Every finding on record at Transitions Healthcare Shook Home

Based on clinical record review and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 16 residents reviewed (Resident 11).Findings include: Review of Resident 11's clinical record revealed diagnoses that included dementia (a chronic disorder of mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning) and hypertension (high blood pressure). Review of Resident 11's current physician orders revealed an order for losartan potassium 50 milligram tablet give one tablet by mouth one time a day hold for systolic blood pressure less than 100 or blood pressure less than 100/60, dated October 15, 2025. Review of Resident 11's Medication Administration Records from October 15, 2025, through March 4, 2026, revealed the following:1) There was no documentation of Resident 11's blood pressure documented with each medication administration.2) The losartan was coded as 5=Hold See Progress Notes on November 2 and 7, 2025, and December 14, 2025. All other doses between October 15, 2025, and March 4, 2026, were documented as being administered. Review of Resident 11's clinical record progress notes revealed the following:1) November 2, 2025, at 10:26 AM, losartan was held due to a pulse of 56 (which was not one of the physician's provided parameters for holding the medication);2) November 7, 2025, at 9:35 AM, losartan was held due to a pulse of 56 (which was not one of the physician's provided parameters for holding the medication); and3) December 14, 2025, at 8:52 AM, losartan was held due to a blood pressure of 99/54. Review of Resident 11's blood pressure documentation in the vitals tab of the clinical record revealed that Resident 11's blood pressure was documented on six occasions that could possibly coincide with the losartan medication administration (October 16, 17, and 18, 2025; December 3, 2025; January 8, 2026; and February 9, 2026). Review of the Resident 11's clinical record revealed no evidence of blood pressures being taken consistently, prior to administration of medication with parameters. During a staff interview with the Nursing Home Administrator and the Director of Nursing (DON) on March 5, 2026, at 2:04 PM, the DON indicated that she could not say whether nurses consistently took Resident 11's blood pressure prior to administering the losartan. She said that the nurses may have just taken the blood pressure and wrote it on their report sheet instead of documenting it in the clinical record. She confirmed that there should have been a corresponding box with the medication administration for nurses to document Resident 11's blood pressure to reflect that the physician's ordered parameters were followed. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.9(a)(1) Pharmacy services.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, observations, facility documentation review, and staff interviews, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the kitchen, in two of two kitchenettes, and a resident unit refrigerator (second floor upper-level unit).Findings include: Review of facility policy, titled Food Storage, dated 2021, revealed, in part, All stock must be rotated with each new order received. Rotating stock is essential to assure freshness and highest quality of all foods. Old stock is always used first. Food should be dated as it is placed on shelves if required by state regulation. All containers or storage bags must be legible and accurately labeled and dated. All refrigerator units should be kept clean and in good working condition at all times. Every refrigerator must be equipped with a thermometer. Refrigerators/freezers on nursing units should be supplied with thermometers. All [refrigerated] foods should be covered, labeled, and dated and routinely monitored. Review of facility policy, titled Food Brought in From Outside Sources and Personal Food Storage, dated 2021, revealed, in part, Foods and beverages brought in from outside sources that require refrigeration or freezing should be labeled with the patient/resident's name and date stored in the refrigerator/freezer apart from facility food. Designated facility staff should be assigned to monitor individual room storage and refrigeration units for food or beverage disposal. All refrigeration units will have internal thermometers to monitor for safe food storage temperatures. Review of facility policy, titled Food Temperatures, dated 2023, revealed, in part, All cold food items must be stored at a temperature of 41 degrees Fahrenheit or below. Temperatures should be taken periodically to assure cold foods stay below 41 degrees Fahrenheit. Foods sent to the units for distribution (such as meals, snacks, nourishments, oral supplements) will be transported and delivered into unit storage areas to maintain temperatures at or below 41 degrees Fahrenheit for cold foods. Observation of the kitchen with Employee 6 (Director of Food Services) on March 2, 2026, at 10:03 AM, revealed the following:1) in the dry storage room, there were two one-gallon containers of honey Dijon mustard dressing and a one-gallon container of ranch dressing with no dates indicated; 2) in the walk-in cooler there were three metal pans of broccoli and the clear wrap noted on top failed to completely cover the broccoli; 3) the drawer containing ladles had a dark colored substance along the edge of the drawer;4) there was substantial grease residue noted on the floor near the deep fryer and Employee 6 indicated that they have not used the fryer in a long time;5) Employee 7 (Cook) was noted to be using a scoop to remove carrots out of a large box that was lined with a plastic bag. She was not wearing gloves. She was observed using her right hand to hold the scoop and using her left hand to hold onto the plastic bag that was rolled out over the edge of the box. When she finished scooping the carrots, she rolled the bag back down inside the box. During an immediate interview with Employee 6, she confirmed that Employee 6 should have been wearing gloves; 6) on the bread rack there was a Ziploc bag containing five hamburger buns with no date indicated and a bag of opened hot dog rolls that contained nine rolls that were not dated; 7) in a single door refrigerator containing desserts for the lunch meal there was noted to food debris on the floor of the refrigerator; and8) in the dish room there were two trays of cups stored upright, as well as stacks of plates that were stored upright. Employee 6 acknowledged all findings observed during the tour. Employee 6 indicated that she expects the evening staff to clean the kitchen each day but indicated that she has no written protocols or cleaning logs that staff complete. Observation of the first-floor kitchenette on March 2, 2026, at 10:35 AM, revealed in the single door reach in refrigerator there was spillage noted on the inside of the door at the bottom. There was food debris noted in the bottom of the side-by-side refrigerator/freezer. There was light food splatter in the microwave. There was spill of a dark colored substance noted in the cabinet where dry goods were stored. There were moderate crumbs noted in the crumb tray on the toaster. The plates and dome lids were noted to be stored upright and uncovered in preparation for lunch to be served. Observation of the refrigerator on the upper-level rehabilitation unit on March 2, 2026, at 11:32 AM, revealed a bottle of Cinnabon International Delight coffee creamer, a squeeze bottle of Parkay butter, and two cans of soda with no names or dates indicated. There was no thermometer noted in the refrigerator. Observation of the second-floor kitchenette on March 2, 2026, at 11:38 AM, revealed in the single door reach in refrigerator that was spillage noted on the inside of the door at the bottom and there was food debris in the bottom of the refrigerator. In the side-by-side freezer/refrigerator, the thermometer was noted to be broken in the refrigerator portion. The toaster was noted to have a moderate amount of crumbs in the crumb tray. The plates and dome lids were noted to be stored upright and uncovered in preparation for lunch to be served. Review of food temperature logs from February 22-28, 2026, and March 1-3, 2026, revealed that staff do not consistently check the temperature of cold food items or beverages at point of service. During a staff interview with the Nursing Home Administrator (NHA) and the Director of Nursing on March 4, 2026, at 1:29 PM, the NHA confirmed that he would expect foods to be labeled/stored properly, dishes to be stored properly, and that food temperatures would be checked according to policy. He also confirmed that he would expect staff to wear gloves when preparing food. 28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 211.6(f) Dietary services.

Based on facility policy review, facility document review, observations, and resident and staff interviews, it was determined that the facility failed to promote care for residents in a manner and environment that enhances each resident's dignity for one of 16 residents reviewed (Resident 56).Findings include: Review of facility policy, titled OPS-331 Resident Rights, dated February 6, 2025, revealed, 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. Review of facility provided information from their employee handbook, dated November 1, 2203, revealed, in part, F. Dress Code Policy: Since the appearance of the staff is a reflection of the employee, the resident, and the Company, the dress code provides for a consistent professional appearance in the dress of the staff. Should an employee report to work improperly dressed or groomed, his/her supervisor may instruct the employee to return home to change. Employees will not be permitted to work when they are improperly dressed. For all employees in all departments: No sweatpants; blouses are to be non-revealing in cut. In addition, the dress coded indicated for nursing department personnel was noted to be a uniform or scrub suit and that the Charge Nurse, Nurse Supervisor, or Director of Nursing may determine the appropriateness of the uniform and has the right to verbally warn the employee or send the employee off duty to change the uniform. Observation on the second-floor nursing unit on March 2, 2026, at 10:50 AM, Employee 2 (Licensed Practical Nurse) was observed to be dressed in sweatpants with Hello Kitty appliques noted on the leg and a short, blue and white striped shirt. Employee 2's abdomen was noted to be exposed. In addition, Employee 2 was not wearing a name tag. During an immediate interview with Employee 2, she confirmed her identity, job role, and indicated that she was aware that she was to wear a nametag. She said it was possibly in her purse or on her jacket. During a resident interview with Resident 56 in her room on March 2, 2026, at 1:10 PM, Employee 2 entered the room without knocking on the door. She was still dressed in sweatpants and the short shirt that exposed her abdomen, and she had no name tag. She did not identify herself to Resident 56. Employee 2 stated, I have your medications. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on March 4, 2026, at 1:34 PM, the DON acknowledged that Employee 2 was not appropriately dressed and indicated that Employee 2 was a new employee and new nurse who cannot afford scrubs. The DON further indicated that she has now instructed Employee 2 to wear her school scrubs until she can afford to purchase her own scrubs. The NHA confirmed that he would expect staff to wear proper identification and to properly identify themselves prior to entering a resident's room. He further indicated that Employee 2 was provided with a name tag. 28 Pa Code 201.14(a) Responsibility of licensee.28 Pa Code 201.18(b)(3) Management.28 Pa Code 201.29(a) Resident rights.28 Pa Code 211.11(d)(1)(2) Nursing services.

Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to implement a comprehensive person-centered care plan to meet a resident's preferences and goals, and address the resident's medical, physical, mental and psychosocial needs for one of 16 residents reviewed (Resident 3).Findings include: Review of facility policy, titled Care Plan-Comprehensive, dated September 28, 2022, revealed, in part, Each resident will have a comprehensive care plan that is individualized, includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident, and reflects the resident's cultural references, values, and practices. Each resident's care plan is designed to: d. reflect the resident's expressed wishes regarding care and treatment goals. Review of Resident 3's clinical record revealed diagnoses that included muscle weakness and depression. During a resident interview with Resident 3 on March 2, 2026, at 1:40 PM, he indicated that he does not get showers very often and described them as few and far between. Review of Resident 3's care plan revealed his bathing preference was to receive a shower once a week, dated January 14, 2024. Review of Resident 3's shower/bath documentation from February 3, 2026 -March 4, 2026, revealed that he was documented as receiving a shower once on February 15, 2026, and received a bed bath all other times. During a staff interview with the Director of Nursing (DON) on March 5, 2026, at 10:20 AM, she indicated that he does occasionally refuse a shower. She said Resident 3's autonomy of care is presumed because of his high level of cognition and that he could voice his concerns or requests to staff when care is being provided. The DON confirmed that Resident 3's preferences should have been care planned so all staff providing care could be aware and make efforts to accommodate them. 28 Pa. Code 201.24(e)(4) admission policy.28 Pa. Code 211.12(d)(2)(3)(5) Nursing services.

