Every finding on record at Warren Manor

Based on review of information submitted by the facility to the State Agency, policies, clinical records, facility documentation, and resident and staff interviews, it was determined that the facility failed to ensure essential resident safety measures were followed to prevent a fall which resulted in the actual harm of a right femur (thigh) fracture requiring surgical repair for one resident (Resident R5); and a fall which resulted in the actual harm of a nasal bone fracture for one resident (Resident R2); failed to provide adequate safety interventions to prevent a fall for one resident (Resident R7) and failed to provide supervision to prevent injury for two residents (Residents R4 and R104).Findings include:A facility policy entitled, 'Smoking Policy dated 12/23/25, indicated that nursing staff will conduct an assessment upon admission to establish frequency and guidelines for each resident who wishes to smoke, any restrictions will be noted in the resident's record, and resident must be accompanied by staff, family, or properly trained volunteers while smoking.A facility document entitled, Instructional Guide to Forms for Incident Investigation Follow-up Form indicated: the form is to be completed by the individual completing the investigation and witness statements are to be completed by the witnesses, and include:Name of investigating supervisor completing this form.Date of investigation.Name of employee who completed the incident form.Body part(s) affected by the incident, if injury occurred.Date the incident occurred or onset of symptoms reported.Supervisor's understanding of what happened.Name of witness (Document who actually saw/witnessed the incident). Witness account of what actually happened (Needs to be completed and signed by the witness).Incident causes. (Detail any equipment, tasks, management practice/behavior, or environmental circumstances that may have contributed to the occurrence).Notes: Document facts and findings, conclusion, root cause possibilities and determinations, specific concerns, any other important factors related to the incident/investigation.Recommended solutions related to the determined root cause and prevention of this type of incident from occurring int eh future.Person assigned the responsibility of ensuring the recommended solution is implemented.Expected completion date, follow-up date to ensure recommended solution was implemented.Supervisor's signature.Administrators' signature.Review of the facility's Van Driver Job Description revealed that the van driver is expected to drive safely in all weather conditions, follow facility policies and procedures, and follow all safety policies and procedures during daily tasks.Resident R5's clinical record revealed a most recent admission date of 10/22/24, with diagnoses that included fractured right femur (thigh), respiratory failure, chronic obstructive pulmonary disease [COPD-lung disease causing restricted airflow and breathing problems], morbid obesity (complex disease involving having too much body fat that increases the risk of many other diseases and health conditions), and pulmonary edema (abnormal buildup of fluid in your lungs that can cause shortness of breath and difficulty breathing).Resident R5's clinical record revealed departmental progress notes dated 12/23/25, which indicated that while on transport in the facility owned van Resident R5 was displaced from his/her wheelchair injured and transported to the hospital by Emergency Medical Services for evaluation and treatment of a fractured femur.Review of the information submitted by the facility to the State Agency on 12/24/25, revealed that Resident R5 was being transported via the facility-owned van by the facility's van driver when he/she heard a loud bang, stopped the van and found Resident R5 lying on the floor of the van. The van driver called 911 and Resident R5 was transported to the hospital for evaluation and treatment of a fractured right femur.Review of a report dated 12/23/25, from emergency services company indicated that they were dispatched at 2:55 p.m. to a motor vehicle accident in which a patient fell from his/her wheelchair while riding in a van, and that the patient reported that the van driver hit the brakes hard causing him/her to slide out of the wheelchair and land on his/her knees and become pinned in-between the rear seats, and reported severe right knee pain, back pain and a developing headache.Review of facility investigation of Resident R5's accident revealed: Lack of witness statements from Resident R5 and the van driver. Lack of evidence of van driver education regarding safety procedures prior to Resident R5's accident and/or after the accident.Review of facility van driver education after Resident R5's accident revealed lack of job specific interventions to ensure resident safety during transport in the facility van.Documentation of an interview on 3/30/26, with Resident R5 by the Ombudsman (official or designated person who investigates complaints, ensures fairness, and helps resolve disputes impartially) indicated that Resident R5 was not secured in his/her wheelchair by a seatbelt and that the van driver suddenly slammed on the brakes and Resident R5 was propelled forward out of his/her wheelchair and landed between the first and second seats of the van. Resident R5's statement stated that he/she was never interviewed by the facility regarding the incidents leading up to his/her fall and fracture.Interview with Resident R5 on 4/01/26, at 8:30 a.m. confirmed that the documented interview with the Ombudsman on 3/30/36, was accurate and that he/she was never interviewed to tell his/her side of the story.During an interview on 4/01/26, at 3:13 p.m. the Nursing Home Administrator (NHA) confirmed there was no evidence of van driver education prior to Resident R5's accident. Resident R2's clinical record revealed an admission date of 10/16/23, with diagnoses that included COPD, Type 2 Diabetes (condition when the body cannot use insulin correctly and sugar builds up in the blood) and Parkinson's Disease (brain disorder that affects movement and causes tremor, stiffness, and slowness), and epilepsy (long-term brain disorder that causes recurrent, unprovoked seizures caused by abnormal electrical activity in the brain). A care plan entitled, I am a smoker dated 11/13/25, included interventions to assess ability to smoke safely, obtain a physician's order and consent, and will smoke at established smoking times and location.Resident R2's most recent smoking assessment dated [DATE], indicated he/she drops ashes on self, follows the facility's policy on location and time of smoking, and requires the application of a smoking apron.Review of information submitted by the facility to the State Agency on 2/06/26, indicated that on 1/30/26, Resident R2 was observed lying on the ground in the designated resident smoking area outside. Resident R2 stated that he/she bent over in his/her wheelchair to pick up a dropped cigarette off the ground, fell, and couldn't get back up. Initial assessment revealed a large (8cm) protruding hematoma, numerous small abrasions on forehead, nasal area and mouth. An ice pack applied to nose & hematoma. On 1/31/26, Resident R2 complained of increasing pain to his/her nose and increased swelling was also noted. Resident R2 was sent to the hospital and was found to have multiple facial soft tissue contusions/ecchymoses, and a slightly comminuted & mildly displaced bilateral nasal bone fracture.Review of the facility's investigation revealed lack of evidence that Resident R2 was supervised while outside smoking in the designated resident smoking area. During an interview on 4/01/26, at 2:19 p.m. the NHA confirmed staff should have been supervising Resident R2 while he/she was outside smoking. Resident R7's clinical record revealed an admission date of 7/17/24, with diagnoses that included paraplegia (type of paralysis that affects the lower half of the body, typically caused by spinal cord injury or neurological disease), Type 2 Diabetes, and spinal stenosis (narrowing of spaces within the spine, which can compress the spinal cord and nerves, leading to pain, numbness, or weakness).Review of the information submitted by the facility to the State Agency on 7/15/25, Resident R7 was being transported via the facility-owned van by the facility's van driver and his/her wheelchair tipped over when the van driver had taken a turn. The van driver was unable to move Resident R7 on his/her own. The security staff for the facility where he was stopped summoned the emergency department staff to assist the van driver. Resident R7 was taken to the hospital emergency department for evaluation and was found to have no injuries via radiological testing and was taken back to the facility.Resident R7's clinical record lacked evidence of an investigation of the incident and/or an assessment of Resident R7 upon