Every finding on record at Wayne Woodlands Manor

Based on a review of the clinical records of Resident 1 and Resident 2, representative of the facility's symptomatic resident population, select facility policies, observations, and staff interviews, it was determined the facility failed to implement an effective infection prevention and control program by failing to recognize and respond to a suspected respiratory outbreak, implement transmission-based precautions for symptomatic residents, and implement outbreak control measures after multiple residents developed similar respiratory symptoms affecting 56 residents out of 97 residents residing in the facility.Findings include: A review of a facility policy titled Transmission- Based Precautions January 8, 2026, revealed it is the policy of the facility to implement transmission-based precautions (additional infection prevention measures used when a suspected or confirmed infection can spread to others and Standard Precautions alone are not sufficient) for resident with suspected or confirmed communicable diseases when standard precautions (basic infection prevention practices used for the care of all residents, including hand hygiene and appropriate use of personal protective equipment when exposure to infectious materials is anticipated) alone were insufficient to prevent transmission. The policy required nursing staff to immediately notify the resident's practitioner and the Infection Preventionist when a communicable disease was suspected so appropriate precautions and diagnostic testing could be implemented. The policy detailed it is the responsibility of the Infection Preventionist to determine which type of precautions were appropriate for the residents. A review of the facility policy titled Respiratory Infection Management Algorithm dated November 25, 2026 revealed the facility was to assess residents with new or worsening respiratory symptoms, document the onset and severity of symptoms, obtain appropriate diagnostic testing, including pulse oximetry (a noninvasive test that measures the amount of oxygen in the blood), a complete blood count (CBC) (a blood test that measures blood cells and may help identify signs of infection or inflammation), a chest x-ray when pneumonia was suspected, a sputum culture (a laboratory test performed on mucus coughed up from the lungs to identify organisms that may cause respiratory infection) when a productive cough was present, and a nasopharyngeal swab (a specimen collected from the back of the nose to test for respiratory viruses and bacteria) for influenza and Coronavirus Disease 2019 (COVID-19), as clinically indicated. Review of the Pennsylvania Department of Health Respiratory Outbreak Toolkit, a resource provided by the Department to assist long-term care facilities in responding to respiratory outbreaks, recommends prompt reporting of respiratory outbreaks, implementation of transmission-based precautions, diagnostic testing, cohorting symptomatic residents, active surveillance, limitation of communal activities, and consultation with public health authorities when multiple residents develop respiratory illness. Observation throughout the facility on July 22, 2026, at 9:15 AM revealed no residents with respiratory symptoms were observed on droplet precautions (a type of transmission-based precaution used for illnesses spread through respiratory droplets and typically includes wearing a surgical mask during resident care, placing the resident in a private room or with another resident with the same illness when appropriate, and limiting unnecessary movement outside the room) or other transmission-based precautions. During an interview on July 22, 2026, at 9:20 AM, Employee 1, Licensed Practical Nurse (LPN), stated multiple residents on every hallway had developed respiratory symptoms during the previous several weeks. Employee 1 stated the practitioner implemented a treatment protocol that included cough suppressants, corticosteroids (steroids, medications used to reduce inflammation and swelling), broad-spectrum antibiotics (antibiotics that treat a wide range of bacteria when the specific bacteria causing an infection has not been identified), and other supportive treatment depending on the resident's symptoms. Employee 1 stated symptomatic residents remained on Standard Precautions and were not placed on transmission-based precautions. A review of a facility provided resident listing revealed Resident 1 was admitted to the facility on [DATE], with diagnoses to include oxygen dependence, and weakness. A review of Resident 1's clinical record revealed a change in respiratory condition assessment completed on June 21, 2026, at 2:35PM, documenting resident displayed symptoms if nasal congestion, a runny nose, and sneezing. Resident 1 was placed on medications to treat her symptoms including cough suppressant and nasal spray. The clinical record revealed that as of survey date July 22,2026, Resident 1 still displayed symptoms of a nonproductive cough and was still using the cough suppressant daily. Resident 1 was not placed on droplet precautions or other transmission-based precautions despite ongoing respiratory symptoms. Review of the clinical record failed to identify evidence Resident 1 underwent a chest x-ray, respiratory panel, or other diagnostic testing to evaluate the cause of the respiratory symptoms. A review of the facility's resident listing revealed Resident 2, admitted on [DATE], had a change in condition assessment dated [DATE], documenting new-onset shortness of breath. The practitioner was notified and ordered a chest x-ray and nebulizer treatment. A review of Resident 2's progress notes revealed the chest x-ray resulted on June 25, 2026, at 4:30PM documenting a negative result. The progress notes revealed Resident 2 continued to have symptoms of shortness of breath, and cough and an additional chest x-ray was completed on July 6, 2026. A progress note dated July 6, 2026, at 1:52pm revealed a verbal order was received for Augmentin 875 mg/125 mg (antibiotic used to treat bacterial infections) to be administered every 12 hours for 7 days, as the resident is symptomatic of an upper respiratory infection with an elevated white blood cell count (which may indicate infection). Review of the clinical records failed to identify evidence Residents 1 and 2 underwent respiratory pathogen testing despite new-onset respiratory symptoms. The facility failed to implement droplet precautions on each resident, despite the new onset of symptoms and ongoing treatment of upper respiratory symptoms. Review of clinical records revealed that from the onset of Resident 1's respiratory symptoms on June 21, 2026, through the survey ending July 22, 2026, a total of 56 residents developed similar respiratory symptoms, including cough, congestion, runny nose, and shortness of breath. Despite the increasing number of symptomatic residents, review of facility records failed to identify evidence the facility initiated outbreak response measures. The facility continued routine dining, group activities, resident movement throughout the facility, and Standard Precautions. A review of hospital transfer records for June and July 2026 revealed 12 residents required transfer to an acute care hospital due to respiratory distress (difficulty breathing requiring immediate medical evaluation and treatment) associated with unidentified respiratory symptoms. As of July 22, 2026, three residents remained hospitalized . Review of clinical records revealed only 18 of the 56 symptomatic residents underwent a respiratory panel (a laboratory test that detects multiple viruses and bacteria that commonly cause respiratory infections). Review of the remaining symptomatic residents' clinical records failed to identify evidence additional respiratory pathogen testing was obtained despite the continued occurrence of similar respiratory symptoms throughout the facility. During an interview on July 22, 2026, at 10:00 AM, the facility's Nurse Practitioner stated she had evaluated and treated numerous residents with new respiratory symptoms. She stated that because testing did not identify a specific infectious organism, residents with mild symptoms generally received supportive treatment such as cough syrup, while residents with respiratory distress received broad-spectrum antibiotics and corticosteroids. During an interview on July 22, 2026, at 10:02 AM, the facility's Infection Preventionist stated she did not implement droplet precautions or any transmission-based precautions because diagnostic testing did not identify a specific infectious organism. She stated the facility continued Standard Precautions only, despite the increasing number of residents developing similar respiratory symptoms throughout the facility, and that the facility encouraged residents to wear masks when outside their rooms but did not implement any further interventions such as, isolate symptomatic residents, cohort residents with similar respiratory symptoms, implement facility-wide universal masking, or notify the Department of Health as required. Review of the facility's clinical records, observations, and staff interviews failed to identify evidence the facility implemented additional infection prevention measures after multiple residents throughout the facility developed similar respiratory symptoms.Specifically, the facility failed to:implement transmission-based precautions for symptomatic residents despite the increasing number of residents with similar respiratory symptoms;ensure appropriate diagnostic evaluation of symptomatic residents consistent with the facility's Respiratory Infection Management Algorithm;implement additional outbreak control measures, including resident cohorting, limitation of communal activities, and enhanced respiratory precautions, despite the increasing number of symptomatic residents; andimplement timely infection prevention interventions designed to reduce the risk of transmission among residents.The findings were reviewed during an interview on July 22, 2026, at 3:45 PM, with the Nursing Home Administrator and acknowledged the facility did not implement transmission-based precautions or other outbreak response measures because diagnostic testing did not identify a specific infectious organism. The facility failed to recognize and respond to a suspected respiratory outbreak by implementing timely infection prevention and control measures after numerous residents throughout the facility developed similar respiratory symptoms. The facility continued Standard Precautions despite an increasing number of symptomatic residents, did not implement transmission-based precautions, did not isolate or cohort symptomatic residents, and did not implement additional outbreak control measures designed to reduce the risk of transmission among residents during the suspected respiratory outbreak. As a result, 56 of 97 residents developed respiratory symptoms during the review period, 12 residents required transfer to an acute care hospital for respiratory distress, and three residents remained hospitalized as of the survey ending July 22, 2026. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management.28 Pa Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on select facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to consistently assess, monitor, and respond to significant weight changes to identify nutritional risks and implement timely nutritional interventions for three of twenty-four residents reviewed (Residents 1, 41, and 28).Findings include: A review of a policy entitled Weight Change Monitoring and Management Policy last reviewed January 1, 2026, indicated that a systematic process for identifying, assessing, and documenting, and addressing significant weight changes in residents to promote optional nutritional status, recent avoidable weight loss or gain, and ensure compliance with federal and state regulations. The facility shall monitor resident weights routinely and promptly investigate significant weight changes. Residents experiencing clinically significant weight loss or gain will receive interdisciplinary assessment and intervention. Significant weights changes are considered clinically significant based on a 5 percent change within thirty days, 7.5 percent change in ninety days, and 10 percent change in one-hundred and eighty days. A significant weight change triggers a verification of weight accuracy with a reweight obtained withing twenty-four to forty-eight hours, a review of intake records, edema assessment, medication review, physician notification, and/or interdisciplinary review. Assessment includes nutritional intake patterns, functional abilities, swallowing function, behavioral factors, psychosocial issues, medical diagnosis, medication effects, and hydration status. The nutrition interventions include dietary consultation, nutritional supplements, food preferences, adaptive equipment, speech evaluation, meal environment modification, medication adjustment, and/or physician evaluation. Care planning includes care plan and review and revision, resident and family involvement as appropriate, measurable interventions and goals, and on-going monitoring. A review of the facility policy entitled Weighing and Measuring a Resident, last reviewed by the facility on January 1, 2026, indicated that a reweight was to be obtained within twenty-four to forty-eight hours when a resident had a 5 percent weight change in one month, a 5 pound change from the previous weight, or a 3 pound weight loss when the resident weighed one hundred pounds or less. The policy indicated that resident weights were reviewed