/26, indicated to reprocess any linen that is not visibly clean upon completion of the cycle or any linen that falls onto the floor. Review of facility policy Dressings, Dry/Clean dated 5/21/26, indicated steps in the procedure include clean bedside stand, establish a clean field. Place the clean equipment on the clean field. Arrange the supplies so they can be easily reached. Review of facility policy Legionella Water Management Program dated 5/21/26, indicated the facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. Review of the admission record indicated Resident R98 was admitted to the facility on [DATE] with the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe), and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Observation on 6/23/26, at 1:22 p.m. Resident R98 was observed in bed. A personal refrigerator was in the room and failed to have a temperature log as required. Interview on 6/23/26, at 1:22 p.m. Resident R98 indicated they'd have to get a log for June 2026. Interview on 6/23/26, at 1:25 p.m. Unit Manager Employee E15 confirmed that the facility failed to properly monitor resident personal refrigerators and that Resident R98's personal refrigerator failed to have a temperature log for June 2026, as required. Observation of the main laundry room on 6/24/26, at 8:35 a.m. Laundry Worker Employee E6 was loading clean linens into the facility's dryer. While loading the clean linen into the dryer, a washcloth fell to the floor. Laundry Worker Employee E6 was observed picking the washcloth off the floor and throwing it in the dryer with the clean linens. Interview on 6/24/26, at 8:45 a.m. the Nursing Home Administrator was informed of Laundry Worker Employee E6's actions and that the facility failed to handle and wash facility linens in a safe an aseptic manner. Review of the clinical record indicated Resident R10 was admitted to the facility on [DATE]. Review of Resident R10's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/20/26, indicated diagnoses of high blood pressure, wound infection, and muscle weakness. Review of a physician order dated 6/16/26, indicated left medial (inner portion) heel and right heel - cleanse with Dakins (a wound cleanser), apply Medihoney (medical-grade honey used for wound healing), then calcium alginate (a highly absorbent dressing), cover with ABD (a highly absorbent dressing), and wrap with Kerlix (a bandage wrap) every day shift for wound care. During a dressing change observation on 6/24/26, from 11:34 a.m. to 11:55 a.m. Wound Care Registered Nurse (WCRN) Employee E5 did not establish a clean field using the bedside stand. WCRN Employee E5 placed a trash can liner on the sheet at the foot of Resident R10's bed and placed opened wound care supplies on the trash can liner during the treatment. During an interview on 6/24/26, at 11:58 a.m. WCRN Employee E5 confirmed the above observations and that the facility failed to prevent cross contamination during a dressing change for Resident R10. Review of the facility's Water Management Program last reviewed 6/17/26, indicated ice machines have a Legionella culture test performed annually. The Water Management Program failed to indicate any additional areas that have Legionella culture testing performed. During an interview on 6/26/26, at 10:25 a.m. the Nursing Home Administrator (NHA) stated, I am unable to find proof of Legionella testing for 2025, I can only find results for 2024. During this interview, the NHA confirmed that the facility failed to implement a comprehensive program for water management to monitor the potential development and spread of Legionella within the facility. 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1)(e)(1) Management.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.

Based on review of facility policy, observations, clinical record review, and staff interview, it was determined that the facility failed to provide bodily privacy during treatment procedures for one of six residents (Resident R10) and failed to maintain the dignity of two of six residents reviewed (Resident R43) who had an indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine) and (Resident 185) who had an urinary condom catheter (non-invasive external urinary catheter worn like a condom it collects urine as it drains from the bladder and sends it to a collection bag).Findings include: Review of the facility policy Dignity dated 5/21/26, indicated demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: helping the resident to keep urinary catheter bags covered. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Review of Resident R185's clinical record indicated re-admission date of 6/16/26, with diagnoses of hypertension (high blood pressure), Benign Prostate Hyperplasia (BPH- the prostrate grows and affects the urinary system in men) and anxiety. During an observation completed on 6/22/26, at 9:57 a.m. Resident R185 was in bed a urinary catheter bag was viewed hanging on the bedframe. The bag failed to be covered as required. Interview completed on 6/22/26, at 9:58 a.m. Registered Nurse (RN) Employee E10 confirmed Resident R185's urinary catheter bag was not covered as required. Review of the admission record indicated Resident R43 was admitted to the facility on [DATE]. Review of Resident R43's Minimum Data Set (MDS- a periodic assessment of care needs) dated 6/9/26, indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), high blood pressure, and obstructive uropathy (a blockage in the urinary tract that prevents normal urine flow). Observation on 6/22/26, at 1:29 p.m. Resident R43 was observed lying in bed with a urinary catheter bag filled with urine. The bag failed to be covered as required. Interview on 6/22/26, at 1:30 p.m. Nurse Aide (NA) Employee E14 confirmed the urinary catheter bag was not covered as required. Review of the clinical record indicated Resident R10 was admitted to the facility on [DATE]. Review of Resident R10's MDS dated [DATE], indicated diagnoses of high blood pressure, wound infection, and muscle weakness. Review of a physician order dated 6/16/26, indicated left medial (inner portion) heel and right heel - cleanse with Dakins (a wound cleanser), apply Medihoney (medical-grade honey used for wound healing), then calcium alginate (a highly absorbent dressing), cover with ABD (a highly absorbent dressing), and wrap with Kerlix (a bandage wrap) every day shift for wound care. During a wound care treatment observation on 6/24/26, from 11:34 a.m. through 11:55 a.m. Wound Care Registered Nurse (WCRN) Employee E5 did not close the door or pull the privacy curtain to provide privacy for Resident R10 during the treatment observation. During an interview on 6/24/26, at 11:58 a.m. WCRN Employee E5 confirmed the facility failed to provide bodily privacy during a treatment procedure for Resident R17. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.12(d)(1)(3) Nursing services.

