Every finding on record at Twinbrook Healthcare and Rehabilitation Center

Based on observations, review of clinical records, and resident and staff interviews, it was determined that the facility failed to ensure that resident call bells were within reach for seven of 18 residents reviewed (Residents R1, R12, R13, R14, R15, R16, R17, and R18).Findings include:The facility could not provide a policy regarding residents' access to call bells.Observations 8/12/26, between 10:18 a.m. and 10:30 a.m. revealed the following: Resident R18 sitting upright in bed and his/her call bell lying across the nightstand and out of reach; Resident R13 sitting upright in bed and his/her call bell lying on the floor behind the bed and out of reach; Resident R1 sitting upright in bed and his/her call bell lying on the floor next to the bed and out of reach; Resident R14 sitting in his/her wheelchair next to the bed with his/her tray table positioned in front of him/her and his/her call bell lying on the opposite side of the bed over the nightstand; Resident R15 sitting in his/her wheelchair at the foot of the bed and his/her tray table positioned in front of him/her and his/her call bell lying across the bed and out of reach.During an interview at that time, Licensed Practical Nurse (LPN) Employee E1 confirmed that Residents R1, R13, R14, R15, and R18 were unable to reach their call bells.Observations on 8/12/26, between 10:36 a.m. and 10:43 a.m. revealed the following: Resident R16 lying in bed and his/her call bell was lying over the nightstand and out of reach; Resident R12 was sitting upright in bed, and his/her call bell was draped over the call light system and out of reach Resident R17 was sitting upright in bed, and his/her call bell was lying on the floor between the two beds.During an interview at that time, LPN Employee E2 confirmed that Residents R12, R16, and R17 were unable to reach their call bells.28 Pa. Code 201.18(b)(1)(3) Management28 Pa. Code 211.10(a)(c) Resident care policies28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on review of facility policy and documentation, and resident interviews, it was determined that the facility failed to treat each resident with respect and dignity in a homelike environment that promotes maintenance or enhancement of his or her quality of life for seven of 18 residents sampled (Residents R2, R4-R9). Findings include:A Facility Policy entitled Homelike Environment dated 2/09/26, indicated that staff would provide person-centered care that emphasizes the residents' comfort and personal needs and preferences, and maintain comfortable sound levels.Review of three months of grievances revealed that on 5/11/26, it was reported that the Nurse Aids have been arguing with the resident and treating him/her poorly. On 7/28/26, it was reported that staff was treating the resident like a baby, was rough, opened that bathroom door to yell at the resident, and makes faces at the resident. On 7/31/26, it was reported that staff stood in the doorway of the resident's room and listened to a private phone conversation and also voiced recommended interjections to the resident during the phone call.Review of three months of Resident Council minutes 6/24/26, revealed when residents receive an undesired meal, floor staff are not reaching out to the kitchen to obtain an alternate option for the residents.Interviews between 10:15 a.m. and 12:00 p.m. with Residents R2 and R4-R9 confirmed that they hear staff yell and argue up and down the hallways, that they hear staff using offensive language, engaging in inappropriate conversations with each other, and swearing.28 Pa. Code 201.14 (a) Responsibility of licensee28 Pa. Code 201.18 (b)(3) Management28 Pa. Code 201.29 (a) Resident rights28 Pa. Code 211.12 (d)(1)(5) Nursing Services

Based on review of clinical records, and resident and staff interviews it was determined that the facility failed to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, include regular re-evaluation of resident's to identify changes that require modification of the discharge plan, update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities for two of 18 residents reviewed (Residents R2 and R3).Findings include:The facility could not provide a policy regarding discharge planning for residents.Resident R2's clinical record revealed an admission date of 1/06/26, with diagnoses including kidney disease, high blood pressure, adult failure to thrive (complex syndrome of gradual physical, functional, and mental decline), and migraine (complex neurological condition that causes recurring, moderate-to-severe throbbing head pain, usually on one side). The clinical record lacked evidence of a discharge plan/assessment.Resident R2's departmental progress note dated 4/15/26, revealed that a referral was made to another skilled nursing facility and that Resident R2 would be placed on a waiting list. The clinical record lacked additional documentation for facility follow-up to this referral.Resident R2's care plan entitled Discharge Planning dated 1/07/26, included one intervention to evaluate care needs and potential for discharge, and lacked evidence of being updated with referral information.Resident R3's clinical record revealed an admission date of 1/06/26, with diagnoses including chronic obstructive pulmonary disease (lung disease that blocks airflow in and out of the lungs), obstructive and reflux uropathy (combines a block in the urinary tract with urine flowing backward toward the kidneys), and agoraphobia with panic disorder (intense fear of having a sudden panic attack in public places or situations where escape feels hard).Resident R3's departmental progress note dated 4/15/26, revealed that a referral was made to another skilled nursing facility and that Resident R2 would be placed on a waiting list. The clinical record lacked additional documentation for facility follow-up to this referral.Resident R3's care plan entitled Discharge Planning dated 1/07/26, included one intervention to evaluate care needs and potential for discharge, and lacked evidence of being updated with referral information.During an interview on 8/12/26, at 1:35 p.m. the Social Worker confirmed that Resident R2 and Resident R3's clinical records/care plans lacked evidence of updates from referrals since 4/15/26, and that there was no discharge plan in their clinical records.28 Pa. Code 201.14 (a) Responsibility of licensee28 Pa. Code 201.18 (b)(2)(3) Management28 Pa. Code 201.29 (a) Resident rights28 Pa. Code 211.10(a)(c) Resident care policies

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to ensure that resident's responsible parties and/or families were afforded the opportunity to participate in the care planning process for one of 18 residents reviewed (Resident R1).Findings include:A facility policy entitled 'Resident Participation-Assessment/Care Plans dated 2/02/26, indicated that spouses and other members of the family may participate in the resident assessment and development of the person-centered care plan with the resident's permission; facility staff supports and encourages resident/representatives participation in the care planning process by ensuring that residents, representatives and families understand the care planning process; hold meetings at times when representatives/family members can attend; and providing sufficient notice in advance to the meeting.Resident R1's clinical record revealed an admission date of 7/24/5, with diagnoses including cognitive communication deficit (trouble with communication caused by disrupted thinking skills-such as memory, focus, or planning), anxiety disorder, paranoid schizophrenia (severe paranoia, fixed persecutory delusions, and auditory hallucinations), and bipolar disorder (mental health condition that causes extreme shifts in mood, energy, and activity levels). Resident R1's admission record revealed that his/her son was listed as an emergency contact.Resident R1's Basic Interview for Mental Status (BIMS [short, standardized test used in skilled nursing and long-term care facilities to check basic brain function, attention, and memory]) dated 12/29/25, 3/27/26, and 6/23/26, revealed a score of eight (moderately impaired cognition).Resident R1's Invitation to Care Plan Meeting dated 1/06/26, 4/01/26, and 6/30/26, lacked evidence that Resident R1 declined the participation of his/her son and lacked documentation that Resident R1's son was provided the opportunity to attend the care plan meeting.During an interview on 8/12/26, at 2:43 p.m. the Social Worker confirmed the clinical record lacked evidence of Resident R1's son being afforded the opportunity to participate in the care planning process, and lacked evidence that Resident R1 declined his/her son's participation in the care planning process. 28 Pa. Code 201.14 (a) Responsibility of licensee28 Pa. Code 201.29(a)(c) Resident rights28 Pa. Code 201.18 (b)(2)(3)(d)(e)(1) Management28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12 (d)(1)(3)(5) Nursing Services

