Every finding on record at University City Rehabilitation and Healthcare CTR

Based on review of facility documentation, review of clinical records, and interview with staff it was determined that the facility failed to implement interventions to reduce the risk of accident/hazards for one of two residents reviewed (Resident R1). Findings Include: Review of Resident 1's clinical record on July 28, 2026, revealed the resident was admitted to the facility on [DATE], and has a Brief Interview for Mental Status (BIMS - cognitive assessment used to evaluate memory and orientation) score of 13 (cognitively intact). Review of Resident R1's clinical record revealed the resident has a diagnosis of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), open wound of the right lower leg, type 2 diabetes mellitus (chronic condition characterized by high levels of sugar in the blood) without complications, abnormalities of gait and mobility, and acute kidney failure. Review of Resident R1's clinical record revealed that on July 19, 2026, Resident R1 gained accessed a stairwell. Resident R1 was subsequently transferred to the hospital for evaluation. Resident R1 was readmitted back to the facility on July 26, 2026, with no injuries. Further review of Resident R1's clinical record revealed no documented evidence that the facility reassessed Resident R1's supervision and safety needs, and/or implemented additional safety/behavioral interventions upon Resident R1's return from the hospital. Interview on July 29, 2026, with the Director of Nursing (DON), Employee E2, revealed that one-to-one supervision should have been implemented upon Resident R1's readmission from the hospital on July 26, 2026. Further interview with DON, Employee E2, revealed one-to-one supervision was not implemented until July 28, 2026. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on record review, staff interview, and physician documentation, the facility failed to ensure that residents were free from significant medication errors for 1 of 2 sampled residents (Resident R2) reviewed for medication administration. Findings include: Review of the facility's policy titled Medication Administration (revised April 2019) indicated that medications are to be administered safely and in accordance with physician orders, including specified time frames. The policy requires that staff verify the correct resident, medication, dose, time, and route prior to administration and perform three label checks. The policy also states that medication errors are to be documented, reported, and reviewed through the QAPI process to identify the need for system improvements or staff re-education. Review of manufacture Sanofi-Aventis U.S. LLC package insert for the drug Lovenox (Enoxaparin sodium) revealed is a low-molecular-weight heparin anticoagulant used to prevent and treat blood clots, such as deep vein thrombosis (DVT) or pulmonary embolism (PE). It is commonly prescribed after orthopedic surgeries, like knee or hip replacement, and for patients at risk for clot formation. Further review of the of the FDA article Aspirin for Reducing Your Risks of Heart Attack and Stroke: Know the Facts dated 2023 revealed When aspirin and Lovenox are used together, they both affect the body's ability to form clots, which further increases the risk of bleeding. (FDA, 2023). Review of the medication Cefadroxil Drugs.com. Last updated on [DATE], revealed is a prescription antibiotic in the first generation cephalosporin class that is used to treat bacterial infections. It works by inhibiting the growth of bacteria and is effective in treating infections such as skin and soft tissue infections, urinary tract infections, and other susceptible bacterial illnesses. The drug is intended only for bacterial infections and will not treat viral illnesses. Review of the medlineplus.gov revealed the medication Cefaclor is a cephalosporin antibiotic prescribed to treat a variety of bacterial infections, including pneumonia, skin infections, ear infections, throat infections, and urinary tract infections. It works by stopping the growth of bacteria, helping the body fight infection, and is available in capsules, extended release tablets, or liquid form to be taken by mouth, usually every 8 to 12 hours depending on the formulation and physician instructions. Cefaclor, like other antibiotics, will not treat viral infections such as colds or the flu and should be taken exactly as directed to ensure efficacy and prevent antibiotic resistance. Further review of Medline plus.gov Cefaclor and Cefadroxil both belong to the cephalosporin class of antibiotics, they are distinct drugs with different dosing and specific bacterial coverage. Cefadroxil is a first generation cephalosporin used similarly to treat bacterial infections, such as sore throat, skin infections, or urinary tract infections. Because these medications are separate antibiotics within the same class, they are not interchangeable without a physician's order. Administering cefaclor when cefadroxil was prescribed may result in incorrect dosing, inappropriate spectrum of bacterial coverage, or reduced effectiveness against the intended bacterial infection, potentially leading to ongoing infection or antibiotic resistance. It may also expose the resident to unnecessary risk of side effects without therapeutic benefit for the condition being treated. Review of facility policy titled Reconciliation of Medications on admission revised July 2017 revealed the purpose of this procedure is to ensure medication safety by accurately accounting for the residents medications roots and delicious dosages upon the mission or readmission to the facility medication reconciliation is the process of comparing pre discharge medications supposed discharge medications by creating an accurate list of both prescription and over-the-counter medications that includes the name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or missions at transition points of care medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs have been taken continue to be administer without interruption and the correct dosages and routes during emission transfer process. Medication reconciliation helps to ensure that all medications routes and dosages on the list are appropriate for the resident and his or her condition. Medication and reconciliation help to ensure that all medications roots and dosages have been accurately communicated to the attending physician and care team. Review of FDA article Aspirin for Reducing Your Risks of Heart Attack and Stroke: Know the Facts dated 2023 revealed safe use of aspirin Aspirin 81 mg, commonly called low-dose or baby aspirin, is an antiplatelet medication that helps prevent blood clots by reducing the ability of platelets to stick together. It is often prescribed to reduce the risk of heart attack or stroke in patients with cardiovascular disease or a history of heart events. While effective in preventing clots, aspirin can increase the risk of bleeding, including gastrointestinal bleeding, so it should only be taken as prescribed and under medical supervision (FDA, 2023; NCBI, 2020).https://www.fda.gov/drugs/safe-use-aspirin/aspirin-reducing-your-risk-heart-attack-and-stroke-know-facts?utm_source=chatgpt.com Review of Resident R2's clinical record revealed the resident was admitted to the facility on [DATE], for rehabilitation following a right total knee arthroplasty (a surgical procedure in which the damaged knee joint is replaced with a prosthetic implant to relieve pain and restore function), hypertension (elevated blood pressure); hyperlipidemia (high cholesterol); coronary artery disease (a condition involving narrowing or blockage of the coronary arteries); obesity (excessive body fat that may contribute to comorbidities); and osteoarthritis (a degenerative joint disease causing cartilage breakdown, pain, and stiffness). Review of Resident R2's hospital records revealed the resident was admitted in March 4, 2026 with a diagnosis of degenerative joint disease of the right knee. Review of the medications provided at the hospital included: Aspirin EC (enteric coated) 81 milligrams (mg), Cefadroxil 500 mg capsule, by mouth every 12 hours, Enoxaparin 30 mg/0.3 ml, inject 30 mg subcutaneously every 12 hours. Review of physician and nursing progress notes date March 12, 2026, for Resident R2 revealed two medication administration errors. Aspirin 81 mg, ordered to be held until March 12, 2026, due to concurrent Lovenox therapy, was administered early. Additionally, Cefadroxil 500 mg, prescribed for infection prophylaxis, was incorrectly replaced with Cefaclor 500 mg. Both errors were promptly reported to the resident, responsible party, and physician. The resident experienced mild nausea but remained stable with no other adverse effects. Nursing staff monitored the resident closely, reinforced medication administration protocols, and implemented corrective actions to prevent recurrence. Further review of Resident R2's Medication Administration Record (MAR) indicates that on March 9, 2026, at 5:00 p.m., Aspirin 81 mg was administered. The original order at that time was: Aspirin tablet chewable 81 mg, give one tablet by mouth twice daily for 5 weeks, monitor for signs and symptoms of bleeding, dated March 9, 2026, and discontinued March 10, 2026. The corrected order directed that Aspirin 81 mg be administered starting March 12, 2026, at 9:00 a.m., twice daily for 5 weeks, with monitoring for signs and symptoms of bleeding. Further review of MAR on March 9, 2026, at 9:00p.m., the MAR revealed that Cefaclor 500 mg, one capsule by mouth every 12 hours for 7 days, start date March 9, 2026, 2100 was administered. The corrected order was Cefadroxil 500 mg, one capsule by mouth every 12 hours for 7 doses for postoperative prophylaxis, with a start date of March 10, 2026, at 9:00 p.m. Review of the physician orders revealed that Lovenox (Enoxaparin) injection 30 mg/0.3 mL, subcutaneously every 12 hours, was to start on March 10, 2026, at 9:00 a.m. and to continue until March 12, 2026. Review of the MAR for March 2026 indicated that Lovenox was administered on March 9, 2026 and discontinued March 10, 2026, which was not in accordance with physician's orders. Review of facility document incident report dated March 11, 2026, revealed Licensed nurse, Employee E4 entered the wrong medication for resident R2's while reconciling her emission orders and as a result there was a medication error. Continued review of the incident report revealed that Licensed nurse, Employee E4 was provided education to ensure discharge orders were carefully reviewed and to select the correct orders in the electronic medical record system in order to prevent future errors. Interview with Resident R2 on March 23, 2026, at 11:00 a.m. confirmed (she/he) had been notified about the administration of the wrong medications. Resident R2 expressed upset and dissatisfaction. Interview with the Director of Nursing, Employee E2 , reported that the medication error occurred due to a transcription error at the time of admission, which resulted in medications not being entered accurately per physician orders. Specifically, the nurse transcribed and administered the wrong antibiotic within the same drug classification, and the error was not identified until a subsequent chart review on March 11, 2026, after one dose had already been administered. In addition, the resident received Aspirin prior to the physician-ordered start date due to incorrect entry of the medication start date. The medication was intended to be held until March 12, 2026; however, it was administered earlier than ordered. Employee E2 acknowledged that these incidents constituted medication errors, as medications were not administered in accordance with physician orders. 28 Pa. Code 211.2 (d)(3) Medical Director 28 Pa. Code 211.9 (a)(i)(d) Pharmacy Services 28 Pa. Code 211.12 (d)(1)(2)(5) Nursing Services

