Every finding on record at Spring Hill Rehabilitation and Nursing Center

Based on a review of clinical records, facility policy, and staff interviews, it was determined that the facility failed to provide pain management consistent with professional standards of practice for one of three residents (Resident R1).Findings include: Review of facility policy Pain Management dated 5/1/26, indicated that facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The interventions for pain management will be incorporated into the components of the comprehensive care plan, addressing conditions or situations that may be associated with pain or may be included as a specific pain management need or goal. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a period assessment of care needs) dated 4/10/26, indicated diagnoses of heart failure, arthritis, and chronic pain. Review of Resident R1's physician order dated 11/26/25, indicated MS Contin oral tablet extended release 15 mg (milligram) (Morphine sulfate), give 15 mg by mouth at bedtime for chronic pain. Review of Resident R1's physician order dated 11/26/25, indicated MS Contin oral tablet extended release 30 mg (Morphine sulfate), give 30 mg by mouth two times a day for chronic pain hold for sedation. Review of Resident R1's physician order dated 7/3/26, indicated Oxycodone HCl oral tablet 5 mg, give 10 mg by mouth every 8 hours as needed for moderate to severe pain hold for sedation. Review of Resident R1's physician order dated 1/8/25, indicated Tylenol Extra Strength oral tablet 500 mg (Acetaminophen), give 1000 mg by mouth three times per day for pain do not exceed 3 grams in 24 hours. Review of Resident R1's physician order dated 10/12/23, indicated Non-pharmacological intervention(s) used before PRN (as needed) pain medication, or before PRN anti-depressant, anti-anxiety, anti-psychotic, or sedative/hypnotic medication - Document by number: (1) Reposition for comfort (2) massage (3) involve in activity/alternative activity to divert (4) provide quiet setting with reduced stimuli (5) relaxation technique (6) music (7) remove from area (8) direction/distraction (10) ambulate (11) provide food/drink (12) educated (13) one: one (14) other, document PN (progress note) as needed. Review of Resident R1's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for July 2026failed to indicate any non-pharmacological interventions for the use of pain medications. Review of Resident R1's clinical progress notes for July 2026, failed to indicate any non-pharmacological interventions for the use of pain medications. During an interview completed on 8/5/26, at 1:12 p.m. the Director of Nursing (DON) confirmed that Resident R1's clinical record failed to indicate any documented non-pharmacological interventions for the use of pain medication and that the facility failed to provide pain management consistent with professional standards of practice for one of three residents (Resident R1). 28 Pa. Code 211. 10(c) Resident care policies28 Pa. Code 211.12(d)(1) Nursing services

Based on a review of policy, observation and staff interview, it was determined that the facility failed to properly label and date food products, maintain kitchen equipment in a sanitary condition, properly store chemicals, and properly restrain hair creating the potential for cross contamination in the Main Kitchen of the facility.Findings include: Review of facility policy Food Safety Requirements, dated 5/1/26, stated that it is the policy of the facility to procure food from sources approved or considered satisfactory by federal, state, and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. Refrigerated food shall be labeled, dated, and monitored. All equipment used in the handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination. Hairnets should be worn. Review of the facility policy Food Storage Dating and Labeling dated 5/1/26, indicated that chemicals must be clearly labeled and stored away from food. Food should be dated as it is placed on the shelves. All food should be stored off the floor. During an observation on 5/17/26, at 8:47 a.m. in the walk-in cooler in the Main Kitchen the following items were found without a label or date: a metal pan of pasta salad, an opened package of lunch meat, a metal pan with cooked chicken, an opened bag of lettuce. During continued observation on 5/17/26, at 8:47 a.m. in the walk-in cooler in the Main Kitchen, the cold air condenser fan covers had a build-up of dust, grime, and dark colored debris. A metal pan of chicken covered with plastic wrap (not labeled and dated) was stored directly beneath the cold air condenser, and when this pan was removed to inspect, it was discovered that a pool of water had accumulated on the top of the plastic wrap. Further inspection revealed that the cold air condenser was dripping water onto the food products below. During an observation on 5/17/26, at 8:50 a.m. in the walk-in freezer in the Main Kitchen a Drumstick ice cream novelty and two bags of ice were stored on the freezer floor, and two angel food cakes were not labeled and dated. During an observation on 5/17/26, at 8:55 a.m. in the dry storage area in the Main Kitchen four cans of fruit cocktail were not dated with received date, an open bag of penne pasta, and an opened bag of macaroni were not labeled and dated, and an aerosol can of Flying Insect Repellant was stored next to the pasta. During an interview on 5/17/26, at 8:57 a.m. [NAME] Employee E12 confirmed that the facility failed to properly label and date food products, maintain kitchen equipment in a sanitary condition, and properly store chemicals. During an observation on 5/18/26, at 9:27 a.m. in the dish room of the Main Kitchen, Dietary Aide Employee E13 was observed with a beard net placed under his chin and not covering his beard, and a ball cap on, however three to four inches of hair hung below the cap and was not restrained. During an interview on 5/18/26, at 927 a.m. Dietary Manager Employee E14 confirmed that the facility failed to properly retrain hair. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1) Management.

Based on facility requirements according to Affordable Care Act (ACA) review of Payroll Based Journal (PBJ) Staffing Data Reports, and staff interviews, it was determined that the facility failed to electronically submit accurate direct care staffing information for one of the last four quarters (Quarter 1 2026).Findings include: Review of Section 6106 of the ACA requires facilities to electronically submit direct care staffing information (including agency and contract staffing) based on payroll and other auditable data to the Center for Medicare and Medicaid Services (CMS). Review of the PBJ staffing data reports revealed that the facility did not submit data for Quarter 1 (October 1 - December 31,2026). During an interview on 5/21/26, at 1:10 p.m. Nursing Home Administrator confirmed that the facility failed to submit direct care staffing information in the Payroll-Based Jornal system as required. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on review of facility documentation, observations, and staff interview, it was determined that the facility failed to make certain that equipment was in safe operating condition for two of two crash carts (First Floor Crash Cart and Second Floor Crash Cart).Findings include: Review of a facility document Crash Cart Management last reviewed 5/1/26, indicated the facility shall maintain fully stocked, operational and secured crash carts and emergency response equipment. Crash carts shall be checked routinely for functionality, completeness, medication integrity and emergency readiness. Daily checks verify medication expiration dates, supply integrity, oxygen pressure levels, suction functionally, and cleanliness of cart exterior. Monthly comprehensive checks performed by the licensed nurse or designee shall perform and document the full inventory, equipment testing, expiration date review, battery checks, restocking verification, infection control review of manufacturer maintenance recommendations. During an observation completed on 5/17/26, at 12:57 p.m. the First Floor Crash Cart contained an Ambu bag (manual resuscitator that forces oxygen into the lungs to maintain life sustaining ventilation) with the expiration date of 10/18/24. During an interview completed on 5/17/26, at 12:57 p.m. Registered Nurse (RN) Employee E4 confirmed the First Floor Crash Cart contained an Ambu bag that had an expiration date of 10/18/24 and confirmed the facility failed to make certain that equipment was in safe operating condition. During an observation completed on 5/17/26, at 1:03 p.m. the Second Floor Crash Cart contained an Ambu bag had an expiration date of 10/18/24. During an interview completed on 5/17/26, at 1:05 p.m. RN Employee E8 confirmed the Second Floor Crash Cart contained an Ambu bag that had an expiration date of 10/18/24, and confirmed the facility failed to make certain that equipment was in safe operating condition 28 Pa. Code: 201.14(a) Responsibility of licensee.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide accurate and timely documentation related to offering the COVID-19 vaccination for five of five residents (discharged Resident R9 and Resident's R12, R55, R56 and R57).Findings include: Review of facility policy COVID-19 Vaccine Administration last reviewed 5/1/26, indicated the facility will offer and administer COVID-19 vaccinations in accordance with state and federal guidelines. Review of the clinical record revealed discharged Resident R9 was admitted to the facility on [DATE]. Review of discharged Resident R9's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/4/26, indicated diagnoses of hypertension (high blood pressure) diabetes (high sugar in the blood) and hyperlipidemia (high fat in the blood) Question O0350 was coded no for Resident's COVID-19 vaccination is up to date. Review of discharged Resident R9's clinical record failed to include documentation that the COVID-19 vaccination was offered and administered or declined. Review of the clinical record revealed Resident R12 was admitted to the facility on [DATE]. Review of Resident R12's MDS dated [DATE], indicated diagnosis of chronic obstructive pulmonary disease (COPD-make it hard to breathe), coronary artery disease (CAD- plaque builds up in the arteries and restricts the blood flow) and orthostatic hypotension (blood pressure drops upon standing). Question O0350 was coded no for Resident's COVID-19 vaccination is up to date. Review of Resident R12's clinical record failed to include documentation that the COVID-19 vaccination was offered and administered or declined. Review of the clinical record revealed Resident R55 was admitted to the facility on [DATE]. Review of Resident R55's MDS dated [DATE], indicated diagnosis of CAD, hypertension and diabetes. Question O0350 was coded no for Resident's COVID-19 vaccination is up to date. Review of Resident R55's clinical record failed to include documentation that the COVID-19 vaccination was offered and administered or declined. Review of the clinical record revealed Resident R56 was admitted to the facility on [DATE]. Review of Resident R56's MDS dated [DATE], indicated the diagnosis of hypertension, diabetes and peripheral vascular disease (PVD- restricts blood flow). Question O0350 was coded no for Resident's COVID-19 vaccination is up to date. Review of Resident R56's clinical record failed to include documentation that the COVID-19 vaccination was offered and administered or declined. Review of the clinical record revealed Resident R57 was admitted to the facility on [DATE]. Review of Resident R57's MDS dated [DATE], indicated the diagnosis of anemia, anxiety and [NAME] syndrome (a complication of long-standing rheumatoid arthritis (auto-immune disease that causes pain, swelling and stiffness in the joint), an enlarged spleen and low white blood cell count). Question O0350 was coded no for Resident's COVID-19 vaccination is up to date. Review of Resident R57's clinical record failed to include documentation that the COVID-19 vaccination was offered and administered or declined. During an interview completed on 05/18/26, upon asking Infection Preventionist Registered Nurse (RN) Employee E8 concerning the process for offering the COVID-19 vaccine replied we did not offer it and confirmed that the facility failed to provide accurate and timely documentation related to offering the COVID-19 vaccination for five of five residents (discharged Resident R9 and Resident's R12, R55, R56 and R57). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.5(f) Medical records.

