Every finding on record at Tucker House Nursing and Rehabilitation Center

Based on review of facility documentation, observations, and staff and resident interviews it was determined that the facility failed to provide a clean, safe, comfortable and homelike environment for seven of seven resident rooms observed (room [ROOM NUMBER], 203, 307, 313, 321, 323, and 324). Findings Include: During a tour of the facility on August 25, 2026, at 12:45 p.m., multiple issues were noted in room [ROOM NUMBER], including: the housing of the air conditioning unit was cracked and missing pieces of plastic and the flat panel buttons were worn to the point of missing button labels; drips of a brown substance were noted on the wall near the clock; the overbed light on the door side was missing a cover; there were cracked and buckled vinyl floor tiles noted beneath both resident beds; multiple drawers in the bedside tables and dressers had missing or broken handles; the toilet was running. Observations were confirmed by the Director of Maintenance, Employee E7, on August 25, 2026, at 1:30 p.m. On August 25, 2026, at 12:53 p.m., an observation in Resident R73's room (room [ROOM NUMBER]) revealed that there was no doorknob on the roommate's bathroom door, and the bathroom was being shared among four residents, resulting in a lack of privacy. The bed frame had four damaged areas (holes). The dresser had two damaged areas on the bottom of the tall closet. The privacy curtain was visibly soiled, with multiple brown spots and areas of discoloration. On August 25, 2026, at 12:59 p.m., the Unit Manager, Employee E6, confirmed the above observations. Observation on August 25, 2026, at 10:21 a.m., room [ROOM NUMBER], had a dark brown substance on the walls of the bathroom. Observation on August 25, 2026, at 10:35 a.m., in the bathroom of room [ROOM NUMBER], there was a sign hung up that read out of order. Observation and interview with Resident R74 on August 25, 2026, at 10:42 a.m., revealed in room [ROOM NUMBER] drawer handles are missing from dresser cabinet and the resident reported the facility is not sanitary. Observation on August 25, 2026, at 10:46 a.m. in room [ROOM NUMBER], drawer handles are missing for Resident R145 and there is a dark brown substance around the A/C unit and cracking around the A/C unit. Observation on August 25, 2026, at 10:48 a.m. room [ROOM NUMBER], drawer handles missing from dresser cabinet and call bell cover light is broken for Resident R141 and wall damaged around the A/C unit with brown substance and cracking around the unit. 28 Pa Code 201.14 (a) Responsibility of licensee.

Based on review of facility policy, clinical record review and staff interview, it was determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed according to the resident assessment and the facility failed to refer residents with diagnosed mental disorder for level II review for four of four residents reviewed (Residents R85, R104, R16, and R59). Findings include: Review of the facility policy titled Pre-admission Screening and Resident Review (PASRR) program, states It is the policy of the facility to assure that all residents admitted to the facility receive a Pre-admission Screening and Resident Review, in accordance with State and Federal Regulations. The PASRR (Preadmission Screening Resident Review), created in 1987 through language in the Omnibus Budget Reconciliation Act (OBRA), has three goals: to identify individuals with mental illness and/or intellectual disability; to ensure they are placed appropriately, whether in the community or in a nursing facility; and to ensure they receive the services they require for their mental illness or intellectual disability. A Level I PASRR must be completed for all persons considering admission to a Medicaid certified nursing facility. A Level II PASRR evaluation must be completed if the Level I PASRR determines that the person is a targeted individual with mental illness or an intellectual disability. The Level II PASRR determines whether placement or continued stay in the requested or current nursing facility is appropriate. Review of Resident R59's clinical record revealed an admission date of May 23, 2025, with diagnoses of psychosis (a mental disorder characterized by a disconnection from reality) not due to a substance or known physiological condition. Review of Resident R59's PASRR, dated September 26, 2024, revealed that the assessment did not include the resident's diagnoses of psychosis not due to a substance or known physiological condition. During an interview on August 27, 2026, at 9:30 a.m., Employee E3, Social Worker, confirmed that Resident R59's PASRR assessment was not updated to include the resident's diagnoses of psychosis not due to a substance or known physiological condition. Review of Resident R85's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including Major Depressive Disorder, Bipolar Disease (mood disorder characterized by low mood, a feeling of sadness, and a general loss of interest in things), Schizophrenia (mental illness associated with loss of reality contact, delusions and hallucinations), and Suicidal ideation (refers to thoughts, preoccupations, or considerations about ending one's own life). Review of the PASRR form for Resident R85 completed on November 10, 2022, revealed in section VIII; Individual has a positive screen for Serious Mental Illness, Intellectual Disability/Developmental Disability, and/or Other Related Condition; he/she requires a further PASRR Level Il evaluation. You must notify the individual that a further evaluation needs to be done. Have the individual or his/her legal representative sign that they have been notified of the need to have a PASRR Level Il evaluation done. Indicate by your signature here that you have given the notification (last page of this form) to the individual or his/her legal representative. Further review of Resident R85's clinical records did not reveal any evidence to prove that the PASRR Level Il evaluation was done. On August 26, 2026, at 10:40 a.m., interview with the Director of Nursing confirmed the findings. Review of Resident R104's clinical record revealed the resident was admitted to the facility on [DATE], with the diagnoses of Hallucinations Unspecified (false perceptions of sensory experiences that feel real to the individual but have no external source), Major Depressive Disorder, and Schizophrenia. Further review of Resident R104's clinical record revealed PASRR Level I was completed on May 17, 2021, with the results of a positive screen. Which means the individual has a positive screen for Serious Mental Illness, Intellectual Disability, and/or Other Related Condition; requires further evaluation (Level II). Continuing further review of Resident R104's clinical record revealed that the PASRR form was updated on May 21, 2023, with the update on page two section III-A – Diagnosis answering no to the question Does the individual have a mental health condition or suspected mental health condition, other than dementia, that may lead to a chronic disability. Then on August 27, 2026, another update was done on page one Section II-Neurocognitive Disorder (NCD)/Dementia answering no to the question Does the individual have a diagnosis of a Mild or Major NCD. Review of Resident R16's clinical record revealed the resident was admitted to the facility on [DATE], with the diagnoses of Post-Traumatic Stress Disorder (PTSD – a disorder in which a person has difficulty recovering after experiencing a terrifying event), Unspecified Dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Anxiety (intense, excessive, persistent worry or fear), and Psychotic Disturbance (loss of contact with reality). Further review of Resident R16's clinical record revealed PASRR Level I was completed on January 11, 2021, with the results of a positive screen. Which means the individual has a positive screen for Serious Mental Illness, Intellectual Disability, and/or Other Related Condition; requires further evaluation (Level II). Continuing further review of Resident R16's clinical record revealed that the PASRR form was updated on May 19, 2023, with the update on page two section III-A – Diagnosis answering no to the question Does the individual have a mental health condition or suspected mental health condition, other than dementia, that may lead to a chronic disability. Then on August 27, 2026, another update was done on page one Section II-Neurocognitive Disorder (NCD)/Dementia answering no to the question Does the individual have a diagnosis of a Mild or Major NCD. Review of Resident R104's and R16's clinical records revealed no documented evidence PASARR Level II Evaluations were completed. Interview with the Social Worker Employee E3 on August 27, 2026, at 9:40 a.m., a copy of the Level II PASRR for Residents R104 and R16 was requested from Employee E3. Interview with the Nursing Home Administrator, Employee E1, on August 28, 2026, at 11:50 a.m. confirmed that the PASRR Level II was not completed for Residents R104 and R16. Employee E1 reported that Level II PASRR has been requested for Residents R104 and R16. 28 Pa. Code 211.12 (d)(5) Nursing services. 28 Pa. Code 211.5 (f) Clinical records.