weekly by the Registered Dietitian, and significant weight losses or gains were reported during the weekly Risk Meeting. The policy indicated that the Registered Dietitian communicated the need for additional weights to nursing administration. The policy indicated that the physician and family were to be notified of significant weight loss or gain, refusal of meals, and failure of interventions. The policy defined unplanned and undesired weight loss as significant when a resident lost 5 percent of body weight in one month, 7.5 percent in three months, or 10 percent in six months. The policy defined weight loss as severe when the loss was greater than 5 percent in one month, greater than 7.5 percent in three months, or greater than 10 percent in six months. A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that included dementia (a brain disorder that slowly destroys a person's memory and thinking skills and characterized by a loss of cognitive functioning such as thinking, remembering, and reasoning that interfere with a person's daily life and activities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and feeding difficulties (problems that interfere with the ability to eat or drink safely and effectively, often involving multiple stages of the feeding process such as choosing and getting food to the mouth, chewing, and swallowing). A review of Resident 1's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 21, 2026, revealed that Resident 1 had moderate cognitive impairment with a BIMS score of 12 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates moderate cognitive impairment) and able to eat independently after staff set-up. A plan of care review revealed a nutrition at risk care plan was initiated on June 19, 2023, identified that Resident 1 had nutritional problems or potential for nutritional problem related to a medical need for a therapeutic diet, feeding difficulties, poor vision and hearing deficits, and history of significant weight loss with goals to maintain adequate nutritional status as evidence by maintaining weight and no signs or symptoms of malnutrition. Planned interventions included to monitor weight and report changes to the physician and Registered Dietitian (RD), provide and serve diet and supplements as ordered, monitor and record meal intakes for each meal, quarterly and PRN (as needed) nutrition assessments, and RD to evaluate and make changes and recommendations PRN. A clinical record review revealed that the most recent comprehensive nutrition assessment for Resident 1 was last completed on October 25, 2024, and no comprehensive nutrition assessments completed by a RD during 2025. Resident 1's clinical record failed to reveal that a comprehensive nutritional assessment was completed annually as required. A clinical record review revealed a late-entry quarterly nutrition/dietary note completed by Employee 4, the facility's former Registered Dietitian (RD), with an effective date of January 21, 2026, at 9:47 AM, and a creation date of February 26, 2026, at 9:56 AM. The note documented that Resident 1 continued a no-added-salt diet (a diet that limits added salt by omitting table salt and salt packets), regular food texture, and thin liquids. The note further documented that the resident required varying levels of assistance with meals, primarily set-up assistance and assistance cutting food. According to the note, the resident had adequate fluid intake and consumed between fifty percent and one hundred percent of meals during the previous thirty days. The note further documented the resident utilized adaptive dining equipment, including a Kennedy cup (a spill-resistant drinking cup) and an inner-lip plate (a plate with a raised edge designed to assist with self-feeding). The documented weight history reflected a current body weight of 139.8 pounds on January 2, 2026, compared to 140.4 pounds on December 2, 2025, 134.3 pounds on October 2, 2025, and 134.9 pounds on July 5, 2025. Employee 4 documented that the resident had no significant weight changes and maintained a relatively stable weight over the previous six months. However, a review of Resident 1's weight record revealed the resident weighed 144.2 pounds on February 2, 2026, 144.7 pounds on March 3, 2026, and 134.5 pounds on April 8, 2026. The weight record review revealed that Resident 1 experienced a significant weight loss of 10.2 pounds, or seven percent, within thirty-six days from March 3, 2026, to April 8, 2026. The clinical record failed to reveal evidence that Employee 4, the facility's former Registered Dietitian (RD), timely assessed the significant weight loss when it occurred. A review of a nutrition/dietary note completed by Employee 4 on April 20, 2026, at 11:54 AM, twelve days after the significant weight loss was identified, documented that Resident 1 continued to have adequate oral and fluid intake, consuming between fifty percent and one hundred percent of meals, and continued to utilize adaptive feeding equipment. The note acknowledged the resident experienced a significant weight loss of 10.2 pounds, or seven percent, from March 3, 2026, to April 8, 2026, but further documented there were no significant weight changes and that the resident's weight remained relatively stable over the previous six months. Employee 4 documented the weight loss was undesirable but related to advanced age and indicated that the February and March weights were unusually high, contributing to the observed weight loss. The note further indicated there had been no significant changes in meal intake, that current weights were consistent with weights obtained three and six months earlier, and that weight fluctuations could occur due to diuretics (medications used to remove excess fluid from the body). Employee 4 documented that the physician and responsible party were notified, the care plan was reviewed and revised, and the resident would continue to be monitored. Continued review of Resident 1's weight records revealed the resident weighed 135.7 pounds on April 13, 2026, and 130.7 pounds on April 22, 2026. The resident lost an additional five pounds within nine days. The clinical record failed to reveal evidence that the continued weight loss was timely identified and assessed or that additional nutritional interventions were developed and implemented to address the ongoing decline. A clinical record review revealed that Employee 5, the facility's RD, completed a nutrition/dietary note on April 30, 2026, at 11:27 AM. The note documented a current weight of 130.7 pounds, a significant weight loss of 7.5 percent in ninety days, continued downward weight trends, and that the resident was at her lowest recorded weight. Although meal intake remained between fifty percent and one hundred percent, Employee 5 recommended initiation of a nutritional juice supplement twice daily to promote weight maintenance. However, Resident 1's clinical record failed to reveal physician notification or responsible party notification regarding the continued significant weight loss. The clinical record failed to reveal a physician's order for the nutritional juice supplement or evidence that the recommended intervention was implemented. The facility failed to ensure comprehensive nutrition assessments were completed by an RD to evaluate Resident 1's nutritional and hydration status and develop interventions to address nutritional decline. The facility failed to ensure Resident 1's significant weight losses were timely identified, assessed, and addressed through appropriate nutritional interventions. Additionally, the facility failed to implement the nutritional juice supplement recommended by the RD. A clinical record review revealed a late-entry dietary note completed on December 29, 2025, documenting that Resident 41 continued on a regular diet with pureed texture and thin liquids and was able to eat mostly independently after staff set-up assistance. The note documented adequate fluid intake and meal intake ranging from twenty-five percent to one hundred percent. The resident also received frozen nutritional supplements and nutritional shakes three times daily with good acceptance. At that time, the Registered Dietitian (RD) documented that the resident's weight had remained relatively stable during the previous six months. However, a review of the clinical record failed to reveal evidence that an annual comprehensive nutrition assessment had been completed by the RD. The record revealed the last comprehensive nutrition assessment was completed on February 3, 2025. A review of Resident 41's weight records revealed the following documented weights: 89.2 pounds on February 1, 2026; 80.9 pounds on March 1, 2026; 97.1 pounds on March 6, 2026; and 81.1 pounds on March 12, 2026. The clinical record failed to reveal that reweights were obtained in accordance with facility policy despite the significant fluctuation in recorded weights. Further review of the weight records revealed Resident 41 experienced a significant weight loss of 8.3 pounds, or 9.3 percent, from February 1, 2026, to March 1, 2026. The March 12, 2026, weight of 81.1 pounds confirmed the resident continued to demonstrate a significant weight loss of approximately nine percent within one month. A review of a nutrition/dietary progress note completed by Employee 4, the facility's former RD, on March 18, 2026, at 10:55 AM, eighteen days after the significant weight loss was identified, documented that Resident 41 weighed 81.1 pounds and had a Body Mass Index (BMI, a measurement that compares a person's weight to height and is commonly used to assess nutritional status) of 16.9, indicating the resident was underweight. The note further documented that the March 6, 2026, weight of 97.1 pounds was considered an outlier, meaning a value that differed substantially from surrounding weight measurements. Employee 4 documented that the resident experienced a significant weight loss of 9.3 percent in one month and a significant weight loss of 10.8 percent in six months. The note identified the weight loss as undesirable and recommended discontinuing small portions, providing regular portions to promote meal intake, and obtaining weekly weights for two weeks to monitor weight trends. The clinical record revealed that Employee 4, the facility's former RD, failed to timely assess Resident 41's significant weight loss of 9.3 percent that occurred between February 1, 2026, and March 1, 2026. Continued review of Resident 41's weight records revealed the resident weighed 81.8 pounds on April 7, 2026, 72.7 pounds on May 1, 2026, 69.2 pounds on May 8, 2026, and 79.6 pounds on May 19, 2026. At the surveyor's request, an additional weight was obtained on May 22, 2026, which recorded the resident's weight as 70.6 pounds. The clinical record failed to reveal that reweights were obtained in accordance with facility policy to verify the accuracy of the substantial weight fluctuations. Further review revealed that a nutrition/dietary progress note was not completed until May 12, 2026, despite the resident experiencing an additional significant weight loss of 11.1 percent from April 7, 2026, to May 1, 2026, and 15 percent from April 7, 2026, to May 8, 2026. The facility failed to obtain reweights as required by facility policy to verify the consistency and accuracy of Resident 41's recorded weights. The facility further failed to ensure timely identification, assessment, and intervention for significant weight loss to develop and implement nutritional interventions to address the resident's continued and progressive weight decline. A review of Resident 28's care plan revealed a nutrition-at-risk care plan was initiated on August 19, 2025. The care plan identified actual or potential nutritional concerns related to osteoarthritis (a condition that causes joint pain and stiffness), generalized muscle weakness, the need for a mechanically altered diet (a diet modified in texture to improve safety with eating), variable meal intake, and a history of significant weight loss. The care plan established goals for the resident to maintain adequate nutritional status, maintain weight, and consume meals as tolerated. Planned interventions included monitoring weights and reporting changes to the physician and Registered Dietitian (RD), providing prescribed diets and nutritional supplements, monitoring and documenting meal intake, completing nutrition assessments quarterly and as needed, and having the RD evaluate the resident and make recommendations as appropriate. However, a review of the clinical record failed to reveal documented evidence that the facility's RD completed a comprehensive nutrition assessment to evaluate Resident 28's nutritional and hydration status and identify interventions to address nutritional decline. A review of Resident 28's weight records revealed the resident weighed 108.9 pounds on December 15, 2025, 111.2 pounds on December 19, 2025, 111 pounds on December 26, 2025, 108.8 pounds on January 3, 2026, 92.2 pounds on February 11, 2026, 92.5 pounds on February 13, 2026, and 93.4 pounds on February 18, 2026. Review of the weight records revealed Resident 28 experienced a significant weight loss of 16.6 pounds, or 15.3 percent, within approximately one month from January 3, 2026, to February 11, 2026. A clinical record review revealed Employee 4, the facility's former RD, completed a nutrition high-risk/significant weight loss note on February 23, 2026, thirteen days after the significant weight loss had been identified. The note documented that the resident remained on a regular diet with regular texture and thin liquids, had adequate fluid intake, and consumed