Based on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for three of 19 residents reviewed (Residents 4, 56, and 60).Findings include: Review of the facility policy, titled Care Plan-Comprehensive, last reviewed April 7, 2025, stated Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. Review of Resident 4's clinical record revealed diagnoses that included hypertension (high blood pressure) and chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats, causing the heart to be unable to pump an adequate amount of blood to the body). Review of Resident 4's clinical record revealed that he was treated for the flu from January 30, 2026 -February 6, 2026. Review of Resident 4's care plan revealed an active care plan focus for influenza, dated January 30, 2026. During a staff interview with the Director of Nursing on March 5, 2026, at 10:20 AM, she confirmed that Resident 4's influenza was resolved in early February 2026, and that his care plan should have been revised at that time. Review of Resident 56's clinical record revealed diagnoses that included vascular dementia (brain damage caused by multiple strokes, which causes memory loss in older adults) and hearing loss. Review of Resident 56's clinical record revealed that she was treated for a urinary tract infection (UTI) from February 1-4, 2026. Review of Resident 56's care plan revealed an active care plan focus for a UTI, dated February 1, 2026. During a staff interview with the Nursing Home Administrator (NHA) on March 5, 2026, at 11:26 AM, the NHA indicated that the care plan should have been revised when the UTI resolved and that Resident 56's care plan has now been revised. Review of the clinical record for Resident 60 revealed diagnoses that included Parkinson's disease with dyskinesia (uncontrolled, involuntary movement) and retention of urine (inability to fully empty the bladder). Review of the clinical record for Resident 60 revealed resident had a UTI on November 1, 2025, that was resolved with treatment. Review of Resident 60's care plan on February 4, 2026, revealed the UTI that occurred November 1, 2025, was still present on the care plan. During an interview with the NHA on February 5, 2026, at 10:45 AM, he agreed that care plans should reflect the Resident's status. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on observations, facility policy, and staff interviews, it was determined that the facility failed to discard expired medications for one of one medication storage rooms observed (2nd floor), and failed to place opened dates on medications in one of two medication carts (2nd floor) and one of one medication storage rooms (2nd floor) observed. Findings Include: Review of facility policy, titled Storage of Medications, last revised April 7, 2025, read, in part, III. Expiration Dating (Beyond-Use Dating) 3. Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmics, nitroglycerin tablets, and blood sugar testing solutions and strips require an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency. Observation of the second floor medication storage room on March 4, 2026 at 10:00 AM, revealed one open multidose vial of tuberculin solution with no open date label. Further observation of the second floor medication storage room on March 4, 2026 at 10:00 AM, revealed one box of 25 gauge needles with an expiration date of February 28, 2026, and one open vial of insulin lispro labeled with an open date of January 17, 2026. An interview with Employee 1 on March 4, 2026, at 10:00 AM, revealed that the tuberculin solution should be labeled with an open date when opened and expired medication and supplies should be discarded. Observation of the second floor medication cart on March 5, 2026 at 11:15 AM, revealed one open bottle of liquacel with no open date label and one open Lantus insulin pen with no open date label. An interview with Employee 1 on March 5, 2026 at 11:15 AM, revealed that liquacel bottles and insulin pens should be labeled with an open date when opened due to a shortened expiration date once opened. During an interview on March 5, 2026, at 1:08 PM, with the Nursing Home Administrator and Director of Nursing, revealed that it was the facility's expectation that medications be labeled with open dates when opened and expired medications and supplies be disposed of. 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.9(a)(1) Pharmacy services

Based on observations, facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure staff implement infection control policies to prevent the spread of infection for one of 19 residents observed on contact precautions (Resident 5).Findings Include: Review of facility policy, titled IC-Enhanced Barrier Precautions, revised April 1, 2024, revealed, Enhanced barrier precautions apply when: A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained; and contact precautions do not otherwise apply. Review of Resident 5's clinical record revealed diagnoses that included pressure ulcer of sacral region, stage 3 (a severe, full-thickness wound where the true depth [Stage III or IV]) and diabetes (a chronic condition when the body cannot properly control blood glucose levels). [[NAME]] I feel the ulcer piece isn't finished Observation of Resident 5's room door on March 2, 2025, at 10:30 AM, failed to reveal any signage that Resident 5 was on enhanced barrier precautions or that it was necessary to use personal protective equipment when caring for Resident 5. Observation of Resident 5's room door on March 3, 2025, at 11:30 AM, failed to reveal any signage that Resident 5 was on enhanced barrier precautions or that it was necessary to use personal protective equipment when caring for Resident 5. Observation of Resident 5's stage 3 pressure ulcer treatment on March 5, 2026, at 9:45 AM, revealed that Resident 5 had a stage 3 pressure ulcer on her sacrum that is healing but still an opening in her skin. Review of Resident 5's wound team consult dated March 2, 2026, at 11:55 PM, revealed that Resident 5 had a stage 3 pressure ulcer on her sacrum. Review of Resident 5's physician orders failed to reveal a physician's order for Resident 5 to be on enhanced barrier precautions. Review of Resident 5's care plan failed to reveal any care plan dealing with Resident 5's need to be on enhanced barrier precautions. Interview with the Director of Nursing on March 3, 2026, at 12:15 PM, revealed that she was under the impression that Resident 5's pressure ulcer had closed and that enhanced barrier precautions were no longer needed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, policy review, other resources, and staff interviews, it was determined that the facility antibiotic stewardship program allows for lapsed doses of antibiotic usage as determined by one of 19 residents reviewed (Resident 60).Findings Include: Review of the facility policy, titled Antibiotic Stewardship- Order for Antibiotics, reviewed April 7, 2025, When a culture and sensitivity (C&S) is ordered, it will be completed, and; lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. Based on National Institute of Health Resource, dated December 11, 2025, lapsed or missed doses particularly early in treatment are critical issues that reduce treatment efficacy, allow for the development of drug resistance, and may necessitate dose increases or adjustments. Based on current Food and Drug Administration recommendations the treatment for Proteus mirabilis (Gram negative rod bacteria capable of causing symptomatic infections including cystitis [inflammation of the bladder] and pyelonephritis [kidney infection] and is present in cases of asymptomatic bacteriuria, particularly in the elderly), complicated urinary tract infections, the dosage should be 500 milligrams twice a day for 7 days. Review of the clinical record for Resident 60 revealed diagnoses that included Parkinson's disease with dyskinesia (involuntary, erratic movements) and retention of urine (inability to empty the bladder completely). Further review of the clinical record for Resident 60 revealed a diagnosis of urinary tract infection (UTI) was confirmed by a laboratory culture on November 28, 2026. The microbiology results revealed > (greater than) 100,000 CFU/ml (colony-forming units per milliliter) Proteus mirabilis (Abnormal). On November 28, 2025, at 3:25 PM, the provider ordered Cipro (ciprofloxacin - a potent antibiotic used to treat serious bacterial infections, including urinary tract infections) 250 milligrams by mouth twice a day for 3 days. The antibiotic started on November 28, 2025, at 6:00 PM. Resident 60 received additional doses on November 29, 2025, at 6:00 AM and 6:00 PM; November 30, 2025, at 6:00 AM and 6:00 PM; and was stopped on December 1, 2025, at 6:00 AM. The Provider's designated Registered Nurse visited Resident 60 and reported the Resident was without any UTI symptoms and the antibiotic was discontinued as ordered initially. Resident 60 received a follow-up visit on December 3, 2025, and during the physical assessment Resident had suprapubic tenderness (pain or sensitivity in the lower abdomen just above the pubic bone) often signaling underlying bladder or pelvic issues like urinary tract infections or cystitis. On December 3, 2025, the provider wrote new orders for Cipro 500 mg twice a day (1000 mg daily) for 7 days due to continued symptoms related to a complicated UTI. During an interview with Employee 9 (ICP-Infection Control Preventionist) on March 5, 2026, at 10:00 AM, Employee 9 stated that residents under the care of this Resident's provider are usually treated for 3 days with antibiotics when diagnosed with UTI with a positive culture. The Resident is evaluated by a Registered Nurse for symptoms and, if there are no symptoms, the antibiotic ends as scheduled. When the Provider reevaluates at the next visit if there are symptoms, the antibiotic is restarted. During an interview with the Nursing Home Administrator (NHA) on March 5, 2026, at 10:45 AM, the NHA stated that antibiotic usage is referred to the provider. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3) Management28 Pa. Code 211.12(c)(d)(3) Nursing services

Based on facility policy review, clinical record review, hospital record review, facility investigation report, facility provided documents, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to prevent a significant medication error, which resulted in actual harm as evidenced by a hospital transfer for low blood pressure, low heart rate and altered consciousness for one of three residents reviewed (Resident 1).Findings include: Review of facility policy, titled CLIN-080 Medication Pass, revealed the following, in part, 2. The MAR [Medication Administration Record] is reviewed for the right resident, right drug, right time, right route, and right dose. 3. As the medications are being poured, the licensed nurse compares the label with the MAR three times: a. When removing medication from the drawer, b. When removing the medication from the container, c. when returning the container to the drawer. 5. The resident is properly identified by 2 forms of identification (bracelet, picture ID, verbally, if resident is able to comprehend). A picture of each resident is taken upon admission to the facility and annually thereafter. Review of Resident 1's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), hypertension (high blood pressure), cognitive communication deficit (a group of disorders that affect a person's ability to communicate, which can cause difficulty with understanding or producing language and nonverbal communication skills such as gestures and facial expressions), and type 2 diabetes mellitus (disease that occurs when your blood glucose, also called blood sugar, is too high, but does not require the use of insulin). Review of Resident 1's clinical record progress notes revealed a note dated July 12, 2025, at 7:35 AM, by Employee 2 (Registered Nurse-Supervisor) that indicated she was notified by Resident 1's Nurse (Employee 1 [Registered Nurse]) that the resident had received the incorrect medications. Resident 1 received Humalog 6 units (short-acting insulin), Insulin Glargine 15 units (long-acting insulin), Pantoprazole 20mg (medication used to treat conditions involving too much acid in the stomach), Vitamin C 500 mg, Carvedilol 12.5mg (medication used to treat high blood pressure and heart failure), Eliquis 5 mg (medication used to thin the blood and prevent blood clot formation), Finasteride 5mg (medication to treat an enlarged prostate), Gabapentin 600mg (medication used to treat seizures and nerve pain), Hydralazine 50 mg (medication used to treat high blood pressure), and Multi-vitamin and Vitamin B complex. The note further indicated that Resident 1's provider was notified, and orders were given to hold Resident 1's oral diabetic medications and to monitor his blood pressure and blood sugar every hour. The note indicated that Resident 1's blood pressure was 103/66 (normal being 120/80), his pulse was 71 (with normal being 60-100), his respirations were 16 (with normal being 16-20), and his blood sugar was 142 (with normal being 70-100). Review of Resident 1's clinical record progress notes revealed a note dated July 12, 2025, at 7:58 AM, by Employee 1 that she was asked by a nurse aide to assist with Resident 1 as he was sliding down out of his wheelchair. The note further indicated that, upon arriving to Resident 1's room, he was noted to be unresponsive in his wheelchair. His heart rate palpable to bilateral radial [wrists]- regular rate. Bilateral pupils equal and reactive to light. Resident warm/dry to touch. Blood sugar 142. At this time, resident was going in and out of responsiveness, resident laid to floor. BP [blood pressure] 135/52, HR [heart rate] 