Every finding on record at Vincentian Home

Based on review of facility policy, facility documents and staff and resident interviews it was determined that the facility failed to provide complete documentation in response to a resident concern and failed to log concerns for one of three residents (Resident R53).Findings include: Review of the facility policy Grievance Policy dated 3/9/26, indicated the resident has the right to voice grievances in writing or orally to the facility or other agency or entity. Grievance Official/Nursing Home Administrator/Designee will be responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions. The Grievance Official/Designee will investigate and provide follow-up within 72 hours to resident/family member. The Pink Encounter Form is logged on the Encounter Form Log for tracking purposes. Review of Resident R53's Pink Encounter Form dated 5/14/26, indicated resident reported an incident that happened on 5/13/26, involving a comment made by Housekeeping Employee E8 to resident in front of the resident's visitor. Further review of R53's Pink Encounter Form on 5/27/26, the Section Below to Be Completed by Facility Staff portion was blank. Review of May 2026, facility provided Encounter Form Log on 5/27/26, failed to include Resident R53's grievance. Interview on 5/27/26, at 1:12 p.m. Chief Nursing Officer Employee E2 confirmed that the facility failed to provide complete documentation in response to a resident concern and failed to log concerns for one of three residents (Resident R53). 28 Pa. Code 201.14 (a) Responsibility of licensee.28 Pa. Code 201.18 (e)(1) Management.28 PA Code: 201.29 (a) Resident rights.

Based on review of facility policy and documentation, staff and resident interviews it was determined that the facility failed to protect residents from abuse for one of three residents (Resident R53).Findings include: Review of the facility policy Freedom from Abuse, Neglect, and Exploitation last reviewed 3/9/26, indicated to maintain an environment where residents are free from abuse, neglect, exploitation and misappropriation of resident's property. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Review of the clinical record indicated Resident R53 was admitted to the facility on [DATE]. Review of Resident R53's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/14/26, indicated diagnoses of anemia (the blood doesn't have enough healthy red blood cells), renal insufficiency (a condition in which the kidneys lose the ability to remove waste and balance fluids), and high blood pressure. Section C0500 indicated a Brief Interview for Mental Status (BIMS is a screening test that aids in detecting cognitive impairment) score of 15, cognitively intact. Review of facility provided documents dated 5/13/26, indicated the facility received a grievance form this afternoon indicating an alleged abuse incident. Resident R53 was interviewed by Social Service Employee E18 stating the resident had gone to bathroom and made a mess. Resident said they tried to clean up what they could see. A friend came in to visit and while visitor was present, Housekeeping Employee E8 said to the resident You made a mess of this bathroom. If this happens again you need to let the nurse or someone know. Resident indicated they were embarrassed and pissed that housekeeper said this in from of resident's friend and not waited until resident was alone. Review of Resident R53's account of the incident dated 5/14/26, indicated the resident used the bathroom in the resident room independently. When the resident was done a housekeeper went into the bathroom. The resident thought the housekeeper was cleaning, then the housekeeper left the room. Later, the resident had a friend visiting. While the visitor was still present, the housekeeper came back into the room and yelled at resident for making a mess in the bathroom. Housekeeper continued to tell resident if they make a mess, they need to tell someone right away and not wait. Resident reported feeling berated and belittled. Resident was unaware that they had made a mess and that is why they did not tell anyone. On top of getting yelled at, the visitor who was an old work colleague now was aware the resident was incontinent. Review of Housekeeping Employee E8's signed witness statement dated 5/14/26, indicated the housekeeper was in Resident R53's bathroom in the afternoon and the bathroom was filled with bowel movement. The bowel movement was on the walls in the bathroom, on the floor and running down the side of the toilet. It was so messy the housekeeper cleaned it up right away. The resident had company and the housekeeper told the resident if the room is messy like this again to ring call bell and let staff know. Housekeeper denied yelling at resident and indicated they were just trying to clean the room. Interview on 5/27/26, at 1:00 p.m. Resident R53 indicated they had a friend visiting, one of the housekeepers came in and said you made a mess in there and you need to tell a nurse. If they had come one on one with me, it would have been fine. The housekeeper said it in front of my friend. Resident indicated they were a younger resident and were completely embarrassed and humiliated by the housekeeper's statements. Interview on 5/27/26, at 1:10 p.m. the Chief Nursing Officer Employee E2 confirmed the facility failed to protect residents from abuse for one of three residents (Resident R53). 28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 201.29(a)(c) Resident Rights28 Pa. Code 211.10(c)(d) Resident Care Policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of the Long-Term Care Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to transmit Minimum Data Set's (MDS -periodic assessment of care needs) to the required electronic system within the mandated time frame for two of six residents reviewed (Resident R51 and R85).Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required MDS assessments, dated October 2025, indicated that Entry, Death and Facility and Discharge tracking MDS assessments must be completed and transmitted within 14 days of the event date. Resident R51 had a discharge date of 2/27/26. Further review of the clinical record failed to reveal a discharge MDS completed for Resident R51. Resident R85 had a discharge date of 2/13/26. Further review of the clinical record failed to reveal a discharge MDS completed for Resident R51. During an interview on 5/27/26, at 1:00 p.m., Resident Nurse Assessment Coordinator 1 (RNAC1) Employee E9 and RNAC2 Employee E10 confirmed that the facility failed to transmit MDS assessments to the required electronic system within the mandated time frame for two of six residents reviewed (Resident R51 and R85) as required. 28 Pa. Code 211.5(d) Medical records.

