Every finding on record at Sugar Creek Care Center

Based on review of facility policies, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards of food safety in two of two unit pantries (East and West); and failed to maintain sanitary conditions in one of two resident refrigerators (East Pantry). Findings include: Review of facility policy entitled, Equipment Temperature Logs with a policy review date of 7/7/26, indicated the dining services manager will be responsible for implementing daily equipment logs to ensure quality and optimal function of food service equipment; the dining service manager will use the refrigeration and freezer temperature log to record the temperatures of all refrigerators and freezers on a daily basis. Review of facility policy entitled, Use and Storage of Food and beverage brought in for Residents with a policy review date of 7/7/26, indicated that It is the policy of this facility to provide safe and sanitary storage, handling, and consumption of all food including food and fluids brought to residents by family and other visitors; follows proper sanitation and food handling practices to prevent the outbreak of food borne illness; Safe food handling for the prevention of foodborne illnesses begins when food is received from the vendor and continues throughout the facility's food handling processes; All refrigerators will be at or below 41 degrees Fahrenheit, freezers will be cold enough to keep foods frozen solid to touch; Facility staff will be appointed to check resident refrigerators for proper temperatures. Observations on 8/25/26, at 12:15 p.m. of the [NAME] Pantry Resident Refrigerator/Freezer revealed thermometers inside to monitor the refrigerator and freezer temperatures. Further observation also revealed a paper temperature log sheet taped to the door that showed recorded temperatures for 8/11/26 and 8/12/26 and all other dates were blank. Observation of the Med Pass Refrigerator on the [NAME] Unit revealed a paper temperature log sheet taped to the door that showed recorded temperatures for 4/26/26 and 4/27/26 and all other dates were blank. Observations of the East Pantry Resident Refrigerator/Freezer revealed thermometers inside to monitor the refrigerator and freezer temperatures and a brown sticky substance on the top shelf and base of the refrigerator. Further observation also revealed a paper temperature log sheet taped to the door that showed recorded temperatures for 8/11/26 and 8/12/26 and all other dates were blank. Observation of the Med Pass Refrigerator on the East Unit revealed a paper temperature log sheet taped to the door that showed recorded temperatures for 8/11/26 and 8/12/26 and all other dates were blank. During an interview on 8/25/26, at the time of observation, the Dietary Manager confirmed that temperature monitoring was not being completed daily in the month of August 2026 for the refrigerators and freezers in the East and [NAME] Unit Pantries. He/she also confirmed that the resident refrigerator in the East Unit Pantry was dirty and should be clean and that temperature logs should be completed daily for all the unit refrigerators and freezers. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on review of review of facility policies and clinical records, and resident and staff interviews, it was determined that the facility failed to ensure that the resident and/or resident representative was offered the opportunity to participate in the development, review, and/or revision of their person-centered care plan for one of 24 residents reviewed (Resident R31).Findings include: Facility policy dated 7/7/26, entitled Care Planning - Interdisciplinary Team revealed The IDT (interdisciplinary team) includes but is not limited to.the resident and/or the resident's representative. The policy further revealed that the resident, the resident's family and/or the resident's legal representative / guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. If it is determined that the participation of the resident or representative is not practicable for development of the care plan, an explanation is documented in the medical record. Facility policy dated 7/7/26, entitled Care Plan, Comprehensive Person-Centered revealed The IDT in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The policy further revealed that each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care and that the resident is informed of his or her right to participate in his or her treatment and provided advance notice of the care planning conferences. Resident R31's clinical record revealed an admission date of 4/11/26, with diagnoses that included Diabetes (a health condition caused by the body's inability to produce enough insulin), High Blood Pressure, and Congestive Heart Failure (CHF - a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply causing blood and fluids collect in your lungs and legs over time). During an interview on 8/25/26, at 1:36 p.m. Resident R31 revealed he/she did not recall being invited to or attending a care plan meeting. Resident R31's clinical record revealed the following MDS (Minimum Data Set - federally mandated standardized assessment conducted at specific intervals to plan resident care needs) assessment with the following Assessment Reference Date (ARD - a lookback period of time for the MDS assessment): quarterly MDS with ARD 7/4/26. Resident R31's clinical record lacked any evidence that the resident and/or resident's representative was invited to or attended a care plan meeting in conjunction with the 7/4/26, quarterly MDS. During an interview on 8/17/26, at 1:30 p.m. Social Worker confirmed that there was an MDS with an ARD of 7/4/26, and a care plan meeting should have been held with the resident and/or resident representative being invited to participate. The Social Worker further confirmed that Resident R31's clinical record lacked evidence of him/her or his/her representative being invited to attend the care plan meeting following the 7/4/26 MDS. 28 Pa. Code 201.29(a) Resident rights

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure physician's orders and residents Physician Order for Life Sustaining Treatment (POLST- a legal document specifying the resident/responsible party choices regarding life-sustaining treatments) were consistent for two of 24 residents reviewed (Residents R6 and R9).Findings include: Review of facility policy entitled Advance Directives dated [DATE], revealed The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive .The interdisciplinary team will be informed of changes and/or revocations so that appropriate changes can be made in the resident medical record and care plan. Review of Resident R6's clinical record revealed an admission date of [DATE], with diagnoses that included dementia (a progressive brain disorder that interferes with activities of daily living), atrial fibrillation (irregular heartbeat), and dysphagia (difficulty swallowing). Review of Resident R6's clinical record revealed a physician's order for DNR (do not resuscitate allow natural death). Review of Resident R6's Electronic Health Record (EHR) revealed a POLST for Full Code (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest). Review of Resident R9's clinical record revealed an admission date of [DATE], with diagnoses that included type two diabetes (the body cannot use insulin properly or make enough insulin), hypoglycemia (low blood sugar), and depression. Review of Resident R9's clinical record revealed a physician's order for DNR. Review of resident R9's EHR revealed two POLSTs for Full Code. During an interview on [DATE], at 10:11 a.m. the Director of Nursing confirmed that Residents R6 and R9's physician's orders and POLST in the EHR were not consistent. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.5(f)(i) Medical records 28 Pa. Code 211.10(c) Resident care policies