his return to the facility. On 7/29/25, a physician's progress note referenced Resident R7's fall from a wheelchair on the bus.There was no evidence of van driver education regarding safety procedures prior to Resident R7's accident and/or after the accident.During an interview on 4/01/26, at 3:13 p.m. the NHA confirmed there was no evidence of van driver education prior to or after Resident R7's accident.During an interview on 4/02/26, at 7:45 a.m. the NHA confirmed that there was no evidence that the facility investigated Resident R7's accident. Resident R4's clinical record revealed an admission date of 8/29/24, with diagnoses that included COPD, post-traumatic stress disorder [PTSD (mental health condition that's caused by an extremely stressful or terrifying event - either being part of it or witnessing it, causing flashbacks, nightmares, severe anxiety and uncontrollable thoughts about the event)], and open sores and infections of both lower legs/feet.Resident R4's care plan entitled, I am a smoker dated 8/29/24, included interventions to agree to follow the smoking policies by not having smoking materials on my person, or in a location that puts others at risk, follow smoking times, adhere to recommendations of safe smoking, and that if the facility is non-smoking, to go off the grounds to smoke, tell staff and sign out each time.Resident R4's most recent smoking assessment dated [DATE], indicated that he/she would follow the facility's policy on location and time of smoking. There was no evidence of specific safety interventions recommended and/or determination of supervision requirements. Resident R104's clinical record revealed an admission date of 12/23/24, with diagnoses that included COPD, respiratory failure, Schizophrenia (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking), and anxiety.Resident R104's most recent smoking assessment dated [DATE], indicated that he/she would follow the facility's policy on location and time of smoking There was no evidence of specific safety interventions recommended and/or determination of supervision requirements.Observation on 3/30/26, at approximately 9:40 a.m. revealed Resident R4 and Resident R104 in their wheelchairs entering the door leading out to the designated resident smoking area. At the time of the observation, the surveyor inquired if staff go out and supervise them when they smoke. Both Residents R4 and R104 shared that staff do not go out to supervise them when they smoke.During an interview on 4/01/26, at 2:19 p.m. the NHA confirmed staff should have been outside supervising residents while they smoke. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services28 Pa. Code 201.18(b)(1)(3) Management28 Pa. Code 201.18(e)(1) Management

Based on a review of facility policy, facility and clinical records, observations, and resident and staff interviews, it was determined that the facility failed to adhere to proper infection control practices related to a gastrointestinal outbreak for four of four resident care units observed (A, B, C, and D Units).Findings include: Facility policy Infection Control - Plan Overview dated 12/23/25, revealed the primary of the MANOR's Infection Control Plan is to establish guidelines to follow in preventing, identifying, reporting, investigation, and controlling the spread of contagious, infectious or communicable diseases. The major activities of the plan are: Surveillance of infections - An on-going surveillance and monitoring for infections among residents and personnel and subsequent documentation of infections that occur. Implementation of control measures - Prevention of spread of infections is accomplished through the use of Standard Precautions and other barriers, appropriate treatment and follow-up, and employee work restrictions for illness. Prevention of Infection - Staff and resident education is done to focus on risk of infection and practices to decrease this risk. Policies, procedures and aseptic practices are followed by personnel in performing procedures and in disinfection of equipment. Immunizations are offered as appropriate to residents and staff to decrease the incidence of preventable infectious diseases. Facility policy Standard Precautions - Transmission Based Precautions General Principles dated 12/23/25, revealed it is the policy of this facility to use Transmission Based Precautions (TBP) in addition to Standard Precautions for a resident with documented or suspected infection or colonization with highly transmissible epidemiologically important pathogens for which additional precautions are necessary. When TBP isolation is necessary, the signage can posted on the resident's door for visitors to see the nurse before entering. Initiating TBP - Should there be reason to believe that a resident has an infection or communicable disease requiring TBP isolation, the Nurse will notify the resident's attending physician for appropriate instructions i.e., TBP for a specific type of isolation. The Nurse will enter the physician's order in the medical record. The physician's orders must be carried out quickly as practicable. The failure of the attending physician, or his/her alternate, to take appropriate action concerning a suspected or confined infectious or contagious disease, will be promptly reported to the Administrator. In the event the attending physician fails to take appropriate actions, the Administrator, Director of Nursing and/or the Infection Preventionist Nurse will have the authority to implement TBP isolation. TBP isolation will remain in effect until discontinued by the attending physician. Orders for discontinuing TBP isolation will be recorded in the medical record. Orders must be signed and dated by the attending physician. When TBP isolation is implemented, the Nurse will notify the dietary, housekeeping and laundry department supervisors that TBP isolation has been implemented. Set up isolation with supplies available to staff in an efficient manner. Post the TBP isolation sign on the outside doorframe so all personnel will be aware that TBPs isolation have been implemented. Make sure that a receptacle is placed in the room and lined with a plastic liner. Make sure laundry placed in the laundry room is properly marked to alert of TBP. After the disease signs and symptoms have resolved with physician order, the precautions may be discontinued. Personal Protective Equipment (PPE - gloves, masks, gowns ) - PPE should be readily available near the entrance to the resident's room. Resident Transport - Limit transport and movement of residents outside of the room for essential purposes only. If transport or movement is necessary, minimize dispersal of droplets by masking the resident if possible. Facility provided infection control documentation revealed nine residents (Residents R61, R39, R16, R55, R51, R106, R24, R36, and R22) on 3/24/26, with a gastrointestinal illness with loose stools, nausea and vomiting on the D unit. Nine residents (Residents R109, R111, R59, R82, R41, R47, R23, R33, and R9) on A, B, C, and D units with similar symptoms of loose stool, nausea and/or vomiting were subsequently noted 3/26/26, through 3/30/26. Review of clinical records for residents involved in the gastrointestinal outbreak revealed a lack of evidence that transmission-based precautions were implemented to prevent the spread of the gastrointestinal illness. Review of clinical records for Resident R9 indicated on 3/29/26 that he/she continued with foul loose stools. Stool was be obtained and evaluated for C. diff (a bacteria that causes severe, watery diarrhea and abdominal pain). Observations of Resident R9 revealed no transmission-based precautions related to a gastrointestinal illness were maintained during days of observations 3/30/26, 3/31/26, and 4/01/26. During an interview with Resident R33 on 3/30/26, at 1:45 p.m. he/she was observed resting in bed with a ginger ale and saltine crackers on the bedside table. Resident R33 stated, I threw up a couple times and just feel awful. No transmission-based precautions were maintained during the interview/observation. Interview with Licensed Practical Nurse (LPN) Employee E3 on the C unit on 3/30/26, at approximately 2:45 p.m. revealed that he/she was leaving work due to feeling nauseous. LPN Employee E3 further indicated that the unit had several residents not feeling well with a gastrointestinal illness. Interview with LPN Employee E1 on the C unit on 3/31/26, at 4:30 p.m. revealed no knowledge or Nurse/Nurse report of any residents on C unit with a gastrointestinal illness. Interview on 4/01/26, at 1:50 p.m. the Infection Control Registered Nurse (RN) confirmed that the facility was not following proper infection control practices and failed to recognize that further residents who were symptomatic with loose stools, nausea and/or vomiting and failed to implement transmission based precautions to mitigate the gastrointestinal illness from spreading throughout A, B, C and D units. Interview on 4/01/26, at 2:40 p.m. the Nursing Home Administrator (NHA) confirmed that the facility lacked evidence of surveillance and implementation of infection control measures to prevent the spread of further gastrointestinal illness throughout the facility from A unit to further residents on A, B, C, and D units. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to appropriately maintain respiratory care equipment according to physician's orders for four of 22 residents reviewed (Residents R1, R28, R30, and R70).Findings include: A facility policy entitled, Portable Oxygen Concentrators Usage, Care and Maintenance dated 12/23/25, indicated cleaning/maintenance for the particle screens that removes dust fragments must be cleaned with mild soap and water and allow to dry to ensure adequate air flow through the device. The policy further indicated the nasal cannula [NC-a flexible tube to deliver oxygen placed in the nose] should be replaced on a weekly basis along with all oxygen disposables the resident uses. Disposable supplies should be stored in supply bags to keep them from contamination from other surfaces such as the floor, other equipment. Resident R70's clinical record revealed Resident R70 was admitted on [DATE], with diagnoses of respiratory failure (a serious condition occurs when not enough oxygen passes from the lungs to the blood), chronic obstructive pulmonary disease (COPD - a lung condition caused by damage to the lungs and airways that restricts your breathing), asthma (a chronic respiratory condition that causes inflammation, narrowed airways and difficulty breathing), and lupus (a chronic disease where the immune system mistakenly attacks healthy tissues causing damage to organs). Resident R70's clinical record revealed a physician's order dated 3/04/26, Oxygen Maintenance: Change O2 [oxygen] tubing and supply bag weekly; wipe down concentrator (medical device that extracts oxygen from ambient air and delivers a concentrated oxygen supply to patients who need supplemental oxygen); clean filter weekly; and change water jug weekly. Directions indicated one time a day every Sunday. Resident R70's physician's orders dated 3/04/26, further indicated him/her to be on 1 liter per minute (LPM) via NC as needed to maintain oxygen levels at or greater than 90%. Observations made on 3/30/26, at 1:30 p.m. revealed Resident R70 resting in bed with oxygen infusing at 1 LPM via NC from an oxygen concentrator at his/her bedside. The oxygen tubing was noted with a label 3/6. Resident R30's clinical record revealed Resident R30 was admitted on [DATE], with diagnoses of diabetes (a group of diseases that affect how the body uses blood sugar), COPD, neutropenia (a blood disorder involving low neutrophils, a type of white blood cells which are part of the immune system fighting infections), and high blood pressure. Resident R30's clinical record revealed a physician's order dated 7/20/25, Oxygen Maintenance: Change O2 tubing and supply bag weekly; wipe down concentrator and clean filter weekly; and change water jug weekly. Directions indicated one time a day every Sunday. Resident R30's physician orders dated 8/14/25, further indicated that he/she is to receive 2 LPM via NC as needed (prn) to maintain oxygen levels at or greater than 90%. Observations made on 3/30/26, at 1:38 p.m. revealed Resident R30 resting in bed with oxygen infusing at 2 LPM via NC from an oxygen concentrator at his/her bedside. The oxygen tubing was noted with a label 3/10. Resident R28's clinical record revealed an admission date of 2/26/26, with diagnoses that included encephalopathy (group of conditions that cause brain dysfunction and can appear as confusion, memory loss, personality changes and/or coma in the most severe form), asthma (condition that causes your airways to swell, narrow and fill with mucus), morbid obesity (when body fat accumulation is so excessive that it poses serious health risks), and lymphedema (tissue swelling caused by an accumulation of protein-rich fluid that's usually drained through the body's lymphatic system). Resident R28's clinical record revealed a physician's order dated 2/28/26, to administer oxygen at 2 LPM via NC prn to maintain oxygen levels at or greater than 90% every shift, if unable to maintain oxygen saturation at or greater than 90% on 2 LPM call the physician. A physician's order dated 2/28/26, Oxygen Maintenance: Change O2 tubing and supply bag weekly; wipe down concentrator and clean filter weekly; and change water jug weekly. Directions indicated one time a day every seven days for oxygen therapy. Resident R28's Medication Administration Record for February 2026 revealed that he/she received oxygen every night on the overnight shift. Observation on 3/30/26, at 3:15 p.m. revealed that Resident R28's oxygen tubing was dated 3/16/26, and that the oxygen tubing was hanging over the top of the water jug. During an interview on 3/30/26, at 3:40 p.m. Registered Nurse (RN) Employee E2 confirmed that the above respiratory equipment was currently used by these residents, and the equipment was not dated/changed/cleaned/maintained as per Resident R28, R30, and R70's physician's orders and facility policy. Resident R1's clinical record revealed an admission date of 2/18/26, with diagnoses that included sudden respiratory failure, lung cancer, nicotine and alcohol dependency, and Schizophrenia (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking). Resident R1's clinical record revealed a physician's order dated 2/18/26, to administer oxygen at 2 LPM via NC prn to maintain oxygen levels at or greater than 90% every shift, if unable to maintain oxygen saturation at or greater than 90% on 2 LPM call the physician. A physician's order dated 2/25/26, Oxygen Maintenance: Change O2 tubing and supply bag weekly; wipe down concentrator and clean filter weekly; and change water jug weekly. Directions indicated one time a day every Sunday. Resident R1's departmental progress notes indicated he/she was wearing the oxygen mask on multiple occasions. Observation on 3/31/26, at 8:40 a.m. revealed Resident R1 lying in bed and an oxygen mask (mask placed over the nose and mouth and connected to a supply of oxygen, used when the body is not able to gain enough oxygen by breathing air) laying in the open top drawer of the bedside stand with the tubing attached to the concentrator and concentrator running, the external concentrator filter was covered with a moderate amount of gray fluffy substance. The tubing connected to the oxygen mask was labeled with white tape and the date was worn and unreadable, and water jug was empty. During an interview on 3/31/26, at 8:50 a.m. Licensed Practical Nurse Employee E1 confirmed the position and functioning of the oxygen mask, the moderate amount of gray fluffy substance on the external concentrator filter, the worn illegible tape on the tubing, and the empty water jug. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies and clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan for trauma-informed care for one of 22 residents (Resident R4).Findings include: A facility policy entitled, Care Plan Policy dated 12/23/25, indicated that the facility will develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timelines to meet a resident's medical, nursing, and mental and psychological needs. The care plan must include 1.) services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychological well-being, 2.) any services that would otherwise be required but are not provided due to the resident's exercise of rights, including the right to refuse treatment. Resident R4's clinical record revealed an admission date of 8/29/24, with diagnoses that included COPD, post-traumatic stress disorder (PTSD-mental health condition that's caused by an extremely stressful or terrifying event - either being part of it or witnessing it, causing flashbacks, nightmares, severe anxiety and uncontrollable thoughts about the even) dated 4/01/25, and open sores and infections of both lower legs/feet. Resident R4's admission Pennsylvania Preadmission Screening Resident Review Identification Level I Form (federal requirement to help ensure that individuals with a neurocognitive disorder or a mental health condition are not inappropriately placed in nursing homes for long term care) Section III-A dated 8/29/24, identified a diagnosis of depression. A behavioral health consultation dated 4/01/25, indicated that Resident R4 required a diagnosis of PTSD added to his/her clinical record. Further review of Resident R4's clinical lacked evidence of a trauma informed plan of care which included: development of trauma-informed approaches; identification and implementation of individualized interventions to eliminate or mitigate triggers that may re-traumatize Resident R4; and describe corresponding interventions for care that are in accordance with professional standards of practice. During an interview on 3/31/26, at 3:10 pm. the Nursing Home Administrator confirmed the facility failed to develop a care plan to address trauma-informed care for Resident R4's diagnosis of PTSD. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, observations, and staff interviews, it was determined that the facility failed to follow physician's orders for four of 26 residents reviewed (Residents R1, R68, CR109, and R3). Findings include: No policy was provided regarding following a physician's order. Resident's R1's clinical record revealed an admitted [DATE], with diagnoses that included neurologic neglect syndrome (a neurological disorder that makes a person lack awareness to stimuli on one side of the body or space), diabetes mellitus (a disease that affects how blood sugar is regulated in the blood), asthma (a chronic condition in which a person's airways become inflamed making it difficult to breathe), and weakness. Resident R1's clinical record revealed a physician's order dated 3/20/25, reposition every two hours offload coccyx. Observations on 4/02/25, at 8:50 a.m., 9:30 a.m., 10:30 a.m., 11:00 a.m., 11:30 a.m., 12:05 p.m., and 12:40 p.m. revealed Resident R1 out of bed in his/her wheelchair sitting upright. A further observation at 12:58 p.m. revealed Resident R1 laying in bed. During an interview with Nurse Aide (NA) Employee E7 on 4/02/25, at 12:58 p.m. revealed that Resident R1 was out of bed to his/her wheelchair before 9:00 a.m. on 4/02/25, and not repositioned until he/she was laid down in bed after lunch at approximately 12:50 p.m. by NA Employee E7. An interview with Licensed Practical Nurse (LPN) Employee E8 on 4/02/25, at 1:00 p.m. confirmed that Resident R1 was out of bed and sitting in his/her wheelchair before 9:00 a.m. and not turned/repositioned until after lunch, a time span of approximately four hours. LPN Employee E8 further confirmed that Resident R1 has a history of a Stage Three (full thickness loss of skin) pressure injury to his coccyx (tailbone), and there were physician's orders to reposition every two hours and offload coccyx. During an interview on 4/0/25, at 12:57 p.m. the Director of Nursing (DON) confirmed Resident R1 has a history of a Stage Three pressure injury to his coccyx and should be repositioned every two hours per the physician's order dated 3/20/25. Review of Resident R3's clinical record revealed an admitted [DATE], with diagnoses including broken left hip, spinal stenosis with disc degeneration (narrowing of the space that houses the spinal cord and nerve roots leading to the spinal disks between the vertebrae to wear down), and difficulty walking. The clinical record also revealed a physician's order dated 3/19/25, for no weight bearing on left leg. Observation on 4/02/25, at 1:38 p.m. revealed NA Employee E7 transfer Resident R3 into bed and permitted weight bearing to his/her left leg during the transfer. During an interview on 4/02/25, at 2:13 p.m. NA Employee E7 confirmed that he/she transfers Resident R3 using a bear hug and pivot and turn into bed. Observation on 4/03/25, at 1:05 p.m. revealed that NA Employee E8 assisted Resident R3 to stand from the toilet to the grab bar in the bathroom and adjusted Resident R3's clothing while he/she held onto the bar and permitted weight bearing to his/her left leg during the transfer. During an interview at that time, NA Employee E8 confirmed that Resident R3 stands and holds onto the bar while transferring from the toilet. During an interview on 4/03/25, a 3:40 p.m. the Director of Nursing confirmed that Resident R3's current transfer order is no weight bearing on left leg and that staff should maintain non-weight bearing until the order is updated. Resident's R68's clinical record revealed an admitted [DATE], with diagnoses that included morbid (severe) obesity due to excess calories, urinary tract infection, hypokalemia (low potassium in the blood), and hypothyroidism (a condition where the thyroid does not produce enough thyroid hormone). Resident R68's clinical record revealed a physician's order dated 10/18/24, BI-PaP at hours of sleep with 4 l/min [liters per minute] oxygen piped in to equal FIO2 of 35% pre set Settings of V=60, Max IPAP=18, EPAP=9 Make Nasal Mask Type. (BiPAP is a non-invasive ventilation therapy that helps a person breathe by delivering pressurized air through a mask). An interview with Resident R68 on 4/02/25, at 12:30 p.m. revealed that Resident R68 has been without his/her BIPAP for several months. Observations during the interview, revealed Resident R68 laying in bed and no BIPAP machine located in his/her room. During an interview with LPN Employee E10 on 4/03/25, at 12:00 p.m. confirmed that Resident R68 did not have a BIPAP machine to utilize per the physician order. During an interview on 4/04/25, at 11:45 a.m. the DON confirmed Resident R68's physician's order dated 10/18/24, was not followed for the resident to utilize a BIPAP at hours of sleep. Resident CR109's clinical record revealed an admitted [DATE], with diagnoses that included osteomyelitis (inflammation of bone caused by infection) of left ankle and foot, anemia (a condition where the blood does not have enough healthy red blood cells to carry oxygen throughout the body), metabolic encephalopathy (a condition where the brain's function is impaired due to an imbalance in chemicals in the brain affecting cognitive function, consciousness, and behavior), and chronic atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow throughout the heart and body). Resident CR109's clinical record revealed a physician's order dated 1/10/25, Active Critical Care two times a day for wound healing 30 ml [milliliters]. Resident CR109's Medication Administration Record (MAR) dated 1/10/25, lacked evidence of amount of Active Critical Care administered to Resident CR109 on: 1/10/25, 8:00 a.m. and 8:00 p.m. 1/11/25, 8:00 a.m. 1/12/25, 8:00 a.m. and 8:00 p.m. 1/13/25, 8:00 a.m. and 8:00 p.m. 1/14/25, 8:00 a.m. and 8:00 p.m. and lacked evidence that Active Critical Care was administered on: 1/11/25, at 8:00 p.m. with documentation noted as HN=Hold/See Nurse Notes with nurse documentation needs clarification on amount 1/17/25, 8:00 p.m. with documentation noted as HN=Hold/See Nurse Notes with no evidence of a nurse's documentation in progress notes. During an interview on 4/04/25, at 11:45 a.m. the DON confirmed Resident R109's physician's order dated 1/10/25, was not followed for the resident to have Active Critical Care 30 ml two times a day for wound healing. 28 Pa. Code 211.10 (a)(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, observations, and staff interview, it was determined that the facility failed to promote cleanliness and help prevent the spread of infection regarding respiratory care equipment for three of three residents and failed to provide oxygen according to physician's orders for one of three residents reviewed for respiratory services (Residents R16, R93 and R95). Findings include: Review of Resident R16's clinical record revealed an admitted [DATE], with diagnoses that included hypertension (high blood pressure), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones). Review of Resident R16's physician's orders revealed an order dated 8/11/23, to apply oxygen 1-2 lpm (liters per minute) per nasal cannula (oxygen tubing that has prongs that go into the nostrils and loops around the ears to secure in place to ensure adequate oxygen delivery) continuously to maintain oxygen saturation at or greater than 88%-92%, and an order dated 8/11/23, for Oxygen Maintenance Change O2 [oxygen] tubing and supply bag weekly, Wipe down concentrator and clean filter weekly, Change water jug weekly. Review of Resident R16's care plan revealed a plan of care with the focus of being at risk for impaired gas exchange and an intervention to administer O2 as ordered dated 3/4/24. Observations on 4/1/25, at 1:00 p.m. revealed an oxygen concentrator with a large amount of a white fluffy substance covering the top and the back of the concentrator. Observations on 4/2/25, at 9:00 a.m., 10:00 a.m. and 10: 22 a.m. revealed that oxygen was not being administered to Resident R16 and his/her nasal cannula was laying on the floor. Further observations revealed the large amount of a white fluffy substance covering the top and back of the oxygen concentrator remained. Review of Resident R93's clinical record revealed an admitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD-when your lungs do not have adequate air flow), anxiety, and hyperlipidemia (high cholesterol). Review of Resident R93's physician's orders revealed an order dated 12/6/24, for Oxygen Maintenance Change O2 tubing and supply bag weekly, Wipe down concentrator and clean filter weekly, Change water jug weekly. Observation on 4/1/25, at 1:05 p.m. revealed an oxygen concentrator with a large amount of a fluffy white substance covering the top and back of the concentrator and drops of a dried