Every finding on record at Silver Stream Rehabilitation and Nursing Center

Based on review of facility policy, review of facility documentation, review of clinical records, and staff interviews it was determined that the facility failed to ensure a complete and thorough investigation was completed related to neglect allegations for two out of 3 residents reviewed (Resident R2 and Resident R3).Findings include:Review of facility policy titled Abuse, Neglect and Exploitation Prevention Policy, revised February 1, 2026 , revealed to ensure all residents are free from abuse, neglect, mistreatment, and exploitation including staff to resident, resident to resident, visitor to resident, contractor to resident, and any other form of abuse- in accordance with federal and state long term care regulations. This facility maintains a zero-tolerance policy toward abuse of any kind. This includes abuse committed by staff, volunteers, contractors, consultants, agency personnel, visitors, or other residents. All residents have the right to live in a safe environment free from physical, emotional, sexual, financial, or verbal abuse. All allegations, suspicions, or observed incidents of abuse must be reported immediately and investigated promptly.Further review of this policy includes the following definitions: Emotional/psychological abuse: Verbal or nonverbal conduct that causes fear, distress, humiliation or mental anguish and Neglect: Failure to provide necessary care, goods, or services to avoid harm, pain, or distress.Review of facility documentation revealed a grievance filed for Resident R3 dated March 31, 2026. Review of the grievance revealed Resident R3 alleged Nurse Aide, Employee E4, has been rude and not answering the call bell. Resident R3 alleged Nurse Aide, Employee E4, failed to inform the nurse of his/her request for Tylenol and denied to remake the resident's bed due to no sheets being available. Further review of grievance for Resident R3, revealed Investigation/ Follow-up to complaint/ grievance: An investigation was performed. There have been multiple incidents regarding this same Nursing assistant. A verbal write-up was given, now nursing assistant will be placed on suspension for 3 days. Nursing assistant will be educated on customer service and round on residents.Interview on June 2, 2026, at approximately 1:00 p.m. with Director of Nursing, Employee E2, revealed no investigation for abuse/neglect was available for review regarding allegations filed by Resident R3.Review of facility documentation revealed a grievance filed for Resident R2 dated May 25, 2026. Review of the grievance revealed Resident R2 alleged Nurse Aide, Employee E4, was asleep during his/her shift on Sunday May 17, 2026, during the 11p.m. to 7 a.m. shift. Resident R2 also alleged that care was inadequate on Sunday May 24, at 11:30 a.m.Further review of grievance dated May 25, 2026, for Resident R2 revealed To ensure abuse and neglect are ruled out promptly, does this grievance require further investigation? and No is checked off.Interview on June 2, 2026, at approximately 3:00 p.m. with Nursing Home Administrator, Employee E1, revealed no investigation for abuse/neglect was available for review regarding allegations filed by Resident R2. 28 Pa. Code 201.18 (a)(1) Management.28 Pa. Code 201.18 (a)(3) Management.28 Pa. Code 211.12 (d)(1) Nursing services. 28 Pa. Code 211.12 (d)(2) Nursing services. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of clinical records and staff interviews, it was determined that the facility failed to provide appropriate pain management services for one of two residents reviewed for pain management (Resident R1).Findings include:Review of Resident R1's clinical record revealed the resident had a diagnosis of encephalopathy (altered mental state or confusion caused by a medical condition affecting brain function) , schizoaffective disorder (mental health disorder that includes symptoms of both schizophrenia and a mood disorder), and type 2 diabetes mellites (chronic disease in which the body does not use insulin properly and/or does not make enough insulin, causing blood sugar (glucose) levels to become too high).Review of hospital discharge documentation, dated May 22, 2026, revealed Resident R1 returned to the facility following a hysterectomy with physician orders for Tramadol 50 mg by mouth every 6 hours as needed for moderate pain (pain score 4-6).Review of Resident R1's clinical record, physician orders, and Medication Administration Record (MAR) revealed the Tramadol order was not entered into the facility's medication system upon the resident's return from the hospital. Further review revealed Resident R1 did not receive the prescribed Tramadol until May 24, 2026, following readmission.Review of Resident R1's nursing progress note, dated May 24, 2026, revealed the order for Tramadol 50 mg was entered into the system.Further review of Resident R1's nursing progress note, dated May 24, 2026, revealed medication on the cart, order placed in system, first dose of medication given.Interview with Director of Nursing on June 02, 206 at 1:10 p.m. confirmed the hospital discharge orders included Tramadol 50 mg for pain management and confirmed the order was not entered into the system until May 24, 2026.28 Pa. Code 211.12 (d)(1) Nursing services28 Pa. Code 211.12 (d)(3) Nursing services28 Pa. Code 211.12 (d)(5) Nursing services28 Pa. Code 211.9 (f)(2) Pharmacy services

Based on observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable and homelike environment on 1 of the 2 Nursing Units observed (2nd floor Nursing Unit).Findings include:A tour of the facility was conducted on June 2, 2026, at 11:30 a.m., with the Maintenance Director, Employee E3, who confirmed the following observations:In room [ROOM NUMBER] was an air conditioner plugged into an outlet with no face plate around outlet and wires exposed. The phone jack removed from wall and wire hanging out of wall.In room [ROOM NUMBER] there was an outlet removed from the wall, with wires and whole outlet dangling out of the wall and an additional hole in wall.28 Pa Code 201.18(b)(1)Management28 Pa Code 201.18(b)(3)Management

Based on staff interviews and the review of clinical records, it was determined the facility failed to conduct a complete and through investigation for an allegation of abuse for 1 out of 3 residents reviewed (Resident R1). Findings include: Review of the facility abuse policy, Abuse Investigating and Reporting, with a revision date of 2016 stated that if an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual, and ensure any further potential abuse, neglect, exploitation or mistreatment is prevented. Review of the April 2026 physician orders for Resident R1 included the diagnoses of dysphasia (difficulty swallowing); aphasia (a language disorder that affects an individual's ability to communicate effectively); dementia (a group of symptoms affecting memory, thinking and social abilities, and cerebral infarction (a stroke). Review of the resident's Minimum Data Set Assessment (MDS-periodic assessment of a resident's needs) dated January 2, 2026, indicated that the resident was cognately impaired. Review of the April 2026 physician orders for Resident R2 included the diagnoses of diabetes ( a chronic condition that occurs when the body cannot properly use blood sugar, leading to high blood sugar levels); seizures (a sudden surge of abnormal electrical activity in the brain that can affect aware ness, muscle control, behavior and sense; chronic kidney disease ( a condition characterized by progressive damage and loss of function in the kidneys); schizoaffective disorder (a serious mental health condition characterized primarily by symptoms of schizophrenia, such as hearing things that are not present, seeing things that are not present, false beliefs, along with symptoms of a mood disorder, such as mania and depression) and front temporal neurocognitive disorders (a progressive brain condition that primarily affects the frontal and temporal lobes, leading to changes in behavior, personality, language, and movement). Review of the resident's quarterly MDS dated [DATE], indicated that the resident was awake, alert and oriented. Review of the documentation submitted to the State Survey Agency dated March 17, 2026, on March 17, 2026, revealed that Resident R3 reported that Resident R1 was inappropriately touched in the dining room by Resident R2. Review of the facility's investigation included an incident report completed by Employee E3 (licensed nurse) dated March 17, 2026 at 6:00 p.m. Employee E3 stated that it was reported to her by a staff member (Activity worker, Employee E4) that Resident R1 was inappropriately touched by Resident R2 in the 1st floor dining room, and that both were immediately separated. Resident R1 was taken back to her 2nd floor bedroom and the resident's daughter was notified, who also called the police. A full body assessment was completed on the resident with no bruises or injuries found. During an interview with Employee E3 (licensed nurse) on April 9, 2026 at 1:05 p.m. lrevealed that she walked into the facility on March 17, 2026 for her shift at 3:00 p.m. on the 2nd floor and was notified by the activity worker that something happened downstairs on the 1st floor. Licensed nurse, Employee E3 reported that at the time she arrived, they were brining Resident R1 up to the 2nd floor. Employee E3 explained that she was not present for the incident, but was notified by the nursing supervisor (Employee E6) for the 3:00 p.m. through the 11:00 p.m. shift that she needed to complete an incident report on what she was told when she started her shift. License nurse, Employee E3 reported that she completed a body assessment on Resident R1 and found no bruises or injuries on the resident.The nursing supervisor contacted the resident's daughter to notify her of the alleged event. Review of a statement by activity staff member (Employee E4 ) dated March 1, 2026 stated that activity staff member witnessed Resident R2 caressing Resident's R1's inner thigh before he came over and removed him from the dining room. Review of a 2nd undated statement from activity staff member indicated that Resident R3 reported to him that he witnessed Resident R2 assaulting Resident R1, and that he stated to him that Resident R1 was being groped. During an interview with activity worker on April 9, 2026 at 1:25 p.m. the activity worker reported that Resident R1 and Resident R2 were sitting at the 2nd to last table near the back of the wall in the 1st floor dining room. Activity worker stated that there was a 2nd activity worker (Employee E7) also present in the first floor dining room who was giving out snacks. Activity worker reported that there were 2 activity aides present in the room and 50 residents. Activity worker reported that he heard Resident R3 call his name while in the activity room and told activity worker to remove Resident R2 from the dining room because he saw Resident R2 touch Resident R1 inappropriately. Activity worker reported that Resident R2 was feeling on Resident R1's thighs/breast and putting his hands in her pants. Activity worker reported that he took Resident R2 to the nursing station and waited for someone from nursing to come around so that he could report it to them. Activity worker reported that he reported to a nurse, whose name he could not remember, of what Resident R3 told him what he saw Resident R2 doing to Resident R1. Activity worker reported that Resident R2 observed back in the activity room after he was taken out and observed by the activity worker in the same area, near Resident R1 with his hand resting on her inner thigh close to her vagina. Activity worker reported that he took Resident R2 back to the nursing station a 2nd time and sat with him until someone came back to the nursing station. Activity worker reported that he felt that Resident R2 was very lucid and you can take his word on things, in regards to Resident R2's account of what he reported to the Activity worker. Review of an incident reported dated March 17, 2026 at 6: 00 p.m. written by licensed nurse (Employee E5) documented that Resident R2 was observed by another resident earlier, and that he was placed at the nursing station for supervision. Licensed nurse reported that during nursing rounds, Resident R2 went back into the same dining room on the 1st floor and was seen kissing the same female resident, Resident R1. Licensed nurse reported that Resident R2 was then placed on 1:1 supervision. During an interview with licensed nurse (Employee E5) on April 9, 2026 at 1:51 p.m. licensed nurse reported that she worker 7:00 a.m. through 7:00 p.m. on March 15, 2026 on the 1st floor. Licensed nurse reported that she was told by the activity aide that Resident R2 was witnessed touching and kissing Resident R1. Licensed nurse reported that she notified the Nursing Home Administrator (NHA) and Unit Manager (Employee E7) of the 1st incident and Resident R2 was removed from the dining room and was sitting at the nursing station. The resident went back in the dining room during nursing rounds and licensed nurse was notified of a 2nd incident that occurred which involved him kissing the same Resident R1 when he returned to the dining room. Licensed nurse reported that she notified the Nursing Home Administrator (NHA) and the Unit manager again, and the resident was assigned a 1:1 staff member for supervision. Review of a nursing note dated March 17, 2026 at 9:36 p.m. written by 3-11 p.m. nursing supervisor (Employee E6) reported that she was notified from a male staff member that Resident R2 was seen in appropriately touching Resident R1. The note documented that Resident R2 was placed on 1:1 supervision with a nurse aide, and that the physician was notified and ordered that Resident R2 be sent out to the emergency room for treatment and evaluation. During an interview with nursing supervisor (Employee E6) on April 10, 2026 at 11:20 a.m. nursing supervisor reported that she was completing an admission on her 3:00 p.m. through 11:00 p.m. shift when she was notified that Resident R2 was observed touching another resident (Resident R1) in the breast area. Nursing supervisor reported that by the time she left her office, both residents were already separated and Resident R2 was placed on a 1:1 with a nurse aide. Nurse supervisor she assed Resident R1 with a nurse aide, the physician was notified and there was an order to send Resident R2 out to the hospital for a change in mental status and in appropriate behavior. Nurse supervisor reported that she contacted Resident R1's daughter who then called the police. Review of the investigation the March17, 2026 incident indicated that the facility unsubstantiated the allegation of resident to resident abuse for inappropriate touching. The activity worker reported to the NHA that he witnessed Resident R2 return to the activity room after the 1st alleged incident witnessed by Resident R3 caressing Resident R1's inner thigh before I came over and removed him from the dining room. She was wearing blue pants and he was touching the outside. Continued review of the unsubstantiated investigation did not include any statements from any residents who were present in the activity room during the alleged incidents. Continued review of the investigation also did not include any statements from the 2nd activity worker, Employee E7 regarding anything he witnessed and/or did not witness. The investigation also did not include a dated, signed interview with Resident R3 who reported inappropriate touching to the facility staff on March 17, 2026. During an interview with the Director of Nursing (DON) on April 9, 2026 at 2:40 p.m. the incident was reviewed and it was discussed that there were no statements from any residents who were present in the activity room, and that there were no statement from Resident R3, and no statement from the 2nd activity worker who was present in the activity room, Employee E7. During an interview on April 10, 2026 at 10:09 a.m. with the Director of Nursing, NHA and the Regional NHA, it was discussed that there were no residents witness statement who were present in the dining room, no witness statements from Resident R2 regarding the various accounts that he reportedly saw, no witness statement from the 2nd activity worker (Employee E7) of what he may/may not have witnessed. 28 Pa. Code 201.18(b)(1)(2)(e)(1) Management 28 Pa. Code 201.29 (a)(c) Resident rights 28 Pa Code 211.12 (c) Nursing services