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for one of five residents reviewed for unnecessary medications (Resident R109). Findings include: Review of facility policy entitled, Antipsychotic Medication Use dated 7/7/26, revealed Diagnoses alone do not warrant the use of antipsychotic medication. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met.behavioral interventions have been documented .pertinent non-pharmacological interventions must be attempted, unless contraindicated, and documented following the resolution of the acute psychiatric situation. Review of Resident R109's clinical record revealed an admission date of 3/6/26, with diagnoses that included dementia (a progressive brain disorder that interferes with activities of daily living), hypertension (high blood pressure), and anxiety. The clinical record revealed that on 7/23/26, Resident R109's physician ordered Lorazepam (medication ordered to treat anxiety) 0.5 milligrams (mg) every 8 hours PRN for anxiety. Review of the July 2026 and August 2026 medication administration record for Resident R109 revealed that the PRN Lorazepam was used on 7/23/26, 7/24/26, 7/25/26, 7/27/26, 7/30/26, 7/31/26, 8/2/26, 8/3/26, 8/5/26, 8/6/26, 8/9/26, 8/11/26, 8/12/26, 8/13/26, 8/14/26, 8/15/26, 8/16/26, 8/17/26, 8/18/26, 8/19/26, 8/24/26, 8/25/26, and 8/26/26. Review of clinical record and progress notes revealed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam for the administrations listed above. During an interview on 8/27/26, at 2:37 p.m., the Director of Nursing confirmed that Resident R109's clinical record lacked evidence that non-pharmacological interventions were attempted prior to the PRN administration of psychotropic medications.28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) for one of three residents reviewed for hospitalization (Resident R38). Findings include: Facility policy entitled Bed-holds and Returns dated 7/7/26, revealed that all residents / representatives are provided written information regarding the facility bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents are provided written information about these policies at least twice: well in advance of any transfer (admission packet) and at the time of transfer, or is the transfer was an emergency, within twenty-four hours. Resident R38's clinical record revealed an admission date of 12/14/24, with diagnoses that included Parkinson's Disease (a movement disorder of the nervous system that may result in tremors, stiffness, slowing of movement, and trouble with balance that worsens over time), Diabetes (a health condition caused by the body's inability to produce enough insulin), and Osteoarthritis (Occurs when protective cartilage that cushions the ends of the bones wears down over time leading to pain, stiffness, and reduced mobility. Commonly affected joints include the hands, knees, hips, and spine) of the right knee. Resident R38's clinical record revealed a progress note dated 10/9/25, and again 7/28/26, indicating transfers and admission to the hospital. Resident R38's clinical record lacked evidence indicating that Resident R38 and/or his/her representative were provided with a copy of the facility bed-hold policy upon transfer or within twenty-four hours of transfer. During an interview on 8/28/26, at 12:44 p.m. the Director of Nursing (DON) confirmed that Resident R38's clinical record lacked evidence that the resident and/or their representative were provided with a copy of the facility bed-hold policy upon transfer or within twenty-four hours of transfer. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c.3)(2) Resident rights

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to promote cleanliness and help prevent the spread of infection regarding respiratory care equipment for one of three residents reviewed for respiratory equipment (Resident R52). Findings include: Review of facility policy entitled Oxygen Administration dated 7/7/26, indicated the purpose of this procedure is to provide guidelines for safe oxygen administration; check the mask, tank, humidifying jar, etc., to be sure they are in good working order. Review of facility policy entitled Cleaning and Disinfection of Resident-Care Items and Equipment dated 7/7/26, indicated Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Centers for Disease Control and Prevention) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens standard. Resident R52's clinical record revealed an admission date of 7/8/26, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), Diabetes (a health condition caused by the body's inability to produce enough insulin), and high blood pressure. Resident R52's clinical record revealed a physician's order dated 8/14/26, for oxygen at 2 to 3 liter per min (lpm) to maintain O2 (oxygen) sat (saturation level) greater than 90 via Nasal Cannula (a thin tube with two prongs that fit in a residents nostrils to deliver oxygen) or mask. Observation on 8/25/26, at 2:00 p.m. revealed Resident R52 sitting in his/her wheelchair with supplemental oxygen in place and the oxygen concentrator liter flow set at 3 lpm via Nasal Cannula. Further observation of the concentrator filter on the top of the oxygen concentrator revealed a large amount of a gray fluffy substance covering the entire filter. During an interview on 8/25/26, at 2:15 p.m. Licensed Practical Nurse Employee E1 confirmed that Resident R52's oxygen concentrator filter contained a large amount of gray dusty substance and should be cleaned. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, manufacturer's guidelines, observations, and staff interviews, it was determined that the facility failed to ensure that medications were properly dated when opened and failed to ensure expired medications were discarded in a timely manner in two of three medication carts reviewed (600-hall medication cart and 300-hall medication cart). Findings include: Review of a facility policy entitled Medication Beyond Use Dating dated 7/7/26, indicated that, All medications will have a beyond use (expiration) date on the medication container. Review of a facility policy entitled Storage of Medications dated 7/7/26, indicated that, The facility stores all drugs and biologicals in a safe, secure, and orderly manner.The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Manufacturer guidelines for budesonide inhalation suspension (a medication used for those with breathing problems by reducing inflammation, chest tightening, wheezing, and coughing), indicated that the inhalation ampules can be stored for two weeks after opening the protective aluminum foil envelope and if not used within two weeks after opening the inhalation ampules should be discarded. Manufacturer guidelines for artificial tears indicate that the eye drops must be thrown away 28 days after they have been opened. Manufacturer guidelines for fluticasone furoate inhalation powder (an inhaler used as a maintenance to reduce inflammation in the airway for individuals with breathing problems), indicate that the use by date is six weeks after the inhaler tray is opened. Manufacturer guidelines for NovoLog insulin (a fast-acting insulin used to manage blood sugar levels in people with diabetes), indicated that after opened vials and pre-filled pens should be discarded after 28 days. Observation on 8/25/26, at 1:59p.m. of the 600-hall medication cart revealed an open foil envelope with budesonide inhalation suspension ampules inside without an open date, therefore staff were unable to determine the discard date and two bottles of artificial tears one with an open date of 7/11/26, and the other with an open date of 7/25/26, therefore the medication was expired. During an interview at that time, Licensed Practical Nurse (LPN) Employee E7 confirmed that the inhalation suspension foil lacked an open date and that the two bottles of artificial tears were expired. Observation on 8/25/26, at 2:21 p.m. of the 300-hall medication cart revealed an open injector pen of Novolog insulin and a fluticasone furoate inhaler without an open date, therefore staff were unable to determine the discard date, and two open bottles of artificial tears, one with an open date of 2/13/26, and the other with an open date of 7/21/26, therefore the medication was expired. During an interview at that time LPN Employee E8 confirmed that the injector pen of insulin and inhaler lacked an open date, and that the two bottles of artificial tears were expired. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure urinary output was documented per physician's orders in the Treatment Administration Record (TAR) for one of five residents reviewed with foley catheters (a medical device that drains urine from the bladder) (Resident R9).Findings include: The facility policy entitled Charting and Documentation dated 7/7/26, revealed The following information is to be documented in the resident medical record.Treatments or services performed. Review of Resident R9's clinical record revealed an admission date of 3/22/25, with diagnoses that included benign prostatic hyperplasia with lower urinary tract symptoms (a noncancerous enlargement of the prostate gland that interferes with the urinary tract), type two diabetes (the body cannot use insulin properly or make enough insulin), hypoglycemia (low blood sugar), and depression. Review of Resident R9's physician's orders dated 5/17/25, revealed an order to document foley output every shift. Review of Resident R9's TAR which is completed by the Licensed Nurses for July 2026, and August 2026 revealed his/her urinary output were not documented every shift per physician's orders on 7/1/26, 7/8/26, 7/14/26, 7/2026, 7/25/26, 7/29/26, 8/3/26, 8/4/26, 8/6/26, 8/16/26, 8/17/26, 8/20/26, 8/21/26, and 8/25/26 During an interview on 8/27/26, at 2:37 p.m. the Director of Nursing confirmed that the clinical record lacked evidence that the TAR documentation was completed per physician's orders for urinary output for Resident R9 on the dates listed above. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, facility records, and staff interview, it was determined that the facility failed to ensure required attendance of the Infection Preventionist to Quality Assurance and Performance Improvement (QAPI) Committee meetings for one of four quarters reviewed (Quarter one).Findings include: Review of facility policy entitled, Quality Assurance and Performance Improvement Program dated 7/7/26, revealed The following individuals serve on the committee.Infection Preventionist.The committee meets at least quarterly (or more often as necessary). Committee members are reminded of meeting day, time and location via e-mail at least two business days prior to the meeting. Review of the QAPI Committee Attendance Records for Quarter one revealed three attendance sign-in sheets (1/26/26, 2/23/26, and 3/30/26) for the required quarterly meetings did not have an Infection Preventionist in attendance. During an interview on 8/28/26, at 12:30 p.m. the Nursing Home Administrator confirmed that the attendance sheets on the dates listed above lacked evidence that the Infection Preventionist was present for the QAPI Committee meetings as required for Quarter one. 28 PA Code 201.18(e)(1)(2)(3) Management

Based on review of facility policy, job descriptions, clinical records, observations, and staff interviews, it was determined that the facility failed to answer a call bell appropriately to provide care and services that are resident centered and failed to uphold professional standards of practices to promote the physical and mental well-being to meet the needs for one resident (Resident R1).Findings include: Review of facility policy entitled, Answering the Call Light dated 7/7/26, indicated, .Answer the resident call system immediately. When answering an auditory request for assistance, identify yourself and politely respond to the resident by his/her name.If the resident's request requires another staff member, notify the individual.If the resident's request is something you can fulfill, complete the task within five minutes if possible. Review of facility job descriptions for a Nursing Assistant (NA) indicated, .Assist resident with bowel and bladder functions.Assist with lifting, turning, moving, positioning, and transporting residents into and out of beds, chairs, bathtubs, wheelchairs, lifts, etc.Answer resident calls promptly. Check each resident routinely to ensure that his/her personal care needs are being met in accordance with his/her wishes. Resident R1's clinical record revealed an admission date of 9/5/2020, with diagnoses that include spastic hemiplegia affecting left non-dominant side (a neuromuscular condition where one side of the body experiences muscle stiffness, weakness, and impaired movement), need for assistance with personal care, and muscle weakness. Review of Resident R1's plan of care revealed an Activities of Daily Living care plan indicating that Resident R1 is to utilize his/her call bell for assistance and a Limited Mobility care plan indicating that Resident R1 requires a lift with an assist of two for transfers. Observations made on 7/20/26, revealed that Resident R1's call bell was activated at approximately 10:56 a.m. and after 10 minutes it was observed that the call bell had been deactivated. At approximately 11:07 a.m. the call bell was reactivated and after three minutes it was observed that the call bell had been deactivated. At approximately 11:10 a.m. the call bell was reactivated, and it was immediately deactivated. Interview conducted on 7/20/26, at approximately 11:12 a.m. with NA Employee E1 revealed that he/she had been deactivating Resident R1's call bell from the nurses' station without going to Resident R1's room to determine what Resident R1 needed. NA Employee E1 indicated that his/her hall partner was on break and that Resident R1 is an assist of two. Observations made on 7/20/26, at approximately 11:29 a.m. revealed that Resident R1's call bell was activated and NA Employee E2 responded at 11:30 a.m. Interview conducted at that time with NA Employee E2 revealed that NA Employee E1 went to break and that he/she was waiting for Licensed Practical Nurse (LPN) Employee E3 to assist with providing care to Resident R1. Observations made on 7/20/26, at approximately 11:31 a.m. revealed NA Employee E1 and LPN Employee E3 assisting Resident R1 with care after approximately 35 minutes had lapsed from the initial activation of Resident R1's call bell. During an interview on 7/20/26, at 12:30 p.m. the Director of Nursing confirmed that the call bell was not answered appropriately to provide care and services that are resident centered and failed to uphold professional standards of practices to promote the physical and mental well-being to meet the needs for Resident R1 and that the call bell should never be deactivated at the nurses station without going to the residents room. 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.12(d)(4)(5) Nursing services

Based on review of clinical records, and staff interview, it was determined that the facility failed to have complete and accurate documentation regarding showers for four of four residents reviewed (Residents R1, R2, R3, and R4).Findings include: Review of facility policy entitled Bath, Shower/Tub dated 1/20/26, indicated Documentation: The date and time the shower/tub bath was performed. The name and title of the individual(s) who assisted the resident with the shower/tub bath. Review of facility policy entitled Activities of Daily Living (ADLs), Supporting dated 1/20/26, indicated Appropriate care and services will be provided for residents who are unable to carry out ADLs [activities of daily living] independently. including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care). Review of Resident R1's clinical record revealed an admission date of 1/14/15, with diagnoses that included diabetes (a health condition that is caused by the body's inability to produce enough insulin), and hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones). Review of Resident R1's shower task (an area in point of care where the nursing assistants document showers) for the months of February 2026, and March 