85. Sterum rub performed by this nurse - effective. BP 84/46 HR 59. Resident continues to come in and out of consciousness, BP 137/90. Resident becomes more aroused, lightly speaking with staff prior to EMS [Emergency Medical Services] arriving BP 87/52 HR 61. EMS arrived in residents' room. Review of Resident 1's clinical record progress notes revealed that he was transferred to the hospital on July 12, 2025, at 8:29 AM. Review of Resident 1's clinical record progress notes revealed a nurse's note by Employee 1 on July 12, 2025, at 4:36 PM, that indicated when she entered Resident 1's room, she said his name as Resident 2's name and that Resident 1 stated yes. The note indicated that Employee 1 administered the medications at 7:13 AM, realized incorrect medications were administered to Resident 1 at 7:19 AM, and she reported the occurrence to Employee 2 at 7:20 AM. The note further indicated that at 8:05 AM, Resident 1's Blood sugar was 142; Blood pressure was 103/66; Pulse was 71; and Respirations were 16. Review of Resident 1's clinical record revealed that his last documented vital signs prior to the medication administration error were completed on July 12, 2025, at 12:46 AM, and were recorded as blood pressure 167/87, pulse 108, respirations 20, and an oxygen saturation of 95%. His last recorded blood sugar was 232 and was noted to be recorded July 12, 2025, at 7:20 AM. Review of Resident 1's hospital emergency department record dated July 12, 2025, at 8:52 AM, revealed that he presented to the hospital with a chief complaint of medication error and that he had no specific complaints but was not able to provide much history. Patient apparently does have some mild dementia. According to paramedics patient was able to stand and answer questions. Because he was somewhat hypotensive with a pressure in 70s systolic, IV fluids were started. Physical assessment findings indicated that he was drowsy but arousable and that he was alert and oriented to person and place with no other abnormal findings. His initial glucose (blood sugar) was greater than 90. Additional notes on timeline indicated the following: at 9:11 AM Resident 1 remained somewhat hypotensive (low blood pressure) and bradycardic (low heart rate/pulse), drowsy but arousable, will be given some intravenous fluids, will closely monitor his blood sugar on recheck 93; and at 10:43 AM Resident 1 was drowsy but arousable; remained relatively hypotensive and bradycardic; had received a liter of normal saline and was receiving D5 [Dextrose 5%] normal saline infusion; and that the plan would be to hold off on any further boluses unless necessary due to concern for developing congestive heart failure, and that Resident 1 was not exhibiting any respiratory distress and oxygen saturation was 97%. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on July 22, 2025, at 9:40 AM, the NHA indicated that Resident 1's and Resident 2's rooms were directly across the hall from one another and that Employee 1 turned the wrong direction in the hallway and ended up in wrong room. He further indicated that Resident 1 was a new resident at the facility, only being admitted on [DATE], and the event occurred on July 12, 2025. The NHA said that Resident 1 remained at the hospital for 3 days under observation and was then discharged to another facility. He further revealed that on-the-spot education on the 5 Rights of Medication Pass was completed immediately with Employee 1. He said that the facility began educating all licensed nursing staff and started medication pass observations of all nursing staff and that the education and observations were being completed on all shifts. He said that there have been no issues were noted with any of the observations. He said that they are continuing these observations as part of the Performance Improvement Plan, they developed when the event occurred. He said that they had achieved compliance on July 14, 2025. Review of facility provided Performance Improvement Plan (PIP) for Medication Error- Med Pass Accuracy revealed the following:1) Immediate education was provided to the nurse involved on July 12, 20252) Immediate audit was completed to identify if any other residents were affected on July 12, 2025. Immediate audit completed that residents have the correct name, room number, and other identifiers in place. 3) All full time and part time licensed nursing staff were educated on the 5 Rights of Medication Administration beginning on July 12, 2025, and concluding July 14, 2025. 4) Medication Pass Observations will be completed on all nurses to ensure they are following the techniques of 5 Rights of Medication Administration. After 2 weeks of daily audits with 100% pass rate, the frequency will move to 3 days a week for 2 weeks, then weekly for 2 weeks, and then monthly for one month. During a staff interview with Employee 3 (Licensed Practical Nurse) on July 22, 2025, at 9:30 AM, Employee 3 confirmed she had received training on the 5 Rights of Medication Administration. Employee 3 indicated that she uses the picture in the electronic health record to identify residents. She said that if there was no picture or she was not sure, she would seek assistance from another staff member. During a staff interview with Employee 4 (Registered Nurse) on July 22, 2025, at 9:35 AM, Employee 4 confirmed she had received training on the 5 Rights of Medication Administration. Employee 4 indicated that she asks resident to state their name and uses the picture in the electronic health record to identify residents. She said if she had any doubt she would seek assistance from another staff member. She also indicated that she does not pass medications very often maybe, one to two times per month. During a staff interview with Employee 5 (Registered Nurse) on July 22, 2025, at 9:35 AM, Employee 5 confirmed she had received training on the 5 Rights of Medication Administration. Employee 5 said she uses the picture in the electronic health record to identify residents as well as asking them to state their name. She said if she had any doubt about a resident's identity, she would seek assistance from another staff member. She further indicated that she always verifies medications twice before administering them to a resident. She said medications are in blister packs and are labeled with each resident's name and room number. She said that insulin vials and pens are also labeled with resident's name and room number. She said that she also places the medication cart in front of the resident room for which she is preparing medications. Review of the POC documentation and interviews with staff revealed no concerns with medication administration. During a final staff interview with the NHA and DON on July 22, 2025, at 12:30 PM, they both confirmed they would expect nurses to follow the facility policy and practice the 5 Rights of Medication Administration with each medication administration to prevent significant medication errors from occurring. The NHA indicated that the facility was in compliance as of July 14, 2025, and that the PIP and audits will be reviewed at the next Quality Assurance Performance Improvement Committee Meeting on August 12, 2025. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.9(a)(1) Pharmacy services28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to post the most recent Federal or State survey results for one of one survey books observed (located in main entrance lobby). Findings Include: Observation of the survey binder located in the main entrance lobby on April 1, 2025, at 11:27 AM, revealed the most recent survey results present were dated August 2023. Review of the facility's survey history revealed the most recent survey result that could have been posted was conducted on March 19, 2025. During an interview with the Nursing Home Administrator on April 2, 2025, at 1:02 PM, he revealed the expectation that the survey books should be up to date and confirmed that they had been updated. 28 Pa. Code 201.14 Responsibility of licensee

Based on clinical record review, facility document review, and staff interviews, it was determined that the facility failed to provide a notice of transfer that included the required information for three of four resident records reviewed for hospitalizations (Residents 47, 50, and 58). Findings include: Review of Resident 47's clinical record revealed diagnoses that included atrial fibrillation (irregular and rapid heartbeats on the upper chamber of the heart) and acute kidney failure (a sudden and significant decrease in kidney function). Further review of Resident 47's clinical record revealed that she had been transferred and admitted to the hospital on [DATE]. Review of facility provided document, titled Notice of Proposed Involuntary Discharge or Transfer, revealed the notice did not contain the location of transfer, statement of the Resident's appeal rights, the mailing address of the entity which receives request for appeals; mailing address of the Office of the State Long-Term Care Ombudsman; the mailing address for the agency responsible for protection and advocacy of individuals with developmental disabilities; nor, the mailing address for agency responsible for the protection and advocacy of individuals with mental disorders. During a staff interview with the Nursing Home Administrator (NHA) on April 3, 2025, at 12:02 PM, the NHA confirmed that the facility transfer notice did not contain all the required information. Review of Resident 50's clinical record revealed diagnoses that included chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats, causing the heart to be unable to pump an adequate amount of blood to the body), atrial fibrillation, and chronic respiratory failure with hypoxia (long-term condition in which the respiratory system is unable to adequately exchange oxygen and carbon dioxide in the body). Review of Resident 50's clinical record revealed that she had been transferred and admitted to the hospital on [DATE]; November 13, 2024; and February 8, 2025. Review of facility provided document, titled Notice of Proposed Involuntary Discharge or Transfer, revealed the notice did not contain the location of transfer, statement of the Resident's appeal rights, the mailing address of the entity which receives request for appeals; mailing address of the Office of the State Long-Term Care Ombudsman; the mailing address for the agency responsible for protection and advocacy of individuals with developmental disabilities; nor, the mailing address for agency responsible for the protection and advocacy of individuals with mental disorders. During a staff interview with the NHA on April 3, 2025, at 12:02 PM, the NHA confirmed that the facility transfer notice did not contain all the required information. Review of Resident 58's clinical record revealed diagnoses that included paroxysmal atrial fibrillation and acute kidney failure. Further review of Resident 58's clinical record revealed that he had been transferred and admitted to the hospital on [DATE]. Review of facility provided document, titled Notice of Proposed Involuntary Discharge or Transfer, revealed the notice did not contain the location of transfer, statement of the Resident's appeal rights, the mailing address of the entity which receives request for appeals; mailing address of the Office of the State Long-Term Care Ombudsman; the mailing address for the agency responsible for protection and advocacy of individuals with developmental disabilities; nor, the mailing address for agency responsible for the protection and advocacy of individuals with mental disorders. During a staff interview with the NHA on April 3, 2025, at 12:02 PM, the NHA confirmed that the facility transfer notice did not contain all the required information. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to monitor hydration to ensure proper hydration for one of two residents reviewed for hydration (Resident 50). Findings include: Review of facility policy, titled CLIN-054 Fluid Intake with a last review date of December 2024, failed to reveal how the facility would manage fluid intake for residents with physician ordered restrictions. Review of Resident 50's clinical record revealed diagnoses that included chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats, causing the heart to be unable to pump an adequate amount of blood to the body), atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating of the upper chamber of the heart), and chronic respiratory failure with hypoxia (long-term condition in which the respiratory system is unable to adequately exchange oxygen and carbon dioxide in the body). Review of Resident 50's clinical record revealed a physician order for no added salt /1500 CC (cubic centimeters) FR [fluid restriction] diet Regular texture, Regular Liquids consistency, small portions at meals, dated November 16, 2024. Further review of Resident 50's clinical record failed to reveal how the Resident's fluid restrictions would be distributed throughout a 24-hour time period or how the facility would monitor Resident 50's overall fluid intakes on a daily basis. Review of Resident 50's clinical record nurse aide task documentation for fluid intake with meals and additional fluids provided from March 4, 2025 -April 1, 2025, revealed that Resident 50's was documented as consuming a total of 3370 cc on March 7, 2025; and 1560 cc's on March 25, 2025. Review of Resident 50's Medication Administration Records from November 2024 through April 1, 2025, failed to include any documentation of how much fluid was provided to Resident 50 during medication administrations on any shift. Review of Resident 50's clinical record progress notes failed to reveal documentation that her physician was made aware of her exceeding her ordered fluid restrictions on March 7 and 25, 2025. During a staff interview with the Nursing Home Administrator and Director of Nursing (DON) on April 3, 2025, at 11:08 AM, the DON confirmed that there was no documentation of how many fluids were being provided by nursing staff with medication passes or nurse monitoring of total fluids consumed in a 24-hour period. She indicated that on March 7, 2025, she believed her fluid intake was a documentation error as Resident 50 does not generally consume that amount of fluid and that there were no notes indicating any change in her status. She confirmed that there was no documentation that Resident 50's physician was notified of her exceeding her fluid restriction on March 25, 2025. In addition, she confirmed that Resident 50 should have had a fluid breakdown in a 24-hour period to include meals, medication passes, and other offerings, established with nurse monitoring of fluids on a daily basis when the order was initially given for the fluid restriction. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on observations, facility policy review, and staff interviews, it was determined that the facility failed to ensure food was prepared and served under sanitary conditions in two of two dining rooms observed (1st and 2nd floor). Findings include: Review of facility policy, Bare Hand Contact with Food and Use of Plastic Gloves, dated 2021, revealed, Bare hand contact with food is prohibited .Gloved hands are considered a food contact surface that can become contaminated or soiled. If used, single-use gloves shall be used for only one task (such as working with ready-to-eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. Hands are to be washed when entering the kitchen and before putting on the single-use gloves (before beginning work with food) and after removing single-use gloves. Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed, and hands must be washed. Observation of tray line service on second floor on March 31, 2025, at 12:38 PM, revealed Employee 7 (Dietary Aide) wearing gloves, touching the paper meal tickets, then reaching into the bag of hamburger buns to retrieve them wearing the same gloves, and touching cheese slices wearing the same gloves. Observation during lunch meal service on second floor on March 31, 2025, at approximately 12:40 PM, Employee 8 (Nurse Aide) brought a resident's plate back up to the serving line to have Employee 7 add a slice of cheese to the burger. Employee 8 was noted to use the tip of her right index finger to slide the top bun off the burger for Employee 7 to add the cheese. Employee 8 then slid the top bun back onto the burger using her same finger. Employee 8 was not wearing gloves. Observation in the first floor dining room on March 31, 2025, starting at approximately 12:40 PM, revealed Employee 6 (Nurse Aide) touching the sandwiches of Residents 26, 27, and 45 with her bare hands while assisting them with cutting and/or placing condiments on their sandwiches. Observation of tray line on first floor on March 31, 2025, at 12:44 PM, revealed Employee 5 (Cook) wearing gloves, touching the paper meal tickets, then reaching into the bag of hamburger buns to retrieve them wearing the same gloves, and touching cheese slices wearing the same gloves. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on April 2, 2025, at 12:43 PM, the DON confirmed that staff should have used tongs to serve hamburger buns and cheese slices, and that nursing staff should wear gloves when touching residents' food. During an interview with the NHA on April 3, 2025, at 10:56 AM, he revealed the expectation that staff should not be touching resident food with bare hands. 28 Pa. Code 211.6(f) Dietary services 28 Pa. Code 211.18(b)(1) Management

Based on review of facility policy, review of select facility documentation, and staff interview, it was determined that the facility failed to ensure all alleged violations involving abuse were reported immediately for one of two residents reviewed for abuse (Resident 52). 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 .Facility staff will be trained to report any oral or written reports of alleged neglect, abuse, mistreatment, and misappropriation of resident's property .Any report or suspicion of an incident is to be reported immediately to the charge nurse/supervisor .The Administrator and the Director of Nursing are to be notified immediately by the charge nurse/supervisor who receives the report. The Administrator or his designated person will notify the Licensing and Regulatory Agency (Department of Health/DHS), Protective Services, Local Police Department, and other state designated agencies as required. Review of Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property, revealed that on December 12, 2024, Resident 52 stated she wanted to attend a church activity, but Employee 3 (Nurse Aide) told her she was going to bed and not the activity. Further review of this form revealed that this incident was reported to Employee 2 (Registered Nurse) on December 13, 2024, who reported it to Employee 4 (Social Worker) on that date. It also stated that the investigation into this alleged incident of abuse did not start until December 16, 2024, and was not reported to the state regulatory agency until December 17, 2024. Review of Employee 2's witness statement (undated) revealed, [Resident 52] reported to this writer on the afternoon of 12/13/24 she wanted to attend the evening activity after supper to listen to a group of Christmas carolers singing in the activity room. [Resident 52] said that a tall colored girl asked her 'where do you think you are going' when [Resident 52] was waiting to go down to the activity. [Resident 52] told the tall colored girl that she wanted to go to the activity to listen to Christmas carolers. [Resident 52] said that 'the tall colored girl then said no you're not doing that you are going to bed.' [Resident 52] was very upset and crying at the time when she shared this with this writer. Review of Employee 4's witness statement (undated) revealed, Spoke to resident on 12/16 about incident on 12/12 (Thursday). Resident stated she was not allowed to go to activities to watch the Christmas carolers sing because she had to go to bed and it was 6 pm. She began to cry because she said she did not want to go to bed and was waiting for activities. I asked her who told her this she said her aide, she didn't know the name, only that it was a 'tall black girl.' During an interview with the Director of Nursing (DON) on April 3, 2025, at 11:03 AM, she acknowledged that there was a delay in reporting the aforementioned allegation of abuse. She revealed that the incident took place on December 12, 2024. The Resident reported the incident to Employee 2 during a care plan meeting on December 13, 2024. Employee 2 passed it along to Employee 4 for follow-up, but Employee 4 was not working that day. Administration did not become aware of the incident until December 16, 2024. The DON also revealed that verbal education was provided to Employee 2 regarding required timeframes and process for reporting allegations of potential abuse/neglect. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for two of 17 residents reviewed (Residents 13 and 24). Findings include: Review of facility policy, titled Care Plan - Comprehensive, last reviewed December 2024, revealed, Each resident will have a comprehensive care plan developed that is individualized, included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident, and reflect the resident's cultural references, values, and practices. Review of Resident 13's clinical record revealed diagnoses that included atrial fibrillation (upper chambers of the heartbeat irregularly and rapidly) and heart failure (the heart cannot pump effectively enough to meet the body's needs). Review of Resident 13's physician orders revealed an order for Apixaban (anticoagulant medication) 2.5 milligrams two times a day, with a start date of June 11, 2024. Review of Resident 13's comprehensive care plan failed to reveal any care planning for Resident 13's anticoagulant medication use or side effect monitoring. During a staff interview on April 3, 2025 at 11:09 AM, with the Nursing Home Administrator (NHA) and Director of Nursing (DON), the NHA stated Resident 13's care plan had been updated and it was the expectation of the facility that comprehensive care plans be developed accurately. Review of Resident 24's clinical record revealed diagnoses that included dementia (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Further review of Resident 24's clinical record revealed she was admitted to the facility on [DATE]. Review of Resident 24's hospital discharge summary dated March 20, 2025, revealed that dementia associated with other underlying disease was noted as one of the problems addressed during her stay. Review of Resident 24's practitioner visit notes dated March 25, 2025, revealed that Resident 24 was discharged home from the facility in January 2025, but had been seen in the emergency room four times since then. Two of the visits were related to increased episodes of confusion, and her MoCA score (Montreal Cognitive Assessment - a highly sensitive tool for early detection of mild cognitive impairment) indicated significant cognitive impairment. Further review revealed that when examined, Resident 24 confirmed she did have confusion and stated she was unsure where she was. Review of Resident 24's care plan failed to reveal any information related to her cognitive impairment or dementia diagnosis. During an interview with the NHA on April 3, 2025, at 11:02 AM, he revealed the expectation that Resident 24's cognitive impairment/dementia diagnosis should have been included in her plan of care. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, review of facility admission agreement, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the resident care plan was reviewed and revised to reflect the resident's current status for two of 21 residents reviewed (Residents 48 and 55). Findings include: Review of facility policy, titled Care Plan - Comprehensive, revised September 28, 2022, revealed, Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. Review of Resident 48's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and depression. Review of Resident 48's clinical record progress notes revealed a nurse's note dated March 17, 2025, at 1:52 PM, that indicated he had edema (swelling caused by too much fluid trapped in the body's tissues) in both of his lower legs. Review of Resident 48's physician orders revealed an order for TED stockings (compression stockings used to reduce chance of blood clots and to promote increased blood flow velocity in the legs), apply in AM and remove in PM, dated March 17, 2025. Review of Resident 48's care plan failed to reveal a focus for his edema or the use of TED hose. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on April 3, 2025, at 10:45 AM, the DON confirmed that Resident 48's care plan should have been updated to reflect his edema and the use of TED hose. Review of the facility admission agreement, effective July 27, 2015, revealed, The facility does not permit smoking anywhere on its premises. Review of Resident 55's clinical record revealed diagnoses that included congestive heart failure (weakness of the heart that leads to buildup of fluid in the lungs and surrounding body tissues) and other symptoms and signs involving cognitive functions and awareness. Review of Resident 55's care plan revealed a focus area of, [Resident 55] wishes to be a smoker; smoking evaluation has determined resident's degree of independence for safe smoking, initiated February 20, 2025. Further review revealed an intervention to inform and orient resident to smoking areas. Review of Resident 55's clinical record failed to reveal that she was an active smoker. During an interview with the NHA on April 1, 2025, at 9:43 AM, he confirmed that the facility was non-smoking. During an interview with the DON on April 3, 2025, at 11:10 AM, she revealed the expectation that smoking should have been removed from Resident 55's care plan. 42 CFR 483.21(b)(2) Comprehensive Care Plans 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to provide care and services in accordance with professional standards of practice to ensure each resident's highest level of well-being for one of three residents reviewed for advanced directives (Resident 51). Findings Include: Review of Resident 51's clinical record revealed diagnoses that included Alzheimer's disease (gradually progressive brain disorder that causes problems with memory, thinking, and behavior) and type 2 diabetes mellitus (impairment in the way the body regulates and uses sugar [glucose] as a fuel, resulting in too much sugar circulating in the bloodstream). Further review of Resident 51's clinical record revealed a POLST form (Pennsylvania Orders for Life Sustaining Treatment), dated December 23, 2024, stating that if Resident 51 was found with no pulse and not breathing, Resident 51 did not wish to be resuscitated. Review of Resident 51's physician orders revealed an order dated July 3, 2024, for Full Code, meaning resuscitation should be attempted if she was found without a pulse and not breathing. During an interview with the Nursing Home Administrator on April 3, 2025, at 10:59 AM, he confirmed that Resident 51's orders should have reflected her DNR (Do Not Resuscitate) status. He also revealed that a whole house audit was completed to ensure accuracy of code statuses. 28 Pa. Code 211.