Based on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day), and failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for nine of 28 residents reviewed (Residents R5, R7, R8, R15, R17, R84, R94, R105, and R109).Findings include:Review of facility policy entitled Transfer and Discharge dated 2/2/26, indicated For a transfer to another provider, for any reason, the following information must be provided to the receiving provider:Contact information of the practitioner who was responsible for the care of the resident;Resident representative information, including contact information;Advance directive information;All other information necessary to meet the resident's needs, which includes, but may not be limited to:Resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs;Diagnoses and allergies;Medications (including when last received); andMost recent relevant labs, other diagnostic tests and recent immunizations.All special instructions and/or precautions for ongoing care, as appropriate.The resident's comprehensive care plan goals;All other information necessary to meet the resident's needs.Review of Resident R5's clinical record revealed an admission date of 12/19/23, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), chronic congestive heart failure (a condition where the heart cannot supply the body with enough blood), and hypertension (high blood pressure).Review of Resident R5's progress notes revealed notes dated 9/22/25, and 2/4/26, indicating transfers to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. His/her clinical record also lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfers on 9/22/25, and 2/4/26. Resident R7's clinical record revealed an admission date of 8/16/22, with diagnoses that included chronic kidney disease ( a long-term condition in which the kidneys are damaged and gradually lose their ability to function properly over time, gastro-esophageal reflux disease (GERD - a condition where stomach acid flows back into the esophagus (tube that passes food from the mouth into the stomach), and hypertension.Review of Resident R7's progress notes revealed a note dated 4/1/26, indicating a transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. His/her clinical record also lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfer on 4/1/26. Review of Resident R8's clinical record revealed an admission date of 11/16/20, with diagnoses that included dependence of renal dialysis (a treatment that helps remove extra fluid and waste products from the blood when the kidneys are not able to), diabetes (a health condition that is caused by the body's inability to produce enough insulin), and gastro-esophageal reflux disease.Review of Resident R8's progress notes revealed notes dated 11/19/25, and 2/3/26, indicating transfers to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. His/her clinical record also lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfers on 11/19/25, and 2/3/26. Review of Resident R15's clinical record revealed an admission date of 7/7/22, with diagnoses that included chronic obstructive pulmonary disease, gastro esophageal reflux disease, and chronic respiratory failure (a condition where your lungs don't exchange air properly).Review of Resident R15's progress notes revealed a note dated 2/3/26, indicating a transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. His/her clinical record also lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfer on 2/3/26. Review of Resident R17's clinical record revealed an admission date of 2/26/25, with diagnoses that included diabetes, muscle weakness, and toe amputation.Review of Resident R17's progress notes revealed notes dated 10/25/25, indicating a transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. His/her clinical record also lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfer on 10/25/25. Review of Resident R84's clinical record revealed an admission date of 6/28/22, with diagnoses that included dysphagia (difficulty swallowing), muscle weakness, and difficulty walking.Review of Resident R84's progress notes revealed notes dated 9/7/25, indicating a transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. His/her clinical record also lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfer on 9/7/25. Review of Resident R94's clinical record revealed an admission date of 2/17/26, with diagnoses that included gastrointestinal hemorrhage (excessive bleeding in the digestive tract), hypertension, and transient ischemic attack and cerebral infraction (also known as a stroke it occurs when blood flow to part of the brain is blocked).Review of Resident R94's progress notes revealed notes dated 2/24/26, 3/19/26, and 4/13/26, indicating transfers to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. His/her clinical record also lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfers on 2/24/26, 3/19/26, and 4/13/26. Review of Resident R105's clinical record revealed and admission date of 12/16/24, with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), depression, and muscle weakness.Review of Resident R105's progress notes revealed notes dated 3/29/26, and 4/14/26, indicating transfers to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. His/her clinical record also lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfers on 3/29/26, and 4/14/26. Resident R109's clinical record revealed an admission date of 3/23/26, with diagnoses that included cellulitis (bacterial infection affecting deeper layers of the skin), hypertension, and dorsalgia (back pain).Review of Resident R109's progress notes revealed notes dated 3/31/26, indicating a transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. His/her clinical record also lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfer on 3/31/26. During an interview on 4/15/26, at 2:00 p.m. the Director of Nursing (DON) confirmed that Residents R5, R7, R8, R15, R17, R84, R94, R105, and R109's clinical records lacked evidence that the necessary clinical information was provided to the receiving healthcare provider and lacked evidence indicating that he/she and/or his/her representative were provided with a copy of the bed-hold policy upon transfer. The DON also confirmed when the transfers occurred clinical information should have been provided to the receiving healthcare provider and bed hold policy should have been provided to the resident/representative upon transfer. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c.3) (2) Resident rights