2026, lacked documentation that a shower was provided on 2/6/26, 2/20/26, 2/24/26, 3/10/26, 3/13/26, and 3/17/26. Review of Resident R2's clinical record revealed an admission date of 2/16/26, with diagnoses that included diabetes, and hypertension (high blood pressure). Review of Resident R2's shower task for the months of February 2026, and March 2026, lacked documentation that a shower was provided on 2/16/26, 2/19/26, 2/23/26, 3/2/26, 3/5/26, and 3/9/26. Review of Resident R3's clinical record revealed an admission date of 9/26/25, with diagnoses that include hypertension and gastro esophageal reflux disease (a condition when stomach acid repeatedly flows back up into your throat). Review of Resident R3's shower task for the months of February 2026, and March 2026, lacked documentation that a shower was provided on 2/11/26, 2/14/26, 2/18/26, 2/21/26, 2/25/26, 3/4/26, 3/11/26, 3/14/26, and 3/18/26. Review of Resident R4's clinical record revealed an admission date of 1/30/26, with diagnoses that included Parkinson's (a progressive disorder that affects movement), overactive bladder, and diabetes. Review of Resident R4's shower task for the month of February 2026, lacked documentation that a shower was provided on 2/3/26, 2/6/26, 2/10/26, 2/13/26, 2/17/26, 2/20/26, and 2/24/26. During an interview on 3/20/26, at 10:23 a.m. the Director of Nursing (DON) confirmed that Resident's R1, R2, R3, and R4's clinical record did not have complete documentation regarding showers. The DON also confirmed that showers should be done as scheduled in the resident's task and documented when completed. 28 Pa. Code 211.5(f)(ix) Medical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to have complete and accurate documentation regarding physician's orders for a gastrostomy (G-tube-tube placed in the stomach for feedings and fluids) for one of three residents reviewed with a G-tube. (Resident R1). Findings include: Review of facility policy entitled Telephone Orders dated 6/4/25, indicated the order must be recorded in the residents clinical record . Review of Resident R1's clinical record revealed an admission date of 8/21/25, with diagnoses that included spastic quadriplegic cerebral palsy (most severe type of cerebral palsy causing severe stiffness and poor control of all limbs, trunk and face due to brain damage), intellectual disabilities, and diabetes (a health condition that is caused by the body's inability to produce enough insulin). Review of Resident R1's nurse's notes dated 12/01/25, indicated that the G-tube was flushed with a 50/50 mix of hydrogen peroxide and water as instructed. Review of Resident R1's current physician's orders, lacked an order dated 12/01/25, to administer a one-time flush with a 50 cubic centimeter (cc) of hydrogen peroxide and 50 cc of hot water to clear clogged G-tube. During a telephone interview on 12/22/25, at 12:29 p.m. the Medical Director confirmed that he did give a telephone verbal order for one time flush with 50 cc of hydrogen peroxide and 50 cc of hot water to unclog Resident R1's G-tube and also confirmed that this was safe practice. During an interview on 12/22/25, at 2:00 p.m. the Director of Nursing confirmed that Resident R1's clinical record lacked evidence of a physician's order for the 50/50 hydrogen peroxide and water G-tube flush completed on 12/01/25. 28 Pa. Code 211.5(f)(i) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of facility policy, clinical and facility records, resident and staff interviews, and observations, it was determined that the facility failed to provide a bath/shower as resident preference for four of 13 residents (Resident R1, R2, R3, and R4) and failed to assure residents attain or maintain the highest practicable mental and psychosocial well-being by not serving meals in the dining room and having group activities for six of 13 residents (Residents R1, R4, R6, R7, R8, and R9). Findings include:No facility policy was provided for showers.Review of a facility policy entitled Coronavirus Disease dated 6/04/25, indicated The interdisciplinary team reviews an outbreak to see if they should refrain from communal activities. This should be reviewed on a daily basis so it can be lifted as soon as the spread of the infection is determined to have slowed. Resident's R1's clinical record revealed an admission date of 9/05/20, with diagnoses that included spastic hemiplegia affecting left nondominant side (a neuromuscular condition causing constant muscle contractions on the side of the body leading to stiffness, weakness, and limited movement), depression, anxiety, and need for assistance with personal care. Resident R1 ' s bath/shower documentation for 10/09/25, through 11/07/25, revealed he/she was scheduled for a bath/shower on Tuesday/Friday 7-3 p.m., however, no bath/shower was provided on the following dates: 10/10/25, 10/14/25, 10/17/25, 10/21/25, 10/24/25, 10/28/25, and 10/31/25.Resident's R2 ' s clinical record revealed an admission date of 3/07/23, with diagnoses that included high blood pressure, chronic kidney disease, coronary artery disease (a condition where the arteries to the heart becomes narrowed or blocked due to build up of plaque), and cardiac heart failure (a condition where the heart is unable to pump the blood effectively to give the body its normal supply). Resident R2 ' s bath/shower documentation for 10/09/25, through 11/07/25, revealed he/she was scheduled for a bath/shower on Wednesday/Saturday 3-11 p.m., however, no bath/shower was provided on: 10/11/2510/15/25, marked as N/A (not applicable)11/01/25, marked as N/A (not applicable).During an interview with Resident R2 on 11/05/25, at 11:00 a.m. he/she stated, I would like to have two showers or baths a week, but I ' m lucky if I get one. Resident's R3's clinical record revealed an admission date of 10/21/25, with diagnoses that included fracture of facial bones, rhabdomyolysis (a serious condition where damaged muscle tissue breaks down and releases muscle fiber content into the blood), high blood pressure, and diabetes mellitus (a condition when you blood sugar is too high due to pancreas not making or releasing enough insulin or both). Resident R3 ' s bath/shower documentation for 10/09/25, through 11/07/25, revealed he/she was scheduled for a bath/shower on Tuesday/Friday 3-11 p.m. however, no bath/shower was provided on: 10/24/25 10/28/25, marked as N/A (not applicable)10/29/25, marked as N/A (not applicable)10/30/25, marked as N/A (not applicable)10/31/25, marked as Resident not available11/01/25, marked as N/A (not applicable)11/03/25, marked as N/A (not applicable)11/04/25, marked as N/A (not applicable).During an interview with Resident R3 on 11/05/25, at 12:20 p.m. he/she stated, I ' ve only received two showers since I ' ve been here. It would feel great to get more, but it hasn ' t happened. An observation at that time revealed Resident R3 with greasy hair.Resident's R4's clinical record revealed an admission date of 12/13/24, with diagnoses that included anoxic brain damage (a type of brain injury caused by a lack of oxygen to the brain), spastic hemiplegia affecting unspecified side, long term use of anticoagulants (a medication that slows down the body ' s process of making clots), and hypothyroidism (a condition that happens when the thyroid gland doesn ' t make enough thyroid hormone to meet the body ' s needs). Resident R4 ' s bath/shower documentation for 10/09/25, through 11/07/25, revealed he/she was scheduled for a bath/shower on Monday and Thursday 3-11 p.m. however, no bath/shower was provided on: 10/20/25, marked as N/A (not applicable)10/27/25, marked as N/A (not applicable).During an interview on 11/05/25, at 1:20 p.m. Resident R4 indicated that he/she does not always get his/her bath as scheduled, and the staff tell him/her if they have time, he/she will get one. Resident R4 indicated that their preference is Monday and Thursday. An observation at that time revealed Resident R4 with greasy hair.An interview with the Nursing Home Administrator (NHA) on 11/07/25, at 