Every finding on record at Transitions Healthcare Allens Cove

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that staff report allegations of possible neglect to the administrator and/or director of nursing for one of five residents reviewed (Resident 2). Findings Include: Review of facility policy, titled Abuse, Neglect, Mistreatment, Exploitation, and Misappropriation of Resident Property, revised June 14, 2023, revealed This facility's policy is to immediately report and investigate all allegations of mistreatment, neglect, abuse, misappropriation of a resident's property or any injury of unknown origin. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) requires but the facility fails to provide them to the resident(s), that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. The charge nurse/supervisor who receives the initial report of the alleged or suspected abuse, neglect, or misappropriation of property will initiate the investigation immediately and report the incident also to the Administrator and Director of Nursing and/or Social Worker immediately. Review of Resident 2's clinical record revealed diagnoses that included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and severe intellectual disabilities (when limitations in a person's mental abilities affect intelligence, learning and everyday life skills). Review of Resident 2's current care plan revealed that he required assistance with toileting tasks, with an intervention, revised July 7, 2022, to offer the toilet every two hours and as required for incontinence. Review of Resident 2's intervention/task list revealed a task for toileting every two hours. Review of Resident 2's nurse aide task documentation, dated June 21, 2026, revealed no documentation that Resident 2 was toileted at 2:00 PM, 4:00 PM, 6:00 PM, or 8:30 PM. On August 13, 2026, at 8:51 AM, the Nursing Home Administrator (NHA) stated that he spoke to Employee 1 (Registered Nurse [RN]), who confirmed that she spoke with Employee 2 (Nurse Aide) after being made aware that Resident 2 was found to be saturated on June 21, 2026. The NHA stated that according to Employee 1, Employee 2's resident care assignment changed for the evening shift and Employee 2 told Employee 1 that she did not realize that Resident 2 was assigned to her on the evening shift. Employee 1 stated that she was going to give Employee 2 a write-up initially, but upon talking with another nurse, they felt it was an honest mistake and not a situation of neglect and did not feel it needed to be escalated. There was no evidence that an investigation was completed for the allegation of possible neglect when Resident 2 was found to be incontinent. There was no documentation that Resident 2 was provided incontinence care, and Employee 2 confirmed in an interview that she did not provide any care to Resident 2 because she didn't know the resident was on her assignment. There was no further investigation to include resident record reviews and interviews with other residents assigned to Employee 2 during that shift, to ensure care was not missed being provided to them also. During an interview with the NHA on August 13, 2026, at 10:47 AM, the surveyor asked the NHA what prompted Employee 1 to call Employee 2 and question her about Resident 2's care. He stated that the LPN (licensed practical nurse) reported that Resident 2 came walking out into the hallway and his pants were saturated. Employee 1 called Employee 2, who left early, at 8:03 PM, and Employee 2 stated she was unaware that Resident 2 was on her assignment. The NHA stated that neither he nor the Director of Nursing were made aware of the allegation or an investigation would have been done. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of five residents reviewed (Resident 2). Findings Include: Review of Resident 2's clinical record revealed diagnoses that included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and severe intellectual disabilities (when limitations in a person's mental abilities affect intelligence, learning and everyday life skills). Review of Resident 2's quarterly minimum data set (MDS - assessment tool utilized to identify a resident's physical, mental, and psychosocial needs), dated June 9, 2026, revealed that the Resident's cognitive skills for daily decision making was severely impaired. Review of Resident 2's current care plan revealed that he required assistance with toileting tasks, with an intervention, revised July 7, 2022, to offer the toilet every two hours and as required for incontinence. Review of Resident 2's intervention/task list revealed a task for toileting every two hours. It further stated that staff will assist Resident 2 to use the bathroom at or approximately at the times listed below, and if Resident 2 is sleeping, 3:00 AM may be skipped. The times for documentation are 3:00 AM, 6:00 AM, 8:00 AM, 10:00 AM, 12:00 AM, 2:00 PM, 4:00 PM, 6:00 PM and 8:30 PM. Review of Resident 2's nurse aide task documentation, dated June 21, 2026, revealed no documentation that Resident 2 was toileted at 2:00 PM, 4:00 PM, 6:00 PM, or 8:30 PM. Further review of Resident 2's nurse aide task documentation, dated June 21, 2026, revealed bed mobility was not documented on the 2 PM-10 PM shift; skin checks were not documented on the 2 PM-10 PM shift; and toileting was not documented for the 2 PM-10 PM shift, which was listed as a separate toileting task than the every two hours toileting task listed above. On August 13, 2026, at 8:51 AM, the Nursing Home Administrator (NHA) stated that Employee 2 (Nurse Aide) did not realize that Resident 2 was on her assignment for the 2 PM-10:30 PM shift on June 21, 2026, and that she left early that shift. Review of Employee 2's timecard revealed Employee 2 clocked out at 8:03 PM on June 21, 2026. In a follow up interview with the NHA on August 13, 2026, at 10:47 AM, he stated that Employee 2 worked the day shift also and didn't realize that her assignment had changed for the evening shift. He stated that the nurse is responsible for communicating any assignment changes to the nurse aides and that nurse aides should be doing change of shift report. 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on facility policy review, observations, and resident and staff interviews, it was determined that the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for five of 16 residents reviewed (Residents 10, 15, 26, 30, and 52). Findings include: Review of facility policy, titled Resident Rights last revised February 6, 2025, read, in part, The 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. To ensure the respect and dignity of each resident during dining and to promote a home-like environment. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. Observation during lunch meal service on March 17, 2026, at 12:47 PM, revealed a cart of beverages with two sleeves of soft plastic cups on the bottom shelf of the cart for tray meal service down the south hall. Observation of Residents 26 and 52 on March 17, 2026, at 1:20 and 1:30 PM, revealed they were eating lunch in their rooms and were served beverages with soft plastic cups on their trays. During an interview with Employee 11 (Registered Dietitian) on March 18, 2026, at 11:20 AM, the surveyor inquired about the use of soft plastic cups for tray meal service, she stated she was also wondering why the facility was not using the hard plastic cups that are easier to grasp and more homelike. During an interview with Resident 10 on March 18, 2026, at 12:44 PM, she revealed when she is served beverages in soft plastic cups, the liquid usually spurts out of the cup, so staff compensate by not filling them the whole way. This results in not getting as much to drink and the plastic cups are more difficult to hold. Observation during lunch meal service on March 18, 2026, at 12:55 PM, revealed residents down the south hall who were eating in their rooms were being served beverages in soft plastic cups on their trays. Interview with Employee 6 (Dietary Manager) on March 18, 2026, at 1:00 PM, revealed she just ordered two cases of hard plastic cups for meal service, which will be plenty to ensure all residents are served beverages in those cups during meals. During an interview with Resident 30 on March 18, 2026, at 1:07 PM, he stated he has difficulty grasping the soft plastic cups during his meals, and when he picks them up they usually squeeze in and the liquid spills all over him. During an interview with Resident 15 on March 18, 2026, at 1:10 PM, she showed the surveyor her thumb that was stained red and stated it was because she has to grab the soft plastic cup with her cranberry juice with her thumb inside to be able to pick it up. During an interview with the Nursing Home Administrator on March 19, 2026, at 11:09 AM, the surveyor revealed the concern with the use of the soft plastic cups during meal service. He revealed he would expect dining equipment to accommodate the residents' needs and preferences and promote a dignified and homelike dining experience. 28 Pa. Code 201.14 (a) Responsibility of licensee28 Pa. Code 201.29 (a) Resident rights

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure residents received a transfer notice with the required included information upon transfer/discharge for two of three residents reviewed for hospitalizations (Residents 5 and 30). Findings include: Review of facility policy titled, Resident Discharge/Transfer from Facility, with an effective date of January 21, 2025, read, in part, Upon a transfer or discharge of a Resident, the facility must: Notify the Resident and the Resident representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to the resident/resident representative. Review of Resident 5's clinical record revealed diagnoses that included congestive heart failure (disease process that results in the decreased ability of the heart to pump blood through the body effectively) and chronic kidney disease (disease of the kidneys that affects kidney function). Review of Resident 5's clinical record revealed she was transferred to the hospital for an acute medical change in condition on October 30, 2025. Resident 5 returned to the facility on November 12, 2025. Further review of Resident 5's clinical record revealed she was also transferred to the hospital for an acute medical change in condition on November 14, 2025. Resident 5 returned to the facility on December 1, 2025. Review of available documentation failed to reveal evidence that Resident 5 was provided with a written notice of transfer for either hospitalization. Review of Resident 30's clinical record revealed diagnoses that included congestive heart failure and pressure ulcer of sacral region stage 4 (injury to the skin and underlying tissue caused by prolonged pressure on the skin). Review of Resident 30's clinical record revealed he was transferred to the hospital for an acute medical change in condition on October 9, 2025. Resident 30 returned to the facility on October 17, 2025. Further review of Resident 30's clinical record revealed he was also transferred to the hospital for an acute medical change in condition on October 22, 2025. Resident 30 returned to the facility on October 30, 2025. Review of available documentation failed to reveal evidence that Resident 30 was provided with a notice of transfer for either hospitalization. Interview with the Nursing home Administrator on March 19, 2026, at 12:38 PM, revealed he was unable to determine if transfer notices were sent for the four aforementioned hospitalizations, and he would expect the facility to provide a written notice of transfer to residents/representatives in the event of a hospitalization. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on personnel training record review and staff interview, it was determined that the facility failed to ensure each nurse aide was provided required in-service training, consisting of no less than 12 hours per year, which included dementia management and resident abuse prevention for four of five nurse aide employee records reviewed (Employees 1, 2, 3, and 5). Findings Include: Review of personnel information revealed Employee 1's hire date was January 5, 2024; Employee 2's hire date was November 13, 2023; Employee 3's hire date was October 12, 2024; and Employee 5's hire date was March 3, 2025. Review of facility training records failed to reveal that the aforementioned Employees completed 12 hours of required annual training in the past 12 months. Further review of facility training records failed to reveal evidence that dementia management training was completed by Employees 1, 2, and 5 within the past 12 months, or that abuse prevention training was completed by Employee 3 within the past 12 months. During an interview with the Nursing Home Administrator on March 19, 2026, at 10:06 AM, he stated he would expect the nurse aide annual training to be done every 12 months and include abuse and dementia. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.19(7) Personnel policies and procedures28 Pa. Code 201.20(a)(d) Staff development

Based on clinical record review and staff interview, it was determined the facility failed ensure that resident and resident representative were involved in developing the comprehensive care plan and making decisions about his or her care for one of 19 residents reviewed (Resident 68). Findings include: Review of Resident 68's clinical record revealed diagnoses that included heart failure (a chronic condition where the heart muscle is unable to pump enough to meet the body's needs for blood and oxygen) and hypertension (high blood pressure). Review of Resident 68's clinical record revealed the Resident was admitted to the facility on [DATE]. Review of Resident 68's clinical record revealed all of their care plan focus areas and interventions were initiated on either December 17 or 30, 2025. Review of Resident 68's clinical record failed to reveal that a care plan meeting was held with an interdisciplinary team and failed to reveal any evidence or documentation that the Resident and their Representative were invited to participate in the care planning process. During an interview with the Nursing Home Administrator on March 19, 2026, at 2:09 PM, he revealed there weas no evidence of a care plan meeting being held with the Resident or their Representative, and that the development of the comprehensive care plan should include the resident and their representative. 28 Pa. Code 211.11 (d) Resident care plan42 CFR 483.21(b) Comprehensive Care Plans