Based on review of the clinical records and staff interview, it was determined that the facility failed to provide documentation that medication regimen reviews (MRR) were completed and reviewed by the resident's attending physician monthly for one of five residents (Resident R3). Findings include: Review of the facility policy Medication Regimen Review dated 5/21/26, indicated the consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. Within twenty-four hours of the MRR, the Consultant Pharmacist provides a written report to the attending physicians for each resident identified as having a non-life threatening medication irregularity. Review of the admission record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS- a periodic assessment of care needs) dated 5/9/26, indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), atrial fibrillation (irregular heart rhythm), and high blood pressure. Review of Resident R3's MRR's on the following dates were signed by a Physician Assistant and not by the physician as required:-1/9/26 - MRR signed by PAC-2/25/26 - MRR signed by PAC-3/29/26 - MRR signed by PAC-5/14/26 - MRR signed by PAC-5/27/26 - MRR signed by PAC Interview on 6/24/26, at 1:19 p.m. the Director of Nursing confirmed that a Physician Assistant signed Resident R3's MRR's on the dates noted instead of the physician as required. 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that residents received proper treatment for pressure ulcers for one of five residents (Resident R10).Findings include: Review of facility policy Review of facility policy Charting and Documentation dated 5/21/26, indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Review of the clinical record indicated Resident R10 was admitted to the facility on [DATE]. Review of Resident R10's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/20/26, indicated diagnoses of high blood pressure, wound infection, and muscle weakness. Review of Resident R10's comprehensive care plan indicated the resident has potential/actual impairment to skin integrity related to deep tissue injury present on admission, stage 3 pressure injury (full thickness tissue loss) to bilateral (both) heels. Interventions include purple offloading boots at all times when in bed - may remove for care and skin checks and wound care as per orders see TAR (Treatment Administration Record). Review of a physician order dated 5/2/26, indicated left medial heel (inner portion of the heel) - cleanse with Dakins (a wound cleanser), apply Medihoney (medical-grade honey used for wound healing), then calcium alginate (a highly absorbent dressing), cover with ABD (a highly absorbent dressing), and wrap with Kerlix (a bandage roll) every day shift for wound care. Review of Resident R10's May 2026 and June 2026 TAR revealed the above treatment was not signed off as completed or refused on the following shifts:5/3/265/5/265/6/265/7/265/15/265/16/265/17/265/26/265/27/265/29/266/2/266/5/266/10/266/14/26 Review of a physician order dated 5/2/26, indicated right heel - cleanse with Dakins 0.125%, apply medihoney, calcium alginate, cover with ABD, and wrap with kerlix every day shift for wound care. Review of Resident R10's May 2026 and June 2026 TAR revealed the above treatment was not signed off as completed or refused on the following shifts:5/3/265/5/265/6/265/7/265/15/265/16/265/17/265/26/265/27/265/29/266/2/266/5/266/10/266/14/26 Review of a physician order dated 5/18/26, indicated purple heel relief boots to both feet while in bed, may remove for care. Review of Resident R10's May 2026 and June 2026 TAR revealed the above treatment was not signed off as completed or refused on the following shifts:5/26/26 7 a.m. - 3 p.m. shift5/27/26 7 a.m. - 3 p.m. shift5/28/26 7 a.m. - 3 p.m. shift5/29/26 7 a.m. - 3 p.m. shift6/2/26 7 a.m. - 3 p.m. shift6/5/26 7 a.m. - 3 p.m. shift6/10/26 7 a.m. - 3 p.m. shift6/15/26 3 p.m. - 11 p.m. shift6/19/26 7 a.m. - 3 p.m. shift6/21/26 3 p.m. - 11 p.m. shift During an interview on 6/25/26, at 2:43 p.m. the Director of Nursing confirmed that the facility failed to make certain that residents received proper treatment for pressure ulcers for Resident R10. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10 (c)(d) Resident care policies.28 Pa. Code: 211.12 (d)(1)(5) Nursing services.

Based on review of facility policy, closed resident records, and staff interviews, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current care needs and services for one of five sampled resident records (Closed Resident Records CR194).Findings include: The facility Care plans, comprehensive person centered policy last reviewed 5/21/26, indicated that a person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented. The person-centered care plan reflects currently recognized standards of practice for problem areas and conditions. Care plans are revised as information about the residents' conditions change. Review of Closed Resident Records CR194's admission record indicated she was admitted on [DATE]. Review of Closed Resident Records CR194's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 5/5/26, indicated she had diagnoses that included Parkinson's Disease (a disorder of the central nervous system which affects movement and includes tremors), chronic kidney disease (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and changes in urination), Sjogren syndrome (a chronic autoimmune disease associated with dry mouth symptoms), acute Lyme disease (an illness caused by borrelia bacteria resulting in fever and fatigue) , and altered mental status. Review of Closed Resident Records CR194's clinical nurse notes dated 5/5/26, indicated Resident CR194 was pacing up and down the hallways stating she wanted to leave. Resident CR194 stated if the staff will not let her leave, she will sleep on the floor. Physician notified and the family was called. Review of Closed Resident Records CR194's care plans dated 5/7/26, indicated Resident CR194 was a high fall risk, follow fall protocols, and she had impaired mobility. Review of Closed Resident Records CR194's physician note dated 5/13/26, indicated that Resident CR194 was seen by physician and during the interview, she stated staff told her that she is wandering at night. Resident CR194 did not recall. Review of Closed Resident Records CR194's clinical nurse note dated 5/20/26, indicated Resident CR194 was confused with no witnessed unwanted behaviors. Review of Closed Resident Records CR194's clinical nurse notes dated 5/21/26, indicated she was discharged from the facility at 10:30 a.m. via private transportation and accompanied by family. Review of Closed Resident Records CR194's clinical nurse notes and care plan documents did not include any care plans about Resident CR194's new behavior-kneeling on the floor purposefully while she wandered the nursing unit. Facility investigation document dated 5/29/26, indicated that Social worker Employee E18 observed Resident CR194 randomly kneel while walking in the hallway then stand right back up. Social worker Employee E18 witnessed her do this three times. Social worker Employee E18 asked nursing staff if it was normal and they stated Resident CR194 did this in the evenings. During an interview on 6/23/26, at 9:52 a.m. Speech therapist Employee E17 was asked if he witnessed Resident CR194 on the floor at all and he stated: I was walking down the hallway, and she would place one knee down and placed her knees on the floor in the hallway. He was asked if she did this often and if It was care planned? Resident CR194 wandered a lot. She only did that once. it was sometime in May. Don't know which day it was. This was not care planned. I mentioned it to a nurse. During an interview on 6/23/26, at 11:19 a.m. Social worker Employee E18 was asked if Resident CR194 was on the floor at any time, and she stated: yes, sometimes she would walk and kneel and stand back up. She was hard to redirect. She would kneel in the evenings. Staff was redirecting her. She would kneel while she was walking. Nursing staff was already aware of her behavior. During an interview on 6/23/26, at 1:30 p.m. Registered Nurse (RN) Employee E19 was asked if a resident has new behaviors, should the family be notified and is the care plan updated, she stated: yes. Staff do that all the time: notify the provider, family and the shift supervisor. And yes, we do update the care plan as well and put in a progress note. During an interview on 6/24/26, at 1:37 p.m. information disseminated to the Director of Nursing (DON), Nursing Home Administrator (NHA) and the Director of Regional clinical services Employee E20 that the facility failed to review and revise comprehensive care plans to reflect the current care and services for Closed Resident Records CR194 as required. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, observation, and staff interviews, it was determined that the facility failed to assess the functional status of the individual resident to determine if the use of a bolster (a long, thick cushion) is a restraint for one of four residents (Residents R23).Findings include: Review of facility policy Use of Restraints dated 5/21/26, indicated physical restraints are defined as any method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Review of the clinical record indicated Resident R23 was admitted to the facility on [DATE]. Review of Resident R23's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/25/26, indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and anemia (too little iron in the blood). Review of physician order dated 12/23/24, indicated bolster mattress to bed. Review of Resident R23's care plan dated indicated the resident is at high risk for falls related to confusion, psychoactive drug use, history of fall at home with left hip fracture, and poor balance and safety awareness. Interventions include bolsters to bed when in bed. During an observation on 6/23/26, at 9:47 a.m. Resident R23 was observed lying in bed and the mattress had bilateral (on both sides) raised edges on the top and bottom portions. Review of Resident R23's clinical record failed to identify any assessments or ongoing evaluations for the usage of bolsters on the resident's mattress. During an interview on 6/26/26, at 9:26 a.m. Unit Manager Employee E13 confirmed that the facility failed to assess the functional status of the individual resident to determine if the use of a bolster is a restraint for one of four residents (Residents R23). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, closed resident records and staff interviews, it was determined that the facility failed to notify the resident's family of behavioral concerns for one of three closed resident records (Closed Resident Record CR194).Findings include: The facility Change in a resident's condition or status policy last reviewed on 5/21/26, indicated that the facility promptly notifies the resident, the attending physician, and the resident's representative of changes in the resident's medical/ mental condition and status. A significant change of condition is a major decline in the residents' status. Review of Closed Resident Records CR194's admission record indicated she was admitted on [DATE]. Review of Closed Resident Records CR194's Minimum Data Set assessment: (MDS -a periodic assessment of resident care needs) dated 5/5/26, indicated she had diagnoses that included Parkinson's Disease (a disorder of the central nervous system which affects movement and includes tremors), chronic kidney disease (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and changes in urination), Sjogren syndrome (a chronic autoimmune disease associated with dry mouth symptoms), acute Lyme disease (an illness caused by borrelia bacteria resulting in fever and fatigue) , and altered mental status. Review of Closed Resident Records CR194's clinical nurse notes dated 5/5/26, indicated Resident CR194 was pacing up and down the hallways stating she wanted to leave. Resident CR194 stated if the staff will not let her leave, she will sleep on the floor. Physician notified and the family was called. Review of Closed Resident Records CR194's care plans dated 5/7/26, indicated Resident CR194 was a high fall risk, follow fall protocols, and she had impaired mobility. Review of Closed Resident Records CR194's physician note dated 5/13/26, indicated that Resident CR194 was seen by physician and during the interview, she stated staff told her that she is wandering at night. Resident CR194 did not recall. Review of Closed Resident Records CR194's clinical nurse note dated 5/20/26, indicated Resident CR194 was confused with no witnessed unwanted behaviors. Review of Closed Resident Records CR194's clinical nurse notes dated 5/21/26, indicated she was discharged from the facility at 10:30 a.m. via private transportation and accompanied by family. Review of Closed Resident Records CR194's clinical nurse notes and physician documentation did not include any notifications about Resident CR194's new behavior-kneeling on the floor purposefully while she wandered the nursing unit. Facility investigation document dated 5/29/26, indicated that Social worker Employee E18 observed Resident CR194 randomly kneel while walking in the hallway then stand right back up. Social worker Employee E18 witnessed her do this three times. Social worker Employee E18 asked nursing staff if it was normal and they stated Resident CR194 did this in the evenings. During an interview on 6/23/26, at 9:52 a.m. Speech therapist Employee E17 was asked if he witnessed Resident CR194 on the floor at all and he stated: I was walking down the hallway, and she would place one knee down and placed her knees on the floor in the hallway. He was asked if she did this often and if It was care planned? Resident CR194 wandered a lot. She only did that once. it was sometime in May. Don't know which day it was. This was not care planned. I mentioned it to a nurse. During an interview on 6/23/26, at 11:19 a.m. Social worker Employee E18 was asked if Resident CR194 was on the floor at any time, and she stated: yes, sometimes she would walk and kneel and stand back up. She was hard to redirect. She would kneel in the evenings. Staff was redirecting her. She would kneel while she was walking. Nursing staff was already aware of her behavior. During an interview on 6/23/26, at 1:30 p.m. Registered Nurse (RN) Employee E19 was asked if a resident has new behaviors, should the family be notified and is the care plan updated, she stated: yes. Staff do that all the time: notify the provider, family and the shift supervisor. And yes, we do update the care plan as well and put in a progress note. During an interview on 6/24/26, at 1:37 p.m. information disseminated to the Director of Nursing (DON), Nursing Home Administrator (NHA) and the Director of Regional clinical services Employee E20 that the facility failed to notify the Closed Resident Records CR194's family of behavioral concerns as required. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, review of clinical records, observations and staff interviews, it was determined that the facility failed to determine whether it was safe to self-administer medications for one of six residents (Resident R74). Findings include: Review of the facility policy Self-Administration of Medications dated 5/21/26, indicated facility should comply with policy with respect to resident self-administration of medications. The facility should assess and determine whether self-administration of medications is safe and clinically appropriate, based on the resident's functionality and health condition. Facility should ensure that orders for self-administration list the specific medications the resident may self-administer. Review of the admission record indicated Resident R74 was admitted to the facility on [DATE]. Review of Resident R74's Minimum Data Set (MDS- a periodic assessment of care needs) dated 5/21/26, indicated the diagnoses of heart failure (heart doesn't pump blood as well as it should), high blood pressure, diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident R74's clinical record failed to include an assessment or physician order to self-administer medications. Observation on 6/22/26, at 11:34 a.m. Resident R74 was sitting on the bed with a bedside table pulled close to the bed. On the bedside table was a container of fluticasone (nasal spray used for inflammation), and an albuterol inhaler (used for asthma). Neither were stored in a bag, and neither were labeled with the date opened. Interview with Resident R74 on 6/22/26, at 11:34 a.m. indicated the resident prefers to keep the medications at bedside so when they need them, they don't have to wait for nursing staff. Interview with Unit Manager Employee E15 on 6/22/26, at 11:36 a.m. confirmed the clinical record failed to include an assessment or physician order to self-administer medications and that the facility failed to determine whether it was safe to self-administer medications for Resident R74. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility documents, clinical record reviews and staff interview it was determined that the facility failed to initiate a thorough investigation for a burn for one of three residents reviewed (Resident R2). Findings include:Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/17/26 indicated diagnoses of mood disorder, brain injury without loss of consciousness and dysphagia (trouble moving food or liquids from the mouth to the stomach). Review of documentation provided by the facility dated 2/17/26, stated Resident R2 burned his hands on hot coffee during the 3-11 shift, it caused a red area and blister. On call physician was contacted and recommended Resident R2 be sent to the hospital for evaluation and treatment, Resident R2 refused. During an interview 6/2/26 at 1:30 p.m. Dietary Manager Employee E1 stated they do not take temperatures of their coffee or hot water before or during tray line service because it has nothing to do with food borne illness. Dietary Manager confirmed she does not have coffee temperatures from 2/17/26. Review of Resident R2 facility investigation failed to include a summary of the investigation/findings, witness statements, employee, and or resident interviews as to how the injury may have occurred. During an interview on 6/2/26, at 3:00p.m. the Director of Nursing (DON) confirmed the facility failed to complete a thorough investigation for a burn of a resident of one of three residents (Resident R2) as required. 28 Pa. Code 201.14 (a) Responsibility of Licensee.28 Pa. Code 201.18 (b)(1)(e)(1) Management.

Based on review of clinical records and staff interview, it was determined that the facility failed have physician orders for colostomy supplies and care for one of six residents (Resident R1). Findings include: A review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included malignant neoplasm vulva, colostomy and anxiety. A review of Resident R1's a MDS 5-Day assessment (minimum data assessment)- periodic assessment of resident care needs) dated 5/6/26, indicated the diagnosis remained current. A review of Resident R1's physician orders dated 5/26/26 indicated:Colostomy Appliance Change Q 7 days and prn- written 5/12/26Conva Tec Natura Plus Pouch Lot #5E013743. 1 1/4- 1 3/4 (33-45mm) [NAME]-Fit-written 5/12/26Colostomy Care-every shift, written 5/12/25 During an interview on 6/2/26, at 2:30 p.m. the Director of Nursing confirmed the facility failed to write colostomy orders on admission for Resident R1 as required. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing Services

Based on review of clinical record review, facility provided documents, and staff interviews, it was determined that the facility failed to ensure a safe environment resulting in a burn for one of three residents (Resident R2). Findings include:Review of the clinical record Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/17/26 indicated diagnoses of mood disorder, brain injury without loss of consciousness and dysphagia (trouble moving food or liquids from the mouth to the stomach). Review of documentation provided by the facility dated 2/16/26, stated Resident R2 burned his hands on hot coffee during the 3-11 shift, it caused a red area and blister. Intact Blister on the second finger knuckle to the top of the right hand measuring approximately 2cm x2cm (centimeters). Review of facility provided investigation dated 2/17/26 indicated coffee temperature from the kitchen approximately 172-178 at time of tray set up with loss of 30-40 degrees during delivery to units and rooms, estimated approximate temperature upon arrival in room [ROOM NUMBER] degrees. During an interview 6/2/26 at 1:30 p.m. Dietary Manager Employee E1 stated they do not take temperatures of their coffee or hot water before or during tray line service because it has nothing to do with food borne illness, they do test trays and take the temperatures of their hot beverages for customer service reasons. Review of test tray monitor & evaluation documentation dated 1/25/26 indicated coffee temperature was 168.7 Fahrenheit when tray was built in the kitchen. When tray was served on the unit, coffee temperature was 147.3 Fahrenheit. Total time of 18 minutes, 21.4-degree Fahrenheit temperature loss. During an interview 6/2/26 at 1:00 p.m. Director of Nursing stated Resident R2 did not tell anyone when the coffee spill happened but waited till later that evening to tell nursing staff. Resident R2 refused to go to the hospital. During an interview on 6/2/26, at 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure a safe environment resulting in a burn for one of three residents (Resident R2). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing Services

Based on review of facility policy, clinical records, resident and staff interview it was determined that the facility failed to have a physician orders for intravenous catheter (IV- a catheter placed into a vein for a medical need of fluids or antibiotics) dressing changes for one of two residents (Resident R56), failed to follow physician orders for wound care for one of five residents (Resident R124), failed to ensure timely follow up physician appointments were ordered for two out of four residents (Residents R2, and R97), and failed to ensure that residents received treatment and care in accordance with standards of practice and physician orders by failing to label a medicated patch with the date and time prior to application for one of three residents (Resident R133) as required. Findings include: Review or the facility policy Central Venous Catheter Care and Dressing Change dated 5/1/25, indicated the purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter related infections that are associated with contaminated, loosened, soiled, or wet dressings. Change the dressing if it becomes damp, loosened, or visibly soiled and at least every seven days. Review of the facility policy Dressings, Dry/Clean dated 5/1/25, indicated verify that there is a physician order for the dressing procedure. Document the date and time the dressing was changed. Review of the facility policy Referrals, Social Services dated 5/1/25, indicated social services personnel shall coordinate most resident referrals with outside agencies. Social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician. Social services will help arrange transportation to outside agencies, clinical appointments as appropriate. Review of the clinical record indicated that Resident R56 was admitted to the facility on [DATE]. Review of Resident R56's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/2/25, indicated diagnoses of high blood pressure, depression, and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Resident R56's physician order dated 4/24/25, indicated cefazolin (an antibiotic to treat an infection) intravenous every eight hours for infection. Physician orders failed to indicate an IV dressing change from 4/24/25 through 6/9/25. Review of Resident R56's care plan dated 5/9/25, indicated wound management post-surgical of right knee. Administer antibiotic therapy as prescribed. During an observation on 6/9/25, at 10:00 a.m. an IV dressing on residents left upper arm was loosened and half peeled away from arm with a date of 5/20/25. During an observation on 6/10/25, at 11:45 a.m. an IV dressing on residents left upper arm was loosened and half peeled away from arm with a date of 5/20/25. During an interview on 6/10/25, at 11:50 a.m. Registered Nurse (RN) Employee E3 stated that IV dressing changes are done every seven days, and it should have been changed. During an interview on 6/10/25, at 11:52 a.m. RN Employee