Every finding on record at Waverly Heights

Based on review of clinical records, facility documentation, and staff interview, it was determined that the facility failed to ensure adequate assistance was provided during a transfer, resulting in a fall for one of three residents reviewed for falls (Resident R1). This was identified as past non-compliance.Findings include:Clinical record review revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses including atherosclerotic heart disease, polymyalgia rheumatica, and a history of falls.Review of Resident R1's care plan, dated October 10, 2023, indicated the resident was at risk for falls related to deconditioning. Further review of the care plan revealed that Resident R1 required a two-person assist for toileting and transfers.Review of the facility's investigation, dated March 30, 2026, revealed that Employee E1, Nurse Aide, attempted to transfer Resident R1 using a standing lift without assistance. During the transfer, the resident let go of the lift and their knees buckled. Employee E1 then called out to the resident's caregiver for assistance to help lower the resident to the floor.Review of Resident R1's private caregiver witness statement, dated March 24, 2026, revealed on March 24, 2026, The (nurse aide), transferred (Resident R1) from bed to bathroom used sit to stand lift by self she gave shower and dressed her. I was sitting in chair by window, (nurse aide) called for my help. I went to bathroom (Resident R1) was slipping out sit stand lift we lowered her to the floor. An interview on April 09, 2026 at 10:54 a.m. with Director of Nursing, Employee E2, confirmed that Resident R1 required a two-person assist at time of the transfer. Following the incident on March 24, 2026, the facility implemented the following corrective actions:On March 24, 2026, Resident R1's care plan was immediately updated to specify the use of two staff members for transfers via Hoyer lift. From March 24, 2026, through March 30, 2026, in-service training was provided to all nurse aides and nurses, with ongoing training continuing as needed. From March 24, 2026, through April 6, 2026, staff competencies for sit-to-stand mechanical lifts were completed for all nurse aides and nursesStarting March 2026 and April 2026 all care plan and care cue cards were audited for accuracy and will continue monthly for the next 12 months. Review of Resident R1's clinical record and cue card confirmed correct transfer status is in place. This deficiency was identified as past non-compliance. 28 Pa. Code 201.14 (a) Responsibility of licensee.28 Pa. Code 211.12 (d)(5) Nursing Services.

Based on observations, Review of facility policies and clinical records. Interview with staff. It was determined that the facility failed to ensure an effective infection control program. related to tube feeding and oxygen administration. Three of 12 residents reviewed. (Resident R1, R8 and R3).Findings Include:Review of facility policy, titled OXYGEN ADMINISTRATION AND CARE OF EQUIPMENT, dated January 1, 20218, revealed, Change cannula bi-weekly and as needed. Date and time should be on bottle and cannula. Oxygen tubing should be placed in a plastic bag attached to the concentrator when not in use.Observation of the facility nurses' station on February 4, 2026, at 12:15 p.m., with Employee E3, Infection Control Nurse, Employee E3, revealed that the tube feeding stand for Resident R1 was inside the nurse's station medication room. It was revealed that the stand had stains of dried tube feeding formula indicating the stand and the machine was not cleaned or disinfected prior to storing in the nurse's station. Employee E3 stated staff removed the stand and the pump after the administration and confirmed that it was not cleaned or disinfected. Employee E3 stated staff should disinfect or clean the pump and stand when removed out of resident room to prevent cross-contamination.Observation of Resident R8 on February 3, 2026, at 11:30 a.m. and on February 4, 2026, at 12:30 p.m revealed Resident R8 had an oxygen concentrator in his room, the oxygen tubing was undated and was not bagged.Observation of Resident R3 on February 3, 2026, at 11:35 a.m. revealed Resident R3 had an oxygen concentrator in his room, the oxygen tubing was undated and was not bagged. There was a nebulizer tubing on the nightstand which was not bagged.Observation of Resident R3 on February 4, 2026, at 12:35 p.m. revealed Resident R3 had an oxygen concentrator in his room, the oxygen tubing was not bagged. There was a nebulizer tubing on the nightstand which was not bagged.Employee E3 confirmed the above finding on on February 4, 2026, at 12:15 p.m., during a tour of the nursing unit.28 Pa. Code 211.12(d)(1)(2)(3)(5)Nursing service

Based on the review of facility provided documentation and interview with staff, it was determined that facility did not ensure to include as part of its Quality Assurance and Performance Improvement (QAPI) program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program for four of five employees reviewed (Employees E4, E5, E6 ,E7 and E8)Findings include:Review of Employee education record for Employee E4, Nurse Aide, revealed no evidence of training provided regarding facility's QAPI program.Review of Employee education record for Employee E5, Nurse Aide, revealed no evidence of training provided regarding facility's QAPI program.Review of Employee education record for Employee E6, Nurse Aide, revealed no evidence of training provided regarding facility's QAPI program.Review of Employee education record for Employee E7, Nurse Aide, revealed no evidence of training provided regarding facility's QAPI program.Review of Employee education record for Employee E8, Nurse Aide, revealed no evidence of training provided regarding facility's QAPI program.Findings confirmed with Administrator on February 5, 2026 at 12:30 p.m 28 Pa Code 201.14(a)Responsibility of licensee28 Pa Code 201.20(a)(d) Staff development