Based on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (G- Tube, a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for two of two residents (Residents R3, and R4). Findings include: Review of the facility policy Care and Treatment of Feeding Tubes last reviewed 5/1/26, indicated it is the facility policy to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Feeding tubes will be utilized according to physician orders. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE], with the diagnoses of aphasia (language disorder that affects communication), hemiplegia (paralysis on one side of the body), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Section K0520 Nutritional Approaches - revealed that resident had a feeding tube while a resident. Review of Resident R3's clinical record revealed a physician's order dated 7/29/25, that indicated to change all enteral tubing (date, time and initials), bottles of feed (resident's name, date, time, rate and initials) and syringes (date and initials enteral feed order one time a day. Review of Resident R3's clinical record revealed a physician order dated 12/22/25, that indicated to provide water flush via enteral feeding tube, of 55 milliliters (ml) of water flush per hour. During an observation on 5/17/26, at 2:40 p.m. Resident R3's water flush bag was observed with no label, initials, date or time, and the enteral feeding pole was found soiled with what appeared to be spilled or leaked enteral formula which was dried covering the surface of the pole, and 4 legs above the casters. During an interview on 5/17/26, at 2:43 p.m. Registered Nurse (RN) Employee E5 confirmed there was no label or date on the water bag used for flushes for Resident R3. During an interview on 5/17/25, at 2:44 p.m. the Director of Nursing confirmed that the enteral feeding pole appeared to be soiled with dried tube feeding formula, and the facility failed to ensure that residents with an enteral feeding tube received appropriate treatment and services to prevent potential complications for Residents R3. Review of Residents R4's admission record indicated the resident was admitted on [DATE], and readmitted [DATE]. Review of Resident R4's care plan dated 2/12/18, indicated to administer tube feeding formula, hydration, and flushes per order. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/2/26, indicated diagnoses of cognitive communication deficit, dysphagia (difficulty swallowing), and depression. Section K0520- Nutritional Approaches revealed the resident had a feeding tube while a resident. Review of Resident R4's physician order dated 8/11/26, indicated to change all enteral tubing (date, time and initials), bottles of feed (resident's name, date, time, rate and initials) and syringes (date and initials). one time a day for change when starting feed each day. Further review of Resident R4's physician order dated 4/30/26, indicated to administer 1.5 Osmolite via g-tube, set pump to 95 millimeter (ml)/hour (hr) for 17 hours daily. Total volume 1615 milliliters (ml) and water flush 65 ml/hr. It was indicated the tube feed should go up at 12 p.m. and come down at 9:00 a.m. or once 1615 ml is administered. During an observation on 5/17/26, at 10:07 a.m. Resident R4 was observed resting in bed with his tube feed disconnected. 600 ml of the resident's tube feed was remaining in the tube feed bag. The resident's enteral tubing, bag of tube feed, and syringes were undated. During an interview on 5/17/26, at 10:10 a.m. Licensed Practical Nurse, Employee E25 confirmed Resident R4's enteral tubing, bag, and syringe were undated. LPN, Employee E25 confirmed Resident R4 failed to receive his enteral feeding as ordered and 600 ml was remaining. Interview on 5/17/26, at 3:00 p.m. the Director of Nursing and Nursing Home Administrator confirmed the facility failed to ensure that residents with an enteral feeding tube received appropriate treatment and services to prevent potential complications for one of two residents (Residents R4). 28 Pa. Code: 201.18(b)(1) Management.28 Pa. Code: 211.10(c) Resident care policies.

Based on review of facility policy, resident trust account balances, closed resident records, and staff interviews it was determined that the facility failed to convey resident funds and close accounts upon discharge within 30 days for one of four closed resident records (Closed resident record CR66).Findings include: The facility Resident personal funds policy last reviewed 5/1/26, indicated that the resident has a right to manage his or her financial affairs. Upon the discharge, eviction, or death of a resident with personal funds deposited with the facility, the facility will convey within 30 days the resident's funds and a final account of those funds to the resident. Review of Closed resident record CR66's admission record indicated he was admitted on [DATE]. Review of Closed resident record CR66's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 1/15/26, indicated he had diagnoses that included lumbar fracture (fracture to back area), hypertension (a condition impacting blood circulation through the heart related to poor pressure), and alcohol dependence. Review of Closed resident record CR66's clinical nurse notes dated 2/6/26, indicated that Closed Resident CR66 was discharged from the facility, all personal belongings taken with him. All available medications taken and reviewed with Closed Resident CR66 and home nurse. Current scripts were called to pharmacy by social services. Review of Closed resident record CR66's record did not indicate evidence that his monies were provided upon discharge. Review of the facility trust fund account dated 5/20/26, indicated Closed resident record CR66 had a remaining balance of $35.04. During an interview on 5/20/26, at 10:05 a.m. Regional Business office manager Employee E11 was asked how soon money from the resident trust fund is provided to discharge residents? I like to do it in real time; it may take up to 30 days to provide a refund to a resident. During an interview on 5/20/26, at 1:40 p.m. the Nursing Home Administrator (NHA) confirmed that the facility to convey resident funds and close accounts upon discharge within 30 days for Closed resident record CR66 as required. 28 Pa. Code 211.5(d) Clinical records.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide supervision with meals to monitor for signs and symptoms of dysphagia and failed to make certain that residents were provided appropriate treatment and care in accordance with professional standards of practice for two of six residents (Residents R1 and Resident R8).Findings include: Review of facility policy Incidents and Accidents dated 5/1/26, indicated choking is an incident/accident. It is the facility policy to assure that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1 MDS (minimum data set - a periodic assessment of care needs), dated 3/13/26, indicated diagnosis of intellectual disabilities, esophageal varices, and GERD(Gastroesophageal reflux disease happens when stomach acid flows back up into the esophagus and causes heartburn). Review of Resident R1's care plan dated 11/21/24, indicated to monitor/document/report to physician as needed for signs and symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, or appears concerned during meals. Review of Resident R1's Speech therapy Discharge summary dated [DATE], revealed discharge recommendations to facilitate safety and efficiency, it is recommended the patient use the following swallow techniques/precautions during the oral intake, alteration of liquid/solids, rate modification, bolus size modifications, small bites/sips, upright posture during meals, and upright posture for more than 30 minutes after meals. During an observation on 5/17/26, at 12:58 p.m. Resident R1's meal was dropped off in his room and left unsupervised. During an observation on 5/17/26, at 12:59 p.m. Resident R1 was observed eating at a fast pace unsupervised. During an interview on 5/17/26, at 1:01 p.m. Nurse Aide (NA), Employee E24 confirmed Resident R1 was not being supervised for pocketing or monitoring. NA, Employee E24 stated she was unsure if the resident was eating at a fast pace because she does not know his baseline to compare to. During an observation on 5/18/26, at 12:23 p.m. Resident R1's meal was observed sitting in his room eating unsupervised. During an interview on 5/18/26, at 12:29 p.m. Nurse Aide (NA), Employee E23 confirmed Resident R1 was not being supervised for pocketing or monitoring. Review of Residents R8's admission record indicated the resident was admitted on [DATE], and readmitted [DATE], with indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), respiratory failure, and cardiac arrest. Review of Resident R8's care plan dated 1/7/26, indicated to monitor/document/report to physician as needed for signs and symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, or appears concerned during meals. Review of Resident R8's MDS dated [DATE], indicated diagnoses were current. During an interview and observation on 5/17/26, at 1:08 p.m. Resident R8 was observed sitting in the common lounge eating unsupervised. During an interview on 5/17/26, at 1:09 p.m. LPN, Employee E25 confirmed Resident R8 was not being monitored during meals for signs and symptoms of dysphagia as the care plan indicated. During an interview and observation on 5/18/26, at 12:23 p.m. Resident R8 was observed sitting in the common lounge eating unsupervised. During an interview on 5/18/26, at 12:31 p.m. the Registered Nurse Supervisor, Employee E28 confirmed Resident R1 and Resident R8 were not supervised with meals and monitored for signs and symptoms of dysphagia. During an interview on 5/19/26, at 10:30 a.m. the Director of Nursing confirmed Resident R1 and Resident R8 should be supervised with meals. It was indicated if someone is a feeding assist, an order is entered and it populates on the Kardex for the nurse aides to view. During an interview on 5/19/26, at 10:32 a.m. the Speech Therapist, Employee E37, Director of Nursing, and Nursing Home Administrator confirmed the facility failed to ensure two of six residents reviewed were supervised during meals (Resident R1 and Resident R8). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of the residents' personal funds account and facility surety bond, it was determined that the facility failed to ensure that the facility surety bond designee was only to the residents of the facility.Findings include: Review of facility previous surety bond indicated that the oblige is the residents of spring hill rehabilitation center or unto the Commonwealth of Pennsylvania, instead of the residents only. During an interview on 5/21/26, Nursing Home Administrator confirmed that the facility failed to list the oblige as only the residents of the facility. 28 Pa. Code 201.18 (e )(1) Management.

Based on review of facility policy, clinical records, staff interview, and observations, it was determined that the facility failed to provide appropriate respiratory care for one of two residents (R8). Findings Include: Review of facility policy Oxygen Administration dated 5/1/26, indicated oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences. The resident's care plan shall identify the interventions for oxygen therapy, based upon assessment and orders. Review of facility policy Comprehensive Care Plans dated 3/16/26, indicated the facility will develop and implement a comprehensive person-centered care plan for each resident. Review of Residents R8's admission record indicated the resident was admitted on [DATE], and readmitted [DATE], with indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), respiratory failure, and cardiac arrest. Review of Resident R8's physician order dated 11/10/25, indicated to administer oxygen continuously between 5 to 7 liters to maintain oxygen saturation above 90% every shift related to acute and chronic respiratory failure with hypercapnia. Review of Resident R8's care plan dated 1/7/26, indicated the resident receives oxygen therapy due to respiratory failure. The care plan failed to include oxygen settings. Review of Resident R8's MDS dated [DATE], indicated diagnoses were current. Section O indicated the resident receives oxygen therapy continuously while a resident. During an interview and observation on 5/17/26, at 11:20 a.m. Resident R8 was observed sitting in his wheelchair in the common area. Resident R8's oxygen tank was noted to be in the red zone, empty. During an interview on 5/17/26, at 11:22 a.m. Licensed Practical Nurse, Employee E25 confirmed Resident R8's oxygen tank was empty and replaced the oxygen tank with a new one. During an interview and observation on 5/18/26, at 10:27 a.m. Resident R8 was observed sitting in his wheelchair in the common area. Resident R8's oxygen tank on the back of his wheelchair was observed to be empty the sleeve holding the oxygen tank was ripped. A oxygen concentrator was observed near the resident and was turned off. The resident was not receiving oxygen as ordered. During an interview and observation on 5/18/26, at 10:27 a.m. Licensed Practical Nurse ,Employee E7 confirmed the resident was not receiving oxygen as ordered and was 86% on room air. LPN, Employee E7 confirmed Resident R8's oxygen sleeve was ripped. During an interview on 5/18/26, at approximately 3:00 p.m. the Nursing Home Administrator confirmed the facility failed to provide appropriate respiratory care for one of two residents (R8). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services

Based on review of facility policy, clinical records, resident council group interview, staff and resident interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for one of five sampled residents (Resident R28).Findings include: The facility Activities of Daily living policy dated 5/1/26, indicated that the facility will ensure resident abilities in ADL's do not deteriorate. Care and services will be provided for the following activities of daily living: bathing, dressing, grooming and oral care. Review of Resident R28's admission record indicated she was admitted on [DATE] and readmitted on [DATE]. Review of Resident R28's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 4/21/26, indicated she had medical diagnoses that included anemia (a deficiency in red blood cells carrying oxygen), hypertension (a condition impacting blood circulation through the heart related to poor pressure), and adult failure to thrive. Review of Resident R28's clinical nurse notes and ADL documentation did not indicate that she received a haircut. During a Resident council group interview on 5/18/26, at 1:00 p.m. nine out of nine residents voiced that they had not received hair services. During an interview on 5/19/26, at 11:34 a.m. Registered Nurse (RN) Employee E17 was asked if hairdresser has been in: Not in the last week. During observations on 5/19/26, at 11:37 a.m. Resident R28 was observed with a hat on and gray hair hanging out of her hat to her shoulders. During an interview on 5/19/26, at 11:38 a.m. Resident R28 was asked the last time she had haircut, and she stated In about a month ago. I would like a haircut. During an interview on 5/19/2026, at 11:40 a.m. Registered Nurse (RN)/Infection Control Preventionist (ICP) Employee E8 was asked the last time hairdresser was at the facility: I believe activities sets up haircuts. I am not sure. During an interview on 5/19/26, at 2:23 p.m. information was disseminated to Director of Nursing (DON) and Nursing Home Administrator (NHA) that the facility failed to provide Activity of Daily Living (ADL) assistance to Resident R28 as required. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(6) Management. 28 Pa. Code: 211.12(a)(c)(d)(1)(2)(3)(4) Nursing services.