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for six of 28 residents reviewed (Residents R1, R10, R55, R56, R94, and R109).Findings include:Review of facility policy entitled Baseline Care Plan dated 2/2/26, revealed The person providing the written summary of the baseline care plan shall:Obtain a signature from the resident/representative to verify that the summary was provided.Make a copy of the summary for the medical record.Resident R1's clinical record revealed an admission date of 12/23/25, with diagnoses that included hemiplegia (a condition where a person is paralyzed and unable to move one side of their body), hypertension (high blood pressure), and diabetes (a health condition that is caused by the body's inability to produce enough insulin)Resident R1's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R1 and/or his/her representative. Resident R10's clinical record revealed an admission date of 2/20/26, with diagnoses that included solitary pulmonary nodule (a small round or oval shaped spot in the lung), pain, and retroperitoneal hematoma (an accumulation of blood behind the abdominal cavity).Resident R10's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R10 and/or his/her representative. Resident R55's clinical record revealed an admission date of 1/6/26, with diagnoses that included chronic kidney disease (a long-term condition in which the kidneys are damaged and gradually lose their ability to function properly over time), low back pain, and hypertension.Resident R55's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R55 and/or his/her representative. Resident R56's clinical record revealed an admission date of 1/6/26, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), Atrial Fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications), and hypertension.Resident R56's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R56 and/or his/her representative. Resident R94's clinical record revealed an admission date of 2/17/26, with diagnoses that included gastrointestinal hemorrhage (excessive bleeding in the digestive tract), hypertension, transient ischemic attack and cerebral infraction (also known as a stroke it occurs when blood flow to part of the brain is blocked).Resident R94's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R94 and/or his/her representative. Resident R109's clinical record revealed an admission date of 3/23/26, with diagnoses that included cellulitis (bacterial infection affecting deeper layers of the skin), hypertension, and dorsalgia (back pain).Resident R109's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R109 and/or his/her representative.During an interview on 4/15/26, at 2:53 p.m. the Assistant Director of Nursing confirmed there was no evidence that a written summary of the baseline care plan and order summary were provided to Residents R1, R10, R55, R56, R94, and R109 and/or their representatives.28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen according to physician's orders and failed to promote cleanliness and help prevent the spread of infection regarding respiratory care equipment for three residents reviewed with respiratory care (Residents R1, R5, and R15).Findings include: Review of facility policy dated 2/2/26, entitled Oxygen Administration indicated Oxygen is administered under orders of a physician. and Clean/rinse O2 concentrator filter weekly. Review of Resident R1's clinical record revealed an admission date of 12/23/25, with diagnoses that included hemiplegia (a condition where a person is paralyzed and unable to move one side of their body), hypertension (high blood pressure), and diabetes (a health condition that is caused by the body's inability to produce enough insulin). Review of Resident R1's physician orders revealed orders dated 12/23/25, for oxygen at four L/min (liters/minute) via nasal cannula (a thin tube with two prongs that fit into the resident's nostrils to deliver oxygen) every shift and to clean O2 (oxygen) concentrator filter every night shift on Tuesdays. Review of Resident R1's care plan revealed a care plan for respiratory impairment with an intervention for oxygen as per physician orders. Observations on 4/13/26, at 1:09 p.m. and again at 2:35 p.m. revealed Resident R1 lying in his/her bed with supplemental oxygen in place and the oxygen concentrator liter flow set at three L/min. Further observations of the oxygen concentrator filters to bilateral sides of the oxygen concentrator revealed no filters on the oxygen concentrator where the filters should be located. Review of Resident R5's clinical record revealed an admission date of 12/19/23, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), diabetes, and chronic respiratory failure (a condition where your lungs don't exchange air properly). Review of Resident R5's physician orders revealed orders dated 2/6/26, for oxygen at two L/min every shift and to clean O2 (oxygen) concentrator filter every night shift on Tuesdays. Review of Resident R5's care plan revealed a care plan for respiratory impairment with an intervention for oxygen as per MD (medical doctor) orders. Observations on 4/13/26, at 1:09 p.m. and again at 2:35 p.m. revealed Resident R5 lying in his/her bed with supplemental oxygen in place and the oxygen concentrator liter flow set at three L/min. Observation of the concentrator filters to bilateral sides of the oxygen concentrator revealed a large amount of gray fluffy substance covering bilateral filters. Review of Resident R15's clinical record revealed an admission date of 7/7/22, with diagnoses that included chronic obstructive pulmonary disease, gastro esophageal reflux disease (a condition when stomach acid repeatedly flows back into your throat), and chronic respiratory failure. Review of Resident R15's physician orders revealed orders dated 7/24/25, for oxygen at 4 L/min via nasal cannula every shift and to clean O2 concentrator filter every night shift on Tuesdays. Review of Resident R15's care plan revealed a care plan for respiratory impairment with an intervention to provide O2 maintenance per MD orders. Observations on 4/13/26, at 1:04 p.m. and again at 2:37 p.m. revealed Resident R15 lying in his/her bed with supplemental oxygen in place and the oxygen concentrator liter flow set at 2 L/min. Observation of the concentrator filter to the back of the oxygen concentrator revealed a large amount of gray fluffy substance covering the filter. During an interview on 4/13/26, at 2:40 p.m. Registered Nurse Employee E3 confirmed that Resident R1's oxygen flow rate was set at 3 L/min, Resident R5's oxygen flow rate was set at 3 L/min, Resident R15's oxygen flow rate was set at 2 L/min and they were not in accordance with the physician's orders. He/she also confirmed that Resident R5's oxygen concentrator did not have filters in place, and Resident R1 and R15's oxygen concentrator filters were covered in a gray fluffy substance, and the filters should be clean per physician orders. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, manufacturer's guidelines, observations, and staff interviews, it was determined that the facility failed to ensure that medications were properly dated when opened and failed to ensure an expired medication was discarded in a timely manner in two of three medication carts reviewed (East Two Cart and South Cart). Findings include: Review of a facility policy entitled Medication Administration dated [DATE], revealed that, Check expiration date on package/container. No expired medication will be administered to a resident .Injectable multi-dose vials: 28 days after open date or per manufacturer's guidelines. Manufacturer's guidelines for Fluticasone Propionate and Salmeterol Powder (an inhaler used long-term for individuals with breathing problems), indicated that the use by date is one month after the inhaler is opened. Manufacturer's guidelines for Humalog insulin (a fast-acting insulin used to manage blood sugar levels in people with diabetes), indicated that after opened vials and pre-filled pens should be discarded after 28 days. Manufacturer's guidelines for Lantus insulin (a long-acting insulin used to manage blood sugar levels in people with diabetes), indicated that after opened vials and pre-filled pens should be discarded after 28 days. Observation on [DATE], at 12:52 p.m. of the East Two medication cart revealed an open Fluticasone Propionate and Salmeterol Powder inhaler without an open date, therefore staff were unable to determine the discard date. During an interview at that time, Licensed Practical Nurse (LPN) Employee E1 confirmed that the Fluticasone Propionate and Salmeterol Powder inhaler lacked an open date. Observation on [DATE], at 2:37 p.m. of the South medication cart revealed an open injector pen of Humalog insulin with an open date of [DATE], therefore the medication was expired; and two open injector pens of Lantus insulin without an open date, therefore staff were unable to determine the discard date. During an interview at that time LPN Employee E2 confirmed that the injector pen of Humalog insulin expired and should have been discarded, and that the two injector pens of Lantus insulin lacked an open date. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policies, clinical records, and staff interview, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14-days and failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for two of 28 residents reviewed (Residents R10 and R56).Findings include: A facility policy entitled Medication Management dated 2/2/26, revealed .The facility's medication management supports and promotes.The use of non-pharmacological approaches, unless contraindicated, to minimize the need for medications, permit use of the lowest possible dose, or allow medications to be discontinued. A facility policy entitled Stop Orders For Acute Conditions dated 2/2/26, revealed The following classes of medications will not automatically be refilled after the indicated number of days . PRN psychotropic medications (14 days). Resident R10's clinical record revealed an admission date of 2/20/26, with diagnoses that included solitary pulmonary nodule (a small round or oval shaped spot in the lung), pain, and retroperitoneal hematoma (an accumulation of blood behind the abdominal cavity). Review of Resident R10's clinical record revealed a physician's order dated 2/23/26, identified to administer Lorazepam (anti-anxiety) oral tablet 1 milligram (mg) give 0.5 tablet by mouth every four hours PRN. The order did not have a stop date. The clinical record lacked the required clinical rationale for continued use beyond 14 days. Review of Resident R10's clinical record revealed a physician's order dated 4/4/26, identified to administer Haloperidol (anti-psychotic) oral concentrate a 0.5 ml (milliliters) by mouth every 4 hours PRN. The order did not have a stop date. The clinical record lacked the required clinical rationale for continued use beyond 14 days. Review of Resident R10's February 2026, March 2026, and April 2026 Medication Administration Record (MAR) revealed that the PRN Lorazepam was used on 2/23/26, 2/24/26, 2/25/26, 2/26/26, 3/6/26, 3/8/26, 3/10/26, 3/11/26, 3/12/26, 3/14/26, 3/16/26, 3/17/26, 3/18/26, 3/24/26, and 4/9/26; the as needed Haloperidol was used on 4/4/26. The clinical record lacked evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam for the four administrations in February 2026, for the 10 administrations in March 2026, and for the one administration in April 2026. The clinical record lacked evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Haloperidol for the one administration in April 2026. Resident R56's clinical record revealed an admission date of 1/6/26, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), Atrial Fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications), and high blood pressure. Resident R56's clinical record revealed a physician's order dated 2/13/26, identified to administer Lorazepam 0.5mg by mouth PRN every four hours. The order did not have a stop date. The clinical record lacked the required clinical rationale for continued use beyond 14 days. Review of Resident R56's MAR from 3/1/26 through 4/15/26 , revealed that the PRN Lorazepam was used daily. The clinical record also lacked evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam from 3/1/26 through 4/15/26. During an interview on 4/15/26, at 3:16 p.m. the Director of Nursing confirmed that Resident R10's PRN Lorazepam, Resident R10's PRN Haloperidol, and Resident R56's PRN Lorazepam, lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days and that Resident R10 and that Resident R56's clinical records lacked evidence that non-pharmacological interventions were being attempted prior to administering the PRN Lorazepam and PRN Haloperidol. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to transcribe a physician order for turning and repositioning for one resident reviewed (Resident R5). Findings include: Review of facility policy entitled Consulting Physician/Practitioner Orders dated 2/2/26, indicated For consulting physician/practitioner orders received in writing. the nurse in a timely manner will:Call the attending physician to verify the orderDocument the verification.Follow facility procedure for verbal or telephone orders including: noting the order. and transcribing to medication or treatment administration record. Review of Resident R5's clinical record revealed an admission date of 12/19/23, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), chronic congestive heart failure (a condition where the heart cannot supply the body with enough blood), and hypertension (high blood pressure). Review of Resident R5's care plan for stage three pressure ulcer revealed an intervention for wound clinic referral and follow up as ordered. Review of Resident R5's visit reports from the wound clinic revealed on 2/12/26, he/she returned with an order for turn and reposition every two hours, avoid direct pressure to wound site. Further review of Resident R5's visit reports from the wound clinic on 2/19/26, 2/27/26, 3/5/26, 3/12/26, 3/19/26, 3/26/26, 4/2/26, and 4/9/26, he/she returned with orders for turn and reposition every two hours, avoid direct pressure to wound site - hip to hip at minimum every two hours. Review of Resident R5's clinical record revealed his/her physician orders lacked evidence that turning and repositioning orders were transcribed into his/her physician orders. Observations on 4/14/26, at 8:00 a.m., 10:55 a.m., 12:10 p.m., and 1:30 p.m. revealed Resident R5 was lying in his/her bed on their back. Observations on 4/15/26, at 9:10 a.m., 11:15 a.m., 12:30 p.m. and 2:35 p.m. Resident R5 was lying in his/her bed on their back. During an interview on 4/16/26, at 10:15 a.m. the Director of Nursing (DON) confirmed that the facility failed to transcribe turning and repositioning orders received from the wound clinic on 2/12/26, 2/19/26, 2/27/26, 3/5/26, 3/12/26, 3/19/26, 3/26/26, 4/2/26, and 4/9/26. The DON also confirmed that Resident R5's turning and repositioning orders should have been transcribed into their physician orders. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of the facility documents and clinical records, and resident and staff interview, it was determined that the facility failed to maintain complete and accurate records relating to dialysis (a medical procedure that filters blood when the kidneys are not functioning properly) communication for one of two residents reviewed for dialysis (Resident R8).Findings include: Review of facility policy entitled Hemodialysis dated 2/2/26, indicated Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The facility will communicate with the dialysis facility.any significant weight changes, nutritional concerns, medication administration or withholding of certain medications prior to the dialysis treatment and document. and As appropriate, the administrator, nursing director. should review the facility's dialysis care and services on an ongoing basis including: Communication and coordination between the facility and the dialysis facility. Review of Resident R8's clinical record revealed an admission date of 11/16/20, with diagnoses that include dependence of renal dialysis (a treatment that helps remove extra fluid and waste products from the blood when the kidneys are not able to), Diabetes (a health condition that is caused by the body's inability to produce enough insulin), and gastro-esophageal reflux disease (a condition when stomach acid repeatedly flows back up into your throat). Review of Resident R8's physician orders revealed an order dated 11/25/25, for Hemodialysis every Tuesday, Thursday, and Saturday. Review of Resident R8's dialysis communication forms lacked evidence that communication forms were completed and/or sent for every dialysis treatment. During an interview on 4/15/26, at approximately 1:00 p.m. Resident R8 revealed that his/her dialysis communication form is not always sent with him/her to his/her dialysis treatments. During an interview on 4/15/26, at 1:52 p.m. the Director of Nursing (DON) confirmed that there was no evidence of dialysis communication forms being completed for every dialysis treatment for Resident R8. The DON also confirmed that a dialysis communication form should be completed and sent with Resident R8 for every dialysis treatment. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.18 (e)(1) Management

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to ensure that the physician signed and dated all orders during visits for one of 28 residents reviewed (Resident R94). Findings include: Review of facility policy entitled Attending Physician Documentation Responsibility dated 2/2/26, indicated The attending physician will visit residents in a timely fashion, consistent with applicable state and federal requirements. Review of facility policy entitled Physician Services date 2/2/26, indicated Physician orders and progress notes shall be maintained in accordance with current OBRA [Omnibus Budget Reconciliation Act] regulations and facility policy. Resident R94's clinical record revealed an admission date of 2/17/26, with diagnoses that included gastrointestinal hemorrhage (excessive bleeding in the digestive tract), hypertension, and transient ischemic attack and cerebral infraction (also known as a stroke it occurs when blood flow to part of the brain is blocked). Review of Resident R94's clinical record lacked evidence of the last time his/her physician reviewed, signed, and dated his/her physician orders. During an interview on 4/15/26, at 12:30 p.m. the Director of Nursing (DON) confirmed that physician orders for Resident R94 lacked evidence that they were reviewed and signed by the physician. The DON also confirmed that physician orders should be reviewed and signed with every physician visit on admission then every 30 days for the first 90 days then every 60 days. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.5(f)(i) Medical records

Based on review of clinical records, resident interviews and staff interviews, it was determined that the facility failed to ensure that physician visits were conducted at least once every 30 days for the first 90 days after admission and at least 60 days thereafter for one of 28 residents reviewed (Resident R94). Findings include: Review of facility policy entitled Attending Physician Documentation Responsibility dated 2/2/26, indicated The attending physician will visit residents in a timely fashion, consistent with applicable state and federal requirements. and The visit schedule will be at least every 30 days for the first 90 days after admission and then at least every 60 days thereafter. Review of facility policy entitled Physician Services date 2/2/26, indicated Physician orders and progress notes shall be maintained in accordance with current OBRA [Omnibus Budget Reconciliation Act] regulations and facility policy. Resident R94's clinical record revealed an admission date of 2/17/26, with diagnoses that included gastrointestinal hemorrhage (excessive bleeding in the digestive tract), hypertension, and transient ischemic attack and cerebral infraction (also known as a stroke it occurs when blood flow to part of the brain is blocked). Review of Resident R94's clinical record lacked evidence that he/she was seen by his/her physician every 30 days for the first 90 days after admission as required. During an interview on 4/12/26, at approximately 11:30 a.m. Resident R94 expressed that he/she has not seen his/her physician. During an interview on 4/15/26, at 12:30 p.m. the Director of Nursing (DON) confirmed that the clinical record lacked evidence that Resident R94 was seen by their physician as required and also confirmed that all residents should be seen by their physician every 30 days for the first 90 days then every 60 days thereafter. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.5(f)(ii)(vii) Medical records

Based on review of facility policy, clinical records, observations, and staff interviews, it was determined that the facility failed to follow acceptable infection control practices regarding enhanced barrier precautions (EBP) during observation of a resident with a foley catheter (tubing inserted into the bladder to drain urine) (Resident R7), and failed to prevent the potential for cross-contamination (transfer of germs from one location to another) for one resident receiving nebulizer treatments (a treatment that delivers medication directly to the lungs to treat respiratory conditions) (Resident R15).Findings include: Review of facility policy entitled Enhanced Barrier Precautions Policy dated 2/2/26, indicated To prevent transmission of Multidrug Resistant Organisms (MDRO's){a germ resistant to many antibiotics} by enhancing personal protective equipment(PPE) use beyond standard precautions during high-contact resident care; gowns and gloves must be worn during device care(central lines, urinary catheters, feeding tubes, tracheostomies);clear signage must be placed at the room entry indicating EBP requirement; gowns and gloves must be immediately accessible. Center for Disease Control and Prevention (CDC) defines Enhanced Barrier Precautions as an infection control intervention designed to reduce transmission of MDRO's using an approach of isolation gown and gloves during high-contact resident care activities including catheter care. CDC further indicates that facilities should post clear signage indicating EBP requirements, and ensure easy access to gowns, gloves, and alcohol-based hand rub. Review of facility policy entitled Nebulizer Use, Cleaning, and Maintenance dated 2/2/26, indicated To provide safe, effective respiratory medication delivery while preventing cross-contamination. and Storage. store the kit in a clean, breathable, labeled bag. inside the residents bedside drawer. Resident R7's clinical record revealed an admission date of 8/16/22, with diagnoses that included Chronic Kidney Disease ( a long-term condition in which the kidneys are damaged and gradually lose their ability to function properly over time, gastro-esophageal reflux disease (GERD - a condition where stomach acid flows back into the esophagus [tube that passes food from the mouth into the stomach]), and high blood pressure. Review of Resident R7's clinical record on 4/13/26, revealed a physician's order dated 4/9/26, for an Indwelling catheter. Resident R7's physician order failed to include an order for Enhanced Barrier Precautions Observations on 4/13/26, at 1:00 p.m. and 2:13 p.m., revealed Resident R7 sitting in a wheelchair in his/her room with an indwelling catheter positioned below the bladder. Observation of Resident R7's room revealed that there was no signage alerting persons entering the room of EBP for infection control and no personal protective equipment (PPE) such as gloves