Based on a review of facility policy, observation, and staff interviews, it was determined that the facility failed to establish, implement and maintain an effective infection control program related to enhanced barrier precaution, relating to staff education, proper signage and available personal protective equipment (PPE) for three of three reviewed. (Resident 3, Resident R10, and Resident 129) Finding includes: Review of facility policy titled Enhanced Barrier Precautions revealed that enhanced barrier is an approach to the use of personal protective equipment (PPE) to reduce transmission of Multi Drug Organisms between residents in skilled nursing facilities. Enhanced barrier precautions (EBP) expand the use of gowns and gloves beyond standard precautions. The strategy calls for healthcare personal to wear specific (PPE) during high contact resident t care activities for resident known to be infected or colonized with an MDRO as well as those with increased risk of MDRO, which includes any resident with a wound or indwelling medical device (e.g., central line, urinary catheter, feeding tube, tracheostomy, ventilator) Example of contact care activities include: dressing, bathing, and provide hygiene, changing linens, changing briefs, device care and wound care. Review of Center for Disease Control and Prevention (CDC) policy titled Enhanced Barrier Precautions in Skilled Nursing Facilities dated November 15, 2025, revealed the focus on use of gown and gloves during high-contact resident care activities that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves and make PPE, including gowns and gloves, available immediately outside of the resident room. Further review of CDC policy titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) revealed Enhanced barrier precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. An effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. When implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this: Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves) o For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves Make PPE, including gowns and gloves, available immediately outside of the resident room Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room) Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room Incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education Provide education to residents and visitors Observation conducted on February 18, 19, 20, and 21, 2025, revealed three residents' doors with signage on the door consisting of instructions that all see the nurse before entering no indication of precaution and no personal protective equipment (PPE) readily available at point of care were viewed. Review of facility documentation matrix implied that three residents were assessed to be requiring enhanced barrier precaution due to indwelling device and wounds. Review of Resident R10's minimum data set (MDS-federal mandated process for clinical assessment of all residents) dated January 20, 2025 revealed that Resident R10 was admitted into the facility on [DATE] with diagnosis' including benign prostatic hyperplasia (prostate gland enlargement that can cause urination difficulty) and obstructive uropathy (a urinary tract disorder that occurs due to obstructive urinary flow) and requiring the use of an indwelling catheter. Review of Resident R10's physician order revealed an order for enhanced barrier precaution dated February 19, 2025, one month after being admitted with a suprapubic urinary catheter. Review of Resident R3's quarterly Minimum Data Set, dated dated dated [DATE], revealed that Resident R3 was admitted into the facility on [DATE] with two pressure ulcers (areas of damaged skin and soft tissue injuries). Review of Resident R129's MDS quarterly Minimum Data Set, dated dated dated [DATE], revealed that Resident R129 was admitted into the facility on [DATE], with a surgical wound. Review of Resident R129's physician order revealed no order for enhanced barrier precaution. Interview with Licensed nurse, infection control preventionist, Employee E 6 on February 19, 2025, at 1:03 p.m. revealed that it is not facility policy that PPE is required during contact such as physical therapy or any contact other than wound care or indwelling device. Employee E6 stated that (PPE) is not required if wounds are covered. Furthermore, Employee E6 stated that is respectful of resident privacy not to place signage on the door that indicated the resident is on any precaution and (PPE) can be obtained at the nurse's station. Interview with Licensed nurse Employee E10 on February 21, 2025, at 8:50 a.m. revealed that this employee has not been educated on enhanced barrier precautions, is unaware of the precaution and what is required. Interview with Licensed nurse, Employee E 11 on February 21, 2025, at 09:00 a.m. revealed that this employee has not been educated on enhanced barrier precautions, did not have any knowledge regarding the precaution and why it is implemented, and believes the posted sign on specific residents door to see the nurse before enter were indicated those residents were receiving hospice program and may not want to be disturbed. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 211.12(d)(5) Nursing Services

Based on the review of clinical records and interview with staff, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer to the hospital and the reasons for the transfer in a timely manner for one of 12 residents reviewed (Resident R8). Findings include: Review of Resident R8's clinical record revealed that the resident was transferred to the hospital on September 7, 2023, due to fever. Further review of Resident R8's clinical record failed to reveal documentation of a written hospital transfer notice provided by the facility to Resident R8 and their representative(s). Interview with the facility Administrator, Employee E1, on April 24, 2024, at 9:43 a.m. confirmed that Resident R8 and their representative were not notified in writing of the reasons for the transfer, and in a language and manner they understood. Further interview confirmed there was no system in place regarding written notice before discharge. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights

Based on review of the clinical records, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that a resident was free of significant medication error related to the receiving wrong medication which was prescribed for another resident for one of 4 residents reviewed for medication administration (Resident R9). Findings include: Review of FDA (Food and Drug Administration) guidelines for Morphine sulfate revealed that Morphine sulfate is an opioid agonist indicated for the relief of moderate to severe acute and chronic pain where an opioid analgesic is appropriate. (1) Morphine sulfate 100 mg per 5 mL (20 mg/mL) solution is indicated for the relief of moderate to severe acute and chronic pain in opioid-tolerant patients. WARNINGS AND PRECAUTIONS Risk of Medication Errors: Use caution when prescribing, dispensing, and administering to avoid dosing errors due to confusion between different concentrations and between mg and mL, which could result in accidental overdose and death. (5.1) Respiratory depression: Increased risk in elderly, debilitated patients, those suffering from conditions accompanied by hypoxia, hypercapnia, or upper airway obstruction. (5.2) Controlled substance: Morphine sulfate is a Schedule II controlled substance with an abuse liability similar to other opioids. (5.3) CNS effects: Additive CNS depressive effects when used in conjunction with alcohol, other opioids, or illicit drugs. Review of Physician orders for Resident R9 for April 2024 revealed no evidence that the resident had a physician order for morphine sulfate. Review of a facility investigation dated April 4, 2024, revealed that the charge nurse administered Morphine Sulfate (This medication is used to help relieve moderate to severe pain. Morphine belongs to a class of drugs known as opioid analgesics) 0.25 milligrams to Resident R1 by error. Nurse recognized error when she signed out the medication. Interview with Resident R9 on April 22, 2024, at 11:00 a.m. stated she received the wrong medication approximately 2 weeks ago. Resident stated she was sleeping and during her sleep she was awaken by a nurse by placing something like a liquid in her mouth. Resident stated she was asleep, and the nurse did not ask her anything to identify her. Interview with Director of Nursing on April 24, 2024, at 2:38 p.m. stated nurse did not follow appropriate practice of medication administration. Nurse did not identify the right resident/patient before she administered the medication which resulted in Resident R9 receiving wrong narcotic pain medication which could potentially cause serious side effects. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on a review of facility documents, observations, and interviews with staff, it was determined that the facility did not establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for two units (Care Base One and Care Base Two). Findings include: Review of the facility policy on Controlled Substance storage with an effective date of January 1, 2019, revealed that under section Policy Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with federal, state, and other applicable laws and regulations. Under section Procedure #D. A controlled substance accountability record is prepared by the pharmacy/facility for all Schedule II, III, IV. Review of facility Narcotic Reconciliation Record (a form where in-coming and the outgoing nurses sign for accountability of the controlled medications in their respective narcotic boxes) for Unit Care Base Two conducted on July 19, 2023, at 9:30 a.m. with licensed nurse Employee E3 revealed that the shift-to-shift accountability had missing signature on July 19, 2023, for the 11 to 7 shift. Further review of the Narcotic Reconciliation record conducted withLicensed staff, Employee E3 revealed that Narcotic Reconciliation only accounted for the count of the controlled substances present at the time of the count but did not account for the individual controlled substance dispensed by the pharmacy. Interview with licensed nurse, Employee E3 conducted at the time of the observation revealed that at the beginning of her shift, she would count the narcotics in the narcotic box located in the medication cart together with the outgoing nurse. Further interview with Licensed nurse, Employee E3 confirmed that there was no list of the current controlled medications that should be present in the narcotic box that needed to be accounted for. Further, Employee E3 revealed that the in-coming and out-going licensed nurses were signing for the controlled substances present in the narcotic box and their corresponding narcotic count sheets in the narcotic binder at the time of the count. Further, Employee E3 confirmed that if an entire blister pack of controlled substance and its corresponding Narcotic count sheet was missing, there was no system in place to account for that missing set of controlled substance and that she would not know that it was missing until the time that the controlled medication has to be administered because there was no list of all the current controlled medications that she can reference during the count. Interview with Director of Nursing, Employee E2 conducted on July 19 20, 2023, at 10:02 a.m. revealed that she will get a running list from pharmacy and use it when nurses are doing narcotic counts between shifts. Review of facility Narcotic Reconciliation Record (a form where in-coming and the outgoing nurses sign for accountability of the controlled medications in their respective narcotic boxes) for Unit Care Base One conducted on July 19, 2023, at 10:31 a.m. with licensed nurse Employee E4 revealed that the shift-to-shift accountability had missing signature on July 19, 2023, for the 11 to 7 shift. Further review of the Narcotic Reconciliation record conducted with Employee E4 revealed that Narcotic Reconciliation only accounted for the count of the controlled substances present at the time of the count but did not account for the individual controlled substance dispensed by the pharmacy. Interview with Licensed nurse, Employee E4 conducted at the time of the observation revealed that at the beginning of her shift, she would count the narcotics in the narcotic box located in the medication cart together with the outgoing nurse. Further interview with Licensed nurse, Employee E4 confirmed that there was no list of the current controlled medications that should be present in the narcotic box that needed to be accounted for. Further, Employee E4 revealed that the in-coming and out-going licensed nurses were signing for the controlled substances present in the narcotic box and their corresponding narcotic count sheets in the narcotic binder at the time of the count. Further, Employee E4 confirmed that if an entire blister pack of controlled substance and its corresponding Narcotic count sheet was missing, there was no system in place to account for that missing set of controlled substance and that she would not know that it was missing until the time that the controlled medication has to be administered because there was no list of all the current controlled medications that she can reference during the count. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services