Based on clinical record review and staff interview it was determined that the facility failed to implement care and services to maintain activities of daily living (communication) for two of three residents reviewed (Resident R4 and R44).Findings include: Review of the facility's Activities of Daily Living (ADLs) policy last reviewed 5/1/26, indicated the facility will based on resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless unavoidable. Care and services will be provided for using speech, language or other functional communication systems. Review of the facility's Communication of Resident Rights, Services, and Facility Practices last reviewed 5/1/26, indicated it the facility policy to promote transparency, protect resident rights, and ensure residents can make informed decisions regarding their care and living environment. Information must be provided in a language and manner the resident understands, including translation services, interpreter services, large print to alternative formats for visually impaired residents. Review of Residents R4's admission record indicated the resident was admitted on [DATE], and readmitted [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/2/26, indicated diagnoses of cognitive communication deficit, dysphagia (difficulty swallowing), and depression. Review of Resident R4's audiology assessment dated [DATE], indicated the resident has known bilateral hearing loss. It was indicated the resident refuses amplifier and uses headset with cellphone for music and videos. Review of Resident R4's progress note dated 4/13/26, revealed the resident was very hard of hearing, difficult to understand at times. During an attempted interview on 5/17/26, at 10:07 a.m. Resident R4 was non-interview able, unable to hear. The resident did not have any assistive devices available to communicate. During an interview on 5/18/26, at 10:14 a.m. this writer interviewed Resident R4 with yes and no questions written on a sheet of paper. Review of Resident R4's clinical record on 5/18/26, failed to include evidence of a care plan for the resident's hearing and communication deficits. Review of Residents R44's admission record indicated the resident was admitted on [DATE], and readmitted [DATE]. Review of Resident R44's care plan dated 1/16/24, revealed the resident has a potential communication problem due to hearing deficit due to bilateral sensorineural hearing loss, and speech and language delay due to hearing loss. The care plan failed to include interventions related to how to communicate with the resident. Review of Resident R44's MDS dated [DATE], indicated diagnoses of sensorineural bilateral hearing loss. Cerebral palsy, and muscle weakness. Section B Hearing, Speech, and Vision revealed the resident's ability to hear was highly impaired and the resident has unclear speech. Review of Resident R44's audiology evaluation fated 2/24/26, revealed the resident has hearing loos and does not use amplification. It was indicated the resident communicates through lip reading and sign language. During an attempted interview on 5/17/26, 10:19 a.m. Resident R44 indicated he was deaf. There was no communication board or interpreter present. During an interview on 5/17/26, at 10:20 a.m. Housekeeper, Employee E27 stated one of the residents know sign language and can interpret for Resident R44. During an interview on 5/18/26, at 10:19 a.m. Licensed Practical Nurse (LPN) E7 confirmed Resident R4 and Resident R44 had no assistive devices to be able to communicate due to being hearing impaired. LPN, Employee E7 stated she just talks loud and does best to mouth the words. During an interview on 5/19/26, at 10:47 a.m. the Nursing Home Administrator stated residents who are hearing impaired should have an interpreter for sign language or a communication board. The NHA confirmed Resident R4 and R44's care plan were not individualized. The NHA confirmed the facility failed to implement care and services to maintain activities of daily living (communication) for two of three residents reviewed (Resident R4 and R44). 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, resident clinical records and staff interviews it was determined that the facility failed to update the care plan for a resident experiencing weight loss one of five sampled residents (Resident R30).Findings include: The facility Weight monitoring policy last reviewed on 5/1/26, indicated that the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range. Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's specific nutritional concerns. The care plan should address the following: identified causes of impairment, residents' goals and preferences, time frame and parameters to monitor, and update as needed such as when resident's condition changes. Review of Resident R30's admission record indicated she was admitted on [DATE] and readmitted on [DATE]. Review of Resident R30's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 4/5/26, indicated she had medical diagnoses that included adult failure to thrive, major depressive disorder (a state of consistent sadness and loss of interest interfering in daily life activities), hypertension (a condition impacting blood circulation through the heart related to poor pressure), and Dementia (a condition characterized by memory loss and progressive or persistent loss of intellectual functioning). Review of Resident R30's care plans dated 5/5/26, indicated she will maintain adequate nutritional status as evidenced by maintaining weight, provide supplements and serve diet as ordered. Review of Resident R30's weight documentation found the following:2/25/26= 103.4lbs.3/4/26= 86 lbs.Resident R30's weight documentation indicated 16.5 percent decrease in one month. Review of Resident R30's Certified Registered Nurse Practitioner note dated 2/6/26, indicated she continued supportive care. Family aware of ongoing weight loss. Review of Resident R30's Registered Dietitian note on 2/25/26, indicated she weight 103lbs, showed weight improvement from 2/3/26. Review of Resident R30's care plan did not indicate the weight loss in March 2026, a review of nutritional interventions to address weight loss, and additional monitoring or potential reweighing Resident R30 more frequently. During an interview on 5/20/26, at 11:09 a.m. Licensed Practical Nurse (LPN) Employee E26was asked if care plans should be updated when weight loss occurs and include interventions, she stated: yes. absolutely. Some type of plan and have re-weighs. During an interview on 5/20/26, at 2:29 p.m. information provided to the Director of Nursing (DON) that the facility failed to update the care plan for Resident R30 after she experienced weight loss as required. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on Based on document review, clinical record review, and staff interview, it was determined that the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of non-coverage (SNF-ABN) form to inform those residents of items and services no longer deemed eligible for coverage under Medicare Part-A for two of three sampled resident records (Residents R4 and R57).Findings include:Review of Resident R4's admission record indicated he was admitted on [DATE]. Review of Resident R4's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 3/2/26, indicated he had medical diagnoses that included hypothyroidism (decrease in production of thyroid hormone), major depressive disorder (a state of consistent sadness and loss of interest interfering in daily life activities), dysphagia (difficulty swallowing)and hyperlipidemia (elevated lipid levels within the blood). Review of Resident R4's clinical social services note dated 3/16/26, indicated Resident R4 was issued a NOMNC (Notice of Medicare Non-Coverage-NOMNC: a form provided to residents to inform them of the facilities determination to end a Medicare based services) with last covered day of 3/18/26. Resident R4 continued to remain in the facility long-term care. Review of Resident R57's admission record indicated she was admitted on [DATE] and readmitted to the facility on [DATE]. Review of Resident R57's MDS assessment dated [DATE], indicated that she had diagnoses that included muscle weakness, arthritis (inflammation of one or more joints, causing pain and stiffness), and anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry). Review of Resident R57's clinical records indicated she was issued a NOMNC on 5/11/26. Review of Resident R57's clinical nurse notes and social services notes did not indicate a review of the NOMNC form provided to her. Review of facility documentation did not include evidence that Skilled Nursing ABN forms (Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage: SNF-ABN, a form providing information that at a specific date Medicare coverage ends and the specific amount of financial liability will be passed onto the residents) were provided to Resident R4 and Resident R57. During an interview on 5/20/26, at 10:28 a.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of non-coverage (SNF-ABN) form to inform those residents of items and services no longer deemed eligible for Residents R4 and R57 as required. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on the review of facility policy, clinical records, observation, and interviews with staff and resident, it was determined that the facility failed to make certain that residents received the necessary services to prevent/treat pressure ulcers (injuries to the skin and underlying tissue resulting from prolonged pressure to the skin) for two of three residents (Residents R3 and R11) and failed to follow a physician order during a dressing change observation for one of three residents (Resident R56). Findings include: Review of the facility policy Pressure Injury Prevention and Management dated 5/1/26, indicated that the facility will provide treatment and services to heal the pressure ulcer/injury, prevent infection, and the development of additional pressure ulcers/injuries. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic care interventions can include but are not limited to: redistribute pressure (such as repositioning, protecting, and/or offloading heels, etc.). Interventions will be documented in the care plan and communicated to all relevant staff. Review of the facility policy Dressings, Dry/Clean last reviewed 5/1/26, indicated the purpose of this procedure is to provide guidelines for the application of dry, clean dressings. Verify that there is a physician order for this procedure. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/7/26, with the diagnoses of aphasia (language disorder that affects communication), hemiplegia (paralysis on one side of the body), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Resident R3's clinical record revealed a physician's order dated 9/20/24, for heel protection boots at all times related to hemiplegia. Review of Resident R3's care plan failed to include interventions of heel protection boots. During an observation on 5/17/26, at 9:19 a.m. Resident R3's heel protection boots were sitting in a wheelchair, while Resident R3 was resting in bed. During an additional observation on 5/17/26, at 10:18 a.m. Resident R3 had no heel protection boots applied. During an additional observation on 5/19/26, at 1:38 a.m. Resident R3 was observed being transported in her wheelchair down the hallway without heel protection boots applied. During an interview on 5/19/26, at 1:38 p.m. Registered Nurse Employee E28 confirmed that Resident R3 was ordered heel protection boots to prevent pressure ulcers and that she did not have them on as ordered. During an interview on 5/20/26, at 1:46 p.m. Assisted Director of Nursing confirmed that the facility failed to include interventions of heel protection boots in Resident R3's care plan to ensure that resident received necessary services to prevent pressure ulcers/injuries. Review of the clinical record indicated Resident R11 was admitted to the facility on [DATE], with diagnoses of Alzheimer's disease with late onset, schizoaffective disorder, and major depressive disorder. Review of Resident R11's MDS assessment dated [DATE], Section M- Skin Conditions revealed the resident was at risk for developing pressure ulcers. It was indicated the resident had zero pressure ulcers. Review of Resident R11's care plan dated 2/6/26, revealed the resident has potential for impaired skin integrity. The resident needs reminding to turn/reposition at least every 2 hours, more often as needed or requested. Review of Resident R11's wound assessment completed by the wound consultant dated 4/9/26, recommended to limit out of bed to no more than 4 hours at a time and must return to bed for at least two hours before getting back out of bed. Recommend ongoing pressure reduction and turning/repositioning precautions per protocol, including pressure reduction to the heels and all bony prominences. Review of Resident R11's Braden Scale assessment dated [DATE], indicated the resident was at a low risk for developing pressure ulcers. No revisions were made to Resident R11's care plan for pressure ulcers. Review of Resident R11's Documentation V2 report from 5/1/26, to 5/15/26, revealed the facility failed to document the resident was provided with toileting each shift for a total of 12 times. A further review failed to include evidence the wound care recommendations of limiting time out of bed to no more than four hours at a time and turning and repositioning precautions were implemented. Review of Resident R11's late entry progress note dated 5/14/26, entered 5/17/26 by Wound Care Nurse, Employee E28 revealed a nurse aide notified this writer of discoloration to resident's buttock. RN assessed, small moveable dark purple area to resident's left buttock at the gluteal cleft. Darker purple circle in the center that is not open but looks scabbed. Dark area measures 0.4x0.4cm. Zinc and dry dressing applied. Nurse Practitioner in facility and made aware. New order for zinc until wound care nurse can assess on next wound rounds. Daughter notified. Immediate intervention: Staff did not put resident in wheelchair, repositioned with pillows frequently. Care plan updated. Review of Resident R11's care plan failed to include evidence it was updated. Review of Resident R11's Braden Scale assessment dated [DATE], indicated the resident was at a low risk for developing pressure ulcers. The facility failed to identify Resident R11 was at risk for developing pressure ulcers. During an interview on 5/20/26, at 11:22 a.m. Wound Care Nurse Practitioner, Employee E35 stated she was unaware Resident R11 developed an unstageable pressure ulcer. It was indicated Resident R11 should limit their time out of bed, be turned and repositioned at least every two to three hours. It was indicated the resident should limit time to wheelchair. Wound Care Nurse Practitioner, Employee E35 stated Resident R11 is at a high risk for developing pressure ulcers due to inability to reposition herself and incontinence of bowel and bladder. It was indicated her limited mobility and incontinence make her a high risk. During an observation on 5/20/26, at 11:35 a.m. Resident R11 was observed sitting in her wheelchair at the nursing station. During an interview on 5/20/26, at 11:38 a.m. Registered Nurse Supervisor, Employee E28 stated she works at the facility three times a week. It was indicated most of the days Resident R11 sits in her wheelchair near the nurses stations because staff need to keep an eye out on her. Staff will take her back to her room to change her then bring her back out. RN Supervisor, Employee E28 stated Resident R11 is at risk for developing pressure ulcers because she sits and has difficulty turning and repositioning herself. During an observation on 5/20/26, at 12:00 p.m. Resident R11 was observed sitting in her wheelchair. During an interview on 5/20/26, at 11:42 a.m. Wound Care Nurse, Employee E28 confirmed the facility failed to update Resident R11's care plan to limit time out of bed as wound care consultant recommended. During an interview on 5/20/26, at 11:45 a.m. the Director of Nursing stated she completed Resident R11's Braden Scale and identified her not to be a risk. The Director of Nursing confirmed the facility failed to provide appropriate care and treatment to prevent the development of Resident R11's left buttock pressure ulcer as recommended by wound care practitioner. Review of the clinical record revealed Resident R56 was admitted to the facility on [DATE]. Review of Resident R56's MDS dated [DATE], indicated the diagnosis of hypertension (high blood pressure, diabetes (high sugar in the blood) and peripheral vascular disease (PVD- restricts blood flow). Review of Resident R56's physician orders dated 5/1/26, indicated left plantar foot-cleanse with wound cleanser, apply a thick layer of Medi-honey (ointment that maintains a moisture balanced environment with antibacterial benefits) then calcium alginate (highly absorbent material) cut to fit, cover with abdominal pad and wrap with kerlix to secure every daylight shift for wound care. During a wound care observation completed on 5/18/26, at 9:58 a.m. Registered Nurse (RN) Employee E6 cleansed the wound applied the Medi-honey directly on the calcium alginate, failed to place the abdominal pad, and wrapped the foot with kerlix. During an interview completed on 5/18/26, at 10:10 a.m. RN Employee E6 confirmed applying the Medi-honey directly on the calcium alginate and not placing the abdominal pad prior to wrapping the left foot with kerlix and that the facility failed to follow a physician order during a dressing change observation for one of three residents (Resident R56). 28 Pa. Code 211.10(c)(d) Resident care policies28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to provide trauma survivors with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for two of two residents (Resident R1 and R33). Findings include: Review of facility policy Trauma Informed Care dated 5/1/26, indicated that the facility will identify triggers which may re-traumatize residents with a history of trauma and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1 MDS (minimum data set - a periodic assessment of care needs), dated 3/13/26, indicated diagnosis of PTSD (a mental health condition that caused by an extremely stressful or terrifying event), depression, and dysphagia (difficulty swallowing). Review of Resident R1's care plan dated 5/19/25, revealed the resident has a diagnoses of PTSD due to sexual abuse. The care plan failed to identify triggers for Resident R1 as related to PTSD. Review of Resident R1 psychiatry note dated 4/29/26, identified the resident's PTSD diagnosis and stated to continue to offer support and care plan for triggers when identified. Patient's triggers: Resident who looks like person who assaulted him. No description was provided of person who assaulted him. During an interview on 5/20/26, at 10:18 a.m. Licensed Practical Nurse (LPN), Employee E33 stated she was unaware of Resident R1's PTSD triggers. During an interview on 5/20/26, at 10:19 a.m. Registered Nurse Supervisor, Employee E28 confirmed the facility failed to identify and care plan Resident R1's PTSD triggers. During an interview on 5/20/26, at 10:27 a.m. the Director of Nursing confirmed the facility failed to provide trauma survivors with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents (Resident R1). Review of Resident R33's admission record indicated he was admitted on [DATE]. Review of Resident R33's MDS assessment dated 51/26, indicated he had diagnoses that included chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), alcohol use, hypertension (a condition impacting blood circulation through the heart related to poor pressure), and Post Traumatic Stress Disorder (PTSD). Review of Resident R33's psychiatric clinical note dated 3/4/26, indicated that he had no recent PTSD symptoms. Review of Resident R33's care plans dated 3/27/26, indicated that he had diagnoses of PTSD related to past trauma and manifested by anxiety. Review of Resident R33's care plans did not indicate specific triggers related to PTSD diagnoses. During an interview on 5/19/26, at 10:39 a.m. Licensed Practical Nurse (LPN) Employee E20 was asked about specific triggers for PTSD: I see some things about psychotropic medications; other than that, nothing about PTSD. During an interview on 5/19/26, at 11:11 a.m. Registered Nurse Assessment Coordinator (RNAC) Employee E34 was asked about specific triggers for PTSD: Resident R33 gets anxious when needs are not met. During an interview on 5/19/26, at 2:23 p.m. information disseminated to Director of Nursing (DON) and Nursing Home Administrator (NHA) that concerns were identified with PTSD care plan being specific to Resident R33's behavioral triggers as required. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1) Management.

