Every finding on record at Twin Pines Health Care Center

Based on review of the facility's policy, clinical records, hospital records, and interviews with staff, nurse practitioner, resident, and family, it was determined the facility failed to timely notify and report accurate information of a resident's change in condition to the physician for one of two residents reviewed (Resident 1). This failure resulted in actual harm of the resident when they were hospitalized , requiring intubation, mechanical ventilation, and ICU (Intensive Care Unit) admission for monitoring. Findings Include: Review of the facility's policy titled Resident Change in Condition Policy, last reviewed on June 2, 2025, revealed The licensed nurse will recognize and intervene in the event of a change in resident condition. The Physician/Provider and the family/Responsible Party will be notified as soon as the nurse has identified the change in condition. Review of Resident 1's diagnosis list includes Multiple Sclerosis (condition that causes breakdown of the protective covering of nerves; causing numbness, weakness, trouble walking, vision changes, and other symptoms) Neurogenic bladder (occurs when nerve damage disrupts the communication between your brain, spinal cord, and bladder muscle), and UTI (Urinary Tract Infection). Review of Resident 1's Quarterly Minimum Data Set (MDS- periodic assessment of resident needs) assessment dated [DATE] revealed the resident had a Basic Interview for Cognitive Status score of 15 indicating the resident had no cognitive impairment. Review of Resident 1's active care plan revealed Resident had an altered elimination r/t (related to) suprapubic catheter (flexible tube inserted through the lower abdomen directly into the bladder to drain urine). The interventions include assessing/recording signs of UTI (pain, burning, blood-tinged urine, cloudiness, change in behavior), catheter output every shift, recording output amount every shift, and as needed. Interview was conducted with Resident 1 on June 22, 2026, at 11:00 a.m. The resident, who was alert and oriented, revealed they had a catheter for a while now and had previous episodes of UTI. The Resident reported starting to have pain in their private area on Saturday (May 23, 2026) and reported to their nurse. The resident revealed they knew they were experiencing a UTI. Resident 1 further revealed feeling so sick they could not remember what happened for the next few days. Review of Resident 1's nursing progress notes from a Licensed Practical nurse Employee E4 dated May 24, 2026, (10:33 a.m.), revealed Resident c/o (complained of) difficulty urinating/pain at cath (catheter) site, states has a UTI. [resident] Thinks hasn't had a BM (bowel movement), and that's what may be blocking [resident]'s urine. Nsg sup (nursing supervisor) made aware and handling concerns. Review of Resident 1's clinical record failed to reveal documentation indicating Resident 1's physician was notified of the resident's complaint of pain at the catheter site on the morning of May 24, 2026. Review of Resident 1's progress notes failed to reveal documentation of the resident expressing pain in their private area. Phone interview conducted with Resident 1's wife on June 22, 2026, (11:30 a.m.) revealed spouse called Resident 1 on May 24, 2026 (Sunday) by phone but was informed Resident 1 could not talk because resident was tired, not feeling well, and just wanted to sleep. Call from the nurse practitioner was received on May 25, 2026, around 9:00 a.m., and informed spouse of the resident not feeling well, but vitals were normal, orders (lab studies, etc ) were initiated. The spouse revealed it didn't feel right, so she decided to come to the facility to visit the resident. She got another call from the NP (Nurse Practitioner) while on the way to the facility and told them she was five minutes away. The wife reported that upon arrival, she observed the resident lying in bed, gurgling in the mouth, and not responding to her. She pressed the call bell and heard licensed nurse Employee E3 approaching and said, I don't know who pressed the call bell, probably [they] recovered. The wife informed Employee E3 that she pressed the call bell and demanded Resident 1 be sent to the hospital immediately. 911 was called, and the resident was sent to the hospital. Interview with Registered Nursing Employee E3 conducted on June 22, 2026, at 12:00 p.m., revealed Employee E3 was not notified of Resident 1's change in condition the morning of May 25, 2026. Employee E3 reported assessing the resident and observed the resident with a decline, change in mental status, and not talking to me. Employee E3 confirmed he/she did not check the resident's vitals, and the information reported to the NP was from Licensed Practical Nursing Employee E4. Interview with Licensed Practical Nurse, Employee E4 conducted on June 22, 2026, at 12:30 p.m. revealed Employee E4 reported the LPN (Licensed Practical Nurse) informs the Supervisor/RN's (Registered Nurses) of a resident's change in condition, and they are the ones who call the physician. Employee E4 confirmed reporting Resident 1's change in condition to Registered Nurse Employee E3 on May 24, 2026. Continued interview with Licensed Practical Nurse (LPN) Employee E4 conducted on June 22, 2026, approximately 12:30 p.m., revealed the resident's vitals provided to Registered Nursing Employee E3 were the same vitals they documented on the nursing progress notes on May 25, 2026. Employee E4 further revealed I cringed when I read [Employee E3] notes indicating the resident's vitals were within normal limits because it wasn't. The Blood pressure of 154/90 and heart rate of 111 were abnormal. Phone interview with Nurse Practitioner (NP) Employee E5 was conducted on June 22, 2026, at 12:45 p.m. The NP confirmed their office did not receive a call from the facility the morning of May 24, 2026, regarding resident 1's complaint of pain at the catheter site. When asked what they would have done if they were notified, the NP responded, I would have ordered to start IV (Intravenous - administered through veins) fluids and an antibiotic, [resident] gets septic quickly. Continued phone interview conducted with Nurse Practitioner (NP), Employee E5, June 22, 2026, revealed as per documentation from the on-call NP on May 25, 2026, a call was received from the facility at 8:44 a.m., indicating Resident 1 was lethargic resulting in an order for IV fluids, antibiotic (Cipro), and lab work. The NP further revealed another call was received from the facility at 10:49 a.m., reporting the resident opens eyes but was not themselves. The vitals reported to the NP by the nurse were HR- 76, B/P 128/74, R- 16, T-98.1, and Spo2 96%, which were all within normal range. The NP revealed a 3-way call with the facility and the wife was made to give an update on the resident's condition. At 1:30 p.m. on May 25, 2026, the office received another call from the facility indicating Resident 1 was sent to the hospital at 12:30 p.m., as requested by the wife. The NP revealed that based on the on-call NP's documentation on May 25, 2026, the on-call NP was not informed that the resident was clammy, pale, drooling, non-verbal, and with a HR of 111 as documented by Employee E4 on the morning of May 25, 2026. The NP further revealed they would have sent Resident 1 to the hospital immediately if they were provided with an accurate assessment. The NP further stated, Assessment (of the resident) was presented differently to us. Review of Resident 1's clinical record failed to reveal documentation indicating Resident 1's vital signs or urine output were monitored May 24, 2026, on the 3-11 (p.m.) and 11 p.m.-7 a.m. shifts. Review of Resident 1's nursing progress notes dated May 25, 2026 (6:28 a.m.), revealed: continue to c/o discomfort, pt (patient) in a stable condition, verbalize I think I have UTI, MD (physician) to be made aware. Review of Resident 1's nursing progress notes authored by Licensed Practical Nurse, Employee E4 dated May 25, 2026, (10:48 a.m.), revealed Resident was lethargic, drooling thick mucus, clearish [clear] pale yellow in color. Attempted to wake the resident up and open their eyes and touch their shoulder. [Resident] was not able to verbalize anything. The resident was clammy and pale in color. The resident has MS and has weakness, but the weakness on the L (left) side appears to be more than usual. No medications administered. Nsg. Sup, made aware and assessed. Nsg. Sup. to follow as Nsg. Sup had received orders from [physician company]. Continued review of same progress note revealed, CNA (Certified Nursing Assistant) reported resident's condition to the nurse at 8:30 a.m. Vitals: HR (heart rate) 111 (normal range 60-100 bpm), R (respirations)- 16, 95% Spo2 in room air, B/P (blood pressure)- 154/90, T (temperature) - 97.8. Review of Resident 1's nursing progress notes authored by Registered Nursing Employee E3 dated May 25, 2026, (12:18 p.m.), revealed Assessed resident this a.m., and found to be arousable but not responsive. [Resident] vital signs were wnl (within normal limit) and were afebrile (no fever). Abdomen distended and hard, tried to irrigate the Foley, but it was blocked, so a new suprapubic catheter was inserted, returning 1000 of blood-tinged urine. The resident did become more comfortable, but still not responsive. [Provider's company] called and ordered an IV, but a site could not be found. [Provider's company] contacted again and stated wife is in transition to the facility, and she will make a determination for future orders. Wife arrived and stated that she wanted resident sent to [hospital], wife followed. Review of Resident 1's hospital records including Discharge Summary dated May 31, 2026, revealed resident was admitted to the hospital on [DATE], with diagnosis of Acute Respiratory Failure with Hypoxia (condition when lungs fail to adequately oxygenate the blood and remove carbon dioxide), Septic shock (severe and dangerous stage of sepsis, occurring when an infection triggers a systemic immune overreaction), Acute Kidney Injury and UTI. Further review of the same report revealed On arrival, [patient] was found to be profoundly hypoxic (state of inadequate oxygen reaching the body's tissues and cells to support normal functions) and Encephalopathic (condition that causes brain dysfunctions), requiring intubation and mechanical ventilation. [Patient] was managed in the ICU with full ventilatory support. Interview with the Director of Nursing (DON) conducted on June 22, 2026, at 1:30 p.m. The DON denied that only the RN/supervisor can call the physician for a resident's change in condition. The above findings were conveyed to the DON and NHA (Nursing Home Administrator) on June 22, 2026, at 1:45 p.m. The facility failed to ensure Resident 1's change in condition was timely and accurately communicated with the physician resulting in actual harm when Resident 1 was admitted to the hospital to ICU on a ventilator with a diagnosis of septic shock and UTI. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing service 28 Pa Code 211.5(f) Clinical Records 28 PA Code 211.10(a) Resident care policies