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, record review, observation, and staff interview, it was determined that the facility failed ensure the resident received care, consistent with professional standards, to treat and prevent pressure ulcers for one of one resident reviewed (Resident 49). Findings Include: Review of facility policy, titled CLIN-046 Dressing Changes, Revised March 28, 2016, revealed in step 11. Write the date, time, and initials on the dressing. Review of facility policy, titled IC- Enhanced Barrier Precautions, with a revision date of April 1, 2024, indicated that residents on enhanced barrier precautions require the use of gloves and a protective gown for high contact resident care activities, including wound care and any skin opening requiring a dressing. Review of Resident 49's clinical record revealed diagnoses that included pressure ulcer of right heel (localized area of damaged skin or tissue that occurs when pressure is applied to the skin for a prolonged period of time) and diabetes (a disease that effects how the body utilizes and regulates blood sugar). Review of Resident 49's current physician orders revealed an order to cleanse Resident 49's right heel with wound cleanser, apply medihoney (wound medication) and apply gauze to cover, with a start date of February 25, 2025. Another order revealed Resident 49 required enhanced barrier precautions related to her right heel, starting on February 11, 2025. Observation of Resident 49's dressing change to right heel on April 2, 2025, at 10:41 AM, revealed Employee 1(Registered Nurse) was completing Resident 49's right heel. When Employee 1 removed the dressing from Resident 49's heel, she confirmed that the dressing was not dated or timed, and she could not tell when it was applied. For the duration of the dressing change, Employee 1 was not wearing a gown at any time during the procedure. Interview with the Director of Nursing on April 3, 2025, at 12:51 PM, revealed that Resident 49's dressing should have been dated and Employee 1 should have followed the enhanced barrier precautions policy. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical record review, observations, and staff interview, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of three residents reviewed for respiratory care (Resident 50). Findings include: Review of facility policy titled CLIN-009 Aerosol Therapy, with a last review date of December 2024, revealed: Following the treatment remove any medication left in the medication cup of the nebulizer. Wash the nebulizer with tap water after shaking excess medication from assembly, then disassemble nebulizer and place on a paper towel and allow to air dry. Rinse the mask and/or mouthpiece with warm water for 30 seconds. Also air dry on a clean paper or towel. When nebulizer equipment is dry, place it back in labeled plastic bag. Plastic bag will have the date that the equipment was opened on the outside of the bag. Once a week, replace all disposable parts. Review of Resident 50's clinical record revealed diagnoses that included chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats, causing the heart to be unable to pump an adequate amount of blood to the body), atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating of the upper chamber of the heart), and chronic respiratory failure with hypoxia (long term condition in which the respiratory system is unable to adequately exchange oxygen and carbon dioxide in the body). Review of Resident 50's clinical record revealed a physician order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 milligrams/3 milliliters inhale orally via nebulizer four times a day, dated February 11, 2025. Further review of orders failed to include frequency of nebulizer tubing/mask change or frequency of cleaning of medication chamber/mask. Observations of Resident 50's room on April 1, 2025, at 10:25 AM, and April 2, 2025, at 11:48 AM, revealed that the tubing connected to her nebulizer machine was not dated and that the mask was laying on top of the machine with a plastic storage bag located beside the nebulizer. During a staff interview with the Nursing Home Administrator and Director of Nursing (DON) on April 2, 2025, at 12:55 PM, the DON indicated that she would expect the nebulizer tubing to be dated and mask to be bagged when not in use. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to adequately monitor psychotropic medications to ensure that residents were free from unnecessary medications for one of five residents reviewed for unnecessary medications (Resident 24). Findings include: Review of facility policy, Use of Psychotropic medications, revised January 21, 2025, revealed, Complete 'Behavior/Interventions' Sheet or other behavior tracking pharmacy form to include : All relevant resident data, target behavior, record the number of episodes, intervention code and outcome by shift, if side effects observed enter code, otherwise leave blank. Review of Resident 24's clinical record revealed diagnoses that included dementia (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and anxiety disorder (mental disorder characterized by feelings of worry about future events and/or fear in reaction to current events). Review of Resident 24's physician orders revealed an order for risperidone (antipsychotic medication) for dementia, effective March 20, 2025. Review of Resident 24's clinical record failed to reveal evidence of side effect monitoring related to use of her antipsychotic medication or monitoring of the target behaviors the medication was to address. During an interview with the Director of Nursing on April 3, 2025, at 12:55 PM, she confirmed that behavior and side effect monitoring was not in place related to Resident 24's use of risperidone, but should have been. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, hospital record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided after a change in condition for one of 16 residents reviewed (Resident 1). This failure resulted in continued decline, which required hospitalization for hypovolemic shock (emergency condition in which severe blood or other fluid loss makes the heart unable to pump enough blood to the body), low blood pressure, and cardiac arrest for Resident 1. This failure placed an additional six out of six residents reviewed who were identified as having a change in condition in an immediate jeopardy situation (Residents 9, 12, 13, 14, 15, and 16). The facility also failed to monitor blood glucose levels for residents with Diabetes Mellitus for two of 16 residents reviewed (Resident 1 and 9). Findings include: Review of facility policy, titled Change of Condition, with a last revision date of February 22, 2024, revealed the following: It is the policy of the Facility to inform residents, physician/CRNP's (Certified Registered Nurse Practitioners), and resident representatives of a change in the resident's condition; Licensed nursing staff will: 1. Evaluate any changes noted through direct observation or by assigned staff or any changes noted in report at change of shift or as noted on 24 Hour Report; 2. Obtain a complete set of vital signs (temperature, pulse respirations, and blood pressure) at the onset of the change and/or more often as appropriate or ordered by the physician/CRNP; 5. Notify the physician/CRNP immediately if the condition appears serious; 6. Notify the resident's representative of the change and any changes made to the resident's plan of care; 7. Address the change on the 24 Hour Report or facility specific form at the nursing station for follow through by the next shift; and 9b. Licensed staff will document findings in the EHR (electronic health record) regarding the change of condition and observations. Review of Resident 1's clinical record revealed diagnoses that included iron deficiency anemia (a condition in which blood lacks adequate healthy red blood cells), Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood), and hypertension (elevated blood pressure). Review of Resident 1 physician orders revealed orders for Lantus SoloStar Subcutaneous Solution Pen-injector 100 units/milliliters (Insulin Glargine-injectable medication to treat high blood sugars) Inject 8 units subcutaneously one time a day for Type 2 Diabetes Mellitus, dated May 14, 2024; and Midodrine HCl Oral Tablet 2.5 MG Give one tablet by mouth three times a day for hypotension dated May 23, 2024. Further review of Resident 1's physician order history revealed an order for Tresiba FlexTouch Subcutaneous Solution Pen-injector 100 units/milliliters (Insulin Degludec-injectable medication to treat high blood sugars) inject 8 unit subcutaneously one time a day for DM, ordered on April 11, 2024, and discontinued on May 15, 2024. There were no orders noted for blood sugar monitoring. Review of Resident 1's physician visit note dated April 12, 2024, revealed that Resident 1 had a FreeStyle Libre 3 sensor (a device used for continuous glucose monitoring). Review of Resident 1's clinical record revealed that blood glucose monitoring was not occurring. There were no routine blood glucose readings documented during Resident 1's admission to the facility, from April 11, 2024, through May 24, 2024. On May 24, 2024, Resident 1 was documented as having a change in condition and was subsequently transferred to the hospital. At that time, Resident 1's blood glucose was checked and it was 552 (normal is 70-100). During an interview with Employee 5 (Licensed Practical Nurse) on June 20, 2024, at 10:08 AM, Employee 5 stated that the facility does not use the FreeStyle Libre blood glucose monitoring. During an interview with the Director of Nursing (DON) on June 20, 2024, at 3:30 PM, she stated that the facility does use the FreeStyle Libre monitors, and that the facility has a written policy on their use. The policy was requested but was never provided to the surveyor, as of June 20, 2024, at 5:45 PM. Review of Resident 9's clinical record revealed that they were admitted to the facility on [DATE], with diagnoses that included Type 2 Diabetes Mellitus with Foot Ulcer, and hypertension (high blood pressure). Review of Resident 9's physician orders revealed orders for metformin hydrochloride tablet (oral medication to manage blood sugar) 1000 milligrams give one tablet by mouth twice daily for Type 2 Diabetes Mellitus dated June 9, 2024; and Trulicity Subcutaneous Solution Pen-injector 4.5 milligrams/0.5 milliliters (duglatide) inject 0.5 milliliters subcutaneously weekly on Wednesday for Type 2 Diabetes Mellitus, dated June 9, 2024. Review of Resident 9's hospital referral records provided to the facility on [DATE], revealed that Resident 9's blood sugar was monitored before every meal and nightly. Further review of Resident 9's clinical record and orders failed to reveal any orders or documentation of the monitoring of Resident 9's blood sugar levels since their admission to the facility on [DATE]. During an interview with the NHA on June 20, 2024, at 5:30 PM, he confirmed that Resident 9 had not been receiving blood sugar monitoring and that a new order had been obtained that day to monitor Resident 9's blood sugar levels. Review of Resident 1's nursing progress note dated May 22, 2024, at 1:30 PM, revealed that Resident 1 was complaining of not feeling well and stating that she felt full. Blood pressure 85/58 (normal is 120/80), abdomen was large, soft, and non-tender, and the Resident denied nausea and pain. The note further indicated that Resident 1 was given ginger ale soda and added to alert charting and the physician list. During an interview with the DON on June 17, 2024, at 12:44 PM, the DON indicated that alert charting was a facility process where a resident with any changes or concerns gets put into the book and that each shift nursing staff will make notes if they are having symptoms. She indicated that the book is at the nurse's station and has in it what the nurses are to monitor for and then the nursing staff will document their findings in the electronic health record. On June 17, 2024, at 1:18 PM, the DON stated when a resident is added to the physician list, it means the physician will see them the next time they are in the building. She further stated that the nurse practioner comes in on Tuesdays and Fridays, so Resident 1 would have been seen on Friday, May 24, 2024. Review of Resident 1's nursing progress note dated May 22, 2024, at 6:10 PM, revealed Assessment completed on resident after CNA [certified nurse aide] stated she was more difficult to transfer than usual. Assessment completed all unremarkable except resident had hypoactive bowel sounds. Day two of no BM [bowel movement] after having a medium on 5/20. Resident is to [see] MD in AM to assess changes noted today. Neurologically intact. Stated that she does feel less full than this AM and did state that she was going to attempt to eat PM meal. Continue with current POC [plan of care], monitor anticipate needs. Review of Resident 1's nursing progress note dated May 23, 2024, at 5:15 AM, revealed Resident has had no complaints r/t [related to] not feeling well/poor appetite this shift. Will continue to monitor. The note did not address the low blood pressure. There were no other nursing progress notes noted between May 23, 2024, at 5:15 AM, and May 24, 2024, at 11:15 AM, indicating the monitoring of Resident 1's identified changes. In addition, the note on May 22, 2024, at 6:10 PM and the note on May 23, 2024, at 5:15 AM, failed to reveal any documentation regarding Resident 1's blood pressure. Review of Resident 1's nursing progress note dated May 24, 2024, revealed that the RN (Registered Nurse) noted the following vital signs: Temperature 96.6; pulse 60 and regular; respirations 12; blood pressure 106/52; pulse ox 84% on room air. Further review of Resident 1's progress notes revealed Employee 1 (Nurse