liquid substance on the top of the concentrator. Observations on 4/2/25, at 9:05 a.m., 10:05 a.m. and 10:22 a.m. revealed the large amount of white fluffy substance and drops of dried liquid substance remained on the oxygen concentrator. Resident R95's clinical record revealed an admitted [DATE], with diagnoses that included acute and chronic respiratory failure (a condition where your lungs don't exchange air properly), COPD, and hypertension. Review of Resident R95's physician's orders revealed an order for Oxygen Maintenance Change O2 tubing and supply bag weekly, Wipe down concentrator and clean filter weekly, Change water jug weekly 12/6/24. Observation on 4/1/25, at 1:05 p.m. revealed an oxygen concentrator with a large amount of a fluffy white substance covering the top and back of the concentrator and drops of a dried liquid substance on the top of the concentrator. Observations on 4/2/25, at 9:05 a.m., 10:05 a.m. and 10:22 a.m. revealed the large amount of white fluffy substance and drops of dried liquid substance remained on the oxygen concentrator. During an interview on 4/2/25, at 10:22 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that Resident R16 was not wearing his/her oxygen, and his/her nasal cannula was laying on the floor. LPN Employee E1 confirmed that there was a large amount of a white fluffy substance and a dried liquid substance on the oxygen concentrators. LPN Employee E1 confirmed that the oxygen concentrators should be clean and Resident R16 should have had his/her oxygen being administered per physician's order and that his/her nasal cannula should not be on the floor. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical and facility records, resident and staff interviews, and observations, it was determined that the facility failed to provide a bath/shower as resident preference for one of 26 residents reviewed (Resident R68). Findings include: A facility policy entitled, Quality of Care Policy/Activities of Daily Living, dated 12/04/24, revealed each resident will receive and the Manor will provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Activities of Daily Living - A resident's abilities in activies of daily living will not diminish unless cirmcumstances of the individuals's clinical condition demonstrate that diminution (the act was unavoidable). A resident who is unable to carryout activites of daily living receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene. Resident's R68's clinical record revealed an admitted [DATE], with diagnoses that included morbid (severe) obesity due to excess calories, urinary tract infection, hypokalemia (low potassium in the blood), and hypothyroidism (a condition where the thyroid does not produce enough thyroid hormone). Review of Resident R68's bath/shower documentation for 3/06/25, through, 4/02/25, revealed he/she was scheduled for a bath/shower on Wednesday/Saturday 3-11 p.m., however, his/her clincial record lacked evidence that a bath/shower was provided on: 3/10/25, documented as not applicable 3/20/25, documented as not applicable 3/24/24, documented as not applicable 3/27/25, documented as not applicable 3/31/25, documented as not applicable An interview with Resident R68 on 4/02/25, at 12:30 p.m. revealed his/her shower was scheduled for Monday and Thursday, but he/she has not received the scheduled shower in the past several weeks. While grabbing his/her hair, Resident R68 stated, Look, my hair is really greasy and full of knots in the back. An observation on 4/02/25, at 12:30 p.m. revealed Resident R68 laying in bed with greasy, knotted hair. An interview with the Director of Nursing on 4/04/25, at 11:45 a.m. confirmed that baths/showers were not provided according to Resident R68's scheduled days and preference for the period of 3/06/25, through 4/02/25. 28 Pa. Code 211.10 (d) Resident care policies 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of facility policy and documents, and resident and staff interviews, it was determined that the facility failed to ensure that resident financial records were made available through quarterly statements for one of 26 residents reviewed (Resident R68). Findings include: A facility policy entitled Resident Personal Funds (Pennsylvania) dated 12/04/24, revealed the resident understands that they have the right to maintain personal money in the Manor while they are a resident. They also understand that in the event that they become eligible for Medicaid, they will receive a personal needs allowance that they may use as they wish. Quarterly accountings - They also understand that they will receive a quarterly accounting of deposits, interest earned, and withdrawals made from their account. Resident's R68's clinical record revealed an admitted [DATE], with diagnoses that included morbid (severe) obesity due to excess calories, urinary tract infection, hypokalemia (low potassium in the blood), and hypothyroidism (a condition where the thyroid does not produce enough thyroid hormone). Facility documentation indicated that the facility was responsible for handling Resident R68's finances through a resident trust fund account which had a balance of $1.74 on 3/07/25. During an interview on 4/02/25, at 12:30 p.m. Resident R68 indicated that he/she has not received any financial statements regarding his/her funds, and that he/she should have a monthly allowance to use as he/she wishes. During an interview on 4/03/25, at 2:15 p.m. the Business Office Manager Employee E5 indicated that he/she has not provided quarterly financial statements at the end of the quarter, or within 30-days of the end of the quarter. He/she further confirmed the facility lacked evidence that Resident R68 was provided financial statements including deposits, interest earned, and withdrawals made from his/her account. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(2) Management

Based on review of clinical and facility records, and staff interviews, it was determined the facility failed to ensure accurate communication regarding information about the resident's Medicare eligibility and coverage for one of 26 residents reviewed (Resident CR109). Findings include: Resident CR109's clinical record revealed an admitted [DATE], and discharge date of [DATE], with diagnoses that included osteomyelitis (inflammation of bone caused by infection) of left ankle and foot, anemia (a condition where the blood does not have enough healthy red blood cells to carry oxygen throughout the body), metabolic encephalopathy (a condition where the brain's function is impaired due to an imbalance in chemicals in the brain affecting cognitive function, consciousness, and behavior), and chronic atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow throughout the heart and body. A facility invoice dated 3/17/25, revealed a balance due of $13,939.05 for Resident CR109's stay/services from 12/09/24, through 1/24/25. An interview with the Business Office Manager (BOM) Employee E5 on 4/03/25, at 2:15 p.m. revealed that he/she communicated to Resident CR109's resident representative on 12/23/24, that Resident CR109 had Medicare days available to cover days of stay/services at the facility, indicating the stay at the facility would be covered by his/her insurance, and that Resident CR109 and/or their responsible party would not be responsible to pay privately. The BOM Employee E5 further confirmed that on 1/28/25, he/she later discovered that Resident CR109 had exhausted his/her Medicare insurance benefits, and Resident CR109 would be financially responsible as private pay for the days of stay/services from 12/09/24, through 1/24/25. The BOM Employee E5 indicated that it is sometimes confusing how insurance and Medicare coverage plays catch up, and referenced the January 2025 billing cycle that Resident CR109 would be financially responsible as private pay since no Medicare days were available to cover days of stay. This failure of adherence to communicating accurate information regarding Medicare eligibility and coverage resulted in Resident CR109/their resident representative not having an opportunity to make an adequate informed decision to continue Resident CR109's stay at the facility, or have the choice to be discharged to alternative home care services and other financial options. 28 Pa. Code 201.18(g) Management