approximately fifty percent to one hundred percent of meals during the previous thirty days. The note further documented that the resident received high-calorie, high-protein oral nutritional supplements twice daily with documented one hundred percent acceptance according to the Medication Administration Record (MAR), as well as frozen nutritional supplements twice daily with acceptance ranging from fifty percent to one hundred percent. These supplements provided an additional 1,020 calories and 40 grams of protein daily. Despite these nutritional interventions, Employee 4 documented that the resident's Body Mass Index (BMI, a measurement comparing a person's weight to height that is commonly used to assess nutritional status) was 17.1, indicating the resident was underweight. The note documented that the resident weighed 93.4 pounds on February 18, 2026, 92.5 pounds on February 13, 2026, and 92.2 pounds on February 11, 2026, compared to 108.8 pounds on January 3, 2026, reflecting an unplanned weight loss of 16.6 pounds, or 15.2 percent, within one month. Additional weight comparisons documented a 15.2-pound weight loss over three months from 107.4 pounds on November 4, 2025, and a 31.3-pound weight loss over six months from the admission weight of 123.5 pounds on August 19, 2025. The note further documented that a weight of 113.3 pounds obtained on November 3, 2025, was considered an outlier, meaning a measurement that differs substantially from surrounding data points. Employee 4 documented that the weight loss was considered questionable due to the resident's reported good meal intake and acceptance of nutritional supplements and initiated weekly weights to evaluate the accuracy and validity of the recorded weights. Although the note documented physician and responsible party notification, the clinical record failed to reveal evidence that the significant weight loss was timely assessed and addressed when initially identified on February 11, 2026. The clinical record revealed that Employee 4, the facility's former RD, failed to timely assess Resident 28's significant weight loss of 15.3 percent that occurred between January 3, 2026, and February 11, 2026. The facility failed to ensure completion of a comprehensive nutrition assessment by an RD to evaluate Resident 28's nutritional and hydration needs and develop interventions to address nutritional decline. The facility failed to ensure Resident 28's significant weight loss was timely identified, assessed, and addressed through appropriate nutritional interventions to prevent continued weight loss. During an interview on May 21, 2026, at 2:25 PM, the Nursing Home Administrator stated that Employee 4 resigned from the facility on April 24, 2026, and that affiliated hospital dietitians were providing coverage for the position. When the above findings were reviewed during the interview, the Nursing Home Administrator confirmed that no additional documentation was available to demonstrate that Resident 28's significant weight loss had been thoroughly assessed by an RD or that interventions had been timely developed and implemented to prevent further weight loss. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c) (d)(3)(5) Nursing services.

Based on select facility policy, clinical record review, and staff interviews it was determined the facility staff failed to follow physician orders when administering pain medication for one resident out of 24 reviewed (Resident 86).Findings include: According to the US Department of Health and Human Services, Interagency Task Force, Executive Summary Draft Final Report May 6, 2021, for Pain Management Best Practices the development of an effective pain treatment plan after proper evaluation to establish a diagnosis with measurable outcomes that focus on improvements including quality of life (QOL), improved functionality, and Activities of Daily Living (ADLs). Achieving excellence in acute and chronic pain care depends on the following: An emphasis on an individualized patient-centered approach for diagnosis and treatment of pain is essential to establishing a therapeutic alliance between patient and clinician. Acute pain can be caused by a variety of different conditions such as trauma, burn, musculoskeletal injury, neural injury, as well as pain due to surgery/procedures in the perioperative period. A multi-modal approach that includes medications, nerve blocks, physical therapy and other modalities should be considered for acute pain conditions. A multidisciplinary approach for chronic pain across various disciplines, utilizing one or more treatment modalities, is encouraged when clinically indicated to improve outcomes. A review of a facility policy last reviewed by the facility on January 1, 2026, revealed the facility staff will implement the medication regimen as ordered. The policy revealed it is the staff responsibility to administer the medication as ordered, monitor, and document the resident's response to the medication. A review of Resident 86's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including muscle weakness and low back pain. A review of Resident 86's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 22, 2026, revealed that Resident 86 was moderately cognitively impaired with a BIMS score of 12 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8 through 12 indicates moderate cognitive impairment). A review of physician orders revealed the following: An order dated April 20, 2026, for Oxycodone 5 milligrams (a prescription opioid pain medication used to treat moderate to severe pain), one capsule by mouth every six hours as needed for moderate pain, defined as a pain rating of 4 through 6 on a 0 to 10 pain scale (a self-reported rating tool in which 0 indicates no pain and 10 indicates the worst pain imaginable). An order dated April 22, 2026, for Oxycodone 10 milligrams, one capsule by mouth every six hours as needed for severe pain, defined as a pain rating of 7 through 10. An order initially dated April 20, 2026, indicating that if the resident requested pain medication with a lower pain scale than the resident's reported pain level, staff could administer the medication of the resident's choice. A review of the April and May 2026 MARs revealed staff administered Oxycodone 5 milligrams on 17 occasions. Four of the 17 doses were administered when the resident's documented pain rating exceeded the ordered pain range of 4 through 6:April 21, 2026, at 12:08 PM, administered for a pain rating of 7.April 25, 2026, at 8:52 PM, administered for a pain rating of 7.April 27, 2026, at 10:06 AM, administered for a pain rating of 7.May 9, 2026, at 7:27 PM, administered for a pain rating of 8. Further review of the April and May 2026 MARs revealed that staff administered Oxycodone 10 milligrams on 20 occasions. On May 17, 2026, at 2:06 PM, staff administered Oxycodone 10 milligrams for a documented pain rating of 3, which was below the ordered pain range of 7 through 10. The clinical record contained no documentation indicating the resident requested a different pain medication than the medication specified for the documented pain rating, as permitted by the physician's order. During an interview on May 22, 2026, at 11:00 AM, the Director of Nursing reviewed the above findings and acknowledged staff did not administer the medications according to the physician-ordered pain scale parameters and the clinical record contained no documentation supporting resident requests for alternative pain medication. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa. Code 211.5(f)(viii)(x) Medical records. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services.

Based on clinical record review and resident and staff interviews, it was determined the facility failed to ensure residents received necessary behavioral health care in a timely manner to attain or maintain the highest practicable mental and psychosocial well-being for one of 24 residents sampled (Resident 41). Findings include: A review of Resident 41's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including neurocognitive disorder with Lewy body dementia (a progressive brain disorder that affects memory, thinking, behavior, movement, and sleep, and may cause confusion, visual hallucinations, and symptoms similar to Parkinson's disease). A review of Resident 41's Quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated [DATE], revealed that Resident 41 was severely cognitively impaired with a BIMS score of 3 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0 through 7 indicates severe cognitive impairment). A review of Resident 14's clinical record revealed the resident was admitted on [DATE], with diagnoses which included hypertension (high blood pressure). A review of Resident 14's Quarterly Minimum Data Set assessment dated [DATE], revealed that Resident 14 was cognitively intact with a BIMS score of 15 (13-15 indicates cognition is intact). During an interview with Resident 14, on [DATE], at 10:30 AM, she stated that her roommate Resident 41, had been exhibiting new behaviors, acting out attempting to hit staff and yelling at staff due to Resident 41 finding out her sister had died. She stated that even though her roommate was confused she had experienced moments of clarity and told her that it was harder because Resident 41's sister was younger than her. Review of Resident 41's clinical record revealed the only documentation regarding the resident's loss was a nursing progress note dated [DATE], completed by the facility's Employee 5 (Registered Dietician) regarding the residents continued weight loss, indicating that Resident 41's recent poor intakes could potentially be related to grief. There was no documented evidence that behavioral health services were provided to help the resident with her grief over the loss of her sister and to meet the behavioral needs of a resident who although confused was displaying psychosocial symptoms of her grief. Review of the resident's clinical record showed no social service notes or psychological services notes regarding the loss of the resident's sister. Review of resident's care plan, initiated by the facility on [DATE], did not reveal a care plan for grief. The resident's care plan did not address the resident's specific mental health concern or expression of psychosocial symptoms. During an interview with the Nursing Home Administrator (NHA), on [DATE], at 10:00 AM the NHA was unable to provide evidence that Resident 41 was being provided psychological services to maintain the highest practicable level of mental and psychosocial wellbeing. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on select facility policy, clinical record review, and staff interview it was determined the facility failed to document the use of non-pharmacological interventions prior to the administration of a psychotropic medication for one of 24 residents reviewed (Resident 101).Findings include: Federal requirements for the use of psychotropic medications expect that psychotropic medications are used only when necessary to treat a specific, documented condition. Non-pharmacological interventions are approaches that do not involve medications, such as verbal reassurance, redirection, environmental adjustments, or comfort measures, and are expected to be attempted and documented when clinically appropriate prior to the use of a PRN psychotropic medication. A review of the facility's policy titled Psychotropic Medication Monitoring and Management, reviewed January 1, 2026, indicated the facility is committed to minimizing the use of chemical restraints and is also committed to employing non-pharmacological interventions as a first line of treatment to maintain each resident's highest practicable mental, physical, and psychosocial well-being. An review of clinical records revealed Resident 101 was admitted to the facility on [DATE], with a diagnosis of instability of internal right knee prosthesis (the right knee replacement doesn't feel solid or secure). A review of Resident 101's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 7, 2026, revealed that Resident 72 was moderately cognitively impaired with a BIMS score of 12 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 12-15 indicates normal thinking and memory, reflecting little to no cognitive impairment). A review of the clinical record revealed a physician order dated May 7, 2026, for Alprazolam 1mg (milligram)(medication that provides fast-acting relief when someone feels overwhelmed by anxiety or panic) every six hours as needed for anxiety. A review of the resident's medication administration record revealed Alprazolam 1mg was administered on the following days and times: May 10, 2026 at 4:16 PMMay 12, 2026 at 4:20 PMMay 13, 2026 at 8:17 AMMay 13, 2026 at 9:27 PMMay 14, 2026 at 8:45 PMMay 15, 2026 at 12:48 PMMay 17, 2026 at 8:38 AMMay 18, 2026 at 8:12 PMMay 19, 2026 at 8:31 AMReview of the the resident's clinical record failed to identify evidence that non-pharmacological interventions were attempted prior to administration of the medication on the above dates. During an interview on May 21, 2026, at 11:48 AM, the Director of Nursing confirmed that the clinical record did not contain documentation of non-pharmacologic interventions prior to the administration of the psychotropic medication used to treat anxiety on nine occasions as required by federal requirements and facility policy. 28 Pa. Code 211.2(3) Medical director. 28 Pa. Code 211.5(ii)(xi) Clinical records. 28 Pa. Code 211.8(e) Use of restraints. 28 Pa. Code 211.9(1) Pharmacy services. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(5) Nursing services.