and gowns available inside or outside of the room for use. During an interview on 4/14/26, at 2:15 p.m. the Licensed Practical Nurse Employee E4 confirmed that Resident R7's room lacked signage of EBP and appropriate PPE, such as gloves and gowns, when providing care for residents who have an Indwelling urinary catheter, and that signage should have been posted and PPE should be readily available. Review of Resident R15's clinical record revealed an admission date of 7/7/22, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), gastro esophageal reflux disease (a condition when stomach acid repeatedly flows back into your throat), and chronic respiratory failure (a condition where your lungs don't exchange air properly). Review of Resident R15's physician orders revealed an order for albuterol sulfate nebulization solution (a liquid medication) 2.5mg (milligrams) 3ml (milliliters) inhale via nebulizer two times a day dated 8/4/25. Observations on 4/13/26, at 1:04 p.m. and again at 2:37 p.m. revealed a nebulizer machine (a medical device that turns liquid medication into a fine mist) sitting on the bedside stand next to resident R15's bed with a mask (a device that is connected to a nebulizer machine allowing a person to inhale medication directly into their lungs) lying on the floor. During an interview on 4/13/26 at 2:40 p.m. Registered Nurse Employee E3 confirmed that the nebulizer mask was lying on the floor. He/she also confirmed that the mask should not be on the floor and should be stored in a bag in Resident R15's drawer. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to ensure adequate assistance and supervision with meals was provided for one of four residents observed in the [NAME] Dining Room (Resident R1); failed to ensure assessment of a resident's nutritional status on admission and as needed thereafter and failed to complete a comprehensive nutritional assessment for a resident identified as being at risk for unplanned weight loss and/or compromised nutritional status for five of 26 residents (Residents R3, R4, R5, R6, and R7); and failed to ensure nutritional interventions were implemented for two of 26 residents reviewed (Residents R8 and R9). Findings include: A facility policy dated 2/02/26, entitled Weight Monitoring and Nutritional Assessment, revealed policy statement - to maintain acceptable parameters of nutritional status, the facility shall establish a consistent process for weighing residents and conducting nutritional assessments under the direction of a Registered Dietitian. The goal is to identify and address significant weight changes and ensure residents receive therapeutic diets tailored to their clinical needs. Procedures for weight monitoring - initial baseline - nursing staff will weigh each resident upon admission or readmission to establish a baseline weight. Routine frequency - new admissions - weekly for the first four weeks. Ongoing - at least monthly thereafter, unless a more frequent schedule is clinically indicated. Verification - any weight change of 5 % or more in one month must be re-taken to confirm accuracy. The Registered Dietitian (RD) responsibilities - Assessment intervals - The RD will complete a comprehensive nutritional assessment within 14 days of admission and periodically (quarterly/annually) to coincide with MDS (Minimum Data Set) schedules. High risk monitoring - residents identified as high risk (e.g., significant weight loss, tube feeding, or wounds) will receive a monthly nutrition review by the RD. Notification and Intervention - The RD will update the interdisciplinary team to evaluate the cause and update the care plan with new interventions (e.g., supplements, diet texture and changes). Documentation - All assessments, weight trends, and physician notifications must be clearly documented in the resident's medical record. A facility policy dated 2/02/26, entitled Resident Dining Support and Dining Services revealed to ensure all residents receive adequate assistance with meals and personalized nutritional support in accordance with Pennsylvania state regulations, fostering independence, optimal nutrition, and resident dignity. Resident Assistance standards - physical support - staff shall provide physical assistance with eating for any resident whose assessment or support plan indicates a need. Supplemental snacks and hydration - supplemental administration - if a resident is ordered a nutritional supplement (e.g., Ensure, Glucerna), it must be provided and documented as part of the medical or dietary record. Resident R1's clinical record revealed an admission date of 1/19/22, with diagnoses that included cerebrovascular accident (CVA - a stroke when blood flow to the brain is stopped or slowed causing damage to the brain tissue), right sided hemiplegia (a severe form of one sided weakness of right side of body caused by brain damage), dysphagia (difficulty swallowing) and depression. Resident R1's clinical record, Kardex (a brief overview of a resident's plan of care) dated 3/03/26, provided by Speech Therapist Employee E1 on 3/03/26, revealed Eating/Nutrition: The resident needs Supervision due history of pocketing food. Resident R1's Activities of Daily Living (ADLs) care plan provided on 3/03/26, revealed Resident R1 requires assist with activities of daily living related to impaired balance and hemiplegia with contractures of right upper extremities, and Resident R1 needs supervision with eating due to history of pocketing food. Observations on 3/03/26, at 12:10 p.m. and 12:20 p.m. with the Social Worker, revealed Resident R1 eating his/her lunch meal with no staff present for supervision or assistance. Speech Therapist Employee E1 confirmed on 3/03/26, at 1:30 p.m. that Resident R1 requires staff supervision with eating due to history of pocketing food and should have had staff present during the lunch meal due to history of pocketing food and diagnosis of dysphagia. Resident R3's clinical record revealed an admission date of 7/22/25, with diagnoses that included muscle wasting and atrophy (loss of muscle tissue resulting in reduced strength), morbid obesity (a disease involving having too much body fat), unstageable pressure ulcer (a full thickness wound where the depth cannot be determined due wound bed is covered by necrotic tissue making it impossible to see the depth of wound), and depression. Resident R3's clinical record revealed weights obtained for dates 12/09/25, as 236.7 pounds, 2/05/26, as 242.8 pounds, and 3/03/26, as 211.0 pounds. Resident R3's clinical record lacked any evidence of a nutritional assessment being completed after 12/08/25, with above noted weight loss. Resident R4's clinical record revealed an admission date of 7/07/21, with diagnoses that included diabetes (a health condition caused by the body's inability to produce enough insulin), morbid obesity, muscle weakness, and depression. Resident R4's clinical record revealed weights obtained for dates 12/09/25, as 209.8 pounds, 2/11/26, as 190.0 pounds, and 3/03/26, as 192.4 pounds. Resident R4's clinical record lacked any evidence of a nutritional assessment being completed after 12/08/25, with above noted weight loss. Resident R5's clinical record revealed an admission date of 10/15/18, with diagnoses that included ischemic cardiomyopathy (a disease of the heart muscle where the weakened, enlarged heart muscle cannot pump well due to damage from a lack of blood supply), heart failure (a chronic condition where the heart cannot pump blood efficiently), chronic obstructive pulmonary disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), and muscle weakness. Resident R5's clinical record revealed weights obtained for dates 8/07/25, 118.8 pounds, 12/09/25, as 109.2 pounds, 2/11/26, as 104.6 pounds, 2/17/26, hospital weight 103.0 and 3/03/26, as 102.8 pounds. Resident R5's clinical record lacked any evidence of a nutritional