Based on review of facility documents, observations, and interviews with staff, it was determined that the facility failed to develop a comprehensive care plan related to communication and skin interventions for two out of 32 residents reviewed (Resident R170 and R20).Findings Include: Review of clinical documents for Resident R170 revealed that the resident was admitted to the facility on [DATE], with diagnoses including, but not limited to, Repeated Falls, Cognitive Communication Deficit, and Mild Cognitive Impairment. On August 28, 2026, at 1:30 p.m., the resident was observed speaking a language other than English. Review of progress notes for Resident R170 revealed an admission note written by the Director of Nursing, Employee E2, on June 17, 2026, at 7:49 p.m., which stated, Resident is Chinese speaking .communication Language line placed at the bedside. A later note written by Licensed Nurse, employee E9, dated August 18, 2026, at 12:00 p.m., stated Able to communicate needs effectively via Mandarin interpreter. Review of Resident R170's care plan revealed no documented evidence that a care plan had been developed for communication related to Mandarin as a primary language.In an interview on August 28, 2026, at 2:30 p.m., Employee E2 confirmed that the resident spoke only Mandarin and no English, and that a care plan should be developed to address communication needs. Review of Resident R20's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses including relapsing remitting multiple sclerosis (a disease in which the immune system attacks nerve cells resulting in nerve damage that disrupts communication between the brain and the body), paraplegia (lower paralysis), and quadriplegia (full paralysis). Review of the Comprehensive Care Plan dated February 27, 2026, indicated focus areas related to skin impairment. Interventions included: use of a pressure reducing mattress, keeping the skin clean and dry, padding bed rails and wheelchair arms or any potential source of injury, promoting good nutrition, educating the resident regarding causative factors, and using a draw sheet or lifting device to move the resident. Review of Resident R20's Minimum Data Set (MDS, federally mandated resident assessment of care needs), dated June 30, 2026, revealed that the resident did not have a Brief Interview for Mental Status (BIMS) score recorded, indicating the resident was unable to participate in the assessment due to severe cognitive impairment. Review of Resident R20's clinical record revealed that the resident was transferred to the hospital on May 20, 2026, and readmitted to the facility on [DATE]. Review of Resident R20's discharge MDS dated [DATE], indicated that the resident was dependent on staff assistance for bed mobility. Upon readmission on [DATE], the resident's Braden Scale (a clinical tool used to assess risk of skin and tissue injury) score was 9, indicating a very high risk for skin breakdown. Review of Resident R20's comprehensive care plan revealed no interventions for turning and repositioning. Interview on August 27, 2026, at 1:45 p.m. the Director of Nursing (DON), Employee E2 confirmed turning and repositioning was not part of Resident R20's interventions within the comprehensive care plan. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 211.12 (c) Nursing services.28 Pa. Code 211.12 (d)(5) Nursing services.

Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for one of ten residents observed during medication administration (R90).Findings include: On August 28, 2026, at 9:36 a.m., observed that Employee E5, a Licensed Nurse, was decanting the medicine, Aspirin Tablet Enteric Coated 81 MG (milligrams), to administer to Resident R90. Before administering Aspirin Tablet Enteric Coated 81 MG, E5 was requested to verify the order for Aspirin Administration. Review of physician order dated August 3, 2026, for R90, revealed an order to administer Aspirin Oral Tablet 325 MG, by mouth one time a day, not Aspirin Tablet Enteric Coated 81 MG. Eventually E5 searched for Aspirin Oral Tablet 325 MG in the medication cart, and among house stock, but could not find any. E5 could not administer Aspirin Oral Tablet 325 MG, to R90. This represents a medication error. On August 28, 2026, at 9:38 a.m., review of physician order dated July 31, 2026, for R90 indicated an order to administer Folic Acid Oral Tablet 1 MG, 1 tablet by mouth one time a day for Folic acid supplement. On August 28, 2026, at 9:39 a.m., observed that Employee E5 was searching for, Folic Acid Oral Tablet 1MG for R 90, in the medication cart, and among house stock, but could not find any. E5 could not administer Folic Acid Oral Tablet 1MG to R90, as ordered. This represents a medication error. At the time of the observation, interview with Employee E5 confirmed the above findings. The facility incurred a medication error rate of 6.67%. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on observations, review of facility policies, and interviews with staff, it was determined that the facility failed to maintain an effective infection prevention and control program during wound treatment for one out of one resident observed (Resident R85), and medication administration for two out of ten residents observed (Resident R72 and R124). Findings Include: Medication administration was observed on August 27, 2026. Before administering medication to Resident R72, licensed nurse, employee E8, checked the resident's blood pressure. After administration was complete, the nurse prepared the medications for Resident R124, also checking that resident's blood pressure before administration. The nurse did not sanitize the blood pressure cuff between residents. An interview with Employee E1, the Nursing Home Administrator, and E2, the Director of Nursing, later that day at 2:30 p.m. revealed that it is the expectation of the facility that all equipment meant for use on multiple residents be sanitized between residents. Review of Policy Statement of the facility about Enhanced Barrier Precautions (EBP), indicated that Enhanced Barrier Precautions are utilized to prevent the spread of Multi-Drug-Resistant Organisms (MDROs) to residents. Enhanced Barrier Precautions require the use of targeted personal protective equipment (PPE) during high contact patient/resident activities. Review of Resident R85 's clinical record revealed that the resident was admitted to the facility on [DATE]. Diagnoses included Pressure Ulcer of Sacral Region, and Pressure Ulcer of Right Elbow. Review of physician order dated August 26, 2026, for R85, indicated an order stating, Cleanse the sacrum with Normal saline, pat dry, pack with 1/4 strength Dakins moistened gauze, cover with bordered gauze QD and PRN; one time a day for wound infection and every 12 hours as needed for wound care. Review of physician order dated August 25, 2026, for R85, indicated an order stating, Cleanse right elbow wound with Normal Saline, Apply Gentell blue cut to fit, cover with Bordered gauze Dressing Change/Application Frequency 3x per week and as needed every day shift every Monday, Wednesday, Friday and as needed. Review of physician order dated August 13, 2026, for R85, indicated an order stating: Enhanced Barrier Precautions in place every shift, due to history of Klebsiella/Strep Bovis in urine, wounds, and due to indwelling catheter. August 26, 2026, at 9:31 a.m., observed wound treatment administered by Employee E4, a License Nurse. The nurse E4 did follow physician order for wound treatments, but did not follow Enhanced Barrier Precaution protocol, and hand hygiene protocol. On August 26, 2026, at 9:47 a.m., and 9:55 a.m., Employee E4 went outside the resident's room without removing his gown to collect items from the treatment cart and gathered treatment items letting the gown to touch the treatment cart. Also, E4 did not change the soiled gloves in between the sacral wound cleaning procedure. At the time of the finding, the same was confirmed with E4, and Director of Nursing. 28 Pa Code 201.18 (d) Management

Based on interviews with residents and staff, a review clinical records, review of facility policy and documents, it was determined that the facility did not ensure that residents were free from misappropriation of resident property related to medication given to another resident for one of two residents reviewed (Resident R4). Findings include: A review of the Administering Medications Policy, Reviewed on December 11, 2024, revealed that medications ordered for a particular resident may not be administered to another resident, unless permitted by State law and facility policy, and approved by the Director of Nursing Services. Further review of this policy revealed the individual administering medications must verify the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: Checking identification band; Checking photograph in PCC; Calling resident by name; and if necessary, verifying resident identification with other facility personnel. Interview with Resident R1 on May 18, 2026, at 11:15 a.m. revealed that when his medication runs out, the nurse just takes it from another resident. He went on to say that this is not right, what happens when that medication runs out? When asked when this last happened he said that it happened this morning. When asked what medication, the resident said it was his 800 milligrams of gabapentin (anticonvulsant used to treat partial seizures, nerve pain from shingles, and restless legs syndrome). Review of Resident R1's clinical records revealed a March 9, 2026, physician's order for Gabapentin 800 mg oral tablet, give one tablet by mouth three times a day for nerve pain and seizures. Interview with Licensed Nurse, Employee E4, on May 1, 2026, at 2:01 p.m. confirmed that Resident R1's gabapentin 800 mg tablet had run out and she gave him an 800 mg tablet from Resident R4's blister pack. The Director of Nursing (DON) asked Employee E4 if she had pulled the medication from the Pyxis machine (an automated medication dispensing system used in healthcare facilities to securely store, track, and manage medications). She said no, that she took it from Resident R4's blister pack. The DON then checked Resident R1's medication, and there was no blister pack for his gabapentin. The DON then pulled Resident R4's 800 mg gabapentin blister pack and confirmed with Employee E4 that she had pulled the medication for Resident R1 from this blister pack. Interview with the Director of Nursing on May 18, 2026, at 2:05 p.m. stated that she could not believe that this nurse would give another resident's medication to a different resident, and that she thought she would know better and to use the Pyxis machine. 28 Pa Code 201.18(b)(2) Management 28 Pa Code 211.9(a)(1) Pharmacy services 28 Pa Code 211.12(d)(5) Nursing services