E3 confirmed that Resident R56's IV dressing was not secure and that the dressing was last changed on 5/20/25. Review of the clinical record indicated that Resident R124 was admitted to the facility on [DATE]. Review of Resident R124's MDS dated [DATE], high blood pressure, bilateral below the knee amputations, and renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids). Review of Resident R124's physician order dated 6/3/25, indicated treatment for right and left below the knee amputation (BKA) trauma wounds - cleanse with Dermaklenz (a wound cleanser) and pat dry. Apply bacitracin (antibiotic ointment) ointment dressings to both stumps daily. Review of Resident R124's care plan dated 5/15/25, indicated resident has an amputation of right and left BKA related to diabetes. Review of Resident R124's Treatment Administration Record (TAR) dated June 2025, indicated the dressing was administered on 6/9/24, and 6/10/24. Observation on 6/10/25, at 11:00 a.m. Resident R124 was out of bed in the wheelchair with shorts on exposing both the right and left amputation stumps. The right stump had a dressing dated 6/8/25, and the left did not have a dressing in place at all. During an interview on 6/10/25, at 11:00 a.m. Registered Nurse (RN) Employee E3 confirmed Resident R124's treatments were completed as ordered and verified the date on the dressing of the right stump was 6/8/25, and the left stump did not have a dressing in place as ordered. Review of the clinical record indicated that Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's MDS dated [DATE], indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), diabetes, and spinal stenosis (a narrowing of the spaces within the spine, which causes pain and weakness). Review of Resident R2's physician orders revealed an order written on 5/13/25, that indicated Urology appointment (a physician that specializes in diagnosing and treating diseases of the urinary system). Needs six month follow up scheduled. Review of Resident R2's clinical record indicated that the facility failed to have an active physician order for a urologist follow up appointment. Review of Resident R2's clinical record indicated resident was seen on 4/23/25, by neurology (a physician who specializes in diagnosing, treating, and managing disorders of the brain and nervous system) and returned to facility with follow up directions. Resident R2's consultant record indicated to return to office in three months with weight loss update. Review of Resident R2's clinical record indicated that the facility failed to have an active physician order for a follow up neurologist visit in three months. During an interview on 6/12/25, Registered Nurse Employee E8 confirmed that no appointment had been made for Resident R2 with urology or neurology. Review of the clinical record indicated that Resident R97 was admitted to the facility on [DATE]. Review of Resident R97's MDS dated [DATE], indicated diagnoses of high blood pressure, depression, and coronary artery disease (damage or disease in the heart's major blood vessels). Review of Resident R97's physician orders revealed an order written on 5/1/25, that indicated follow up with endocrinology (a physician that specializes in diagnoses and treatment of hormone-related diseases such as diabetes). Resident overdue, last seen 3/2024. Review of Resident R97's clinical record indicated that the facility failed to have an active physician order for a follow up with endocrinology. During an interview on 6/12/25, at 1:21 p.m. Registered Nurse Employee E7 confirmed that no appointment had been made for Resident R97 with endocrinology. Review of the clinical record indicated that Resident R133 was admitted to the facility on [DATE]. Review of Resident R133's MDS dated [DATE], indicated the diagnosis of hypertension (high blood pressure), gastroesophageal reflux disease (GERD- stomach acid flows back up and causes heartburn) and cerebrovascular accident (CVA- loss of blood flow to the brain). Review of 133's physician orders dated 6/3/25, indicated to apply a lidocaine external patch (for pain) 4 % transdermally (to the skin) daily. During a medication pass observation completed on 6/10/25, at 8:57 a.m. Licensed Practical Nurse (LPN) Employee E21 was preparing Resident R133's medication. LPN Employee E21 applied Resident R133's lidocaine patch without labeling with the date and time as required. During an interview completed on 6/10/25, at 9:08 a.m. LPN Employee E21 confirmed applying Resident R133's lidocaine patch without labeling with the date and time as required. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code: 201.29(a) Resident rights 28 Pa. Code: 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to identify and investigate an incident of possible abuse and/or neglect for three of five incidents reviewed (Residents R5, R54 and R119). Findings include: The facility Accidents and Incidents-Investigating and Reporting policy dated 5/1/25, indicated all accidents or incidents occurring on our premises must be investigated and reported to the administrator. Regardless of how minor an accident or incident, injuries of unknown origin, it must be reported to the nursing supervisor and included on the facility 24- hour report. Review of the clinical record indicated that Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/1/25, indicated the diagnosis of hypertension (high blood pressure) diabetes (high sugar in the blood) and hyperlipidemia (high fats in the blood). Review of Resident R5's physician progress note dated 4/10/25, at 11:58 a.m. indicated saw resident today for skin concerns on right toes. Per nursing, she was being pushed in the shower chair and the right foot was drug on carpet causing brush burn. Several faint, scabbed areas noted on three toes of right foot. Review of the facility's incidents dated 12/9/24, through 6/9/25, failed to include information pertaining to Resident R5's abrasions to toes. During an interview completed on 6/12/25, at 11:15 a.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to conduct an investigation regarding Resident R5's incident, as required. Review of the clinical record indicated that Resident R54 was admitted to the facility on [DATE]. Review of Resident R54's MDS dated [DATE], indicated with the diagnoses of diabetes mellitus (a chronic metabolic disease characterized by high blood sugar levels), post-traumatic stress disorder and hypotension (medical condition characterized by low blood pressure). Review of Resident R54's progress notes dated 12/19/24, revealed Resident R54 was noted to get on elevator and proceed downstairs to lobby and front door, Resident R54 was later recovered from the front door by Registered Nurse supervisor and floor nurse. Review of Resident R54's progress notes dated 5/22/25, revealed Resident R54 tried to go out the front doors to go home. During an interview 6/12/25, at 1:15 p.m. Nursing Home Administrator confirmed the facility did not conduct an investigation regarding Resident R54's incident, as required. Review of the clinical record indicated that Resident R119 was admitted to the facility on [DATE]. Review of Resident R119's MDS dated [DATE], indicated with the diagnoses of hypertension, cancer, and hyperlipidemia. Review of Resident R119's progress notes date 5/31/25, at 3:00 p.m. revealed Resident R119 was found on first floor, Resident R119 did not have watchmate (a device that alarms) on wheelchair (w/c) like the order reflects. Supervisor, is going to put a new watchguard on residents w/c. Review of the facility's incidents dated 12/9/24, through 6/9/25, failed to include information pertaining to Resident R119's elopement. During an interview completed on 6/9/25, at 12:42 p.m. the Director of Nursing indicated she was not aware of Resident R119's elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge). During an interview competed on 6/12/25, at 11:15 a.m. the Nursing Home Administrator confirmed the facility failed to identify and investigate an incident of possible abuse and/or neglect for three of five incidents reviewed (Residents R5, R54 and R119). 28 Pa Code: 201.18 (e)(1)(2) Management. 28 Pa Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing services.

Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an incident involving the potential for neglect for two of five residents (Resident R5, and R119), and failed to conduct a criminal background check prior to the start of employment for two of five staff ( Licensed Practical Nurse (LPN) Employee E10, and Registered Nurse (RN) Employee E11). Findings include: Review of the facility Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy last reviewed 5/1/25, indicated residents have the right to be free from abuse, neglect, misappropriation of resident ' s property and exploitation. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives that include but not inclusive to developing and implementing policies and protocols to prevent and identify abuse or mistreatment and neglect of residents. Conduct employee background checks. Provide staff orientation and training programs that include topics such as abuse prevention, identification and reporting of abuse. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Review of the facility Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating policy last reviewed 5/1/25, indicated all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, and or theft/misappropriation are reported to local, state and federal agencies and thoroughly investigated by facility management Review of the facility Wandering and Elopements policy last reviewed 5/1/25, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the residents care plan will include strategies and interventions to maintain the resident's safety. If a resident is missing, initiate the elopement/missing resident emergency procedure. Review of the facility Background Screening Investigations policy last reviewed 5/1/25, indicated facility conducts employment background screening checks, reference checks, and criminal conviction investigation checks on all applicants. Review of the clinical record indicated that Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/1/25, indicated the diagnosis of hypertension (high blood pressure) diabetes (high sugar in the blood) and hyperlipidemia (high fats in the blood). Review of Resident R5's physician progress note dated 4/10/25, at 11:58 a.m. indicated saw resident today for skin concerns on right toes. Per nursing, she was being pushed in the shower chair and the right foot was drug on carpet causing brush burn. Several faint, scabbed areas noted on three toes of right foot. Review of the facility's incidents dated 12/9/24, through 6/9/25, failed to include information pertaining to Resident R5's abrasions to toes. During an interview completed on 6/12/25, at 11:15 a.m. the Nursing Home Administrator (NHA) confirmed that the incident concerning injuries to Resident R5's toes was not investigated or reported and that the facility failed to follow the facilities policy for investigation. Review of the clinical record indicated that Resident R119 was admitted to the facility on [DATE]. Review of Resident R119's MDS dated [DATE], indicated with the diagnoses of hypertension, cancer, and hyperlipidemia. Review of Resident R119's progress notes date 5/31/25, at 3:00 p.m. revealed Resident R119 was found on first floor, Resident R119 did not have watchmate (a device that alarms) on wheelchair (w/c) like the order reflects. Supervisor, is going to put a new watchguard on residents w/c. Review of the facility's incidents dated 12/9/24, through 6/9/25, failed to include information pertaining to Resident R119's elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge). During an interview completed on 6/9/25 at 12:42 p.m. the Director of Nursing indicated she was not aware of Resident R119's elopement. During an interview competed on 6/12/25 at 11:15 a.m. the Nursing Home Administrator confirmed that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an incident involving the potential for neglect for three of five residents (Resident R5 and R119). Review of Licensed Practical Nurse (LPN) Employee E10's personnel record indicated she was hired on 4/14/25. Review of LPN Employee E10's personnel record did not include a completed state criminal background check prior to date of hire. Review of Registered Nurse (RN) Employee E11's personnel record indicated she was hired on 4/15/25. Review of RN Employee E11's personnel record did not include a completed state criminal background check prior to date of hire. During an interview on 6/11/25, at 1:45 p.m. the Human Resource Employee E6 stated, The background checks should have been completed prior to their start date. During an interview on 6/11/25, at 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to properly screen LPN Employee E10, and RN Employee E11 by completing a state criminal background check prior to hire, as required. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa Code: 201.19 Personnel policies and procedures 28 Pa Code: 201.20 (a)(d) Staff development 28 Pa Code: 201.29 (d) Resident Rights

Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs for three of six residents (Residents R62, R118, and R292). Findings include: Review of facility policy Care Plans, Comprehensive Person-Centered dated 5/1/25, indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of the clinical record indicated Resident R62 was admitted to the facility on [DATE]. Review of Resident R62's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/7/25, indicated diagnoses of anemia (too little iron in the blood), high blood pressure, and muscle wasting. Review of a physician progress note dated 3/13/25, stated, Patient seen and evaluated today for diarrhea and vomiting. 2 episodes of diarrhea and 2 episodes of vomiting this morning. There is concern for norovirus in the facility. Will send out stool sample to confirm. Review of a Lab Results Report indicated Resident R62's stool was positive for Norovirus on 3/13/25. Review of Resident R62's care plan failed to reveal goals and interventions related to the resident's positive Norovirus status. Review of the clinical record indicated Resident R118 was admitted to the facility on [DATE]. Review of Resident R118's MDS dated [DATE], indicated diagnoses of anemia, high blood pressure, and hyperlipidemia (high levels of fat in the blood). Review of a physician order dated 3/19/25, indicated to send stool for C. diff and Norovirus. Review of a Labs Result Report indicated Resident R118's stool was positive for Norovirus on 3/19/25. Review of Resident R118's care plan failed to reveal goals and interventions related to the resident's positive Norovirus status. During an interview on 6/13/25, at 8:28 a.m. the Director of Nursing confirmed that the facility failed to revise Resident R62's and Resident R118's care plans to reflect the residents' specific care needs as required. Review of the clinical record indicated Resident R292 was admitted to the facility on [DATE]. Review of Resident R292's MDS dated [DATE], indicated diagnoses of high blood pressure, hyperlipidemia, and muscle weakness. Review of the clinical record revealed Resident R292 had a physician's order dated 6/2/25, for an indwelling urinary catheter. Review of Resident R292's care plan failed to reveal goals and interventions related to the resident's indwelling urinary catheter usage. During an interview on 6/10/25, at 2:30 p.m. Registered Nurse Employee E1 confirmed that the facility failed to revise Resident R292's care plan to reflect the resident's specific care needs as required. 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to provide appropriate respiratory care relating to CPAP/BIPAP (a continuous positive airway pressure machine used to keep airways open while you sleep/a positive airway pressure machine when breathing in and breathing out) for three of three residents (Residents R19, R50, and R93). Findings include: Review of the facility policy CPAP/Bipap Support dated 1/2/25, indicated Bipap delivers continuous positive airway pressure, but allows separate pressure settings for expiration (EPAP -breathing out) and inspiration (IPAP- breathing in). Document in the resident's medical record how the resident tolerated the procedure. Review the physician's order to determine the oxygen concentration and flow, and the pressure measurement for the machine. Review of the admission record indicated Resident R19 was admitted on [DATE]. Review of Resident R19's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/10/25, indicated the diagnoses of chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and high blood pressure. Review of Resident R19's physician order dated 6/6/25, indicated Cpap - central supply to clean face mask and reservoir and change tubing weekly. Review of Resident R19's care plan dated 5/1/25, indicated CPAP settings: 20/4 AUTO. Observation on 6/9/25, at 8:45 a.m. Resident R19 was in bed watching television. On the bedside stand was a Cpap machine with the mask lying on the table not bagged as required. Observation on 6/10/25, at 9:00 a.m. Resident R19 was in bed finishing breakfast. On the bedside stand was a Cpap machine with the mask lying on the table not bagged as required. Interview on 6/10/25, at 9:10 a.m. Registered Nurse (RN) Employee E3 confirmed Resident R19's Cpap mask was lying on the table and not bagged as required. Review of the admission record indicated Resident R50 was admitted on [DATE]. Review of Resident R50's MDS dated [DATE], indicated the diagnoses of stroke (damage to the brain from an interruption of blood supply), hemiplegia (paralysis of one side of the body), and high blood pressure. Review of Resident R50's physician order dated 5/30/25, indicated apply Cpap at bedtime and remove in the morning. Check for placement overnight. Review of Resident R50's current care plan indicated CPAP settings: Dream Station AUTO settings 12/8. Observation on 6/9/25, at 8:50 a.m. Resident R50 was in bed watching television. On the bedside stand was a Cpap machine with the mask lying on the table not bagged as required. Observation on 6/10/25, at 8:55 a.m. Resident R50 was in bed finishing breakfast. On the bedside stand was a Cpap machine with the mask lying on the table not bagged as required. Interview on 6/10/25, at 9:15 a.m. Registered Nurse (RN) Employee E3 confirmed Resident R50's Cpap mask was lying on the table and not bagged as required. Review of the admission record indicated Resident R93 was admitted on [DATE]. Review of Resident R93's MDS dated [DATE], indicated the diagnoses of anemia (the blood doesn ' t have enough healthy red blood cells), diabetes, and high blood pressure. Review of Resident R93's physician order dated 5/30/25, indicated apply Cpap at bedtime and remove in the morning. Check for placement overnight. Review of Resident R93's current care plan indicated Bipap - encourage resident to be compliant with Bipap application. Observation on 6/9/25, at 8:53 a.m. Resident R93 was in bed resting. On the bedside stand was a Cpap machine with the mask lying on the table not bagged as required. Observation on 6/10/25, at 8:58 a.m. Resident R93 was in bed. On the bedside stand was a Cpap machine with the mask lying on the table not bagged as required. Interview on 6/10/25, at 9:15 a.m. Registered Nurse (RN) Employee E3 confirmed Resident R93's Cpap mask was lying on the table and not bagged as required. Interview on 6/13/25, at 11:00 a.m. the Director of Nursing confirmed that the facility failed to provide appropriate respiratory care relating to CPAP/BIPAP for three of three residents (Residents R19, R50, and R93). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12 (d)(1)(5) Nursing services.