Based on observation, record review, review of facility policy, interview with staff and residents, it was determined that the facility did not ensure that medications were stored and labeled according to professional standards for one of five residents reviewed. (Resident R1) Findings include:Review facility policy for Medication Labeling and Storage revealed that under section Policy Statement: The facility stores all medications and biologicals and locked compartments under proper temperature humidity and light controls only authorized personnel have access to keys. Under section Policy Interpretation and Implementation sub-section Medication Storage #1 Medications and biologicals are stored in the packaging containers or other dispensing systems in which they are received only the issuing pharmacist authorize the transfer medications between containers.#4 Compartments including but not limited to drawers cabinets rooms refrigerators cards and boxes containing medications and biologicals are locked when not in use and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. #5 Medications are stored in an orderly manner in cabinets Jewelers carts or automatic dispensing systems its residence medications are assigned to an individual cubicle drawer or other holding area to prevent the possibility of mixing medications of several residents. Under subsection Medication Labeling #1 Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices #2 The medication label includes at a minimum: a. medication name, b. prescribed dose, c. strength, d. expiration date when applicable, e. resident's name, e. route of administration and g. appropriate instructions and precautions. #10. Only the dispensing pharmacy may label or alter the label on a medication container or package. Review of resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnosis of Acute Respiratory Failure. Review of Resident R1's MDS (Minimum Data Set, a federally required resident assessment conducted at a specific interval) dated February 18, 2026, revealed that section C500 BIMS (brief interview for mental status) score was 15, suggesting that resident R1 was cognitively intact. Review of Resident R1 physician's orders revealed that there was no order for fluticasone nasal spray. Observation during tour of the first-floor unit conducted on March 3, 2026, at 9:30AM revealed that Fluticasone Propionate nasal spray was on Resident R1's bedside table. Further, the Fluticasone Propionate nasal spray did not have a label with resident's name affixed to the bottle. Further, the Fluticasone Propionate nasal spray bottle was full. Interview conducted with Resident R1 at the time of the observation revealed that the physician gave Resident R1 the Fluticasone Propionate nasal spray the day before. Interview with Assistant Director of Nursing, Employee 3 conducted on March 5, 2026, at 9:34AM confirmed that Fluticasone Propionate nasal spray was on Resident R1's bedside table. Interview with Licensed nurse, Employee E4 conducted on March 5, 2025, at 9:40AM revealed that there was no physicians order for Fluticasone Propionate nasal spray for Resident R1. Follow-up observation of Resident R1's bedside table conducted on March 5, 2026, at 10AM with Director of Nursing Employee E2 revealed an unlabeled Fluticasone Propionate nasal spray bottle was at Resident R1's bedside table. Further, the Fluticasone Propionate nasal spray bottle was full. Interview with Employee E2 conducted at the time of the observation confirmed that an unlabeled Fluticasone Propionate nasal spray was on resident R1's bedside table. Employee E3 removed the fluticasone from resident R1. 28 Pa. code 211.9 (a)(1)(d) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

Based on observations, review of facility policies, clinical record review and interviews with staff, it was determined that the facility did not ensure that the medication error rate was less than five percent for two of five residents observed during medication administration (Resident 53 and Resident 110).Findings Include: The facility's medication error rate was 20% based on observation of 25 medication administration opportunities with five errors observed. Review of facility policy, Administering Medications revised April 2019, revealed, Medications are administered in accordance with prescriber orders, including any required time frame. Further review of facility policy indicates Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Review of Resident R53's clinical records revealed she was admitted to the facility on [DATE] and has diagnoses including hypertension (high blood pressure), anemia (lack of healthy red blood cells in blood), vitamin D insufficiency and hypokalemia (low potassium).Review of Medication Administration Records (MARs) for Resident R53 revealed the following physicians orders:An order for Iron 325 (65 Fe) oral tablet; Original order reads: Give 1 tablet by mouth two times a day for Anemia. Order was scheduled to be administered at 9 AM. Observation on during morning medication pass on January 7, 2026 with Licensed Nurse E8, 2nd Floor Cart 1 nurse, revealed medication was administered at 12:06 PM, which was outside the one hour timeframe indicated in facility policy and over two hours late. An order for Amlodipine besylate 10 mg oral tablet; Original order reads: Give 1 tablet by mouth one time a day for HTN [hypertension]. Order was scheduled to be administered at 9 AM. Observation during morning medication pass with Licensed Nurse E8 revealed medication was administered at 12:06 PM, which was over two hours late.An order for Carvedilol 3.125 MG Oral Tablet [Coreg]; Original order reads: Give 1 tablet by mouth every 12 hours for HTN [hypertension], Hold if SBP (systolic blood pressure) is <100mgHg or HR (heart rate) <60 bpm (DO NOT GIVE MEDS IF SBP LESS THAN 100 OR HR LESS THAN 60). Order was scheduled to be administered at 9 AM. Observation during medication pass with Licensed Nurse E8 revealed medication was administered at 12:06 PM, which was over two hours late.An order for Potassium oral tablet (potassium); Original order reads: Give 20 mEq by mouth two times a day for hypokalemia. Order was scheduled to be administered at 9 AM. Observation during medication pass with Licensed Nurse E8 revealed medication was administered at 12:06 PM, which was over two hours late.An order for Vitamin D3 25 mcg tablet; Original order reads: Give 2 tablet by mouth one time a day for Vitamin D insufficiency. Order was scheduled to be administered at 9 AM. Observation during medication pass with Licensed Nurse E8 revealed medication was administered at 12:06 PM, which was over two hours late. Furthermore, Licensed Nurse E8 almost gave four tablets, believing the order was 100 mcg total, surveyor intervened. Both of these errors were confirmed by Licensed Nurse E8 at the time of the administration.Interview with 2nd floor Unit Manager Employee E11 at 1:15 PM confirmed Licensed Nurse Employee E8 was giving out morning medications scheduled for 9:00 AM at 12:06 PM. Review of clinical records for Resident R110 revealed that resident was admitted to facility with diagnoses including Constipation.Further review of Resident R110's clinical records revealed a physician order, dated December 2, 2025, for Sennosides 8.6 mg tablet (oral) sennosides, to be administered in the morning and at bedtime for constipation, scheduled for 9:00 AM and 9:00 PM.Observation conducted at 9:10 AM on January 7, 2026 revealed Licensed Nurse E7 administered to Resident R110 Senna-Plus (docusate sodium-sennosides 50mg-8.6 mg) due to the originally prescribed medication being out of stock. Further observation revealed Resident R110 refused this medication. 28 Pa. Code 211.9(a)(1) Pharmacy services28 Pa. Code 211.12 (d)(5) Nursing services