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medications for one of five residents reviewed for unnecessary medications (Resident 8). Findings Include: Review of facility policy, titled Use of Psychotropic medications, with a revision date of January 21, 2025, revealed It is the policy of the Facility to assess the interventional necessity of psychotropic medication prior to delivery when related to the escalation of Resident behaviors Attempt to meet needs by the care plan and/or the behavior modification program, if appropriate. Use calm, friendly approach and try to redirect thoughts. Attempt to reassure and console. Document behavior, interventions tried and effectiveness on the 'Behavioral/Interventions' Sheet. Offer PO [by mouth] PRN [as needed] medications if above steps ineffective. Review of Resident 8's clinical record revealed diagnoses that included stroke, dementia with behavioral disturbance, anxiety, and major depressive disorder with psychotic symptoms. Resident 8 was admitted to hospice on July 28, 2025. Review of Resident 8's psych consult note dated January 11, 2026, revealed the reason for the visit was for the Resident yelling out and heightened anxiety, and the chief complaint/symptoms and concerns were staff reporting an increased in anxiety levels and yelling out for help. Further review of the consult revealed a recommendation to increase Resident 8's Lexapro (antidepressant medication) to 10 mg to assist with Resident's mood and anxiety. Review of Resident 8's psych consult note dated February 3, 2026, revealed that the Resident was being seen for increased anxiety reported by nursing. Resident reported anxiety was keeping her from falling asleep and the note further stated that Resident had no overt psychosis. Further review revealed that the prior recommendation to increase the Lexapro to 10 mg was not initiated. Recommendation was again made during this visit, to increase the Lexapro to 10 mg for anxiety and also encouraged staff to utilize PRN Ativan for anxiety that is not redirectable. Review of Resident 8's physician progress note dated February 11, 2026, revealed that Resident 8 was in bed at the time of the examination and was calling out loud saying help me help me. When asked what she wanted, Resident 8 replied she wanted her husband so she can go shopping. The note further states that Resident 8 has been having agitation and episodes with calling. She is currently on 25 mg of Seroquel twice daily. Will increase it to 50 mg twice daily. Drowsy but responded to questions by opening her eyes. Further review of Resident 8's physician note on February 11, 2026, revealed under the section Assessment and Plan, the Seroquel will be increased because of repetitive calling out episodes. Review of Resident 8's physician orders revealed an order dated February 11, 2026, for Seroquel, 25 mg, take two tablets (to equal 50 mg), twice a day. Further review of Resident 8's physician orders revealed an order dated February 13, 2026, for Seroquel, 25 mg, take two tablets (to equal 50 mg), three times a day. Review of Resident 8's current physician orders revealed an order dated March 14, 2026, for Seroquel 50 mg, take one tablet three times a day. Review of Resident 8's clinical record revealed no indication for the Seroquel being increased from 50 mg twice a day to 50 mg three times a day. Review of Resident 8's physician orders revealed the Lexapro 10 mg, that was recommended by psych consult was not ordered until March 4, 2026, to start on March 5, 2026. Review of Resident 8's antipsychotic medication target behaviors revealed her target behaviors to be monitored included: yelling/calling out; continuously ringing call bell; expressing multiple complaints including stating she cannot breathe with SpO2 being 100% on room air; asking for bed covers to be taken off/put on; and removing clothing/disrobing. Staff are to document behavior noted and interventions attempted in progress note, every shift. Review of Resident 8's behavior documentation for January 2026, February 2026, and March 2026, revealed no documentation that Resident 8 displayed any of her targeted behaviors for her antipsychotic medication. Review of Resident 8's clinical record revealed no documented behaviors of Resident 8, with the exception of the two aforementioned psych consults stating the Resident was having increased anxiety and the one physician documentation of resident yelling out during his visit. There was also no documentation that any non-pharmacological interventions were attempted prior to increasing Resident 8's Seroquel. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on March 19, 2026, at 11:05 AM, the surveyor asked if Resident 8's behavior of yelling out was an appropriate indication for the increase in her Seroquel dose, and if there were any additional behaviors documented, or any documentation of any non-pharmacological interventions that were attempted prior to increasing the Seroquel. In a follow up interview with the NHA and DON on March 19, 2026, at 12:34 PM, the NHA stated that Resident 8 does have a behavior of yelling out continuously but stated that it is not well documented by staff. He stated that staff should be documenting Resident 8's behaviors as well as any non-pharmacological interventions. The DON stated that Resident 8's Seroquel was increased due to repetitive yelling out with delusional thoughts, but he also confirmed that there is no documentation of the continuous behaviors that Resident 8 was displaying around the time the Seroquel dose was increased. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.2(d)(3) Medical director.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policy review, clinical record review, select facility investigative documentation, and staff interviews, it was determined that the facility failed to have evidence that all alleged violations are thoroughly investigated and report the results of all investigations to officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for one of two residents reviewed for abuse (Resident 9). Findings include: Review of facility policy, titled Abuse, Neglect, Mistreatment, Exploitation, and Misappropriation of Resident Property last revised June 14, 2023, read, in part, Facility staff will be trained to report any oral or written reports of alleged neglect, abuse, mistreatment, and misappropriation of resident's property. Facility staff must also report injuries of unknown etiology. Proper reporting procedures are as follows: Any report or suspicion of an incident is to be reported immediately to the charge nurse/supervisor. The administrator or his designated person will notify the Licensing and Regulatory Agency (Department of Health/DHS), Protective Services, Local Police Department, and other designated agencies as required. Steps will be taken to prevent further potential abuse by reporting all alleged violations/allegations and investigation within the required timeframes and conducting a thorough investigation of the alleged violation. Review of Resident 9's clinical record revealed diagnoses that included dementia (a condition characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), insomnia (a sleep disorder in which you have trouble falling & staying asleep), and osteoarthritis (when protective cartilage that cushions the ends of the bones wears down over time). Review of Resident 9's clinical record revealed a nursing progress note dated January 17, 2026, that read, [Nurse Aide] came to this writer and reported that resident had large bruise on both hands, one large bruise on her left forearm and a skin tear that had a border dressing on it. Border dressing peeled back and 1 inch skin tear observed with small amount of bleeding. Resident states that [Nurse Aide] was 'too rough' and that the aide was yelling at her while providing care to resident on night shift. Witness statement gathered from roommate. Witness reports this happened yesterday, January 16, 2026, on evening shift. Treatment order placed. Resident assessed for pain, discomfort and further skin concerns. POA [Power of Attorney] contacted. Son requested follow-up information once investigation is complete. During an interview with the Director of Nursing (DON) on March 17, 2026, at 2:23 PM, he revealed he investigated the day the alleged