Based on interviews and the review of clinical records, it was determined that the facility failed to ensure that 1 resident (Resident R2) with an allegation of inappropriately touching a cognitively impaired resident (Resident R1) was properly supervised for 1 out of 3 residents reviewed.Findings include:Findings include: Review of the facility abuse policy, Abuse Investigating and Reporting, with a revision date of 2016 stated that if an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual, and ensure any further potential abuse, neglect, exploitation or mistreatment is prevented. Review of the April 2026 physician orders for Resident R1 included the diagnoses of dysphasia (difficulty swallowing); aphasia (a language disorder that affects an individual's ability to communicate effectively); dementia (a group of symptoms affecting memory, thinking and social abilities, and cerebral infarction (a stroke). Review of the resident's Minimum Data Set Assessment (MDS-periodic assessment of a resident's needs) dated January 2, 2026, indicated that the resident was cognately impaired. Review of the April 2026 physician orders for Resident R2 included the diagnoses of diabetes ( a chronic condition that occurs when the body cannot properly use blood sugar, leading to high blood sugar levels); seizures (a sudden surge of abnormal electrical activity in the brain that can affect aware ness, muscle control, behavior and sense; chronic kidney disease ( a condition characterized by progressive damage and loss of function in the kidneys); schizoaffective disorder (a serious mental health condition characterized primarily by symptoms of schizophrenia, such as hearing things that are not present, seeing things that are not present, false beliefs, along with symptoms of a mood disorder, such as mania and depression) and front temporal neurocognitive disorders (a progressive brain condition that primarily affects the frontal and temporal lobes, leading to changes in behavior, personality, language, and movement). Review of the resident's quarterly MDS dated [DATE], indicated that the resident was awake, alert and oriented. Review of the documentation submitted to the State Survey Agency dated March 17, 2026, on March 17, 2026, revealed that Resident R3 reported that Resident R1 was inappropriately touched in the dining room by Resident R2. Review of the facility's investigation included an incident report completed by Employee E3 (licensed nurse) dated March 17, 2026 at 6:00 p.m. Employee E3 stated that it was reported to her by a staff member (Activity worker, Employee E4) that Resident R1 was inappropriately touched by Resident R2 in the 1st floor dining room, and that both were immediately separated. Resident R1 was taken back to her 2nd floor bedroom and the resident's daughter was notified, who also called the police. A full body assessment was completed on the resident with no bruises or injuries found. During an interview with Employee E3 (licensed nurse) on April 9, 2026 at 1:05 p.m. lrevealed that she walked into the facility on March 17, 2026 for her shift at 3:00 p.m. on the 2nd floor and was notified by the activity worker that something happened downstairs on the 1st floor. Licensed nurse, Employee E3 reported that at the time she arrived, they were brining Resident R1 up to the 2nd floor. Employee E3 explained that she was not present for the incident, but was notified by the nursing supervisor (Employee E6) for the 3:00 p.m. through the 11:00 p.m. shift that she needed to complete an incident report on what she was told when she started her shift. License nurse, Employee E3 reported that she completed a body assessment on Resident R1 and found no bruises or injuries on the resident.The nursing supervisor contacted the resident's daughter to notify her of the alleged event. Review of a statement by activity staff member (Employee E4 ) dated March 1, 2026 stated that activity staff member witnessed Resident R2 caressing Resident's R1's inner thigh before he came over and removed him from the dining room. Review of a 2nd undated statement from activity staff member indicated that Resident R3 reported to him that he witnessed Resident R2 assaulting Resident R1, and that he stated to him that Resident R1 was being groped. During an interview with activity worker on April 9, 2026 at 1:25 p.m. the activity worker reported that Resident R1 and Resident R2 were sitting at the 2nd to last table near the back of the wall in the 1st floor dining room. Activity worker stated that there was a 2nd activity worker (Employee E7) also present in the first floor dining room who was giving out snacks. Activity worker reported that there were 2 activity aides present in the room and 50 residents. Activity worker reported that he heard Resident R3 call his name while in the activity room and told activity worker to remove Resident R2 from the dining room because he saw Resident R2 touch Resident R1 inappropriately. Activity worker reported that Resident R2 was feeling on Resident R1's thighs/breast and putting his hands in her pants. Activity worker reported that he took Resident R2 to the nursing station and waited for someone from nursing to come around so that he could report it to them. Activity worker reported that he reported to a nurse, whose name he could not remember, of what Resident R3 told him what he saw Resident R2 doing to Resident R1. Activity worker reported that Resident R2 observed back in the activity room after he was taken out and observed by the activity worker in the same area, near Resident R1 with his hand resting on her inner thigh close to her vagina. Activity worker reported that he took Resident R2 back to the nursing station a 2nd time and sat with him until someone came back to the nursing station. Activity worker reported that he felt that Resident R2 was very lucid and you can take his word on things, in regards to Resident R2's account of what he reported to the Activity worker. Review of an incident reported dated March 17, 2026 at 6: 00 p.m. written by licensed nurse (Employee E5) documented that Resident R2 was observed by another resident earlier, and that he was placed at the nursing station for supervision. Licensed nurse reported that during nursing rounds, Resident R2 went back into the same dining room on the 1st floor and was seen kissing the same female resident, Resident R1. Licensed nurse reported that Resident R2 was then placed on 1:1 supervision. During an interview with licensed nurse (Employee E5) on April 9, 2026 at 1:51 p.m. licensed nurse reported that she worker 7:00 a.m. through 7:00 p.m. on March 15, 2026 on the 1st floor. Licensed nurse reported that she was told by the activity aide that Resident R2 was witnessed touching and kissing Resident R1. Licensed nurse reported that she notified the Nursing Home Administrator (NHA) and Unit Manager (Employee E7) of the 1st incident and Resident R2 was removed from the dining room and was sitting at the nursing station. The resident went back in the dining room during nursing rounds and licensed nurse was notified of a 2nd incident that occurred which involved him kissing the same Resident R1 when he returned to the dining room. Licensed nurse reported that she notified the Nursing Home Administrator (NHA) and the Unit manager again, and the resident was assigned a 1:1 staff member for supervision. Review of a nursing note dated March 17, 2026 at 9:36 p.m. written by 3-11 p.m. nursing supervisor (Employee E6) reported that she was notified from a male staff member that Resident R2 was seen in appropriately touching Resident R1. The note documented that Resident R2 was placed on 1:1 supervision with a nurse aide, and that the physician was notified and ordered that Resident R2 be sent out to the emergency room for treatment and evaluation. During an interview with nursing supervisor (Employee E6) on April 10, 2026 at 11:20 a.m. nursing supervisor reported that she was completing an admission on her 3:00 p.m. through 11:00 p.m. shift when she was notified that Resident R2 was observed touching another resident (Resident R1) in the breast area. Nursing supervisor reported that by the time she left her office, both residents were already separated and Resident R2 was placed on a 1:1 with a nurse aide. Nurse supervisor she assed Resident R1 with a nurse aide, the physician was notified and there was an order to send Resident R2 out to the hospital for a change in mental status and in appropriate behavior. Nurse supervisor reported that she contacted Resident R1's daughter who then called the police. Review of the investigation the March17, 2026 incident indicated that the facility unsubstantiated the allegation of resident to resident abuse for inappropriate touching. The activity worker reported to the NHA that he witnessed Resident R2 return to the activity room after the 1st alleged incident witnessed by Resident R3 caressing Resident R1's inner thigh before I came over and removed him from the dining room. She was wearing blue pants and he was touching the outside. Continued review of the unsubstantiated investigation did not include any statements from any residents who were present in the activity room during the alleged incidents. Continued review of the investigation also did not include any statements from the 2nd activity worker, Employee E7 regarding anything he witnessed and/or did not witness. The investigation also did not include a dated, signed interview with Resident R3 who reported inappropriate touching to the facility staff on March 17, 2026. During an interview with the Director of Nursing (DON) on April 9, 2026 at 2:40 p.m. the incident was reviewed and it was discussed that there were no statements from any residents who were present in the activity room, and that there were no statement from Resident R3, and no statement from the 2nd activity worker who was present in the activity room, Employee E7. During an interview on April 10, 2026 at 10:09 a.m. with the Director of Nursing, NHA and the Regional NHA, it was discussed that there were no residents witness statement who were present in the dining room, no witness statements from Resident R2 regarding the various accounts that he reportedly saw, no witness statement from the 2nd activity worker (Employee E7) of what he may/may not have witnessed. During an interview on April 10, 2026 at 10:09 a.m. with the DON, NHA and the Regional NHA, it was discussed that when an allegation of in appropriate touching was reported the 1st time by Resident R3, Resident R2 was removed from the dining room, but went back in and was observed by Activity worker (Employee E4) observed by the activity worker touching a cognitively impaired resident a 2nd time due to in appropriate supervision by the facility. 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(1)Management 28 Pa. Code 201.18 (b)(3)Management 28 Pa. Code 201.18(d) Management 28 Pa. Code 211.10(b) Resident care policies

Based on clinical record review and interviews with staff it was determined that the facility did not ensure that the resident was provided needed care and services related to turning and repositioning for one of ten residents reviewed (Resident R2).Findings include: Review of Resident R2's medical records revealed that she was admitted on [DATE], with diagnosis including, but not limited to paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease) requiring total care. Further review revealed a January 6, 2026, physician's order to turn and re-position the resident every two hours every shift. A review of Resident R2's Treatment Administration Record for March 2026, reveled one box for the nurse to check off for turning and repositioning for each eight-hour shift. Interview with the Director of Nursing on March 25, 2026, at 1:15 p.m. confirmed that the order was not input into the software program to allow for every two hour checks, and that there was no place for the nurse aides to document the every two hour turning and repositioning. She also confirmed that the current documentation did not follow the physician's orders. 28 Pa. Code:201.18(a)(b)(1)(3) Management. 28 Pa. Code:211.12(d)(1)(5) Nursing services.