Based on interviews, and a review of facility policies and documentation, it was determined that the facility was not maintaining an effective pest control program. Findings include: A review of the facility Pest Control policy revised on September 27, 2024, revealed that it states that the facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Interview with Resident R5 on May 18, 2026, at 11:35 a.m. revealed that pests were a problem and that she saw a mouse about a month ago in her room. Interview with Resident R8 on May 18, 2026, at 11:47 a.m. revealed that pest are an ongoing problem she sees bugs and heard about mice too. Interview with Resident R13 on May 18, 2026, at 11:58 a.m. revealed that mice are an issue, he sees them running around from the hall into his room, they need to get rid of them. Interview with Resident R1 on May 18, 2026, at 12:05 p.m. revealed that he was concerned about an infestation of cockroaches and mice in the building, that they have been putting roach traps in his room, but he still saw one on the sink yesterday. He said that he was sitting in the dining room the other day and one was on the wall. It is just disgusting; how can you eat after that. A review of the pest logs from the third floor revealed the following entries: March 3, 2026, mice droppings in rooms 320, 321, 323, 324March 19, 2026, mice in room [ROOM NUMBER]March 24, 2026, mice in room [ROOM NUMBER]April 23, 2026, mice roaming near room [ROOM NUMBER]April 23, 2026, mice in the dining room and room [ROOM NUMBER]May 8, 206, mice in room [ROOM NUMBER]May 10, 2026, mice in room [ROOM NUMBER], 314, 320 A review of the pest control company's reports revealed the following concerns: Invoice A579209 revealed that on April 23, 2026, the pest control technician found mouse droppings in the maintenance office which was treated, and the report indicated mouse activity in room [ROOM NUMBER] and room [ROOM NUMBER] which both had voids in the walls that need to be sealed along with voids in the third floor dining room. Invoice A579208 from an April 16, 2026, visit revealed that technician received a verbal report from the Administrator about mice activity in room [ROOM NUMBER], and that the technician observed a void in the corner of the room, took picture and shared it with the Administrator. Technician received a verbal report with the resident in room [ROOM NUMBER] about mouse activity, observed a void along the baseboard and this was reported to the Administrator. Invoice 577161 from an April 15, 2026, visit where the technician indicated that he found a heavy infestation of German cockroaches throughout the dresser, underneath the bed and throughout the clothing. Invoice 577155 from and April 10, 2026, visit where the technician indicated activity in the dresser drawers in rooms 221, 410 and 411 which need to be cleared for the next treatment. Invoice A574490 from a visit on March 26, 2026, when following up on a report of mice in room [ROOM NUMBER] where he found a hole in the wall in the corner near the window. An interview on May 18, 2026, at 2:45 p.m., with the Administrator, confirmed the third floor pest log entries and the reports from the pest control company showing the voids and holes in the walls and cockroach and mouse activity in the building in the past three months. 28 Pa. Code: 207.2(a) Administrator's responsibility

Based on observations, and resident interviews, it was determined that the facility failed to provide food and drink that was palatable and served at the proper temperature for five of nine residents reviewed (Residents R1, R5, R6, R9, R10, R12 and R13).Findings include: A review of the Food and Nutrition Services Test Tray Evaluation form- revealed that the hot foods should be served at or above 135 degrees, and the cold beverage and dessert should be served at or below 50 degrees. During a tour of the facility on May 18, 2026, the following resident interviews were obtained: Interview with Resident R1 at 12:05 p.m. revealed that he does not like the food, it is overprocessed to the point that you don't know what you're eating, it makes me sick to my stomach. Interview with Resident R5 at 11:35 a.m. revealed that she thought that the food was really bad, it is always cold. I am a diabetic and I can't have apple juice, it shoots up my blood sugar, and that is what they send me. I am a brittle diabetic and on Friday they did not send me my evening snack. Interview with Resident R6 at 11:39 a.m. revealed that the meals are bad, that there is a lot of repetition, like chicken all the time. And it is not always hot. Interview with Resident R9 at 11:46 a.m. revealed that the food either has no taste or it is too spicy. Interview with Resident R10 at 11:51 a.m. revealed that the food is horrible, like dog food, I have to get a sandwich all the time. Interview with Resident R12 at 11:54 a.m. revealed that the food is no good, not always hot. Interview with Resident R13 at 11:58 a.m. revealed that the food is lousy, always cold. Observations during a test tray conducted by the Food Service Director (FSD), Employee E5 on May 18, 2026, at 12:55 p.m. revealed that the apple juice was served at 55 degrees Fahrenheit, and the sliced apples dessert was served at 68 degrees Fahrenheit, both well above an acceptable range. The pulled pork was served at 126 degrees Fahrenheit, the diced potatoes were served at 111 degrees Fahrenheit, the peas were served at 109 degrees, and the coffee was served at 124 degrees Fahrenheit all below the acceptable 135 degrees Fahrenheit. Interview with the FSD on May 18, 2026, at 1:05 p.m. confirmed the results of the test tray. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on observations, resident and staff interviews, and a review of facility documentation, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures for four of 32 residents reviewed (Residents R24, R79, R32, and R63). Findings include: A review of the undated Bedrock Food and Nutrition Services Test Tray Evaluation form revealed that the acceptable temperature range for hot food and beverages was greater than 135 degrees and for cold food and beverage was 50 degrees or less and for milk 45 degrees or less. Interview with Resident R24 on September 29, 2025, at 11:15 a.m revealed that she did not like a lot of the food that they serve. Interview with Resident R79 on September 29, 2025, at 11:23 a.m. revealed that she can't eat the meals, that the food is really bad, and that all she is able to eat is the chicken noodle soup and they don't always have that. Interview on September 29, 2025, at 10:29 a.m. Resident R63 stated that the food was served cold, the meats were rubbery, that the coffee doesn't taste good and that the beverages taste watered down. Interview on September 29, 2025, at 10:58 a.m. Resident R32 stated that the food was not good and that the food was served cold. Observations during a test tray conducted on October 1, 2025, at 12:45 p.m. revealed that the last tray was passed at 12:45 p.m. Temperatures were taken by the Food Service Director (FSD), Employee E3, which revealed that the chicken and dumplings served over rice were only 129.4 degrees, and the spinach was only 123.4 degrees, all outside the acceptable temperature range for palatability. During the taste test the spinach was very bland and not warm enough and the dumplings were melted and stuck to the chicken and tasted slimy and uncooked dough, which was very starchy and unpleasant. An interview with the FSD, on July 23, 2025, at 12:55 p.m. confirmed that these food items were outside the acceptable temperature range and therefore not palatable, and that the cook was having trouble with the dumplings and that they did not turn out right. Observations in the second-floor dining room at 1:00 p.m. revealed that many of the residents were not eating the chicken and dumplings. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