Based on review of resident clinical records, facility policy and staff interview it was determined the facility failed to provide consistent and complete communication with the dialysis center for two of three residents reviewed (Residents R4 and R44), failed to have physician orders for access device care and management for two of three residents (Resident R4, and R109) and failed to have appropriate care plans for two of three resident's (Resident R4 and R109). Findings include: Review of the facility policy End-Stage Renal Disease (ESRD), Care of Resident With dated 5/1/25, indicated the nature and clinical management of ESRD, the care of grafts and fistulas, and agreements between the facility and the contracted ESRD facility include all aspects of how the resident's care will be managed including how the care plan will be developed and implemented, and how information will be exchanged between facilities. Review of the clinical record indicated that Resident R44 was admitted to the facility on [DATE]. Review of Resident R44's Minimum Data Set (MDS- a periodic assessment of care needs) dated 5/27/25, indicated with the diagnoses of end stage kidney disease (a condition where the kidney reaches advanced state of loss of function), diabetes mellitus (a chronic metabolic disease characterized by high blood sugar levels), and anxiety disorders. Review of R44's physician order dated 5/19/25, indicated the resident has dialysis one time a day every Monday, Wednesday, and Friday. Further review of the physician orders failed to include orders for care and management of access site to right upper arm - fistula (arteriovenous fistula - a connection made by a surgeon of an artery to a vein for vascular access for dialysis). Review of Resident R44's Dialysis Communication Records for from 5/30/25, - 4/4/25, with twenty four days of incomplete or missing communication records 5/30/25, 5/28/25, 5/26/25, 5/23/25, 5/21/25, 5/19/25, 5/16/25, 5/14/25, 5/12/25, 5/9/25, 5/7/25, 5/5/25, 5/2/25, 4/30/25, 4/28/25, 4/25/25, 4/23/25, 4/21/25, 4/18/25, 4/16/25, 4/14/25, 4/11/25, 4/9/25 and 4/4/25. Review of the clinical record indicated that Resident R4 was admitted to the facility on [DATE]. Interview on 6/9/25, at 9:47 a.m. Licensed Practical Nurse (LPN), Employee E10 indicated Resident R4 has a fistula to the right upper arm for dialysis treatments. Observation and interview on 6/10/25, at 10:00 a.m. Resident R4 indicated dialysis uses the right upper arm fistula and pointed to the arm. Interview on 6/10/25, at 1:15 p.m. Registered Nurse (RN) Employee E3 confirmed Resident R4's dialysis communication records were incomplete or missing for fourteen days as listed. Interview on 6/10/25, at 2:00 p.m. the Director of Nursing confirmed Resident R4's physician orders and care plan failed to include care and management of the right upper arm fistula. Review of the clinical record indicated that Resident R109 was admitted to the facility on [DATE]. Review of Resident R109's MDS dated [DATE], indicated with the diagnoses of end stage kidney disease, dependence on dialysis, and anxiety. Review of R109's physician order dated 2/12/25, indicated the resident has dialysis one time a day every Tuesday, Thursday, and Saturday. Further review of the physician orders failed to include orders for care and management of the tessio catheter (a type of dialysis catheter designed for long-term vascular access in residents undergoing hemodialysis). Review of Resident R109's care plan dated 5/20/25, indicated to monitor, document, and report any signs and symptoms of infection to access site: redness, swelling, warmth or drainage. The plan of care failed to identify the type of access site or its location. Observation and interview on 6/12/25, at 2:37 p.m. Resident R109 indicated dialysis uses the right upper chest tessio catheter and indicated the dressing was changed today at dialysis. Interview on 6/10/25, at 2:00 p.m. the Director of Nursing confirmed Resident R109's physician orders and care plan failed to include care and management of the tessio catheter. Interview on 6/11/25, at 11:00 a.m. the Director of Nursing confirmed the facility failed to provide consistent and complete communication with the dialysis center for two of three residents reviewed (Residents R4 and R44), failed to have physician orders for access device care and management for two of three residents (Resident R4 and R109) and failed to have appropriate care plans for two of three resident's (Resident R4, and R109). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.5(f) Medical records. 28 Pa. Code: 211.12(c)(d)(1)(3)(5) Nursing services.

Based on review of facility policies, clinical records, incident reports, employee statements and resident and staff interview, it was determined that the facility failed to ensure that a resident was free from neglect by not providing the necessary services, which resulted in actual physical harm (laceration to the back of the head) for one of four residents reviewed (Resident R1). Findings include: A review of the facility policy Abuse Neglect Exploitation General Policy dated August 2022 indicated the facility will provide a safe environment where residents are protected from all forms of abuse and neglect. Residents must not be subjected to abuse/neglect by anyone including facility staff. Through elements of screening, training, prevention, identification, investigation, protection, and reporting, the facility will act to prevent abuse. A review of the facility policy Safety-LIFT dated August 2022 indicated two staff members must always be present to perform lifts with a full body lift (mechanical lift used to move residents). A review of the clinical record face sheet indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included brain injury, quadriplegia (paralysis of all four limbs) and diabetes. A review of Resident R1's MDS assessment (MDS-Minimum Data Set Assessment: periodic assessment of resident care needs) dated 11/23/22, indicated that the diagnoses remained current. Resident R1 is alert and oriented and able to make needs known. Resident R1 requires extensive assist of two persons for transfers. A review of Resident R1's care plan dated 12/1/22, indicated that Resident R1 was at risk of falls due to brain injury and quadriplegia. Facility staff would provide Resident R1 with appropriate physical assistance for safe transfers. The care plan stated that the resident required a full body lift and assist of two persons for transfers. A review of Resident R1's Kardex (document that provides resident level of assistance for nursing staff) dated December 2022, indicated that the resident required a full body lift and assist of two persons for transfers. A review of an incident report dated 12/5/22, indicated NA (nursing assistant) Employee E1 transferred Resident R1 from the bed to the shower chair via mechanical lift without a second person and the resident fell to the floor. Resident R1 was laying on the left side with a pool of blood. A 3.0 cm (centimeter) laceration was noted to occiput (back of the head). A review of a nurse progress note dated 12/6/22, indicated Resident R1 was sent to the hospital on 12/5/22, and returned to the facility with two staples to the back of the head. A review of a hospital Final Report dated 12/5/22, indicated a 3.0 cm laceration to the posterior (back) scalp that required 2 staples to close the skin. A review of NA Employee E1 Witness Statement dated 12/5/22, indicated that the NA was alone when transferring Resident R1 with a full body lift and he fell to the floor. During a phone interview on 1/12/23, at 11:20 a.m., NA Employee E1 confirmed that they were aware that Resident R1 was a transfer with full body lift and assist of two persons for transfers on 12/5/22. NA Employee E1 stated I thought I could do it myself, I just made a mistake. During an interview on 1/12/23, at 3:00 p.m. Resident R1 confirmed that on 12/5/22, a nurse put me in the lift and I slipped out and hit my head on the floor Resident R1 stated I had to go to the hospital. A review of NA Employee E1's employee transcript dated 11/2/22, indicated they had received education on proper resident transfers, and abuse/neglect. During an interview on 1/12/23, at 3:30 p.m. the Director of Nursing (DON) confirmed the facility failed to ensure that a resident was free from neglect by not providing the necessary services, which resulted in actual physical harm (laceration to the back of the head) for Resident R1. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa Code 201.14(a) Responsibility of licensee. 28 Pa Code 201.18(b)(1)(e)(1) Management. 28 Pa Code 201.29(a)(j) Resident rights. 28 Pa Code 211.12(d)(1)(5) Nursing services. 28 Pa Code 211.12(d)(3) Nursing services.