Based on observation, staff and resident interviews, it was determined that the facility failed to ensure that call bells were available and operable for resident use for one of nine residents interviewed. (Residents R7) Findings include: Interview with Resident R7 in room [ROOM NUMBER], Bed C, conducted on March 25, 2026, at 11:35 a.m. revealed that the resident's call bell did not work. After pushing the red button, the red light at the panel that the cord was plugged into did not light. The whit light in the hall above the door frame also did not light. Interview on March 25, 2026, at 11:40 a.m. with licensed nurse, Employee E6 confirmed that the call light was not working and that she would follow up with maintenance to get the call bell fixed. Interview with Employee E4, the Assistant Maintenance Manager, on March 25, 2026, at 12:15 p.m. revealed that he had repaired the call bell. When the call bell was tested at 12:20 p.m. it was still not working. Employee E4 again said that he had just had the call bell working and that he has had ongoing issues with this call bell and that he would have to replace the wall panel again. Interview with the Administrator on March 25, 2026, at 11:35 at 1:20 p.m. confirmed that the maintenance department was having ongoing issues with the call bell in room [ROOM NUMBER], Bed C and that he believed the bed was hitting the wall panel causing the bell to malfunction. 28 Pa. Code 205.67(k) Electric requirements for existing construction 28 Pa. Code 201.18 (b)(1) Management 28 Pa Code 211.12(d)(1)(3)(5) Nursing services

Based on observations and resident interviews, it was determined that the facility failed to maintain the facility in a clean, comfortable and homelike condition for three of 22 residents reviewed (Resident R1, R55, R56). Findings include: Observations during the initial tour of the facility on January 20, 2026, revealed the following concerns: Observations on January 20, 2026, at 11:45 a.m., in room [ROOM NUMBER] revealed Resident R1 in the bed near the door who had her winter coat on and was under the blankets on her bed. It was very cold in the room. When asked about the temperature in the room, the resident said she was cold and while she liked the room cool, it was way too cold. It was dark in the room and when the PTAC heating unit was looked at there was light from outside shining through a gap in the wall between the heating unit and the wall and the 20 degree wind from outside was blowing through the crack into the room. Observation of the newly admitted resident in the bed near the heating unit revealed that she had only a t-shirt on and a thin blanket pulled up around her neck and she stated that she was freezing. Interview with Employee E7, Maintenance Director, on January 20, 2026, at 12:05 p.m. confirmed that there should not be a gap in the wall, that it was too cold in the room. Observation of his infrared temperature gun revealed temperatures of 49 degrees, 60 degrees and 53 degrees, well below the facilities acceptable range of 71-81 degrees. Interview with the Administrator on January 20, 2026, at 12:10 p.m. confirmed that the temperature in the room was too cold and he stated that the maintenance department was in the process of sealing the wall to get the temperature under control. Observation of his infrared temperature gun revealed temperatures of 57 degrees, 60 degrees and 55 degrees, below the acceptable temperature range. Observations on January 20, 2026, at 12:10 p.m., in room [ROOM NUMBER] revealed that the light above the bed near the door had a broken pull string which was only a few inches long and could not be reached by the resident in the bed and she said that it has been this way for a few days and she was tired of having to wait for staff to turn it on and off. Interview with Resident R1on January 23, 2026, at 10:15 a.m. revealed that she was upset that her ceiling was leaking and the wall beside her bed near the hallway was wet. Observation of this wall revealed it was damp to the touch and that the ceiling tile was also wet, and the ceiling tile out in the hall near this spot was also dark and wet. The resident said that there had also been a leak in the first floor dining room where they wait to go out to smoke. Observation on January 23, 2026, at 11:30 p.m. in first floor dining room revealed a dark and wet ceiling tile in the first-floor dining room between the hall doorway and the door going outside to the smoking area. These findings were acknowledged by the Administrator during a discussion on January 23, 2026, at 1:15 p.m. 28 Pa. Code 207.2(a) Administrator's responsibility Observation of resident room [ROOM NUMBER] on January 20, 2026, at 10:48 a.m. revealed that the resident room had curtains with stains on it appeared like liquid spill. Resident R56 and Resident R55 who lived in the resident room stated the curtain was dirty for a long time and staff did not clean or change it. Observation of the resident room also revealed that there was a towel placed on top of the air condition unit. Resident R55 and R56 stated there was cold air coming though the panel and the unit were not sealed properly. Observation of resident room [ROOM NUMBER] on January 21, 2026, at 10:46 a.m. revealed that the bathroom door did not close properly.

Based on interviews and the review of clinical records, it was determined that the facility failed to ensure that a complete and through investigation was completed to rule out neglect for 1 out of 22 residents reviewed (Resident R8).Findings include: Review of the facility's policy, Abuse, Neglect, and Exploitation Prevention Policy, with an effective date of April 1, 2025 indicated that in reference to responding and investigating abuse, immediate protective measures are taken, which included ensuring immediate protective measure are taken which may include separating residents involved in the incident; staff documenting the incident factually and notifying leadership; the administrator of designee initiates an investigation and ensures external reporting. The policy also indicated that care plans are also updated to include interventions to prevent recurrences. Review of the January 2026 physician orders for Resident R8 included the following diagnosis: congestive heart failures (CHF-a long-term condition that affects your heart's ability to pump blood well); epilepsy (a brain disorders that causes recurring seizures); schizophrenia (a serious mental health disorder characterized by symptoms that include false beliefs seeing things that are not present, hearing voices, and sounds that are not real, and disorganized thinking, affecting how individuals perceive reality and interact with the world); intellectual abilities (a neurodevelopmental condition characterized by significant limitations in intellectual functioning and adaptive behavior, affecting everyday life skills and learning abilities); cognitive communication deficit (a condition that affects an individual's ability to communicate effectively due to impairments in cognitive processes such as attention, memory, reasoning, and problem-solving); anxiety (intense, excessive and persistent worry and fear about everyday situations), and psychosis (the term for a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not).Review of a nursing note written by Employee E8 (license nurse) dated July 21, 2025 at 7:20 a.m. documented that a resident took a nurse aide's pocket book and ingested the medication, Zofran (4 milligram tablet), a prescription medication that the nurse aide reportedly had in her pocketbook, in addition to other items: At approximately 0630 at the nursing station, an aide observed that a patient had taken her pocket book. Upon being notified, this nurse conducted a search for the patient and her wheelchair, during which the pocketbook and other personal belongings were found in patient possession, IT was discovered that the patient had ingested medication from the pocketbook, specifically Zofran 4mg. The owner reported that her credit card, $6 in cash and drivers license were not recovered. The authorities were notified, and a report was filed. The supervisor was made aware of the incident DON was contacted. Provider to be called for medication ingestion.During an interview with Employee E8 on January 22, 2026 at 5:05 p.m. licensed nurse nursing note regarding the above referenced incident was reviewed and confirmed by the licensed nurse. Licensed nurse informed her that she was in the medication room when nurse aide (Employee E8) informed her that her pocketbook was missing from the nursing station. Licensed nurse reported that the nurse aide told her that she (nurse aide) knew that the resident took it because she (the resident) was just taking things. Licensed nurse reported that both she and the nurse aide found the resident in the dining room or her bed room and when the pocketbook was retrieved from the resident, the nurse aide reported that her keys,money and her Zofran were all missing. Licensed nurse reported that the nurse aide indicated that she was prescribed Zofran for nausea. Licensed nurse reported that the empty blister packs from the Zofran prescription were found in the trash can in the resident's room. Licensed nurse reported that the resident denied taking the nurse aide's pocket book, money, keys and medication when she was asked. Licensed nurse reported that while in the residents room, the resident opened her mouth and stated to both she and the nurse aide, Mommy look, but did not have anything in her mouth when they looked. Licensed nurse reported that she contacted the police because the nurse aide's money and keys had not been found. During an interview with the Nursing Home Administrator on January 22, 2026 at 9:51 a.m. the NHA confirmed that there was not documentation to show evidence that an investigation was completed to rule out neglect of an allegation that the resident ingested Zofran due to a nurse aide leaving her pocketbook unattended at the nursing station.

Based on review of clinical records, review of facility policy and interview with residents, it was determined that the facility failed to develop a person-centered resident care plan for one of twenty-two residents reviewed (Resident R77) Findings Include: Review of facility policy on care plans comprehensive persons-centered dated December 2016 Under section policy statement a comprehensive present-centered care plan that includes measurable goals and timetables must meet the residents physical psychological and functional needs is developed and implemented for each resident. Under section policy interpretation and implementation number one the interdisciplinary team in conjunction with a resident and his or her family or legal representative develops and implements a comprehensive person centered care plan for each resident #9 areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan #12 the comprehensive person centered care plan is developed within seven days of the completion of the required comprehensive assessment MDS (minimum data set, a federally required resident assessment completed at a specific interval) #13 assessments of residents are ongoing and care plans revised as information about the resident and the residents condition change #14 the interior disciplinary team must review and update the care plan at least quarterly in conjunction with a required quarterly MDS assessment. Review of resident R77 clinical record revealed that resident R77 was admitted to the facility on [DATE], with diagnoses of diagnosis of but not limited to Type 2 Diabetes Miletus, Dry Eyes Syndrome of Bilateral Lacrimal Glands. Review of Resident R77's MDS dated [DATE], section B1000 (Vision) revealed that Resident R77 was visually impaired; Section C - Cognitive Patterns, C0500. BIMS Summary Score (brief interview for mental status) was coded 15 suggesting that Resident R77 was cognitively intact. Further review of Resident R77's clinical record revealed that there was no care plan developed to address resident R77's visual impairment. Interview with resident R77 conducted on January 20, 2026, at 1:37PM revealed that he cannot see. 28 Pa. Code 211.11(a) Resident care plan