Based on review of facility documentation, review of clinical records, observations, and staff interviews it was determined that the facility failed to provide treatment/services for a resident with limited mobility/range of motion to increase range of motion and/or to prevent further decrease for one of 4 residents reviewed (Resident R10). Review of Resident R10's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated November 17, 2025, revealed the resident was assessed with severe cognitive impairment and had diagnoses of arthritis (joint inflammation), aphasia (communication deficits), and hemiplegia (one sided paralysis) or hemiparesis (one sided muscle weakness).Continued review of Resident R10's comprehensive MDS dated [DATE], revealed the resident had impairment in functional limitation in range of motion in the upper and lower extremity and was dependent on staff with personal hygiene.Review of Resident R10's comprehensive care plan dated May 13, 2024, revealed Resident R10 had right side weakness and right-hand contracture (a shortening and stiffening of muscles that limits joint movement).Further review of Resident R10's comprehensive care plan revealed interventions dated November 20, 2025, for passive range of motion (somebody or something else, such as a therapist or machine, is moving a body part or a joint) to the right upper extremity, and active range of motion (how far a person can move a joint themselves) to the left upper extremity.Observations on January 8, 2026, at 12:15 p.m. confirmed Resident R10 had a right-hand contracture. Resident R10's right hand was observed to lay naturally in a fist. Resident R10 was unable to open the right hand by him/herself. Continued observations on January 8, 2026, at 12:15 p.m. revealed Licensed Nurse, Employee E11, needed to physically help Resident R10 open his/her hand.Review of Therapy to Restorative Nursing Communication documentation dated February 18, 2025, revealed that occupational therapy recommended passive range of motion to the right upper extremity and active range of motion to the left upper extremity.Interview on January 8, 2026, at 12:45 p.m. with the Director of Rehabilitation, Employee E15, revealed restorative nursing recommendations were intended to be completed daily with nursing staff. Review of Resident R10's clinical record revealed the active and passive range of motion recommended by therapy was only documented as completed three times from 12/20/2025 through 01/07/2026. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on observations, review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to medication administration (Residents R110, R117, R49 and R53) and Enhanced Barrier Precautions for two of 10 residents reviewed (R32, R49). Findings include: Review of facility policy titled, Administering Medications, revised April 2019, revealed 25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. An observation of medication pass with Employee E7, Licensed Nurse on 1st Floor Cart 1, on January 7, 2026 at approximately 9:27 AM, on the first floor nursing unit revealed an open employee [NAME] energy drink can, the opening covered by an empty medicine cup, while administering medications to Residents R110 (9:10 AM), R117 (9:36 AM) and R49 (9:51 AM). Further observation of medication pass of Employee E7, Licensed Nurse on the first floor nursing unit revealed that Employee E7 touched the medication pills with his fingers as he popped them out of the medication cards for Residents R110, R117 and R49. This finding was discussed with the Director of Nursing, Employee E2, and the Assistant Director of Nursing/Infection Preventionist, Employee E9, upon Exit Conference on January 9, 2026 around 1:15 PM. An observation of medication pass with Employee E8, Licensed Nurse on 2nd Floor Cart 1, on January 7, 2026 around 12:06 PM on the second floor nursing unit revealed that she touched the medication pills with her fingers as she popped them out of the medication cards for Resident R53. When the above was confirmed during interview with Employee E8, Licensed Nurse revealed in her statement: It is difficult not to touch the medications while popping them out with these (artificial nails). This finding was discussed with the Director of Nursing, Employee E2, and the Assistant Director of Nursing/Infection Preventionist, Employee E9, upon Exit Conference on January 9, 2026 around 1:15 PM. Further observation of Employee E8, Licensed Nurse on 2nd Floor Cart 1, on January 7, 2026 around 12:06 PM revealed she brought a small zippered bag into the room with her containing her vital sign equipment (Blood pressure cuff, etc.) to take the vital signs of Resident R53 just prior to medication administration. She was not observed sanitizing the bag or its contents after use on Resident R53. Interview with Employee E8 at this same time revealed she keeps her vital sign equipment in this bag and brings it into each resident's room for whom she has to administer medications in order to take residents' vital signs at the time of their medication administration. Review of Policy Statement of the facility about Enhanced Barrier Precautions (EBP), revised in April 2025, indicated that Enhanced Barrier Precautions are utilized to prevent the spread of Multi-Drug-Resistant Organisms (MDROs) to residents. Enhanced Barrier Precautions require the use of targeted personal protective equipment (PPE) during high contact patient/resident activities. Review of Resident R32 's clinical record revealed that the resident was admitted to the facility on [DATE]. Diagnoses included Pressure Ulcer of Right Heel, and Pressure Ulcer of Left Heel. Review of physician order dated November 26, 2025, for R32, indicated an order stating, Cleanse bilateral heel with Normal Saline Solution (NSS), apply Santyl, cover with bordered dressing, one time a day for Wound Care and as needed for Soilage/ Dislodgement. Review of physician order dated November 20, 2025, for R32, indicated an order stating: Enhanced Barrier Precautions, every shift for dialysis access/wound. On January 7, 2026, at 10:42 a.m., observed wound treatment administered by a License Nurse, Employee E13, the nurse did follow physician order for bilateral heel, except for the Enhanced Barrier Procedure. E13 did not use proper Personal Protective Equipment (PPE) including targeted gown as directed in the Enhanced Barrier Precaution Policy of the Facility. At the time of the finding, the same was confirmed with E13, and Nursing Supervisor, E14. Review of Resident R49 's clinical record revealed that the resident was admitted to the facility on [DATE]. Diagnoses included Pressure-Induced Deep Tissue Damage of Sacral Region. Review of physician order dated December 19, 2025, for R49, indicated an order stating, Sacrum: Cleanse with NSS, apply Medi Honey, NSS moistened gauze, cover with Silicone Super Absorbent dressing; one time a day for Wound Care, AND as needed for Soilage/ Dislodgement. On January 8, 2026, at 10:48 a.m., observed wound treatment administered by a License Nurse, Employee E13. The nurse did follow physician order for Sacral Wound, except for the Enhanced Barrier Precaution Procedure. After the wound treatment, Employee E13 could not discard the used gown in a protective bag, but carried the used gown exposed, outside the resident room, and placed in an open trash box attached with the treatment cart. At the time of the finding, the same was confirmed with E13. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(d) Management

Based on clinical record review, observation, and interview, the facility failed to ensure timely follow-up and provision of recommended dental services for a resident with an identified dental need for one of 26 residents reviewed (Resident R95).Findings include: Review of Resident R95s clinical records indicated that R95 was admitted in the facility on February 27,2020 with Diagnoses included but not limited to Unspecified Convulsions: (Seizure activity), Essential Hypertension: (High blood pressure) Type 2 Diabetes:(High blood sugar).Interview with the resident on January 6, 2026, at 10:34 am revealed complaints regarding not having dentures and lack of follow-up after the dental appointment. Interview with the resident's representative on January 6, 2026, at 10:36 am confirmed the resident's concerns that dentures had been recommended but not provided and stated she had not been informed of any progress or next steps regarding denture services. Observations during the survey, the resident R95 was observed eating meals without teeth or dentures.Review of the resident R95 dental record on January 7, 2026, revealed the resident had a routine dental appointment on 9/2/2025. Dental documentation indicated the resident was edentulous and the dentist recommended full upper and full lower dentures.Further review of the medical record showed no documentation of denture impressions, fittings, delivery, or scheduling of follow-up dental appointments after the recommendation was made. There was no evidence of a care plan addressing the resident's dental needs following the dental visit. There was no documentation of resident's refusal of services. Additional record review revealed that procedure authorization was not initiated until January 9, 2026, approximately four months after the dental recommendation. No documentation was found explaining the delay or demonstrating interim efforts by the facility to obtain the recommended dentures. 28 Pa. Code S 211.12(d)

Based on observations, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that medications were stored in accordance with currently accepted professional principles for one of three medication carts reviewed (second floor front cart/cart 1).Findings Include:Review of facility policy, Medication Labeling and Storage, revealed that Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. Further review of facility policy indicates that, 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Additionally, policy states, 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. 5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.Observation conducted on January 7, 2026, at approximately 12:06 PM of Employee E8, Licensed Nurse for 2nd Floor Cart 1 (front cart), revealed three distinct cups of unidentified medications in individual medicine cups sitting in the top drawer of her cart.Interview with Employee E8 at the time of this observation confirmed that these cups were for residents for whom she had attempted to administer medications, but the residents were otherwise unavailable, so she stored the pre-poured cups containing medicine pills in the top drawer to reattempt administration at a later time. Further interview with Employee E8 revealed she was aware this was not in compliance with the facility's medication administration/storage policy.Observations during Employee E8's morning medication pass, which was at the same time or 12:06 PM and later, revealed at least two instances wherein the nurse walked away from the cart to enter a resident's room without having locked her medication cart.Interview with Employee E8 during this time revealed her statement, I guess I should not have done that [walked away from an unlocked cart] in front of you.28 Pa Code 561.13 Storage28 Pa Code 561.15 Locked storage

Based on interviews and the review of clinical records, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of three Dialysis-Residents reviewed (Residents R32).Findings include:Review of Resident 32's clinical records indicated that R32 was admitted in the facility on November 18, 2025, with Diagnoses including End Stage Renal Disease (the final stage of Chronic Kidney Disease -CKD-, where kidneys fail, requiring dialysis or a kidney transplant for survival, as they can no longer filter waste effectively). Review of physician order, dated November 19, 2025, revealed; R32 receives Dialysis Treatment on Mondays, Tuesdays, Wednesdays, Thursdays, and Fridays. It also included an order to Check Dialysis Communication form, upon return from Dialysis; Vital Signs upon return; one time a day every Mondays, Tuesdays, Wednesdays, Thursdays, and Fridays.Review of Resident R32 's Hemodialysis Communication Record revealed that it lacked the following information as required per the communication log:On December 30, 2025; the Section to be completed by Dialysis Unit and Returned with Resident such as Pre Dialysis Weight, Post Dialysis Weight, Estimated Dry Weight, Total Fluid Removed, Post Treatment Vitals, Among Fluid Consumed During Dialysis, Medications Given During Dialysis, and Issues During Treatment.On December 30, 2025; December 24, 2025; December 16, 2025; December 15, 2025; December 12, 2025; and December 10, 2025; the Section to be completed upon return following Dialysis, such as AVG/AVF ( AVG -Arteriovenous Graft- and AVF-Arteriovenous Fistula- are surgical connections for hemodialysis, with an AVF being a direct joining of an individual's own artery to a vein : the preferred, longer-lasting option, and an AVG using a synthetic tube to connect them when veins are inadequate. Both create high-flow access for needles, but AVFs are best for durability, while AVGs are used when fistulas fail or can't mature, though AVGs have higher infection/clot risks), Bruit/Thrill Present (In dialysis, the bruit-a whooshing sound- and thrill -a buzzing vibration- are crucial signs of a healthy arteriovenous (AV) fistula, indicating good blood flow; care givers check these daily with a stethoscope and fingertips, and a loss of either can signal a dangerous clot or blockage, requiring immediate medical attention); Catheter Dressing Dry/Intact; Signs/Symptoms Of Infection; and Additional Comments.Interview with the Charge Nurse, a Licensed Nurse, Employee E13, on January 8, 2026, at 11:22 a.m., confirmed lack of information in the Hemodialysis Communication Record of R32.28 Pa Code 211.5(f) Clinical records

Based on review of facility documentation, review of clinical records, and staff interview it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers to the hospital for one of two residents reviewed for hospitalizations (Resident R10). Findings Include: Review of Resident R10's clinical record revealed a nursing note dated November 10, 2025, which indicated that the resident had a change in condition and was ordered by the physician to be transferred to a local hospital for evaluation. Review of Resident R10's clinical record revealed no documented evidence that the Office of the State Long-Term Care Ombudsman was notified of the facility-initiated emergency transfer. Interview on January 9, 2026, at 11:54 a.m. with Employee E1, Nursing Home Administrator, confirmed that the Office of the State Long-Term Care Ombudsman was not notified of facility-initiated emergency transfers for October and November 2025 Further, interview on January 9, 2026, at 12:05 p.m. with the Administrator, confirmed that the Long-Term Care Ombudsman has not been notified of facility-initiated emergency transfers and discharges since October 21, 2025, when the list of these transfers and discharges was sent for the month of September 2025. He further indicated that they had hired a new Social Worker and that this requirement had not been communicated to her, and that they sent out the notice for December 2025 transfers and discharges on January 9, 2026. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on clinical record review, observation, and staff interviews, it was determined the facility did not provide services in accordance with accepted professional standards of quality related to daily weights for one of 26 clinical records reviewed (R19).Findings Include: Record review of Resident 19's medical record revealed a physician order for daily weights for cardiac monitoring with active dates 12/15/2025 through 1/12/2026. Cardiac documentation stated: [R19] was seen on cardiac rounds today. She was coughing, crackles to lower base with rhonchi. Jugular vein slightly distended. [ R19's] diuretic dose was changed. CXR ordered. BNP ordered. Changes discussed with resident. UM to put resident on report so that staff can monitor patient and maintain her daily weights. On January 8, 2026, at 10:23 AM, an interview with Resident 19 revealed she had not been weighed, despite an active daily weight order. Record review of the MAR and EMR on January 8, 2026, at 10:39 AM showed weight entries that had been documented and initialed, although no weights were taken. Multiple daily weight entries were missing for the review period.