Based on review of clinical records and staff interview, it was determined that the facility failed to follow a physician order for one of six residents (Resident R83).Findings include: A review of the clinical record indicated Resident R83 was admitted to the facility on [DATE], with diagnoses that included congestive heart failure (long-term condition in which your heart can't pump blood enough to meet your body's needs), vascular dementia (cognitive decline caused by decreased blood flow to the brain) and diabetes mellitus. A review of Resident R83's a MDS annual assessment (minimum data assessment)- periodic assessment of resident care needs) dated 4/28/26, indicated the diagnosis remained current. A review of Resident R83's physician orders dated 3/17/26 indicated monitor blood pressure daily- call MD if BP > 140. A review of Resident R83's MAR (Medication Administration Record) for March and April 2026 revealed no daily blood pressure were taken. During an interview on 5/28/26, at 1:30 p.m. the Interim Director of Nursing Employee E19 confirmed the facility failed to follow physician orders for Resident R83's as required. 28 Pa. Code: 211.12 (d)(1)(5) Nursing Services

Based on review of the clinical records and staff interview, it was determined that the facility failed to provide documentation that medication regimen reviews (MRR) were completed and reviewed by the resident's attending physician monthly for two of five residents (Residents R10, and R13).Findings include: Review of the facility policy Medication Regimen Review dated 3/9/26, indicated the consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. Findings and recommendations are reported to the resident's attending physician, the facility's Medical Director and Director of nursing. Review of the clinical record indicated Resident R10 was admitted to the facility on [DATE]. Review of Resident R10's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/7/26, indicated diagnoses of renal insufficiency (a condition in which the kidneys lose the ability to remove waste and balance fluids), obstructive uropathy (a blockage in the urinary tract that prevents normal urine flow), and high blood pressure. Review of Resident R10's MRR dated 10/17/25, indicated the following recommendation from the pharmacist to the physician: This patient has been taking Pantoprazole 40 mg daily at 6:00 a.m. for GERD (gastroesophageal reflux disease) since at least 8/2024. Please review current therapy and select an option below. Review of Resident R10's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 10/17/25. Review of the clinical record indicated Resident R13 was admitted to the facility on [DATE]. Review of Resident R13's MDS dated [DATE], indicated diagnoses of anemia (the blood doesn't have enough healthy red blood cells), heart failure (heart doesn't pump blood as well as it should), and high blood pressure. Review of Resident R13's MRR dated 1/13/26, indicated the following recommendation from the pharmacist to the physician: Please review the following medication for a possible dose reduction in attempts to eliminate or find the minimally effective dose. ABR gel (Ativan 1mg (milligram)/Benadryl 25 mg/Reglan 10mg) topically to upper back four times a day. Review of Resident R13's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 1/13/26.y Review of Resident R13's MRR dated 2/13/26, indicated the following recommendation from the pharmacist to the physician: This patient's as needed order below has not been used within the previous 90 days. Albuterol, Geri-Tussin, and Imodium. Please consider discontinuing due to lack of use. Review of Resident R13's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 2/13/26. Review of Resident R13's MRR dated 4/10/26, indicated the following recommendation from the pharmacist to the physician: This patient is ordered as needed lorazepam. On 2/1/26, the directions were changed, stating to give as needed for anxiety/insomnia, though lorazepam is not indicated for use in insomnia. Please consider clarifying the reason for use of the lorazepam. Review of Resident R13's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 4/10/26. During an interview on 5/29/26, at 9:30 a.m. Clinical Records Manager Employee E20 confirmed the MRR's were completed by Certified Registered Nurse Practitioners (CRNPs) and not the resident's attending physician as required for Residents R10, and R13. 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa. Code 211.5(f) Medical records.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility to properly to properly store medication in two of three medication carts (First Floor 119 Hall Medication Cart and the Second Floor Low End Hall Medication Cart).Findings include: Review of the facility policy Drug Acquisition, Storage, Inspection, and Dispensing Last reviewed 3/9/26, indicated drugs used in the facility shall be labeled in accordance with current accepted principles and include:Appropriate contents, accessories, and cautionary instructions.Expiration date, when applicableMedications shall be stored under proper conditions as stated by the medication manufacturer to ensure stability of that medication. During an observation completed on 5/26/26, at 9:23 a.m. the First Floor 119 Hall Medication Cart contained the following: 1 Tube of Nystatin cream not stored in a bag and not labeled with a date opened as required. During an interview completed on 5/26/26, Licensed Practical Nurse (LPN) Employee E16 confirmed the above observation and that the facility to properly store medications in First Floor 119 Hall Medication Cart. During an observation completed on 5/26/26, at 9:35 a.m. the Second Floor Low End Medication Cart contained the following: 1 bottle of nystatin liquid not labeled with a date opened as required1 Breo inhaler not labeled with name or date opened as required.1 albuterol inhaler not labeled with a date opened as required. During an interview completed on 5/26/26, at 9:43 a.m. Registered Nurse (RN) Employee E4 confirmed the above observations and that the facility to properly to properly store medications in the Second Floor Low End Medication Cart. 28 Pa. Code: 211.9(a)(1) Pharmacy services.28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on facility policy, menu, observations, and staff interviews, it was determined that the facility failed to follow the menu and preferences for three of eight residents (Resident R14, R30, and R49). Findings include: The facility policy entitled Therapeutic Diet Policy dated 3/9/26, indicated therapeutic diets must be prescribed and authenticated by the practitioners responsible for the care of the resident, or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff and in accordance with state law. Review of the facility policy Meal Service to Residents dated 3/9/26, indicated Nutritional Services shall work with Nursing Services and the Registered Dietician to provide the correct meals to each resident. Residents shall be verified using the Diet Sheets and proper diet will be confirmed before plating and presenting the resident with their meal. Trays shall be assembled according to the residents' choice and delivered to the resident by Nurse Aides or Culinary staff. Review of Resident R14's Diet Sheet dated 5/26/26, indicated mechanical soft heart healthy. Prosource twice daily by nurse. Shake em up with each meal. Observation of Resident R14 on 5/26/26, at 11:49 a.m. indicated resident was almost