Based on interviews, and reviews of clinical records, facility documentation and employee records, the facility failed to ensure that staff assigned to supervise residents during dining and provided cardio-pulmonary resuscitation (CPR) to a resident who was choking were certified in cardio-pulmonary resuscitation (CPR). One of 22 residents reviewed. Findings Include:Review of facility policy Cardiopulmonary Resuscitation (CPR) dated 2025, revealed that Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. Obtain and/or maintain American Red ' Cross or American Heart Association certification in Basic Life Support (BLS)/ Cardiopulmonary Resuscitation (CPR) for key clinical staff members who will direct resuscitative efforts.Review of facility policy Meal Supervision Policy dated January 2025, revealed that This policy applies to all nursing staff, healthcare assistants, dietary aids and any designated personnel involved in supervision of patient meals. All patients who require meal supervision will be supported According to. Individualized care plans promote safety, nutritional adequacy, and dignity during meals. Nursing staff are responsible for ensuring appropriate supervision is provided based on clinical risk assessments. Mealtime Supervision Protocol.Ensure a calm, respectful, and safe dining environment.Confirm the correct tray/Diet is delivered as per the diet order.Monitor for signs of aspiration or choking.Offer verbal cues or physical assistance if needed.Limit distractions or stressorsEncourage independence while maintaining safety.Do not leave high-risk patients unsupervised while eating or drinking. Review of facility document Dining Room Supervision standard revealed that Supervision Guidelines: High-risk residents (e.g., on thickened liquids or pureed diets) must have direct observation throughout their meal. CNAs and floor staff must remain alert and within close proximity. Never walk away from a resident mid-meal if they require supervision. Ensure proper seating posture (upright, 90-degree angle). Minimize distractions; no talking with residents while chewing/swallowing. Assist only one resident at a time during feeding to ensure safety and focus. Signs of Distress During Meals: Coughing or throat clearing Pocketing food in the cheeks Wet or gurgled voice Shortness of breath Sudden change in color or alertnessif any of these are observed, STOP feeding immediately and notify the nurse.Review of facility investigation dated May 20, 2025 revealed that Nurse Aide, Employee E12 provided Resident R114 with his lunch tray in the main dining room. Employee E13, Nurse Aide, also in the dining room, observed Resident R114 sitting with his tray and started coughing and his hands up by his chest. Resident R114 was sitting upright in chair. Employee E12 immediately administered back blows and started the Heimlich maneuver(clears airway obstructions by applying sharp, upward pressure above the navel to force out lodged objects) while calling for Assistance. Two nurses immediately came over and administered CPR which included Heimlich maneuver. Further review of the facility investigation revealed that Employee E12 and Employee E13 were the only two staff available at the nurse's station. Review of personal file for Employee E12 and Employee E13 revealed that both employees did not possess a valid CPR certification at the time of the incident. Review of personal file for Employee E12 revealed that the employee completed an online CPR certification, (not AHA or American Red Cross) the day of the incident.Interview with the Director of Nursing on January 22, 2026, at 2:00 p.m. revealed that the employee realized that the CPR certification was expired after providing CPR to Resident R114 and took the online certification after the incident. Interview with the Unit Manager, Employee E11 on January 22, 2026, at 1:00 p.m. stated there should at least a nurse in the dining room where residents who were at risk for aspiration or on aspiration precaution eat to supervise.Interview with the Administrator and Director of Nursing on January 23, 2026, at 12 p.m., confirmed that both employees who were assisting in the dining room did not possess a valid CPR certification at the time of the incident and the nurses were present in the dining room. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 201.18(e)(1) Management28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1) Nursing services28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to follow the physician orders related to Medication Administration for one of 23 residents reviewed (Resident R53) Review facility policy on administering medications dated December 2012 reveal that under section policy statement medication shall be administered in a safe and timely manner and as prescribed. under section policy interpretation and implementation #2 the director of nursing services will supervise and direct all nursing personnel who administer medications and or have related functions #3 medications must be administered in accordance with the orders including any required time frame #4 medications must be administered within one hour of their prescribed time unless otherwise specified for example before and after meal orders #7 the individual administering the medication must check the label three times to verify the right resident the right medication the right dose the right time and right method.Review of Resident R53's clinical record revealed that Resident R53 was admitted to the facility on [DATE], with diagnosis of but not limited to Hypokalemia (low potassium level in the blood), Hypertension, Congestive Heart Failure (co0ndition where the heart pumps inefficiently)Review of Resident R53's physician's orders revealed an order for the following medications: Potassium Chloride (KCl) ER tablet Extended Release 20 MEQ Give 2 tabs by mouth two times a day, Toprol XL oral tablet extended release 24-hour 50 mg, give 1 tab by mouth one time a day for HTN (hypertension) to be given with meals, Metformin hydrochloride oral tablet 500 milligrams give one tablet by mouth in the morning for diabetes take with breakfast, Lasix oral tablet 40mg give one tablet by mouth one time a day every Monday, Tuesday, Wednesday, Thursday, Saturday for CHF (congestive heart failure), Eliquis tablet 5MG give one tablet by mouse two times a day for DVT (deep vein thrombosis), Diltiazem Hydrochloride oral tablet 30MG give one tablet by mouth one time a day for A-fib (At fibrillation), Gabapentin 100mg give one capsule by mouth two times a day for a neuropathy, Alopurinol Oral tablet 100kg give one tablet by mouth one tab a day for gout.Review Resident R53's quarterly MDS (minimum data set, a federally required resident assessment completed at a specific interval) dated November 14, 2025, revealed that section C Cognitive Patterns, C0500. BIMS Summary Score revealed that resident R53 was coded 15 suggesting that Resident R53 was cognitively intact.Review of Resident R53's Medication Administration Audit Report revealed the following: Potassium Chloride (KCl) ER tablet Extended Release 20 MEQ Give 2 tabs by mouth two times a day which was scheduled to be administered on December 6, 2025, at 9:00AM was administered on December 6, 2026, at 4:05PMToprol XL oral tablet extended release 24-hour 50 mg, give 1 tab by mouth one time a day for HTN (hypertension) to be given with meals which was scheduled to be administered on December 6, 2025, at 9:00 AM was administered on December 6, 2025, at 4:05PM.Metformin hydrochloride oral tablet 500 milligrams give one tablet by mouth in the morning for diabetes take with breakfast, which was scheduled to be administered on December 6th, 2025, at 9:00 AM was administered on December 6, 2025, at 4:05 PMLasix oral tablet 40mg give one tablet by mouth one time a day every Monday, Tuesday, Wednesday, Thursday, Saturday for CHF (congestive heart failure) which was scheduled to be administered on December 6, 2025, at 9:00 AM was administered on December 6, 2025, at 04:08 PM.Eliquis tablet 5MG give one tablet by mouth two times a day for DVT (deep vein thrombosis) which was scheduled to be administered on December 6, 2025, at 9:00 AM was administered on December 6, 2025, at 4:08PMDiltiazem Hydrochloride oral tablet 30MG give one tablet by mouth one time a day for A-fib (At fibrillation) which was scheduled to be administered on December 6, 2025, at 9:00 AM was administered on December 6, 2025, at 4:08PMGabapentin 100mg give one capsule by mouth two times a day for a neuropathy which was scheduled to be administered on December 6, 2025, at 9:00 AM was administered on December 6, 2025, at 4:08PM.Alopurinol Oral tablet 100kg give one tablet by mouth one tab a day for gout which was scheduled to be administered on December 6, 2025, at 9:00 AM was administered on December 6th, 2025, at 4:08 PMInterview with Resident R53 conducted on January 20, 2026, at 1:15PM revealed that the nurses give him his medications very late.Interview with licensed nurse Employee E2 confirmed that medications that were scheduled to be administered on December 6, 2025, at 9:00AM were documented as administered after 4:00 PM on December 6, 2025. 28 Pa. Code 211.10(a) Medication administration

Based on the review of clinical records, it interviews with staff, it was determined that the facility failed to prevent accident hazards for 1 out of 22 residents reviewed (Resident R8). Findings include:Review of the January 2026 physician orders for Resident R8 included the following diagnosis: congestive heart failures (CHF-a long-term condition that affects your heart's ability to pump blood well); epilepsy (a brain disorders that causes recurring seizures); schizophrenia (a serious mental health disorder characterized by symptoms that include false beliefs seeing things that are not present, hearing voices, and sounds that are not real, and disorganized thinking, affecting how individuals perceive reality and interact with the world); intellectual abilities (a neurodevelopmental condition characterized by significant limitations in intellectual functioning and adaptive behavior, affecting everyday life skills and learning abilities); cognitive communication deficit (a condition that affects an individual's ability to communicate effectively due to impairments in cognitive processes such as attention, memory, reasoning, and problem-solving); anxiety (intense, excessive and persistent worry and fear about everyday situations), and psychosis (the term for a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not).Review of a nursing note written by Employee E8 (license nurse) dated July 21, 2025 at 7:20 a.m. documented that the resident took a nurse aide's pocketbook and ingested the medication, Zofran (4 milligram tablet), a prescription medication that the nurse aide reportedly had in her pocketbook, in addition to other items: At approximately 0630 at the nursing station, an aide observed that a patient had taken her pocketbook. Upon being notified, this nurse conducted a search for the patient and her wheelchair, during which the pocketbook and other personal belongings were found in patient possession, IT was discovered that the patient had ingested medication from the pocketbook, specifically Zofran 4mg. The owner reported that her credit card, $6 in cash and driver's license were not recovered. The authorities were notified, and a report was filed. The supervisor was made aware of the incident DON was contacted. Provider to be called for medication ingestion.During an interview with Employee E8 on January 22, 2026 at 5:05 p.m. licensed nurse nursing note regarding the above referenced incident was reviewed and confirmed by the licensed nurse. Licensed nurse informed her that she was in the medication room when nurse aide (Employee E8) informed her that her pocketbook was missing from the nursing station. Licensed nurse reported that the nurse aide told her that she (nurse aide) knew that the resident took it because she (the resident) was just taking things. Licensed nurse reported that both she and the nurse aide found the resident in the dining room or her bedroom and when the pocketbook was retrieved from the resident, the nurse aide reported that her keys, money and her Zofran were all missing. Licensed nurse reported that the nurse aide indicated that she was prescribed Zofran for nausea. Licensed nurse reported that the empty blister packs from the Zofran prescription were found in the trash can in the resident's room. Licensed nurse reported that the resident denied taking the nurse aide's pocketbook, money, keys and medication when she was asked. Licensed nurse reported that while in the residents room, the resident opened her mouth and stated to both she and the nurse aide, Mommy look, but did not have anything in her mouth when they looked. Licensed nurse reported that she contacted the police because the nurse aide's money and keys had not been found. During an interview with the Nursing Home Administrator on January 22, 2026 at 9:51 a.m. the NHA confirmed that it is expected that nursing staff personal belongings are kept in the employee break room in the basement and not at the nursing station.

Based on interviews and the review of facility documentation, it was determined that the facility failed to ensure that a resident's significant weight loss was addressed in a timely manner for 1 out of 22 residents reviewed (Resident R6).Findings include:Review of the facility policy, Weight Assessment and Intervention, with a revision date of March 2022 indicated that any weight change of 5% or more since the last weight assessment is taken is retaken the next day for confirmation. Review of the resident's January 2026 physician orders included the following diagnosis: hypertension (high blood pressure); cerebral infarction (a stroke); chronic kidney disease (when the kidneys have become damaged over a specific period of time and have a hard time doing all their important jobs).Review of a monthly weight in the resident's clinical record dated May 3, 2025 documented the resident's weight at 138 pounds. Review of a monthly weight dated June 6, 2025 documented the resident's weight as 129 pounds, which is -9 pounds weight loss and a significant weight loss of -6.5%. Continued review of a clinical record did not show that a re-weight was taken for the significant weight loss from May 2026 through June 2026 to ensure that any interventions related to the resident's weight loss, if needed, can be identified and implemented in a timely manner. Review of a note written by a dietician on June 11, 2025 at 7:50 a.m. indicated that a weight loss for the resident was noted and that she was waiting on a reweight. Weight loss noted. Reweigh requested.Continued review of the resident's clinical record did not show evidence that a re-weight was completed in a timely manner to verify the actual weight loss, and to ensure that any services and interventions were in implemented, if needed, were in implemented in a timely manner.Review of a note written by the dietician (Employee E10) on June 25, 2025 at 12:33 p.m. indicated that the dietician was still awaiting the re-weight. The dietician also recommended an increase in house shakes until an accurate weight is determined. During an interview with the dietician (Employee E10) on January 23, 2026 at 10:40 a.m. it was reviewed and confirmed with the dietician during this time that the resident sustained at a -6.5 significant weight loss. The dietician's notes regarding the request and need for a reweight was also reviewed (June 11 and June 25 note). It was also discussed with the dietician that there was no documentation that a re-weight was completed on the resident to verify the weight loss and that the next weight recorded in the clinical record was recorded on July 1, 2025, which was 25 days after a significant weight loss was recorded by facility staff. The dietician also reported during the interview that the facility did not have a standard time frame for obtaining re-weights for residents who show a possible significant weight loss.

Based on review of facility policy and clinical records, resident and staff interviews, it was determined that the facility failed to offer routine dental services for one of 22 residents reviewed (Resident R74).Findings include: Review of the clinical record for Resident R74 revealed that the resident was admitted to the facility on [DATE], and the resident was a long-term care resident. The payment source for resident's stay was listed as Medicaid/Medicaid plans. Review of Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 74, dated December 10, 2025, revealed that the resident was cognitively intact. Review of Pennsylvania Medical Assistance Dental Coverage for Adults revealed that an adult can receive exams, x-rays, and cleanings once every 6 months.An interview with Resident R74 on January 20, 2026, at 2:01 p.m. stated he did not see dentist since she was admitted to the facility in March of 2025. He said he was having tooth pain, and he needed his tooth extracted. Review of clinical records revealed no documented evidence that Resident 74 had seen a dentist or was scheduled for an appointment to see the dentist since his admission to the facility in March of 2025 till January 2026.Interview with the Unit Manager, Employee E11 on January 23, 2026, at 11:20 a.m. confirmed that Resident R74 had not seen a dentist or had a consult with a dentist since his admission. Employee Said there was no documented evidence that the resident refused the appointment/consult. Employee stated there is an appointment scheduled after he reported tooth pain but no routine dental exams/visits were scheduled. 28 Pa. Code 211.12(c)(d)(3)(5) Nursing Services 28 Pa. Code 211.15(a) Dental Services.