Based on observations and interviews with staff it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.Findings include: An initial tour of the Food Service Department (FSD) was conducted on September 29, 2025, at 9:45 a.m. with Employee E3, Food Service Director, which revealed the following: Observations in the area near the compacting dumpster revealed a large blue container (10 gallons) of roofing adhesive, a case of four silver pouches of roofing sealant with 6 long screws and several tubes of roofing caulk. Also, a large pile of old resident equipment including a bedside commode, wheelchair, leg rests, walker, bedside nightstand and a microwave oven piled up next to the trash compactor. Observation in the dry food storage room revealed a large cardboard box of dishware sitting directly on the floor. Observation in the walk-in freezer revealed no thermometer to monitor temperatures. Observation in the walk-in cooler revealed a stainless-steel pan of cooked roast beef labeled September 24, 2025, or six days old. Observation in the prep sink revealed semi-frozen chicken breast floating in standing water. Observations in the second-floor dining room revealed the undershelf on the steam table covered in dirt and dust and the metal was oxidizing and could not be wiped clean. Observations in the refrigerator in the second-floor pantry revealed three Styrofoam containers of leftover food, seven plastic leftover food containers, one gallon jug of milk, and three plastic shopping bags of food and none were labeled with dates or names. There were three nutritional supplements labeled with resident names that were dated September 14, 2025. Interview with FSD on September 29, 2025, at 9:55 a.m., confirmed the above findings. Observation of the 4th floor resident food pantry on September 30, 2025, at 9:11 a.m. revealed that there was a frozen Styrofoam cup of juice with a straw in it that was unlabeled (no resident identification) and undated; a container of potato salad dated September 8 but was unlabeled; an open container of almond milk that was unlabeled and no date as to when the container was opened; and two containers of sushi that were purchased on September 29, 2025 but was unlabeled. Interview on September 30, 2025, at 9:25 a.m. Employee E9, unit manager, confirmed the above findings. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management

Based on clinical record review and staff interviews, the facility failed to ensure pain management was provided in accordance with professional standards of practice for one of one resident reviewed for pain management. (Resident R8) Findings include: Review of facility policy titled Pain Management Program dated October 16, 2024 revealed the facility must ensure that each resident receives care and services consistent with professional standards of practice to effectively manage pain, ensuring that pain does not interfere with the residents functioning or quality of life.Further review of the facilities policy stated that pain assessments are to be completed upon a mission, on a routine basis, and whenever there's a change in the residence condition or behavior that may indicate pain. The policy emphasizes that all pain management should be individualized to meet the specific needs of each resident, incorporating both pharmacological and nonpharmacological interventions. Non drug approaches such as repositioning application of heat or cold, relaxation techniques, or other comfort measures are encouraged as first line or supportive strategies. When oh poisoned clinically appropriately, they are to be used only as the lowest effective dose and for the shortest duration necessary. The policy further directs that pain control and medication effectiveness must be continuously reassessed and thoroughly documented to ensure appropriate management. A review of the National Institute of Health NIH .gov revealed that oxycodone is an opioid medication used to relieve moderate to severe pain it works by binding to specific receptors in the brain and spinal cord, reducing the perception of pain. It is typically prescribed for pain following surgery, injury, or chronic conditions. Side effects can include dizziness, drowsiness, constipation, nausea, and respiratory depression if taken in high doses. Because it can be habit forming, it is prescribed. Monitored with caution by health care providers.Review of Resident R8's quarterly minimum data set (MDS- a federal mandated assessment tool for all residents) dated September 5, 2025, indicated the resident was admitted into the facility on November 11, 2022. The residents brief interview for mental status (BIMS) score was 15 indicating intact cognition. Resident's diagnoses included stroke (a sudden interruption of blood flow to the brain), hemiplegia (paralysis or severe weakness on one side of the body), anxiety (mental health condition characterized by excessive worry, fear and unease), depression (mental health condition characterized by persistent sadness, hopelessness and loss of interest), and muscle wasting atrophy (decrease in size or wasting away of body part or tissue). The residents routinely receive antidepressants and opioid medications.Review of resident's care plan initiated in November 2022 and revised on March 30, 2023 identified the resident as being at risk for pain related to spasms and nerve pain. Interventions included administration of analgesic as ordered by the physician, anticipating the residents need for pain relief and responding promptly, and evaluating the effectiveness of all interventions while notifying the physician. If the interventions were unsuccessful or if the resident pain complaints indicated a significant change in condition. Review of resident's physician orders revealed in order day that June 24, 2025, for the pain medication Oxycodone 5 milligrams, to be administered every eight hours as needed for moderate pain, with documentation of pain level, location and non- pharmacological interventions.Further review of active and discontinued Physician orders showed that Resident R8 had been receiving Oxycodone continuously since November 11, 2022, without any documented re-valuation or tapering.Review of Resident R8's medication administration record (MAR) revealed the following: July 2, 5, 17, 19, 24, 25, and 26, 2025 the resident's reported pain levels ranged from 0-1 (no or very mild pain). Oxycodone was administered for moderate pain. August 24 and 28, 2025 pain level recorded as 1. Oxycodone was administered.September 6, 2025 pain level recorded as 0, Oxycodone was administered. On September 11 and 12, 2025 pain level recorded as 1, and Oxycodone was again administered.October 8, 21, and 23, 2025 pain level recorded as 0, and Oxycodone was administered.Interview with Director of Nursing (DON), Employee 2 on October 23, 2025 at approximately 1:30 PM, confirmed that the medication administration records for the resident were accurate and that the resident had received Oxycodone even when reporting little or no pain. Employees E2 further acknowledge that the facility did not have a defined pain scale to guide staff in distinguishing between mild moderate or severe pain levels. Additionally, it was confirmed that the residents care plan did not include any nonpharmacological interventions to address pain management or provide comfort measures. 28 Pa. Code 211.2(c)(3)(9) Medical Director28 Pa. Code 211.9 (b)(d) Pharmacy Services28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services

Based on review of facility provided documentation, interview with staff and review of clinical records it was determined that facility did not ensure to provide appropriate supervision during smoking break and during Hoyer lift transfer for two of 32 residents reviewed (Resident R7, R111)Findings include: Review of facility policy titled Abuse Dated October 24,2022, revealed the facility is committed to ensuring all residents are free from abuse common neglect, and harm. Neglect is recognized as a form of abuse and occurs when they facility, its staff, or service providers fail to provide necessary goods or services, placing residents at risk of physical harm, pain, or emotional distress. this includes Indifference or disregard for resident care, comfort, or safety, whether from a single incident or a pattern of failures, including not following proper procedures. all staff receive ongoing training to prevent abuse and neglect, and residents are monitored to maintain a safe, protective environment.Review of facility policy titled Lift dated January 1, 2022, revealed that transferring a resident with a Hoyer lift requires two staff members working together. One staff positions the sling under the resident and prepares the lift, while the other ensures the lift and chair are correctly placed. During the transfer, one person operates the lift controls to raise and move the resident, while the second monitors for safety, supports the resident's legs, and prevents the lift from striking the resident. Both staff guide the resident into the chair, lower them slowly, and ensure comfort. One staff removes the sling, while the other confirms the resident is safely positioned. Teamwork ensures a safe, smooth, and comfortable transfer. Review of Resident R7's quarterly Minimum Data Set (MDS -federal mandated assessment tool for all residents) dated July 7, 2025, revealed that Resident R7 was admitted to the facility on [DATE]. The resident's brief interview for mental status (BIMS) score was 15 indicating he is cognitively intact. Resident medical diagnosis's includes cerebral vascular accident (CVA -stroke), aphasia (language disorder that effects communication), anxiety (mental health condition characterized by excessive worry, fear and unease) and depression (Mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest).Further review of Resident R7's MDS revealed that the resident's functional abilities included impairment on one side and required maximal assistance for toileting dressing and personal hygiene. This resident was totally dependent when staff assistance for bed mobility sit-to-stand transfers and bed to chair transfers. Observation on September 30, 2025, at 10:15 a.m., on the fourth-floor nursing unit outside Resident R7's room, revealed that Nurse aide, Employe E13 was observed providing care to Resident R7 in bed. After completing care, Employee E13 positioned the facility Hoyer lift (mechanical lift that aide with transfers from one surface to another), came to the doorway, looked down the hall, and then closed the door. Approximately five minutes later, nursing aide, Employee E7 opened the resident's door. Resident R7 was observed sitting in his wheelchair. Nurse Aide, Employee E13 was the only staff member in the room during this time. After it was confirmed that the resident had been transferred to the wheelchair and was comfortable, Employee E7 exited the room. Interview at time of the above observation with Nurse aide, Employee E13, revealed that he alone transferred Resident R7 using the Hoyer lift and then into the wheelchair without assistance. He reported that he regularly performs this transfer alone, referring to the resident as his buddy.Interview with Nurse aide, Employee E14 on the fourth-floor nursing unit on September 30, 2025, at approximately 10:30 am, this employee stated that she is frequently assigned to this resident and lift transfers are always required to be performed by two staff members. This is a facility rule for all residents. Review of Nursing aide, Employee E13's employee file revealed that on 8/26/2025, Employee 13 successfully demonstrated competency in transferring residents using both a Stand Assist Lift and a Hoyer Lift. The employee correctly inspected the lifts and slings for defects, prepared the environment by removing hazards, and ensured proper bed/chair positioning. Two staff members were present during each procedure to safely assist with the lift. The employee provided reassurance to residents, positioned them properly, and executed lifts and transfers in a controlled and safe manner, maintaining contact and support throughout. Hand hygiene and proper sling handling were consistently observed. Review of facility policy 'Abuse,' revised October 24, 2022, under E. Investigation, states that It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation, and misappropriation of property) are promptly and thoroughly investigated.Review of facility reported incident, dated August 28, 2025, at 11:00 am, revealed that Resident R111, was observed on the ground floor of facility sleeping in chair towards the elevators. Resident R111 was observed to have abrasion on the top of his head with scant red blood. Per R111's statement - he fell outside, tripped over the bench.Further review of R111's fall incident report indicated contradictory documentation related to his head injury. Resident R111 was sent to emergency room for evaluation but under 'injury type' R111 was noted with no injuries observed post incident.Further review of fall incident report revealed contradictory documentation related to R111's orientation; stating he is AAOx1 (people) as well as AAO x 4 (people, places, time and situation).Review of Resident R111 Minimum Data Set (MDS) - Resident Assessment and Care Screening, completed on October 10, 2025, indicates his Brief Interview for Mental Status (BIMS) score is 12.Review of statement completed by activities therapist, employee E12, on August 28, 2025, states I supervised residents during smoke break. R111 did not fall. I was present the whole time.Interview with facility's director of nursing and administration on Thursday, October 23, 2025 revealed that activities employee forgot to lock the smoking section area after smoking time was over, therefore - no one witnessed the fall incident. 28 Pa Code 201.14(a) Responsibility of licensee28 Pa Code 201.18(b)(1) Management28 Pa Code 211.12(d)(5) Nursing services