abuse was reported on January 17, 2026, but based on the statements he collected and information gathered, it was determined the abuse allegation was unsubstantiated. He further revealed he did not notify any outside agencies of the alleged abuse and did not suspend the alleged perpetrator due to her not being there when the investigation was conducted on January 17, 2026. Also, he stated that he tried to interview Resident 9 about the incident and he was unable to get any information from her, but failed to note that in the investigation details. Review of statement from Employee 9 (Nurse Aide) on January 17, 2026, revealed I gave [Resident 9] her breakfast tray and noticed her hands had two large bruises that looked new. Reported to [Employee 10 (Registered Nurse)]. Unsure of how the bruises got on her hands. Review of statement from Employee 10 on January 17, 2026, revealed [Employee 9] informed me that resident had large purple bruises on her hands and arms. Resident stated '[employee description] hurt her.' Her roommate stated she heard her yelling at night while a nurse aide was providing care. Upon further investigation [Employee 7] and [Employee 8] have reported that resident has become combative at night yelling and hitting staff members. Review of statement written by Employee 8 on January 17, 2026, revealed Resident can be combative (hitting, kicking) with care. She can be aggressive with staff (get the hell out, I'll call my son, don't you touch me). She is difficult to redirect; demanding staff do what she wants. If it isn't possible she threatens to call her granddaughter or son. Review of statement written by the DON on January 17, 2026, revealed Resident roommate stated she believed the incident during care in which she overheard yelling occurred on January 16, 2026, involved [Employee 3 (Nurse Aide)]; however, she could not visualize at the time due to the curtain pulled while care was being provided. Review of additional statement written by the DON on January 17, 2026, revealed, This writer spoke to [Employee 3] via telephone who stated that [Resident 9] had become very combative during care, on Thursday January 16, 2025, swinging and trying to hit the caregiver at that time. Nurse aide did not notice any injury at that time. Educated nurse aide to stop providing care if resident becomes combative and reapproach later. Review of statement written by Employee 7 on January 17, 2026, revealed I worked 10-6:30 AM, Friday night into Saturday and did first rounds on [Resident 9] @ 12:00 AM (assisted with another aide) we noticed the bruises & skin tear then. I also worked Thursday into Friday when these bruises were reported. Resident has become combative/aggressive during night shift changes. During changes she refuses changes or just fights (trying to punch & kick or jump out of bed). During an interview with Employee 7 on March 18, 2026, at 5:15 PM, she revealed she went to the Licensed Practical Nurse (LPN) on duty on the night shift of Thursday into Friday to notify her of the bruises, but she doesn't remember who it was, and they told her they were already aware of the bruises and would handle it. During an interview with the DON on March 19, 2026, at 9:21 AM, he revealed, in hindsight, he should have reported the allegation of abuse and details of the investigation to the appropriate agencies. Follow up interview with the DON on March 19, 2026, at 11:08 AM, he revealed he spoke with the two LPNs on duty Thursday into Friday in response to Employee 7's statement, and both denied the bruises were reported to them, but he failed to note that in the investigation details and now does not remember who they were. No further information was provided. 28 Pa. Code 201.14 (a) Responsibility of licensee28 Pa. Code 201.18 (b)(1) Management28 Pa. Code 201.29 (a) Resident rights

Based on clinical record review and staff interview, it was determined the facility failed to develop and implement a baseline person-centered care plan within 48 hours of a resident's admission to include the minimum healthcare information necessary to properly care for a resident and failed to provide the resident and their representative with a summary of the baseline care plan for two of 19 residents reviewed (Residents 4 and 68).Findings include: Review of Resident 4's clinical record revealed diagnoses that included hypertension (high blood pressure) and chronic kidney disease (when the kidneys are damaged and can't do their important jobs). Review of Resident 4's clinical record revealed the Resident was admitted to the facility on [DATE]. Review of Resident 4's clinical record revealed their care plan was initiated on February 17, 2026, and was completed on March 16, 2026. Further review of the Resident's care plan revealed their activities, dietary, nursing, social services, and therapy focus areas and interventions on the care plan were initiated and completed on March 16, 2026. The only care plan focus area that was initiated timely was the Resident's advanced directive care plan, initiated on February 17, 2026. Review of Resident 68's clinical record revealed diagnoses that included heart failure (a chronic condition where the heart muscle is unable to pump enough to meet the body's needs for blood and oxygen) and hypertension. Review of Resident 68's clinical record revealed the Resident was admitted to the facility on [DATE]. Review of Resident 68's clinical record revealed all of their care plan focus areas and interventions were initiated on either December 17, 2025, or December 30, 2025. Resident 4 and 68 did not have timely development and implementation of the baseline care plan. The resident and their representative were also not provided a summary of the baseline care plan. During an interview with the Nursing Home Administrator on March 19, 2026, at 11:00 AM, he confirmed that the Residents' baseline care plans were not completed within 48 hours of their admission and would expect them to be. 28 Pa. Code 211.11 (d) Resident care plan42 CFR 483.21(b) Comprehensive Care Plans

Based on clinical record review and staff interview, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of 19 residents reviewed (Resident 48). Findings Include: Review of Resident 48's clinical record revealed diagnoses that included colon cancer and bladder cancer. Review of Resident 48's physician progress note dated March 13, 2026, revealed Resident 48 was being seen due to excessive blood draining into Resident's urostomy bag (a surgically created opening in the abdominal wall that allows urine to bypass a diseased or dysfunctional bladder. It is commonly used when the bladder is removed due to cancer, birth defects, or nerve damage, allowing urine to flow continuously into an external pouching system). The note further stated that the physician spoke to Resident 48's responsible party (RP), who stated she was also going to call and speak with Resident's urologist. Further review of Resident 48's physician note dated March 13, 2026, revealed an addendum that at 4:45 PM the physician was contacted by the facility nurse, stating Resident 48's urologist called the facility and was requesting a urinalysis and culture to rule out a UTI (urinary tract infection). Review of Resident 48's nursing progress notes revealed a note dated March 13, 2026, stating that the nurse spoke with Resident 48's urologist's office and they recommended a UA C&S (urinalysis with culture and sensitivity). Review of Resident 48's physician orders revealed an order dated March 13, 2026, for a UA C&S. The order was marked as completed. Review of Resident 48's clinical record revealed no evidence that the UA C&S was collected and sent to the lab on March 13, 14, or 15, 2026. Review of Resident 48's physician progress note dated March 16, 2026, revealed A UA has not yet been collected. Review of Resident 48's physician orders revealed an order for a UA C&S ordered on March 15, 2026, with a start date of March 16, 2026. Review of Resident 48's nursing progress notes revealed a note on March 16, 2026, at 1:35 PM, stating that the UA C&S was collected. Review of a follow up physician note dated March 16, 2026, revealed the UA was suggestive of a UTI and new orders were given to start an antibiotic for treatment. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing on March 18, 2026, at 1:47 PM, the NHA stated that Resident 48's UA C&S should have been collected and sent to the lab on March 13, 2026, when it was first ordered. 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food and utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen. Findings include: Review of facility policy, titled Food Storage last reviewed [DATE], read, in part, All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods. All containers or storage bags must be legible and accurately labeled and dated. All foods should be covered, labeled, and dated and routinely monitored to assure that foods will be consumed by their safe use by dates, or frozen (where applicable), or discarded. Observation in the dry storage area on [DATE], at 10:03 AM, revealed four bags of white bread with a use by date of [DATE], and six packs of English muffins not dated. Observation of the dish machine in the main kitchen on [DATE], at 10:07 AM, revealed it was heavily soiled with a brown substance on the top; further observation revealed a brown substance consistent with food debris was observed in the corners of the top of the dish machine. Observation of the exhaust vent over top of the dish machine in the main kitchen on [DATE], at 10:08 AM, revealed it was soiled with a fuzzy black substance. Interview with Employee 4 (Dietary Manager) on [DATE], at 10:08 AM, revealed she was unsure of where the substance on the dish machine was coming from, that a kitchen staff member had just wiped the entire machine down three days prior, and she was unsure about when maintenance staff had last cleaned the exhaust hood. Observation of the dish machine temperature log in the main kitchen on [DATE], at 10:09 AM, revealed the record final rinse temperature was below the minimum safe temperature during breakfast on [DATE], and 20, 2025. Further observation of the log failed to reveal any corrective action noted on those days. Observation in the walk-in refrigerator on [DATE], at 10:11 AM, revealed a tub of hard-boiled eggs that was dirty on the top and not properly sealed. Further observation of the tub revealed the eggs had a use by date of February 23, 2025. Observation in the main kitchen on [DATE], at 10:14 AM, revealed one bag of white bread open with a half of a loaf left. Further observation of the bread revealed a use by date of [DATE]. Review of the [DATE] dish machine temperature log revealed the record final rinse temperature was below the minimum safe temperature during breakfast on [DATE]-24, 30, and 31; during lunch on [DATE]-14, 18, 20, 21, 24, and 27; and during dinner on [DATE]-13, 15, 19, 20, 24, 25, 27, 29, and 30. Further observation of the log failed to reveal any corrective action noted on those days. Return visit to the kitchen on [DATE], at 12:29 PM, revealed the dish machine remained dirty with a brown substance on the top and a brown substance consistent with food debris was observed in the corners of the top of the dish machine. Observation of the exhaust vent over top revealed it was soiled with a fuzzy black substance. Interview with Employee 4 on [DATE], at 12:46 PM, revealed staff should be regularly cleaning kitchen equipment and surfaces daily, but that she does not have a routine cleaning schedule checklist for review. Follow-up interview with Employee 4 on [DATE], at 12:54 PM, revealed she was unable to locate dish machine temperature logs from [DATE] to [DATE]. During an interview with the Nursing Home Administrator (NHA) on [DATE], at 2:12 PM, the surveyor revealed the concern with food storage in the kitchen, as well as the dirty kitchen equipment, rinse temperature below safe minimum temperature on select days, and lack of dish machine temperature logs for review from [DATE] to [DATE]. The NHA revealed his expectation that expired items are discarded, foods items are labeled and dated per facility policy, and food items and kitchen equipment are stored, cleaned, and utilized in accordance with professional standards. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.6(f) Dietary services

Based on facility policy review, observation, staff interview, and facility document review, it was determined that the facility failed to store medications under proper temperature controls in one of one medication rooms reviewed. Findings include: Review of facility policy, titled Storage of Medications with a last revised date of August 2020, and a last review date of May 2024, revealed the following: II. Temperature 1. All medications are maintained within the temperature ranges noticed in the United States Pharmacopeia (USP) and by the Centers for Disease Control (CDC); c. Refrigerated: 36 F to 46 F (2 C to 8 C) with a thermometer to allow temperature monitoring; 2. Medications and biologicals are stored at their appropriate temperatures and humidity according to the USP guidelines for temperature ranges; 4. Medications requiring refrigeration are kept in a refrigerator at temperatures between 36 F (2 C) and 46 F (8 C) with a thermometer to allow temperature monitoring; and 6. The facility should maintain a temperature log in the storage area to record temperatures at least once a day or in accordance with facility policy. Observation of the medication room refrigerator on April 22, 2025, at 9:06 AM, with Employee 2, revealed that the thermometer was sitting inside the small freezer portion of the refrigerator, which had approximately one inch of ice build-up and the temperature read 20 degrees Fahrenheit (F). Review of facility provided medication room refrigerator temperature log for April 2025 revealed the following: April 1 temperature was recorded as 18 degrees F; April 2 temperature was recorded as 34 degrees F; April 3 temperature was recorded as 32 degrees F; April 6 temperature was recorded as 34 degrees F; April 7 temperature was recorded as 34 degrees F; April 8-11 no temperatures were recorded; April 12 temperature was recorded as 34 degrees F; and April 13 temperature was recorded as 32 degrees F. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing on April 22, 2025, at 2:38 PM, the NHA indicated that he would expect medications to be stored at appropriate temperatures and that temperatures would be taken and recorded daily. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(c)(d)(2)(3) Nursing services