Based on review of facility policy, review of clinical records, observations, and staff interview it was determined that the facility failed to maintain personal care needs for dependent residents for two of 26 residents reviewed (Resident R68 and R10).Findings Include: Findings Include:Review of facility policy Activities of Daily Living (ADL), Supporting revealed appropriate care and services are provided for residents who are unable to carry out ADLs independently, to include hygiene (bathing, dressing, grooming, and oral care).Review of Resident R68's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated December 10, 2025, revealed the resident had impairment in functional limitation in range of motion in the upper and lower extremity and required set-up assistance with personal hygiene.Further review of Resident R68's MDS revealed the resident was assessed with moderate cognitive impairment and had diagnoses of cerebrovascular accident (CVA - a sudden interruption of blood flow to the brain), hemiplegia (one sided body paralysis) affecting right dominant side, malnutrition (when the body does not get the right amount of nutrients).Review of Resident R68's comprehensive care plan dated October 25, 2024, revealed the resident had an ADL self-care performance deficit and was dependent on staff for grooming/personal hygiene. Intervention dated December 4, 2025, revealed to check nail length and clean on bath day and as necessary.Observations on January 7, 2026, at 10:15 a.m. revealed Resident R68 had a right-hand contracture (a shortening and stiffening of muscles that limits joint movement). Resident R68's right hand was observed to lay naturally in a fist. Further observations on January 7, 2026, at 10:15 a.m. revealed the fingernails on Resident R68's right hand were long, folding into the palm of his/her hand. Resident R68 confirmed wanting the nails trimmed.Review of Resident R10's comprehensive MDS dated [DATE], revealed the resident had impairment in functional limitation in range of motion in the upper and lower extremity and was dependent on staff with personal hygiene.Further review of Resident R10's MDS revealed the resident was assessed with severe cognitive impairment and had diagnoses of arthritis (joint inflammation), aphasia (communication deficits), CVA, and hemiplegia or hemiparesis (one sided muscle weakness).Review of Resident R10's comprehensive care plan dated May 14, 2021, revealed the resident had an ADL self-care performance deficit and required assistance for grooming/personal hygiene. Intervention dated November 5, 2021, revealed to check nail length and clean on bath day and as necessary.Observations on January 8, 2026, at 12:15 p.m. revealed Resident R10 had a right-hand contracture. Resident R68's right hand was observed to lay naturally in a fist. On January 8, 2026, at 12:15 p.m. with the assistance of Licensed Nurse, Employee E11, he/she opened Resident R10's right hand to find the resident's long, thick, and dirty beneath the nail. Licensed Nurse, Employee E11, confirmed Resident R10's nails required care.28 Pa. Code 211.12 (d)(5) Nursing services.

Based on observations and interviews, it was determined that the facility failed to ensure that two of two passengers elevators were in operating condition. (#1 and #2 elevators) Findings include: Review of information reported to the State Survey Agency on May 23, 2025 included a concern regarding the elevators not working properly in the facility since December 2024. Concerns regarding resident's not going to dialysis treatment on the first floor due to an inoperable elevator on May 3, 2025 was also reported in the to the State Survey Agency on May 23, 2025. Review of facility documentation received on June 9, 2025 from the facility regarding the elevators indicated that on December 11, 2024 at 1:24 p.m. someone from the facility reported #2 passenger elevator as being shut down. Continued review of the documentation indicated that on December 12, 2024 elevator technicians arrived at 11:40 a.m. left the elevator out of services, and indicated in the above referenced documentation additional resources required. Review of facility documentation received on June 9, 2025 from the facility regarding the facility elevators indicated that on May 3, 2025 at 5:51 a.m. someone from the facility reported #1 passenger elevator as being shut down. Continued review of the documentation indicated that on May 3, 2025 at 8:36 a.m., elevator technicians arrived at the facility regarding the concern, and checked unit to verify proper and safe operation. During an interview on May 28, 2025 at 1:21 p.m. with the Regional Director of Operations (Employee E6) of the facility's onsite dialysis center, Employee E6 reported that on May 2, 2025, dialysis treatments were cancelled due to inadequate staffing in the onsite dialysis center. Employee E6 reported that dialysis treatments for May 2, 2025 were rescheduled for residents on May 3, 2025, but that facility's elevator was broken, so some residents did not get their dialysis treatments on the rescheduled day, May 3, 2025. During an interview with the unit manager (Employee E5) on May 28, 2025, at 11:52 a.m. the unit manager confirmed that due to an inoperable elevator on May 3, 2025, residents on the 2nd floor who were scheduled for their dialysis treatment make up session could not receive their treatment on May 3, 2025, due to the 2nd floor elevator not being able to go to the 1st floor, which is where the onsite dialysis center is located. During an interview with the Nursing Home Administrator (NHA) on May 27, 2025 at 11:15 a.m. the NHA reported that the #2 passenger elevator has been inoperable for a couple of months. It was clarified with the NHA that the #2 passenger elevator had actually been inoperable since December 2024, was still inoperable, and that it need to be repaired. The NHA reported that the repairs are scheduled to start on June 2, 2025. It was also confirmed during the above referenced interview that resident who resided on the 2nd floor were not able to receive their dialysis treatment on May 3, 2025, due to the inoperable #1 passenger elevator. 28 Pa Code 201.14 (a)(c)Responsibility of licensee 28 Pa Code 201.18 (b)(1)(3)(e)(1) Management 28 Pa 201.29 (a) Resident rights