Based on review of clinical records, review of facility policy and interview with staff, it was determined that facility did not ensure to provide care according to professional standards of practice for one of 32 residents reviewed related to hypoglycemia management. (Resident R3) Findings include:Review of facility policy 'hypoglycemic management,' revised February 24, 2025, indicates that The licensed nurse will monitor and evaluate for signs of hypoglycemia. These signs may be different for individual patients and may be identified by the patient or responsible party during interview. Signs of hypoglycemia may include diaphoresis, tremors, pallor, tachycardia, cold, clammy skin, lightheadedness, dizziness, changes in vision.Further review of policy indicates that The licensed nurse will follow a standard protocol for diabetic patients. The protocol will be followed unless specific physician orders direct otherwise. This protocol includes: The licensed nurse will complete a finger stick on a patient who is experiencing signs of hypoglycemia. Finger stick blood sugar less than 60: i. If the resident is awake and alert administer: 8oz orange juice with 5 packs of sugar. ii. Repeat finger stick in 30 minutes. iii. Give another 8oz orange juice and sugar if finger stick is LESS than 100. iv. Repeat finger stick in 30 minutes. v. If finger stick is less than 100 administer: IV D5 1/2 normal saline at 100mL per hour x 24 hours. Repeat finger stick in 30 minutes and notify physician.Review of Resident R3's clinical record revealed medical diagnosis of type two diabetes mellitus (failure of the body to produce insulin), end stage renal disease, hypoglycemia (low blood sugar levels), dependance on renal dialysis.Review of Resident R3's fall incident investigation report, dated December 5, 2024, revealed that Resident R3 had an unwitnessed fall in main dining room. Upon arrival resident was lying on his side. Resident was alert and talking and denied pain at the time. Writer observed a huge hematoma on back of resident's head. Per resident he was sitting in the chair and was about to use the restroom and he just fell out.Further review of Resident R3's clinical record as well as investigation report revealed no evidence of facility following their protocol for hypoglycemic management; no evidence of blood sugar check post incident and no evidence of vital signs taken post incident on December 5, 2025. Resident R3 had a fall at 7:15 pm and transferred to emergency room for evaluation at 7:50 pm.Review of hospital records, dated December 9, 2024, indicated his blood glucose upon arrival was 43 mg/dl with mild lethargy from poor PO intake. 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on observations, review of facility documentation, review of personnel files and interviews with staff, it was determined that the facility failed to ensure that the activities program was directed by a qualified professional for one of one activities personnel files reviewed (Employee E7). Findings include: Review of the facility's Department Heads Contact List revealed that Employee E7 was listed as the Therapeutic Recreation Director. Review of Employee E7's personnel file revealed that the employee was hired by the facility on March 17, 2025, as the Activities Director. Continued review revealed that the job description signed by Employee E7 on March 17, 2025, revealed The Activities Director assumes administrative authority, responsibility and accountability for the provision of a program of therapeutic activities designed to meet the interests and enhance the functional abilities and self-esteem of each resident. Continued review of Employee E7's personnel file revealed that the employee previously worked as a cook and as a housekeeper. Further review revealed that there was no evidence that Employee E7 was a certified therapeutic recreation specialist, or had previous experience in a therapeutic activities program, or was a qualified occupational therapist or completed an approved training course for therapeutic recreation specialists. Observation on September 30, 2025, at 11:18 a.m. revealed Employee E7, Activities Director, was overseeing and assisting with an activities program with residents in the main dining room area. Interview, at the time of the observation, Employee E7 confirmed that he has not completed any credentialling or training courses to be a qualified therapeutic recreation specialist. Employee E7 stated that he trained with another employee for two weeks upon being hired into this position and that he had no prior experience in therapeutic activities programs. 28 Pa code 201.19(3) Personnel policies and procedures

Based on observation, staff interview, review of facility policy and clinical record review, the facility failed to maintain and protect personal privacy and dignity while providing care to one of nine residents observed. (Resident R7)Findings Include:Review of facility policy titled Dignity dated April 1, 2022, revealed that all residents shall be cared for in a way that promotes quality of life, dignity, respect, and individuality. Staff must treat residents respectfully, supporting personal choices in grooming, clothing, and activities, while always maintaining privacy and confidentiality. Personal spaces and belongings are protected, and bodily privacy is preserved during personal care and medical procedures. Clinical information is shared discreetly, with sensitive details posted only when necessary for safety, and isolation or precaution status indicated without revealing specific infections. Communication should be respectful, using residents' chosen names, explaining procedures, and keeping them informed of changes. Cognitively impaired residents are treated with sensitivity, and demeaning practices are prohibited. Residents are encouraged to participate in preferred meals and activities, and dignity is supported through timely assistance and appropriate coverage of medical devices. Protecting privacy, honoring choices, and maintaining dignity are central to all aspects of care. Observation on September 30, 2025, 10:00am on the fourth-floor nursing unit outside resident R7's room, the door was left wide open. Nurse aide, Employee E13 was present in the room providing personal care and assisting Resident R7 with dressing. The resident's privacy curtain was also open allowing the activity to be visible from the hallway. Review of Resident R7s quarterly Minimum Data Set (MDS -federal mandated assessment tool for all residents) dated July 7, 2025, revealed that Resident R7 was admitted to the facility on [DATE]. The resident's brief interview for mental status (BIMS) score was 15 indicating he is cognitively intact. Resident medical diagnoses includes cerebral vascular accident (CVA -stroke), aphasia (language disorder that effects communication), anxiety (mental health condition characterized by excessive worry, fear and unease) and depression (Mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest).Further review of Resident R7's MDS revealed that the resident's functional abilities included impairment on one side and required maximal assistance for toileting dressing and personal hygiene. This resident was totally dependent when staff assistance for bed mobility sit-to-stand transfers and bed to chair transfers. The resident is in content incontinent.Interview with nurse aide, Employee E13 at time of the above observation confirmed that he had left the curtain and door open during care stating he did it purposely because the resident is claustrophobic (extreme fear of confined places).Review of Resident R7's nursing notes, current care plan and psychological note revealed there no evidence that Resident R7 was claustrophobic and no documentation that this resident has any preference or need for accommodations of Claustrophobia.Interview with Resident R7 on September 30, 2025, at approximately 10:30 am, resident stated that he is not claustrophobic and would prefer privacy during care. 28 Pa. Code 201.20(a)(5) Staff Development 28 Pa. Code 201.29(a) Resident Rights 28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services