Based on observations and an interview with staff it was determined that the facility did not ensure that garbage and refuse was disposed of properly. Findings include:An initial tour of the Food Service Department was conducted on January 20, 2026, at 10:15 a.m. with Employee E5, Food Service Director (FSD), which revealed the following:Observation in the receiving area revealed a green dumpster with equipment piled behind it including a hospital style bedframe on the ground partially covered in snow, a stainless-steel counter height ice machine and a wheelchair with six leg rests piled on top of the armrests.Interview with the FSD at 9:30 a.m. on January 20, 2026, confirmed the above findings, and that the ice machine was no longer working. Interview with the Administrator on January 21, 2026, at 11:30 a.m. confirmed that the equipment did not belong in the receiving area and that it had been moved. 28 PA Code: 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(3) Management

Based on the review of facility documentation, clinical records and staff and resident interviews, it was determined that the facility failed to provide necessary pharmaceutical services for one of five residents reviewed. (Resident R1).Findings include: Review of physician order for Resident R1 dated May 28, 2025, revealed that the resident was ordered for Lidocaine external patch 4% to skin topically one time a day for pain; Bacitracin (Antibiotic ointment) zinc external ointment to left ear topically two times daily; Balsam Peru Castor Oil (used to promote healing and treat certain types of skin ulcers and wounds.) external ointment to bilateral elbows and heels topically two times a day; Naproxen (a nonsteroidal anti-inflammatory drug ) oral Tablet 500 MG tablet by mouth two times a day for pain for 14 days. Review of Medication Administration Record for Resident R1 for the month of May 2025 revealed that the resident did not receive the above medications as ordered by the physicians on May 28, 2025. The reason documented was that the medications were not available. Interview with Director of Nursing, Employee E2 on July 1, 2025, at 12:00 p.m. stated that the residents arrived from the hospital on May 27, 2025. There were no medications available in the facility to administer as the pharmacy did not deliver the medications in a timely manner. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.9(a)(1)(f)(2)(4)(k) Pharmacy services.

Based on clinical record reviews, interviews with staff and hospital record and policy and procedure review, it was determined that the facility failed to ensure that breathing treatments were prescribed upon admission and that medications were administered as order by the physician for one of fourteen residents reviewed. (Resident R1) Findings include: A review of the facility policy titled administering medications dated December, 2012 revealed that the all medications were to be administered by a licensed person(s) in a safe and timely manner as prescribed by the attending physician. The policy indicated that medications must be administered in accordance with orders, including any required time frames. A review of the policy titled reconciliation of medications on admitted d July 2027 revealed that it was the responsibility of the nurse to ensure the accurate accounting of residents' medications, routes and dosages upon admission to the facility. The nurse was to use the discharge summary from the referring facility and reconcile any medications and orders for treatments such as: (patches, eye drops, inhalers, shots) for dose, route, frequency and last time taken. The nurse was also responsible to ask the physician the reason for taking the medication or treatment and document in the resident's clinical record. Clinical record review for Resident R1 revealed that this resident was admitted to the facility on [DATE] at 9:38 p.m., the resident had diagnoses that included: chronic obstructive pulmonary disease (disease process that causes decreased ability of the lungs to perform), chronic hypoxic (low levels of oxygen) and, emphysema (abnormal enlargement of the air spaces in the lungs) and chronic obstructive sleep apnea (breathing stops during sleep due to a blockage). Review of hospital discharged record dated March 14, 2025 indicated that this resident was to receive supplemental oxygen and continue with NiPPV (noninvasive ventilation technique) called a BiPAP (bilevel positive airway pressure machine) to enhance breathing by delivering two levels of air pressure. There was no documentation to indicate that physician's orders for oxygen or breathing therapy were obtained for Resident R1 upon admission to the facility on [DATE]. Interview with the Director of Nursing, Employee E2, at 10:30 a.m., on April 1, 2025, confirmed that the nurse who admitted the resident failed to obtain,supplemental oxygen therapy and continous breathing therapy with the BiPAP machine for Resident R1 upon admission to the facility on [DATE]. Review for Resident R1 March 2025 physican's orders revealed an order for Bromide inhalation 62.5 MCG/ACT aerosol powder breath activated one puff inhale orally one time a day for shortness of breath administer at 9:00 a.m., daily with a start date of March 15, 2025. Review of Resident R1's Medication Administration Record revealed no documented evidence that this medication was administered to Resident R1 as ordered by the physician on March 15, 2025. Interview with the Director of Nursing, Employee E2 on April 1, 2025 at 10:00 a.m. confirmed no evidence of the administration of the medication. Continued review of physician's orders revealed an order for Albuterol inhalation solution .5-2.5MG/3ml inhale orally three times a day for shortness of breath at 10 a.m., 2:00 p.m., and 8:00 p.m., start on March 15, 2025. Review of Resident R1's Medication Administration Record revealed no documented evidence that this medication was administered to Resident R1 as ordered by the physician on March 15, 2025. Interview with the Director of Nursing, Employee E2 on April 1, 2025 at 10:00 a.m. confirmed no evidence of the administration of the medication. Review of Reisdent R1's hospital recordswas admitted to the hospital emergency room from the facility on March 15, 2025 at 7:00 p.m., after experiencing the shortness of breath, change in mental status because of inadequate duration of time on NiPPV (noninvasive ventilation technique) with the use of a BiPAP or CPAP (resident care equipment with a mask) to treat breathing problems. The hospital record indicated that Resident R1's respiratory rate was alarmingly high at 32 breaths per minute. Normal respiratory rate was 10 to 20 breaths per minute for an adult. 28 PA. Code 211.10(c) Resident care policies 28 PA. Code 211.12(d)(1) Nursing services

Based on observations of the Food and Nutrition Services Department, interviews with residents and staff, reviews of clinical records and policies and procedures, it was determined that essential pieces of food service equipment used for the transportation, holding and delivery of hot foods from the dietary services department to the nursing units, resident rooms and dinning areas were not in use, to ensure consistently safe and satisfactory food temperatures of foods for the residents. (Residents R11, R57, R56, R5, R55, R28, R64, R46, R37, R34, R41, R27, R14 and R19). Findings include: A review of the undated facility policy titled resident tray assessment indicated that all hot foods were to be served hot at a temperature greater than or equal to 130 degrees Fahrenheit and served satisfactory for the residents' preferences and dietary care planning. A review of the undated policy titled service of hot liquids to prevent spills revealed that hot beverages were to be served hot and at a temperature less than 140 degrees Fahrenheit to meet the food preferences of the residents. Observations between 11:30 a.m. and 1:00 p.m., on December 9, 2024 of the food delivery service system from the main kitchen of the Food and Nutrition Services Department to the first and second floor nursing units revealed that the facility was not utilizing a complete and standard thermal system to transport, hold and deliver hot foods to the residents. The lack of essential equipment for dietary staff use did not ensure that hot foods were being served safe, palatable and in accordance with residents' appetite satisfaction on a regular basis. Individual interviews with Residents R57, R11 and R34 between 10:00 a.m. and 10:30 a.m., on December 9, 2024 revealed the the temperature and taste of the foods are luke warm and taste was undesirable. The residents described the foods as tasting burnt although at times they don't look black or burnt. The residents reported that the hot beverage was never hot. They said they can not get the powdered creamer to dissolve in the coffee because it was too cold. The residents said that the kitchen staff can not serve a grilled cheese sandwich that was appetizing. The cheese would be served hard and unmelted. One of the residents reported that he mostly eat meals in his room and by the time I get a hot meal it would be cold. Interviews with alert and oriented residents assembled in a group at 9:30 a.m., on December 10, 2024 revealed that the hot foods during breakfast, lunch or dinner meals were always served to them cold. Clinical record review revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated October 18, 2024 for Resident R11 that indicated that this resident was cognitively intact. Clinical record review revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated August 31, 2024 for Resident R57 that indicated that this resident was cognitively intact. Clinical record review revealed an annual comprehensive assessment MDS (an assessment of care needs) dated November 10, 2024 for Resident R56 that indicated that this resident was cognitively intact. Clinical record review revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated November 2, 2024 for Resident R5 that indicated that this resident was cognitively intact. Clinical record review revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated November 5, 2024 for Resident R55 that indicated that this resident was cognitively intact. Clinical record review revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated November 13, 2024 for Resident R28 that indicated that this resident was cognitively intact. Clinical record review revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated October 18, 2024 for Resident R64 that indicated that this resident was cognitively intact. Clinical record review revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated October 23, 2024 for Resident R46 that indicated that this resident was cognitively intact. Clinical record review revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated October 25, 2024 for Resident R37 that indicated that this resident was cognitively intact. Clinical record review revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated November 6, 2024 for Resident R34 that indicated that this resident was cognitively intact. Clinical record review revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated November 14, 2024 for Resident R41 that indicated that this resident was cognitively intact. Clinical record review revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated November 13, 2024 for Resident R27 that indicated that this resident was cognitively intact. Clinical record review revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated October 18, 2024 for Resident R14 that indicated that this resident was cognitively intact. Clinical record review revealed a quarterly comprehensive assessment MDS (an assessment of care needs) dated October 25, 2024 for Resident R19 that indicated that this resident was cognitively intact. Interviews with the director of dietary services, Employee E10 and the registered dietitian, Employee E8 at 1:30 p.m., on December 11, 2024 confirmed that the food and nutrition department's essential equipment was lacking; that was the dietary staff were not using a complete system of standard dietary equipment to transport foods that were being prepared hot in the main kitchen to the residents on the first and second floor nursing unit. Further interview with the dietary staff, Employees E8 and E10, that were responsible for the delivery of safe and appetizing hot foods for the residents revealed that the equipment that was not in use were the heated pellet and thermal pellet holder. The pellet was heated to 160 to 170 degrees Fahrenheit inside a lowerator. The pellets and lowerator were used to keep hot foods hot for twenty minutes beyond the time the food leaves the kitchen and was transported to the nursing units for the residents. 28 PA. Code 211.10(a)(b)(c)(d) Resident care policies 28 PA. Code 201.14(a) Responsibility of licensee 28 PA. Code 201.18(b)(1)(3)(d)(e)(1) Management

Based on review of facility financial and accounting documentation and interview with administrative staff, it was determined that the facility failed to demonstrate the maintenance of a complete, separate, and accurate accounting of each residents personal funds entrusted to the facility on the residence behalf for one of 24 residents reviewed (resident R28). Findings include: Review of facility policy Titled Personal Funds revealed If the facility has been designated to handle the personal funds of the resident, the business office will maintain a full complete and separate accounting according to generally accepted accounting principles of each resident's personal fund entrusted to the facility. A copy of the quarterly statement will be submitted to the resident, or the residents designated representative on a quarterly basis and or at the request of the designated representative or resident. Review of information submitted to the Department revealed that On October 21, 2024, nursing home administrator employee E1 became aware that resident R28 alleged that there were inaccuracies with her most recent quarterly statement including charges she did not recognize. Continued review of this event revealed that resident R28 had questions about her statement and the director of nursing, employee E2, presented a withdrawal receipt to resident R28 of funds received with Residents R28's signature. The NHA, employee E1, interviewed the previous business office manager who stated that resident R28 withdrew sums of 100 dollars 200 dollars and 300 dollars. The NHA employee E1 determined that resident R28 had inconsistencies with the relaying information of use of the funds and the facility was unable to substantiate the residence funds have been misappropriated. Interview with resident R28 on December 09, 2024, at 09:55 a.m. revealed that she had concerns regarding her financial statement. Resident R28 stated she never withdrew any money other than the allotted $45 dollar allowance monthly. This resident was given her monthly statements and did not recognize the withdraws of money. Interview with Business office manager E4 on December 11, 2024, at 3:45 pm, revealed that is it the facility's protocol of when a resident requests money, the business director will withdraw the requested amount of money and provide a receipt to be signed by the resident confirming that they have received the money. This employee stated that there is a scheduled banking day once a month for residents to requests funds, if any resident should request funds other than on the banking day, they are to contact employee E4 and requests a transaction, the resident will then sign a statement that they are withdrawing from their account and the resident is then given the funds and a receipt. Continued interview with business officer manager employee E4 on December 12, 2024, at 10:00 a.m. revealed that she recently started the position of business office manager and has no knowledge of the above event. Employee E4 was unable to locate any copies of receipts of money paid out to resident R28. Interview with Nursing home administrator employee 1 on December 12, 2024 at 3:10 p.m. revealed there were only two dates of question regarding withdraw funds on resident R28 statement. The facility was unable to locate one of the receipts therefore reimbursing the resident for the money total of $300. 28 pa code 201.18(e)(1) management