through with the lunch meal and had not received a beverage of any type. A review of the menu indicated that the menu for breakfast on Tuesday, 5/26/26 was as follows:Frittata, Juice, hot or cold cereal. During an observation of breakfast meal rounds in building four on 5/26/26, at 9:05 a.m., it was revealed Resident R30 had the following: Frittata, regular sausage patty, coffee Review of Resident R30 physician orders dated 3/25/26 indicated a diet order of Heart Healthy/Diabetic, Mechanical Soft texture, Regular/Thin consistency. During an interview on 5/26/26, Licensed Practical Nurse (LPN) Employee E1 confirmed Resident R30 should have a mechanical soft sausage patty as ordered. Review of Resident R49's Diet Sheet Dated 5/26/26, indicated Mechanical Soft Diet. Ok to have regular finger foods, sandwiches, and cut fruit. Cut crust off sandwiches. Ensure Plus twice a day. Prosource 30mls (milliliters) in the morning. Inner lip plate, built up utensils, two handled cup with lid and straw. Observation of Resident R49 on 5/26/26, at 11:50 a.m. indicated resident was provided with a sandwich as an alternative. The sandwich failed to have the crust cut off as indicated on the Diet Sheet. Resident was not provided with a beverage of any type with the meal. During an interview on 5/26/26, at 11:52 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed Resident R14 and R49 were not served beverages with their lunch meal and that Resident R49's sandwich did not have the crust cut off as indicated on the Diet Sheet. 28 Pa. Code: 211.6(a) Dietary services

Based on observation and staff interview, it was determined that the facility failed to maintain food service equipment in accordance with professional standards for food service safety on one of two Country Kitchens (Building Four Country Kitchen).Findings include: Observation on 5/26/26, at 9:27 a.m. of the Building Four Country Kitchen indicated a freezer filled with resident ice cream and frozen treats. The ice buildup in the base of the freezer floor was greater than eight inches thick. Tour and interview on 5/26/26, at 9:30 a.m. Dining Manager Employee E3 confirmed the ice buildup in the base of the freezer floor was greater than eight inches thick and not in accordance with professional standards for food service safety28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1) Management.

Based on review of regulations, documents submitted to the State agency and staff interviews, it was determined that the facility failed to notify the State agency of a change in the facility's Director of Nursing at the time of the change. Findings include: Review of facility provided Employee Information Sheet on 5/27/26, at 11:45 a.m. indicated the Director of Nursing started a leave on 5/14/26. Interview on 5/27/26, at 12:00 p.m. the Chief Nursing Officer Employee E2 confirmed the facility failed to notify the State Agency that the Interim Director of Nursing Employee E19 assumed the position on 5/14/26. 28 PA Code: 201.14(a) Responsibility of licensee.

Based on facility policies, clinical record review, facility documents, observation, and staff interview, it was determined that the facility failed to prevent cross contamination during a dressing change for one of two residents (Resident R15).Findings include: Review of facility policy Hand Hygiene last reviewed 3/9/26, indicated always follow standard precautions, gloves shall be worn when contact with -blood, bodily fluids, mucus membranes, dressings, non-intact skin. Change gloves and discard after each resident. Change gloves when moving from a contaminated body site to a clean site. Review of the facility policy Skin and Wound Assessment last reviewed 3/9/26, indicated the facility will provide wound care in a manner to decrease potential for infection and cross-contamination. Physician's orders will specify type of dressing and frequency of changes. Guidelines for the application of dry, clean dressings include but not inclusive to:Wash and dry hands thoroughly. Put on clean gloves.Establish a clean field.Remove soiled dressing, pull glove over dressing and discard into waste basket.Wash and dry hands put on clean gloves.Cleanse the wound with ordered cleanser.Use dry gauze to pat the wound dry.Wash and dry hands.Put on clean gloves Review of the clinical record indicated Resident R15 was admitted to the facility on [DATE]. Review of Resident's R15's Minimum Data Set (MDS- a periodic assessment of needs) dated 5/11/26, indicated the diagnosis of anemia (low iron in the blood), hypertension (high blood pressure) and diabetes (high sugar in the blood). Review of Resident R15's physician orders dated 5/13/26, indicated cleanse sacral/coccyx area with soap and water, pat dry apply medical grade honey and calcium alginate then cover with a border gauze dressing daily and as needed. During a dressing change observation completed on 5/27/26, at 10:54 a.m. Registered Nurse (RN) Employee E5 donned a pair of gloves then gown, she then donned another pair of gloves on top of the prior placed gloves (double gloved). RN Employee E5 placed a towel under Resident R15's buttock area removed Resident R15's brief and completed peri care. Removed the towel and placed it onto the bed. RN Employee E5 removed the outer layer gloves. RN Employee E5 failed to complete hand hygiene and reapplied a pair of gloves onto the prior placed gloves. RN Employee E5 picked the towel up that was placed on the bed and dipped a corner of the towel into a basin that contained soap and water, cleansed the wound and used another portion of the towel to dry the wound. During an interview completed on 5/27/26, at 11:35 a.m. RN Employee E5 confirmed to double gloving, not completed hand hygiene and cleansing and drying the wound area with a towel that had been placed on the bed and that the facility failed to prevent cross contamination during a dressing change. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3)(d)(e)(1) Management.28 Pa. Code 211.10(d) Resident care policies.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observations, review of facility documentation, and staff interview, it was determined that the facility failed to make certain that equipment was in safe operating condition for two of three crash carts (Second Floor High Side Crash Cart and Second Floor Low Side Crash Cart).Findings include: Review of the facility Emergency Crash Cart policy dated 3/9/26, indicated the facility shall maintain an Emergency/Crash Cart in a readily accessible location to provide emergency equipment and supplies for resident emergencies. Minimum Crash Cart Contents include but are not inclusive of: Portable suction equipment. Weekly Crash Cart Checks: The nursing supervisor or designee shall verify:Crash carts are present and accessibleOxygen tank is adequately filledNo visible missing equipment. Following any emergency the nursing staff or nursing supervisor shall be responsible for re-stocking supplies or used equipment. During an observation completed on 5/27/26, at 11:39 a.m. it was revealed that the Second Floor High Side Crash Cart (a cart maintained with equipment used in cardiac emergencies) failed to have a suction machine or a check list for the emergency supplies to be included on the crash cart. During an interview completed on 5/27/26, at 11:39 a.m. Registered Nurse (RN) Employee E5 confirmed that the crash cart did not contain a suction machine. Upon asking RN Employee E5 concerning a check list for emergency supplies included on the crash cart replied, I have never seen a check list. During an observation completed on 5/27/26, at 11:58 a.m. the Second Floor Low Side Crash Cart failed to reveal a check list for the emergency supplies to be included on the crash cart. During an interview completed on 5/27/26, at 11:58 a.m. RN Employee E6 confirmed a check list for the emergency supplies failed to be included on the crash cart. RN Employee E6 referred to a piece of paper that was taped to the cupboard in the storage room titled Emergency Supplies QA - to be done by the 11-7 nurse Sunday and stated, this does not contain the crash cart supplies and it was not completed for two of the four weeks 5/10/26, and 5/24/26. During an interview completed on 5/28/26, at 2:00 p.m. the interim Director of Nursing Employee E19 confirmed no check list were available for the accountability of the crash carts emergency supplies and that the facility failed to make certain that equipment was in safe operating condition for two of three crash carts (Second Floor High Side Crash Cart and Second Floor Low Side Crash Cart). 