Based on staff interviews, review of facility policy and the review of clinical records, it was determined that the facility failed to notify the physician when residents did not receive their hemodialysis treatment from the onsite dialysis center for 2 out of 2 residents reviewed (Resident R1 and Resident R2). Findings include: Review of the facility policy, End Stage Renal Disease dated September 2010 indicated that residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Review of Resident R1's May 2025 physician orders included the diagnoses of hypertension (high blood pressure); cerebral infarction (a stroke); cognitive communication deficit (difficulty performing activities of daily living safely & efficiently as well as communicating effectively); end stage renal disease (the gradual loss of kidney function reaches an advanced state) and dependance on renal dialysis (the process of filtering the blood of a person whose kidneys are not working normally). Review of Resident R1's May 2025 physician orders included a physician's order dated May 4, 2024, and monthly thereafter, for the resident to receive dialysis treatment onsite on Monday, Tuesday, Wednesday, Thursday and Friday. Review of information submitted to the State Survey Agency on May 23, 2025 indicated concerns regarding the resident not receiving dialysis treatment on his scheduled days due to the facility's onsite dialysis treatment center having to cancel the treatments due to inadequate staffing in the onsite dialysis center. During an interview on May 28, 2025 at 1:21 p.m. with the Regional Director of Operations (Employee E6) of the facility's onsite dialysis center, Employee E6 reported dates that dialysis services could not be provided due to the following reasons: - February 17, 2025, dialysis was cancelled for resident due to a flood on the 1st floor where the onsite dialysis is located. - March 31, 2025, dialysis was canceled due to inadequate staffing in the onsite dialysis center. Dialysis treatments for March 31, 2025 were rescheduled to April 5, 2025. - May 2, 2025, dialysis treatments were cancelled due to in adequate staffing in the onsite dialysis center. Dialysis treatments for May 2, 2025 were rescheduled for residents on May 3, 2025, but that facility's elevator was broken some residents did not get their dialysis treatments on the rescheduled day, May 3, 2025. Review of Resident R1's nursing notes dated February 17, 2025, at 11:13 a.m. indicated Resident R1 did not attend his scheduled dialysis treatment due to a doctor's appointment that he had scheduled for that day. Resident did not receive dialysis today due to an appointment. Left for appointment via stretcher accompanied by 3 EMT (Emergency Services) drivers @ 0815 (8:15 a.m.). During the above referenced interview with Employee E6, it was also reported that there was a flood in the onsite dialysis center and that treatment was not provided to any resident scheduled for dialysis on the above referenced day. Review of nursing notes did not show evidence that the facility ensured that the physician was notified that the resident did not receive dialysis treatment, as ordered on February 17, 2025 due to the flooding that occurred in the onsite dialysis center. During an interview with the unit manager (Employee E5) on May 28, 2025 at 11:52 a.m. the unit manager confirmed that there was no evidence in the clinical record that the physician was notified of the resident's missed dialysis treatment appointment on February 17, 2025. Review of a nursing note dated March 31, 2025 at 12:57 p.m. indicated that the resident's dialysis treatment for March 31, 2025 would be rescheduled for April 5, 2025 due to inadquate staffing in the onsite dialysis center on March 31, 2025. Review of nursing notes did not show evidence that the physician was notified that the resident did not attend his rescheduled dialysis appointment on April 5, 2025. During an interview with the unit manager on May 28, 2025, at 11:52 a.m. the unit manager (Employee E 5) confirmed that there was no evidence in the clinical record that the physician was notified of the resident's missed his rescheduled dialysis treatment appointment on April 5, 2025. Review of nursing notes on May 2, 2025 at 8:07 a.m. indicated that that resident did not receive dialysis treatment on May 2, 2025. During the above-referenced interview on May 28, 2025 at 1:21 p.m. with the Regional Director of Operations (Employee E6) of the facility's onsite dialysis center, Employee E6 reported that dialysis treatments for May 2, 2025 were cancelled due to inadquate staffing issued, and rescheduled for May 3, 2024 Review of nursing notes did not show evidence that the physician was notified that the resident did not attend his rescheduled dialysis appointment on May 2, 2025. Continued review of the nursing notes indicated that the physician was not notified that the resident did not attend his rescheduled dialysis appointment on May 3, 2025. During an interview with the unit manager on May 28, 2025, at 11:52 a.m. the unit manager (Employee E5) confirmed that due to an inoperable elevator on May 3, 2025, residents on the 2nd floor who were rescheduled for dialysis treatment on May 3, 2025 could not attend, due to the 2nd floor elevator not being able to go to the 1st floor, which is where the onsite dialysis center is located. Continued interview with the unit manger revealed that was no evidence in the clinical record that the physician was notified of the resident's missed dialysis treatment appointment on May 2, 2025 or on May 3, 2025. Review of the resident's dialysis attendance from February 2025 through May 2025 provided by Employee E6 also indicated that the resident also did not attend a dialysis treatment session on February 7, 2025. Review of the resident's nursing notes dated February 7, 2025 at 7:27 p.m. indicated that the resident did not attend dialysis treatment on the referenced date. Continued review of the clinical record did not show evidence that the physician was notified that the resident did not attend this appointment. During an interview with the unit manager on May 28, 2025, at 11:52 a.m. the unit manager confirmed that the clinical record did not show evidence that the physician was notified that the resident did not attend the treatment appointment on February 7, 2025. Review of Resident R2's May 2025 physician orders included the following diagnoses of adult failure to thrive (weight loss, decreased appetite, poor nutrition); cerebral infarction (a stroke); end stage renal disease (the gradual loss of kidney function reaches an advanced state) and dependance on renal dialysis. Review of Resident R2's May 2025 physician orders included a physician's order dated May 7, 2024, and monthly thereafter, for the resident to receive dialysis treatment onsite on Monday, Tuesday, Thursday and Friday. Review of the resident dialysis treatment schedule for Resident R2 provided by Employee E6 indicated that that resident did not receive dialysis treatment on May 2, 2025 due to inadequate nursing staff in the dialysis center. Employee E6 stated that the onsite dialysis center would reschedule the missed May 2, 2025 dialysis appointments to May 3, 2025. Review of nursing notes did not show evidence that the physician was notified that Resident R2 did not attend his rescheduled dialysis appointment on May 2, 2025. Continued review of the nursing notes indicated that the physician was not notified that the resident did not attend his rescheduled dialysis appointment on May 3, 2025. During an interview with the unit manager (Employee E5) on May 28, 2025, at 11:52 a.m. the unit manager confirmed that due to an inoperable elevator on May 3, 2025, residents on the 2nd floor who were scheduled for dialysis treatment located on the 1st floor could not attend, due to the 2nd floor elevator not being able to go to the 1st floor. Continued interview with the unit manger revealed that was no evidence in the clinical record that the physician was notified of the resident's missed dialysis treatment appointment on May 2, 2025, or on May 3, 2025. 28 Pa. Code 211.5(f) Medical records 28 Pa Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of clinical records, facility policy and interview with staff, it was determined that the facility failed to conduct a complete and through investigation for an allegation of potential abuse/neglect for 1 out of 2 residents reviewed (Resident R1). Findings include: Review of the facility policy, Abuse, Neglect, Exploitation or Misappropriation - Reporting, with a revision date of September 2022 indicated that reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations), and are thoroughly investigated by facility management. The policy also stated that the administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. Review of Resident R1's May 2025 physician orders included the diagnoss of hypertension (high blood pressure); cerebral infarction (a stroke); cognitive communication deficit (difficulty performing activities of daily living safely & efficiently as well as communicating effectively); end stage renal disease (the gradual loss of kidney function reaches an advanced state); dependance on renal dialysis (the process of filtering the blood of a person whose kidneys are not working normally). Review of information reported to the State Survey Agency on May 23, 2025 include a copy of a grievance that was addressed to the Nursing Home Administrator and the Regional Director of Operations for the facility (Employee E3) regarding concerns related to the resident's care. The concern indicated that On the evening of February 10, 2025, at 9:00 p.m. the resident contacted his wife stating that he needed assistance with changed, staff did not respond in a timely manner and that the resident was found to be lying in soiled pajamas that were soaked in urine with feces. Review of the report form investigation of alleged abuse, neglect, misappropriation of property (PB-22) revealed that the investigation regarding the matter was initiated by the facility on February 11, 2025, at 11:00 a.m. and was completed by the facility on February 13, 2025 at 3:00 p.m. Review of the interview the facility conducted with Employee E4 (assigned nurse aide for Resident R1) on February 13, 2025 included the following statement from Employee E4: I checked on [name of resident] at the beginning of the shift asked if he needed anything no. throughout the resident my shift I was checked upon [name of resident] took him his dinner Tray he never complained or ask for anything said he was ok just sleepy and tired. Upon doing my last around his family was on unit and asked for him to be changed. I went ahead and changed [name of resident]. Review of the undated interview that the facility conducted with the resident included the following statement: I was given my dinner at 5p.m. by [name of a nursing staff member]. I hit my call light, but nobody came. My dinner was still on my table. My wife and daughter came back up around 9:30 p.m. I was soiled and it went always[sic] through my pants. The big girl with the dreads [name of Employee E4] came and took my tray and changed me about 10 p.m. Review of an undated interview that the facility conducted with Employee E5 (nurse aide) indicated that the resident' daughter and mother came on the unit and the resident was harassing a nurse (Employee E6) .was belligerent and threatening as usually. Review of an undated interview that the facility conducted with the licensed nurse (Employee E6) who worked the 3:00 p.m. through the 11:00 p.m. on the resident's floor included the following statement I was on the cart for 3-11 and did not see resident' call light on. Some residents did not get changed earlier than usually. However, everyone was taken care of before the end of the shift including [named resident R1]. Continued review of the investigation indicated that the facility found that the allegation of neglect was found to be unsubstantiated. Review of the facility's investigation did now provide any evidence that a complete and through investigation was conducted to rule out potential abuse/ neglect. There was no evidence that the facility asked the resident's assigned nurse aide (Employee E5) what time, if any, did she assisted the resident with his toileting needs during her shift that was from 3:00 p.m. through 11:00 p.m. on February 10, 2025. During an interview on May 28, 2025 at 1:44 p.m. with the Nursing Home and the facility's Regional Director of Operation's (Employee E3) the facility could not provide any evidence that the facility asked the assigned nurse aide, if she assisted the resident with his toileting needs and/or assisted the resident with changing his brief at any time during her shift, and if so, when. 28 Pa. Code 201.14(a)(e) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.10(d) Resident care policies