Based on review of facility policy, resident records, resident and staff interviews it was determined that the facility failed to provide residents with their quarterly banking statements for two of four sampled resident records (Resident R56 and R57). Findings include: During an interview on 5/20/26, at 10:05 a.m. Regional Business office manager Employee E11 was asked how often are trust fund statements sent and she stated: residents should receive their statements quarterly. During an interview on 5/20/26, at 10:25 a.m. Nursing Home Administrator (NHA), indicated that the quarterly statements should be in the former Business Office Manager (BOM) office. NHA went in the office, and there was no documentation of quarterly statements being sent to residents/responsible parties. During an interview on 5/20/26, at 1:09 p.m. NHA provided 1/4 statements for residents who have trust funds with the facility - but was unable to provide documentation showing that they were mailed and or handed out to the residents or the responsible parties. During an interview on 5/20/26, between 1:40 p.m. and 2:00 p.m., Resident R56 and Resident R57 Indicated they have not seen, nor ever seen their quarterly statements. During an interview on 5/21/26, at 10:20 a.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to provide residents with their quarterly banking statements as required. 28 Pa. Code 201.18(b)(2) Management. 28 Pa. Code 201.29(a) Resident rights.

Based on review of facility policy, resident trust account balances, closed resident records, and staff interviews it was determined that the facility to obtain an authorization to open a resident fund account for one four closed resident records (Closed resident record CR66) and failed to ensure residents have access to their funds for one of three sampled resident records (Resident R18).Findings include: The facility Resident personal funds policy last reviewed 5/1/26, indicated that the resident has a right to manage his or her financial affairs to include the right to know, in advance, what charges a facility may impose against a resident's personal funds. If a resident chooses to deposit personal funds with the facility, upon written authorization of a resident, the facility must act as a fiduciary of the resident's funds. Review of Closed resident record CR66's admission record indicated he was admitted on [DATE]. Review of Closed resident record CR66's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 1/15/26, indicated he had diagnoses that included lumbar fracture (fracture to back area), hypertension (a condition impacting blood circulation through the heart related to poor pressure), and alcohol dependence. Review of Closed resident record CR66's clinical nurse notes dated 2/6/26, indicated that Closed Resident CR66 was discharged from the facility, all personal belongings taken with him. All available medications taken and reviewed with Closed Resident CR66 and home nurse. Current scripts were called to pharmacy by social services. Review of Closed resident record CR66's record did not include an authorization to open a resident trust fund account. Review of the facility trust fund account dated 5/20/26, indicated Closed resident record CR66 had a balance of $35.04. Review of Resident R18's admission record indicated she was admitted on [DATE]. Review of Resident R18's MDS assessment dated [DATE], indicated she had medical diagnoses included diabetes (a metabolic disorder impacting organ function related to glucose levels in the human body), chronic kidney disease (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and changes in urination), and hypertension (a condition impacting blood circulation through the heart related to poor pressure). Review of Resident R18's clinical record and social services notes did not indicate any concerns with accessing money from the business office. During a Resident council group interview on 5/18/26, at 1:00 p.m. two of nine residents voiced concerns with accessing their money from the business office. During an interview on 5/19/26, at 12:16 p.m. Resident R18 was asked about accessing her resident money: I have not gotten social security. It happened last month and this month. I do not know who to talk to. The bill for here comes to me. I want to know what is happening with my check. I used to get snacks and the money I received was less than $100.00 per month. During an interview on 5/20/26, at 10:05 a.m. Regional Business office manager Employee E11 was asked where resident fund account authorizations are kept and she stated: they should be in their charts. Regional Business office manager Employee E11 was asked how residents access money when she is not present: the Administrator. If the NHA is not present, then the Admissions staff. During an interview on 5/21/26, at 9:29 a.m. the Nursing Home Administrator (NHA) confirmed that the facility to obtain an authorization to open a resident fund account for Closed resident record CR66 as required. During an exit interview on 5/21/26, at 3:00 p.m. information was disseminated to the Nursing Home Administrator (NHA) that the facility failed to ensure residents have access to their funds for Resident R18 as required. 28 Pa. Code 201.18(b)(2) Management. 28 Pa. Code 201.29(a) Resident rights.

Based on review of facility policy, documentation, and staff interviews it was determined that the facility failed to protect residents from neglect for two of three residents (Resident R4 and R8). Findings include: Review of facility's policy dated 6/1/25, Abuse, Neglect, and Exploitation stated neglect is the failure of the facility, its employees, or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. It is indicated it is the policy of the facility that each resident will be free from abuse. Review of Residents R4's admission record indicated the resident was admitted on [DATE], and readmitted [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/2/26, indicated diagnoses of cognitive communication deficit, dysphagia (difficulty swallowing), and depression. Section GG- Functional Abilities revealed the resident is dependent for toileting hygiene. Review of information submitted to the State Agency on 5/12/26, by the Director of Nursing revealed on 5/12/26, it was reported by the oncoming shift that Resident R4 was saturated. The resident had his call bell on at the start of the shift and stated to the aide that he needed changed. Resident was interviewed and stated that he was not changed on the night shift. Resident is alert and orient to person, place, and time and able to make needs known. Review of the facility's investigation dated 5/12/26, revealed statements from staff and resident were obtained. The nurse aides stated they shared the assignment and the facility was unable to determine an alleged perpetrator. Review of Resident R4's grievance dated 5/12/26, revealed Resident R4 had their light on at the start of the shift and stated he was not changed at all on the night shift. Review of Resident R4's witness statement dated 5/12/26, stated I wasn't changed until Nurse Aide, Employee E15 came in. There were two idiots and they didn't do their job. Review of Nurse Aide, Employee E15's witness statement dated 5/12/26, stated when NA, Employee E15 arrived on the unit at 7:00 a.m. Resident R4's call light was ringing. When NA, Employee E15 answered the call light, Resident R4 stated he was not changed all night long. When she asked who was assigned the resident, Nurse Aide, Employee E18 stated oh we forgot to change him. It was indicated the nurse aides worked together last night. Review of NA, Employee E19 witness statement dated 5/12/26, stated on the overnight shift each aide did not have a choice and had to take a whole hall. It was indicated NA, Employee E19 asked NA, Employee 18 to help with the heavier residents, and she assisted her with the residents she needed. Review of NA, Employee E20 witness statement dated 5/12/26, stated she was present when NA, Employee E15 asked NA, Employee E18 if she changed Resident R4 because he is ringing his call bell and stated I wasn't changed. NA, Employee E19 stated :I changed him. NA, Employee E15 checked him he was wet and NA, Employee E18 left. Review of Residents R8's admission record indicated the resident was admitted on [DATE], and readmitted [DATE]. Review of Resident R8's care plan dated 1/7/26, indicated to always transfer with the assist of two. Review of Resident R8's MDS dated [DATE], indicated diagnoses of morbid obesity, difficulty walking, and depression. Section GG- Functional Abilities revealed the resident requires partial/moderate assistance for toileting hygiene. Review of information submitted to the State Agency on 5/12/26, by the Director of Nursing revealed on 5/12/26, it was reported by oncoming shift that the resident was saturated. Resident was interviewed and stated that he was not changed on the night shift. The resident is alert and oriented to person, place, and time, and able to make all needs known. Review of Resident R8's grievance form dated 5/12/26, revealed the resident was found saturated the start of the 7 a.m. t o3 p.m. shift by the daylight nurse aide. When resident was interviewed, he indicated no one changed him all night. Review of Resident R8's witness statement dated 5/12/26, stated I don't think I was changed overnight. It was indicated staff came in a few times but never changed him. Resident R8 stated I was lying in pee, and it was uncomfortable, started to get cold. NA, Employee E15 changed him, the sheets, and have him a shower in the morning. Review of Nurse Aide, Employee E15's witness statement dated 5/12/26, stated while checking residents at 7:30 a.m. she found Resident R8 soiled from head to toe. The resident stated he was not changed at all during the night shift. The nursing supervisor was notified. Nurse Aide, Employee E18 came down the hall saying she didn't know if he was changed and proceeded to try to clean him, but NA, Employee E15 ended up giving him a shower. Review of NA, Employee E18's witness stated dated 5/12/26, stated she started on the other side and had no idea Resident R8 was not changed at all. During an attempted phone interview on 5/20/26, at 2:03 p.m. NA, Employee E19 was unavailable for an interview. During a phone interview on 5/20/26, at 2:16 p.m. NA, Employee E18 confirmed she recalled the night Resident R4 and Resident R8 did not get changed. It was indicated there were two nurse aides for approximately 50 residents. NA, Employee E18 stated she was unaware the residents were not changed. It was revealed originally four nurse aides were scheduled, but there were two call offs. It was indicated the assignment sheets were not revised. NA, Employee E18 confirmed Resident R4 and R8 were not changed throughout the night and stated their sheets needed to be changed as well. During an interview on 5/20/26, at 2:16 p.m. the Director of Nursing confirmed the facility failed to protect resident from neglect for two of three residents (Resident R4 and Resident R8). 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.10 (a) (d) Resident care policies