Based on review of facility documentation and staff interview, it was determined that the facility failed to provide the required notice to the resident, or the resident's representative, following the end of Medicare covered services for one of two residents reviewed who remained in the facility for long-term care (Resident R166). Findings include: Review of Resident R166's clinical record revealed that he/she began Medicare covered services following the return from a qualifying hospital stay on 12/6/24, and the facility-initiated discharge from Medicare Part A coverage was starting 12/21/24. The resident's benefit days were not exhausted. Resident R166 remained in the facility until 3/02/25. There was no evidence that a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) of Non-coverage (document that provides information to residents so they can decide if they wish to continue skilled services that may not be paid for by Medicare and assume financial responsibility) was provided as required in advance of the time that Medicare Part A was discontinued. During an interview on 4/03/25, at 2:14 p.m. the Business Office Manager confirmed that the facility did not provide SNFABN form to Resident R166, or his/her representative, when the facility discharged the resident from Medicare covered services. 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.18(e)(1) Management

Based on a review of facility policy, facility grievances, and resident and staff interviews, it was determined that the facility failed to resolve resident and resident representative's grievance concerns related to care/treatment for four of 26 residents reviewed (Residents R19, R50, R58, and R68). Findings include: A facility policy entitled, Grievances - Resident Rights dated 12/04/24, revealed The Manor will assist residents, their representatives, other interested family members, or advocates in filing grievances when such requests are made. It is the policy of the Manor to encourage all residents and visitors to bring to the attention of the Administrator their complaints. The Administrator is the designated Grievance Officer. The Grievance Officer can be reached at the main phone number or by writing the Manor's main mailing address. All persons will be provided with an opportunity to present their complaints through a formal grievance procedure. All complaints or grievances will be resolved promptly and fairly. Sharing concerns with us. If you or another interested party has a concern regarding the Manor's delivery of services, the behavior of other residents or staff members, or any other concern, we encourage you to share your thoughts with us. You are encouraged to discuss your concern with the immediate supervisor or director of the involved department. It is our policy that concerns raised with us will be reviewed, and that we will report back to the person registering the concern with a prompt resolution. Filing of written grievance form. Grievance forms are located in the Administrator's office. A formal grievance must be submitted in writing to the Grievance Officer and signed by the resident or the person filing the grievance. It is our policy to assist residents/sponsors in filing a grievance. A review of facility Grievances for January through April 2025, lacked evidence of Grievances from Resident 19, Resident 58, Resident R68, and Resident R50's family member. No Grievances were noted for January 2025. Four Grievances for February 2025, involved four residents with missing belongings. Two Grievances for March 2025, involved a resident with hearing aides not working and a resident with missing diabetic slippers. No Grievances were noted for April 2025. An interview with Resident R19 on 4/01/25, at 1:30 p.m. revealed he/she has concerns with the communication by the nursing staff, as he/she must ask several times for lab and test results. Resident R19 stated, I am currently awaiting results from a sleep study that I've asked about several times. Resident R19 further indicated that he/she has talked to different employees regarding this concern with no resolve. An interview with Resident R58 on 4/01/25, at 1:45 p.m. revealed that he/she has communicated a concern to facility staff without any resolution about the resident smoking area which is located outside of his/her window, and frequently the noise level and lingering smoke can be a problem. He/she further indicated that the smoke prevents him/her from opening his/her window, and the noise level prevents him/her from sleeping. An interview with Resident R68 on 4/2/25, at 12:30 p.m. revealed that he/she has asked several different facility employees regarding his/her BIPAP (BiPAP is a non-invasive ventilation therapy that helps a person breathe by delivering pressurized air through a mask) machine. Resident R68 indicated he/she has been without his/her machine for numerous days with no prompt resolution. An interview with Resident R50's family member on 4/01/25, at 2:50 p.m. revealed that numerous care concerns were communicated to several different employees of the facility with no prompt resolution. Specific concerns were related to the location of the resident smoking area, which is adjacent to resident rooms, allowing smoke to linger near the rooms, and intrusive noise levels preventing residents from sleeping. Additional Resident R50's family member's concerns were related to resident hydration and times that residents are awakened for morning care. An interview with the Nursing Home Administrator (NHA) on 4/04/25, at 10:00 a.m. indicated that the facility Grievance process typically only addressed missing/broken items. The NHA further confirmed that the facility lacked evidence of Grievances for Residents R19, R50 (family member), R58, and R68's care and treatment concerns, and the care and treatment concerns were not addressed timely. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1)(3) Management 28 Pa. Code 201.29(a) Resident rights

Based on review of clinical records and facility policy and staff interview, it was determined that the facility failed to show evidence of having resident care plan conference meetings or invitation to care plan meetings and failed to revise comprehensive care plans to reflect the current necessary care and services for two of 26 residents reviewed (Residents R3 and R93) Findings include: Review of facility policy entitled Comprehensive Care Plan dated 12/04/24, indicated Residents will have the opportunity to discuss their goals for care . and Periodically reviewed and revised by a team of qualified persons after each assessment. Review of Resident R3's clinical record revealed an admitted [DATE], with diagnoses including broken left hip, spinal stenosis with disc degeneration (narrowing of the space that houses the spinal cord and nerve roots leading to the spinal disks between the vertebrae to wear down), and difficulty walking. Further review of Resident R3's clinical record revealed a physician's order dated 3/19/25, for no weight bearing on left leg. A care plan entitled Self-Care Deficit dated 3/01/22, and updated 2/18/25, revealed to transfer with extensive assistance and a rolled walker. A care plan entitled At Risk for Falls dated 3/01/22, revealed it was updated 8/13/24, to include to walk three to six days per week (supervised by staff) with a wheeled walker. Resident R3's clinical record lacked evidence that his/her care plan was updated to reflect the non-weight bearing status of the left leg. During an interview on 4/03/25, at 3:40 p.m. the Director of Nursing confirmed that Resident R3's care plan was not updated to reflect his/her current status. Review of Resident R93's clinical record revealed an admitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (condition when your lungs do not have adequate air flow), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and hyperlipidemia (high cholesterol). Review of Resident R93's clinical record lacked evidence that he/she and/or resident representative had been invited/attended a care plan conference meeting. During an interview on 4/01/25, at 1:40 p.m. Resident R93 disclosed that he/she had not attended and/or been invited to a care plan conference meeting. During an interview on 4/03/25, at 12:25 p.m. the Social Service Manager Employee E2 confirmed there was no evidence that Resident R93 and/or his/her representative had attended and/or had been invited to a care plan conference meeting after his/her last assessment dated [DATE]. 28 Pa. Code 211.5(f)(ii)(ix) Medical records 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to ensure a safe environment related to smoking for one of two residents reviewed who smoke at the facility (Resident R42). Findings include: A facility policy entitled, Smoking Policy, dated 12/4/24, revealed for those Manors that permit smoking the purpose is to provide maximum safety to all residents at all times. It is the intent of the Manor to provide an environment to all those residents, who wish to smoke, the opportunity to do so in a safe environment, with optimal safety to themselves, other residents, volunteers, visitors, and staff members. For the purpose of this policy, all references to smoking will also include the use of electronic cigarettes and vaporizers. Residents will be informed of the written smoking policy prior to admission. Smoking in bed is strictly prohibited, this includes the use of electronic cigarettes and vaporizers. Smoking will be allowed in designated areas only. Residents must be accompanied by staff, family, or properly trained volunteers while smoking. Smoking materials will be kept in a designated area accessible only by staff. This includes the safekeeping of electronic cigarettes. Staff members are strictly prohibited from furnishing their personal smoking materials to residents. Residents electing to smoke must provide their own smoking materials. Observations during the full health survey on 4/1/25, 4/2/25, and 4/3/25 throughout each day revealed Resident R42 had several electronic cigarettes/vaporizers sitting on his/her bedside table and one electronic cigarette/vaporizer in his/her hand and on 4/2/25, at approximately 2:30 p.m. Resident R42 was observed smoking his/her electronic cigarette/vaporizer in his/her room. An interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on 4/3/25, at approximately 4:00 p.m. confirmed that Resident R42 smokes his/her electronic cigarette/vaporizer in his/her room, which is an unauthorized smoking area and against facility policy. The NHA and DON further confirmed that this resident also keeps his/her own electronic cigarettes/vaporizers, therefore the facility has no accountability of them, and Resident R42 refuses to follow the facility smoking policy which places other residents, staff, and visitors at a safety risk. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 209.3(a) Smoking