28 Pa. Code: 201.14(a) Responsibility of licensee.

Based on review of facility policy, clinical record reviews and staff interviews, it was determined that the facility failed to initiate a thorough investigation to rule out physical abuse or neglect for one of three residents (discharged Resident R1). Findings include: Review of the facility policy Freedom from Abuse, Neglect, and Exploitation last reviewed 3/23/26, indicated to maintain an environment where residents are free from abuse, neglect, exploitation and misappropriation of resident's property. All residents, staff, families, visitors, volunteers and resident representatives are encouraged to report and suspected acts of abuse, neglect, misappropriation of resident property or exploitation. The facility must take the following actions in response to an alleged violation of abuse, neglect, exploitation or mistreatment:Thoroughly investigate the alleged violationPrevent further abuse, neglect, exploitation and mistreatment from occurring while the investigation is in progressTake appropriate corrective, because of investigation findings.Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental or physical condition, cause physical harm, pain or mental anguish. Review of the clinical record indicated discharged Resident R1 was admitted to facility on 2/12/26. Review of discharged Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/9/26, indicated diagnoses of high blood pressure, Benign Prostatic Hyperplasia (prostate gland enlargement that can cause urinary difficulty), and muscle wasting and atrophy of multiple cites (loss of muscle tissue). Review of discharged Resident R1's physician order dated 3/18/26, indicated transfers x1 with wheeled walker. Review of the facilities grievance log encounter form dated 4/1/26, indicated the following:Category: StaffingConcern: Spouse reports Nurse Aid (NA) exhibiting rude behavior.Steps taken/Summary/Corrective Action: Director of Nursing investigated and found concerns unsubstantiated.Date resolved: 4/1/26. Review of the facility provide grievance form dated 4/1/26, completed by discharged Resident R1's wife indicated:Incident 1: When resident used call bell the NA was very sharp and rude: what do you want and said someone will help you (with toileting). She left the room and did not return for 2 hours. After the resident used call light.Incident 2: NA grabbed discharged Resident R1's right arm to re-position him, again during toileting. A bruise was evident on right forearm.Further documentation on grievance form: The NA has been rude and disrespectful, impatient and inattentive on several other occasions during toileting needs. She scolded him for being wet when he was made to wait for assistance for an unreasonable amount of time. Review of the facilities provided statements revealed the following: Nurse Aid Employee E5's statement dated 4/1/26, revealed discharged Resident R1 asked to use the restroom. In his assistance of daily (ADL's) living sheet it is stated he is considered a two-person transfer. I requested the nurse to assist she never came upon my request. Due to the lack of help for the two person transfer I informed the resident that he would have to utilize a bed pan; the resident did show irritation. I communicated and informed him that due to his ADL's it was not safe to move him with one NA no other communication was conducted, no complaints were made at that time.An interview completed by Director of Nursing (DON) on 4/1/26, at 6:00 p.m. He made the statement that she was not nice and rude, did not respect him. Two weeks ago, she was rough and grabbed his arm and caused a bruise, which hurt. Her attitude was dismissing of him. He got to the point where he no longer wanted to tolerate her.On 4/2/26, the Nursing Home Administrator (NHA) went to speak with resident and wife. Wife requested that the NA not care for her husband. The NHA informed wife and resident that allegations are taken seriously and will follow up.On 4/4/26, a statement was completed by Registered Nurse Employee E8, I wasn't informed or aware of anything that had transpired. No NA on duty has reported to me about any resident being abused by staff. During an interview completed on 4/23/26, at approximately 2:00 p.m. The Director of Nursing (DON) confirmed that no other residents were interviewed that the Nurse Aid took cared for, no other staff interviews were completed and stated, the claim was only on this Nurse Aid so we only looked at her. During an interview completed on 4/23/26, at 11:45 a.m. the Nursing Home Administrator stated the family filed a grievance, it was investigated and completed, their complaint was they just didn't like NA Employee E5 and preferred not to have her. We got statements. NA Employee E5 deflected the allegation onto other employees, it was her, she never returned any further calls she was not cooperative. NA Employee E5 was self-terminated due to lack of response to the facility. When asked if other staff members or residents were interviewed concerning physical/verbal abuse or neglect stated, at what point do you stop the investigation? and confirmed that the facility failed to initiate a thorough investigation to rule out physical abuse or neglect for one of three residents (discharged Resident R1). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.10 (c)(d) Resident Care policies.28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of three residents (discharged Resident R1) and failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for three of three resident hospital transfers (discharged Resident R1, discharged Resident R2 and Resident R3).Findings include: Review of facility policy Resident Notice of Transfer or Discharge last reviewed 3/23/26, indicated before this facility transfers or discharges a resident admission coordinator/designee shall notify the resident/representative of the transfer or discharge and the reason for the move in writing and in the language and manner they understand. Record the reasons for the transfer or discharge in the resident's medical record. Review of the facility policy Notice of Bed Hold and Return last reviewed 3/23/26, indicated the long-term care facility shall provide written information to the resident and his/her family member or legal representative about the bed hold policy before a resident is transferred to the hospital or goes on a therapeutic leave. In the case of an emergency transfer the resident representative/family shall be provided with written notice within 24 hours after the transfer. Review of the clinical record indicated discharged Resident R1 was admitted to facility on 2/12/26. Review of discharged Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/9/26, indicated diagnoses of high blood pressure, Benign Prostatic Hyperplasia (BPH-prostate gland enlargement that can cause urinary difficulty), and muscle wasting and atrophy of multiple cites (loss of muscle tissue). Review of the nursing progress notes dated 2/18/26, indicated discharged Resident R1 was sent to local hospital on 2/16/26, in the am. Resident returned to the facility on 2/26/26. Review of discharged Resident R1's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, on 2/16/26, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility or evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 2/16/26. Review of Nursing progress notes dated 4/15/26, indicated discharged Resident R1 was sent to local hospital. Review of discharged Resident R1's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 4/15/26. Review of the clinical record indicated discharged Resident R2 was admitted to facility on 4/14/26, with the diagnosis of muscle weakness, high blood pressure and hyperlipidemia (high fat in the blood), Review of the nursing progress notes dated 4/22/26, indicated discharged Resident R2 was sent to local hospital. Review of discharged Resident R2's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 4/22/26. Review of the clinical record indicated Resident R3 was admitted to facility on 4/14/26, with the diagnosis of trigeminal neuralgia (causes intense facial pain) and high blood pressure. Review of nursing progress note dated 4/20/26, indicated Resident R3 was transferred to local hospital. Review of discharged Resident R3's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 4/20/26. During an interview completed on 4/25/26, the Director of Nursing confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of three residents (discharged Resident R1) and failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for three of three resident hospital transfers (discharged Resident R1, discharged Resident R2 and Resident R3). 28 Pa. Code: 201.14.(a) Responsibility of licensee.28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights.

Based on review of facility policies, documents, clinical records, and staff and resident interviews it was determined was determined that the facility failed to protect resident from neglect for one of three residents (Residents R1). Findings include: Review of the facility policy Freedom from Abuse, Neglect, and Exploitation last reviewed 3/19/25, stated it is the policy of the facility to maintain an environment where residents are free from abuse, neglect, and misappropriation of resident property. Neglect is defined as the failure of the facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the facility policy Resident Transfer Protocol last reviewed 3/19/25, stated appropriate transfer techniques shall be used according to each resident's strength, stamina, and ability to assist with the residents. Necessity for the amount and type of assistance shall be assessed upon admission and on an ongoing basis. Review of the facility policy Falls and Falls with Major Injury last reviewed 3/19/25, stated all facility staff is responsible for implementing the intent and directives contained within this policy, and for creating a safe environment of care. It is the facility's policy to minimize the risk of falling, and injuries sustained from falls, without compromising the mobility and functional independence of residents. Review of Residents R1's admission record indicated the resident was admitted on [DATE], and readmitted [DATE], with diagnoses of muscle wasting and atrophy, muscle weakness, and abnormalities of gait and mobility. Review of Residents R1's care plan dated 11/28/22, revised 3/6/25, revealed the resident required a full body (Hoyer) mechanical and a two person assist for transfers and all hygiene and repositioning while the resident is in bed. Review of Residents R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/18/25, indicated the diagnoses were current. Section GG- Functional Abilities revealed the resident was dependent with rolling left to right and required the assistance of two or more helpers. Review of physician order dated 4/12/25, revealed Resident R1 required assistance of two persons with bed positioning, hygiene, and transfers. Review of Resident R1's progress note dated 5/3/25, entered at 8:45 a.m., by Registered Nurse (RN) Employee E4 revealed Nurse Aide (NA) Employee E1 reported Resident R1 was on the floor and needed assistance. It was stated the NA Employee E1 was performing care when the resident rolled out of bed. The resident was observed lying on their right side with their head up against night stand. The resident had a partial head laceration and complained of a headache. The resident was transferred to hospital for further evaluation. Review of information submitted to the State Agency on 5/5/25, indicated on 5/3/25, Resident R1 was found to be incontinent of a large bowel movement. NA Employee E1 was providing care for the resident. As the aide rolled the resident the aide lost their balance. The resident rolled to the floor and sustained a fall. The nurse assessed the resident and a small laceration was observed on the resident's right side of head. The resident was sent to the hospital and returned with no new orders. Review of the facility's investigation on 6/25/25, revealed NA Employee E1's witness statement that stated Resident R1 had a bowel movement and NA Employee E1 went to change the resident. NA Employee E1 stated Typically I always get help but I just wasn't thinking that morning. The resident rolled out of bed. Review of Resident R1's witness statement on 6/25/25, revealed when NA Employee E1 rolled the resident, Resident R1 fell of the bed. It was indicated NA Employee E1 rolled Resident R1 away from themselves. During an attempted phone interview on 6/25/25, at 10:00 a.m. NA Employee E1 was unavailable. During an interview on 6/25/25, at 10:12 a.m. Licensed Practical Nurse (LPN) Employee E2 stated the nurse aides can find a resident's transfer status from the Kardex (a documentation system that enables nurses to write, organize, and easily reference key patient information that shapes their nursing care plan) and report sheets. Nurse aides are expected get assistance for residents who require assistance of two persons. During an interview on 6/25/25, at 10:14 a.m. Resident R1 stated everything happened so fast when asked about the fall that occurred on 5/3/25. Resident R1 stated I rolled out of bed while getting changed. During an interview on 6/25/25, at 10:28 a.m. NA Employee E3 stated if a resident is ordered to be transferred with an assist of two, then two people must assist the resident with bed mobility. NA Employee E3 stated I would wait, I don't want to drop anyone. During an interview on 6/25/25, at 12:41 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to protect residents from neglect for one of three residents (Residents R1). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1) Management. 28 Pa. Code: 207.2(a) Administrator's responsibility. 28 Pa. Code: 211.10(d) Resident care policies.