Based on a clinical records review, interview with staff and Nurse Practitioner (NP), it was determined that the facility failed to practice professional standards of nursing by performing a procedure without a physician's order for one of two residents reviewed (Resident 1). Findings: A review of Resident 1's diagnosis list includes Multiple Sclerosis (a disease that causes breakdown of the protective covering of nerves, causing numbness, weakness, trouble walking, vision changes, and other symptoms), Neurogenic bladder (Occurs when nerve damage disrupts the communication between your brain, spinal cord, and bladder muscle), and UTI (Urinary Tract Infection). A review of Resident 1's active care plan revealed Resident had an altered elimination r/t (related to) suprapubic catheter (A flexible tube inserted through the lower abdomen directly into the bladder to drain urine). A review of Resident 1's nursing progress notes dated May 24, 2026, at 10:33 a.m., revealed Resident c/o (complained of) difficulty urinating/pain at Cath (catheter) site, states [resident] has a UTI. Thinks [resident] hasn't had a BM (bowel movement), and that's what may be blocking [resident]'s urine. Nsg sup (nursing supervisor) made aware and handling concerns. A review of Resident 1's nursing progress notes dated May 25, 2026, at 12:18 p.m., revealed Assessed resident this a.m., and found to be arousable but not responsive. [Resident] vital signs were wnl (within normal limits) and were afebrile (no fever). Abdomen distended and hard, tried irrigating the Foley, but it was blocked, so a new suprapubic catheter was inserted, returning 1000 of blood-tinged urine. A review of Resident 1's physician order revealed that there was no order to replace Resident 1's suprapubic catheter. A phone interview with the NP, Employee E5, conducted on June 22, 2026, at 12:45 p.m., confirmed that there was no order to replace Resident 1's suprapubic catheter on May 25, 2026. An interview with the DON on June 22, 2026, at 12:45 p.m., confirmed that there were no written orders to change Resident 1's suprapubic catheter on May 25, 2026. The facility failed to practice professional standards of nursing by changing Resident 1's suprapubic catheter without a physician's order. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing service

Based on clinical records review and staff interviews, it was determined that the facility failed to provide consistent monitoring of the resident's urine output and perform a procedure with a physician's order for one of the two residents reviewed (Resident 1). Findings: A review of Resident 1's diagnosis list includes Multiple Sclerosis (a disease that causes breakdown of the protective covering of nerves, causing numbness, weakness, trouble walking, vision changes, and other symptoms), Neurogenic bladder (Occurs when nerve damage disrupts the communication between your brain, spinal cord, and bladder muscle), and UTI (Urinary Tract Infection). A review of Resident 1's active care plan revealed Resident had an altered elimination r/t (related to) suprapubic catheter (A flexible tube inserted through the lower abdomen directly into the bladder to drain urine). The interventions include assessing/recording signs of UTI (pain, burning, blood-tinged urine, cloudiness, change in behavior), Catheter output every shift, recording output amount every shift, and as needed. A review of Resident 1's nursing progress notes dated May 24, 2026, at 10:33 a.m., revealed Resident c/o (complained of) difficulty urinating/pain at Cath (catheter) site, states [resident] has a UTI. Thinks [resident] hasn't had a BM (bowel movement), and that's what may be blocking [resident ]'s urine. Nsg sup (nursing supervisor) made aware and handling concerns. A review of Urine output monitoring records provided by the Director of Nursing (DON) revealed that residents had 450 ml of urine on May 24, 2026, at 1:20 p.m. There was no urine output documented on May 24, 2026, at the 3-11 and 11-7 shift. A review of Resident 1's nursing progress notes dated May 25, 2026, at 12:18 p.m., revealed Assessed resident this a.m., and found to be arousable but not responsive. [Resident] vital signs were wnl (within normal limits) and were afebrile (no fever). Abdomen distended and hard, tried irrigating foley but it was blocked, so a new suprapubic catheter was inserted, returning 1000 of blood-tinged urine. A review of Resident 1's physician order revealed that there was no order to replace Resident 1's suprapubic catheter on May 25, 2026. An interview with the DON on June 22, 2026, at 12:45 p.m., confirmed that there were no written orders to change Resident 1's suprapubic catheter on May 25, 2026. The facility failed to ensure Resident 1's urine output was monitored, and a procedure to replace the resident's suprapubic catheter was done with a physician's order. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing service 28 Pa Code 211.5(f) Clinical Records

Based on observations and staff interview, it was determined that the facility failed to ensure that food stored in the walk-in fridge and freezer were properly stored to prevent contamination and ensure safe storage in accordance with professional standards for food service safety in the main kitchen. Findings include: Observations in the walk-in freezer in the kitchen on April 27, 2026, at 9:30 a.m., in the presence of the Dietary Manager Employee E5 revealed the following: one bag of frozen biscuits inside an open plastic bag placed within an open cardboard box, frozen diced carrots inside an opened plastic bag placed within an open cardboard box. Observations on April 28, 2026, at 1:30 p.m., in the presence of Employee E5 revealed the following: frozen spinach inside an opened plastic bag placed within a cardboard box and frozen hamburger patties inside an opened plastic bag placed within a cardboard box. Interview with Employee E5 on April 30, 2026, at 1:00 p.m., confirmed that the above-mentioned foods observed on April 27, 2026, and April 28, 2026, were not properly stored. The above findings were conveyed with the Nursing Home Administrator (NHA) on April 30, 2026, at 1:40 p.m. The facility failed to ensure that food stored in the walk-in freezer in the main kitchen was properly stored to prevent contamination and ensure safe storage in accordance with professional standards for food service safety. 28 Pa. Code 211.6(f) Dietary services.