Based on review of the Resident Assessment Instrument (RAI) Manual, Minimum Data Set (MDS) assessments, clinical record review, resident observation, and staff interviews, it was determined the facility failed to ensure the MDS assessments accurately reflected the residents' status for two of 24 residents reviewed (Resident 3 & Resident 26). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual (October 2025), which provides instructions for completing the Minimum Data Set (MDS, a federally required standardized assessment used to evaluate resident status and develop care plans), indicates the assessment must accurately reflect the resident's functional status and be completed with participation from appropriate health professionals. Facilities are required to code the MDS according to the specific instructions outlined in the RAI Manual to ensure accuracy, consistency, and regulatory compliance. Resident 3 was admitted to the facility on [DATE], with a diagnosis of chronic obstructive pulmonary disease (long term lung condition that makes it harder to breathe). A review of Resident 3's quarterly Minimum Data Set assessment dated [DATE], revealed Resident 3 was moderate cognitive impairment with a BIMS score of 8 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 means noticeable difficulties in memory, orientation, or both). The quarterly MDS, dated [DATE], section P (section related to physical restraints, any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot easily remove which restricts freedom or normal access to the body) documented Resident 3 used a trunk restraint when out of bed. Observation of Resident 3 on May 19, 2026, at 12:30 PM in the dining room and again on May 20, 2026 at 10:01 in the activities room did not reveal the use of any device restricting access to one's body, specifically the trunk. Resident 26 was admitted to the facility on [DATE] with a diagnoses of metabolic encephalopathy (the brain isn't working properly due to a chemical imbalance in the body). A review of Resident 26's quarterly Minimum Data Set assessment dated [DATE], revealed that Resident 26 was cognitively impaired with a BIMS score of 3 (a score of 0-7 means severe cognitive decline indicating Resident 26 had significant challenges with memory, orientation, or both). The quarterly MDS, dated [DATE], section J (section addressing falls) documented Resident 26 did not experience any falls since the prior assessment. A clinical record review revealed Resident 26 experienced a fall on February 23, 2026. During an interview on May 20, 2026, at 2:30 PM the Nursing Home Administrator (NHA) and Director of Nursing (DON) reviewed the above information and confirmed the MDS assessment data was inaccurate. 28 Pa. Code 211.5(f)(iii) Medical records. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on select facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to develop and maintain a comprehensive, person-centered care plan that accurately reflected a resident's pain management needs and interventions for one of 24 residents reviewed (Resident 3).Findings include: Review of the facility's Care Plan policy, last reviewed January 1, 2026, revealed that a comprehensive care plan should include measurable goals and services necessary to meet a resident's medical, nursing, mental, and psychosocial needs. The policy indicated that the comprehensive care plan is intended to reflect treatment goals, identify services necessary to meet resident needs, and assist in preventing or reducing decline in functional status. Clinical record review revealed that Resident 3 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD, a long-term lung disease that makes breathing difficult). A review of Resident 3's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 25, 2026, revealed that Resident 3 was moderate cognitive impairment with a BIMS score of 8 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 means noticeable difficulties in memory, orientation, or both). Review of the resident's current comprehensive care plan, initially developed June 17, 2025, identified a care-planned problem related to pain associated with degenerative joint disease (arthritis that causes wear and tear of the joints affecting areas such as the neck, back, and spine). The care plan goal indicated the resident would experience effective pain relief. Review of a nursing progress note dated February 16, 2026, revealed the resident's family requested the remote control for the resident's spinal cord stimulator (an implanted device that delivers mild electrical impulses to interrupt pain signals before they reach the brain). The note documented that the remote was provided to the family; however, the family subsequently reported the remote would not power on and left the facility with the device. Review of a physician order dated April 21, 2026, revealed the resident was scheduled to attend an appointment on May 26, 2026, with a consulting physician for evaluation of the spinal cord stimulator. Review of the resident's comprehensive pain management care plan failed to identify the presence of the implanted spinal cord stimulator, the location of the device remote, or the need for the remote to accompany the resident to appointments related to management of the device. During an interview conducted on May 22, 2026, at 8:45 a.m., the Director of Nursing stated that Resident 3 had an implanted spinal cord stimulator used for pain management. The Director of Nursing stated that the remote control for the device was stored in the medication room and was required to accompany the resident to appointments involving evaluation or management of the implanted device. The Director of Nursing confirmed the resident's comprehensive, resident-centered care plan did not include the implanted spinal cord stimulator or related care-planning interventions. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa. Code 211.10 (c)(d) Resident care policies.

Based on a review of clinical records, select facility policies, facility-provided investigative documentation, and staff interviews, it was determined the facility failed to prevent the development of pressure injuries and failed to perform timely and thorough assessments of pressure injuries resulting in actual harm for one (Resident 55) of two residents out of 20 sampled residents (Residents 55 and 49). Findings include:According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment, and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair. A review of a facility policy entitled Wound Care Policy/Procedure last reviewed by the facility January 2025, indicated all wounds would be documented, investigated, and treatments obtained. The policy required nursing staff to assess every wound and document the site, measurements, wound type, stage (the classification of a pressure injury based on the depth and extent of tissue damage), drainage, appearance, odor, peri wound (the skin surrounding the wound), tunneling (a channel that extends from the wound base into deeper tissue), and undermining (tissue destruction that occurs under intact skin at the wound edges, creating a shelf-like space), and to enter this information into the facility's electronic medical record (EMR). A review of Resident 55's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of a closed fracture (a broken bone that does not penetrate the skin) of the right lower femur (thigh bone), cerebral infarction (also referred to as an ischemic stroke, caused by a blocked blood vessel in the brain), peripheral vascular disease (PVD a medical condition which blood vessels in the arteries of the legs and feet become narrowed or blocked causing pain, slow wound healing discoloration and risk for pressure ulcers), and generalized muscle weakness. A review of the resident's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated August 23, 2025, revealed the resident was cognitively intact as evidence by a BIMS score of 13 (Brief Interview for Mental Status is a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognitively intact). Additionally, this MDS indicated Resident 55 used a wheelchair for mobility, required substantial/maximal assistance with upper dressing and personal hygiene, dependent with lower body dressing, bed mobility, and toileting. A review of the resident's plan of care initiated on August 15, 2025, and revised August 28, 2025, indicated assistance was required performing ADLs (activities of daily living) due to a right femur fracture. Interventions and tasks initiated to address ADL deficits included weight bearing right lower extremity immobilizer (is a brace or support device designed to keep the leg straight and restrict knee movement) at all times. The care plan also identified risk for impaired skin integrity due to decreased mobility and directed staff to implement preventative interventions including a low air loss mattress, treatment of any injury per facility protocol, and identification and documentation of any causative factors. A review of a nursing progress note completed by the Director of Nursing (DON) on August 16, 2025, at 1:09 PM documented that the brace on Resident 55's right lower leg was very loose. The DON noted she was able to easily place her hand inside both the top and bottom of the brace even when it was fully tightened. A smaller brace of the same type was obtained from therapy and applied to provide improved support to the resident's distal femur fracture. A review of the facility's investigative documentation for an injury of unknown cause, completed by Employee 1, Registered Nurse, on September 6, 2025, at 5:30 PM revealed that staff discovered a new open area slightly beneath the brace on the resident's right calf during evening care. The RN documented that it was unknown at the time whether the area was pressure-related or vascular in nature and indicated wound care would further assess the area. Resident 55 stated, It hurts when you touch it. Further review of the investigative documentation revealed that Employee 1 reported the immediate actions taken by the facility after the new wound was discovered. The physician and the resident's responsible party (RP) were notified, and the wound was cleansed with normal saline solution (NSS). Xeroform, which is a medicated dressing used to protect wounds from infection and support healing, was applied along with an abdominal pad (ABD). Employee 1 documented these interventions were completed to the best of her ability until a physician order could be obtained to remove the brace or until further wound care orders were issued. The physician also ordered Cephalexin 500 mg twice daily for seven days. Cephalexin is an antibiotic that prevents the growth of bacteria and is commonly prescribed for infections such as pneumonia, ear infections, skin infections, urinary tract infections (UTIs), and bone infections. It was ordered prophylactically, meaning it was prescribed to prevent infection or stop a suspected infection from worsening. A review of the clinical record revealed a nursing progress note completed by Employee 1 on September 6, 2025, at 6:16 PM, which further described the newly discovered open area on Resident 55's right calf. Employee 1 documented the wound was located on the rear aspect of the right lower leg and measured 7.0 centimeters (cm) in length by 8.0 cm in width by 0.8 cm in depth. The nurse recorded N/A (not applicable) for the wound stage. The note described a rancid odor and drainage, with infection suspected based on the color and characteristics of the discharge. Employee 1 documented the wound would require wound care follow-up. A review of Resident 55's physician orders dated September 6, 2025, at 5:58 PM directed staff to cleanse the right calf with NSS, apply Xeroform, and cover the site with an ABD dressing once daily and as needed (PRN) for excessive drainage, soiling, or dressing dislodgement. The physician also ordered an appointment with an outside wound care specialist on September 8, 2025, at 2:30 PM for evaluation of the pressure ulcer. A review of the September 2025 Treatment Administration Report (TAR), which serves as the legal medical record for documenting the administration of prescribed treatments, revealed no evidence that licensed nursing staff completed the ordered wound treatments on September 7, 2025. Additionally, a review of a nurse's progress note completed by Employee 2, a Licensed Practical Nurse (LPN), on September 8, 2025, at 1:58 PM documented that the scheduled wound care specialist appointment for that date was cancelled. A review of the wound assessment completed by the contracted Certified Registered Nurse Practitioner (CRNP) on September 11, 2025, five days after the wound was discovered, identified an in-house acquired Stage III pressure ulcer/injury. A Stage III pressure ulcer is characterized by full-thickness skin loss in which the wound extends into the fatty tissue below the skin. The wound measured 3.0 cm in length by 1.50 cm (centimeters) width, and 0.20 cm in depth. The wound contained 80 percent granulation tissue (new healing tissue) and 20 percent slough (dead tissue requiring removal), with light serosanguineous drainage (thin, blood-tinged fluid). There was no odor after being cleansed. The facility could not provide documented evidence that the newly discovered wound that was found on September 6, 2025, was thoroughly assessed or staged by nursing staff prior to the CRNP's assessment on September 11, 2025. A review of Resident 55's hospital record revealed a wound consultant progress note dated August 13, 2025, at 1:09 PM. The note documented that the resident was non-weightbearing due to a right distal femur fracture and had severe vascular disease of the lower extremities with a history of vascular ulcers. However, the wound care consultant documented that no wounds were present on either lower extremity at the time of the assessment, and that the resident's skin was intact. The record further indicated that prior to discharge from the hospital, a knee immobilizer was in place, and the legs were wrapped as prescribed. During an interview with Employee 3, the facility's Director of Physical Therapy, on November 20, 2025, at 10:17 AM she reported that the knee immobilizer applied to Resident 55's right leg at admission was too large. She stated that physical therapy provided a smaller immobilizer; however, no physical therapy assessment was completed prior to issuing the smaller device, despite the change in equipment. Employee 3 also confirmed that the resident's plan of care required the resident to remain non-weight bearing on the right lower extremity and to wear the immobilizer at all times. The facility could not provide any documented evidence that physician orders were obtained at the time of admission for the use of a knee immobilizer, despite the resident arriving from the hospital with one in place. The facility also could not provide documentation that staff routinely monitored the skin beneath the immobilizer to detect early signs of pressure or irritation. During an interview with the Director of Nursing (DON) on November 20, 2025, at 12:30 PM the above information was reviewed. The DON confirmed that no additional documentation could be provided to demonstrate the facility had effective measures in place to prevent the development of Resident 55's Stage III pressure ulcer. A review of Resident 49's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included multiple sclerosis (a chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue) and dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain.) A review of the resident's readmission evaluation dated May 30, 2025, at 8:43PM revealed the resident was observed with skin impairments that included a pressure area of the left buttock, and other skin impairments that included bruising. The clinical record revealed no additional skin assessments were documented after May 30, 2025. A review of Resident 49's progress notes revealed an entry dated November 17, 2025, at 11:35 AM written by Employee 1, Registered Nurse Supervisor (RN). The progress note documented Resident 49 was observed to have a skin area on the right buttock that was pressure in nature. The progress note further recommended utilizing pressure reduction items, and for staff to follow a turning and repositioning schedule despite these interventions already being in place. A review of a wound observation documented by Employee 1 on November 17, 2025, at 11:35 AM revealed a pressure area located on the right buttock measuring 1 cm x 1 cm. However, the documentation did not include a complete wound assessment. Missing elements included depth, surface area calculations, wound characteristics, and staging, as required by facility policy. An observation of Resident 49's wound was conducted with the facility's contracted wound care specialist CRNP (Certified Registered Nurse Practitioner) on November 20, 2025, at 10:30 AM (three days after identification of the wound). The CRNP's assessment identified the wound as a Stage II pressure ulcer/injury. A Stage II pressure ulcer is defined as partial-thickness loss of skin presenting as a shallow open wound with a red or pink wound bed. The wound measured 0.3 cm in length by 0.6 cm in width by 0.1 cm in depth. The facility was unable to provide documentation that a timely and thorough assessment of the pressure ulcer was completed by a Registered Nurse upon identification, including proper staging and a detailed description of the wound. The facility also could not provide the witness statements required by its policy from staff caring for the resident within 24 hours of the wound's identification. During an interview with the Director of Nursing (DON) on November 20, 2025, at 1:00 PM the above findings were reviewed. The DON confirmed no additional documentation could be provided to demonstrate the facility completed a timely and thorough wound assessment for Resident 49. 8 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on observation, staff interviews, and review of facility policy, the facility failed to maintain a fully functioning resident call bell system that ensured residents could directly and promptly request assistance from staff for three of four halls in the facility (Green Hall, Mauve Hall, and Blue Hall).Findings include:A review of the facility policy titled Call Light and Procedure last reviewed by the facility in January 2025, revealed it is the responsibility of all staff to respond to call bells, to ensure all resident's requests and needs. The policy revealed it is the responsibility of staff to report all defective call lights to the nurse supervisor promptly and then provide hand bells to residents for use (a manual device used to request help when the main system does not work).An observation conducted on November 17, 2025, at 10:20 AM, revealed that multiple call bell lights were illuminated on three of four halls: four lights on Mauve Hall, five on Blue Hall, and two on [NAME] Hall, as well as one light on Peach Hall. However, there was no audible alert for any of these active call bells. Staff could only detect a resident request for assistance if they visually noticed the small, illuminated light above the resident room door while physically standing in the hallway. The absence of an audible alert prevented staff from being notified promptly when not in direct view of the lights. An interview with Employee 1 on November 18, 2025, at 10:22 AM, revealed the call bell system sometimes activates the sound but not often, and staff identify resident requests only by visually checking the door lights. The interview did not identify any alternate alerting mechanism in use. An interview with the Nursing Home Administrator (NHA) on November 18, 2025, at 11:00 AM, revealed the facility had previously identified the issue with the call bell system and planned to replace the system in 2026. The interview also revealed that although the facility had previously purchased handheld bells for emergencies, residents had not been provided with these or any other alternative method to call for assistance while the system was malfunctioning. After multiple requests during the survey, the facility was unable to provide documentation demonstrating that a work order or repair request had been submitted to address the ongoing malfunction of the call bell system, despite having prior knowledge that it was not functioning as intended.An interview with the NHA on November 19, 2025, at 11:05 AM, acknowledged the findings that the call bell system was not functioning according to the manufacturer's design, which resulted in delayed identification of resident call bell requests. 28 Pa Code 207.2(a) Administrators responsibility 28 Pa Code 205.28 (c)(1)(4) Nurses station 28 Pa Code S211.10 (c)Resident Care Policies

Based on observation, review of select facility policy and clinical records, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling practices for multi-dose medications in one of two medication carts observed (Blue Hall C Unit). Findings include: Review of the facility policy titled Medication Administration last reviewed by the facility January ,2025, indicated that the expiration date/beyond use date on the medication label must be checked prior to the administering. When opening multi-dose container, the date opened shall be recorded on the container. labels are checked prior to administration. A multi-dose medication is a container designed to be used for more than one dose and must be dated when first opened so staff can determine when it expires and whether it is safe to use. Failure to date a multi-dose container prevents staff from knowing the beyond-use date, which is the date after which the medication should no longer be used for resident safety. An observation of the medication cart located on the Blue Hall C Unit on November 20, 2025, at 8:25 AM, in the presence of Employee 4 (Licensed Practical Nurse), revealed two multi-dose insulin pens of Humalog (Insulin Lispro, a rapid-acting insulin used to lower blood sugar) that were opened and available for resident use but were not dated to indicate when they were initially opened.A continued observation of the same medication cart on November 20, 2025, at 8:25 AM, in the presence of Employee 4, revealed two multi-dose insulin pens of Novolog (Insulin Aspart, a fast-acting insulin used to lower blood sugar) that were opened and available for resident use but were not dated when initially opened.A further observation of the medication cart on November 20, 2025, at 8:25 AM, in the presence of Employee 4, revealed one multi-dose insulin pen of Novolog 70/30 (Insulin Aspart Protamine and Insulin Aspart injectable suspension, a combination insulin used to lower blood sugar) that was opened and available for resident use but was not dated when initially opened. An interview with Employee 4 (LPN) on November 20, 2025, at 8:30 AM confirmed that the five multi-dose insulin pens observed (Humalog Insulin Lispro, Novolog Insulin Aspart, and Novolog 70/30 Insulin Aspart Protamine and Insulin Aspart injectable suspension) were opened and available for resident use without any date indicating when they were first opened.An interview was conducted with the Director of Nursing on November 20, 2025, at 11:00 AM regarding the above findings related to the facility's failure to follow acceptable storage and labeling practices for multi-dose medications. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services 28 Pa. Code 211.10(c) Resident Care Policies

Based on review of scheduled mealtimes, review of select facility policy, resident interviews, and staff interviews, the facility failed to ensure that residents were consistently offered a nutritious evening snack during the time interval between dinner and breakfast, resulting in the potential for more than 14 hours between meals without the required nutritional snack. This deficient practice was identified for 6 of 6 residents participating in a group interview who desired a bedtime snack. (Residents 35, 47, 50, 51, 51, and 75).Findings include: A review of the facility policy titled Snack Policy, last reviewed by the facility in January 2025, revealed it is the facility's policy to offer a safe, consistent, and nutritionally adequate snack three times daily at 10:00 AM, 2:00 PM, and at H.S. (hour of sleep/bedtime). A review of scheduled facility mealtimes revealed that the interval between dinner and breakfast exceeds 14 hours for multiple resident care areas. The substantial evening meal is served between 4:45 PM and 5:25 PM depending on unit, and breakfast is served between 7:10 AM and 7:45 AM the following morning, resulting in time intervals ranging from 14 hours 15 minutes to 15 hours. Blue Hall: Dinner 4:55 PM, Breakfast 7:10 AM (14 hours 15 minutes)Dining Room: Dinner 4:45 PM, Breakfast 7:45 AM (15 hours)Peach Hall: Dinner 5:05 PM, Breakfast 7:20 AM (14 hours 15 minutes)Green Hall: Dinner 5:15 PM, Breakfast 7:30 AM (14 hours 15 minutes)Mauve Hall: Dinner 5:25 PM, Breakfast 7:40 AM (14 hours 15 minutes) When more than 14 hours elapse between the substantial evening meal and breakfast the next day, the resident must be offered a nutritious snack at bedtime. Because the facility's scheduled meal intervals exceeded 14 hours, offering an evening snack was required to ensure residents received adequate food intake during this extended overnight period. During a resident council interview on November 19, 2025, at 10:00 AM, 6 out of six residents (Residents 35, 47, 50, 51, 51, and 75) indicated that a snack is not offered in the evenings. All residents reported that they do not receive a snack before bedtime. During an interview on November 20, 2025, at approximately 2:00 PM, the Nursing Home Administrator was unable to provide documentation showing that evening snacks were consistently offered to residents. 28 Pa. Code 211.12 (d)(3)(5) Nursing services. 28 Pa. Code 211.10 (c) Resident Care Policies.