Based on observations, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that staff were knowledgeable of smoking policies during one of one smoke breaks observed (September 30, 2025, morning smoke break). Findings include: Review of facility policy, Smoking Safety Policy dated October 3, 2024, revealed, It is the facility policy to provide a safe environment for our residents, staff and visitors by defining and enforcing safe smoking practices. Continued review revealed, The facility will maintain safety equipment near and/or at the designated smoking area: emergency fire blanket, fire extinguisher . [and] aprons for residents if they are not on their possession. Review of the facility's smokers list revealed that four residents required smoking aprons, including Resident R83. Observation on September 30, 2025, at 9:31 a.m. of the morning smoke break revealed that Resident R83 was smoking in the designated smoking area. Resident R83 had a cigarette hanging from her lips while seated in her wheelchair with her hands resting at her sides. Resident R83 was observed not wearing a smoking apron. Interview, at the time of the observation, Employee E8, Business Office Manager, revealed that she was monitoring the residents during the smoke break. Employee E8 stated that she did not know which residents required smoking aprons and that no aprons or list of smokers were ever provided to her. Continued interview revealed that Employee E8 did not know where the smoking aprons or emergency fire blanket were located. Employee E8 revealed that she did not know what a fire blanket was or how to use one. Employee E8 stated that Employee E7, Activities Director, was responsible for overseeing the resident smoking program. Interview, on September 30, 2025, at 9:38 a.m. Employee E7, Activities Director, revealed that he did not have the list of smokers, including which smokers required smoking aprons, readily available and that he would have to retrieve it from his office. Employee E7, Activities Director, confirmed that there was no emergency fire blanket in the designated fire blanket storage box next to the entrance of the smoking area. Employee E7, Activities Director, did not know where the smoking aprons were stored and confirmed that they were not readily available to staff responsible for monitoring the smoking area. After searching the area for several minutes, Employee E7, Activities Director, found two smoking aprons in a dining room kitchen cabinet. Employee E7, Activities Director, was not able to find any additional smoking aprons to accommodate all the residents that were listed as needing smoking aprons. 28 Pa code 209.3(a) Smoking

Based on observations and interviews with staff, it was determined that the facility did not ensure that that trash and recyclables were properly disposed of in the receiving and dumpster area.Findings include: An initial tour of the Food Service Department was conducted on September 29, 2025, at 9:45 a.m. with Employee E3, Food Service Director, (FSD) which revealed the following: Observations in the area near the compacting dumpster revealed a large blue container (10 gallons) of roofing adhesive, a case of four silver pouches of roofing sealant with 6 long screws and several tubes of roofing caulk. Also, a large pile of old resident equipment including a bedside commode, wheelchair, leg rests, walker, bedside nightstand and a microwave oven piled up next to the trash compactor. Interview with the FSD on September 29, 2025, at 9:50 a.m. confirmed the above findings. Interview with the Administrator on September 29, 2025, at 1:20 p.m. confirmed that the facility recently had roof work completed and that these chemicals and other debris should not be left outside of the dumpster. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management

Based on observations, review of facility policy/protocols, and interview with staff, it was determined that facility did not ensure to store drugs and biologicals according to professional standards of practice in two of two medication storage rooms observed (2nd floor and 3rd floor units) Findings include:Review of facility policy 'Medication Storage,' reviewed December 17, 2024, indicates that medication preparation and storage areas will have sufficient lighting, and medications requiring refrigeration will be stored in a refrigerator that is maintained between 2 - 8 degrees Celsius ( 36 to 46 degrees F) . temperatures will be checked daily to ensure it is within the specific range. If temperature is out of range, the refrigerator thermostat will be adjusted.Review of 'Refrigerator temperature control log,' for month of October 2025, on 3rd floor unit, indicated that The RN (Registered Nurse) or LPN (Licensed Practical Nurse) will check and record the refrigerator temp. every shift, initial and sign. Temp (F- Fahrenheit) should be between 36 degrees - 46 degrees F. If out of range, readjust temp. If still out of range, notify maintenance and document in the maintenance log.Further review of temperature log on 3rd floor unit, revealed no record that the temperature was monitor and documented on the following dates/shifts: October 1, 2025 day and evening shift, October 2, 2025 day and evening shift, October 6, 2025 through October 23, 2025 day shifts, October 9, 2025 evening shift, October 11, 2025 through October 13, 2025 evening shift, October 15, 2025 through October 23, 2025 evening shift, October 22, 2025 night shift.Further observations of medication storage room on 3rd floor unit indicated refrigerator temperature out of range - at 48F. Finding confirmed by charge nurse, Employee E10 at the time of the observation.Further review of temperature log in 2nd floor medication storage room revealed missing temperature checks, dates and initials on following dates: October 1, 2025 through October 8, 2025 day shifts, October 11, 2025 through October 22, 2025 day shifts, October 5, 2025 through October 6, 2025 evening shifts, October 11, 2025 through October 12, 2025 evening shifts, October 17, 2025 evening shift, October 20, 2025 through October 22, 2025 evening shifts, October 3, 2025 through October 5th, 2025 night shifts, October 9, 2025 night shift, October 11, 2025 night shift, October 15, 2025 night shift, October 17, 2025 through October 18, 2025 night shift, October 21, 2025 through October 22, 2025 night shift.Findings confirmed with 2nd floor unit charge nurse, Employee E11 on Thursday, October 23, 2025, at 11:54 am.28 Pa Code 211.12(d)(5)(e) Nursing services

Based on a review of resident clinical record, interview with staff and review of facility policy, it was determined that the facility failed to notify the ordering physician of a critical laboratory results for one of eight resident records reviewed (Resident R2).Findings include: Review of the facility policy titled, ‘Clinical Guideline; Labs and Diagnostics', dated 2021, without date and Month, indicated; ‘Facility staff will notify the ordering prescriber of results that are outside of clinical reference ranges or per prescribers' order. The prescriber or designee prescriber will sign and date that notification has occurred, and this can be done manually or by e-signature, if available'.Review of Resident R2's clinical record revealed that Resident R2 was admitted in the facility on August 30, 2025. Resident R2's diagnoses included Malignant Neoplasm of Unspecified site of Right Female Breast (commonly known as breast cancer, is a cancerous tumor that develops in breast tissue. These tumors are characterized by their ability to grow rapidly, invade surrounding tissues, and potentially spread to other parts of the body), and cellulitis of left lower limb (an infection of the deeper layers of the skin and subcutaneous tissues. It is usually caused by bacteria entering the skin through a break or cut, such as a wound, surgical incision, or even insect bites).Review of Resident R2's clinical record revealed a laboratory result of a BNP (is a peptide (a short chain of amino acids) that the heart and blood vessels make. It works as a hormone) which indicated critical values on June 6, 2025.Review of nursing note by a Registered Nurse, Employee E4, dated June 7, 2025, revealed; Critical lab value received at 1:24 a.m Efforts to reach MD for review proved futile. Nursing will continue to reach out to MD for review and new orders.On July 24, 2025, at 12:43 p.m., interview with the Nursing Home Administrator, reveled that the Registered Nurse, Employee E4, was not available for interview.On July 24, 2025, at 1:57 p.m., interviewed the Medical Director, E3. revealed I am unclear why the nurse was unable to call the lab result of [Resident R2] into the physician on call.On July 24, 2025, further review of the clinical records indicated no documented evidence the physician was informed of the results. 28 Pa Code 211.12(d)(1) Nursing services28 Pa Code 211.12(d)(3) Nursing services