Based on review of facility policies, resident clinical records, resident council group interviews, resident and staff interviews, it was determined that the facility failed to uphold residents right to vote for two of five sampled residents (Resident R27 and Resident R37), and failed to ensure that care was provided in a manner which maintained resident dignity for one of two residents (Resident R46). Findings include: The facility Resident right to vote policy last reviewed on 5/1/26, indicted that the facility will support residents in exercising their right to vote. All residents should have access to timely information about upcoming elections. Review of Resident R27's admission record indicated she was admitted on [DATE] and readmitted on [DATE]. Review of Resident R27's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 4/4/26, indicted she had diagnoses that included bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), muscle weakness, and epilepsy (a long-term disease that causes repeated seizures due to abnormal electrical signals produced by damaged brain cells). Review of Resident R27's clinical social services note dated 7/15/25, indicated Resident R27 met with voting services group to update her registration. Review of Resident R27's clinical record, activity documents and social services notes did not indicate Resident R27 was assisted with voting during the 2026 election cycle. Review of Resident R37's admission record indicated he was admitted on [DATE] and readmitted on [DATE]. Review of Resident R37's MDS assessment dated [DATE], indicated he had diagnoses that included diabetes (a metabolic disorder impacting organ function related to glucose levels in the human body), morbid obesity, and major depressive disorder (a state of consistent sadness and loss of interest interfering in daily life activities). Review of Resident R37's clinical record, activity documents and social services notes did not indicate Resident R27 was assisted with voting during the 2025 and 2026 election cycle. During a Resident council group interview on 5/18/26, at 1:00 p.m. three out of nine residents voiced that they received no assistance with voter registration during 2025 or 2026 elections. During an interview on 5/19/26, at 10:33 a.m. Activity Aide Employee E21 was asked about voting documentation: That is something the director of activities would have. I have helped some of the residents fill out voting documentation. During an interview on 5/19/26, at 2:23 p.m. information was disseminated to Director of Nursing (DON) and Nursing Home Administrator (NHA) that the facility failed to uphold residents' rights and assist with voter registration for Resident R27 and Resident R37 as required. Review of facility policy Catheter Care dated 5/1/26, indicated that privacy bags will be available and catheter drainage bags will be covered at all times while in use. Review of the clinical record indicated Resident R46 was admitted to the facility on [DATE]. Review of Resident R46's MDS dated [DATE], indicated diagnoses of high blood pressure, chronic pain, and muscle weakness. Review of Resident R46's care plan revised on 2/1/25, indicated the resident has an indwelling urinary catheter related to neuromuscular dysfunction of bladder (when nerves are damaged that disrupts the signals between the bladder and the brain). During an observation on 5/17/26, at 10:38 a.m. Resident R46's catheter draining bag was observed beside the bed without a privacy cover applied. During an interview on 5/17/26, at 10:54 a.m. Nurse Aide Employee E24 confirmed Resident R46's catheter draining bag did not have a privacy cover to ensure dignity 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 201.29(a)Resident Rights.

Based on review of facility policies and clinical records, resident and staff interviews, it was determined that the facility failed to provide effective pain management for one of five residents reviewed (Resident R1), which resulted in excessive pain, poor sleeping, and decreased level of functioning of activities of daily living, causing harm to Resident R1.Findings include: Review of the facility policy Medication Ordering and Receiving from Pharmacy dated 9/22/25, indicated medications are administered in an organized and safe manner. Pour the correct number of tablets or capsules into the medication cup. Administer medication and remain with resident while medication is swallowed. Review of Resident R1's admission record indicated she was admitted to the facility on [DATE]. Review of the Resident R1's Minimum Data Set (MDS- periodic assessment of resident care needs) dated 1/10/26, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and depression. Review of Resident R1's care plan dated 7/17/25, revealed the resident was care planned for chronic pain. Interventions included to administer medication per physician orders. Review of Resident R1's physician order dated 12/23/25, indicated to administer Oxycodone (a pain medication) 5 milligrams, one tablet by mouth, every eight hours as needed. During an interview on 2/25/26, at 11:45 a.m. Resident R1 reported that he requested an Oxycodone for breakthrough pain and did not receive his Oxycodone Sunday, Monday, and Tuesday this week according to the physician order and stated, I was in a lot more pain than normal. It affected some activities that I do. I didn't do my laundry, I didn't sleep well. I didn't stay out of bed as long as I usually do. I was pretty miserable. During a review of Resident R1's clinical record on 2/25/26, revealed that the Medication Administration Record (MAR) was blank, which indicated that resident did not receive Oxycodone as needed. During a review of Resident R1's chart on 2/25/26, at 2:30 p.m. failed to contain the controlled substance record to review documentation of Oxycodone. During an interview on 2/25/26, at 2:35 p.m. Registered Nurse Employee E11 confirmed that the controlled substance record was missing and unable to identify if Resident R1 had Oxycodone given per request. During an interview on 2/26/26, at 2:55 p.m. Clinical Consultant Employee E9 reviewed February MAR and confirmed that 2/22/26, 2/23/26, and 2/24/26 were blank, indicating Resident R1 did not receive Oxycodone per request. During an interview on 2/26/26, at 3:00 p.m. Clinical Consultant Employee E9 confirmed that the facility failed to provide effective pain management for one of five residents reviewed (Resident R1), which resulted in excessive pain, poor sleeping, and decreased level of functioning of activities of daily living, causing harm to Resident R1. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on reviews of facility policy, employees files, facility documentation, and staff interviews, it was determined that the facility failed to ensure annual abuse and neglect prevention training was completed for five of seven staff members (Nurse Aide (NA) Employee E1, Registered Nurse (RN) Employee E3, NA Employee E4, RN Employee E6, and the Director of Nursing (DON) identified in an incident of reported neglect. The facility also failed to provide annual abuse and neglect training for 88 of 90 current Facility Employees for 12 of 12 months (January through [DATE]). The facility also failed to screen employees for a potential history of abuse by completing pre-employment criminal background checks for one of seven employees (Licensed Practical Nurse (LPN) Employee E2). The facility also failed to verify current, valid license from licensing and registration boards to verify any disciplinary actions prior to employment for five of seven employees (NA Employee E1, RN Employee E3, NA Employee E4, RN Employee E6, and the DON) resulting in an Immediate Jeopardy for 66 of 66 residents. The facility also failed to conduct a Federal Bureau of Investigation (FBI) background check as required for one of two out-of-state employees (Employee E14). Findings include: Review of facility policy Abuse, Neglect, & Mistreatment, reviewed [DATE], indicated that the facility prohibits the mistreatment, neglect, and abuse of residents. Abuse, Neglect and Misappropriation of Resident Funds and Property education is completed upon hire and at least annually for all employees. Implementation and ongoing monitoring consist of screening, training, prevention, identification, protection, investigation, and reporting. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect of goods and services may occur when staff are aware, or should be aware, of resident's care needs, based on assessment and care planning, but are unable to meet identified needs due to other circumstances, such as lack of training to perform an intervention, lack of sufficient staffing to be able to provide the services, lack of supplies, or staff lack knowledge of the needs of a resident. All potential employees are screened for history of abuse, neglect, or mistreating residents during the hiring process. Screening will consist of but limited to inquiries into State licensing authorities and or State nurse aide registry, criminal background checks. During an interview on [DATE], at 11:55 a.m. NA Employee E1 stated that there was an assignment of 12 residents on the Second Floor who did not receive any morning care on [DATE], as there was no one assigned to rooms 209-A- 217B. During an interview on [DATE], at 12:26 p.m. the Nursing Home Administrator (NHA), and DON were informed by State Agency (SA) that 12 residents on the Second Floor had not yet received morning care as there was no one assigned to do so. During an additional interview on [DATE], at 2:18 p.m. the NHA and DON were made aware by SA that the same 12 residents still have not received any morning care. During an interview on [DATE], at 1:52 a.m. Human Resources Director Employee E5 stated that annual education is completed January through December, but that no education was completed January through [DATE] which was when she started working at the facility. During an interview on [DATE], at 12:02 p.m. the DON stated that the facility no longer has an account to run background checks on new employees. During an interview on [DATE], at 12:02 p.m. the NHA confirmed that the facility identified seven alleged perpetrators (APs) of neglect for the above incident that occurred on [DATE], which were confirmed to be NA Employee E1, LPN Employee E2, RN Employee E3, NA Employee E4, RN Employee E6, DON, and NHA. During an interview on [DATE], at 12:37 p.m. the Human Resources Director Employee E5 brought in folders that contained the education that was completed in 2025, and confirmed that this was a complete list. The topics included Workplace Safety, Double Briefing, Sexual Harassment, Dementia, Corporate Compliance, and Disaster Drill. Abuse and Neglect education was not on the list of facility provided education for 2025. Review of Employee Files for the seven above employees listed as APs indicated the following: NA Employee E1 who had a start date at the facility of [DATE], had no documentation that education on Abuse and Neglect was received for the year of 2025, and had a NA license on file that expired [DATE]. LPN Employee E2 who had a start date at the facility of [DATE], had no documentation that a pre-employment background check had been completed prior to the start date of employment. RN Employee E3 who had a start date at the facility of [DATE], had no documentation that education on Abuse and Neglect was received for 2025, and no RN license on file. NA Employee E4 who had a start date at the facility of [DATE], had no documentation that education on Abuse and Neglect was received for 2025, and had a NA license on file that expired [DATE]. RN Employee E6 who had a start date at the facility of [DATE], had no documentation that Abuse and Neglect education was received for 2025, and had a RN license on file that expired 10-31-24. DON who had a start date at the facility on [DATE], had no documentation that Abuse and Neglect education was received for 2025, and had a RN license on file that expired on [DATE]. During an interview on [DATE], at 3:41 p.m. the NHA confirmed that there was no annual abuse training for five of seven staff members NA Employee E1, RN Employee E3, NA Employee E4, RN Employee E6, and the DON identified in an incident of reported neglect, no annual Abuse and Neglect training for 90 of 90 current Facility staff for 12 of 12 months (January through [DATE]), had expired licenses, or no license on file for five of seven employees (NA Employee E1, RN Employee E3, NA Employee E4, RN Employee E6, and DON) and failed to complete pre-employment background checks for one of seven employees (LPN Employee E2). On [DATE], at 3:49 p.m. the Nursing Home Administrator was made aware that an Immediate Jeopardy situation existed and the Immediate Jeopardy template was provided to facility administration. On [DATE], at 4:53 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Facility has reviewed current policy on abuse and neglect. All current facility staff including agency will receive training on current facility policy for abuse/neglect by 4:00 p.mXXX[DATE]. Those who do not complete education will not be permitted to work until education is completed.All current facility employee files, including agency, will be reviewed by 4:00 p.m. on [DATE] to ensure that they have education on facility policy for abuse and neglect and a current and active license on file as well as a background check present in their file. Missing items that are identified in audit will be immediately corrected.Facility will audit all new hire and all new agency staff files to ensure that files contain evidence of abuse education and current, active license as well as background check.Results of the audit will be reported to Ad Hoc Quality Assurance Performance Improvement Committee on [DATE]. During an interview on [DATE], at 11:24 a.m. the NHA stated I don't even know the process of checking expired license. Note that on [DATE] at 3:00 p.m. none of the above information in the Corrective Action Plan was received. Review of facility documents on [DATE], indicated that 99 of 107 Facility and Agency Employees received education from the facility on Abuse and Neglect, and Mistreatment. Eleven of these employees received education via telephone as they were not currently working in the building. During staff interviews conducted on [DATE], at 12:45 p.m. through [DATE], at 2:51 p.m. 37 staff members confirmed they received education on abuse and neglect. Three of these employees had confirmed receiving education via telephone. During an interview on [DATE] at 1:16 p.m. NA Employee E17 stated that she received education on abuse and neglect but added It's been a long time since I received it before this week. During an interview on [DATE], at 1:18 p.m. NA Employee E18 confirmed that she received education on abuse and neglect at the facility but added I get it all the time at my other job, but not here. Review of facility audits on [DATE], at 3:00 p.m. revealed that 17 out of 17 Agency Employees had completed pre-employment background checks and active, valid licenses on file. Review of facility audits on [DATE], at 3:01 p.m. revealed that 64 out of 66 licensed Facility Employees had an active, valid license. During an interview on [DATE], at 3:05 p.m. NHA 3 stated that two employees were sent home due to an inactive license. These employees were identified as NA Employee E15 whose license had expired on [DATE], and NA Employee E16 whose license had expired on [DATE]. NA Employee E15's last day working at the facility was [DATE], and NA Employee E16's last day working at the facility was [DATE]. Review of facility audits on [DATE], at 5:24 p.m. revealed that 64 of 90 Facility Employees had background checks completed prior to hire, and present in employee file. 26 employees had no pre-employment background check in employee file. Facility completed background checks on these 26 employees on [DATE], which brought facility to 100% compliance. Review of Scheduler Employee E14's personnel file on [DATE], revealed that she lives out of state, and although she had a state background check prior to employment, no documentation was present in the file that the facility conducted an FBI background check as required for out-of-state employees prior to employment. Employee E14 was sent home pending the FBI background check. The Immediate Jeopardy was lifted on [DATE], at 6:03 p.m. when the action plan implementation was verified. During an interview on [DATE], at 9:06 a.m. NHA 3 confirmed that the facility failed to conduct an FBI background check for one of two out-of-state employees (Scheduler Employee E14) prior to employment, and that Employee E14 remained out of the facility as she was actively working on getting the FBI background check completed. During an interview on [DATE], at approximately 2:00 p.m. NHA 2 confirmed that the facility failed to ensure annual abuse and neglect prevention training was completed for five of seven staff members identified in an incident of reported neglect, and failed to provide documentation of annual abuse and neglect training for 90 of 90 current facility employees for 12 of 12 months (January through [DATE]), and failed to screen potential employees for a history of abuse by completing pre-employment criminal background checks for two of seven employees, and failed to verify current, valid license from licensing and registration boards to verify any disciplinary actions prior to employment for five of seven employees resulting in an Immediate Jeopardy for 66 of 66 residents. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.19 (3)(7) Personnel policies and procedures.