Based on observations, clinical records review and staff interviews, it was determined that the facility failed to ensure care plans were updated for appropriate wheelchair positioning for one of eight residents reviewed (Resident 9).Findings revealed:A review of Resident 9's quarterly Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated August 7, 2025, revealed resident had a diagnosis of Alzheimer's' Disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), Seizure disorders (A chronic neurological condition characterized by recurrent seizures caused by abnormal electrical activity in the brain), and Contracture-knee (A permanent, stiffening of muscles, tendons, ligaments or skin, causing restriction in joint movement). The same MDS revealed that residents' cognition was severely impaired and dependent on all ADL's (activities of daily living).A review of Resident 9's progress notes dated September 17, 2025, at 11:01 a.m., revealed Resident observe laying on the floor in the common living room area. Resident was laying prone in front of (their) wheelchair when staff observed (them). Resident was assessed for injury, noted with hematoma (Localized collection of clotted blood outside blood vessel) to R (right) frontal area of forehead, abrasion noted on the area with minimal bleeding, pressure dressing applied.An observation conducted on April 29, 2026, at 9:45 a.m., revealed Resident 9 was lying in bed with eyes closed, both legs and arms were flexed. Further observations revealed licensed Employee E6 approached and spoke to the resident, raised the head of the bed and administered the resident's medications. The resident did not move during the entire observation. A high back chair reclined at 45 degrees with a footrest and board was observed in the resident's room.An interview conducted with Employee E6 on April 29, 2026, at 9:50 a.m., revealed that they were the residents' full-time nurses. Employee E6 reported Resident 9 was unable to reposition self but had jerking movements episodes. Employee E6 reported that they assessed Resident 9 after the fall on September 17, 2026. Employee E6 confirmed that the high back chair in the resident's room was the same chair in use when they fell. Employee E6 further stated It's reclined now (pointing at the chair in the room) but it was straight up during the fall because they just finish eating. Employee 6 further stated I don't remember the footrest being there.A review of Resident 9's Rehabilitation Services Screening dated May 5, 2025, revealed Recommend semi-reclining wheelchair for OOB (out of bed) slightly reclined high back and position trunk in midline for comfort. Feet may rest on leg rest calf pads due to reduced knee extension ROM (range of motion).A review of Resident 9's active care plan revealed rehab recommendations for appropriate wheelchair positioning were not added into the residents' plan of care.An interview with the Director of Nursing on April 30, 2026, at 11:00 a.m., confirmed that rehab recommendations for appropriate wheelchair positioning were not reflected in the resident's care plan.The facility failed to ensure Resident 9 care plan was revised to reflect appropriate wheelchair positioning. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on clinical records review, and staff interview, it was determined that the facility failed to ensure physicians were notified and an intervention was put in place for a significant weight loss for two of two residents reviewed (Resident 27 and 83).Findings:Review of Resident 27's diagnosis includes Dysphagia, oropharyngeal phase (Trouble starting a swallow because the mouth and throat muscles aren't working smoothly, making it hard to move food or liquid from the mouth into the throat) and Type 2 Diabetes (DM- failure of the body to effectively use insulin produced in the body, insulin regulates blood sure to pass from blood stream to cells).A review of Resident 27's clinical records weight and vitals revealed, December 5, 2025, Resident 27 weighed 151.9 pounds and on January 1, 2026, the resident weighed 140.9 pounds a 7.2% weight loss in 27 days. There were no documented evidence indicating that the physician was notified of the significant weight loss and that an intervention was put in place after the significant weight loss was identified until March 7, 2026, Boost Breeze supplementation will increase from BID to TID to support caloric and protein needs. Resident remains at high nutrition risk due to chronic illness, cognitive impairment, and ongoing weight loss.An interview with the Registered Dietician Employee E3 conducted on April 30, 2026, at 1:30 p.m., Employee E3 reported that nursing is responsible for taking Residents weight. Any identified significant weight loss is to be reported to the Registered Dietician by Nursing. Employee E3 confirmed that they were not notified of the residents' significant weight loss on January 1, 2026. There was no documented evidence that Residents physician was notified of the significant weight loss identified on January 1,2026.Review of Resident 83's diagnosis includes Dysphagia, oropharyngeal phase (Trouble starting a swallow because the mouth and throat muscles aren't working smoothly, making it hard to move food or liquid from the mouth into the throat). A review of Resident 83's clinical records weight and vitals revealed, that on February 28, 2026, Resident 83 was readmitted to the facility, and staff used her hospital weight of 88 pounds. On March 2, 2026, the resident weighed 79.5 pounds, reflecting a 9.7% weight loss in 3 days. Clinical record review revealed that weight was not taken upon readmission and was completed 3 days later. There was no documented evidence indicating that the Physician was notified of the significant weight loss identified March 2, 2026.A review of Resident 83 nutritional monitoring completed by the Registered Dietician on March 7, 2026, identified the resident's weight loss on March 2, 2026. The same notes revealed Resident remains at nutritional risk due to variable oral intake, recent weight fluctuations, and acute medical status following trauma-related injuries and fractures. Weight trends demonstrate a decline from 88 lbs (02/28/2026) to 79.5 lbs (03/02/2026), with historical weights consistently reflecting an underweight BMI (Body Mass Index) status. Oral intake continues to fluctuate from poor to fair across meals, with slightly better intake noted later in the day. Resident remains on a pureed diet (All your food is blended until it's completely smooth like the texture of applesauce, mashed potatoes, or yogurt. No chunks, no seeds, nothing to chew) with thin liquids following recent speech therapy advancement. Nutritional supplements are ordered (Boost BID and Magic Cup daily) to support caloric intake. The same notes revealed that Resident at high nutrition risk due to severe underweight and inadequate intake. Nutrition diagnosis: Severe malnutrition related to poor oral intake as evidenced by BMI 13.35 and <25% meal intake. Plan: Continue pureed diet with assistance, initiate oral nutrition supplement Boost 8 oz BID and Magic Cup daily, encourage fluids, monitor weekly weights. A review of Resident 83's March 2026, Medication Administration Records revealed that the Boost BID and the Majic Cup ordered on October 5, 2025, was discontinued on March 7, 2026.An interview with the Registered Dietician Employee E3 on April 30, 2026, at 1:30 p.m., confirmed that the Boost BID and Majic cup was discontinued due to Resident 83's refusal. A review of residents Medication Administration Record March 2026 revealed that the Majic cup was not administered on March 2, 2026, March 4, 2026, and March 5, 2026, at 8:00 a.m., due to drug/item unavailable. Further Medical Administration Record revealed that Boost 8ox BID was not administered on March 2, 2026, March 4, 2026, March 5, 2026, and March 7, 2026, at 8 a.m. due to drug item/ unavailable. On March 1, 2026, March 2, 2026, March 3, 2026 and March 4, 2026, March 5, 2026, March 6, 2026, and March 7, 2026, the resident at 4:00 p.m. consumed (March 1,2026, 25%, March 2, 2026, 25%, March 3, 2026, 100%, March 4, 2026, 50%, March 5, 2026, 25%, and March 6, 2026, 25% at 4 p.m.)An interview with Employee E3 conducted on April 30, 2026, at 1:30 p.m., confirmed that resident 27 and 83's physician was not notified of the significant weight loss and that the interventions were not put in place. The facility failed to ensure the physician was notified of Resident 27 and 83's significant weight loss and further interventions were put in place to prevent further weight loss timely.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based upon clinical record review and interview, it was determined the facility failed to ensure residents' physician was notified regarding a resident and failed to ensure residents' physician was notified of a significant weight loss for two of two residents reviewed (Resident 72 and Resident 104). Findings include: Review of Resident 72's clinical progress notes dated July 27, 2024, at approximately 5:45 a.m. revealed Resident 72 suffered a fall out of bed and was found laying on the floor on resident's right side. Further review of Resident 72's clinical progress notes revealed Resident 72 complained of pain upon leg movement. After assessment by facility staff, Resident 72 was returned to bed. Review of clinical documentation failed to reveal evidence that Resident 72''s physician or nurse practitioner were notified of the fall that occurred at 5:45 a.m. Further review of Resident 72's progress notes dated July 27, 2024, at 7:20 a.m. revealed Resident 72 was unable to bear weight and continued to complain of pain in the left lower extremity. Resident 72's nurse practitioner was then notified of the fall that had occurred at 5:45 a.m. and an x-ray was ordered at that time. Review of Resident 72's x-ray report dated July 27, 2024, revealed Resident 72 sustained a fracture of the left femoral (large bone in leg) neck and was subsequently transferred to an acute care facility. Interview with the Director of Nursing on March 7, 2025, at 10:00 a.m. confirmed Resident 72's physician was not notified at the time of Resdient 72's fall with injury. 28 Pa. Code 211.12(d)(1)(2)(3) Nursing Services Previously cited 4/5/2024

Based on clinical record reviews, interviews with staff and residents, it was determined that the facility failed to conduct an accurate comprehensive assessment for one of 32 residents reviewed. (Resident 51) Findings include: Clinical record review revealed a quarterly assessment MDS (a minimum data set, which was part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes) dated January 1, 2025, that indicated Resident 51 obtained a stage 2 pressure ulcer (a shallow, open sore or an intact or ruptured blister, with a red or pink wound bed caused by prolonged exposure to pressure) while residing in the facility. Further review of Resident 51's MDS revealed a Brief Interview for Mental Status (BIMS) score of 15. Review of Resident 51's clinical records revealed wound care notes dated February 18, 2025, documenting the resident had a skin tear (a traumatic wound that occurs when the top layer of skin separates from the deeper layers) on his/her inner thigh that was being treated with Medihoney (a typical first aide and wound care product) and dressing. Review of Resident 51's clinical records revealed wound care notes dated February 25, 2025, documenting the resident had a skin tear on inner thigh with treatment changed to skin prep. Further review of Resident 51's clinical records revealed wound care notes dated March 4, 2025, documenting the resident had a skin tear on inner thigh that was improving. Review of Resident 51's clinical records revealed that the resident did not have orders for treatment of a stage 2 pressure ulcer. Review of Resident 51's clinical records revealed a care plan last revised on November 15, 2024, documenting the resident is at risk for skin injury related to immobility, paraplegia (paralysis to lower half of body), a history of stage 4 wounds, and a history of tendon release surgery (procedure used to treat muscular skeleton conditions). Interview of Resident 51 on March 5, 2025, at 9:37 am revealed they currently did not have a pressure ulcer. Resident 51 was unable to state the last time he/she had a pressure ulcer. Interview with Register Nurse Employee E4 on March 6, 2025, at 11:58 AM revealed the resident did not have a stage 2 pressure ulcer at the time of the MDS assessment and the resident only had a skin tear. Interview with the MDS Coordinator, Employee E5 on March 6, 2025, at 2:05 p.m., confirmed a data entry error was made on Resident 51's MDS and the resident did not have a facility acquired pressure ulcer at the time of its completion on January 1, 2025. 28 Pa Code 211.12 (d)(1) Nursing services