Based on staff interviews, and the review of clinical records, it was determined that the facility failed to ensure that one person who expressed suicidal ideation was assessed and monitored after both occurrences for 1 out 12 residents reviewed (Resident R19). Findings include: Review of the facility's policy, Behavioral Health, with an effective dates of January 1, 2018 indicated that the interdisciplinary team will put appropriate interventions in place to reduce the risk of adverse outcomes related to behavioral health among residents. The policy also indicated that for residents with identified behavioral health issues or those who are deemed at risk of adverse outcomes related to behavioral health, the care plan will be updated to identify appropriate interventions. Continued review of the policy indicated that residents identified at risk of self-harm shall be provided with access to counseling, therapy, or other appropriate mental health interventions, and that all incidents, assessments, interventions, and follow up actions shall be thoroughly documented in the resident's record, ensuring accuracy and consistency. Review of Resident R19's diagnosis provided by the facility included the following: muscle weakness; dementia; sleep apnea; respiratory failure; and pain in left wrist. Review of Resident R19's Quarterly Minimum Data Set Assessment (MDS-a periodic assessment of a resident's needs) indicated that the resident alert and oriented. Review of a nursing note dated April 5, 2023, at 11:38 a.m. written by Employee E4 indicated that Resident R19 was refusing to get out of bed and take a shower. Continued review of the note indicated that resident reported that she had pain all over and that she just wants to die and stated, why don't you just shoot me. Continued review of the nursing documentation included no evidence in the resident's clinical record that the facility supported the resident's above referenced behavior heath need by not providing appropriate treatment, care and services to the resident. There was no documentation that the facility implemented any measures to ensure the safety of the resident, conducted an assessment or monitor the resident after the resident verbalized statements of self-harm. Review of the nursing note on April 7, 2023 at 4:33 p.m. written by a therapeutic staff member (Employee E11) indicated that resident reported to the employee during her activity session, the resident stated during their session, If I could kill myself I would. The note also indicated that the resident continued to make comments about how she wasn't able to walk, and that her whole body was in pain. Continued review of the nursing documentation included no evidence in the resident's clinical record that nursing staff documented knowledge of the knowing about the comments regarding self-harm that she verbalized to Employee E11, no documentation that the physician was notified regarding resident's statements of self-harm on April 7, 2023 and no evidence that the facility supported the resident's above referenced behavior heath need by providing appropriate treatment, care and services to the resident. Review of Resident R19's psychiatric consult, Psychiatric Evaluation and Management Form, documented that the resident was seen by the psychiatrist on April 17, 2023 regarding her statements of self-harm that were made 10-11 days prior. Review of the resident's current person-centered plan of care did show evidence that a plan of care was developed for resident's statements of self-harm, to ensure that individualized approaches to care are provided to the residents, and to also ensure that staff is understanding, preventing, relieving, and/or accommodating Resident R19's behavioral health needs. During an interview with the Director of Nursing (DON) on July 20, 2023, at 9:21 a.m. regarding the above referenced events related to the resident's statements related to self-harm, it was confirmed that no information could be produced to show evidence that the resident was properly assessed, monitored, and had interventions in place to ensure resident safety. It was also confirmed during this time that the resident's person-centered plan of care did not include a plan of care for the resident's behavioral health needs. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on observations, interviews with facility staff, review of clinical records and facility documentation, it was determined that the facility failed to ensure that two bruises of unknown origin were reported to the State Survey Agency for 1 out of 12 residents reviewed (Resident R15). Findings include: Review of the facility's policy, Abuse, with an effective date of January 1, 2018 indicated that all incidents of bruising, skin tears or any other abnormality shall be reported to the nurse and an event report completed. The policy also stated that the Director of Nursing (DON) will conduct an investigation on all events deemed to be suspicious or unexplained. If abuse is suspected, the procedure for investigating/reporting abuse shall be followed. Review of the facility policy, Bruises of Unknown Origin, with an effective date of January 1, 2018, the policy indicated that upon identification of a new bruise, the following information should be included in the nurses documentation: date and time of the discovery, size, color and appearance of the bruise, and any potential witnesses or circumstances surrounding the discovery of the bruises. Review of the diagnosis list for Resident R15 provided by the facility included the following: hypertension (high blood pressure); dementia (the loss of cognitive functions such as thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities); and dysphagia (difficulty swallowing). Review of Resident R15 Quarterly Minimum Data Set Assessment (MDS-a periodic assessment of a resident's needs) indicated that the resident was cognitively impaired. Review of nursing note dated August 21, 2022, a 11:59 p.m. indicated that while providing care to the resident during the 3:00 p.m. through the 11:00 p.m. nursing shift, a nursing assistant (Employee E7) reported to licensed nursing staff (Employee E8) that a bruise on the resident's right forearm was found. Continued review of the nursing note indicates that when the Employee E8 went to assess the resident after being notified by the nursing assistant, she indicated that the resident had a large dark bruised area on her forearm. Review of the facility's investigation indicated that staff report resident with some behaviors that she move haphazardly and my [sic] have caused bruising. Continued review of the investigation did not show evidence of what staff reported this and when this behavior was observed. Review of resident's nursing notes provided by the facility from August 1, 2022, through August 21, 2022, did not show evidence of documentation of any events documented by nursing staff that could be related to the bruise (e.g. aggressiveness, combative with care) that may have occurred during this time period within which the resident's bruise was found. Review of a nursing note dated October 24, 2022 at 1:42 p.m. indicated that Resident R15 was noted to have a bruise to her right lower arm that was purple in color. Information reviewed from the facility indicated that the resident's nursing assistant (Employee E9) noticed the bruise to the arm while providing care to the resident and reported it to the nurse (Employee E10). Review of the facility's investigation indicated that staff report patient as striking out during care. Continued review of the investigation did not show evidence of what staff reported this and when this behavior was observed. Review of the resident's nursing notes from October 1, 2022-October 24, 2022 did not show evidence of documentation of any events documented by nursing staff that could be related to the bruise (e.g. aggressiveness, combative with care) that may have occurred during this time period in which the resident's bruise was found. Review of information in the State Survey agency system included no evidence that the facility reported the two referenced bruises of unknown origin to ruled physical abuse. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.14(a) Responsibility of licensee