1:30 p.m. confirmed showers are given per resident ' s preference and are encouraged twice a week. The NHA further confirmed that baths/showers were not provided according to Resident R1, R2, R3, and R4 ' s scheduled days and preference for the period of 10/09/25, through 11/07/25. The facility line listing report for respiratory illness on 11/12/25, revealed no new positive residents since 11/4/25, which indicated that the spread of the infection had slowed.Resident interviews on 11/5/25, between 11:35 a.m. and 12:30 p.m. with Residents R1, R4, R6, R7, R8, and R9 indicated they enjoy eating their meals in the dining room with other residents. They also indicated that they enjoy attending group activities, however the dining room and group activities have been stopped. Observations on 11/5/25, between 9:30 a.m. and 3:30 p.m. revealed residents participating in therapy, interacting with staff and ambulating throughout the facility. No observations were made of residents participating in individual activities, social distancing activities, or social distancing with meals in the dining room. During an interview on 11/5/25, at 2:40 p.m. the NHA and the Director of Nursing (DON) confirmed that the residents do not eat in the dining room or attend group activities, due to COVID in the building. 28 Pa. Code 211.10 (d) Resident care policies28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of the facility admission process and policies, observations, and staff interviews, it was determined that the facility failed to maintain resident dignity for one of two residents observed related to incontinence care (Resident R1).Findings include: Facility provided documentation of the facility ' s admission packet revealed that a resident has a right to be treated with respect and dignity. Resident rights - The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident ' s individuality. The facility must protect and promote the rights of the resident. Facility policy entitled, Perineal Care, dated 6/04/25, indicated the purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident ' s skin condition. Review the resident ' s care plan to assess for any special needs of the resident.Facility policy entitled, Activities of Daily Living (ADL), Supporting, dated 6/04/25, indicated residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Resident's R1's clinical record revealed an admission date of 9/05/20, with diagnoses that included spastic hemiplegia affecting left nondominant side (a neuromuscular condition causing constant muscle contractions on the side of the body leading to stiffness, weakness, and limited movement), depression, anxiety, and need for assistance with personal care. Resident R1 ' s care plans dated 9/03/25, revealed a plan of care for bladder incontinence related to impaired mobility with interventions to clean peri-area with each incontinence episode, and staff will provide incontinence products to contain urine, promote skin integrity and provide dignity. Observations on 11/05/25, at 9:30 a.m. revealed Resident R1 was sitting in his/her wheelchair in his/her room on his/her buttocks. Observations at 10:00 a.m., 10:40 a.m., 11:15 a.m., 11:35 a.m., 12:00 p.m., 12:10 p.m., 1:30 p.m., revealed Resident R1 remained sitting in his/her wheelchair in their room on his/her buttocks. At 1:45 p.m. Resident R1 was transferred to his/her bed and incontinence care was provided by Nursing Assistant (NA) Employee E2 and Licensed Practical Nurse (LPN) Employee E3. Resident R1 was observed with his/her incontinence briefs (two briefs) filled with feces overflowing outside of briefs and onto pants and skin of both extremities. Resident R1 ' s peri area and buttocks were observed extremely red. NA Employee E2 and LPN Employee E3 confirmed during incontinence care at 1:45 p.m. that Resident R1 should have been checked/changed every two hours, but was not due to large amount of feces overflowing the two incontinence briefs onto his/her clothing and legs, and Resident R1 had severely reddened skin from not being repositioned and checked/changed timely. NA Employee E2 and LPN Employee E3 confirmed also that having two briefs placed on a resident is not the facility ' s protocol for incontinence/prevention of skin breakdown. Interviews with Resident R1 on 11/05/25, at 10:40 a.m., 11:35 a.m., and 1:30 p.m. indicated he/she had been out of bed sitting in his/her wheelchair since 6:30 a.m. and not checked/changed or repositioned since 6:30 a.m. During an interview on 11/12/25, at 12:30 p.m. the Nursing Home Administrator (NHA), confirmed that the facility failed to maintain dignity for Resident R1 by placing two briefs on for incontinence care. The NHA further confirmed that it is not the facility ' s policy to have two briefs on a resident for incontinence care. 28 Pa. Code 211.12(d)(3)(5) Nursing services. 28 Pa. Code 211.10(d) Resident care policies

Based on review of facility policies, clinical records, and the Long Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual 2025 (RAI-assessment guide used to plan the provision of care for residents), observations, and resident and staff interviews, it was determined that the facility failed to provide care in accordance with professional standards for repositioning and pressure relief for two of two residents reviewed (Residents R1 and R5), and incontinence care for one of two residents observed (Resident R1). Findings include: Facility policy entitled Repositioning dated 6/04/25, indicated Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. and Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. Facility policy entitled, Perineal Care, dated 6/04/25, indicated the purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident ' s skin condition. Review the resident ' s care plan to assess for any special needs of the resident.Facility policy entitled, Activities of Daily Living (ADL), Supporting, dated 6/04/25, indicated residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.Resident's R1's clinical record revealed an admission date of 9/05/20, with diagnoses that included spastic hemiplegia affecting left nondominant side (a neuromuscular condition causing constant muscle contractions on the side of the body leading to stiffness, weakness, and limited movement), depression, anxiety, and need for assistance with personal care. Resident R1 ' s care plans dated 9/03/25, revealed a plan of care for potential impairment to skin integrity/potential for pressure ulcer related to fragile skin/incontinence/limited mobility, with interventions to encourage resident to be turned and repositioned for comfort and relief of pressure. Care plans for limited mobility revealed the resident has limited physical mobility related to limited mobility with interventions for the Maxi lift (a mechanical lift to move a person from a chair to bed/bed to chair) as needed for all transfers and for out of bed to chair and resident is able to complete bed mobility with a two person assist. Care plans for bladder incontinence revealed the resident has bladder incontinence related to impaired mobility with interventions to clean peri-area with each incontinence episode, and staff will provide incontinence products to contain urine, promote skin integrity and provide dignity. Resident R1 ' s MDS (Minimum Data Set) dated 9/03/25, under section GG0170 mobility revealed A. roll left and right response was 01 Dependent, E. chair to bed/bed to chair transfer response was 01 Dependent. Section H0300 urinary continence revealed the resident is frequently incontinent of urine. Section H0400 bowel continence revealed the resident is frequently incontinent of bowel. Section C0500 Brief Interview for Mental Status (BIMS) revealed that a score of 13-15 identified a resident as cognitively intact and a score of 8-12 identified a resident as moderately impaired, and a score of 0-7 as severely impaired. Resident R1 ' s BIMS is 15/15. Resident R1 ' s clinical documentation revealed a note from the wound Nurse Practitioner dated 