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for one of three residents reviewed for hospitalization (Resident 45). Findings Include: Review of facility policy, titled Bed Holds and Returns and Therapeutic Leave of Absence, last dated January 3, 2024, revealed The Facility is required to provide a bed hold under certain circumstances and make the Resident aware of the Facility's bed hold and return policy as related to hospitalization and therapeutic leave. The facility will provide information on bed hold requirements to all residents upon admission and again at time of transfer from the Facility. Bed Hold requirements will be included in the Facility admission packet to be reviewed during the admission process and will be considered the first notice of the Facility Bed Holds and Returns policy .The second notice, which details the duration of the bed hold policy, will be issued at the time of transfer. In cases of emergency transfer, notice 'at the time of transfer' means that the family, surrogate, or representative are provided with written notification within 24 hours of the transfer. The requirement is met if the resident's copy of the notice is sent with other papers accompanying the resident to the hospital. Review of Resident 45's clinical record revealed diagnoses that included hypertension (high blood pressure) and Type 1 Diabetes Mellitus (a lifelong condition where the pancreas makes little or no insulin, which leads to high blood sugar levels). Further review of Resident 45's clinical record revealed that she was transferred and admitted to the hospital on [DATE], and March 15, 2025. During an interview with the Nursing Home Administrator on April 23, 2025, at 10:19 AM, it was revealed that there is no evidence that Resident 45 and/or her Representative were provided with a written notice of the facility's bed hold notice at the time of either hospitalization. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good grooming and personal hygiene for one of two residents reviewed for ADLs (Resident 23). Findings Include: Review of the facility policy, titled Activities of Daily Living last reviewed May 31, 2024, read, in part, Residents will gain and/or maintain as much independence as possible in ADLs which are essential to the individual's lifestyle. This refers to activities an individual performs on a regular basis, such as eating, dressing, hygiene (make-up, shaving, washing), transfers, reading, writing, housework, smoking, walking, and even driving. The resident's performance may vary depending on the time of day, how the resident feels, setting, and the person with him/her. Review of Resident 23's clinical record revealed diagnoses that included spinal stenosis (a condition that narrows the space in the spine, putting pressure on the spinal cord or nerves), repeated falls, and muscle weakness. During an interview with Resident 23 on April 21, 2025, at 10:22 AM, she revealed she has sometimes not received a shower for over two weeks at a time, and recently did not receive a shower for eight days. Review of Resident 23's clinical record revealed she has a preferred shower schedule of Wednesday and Saturday on the 2-10 shift. Review of Resident 23's nurse aide task for showers revealed she did not receive a shower per her preferred schedule on January 8 and 11, 2025; February 5, 15, 22, and 26, 2025; March 1, 5, and 15, 2025; and April 16, and 19, 2025. During an interview with the Nursing Home Administrator on April 22, 2025, at 2:15 PM, he revealed sometimes Resident 23 refuses to get out of bed for the staff during her shower days. Further review of Resident 23's clinical record failed to revealed notation to indicate she refused to get out of bed or was reapproached for a shower at a later time on the aforementioned days. Interview with the Director of Nursing on April 23, 2025, at 10:41 AM, revealed he would expect staff to document refusal of showers and reapproach residents at a later day or time who refused a shower as per their preferred schedule. 28 Pa Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to maintain an effective infection control program related to the preparation and administration of medications for three of three residents observed (Residents 9, 27, and 155). Findings include: Review of facility policy, titled General Guidelines for Medication Administration with a last revised date of August 2020, and a last review date of May 2024, revealed the following, The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly: i. Before beginning a medication pass; ii. Prior to handling any medication; iii. After coming into direct contact with a resident and Hand sanitization is done with a facility approved sanitizer ii. At regular intervals during the medication pass such as after each room, again assuming handwashing is not indicated. Review of facility policy, titled Transitions Healthcare Allen's Cove IC-Infection Control Plan 2024 with a last revision date of September 1, 2024, revealed, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of MDRO's [multiple drug resistant organism] through gown and glove use by HCP [health care providers] in long-term care settings in accordance with the CDC [Centers for Disease Control] .EBP are recommended during high contact care .activities with residents who are at higher risk of acquiring or spreading an MDRO such as Residents with .indwelling medical devices .e[xample g[[NAME]] central line (a catheter placed into a large vein used to administer medication or fluids). Review of facility policy, titled IC-519 Glucometer Cleaning, Disinfecting and Use with a last revised date of October 1, 2017, and a last review date of May 2024, revealed, 1. All glucometers [device used to test blood sugar level] must be cleaned and disinfected after each use and between residents as follows: a) Clean the outside of the glucometer with a damp cloth with soap and water or an alcohol swab to remove any visible blood or body fluids. b) Disinfect the meter using a pre-moistened germicidal disposable wipe (PDI). During a medication pass observation on April 22, 2025, at approximately 8:30 AM, Employee 2 removed her gloves after administering an insulin injection to Resident 9, administered Resident 9 her oral medications, returned to the medication cart, and then began to prepare Resident 27's medications for administration. During the ongoing medication pass observation on April 22, 2025, at approximately 8:36 AM, Employee 2 entered Resident 27's room and was observed applying gloves to perform a blood glucose test. Resident 27 requested that the window be closed, and Employee 2 was observed using her gloved right hand to close the window and then proceeded to perform the glucose test. After completion of the test, Employee 2 returned to her medication cart and wiped down the glucometer with an alcohol pad. She then wrapped the glucometer in an alcohol pad and placed it in a clear plastic cup on top of the medication cart. Employee 2 indicated that she was not sure how the glucometer was to be cleaned, but that this is how she does it. Employee 2 removed her gloves and began to prepare the rest of Resident 27's medications when she was notified that Resident 155's intravenous medication administration pump was beeping. Employee 2 then proceeded to Resident 155's room. Observation of Resident 155's room on April 22, 2025, at approximately 8:39 AM, revealed that an Enhanced Barrier Precautions (EBP) sign was posted outside the door to the room, which indicated that staff were to wash/cleanse hands before entering the room and that staff should wear gloves and gowns when caring for a central line. During the ongoing medication pass observation on April 22, 2025, at approximately 8:40 AM, Employee 2 entered Resident 155's room without cleansing her hands, applied gloves, and flushed Resident 155's central line. Employee 2 then left the room and discarded intravenous fluid bag in the biohazard container in the dirty utility room. Employee 2 then cleansed her hands with hand sanitizer. This was the first observation of hand cleansing since medication pass observation began at 8:26 AM. During a medication pass observation on April 22, 2025, at approximately 8:46 AM, Employee 2 was observed to apply gloves in preparation of administering Resident 27 an insulin injection. Resident 27 requested that her trash can be moved closer to her chair. Employee 2 scooted the trash can across the floor with her feet, but when she got to Resident 27's chair, she used her gloved left hand to pick up the open top trash can and place it where Resident 27 requested. Employee 2 then proceeded to administer Resident 27's insulin injection wearing the same gloves. Employee 2 then removed her gloves and applied another pair of gloves to administer Resident 27 her nasal spray and her oral medications. Employee 2 then removed her gloves and used hand sanitizer to cleanse her hands. During a staff interview with Employee 2 on April 22, 2025, at 9:06 AM, Employee 2 indicated that she should have cleansed her hands between residents, between glove changes, and that she thought she only needed to wear a gown for a resident on EBP if she was going to be in close contact. After reading the EBP posting, Employee 2 confirmed that she should have worn a gown when flushing Resident 155's central line. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on April 22, 2025, at 2:36 PM, the NHA and DON confirmed that they would expect staff to follow personal protective equipment guidance for EBP and to wash and/or cleanse hands when changing gloves, between residents, and after touching dirty items. During a staff interview with the NHA on April 23, 2025, at 10:53 AM, the NHA confirmed that he would expect nursing staff to follow the facility glucometer cleaning policy. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28. Pa Code 211.12(c)(d)(1)(2)(5) Nursing services

Based on review of clinical records and staff interviews, it was determined that the facility failed to provide restorative nursing care for range of motion exercises for one of three residents reviewed for position and mobility (Resident 29). Findings include: Review of Resident 29's clinical record revealed diagnoses that included peripheral vascular disease (a slow and progressive circulation disorder) and hypertension (high blood pressure). Review of Resident 29's clinical record revealed a Restorative Program Progress Note written on February 24, 2025, at 12: 17 PM, that read, in part, restorative nursing programs from passive range of motion (PROM) of right upper extremity (RUE) and right lower extremity (RLE) and active range of motion (AROM) of left lower extremity (LLE) continue. Resident 29 has a diagnosis of flaccid hemiplegia to right side; she is able to tolerate both PROM programs to right upper and lower extremities and continues to participate and complete three sets of ten reps for each of the exercises listed within the AROM LLE programs. Review of Resident 29's clinical record revealed a restorative nursing program task for AROM of LLE for 15 minutes twice daily. Further review of the documentation for restorative nursing revealed that for April 2025, there were 13 days where restorative nursing was not completed twice a day or was marked as not applicable. Review of Resident 29's clinical record revealed a restorative nursing program task for PROM of RLE for 15 minutes twice daily. Further review of the documentation for restorative nursing revealed that for April 2025, there were 13 days where restorative nursing was not completed twice a day or was marked as not applicable. Review of Resident 29's clinical record revealed a restorative nursing program task for PROM of RUE for 15 minutes twice daily. Further review of the documentation for restorative nursing revealed that for April 2025, there were 12 days where restorative nursing was not completed twice a day or was marked as not applicable. During an interview with the Nursing Home Administrator on April 23, 2025, at 10:35 AM, revealed that he would expect for Resident 29 to receive restorative nursing program services twice daily. 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 19 residents reviewed (Residents 9 and 32). Findings Include: Review of Resident 9's clinical record revealed diagnoses that included Multiple Sclerosis (MS - a disease that causes breakdown of the protective covering of nerves; can cause numbness, weakness, trouble walking, vision changes, and other symptoms) and neurogenic bladder (bladder dysfunction caused by nervous system conditions). Review of Resident 9's physician orders revealed an order dated June 28, 2024, for a Foley catheter (a thin, flexible tube inserted into the bladder through the urethra to drain urine; also known as an indwelling catheter). Review of Resident 9's Quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs) dated February 16, 2025, revealed in section H, it was coded that Resident 9 had an indwelling catheter and was also occasionally incontinent of urine. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on April 23, 2025, at 10:45 AM, the DON confirmed that the MDS was coded in error, as Resident 9 was not occasionally incontinent of urine due to her Foley catheter. Review of Resident 32's clinical record revealed diagnoses that included heart failure (a condition where the heart cannot pump enough blood to meet the body's needs) and chronic kidney disease (a progressive condition where the kidneys gradually lose their ability to filter waste and excess fluid from the blood). Review of Resident 32's clinical record revealed she had an unwitnessed fall on March 2, 2025, at 2:00 AM, which resulted in an abrasion on the left thigh. Review of Resident 32's Significant Change MDS dated [DATE], revealed in section J, it was coded that Resident 32 has not had any falls since admission/entry or reentry or prior assessment. During an interview with the NHA and DON on April 23, 2025, at 10:03 AM, the DON confirmed that the MDS was coded in error, as Resident 32's fall on March 2, 2025, should have been reflected. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of one of 16 residents reviewed (Resident 24). Findings include: Review of Resident 24's clinical record revealed diagnoses that included Alzheimer's disease (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), atrioventricular heart block (a type of heart block that occurs when the electrical signal traveling from the atria, or the upper chambers of the heart, to ventricles, or the lower chambers of the heart, is impaired), and presence of a cardiac pacemaker. Observation of Resident 24 on April 21, 2025, at 10:02 AM, revealed the presence of a [NAME] at Home (a remote telephonic pacemaker check device) on her bedside stand. Review of Resident 24's current physician orders failed to reveal any orders for a cardiology consult or pacemaker checks. Review of Resident 24's physician order history revealed an order for a yearly cardiology appointment on November 29, 2024, with a completion date of November 30, 2023; and an order for pacemaker check in 3 months by remote monitoring, with a completion date of January 25, 2023. Review of Resident 24's care plan revealed a care plan focus for a pacemaker with an intervention for pacemaker checks as ordered by cardiology and document in chart: Heart rate, Rhythm, Battery check, with a last revision date of July 7, 2022. Review of Resident 24's clinical record revealed that her last pacemaker remote check was completed on September 18, 2024. During a staff interview the Director of Nursing (DON) on April 23, 2025, at 9:19 AM, the DON indicated that, after being made aware of the concern regarding Resident 24's cardiology and pacemaker testing was shared, that he began to investigate. The DON indicated that Resident 24 should have a