Based on review of clinical records, staff interviews and review of facility policy, it was determined that the facility failed to ensure that grievences were investigated and prompt efforts were made to resolve grievances for 1 out of 2 residents reviewed (Resident R1). Findings include: Review of the facility policy, Grievances Complaints, Filings, with a revision date of April 2017 indicated that all grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered, and that actions on such issues will be responded to in writing, including a rationale for the response. The policy also stated that upon receipt of a grievance and/or complaint, the grievance officer or designee will review and investigate the allegations and submit a written report of such findings within five (5) working days of receiving the grievance and/or complaint. Continued review of the policy indicated that the grievance officer and associated department director will review the findings to determine what corrective actions, if any, need to be taken, and that the resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems. Review of Resident R1's May 2025 physician orders included the diagnoses of hypertension (high blood pressure); cerebral infarction (a stroke); cognitive communication deficit (difficulty performing activities of daily living safely & efficiently as well as communicating effectively); end stage renal disease (the gradual loss of kidney function reaches and advanced state); dependance on renal dialysis. Review of information reported to the State Survey Agency on May 23, 2025 include a copy of a grievance that was sent by electronic correspondence regarding concern related to Resident R1's care. The grievance was addressed to the Nursing Home Administrator and the Regional Director of Operations for the facility (Employee E3), in addition to others. The electronic correspondence was dated as being sent to the above referenced parties on February 13, 2025 consisted of the following concerns: Dear Authorities of [name of facilitiy] and All Concerned Parties, This email is addressed to all individuals responsible for the care and well-being of my father, [name of resident], particularly the staff at [facility name] and its partner organizations. On the evening of February 10, 2025, at 9:00 PM, my father called my mother [name of mother] pleading for assistance in getting someone to change him. He reported that he had been requesting to be changed since 7:00 PM, yet no one had responded. When my mother and I arrived at the facility, we spoke with the supervising nurse[name of nurse] who informed us that the second floor has been understaffed for some time. It is important to note that this is not the first time I have heard from both nurses and CNAs (nurse aides) about inadequate staffing levels. This is why, in my last email/grievance to [name of the facility's nursing home administer]. I specifically inquired about staffing and was assured that the facility had adequate coverage. However, when I asked about the staffing ratio for the evening, Nurse [name] confirmed that only five staff members-three CNAs and two nurses, including herself-were responsible for all patients on the second floor. Additionally, upon our arrival, there was no attending nurse at the second-floor desk, and the front desk phone was not functioning properly. When we attempted to call the facility at [facility phone number], the phone rang continuously without an answer. When I requested that my father be changed, my mother informed Nurse [name] that she had already been calling for over an hour with no response. Nurse [name] then called a CNA named [name], who eventually arrived to assist. At this time, my father stated that he had not been changed since earlier that afternoon. His pajama pants were soiled and soaked through, and feces had spread up his legs. (I have photos and video of the solid depend and pajama pants bagged and given to me by CNA [name]. As we left, Nurse [name] attempted to justify the situation, stating: I am not going to lie. We are understaffed, and it's frustrating. We are doing our best to work as a team to provide care.While I acknowledge her honesty, this is not just a staffing issue-it is a serious matter of safety and quality of care. The conditions my father is enduring are unacceptable, and as I stated to Nurse [name], they pose a direct risk to his health and dignity. This raises several critical concerns that require immediate clarification: 1.Is a 5:62 patient-to-staff ratio within state regulations for a skilled nursing facility? 2.Is it within CNA protocol to leave a patient unchanged and unattended for hours? 3.Is it within state regulations to leave a patient unshowered for five days? These ongoing issues must be addressed without delay. At this time, my family is formally submitting another official grievance. We demand a written response that provides a logical, compassionate, and consistent resolution to these serious deficiencies in care. Please provide a clear plan of action detailing how these persistent staffing failures will be resolved. The current conditions do not align with your facility's written mission statement and endanger the well-being of the patients in your care. We expect a prompt response and a concrete resolution. Sincerely, [name of resident's daughter] Review of information submitted to the State Survey agency in February 2025 indicated that on February 10, 2025 at 8:00 p.m. indicated the following: .The facility received a notification from the resident's daughter that on the 3:00-11:00 shift on 2/10, she alleged that her father was left in his soiled diaper for extended period of time. During this time the family has an allegation of neglect. The investigation was found to be unsubstantiated. Review of the facility's grievances from February 2025 through May 28, 2025 did not list the above referenced grievance dated February 10, 2025. No documentation could be found to show evidence that the facility investigated all of the above referenced grievences outline in the February 10, 2025 written correspondence or made any prompt efforts to resolve all of the above the above referenced grievances that was sent to them related to the resident's care. Review of information reported to the State Survey Agency on May 23, 2025 include copies a grievance dated May 6, 2025 that was addressed to the Nursing Home Administrator and the Regional Director of Operations for the facility (Employee E3): Hi [name of Regional Director of Operations] I wanted to bring to your attention another ongoing concern regarding my father's care. Tonight, [name of CNA] was asked at 7:00 PM to assist with changing [name of resident]. He waited until 8:30 PM, but she never arrived. Maybe it was during a shift change, but someone should have assisted him. It appears the call system may not be functioning properly. At 8:30 PM, my father used the call bell again with no response. My mother ultimately called the second-floor nursing station at 9:23 PM, and someone finally came to assist. Unfortunately, this is not an isolated incident. These delays are happening frequently, and despite the recent care plan meeting, there have been no noticeable improvements. Can you please confirm whether the call system is working as expected, and clarify who is supervising the CNAs? We're concerned that basic shift responsibilities are not being met, and it seems patients are not being checked on consistently. I do not want another incident to occur. Thank you for looking into this. Review of the facility's grievances from February 2025 through May 28, 2025 did not list the above referenced grievance dated May 6, 2025. No documentation could be found to show evidence that the facility to investigated the grievance, or made any prompt efforts to resolve the grievences related to the resident's care (e.g. allegation that the resident was not provided with care in a timely manner and a concern that the resident's call bell was not working). During an interview with the resident's daughter on May 28, 2025 at 2:28 p.m. the resident's daughter reported that she still has not received a response from the facility regarding the grievance that she reported in February 2025 or on May 6, 2026 regarding her father's care. She reported that she received, no findings or anything on what went on. The resident's daughter reported I asked for a written response when I wrote the grievance but did not get anything. During an interview on May 28, 2025 at 1:44 p.m. with the Nursing Home and the facility's Regional Director of Operation's (Employee E3) did acknowledge receiving the grievance on February 10, 2025 and May 6, 2026. During the interview the facility could not provide any evidence that all of the concerns documented in the resident's daughter's grievance dated February 10, 2025 and May 6, 2025 were investigated by the facility, and prompt efforts were made to resolve them. 28 Pa. Code 201.18 (b)(1)(3)(2.1)(4) Management 28 Pa. Code 201.29 (a) Resident Rights

Based on observations, and staff interviews, it was determined that the facility failed to ensure that a 1 out of 3 residents reviewed was assess for self administration of medications. (Resident R3). Finding include: During an observation in Resident R3's room on May 28, 2025 at 2:30 p.m. a bottle of the above referenced medicated lotion was observed a 2nd time sitting on top of the resident's dresser, and not secured. In addition, a medication cup with 3 white pills were observed on the resident's bedside table. When resident asked if they were left there for him to take, Resident R2 reported, yes, the nurses leave them here for me all the time. During an interview with Employee E7 (licensed nurse) on May 28, 2025 at 2:50 p.m. the licensed nurse confirmed that she provided the resident with his medication in his room, and did not observe him take it. She reported that the three pills that were observed in the resident's medication cup were 2-5 milligram tablets of the medication, baclofen, that is prescribed for chronic pain, and 1-5 milligram tablet of oxycodone that is prescribed to the resident for pain levels. Review of Resident R3's clinical record revealed no evidence that the facility assess the resident to self administer medications. 28 Pa. Code 211.12(d)(1) Nursing services

Based on observations, staff interviews, review of facility policy and the review of clinical records, it was determined that the facility failed to ensure that medications were properly labeled and stored according to professional standards for 1 out of 3 residents reviewed (Resident R3). Findings include: Review of the facility policy, Medication Labeling and Storage with a revision date of February 2023 indicated that the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner, and that medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Continued review of the policy indicated that each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. Review of the May 2025 physician orders for Resident R3 included the diagnoses of glaucoma (an eye condition that can lead to vision loss or blindness); chronic obstruction pulmonary disease (COPD-a progressive lung condition that makes it difficult to breath); xerosis cutis (abnormally dry skin); dermatitis (causes swelling and irritation of the skin). Continued review of May 2025 physician orders included a physician's order dated February 26, 2025 for the resident to have the medicated lotion, Amlactin applied to his legs, once a day, for dry skin. Amlactin Daily External Lotion 12 % (Lactic Acid (Ammonium Lactate) Apply to Legs topically one time a day for dry skin. During an observation in Resident R3's room on May 27, 2025 at 1:47 p.m. a bottle of the above referenced medicated lotion was observed sitting on top of the resident's dresser, and not secured. During the observation, it was noted that there was no labeling on the bottle indicating who the medication was prescribed to, as there was no individual's name listed on the medication bottle. The facility Nursing Home Administrator (NHA) , Director of Nursing (DON) were notified of this observation on May 27, 2026 at 3:00 p.m. 28 Pa Code 201.18(b)(1) Management 28 Pa Code 211.12(d)(1)(2)(5) Nursing services

Based on the review of clinical records, interviews with staff, it was determined that the facility failed to administer medication as ordered by the physician for one of 8 residents reviewed. (Resident R1). Findings Include: Interview with Resident R1 conducted on May 8, 2025, at 10:00 a.m. revealed that the nurse does not apply the moisturizer cream, she is supposed to do it all the time. Review of Resident R1's clinical record revealed resident was admitted to the facility on [DATE]. Review of physician orders for Resident R1 revealed an order dated February 26, 2025, which indicated Apply moisturize cream within 3 mins of shower to lock in moisture (CervaVe, Eucerin, Cetaphil, Aveeno) Repeat application as needed to establish dry areas. Review of Resident R1's clinical record revealed that the resident receives showers on Tuesdays and Fridays during the week. Review of April 2025's Medication Administration Record for Resident R1 revealed resident was receiving moisturizer as ordered on Fridays, after showers. Continued review failed to reveal documented evidence that the moisturizer was applied by facility staff after shower on Tuesdays, as ordered. Interview conducted on May 8, 2025, at approximately 11:30 a.m. with the facility Administrator and Director of Nursing confirmed that the moisturizing cream was not applied by facility staff on Tuesdays after the resident's shower. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observations and resident and staff interviews, it was determined that the facility failed to maintain the facility in a clean, comfortable, and homelike condition for four of 15 residents reviewed (R12, R13, R14 and R15). Findings include: Observations during a tour of the facility on March 25, 2025, at 11:15 a.m. revealed the following concerns: Observations on March 25, 2025, at 11:15 a.m., in room [ROOM NUMBER], revealed that the room had a very strong urine odor. Interview with Resident R12, room [ROOM NUMBER] Bed D revealed that the room always smells of stale urine as Resident R14, who is in Bed A in room [ROOM NUMBER], always urinates on the floor. She said that is goes on every day. She said that the room is also very cold, that when the nurse aides come in the turn down the temperature on the heating unit under the window. She said that she has been complaining about this, but nothing is done. She said that her bed is broken, that the head of the bed does not go up all the way. She also said that the cord on her overbed light is too short for her to reach when she is in bed, so she is unable to turn the light on or off unless she is out of bed which is difficult for her at night. Attempts to interview Resident R14 were unsuccessful, as she refused to speak to anyone at 11:25 a.m. on March 25, 2025. Resident R13, room [ROOM NUMBER] Bed C and Resident R15, room [ROOM NUMBER] Bed B, were resting in bed with their eyes closed during the tour of their room. Interview with Employee E4, the Unit Manager on the second floor on March 25, 2025, at 11:55 a.m. confirmed that the odor in room [ROOM NUMBER] was overwhelming. She said that Resident R14 has behavior issues and refuses to use the toilet to urinate, that she goes in her trash can and she does not allow anyone to empty the trash can and it spills onto the floor. He said that the resident refuses to allow staff to place a bedside commode next to her bed. She also refuses to allow staff to bathe her, except one nurse aide who she will occasionally allow to clean her up. Interview with the Administrator and Regional Director of Operations at 1:15 p.m. on March 25, 2025, confirmed that the conditions in room [ROOM NUMBER], including the pervasive odor of urine does not provide a clean, safe, homelike environment for the other three residents who live in the room with Resident R14. 28 Pa Code 201.18(e)(2.1) Management