Based on observations, clinical record review, and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of two residents reviewed regarding oxygen use. (Resident R6) Findings include: Resident R6's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of acute on chronic systolic heart failure (long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), chronic obstructive pulmonary disease, unspecified (a progressive lung disease that makes it difficult to breathe due to obstruction of airflow). Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) upon admission, revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated that the resident was cognitively intact. On March 4, 2025, Resident R6 was observed in their room using supplementary oxygen. Review of Resident R6's clinical records revealed the following order administer oxygen via nasal cannula continuously at 2 liters/minute. A review of the current care plan, dated January 21, 2025, found no evidence of a comprehensive, person-centered plan of care addressing oxygen interventions. During an interview on March 7, 2025, at 11:23 a.m., the Director of Nursing (DON), confirmed that Resident R6 had an active order for continuous oxygen and acknowledged that no comprehensive care plan had been developed to address oxygen interventions. 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)(3)(5) Nursing services

Based on closed clinical record review and interviews with staff, it was determined the facility failed to ensure discharge instructions included all necessary information, including a recapitulation of stay, resident status, medication reconciliation, living arrangements, follow-up care and individualized care instructions, for a one of three closed records reviewed (Resident 111). Findings include: Clinical record review for Resident 111 revealed a Nursing Progress Note, dated December 16, 2024, at 5:19 a.m. which indicated that the resident was admitted to [NAME] County Hospital. Admitting diagnosis was unknown at the time. The hospital nurse was unable to disclose information due to resident request. No further information was noted concerning Resident 111's hospital discharge. Continued review of Resident R111's clinical records revealed no discharge summary documenting the resident's personal belongings were returned, their primary physician information, pharmacy information, housing arrangements, medication list, medication education, medication disposition, disease management education, emergency information, brief medical history, current treatment and therapies, scheduled appointments and tests or contact information for the nursing facility. There was no indication that the information was provided to the resident or his/her family. Interview conducted with Director of Nursing (DON) on March 7, 2025, at 10:05 a.m. when the above information was presented the DON stated the resident had no personal belonging to return or medications to be reconciled and confirmed that no additional discharge instruction information was available for review at the time of the survey for Resident R111. 28 Pa Code 201.25 Discharge policy 28 Pa Code 211.11(e) Resident care plan

Based upon clinical record review and interview, it was determined the facility failed to ensure a fluid restriction, ordered by resident's physician, was monitored for one of one resident reviewed (Resident 99). Findings include: Review of Resident 99's diagnosis list revealed diagnoses including congestive heart failure (CHF - excessive body/lung fluid caused by a weakened heart muscle) and dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability). Review of Resident 99's clincal record revealed the resident was admitted to the facility on [DATE] with an order for a 2-liter (2L) a day fluid restriction. Review of Resident 99's clinical record failed to reveal evidence that nursing was monitoring Resident 99's daily 2L fluid restriction. Interview with the Director of Nursing on March 7, 2025, at 9:35 a.m. confirmed that nursing was not monitoring Resident 99's 2L fluid restriction as ordered by the physician. This interview further revealed that, per the Director of Nursing, upon review Resident 99 should not have been on a fluid restriction from admission and the fluid restriction was removed on March 7, 2025. 28 Pa. Code 211.12(d)(1)(2)(3) Nursing Services Previously cited 4/5/2024

Based upon clinical record review and interview, it was determined the facility failed to ensure adequate monitoring of a resident with a significant weight loss (Resident 104). Findings include: Review of Resident 104's diagnosis list revealed diagnoses including protein-calorie malnutrition and adult failure to thrive. Review of Resident 104's weight summary revealed the resident weighed 136.6 pounds on December 8, 2024, and weighed 128.4 pounds on December 22, 2024, indicating a 6 percent weight loss in 14 days. Review of Resident 104's clinical record failed to reveal evidence that Resident 104's physician was not notified of Resident 104's significant weight loss. Review of clinical documentation revealed no re-weight was obtained to ensure accuracy of the weight loss. Interview with Licensed Employee E3 on March 7, 2025, at 9:38 a.m. revealed a re-weight should have been obtained to ensure accuracy of the weight loss. Further interview with Licensed Employee E3 on March 7, 2025 confirmed that Resident 104's physician was not notified of the weight loss and the loss was not address. 28 Pa. Code 211.12(d)(1)(2)(3) Nursing services Previously cited 4/5/2024

Based upon observations, clinical record review and staff interviews, it was determined that the facility failed to ensure fluid restrictions were followed for one of one dialysis resident reviewed. (Resident 16). Findings include: Review of Resident 16's clinical record revealed diagnoses including but not limited to end stage renal disease (ESRD- failure of kidney function to remove toxins from blood) and dementia (general loss of cognitive abilities, including memory). Review of Resident physician's orders revealed an order for daily fluid restriction of 1500 ml daily as follows: Nursing to give 7-3 shift 240 ml; 3-11 shift 660 ml; 11-7 shift 120 ml; dietary daily 480 ml. Review of Resident 16's Fluid Task sheet revealed Resident 16 exceeded the daily fluid restriction allotment as follows: February 11, 2025 - 420 ml; February 14, 2025- 420 ml; February 15, 2025- 540 ml; February 17, 2025 - 300 ml; March 1, 2025 - 780 ml; March 2, 2025 - 420 ml; March 5,2025-180ml; March 6, 2025-300ml. Interview with Director of Nursing on March 7, 2025, at approximately 12:25pm confirmed the above findings. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based upon clinical record review, it was determined the facility failed to monitor for effectiveness or side effects of anti-depressant medication for one of five residents reviewed (Resident 93). Findings include: Review of Resident 93's diagnosis list revealed diagnoses including psychotic disorder with hallucinations, Parkinson's disease (progressive disease of the central nervous system characterized by tremors, muscle weakness and unsteady gait), persistent mood disorder and dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability.) Review of Resident 93's physician orders revealed order and order dated December 21, 2024, for Lexapro (anti-depressant medication) 10 milligrams (mg) to be administered daily for behaviors and an order dated January 7, 2025, for Wellbutrin (anti-depressant medication) 150 mg to be administered daily. Review of Resident 93's active care plan revealed attempts were to be made for non-pharmaceutical interventions and to monitor Resident 93's mood and behavior while receiving Lexapro and Wellbutrin. Review of Resident 93's clinical record including Resident 93's Medication Administration Record (MAR) failed to reveal evidence that Lexapro and Wellbutrin were being monitored for effectiveness, i.e. reduction in behaviors. Further review of Resident 93's clinical record failed to reveal evidence that Resident 93 was being monitored for side effects of Wellbutrin or Lexapro. Interview with the Director of Nursing on March 7, 2025, at 11:07 a.m. confirmed that no monitoring for effectiveness was completed during Resident 93's use of Wellbutrin or Lexapro. This interview further confirmed that no monitoring for side effects was completed for the use of Lexapro and Wellbutrin. 28 Pa. Code 211.12(d)(1)(2)(3) Nursing services

Based on observation, it was determined that the facility failed to provide privacy and confidentiality of residents ' personal information on two of four nursing units (South and East). Findings include: Observation on the East unit on April 2, 2024, at approximately 10:00 a.m. revealed the computer on the medication cart was left unattended with Resident 85's physician orders displayed. Several residents and other staff were noted nearby the medication cart. Observation on the South unit on April 3, 2024, at approximately 8:00 a.m. revealed the computer on the medication cart was left unattended with Resident 59's physician orders displayed. Several residents and other staff were noted nearby the medication cart. Observation on the East unit on April 5, 2024, at approximately 8:30 a.m. revealed the computer on the medication cart was left unattended with Resident 29's physician orders displayed. Several residents and other staff were noted nearby the medication cart. Interview with the Director of Nursing on April 5, 2024, at 10:20 a.m. confirmed the above findings. 28 Pa. Code: 201.18 (e)(1) Management 28 Pa. Code: 201.29 (j) Resident rights 28 Pa. Code: 211.5 (f) Clinical records

Based upon clinical record review, it was determined the facility failed to complete discharge summary on the day of planned discharge for one of three residents reviewed (Resident 109). Findings include: Review of Resident 109's clinical record revealed Resident 109 was admitted to the facility on [DATE], and was discharged to home on March 23, 2024. Review of Resident 109's clinical record failed to reveal a discharge summary completed on March 23, 2024, the day of a planned discharge. The above information was conveyed to the Nursing Home Administrator on April 5, 2024, at 11:00 a.m. 28 Pa. Code 211.5(f) Clinical Records