Based on review of clinical records, select facility policy, observation, and staff interview, it was determined that the facility failed to implement effective procedures to maintain accurate records of controlled drugs and ensure accurate drug administration for one resident out of 20 sampled (Resident 74). Findings include: A facility policy titled Controlled Substances last reviewed by the facility on January 2025, revealed that during medication administration, the facility shall comply with all laws regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II narcotics (pain medications that have a high potential for abuse and require strict documentation). The Director of Nursing and/or designee will audit narcotics received using the signed invoices and a printout of all narcotics dispensed from the pharmacy on a periodic basis to identify potential signs of diversion. A clinical record review revealed Resident 74 was admitted to the facility on [DATE], with diagnoses that include spinal stenosis (abnormal narrowing of the spinal canal that results in pressure on the spinal cord or nerve roots) and unspecified open wound of the lower left leg. A review of the clinical record revealed a physician's order dated July 30, 2025, for Tramadol HCL 25 mg, an oral Schedule IV controlled substance (have a lower potential for abuse but still require secure handling and accurate record-keeping), one tablet every six hours as needed for severe pain rated seven to ten (a pain scale involves the use of numbers to rate pain intensity, most often from 0 to 10, where 0 corresponds to no pain and 10 corresponds to the worst possible pain. Mild pain is typically rated 1 to 3, moderate pain 4 to 6, and severe pain 7 to 10), for 14 days. A review of facility clinical records revealed the facility utilizes a Controlled Substance Record to track, monitor, and reconcile each controlled medication, such as Tramadol and Oxycodone. Further review of facility clinical records revealed the facility tracks medication administration for each resident by way of the Medication Administration Record (MAR). The MAR indicates the medication administered, time and date of administration, staff administering the medication, pain prior to the administration of medication, and clinical rationale for the administration of medication.A comparison of Resident 74's Controlled Substance Record with the MAR from August 8 through August 30, 2025, revealed 10 entries showing Tramadol 25 mg signed out on the Controlled Substance Record without corresponding documentation on the MAR indicating that the medication was administered. The following is a list of the dates where there is a discrepancy in Resident 74's Controlled Substance Record and the MAR: August 8, 2025, at 8:30 AMAugust 13, 2025, at 7:30 AMAugust 15, 2025, at 8:00 AMAugust 18, 2025, at 12:00 PMAugust 19, 2025, at 8:30 AMAugust 22, 2025, at 12:00 PMAugust 23, 2025, at 11:00 AMAugust 26, 2025, at 12:00 PMAugust 28, 2025, at 7:30 AMAugust 29, 2025, at 1:00 PM Further comparison revealed that on August 12, 2025, Tramadol 25 mg was signed out twice on the Controlled Substance Record (at 8:15 AM and 8:30 AM), while the MAR showed the medication documented as administered once at 11:36 AM.A review of the MAR revealed an additional discrepancy on August 30, 2025: the MAR documented administration at 11:14 AM, but the Controlled Substance Record showed no entry indicating that a dose had been signed out. A physician's order dated August 16, 2025, initiated Tramadol HCL 50 mg, a Schedule IV controlled substance, to be given every six hours as needed for moderate pain.A comparison of the Controlled Substance Record and MAR from September 1 through September 30, 2025, revealed five entries indicating the medication was signed out without evidence on the MAR of administration. The dates included: September 1,2025, at 11:55 AMSeptember 9,2025 at 12:00 PMSeptember 10,2025 at 1:00 PMSeptember 19,2025 at 11:00 AMSeptember 20,2025 at 10:00 AM A comparison from October 1 through October 30, 2025, revealed five additional discrepancies in which Tramadol 50 mg was signed out on the Controlled Substance Record without documented administration on the MAR. These dates included: October 3,2025 at 2:20 PMOctober 4,2025 at 1:00 PMOctober 7,2025 at 1:30 PMOctober 10,2025 at 2:00 PM A clinical record review revealed a physician's order dated October 13, 2025, for Oxycodone HCL 5 mg, a Schedule II controlled substance (high potential for abuse), one tablet by mouth every Monday morning for pain related to skin substitute placement (a procedure used to assist healing of wounds such as diabetic foot ulcers and venous leg ulcers).A comparison of the Controlled Substance Record with the MAR from October 1 through November 17, 2025, revealed two entries showing Oxycodone signed out without documentation on the MAR that the medication was administered: October 13,2025 at 7:30 AMNovember 3,2025 at 7:30 AM An interview was conducted on November 20, 2025, at 1:30 PM with the Director of Nursing to review the above findings. The information reviewed during the interview confirmed that the documentation did not reconcile between the Controlled Substance Record and the MAR for Resident 74. 28 Pa Code 211.5(f)(xi) Medical records. 28 Pa Code 211.9(a)(1)(k) Pharmacy services. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa Code 211.10 (c)(d) Resident care policies.

Based on clinical record review and staff interview, the facility failed to ensure that laboratory and diagnostic test results were promptly provided to the ordering physician for one of twenty sampled residents (Resident CR1).Findings include: A review of resident CR 1's record revealed the resident was admitted to the facility on [DATE], with diagnoses to include chronic obstructive pulmonary disorder (a condition caused by damage to the airways or other parts of the lung) and muscle weakness. A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 11, 2025, revealed that Resident CR 1 had intact cognition with a BIMS score of 13 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A nursing progress note dated October 9, 2025, at 8:03 AM documented a phone call from the resident's family reporting the resident was experiencing uncontrolled head and neck pain following a fall within the facility. A cervical spine x-ray (a diagnostic test that uses radiographs to visualize the bones of the neck) was completed on October 9, 2025, at 11:24 AM. The x-ray report identified an apparent right-lung infiltrate, which is an abnormal substance or fluid in lung tissue that can occur for various reasons, including infection. The report recommended clinical correlation and a follow-up chest x-ray. A review of Resident CR1's clinical record revealed no documentation that the physician was notified of the abnormal x-ray findings. The clinical record also revealed no documentation that the recommended follow-up chest x-ray had been completed. During an interview on November 21, 2025, at approximately 12:00 PM, the Director of Nursing (DON) reviewed the above findings with the surveyor. The DON did not provide an explanation for the absence of documentation showing the physician had been notified of the abnormal results or had reviewed the x-ray findings. The DON confirmed that it is the facility's responsibility to ensure the physician is promptly provided with laboratory and diagnostic test results. 28 Pa Code 211.2 (d)(3) Medical director. 28 Pa Code 211.12 (d)(3) Nursing services.