Based on review of facility policies, clinical records, and staff and resident interviews it was determined the facility failed to report an incident of neglect within 24 hours to the local state field office for one of three residents (Residents R1). Findings include: Review of the facility policy Incident-Clinical Protocol last reviewed 3/19/25, stated anyone who witnesses, discovers or is involved in an incident is responsible for reporting to the Licensed Nurse on the unit as soon as possible, on the day of discovery. In the event, that it was determine the :incident was reportable to the State Agency , it will be done timely and submitted by the Director of Nursing or Designees. Review of the facility policy Freedom from Abuse, Neglect, and Exploitation last reviewed 3/19/25, stated it is the policy of the facility to maintain an environment where residents are free from abuse, neglect, and misappropriation of resident property. Neglect is defined as the failure of the facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The Administrator or designee will make an initial (immediate or within 24 hours) report to the State Agency. Review of Residents R1's admission record indicated the resident was admitted on [DATE], and readmitted [DATE], with diagnoses of muscle wasting and atrophy, muscle weakness, and abnormalities of gait and mobility. Review of Residents R1's care plan dated 11/28/22, revised 3/6/25, revealed the resident required a full body (Hoyer) mechanical and a two person assist for transfers and all hygiene and repositioning while the resident is in bed. Review of Residents R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/18/25, indicated the diagnoses were current. Section GG- Functional Abilities revealed the resident was dependent with rolling left to right and required the assistance of two or more helpers. Review of physician order dated 4/12/25, revealed Resident R1 required assistance of two persons with bed positioning, hygiene, and transfers. Review of Resident R1's progress note dated 5/3/25, entered at 8:45 a.m., by Registered Nurse (RN) Employee E4 revealed Nurse Aide (NA) Employee E1 reported Resident R1 was on the floor and needed assistance. It was stated the NA Employee E1 was performing care when the resident rolled out of bed. The resident was transferred to hospital for further evaluation. Review of information submitted to the State Agency on 5/3/25, and 5/4/25, failed to include Resident R1's incident of neglect. During an interview on 6/25/25, at 12:41 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to report an incident of neglect within 24 hours to the local state field office for one of three residents (Residents R1).

Based on review of facility policies, documents, clinical records, and staff and resident interviews it was determined that the facility failed to ensure the appropriate assistance for bed mobility was provided to prevent a roll out of bed for one of five residents (Residents R1). Findings include: Review of the facility policy Resident Transfer Protocol last reviewed 3/19/25, stated appropriate transfer techniques shall be used according to each resident's strength, stamina, and ability to assist with the residents. Necessity for the amount and type of assistance shall be assessed upon admission and on an ongoing basis. Review of the facility policy Falls and Falls with Major Injury last reviewed 3/19/25, stated all facility staff is responsible for implementing the intent and directives contained within this policy, and for creating a safe environment of care. It is the facility's policy to minimize the risk of falling, and injuries sustained from falls, without compromising the mobility and functional independence of residents. Review of Residents R1's admission record indicated the resident was admitted on [DATE], and readmitted [DATE], with diagnoses of muscle wasting and atrophy, muscle weakness, and abnormalities of gait and mobility. Review of Residents R1's care plan dated 11/28/22, revised 3/6/25, revealed the resident required a full body (Hoyer) mechanical and a two person assist for transfers and all hygiene and repositioning while the resident is in bed. Review of Residents R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/18/25, indicated the diagnoses were current. Section GG- Functional Abilities revealed the resident was dependent with rolling left to right and required the assistance of two or more helpers. Review of physician order dated 4/12/25, revealed Resident R1 required assistance of two persons with bed positioning, hygiene, and transfers. Review of Resident R1's progress note dated 5/3/25, entered at 8:45 a.m., by Registered Nurse (RN) Employee E4 revealed Nurse Aide (NA, Employee E1 reported Resident R1 was on the floor and needed assistance. It was stated the NA Employee E1 was performing care when the resident rolled out of bed. The resident was observed lying on their right side with their head up against night stand. The resident had a partial head laceration and complained of a headache. The resident was transferred to hospital for further evaluation. Review of information submitted to the State Agency on 5/5/25, indicated on 5/3/25, Resident R1 was found to be incontinent of a large bowel movement. NA Employee E1 was providing care for the resident. As the aide rolled the resident the aide lost their balance. The resident rolled to the floor and sustained a fall. The nurse assessed the resident and a small laceration was observed on the resident's right side of head. The resident was sent to the hospital and returned with no new orders. Review of the facility's investigation on 6/25/25, revealed NA Employee E1's witness statement that stated Resident R1 had a bowel movement and NA Employee E1 went to change the resident. NA Employee E1 stated Typically I always get help but I just wasn't thinking that morning. The resident rolled out of bed. Review of Resident R1's witness statement on 6/25/25, revealed when NA Employee E1 rolled the resident, Resident R1 fell of the bed. It was indicated NA Employee E1 rolled Resident R1 away from themselves. During an interview on 6/25/25, at 10:12 a.m. Licensed Practical Nurse (LPN) Employee E2 stated the nurse aides can find a resident's transfer status from the Kardex (a documentation system that enables nurses to write, organize, and easily reference key patient information that shapes their nursing care plan) and report sheets. Nurse aides are expected get assistance for residents who require assistance of two persons. During an interview on 6/25/25, at 10:14 a.m. Resident R1 stated everything happened so fast when asked about the fall that occurred on 5/3/25. Resident R1 stated I rolled out of bed while getting changed. During an interview on 6/25/25, at 10:28 a.m. NA Employee E3 stated if a resident is ordered to be transferred with an assist of two, then two people must assist the resident with bed mobility. NA Employee E3 stated I would wait, I don't want to drop anyone. During an interview on 6/25/25, at 12:42 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to ensure the appropriate assistance for bed mobility was provided for one of five residents (Residents R1), which resulted in a fall. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1) Management.