Based on review of a facility policy, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in one of one walk-in coolers reviewed in the kitchen. Findings include: Review of facility policy entitled Storage of Perishable Foods dated 12/4/24, indicated Prepared or leftover foods should be stored tightly covered, clearly labeled, dated, and used within 3 days or discarded. Observation during kitchen tour on 4/1/25, at 12:00 p.m. revealed a clear plastic container containing five leftover potato triangles (hashbrowns) with a prepared date of 3/28/25, and no discard date. During an interview with the Dietary Manager Employee E3 on 4/1/25, during the time of observations he/she confirmed that the clear plastic container containing five leftover potato triangles were beyond their use by date. He/she also confirmed that the potato triangles should have been discarded by their use by date. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on review of clinical and facility records, and staff interviews, it was determined the facility failed to follow professional standards by ensuring accurate accounts in communication and writing for insurance coverage for resident services for one of 26 residents reviewed (Resident CR109). Findings include: Resident CR109's clinical record revealed an admission date of 12/09/24, and discharge date of 1/24/25, with diagnoses that included osteomyelitis (inflammation of bone caused by infection) of left ankle and foot, anemia (a condition where the blood does not have enough healthy red blood cells to carry oxygen throughout the body), metabolic encephalopathy (a condition where the brain's function is impaired due to an imbalance in chemicals in the brain affecting cognitive function, consciousness, and behavior), and chronic atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow throughout the heart and body. A facility invoice dated 3/17/25, revealed a balance due of $13,939.05 for Resident CR109's stay/services from 12/09/24, through 1/24/25. An interview with the Business Office Manager (BOM) Employee E5 on 4/03/25, at 2:15 p.m. revealed that he/she communicated to Resident CR109's resident representative on 12/23/24, that Resident CR109 had Medicare days available to cover days of stay/services at the facility, indicating the stay at the facility would be covered by his/her insurance, and that Resident CR109 and/or their responsible party would not be responsible to pay privately. The BOM Employee E5 further confirmed that on 1/28/25, he/she later discovered that Resident CR109 had exhausted his/her Medicare insurance benefits, and Resident CR109 would be financially responsible as private pay for the days of stay/services from 12/09/24, through 1/24/25. The BOM Employee E5 indicated that it is sometimes confusing how insurance and Medicare coverage plays catch up, and referenced the January 2025 billing cycle that Resident CR109 would be financially responsible as private pay since no Medicare days were available to cover days of stay. This failure to follow professional standards and adherence to thorough principles of communication resulted in Resident CR109/their resident representative not having an opportunity to make an adequate informed decision to continue Resident CR109's stay at the facility, or have the choice to be discharged to alternative home care services and other financial options. 28 Pa. Code 201.18(g) Management

Based on observations, review of manufacturer's guidelines and facility documents, and staff interviews, it was determined that the facility failed to properly clean and prevent the potential for cross contamination during the use of a blood glucose meter (BGM-a device to collect and measure the level of glucose [sugar] in the blood) for two of nine residents observed during the administration of medications (Residents R17 and R65). Findings include: Review of manufacturer's cleaning and disinfecting procedures indicated that the BGM should be cleaned and disinfected after use on each patient. Review of a facility skills demonstration/evaluation form for Blood Glucose Testing revealed that staff are instructed to disinfect the BGM per manufacturer's guidelines after completion of sample testing. Observation of blood glucose monitoring for Resident R51 on 4/01/25, at 3:27 p.m. revealed that Licensed Practical Nurse (LPN) Employee E9 entered Resident R51's room, obtained the blood specimen using the BGM, then exited Resident R51's room and laid the soiled BGM on the top of the medication cart and failed to clean the BGM per manufacturer's guidelines. It was unable to be determined if the the BGM was cleaned prior to/after use for blood glucose monitoring for Resident R51. Observation of blood glucose monitoring for Resident R65 on 4/01/25, at 3:39 p.m. revealed that LPN Employee E9 entered Resident R65's room, obtained the blood specimen using the BGM, then exited Resident R65's room and laid the soiled BGM on the top of the medication cart and failed to clean the BGM per manufacturer's guidelines. Observation of blood glucose monitoring for Resident R17 on 4/01/25, at 4:07 p.m. revealed that LPN Employee E9 entered Resident R17's room, obtained the blood specimen using the BGM, then exited Resident R17's room and laid the soiled BGM on the top of the medication cart and failed to clean the BGM per manufacturer's guidelines. During an interview on 4/01/25, at 4:10 p.m. LPN Employee E9 confirmed that he/she failed to clean the BGM unit prior to obtaining blood specimens from Residents R65 and R17. During an interview on 4/02/25, at 12:49 p.m. Infection Control/Infection Preventionist Employee E6 confirmed that the BGM unit should have been cleaned and disinfected after use on each patient. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on review of clinical records, facility documentation, and staff interview, it was determined that the facility failed to complete the Minimum Data Set (MDS-periodic assessment of resident care needs) to accurately reflect the resident's status at the time of the assessment for one of 26 residents reviewed (Resident R43). Findings include: Resident R43's admission record revealed an admitted [DATE], with diagnoses that included bacterial bone infection in the right ankle and foot, Type 2 diabetes (conditiona when the body cannot use insulin correctly and sugar builds up in the blood), and irregular heartbeat. Review of Resident R43's Medication Administration Records (MARs) revealed he/she received Trulicity (a non-insulin injectable diabetes medication to help improve blood sugar control by stimulating insulin release) every seven days in May 2024, July 2024, September 2024, October 2024, November 2024, and February 2025. The Quarterly MDS dated [DATE], Medications Section N0350A indicated that Resident R43 received insulin one time during the seven-day look back period. The Quarterly MDS dated [DATE], Medications Section N0350A indicated that Resident R43 received insulin one time during the seven-day look back period. The Quarterly MDS dated [DATE], Medications Section N0350A indicated that Resident R43 received insulin one time during the seven-day look back period. The Quarterly MDS dated [DATE], Medications Section N0350A indicated that Resident R43 received insulin one time during the seven-day look back period. The Quarterly MDS dated [DATE], Medications Section N0350A indicated that Resident R43 received insulin one time during the seven-day look back period. The Annual MDS dated [DATE], Medications Section N0350A indicated that Resident R43 received insulin one time during the seven-day look back period. During an interview on 4/03/25, 11:00 a.m. Registered Nurse Assessment Coordinator Employee E4 confirmed that Section N - Medications category N0350A Insulin of the Quarterly MDS's dated 5/15/24, 7/12/24, 9/27/24, 10/31/24, 11/02/24, and the Annual MDS dated [DATE], were incorrectly coded for Resident R43 (as related to Trulicity) and should have been zero days. 28 Pa. Code 211.5(f)(x) Medical records