Based on a review of clinical records, select facility policy and staff interviews, it was determined the facility failed to ensure that a resident's drug regimen was free of unnecessary antibiotics for one out of 20 residents sampled (Resident CR1). Findings included: A review of a facility policy labeled Antibiotic Stewardship Program last reviewed by the facility in January 2025, revealed the facility will confirm the presence of clinical symptoms of infection before collecting cultures or starting antibiotics. The policy revealed the facility will use standardized forms/checklists for urinary tract infections, and the facility will obtain cultures before starting antibiotics whenever feasible. The policy further revealed that a resident will only be started on empiric antibiotics (antibiotic use before laboratory results are available) only if the resident meets clinical criteria and appears systemically ill (fever, tachycardia, hypotension, rigors). A review of Resident CR1's clinical record revealed the resident was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disorder (a lung disease that causes airway damage and breathing difficulty) and muscle weakness. A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 11, 2025, revealed that Resident CR 1 had intact cognition with a BIMS score of 13 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). Review of resident CR1's progress notes revealed a progress note documented on October 5, 2025, at 1:34 PM indicating the resident's family had expressed concerns about the resident's increased hallucinations (sensory experiences such as seeing, hearing or feeling something that appear real but are not present in the environment), the progress note revealed at the request of the family a urinalysis with culture and sensitivity (a laboratory test used to detect and identify bacteria or fungi in urine, A urine culture is a method to grow and identify bacteria that may be in the urine. The sensitivity test helps select the best medicine to treat the infection) to assess for possible infection) was ordered. Further review of CR1's progress notes revealed a progress note dated October 6, 2025, at 2:52PM documenting that the resident had no signs of a urinary tract infection. A progress note dated October 6, 2025, at 2:52 PM documented that the resident had no signs or symptoms of a urinary tract infection, and the physician was notified of the abnormal urinalysis results while awaiting culture and sensitivity (C&S) results. A progress note dated October 7, 2025, at 11:46 AM revealed the physician was made aware of preliminary urinary culture results and had no new orders at that time. Another progress note dated October 7, 2025, at 2:25 PM again documented that the resident was not experiencing any urinary symptoms, including no confusion. Despite the absence of urinary symptoms, a physician order dated October 8, 2025, directed initiation of Macrobid 100 mg twice daily for 5 days. Macrobid is an antibiotic used to treat urinary tract infections. A review of the urine culture and sensitivity report, resulted on October 9, 2025, at 7:16 AM, revealed the presence of two organisms:Citrobacter werkmanii, a bacterium that can cause urinary tract infections, andProteus mirabilis, a gram-negative bacterium known to cause urinary tract infections.The sensitivity results revealed that Proteus mirabilis was resistant to Macrobid, meaning Macrobid would not effectively treat the infection. A progress note dated October 9, 2025, at 3:22 PM documented that the provider reviewed the culture and sensitivity results and discontinued Macrobid. A new order was entered for Bactrim DS, an antibiotic active against the identified organism, for 10 days. A review of Resident CR1's clinical record revealed that three Urinary Change Forms, documented on October 7, 2025, at 2:38 PM, October 8, 2025, at 10:32 PM, and October 9, 2025, at 2:40 PM, all indicated no changes in the resident's condition that would justify initiating Macrobid prior to receiving culture results. A review of the October 2025 Medication Administration Record revealed the resident received two doses of Macrobid before laboratory confirmation of an infection requiring antibiotic therapy and before the organism's resistance to Macrobid was known. The clinical record did not contain any documentation of urinary symptoms that would meet clinical criteria for initiating empiric antibiotic therapy (use of antibiotics before laboratory results are known). The facility was unable to provide documentation of McGeer's criteria, a standardized set of infection surveillance criteria used in long-term care settings to determine when an infection is present. These criteria require documented urinary symptoms to justify antibiotic treatment, and no such symptoms were documented. During an interview with the Director of Nursing (DON) on November 20, 2025, at 1:15 PM, the DON reviewed the clinical findings with the surveyor. The DON acknowledged the documented sequence of events and discussed that the antibiotic had been started before culture confirmation and without documented clinical symptoms. 28 Pa. Code 211.10 (c) Resident care policies.28 Pa. Code 211.12 (d)(3)(5) Nursing services

Based on clinical record review, review of facility-provided investigative documentation, care plan review, and facility staff interview, it was determined that the facility failed to develop and implement an individualized, person-centered plan of care to address dementia-related behaviors for one resident (Resident 31) out of a sample of 20 residents reviewed. Findings include:A review of Resident 31's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included dementia (a chronic or persistent disorder of mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning).A review of Resident 31's Annual Minimum Data Set Assessment (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 22, 2025, revealed the resident was severely cognitively impaired.A review of nursing progress notes between July 2025 and the end of survey on November 21, 2025, revealed Resident 31 demonstrated ongoing behavioral symptoms including physical and verbal aggression toward residents and staff, intrusive wandering (entering others' rooms or personal spaces without understanding boundaries), and resistance to care. Documentation showed that intrusive wandering occurred almost daily during this period.Further review of Resident 31's facility provided investigative documentation revealed the following:On July 23, 2025, staff heard yelling from a resident room. Upon entering, staff observed Resident 31 slap Resident 25. The residents were separated, and no injury was noted. Resident 31 and Resident 25 were roommates at that time, and Resident 31 was subsequently moved to a private room.On July 26, 2025, staff found Resident 31 in Resident 93's room. Resident 31 slapped Resident 93 and poured water on her. The residents were separated, and no injury was noted.On September 13, 2025, while staff were walking with Resident 31 in the hallway, the resident wandered into Resident 51's room and grabbed at Resident 51's arm. Residents were separated and no injury was noted.A review of the Resident 31's current care plan initially dated July 13, 2025, and last revised August 26, 2025, revealed no new interventions added in response to the repeated incidents of physically aggressive behaviors, intrusive wandering, and resistance to care. Further review revealed no documented evidence that the facility developed an individualized, person-centered dementia care plan, which would include approaches intended to support the resident's dignity, autonomy, safety, socialization, and daily functioning. A person-centered dementia care plan includes individualized, non-pharmacological interventions (non-medication-based actions such as structured activities, environmental modifications, redirection, music therapy, sensory activities, or schedules tailored to a resident's preferences) designed to address the resident's customary routines, past life history, interests, and behavioral triggers. There was no documented evidence that the facility identified or implemented individualized strategies to manage, modify, or decrease the resident's ongoing dementia-related behaviors despite multiple documented behavioral incidents. An interview with the Nursing Home Administrator on November 21, 2025, at 10:00 AM, confirmed that the facility was unable to provide evidence that an individualized, person-centered plan of care had been developed or implemented to address Resident 31's dementia-related behavioral symptoms 28 Pa Code 211.12 (d)(3)(5) Nursing services

Based on a review of clinical records, facility policy, and staff interviews, it was determined the facility failed to develop and implement an individualized pain management program consistent with professional standards of practice, failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis, and failed to follow physician orders when administering pain medication for two residents out of 20 residents reviewed (Resident 74 and Resident CR1).Findings include: According to the US Department of Health and Human Services, Interagency Task Force, Executive Summary Draft Final Report May 6, 2021, for Pain Management Best Practices, the development of an effective pain treatment plan after proper evaluation to establish a diagnosis with measurable outcomes that focus on improvements including quality of life (QOL), improved functionality, and Activities of Daily Living (ADLs). Achieving excellence in acute and chronic pain care depends on the following: An emphasis on an individualized patient-centered approach for diagnosis and treatment of pain is essential to establishing a therapeutic alliance between patient and clinician. Acute pain can be caused by a variety of different conditions such as trauma, burn, musculoskeletal injury, neural injury, as well as pain due to surgery/procedures in the perioperative period. A multi-modal approach that includes medications, nerve blocks, physical therapy and other modalities should be considered for acute pain conditions. A multidisciplinary approach for chronic pain across various disciplines, utilizing one or more treatment modalities, is encouraged when clinically indicated to improve outcomes. A review of the facility policy labeled Pain Management last reviewed by the facility in January 2025, revealed the facility will recognize when a resident is experiencing pain, identify circumstances when pain can be anticipated, evaluate the existing cause of pain, and manage and prevent pain for residents. A clinical record review revealed Resident 74 was admitted to the facility on [DATE], with diagnoses that included spinal stenosis (abnormal narrowing of the spinal canal that results in pressure on the spinal cord or nerve roots) and unspecified open wound, of the lower left leg. An admission MDS assessment (Minimum Data Set, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 16, 2025, indicated the resident was cognitively intact, with a BIMS score of 14 ( Brief Interview for Mental Status a tool to assess the residents attention, orientation and ability to register and recall new information , a score of 13 to 15 indicates intact cognition). A physician's order dated December 19, 2022, directed staff to administer Resident 74 Acetaminophen 325 mg, give two tablets by mouth four times a day for primary general osteoarthritis (occurs when the cartilage that cushions the ends of the bones in the joints deteriorates causing pain). A physician's order dated March 20, 2025, directed staff to administer Acetaminophen 325 mg, one tablet every twenty-two hours as needed for pain that is mild on a pain scale rated 1 to 3. A pain scale involves the use of numbers to rate pain intensity, most often from 0 to 10, where 0 corresponds to no pain and 10 corresponds to the worst possible pain. Mild pain is typically rated 1 to 3, moderate pain 4 to 6, and severe pain 7 to 10. The March 20, 2025, order also directed that non-pharmacological interventions be attempted prior to administration, including back rub, repositioning, applying ice, turning the lights out, and one-to-one interaction, and further specified that the resident may only have one tablet in twenty-four hours due to a separate scheduled order not to exceed 3 grams in twenty-four hours. A physician's order dated July 30, 2025: Tramadol HCL 25 mg (a Schedule IV narcotic pain medication) every six hours as needed for severe pain rated 7-10. A pain scale is a tool that assigns a number from 0 ( no pain) to 10 ( worst possible pain) to measure pain intensity. Mild pain is typically 1-3, moderate pain 4-6, and severe pain 7-10. August 16, 2025: Tramadol HCL 50 mg every six hours as needed for moderate pain. A review of the August 2025 MAR (medication administration record) documented the following:Acetaminophen 325 mg, one tablet every twenty-two hours as needed for mild pain, was administered one time.Tramadol 25 mg was administered six times from August 1 through August 13, 2025. Four of these administrations were outside the physician-ordered pain-rating parameters, meaning the narcotic was not administered in accordance with the provider's instructions for pain rating.Medication administrations outside of ordered parameters included:August 5, 2025, at 9:45 AM: Tramadol given for a reported pain rating of 3 (severe pain order required 7-10).August 9, 2025, at 8:48 AM: Tramadol given for a pain rating of 4.August 10, 2025, at 8:51 AM: Tramadol given for a pain rating of 4.August 12, 2025, at 11:36 AM: Tramadol given for a pain rating of 4. A review of associated documentation revealed no evidence that non-pharmacological interventions were attempted before medication administration, despite orders to attempt interventions such as repositioning, back rub, ice application, reducing stimulation, or one-to-one interaction. Non-pharmacological interventions are methods used to decrease pain without medication, such as changing position, relaxation techniques, heat or cold, or distraction activities. Further clinical record review revealed no documentation explaining the clinical reasoning for selecting a narcotic pain medication when the resident's reported pain level did not meet the provider's parameters.A review of MARs from August 13 through August 31, 2025, revealed Acetaminophen 325 mg was not administered at all during this period. A separate physician's order dated August 16,2025, directed staff to administer Tramadol HCL oral tablet 50 mg (Tramadol is a schedule IV opiate narcotic medication; schedule IV drugs have low potential for abuse) one tablet every six hours as needed for moderate pain. A review of August 13, 2025, through August 31, 2025, MAR revealed that Tylenol 325 mg was not administered to Resident 74. during this period. On August 30, 2025, at 11:05 AM staff administer narcotic pain medication for a pain rating of 3 regardless of a physician's order to give one tablet every 6 hours for moderate pain. Continued review of the clinical record revealed there was no documentation explaining the clinical reasoning for choosing a narcotic pain medication instead of the non-narcotic option when the resident ' s reported pain level did not match the physician's parameters. A review of August 13, 2025, through August 31, 2025, MAR revealed that Tramadol 50 mg was administered seven times. A review of the Controlled Substance Log revealed staff gave an incorrect dose of Tramadol HCL oral tablet 25 mg on five of those administrations On August 20,2025, at 8:49 AM staff administered Tramadol HCL oral tablet 25 mg when the physician's order was for Tramadol HCL 50 mg. On August 21,2025 at 7:44 AM staff administered Tramadol HCL oral tablet 25 mg when the physician's order was for Tramadol HCL 50 mg. On August 24,2025 at 11:56 AM staff administered Tramadol HCL oral tablet 25 mg when the