Based on review of facility policy, observations and staff interview, it was determined that that the facility failed to determine it was safe to self-administer medications, did not have a current order or care plan to self-administer medications, or an interdisciplinary assessment for one of five residents (Resident R302). Findings include: Review of the facility policy Self-Administration of Medications by Residents last reviewed 3/19/25, indicated self-administration of medication is the ability of a resident to take medications independently without assistance from another person. The resident shall be assessed for competency using the assessment for self-administration of medications. The results shall be documented in the resident's record and care plan. Specific orders for self-administration of medication shall be documented in the resident's medical record and care plan. Each resident's medication shall be clearly labeled by the prescribing pharmacy. Review of the facility policy Skin and Wound Assessment last reviewed 3/19/25, indicated residents identified with a pressure ulcer or non-pressure related skin conditions will be monitored for evidence of further breakdown or complication. Verify a physician's order for the procedure. Review of the facility policy Medications Administration last reviewed 3/19/25, indicated medications shall be administered only upon the order of physicians and physician extenders who are authorized and have been granted clinical privileges to write such orders. Licensed nurses shall administer prescribed medications, fluids and treatments. Review of the admission record indicated Resident R302 was admitted to the facility on [DATE], with diagnosis that included irritable bowel syndrome (IBS- a gastro-intestinal disorder that causes abdominal pain, bloating and changes in bowel patterns), overactive bladder (sudden urges to urinate that are hard to control), and dysphagia (difficulty in swallowing). During an interview and observation completed on 4/28/25, at 10:51 a.m. Resident R302 voiced that she has frequent episodes of incontinence and her bottom was raw, bleeding and sore. Resident 302 stated I wash and clean myself and apply Aquaphor ointment and desitin cream, and further stated I would like a good look over when I get my shower. The Aquaphor ointment was observed sitting next to the commode in her bathroom. During an interview completed on 4/28/25, at 10:58 a.m. Registered Nurse (RN) Employee E1 confirmed the Aquaphor ointment was in Resident R302's bathroom and stated, there is not a label, I think her family brought it in for her to use. Review of Resident R302's clinical record on 4/28/25, at 11:00 a.m. failed to include orders for the Aquaphor ointment or for self-administration of medications, failed to include a care plan, or an interdisciplinary assessment. During an interview completed on 4/30/25, at 2:43 p.m., the Director of Nursing confirmed Resident R1 did not have a current order, care plan to self-administer medications, or an interdisciplinary assessment, and that the facility failed to determine it was safe to self-administer medications for one of five residents (Resident R1). 28 Pa. Code 201. 18(b)(1) Management 28 Pa code:211.10(c)(d) Resident care policies 28 Pa Code:211.12(c)(d)(1)(2)(5) Nursing services

Based on facility policy, clinical record review, and interview, it was determined that the facility failed to have physician order specifications relating to the size of indwelling catheter (a thin, flexible tube inserted into the bladder through the urethra to drain urine) and balloon inflation amount (secures catheter to bladder) for one of three residents (Resident R305). Findings include: Review of the facility policy Foley Catheter Care last reviewed 3/19/25, indicates to maintain a closed, sterile drainage system and minimize the risk of infection. Obtain physician order for foley catheter use. Include bulb and catheter size, frequency of catheter changes and catheter care instructions. Review of Admission record indicated Resident R305 was admitted to the facility on [DATE], with the diagnosis of dysphagia (difficulty in swallowing), chronic kidney disease (affects the kidneys ability to filter waste), and urinary retention (bladder doesn't completely empty). Review of Resident R305's physician orders dated 4/22/25, indicated exchange Foley catheter on the 22nd of each month and when directed by provider. Review of Resident R305's physician orders dated 4/22/25, indicated Foley catheter bag dignity cover on at all times. Review of Resident R305's physician orders dated 4/22/25, indicated irrigate Foley catheter with 50 milliliters (mL) Normal Saline Solution (NSS) if complete or partial occlusion suspected. May irrigate once each shift. Notify provider if irrigation ineffective. Exchange Foley if directed by provider as needed Review of Resident R305's physician orders on 4/4/25, failed to include specifications for size and balloon inflation amount for the indwelling foley catheter. Interview on 4/30/25, at 3:02 p.m. the Assistant Director of Nursing (ADON) Employee E7 confirmed Resident R305's clinical record failed to provide specifications for size and balloon inflation amount of the indwelling catheter and that the facility failed to have physician order specifications relating to size of an indwelling catheter and balloon inflation amount for one of three residents (Resident R305). 28 Pa. Code 201. 18(b)(1) Management. 28 Pa code:211.10(c)(d) Resident care policies. 28 Pa Code:211.12(c)(d)(1)(2)(5) Nursing services.