10/23/25, indicated resident ' s wounds to be resolved and recommend applying zinc-based barrier cream to the peri sacral region at least three times daily and as needed incontinence/prevention.Observations on 11/05/25, at 9:30 a.m. Resident R1 was sitting in his/her wheelchair in his/her room on his/her buttocks. Observations at 10:00 a.m., 10:40 a.m., 11:15 a.m., 11:35 a.m., 12:00 p.m., 12:10 p.m., 1:30 p.m., Resident R1 remained sitting in his/her wheelchair in his/her room on his/her buttocks. At 1:45 p.m. Resident R1 was transferred to his/her bed and incontinence care was provided by Nursing Assistant (NA) Employee E2 and Licensed Practical Nurse (LPN) Employee E3. Resident R1 was observed with his/her incontinence briefs (two briefs) filled with feces overflowing outside of briefs and onto pants and skin of both extremities. Resident R1 ' s peri area and buttocks were observed extremely red. NA Employee E2 and LPN Employee E3 confirmed during incontinence care at 1:45 p.m. that Resident R1 should have been checked/changed every two hours, but was not due to large amount of feces overflowing the two incontinence briefs onto his/her clothing and legs, and Resident R1 had severely reddened skin from not being repositioned and checked/changed timely. NA Employee E2 and LPN Employee E3 confirmed also that having two briefs placed on a resident is not the facility ' s protocol for incontinence/prevention of skin breakdown. Interviews with Resident R1 on 11/05/25, at 10:40 a.m., 11:35 a.m., and 1:30 p.m. indicated he/she had been out of bed sitting in their wheelchair since 6:30 a.m. and not checked/changed or repositioned since 6:30 a.m. Review of Resident R5 ' s clinical record revealed an admission date of 7/2/24, with diagnoses that included Parkinson ' s (a chronic and progressive movement disorder that causes shaking, slows a person ' s ability to move and worsens over time), and peripheral vascular disease (a condition when there is restricted blood flow to the limb, usually legs).Review of Resident R5 ' s care plans revealed a plan of care for potential impairment to skin integrity, with interventions for pressure relieving cushion while up in chair. Care plan also revealed pressure ulcer and skin break down to right hip and buttock. Review of Residents R5 ' s MDS dated [DATE], under section GG0170 mobility revealed A. roll left and right response was 01 Dependent, B. sit to lying response was 01 Dependent, C. lying to sitting response was 01 Dependent, D. sit to stand response was 01 Dependent, E. chair to bed/bed to chair transfer response was 01 Dependent.Review of Resident R5 ' s physician orders revealed treatment orders for wound to right buttock and treatment orders for wound to right trochanter (hip). Review of Resident R5 ' s clinical documentation revealed a note from the wound Nurse Practitioner dated 11/05/25, indicating to continue with turning and repositioning schedule per protocol for pressure prevention.Observations on 11/05/25, at 9:30 a.m. revealed Resident R5 was sitting in his/her recliner chair in their room on his/her buttocks, and no pressure relieving cushion was on their recliner. Observations at 10:00 a.m., 10:40 a.m., 11:15 a.m., 11:35 a.m., 12:00 p.m., 12:10 p.m., 1:30 p.m. and 1:45 p.m. revealed Resident R5 remained sitting in his/her recliner in their room on his/her buttocks and no pressure relieving cushion was in place. Observations on 11/05/25, at 2:15 p.m. of incontinence care for Resident R5 revealed that he/she had an open area to his/her right buttock and his/her bilateral buttocks were red. During an interview on 11/05/25, at 2:35 p.m. Nursing Assistant Employee E2 confirmed that residents that can not reposition independently should be repositioned by staff.During an interview on 11/05/25, at 2:40 p.m. the Director of Nursing and Regional Clinical Director, confirmed that residents' pressure relieving devices should be in place and residents should be repositioned with incontinence care provided timely. It was also confirmed that it is not the facility ' s policy to have two briefs on a resident for incontinence care. 28 Pa. Code 211.12(d)(3)(5) Nursing services. 28 Pa. Code 211.10(d) Resident care policies

Based on review of facility policy and records, observations, and resident and staff interview it was determined that the facility failed to provide food that was palatable and at an appetizing temperature for one of one test trays completed. Findings include:A facility policy entitled, Meal Service Line dated 6/4/25, revealed Food will be prepared by methods that conserve nutritive value, flavor and appearance, and will be placed on trays in an attractive manner as near to the time of actual tray service as possible. This is done to ensure acceptable temperatures of food when the tray is served to the resident. Resident council and food committee minutes from 8/5/25, and 10/13/25, indicated that a toasted cheese sandwich was cold and that lunch and dinner trays on the unit are being served up to 45 minutes late. During an interview on 11/5/25, at 12:30 p.m. Resident R6 who resides on 600 Hall indicated his/her food is often served cold. Review of temperature logs completed by kitchen staff on 11/5/25, revealed the following lunch meal temperatures: Pork 170 degrees Fahrenheit (F)Baked Potatoes 170 degrees FCorn 169 degrees FObservations on 11/5/25, at approximately 11:55 a.m. in the main kitchen revealed Cart 1 for the 600 Hall had just left the kitchen. Tray line was observed for Cart 2 of the 600 Hall and a test tray was prepared last and placed on the cart. The Dietary Manager escorted the cart to the 600 Hall at 12:26 p.m. and arrived at the 600 Hall at 12:27 p.m. Cart 1 was still sitting in the hall and had not been passed to the residents. Tray pass was completed for 600 Hall Cart 1 and Cart 2 at 12:42 p.m.A test tray at the conclusion of resident room tray delivery on the 600 Hall was completed at 12:42 p.m. and revealed the following temperatures:Pork 138 degrees FBaked Potatoes 145 degrees FCorn 143 degrees FAll the items were tasted and were not palatable due to the cool temperatures. Dietary Manager Employee E4 confirmed the unacceptable temperatures and poor palatability at the time of the tray testing. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to prevent the potential for cross-contamination during completion of incontinence care (care provided for someone who has lost control of their bladder and/or bowel movements) for two of two residents observed (Residents R1 and R5). Findings include:Review of facility policy entitled Perineal Care dated 6/4/25, indicated Steps in the procedure . discard disposable items into designated containers. Review of facility policy entitled Diarrhea and Fecal Incontinence dated, 6/4/25, indicated Disposable items soiled with feces (i.e., disposable briefs .) must be handled as so to prevent contamination of the environment with feces. Observations on 11/5/25, at 1:45 p.m. revealed Nursing Assistant (NA) Employee E1, NA Employee E2, and Licensed Practical Nurse (LPN) Employee E3 completing incontinence care for Resident R1. During incontinence care NA Employee E2 removed resident R1 ' s pants and brief (a disposable incontinence pad) which was soiled (contained urine and feces). NA Employee E1 then placed the pants and brief onto the floor. After completing incontinence care NA Employee E2 picked up Resident R1 ' s pants and brief and placed them in a garbage can. Employees E1, E2 and E3 walked across the floor where the soiled pants and soiled brief had been lying.Observations on 11/5/25, at 2:15 p.m. revealed NA Employee E1 and NA Employee E2 completing incontinence care for Resident R5. During incontinence care NA Employee E1 removed resident R5 ' s pants and brief, NA Employee E1 then placed Resident R5 ' s soiled brief onto the floor. After completing incontinence care, NA Employee E1 picked up Resident R5's soiled brief and took it out of the room. Both NA Employees E1 and E2 walked across the floor where the soiled