Based on interviews, the review of clinical records and the review of facility documentation, it was determined that the facility failed to ensure that a complete and through investigation was completed to rule out abuse for two bruises of unknown origin for 1 out of 12 residents reviewed (Resident R15). Findings include: Review of the facility's policy, Abuse, with an effective date of January 1, 2018 indicated that all incidents of bruising, skin tears or any other abnormality shall be reported to the nurse and an event report completed. The policy also stated that the Director of Nursing (DON) will conduct an investigation on all events deemed to be suspicious or unexplained. If abuse is suspected, the procedure for investigating/reporting abuse shall be followed. Review of the facility policy, Bruises of Unknown Origin, with an effective date of January 1, 2018, the policy indicated that upon identification of a new bruise, the following information should be included in the nurses documentation: date and time of the discovery, size, color and appearance of the bruise, and any potential witnesses or circumstances surrounding the discovery of the bruises. Review of the diagnosis list for Resident R15 provided by the facility included the following: hypertension (high blood pressure); dementia (the loss of cognitive functions such as thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities); and dysphagia (difficulty swallowing). Review of Resident R15 Quarterly Minimum Data Set Assessment (MDS-a periodic assessment of a resident's needs) indicated that the resident was cognitively impaired. Review of nursing note dated August 21, 2022, a 11:59 p.m. indicated that while providing care to the resident during the 3:00 p.m. through the 11:00 p.m. nursing shift, a nursing assistant (Employee E7) reported to licensed nursing staff (Employee E8) that a bruise on the resident's right forearm was found. Continued review of the nursing note indicates that when the Employee E8 went to assess the resident after being notified by the nursing assistant, she indicated that the resident had a large dark bruised area on her forearm. Review of the facility's investigation indicated that staff report resident with some behaviors that she move haphazardly and my [sic] have caused bruising. Continued review of the investigation did not show evidence of what staff reported this and when this behavior was observed. Review of resident's nursing notes provided by the facility from August 1, 2022, through August 21, 2022, did not show evidence of documentation of any events documented by nursing staff that could be related to the bruise (e.g. aggressiveness, combative with care) that may have occurred during this time period within which the resident's bruise was found. Review of facility documentation regarding the reported bruise provided no evidence of documentation that the facility conducted an interview with Employee E7 who was assigned to the resident during the noted shift after she reported the bruises. In addition, review of facility documentation also did not show evidence of any interviews with staff on previous shifts (e.g., nurses, nursing assistants, activities staff) that may have witnessed something, observed something, or overheard something, or know of something that would have provided insight/information as to how Resident R15 sustained a bruise on the above noted area to ensure that abuse could be ruled out for the bruise of unknown. Review of a nursing note dated October 24, 2022 at 1:42 p.m. indicated that Resident R15 was noted to have a bruise to her right lower arm that was purple in color. Information reviewed from the facility indicated that the resident's nursing assistant (Employee E9) noticed the bruise to the arm while providing care to the resident and reported it to the nurse (Employee E10). Review of the facility's investigation indicated that staff report patient as striking out during care. Continued review of the investigation did not show evidence of what staff reported this and when this behavior was observed. Review of the resident's nursing notes from October 1, 2022-October 24, 2022 did not show evidence of documentation of any events documented by nursing staff that could be related to the bruise (e.g. aggressiveness, combative with care) that may have occurred during this time period in which the resident's bruise was found. Review of facility documentation regarding the reported bruise provided no evidence of documentation of any interviews with staff on previous shifts (e.g., nurses, nursing assistants, activities staff) that may have witnessed something, observed something, or overheard something, or know of something that would have provided insight/information as to how Resident R15 sustained a bruise on the above noted area to ensure that abuse could be ruled out for the bruise of unknown. During an interview with the Director of Nursing on July 20, 2023, at 1:02 p.m. it was confirmed that there were no additional information/interviews related to the two referenced incidents regarding the resident sustaining two bruises of unknown origin that were discovered on August 21, 2022 and October 24, 2022. 28 Pa. Code 201.14(a)(e) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.10(d) Resident care policies

Based on review of facility documents, interview with staff and review of policies and procedures, it was determined that the facility failed to develop and implement written standards, policies, and procedures to ensure that positive results of Legionella (Bacteria that causes disease found in contaminated water) culture test the facility's water system is reported to the Infection Control Preventionist or to the designated person, who is responsible for implementing infection control interventions. Findings include: Review of the facility policy and procedure Legionella Surveillance dated March 7, 2016 revealed that under section Policy: this policy reviews the surveillance steps used should Legionella be diagnosed at [NAME]. Inder section Background: Legionnaire's disease is a very serious type of pneumonia caused by a bacteria called Legionella. Under section Surveillance: If a single case of legionnaire's disease is confirmed, the following measure will take place; Bullet #3: Per water management policy- the area that test positive will be removed until from service until cleaned by our contracted water management company. Further review of the facility policy on Legionella Surveillance revealed that the policy did not indicate when and to whom a positive Legionella culture test of the facility's water system is reported to. Review of the facility's governing guideline for its Water Management Program for building water systems revealed that guideline did not indicate when and to whom a positive Legionella culture test of the facility's water system is reported to. Review of facility's water testing record conducted on July 20, 2023, revealed that the water sample from the oxygen room was obtained on June 29, 2023, and test result completed on July 13, 2023, and authorized on July 14, 2023. Further review of the water testing record revealed that test result was 1 CFU (colony forming unit)/milliliter. Interview with the Director of Maintenance, Employee E6 conducted on July 20, 2023, at 9:30 a.m. confirmed that the test result for the water testing in the oxygen room tested positive for legionella. Further, Employee E6 revealed that he informed the infection preventionist, Employee E5 of the water testing result the morning of July 20, 2023, when the test result of the facility's most recent water testing was requested by the surveyor. Further interview with Employee E6 revealed that he did not know that he has to inform Employee E5. Further, Employee E 6 confirmed that the facility Water Management Program did not indicate who needed to be informed of a positive legionella culture test. Interview with the infection preventionist, Employee E5 conducted on July 20, 2023, at 9:48 a.m. confirmed that she didn't know about the positive result until this morning, July 20, 2023. Further interview with infection preventionist, Employee E5 revealed that the facility did not have a policy on when and whom to report a positive Legionella culture and that there was no policy on what to do when a positive result for Legionella is detected in the facility water system. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management