assessment being completed after 8/11/25, with above noted weight loss. Resident R6's clinical record revealed an admission date of 1/01/26, with diagnoses that included respiratory failure (a condition where you don't get enough oxygen or you get too much carbon dioxide in your body), heart failure, flu, and high blood pressure. Resident R6's clinical record revealed weights obtained for dates 1/01/26, 189.0, and 3/07/26, 178.2. Resident R6's clinical record lacked any evidence of a comprehensive nutritional assessment being completed after admission and/or throughout his/her stay at the facility at this time. Resident R7's clinical record revealed an admission date of 6/29/25, with diagnoses that included muscle wasting and atrophy, arthritis, repeated falls, and muscle weakness. Resident R7's clinical record revealed weights obtained for dates 11/01/25, 264.5, and 3/03/26, 238.4. Resident R7's clinical record lacked any evidence of a nutritional assessment being completed after 10/06/25, with above noted weight loss. Resident R8's clinical record revealed an admission date of 3/14/24, with diagnoses that included schizoaffective/bilpolar disorder (a mental health condition combining hallucinations, delusions, disorganized thinking with severe mood swings), heart failure, respiratory failure, and morbid obesity. Resident R8's clinical record revealed a nutritional assessment dated [DATE], that indicated there had been a 9.2% weight change within the past 180 days - not significant. Weights have been stable around 230 pounds the past six months and have shown a 20 pound weight decrease in the past month. Further recommendation Unsure if most recent wt. is an error, will have staff reweigh. The facility lacked evidence of a reweigh. Resident R9's clinical record revealed an admission date of 2/26/25, with diagnoses that included COPD, heart failure, muscle weakness, and history of a fall. Resident R9's clinical record revealed a nutritional assessment dated [DATE], indicated weight warning: 146.2 pounds obtained on 2/01/26, weight noted as unplanned significant loss x 30 days. Resident currently receives 2 p.m. snack as per his preference. Will add to meal plan House Shake at dinner with notification of Dietary Department this date. The facility lacked evidence of the House Shake being added to Resident R9's meal plan or orders. During an interview on 3/09/26, at 1:20 p.m. the Nursing Home Administrator (NHA) confirmed there was no documented nutritional assessments for the above identified residents on admission or thereafter as required. The NHA further confirmed the facility failed to ensure staff supervision with meals was provided for Resident R1, and recommended interventions following a nutritional assessment were not completed for Residents R8 and R9. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure the physician was notified timely regarding laboratory studies for one of four residents reviewed (Resident R2).Findings include: A facility policy, Change in a Resident's Condition, dated 2/02/26, revealed Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Resident R2' s clinical record revealed an admission date of 1/22/22, with diagnoses that included Alzheimer's (a disease of the brain affecting mood, behavior, and decision making), atrial flutter (a type of fast heart rhythm where the heart's upper chambers, the atria, beat rapidly in a regular pattern), muscle weakness, and high blood pressure. Resident R2's clinical record revealed a lab finding report dated as - collected 11/26/25, received 11/27/25, reported 11/27/25, with an abnormal potassium level. Progress notes revealed that on 12/11/25, Resident R2's abnormal potassium findings were reviewed with the physician, and he/she was then transferred to the hospital related to his/her potassium level obtained on 11/26/25. The facility lacked evidence that the physician was notified timely regarding the abnormal potassium level. During an interview on 3/04/26, at 2:55 p.m. the Assistant Director of Nursing confirmed that the facility lacked evidence that the physician was notified timely in regard to the abnormal potassium level, and a lack of immediate physician notification for Resident R2's change in condition regarding his/her abnormal potassium level obtained on 11/26/25. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on observations and staff interview, it was determined that the facility failed to maintain a sanitary, orderly, and comfortable interior/homelike environment for two of five nursing units observed (East 1 and [NAME] units). Findings include: Observations on 2/8/26, with the Director of Nursing (DON), at approximately 1:10 p.m. revealed several brown stained ceiling tiles in the secured unit's common hallway and in the East 1 resident lounge. Further observations revealed broken or missing sections of the baseboard registers in rooms [NAME] 919 and [NAME] 928. The DON confirmed these observations during this same time. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on observations and staff interview, it was determined that the facility failed to ensure that the required nursing staffing information was posted on a daily basis. Findings include: Observations on 2/7/26, at 11:45 a.m. revealed that the daily staffing posting was not publicly posted in the facility. During interview at the time of the observation, the lack of the posting was confirmed by the Director of Nursing. 28 Pa. Code 201.14 (a) Responsibility of Licensee

Based on review of facility policy, facility documents, and clinical records, and staff interviews, it was determined that the facility failed to have sufficient staff with the appropriate skill sets to provide nursing services. Findings include: A facility policy entitled Nursing Services and Sufficient Staff dated 11/8/24, indicated, The facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans . Providing care includes, but is not limited to, assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. Review of Resident R1's clinical record and documentation for 5/25/25, revealed that Resident R1 was ordered an enteral feeding (method of providing nutrition directly to the stomach through a tube) to be started at 4:00 p.m. and Lispro Insulin (medication to control blood sugar levels) before meals. The May 2025 Medication Administration Record (MAR) revealed that the feeding was not started until 9:42 p.m. and the Lispro Insulin ordered before dinner at 5:00 p.m. was not administered until 9:42 p.m. Review of Resident R2's clinical record and documentation for 5/25/25, revealed that Resident R2 was ordered an enteral feeding to be started at 4:00 p.m. The May 2025 MAR revealed that the feeding was not started until 10:24 p.m. Review of Resident R3's clinical record and documentation for 5/25/25, revealed that Resident R3 was ordered an enteral feeding to be started at 6:00 p.m. The May 2025 MAR indicated the feeding was not started until 7:46 p.m. During an interview with Registered Nurse (RN) Employee E1 on 5/29/25, at 12:05 p.m. revealed that on 5/25/25, at the time of shift change he/she was the only nurse for the 3:00 p.m.-11:00 p.m. shift from 4:00 p.m. to 7:00 p.m. and he/she was responsible for all the medication cart keys. RN Employee E1 confirmed that there was a significant delay in medication administration times related to short staffing. During an interview with Licensed Practical Nurse (LPN) Employee E2 on 5/29/25, at 11:45 a.m. revealed that there were concerns with staffing levels on 5/25/25. He/she confirmed that there was not enough nursing staff in the facility on 5/25/25, which caused a significant delay in medication administration. Staff Interview conducted with LPN Employee E3 on 5/29/25, at 11:25 a.m. revealed that on 5/25/25, he/she worked the 7:00 a.m.-3:00 p.m. shift and during shift change for the 3:00 p.m.-11:00 p.m. shift there was only one nurse for the entire building. He/she confirmed that there was a significant delay in medication administration times related to short staffing. During an interview on 6/11/25, at approximately 1:50 p.m. the Nursing Home Administrator confirmed that the facility's nursing staff shortages on 5/25/25, led to a significant delay in medication administration for Resident R1 and a delay starting enteral feedings for Residents R1, R2, and R3. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(4)(5) Nursing services 28 Pa. Code 211.12 (f.1)(4) Nursing services