Based on review of facility policy, review of clinical records, and staff interviews, it was determined that the facility failed to ensure that Resident R1 was properly secured during transfer via the use of a sit-to-stand mechanical device and failed to ensure that the safest mechanical device was utilized during transfer for one of four residents reviewed (Resident R1). This failure resulted in actual harm to Resident R1 who sustained a fracture of the right tibia and fibula. Findings include: Review of undated facility policy Lifting Machine, Using a Mechanical revealed the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. Mechanical lifts may be used for tasks such as transferring a resident from bed to chair. Types of lifts include sit-to-stand and floor-based full body sling lifts (also known as a Hoyer Lift). Before using a lifting device, staff should assess the resident's current condition including assessment of the resident's weight and medical condition to ensure appropriate use of a lift. Staff should double check the sling and machine's weight limits against the resident's weight. Review of Resident R1's Comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated March 8, 2023, revealed the resident had diagnoses of hemiplegia (paralysis on one side of the body) following cerebral infarction (stroke - lack of blood to the brain) affecting right side dominant, osteoporosis (weakened bones), muscle weakness, and muscle wasting. Continued review of the MDS revealed the resident required extensive, two persons physical assistance during transfers. Review of Resident R1's care plan dated initiated July 9, 2019, revealed the resident was at risk for falls related to deconditioning, gait/balance problems, and osteoporosis. Further review of Resident R1's care plan dated initiated July 29, 2019, revealed the resident had an activities of daily living self-care performance deficit with activity intolerance, fatigue, and impaired balance. Intervention dated August 8, 2019, revealed the resident required mechanical Hoyer Lift for transfers with 2-person physical assistance. Review of Resident R1's clinical record revealed a progress note dated April 12, 2023, by Licensed Nurse, Employee E6, that the resident's right leg pushed back during a transfer to the wheelchair with the sit-to-stand mechanical lift. Review of facility documentation revealed on April 12, 2023, Resident R1 was being transferred from the bed to wheelchair using sit-to-stand mechanical left with assistance from nurse aide, Employee E5, and nurse aide, Employee E4. During use of the sit-to-stand mechanical lift, the belt that buckled around Resident R1's waist was noted to be secure, but loosely fitted. Statement by nurse aide, Employee E5, revealed the resident slid down and the right foot went backwards during transfer. Upon a full body assessment, Resident R1 complained of pain of 8 out of 10 and the right lower leg appeared to be in an abnormal position. Resident R1 was subsequently transferred to the hospital for evaluation and diagnosed with fracture of the right tibia/fibula (two long bones located in the lower leg) . Review of Resident R1's orthopedic consult dated April 18, 2023, revealed Resident R1 was seen for follow-up for fracture of the right tibia/fibula. Review of the consult revealed Resident R1 had a stroke about a year ago and had been nonambulatory since then, and did not use right leg for transfers. Further review of the consult revealed Resident R1 complained of a pain of 10 (on a scale of 1-10, worst pain ever) to the right ankle. Visual instruction and interview on April 24, 2023, at 12:40 p.m. with the Director of Nursing, Employee E2, and Regional Clinician, Employee E8, revealed to use the mechanical sit-to-stand lift and how the strap is buckled around the resident's waist. Visual instruction by Regional Clinical, Employee E8, revealed the strap was buckled, but not tightened to securely fit around Resident R1's waist. Interview on April 24, 2023, at 12:55 p.m. with Licensed Nurse, Employee E6, confirmed Resident R1 had lower extremity weakness and was unable to stand supporting her own weight. Further interview confirmed that the waist strap should be securely tightened to help provide support when using sit-to-stand lift. Interview on April 24, 2023, at 1:45 p.m. with Director of Rehabilitation, Employee E7, confirmed nursing staff should have used a mechanical Hoyer lift to transfer Resident R1 from the bed to wheelchair. Employee E7 reported that Resident R1 was not deemed safe for use of sit-to-stand lift due to lower extremity weakness and unable to support self. Interview on April 24, 2023, at 1:55 p.m. with nurse aide, Employee E4, revealed when she walked into Resident R1's room, the nurse aide, Employee E5, already had Resident R1 situated on the mechanical sit-to-stand lift. Employee E4 reported that she noticed the wrong strap was being used based on Resident R1's size. When they began to move the sit-to-stand lift Resident R1's right leg buckled, and the resident fell . Interview on April 24, 2023, at 2:00 p.m. with nurse aide, Employee E5, revealed the nurse aide was unaware the resident required a mechanical Hoyer lift for transfers. Employee E5 reported staff have been using mechanical sit-to-stand lift for at least a year. Further interview with Employee E5 confirmed the wrong strap was used to support the resident's size. The facility failed to ensure that Resident R1 was properly secured during transfer via the use of a sit-to-stand mechanical device and failed to ensure that the safest mechanical device was utilized which resulted in actual harm to Resident R1 who sustained a fracture of the right tibia and fibula. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.29(c) Resident rights

Based on observations, review of facility policies, facility documentation and interviews with staff, it was determined that the facility failed to ensure that water temperatures in resident bathroom hand sinks were maintained at a safe temperature for two of two nursing units observed (First Floor and Second Floor Nursing Units). This failure placed residents on the First and Second Floor Nursing Units at risk for serious injury from a burn and resulted in an Immediate Jeopardy situation for 52 of 109 residents (Resident R4, R5, R7, R8, R10, R12, R13, R14, R15, R16, R18, R29, R30, R33, R37, R40, R44, R45, R46, R48, R49, R51, R52, R62, R64, R72, R73, R74, R79, R83, R85, R88, R89, R90, R91, R92, R93, R104, R105, R107, R110, R112, R114, R116, R118, R121, R124, R128, R230, R300, R301, and R302) who were identified as having the physical ability to access the hot water outlets in the sinks and/or shower rooms throughout the entire facility. Findings include: Review of facility policy titled Physical Environment: Housekeeping and Maintenance, dated June 2020, revealed: -The facility will be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel, and the public. - Hot water to residents shall be controlled so that the water temperature of the outlets does not exceed 110 degrees Fahrenheit (°F). -The maintenance department is to keep water temperature logs. -Direct-care staff shall be informed to feel the water to make sure it is comfortable and to report to the Supervisor if it feels too warm or too cold. Review of the, American Burn Association Scald Injury Prevention Educator's Guide, dated 4/25/17, indicated older adults have thinner skin therefore hot liquids cause deeper [CONDITION(S)] with even brief exposure, and older adults' ability to feel heat may be decreased due to certain medical conditions or medications. The American Burn Association Guide also provided this table: Time and Temperature Relationship to Serious [CONDITION(S)] Water Temperature and Time Required for a 3rd Degree Burn to Occur 155°F - 1 sec 148°F - 2 sec 140°F - 5 sec 133°F - 15 sec 127°F - 1 min 124°F - 3 min 120°F - 5 min 100°F - Safe Temperatures for Bathing Observation conducted on 6/28/21, at 12:00 p.m. of the conference room bathroom hand sink on the first floor revealed that the hot water felt uncomfortably too hot to the touch. Facility water temperature log indicated that weekly testing was preformed and was due on 6/28/21. All previous entries had temperatures no higher than 109 °F. During an interview and observation on 6/28/21, at 4:15 p.m. Maintenance Director Employee E10 revealed the water temperatures of above 125 °F. On 6/28/21, at 4:30 p.m. the Maintenance Director Employee E10 began an audit of all resident rooms and bathing areas. The following was revealed: 68 water outlets tested . -2 out of 68 outlets were at a safe temperature. -16 of 68 outlets were between 111 °F and 119 °F. -37 of 68 outlets were between 120 °F and 129 °F. -9 of 68 outlets were above 130 °F. -3 of 68 outlets were non-operable. First Floor Shower Room One Shower 111 °F. Sink 132 °F. First Floor Shower Room Two Shower 111 °F. Sink 112 °F. First Floor resident sinks: 151 124 °F. 152 113 °F. 153 126 °F. 154 128 °F. 155 130 °F. 156 121 °F. 157 132 °F. 158 119 °F. 159 117 °F. 160 129 °F. 161 130 °F. 162 118 °F. 163 111 °F. 164 130 °F. 165 122 °F. 166 124 °F. 167 125 °F. 168 129 °F. 169 111 °F. 170 121 °F. 171 124 °F. 172 121 °F. 173 118 °F. 174 132 °F. 175 121 °F. 176 125 °F. 177 114 °F. 178 112 °F. 179 128 °F. 180 108 °F. 181 109 °F. Second Floor Shower Room One Shower: 111 °F. Sink: 130 °F. Second Floor Shower Room Two Shower: 117 °F. Sink: 130 °F. Second Floor resident sinks: 251 131 °F. 252 130 °F. 253 120 °F. 254 No running hot water 255 119 °F. 256 127 °F. 257 126 °F. 258 107 °F. 259 129 °F. 260 124 °F. 261 129 °F. 262 125 °F. 263 No running hot water 264 119 °F. 265 128 °F. 266 124 °F. 267 126 °F. 268 127 °F. 269 No running hot water 270 127 °F. 271 121 °F. 272 126 °F. 273 124 °F. 274 128 °F. 275 128 °F. 276 125 °F. 277 127 °F. 278 123 °F. 279 121 °F. 280 125 °F. 281 126 °F. During an interview on 6/28/21, at 7:30 p.m. Unit Manager Employee E1 and Licensed Practical Nurse Employee E10 determined which residents had the physical ability and dexterity to access the hot water outlets in the sinks and/or shower rooms independently. (52 out of 109 residents). The Nursing Home Administrator (NHA) and the Director of Nursing (DON) were made aware that Immediate Jeopardy existed on 6/28/21, at 8:29 p.m. and a corrective action plan was requested. On 6/28/21, at 8:32 p.m. the Immediate Jeopardy template was provided to the facility administration. On 6/29/21, at 12:57 a.m. an acceptable Corrective Action Plan was approved which included the following interventions: 1. The hot water was turned off. The plumber was on site to fix the hot water issue. Mixing supply valve adjusted. 2. Temporary out of hot water signs placed at all nurse's stations. 3. Hot water outlets in resident areas were taped and staff notified that the hot water should not be used until further notice. 4. Maintenance staff or designee will remain on site making hourly rounds to ensure that the hot water temperatures are below 110 °F, recorded in the temperature log, until temperature remains stable at <110 °F x four hours. 5. Administrator, DON, or designee will review the logbook daily for two weeks, weekly for 4 weeks, and then quarterly at the QAPI (Quality Assurance and Performance Improvement) meetings to ensure that the temperatures are at a safe level. Will review to make sure that water temperatures are in a safe range. 6. DON or designee will in-service care staff and therapy on how to check water temperatures before use and what to do when the temperatures are above 110°F. Upon arrival to work, staff will be immediately, prior to them beginning their shift, will be provided education on (a. hot water safety policy, b. use of a thermometer to test water temperature prior to resident shower use, or providing a bed bath to ensure safe temperature). 7. It will not affect kitchen, boiling water available. Laundry services will be affected. But we have emergency linen and towels supply on hand, easily accessible. 8. The facility will educate 80% of active staff within 24 hours, and 100% of active staff within 48 hours. During staff interviews on 6/29/21, between 12:00 p.m. and 3:45 p.m. 17 direct care nursing staff (Registered Nurse Employee E1, E6, Licensed Practical Nurse Employee E5, E7, E8, E9, E20, E21, E22, E23, Nurse Aide Employee E16, E17, E18, E19, E24, E25, E26) confirmed they had attended trainings, understood how to check water temperature, and knew what to do if water temperatures exceeded 110°F. A review of the documentation received from the facility on 6/29/21, at 4:30 p.m. revealed that all elements of the Corrective Action Plan were substantially completed per the facility's action plan. The Immediate Jeopardy was lifted on 6/29/21, at 5:15 p.m. when the action plan implementation was verified. During an interview on 6/29/21, at 5:15 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to ensure that water temperatures in resident bathroom hand sinks were maintained at a safe temperature for two of 2 nursing units. This failure placed the facility in an Immediate Jeopardy situation for 52 of 109 residents. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/supervision/devices Previously cited 5/29/19, 9/18/18 28 Pa Code 201.14(a) Responsibility of licensee Previously cited 2/24/21, 5/29/19, 9/3/20, 6/14/18 28 Pa Code 201.18(a) Management Previously cited 5/29/19, 6/14/18 28 Pa Code 201.18(b)(1)(3) Management Previously cited 9/3/20, 5/29/19, 6/14/18 28 Pa Code 205.63(c) Plumbing and piping systems required for existing and new construction Previously cited 9/18/18 28 Pa Code 211.12(d)(3) Nursing services Previously cited 2/24/21, 10/4/19, 5/29/19, 6/14/18 28 Pa Code 211.12(d)(5) Nursing services Previously cited 2/24/21, 10/4/19, 5/29/19, 9/5/18, 6/14/18