Based on review of facility document, review of facility policy, review of clinical records, and staff interviews, it was determined that the facility failed to ensure that medications were delivered and by the contracted pharmacy to be administered to a newly admitted resident (Resident R1) resulting in Resident R1 experiencing an uncontrollable seizure requiring transfer via emergency medical services and hospitalization into the intensive care unit for the treatment of seizures. This failure resulted in an Immediate Jeopardy situation for one of five residents reviewed (Resident R1). Findings include: Review of facility policy Medication Ordering dated June 1, 2021, revealed it is the policy of the facility to ensure all medications ordered by the physician are available in a timely manner. Licensed nursing staff will contact pharmacy as needed to alert medications that require special attention or STAT delivery. For narcotic medications call MD for scripts necessary to get authorization code. Review of facility policy Policies and Procedures for Management of the Automated Dispensing System (ADS) revealed the ADS Station (also known as the facility Omnicell) will be used for distribution of medications for Emergency, First-Dose use and other situations where medications are not available from the pharmacy. Upon receipt of a new medication order and the medication is not in designated emergency box area the nurse will ascertain whether the ordered medication is contained in the ADS and determine that the order is a true emergency, such as cannot be delayed until the scheduled pharmacy delivery and thus will be taken from ADS. Emergency doses for narcotic medications removed from the ADS system will require a written order (script) from prescriber. The facility must contact the pharmacy and obtain an authorization code for removal of any controlled substance. Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of epilepsy (a neurological disorder that causes seizures or unusual sensations and behaviors), surgical aftercare following surgery on the nervous system (history of surgery on the brain), tracheostomy status (small surgical opening in the neck allowing air to flow in and out of the windpipe), and hypotension (low blood pressure). Review of Resident R1's hospital records dated August 19, 2022, revealed Resident R1 arrived as a medical transfer to the epilepsy monitoring unit on May 20, 2022, for further medical management of his complex epilepsy. It was noted in the hospital record that after the resident was transferred to the hospital Resident R1 continued to have multiple seizures. Further review of the hospital record revealed that throughout Resident R1's prolonged hospital stay his medications were adjusted to reduce polypharmacy and promote wakefulness, he underwent extensive laboratory testing and imaging. Resident R1's medications were slowly titrated down and that the resident had no clinical seizures since July 27, 2022. Further Review of Resident R1's hospital records revealed an occupational therapy evaluation dated August 11, 2022, that revealed the resident was making good steady gains and had improved participation and command following. Resident R1 was able to say his name and count throughout the session. Therapy evaluation indicated that Resident R1 would benefit from inpatient rehab setting to increase overall independence and decreased burden of care. Review of Resident R1's hospital discharge medications dated August 19, 2022, revealed the resident was prescribed the following seizure medications and doses were due in the evening of the resident's admission and in the following morning: Cannabidiol 600 milligrams (mg) every 12 hours, Levetiracetam (also known as Keppra 1500 mg every 12 hours, Perampanel 6 mg two times per day, Clobazm 20mg at 6 a.m./10mg at 2 p.m./20mg at 10 p.m. -Phenobarbital 48.6 mg in the morning and 64.8 mg in the evening, Lacosamide (also known as Vimpat) 300 mg two times per day, Lorazepam 4 mg as needed (also known as Ativan - can be used to treat seizures that do not stop). Continued review of hospital records revealed Seizure rescue plan: 4 milligrams Ativan for an increase in generalized tonic clonic seizures (a symptomatic form of epilepsy often preceded by an aura; characterized by loss of consciousness) in 24 hours. Review of Resident R1's medication administration record revealed the resident did not receive prescribed seizure medications when he was admitted to the facility or on the following day. Review of Resident R1's August 2022, Medication Administration Record revealed no documented evidence that the Resident R1 was administered the following medications as prescribed for seizure on admission Cannabidiol 600 mg, Clobazm 20 mg, Levetiracetam 1500 mg, Perampanel 6 mg, Phenobarbital 64.8 mg, and Lacosamide 300 mg. Further review of August 2022 Medication Administration Record revealed that on August 20, 2022 the following medication were not administered in the morning Cannabidiol 600 mg, Clobazm 20 mg, Perampanel 6 mg, Phenobarbital 48.6 mg, and Lacosamide 300 mg. Interview with the Director of Nursing, Employee E1, on August 24, 2022, at 10:00 a.m. confirmed that Resident R1 was on multiple seizure medications, with a few that required a script from the physician, and the facility pretty much didn't get them in time. It was revealed that the following medications required a script from the physician: Phenobarbital, Vimpat, Perampanel, Clobazm, and Ativan. Interview with the Director of Nursing and Nursing Home Administrator on August 24, 2022, at 11: 15 a.m. revealed Resident R1 was admitted to the facility at approximately 3:30 p.m. on August 19, 2022. It was reported that medications were put in the electronic medical record (which sends orders to the pharmacy) between 6:00 p.m. and 8:30 p.m. and were delivered to the facility the next morning on August 20, 2022, at 4:37 a.m. Medications that required a script from the physician were not delivered. The Director of Nursing and Nursing Home Administrator revealed they were unaware narcotic medications do not get sent to the pharmacy through the electronic medical record. A script must be obtained by the physician and orders need to be faxed to the pharmacy. Review of communication from the pharmacy dated August 21, 2022, revealed physician orders were electronically sent over to the pharmacy and toted for the 11:00 p.m. delivery, medications were delivered at 4:19 a.m., the order for Cannabidol was unavailable and had to be ordered. It was further noted that narcotic orders were not faxed over to the pharmacy upon [Resident R1's] admission. There was no documentation of the facility contacting the pharmacy for [Resident R1's] narcotics or for an authorization code to pull from the Omnicell (automated dispensing system). The following medications were available in the Omnicell during Resident R1's admission: Vimpat, Phenobarbital, and Ativan. Interview with Registered Nurse, Employee E4, on August 24, 2022, at 1:15 p.m. revealed this nurse was responsible for passing medications on the front hall of the 1st floor nursing unit and was assigned to Resident R1. Registered Nurse, Employee E4 confirmed that no medications were administered for Resident R1 due to lack of orders in the electronic medical record. Registered Nurse, Employee E4 reported to have completed his shift about 9:30 p.m. and Licensed Nurse, Employee E18, became the nurse responsible on that unit. Registered Nurse, Employee E4 reported the Nursing supervisor, Employee E3, was responsible for obtaining orders from the physician. Interview with Licensed Nurse, Employee E18, on August 24, 2022, at 12:55 p.m. revealed this nurse got to the facility about 9:30 p.m. and was responsible for medication administration on the back hall of the 1st floor nursing unit. Employee E18 reported they were not aware Resident R1 did not get prescribed medications. Interview with Nursing Supervisor, Employee E3, on August 24, 2022, at 12:45 p.m. revealed this nurse was responsible for putting the physician orders in Resident R1's electronic medical record, which subsequently sends orders to the pharmacy. Nursing Supervisor, Employee E3 indicated that the pharmacy should get a script from the physician for the required medications. Nursing Supervisor, Employee E3 reported a call was placed to the on-call center to obtain physician orders for Resident R1's medications. Interview on August 24, 2022, at 1:30 p.m. with Employee E16, Practice Administrator for the Physician's office, revealed the Nurse Practitioner, Employee E17, gave verbal orders to continue medications as ordered for Resident R1 at 8:00 p.m. on August 19, 2022. It was revealed that the Nurse Practitioner was not aware the resident did not come with a supply of medications from the hospital. The Nurse Practitioner reported the facility did not request scripts for Resident R1's medications and did not make the Nurse Practitioner aware the resident missed doses of required medications. Interview on August 24, 2022, at 1:45 p.m. with Licensed Nurse, Employee E6, revealed this nurse was assigned to Resident R1 during the 7:00 a.m. to 7:00 p.m. shift on August 20, 2022. Employee E6 reported they were not made aware during report from the previous shift that Resident R1 was on seizure precautions and required seizure medications. Employee E6 stated Resident R1 was checked on during rounds at approximately 8:30 a.m. Employee E6 confirmed no medications were given at that time. Employee E6 went on to tend to other residents when she was made aware at 10:00 a.m. that Resident R1's family was requesting attention in the resident's room. Employee E6 stated when she arrived at the room the resident had a blank stare, no movement, was unresponsive and pale. Employee E6 confirmed Resident R1 had still not received any scheduled morning medications at 10:00 a.m. Continued interview with Employee E6 revealed upon arrival to Resident R1's room, Registered Nurse, Employee E4 was already in the room. Employee E6 stated Employee E4 checked the Omnicell for medications, who reported medications were not available. Employee E6 reported she was able to find one seizure medication, Keppra, which was administered after the seizures started. Continued interview with Licensed Nurse, Employee E6 revealed Emergency Medical Services (9-1-1) was called and Resident R1 was ultimately transferred to the hospital. Review of Resident R1's hospital records dated August 20, 2022, revealed total time of witnessed seizure activity 25 minutes. When medics arrived, patient [Resident R1] had been seizing for 10 minutes at his nursing facility. No meds other than 15mL of Keppra were administered . upon seeing his accompanying paperwork and seeing his extensive list of antiepileptics and hearing that the patient has not received any of those since being discharged [from hospital August 19, 2022], patient intubated (tube inserted into the trachea for ventilation) immediately . patient intermittently continued to demonstrate right-sided myoclonic (involuntary muscle jerk) activity concerning for seizure disorder. Continued review of hospital records revealed Resident R1's condition was time critical requiring rapid air transportation to alternative hospital in order to minimize morbidity (condition of suffering from a medical condition)/mortality (state of being subject to death). Once Resident R1 was transferred to alternative hospital for treatment, the resident was admited to the intensive care unit for treatment and monitoring of seizures. An Immediate Jeopardy situation was identified to the Nursing Home Administrator and Director of Nursing on August 24, 2022, at 12:08 p.m. related to the facility's failure to timely obtain and administer seizure medications. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator on August 24, 2022, at 12:08 p.m. The corrective action plan included the following interventions: -Facility will review and revise admissions policy related to availability of medications. -Facility will review and revise policy related to medication availability from pharmacy for administration. If medication is not available through [contracted] pharmacy and/or unable to deliver within allotted medication window, [contracted pharmacy] will notify local [pharmacy] to deliver STAT (immediately). In addition, nurse will follow-up with phone call to pharmacy to confirm delivery on time. -Facility will review and revise steps to be taken with contracted pharmacy to ensure timely delivery of medications. Nursing management will review current list of stock medications in the Omnicell system with medical director and pharmacy consultant on August 25, 2022, to make necessary changes. -The Director of Nursing will in-service all nursing staff (LPNs, RNS) in reference to medication available, Omnicell inventory and medication availability. All licensed nurses will be educated on revised policies and procedures beginning immediately. Approximately 50% of nursing staff will have completed education by August 25, 2022, and more than 75% of nursing staff by August 26, 2022, with goal at 100% completion if attainable. Lesson place will include timely administration of medications, steps to be taken to procure medications from the pharmacy, physician notification and follow up if any medication not available. -The Director of Nursing or designee will audit new admission upon arrival to facility to ensure all medications are available at time of admission and/or delivered timely. This will be audited daily x 4 weeks, then weekly x 4 weeks, then monthly x 6 months. Findings will be brought to QAPI (Quality Assurance Plan Improvement) and reviewed for necessary changes if indicated. Interviews were conducted with facility staff on August 25, 2022, between 12:00 p.m.-6:00 p.m. and on August 26, 2022, between 6:15 a.m-10:45 a.m. to verify the implementation of the action plan. Facility staff was able to verbalize the process to order medications, how to obtain medications from the Omnicell, and what they would do if medications were unavailable. A review was conducted of the education provided to facility staff related to obtaining and administering medications. Following the verification of the immediate action plan the Immediate Jeopardy was lifted on August 26, 2022, at 10:15 a.m. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services