brief had been lying.During an interview on 11/5/25, at 2:35 p.m. NA Employees E1 and E2 confirmed that Resident R1 and Resident R5 ' s briefs contained urine and feces, and the soiled briefs were placed on the floor. They confirmed that they had walked across the floor where the soiled briefs had been lying, and the floor should have been sanitized after the briefs were removed. During an interview on 11/5/25, at 2:40 p.m. the Director of Nursing confirmed that soiled briefs should not be placed on the floor and that the soiled briefs should be placed in a designated container.28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure physician's orders and resident Pennsylvania Order for Life Sustaining Treatment (POLST - a legal document specifying the resident/responsible party choices regarding life-sustaining treatments) were consistent for one of 20 residents reviewed (Resident R19). Findings include:A facility policy entitled Advanced Directives dated [DATE], indicated that the plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive. Resident R19's clinical record revealed an admission date of [DATE], with diagnoses that included gastro-esophageal reflux disease (GERD - happens when stomach acid flows back up into the esophagus and causes heartburn), diabetes (a health condition caused by the body's inability to produce enough insulin), and high blood pressure. Resident R19's clinical record revealed a physician's order dated [DATE], for Full Code (staff to implement Cardiopulmonary Resuscitation [CPR] - emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest). Further review revealed additional physician's orders dated [DATE], for Full Code - POLST on file; [DATE], Living Will - see chart for instructions; and [DATE], DNR (Do not attempt resuscitation and allow natural death). Resident R19's clinical record revealed a Living Will signed and dated on [DATE], that indicated DNR and to follow if I become incompetent. Further review revealed a POLST signed and dated by Resident R19 and his/her physician on [DATE], indicating Full Code. Resident R19's clinical record revealed progress notes completed by Resident R19's physician dated [DATE], indicating he/she was a Full Code per resident. Further review revealed a progress note dated [DATE], completed by Social Services indicating The resident is no longer a full code, DNR per Living Will [DATE]. Progress note dated [DATE], by nursing indicated Resident's advanced directives updated in electronic chart to match most recent Advance directive/ living will. Progress note dated [DATE], completed by physician indicating Now DNR as of [DATE]. Progress note dated [DATE], completed by physician indicating No CPR- see POLST.During an interview on [DATE], at 2:34 p.m. Licensed Practical Nurse (LPN) Employee E3 stated each unit has a binder with each resident's face sheet and advanced directive or POLST. Review of the binder revealed Resident R19's face sheet and POLST dated [DATE], indicating Full Code were present. During an interview on [DATE], at 11:03 a.m. LPN Employee E3 revealed that the License Nurse Report sheet that included Resident R19 indicated that Resident R19 was a Full Code. LPN Employee E3 reviewed and confirmed that Resident R19's POLST dated [DATE], also indicated he/she was a Full Code, and this was the most recent document signed by Resident R19. LPN Employee E3 reviewed and confirmed that Resident R19's physician's orders indicated he/she was a DNR. LPN Employee E3 confirmed that Resident R19's physician's orders and POLST did not match. 28 Pa. Code 201.18 (b)(1)(e)(1) Management28 Pa. Code 201.29(a) Resident rights28 Pa. Code 211.5(f)(i) Medical records28 Pa. Code 211.10(c) Resident care policies

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to provide resident privacy during medication administration for one of six residents observed (Resident R107).Findings include: Review of facility policy entitled Dignity dated 6/4/25, indicated Residents are treated with dignity and respect at all times. And Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. During observation of medication administration for Resident R107 on 8/27/25, at 1:33 p.m. Licensed Practical Nurse (LPN) Employee E2 was administering medications through Resident R107's G-Tube (a tube placed in the stomach to provide nutrition). Resident R107's night gown was pulled up exposing his/her legs, incontincence care product, and stomach. Resident R107 was able to be viewed from the hallway. LPN Employee E2 failed to close the residents' door and/or pull the privacy curtain while administering medications through Resident R107's G-Tube. During an interview on 8/27/25, at 1:54 p.m. LPN Employee E2 confirmed that the door and/or privacy curtain was not closed during medication administration for Resident R107. He/she confirmed that Resident R107 was exposed and was able to be viewed from the hallway and also confirmed that Resident R107's door and/or privacy curtain should be closed during medication administration to maintain privacy. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies, clinical records, and staff interviews it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day); failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital; and failed to complete a discharge summary for four of 20 residents reviewed (Residents R1, R2, R103, and R105). Findings include: Review of facility policy entitled “Bed-Holds and Returns” dated 6/4/25, indicated “All residents/representatives are provided written information regarding the facility bed-hold policies… at the time of transfer…” Review of facility policy entitled “Discharge Summary and Plan” dated 6/4/25, indicated that when a facility anticipates a resident’s discharge to a private residence, another nursing care facility a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living arrangements. The discharge summary will include a recapitulation of the resident’s stay at the facility and a final summary of the resident’s status at the time of discharge. The policy further stated that a copy will be provided to the resident and receiving facility and a copy will be filed in the resident’s medical records. Review of facility policy entitled “Transfer or Discharge, Emergency” dated 6/4/25, indicated “Should it become necessary to make an emergency transfer… to a hospital… prepare a transfer form to send with the resident.” Resident R1’s clinical record revealed an admission date of 1/5/23, with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), obstructive and reflux uropathy (a condition that will not let the urine drain naturally), and chronic obstructive pulmonary disease (when your lungs do not have adequate air flow). Resident R1’s progress notes revealed a note dated 4/23/25, indicating a transfer to the hospital. The clinical record lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfer. Resident R2’s clinical record revealed an admission date of 12/8/22, with diagnoses that included congestive heart failure (the inability of the heart to maintain an adequate supply of blood to organs and tissues), hypertension (high blood pressure), and hyperlipidemia (high cholesterol). Resident R2’s progress notes revealed a note dated 3/14/25, indicating a transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. His/her clinical record also lacked evidence indicating that the resident and/or his/her representative were provided with a copy of the bed-hold policy upon transfer. Review of Resident R103's clinical record revealed an admission date of 6/11/25, with diagnoses that included sciatica (pain that radiates along the sciatic nerve from the lower back through the buttocks and down the back of the thigh), hypertension, and hyperlipidemia. Resident R103’s progress notes revealed a note dated 7/11/25, indicating a transfer to the hospital. The clinical record also lacked evidence indicating that the resident and/or their representative were provided with a copy of the bed-hold policy upon transfer. Resident R105’s clinical