Based on interview with residents and staff and review of facility documentation, it was determined that facility failed to ensrue that residents' clothing was properly identified for two of eight residents reviewed. (Resident R1, and Resident R2) Findings include: Review of facility policy 'Laundry Services - Personal Clothing, Handling,' unknown date, indicates that all resident clothing must be labeled clearly with the resident's name upon admission or upon new clothing being brought in, and personal clothing is separated from facility linens. Interview with Resident R1and Resident R1's relative, on fourth floor unit, at 11:45 am, revealed that he has been waiting to receive his personal laundry for about two weeks. Interview with facility's laundry aides, Employee E3 and E4, on [DATE] at 12:10 p.m., revealed that delayed personal laundry services has been an ongoing issue, stating that nurse aides need to label residents' clothing otherwise we will wait until someone complains and asks for their belongings .then nurse aides have to come down here and figure out who it belongs to . During interview with Laundry aide, Employee E3, on [DATE] at 12:10 pm, Employee E3 uncovered a dirty bin filled with bed linens and residents personal belongings mixed. Further observations during laundry room tour revealed a pile of residents' clothing, unidentified. Review of facility provided grievances for months of [DATE] and [DATE], revealed ten submitted grievances related to laundry delay and missing items. Review of grievance report, completed on [DATE], indicated that facility returned deceased Residents R2 belongings to family member in a wet condition. 28 Pa Code 201.29(a) Resident rights

Based on clinical record reviews and review of facility's documentation, it was determined that the facility failed to provided one of nine residents reviewed (Resident R 1) with two person assistance during dressing which resulted in actual harm to Resident R1 falling out of bed, requiring emergency medical services, transfer to the hospital and [DIAGNOSES REDACTED]. Further, the facility failed to ensure that an order given by the Certified Registered Nurse Practicioner was followed, for one of nine residents reviewed, resulting in actual harm to Resident R2 who experienced severe left leg pain, resulting from a left tibia/fibula fracture. (Resident R2) Findings include: Review of Resident R1's clinical record revealed that the resident was admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of the quaterly Minimum Data Set (MDS-a periodic assessment of the resident's needs) completed on April 25, 2019 revealed that the resident was cognitively impaired; there were no behavior symptoms identified and no indication that the resident reject care. Resident R1 was totally dependent for bed mobility, dressing, personal hygiene and full body bath/ shower requiring one person assistance. The resident was totally dependent with transfers and toilet use requiring 2 person assistance. The resident's balance for surface to surface transfer (transfer between bed and chair or wheelchair) was coded not steady, only able to stabilize with staff assistance. Review of the resident's care plan initiated July 12, 2019 identified the resident with Activities of Daily Living with self care performance deficit related to aggressive behavior, dementia and contracture. The interventions included in the resident's plan of care included to transfer the resident via mechanical lift with 2 person assist, bath/shower the resident with assistance of 1 staff member, for bed mobility the resident required assistance of 2 staff for reposition and to be turn in bed, for dressing the resident required assistance of 2 staff members and 2 staff members with personal hygiene. Review of physician's notes revealed a Certified Registered Nurse Practitioner (CRNP) note dated July 2, 2019 documented, patient has no medical problem to report. Nursing staff reports that the resident is verbally aggressive and refuses care. Further review of the CRNP's note indicated that the resident had a history of [REDACTED]. Dementia-progressive. Reviewed of nurse's notes dated July 21, 2019 completed by licensed staff, Employee E4 revealed at approximately 7:30 am, (Employee E4) was called the resident's room by the CNA (nursing assistant) to assess the resident because she had a fall, upon entering the room (Employee E4) observed the resident lying on her right side on the floor next to her bed, resident was noted with a large hematoma to her forehead, resident assessed for pain and resident denied pain at the time .supervisor called to assess the resident's injury, resident assisted back into bed with 2 person assitance and resident was combative during transfer, supervisor assisted for injury and stated to call 911 rescue, MD (physician) and RP (responsible party) notified of resident's condition and transfer, CNA questioned as to what happened and the CNA reported that while she was getting the resident dressed for the morning, she had the resident sitting on the side of the bed while supporting her in an upright position and at that time she proceeded to fix the back of the resident's shirt; the CNA stated that she leaned over the resident in an attempt to fix the back of the resident's shirt, and art that time the resident bit her in the chest, the CNA reported that she jumped back in reaction to the resident biting her causing her to let go of the resident, at that time the resident lost her balance and fell to the floor, 911 rescue was called and arrived to the unit at approximately 7:45 am. Further review of nursing notes dated July 21, 2019 at 11:02 a.m. noted that at approximately 10:30 a.m. the resident's physician form the hospital called and informed the Employee E4 that the resident had a C1,C2 (spinal vertebrate at the top of the neck) fracture and the resident was being admitted to the hospital. Review of hospital record revealed patient reportedly bit her aide during a transfer from bed and was dropped. She reported neck pain, was found to have a scalp hematoma (a collection of blood outside of a blood vessel), acute type 2 odontoid fracture (a break that involves the second vertebrae (Cervical 2) high in the neck), and nondisplaced fracture posterior ring C1 left and right. Reviewed facility's investigation into the fall sustained by Resident R1 including witness statements revealed a statement obtained from nursing staff Employee E3 who reiterated I was giving care to the resident I sit the resident up right position with my support I lean to the back to fix her shirt the resdient became combative and bit me on my chest I jumped back cause me to let go of the resident. So the resident lost her balance and fell to the floor. Employee E4 indicated on her statement that the resident could not sat up by herself. Further review of Employee E3 revealed that Employee E3 also stated that prior to this incident, she was bitten on the arm by the resident in the presence of the charge nurse. Employee E3 indicated that her skin was not broken and that she did not feel like going through making a report. Review of the charge nurse, Employee E4's statement revealed that she witness the resident bite the care nurse on her arm. The event occurred between July 1st and July 3rd. The charge did not document the behavior. She stated I forgot to put it in. Review of the statement from the care nurse that provided care to the resident during night shift, Employee E5 revealed that he did not wash and dress the resident that morning because the resident was combative. He also said that he did not report the resident's behavior to the charge nurse. The facility failed to ensure that Resident R1 was provided with two person assistance during dressing which resulted in actual harm to Resident R1 falling out of bed, requiring emergency medical services, transfer to the hospital and [DIAGNOSES REDACTED]. Review of Resident R2's clinical record revealed that the resident was admitted to the facility on [DATE]. with the [DIAGNOSES REDACTED]. A review of the resident's quaterly Minimum Data Set, dated dated dated [DATE] revealed that the resident required extensive assistance with 2 person assistance with bed mobility and transfers; total dependence with 2 person assistance for toilet use and full body bath/shower. Resident was non-ambulatory. Review of the nurse's note for July 12, 2019 10:40 p.m. revealed that the nurse assistant notified the licensed nurse that resident was complaining of pain during evening care. Resident was assessed for injury. No injury noted. Resident often cries out during evening care. Resident was put to bed without further incident. Reviewed the Incident/Accident report dated 7/16/2019 and witness statements revealed the resident attended a group activity on 7/12/19 and returned to her nursing unit between 3:30 p.m. and 4:00 p.m. The resident participated in the activity while being seated in her wheelchair and did not complain of any pain. Review of the written statement from the nurse aide assigned to the resident, Employee E9 stated that after dinner on 7/12/19, she noted that the resident's leg was not on the footrest. When she attempted to place the foot on the leg rest the resident screamed out in pain. She and two other nurse aides lifted the resident into bed. The resident continue to screamed about her leg after being laid down. The nurse aide notified the charge nurse. The charge nurse looked at the leg, touch it and the resident scream out. A second care nurse that was in the room also stated that when the charge nurse touched the resident's leg, the resident started hollering. Review of nursing notes dated on July 13, 2019 at 1:47 p.m., revealed charge nurse asked supervisor to assess resident left lower extremity, upon my assessment resident range of motion performed to left hip and left leg. Resident started screaming very loudly and left leg swollen warm to touch, positive pedal pulses. CRNP (certified registered nurse practioner) notified, ordered bilateral hip x-ray and bilateral leg x-rays .Resident medicated for pain, nurse will continue to monitor. Review of July 2019 Medication Review Report confirmed that a physician's orders [REDACTED]. The result of Resident R1 bilateral hip x-ray report dated July 13, 2019 revealed no acute [MEDICAL CONDITION] or left hip. There was evidence that an x-ray was obtained of the resident bilateral legs as ordered by the physican on July 13, 2019. Review of nurse's note dated July 13, 2019 at 10:13 p.m. indicated that the physician was made aware that there was no acute abnormality seen on x-ray. There were no nurse's notes on July 14th or 15th regarding the resident's activity level, comfort level or condition. Further review of nursing notes revealed that on July 16, at 1:30 p.m., the Unit Manager, Employee 13 noted that the staff reported that the resident received morning care; ate 70% of breakfast and lunch; received incontinent care with no complaint of pain. At 7:07 p.m. licensed nursing staff, Employee E14 noted that the resident was in severe pain. Further review of nursing notes dated July 16, 2019 at 10:21 p.m. Employee E14 revealed, resident received in bed awake and alert upon my arrival. I overheard the care nurse speaking of the resident showing s/s (signs and symptoms) of extensive pain to her left leg, how it had been reported to a charge nurse previously, and that an x-ray had been completed and came back no injuries. I had not received any reports of this situation and it was not on the 24 hour report since I returned back on Monday 7/15/2019. Upon learning this I assess the resident's leg. I asked the resident was she having pain in her leg and she shook her head yes. When I pulled back the sheet, I immediately observed the left lower anterior leg was indented, yellow in color, warm to the touch, with intense pain upon touch. The resident screamed out from the touch of my index finger (physician) notified, new order given for stat x-ray to left knee, tibia/fibula, and foot. Nursing note dated July 16, 2019 at 11:43 p.m. revealed that the x-ray technician was not able to complete all views as order due to excruciating pain on movement. The resident's physician notified and order obtained to send resident to hospital. Review of nursing note dated July 17, 2019 at 1:16 a.m. revealed that the resident was transported by ambulance to the hospital at approximately 12:00 a.m. Further review of this note indicated her radiology report came back with the conclusion: Acute fractures of the left lower leg. Review of the x-ray report dated July 16, 2019 confirmed acute fractures of the left lower leg. Review of hospital documentation revealed that on July 20, 2019 resident had left tibia open reduction and intramedullary fixation and open treatment of [REDACTED]. The facility failed to ensure that an order given by the Certified Registered Nurse Practicioner was followed, resulting in actual harm to Resident R1 who experienced severe left leg pain, resulting from a left tibia/fibula fracture. 28 Pa Code 201.14 (a) Responsibility of licensee Previously cited 06/20/19 28 Pa Code 201.18 (b)(1) Management 28 Pa Code: 211.10(d) Resident care policies Previously cited 02/06/19 28 Pa Code 211.12 (d)(1) Nursing services Previously cited 02/06/19 28 Pa Code 211.12 (d)(2) Nursing services Previously cited 02/06/19 28 Pa Code 211.12 (d)(5) Nursing services Previously cited 02/06/019