Practitioner) reported that resident was confused and lethargic. Upon assessment, resident was gray in color and diaphoretic. Denies pain. Resident slowly to respond. Resident kept closing her eyes. BS [blood sugar] 552 [normal is 70-100]. Resident unable to state what was wrong. A new order was received to send Resident 1 to the emergency department. The Facility called 911 and Resident 1 left the facility via ambulance at 7:40 AM. Review of Resident 1's EMS (Emergency Medical Services) record, dated May 24, 2024, revealed that, upon arrival to the facility, the RN told EMS that Resident 1 had been hypotensive (low blood pressure), very pale, clammy, and had an altered mental status for two days. The RN stated that Resident 1's blood sugar was 552 on the morning of May 24, 2024, no insulin was given, and that no other glucose readings were documented during Resident 1's admission to the facility. The EMS report further noted that the RN stated Resident 1's blood pressure was in the 60's over the 40's over the past two days. Initial blood pressure from EMS at 7:34 AM was 82/51. It was also noted on assessment that Resident 1 was very cold and very pale as if in a GI bleed. Further review of the EMS report for Resident 1 revealed the following blood pressure readings: 7:48 AM 72/43 7:52 AM 85/59 7:57 AM 86/63 8:03 AM 81/58. Review of Resident 1's hospital records dated May 24, 2024, revealed that they arrived at the emergency department at 8:06 AM, and was being treated for shock, hypotension (low blood pressure), gastrointestinal bleeding, and acute kidney injury. Resident 1 was noted to be profoundly pale, clammy to touch, with a low blood pressure of 84/64. At 9:08 AM, Resident 1 was noted to have no pulse and resuscitation efforts were initiated but were unsuccessful. Review of the alert charting list dated May 2024 revealed that Resident 1 had been entered on the list on May 22, 2024, on day shift for not feeling well, decreased appetite, and low blood pressure. The list further revealed the following: 1) on May 22, 2024, evening shift was blank; 2) on May 23, 2024, night shift had initials entered and day and evening shift were blank; 3) on May 23, 2024, all shifts were blank; and 4) on May 24, 2024, the night shift was blank. Review of Resident 1's nursing progress notes revealed there were no corresponding nursing progress notes for the alert charting, with the exception of a note on May 22, 2024, evening shift and a note on May 23, 2024, night shift. On June 17, 2024, at 1:18 PM, the DON provided daily assignment sheets for review, which are not part of the clinical record, but did reflect Resident 1's low blood pressures. Review of the facility form, titled Daily Assignment Sheet, revealed Resident 1 had the following blood pressures documented on the form: May 22, 2024, 10 PM-6 AM shift- 120/60 May 23, 2024, 6 AM-2 PM shift- 80/60 May 23, 2024, 2 PM-10 PM shift- 80/58. Review of Resident 1's clinical record revealed the aforementioned blood pressures were not documented in Resident 1's clinical record and there is no evidence that the provider was made aware of those blood pressures. During an interview with Employee 1 on June 18, 2024, from 8:30 AM to 8:37 AM, Employee 1 confirmed that Resident 1 was started on Midodrine (medication to treat low blood pressure) after notification of a low blood pressure. Employee 1 stated that she was only aware of one low blood pressure and then she was told that Resident 1's blood pressure went back up. Employee 1 stated, .if I knew [Resident 1] was running in the 80's on multiple occasions, it may have changed the treatment course. Employee 1 indicated that when she arrived to visit Resident 1 on May 24, 2024, she noted a change in Resident 1's condition and gave the order to send Resident 1 to the hospital. Review of Resident 1's clinical record revealed that the 80/60 blood pressure on May 23, 2024, was not documented in Resident 1's clinical record and there was no evidence that Employee 1, or any other provider, was made aware of the low blood pressure. During a phone interview with the Nursing Home Administrator (NHA) on June 18, 2024, at approximately 10:00 AM, the NHA stated that they placed Resident 1 on charting and the physician list to be checked. The NHA indicated that he had spoken with Employee 4 (Registered Nurse) and that it was his understanding that when Employee 4 called Employee 1, Resident 1 was placed on alert charting, both low blood pressures were shared, and Employee 1 ordered a medication to treat the low blood pressure. During this conversation, it was shared with the NHA that Employee 1 indicated that they were not informed of the multiple low blood pressures and that there was no documentation in Resident 1's clinical record that Employee 1 was made aware of the blood pressures, that a treatment order was obtained, or that Resident 1's Representative was made aware of the additional low blood pressure and new treatment order. The NHA indicated that Employee 4 said that they missed writing the note. During an interview with Employee 4 on June 20, 2024, at 9:49 AM, Employee 4 indicated they had received reports on the afternoon of May 22, 2024, from nurse aides and therapy that Resident 1 was not acting right and was not feeling well. Resident 1's blood pressure was noted to be 85/58, but all other assessment findings were within normal limits. Employee 4 confirmed that she did not speak to Resident 1's physician/CRNP (Certified Registered Nurse Practitioner). Employee 4 further stated that on May 23, 2024, Resident 1 still said that she did not feel well. Employee 4 said that she took Resident 1's blood pressure after she returned from an activity, and it was 80/60. Employee 4 then said that when Employee 1 came in to assess Resident 1 on May 24, 2024, in the early morning, Employee 1 called Employee 4 to Resident 1's room because Resident 1 was confused and lethargic. Employee 4 indicated that Resident 1 was gray in color and diaphoretic (sweaty) and slow to respond but denied pain. Employee 4 said that Resident 1 appeared as if she might be experiencing a cardiac (heart) related issue. Review of the clinical record revealed no documented blood pressure on May 23, 2024. During an interview with Employee 6 (Physical Therapy Assistant) on June 20, 2024, at 10:23 AM, Employee 6 indicated that they could not recall specific dates, but remembered that Resident 1 was noted to decline in therapy participation and was not doing as well as when the Resident was first admitted . Review of Resident 1's physical therapy treatment notes revealed a note dated May 21, 2024, at 3:09 PM, that indicated Resident 1 was completing multiple trials of sit to stands and transfers with moderate assistance of one person to rise and was making attempts with grab bars/railing with minimal assistance of one person. Review of Resident 1's physical therapy treatment notes revealed a note dated May 22, 2024, at 2:29 PM, that indicated Resident 1 was attempting bed mobility with increased need for assistance, difficulty sitting on edge of bed, and increased assist during sit to stand trials. Review of physical therapy note dated May 22, 2024, at 3:31 PM, indicated that Resident 1 was requiring maximum assistance for sit to stand transfers. Review of Resident 1's physical therapy treatment note dated May 23, 2024, at 12:06 PM, indicated Resident 1 had been trialed standing in supported position, with evidence of decreased ability to stand upright and to stand pivot. The note further indicated that Resident 1 had poor alertness throughout the session and that Resident was being downgraded to a stand pivot disc with the assistance of two staff due to safety concerns. Review of Resident 1's occupational therapy treatment note dated May 22, 2024, at 4:01 PM, indicated Resident 1 tolerated standing two minutes with minimal assistance for safety. Review of Resident 1's occupational therapy treatment note dated May 23, 2024, at 10:33 AM, indicated Resident 1 attempted to engage in sit to stand transfers and stand pivot disc transfers, but was very lethargic and fatigued, requiring moderate to maximum assistance of two people. The note further indicated that Resident 1 was reporting that the Resident had a headache and did not feel well and that nursing was made aware. Review of facility's alert charting documentation, which reflected residents who had a change in condition revealed that Residents 9, 12, 13, 14, 15, and 16 were all on alert charting for additional monitoring on June 20, 2024, after a change in condition. On June 20, 2024, at 11:51 AM, the NHA was provided the Immediate Jeopardy template and an immediate action plan was requested to ensure that resident's were being assessed for and receiving adequate monitoring for changes in condition. The facility was notified at 5:25 PM that the action plan was accepted. The plan of action included: 1) Running an exception report to identify abnormal pressures of any other resident that may be at risk of a change in condition and notifying the physician of any residents that triggered on the report; 2) any resident's identified at risk based on the exception report were added to alert charting; 3) Education would be provided to nursing staff that all clinical information will be entered into the electronic medical record; 4) Running a report to identify residents with a diabetic medication and cross check for blood sugar monitoring; 5) All residents identified as having a change in condition will have alert charting initiated; 6) All alert charting will be initiated by Registered Nurses or Licensed Practical Nurses and entered as orders on the Medication Administration Record for nursing staff to sign off and the order will include vital signs and/or blood sugars if needed; 7) Nurse Aides will obtain vital signs at the beginning of the shift and turned into the Licensed Practical Nurse to review. Any abnormal vital signs will then be rechecked by the Licensed Practical Nurse at that time and reported to the Registered Nurse for notification to the physician/CRNP; 8) Education would be provided to nursing staff (Registered Nurses and Licensed Practical Nurses) to identify any resident with diabetic medication if an order to monitor blood sugar should be obtained if not on the hospital discharge summary; 9) an audit had been completed of all residents on diabetic medication to ensure blood sugar monitoring is being completed; 10) Education to nursing staff (Registered Nurses and Licensed Practical Nurses) that all insulins must have a blood sugar entered into the insulin order; and 11) Education was provided to staff currently working and staff not currently working at the facility will be called and educated before working their next shift. On June 20, 2024, at 5:30 PM, interviews, review of education, and review of the exception report revealed the facility had run the exception report and that it had been reviewed and signed by Employee 1. Interviews were conducted with one Registered Nurse and four Licensed Practical Nurses; all were able to verbalize their role in obtaining vital signs, the facility Change in Condition policy, the new process to follow for alert charting, proper order entry for blood sugar monitoring, and documentation of all clinical information in the resident's clinical record. Interviews were conducted with five nurse aides, and all were able to verbalize their role in obtaining vital signs, reporting vital signs to the Licensed Practical Nurse and/or Registered Nurse, and reporting changes in a resident's condition. On June 20, 2024, at 5:45 PM, the Immediate Jeopardy was lifted. The facility failed to ensure care and services were provided to Resident 1 after a change in condition and failed to continue monitoring Resident 1's blood pressure, resulting in continued decline and hospitalization for hypovolemic shock, cardiac arrest, and death. At the time of the survey, this failure placed six additional residents on alert charting in an immediate jeopardy situation. 201.14(a) Responsibility of licensee 201.18(b)(1) Management 211.12(d)(1)(2)(3)(5) Nursing services