Based on a comprehensive review of clinical records, observations, and interviews with residents and staff, it was determined that the facility failed to consistently implement and maintain infection control practices, thereby risking the potential spread of infection for one resident requiring contact precautions (a method to prevent the transmission of infectious agents spread by direct or indirect contact with the patient or the patient's environment) out of 32 residents sampled (Resident 90). Findings include: Review of the facility's policy Transmission-Based Precautions and Isolation Policy with a revision date of March 3, 2024, states that Contact precautions also apply where the presence of excessive wound drainage, urine, or fecal incontinence, or other discharges from the body suggest an increased potential for environmental contamination and risk of transmission. Personal Protective Equipment (PPE) recommended includes gloves and gowns. Review of the CONTACT PRECAUTIONS sign reveals instructions for all personnel to clean their hands before entering and leaving the room, and for providers and staff to don gloves and gowns before room entry and discard them before room exit. A review of Resident 90's clinical medical record revealed a progress note dated March 28, 2024 at 1:01 p.m. stating Resident 90's urinary analysis (UA) came back positive for Extended Spectrum Beta-Lactamase e-coli (ESBL, are enzymes produced by certain bacteria, including Escherichia coli that make bacteria resistant to certain antibiotic medicines) (Escherichia-coli, is a group of bacteria that can cause infections in one's gut, urinary tract and other parts of your body). During a tour of nursing unit East on April 2, 2024, at 10:31 a.m., it was observed that the PPE station, including gloves, gowns, and face shields, was available, but the contact precaution sign was placed face down on top of the container outside Resident 90's room. Additional observations conducted on nursing unit East on April 2, 2024, at 10:33 a.m. revealed three nursing staff performing incontinence care (helping an individual with any type of urinary or bowel leakage to maintain their health, and wellbeing) on Resident 90 with only gloves on. Observations conducted on April 3, 2024, at 9:36 a.m., witnessed a nursing staff exiting Resident 90's room holding soiled bed linens without wearing a gown. Additional observations of Resident 90's room on April 3, 2024, at 9:39 a.m. observed two nursing staff entering Resident 90's room without washing their hands or dawning PPE. At 9:35 a.m. licensed practical nurse (LPN) licensed employee (E4) exited Resident 90's room without washing her hands. Interview conducted with licensed employee E4 on April 3, 2024, at 9:35 a.m. revealed E4 was unaware resident 90 was on contact precautions or that Resident 90's UA returned positive for ESBL E-coli. Interview conducted with Infection Preventionist (IP) licensed employee (E3) on April 3, 2024, at 1:18 p.m. confirmed Resident 90 is on contact precaution and that all staff need adhere to the facility's transmission-based precautions and isolation policy. The above information was confirmed by licensed employee E3 on April 3, 2024, at 1:24 p.m. 28 Pa. Code 211.10 (a)(d) Resident care policies 28 Pa. Code 211.12 (c)(d)(1)(2)(5) Nursing Services.

Based on clinical record review and interview it was determined that the facility failed to ensure that a resident was free from neglect by not providing the two person assistance needed during incontinence care which resulted in actual harm of a left foot fracture for one of two residents reviewed (Resident R2). This was identified as a past non compliance situation. Findings include: Review of Resident R2's clinical record revealed diagnoses including but not limited to the following: Abnormalities of Gait; Muscle Weakness; Obesity (excessive amount of body fat); and Osteoarthritis (common form of arthritis, affects the joints, causing pain, stiffness and reduced movement). Review of Resident R2's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated October 19, 2022 revealed in Section G (Functional Status) subsection A. Bed Mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) was rated 3/3; indicating resident needed extensive assistance of two or more staff/persons for physical assist. Review of Resident R2's Kardex (document used to indicate how individual resident care should be performed) revealed under category of Mobility; Transfer with two assist and hoyer lift. Review of Resident R2's care plans revealed a goal of Risk for Self Care deficient r/t [related to] immobility. The care plan included intervention of Assist of 2 with ADL [Activities of Daily Living]. Staff assist of 2 for mobility, upper and lower body ADLs, toileting/incontinence care, bath/showers. Further review of Resident R2's care plans revealed a focus goal of Resident fall/at risk for falls characterized by impaired mobility, hx [history] of anxiety with moving around, obesity, and decline in health. Additional review of this focus goal revealed an intervention of re-educate and reinforce adherence to 2 person assist for bed mobility initiated December 13, 2022. Review of Resident R2's clinical record revealed an Incident Note dated December 13, 2022 (22:21 AKA 10:21 p.m.) which revealed, Called in by CNA [certified nurse assistant] to assess resident post fall. Upon arrival to room, resident observed on floor on [his/her] stomach, AAOx3, verbal, c/o feeling dizzy, unable to roll over to sides and c/o headache and B/L knee pain. Resident noted with a laceration to the leftside of head and also to the right Forearm. VS- 207/127, 91. Resident had a witnessed fall and did hit her head on the dresser at the time of fall. On call CRNP (Certified Registered Nurse Practitioner) called and made aware of clinical situation, new order received to transfer resident to the ER (emergency room ) for further evaluation. 911 called, team arrived, and resident transferred at 10pm to [local] Emergency. Further review of Resident R2's clinical record revealed a Head to Toe Evaluation Progress note dated December 13, 2022 (23:31 aka 11:31 p.m.) indicating, Resident had a witnessed fall and did hit her head on the dresser at the time of fall. Upon arrival to room, resident observed on floor on her stomach, verbally responsive, c/o feeling dizzy, unable to roll over to sides and c/o [complaint/of] headache and B/L [bilateral] knee pain. Resident noted with a laceration to the left-side of head and also to the right Forearm. The same progress note further revealed, Evidence of pain noted pain to head Pain is throbbing Pain level is 7 out of 10. The pain is constant. Additional review of Resident R2's clinical record revealed a Nursing progress note dated December 14, 2022 at 06:54 (a.m.) which indicated, (RN) from [hospital emergency department] called back to report that resident does have a left foot fracture and got a splint and need to follow up with orthopedics. Review of X-ray results dated December 14, 2022 (00:52:19 a.m.) revealed under category of Impressions a subcategory of history indicating fell out of bed. Further review under subcategory Findings revealed Acute nondisplaced intra-articular fracture proximal end first metatarsal. Review of facility documents of fall investigation including Witness Statement, Incident/Accident or Injury of Unknown Origin by non licensed Employee E3 revealed telephone interview statement of I was doing my last rounds. I had cleaned [resident] all up, I had her all cleaned up, I was on the other side of the bed and I was getting ready to roll her back, it seems like she was moving too fast, she had started rocking and I started to head towards the other side of the bed and when I rounded toward the foot of the bed she fell . Further review of witness statement revealed after asked question, are you aware that [he/she's] a two person with bed mobility? Employee E3 responded, I have always had two people in there with me and yes, I am aware that [he/she]'s a two person. Additional review of witness statement/telephone interview document revealed Employee E3 was questioned of When you went in the room to check on [him/her] who did you ask to come in with you? with Employee E3 responding, I didn't ask anybody. Interview on February 24, 2023 at approximately 8:00 p.m. with Interim Director of Nursing, confirmed the resident was a two person assist needed for bed mobility and nurse aide provided incontinence care alone instead of using second aide. The facility failed to ensure the incontinence care for Resident R2 was conducted with two staff members which resulted in neglect and actual harm of a fracture to the left foot. The facility submitted a corrective action plan that included a full house sweep to determine any other residents affected by deficient practice including interviews with residents and observations of staff's incontinence care. Care plans were reviewed for accuracy of incontinence care needs. Each nurse and aide received education regarding following care plans for assistance needed during care. Random audits were completed to ensure incontinence care was completed safely and appropriately. Interviews conducted with licensed staff member Employee E2, Employee E4, non licensed staff member Employee E5, and Employee E6 revealed understanding of abuse/neglect definitions as well as safety/supervision during incontinence care and following Kardex and/or care plan regarding bed mobility needs of residents. Review of facility documentation showed that the corrective action had been fully implemented and completed by February 8, 2023. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 483.25 Free of Accidents/Hazards/Supervision Previously cited 04/19/22 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 06/03/22 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited 6/03/22 28 Pa. Code 211.12(c) Nursing services Previously cited 6/03/22; 4/19/22 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 4/19/22 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 6/03/22; 4/19/22