Based on review of clinical records and facility documentation, and interviews with staff, it was determined that the facility failed to implement planned interventions to reduce the risk of injury and accidents for two of 27 residents reviewed resulting in injury to two residents actual harm for one resident (Resident R135) and injury to another resident (Resident R33). Findings include: The MDS (minimum data set) comprehensive assessment (an assessment of care needs) dated December 21, 2014, for Resident R135 indicated that this resident's cognitive skills for daily decision making were severely impaired. The comprehensive assessment also indicated that this resident's functional status for activities of daily living was for two staff to physically support this resident with extensive assistance for transfers (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position). The assessment also indicated that Resident R135 had bilateral lower extremity impairment and was identified as incontinent of bladder and bowel. Resident R135's clinical record indicated that this resident had [DIAGNOSES REDACTED]. A care plan, dated December 1, 2014, to prevent injuries and provide a safe environment during activities of daily living (transfers and toilet use) for Resident R135 indicated that this resident was to receive assistance of two nursing staff for all care needs. This care plan for Resident R135 was confirmed during an interview with the registered nursing unit manager, Employee E3, at 10:30 a.m., on March 18, 2015. Nursing progress notes dated February 21, 2015, at 2:59 p.m., indicated that Resident R135 was assessed and noted that the resident's left foot and ankle were misaligned . The progress note indicated that Resident R135 had no complaint of pain until the left foot was moved. The physician was made aware on February 21, 2015 at 2:59 p.m. of the resident's change in condition and sent the resident to the hospital for further evaluation on February 21, 2015 at 6:00 p.m. with the resident's daughter. Hospital records on February 21, 2015 for Resident R135 revealed that the resident had sustained fractures of the left leg at the distal tibia (the inner and larger bone of the leg between the knee and the ankle) and distal fibula (the outer smaller bone of the leg from the ankle to the knee situated above with the tibia and talus). A facility incident/accident investigation form dated February 21, 2015 and the report form for investigation of alleged neglect dated February 22, 2015, indicated that Resident R135 was transferred from the bed to the chair with only one nursing staff at 8:45 a.m. on February 21, 2015. Resident R135's care plan for safe transfers was that this resident required the physical assistance of two nursing staff. The documentation in this incident/accident report indicated that a nursing assistant, Employee E4, stood and pivoted/turned Resident R135 during this transfer. The forms also indicated that during the provision of morning incontinence care on February 21, 2015, Resident R135 made an expression of pain to the nursing assistant. This information was confirmed during an interview with the director of nursing at 10:00 a.m., on March 19, 2015. A signed witness statement from Employee E4, dated February 24, 2015, confirmed that the staff member transferred the resident without the assistance of a second staff person and failed to notify staff in a timely manner of an injury. The facility failed to transfer a resident, who was assessed to require two persons for a safe transfer and who was at risk for injury based on the [DIAGNOSES REDACTED]. A review of Resident R33's physician orders [REDACTED]. A review of Resident R33 MDS (minimum data set/assessment of care needs) dated November 22, 2014, revealed this resident's cognitive skills for daily decision making were severely impaired. The MDS assessment also indicated that this resident's functional status for activities of daily living was for two staff to physically support this resident with total dependence for transfers and bathing and extensive assistance of two persons for dressing and personal hygiene. Review of nursing documentation, from October 2014 throughout December 2014, revealed that Resident R33 was total care with two person assistance for bathing, dressing, toileting, bed mobility and transfers. A review of the reportable event, submitted to the State Survey Agency on December 19, 2014 and updated on December 22, 2014, revealed that the resident was receiving care from only one staff member and the bed was elevated in the high position for care. The nursing assistant washed Resident R33's upper torso and extremities and then focused on the resident's lower extremities. The resident had unexpected movement which was described by the nursing assistant in the event report, dated December 18, 2014, as a "spasm" and that the resident was kicking and swinging her hands, which caused the resident to fall out of bed and sustain a laceration to the forehead. A review of the facility's investigative report, dated December 18, 2014, revealed that the resident fell /rolled from the bed to the floor during care and sustained a laceration to the right eyebrow with a moderate amount of bleeding. Another laceration was later found on the right side of Resident R33's head just above the right earlobe. An interview with, the Director of Nursing, on March 23, 2015, at approximately 11:00 a.m., confirmed that there were not two staff members present during care as indicated as needed in the MDS assessment and nurses' notes. The failure to ensure the safety of the resident during care resulted in injury to the resident. The facility failed to provide assistance of two staff members for bathing and personal hygiene resulting in a fall with injuries. 28 PA Code 201.14(a) Responsibility of licensee. 28 PA Code 201.18(b)(1)(3) Management. 28 PA Code 211.12(d)(1)(5) Nursing services.