Based on review of clinical records, resident interview, and staff interviews, it was determined that the facility failed to make certain that proper pain management was provided for one of 10 residents reviewed (Resident R67), resulting in harm when the resident suffered severe pain without effective relief. Findings include: A clinical record review revealed that Resident R67 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual Minimum Data Set assessment (MDS - a comprehensive, standardized assessment of each resident's functional capabilities and health needs) dated 5/7/21, indicated that the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A clinical record review revealed Resident R67 was admitted to Hospice services (supportive care given to people in the final phase of a terminal illness and focus on comfort and quality of life) on 5/7/21. A review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR failed to reveal the administration of acetaminophen during that time. A review of the care plan revealed Resident R67 was at risk for chronic pain and nursing staff will monitor/record/report to the nurse, resident complaints of pain or requests for pain treatment. During an interview on 6/30/21, at 8:21 a.m. Resident R67 stated that she has been in pain all night, rating pain as 10/10 (on a pain scale with 10 being the worst pain she could imagine, and 0 being no pain at all) in the right shoulder, and left arm and hand was rated at 6/10 on a pain scale. Resident R67 stated that pain is frequent and happens daily. Resident R67 stated that when the nurse is told about the pain they only bring acetaminophen which is not effective for the pain. During an interview on 6/30/21, at 8:25 a.m. Unit Manager Employee E1, confirmed Resident R67 is only ordered acetaminophen for pain, stating, but she has cancer all through there, while motioning to her left arm in an up and down gesture. During an interview on 6/30/21, at 9:12 a.m. Nurse Aide Employee E2, confirmed that Resident R67 had complained of pain on more than one occasion. During an interview on 6/30/21, at 9:14 a.m. Unit Manager Employee E1 stated that she was calling the doctor, to activate her [MEDICATION(S)], and further stated that Resident R67 's pain medication would be [MEDICATION(S)] 5 mg every 3 hours as needed for pain, but she won't be getting it that often, because I don't feel she needs it. During an interview on 6/30/21, at 9:54 a.m. Licensed Practical Nurse Employee E3 confirmed that Resident R67 does complain of pain that is usually stated as a 5-6/10, on the pain scale, for which she is ordered acetaminophen. LPN Employee E3 stated that her pain was charted as zeros because it is, occasional pain. He was not able to answer why there was not an administration record for the acetaminophen. There was no evidence to indicate that the resident received acetaminophen for pain management or documentation that pain was assessed prior to or following medication administration. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited: 2/24/21, 5/29/19, 9/3/20, 6/14/18 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. Previously cited: 9/3/20, 5/29/19, 6/14/18 28 Pa. Code 201.20(a)(b)(c)(d) Staff development. 28 Pa. Code 201.29(j) Resident rights. Previously cited 5/29/19, 6/14/18 28 Pa. Code: 207.2(a) Administrator's responsibility. Previously cited: 9/3/20, 5/29/19 28 Pa. Code 211.5(f) Clinical records. Previously cited: 9/3/20, 5/29/19, 6/14/18 28 Pa. Code 211.10(a) Resident care policies. Previously cited 5/29/19 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.10(d) Resident care policies. Previously cited: 10/4/19, 5/29/19, 6/14/18 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 2/24/21, 10/4/19, 5/29/19, 9/5/18, 6/14/18 28 Pa. Code 211.12(d)(2) Nursing services. Previously cited 5/29/19, 6/14/18 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 2/24/21, 10/4/19, 5/29/19 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 2/24/21, 10/4/19, 5/29/19, 9/5/18, 6/14/18

Based on a review of medical records and facility documentation and interviews with staff, it was determined that the facility failed to provide the appropriate assistance to one resident while drinking a hot beverage which resulted in actual harm, related to a burn, for one of 34 residents reviewed (Resident R68). Findings include: Review of medical records for Resident R68 revealed diagnoses, including but not limited to, dementia (a broad category of brain diseases most notable for decline in memory and other mental abilities), absolute [MEDICAL CONDITION] (this is the end stage of all types of [MEDICAL CONDITION] where the eye has no vision) and paresis (muscular weakness caused by nerve damage or disease-a state of [DIAGNOSES REDACTED]). Further review of Resident R68's medical records revealed an Occupational Therapy (OT) discharge summary dated (MONTH) 13, (YEAR) to (MONTH) 29, (YEAR). The discharge summary indicated that Resident R68's baseline for self-feeding as of (MONTH) 29, (YEAR), was contact guard assistance (there is a high probability of the resident needing assistance and the helper should have a hand on the resident but not give assistance unless needed) while trying the task herself. Interview with the Director of Rehabilitation Services (DRS) on (MONTH) 28, 2019, at 11:34 a.m. confirmed that Resident R68 was discharged from therapy on (MONTH) 29, (YEAR), with recommendations to nursing staff which included assistance with eating and self-feeding which meant the resident required cueing (the caregiver provides verbal and tactile reminders to facilitate safe functional mobility to perform the task) and contact guard assistance. The DRS confirmed that recommendations made by the therapy department are expected to be adopted by the nursing and do not require a physician's orders [REDACTED]. Review of facility documentation revealed that Resident R68 sustained a burn during a daytime activity involving a hot drink on (MONTH) 11, (YEAR). The burn formed three fluid filled blisters along the right hip and right lateral (side) thigh measuring 34.5 cm (centimeter) by 5.4 cm, 3.5 cm by 2.0 cm and 1.7 cm by 1.5 cm. Interview with the Director of Nursing (DON) on (MONTH) 28, 2019, at 11:04 a.m. revealed that one nursing assistant poured a drink of hot tea for Resident R68 during a group activity on (MONTH) 11, (YEAR) and continued around the table pouring hot drinks for other residents. Another nursing assistant arrived and notified the first nursing assistant that there was water on the floor under Resident R68's wheelchair and an empty hot beverage cup with the lid on, lying next to the resident's right leg in the wheelchair, along the edge of the chair. Interview with the DON on (MONTH) 29, 2019, at 11:00 a.m. confirmed that Resident R68 was left alone with a hot beverage on (MONTH) 11, (YEAR), and that two nursing assistants found the same container between the resident's right leg and the arm of the wheelchair with a puddle of water under the wheelchair. The facility failed to provide the appropriate level of assistance to one resident during an activity involving a hot drink that resulted in actual harm in the form of a burn. 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 06/14/18, 05/09/17 28 Pa. Code 201.18(e)(1) Management Previously cited 06/14/18 28 Pa. Code 201.29(j) Resident rights Previously cited 06/14/18 28 Pa Code 211.10(d) Resident care policies Previously cited 06/14/18, 05/09/17 28 Pa Code 211.12(d)(5) Nursing services Previously cited 06/14/18, 05/09/17