Based on clinical record review and interview it was determined that the facility failed to ensure Resident R2 was free from accidents and hazards and appropriately supervised during incontinence care which resulted in the actual harm of a left foot fracture for one of two residents reviewed. This was identified as a past non compliance situation. Findings include: Review of Resident R2's clinical record revealed diagnoses including but not limited to the following: Abnormalities of Gait; Muscle Weakness; Obesity (excessive amount of body fat); and Osteoarthritis (common form of arthritis, affects the joints, causing pain, stiffness and reduced movement). Review of Resident R2's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated October 19, 2022 revealed in Section G (Functional Status) subsection A. Bed Mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) was rated 3/3; indicating resident needed extensive assistance of two or more staff/persons for physical assist. Review of Resident R2's Kardex (document used to indicate how individual resident care should be performed) revealed under category of Mobility; Transfer with two assist and hoyer lift. Review of Resident R2's care plans revealed a goal of Risk for Self Care deficient r/t [related to] immobility. The care plan included intervention of Assist of 2 with ADL [Activities of Daily Living]. Staff assist of 2 for mobility, upper and lower body ADLs, toileting/incontinence care, bath/showers. Further review of Resident R2's care plans revealed a focus goal of Resident fall/at risk for falls characterized by impaired mobility, hx [history] of anxiety with moving around, obesity, and decline in health. Additional review of this focus goal revealed an intervention of re-educate and reinforce adherence to 2person assist for bed mobility initiated December 13, 2022. Review of Resident R2's clinical record revealed an Incident Note dated December 13, 2022 (22:21 AKA 10:21 p.m.) which revealed, Called in by CNA [certified nurse assistant] to assess resident post fall. Upon arrival to room, resident observed on floor on [his/her] stomach, AAOx3, verbal, c/o feeling dizzy, unable to roll over to sides and c/o headache and B/L knee pain. Resident noted with a laceration to the leftside of head and also to the right Forearm. VS- 207/127, 91. Resident had a witnessed fall and did hit her head on the dresser at the time of fall. On call CRNP (Certified Registered Nurse Practitioner) called and made aware of clinical situation, new order received to transfer resident to the ER (emergency room ) for further evaluation. 911 called, team arrived, and resident transferred at 10pm to [local] Emergency. Further review of Resident R2's clinical record revealed a Head to Toe Evaluation Progress note dated December 13, 2022 (23:31 aka 11:31 p.m.) indicating, Resident had a witnessed fall and did hit her head on the dresser at the time of fall. Upon arrival to room, resident observed on floor on her stomach, verbally responsive, c/o feeling dizzy, unable to roll over to sides and c/o [complaint/of] headache and B/L [bilateral] knee pain. Resident noted with a laceration to the left-side of head and also to the right Forearm. The same progress note further revealed, Evidence of pain noted pain to head Pain is throbbing Pain level is 7 out of 10. The pain is constant. Additional review of Resident R2's clinical record revealed a Nursing progress note dated December 14, 2022 at 06:54 (a.m.) which indicated, (RN) from [hospital emergency department] called back to report that resident does have a left foot fracture and got a splint and need to follow up with orthopedics. Review of x-ray results dated December 14, 2022 (00:52:19 a.m.) revealed under category of Impressions a subcategory of history indicating fell out of bed. Further review under subcategory Findings revealed Acute nondisplaced intra-articular fracture proximal end first metatarsal. Review of facility documents of fall investigation including Witness Statement, Incident/Accident or Injury of Unknown Origin by non licensed Employee E3 revealed telephone interview statement of I was doing my last rounds. I had cleaned [resident] all up, I had her all cleaned up, I was on the other side of the bed and I was getting ready to roll her back, it seems like she was moving too fast, she had started rocking and I started to head towards the other side of the bed and when I rounded toward the foot of the bed she fell . Further review of witness statement revealed after asked question, are you aware that [he/she's a two person with bed mobility? Employee E3 responded, I have always had two people in there with me and yes, I am aware that [he/she]'s a two person. Additional review of witness statement/telephone interview document revealed Employee E3 was questioned of When you went in the room to check on [him/her] who did you ask to come in with you? with Employee E3 responding, I didn't ask anybody. Interview on February 24, 2023 at approximately 8:00 p.m. with Interim Director of Nursing, confirmed the resident was a two person assist needed for bed mobility and nurse aide provided incontinence care alone instead of using second aide. The facility failed to ensure Resident R2 was free from accidents and supervised during care which resulted in actual harm of fracture to foot. The facility submitted a corrective action plan that included a full house sweep to determine any other residents affected by deficient practice including interviews with residents and observations of staff's incontinence care. Care plans were reviewed for accuracy of incontinence care needs. Each nurse and aide received education regarding following care plans for assistance needed during care. Random audits were completed to ensure incontinence care was completed safely and appropriately. Interviews conducted with licensed staff member Employee E2, Employee E4, non licensed staff member Employee E5, and Employee E6 revealed understanding of abuse/neglect definitions as well as safety/supervision during incontinence care and following Kardex and/or care plan regarding bed mobility needs of residents. Review of facility documentation showed that the corrective action had been fully implemented and completed by February 8, 2023. 483.25 Free of Accidents/Hazards/Supervision Previously cited 04/19/22 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 06/03/22 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited 6/03/22 28 Pa. Code 211.12(c) Nursing services Previously cited 6/03/22; 4/19/22 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 4/19/22 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 6/03/22; 4/19/22

Based on observations, resident and staff interviews, it was determined that the facility failed to treat residents in a dignified manner for five out of 32 residents interviewed (Residents 4, 7, 26, 39, and two others who wish to remain anonymous). Findings include: Review of facility policy titled Resident smoking policy, revision date of 01/10/2022; revealed the facility is a smoke free facility. Further review revealed following items G). For residents who desire [to smoke], the facility will assist residents with smoking cessation efforts. H) Failure to adhere to the provisions outlined in this smoking protocol will result in progressive restrictions . and risk of discharge if resident imposes on safety of other residents. Additional interventions that may occur to ensure safety of others, (i.e , room searches, 1:1 observation as needed, behavior contracts, and 15- and 30-minute checks as needed). Review of Resident 26 clinical record revealed a quarterly assessment Minimal Data Set (resident care assessment and screening) dated November 25, 2021, indicating a short-term memory loss. Additional review of Resident 26's clinical record revealed an quarterly MDS assessment dated [DATE], revealed the resident scored a 13 out of 15 on the BIMS (cognition evaluation) which represents a minor cognitive deficit. Further review of the clinical record revealed a Social Work note dated December 19, 2021, stating the resident was seen outside smoking. The Social Worker spoke to the resident about smoking and stated he was doing it out of boredom. At this time, he was offered a nicotine patch which he declined, and the smoking materials were taken and locked. Additional review of Resident 26's clinical record revealed a smoking assessment completed by the facility on March 20, 2022, indicating the resident does not smoke and the assessment is complete. On April 14, 2022, a nursing note states that the resident was seen by another resident that he was smoking outside. Resident 26 denied smoking at this time. Nursing made aware that a room search may be done if observed smoking and reminded him that the facility is smoke free. A room search was conducted, and smoking materials were removed. On April 20, 2022, an incident report was made by a staff member stating that Resident 26 was seen smoking outside the facility during the 7-3 shift and was reminded that this was a smoke-free facility. A behavior contract was signed by the facility and Resident 26 stating he agreed not to smoke in the facility. An interview with Resident 26 was conducted on May 31, 2022, at 11:30 a.m. Resident stated he feels like he is a prisoner here. The facility doesn't let him smoke or go outside. The resident continued to say he is being harassed and followed by the staff to make sure he doesn't smoke. When asked if they have provided him with any other source of nicotine (i.e., gum, patches, etc) the resident said no, that they are just trying to kick me out. Review of Resident 26's care plan reveals a focus for smoking outside of the facility, but interventions do not state to offer smoking cessation. An interview with the Nursing Home Administrator and Director of Nursing on June 3, 2022, at 1:00 p.m. revealed that they did not offer smoking cessation to the resident since December and could not provide further documentation stating such. A group interview was conducted with seven alert and oriented residents on June 1, 2022, revealed three out of seven residents stated that they wish they could go outside when they wanted. Residents stated that the administration has changed the code to the courtyard and removed the benches from the front of the building and won't give anyone the code to the courtyard. An interview with two residents (who wish not to be identified) in the lounge area next to the courtyard stated that they could not go outside and did not know the code. An interview with Licensed Employee E5 on June 1, 2022, at 11:12 a.m. revealed that they did not know the code to the courtyard, and she would have to get the Maintenance man to give it to me. A second interview with Employee E6 on June 1, 2022, at 11:14 a.m. revealed that they did not know the code to the courtyard, but she could ask the nursing staff. A third interview with Employee E7 on June 1, 2022, at 11:30 a.m. revealed that they did not know the code to the courtyard and didn't know who knows it. A fourth interview with Licensed Nurse Employee E4 on June 1, 2022, at 11:45 a.m. revealed that they did not know the code to the courtyard and did not know who knew the code. An interview with the receptionist at the front desk on June 1, 2022, at 11:45 a.m. revealed that if a resident goes out front, they must by accompanied by staff or family. An interview with the Nursing Home Administrator and Director of Nursing on June 3, 2022, at 1:15 p.m. confirmed the above interviews. 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.29(j) Resident's rights