Based on review of facility policy, resident and staff interviews, and observations, it was determined that the facility failed to have sufficient nursing staff to provide nursing related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, which created an Immediate Jeopardy situation for 12 of 12 residents residing on one of two halls (West Hall) for Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, and R12).Findings Include:Review of the facility policy Resident Rights dated 9/22/25, indicated all residents will be treated with respect, and dignity. Residents have the right to reside and receive services in the facility. The residents have the right to a safe, clean, comfortable and homelike environment including but not limited to receiving treatment and support for daily living.Review of the facility Facility Assessment Tool dated 9/22/25, indicated specific staffing needs, including nights, holidays, and weekends, ratios, knowledge and skills, maximizing direct care staff recruitment and retention to meet the needs of the residents. The facility implements a proactive and systematic approach involving regular review of staffing and other potential disruptions. The facility cross trains staff members for work within the facility, and on-call staff are available, and partnerships with staffing agencies.During a tour of the second-floor nursing floor on 1/14/26, at 11:55 a.m. Nurse Aide (NA) Employee E1 stated, There are only two NA's on the floor, the third one didn't show up. We have told management. The administrator, the Director of Nursing (DON), and the supervisor. Those people down that hall haven't been touched since probably overnight shift. When State Agency (SA) clarified what hallway, the NA Employee E1 pointed to the [NAME] Hall, Third Assignment (Resident rooms 209-A through 217-B).During a review of facility provided documentation, labeled Daily Assignment Sheets, on 1/14/26, at 12:05 p.m. revealed that the assignment labeled West, Rooms 209-A through 217-B were assigned to a NA who failed to show up for scheduled work shift and the assignment was not reassigned to another staff member.Review of residents in section 209-A through 217-B revealed that twelve residents reside in that section and need assistance with Activities of Daily Living. During an interview on 1/14/26, at 12:11 p.m. Licensed Practical Nurse (LPN) Employee E2 stated, When I found out we didn't have a third NA, I talked to the supervisor. She said the nurses will need to help the NA's. I told her I can't help today; I can barely walk. No care has been done since overnight shift. No baths, no showers, no incontinence care, no repositioning, residents have not gotten out of bed.During an interview on 1/14/26, at 12:14 p.m. Registered Nurse Employee E6 stated, I offered to help them but LPN Employee E2 said she isn't helping because that's why she became a nurse. She doesn't want to help me. I'm just a cart nurse today.During an interview on 1/14/26, at 12:26 p.m. the SA met with the Nursing Home Administrator (NHA)1 and DON1 and reported the observations and interviews from the second floor. The SA informed and reported 12 allegations of neglect to the NHA1 and DON1 at this time.Observations of residents on January 14, 2026, at 12:50 p.m. revealed all residents in section 209-A through 217-B were in their bed with a disheveled appearance.Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE].Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/3/26, indicated diagnoses of high blood pressure, depression, and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time).During an observation on 1/14/26, at 12:59 p.m. Resident R1 was lying in bed.During an interview on 1/14/26, at 1:00 p.m. Resident R1 stated, The nurse came in this morning for medication. Nobody else has been in to check on me or to see if I need anything. I wanted to talk to the nurse practitioner and had to go find someone to ask to see her. I wish someone would have come into my room.Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE].Review of Resident R7's MDS dated [DATE], indicated diagnoses of diabetes, depression, and asthma (condition where the airways narrow and swell).During an observation on 1/14/26, at 1:06 p.m. Resident R7 was lying in bed with a night gown on.During an interview on 1/14/26, at 1:07 p.m. Resident R7 stated, The NA just got me towels to get cleaned up. Nobody has been in today to check on me.Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE].Review of Resident R2's MDS dated [DATE], indicated diagnoses of high blood pressure, anxiety, and gastroesophageal reflux disease (GERD) (a condition where stomach acid frequently flows back into the throat).During an observation on 1/14/26, at 1:08 p.m. Resident R2 was lying in bed with a night gown on.During an interview on 1/14/26, at 1:09 p.m. Resident R2 stated, I need to get cleaned up. So far, I haven't gotten cleaned up. Nobody has been in the check on me.Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE].Review of Resident R3's MDS dated [DATE], indicated diagnoses of diabetes, hemiplegia (paralysis on one side of the body), and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain).During an observation on 1/14/26, at 1:12 p.m. Resident R3 was lying in bed with a nightgown on.During an interview on 1/14/26, at 1:13 p.m. Resident R3 stated, Nobody has been in to clean me up. No one has changed by brief since last night. I asked about getting up when someone brought my lunch tray in, but they said no one came in to work so they couldn't get me up. I would like to get up and move around. My bottom is somewhat sore. I haven't had any cream on because I haven't been changed.Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE].Review of Resident R8's MDS dated [DATE], indicated diagnoses of high blood pressure, depression, and arthritis (inflammation of one or more joints, causing pain and stiffness).During an observation on 1/14/26, at 1:18 p.m. Resident R8 was resting her eyes closed in bed with a night gown on.Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE].Review of Resident R4's MDS dated [DATE], indicated diagnoses of cerebral infarction, depression, and Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking).During an observation on 1/14/26, at 1:19 p.m. Resident R4 was lying in bed with a night gown on.During an interview on 1/14/26, at 1:20 p.m. Resident R4 stated, No one has been into clean me up today. My brief hasn't changed and it needs to be changed. Nobody has been in to check on me.Review of the clinical record indicated Resident R9 was admitted to the facility on [DATE].Review of Resident R9's MDS dated [DATE], indicated diagnoses of high blood pressure, depression, and heart failure (a progressive heart disease that affects pumping action of the heart muscles).During an observation on 1/14/26, at 1:21 p.m. Resident R9 was lying in bed with a night gown on.During an interview on 1/14/26, at 1:22 p.m. Resident R9 stated, Nobody has been in the check on me today. I need towels, and wash towels to wash up but nobody has been in. I wasn't able to get cleaned up today.Review of the clinical record indicated Resident R10 was admitted to the facility on [DATE]. Review of Resident R10's MDS dated [DATE], indicated diagnoses of heart failure, coronary artery disease (damage or disease in the heart's major blood vessels), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life).During an observation on 1/14/26, at 1:25 p.m. Resident R10 was sitting at the side of bed with a night gown on.During an interview on 1/14/26, at 1:26 p.m. Resident R10 stated, I haven't gotten up yet. I haven't gotten cleaned up. It seems like they expect me to do it, but I can't. I had diarrhea yesterday. I need to be cleaned. Nobody has been in to check on me.Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE].Review of Resident R5's MDS dated [DATE], indicated diagnoses of diabetes, difficulty in walking, and osteomyelitis (an infection in the bone).During an observation on 1/14/26, at 1:28 p.m. Resident R5 was sitting in bed with a night gown on.During an interview on 1/14/26, at 1:29 p.m. Resident R5 stated, I'm still in my night gown. No one has been into help me. I need help. I can't get up myself. I have had diarrhea and I have been soiled since early this morning. I kept ringing my call bell and someone came in and said they didn't have an NA. No one else was in. My bottom gets a little raw and I make sure they put cream on, but nobody's been in today.Review of the clinical record indicated Resident R11 was admitted to the facility on [DATE].Review of Resident R11's MDS dated [DATE], indicated diagnoses of high blood pressure, diabetes, and paraplegia (loss of motor and sensory function in the lower half of the body).During an observation on 1/14/26, at 1:35 p.m. Resident R11 was lying in bed with a night gown on.During an interview on 1/14/26, at 1:36 p.m. Resident R11 stated, No one has cleaned me up today. My brief hasn't been changed today. It needs changed. It's been soiled all day. I usually get cream put on but I haven't gotten it today.Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE].Review of Resident R6's MDS dated [DATE], indicated diagnoses of high blood pressure, peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and cerebral infarction.During an observation on 1/14/26, at 1:37 p.m. Resident R6 was lying in bed with a night gown on.During an interview on 1/14/26, at 1:38 p.m. Resident R6 stated, I haven't been cleaned up today.Review of the clinical record indicated Resident R12 was admitted to the facility on [DATE].Review of Resident R12's MDS dated [DATE], indicated diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), muscle weakness, and depression.During an observation on 1/14/26, at 1:41 p.m. Resident R12 was resting in bed with eyes closed, with a night gown on.During an observation on 1/14/26, at 1:42 p.m. RN Employee E6, LPN Employee E2, and NA Employee E1 were at the nurse's station talking amongst themselves.During an interview on 1/14/26, at 1:43 p.m. LPN Employee E2 stated I don't have a problem pitching in, but it seems like we are pushed to the side up here. No one from downstairs came up to help us. I just can't do care. I'm not good with care now. The whole section hasn't had a NA all day. No care has been provided yet. Incontinence care has not been done. Some people have not been repositioned. I feel very bad. When asked what could happen when care is not provided, LPN Employee E2 replied, Skin breakdown can happen, they feel like no one cares. I know some want to get up but they haven't gotten up.During an interview on 1/14/26, at 1:49 p.m. RN Employee E6 stated, I am the nurse on the unit. I'm not the supervisor. I function as a nurse on the cart. Even though I am in a different hall, there is no reason to let residents go. I offered to help LPN Employee E2, but she said she doesn't want to. When asked what could happen when care is not provided, RN Employee E6 replied, we need to help each other. Nothing has been done today. Lots of things could happen such as ulcers, they are being neglected. There could be a situation in the room and wouldn't know it. They might not be breathing and we wouldn't know.During an interview on 1/14/26, at 1:55 p.m. NA Employee E1 stated, That section didn't have a NA assigned after someone didn't show up for work. No morning care was done, no baths or showers, no one has been gotten out of bed, no teeth brushed, and no incontinent care has been done. When asked what could happen when care is not provided, NA Employee E1 replied, they can break down. Skin is at risk. Pressure sores can happen.During an interview on 1/14/26, at 1.58 p.m. NA Employee E4 stated, Residents in Section 209-A through 217-B were not taken care of today, that includes bathing, showering, dressing, getting out of bed, teeth brushing, changing. When asked what could happen when care is not provided, NA Employee E4 replied, Its neglect. They can get bed sores and start to lose mobility.During an interview on 1/14/26, at 2:05 p.m. RN Employee E3 stated, One NA did not show up on the second floor. I was made aware and started making calls. I let the DON1 and scheduler know. I informed nurses that we were down a NA, and they would have to pitch in and assist today. The two NA's did not venture to help and split the floor into two sections, instead of three. Residents did not get care. I have a problem with that. Our job is to take care of the residents and not separate. It's not fair. It's wrong.During an interview on 1/14/26, at 2:15 p.m. the SA met with the NHA1 and DON1 for the second time and reported the observations and interviews from the second floor. The SA reported that residents in section 209-A through 217-B, which included 12 residents, still failed to have any care provided and neglect was reported almost two hours prior.On 1/14/26, at 7:00 p.m. the NHA1 and DON1 were notified that Immediate Jeopardy was called due to the facility failing to have sufficient nursing staff to meet the needs of the residents, for 12 of 12 residents (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, and R12). The NHA1 and DON1 were provided with the Immediate Jeopardy template, and a corrective action plan was requested.On 1/15/26, at 12:57 a.m.an immediate action plan was received and accepted which included the following interventions:Facility DON, NHA, Scheduler, and Designee will review current staffing sheets for facility to ensure that adequate staff are present in the facility to meet the residents' needs.Facility will prepare and review current emergency staffing policy and procedures to determine appropriate actions in case of emergency staffing needs.Facility will review all agency staffing contracts and/or obtain and request additional agency staffing contracts as a back-up to current existing agency contracts.NHA, DON, Scheduler or Designee will be educated on how to staff the facility to meet the needs of the facility residents by 3:00 p.m. on January 15, 2026.Facility NHA, DON, Scheduler or Designee will review the current schedule to ensure adequate staff are scheduled to ensure adequate care is provided and neglect is avoided.Facility nursing staff, including agency, will be educated on meeting staffing needs for each nursing unit by 3:00 p.m. on January 15, 2026, and sign the education prior to their next working shift.The facility identified a shortage in nurse aides on the night shift on January 14, 2026. The facility immediately re-aligned the nurse aide assignments to ensure that all residents are taken care of. The facility will maintain the projected weekend ratios.The facility will hold admissions for a period of two weeks to ensure that adequate staffing is maintained for the current census.The facility will maintain the following staffing pattern to meet the needs of the residents: First floor- First shift = 2 nurses/4 nurse aidesFirst floor -Second shift = 2 nurses/3 nurse aidesFirst floor- Third shift = 1 nurse/3 nurse aidesSecond floor - First shift = 2 nurses/3 nurse aidesSecond floor- Second shift = 2 nurses/3 nurse aidesSecond floor- Third shift = 1 nurse/ 2 nurse aidesOne RN Supervisor for each shiftFacility DON/Designee will perform audits to ensure that the facility staffing meets the care needs for the residents five times a week for four weeks, then weekly for four weeks to ensure that no abuse or neglect is identified.Results of the audit will be reported to an Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee on January 15, 2026.During a SA review of the immediate action plan on 1/20/26, at 4:30 p.m. revealed the following:On 1/14/26, the facility re-aligned the nurse aide assignment for night shift assignments to ensure that all residents are taken care of.On 1/15/26, the NHA1 confirmed that the facility will not be accepting any new residents for two weeks to ensure that adequate staffing is maintained for the current census.On 1/18/26, the NHA, DON, and scheduler reviewed the current schedule and assignment sheets to identify nursing staff needs to ensure adequate staff are scheduled to provide care and neglect is avoided. The facility will maintain the staffing pattern to meet the needs of the residents as part of the plan of correction.On 1/18/26, the facility reviewed current emergency staffing policy and procedures and updated with additional information.On 1/18/26, through 1/20/26, the facility signed additional agency nursing staff contracts as a back-up to current existing agency contracts.On 1/18/26, the NHA, DON, Scheduler and Designee was educated on how to staff the facility to meet the needs of the facility.On 1/18/26, the DON/Designee performed audits to ensure facility staffing meets the care for the residents.On 1/18/26, the facility conducted an Ad Hoc QAPI meeting and provided signatures for attendees.On 1/20/26, the facility nursing staff, including agency nursing staff, was educated on meeting staffing needs for each nursing unit.Staff education was verified with dated sign-in sheets and review of all current staff and agency staff utilized in the facility having signed and/or educated over the phone as indicated.During in-person and phone interviews completed on 1/20/26, from 11:00 a.m. until 3:30 p.m. 20/44 nursing staff confirmed that they were educated in person and 1/44 staff were educated via phone. Staff were educated on that all residents must be assigned to a staff member who is working in facility and if a staff member notices that someone is missing, notify supervisor and assignments will be changed to ensure all residents are cared for. Staff were also educated on the facilities, abuse and neglect policies, definition, the kinds of abuse and were given verbal examples of what abuse and neglect would be considered. Staff were educated on when to report allegations of abuse and neglect. All staff educated in person signed the education sheet. 43/44 nursing staff members were educated. All other staff will be educated prior to their next shift and sign the education sheet.During an interview on 1/20/26, at 2:28 p.m. NA Employee E17 stated, I was educated on abuse and neglect. If there are not enough staff, they will change assignments, so all residents are taken care of. It doesn't matter if I'm assigned to them or not, their needs and care come first.During an interview on 1/20/26, at 2.42 p.m. NA Employee E18 stated, I was educated on staff to residents. Assignments are made to make sure that all residents are cared for.During an interview on 1/20/26, at 2:51 p.m. NA Employee E19 stated, I have been educated on abuse and neglect. If you see a section short, make sure everyone is reassigned to a resident.Verification of the facility's Corrective Action Plan revealed all elements of plan were met. The Immediate Jeopardy was lifted on 1/20/26, at 5:51 p.m. NHA2 was made aware.During an interview on 1/14/26, at 2:15 p.m. the NHA1 and DON1 confirmed that the facility failed to have sufficient nursing staff to provide nursing related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, which created an Immediate Jeopardy situation for 12 of 12 residents residing on one of two halls (West Hall) for Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, and R12). This failure created an immediate jeopardy situation by potentially putting residents at risk of harm or injury.28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 211.12(d)(1)(4)(5) Nursing services