Based on review of facility policies, clinical records, and facility documentation, and staff interview, it was determined that the facility failed to ensure that one resident reviewed with food allergies (Resident R1) was free from exposure to a food allergen resulting in an allergic reaction. Findings include: The facility policy entitled, Nutrition Services Communication Form dated June 2016 revealed that it will be used to enhance communication between nursing and dietary of the need to change in diet or for nutritional interventions. The facility policy entitled Food Allergen Awareness dated January 2018, revealed that food allergies will be identified by a common name of the food or any part of the food that contains a food allergen with the purpose to prevent an allergic reaction. Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included anemia (iron deficiency), major depression, and anxiety disorder. Resident R1's clinical record included a diet that identified a food allergy to fish. Facility documentation revealed that on 11/11/2024, Resident R1 was served dinner with his/her son present with a meal tray ticket that specified breaded pork patty. When Resident R1's son questioned the food item and the meal tray, a staff member read the ticket and said it was a pork patty. Resident R1 ate a portion of the patty and began to develop a rash. The patty was then determined to actually be a breaded fish patty. Facility documentation verified that there was an error in the provision of an alternate food item related to a food allergy. During an interview on 12/23/2024, the Nursing Home Administrator, confirmed that the facility did not follow the physician's orders to not provide a food allergen to Resident R1 that resulted in an allergic reaction to fish. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to review and/or revise resident care plans for three of 13 residents reviewed (Resident R8, R11, and R13). Findings include: Review of facility policy dated 12/19/23, entitled Comprehensive Care Plans indicated A Comprehensive Care Plan must be developed within seven days after completion of the comprehensive assessment and Periodically reviewed and revised by a team of qualified persons after each assessment. Resident R8's clinical record revealed an initial admitted [DATE], and a readmitted [DATE], with diagnoses that included diabetes, high blood pressure, and chronic kidney disease (kidneys do not function properly in removal of excessive fluids and waste that is then removed through your urine). Review of Resident R8's comprehensive care plan on 8/19/24, revealed that of the 16 care plans present, 16 had an outstanding target date of 8/13/24. The care plans included the problem categories of: self-care, discharge plan, skin integrity, falls, activities, nutrition, code status, anti-anxiety medications, cardiovascular, ostomy, diabetes, antibiotic use, pain, constipation, catheter, and hypothyroid. Resident R11's clinical record revealed an admitted [DATE], with diagnoses that included left hip fracture, diabetes, and high blood pressure. Review of Resident R11's comprehensive care plan on 8/19/24, revealed that of the 14 care plans present, 14 had an outstanding target date of 8/12/24. The care plans included the problem categories of: self-care, falls, bleeding due to anticoagulant use, cardiovascular, skin integrity, discharge plan, constipation, GERD, nutrition, activities, pain, code status, bladder incontinence, and antibiotic use. Resident R14's clinical record revealed an admitted [DATE], with diagnoses that included dementia (loss of cognitive functioning affecting a persons memory and behaviors) chronic obstructive pulmonary disease (COPD - a lung disease that affects airflow from the lungs resulting in difficulty breathing, cough, mucus production and wheezing), and gastroesophageal reflux disease (GERD - a chronic disease when the stomach acids frequently flow back into the esophagus causing irritation and discomfort). Review of Resident R14's comprehensive care plan on 8/19/24, revealed that of the 17 care plans present, 17 had an outstanding target date of 8/10/24. The care plans included the problem categories of: falls, skin integrity, code status, self-care, discharge plan, pain, nutrition, activities, psychotropic medication use, constipation, cognition, bladder incontinence, COPD, anti-anxiety medication, anti-depressant medication, behaviors, and GERD. During a telephone interview on 8/21/24, at approximately 12:00 p.m. the Nursing Home Administrator confirmed that Residents R8, R11, and R14's care plans were not reviewed and/or revised within the required timeframe. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current care and services for four of 23 residents reviewed (Residents R99, R106, R31, and R85). Findings include: A facility policy entitled, Comprehensive Care Plan, dated [DATE], indicated that resident care plans would include measurable objectives and timetables to meet a resident's medical, nursing, mental and physiological needs, include the services that are to be furnished to attain or maintain the resident's highest practicable physicial, mental and psychosocial well-being, and periodically be reviewed and revised by a team of qualified persons after each assessment. Resident R99's clinical record revealed an admitted [DATE], with diagnoses including dysphagia (difficulty swallowing), hypertension (high blood pressure), and cerebral infarction (stroke). Resident R99's physician orders dated [DATE], revealed an order for Do Not Resuscitate (Allow Natural Death) - DNR. Resident R99's clinical record revealed a POLST dated [DATE], that revealed Resident R99 requested Do Not Resuscitate (DNR), Comfort Measures Only. Resident R99's care plan dated [DATE], revealed Full Code (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest), indicating that the care plan was not reviewed and revised to reflect the current care and services. Resident R106's clinical record revealed an admitted [DATE], with diagnoses including fractured right hip, high blood pressure, and anxiety. Resident R106's physician order dated [DATE], revealed an order for DNR - Limited interventions, antibiotics as needed and no artificial feeding. Resident R106's clinical record revealed a POLST dated [DATE], that identified for DNR, limited interventions, antibiotics as needed, intravenous (IV) fluids if needed, and no artificial feeding. Resident R106's care plan dated [DATE], revealed Full Code, indicating that the care plan was not reviewed and revised to reflect the current care and services. During an interview on [DATE], at 1:46 p.m. the Director of Nursing (DON) confirmed that the care plans for Residents R99 and R106 were not reviewed and revised to reflect current resident care and services. Resident R31's clinical record revealed an admitted [DATE], with diagnoses including stage four pressure ulcers (full thickness loss of skin) to the left and right buttocks, bacterial infection of the bone, and Methicillin-resistant Staphylococcus aureus (MRSA- infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections). Resident R31's clinical record revealed a physician's order dated [DATE], to apply a wound vacuum to his/her wounds on the left buttock and right hip pressure ulcers three times per week. Resident R31's care plan dated [DATE], lacked evidence to address the application of the wound vacuum to his/her wounds on the left buttock and right hip three times per week, and that the care plan was not reviewed and revised to reflect the current care and services. Resident R85's clinical record revealed an original admitted [DATE], with diagnoses including flaccid neuropathic bladder (nerves to the bladder are interrupted and cause the bladder to become underactive), kidney failure, stage four (extend into muscle and/or supporting structures) pressure ulcer at the base of the spine, and malnutrition. Resident R85's clinical record revealed a physician's order dated [DATE], to apply a wound vacuum to his/her wound at the base of the spine three times per week. Resident R85's care plan dated [DATE], lacked evidence to address the application of the wound vacuum to his/her wound at the base of the spine three times per week, and that the care plan was not reviewed and revised to reflect the current care and services. During an interview on [DATE], at 10:30 a.m. the DON confirmed that there was no evidence that the wound vacuum was added to Residents R31 and R85's care plans. 28 Pa. Code 211.12(d)(1)(5) Nursing services