Based on review of facility policy, review of clinical records, and interview with staff, it was determined that the facility failed to ensure that seizure medications were administered as ordered by the physician to Resident R1, resulting in a significant medication error causing Resident R1 to experience an uncontrollable seizure, requiring transfer via emergency medical services and hospitalization into the intensive care unit for the treatment of seizures. This failure resulted in an Immediate Jeopardy situation for one of five residents reviewed (Resident R1). Findings include: Review of facility policy Administering Medications, not dated, revealed medications shall be administered in a safe and timely manner, as prescribed. Medications must be administered within one hour of their prescribed time, unless otherwise specified. Review of facility document Missing Medications Process & Education not dated, revealed medications not administered per physician order is considered a medication error. Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE], with the diagnoses of epilepsy (a neurological disorder that causes seizures or unusual sensations and behaviors), surgical aftercare following surgery on the nervous system (history of surgery on the brain), tracheostomy status (small surgical opening in the neck allowing air to flow in and out of the windpipe), and hypotension (low blood pressure). Review of Resident R1's hospital records revealed Resident R1 arrived at the hospital as a medical transfer to the epilepsy monitoring unit on May 20, 2022, for further medical management of his complex epilepsy. After the transfer Resident R1 continued to have multiple seizures. Throughout Resident R1's prolonged hospital stay his medications were adjusted to reduce polypharmacy and promote wakefulness, and he underwent extensive laboratory testing and imaging. Resident R1's medications had slowly been titrated down without any clinical seizures since July 27, 2022. Review of Resident R1's hospital discharge medications dated August 19, 2022, revealed the resident was prescribed the following seizure medications and doses were due in the evening of the resident's admission and in addition on the following morning: -Cannabidiol 600 milligrams (mg) every 12 hours -Levetiracetam (also known as Keppra) 1500 mg every 12 hours -Perampanel 6 mg two times per day -Clobazm 20mg at 6 a.m./10mg at 2 p.m./20mg at 10 p.m. -Phenobarbital 48.6 mg in the morning and 64.8 mg in the evening -Lacosamide (also known as Vimpat) 300 mg two times per day -Lorazepam 4 mg as needed (also known as Ativan - can be used to treat seizures that do not stop). Continued review of hospital records revealed Seizure rescue plan: 4 milligrams Ativan for in increase in generalized tonic clonic seizures (a symptomatic form of epilepsy often preceded by an aura; characterized by loss of consciousness) in 24 hours. Review of Resident R1's August 2022, Medication Administration Record revealed no documented evidence that the Resident R1 was administered the following medications as prescribed for seizure on admission Cannabidiol 600 mg, Clobazm 20 mg, Levetiracetam 1500 mg, Perampanel 6 mg, Phenobarbital 64.8 mg, and Lacosamide 300 mg. Further review of August 2022 Medication Administration Record revealed that on August 20, 2022 the following medication were not administered in the morning Cannabidiol 600 mg, Clobazm 20 mg, Perampanel 6 mg, Phenobarbital 48.6 mg, and Lacosamide 300 mg. Interview with the Director of Nursing, Employee E1, on August 24, 2022, at 10:00 a.m. confirmed that Resident R1 was on multiple seizure medications, and the facility pretty much didn't get them in time. Interview with the Director of Nursing and Nursing Home Administrator on August 24, 2022, at 11: 15 a.m. revealed Resident R1 was admitted to the facility at approximately 3:30 p.m. on August 19, 2022. It was reported that medications were put in the electronic medical record (which sends orders to the pharmacy) between 6:00 p.m. and 8:30 p.m. and were delivered to the facility the next morning on August 20, 2022, at 4:37 a.m. Medications that required a script from the physician were not delivered (Phenobarbital 48.6 mg, Lacosamide 300 mg, Perampanel 6 mg, Clobazm 20 mg, and Lorazepam 4 mg). Interview with Resident R1's physician, Employee E15, on August 24, 2022, at 11:30 a.m. revealed that the physician was not made aware of Resident R1's missed medication dosages on August 19, 2022, and August 20, 2022. Review of communication from the pharmacy dated August 21, 2022, revealed physician orders were electronically sent over to the pharmacy and toted for the 11:00 p.m. delivery. Medications [cholecalciferol (Vitamin D supplement), escitalopram (for depression), levothyroxine (for thyroid hormone imbalance), and midodrine (for blood presure)] were delivered at 4:19 a.m. on August 20, 2022, the order for Cannabidol was unavailable and had to be ordered. It was further noted that narcotic orders (Phenobarbital, Lacosamide, Perampanel, Clobazm, and Lorazepam) were not faxed over to the pharmacy upon [Resident R1's] admission. Review of Resident R1's entire clinical record revealed no documented evidence that the facility contacted to the pharmacy for [Resident R1's] narcotics or for an authorization code to pull from the Omnicell (automated dispensing system). The following medications were available on the Omnicell during Resident R1's admission: Lacosamide, Phenobarbital, and Ativan. Interview with Registered Nurse, Employee E4, on August 24, 2022, at 1:15 p.m. confirmed that he was the licensed nurse on August 19, 2022 during the 7 a.m.-7 p.m. shift. Registered Nurse, Employee E4 confirmed that no seizure medications were administered to the resident. Further during interview Employee E4 reported to have completed his shift about 9:30 p.m. and Licensed Nurse, Employee E18, became the nurse responsible on that unit. Interview with Licensed nurse, Employee E18, on August 24, 2022, at 12:55 p.m. who was scheduled on August 19, 2022 for 7 p.m. -7 a.m. shift revealed he was not aware Resident R1 did not get prescribed medications during the 7 a.m.-7 p.m. shift. Employee E18 confirmed he did not administer any medications for Resident R1 during the 7 p.m. -7 a.m. shift. Interview on August 24, 2022, at 1:45 p.m. with Licensed Nurse, Employee E6, revealed Resident R1 was checked on during rounds at approximately 8:30 a.m. on August 20, 2022. Employee E6 confirmed no medications were given at that time. Employee E6 went on to tend to other residents when she was made aware at 10:00 a.m. that Resident R1's family was requesting attention in the room. Employee E6 stated when she arrived at the room the resident had a blank stare, no movement, was unresponsive and pale. Employee E6 confirmed Resident R1 had still not received any scheduled morning medications. Employee E6 was able to find one seizure medication, Keppra, which was administered after the seizures started. Continued interview with Licensed nurse, Employee E6 revealed Emergency Medical Services (9-1-1) was called and Resident R1 was ultimately transferred to the hospital. An Immediate Jeopardy situation was identified to the Nursing Home Administrator and Director of Nursing on August 24, 2022, at 12:08 p.m. related to the facility's failure to ensure that seizure medications were administered.as ordered by the physician to Resident R1, resulting in a significant medication error. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator on August 24, 2022, at 12:08 p.m. The corrective action plan included the following interventions: -Facility will review and revise admissions policy related to availability of medications. -Facility will review and revise policy related to medication availability from pharmacy for administration. If medication is not available through [contracted] pharmacy and/or unable to deliver within allotted medication window, [contracted pharmacy] will notify local [pharmacy] to deliver STAT (immediately). In addition, nurse will follow-up with phone call to pharmacy to confirm delivery on time. -Facility will review and revise steps to be taken with contracted pharmacy to ensure timely delivery of medications. Nursing management will review current list of stock medications in the Omnicell system with medical director and pharmacy consultant on August 25, 2022, to make necessary changes. -The Director of Nursing will in-service all nursing staff (LPNs, RNS) in reference to medication available, Omnicell inventory and medication availability. All licensed nurses will be educated on revised policies and procedures beginning immediately. Approximately 50% of nursing staff will have completed education by August 25, 2022, and more than 75% of nursing staff by August 26, 2022, with goal at 100% completion if attainable. Lesson place will include timely administration of medications, steps to be taken to procure medications from the pharmacy, physician notification and follow up if any medication not available. -The Director of Nursing or designee will audit new admission upon arrival to facility to ensure all medications are available at time of admission and/or delivered timely. This will be audited daily x 4 weeks, then weekly x 4 weeks, then monthly x 6 months. Findings will be brought to QAPI (Quality Assurance Plan Improvement) and reviewed for necessary changes if indicated. Interviews were conducted with facility staff on August 25, 2022, between 12:00 p.m.-6:00 p.m. and on August 26, 2022, between 6:15 a.m-10:45 a.m. to verify the implementation of the action plan. Facility staff was able to verbalize the process to order medications, how to obtain medications from the Omnicell, and what they would do if medications were unavailable. A review was conducted of the education provided to facility staff related to obtaining and administering medications. Following the verification of the immediate action plan the Immediate Jeopardy was lifted on August 26, 2022, at 10:15 a.m. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services

Based on clinical record review and interviews with staff, it was determined that the facility failed to supervise and monitor a resident with a known history of self-harm when he cut himself with a razor blade which caused harm to a resident (Resident R59) and the facility failed to supervise a resident with a history of wandering for one of thirty-three sampled residents (Resident R232). Findings include: A review of Resident R59's clinical record revealed the resident was admitted to the facility on [DATE], with diagnosis that included [CONDITION(S)] ([CONDITION(S)]), Impulsive disorder (inability to control urges), Major Depressive disorder (persistent feelings of sadness), [CONDITION(S)] (hallucinations, delusions and disorganized thoughts), [CONDITION(S)] disorder (combination of symptoms of [CONDITION(S)] and mood disorder), Suicidal ideation, borderline personality disorder (unstable moods and thoughts) and [NAME] (eating disorder in which a person eats things not usually considered food). A review of Resident R59's clinical record revealed a nurse progress note dated October 15, 2021, at 3:44 PM, which revealed: at approximately 2PM nurse entered room to give Bolus feed via G tube and found resident had cut up his G tube so he could then eat by mouth. A review of Resident R59's clinical record revealed on November 9, 2021, at 5:19 PM, during a Risk Meeting documentation revealed resident noted with three small foreign objects in his ear, found during an audiology appointment. A review of Resident R59's clinical record progress note dated April 17, 2022, at 8:31 a.m. revealed: At 12:55 AM [Resident R59] came to nurses with his shirt lifted and visible bleeding from a superficial cut on the abdominal area, when he was asked what happened [Resident R59] stated that I cut myself with a razor, the nurse asked why did you cut yourself, and he responded I have no reason to live, I want to die., I am only [AGE] years old and I have no future, I am just here day after day doing nothing, I just want to die. [Resident R59] was asked where he got razor, he stated I just took it, the blades from the disposable razor were removed. A review of a clinical progress note dated April 17, 2022, at 3:51 p.m. revealed: Resident risk meeting held with behavioral IDT team which revealed Resident does have history of suicidal ideations, self-harm and behavioral problems, all contributory factors to resident self-infliction for injury. Intervention identified in IDT meeting, Resident sent out 911 and admitted to Behavioral health unit for intention to harm self, DOH reportable to be submitted. A review of Resident R59's Care Plan revealed documented under [CONDITION(S)] medications, Behavior management, Potential for injury to self or others. History of suicidal ideation and self-harm (cutting). Further review revealed Interventions: revised date on intervention revealed April 17, 2022, transfer to Behavior Unit. Last revised intervention dated March 27, 2020, revealed interventions listed; Take all suicidal ideation seriously, resident on behavior management, offer emotional support. Further review of the resident's Care Plan dated March 20, 2022, under Behavior problem, Resident R59, has a behavior problem surrounding making false accusations, swallowing small items - batteries, potential to barricade himself in his room and to harm himself. [NAME], resident is also monitored for severe recalcitrant, aggressive and explosive behaviors. Interventions documented reveal, s/p incident April 17, 2022, date-initiated April 18, 2022. Support care to follow; toiletries will not be left in room. During an interview June 10, 2022, 1:30 p.m., discussed with Administrator and DON Incident on Resident R59's suicidal attempt on April 17, 2022. Administrator verified in statement it was not reported to DOH. Discussion on monitoring room and resident for hazards revealed there were no interventions to monitor and assess resident for self-harm aside from only allowing resident to have plastic wear for dining. Facility failed to adequately supervise and provide an environment free of accident hazards to a resident with a history of self harm which caused harm to Resident R59 on April 17, 2022, when he used a razor to cut himself on the abdomen. Review of the Elopements and Wandering Residents policy with a date implemented of June 2021 stated that the facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Further review of the policy stated that the facility is equipped with door locks/alarms to help avoid elopements, and that alarms are not a replacement for necessary supervision, and that staff are to be vigilant in responding to alarms in a timely manner. Review of the resident's clinical record indicated that the resident was admitted into the facility on [DATE]. Review of the January 2022 physician orders for Resident R232 included the following diagnosis: cognitive communication deficit (problems with communication), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), dysphasia (difficulty with swallowing), and difficulty in walking. Review of the resident's physician orders for the resident also revealed a physician order for a wander guard bracelet (an electronic monitoring device tis secured on a resident's wrist of ankle and will sound an alarm when a resident wearing one is in the vicinity of exit areas) with a start date of August 31, 2021. Review of the resident's person-centered plan of care indicated initiated on September 7, 2021, that Resident R232 was an elopement risk and wandered, related to attempts to leave the facility unattended. The care plan also indicated that the resident had impaired safety awareness, and that he wandered aimlessly. Review of the resident's Quarterly Minimum Data Set (MDS is an assessment of resident's care needs) dated August 23, 2021, revealed the resident was severerly cognitive impaired. Review of the resident's interdisciplinary notes indicated that on September 5, 2021, Resident R232 eloped from the facility. Review of the facility investigation indicated that the resident was last seen in the facility at 3:40 p.m. Employee E11, Nursing Assistant, alerted the facility at approximately 4:00 p.m. that the resident was across the street from the facility at approximately 4:00 p.m. During a discussion with the Nursing Home Administrator (NHA), on June 10, at approximately 1:54 p.m. it was discussed that the resident exited out of the first-floor door with a vendor who was in the building. The first-floor alarm door that was equipped with a wander guard alarm, which did sound an alarm to indicate that a resident with a wander guard was near the vicinity of the door. The NHA reported that the staff heard the alarm but did not go check to see if anyone exited the premises. 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.10(d) Resident care policies