Based on review of facility policy, clinical records, staff interviews, resident interviews, and observations it was determined that the facility failed to ensure that residents were free from neglect and failed to timely and effectively manage 12 allegations of resident neglect, which created an Immediate Jeopardy situation for 12 of 12 residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, and R12). Findings include:Review of facility Abuse, Neglect, Mistreatment policy dated 9/22/25, indicated the facility prohibits the mistreatment, neglect, and abuse of residents and misappropriation of resident property by anyone including staff, family, friends, etc. The facility has designed and implemented processes, which stive to ensure the prevention and reporting of suspected or alleged resident abuse, neglect, mistreatment, and misappropriation of property. The facility must provide a safe resident environment and protect residents from abuse and neglect. The administrator and Director of Nursing are responsible for investigating and reporting. Upon receiving an incident or abuse, neglect, misappropriation of resident property, an investigation will be conducted.Neglect is defined as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress.During a tour of the second-floor nursing floor on 1/14/26, at 11:55 a.m. Nurse Aide (NA) Employee E1 stated, There are only two NA's on the floor, the third one didn't show up. We have told management. The Administrator, the Director of Nursing (DON), and the supervisor. Those people down that hall haven't been touched since probably overnight shift. When State Agency (SA) clarified what hallway, the NA Employee E1 pointed to the [NAME] Hall, Third Assignment (Resident rooms 209-A through 217-B).During a review of facility provided documentation, labeled Daily Assignment Sheets, on 1/14/26, at 12:05 p.m. revealed that the assignment labeled West, Rooms 209-A through 217-B were assigned to a NA who failed to show up for scheduled work shift and the assignment was not reassigned to another staff member.Review of residents in section 209-A through 217-B revealed that twelve residents reside in that section and need assistance with Activities of Daily Living. During an interview on 1/14/26, at 12:11 p.m. Licensed Practical Nurse (LPN) Employee E2 stated, When I found out we didn't have a third NA, I talked to the supervisor. She said the nurses will need to help the NA's. I told her I can't help today; I can barely walk. No care has been done since overnight shift. No baths, no showers, no incontinence care, no repositioning, residents have not gotten out of bed.During an interview on 1/14/26, at 12:14 p.m. Registered Nurse Employee E6 stated, I offered to help them but LPN Employee E2 said she isn't helping because that's why she became a nurse. She doesn't want to help me. I'm just a cart nurse today.During an interview on 1/14/26, at 12:26 p.m. the SA met with the Nursing Home Administrator (NHA)1 and DON1 and reported the observations and interviews from the second floor. The SA informed and reported 12 allegations of neglect to the NHA1 and DON1 at this time.Observations of residents on January 14, 2026, at 12:50 p.m. revealed all residents in section 209-A through 217-B were in their bed with a disheveled appearance.Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE].Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/3/26, indicated diagnoses of high blood pressure, depression, and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time).During an observation on 1/14/26, at 12:59 p.m. Resident R1 was lying in bed.During an interview on 1/14/26, at 1:00 p.m. Resident R1 stated, The nurse came in this morning for medication. Nobody else has been in to check on me or to see if I need anything. I wanted to talk to the nurse practitioner and had to go find someone to ask to see her. I wish someone would have come into my room.Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE].Review of Resident R7's MDS dated [DATE], indicated diagnoses of diabetes, depression, and asthma (condition where the airways narrow and swell).During an observation on 1/14/26, at 1:06 p.m. Resident R7 was lying in bed with a night gown on.During an interview on 1/14/26, at 1:07 p.m. Resident R7 stated, The NA just got me towels to get cleaned up. Nobody has been in today to check on me.Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE].Review of Resident R2's MDS dated [DATE], indicated diagnoses of high blood pressure, anxiety, and gastroesophageal reflux disease (GERD) (a condition where stomach acid frequently flows back into the throat).During an observation on 1/14/26, at 1:08 p.m. Resident R2 was lying in bed with a night gown on.During an interview on 1/14/26, at 1:09 p.m. Resident R2 stated, I need to get cleaned up. So far, I haven't gotten cleaned up. Nobody has been in the check on me.Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE].Review of Resident R3's MDS dated [DATE], indicated diagnoses of diabetes, hemiplegia (paralysis on one side of the body), and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain).During an observation on 1/14/26, at 1:12 p.m. Resident R3 was lying in bed with a nightgown on.During an interview on 1/14/26, at 1:13 p.m. Resident R3 stated, Nobody has been in to clean me up. No one has changed by brief since last night. I asked about getting up when someone brought my lunch tray in but they said no one came in to work so they couldn't get me up. I would like to get up and move around. My bottom is somewhat sore. I haven't had any cream on because I haven't been changed.Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE].Review of Resident R8's MDS dated [DATE], indicated diagnoses of high blood pressure, depression, and arthritis (inflammation of one or more joints, causing pain and stiffness).During an observation on 1/14/26, at 1:18 p.m. Resident R8 was resting her eyes closed in bed with a night gown on.Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE].Review of Resident R4's MDS dated [DATE], indicated diagnoses of cerebral infarction, depression, and Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking).During an observation on 1/14/26, at 1:19 p.m. Resident R4 was lying in bed with a night gown on.During an interview on 1/14/26, at 1:20 p.m. Resident R4 stated, No one has been into clean me up today. My brief hasn't changed and it needs to be changed. Nobody has been in to check on me.Review of the clinical record indicated Resident R9 was admitted to the facility on [DATE].Review of Resident R9's MDS dated [DATE], indicated diagnoses of high blood pressure, depression, and heart failure (a progressive heart disease that affects pumping action of the heart muscles).During an observation on 1/14/26, at 1:21 p.m. Resident R9 was lying in bed with a night gown on.During an interview on 1/14/26, at 1:22 p.m. Resident R9 stated, Nobody has been in the check on me today. I need towels, and wash towels to wash up but nobody has been in. I wasn't able to get cleaned up today.Review of the clinical record indicated Resident R10 was admitted to the facility on [DATE]. Review of Resident R10's MDS dated [DATE], indicated diagnoses of heart failure, coronary artery disease (damage or disease in the heart's major blood vessels), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life).During an observation on 1/14/26, at 1:25 p.m. Resident R10 was sitting at the side of bed with a night gown on.During an interview on 1/14/26, at 1:26 p.m. Resident R10 stated, I haven't gotten up yet. I haven't gotten cleaned up. It seems like they expect me to do it, but I can't. I had diarrhea yesterday. I need to be cleaned. Nobody has been in to check on me.Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE].Review of Resident R5's MDS dated [DATE], indicated diagnoses of diabetes, difficulty in walking, and osteomyelitis (an infection in the bone).During an observation on 1/14/26, at 1:28 p.m. Resident R5 was sitting in bed with a night gown on.During an interview on 1/14/26, at 1:29 p.m. Resident R5 stated, I'm still in my night gown. No one has been into help me. I need help. I can't get up myself. I have had diarrhea and I have been soiled since early this morning. I kept ringing my call bell and someone came in and said they didn't have an NA. No one else has been in. My bottom gets a little raw and I make sure they put cream on, but nobody's been in today.Review of the clinical record indicated Resident R11 was admitted to the facility on [DATE].Review of Resident R11's MDS dated [DATE], indicated diagnoses of high blood pressure, diabetes, and paraplegia (loss of motor and sensory function in the lower half of the body).During an observation on 1/14/26, at 1:35 p.m. Resident R11 was lying in bed with a night gown on.During an interview on 1/14/26, at 1:36 p.m. Resident R11 stated, No one has cleaned me up today. My brief hasn't been changed today. I need changed. It's been soiled all day. I usually get cream put on but I haven't gotten it today.Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE].Review of Resident R6's MDS dated [DATE], indicated diagnoses of high blood pressure, peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and cerebral infarction.During an observation on 1/14/26, at 1:37 p.m. Resident R6 was lying in bed with a night gown on.During an interview on 1/14/26, at 1:38 p.m. Resident R6 stated, I haven't been cleaned up today.Review of the clinical record indicated Resident R12 was admitted to the facility on [DATE].Review of Resident R12's MDS dated [DATE], indicated diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), muscle weakness, and depression.During an observation on 1/14/26, at 1:41 p.m. Resident R12 was resting in bed with eyes closed, with a night gown on.During an observation on 1/14/26, at 1:42 p.m. RN Employee E6, LPN Employee E2, and NA Employee E1 were at the nurse's station talking amongst themselves.During an interview on 1/14/26, at 1:43 p.m. LPN Employee E2 stated I don't have a problem pitching in, but it seems like we are pushed to the side up here. No one from downstairs came up to help us. I just can't do care. I'm not good with care now. The whole section hasn't had a NA all day. No care has been provided yet. Incontinence care has not been done. Some people have not been repositioned. I feel very bad. When asked what could happen when care is not provided, LPN Employee E2 replied, Skin breakdown can happen, they feel like no one cares. I know some want to get up but they haven't been gotten up.During an interview on 1/14/26, at 1:49 p.m. RN Employee E6 stated, I am the nurse on the unit. I'm not the supervisor. I function as a nurse on the cart. Even though I am in a different hall, there is no reason to let residents go. I offered to help LPN Employee E2 but she said she doesn't want to. When asked what could happen when care is not provided, RN Employee E6 replied, we need to help each other. Nothing has been done today. Lots of things could happen such as ulcers. They are being neglected. There could be a situation in the room and wouldn't know it. They might not be breathing and we wouldn't know.During an interview on 1/14/26, at 1:55 p.m. NA Employee E1 stated, That section didn't have a NA assigned after someone didn't show up for work. No morning care was done, no baths or showers, no one has been gotten out of bed, no teeth brushed, and no incontinent care has been done. When asked what could happen when care is not provided, NA Employee E1 replied, they can break down. Skin is at risk. Pressure sores can happen.During an interview on 1/14/26, at 1.58 p.m. NA Employee E4 stated, Residents in Section 209-A through 217-B were not taken care of today, that includes bathing, showering, dressing, getting out of bed, teeth brushing, changing. When asked what could happen when care is not provided, NA Employee E4 replied, Its neglect. They can get bed sores and start to lose mobility.During an interview on 1/14/26, at 2:05 p.m. RN Employee E3 stated, One NA did not show up on the second floor. I was made aware and started making calls. I let the DON1 and scheduler know. I informed nurses that we were down a NA, and they would have to pitch in and assist today. The two NA's did not venture to help and split the floor into two sections, instead of three. Residents did not get care. I have a problem with that. Our job is to take care of the residents and not separate. It's not fair. It's wrong.During an interview on 1/14/26, at 2:15 p.m. the SA met with the NHA1 and DON1 for the second time and reported the observations and interviews from the second floor. The SA reported that residents in section 209-A through 217-B, which included 12 residents, still failed to have any care provided and neglect was reported almost two hours prior.On 1/14/26, at 7:00 p.m. the NHA1 and DON1 were notified that Immediate Jeopardy was called due to resident neglect of 12 residents that was reported twice on 1/14/26, for Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, and R12 at 12:26 p.m. and again at 2:15 p.m. The NHA1 and DON1 were provided with the Immediate Jeopardy template, and a corrective action plan was requested.On 1/15/26, at 12:57 a.m. an immediate action plan was received and accepted which included the following interventions:All residents will be assessed and a full body head to toe skin check will be performed for any indications of skin concerns. Any identified concerns will be immediately addressed; findings will be documented in resident's medical records and attending physician and responsible parties will be notified of adverse findings.Facility Medical Director, attending physician for resident (if different from Medical Director), and responsible party for resident will be notified of the neglect that was identified on 1/14/26, as well as any potential indications of skin concerns or ill effects secondary to alleged neglect.Report will be called into Adult Protective Services. Department of Health event report will be completed and applicable PB22's.Resident care plans will be updated as applicable to reflect changes as identified.Facility NHA, DON, Scheduler and/or Designee will review the current schedule and ensure adequate staff are scheduled to ensure that care is provided to avoid neglect.All current nursing staff, including agency, will be educated on facility policy for abuse and neglect by 3:00 p.m. January 15, 2026, and sign the education prior to their next working shift.DON/Designee will conduct audits for resident care needs five times a week for four weeks, then weekly for four weeks to ensure that no abuse or neglect is identified.Results of the audit will be reported to Ad Hoc Quality Assurance Performance Improvement (QAPI) committee on January 15, 2026.During a SA review of the immediate action plan on 1/20/26, at 4:00 p.m. revealed the following:On 1/16/26, all residents were assessed and skin evaluations were completed and documented in residents' medical records. No negative outcomes were identified.On 1/16/26, responsible parties were made aware of the neglect that was identified on 1/14/26.On 1/16/26, Department of Health event report was completed by NHA1.On 1/17/26, Medical Director was made aware of the neglect that was identified on 1/14/26.On 1/18/26, Adult Protective Service were notified of 12 allegations of neglect that were identified on 1/14/26.On 1/18/26, the DON, scheduler, designee reviewed current schedule, identified areas that need more staff to meet the needs of the residents, and reviewed assignment sheets to avoid neglect.On 1/18/26, DON/designee started audits to ensure that no neglect was identified.On 1/18/26, Ad Hoc QAPI meeting was held and signatures provided that attended meeting.On 1/19/26, resident care plans were updated to reflect resident neglect, outcomes, and interventions were completed for the 12 residents that were neglected.On 1/19/26, current nursing staff, including agency, educated on abuse and neglect policy. Staff will sign the education prior to their next working shift if education isn't completed in person.Staff education was verified on 1/20/26, with dated sign-in sheets and review of all current staff and agency staff utilized in the facility having signed and/or educated over the phone as indicated.During in-person and phone interviews completed on 1/20/26, from 11:00 a.m. until 3:30 p.m. 20/44 nursing staff confirmed that they were educated in person, and 1/44 staff were educated via phone. Staff were educated on the facilities, abuse and neglect policies, definition, the kinds of abuse and were given verbal examples of what abuse and neglect would be considered. Staff were educated on when to report allegations of abuse and neglect. They were also educated that all residents must be assigned to a staff member who is working in facility and if a staff member notices that someone is missing, notify supervisor and assignments will be changed to ensure all residents are cared for. All staff educated in person signed the education sheet. 43/44 nursing staff members were educated. All other staff will be educated prior to their next shift and sign the education sheet.During an interview on 1/20/26, at 2:28 p.m. NA Employee E17 stated, I was educated on abuse and neglect. If there are not enough staff, they will change assignments, so all residents are taken care of. It doesn't matter if I'm assigned to them or not, their needs and care come first.During an interview on 1/20/26, at 2.42 p.m. NA Employee E18 stated, I was educated on staff to residents. Assignments are made to make sure that all residents are cared for.During an interview on 1/20/26, at 2:51 p.m. NA Employee E19 stated, I have been educated on abuse and neglect. If you see a section short, make sure everyone is reassigned to a resident.Verification of the facility's Corrective Action Plan revealed all elements of plan were met. The Immediate Jeopardy was lifted on 1/20/26, at 5:51 p.m. NHA2 was made aware.During an interview on 1/14/26, at 2:15 p.m. the NHA1 and DON1 confirmed that the facility failed to ensure that residents were free from neglect and failed to timely and effectively manage 12 allegations of resident neglect, which created an Immediate Jeopardy situation for 12 of 12 residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, and R12). This failure created an immediate jeopardy situation by potentially putting residents at risk of harm or injury.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(d)(1)(3)(e)(1) Management.