Based on observations, review of dishwashing machine manufacturer's instructions, and staff interviews, it was determined that the facility failed to maintain dishwashing machine water temperatures in accordance with manufacturer recommendations for food service safety for the kitchen dishwasher. Findings include: Review of manufacturer's instructions for the facility dishwashing machine revealed that the hot water sanitizing mode minimum wash temperature and recommended wash temperature was 150-165 degrees Farenheit (F). The rinse temperature was 180-194 degrees F. Review of the Dishwashing/Warewashing machine temperature log sheet revealed that the minimum temperature requirements for the wash cycle was: Wash 150 degrees F and the Rinse 180 degrees F. If temperatures were below standard, the person in charge was notified and dismachine was stopped. Observations of the dishwashing machine operation on 4/25/2025, at 10:10 a.m. in the kitchen dishroom, in the presence of the Dietary Manager, revealed a dishwasher temperature of 152-154 degrees F during the wash cycle and 166-168 degrees F on the rinse cycle. Dietary Manager confirmed, at the time of observation, that the rinse cycle was lower than the required 180 degrees F. Review of dishwasher temperature log for the kitchen for the month of April 2025 revealed that the kitchen dishwashing machine temperatures were not logged for the evening shift for dishwasher temperatures of the wash and rinse cycles for the entire month of April 2025. During an interview on 4/25/2025, at 10:15 a.m. the Dietary Manager confirmed that dishwashing machine temperatures are supposed to meet the 150 degrees F during the wash cycle and 180 degrees during the rinse cycle. Staff should record their readings on the dishwasher temperature log and are to inform management and maintenance if the dishwashing machines do not meet the required temperatures for wash and rinse cycles. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on observations, review of facility policies and documentation, and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program by failing to follow infection control guidelines from the Centers for Disease Control and Prevention (CDC) and the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections and prevent cross-contamination during the COVID-19 pandemic. This failure placed the facility in an Immediate Jeopardy situation for two of eight residents reviewed (Residents R1 and R5). Findings include: Review of the original facility policy entitled COVID-19 Pandemic Policy dated 6/3/22, did not address practices to include not cohorting COVID-19 positive and negative residents together in the same room. Review of the Pennsylvania Health Alert Network (PA-HAN) - 627, Long-Term Care Facility Guidance regarding Response to an Outbreak and Residents with Exposure to COVID-19 (a contagious [CONDITION(S)] disease that can cause a variety of symptoms, including breathing problems, fever and cough), dated February 15, 2022, disclosed the following: A. Definition of an outbreak - a single new case of [CONDITION(S)]-CoV-2 infection in any resident or HCP [Healthcare Personnel] should be evaluated as a potential outbreak. Residents with confirmed COVID-19 infection should be placed in the COVID Care Unit under isolation as described in PA-HAN-624 or its successor, Residents with confirmed COVID-19 infection should be placed in the COVID Care Unit (Red zone) under isolation as described in PA-HAN-624 or its successor, Regardless of the approach for contact tracing and quarantine, residents with confirmed COVID-19 infection should be placed in the COVID Care Unit (Red Zone). Review of PA-HAN 624 as referenced above, directed the following on page 7: .However, quarantined patients and those with suspected infection should NOT be cohorted with patients with confirmed [CONDITION(S)]-CoV-2 infection unless they are confirmed to have [CONDITION(S)]-CoV-2 infection through testing. Review of CDC guidance Responding to Coronavirus (COVID-19) in Nursing Homes, dated 4/30/2020, indicated that Residents of nursing homes who have a confirmed COVID-19 infection, regardless of symptoms, should be transferred to a designated COVID-19 care unit. Roommates of residents with COVID-19 should be considered exposed and potentially infected, and if at all possible should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for COVID-19 fourteen days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). Exposed residents may be permitted to room share with other exposed residents, if space is not available for them to remain in a single room. Review of facility room assignments documented that two residents who tested negative for COVID-19 remained in the same room with roommates that tested positive for COVID-19. The facility employs the antigen testing which confirms positive or negative results within 15 minutes. During interview on 7/12/22, at 11:05 a.m. the Assistant Nursing Home Administrator (ANHA) confirmed that COVID-19 negative residents, one in room [ROOM NUMBER] and one in room [ROOM NUMBER] remained housed in those same rooms as a COVID-19 positive resident in each room. Resident R104 tested positive on 7/11/22, and remained in the same room, room [ROOM NUMBER], with Resident R1 who tested negative on 7/11/22. Resident R67 tested positive on 7/12/22, and remained in the same room, room [ROOM NUMBER], with Resident R5 who tested negative on 7/11/22. Observations on 7/12/22, at 11:15 a.m., revealed that there were zippered plastic barriers at the entrances to rooms [ROOM NUMBERS]. The ANHA and Director of Nursing were made aware that Immediate Jeopardy (IJ) existed for two of eight residents on unit East Two on 7/12/22, at 5:00 p.m. and a corrective action plan was requested. The IJ template was provided to the facility at that time. On 7/12/22, at 7:38 p.m. an acceptable corrective action plan was approved which included the following interventions: 1. Resident's that were exposed to covid positive roommates and have tested covid negative will be moved immediately. No covid positive residents will co-habitate with a covid negative resident. 2. The staff will be educated on the process of infection control prevention by not permitting covid positive residents to co-habitate with covid negative residents. Immediate education provided to staff present in facility and will be ongoing at the beginning of each shift. 3. Residents are covid tested prior to admission and are placed in the appropriate room with either a covid positive resident or a covid negative resident, upon what their test confirms. 4. If there is a covid outbreak at facility, the covid positive residents are kept on one unit to prevent the spread of infection. The facility policy will be updated to reflect the current Infection Control policy & procedures to include the guidance related to COVID-19 from CMS, Center of Disease Control, and PA Dept. of Health. On 7/14/22, between 9:30 a.m. and 3:00 p.m. observations, staff interviews, and review of facility policy, and education, verified that the facility had implemented the above identified action plan. The Immediate Jeopardy was removed on 7/14/22, at 3:15 p.m. when the action plan implementation was verified. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services