Based on facility policy review, clinical record review, hospital record review, and resident representative and staff interviews, it was determined that the facility failed to notify the physician after a change in a resident's condition and failed to notify a resident's representative of a change in treatment for one of four residents reviewed (Resident 1). Immediate Jeopardy was identified because the failure to notify the physician resulted in a lack of physician oversight. This caused a delay in treatment, which resulted in transfer to the hospital for hypovolemic shock (emergency condition in which severe blood or other fluid loss makes the heart unable to pump enough blood to the body), hypotension (low blood pressure), hyperglycemia (elevated blood sugar), and cardiac arrest for Resident 1. Findings include: Review of facility policy, titled Change of Condition, with a last revision date of February 22, 2024, revealed the following: It is the policy of the Facility to inform residents, physicians/CRNP's (Certified Registered Nurse Practitioners), and resident representatives of a change in the resident's condition; Licensed nursing staff will: 1. Evaluate any changes noted through direct observation or by assigned staff or any changes noted in report at change of shift or as noted on 24 Hour Report; 2. Obtain a complete set of vital signs (temperature, pulse respirations, and blood pressure) at the onset of the change and/or more often as appropriate or ordered by the physician/CRNP; 5. Notify the physician/CRNP immediately if the condition appears serious; 6. Notify the resident's representative of the change and any changes made to the resident's plan of care; 7. Address the change on the 24 Hour Report or facility specific form at the nursing station for follow through by the next shift; and 9b. Licensed staff will document findings in the EHR (electronic health record) regarding the change of condition and observations. Review of Resident 1's clinical record revealed diagnoses that included iron deficiency anemia (a condition in which blood lacks adequate healthy red blood cells), Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood), and hypertension (elevated blood pressure). Review of Resident 1's nursing progress note dated May 22, 2024, at 1:30 PM, revealed that Resident 1 was complaining of not feeling well and stating that she felt full. Blood pressure 85/58 (normal is 120/80), abdomen was large, soft, and non-tender, and the Resident denied nausea and pain. The note further indicated that Resident 1 was given ginger ale soda and added to alert charting and the physician list. On June 17, 2024, at 12:44 PM, the Director of Nursing (DON) stated that alert charting means that the resident's name and symptoms to monitor will be put on a paper in a book at the nurse's station. She stated that nursing staff are then to document their findings in the resident's medical record. On June 17, 2024, at 1:18 PM, the DON stated when a resident is added to the physician list, it means the physician will see them the next time they are in the building. She further stated that the Nurse Practioner (Employee 1) comes in on Tuesdays and Fridays; so Resident 1 would have been seen on Friday, May 24, 2024. In addition, the DON provided daily assignment sheets for review, which are not part of the clinical record but did reflect Resident 1's low blood pressures. Review of the facility form, titled Daily Assignment Sheet, revealed Resident 1 had the following blood pressures documented on the paper form: May 23, 2024, 6 AM-2 PM shift- 80/60 May 23, 2024, 2 PM-10 PM shift- 80/58. Review of Resident 1's clinical record revealed the aforementioned blood pressures were not documented in Resident 1's clinical record and there is no evidence that the provider was made aware of those blood pressures. Review of Resident 1's nursing progress note dated May 22, 2024, at 6:10 PM, revealed that an assessment was completed on Resident 1 after the nurse aide stated she was more difficult to transfer than usual. Assessment completed all unremarkable except resident had hypoactive bowel sounds. Day two of no BM [bowel movement] after having a medium on 5/20. Resident is to MD in AM to assess changes noted today. Neurologically intact. Stated that she does feel less full than this AM and did state that she was going to attempt to eat PM meal. Continue with current POC [plan of care], monitor anticipate needs. Review of Resident 1's clinical record revealed no evidence that Resident 1 was assessed by the physician on May 22 or 23, 2024. Review of Resident 1's physical therapy treatment notes revealed a note dated May 23, 2024, at 12:06 PM, that indicated Resident 1 had been trialed standing in supported position, with evidence of decreased ability to stand upright and to stand pivot. The note further indicated that Resident 1 had poor alertness throughout the session and that they were being downgraded to a stand pivot disc with the assistance of two staff due to safety concerns. Review of Resident 1's occupational therapy treatment notes revealed a note dated May 23, 2024, at 10:33 AM, that indicated Resident 1 attempted to engage in sit to stand transfers and stand pivot disc transfers but was very lethargic and fatigued requiring moderate to maximum assistance of two people. The note further indicated that Resident 1 was reporting that they had a headache and did not feel well and that nursing was made aware. Review of Resident 1's nursing progress note dated May 24, 2024, revealed that the RN (Registered Nurse) was called to assess the Resident and noted the following vital signs: Temperature 96.6; pulse 60 and regular; respirations 12; blood pressure 106/52; pulse ox 84% on room air. Further review of Resident 1's progress notes revealed Employee 1 (Nurse Practioner) reported that resident was confused and lethargic. Upon assessment, resident was gray in color and diaphoretic. Denies pain. Resident slowly to respond. Resident kept closing her eyes. BS [blood sugar] 552 [normal is 70-100]. Resident unable to state what was wrong. A new order was received to send Resident 1 to the emergency department. The Facility called 911 and Resident 1 left the facility via ambulance at 7:40 AM. Review of Resident 1's EMS (Emergency Medical Services) record dated May 24, 2024, revealed that, upon arrival to the facility, the RN told EMS that Resident 1 had been hypotensive (low blood pressure), very pale, clammy, and had an altered mental status for the past two days. The RN stated that Resident 1's blood sugar was 552 on the morning of May 24, 2024, no insulin was given, and that no other glucose readings were documented during Resident 1's admission to the facility. The EMS report further revealed that the RN stated Resident 1's blood pressure was in the 60's over the 40's the past two days. Initial blood pressure from EMS at 7:34 AM was 82/51. It was also noted on assessment that Resident 1 was very cold and very pale as if in a GI [gastrointestinal] bleed. Further review of the EMS report for Resident 1 revealed the following blood pressure readings: 7:48 AM 72/43 7:52 AM 85/59 7:57 AM 86/63 8:03 AM 81/58. Review of Resident 1's hospital records dated May 24, 2024, revealed that they arrived at the emergency department at 8:06 AM, and the Resident was being treated for shock, hypotension (low blood pressure), gastrointestinal bleeding, and acute kidney injury. Resident 1 was noted to be profoundly pale, clammy to touch, with a low blood pressure of 84/64. At 9:08 AM, Resident 1 was noted to have no pulse and resuscitation efforts were initiated but were unsuccessful. During an interview with Employee 1 (Nurse Practioner) on June 18, 2024, from 8:30 AM to 8:37 AM, Employee 1 confirmed that Resident 1 was started on Midodrine (medication to treat low blood pressure) after notification of a low blood pressure. Employee 1 stated that she was only aware of one low blood pressure and then she was told that Resident 1's blood pressure went back up. Employee 1 stated, .if I knew [Resident 1] was running in the 80's on multiple occasions, it may have changed the treatment course. Employee 1 indicated that when she arrived to visit Resident 1 on May 24, 2024, she noted a change in Resident 1's condition and gave the order to send Resident 1 to the hospital. Further review of Resident 1's clinical record failed to reveal any documentation that Resident 1's Representative was made aware of the additional low blood pressures or that a new medication was ordered. During a phone interview with the Nursing Home Administrator (NHA) on June 18, 2024, at approximately 10:00 AM, the NHA stated that they placed Resident 1 on charting and the physician list to be checked. The NHA indicated that he had spoken with Employee 4 (Registered Nurse) and that it was his understanding that when Employee 4 called Employee 1, Resident 1 was placed on alert charting, both low blood pressures were shared, and Employee 1 ordered a medication to treat the low blood pressure. During this conversation, it was shared with the NHA that Employee 1 indicated that they were not informed of the multiple low blood pressures and that there was no documentation in Resident 1's clinical record that Employee 1 was made aware of the blood pressures, that a treatment order was obtained, or that Resident 1's Representative was made aware of the additional low blood pressure and new treatment order. The NHA indicated that Employee 4 said that they missed writing the note. The NHA also indicated that Resident 1's Representative was present when their first low blood pressure was obtained on May 22, 2024, and that Resident 1's Representative was there 24/7. He indicated that notifications should be made and documented in a Resident's clinical record. During an interview with Resident 1's Representative on June 18, 2024, at 10:19 AM, she stated that she was not aware of Resident 1's low blood pressures or that a new medication was ordered for the low blood pressure. On June 20, 2024, at 11:51 AM, the NHA was provided the Immediate Jeopardy template and an immediate action plan was requested to ensure that physicians/CRNP's are notified timely of changes in a resident's condition. The facility provided a plan of action at 5:15 PM. The facility was notified at 5:25 PM that the action plan was accepted. The plan of action included: 1) Running an exception report to identify abnormal pressures of any other resident that may be at risk of a change in condition and notifying the physician of any residents that triggered on the report; 2) Education would be provided to nursing staff that all clinical information will be entered into the electronic medical record; 3) Education would be provided to nursing staff on the facility's Change in Condition policy and adherence to the policy; 4) Education would be provided to nursing staff (Registered Nurses and Licensed Practical Nurses) to notify physicians/CRNP's of change in condition/abnormal values; 5) Education would be provided to nurse aides to report vital signs to licensed nursing staff; and 6) Education was provided to staff currently working and staff not currently working at the facility will be called and educated before working their next shift. On June 20, 2024, at 5:15 PM, interviews with staff, review of education, and review of the exception report revealed the facility had run the exception report and it had been reviewed and signed by Employee 1. Interviews were conducted with one Registered Nurse, four Licensed Practical Nurses, and five Nurse Aides; all were able to verbalize their role in monitoring, reporting, and documenting a resident's change in condition. On June 20, 2024, at 5:45 PM, the Immediate Jeopardy was lifted. The nursing staff failed to notify Resident 1's physcian of the repeated low blood pressures and overall decline in condition. This resulted in a delay in physcian assessment and oversight and a delay in treatment. 201.14(a) Responsibility of licensee 201.18(b)(1) Management 211.12(d)(1)(2)(3)(5) Nursing services

Based on clinical record review, review of select facility documentation, policy review, and staff interviews, it was determined that the facility failed to prevent neglect for one of seven residents reviewed (Resident 1) resulting in a change in mental status due to head injury requiring hospitalization . Findings include: A review of the facility's policy title, Resident Abuse, Neglect, & Exploitation Prevention Policy, last revised 12/2017, states the definition of neglect, the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of Resident 1's closed clinical record revealed a history of diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1's care plan for fall risk, effective December 5, 2021, revealed an intervention to place chair alarm on chair or wheelchair. The care plan revealed Resident 1 required the assistance of one staff and a rolling walker to transfer. Resident 1's fall Risk assessment completed January 1, 2022 revealed a score of 21, indicating a high risk for falls. Review of facility's incident report dated January 8, 2022, revealed that Resident 1 experienced a fall on January 8, 2022, at 6:00 PM. Further review of the incident report revealed Nursing Assistant (NA) 1 and NA 2 responded to Resident 1's room because NA 1 walked by and saw Resident 1 attempting to climb out of bed. NA 1 called for NA 2 to assist her to place Resident 1 in the wheelchair because that is what Resident 1 desired. NA 1 and NA 2 placed Resident 1 in the wheelchair and left the room. On January 8, 2022, at 6:00 PM staff were alerted initially by the roommate of Resident 1, and by Resident 1 yelling help me. Further review of the incident report revealed a few minutes after the NA's assisted Resident 1 to her wheelchair a code F was called (code called to indicate a resident has fallen with the location). Resident 1 was found lying prone (face down) on the side of her bed. A review of the Registered Nurse Assessment revealed Resident 1 had a hematoma (bruise) over her left eyelid and a small cut on the eyelid. Resident 1 denied any pain at that time. The facility's abuse investigation of the fall revealed that NA 1 and NA 2 were both educated on abuse and neglect in 2021. At the time of the fall Resident 1's chair alarm was not on the wheelchair. A statement written by NA 1 on January 10, 2022, stated no chair alarm pad was in chair when I transferred her (Resident 1) onto the wheelchair. Placed bedside table in front of Resident 1, left the room. During an interview with the Nursing Home Administrator on January 14, 2022, at 4:30 PM, he revealed that NA 1 and NA 2 should have followed the care plan and ensured that the alarm was on the wheelchair. The facility neglected to ensure Resident 1's safety and prevent physical harm by failing to follow the care plan to have a chair alarm in place, which resulted in harm from a fall. The resident had a change in mental status requiring Resident 1 to be sent to the hospital. Imaging conducted at the hospital showed prominent acute left subdural hematoma (bleed occurring between the brain and skull) with mass effect (pressure on the brain from the accumulation of blood) and midline shift (shift of the brain past the natural center line). The resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(2)(3)(5)Nursing services.