Based on review of clinical records, facility policies and procedures, facility documentation and interviews with staff, it was determined that the facility failed to provide adequate assessment and monitoring for residents at risk for fluid weight gain which resulted in actual harm for one of 23 residents reviewed (Resident R78) when the resident gained 30 pounds and suffered difficulty breathing that required transfer to a hospital. The facility also failed to administer medication as ordered by the physician, implement a bowel protocol procedure and provide an assistive device for three of 23 residents reviewed (Resident R9, R8 and R40). Findings include: Review of facility policy, Weights and Heights, dated as last revised on November 30, 2015, defined that a significant weight change was five percent in one month. The policy further indicated that if a resident's weight is greater than five pounds from the previous weight, the resident would be reweighed, the weight would be verified by a Licensed Nurse to determine accuracy, and that the resident's physician would be notified of the significant weight change. Review of the clinical record for Resident R78 revealed an admission physician's orders [REDACTED]. Review of the plan of care for Resident R78, dated as October 23, 2016, revealed that the resident was dependent on staff for the activities of daily living (bathing, grooming, personal hygiene, etc.) related to the [DIAGNOSES REDACTED]. status (including unplanned weight loss or gain) and to report these changes to the resident's physician. Review of an outside cardiology (a physician that specializes in the heart and the cardiovascular system) consultation report dated January 12, 2017, revealed that the resident had some shortness of breath, a productive cough (was able to cough up phlegm/mucous) and that Resident R78 may need a chest X-ray to follow-up on the resident's cough and slight wheezes (a sound heard through a stethoscope when listening to the lungs which can be a symptom of [MEDICAL CONDITION]). The consultation report futher indicated that the chest X-ray would be left up to the resident's other physicians and that the cardiologist would forward a recommendation for a chest X-ray. Review of the facility's, Report of Consultation completed by the cardiologist, on January 12, 2017, recommended to consider a chest X-ray to evaluate the resident's productive cough. Further review of the clinical record revealed a Certified Registered Nurse Practitioner's (CRNP) progress note, dated January 13, 2017, that indicated no documentation regarding the cardiologist's recommendation to obtain a chest X-ray. An interview with the Director of Nursing on March 17, 2017, at approximately 12:30 p.m. confirmed that the cardiology consultation report, with the recommendation for the chest X-ray, was initialed as acknowledged by the CRNP with no documentation regarding why the chest X-ray was not ordered or required. Review of Resident R78's weights as documented in the facility's electronic clinical records system revealed the following: 206.4 pounds on January 12, 2017, and 237 pounds on February 14, 2017, which indicated a 30 pound weight gain in 33 days (approximately one month). Review of a Nutritional assessment dated [DATE], revealed that the resident's most recent weight was 237 pounds, a 2.6 percent weight gain, and that the resident's significant weight gain was not desirable, but that the resident declined to make any changes (to Resident R78's diet). An interview with Employee E3, a Registered Dietitian, on March 16, 2017, at approximately 10:45 a.m. revealed that the 2.6 percent weight gain, as documented on the Nutritional assessment dated [DATE], was an error in calculation and Resident R78's actual weight gain was 14.8 percent. Further interview with Employee E3 revealed that from a nutritional standpoint, the dietitian did not identify this weight gain as significant because there was no documented reweigh by the facility staff to confirm the 30 pound weight gain as an accurate weight. Review of a nursing progress note dated February 27, 2017, at 2:59 p.m. revealed that Resident R78 was complaining of chest pain and had one episode of emesis (vomiting) of clear liquids, the resident had a chronic (long-term) history of [MEDICAL CONDITION] with cough, and the resident's oxygen level in the blood was 93 percent (oxygen level for persons with respiratory disease ranges 90-100 percent) on four liters of oxygen. The nursing progress note further stated that the resident was transferred to an acute care hospital for evaluation. Review of another nursing progress note dated February 27, 2017, at 8:11 p.m. revealed that Resident R78 was admitted to the hospital intensive care unit. Review of readmission physician's orders [REDACTED]. The physician's orders [REDACTED]. Further review of Resident R78's weights in the facility's electronic clinical records system revealed no documented weight after February 14, 2017, until readmission on March 7, 2017, and indicated a weight of 212 pounds. Review of a Nutritional assessment dated [DATE], revealed that the resident's current weight was 212 pounds and the resident's hospital records indicated diuresis (fluid removed from the body using medication) for 30 pounds of fluid from Resident R78 during the hospitalization which was the same as the approximate amount of weight gain documented at the facility from January 12, 2017, through February 14, 2017. Further review of the clinical record for Resident R78 revealed no documentation that a reweigh was obtained on or around February 14, 2017, to confirm a possible significant weight gain of approximately 30 pounds in one month; no documentation that a Licensed Nurse verified this weight to determine and verify accuracy; no documentation that the weight gain percent calculation error in the Nutritional Assessment was identified and addressed by the facility staff; no documentation that Resident R78's physician was notified regarding the 30 pound weight gain; and no documentation that a plan of care was updated or initiated to address Resident R78's potential for weight loss or gain related to a history of fluid overload from [MEDICAL CONDITION]; and no documentation of the initiation of new diuretic medication upon the resident's readmission to the facility on [DATE]. An interview with the Director of Nursing and the Nursing Home Administrator on March 17, 2017, at approximately 2:30 p.m. confirmed these findings. The facility failed to adequately assess and monitor one resident at high risk for fluid volume overload related to an established documented medical condition. This failure caused actual harm to Resident R78, and required an admission to the hospital intensive care unit. Review of the clinical record for Resident R9 revealed [DIAGNOSES REDACTED]. heart conditions that includes diseased vessels, structural problems, and blood clots). Review of the physician's orders [REDACTED]. Review of Resident R9's Medication Administration Record [REDACTED]. An interview on March 20, 2017, at 12:00 p.m. with Employee E7, a Nurse Manager, confirmed that Resident R9 did not have a documented bowel movement on March 9, March 10, March 11, March 12, March 13, March 14, March 15, March 16, March 17, and on March 19, 2017, and Employee E7, confirmed that the resident was not given the Milk of Magnesia 30 ml as ordered for constipation for the above mentioned dates. The facility failed to implement a prescribed Bowel Protocol intervention for constipation. Review of the clinical record for Resident R8 revealed [DIAGNOSES REDACTED]. Review of Resident R8's physician's orders [REDACTED]. During an interview on March 15, 2017, at 2:15 p.m. with Employee E7, it was confirmed that Resident R8 had a physician's orders [REDACTED]. The facility failed to implement a physician's orders [REDACTED]. Resident R40 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. disconnection from reality) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of the resident's clinical record revealed that on February 19, 2017, the physician ordered medications were not documented as administered during the day shift between the hours of 7:00 a.m. and 3:00 p.m. The medications were: -[MEDICATION NAME] 10 mg tablet (for muscle spasms) - 1 tablet at 9:00 a.m., 2:00 p.m., and 10:00 p.m. The 2:00 pm dose was not documented as being administered. -[MEDICATION NAME] 2 mg tablet ([MEDICATION NAME]- used to treat anxiety disorders) -1 tablet at 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. The 9:00 a.m. & 1:00 p.m. doses were not documented as being administered. -[MEDICATION NAME] Sodium 250 mg tablet (for [MEDICAL CONDITION]) - 1 tablet twice daily taken with a 500 mg tablet - total 750 mg at 9:00 a.m. and 9:00 p.m. The 9:00 a.m. 250 mg dose was not documented as being administered. - [MEDICATION NAME] Sodium 500 mg tablet (for [MEDICAL CONDITION]) - 1 tablet twice daily taken with a 250 mg tablet-total 750 mg at 9:00 a.m. and 9:00 p.m. The 9:00 a.m. 500 mg dose was not documented as being administered. -[MEDICATION NAME] 1000 mg tablet (for [MEDICAL CONDITION]) - 1 tablet twice a day at 9:00 a.m. and 9:00 p.m. The 9:00 a.m. dose was not documented as being administered. -[MEDICATION NAME] (a narcotic pain medication) 20 mg/1ml solution - .25 ml (5 gm) once a day at 9:00 a.m. The 9:00 a.m. dose was not documented as being administered. -[MEDICATION NAME] 20 mg capsule (for GERD) - 1 cap per day at 9:00 a.m. The 9:00 a.m. dose was not documented as being administered. -[MEDICATION NAME] HCL F/C 100 mg (for depression) - 1 tablet with a 50 mg tablet for a total 150 mg - 1 tablet per day at 9:00 a.m. The 9:00 a.m. dose of 100 mg was not documented as being administered. -[MEDICATION NAME] HCL F/C 50 mg (for depression) - 1 tablet along with a 100 mg tablet for a total 150 mg - 1 tablet per day at 9:00 a.m. The 9:00 a.m. 50 mg dose was not documented as being administered. In an interview with the Director of Nursing on March 20, 2017, at 1:00 p.m. she verified that the narcotic pain medication, [MEDICATION NAME], was not signed out on February 19th for Resident R40 and that the resident did not receive the other physician ordered 9:00 a.m. and 1:00 p.m. medications for February 19, 2017, as listed above. The facility failed to administer medications as ordered by the physician. 42 CFR 483.24 Provide Care/Services for Highest Well Being Previously cited 04/16/15 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 04/16/15, 06/27/16 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 04/16/15 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.5(f) Clinical records Previously cited 04/16/15 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services Previously cited 04/16/15