Intakes: PA 238, PA 236 Based on observation, facility policy review, and staff interviews, it was determined that the facility failed to ensure the hot beverage policy included parameters identifying safe beverage temperatures for hot liquids resulting in actual harm to one resident who sustained [CONDITION(S)] on the right thigh/hip. This resulted in an Immediate Jeopardy, past non-compliance situation when it was determined that the policy failed to identify hot beverage temperature parameters which had the potential to cause the residents discomfort or pain, to jeopardize the health and safety of 25 residents of 108 total skilled nursing residents. Findings Include: Review of facility policy titled, Hot Beverage Service with a revision date of October 22, 2018, revealed policy does not include safe hot beverage temperature range for resident safety. Further review of the facility policy revealed bullet point number 6 indicating Staff will monitor hot beverage temperatures periodically at the point of service and make adjustments as needed. The policy fails to identify guidelines for safe adjustments. Review of clinical record of Resident R1 revealed that resident was admitted on [DATE], with diagnoses including but not limited to the following: [CONDITION(S)] (chronic condition in which the heart doesn't pump blood as well as it should), Anxiety Disorder (intense, excessive and persistent worry and fear about everyday situations), [CONDITION(S)] (irregular heartbeat), and [CONDITION(S)] (progressive nervous system disorder that affects movement). Progress note dated April 6, 2022, at 3:34 p.m. by the physician revealed, Pt [patient] seen and examined. Sustained burn to RIGHT hip this morning while drinking her hot cocoa. New order from provider for [MEDICATION(S)] Cream 1%, Apply to RIGHT hip topically every day and evening shift for burn for 7 Days. Further review of the progress note dated April 6, 2022, at 3:34 p.m. by the physician revealed reddened skin to right hip extending towards R [right] inguinal area approximately 10 cm [centimeters] in diameter, moderate sized fluid filled blister centrally. Monitor closely, notify if not healing or for s/s [signs/symptoms] infection. Review of facility provided investigation documentation revealed Activities Aide, Employee E3's written statement indicating, I was visiting room to room with beverage cart. I asked [resident] if she would like coffee, tea or hot cocoa this morning. [Resident] requested hot cocoa. I made her hot cocoa. [Resident] was sitting in her reclining chair. I had her sit all the way up before handing her the cup of hot cocoa. As I left the room, wishing her a good day, she was sitting upright while taking a sip of her drink. Further review of facility provided investigation documentation revealed Nurse Aide, Employee E7's written statement indicating, I heard a scream, went to room, resident was sitting in chair with empty cup, says she spilled hot chocolate. I called the nurse. Additional review of facility provided investigation documentation revealed licensed staff, Employee E5's written statement indicating, Nurse was at medication cart, staff approached this nurse and reported that resident spilled hot cocoa on self. Nurse went to assess resident, resident in bathroom and nurse observed redden area on RLQ [right, lower, quadrant] abdominal, right upper thigh and right posterior buttocks. Interview on April 19, 2022, at approximately 9:30 a.m. with Activities Aide, Employee E3, revealed that hot beverages have temperatures taken by dietary staff prior to being served to residents. Employee E3 stated she picks up the beverage cart outside of dining room door, coffee is premade, and she receives hot water to make tea or hot cocoa as residents' request. Review of the Food Temperature Record for April 9, 2022, revealed a temperature of 173 degrees for the hot beverage at dinner. Further review of the temperature log did not reveal a recommended temperature range for hot beverages. Interview on April 19, 2022, at approximately 1:30 p.m. with Dietary Manager, Employee E9, revealed there was no temperatures recorded for hot beverages served during activity service of coffee time but only recorded at mealtimes. There was no evidence that the facility could identify when temperatures of hot beverages exceed a safe temperature for consumption during non-mealtime consumption. An Immediate Jeopardy situation was identified on April 19, 2022, at 4:30 p.m. and the Immediate Jeopardy template was presented to the Nursing Home Administrator, the Director of Nursing, and the Executive Director at 4:40 p.m. on April 19, 2022, regarding the facility's failure to ensure the prevention of [CONDITION(S)] sustained by one resident and placing additional residents at risk of serious [CONDITION(S)] due lack of policy and practice identifying unsafe beverage temperatures during meal service and activities. The facility identified the jeopardy at the time of incident, April 6, 2022. The facility submitted and completed an immediate action plan on April 12, 2022, which included completing resident hot liquid safety assessments for all current residents and audits of hot liquids on each skilled nursing unit. The facility staff were educated on an updated hot beverage policy which indicated that hot beverages should have a temperature of 135-155 degrees Fahrenheit to be deemed safe for service. The staff are directed to wait for the hot beverage to cool and retake the temperature to ensure it's below 155 degrees before servicing resident. Education and competencies were given to staff regarding identification of and procedure to remedy unsafe beverage temperatures prior to the start of their work shift. The Registered Dietician or designee will continue auditing temperature logs weekly x 4 then monthly x 2 to ensure that hot beverages served during activities and/or meal times will be recorded and not leave the kitchen above 155. The results of the audits will be forwarded to the facility QAPI (Quality Assurance and Performance Improvement) committee for further review and recommendations. Audits were performed daily starting April 13, 2022. Education was provided by the Nursing Home Administrator, the Director of Nursing, and the RN Supervisor regarding the safe beverage temperature range of 135-155 degrees Fahrenheit and the procedure if unsafe beverage temperatures were identified. The action plan was accepted on April 19, 2022, at 8:36 p.m. On April 19, 2022, a review of audits, documentation of completed employee education, and interviews with 30 staff members revealed the facility had completed the interventions developed for the action plan on April 12, 2022. The Immediate Jeopardy was lifted on April 19, 2022, at 8:49 p.m. after confirmation that the action plan was implemented and completed. The Nursing Home Administrator and the Director of Nursing were informed the residents were no longer in immediate jeopardy, past non compliance. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.18(e)(3) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on a review of the facility's policy, facility documentation review, clinical record review, resident and staff interviews, it was determined that the facility failed to ensure that one of eight residents reviewed (Resident #1) was free of neglect during care which resulted in actual harm by sustaining a right distal femoral (the area of the leg just above the knee joint space) fracture due to a fall from the bed. Findings include: A review of the facility's policy titled, Abuse, Neglect, and Exploitation, with a revision date of May 2019, revealed that neglect is the failure of the facility, its employees, or service providers, to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or mental illness. A review of Resident #1's clinical record revealed that the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's Quarterly Minimum Data Set (MDS- an assessment tool used to facilitate the management of care) dated January 14, 2021, revealed that the resident was cognitively intact. The same MDS also revealed that the resident required extensive two-person physical assistance in bed mobility, transferring, dressing, and toileting. Further review of Resident #1's MDS, revealed that the resident's vision was impaired indicating that the resident was able to see large print, but not regular print in newspaper/books. A review of Resident #1's current care plan developed on July 9, 2019, revealed an intervention for at-risk for self-care deficit for the assistance of two (people) with ADL's (activities of daily living). A review of the facility's progress note dated March 21, 2021, at 10:25 a.m. revealed that Resident #1 was observed seated on the floor. The resident slid out of the bed during, bed change. It was a witnessed fall from the staff, the resident did not hit her/his head. The physician assessed the resident in-house and ordered for the resident to transfer to the hospital due to pain with movement and outward rotation of the right leg. A review of the hospital records dated March 22, 2021, revealed that Resident #1 presented to the emergency department (ED) [March 21, 2021], after the fall. The hospital record stated that The patient was at a nursing home and is essentially bed-bound, during nursing assisted role, she felt a bad landing (fell from bed to the floor) on her right side. Complaint of right leg pain. ED work-up demonstrated distal femur fracture. The patient was subsequently admitted to the hospital, evaluated by an orthopedic (a physician who specializes in musculoskeletal system) surgeon, and the case was determined to be nonsurgical in nature. The patient was medically stable for discharge to the nursing facility, a knee immobilizer was placed. A review of the facility physician's progress notes dated March 23, 2021, at 2:33 p.m. revealed that the resident's fracture is non-surgical in nature as per the evaluation in the hospital. The resident had an order of [MEDICATION(S)] five milligrams every four hours (a narcotic used to treat severe pain), and [MEDICATION(S)] 50 mg every six hours as needed for pain (a medication to treat moderate pain). The resident was ordered non-weight bearing for six to eight weeks, immobilizer to right lower extremity at all times. A review of the facility's documentation, incident report, Nurse Aide, Employee E3's, written statement completed on March 21, 2021, revealed, I was changing the resident when she/he slid off the bed. On March 22, 2021, Employee E3's completed another statement, Employee E3 wrote, To my knowledge, she/he is a one-person assist. The statement also indicated that Resident #1 must have misjudged where the end of the bed was, and while kicking her leg over, the resident fell off the bed before Employee E3 could tell her/him to stop. An interview with Resident #1 on April 7, 2021, at 12:25 p.m. revealed that on the day of the fall (March 21, 2021), Nursing Assistant (NA) Employee E3 was changing her/his bed because it was wet. Employee E3 pulled the sheet while standing at the left side of the bed. Resident R#1 stated that she informed the employee a few times that she/he will fall, and the resident fell from the right side of the bed to the floor. Resident #1 stated that Employee E3, was not her/his regular aide. An interview with NA Employee E5 on April 8, 2021, at 10:00 a.m. revealed that she/he worked on the morning of March 21, 2021. Employee E5 stated that she was not asked by Employee E3 to help with Resident #1's care. An interview with licensed nurse Employee E4 on April 7, 2021, at 12:30 p.m. revealed that she/he was aware of the resident's care plan of two-person assist with ADL's. Employee E4 stated that the resident was able to roll from side to side, but the resident tended to roll too far off the edge of the bed, but unable to see due to [CONDITION(S)]. Employee E4 also stated that the resident was on a bariatric bed during the fall incident. An interview with Resident #1 on April 7, 2021, at 12:42 p.m. revealed that she/he was not able to see anything from her/his right eye, and was only able to see shapes out of her/his left eye. The resident stated that she's unable to see the edge/side of her/his bed. A review of documentation submitted by the facility dated March 21, 2021, revealed that the facility initiated an investigation, regarding resident neglect on March 21, 2021. The investigation was completed on March 23, 2021, and the facility determined that Employee E3 did not review the resident's care Kardex (care guide) prior to providing care. The resident's care Kardex indicated that the resident required two people to assist with ADL's. The investigation concluded that Employee E3 did not follow the care Kardex to support providing safe care to the resident. An interview with nurses' aides Employee E5 on April 8, 2021, at 10:00 a.m. Employee E6 at 1:00 p.m. and Employee E7 at 1:30 p.m. was conducted. All three NA's interviewed were able to show knowledge on how to check for the resident's care needs in the care Kardex. An interview with the Director of Nursing (DON) on April 8, 2021, at 3:00 p.m. confirmed that Employee E3 did not review Resident #1's care Kardex before providing care indicating that Resident #1 required 2 people to assist with ADL's. The facility failed to ensure that Resident #1 was free from neglect resulting in actual harm by sustaining a right distal femur fracture from a fall from the bed. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 8/1/19 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited 3/6/20, 8/1/19 28 Pa. Code 210.18(b)(3)(e)(1) Management Previously cited 8/1/19 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 3/5/21, 8/1/19