Based on observation, review of clinical records, and staff interview, it was determined that the facility failed to follow physican orders related to a skin protective device for one of 12 records reviewed (Resident R12). Findings include: Review of Resident R12's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident R12 on June 30, 2021, at 11:15 a.m., revealed that the resident was not wearing geri sleeves to bilateral legs and leg / foot protectors (with geri sleeves under). Interview with the DON on June 30, 2021, at 11:20 a.m. where she confirmed Resident R12 was not wearing geri sleeves to bilateral legs and leg / foot protectors (with geri sleeves under) as ordered by the physician. Interview with licensed nursing staff, Employee E4, on June 30, 2021, at 11:25 a.m. where she stated that she could not locate Resident R12's geri sleeves for her bilateral legs or the resident's leg / foot protectors that were ordered by the physician. Licensed nursing staff, Employee E4, stated that the resident has not had the geri sleeves or the leg / foot protectors available in over a week's time and the resident's physician needs to be called to clarify the order. 28 Pa Code: 211.5(f) Clinical records 28 Pa Code: 211.12(d)(1) Nursing services.

Based on observations, clinical record review, and staff interviews, it was determined that the facility failed to dispose of expired sterile saline to be used during wound care treatment for one of 12 residents (Resident R17). Findings include: Review of Resident R17's clinical record revealed the resident was readmitted to the facility on [DATE], with a diagnosis to include Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Further review of the resident's clinical record revealed that Resident R17 had a Stage 2 (partial-thickness skin loss ) pressure ulcer to her gluteal fold. Review of [DATE] physician orders revealed an order for to wound care to right gluteal fold, wound-cleanse with wound cleaner, apply skin prep to surrounding area, apply (dime size amount of triad hydrophilic) wound dressing pansement hydrophile and 3 x 3 a Allevyn pad. Observation of Resident R17's wound care treatment on [DATE], at 12:00 p.m. revealed licensed nursing staff, Employee E3, had set up the supplies needed for Resident R17's wound care treatment on a protective barrier. The supplies included a bottle of sterile saline. Employee E3 was in the process of starting wound care treatment, where it was brought to his attention by the surveyor that the sterile saline was marked with an expired date of [DATE]. Interview on [DATE], at 12:10 p.m. with licensed nursing staff, Employee E3, where he confirmed that the sterile saline was marked expired [DATE], where Employee E3, RN, was going to use the sterile saline to cleanse the wound. 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of clinical record, facility policy and procedure, and staff interview it was determined the facility failed maintain documentation of information related to a resident's code status wishes for one of 17 clinical records reviewed (Resident R23). Findings include: Review of facility policy and procedure, titled Advance Medical Directives, dated Janaury 10, 2019, indicated Advance Medical Directive is a generic term for documents expressing an individual is unable to express him/herself. The two most commonly known Directives are, Durable Power of Attorney for Healthcare and Living Will, which indicate wishes related to advance directive wishes that should be performed. Review of clinical record for Resident R23, revealed a physician order, dated, (MONTH) 16, (YEAR), which indicated an advance directive of DNR (Do not Resuscitate). Further review of the clinical record for R23 revealed a facility form titled Health Care Center - Advance Directives, which indicated, R23, gave the facility a copy of Advance Directive wishes. An interview with Employee E4, Social Worker, on (MONTH) 11, 2019, at 10:40 a.m. confirmed that the facility did not have any of Resident R23's Advance Directive paperwork that indicated wishes of DNR, as indicated in the physician order [REDACTED]. Facility failed to ensure that a resident's clinical record was complete and accurate related to paperwork about Advance Directive wishes. 28 Pa Code: 211.5(f) Clinical records. 28 Pa Code: 211.12(d)(1) Nursing services. 28 Pa. Code: 211.5(b)(i) Clinical Records 28 Pa. Code: 201.18(a) Management 28 Pa. Code 201.29(j) Resident rights

Based on clinical record review, review of facility documentation and policy and procedure and staff interviews, it was determined the facility failed to obtain a physician order for [REDACTED]. Findings include: Review of facility policy and procedure, titled, Hospice Care, dated, (MONTH) 10, 2019, indicated, Upon physician order for [REDACTED].>During the initial tour of the facility on (MONTH) 10, 2019, at 12:20 p.m. Employee E3, Licensed Nurse, indicated, Resident R91, was receiving hospice services. Review of Resident R91's clinical record revealed a physician order, dated, (MONTH) 1, 2019, which indicated a [DIAGNOSES REDACTED]. Further review of R91's physician order's did not indicate a physician order was in place for R91 to receive Hospice services. An interview with the Director of Nursing on (MONTH) 11, 2019, at 11:45 a.m. confirmed no physician order was obtained related to Hospice services for Resident R91, as indicated in the facility policy and procedure related to Hospice services. The facility failed to ensure that a physcian order was obtained for one resident receiving Hospice services. 483.25 Quality of Care 28 Pa. Code: 211.3(b) Oral and telephone orders 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(d)(1) Nursing services 28 Pa. Code: 211.10(a)(b)(c) Resident care policies