Based on clinical record review, review of select facility documentation and staff interviews, it was determined that the facility failed to provide a timely assessment on a resident with neurological changes and delayed transfer of the resident to the hospital for one of seven residents reviewed (Resident 1) resulting in a delay in diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: Review of Resident 1's closed clinical record revealed a history of diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility's incident report dated January 8, 2022, revealed that Resident 1 experienced a fall on January 8, 2022, at 6:00 PM. Resident 1's neurological assessment from the time of the fall until January 9, 2022, at 5:45 AM was documented as within normal limits. On January 9, 2022, at approximately 8:00 AM Resident 1 developed changes in her mental status that included requiring much encouragement to take her AM medications, refusing her breakfast at 8:30 AM, and became more difficult to arouse at 11:00 AM. At 11:45 AM Resident 1 became febrile (elevated temperature of 100.2 degrees) and had a change in neurological assessment which included responding only to painful stimuli, absence of hand grasps, and fixed pupils. During the interview with Licensed Practical Nurse (LPN 1) on January 14, 2022, at approximately 4:00 PM, LPN 1 stated that she notified Registered Nurse (RN 1) on January 9, 2022, between 10:30 AM and 11:00 AM regarding Resident 1's change in condition. Review of the clinical record revealed no documentation that LPN 1 made the RN aware of the change in condition. RN 1 began an assessment of Resident 1 at 12:15 PM. RN 1 assessment revealed resident as lethargic and unresponsive to verbal stimuli. After assessing Resident 1, RN 1 notified the physician at 1:12 PM who ordered the resident to be transferred to the hospital. RN 1 notified the physician again at 1:15 PM to obtain an order to treat Resident 1's elevated temperature (now 101.2 degrees). The clinical record revealed that RN 1 took time to document the assessment of Resident 1, notification of the physician, vital signs, administration of Tylenol (medication to reduce fever) on January 9, 2022, at 1:28 PM but delayed the notification of EMS (Emergency Medical Services) to have Resident 1 transported to the hospital until January 9, 2022, at 2:04 PM. The EMS transport team arrived at 2:16 PM to transport Resident 1 to the hospital. Based on hospital record review, Resident 1 was diagnosed with traumatic hemorrhage of the right cerebrum without loss of consciousness (bleeding in the largest uppermost portion of the brain) and traumatic subdural hematoma (a type of bleed that occurs within the skull of the head but outside the actual brain tissue). During an interview with the Nursing Home Administrator on January 14, 2022, at 4:30 PM, agreed that RN 1 should have assessed Resident 1 immediately after being informed of neurological change and should have notified EMS immediately after receiving the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to assess a resident immediately after a change in neurological status, and delayed transfer to the hospital after receiving a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN 1 reported that RN 1 was informed of the residents neurological change in condition January 9, 2020, between 10:30 AM and 11:00 AM. The RN assessment was initiated until 12:15 PM, over four hours after the change in mental status. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the hospital records revealed that due to the extent of injury, Resident 1's family opted for comfort care and Resident 1 passed away at the hospital on January 14, 2022. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on clinical record review, review of select facility documentation, policy review, and staff interview, it was determined that the facility failed to implement established interventions to prevent a fall, resulting in major injury from a fall requiring the resident to be hospitalized , and revealing a diagnoses of traumatic brain injury for one of seven residents reviewed (Resident 1). Findings include: A review of the facility policy titled, Fall Prevention last revised July 2009, states that the facility will provide an environment that is free from environmental hazards over which it has control and will provide supervision and assistive devices to each resident to prevent avoidable accidents such as falls. A review of the facility policy titled, Bed and Chair Alarm Policy last revised January 10, 2010, states if bed and/or chair alarm is recommended .include appropriate alarm when in bed and/or in a chair. Review of Resident 1's closed clinical record revealed a history of diagnoses that included Type 2 Diabetes mellitus (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin) and [CONDITION(S)] ([CONDITION(S)]) on Hemodialysis (severely limited kidney function that is insufficient to maintain life, thus, most patients with [CONDITION(S)] require renal replacement therapy via hemodialysis). Review of Resident 1's care plan for fall risk, effective December 5, 2021, revealed an intervention to place a chair alarm on chair or wheelchair. The care plan revealed Resident 1 required the assistance of one staff and a rolling walker to transfer. The resident Fall Risk assessment, dated January 1, 2022, revealed a score of 21, indicating a high risk for falls. Review of facility's incident report dated January 8, 2022, revealed that Resident 1 experienced a fall on January 8, 2022, at 6:00 PM. Further review of the incident report revealed Nursing Assistant (NA) 1 and NA 2 responded to Resident 1's room because NA 1 walked by and saw resident attempting to climb out of bed. NA 1 called for NA 2 to assist her to place Resident 1 in her wheelchair because that is what Resident 1 desired. Further review of the incident report revealed a few minutes after the NAs assisted Resident 1 to her wheelchair a code F was called (code called to indicate a resident has fallen). The fall occurred at 6:00 PM and staff were alerted initially by the roommate of Resident 1, and by Resident 1 yelling help me. Resident 1 was found lying prone (face down) on the side of her bed. A review of the Registered Nurse Assessment revealed Resident 1 was alert and oriented at baseline, PERRLA (pupils, equal, round, reactive to light accommodation) had a hematoma over her left eyelid and a small cut on the eyelid measuring 1.5 centimeters x 1.0 centimeters (centimeters is metric measurement 1.5 centimeters equals 1 inch). Resident 1 denied any pain at that time. On January 9, 2022, at approximately 8:00 AM, Resident 1 began to have changes in her condition and was transferred to the hospital at 2:16 PM. Prior to transfer Resident 1 required much encouragement to take her AM medications, refused her breakfast, and became difficult to arouse. At 11:45 AM Resident 1 became febrile (elevated temperature), had a change in neurological assessment that included responded only to painful stimuli, no hand grasps, and fixed pupils. Based on hospital record review Resident 1 was diagnosed with traumatic hemorrhage of the right cerebrum without loss of consciousness (bleeding in the largest uppermost portion of the brain) and traumatic subdural hematoma (a type of bleed that occurs within the skull of the head but outside the actual brain tissue). The facility's investigation of the fall revealed that NA 1 and NA 2 were both educated regarding following the care plan for all residents. At the time of the fall Resident 1's chair alarm was not on the wheelchair. NA 1 stated no chair alarm pad was in chair when she transferred resident 1 onto the wheelchair. Placed bedside table in front of Resident 1, left the room. During an interview with the Nursing Home Administrator on January 14, 2022, at 4:30 PM, he revealed that NA 1 and NA 2 should have followed Resident 1's fall care plan. The facility failed to implement established fall prevention interventions to assure Resident 1's safety while out of bed in the wheelchair, which resulted in harm from a fall requiring resident to be sent to the hospital. Resident 1 was diagnosed with traumatic hemorrhage of the right cerebrum without loss of consciousness (bleeding in the largest uppermost portion of the brain) and traumatic subdural hematoma (a type of bleed that occurs within the skull of the head but outside the actual brain tissue). Resident 1's family opted for comfort care and the resident passed away at the hospital on January 14, 2022. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services.

Based on review of facility documentation, facility policy review and staff interviews, it was determined that the facility failed to establish/implement a staff screening procedure to identify staff who have signs/symptoms of COVID-19 and did not prohibit a symptomatic staff member who had COVID-19 from providing direct care to residents, which exposed residents to the COVID-19 virus, resulting in an immediate jeopardy. Findings include: During an interview with the Nursing Home Administrator (NHA) on September 28, 2021, at 10:55 AM he confirmed he did not have a policy that addressed the COVID-19 screening process and what to do if a staff reported to work with positive symptoms. He stated that they follow the PA-HAN 553. PA-HAN 553, titled, Return to Work for Healthcare Personnel [HCP] with Confirmed or Suspected COVID-19 states, HCP with mild to moderate illness who are not severely immunocompromised [should return to work after] at least 10 days have passed since symptoms first appeared and at least 24 hours have passed since last fever without the use of fever-reducing medications and symptoms (e.g., cough, shortness of breath) have improved. If there are no longer enough staff to provide safe patient care, and other contingency capacity strategies have been exhausted (see CDC strategies), healthcare facilities and employers may need to implement crisis capacity strategies to continue to provide patient care. CDC Strategies to Mitigate Healthcare Personnel Staffing Shortages, last updated March 2021, states, This guidance is for healthcare facilities that may be experiencing staffing shortages due to COVID-19. If shortages continue despite other mitigation strategies, as a last resort consider allowing HCP with suspected or confirmed [CONDITION(S)]-CoV-2 infection who are well enough and willing to work but have not met all Return to Work Criteria to work. The CDC also instructs facilities to consider where the individual is in the course of illness ([CONDITION(S)] shedding is higher earlier in the course of illness), the symptoms the individual is experience, degree of interaction with residents and other HCP in the facility, and the type of residents they care for. The PA-HAN also states, Under crisis capacity strategies, HCP [health care personnel] who have recovered from COVID-19, and are well enough to work, are permitted to return to work before meeting above criteria. The PA-HAN also states to first have COVID-19 positive staff perform job duties where they do not interact with others, second to provide direct care for COVID-19 confirmed residents, and third to allow positive staff to provide direct care to residents with suspected COVID-19. Review of the nursing staffing schedule for September 4, 2021, the day that the symptomatic staff member worked, September 4, 2021, revealed a census of 54 residents, and the calculated hours of care per resident for the day (PPD) was 3.93. Review of facility documentation revealed that Licensed Practical Nurse (LPN) 1, was scheduled to work on September 1, 2021. LPN 1 called off due to diarrhea and a low-grade temperature. On September 2, 2021, LPN 1 arrived to work on the first-floor nursing unit at 1:46 PM and reported no signs or symptoms of COVID upon screening. At 4:30 PM, LPN 1 was tested for COVID due to missing the universal testing on September 1, 2021, the test results were positive. LPN 1 was instructed to wear PPE (personal protective equipment) including a N-95 mask, face shield and gown, and continue his assignment until a replacement nurse arrived. At 6:40 PM LPN 1 left the facility. At the time LPN 1 tested positive, the facility had no COVID-19 positive residents or staff. The evening of September 2, 2021, the facility tested all residents for COVID. Review of the COVID-19 Positive resident line on September 3, 2021, revealed Resident 1's test results were positive for COVID-19. Resident 1 resided on the first-floor nursing unit. On September 3, 2021, LPN 1 was not scheduled to work. On September 4, 2021, LPN 1 worked the scheduled shift from 2:00 PM until 10:00 PM. Upon the start of shift, LPN 1 noted on the COVID-19 screening form that his temperature was 100.7 and he was having shortness of breath and two or more other symptoms including Fever, repeated shakes with chills, headache, new loss of taste or smell, diarrhea, chills, muscle pain, sore throat or vomiting. During an interview with LPN 1 on September 28, 2021 at 11:28 AM, he confirmed that on September 4, 2021, he had a temperature, shortness of breath and fatigue, loss of taste and smell, chills and weakness. LPN 1 confirmed that he did not report his symptoms because he spoke with the DON (Director of Nursing) early that day and was directed that if he did not have a fever he could work. Review of the Nursing staff scheduled for September 4, 2021, revealed that there was one RN (registered nurse) two LPN's and seven nurse aids scheduled for day shift and evening shift to care for 54 residents. On September 5, 2021, Resident 2, who resided on the first floor, developed symptoms, and tested positive for COVID-19. On September 6, 2021, Resident 3, who resided on the first floor, developed symptoms, and tested positive for COVID-19. On September 9, 2021, Resident 4, who resided on the first floor, developed symptoms, and tested positive for COVID-19. On September 13, 2021, Residents 5 and 6, who resided on the first floor, developed symptoms, and tested positive for COVID-19. On September 14, 2021, Resident 7, who resided on the first floor, developed symptoms, and tested positive for COVID-19. On September 16, 2021, Resident 8, who resided on the first floor, developed symptoms, and tested positive for COVID-19. On September 19, 2021, Resident 9, who resided on the first floor, developed symptoms, and tested positive for COVID-19. During an interview with the Nursing Home Administrator on September 28, 2021 at 10:52 AM, he revealed that he did not know that LPN 1 had a positive COVID-19 screen on September 4, 2021. He also stated that he felt the facility was in crisis capacity and that is why the facility allowed positive staff to provide direct care to residents. Upon review of the facility policy and procedures, it was discovered that the facility did not establish/implement a staff screening procedure to identify staff who have signs/symptoms of COVID-19. The facility does not have a policy to include who staff should discuss their positive screening with and what actions the facility staff should take. On September 28, 2021, at 4:30 PM the NHA and the DON were made aware that an immediate Jeopardy existed due to the failure to establish/implement a staff screening procedure to identify staff who have signs/symptoms of COVID-19 and allowing a positive, symptomatic employee to provide direct care to residents resulting in a COVID-19 outbreak. The IJ template was provided to the NHA at this time. On September 28, 2021, at 10:42 PM an acceptable corrective action plan was approved which included the following interventions: Immediate Actions: The facility developed a COVID-19 screen policy to establish guidelines and direction to the screening process for COVID-19. The Director of Nursing updated the staff surveillance log The Director of Nursing developed supervisor guidance for staff that do not clear the screening criteria. The Director of Nursing created a failed staff infection surveillance log Education will be provided to all staff, including, Nursing, Activities, Dietary, Social services, Maintenance, Housekeeping/laundry, and Therapy. The Director of Nursing or Designee will provide the education. The Director of Nursing (or designee) will audit the failed staff infection surveillance log for all three shifts daily (weekends and holiday audits will be completed on the next business day) to ensure staff who did not pass the COVID-19 surveillance screening were COVID-19 tested by the supervisor and placed off work if required. The results of the audit will be reported to the Quality Assurance/Performance Improvement Committee monthly until no longer deemed necessary by the Committee. Observations on September 29, 2021 at 2:25 PM revealed the facility implemented the immediate action plan. Review of facility documentation revealed that the facility developed and implemented a COVID-19 screening policy. All staff were made aware of the new policy. Staff were educated upon arrival to work of the new policy. Interviews with staff revealed that they were knowledgeable of the new process and knew what to do if they had a positive COVID-19 screen. Interview with RN 2 revealed the correct procedure if a staff member would have a positive COVID-19 screen. On September 29, 2021 at 2:47 PM, the NHA was made aware that the IJ was lifted. 42 CFR 483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.12(d)(1)(5) Nursing Services