record revealed an admission date of 7/1/25, with diagnoses that included ulnar fracture (broken bone in forearm), gastro-esophageal reflux disease (GERD - happens when stomach acid flows back up into the esophagus and causes heartburn), and high blood pressure. Resident R105’s clinical record revealed he/she was discharged to home on 7/23/25. The clinical record lacked evidence that a discharge summary was completed and/or provided to Resident R105 at the time he/she was discharged home. During an interview on 8/29/25, at 11:10 a.m. the Director of Nursing (DON) confirmed that there was no evidence that Residents R1, R2 and R103 and/or their representatives were provided with a copy of the bed-hold policy that included the cost per day. The DON also confirmed that there was no evidence that Resident R2’s necessary clinical information was provided to the receiving healthcare provider upon transfer and that when the transfers occurred the resident and/or his/her representative should have been provided with bed hold policy and clinical information should be provided to the receiving healthcare provider upon transfer. During an interview on 8/29/25, at 11:11 a.m. the DON confirmed that Resident R105’s clinical record lacked evidence of a discharge summary being completed and/or provided to Resident R105 at the time he/she was discharged home. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c.3) (2) Resident rights

Based on review of clinical records and incident report, observation and staff interviews, it was determined that the facility failed to provide adequate supervision, monitoring and timely assessment of a resident at risk for injury from a heat producing device resulting in actual harm for one resident (Resident R1). Findings include: Resident R1's most recent annual Minimum Data Set Assessment (MDS- a periodic assessment of the resident's needs and status), dated 5/2/13, identified the resident as being in a persistent vegetative state/no discernible consciousness, as being totally dependent on the facility staff for all needs, and as receiving all nutrition via a feeding tube. An event report submitted to the State Department of Health, dated 6/22/13, disclosed an event that occurred on 6/21/13, at 12:15 p.m. The report revealed that Licensed Practical Nurse (LPN), Employee E1, noticed that Resident R1's shirt was wet. The LPN attempted to dry the resident's shirt with a hairdryer while the resident was still wearing the shirt and during the process placed the hairdryer on the resident's lap causing the resident's skin to burn. A facility wound documentation sheet dated 6/22/13, the following day, documented the burned areas as full thickness burns as follows: left inner wrist/palm a 1.2 cm by 1 cm burn, left forearm a 6 cm by 3.3 cm burn, right abdomen a 3.5 cm by 3 cm burn, right inner thigh an 8 cm by 6 cm burn, and left inner thigh an 8.8 cm by 5 cm burn. Resident R1's nurses' notes, dated 6/21/13 at 1:15 p.m., indicated that a physician was notified of Resident R1's condition and ordered Silvadene (a cream used to treat burns) topically and cover with a Telfa (non-stick) dressing. On 6/22/13 at 1:00 p.m., the facility notified the physician due to the leg wounds and received an order for [REDACTED]. Three days following the incident, on 6/24/13, a physician's orders [REDACTED]. During interview on 6/24/13 at 2:00 p.m., the Nursing Home Administrator, confirmed that LPN Employee E1 inappropriately used a hairdryer on Resident R1, causing the resident to be burned. Observations on 6/25/13 at 11:00 a.m., of Resident R1, confirmed the presence of burned areas on the resident's left inner wrist/palm, left forearm, right abdomen, and right and left inner thighs. These open areas had a red border surrounding moist white eschar (dead tissue). In a statement dated 6/27/13, LPN Employee E1 indicated that the hair dryer was placed on Resident R1's lap while still producing hot air. The facility failed to provide adequate supervision and monitoring of a resident at risk for injury from a heat producing device resulting in actual harm to the resident. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 7/2/12. 28 Pa. Code 201.18(b)(2)(3) Management. 28 Pa. Code 211.12(d)(2) Nursing services. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 7/2/12, 5/31/13.

Based on review of clinical records, facility policy, observation and staff interviews, it was determined that the facility failed to accurately assess, timely identify and provide the necessary care and services to prevent the development of and/or to promote healing of pressure ulcers for one of three residents reviewed resulting in actual harm (Residents R6). Findings include: A facility policy "Stage II Pressure Ulcer Protocol" reviewed by the facility on 4/19/12, directed facility staff that if an area of skin breakdown did not improve in three to five days or worsened, to re-evaluate the treatment plan and notify the physician to report the current appearance in relation to original. A Minimum Data Set (MDS) assessment dated [DATE], showed that the resident was severely cognitively impaired, required complete assistance of two staff members for bed mobility and required extensive to total assistance for all care and had no control of bowel and bladder function. It also included [DIAGNOSES REDACTED]. Nurses' notes for Resident R6 dated 7/1/11, documented the discovery of a new Stage II (partial thickness skin loss) pressure area on the resident's coccyx and the application of [MEDICATION NAME] (a thick adhesive waxy cover) to the area of breakdown. Two pressure ulcer records for Resident R6 identified the coccyx ulcer as having been first observed on 7/17/11. During an interview on 6/29/12, at 10:30 a.m., the Wound Care Nurse revealed that Resident R6 had a Stage IV coccyx wound and confirmed that the Wound Assessment Sheets failed to consistently document an assessment of the wound or the effectiveness of the wound treatment. A fax to Resident R6's physician dated 8/25/11, indicated that the coccyx wound was a Stage IV (pressure ulcer includes full thickness skin loss with extensive destruction, tissue death, or damage to muscle, bone or supporting structures) ulcer on that date. A nurses' note dated 9/1/11, revealed that physical therapy notified nursing of a discovery that the wound to the coccyx had deteriorated from a Stage II pressure ulcer to a Stage IV. The note documented that the Wound Care Nurse, the physician and Resident R6's responsible party were notified that the wound had deteriorated to a Stage IV ulcer. The Care Plan for Resident R6 in use from July through the end of August 2011 did not address or mention the coccyx ulcer. A care plan for the coccyx ulcer was dated as not having been initiated until 9/8/11, and directed that an air mattress would be used to promote wound healing. A review of facility turning and repositioning records for July 1, 2011, through August 31, 2011, revealed multiple omissions daily in documentation of repositioning during these two months. A review of facility toileting and incontinence check records for July 1, 2011, through August 31, 2011, revealed multiple omissions daily in documentation of incontinence care or checking for moisture during these two months. During an interview on 6/29/12, at 1:45 p.m., the Wound Care Nurse confirmed the deterioration of the ulcer to a Stage IV ulcer on 8/25/11, that the treatment plan was not re-evaluated, the physician was not notified and that the treatment remained unchanged. The Wound Care Nurse also revealed that an air mattress was not provided. A nurse's note dated 9/21/11, revealed that Resident 6 was admitted to the hospital for surgical treatment of [REDACTED]. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(e)(1) Management. Previously cited 7/8/11. 28 Pa. Code 211.5(f)(g)(h) Clinical record. 28 Pa. Code 211.10(a)(c) Resident care policies. 28 Pa Code 211.10(d) Resident care policies . Previously cited 7/8/11. 28 Pa. Code 211.11(a)(c)(d) Resident care plan.