Based on review of facility policies, observations, clinical record review, and staff, resident, and family interviews, it was determined that the facility failed to provide appropriate respiratory care for two of five residents (Residents R67 and R307). Findings include: Review of the facility policy C-PAP/Bi-PAP Storage dated 3/19/25, indicated it is the policy of the facility to store CPAP (a method of positive pressure ventilation used with patients who are breathing spontaneously) machine in a clean dry environment. When not in use, place clean mask in a plastic bag (not airtight). Review of the facility policy Oxygen Concentrators-Usage and Care last reviewed 3/19/25, indicates Nasal cannulas, masks, tubing and water bottles are to be changed weekly. The water bottle and tubing are to be dated and stored in a plastic bag attached to the concentrator when not in use. Review of the clinical record indicated that Resident R67 was admitted to the facility on [DATE], with diagnoses of anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells), heart failure (condition where the heart muscle doesn't pump blood as well as it should), and dysphagia (difficulty swallowing). Review of Resident R67's physician order dated 4/4/25, indicated to apply CPAP on at bedtime. Reconnect mask and tubing (mask, reservoir, and tubing cleaned every morning and allowed to air dry). Utilize pre-programmed adaptive settings calibrated by pulmonology. Fill humidification reservoir with distilled water to level indicated. The order failed to include the settings for the CPAP and a diagnosis. Review of Resident R67's unsigned and undated baseline care plan failed to include care interventions related to the resident's CPAP. Review of Resident R67's MDS dated [DATE], indicated the diagnoses were current. Review of Resident R67's care plan dated 4/18/25, indicated to provide CPAP maintenance per protocol. During an observation and interview on 4/28/25, at 10:31 a.m. Resident R67's CPAP mask was observed not in a bag, sitting on the bed. Resident R67 stated I use my CPAP every night. During an observation on 4/29/25, at 10:05 a.m. Resident R67's CPAP mask was sitting on the resident's dresser not stored in a bag. During an observation on 4/30/25, at 9:40 a.m. Resident R67's CPAP mask was sitting on the resident's dresser not stored in a bag. During an interview on 4/30/25, at 9:58 a.m. Registered Nurse, Employee E3 confirmed Resident R67's CPAP mask was not stored properly. During an interview on 4/30/25, at 11:03 a.m. the Director of Nursing (DON) confirmed the facility failed to implement a baseline care plan for Resident R67's CPAP. Review of the admission record indicated Resident R307 was admitted to the facility on [DATE], with the diagnosis of pneumonia (infection in the lungs), congestive heart failure (CHF- heart can ' t pump blood as well as it should) and emphysema (chronic lung disease that causes shortness of breath and damage to the lung). During an observation completed on 4/28/25, at 10:34 a.m. Resident R307 was in bed with his oxygen on via nasal canula (flexible tubing used to deliver oxygen) the tubing failed to be labeled with a date. During an interview completed on 4/28/25, at 10:36 a.m. LPN Employee E2 confirmed the tubing failed to be labeled with a date. During an interview on 5/2/25, at 11:56 a.m. the Nursing Home Administrator (NHA) and DON confirmed the facility failed to provide appropriate respiratory care for two of five residents (Residents R67 and R307). 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to implement pharmaceutical services to ensure accurate provision of medications for one of five residents (Resident R250). Findings include: Review of the facility policy, Pharmacy Requirements last reviewed 3/19/25, indicated regular and reliable pharmaceutical service is available to provide residents with prescriptions and non-prescriptions medications, services, and related equipment and supplies. Pharmacy services will be provided routine and timely. Review of Residents R250's admission record indicated admission to the facility on [DATE], with diagnoses of anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells), calculus of kidney, and Alzheimer's Disease (a progressive brain disorder that gradually destroys memory, thinking skills, and the ability to carry out daily tasks). Review of Resident R250's physician order dated 4/24/25, indicated to administer two tablets of TheraLith XR (medication formulated to support and maintain normal urine chemistry), two times a day, related to calculus of kidney. Review of Resident R250's April 2025 Medication Administration Record revealed the resident did not receive TheraLith as ordered from 4/24/25, through 4/28/25. A total of nine dose were missed. Review of Resident R250's progress note dated 4/28/25, revealed the resident's TheraLith was unavailable from the pharmacy. During an observation of a medication pass, on 4/29/25, at 10:16 a.m. Resident R250's Theralith was unavailable. Registered Nurse, Employee E10 confirmed Resident R250's TheraLith was not in stock and available for administration. During an interview completed on 4/29/25, at 11:15 a.m. the Nursing Home Administrator (NHA) confirmed the facility failed to implement pharmaceutical services to ensure accurate provision of medications for one of four residents (Resident R250). During an interview on 4/29/25, at 2:51 p.m. the Director of Nursing (DON) stated the pharmacy was out of stock of TheraLith and that was the reason resident did not receive the medication as ordered. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.9 (a)(1)(k)(l)(1)(2)(3)Pharmacy services 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d)(1)(5) Nursing services.