Based on clinical record review, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that resident assessments were transmitted in a timely manner for six out of 17 residents reviewed (Residents R9, R8, R7, R2, R6 and R1). Findings include: Review of facility policy Minimum Data Set Completion, (MDS - a mandatory periodic resident assessment tool), undated, revealed that MDS assessments will be completed and encoded timely. Clinical record review for Resident R9 revealed a quarterly MDS assessment dated (MONTH) 3, (YEAR), was not submitted until (MONTH) 25, (YEAR). Continue clinical record review revealed another quarterly MDS assessment dated (MONTH) 3, (YEAR), that was not submitted until (MONTH) 11, 2019. Further clinical record review revealed a comprehensive MDS assessment dated (MONTH) 4, 2019, that has not yet been submitted as of (MONTH) 12, 2019. Clinical record review for Resident R8 revealed a quarterly MDS assessment dated (MONTH) 3, (YEAR), that was not submitted until (MONTH) 25, (YEAR). Continue clinical record review revealed another quarterly MDS assessment dated (MONTH) 3, (YEAR), that was not submitted until (MONTH) 11, 2019. Further clinical record review revealed a comprehensive MDS assessment dated (MONTH) 4, 2019, that has not yet been submitted as of (MONTH) 12, 2019. Clinical record review for Resident R7 revealed a comprehensive MDS assessment dated (MONTH) 6, (YEAR), that was not submitted until (MONTH) 25, (YEAR). Continue clinical record review revealed a quarterly MDS assessment dated (MONTH) 3, (YEAR), that was not submitted until (MONTH) 11, 2019. Further clinical record review revealed another quarterly MDS assessment dated (MONTH) 4, 2019, that has not yet been submitted as of (MONTH) 12, 2019. Clinical record review for Resident R2 revealed a quarterly MDS assessment dated (MONTH) 19, (YEAR), that was not submitted until (MONTH) 25, 2019. Continue clinical record review revealed a comprehensive MDS assessment dated (MONTH) 18, 2019, that was not submitted until (MONTH) 9, 2019. Clinical record review for Resident R6 revealed a quarterly MDS assessment dated (MONTH) 3, (YEAR), that was not submitted until (MONTH) 23, (YEAR). Continue clinical record review revealed another quarterly MDS assessment dated (MONTH) 3, (YEAR), that was not submitted until (MONTH) 11, 2019. Further clinical record review revealed a comprehensive MDS assessment dated (MONTH) 4, 2019, that has not yet been submitted as of (MONTH) 12, 2019. Clinical record review for Resident R1 revealed a quarterly MDS assessment dated (MONTH) 3, (YEAR), that was not submitted until (MONTH) 14, 2019. Continued clinical record review revealed another quarterly MDS assessment dated (MONTH) 4, 2019, that has not yet been submitted as of (MONTH) 12, 2019. Interview on (MONTH) 12, 2019, at 1:15 p.m., the Registered Nurse Assessment Coordinator (RNAC) confirmed that the above assessments were not submitted timely. Interview on (MONTH) 12, 2019, at 1:50 p.m., the Director of Nursing confirmed that the above assessments were not submitted within the required timeframes. The facility failed to ensure that that resident assessments were transmitted in a timely manner. 28 Pa Code 211.5(f) Clinical records

Based on clinical record review, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that comprehensive resident assessments were completed in a timely manner for two out of 17 residents reviewed (Residents R9 and R8). Findings include: Review of facility policy Minimum Data Set Completion, (MDS - a mandatory periodic resident assessment tool), undated, revealed that MDS assessments will be completed timely and that the Registered Nurse Assessment Coordinator (RNAC) is responsible for reviewing each MDS section for completion. Clinical record review for Resident R9 revealed that a comprehensive MDS assessment was initiated (MONTH) 4, 2019. As of (MONTH) 12, 2019, the assessment still had not been completed. Clinical record review for Resident R8 revealed that a comprehensive MDS assessment was also initiated (MONTH) 4, 2019. As of (MONTH) 12, 2019, the assessment still had not been completed. Interview on (MONTH) 12, 2019, at 1:15 p.m., the RNAC confirmed that the above assessments were incomplete. Interview on (MONTH) 12, 2019, at 1:50 p.m., the Director of Nursing confirmed that the above assessments were not completed within the required timeframes. The facility failed to ensure that comprehensive resident assessments were completed in a timely manner. 28 Pa Code 211.5(f) Clinical records

Based on observation, clinical record review, review of facility policy and procedure, interview with staff, it was determined the facility failed, to provide an environment free of physical restraint for one of 17 clinical records reviewed (Resident R89). Findings include: Review of facility policy and procedure, titled, Use of Restraints, dated, (MONTH) 10, 2019, indicated, Facility prohibits the use of restraints. The policy and procedure, further indicated the procedure for a restraint would be, As appropriate, residents will be evaluated by their physician for consultation and guidance regarding needed interventions to promote resident safety. During the initial observation of Resident R89, on (MONTH) 10, 2019, at 2:15 p.m. revealed, R89, was laying in her bed, during the initial observation, it was observed a tall back chair, was placed by the left hand side of R89's bed, immediately at the end of the quarter bed rail, which was located at the head of the bed. At the time of the observation, an interview with R89's daughter indicated, the tall back chair is placed in that position, to keep R89, from getting out of bed. Resident R89's daughter further indicated, the tall back chair that she was sitting in is placed on the right side of R89's bed, in the same position as the chair on the left hand side of the bed at night and also when R89's daughter leaves R89's room, for a long period of time, to keep her mother in the bed. Clinical record review for Resident R89, revealed an admission physician order, dated, (MONTH) 29, 2019, which indicated a [DIAGNOSES REDACTED]. Continued review of the clinical record revealed a Side Rail Assessment Tool, completed on (MONTH) 29, 2019, which indicated R89 displayed behaviors such as agitation, restlessness, periods of altered perception or awareness of surroundings. The assessment also indicated R89 had a history of [REDACTED]. The Side Rail Assessment Tool also indicates Risk factors for entrapment include, but are not limited to confusion, pain, agitation, uncontrolled body movements, [MEDICAL CONDITION], attempts to get out of bed with side rails raised. An interview with the Director of Nursing, on (MONTH) 11, 2019, at 10:30 a.m. confirmed that the quarter rails for Resident R89 were recommended to assist with transfers and to assist with bed positioning. An observation of Resident R89 on (MONTH) 11, 2019, at 1:45 p.m. in the presence of the Director of Nursing revealed R89 was laying in her bed, with both quarter rails and the top of the bed in the up position and a tall back chair on both sides of the bed, at the end of each quarter rail. At the time of the observation, an interview with the Director of Nursing, confirmed that with both quarter rails in the up position and than the single tall back chairs in place as they were observed was preventing R89 in being able to indepently and freely get out of bed, creating an environment in which R89 was restrained and entrapped in her bed. The facility failed to ensure that one resident was not restrained, entrapped while laying in bed. 28 Pa Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. Previously cited 5/5/17 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.5(d)(1) Nursing services. 28 Pa. Code 211.8(c)(d)(e)(f) Use of restraints