Based on observation, clinical records review, facility documentation review, staff, and resident interview, it was determined that the facility failed to provide the assistance indicated on the resident's plan of care in regard to their ADL's (Activities of Daily Living) which resulted in actual harm of sustaining a right distal femoral fracture (the area of the leg just above the knee joint) from a fall for one of 8 residents reviewed (Resident #1). Findings include: A review of Resident #1's diagnosis list revealed diagnoses of [CONDITION(S)] (CHF- excessive body/lung fluid caused by a weekend heart muscle), obesity (a disorder involving excessive body fat that increases the risk of health problems), muscle weakness, and anxiety disorder (a group of mental disorders characterized by significant feelings of anxiety and fear). A review of Resident #1's Quarterly Minimum Data Set (MDS- an assessment tool used to facilitate the management of care) dated January 14, 2021, revealed that the resident was cognitively intact. The same MDS also revealed that the resident required extensive two-person physical assist in bed mobility, transferring, dressing, and toileting. Further review of Resident #1's MDS revealed that the resident's vision was impaired indicating that the resident was able to see large print, but not regular print in newspaper/books. A review of Resident #1's current care plan for at-risk self-care deficit, immobility revealed an intervention developed on July 9, 2019, for the assist of two (people) with ADL's Activities of Daily Living). A review of the nursing progress note dated March 21, 2021, at 10:25 a.m. revealed that Resident #1 was observed seated on the floor. The resident slid out of bed during, bed change. The staff witnessed the fall, the resident did not hit her/his head. A small abrasion was noted on the right arm with a scant amount of blood. The physician was notified and assessed the resident. The resident had pain with movement and outward rotation of the right leg. The resident was transferred to the hospital via 911. A review of the hospital records dated March 22, 2021, revealed that the resident had a fracture (a break of the bone) of the right distal femur. The hospital records also revealed that the resident was admitted to the hospital and evaluated by orthopedic surgery (a branch of surgery concerned with conditions involving the musculoskeletal system), the case was determined to be nonsurgical in nature. The patient was placed in a knee immobilizer and is medically stable for discharge to the nursing facility. A review of the facility physician's progress notes dated March 23, 2021, at 2:33 p.m. revealed that the resident was evaluated by the orthopedic surgeon in the hospital and determined that the fracture is non-surgical in nature. The physician ordered [MEDICATION(S)] five milligrams every four hours (a narcotic used to treat severe pain), and [MEDICATION(S)] 50 mg every six hours as needed for pain (a medication to treat moderate pain). Non-weight-bearing for six to eight weeks, immobilizer to right lower extremity at all times. A review of the facility documentation, Employee E3's written statement completed on March 21, 2021, revealed, I was changing the resident when she/he slid off the bed. A review of Employee E3's written statement completed on March 22, 2021, revealed that the employee went to change the resident. Employee E3 wrote, To my knowledge, she/he is a one-person assist. The statement also indicated that Resident #1 must have misjudged where the end of the bed was, and while kicking her leg over, the resident fell off the bed before Employee E3 could tell her/him to stop. An observation on April 7, 2021, at 12:25 p.m. was conducted and revealed Resident #1 laying on a bariatric bed (a bed that is reinforced to support a higher weight capacity than a traditional bed). An interview with Resident #1 on April 7, 2021, at 12:25 p.m. was conducted. The surveyor asked Resident #1 to relay what happened on the morning of March 21, 2021. The resident stated that Employee E3 was changing the sheet of the bed while she/he was on the bed. Employee E3 was standing on the left side of the bed while pulling the sheet. Resident #1 stated, I keep telling her/him that I will fall, then I fell on the floor (right side of the bed). Resident #1 stated that Employee E3 was not her/his regular aide. An interview with licensed nurse Employee E4 on April 7, 2021, at 12:30 p.m. revealed that she/he was aware of the resident's care plan of two-person assist with ADL's. Employee E4 stated that the resident was able to roll from side to side, but the resident tended to roll too far off the edge of the bed, but unable to see due to [CONDITION(S)]. Employee E4 stated that the resident was on a bariatric bed during the fall. An interview with Resident #1 on April 7, 2021, at 12:42 p.m. revealed that she/he was not able to see anything from her/his right eye and was only able to see shapes out of her/his left eye. The resident stated that she's unable to see the edge/side of her/his bed. A review of the facility's documentation, the incident investigation completed on March 25, 2021, revealed that Employee E3 did not review the resident's care Kardex (a care guide) prior to caring for the resident. The resident's care Kardex indicated that the resident required two people to assist with ADL's. An interview with nurses' aides Employee E5 on April 8, 2021, at 10:00 a.m., Employee E6 at 1:00 p.m., and Employee E7 at 1:30 p.m., was conducted. All three NA's interviewed were able to show knowledge on how to check for the resident's care needs in the care Kardex. An interview with the Director of Nursing (DON) on April 8, 2021, at 3:00 p.m. confirmed that Employee E3 did not review Resident #1's care Kardex before providing care indicating that Resident R#1 required two people to assist with ADL's. The facility failed to follow Resident #1's plan of care which indicated that the resident required two people to assist with ADL's resulting in a fall and sustaining a right distal femoral fracture. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 8/1/19 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited 3/6/20, 8/1/19 28 Pa. Code 210.18(b)(3)(e)(1) Management Previously cited 8/1/19 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 3/5/21, 8/1/19

Based on the review of position descriptions and staff interview, it was determined that the Nursing Home Administrator failed to follow the facility's evacuation plan and to ensure the health and safety of the residents. Findings include: The position description for the Administrator indicated that the Administrator was to lead and direct the overall operations of the nursing facility in accordance with Saber Health Care policies and procedures, customer and resident needs, and both state and federal guidelines. Deficiencies cited in this report revealed that the Nursing Home Administrator failed to ensure the health and safety of the residents. Cross Refer to F518. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 5/8/2012. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. Previously cited 6/13/2013, 9/19/2012, 5/8/2012. 28 Pa. Code 209.7(a) Disaster preparedness.