yearly cardiology appointment and would have been due for an appointment in November 2024 or December 2024. The DON indicated that the cardiology office did not call to set up the yearly appointment as was their typical practice. The DON said when he called the cardiology office yesterday and they indicated that they had sent letters in November 2024 and December 2024 to a local address that they had on file for Resident 24, which was not the facility address. He said that the office said since they did not receive a response to the letters, they dropped it. The DON indicated that the cardiology office indicated that the pacemaker was still transmitting, and they would notify the emergency contacts if there was an issue; however, they did not have the facility listed as the primary contact. The DON confirmed that Resident 24 has a cardiology office appointment the following week, and that the three-month remote pacer checks will be scheduled at that time. He also indicated that he had once again notified the cardiology office that Resident 24 plans to permanently reside at the facility. During a final staff interview with the Nursing Home Administrator and DON on April 23, 2025, at 10:53 AM, the DON confirmed that facility staff should have followed up and made sure Resident 24 had her annual cardiology appointment and remote pacemaker checks when the cardiology office did not follow up with the facility. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on employee handbook review, review of select facility documentation, and staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least once every 12 months for three of five nurse aides reviewed (Employees 2, 3, and 4). Findings include: Based on facility document, titled Employee Handbook effective July 1, 2022, read, in part, All employees will be subject to a written annual rating and evaluation by the department supervisor based on his/her employment anniversary date to ensure that strengths, areas for improvement, and job goals for the next review period have been clearly communicated. An employee's evaluation will be reviewed with the employee by the supervisor at the time of presentation for the employee's signature. Review of select facility documentation revealed a list of nurse aide's that had worked at the facility for greater than a year. Employee 2 had a hire date of January 5, 2024; Employee 3 had a hire date of April 15, 2023; and Employee 4 had a hire date of July 1, 2022. During an interview with the Nursing Home Administrator (NHA) on March 31, 2025, at 9:54 AM, he revealed he was unable to locate the most recent annual evaluations for Employees 2, 3, and 4. He further revealed the facility recently switched electronic systems for their employee evaluations, so if any of the files hadn't been printed before the new system took over they were no longer able to be accessed. Interview with Employee 2 at the facility on March 31, 2025, at 11:48 AM, revealed she had not yet received an annual evaluation. During an interview with the NHA on March 31, 2025, at 12:44 PM, he revealed he would expect annual evaluations to be completed annually and available for review. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like environment in common areas and one of three resident rooms observed (South and East Hallways, Nurses Station, and Resident 1's room). Findings include: Review of facility policy, titled Cleaning & Disinfecting Environmental Surfaces last revised October 1, 2017, read, in part, Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. Observation in the South Hallway on March 31, 2025, at 10:41 AM, revealed three ceiling tiles with ring circle stains on them. Observation at the Nurse's Station on March 31, 2025, at 10:44 AM, revealed a large ceiling tile to the left of the station with a large brown ring circle stain. Observation in the East Hallway on March 31, 2025, at 10:46 AM, revealed one ceiling tile with a large brown ring circle stain on it, and a brown liquid stain that was dripping down the side of the wall. Further observation down the hallway revealed three ceiling tiles with ring circle stains on them. During an interview with Employee 1 (Maintenance Director) on March 31, 2025, at 11:12 AM, he revealed maintenance staff conduct environmental rounds and room checks throughout the facility on a regular basis to identify issues that require repair or replacement. He further revealed the facility has issues with the roof leaking during periods of heavy rain, and that staff should have identified the soiled ceiling tiles and replaced them, and the soiled wall should have been cleaned. Observation in Resident 1's room on March 31, 2025, at 11:23 AM, revealed one ceiling tile at the entrance to the room with a brown ring circle stain, and two large ceiling tiles in the middle of the room stained with brown liquid. During an interview with the Nursing Home Administrator on March 31, 2025, at 12:42 PM, he revealed he would expect the ceiling tiles to be identified as soiled and replaced, and environmental surfaces to be cleaned when soiled. 28 Pa. Code 201.18(e)(2.1) Management

Based on review of facility clinical records, and staff interview, it was determined that the facility failed to ensure the safety of the resident's for one of 3 Residents reviewed resulting in harm (Resident 1). Findings include: Review of Resident 1's clinical record reveals [DIAGNOSES REDACTED]. Review of an Incident/Accident Report dated March 3, 2016 at 6:30 p.m., revealed Resident 1 was being transferred from the wheel chair to the bed and bumped her leg (LLE - left lower extremity (leg)) on the lower part of the wheel chair near the foot rest (support for the foot), causing a laceration (cut) on her LLE. The laceration measured 14 centimeters by 7 centimeters by 2.5 centimeters (measurements of length, width and depth). The physician was notified at 6:39 p.m. and a family member was notified at 6:35 p.m., Resident 1 was sent to the hospital at 6:40 p.m. Review of the, Investigation Report for Incidents and Accidents (a form use by the facility to obtain information) dated March 4, 2016 at 6:30 p.m., revealed the incident which resulted to an injury to Resident 1 could have been prevented by using an assist of two to transfer the resident. Review of Resident 1's Plan of Care for ADL (Activities of Daily Living) dated December 30, 2015 revealed updated interventions (new changes to care) dated February 16, 2016, indicating that Resident 1 requires two person assistance to transfer both to the bathroom and to bed. Further review of the Care Plan for ADL's dated February 25, 2016 revealed an intervention for two assist transfers with a Hoyer Lift (mechanical device used to transfer a resident from one place to another by means of sling (reinforced cloth) which is attached to the Hoyer Lift and the resident is position in the sling for transfer). An interview with the Nursing Home Administrator (NHA) on March 17 at 12:15 a.m., revealed his expectation is all staff read and sign the, Spot Education book (a book that contains new or updated intervention for the care of residents) prior to the start of each shift. The NHA further revealed that the nursing assistant should have transferred Resident 1 with an assist of two as care planned. 42 CFR 483.25(h)(2) Accidents Previously cited 6/5/14 28 Pa. Code 201.18(e)(1) Management. Previously cited 6/5/14 28 Pa. code 211.10(a) Resident care policies. Previously cited 6/5/14, 11/7/13. 28 Pa. code 211.10(d) Resident care policies. Previously cited 6/5/14 28 Pa. code 211.12(d)(1)(5) Nursing services. Previously cited 6/5/14, 11/7/13.