Based on observation, review of facility documentation and interview with facilty staff it was determined that the facility failed to maintain clean and sanitary conditions within the dietary department. Findings include: During the initial tour of the Dietary Department on May 3, 2017, between 11:35 a.m. - 12:20 p.m. revealed the following observations, in the presence of Employee E6, Dietary Manager. Observation of the loading dock area revealed that the three dumpsters were completely filled with cardboard, other types of recyclable materials and trash, the dumpsters were not covered with the lids. Various pieces of trash were observed on the ground around the loading dock area. The steamer was observed to have stagnant water at the base of the steamer that had a heavy accumulation of food particles and also had a heavy lime build up. Numerous air gaps observed throughout the dietary department were not affixed properly. Air gaps were observed touching floor tiles and floor drains. Employee E7, Dietary aide, was observed washing pots and pans at the three compartment sink, further observation of the three compartment sink revealed the height of the water for all three sections was well over the water line marker. The entire flooring areas including the permitter, under cook ware equipment and prep areas and inside the walk in freezer had a heavy acculmation of food debris and dust build up. Some of the flooring areas were revealed to be sticky. The walk in freezer had a large amount of spilled/poured salt at the door on the inside of the walk in freezer. Numerous observations were made of 3/4 quart buckets of chemical sanitizer sitting on several different food prep counter tops. One sanitizer bucket was observed sitting next to a carrot cake. Observation was made of Employee E8, dietary aide, using a 16 ounce plastic container to scoop flour out of the flour bin. Further observation revealed that no scoop was available for the flour and/or sugar bins. Observation of the satellite kitchen revealed that no scoop was available in this area for the flour bin. Observation was made of the food prep sink in the satellite kitchen which revealed, lobster and ravioli wraps were thawing by sitting in a stagnant metal bowl of water. Numerous trash cans within the main area of the dietary department and the satellite kitchen were observed to be without lids. Numerous employee's throughout the dietary department were observed to be with out proper fitting hair guards. These employee's were observed handling food at the time they were without proper fitting hair guards. Observation of the deep fryer revealed a heavy accumulation of food particles floating at the top of the deep fryer and the grease was observed to be old. A review of the [MEDICATION NAME] County Health Department - inspection report dated, December 14, 2016, revealed many of the observations made during the initial tour of the Dietary department on May 3, 2017 and a follow up visit on May 4, 2017, were observed during the County inspection of the Dietary department. A review of Utility Job Assignments Sheet, revealed that there was no indication of the last time assigned cleaning duties were completed by the Dietary department staff. Employee E6, confirmed in an interview on May 4, 2017, at 12:30 p.m. that Dietary employee's are not completing assigned cleaning duties and Dietary manager and supervisor are not overseeing assigned cleaning duties. Employee E6, Dietary manager could not share with the surveyor any documentation that indicated the last time Dietary manager reviewed assigned cleaning duties assignments were completed by dietary employee's as assigned. The facility failed to ensure that food was prepared and stored under clean and sanitary conditions within the Dietary Department. 42 CFR 483.60(i)(1)(3) Food Procure, Store/Prepare/Serve-Sanitary 28 PA. Code 201.14(a) Responsibility of licensee 28 PA. Code 201.18(b)(1)(3) Management 28 PA. Code 211.6(f) Dietary Services

Based on a review of clinical records and interview with staff it was determined that the facility failed to insure that residents' choice of advanced directives (written or spoken healthcare instructions) were reflected in physician orders [REDACTED]. Findings included: Review of Resident R24's physcian orders dated May, 2017 indicated [DIAGNOSES REDACTED]. Review of the physcian progress notes dated [DATE] stated that the physcian had discussed the resident's code status in detail with the residents family member. The notes stated further that the family member had stated that if the resident could answer that she would say DNR-do not resuscitate (no CPR be attempted in the event of a life threatening situation). There was no evidence available for review at the time of the survey that a code status had been placed on the residents record. In an interview on [DATE] at approximately 1:30 p.m. the Director of Nursing stated that if there is no code status indicated on the physcian orders then CPR (cardiopulmonary resuscitation) was to be attempted in the event of a life threatening situation. The facility failed to insure advanced directives were formulated and reflected in the physcian orders for one resident reviewed. 28 PA Code: 201.29(a)Resident rights.