physician's order was for Tramadol HCL 50 mg. On August 24,2025 at 7:51 PM staff administered Tramadol HCL oral tablet 25 mg when the physician's order was for Tramadol HCL 50 mg. On August 25,2025 at 10:27 AM staff administered Tramadol HCL oral tablet 25 mg when the physician's order was for Tramadol HCL 50 mg. On August 27,2025 at 12:02 PM staff administered Tramadol HCL oral tablet 25 mg when the physician's order was for Tramadol HCL 50 mg. An interview was conducted on November 21, 2025, at 12:30 PM with the Director of Nursing (DON), to review the above findings related to the facility's failure to attempt non-pharmacological interventions, failed to follow physician orders when administering pain medication and failed to ensure that pain management is provided to residents consistently with professional standards of practice. A review of CR 1's record revealed the resident was admitted to the facility on [DATE], with diagnoses to include chronic obstructive pulmonary disorder (a condition caused by damage to the airways or other parts of the lung) and muscle weakness. A physician order for August 2025 directed staff to administer Hydrocodone/Acetaminophen 5/325 mg (a narcotic pain medication) one tablet every six hours as needed for pain rated 1-5 on the pain scale. A review of CR1's August 2025 MAR revealed repeated administration of the narcotic medication outside the provider's parameters from August 1 through August 30, 2025. Medication was administered for pain ratings ranging from 6 to 10, although the order specified use for pain rated 1-5. The MAR documented more than 40 separate administrations outside the ordered parameters. August 1, 2025, at 09:36AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale of 7 despite the provider order indication it is it be administered for a scale of 1-5. August 1, 2025, at 4:37PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale of 10 despite the provider order for the medication to be administered for a scale of 1-5. August 2, 2025, at 04:39AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale of 6 despite the provider order. August 2, 2025, at 8:14PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale of 7 despite the provider order. August 3, 2025, at 02:35AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale of 6 despite the provider's order. August 3, 2025, at 09:48AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale of 8 despite the provider order. August 3, 2025, at 4:30PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale of 8 despite the provider order. August 4, 2025, at 8:17PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. August 5, 2025, at 03:18AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 9 despite the provider's order. August 5, 2025, at 10:16AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 9 despite the provider order. August 5, 2025, at 09:00PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale of 8 despite the provider order. August 6, 2025, at 03:07AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. August 6, 2025, at 09:23AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider's order. August 6, 2025, at 7:34PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. August 7, 2025, at 08:45AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. August 8, 2025, at 5:15PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 9 despite the provider order. August 9, 2025, at 08:03AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. August 9, 2025, at 3:41PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. August 10, 2025, at 8:17AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. August 11, 2025, at 09:10AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. August 12, 2025, at 10:06AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. August 13, 2025, at 07:53AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order.August 14, 2025, at 3:40PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. August 15, 2025, at 09:33AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 6 despite the provider order. August 16, 2025, at 02:07AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 10 despite the provider order. August 16, 2025, at 4:28PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 6 despite the provider order. August 18, 2025, at 11:55PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 9 despite the provider order. August 19, 2025, at 09:00AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider's order. August 20, 2025, at 09:06AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. August 20, 2025, at 8:26PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. August 21, 2025, at 03:32AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. August 21, 2025, at 09:38AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. August 21, 2025, at 5:42PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. August 22, 2025, at 01:07AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 9 despite the provider order. August 22, 2025, at 3:14pm- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 6 despite the provider order. August 23, 2025, at 05:26AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 9 despite the provider order. August 23, 2025, at 1:21PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 6 despite the provider order. August 25, 2025, at 09:52AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider's order. August 25, 2025, at 5:59PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. August 25, 2025, at 11:40PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 10 despite the provider's order. August 26,2025, at 06:29AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. August 26, 2025, at 6:53PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. August 27, 2025, at 01:44AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. August 27, 2025, at 8:01PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. August 28, 2025, at 04:12AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. August 30, 2025, at 7:21PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. A review of CR1's September 2025 MAR revealed medication was again administered outside the physician's ordered parameters on multiple occasions from September 1 through September 17, 2025, with pain scores recorded between 6 and 10.September 1, 2025, at 1:57PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. September 1, 2025, at 8:05PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. September 2, 2025, at 03:22AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. September 2, 2025, at 10:19AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. September 2, 2025, at 7:53PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. September 3, 2025, at 05:24AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. September 3, 2025, at 12:30PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. September 4, 2025, at 05:35AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider's order. September 4, 2025, at 1:20PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. September 5, 2025, at 04:44AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 9 despite the provider order. September 5, 2025, at 11:20AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. September 6, 2025, at 1:33PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 9 despite the provider order. September 7, 2025, at 04:47AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 9 despite the provider order. September 8, 2025, at 07:41AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. September 8, 2025, at 7:51PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider's order. September 9, 2025, at 08:13AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. September 9, 2025, at 8:14PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. September 10, 2025, at 5:18PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider's order. September 12, 2025, at 08:44AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. September 13, 2025, at 08:17AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. September 14, 2025, at 06:39AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 6 despite the provider order. September 14, 2025, at 7:10PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 9 despite the provider order. September 15, 2025, at 05:49AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 6 despite the provider order. September 15, 2025, at 8:20PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. September 16, 2025, at 10:19AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. September 16, 2025, at 7:51PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. September 17, 2025, at 02:37AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. September 17, 2025, at 08:54AM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 7 despite the provider order. September 17, 2025, at 4:31PM- Hydrocodone/Acetaminophen 5/325mg was administered for a pain scale 8 despite the provider order. The clinical record did not contain documentation explaining clinical reasoning for these administrations when the pain levels did not meet the ordered parameters.An interview was conducted on November 21, 2025, at 12:35 PM with the Director of Nursing to review the findings related to CR1. 28 Pa. Code 211.10(d) Resident care policies.28 Pa Code 211.12 (d)(3)(5) Nursing Services.

Based on a review of clinical records, information submitted to the State Survey Agency through the Electronic Reporting System, facility email communication, and staff interviews, it was determined the facility failed to ensure that all allegations of resident abuse and misappropriation were thoroughly investigated and that complete investigation results were submitted to the State Survey Agency within five working days of the incident, as evidenced by one of one allegation of misappropriation reviewed involving two residents of six residents sampled (Residents CR1 and CR2). Findings include: A review of the facility's policy titled Abuse Protection, last reviewed by the facility in February 2024, revealed that it is the policy of the facility to submit the required investigative documentation through the Electronic Event Reporting System within five working days of a reported allegation when an alleged perpetrator is identified. A review of incidents of alleged abuse, neglect, and misappropriation showed that the facility reported the following incident through the Electronic Reporting System but failed to submit a complete investigation report and documentation of corrective actions within the required timeframe: On May 25, 2025, the facility reported an incident involving an alleged misappropriation of property. According to the report, Resident CR1 had been discharged home from the facility on May 24, 2025, with a prescription for 28 tablets of Oxycodone 5 mg (narcotic medication) tablets. Upon arrival home, Resident CR1's responsible party (RP) discovered that 11 tablets were missing. The RP contacted the facility and spoke with Employee 1 (Licensed Practical Nurse), who had been assigned to Resident CR1 on the day of discharge. Employee 1 informed the RP that she had the remaining pills in a prescription bottle and offered to deliver them directly, however, the RP instead notified the facility administration. It was noted the facility's standard practice is to dispense prescription medications on a unit-dose card, not in a bottle. An internal review was initiated and further revealed that Resident CR2, who had recently been discharged to the hospital, was also missing 32 remaining Hydrocodone 10 mg tablets. In addition, the required controlled substance sign-out sheets for both residents' medications were missing. Although the facility initiated an investigation, the submitted investigative report was incomplete and did not include required supporting documentation such as witness statements or confirmation that the investigation contained all necessary components. The incomplete report was rejected by the State Survey Agency on June 5, 2025, due to insufficient detail, and the facility failed to submit a revised, complete investigation for review. A review of the State Agency's Electronic Reporting System confirmed that no complete investigation report was resubmitted after June 5, 2025. During an interview with the Director of Nursing and the Nursing Home Administrator on July 8, 2025, at approximately 1:30 PM, the facility was unable to provide documented evidence the investigation was completed in full and submitted to the State Survey Agency within the required five working days. These findings were reviewed with the Nursing Home Administrator and Director of Nursing during the exit conference. 28 Pa Code 201.1 (a) Responsibility of licensee. 28 Pa Code 201.18 (e)(1) Management.

Based on review of clinical records, the facility's abuse prohibition policy, and select investigative reports, and interviews with staff and residents, it was determined the facility failed to ensure that a resident was free from neglect by not utilizing a mechanical lift as planned to ensure safety and prevent major injury, fracture of the right femoral neck, for one resident, (Resident 5), out of 18 sampled residents reviewed for abuse prohibition. Findings included: Review of the facility's policy entitled Abuse, Neglect, Mistreatment, Misappropriation of Resident Property and Exploitation Prevention last reviewed by the facility January 2025, indicated that abuse, neglect, misappropriation of resident property, and exploitation of residents would not be tolerated in any manner. All staff will be provided education related to abuse and components to prevent potential abuse. A review of Resident 5's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including cerebral palsy (CP a group of neurological disorders that appear in infancy or early childhood and permanently affect body movement and muscle coordination and is caused by damage to or abnormalities inside the developing brain that disrupt the brain's ability to control movement and maintain posture and balance), dysphagia (difficulty swallowing), contractures (shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement) to the right elbow and right and left hand, and cerebral infarction (occurs when the blood supply to part of the brain is blocked or reduced and prevents brain tissue from getting oxygen and nutrients resulting in brain cells dying). Resident 5's comprehensive person-centered plan of care was initiated on June 26, 2020, indicated that the resident required assistance with ADLs (activities of daily living) related to cerebral palsy, decreased mobility, and hemiplegia with a resident goal to participate at the highest level of function. Planned interventions for the resident to meet her goals included to utilize a Hoyer lift (mechanical device designed to lift/transfer individuals that have limited mobility in a safe manner and reduce injuries) for all transfers. Review of Resident 5's Annual MDS (Minimum Data Set - a federally mandated standardized assessment process conducted periodically to plan resident care) assessment dated [DATE], section C Cognitive Patterns revealed the resident had a BIMS score (Brief Interview for Mental Status a tool used to evaluate cognitive impairment and assist with dementia diagnosis) of 12, which indicated the resident had moderate cognitive impairment. Additionally, the annual MDS was coded that the resident had functional limitations in range of motion to the upper extremity (shoulder, elbow, wrist, hand) on one side and lower extremity (hip, knee, ankle, foot) to both sides. The resident was dependent on staff for toileting, dependent on staff for sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed), dependent with bed-to-chair transfer (the ability to transfer to and from a bed to a chair or wheelchair), dependent with toilet transfers (the ability to get on and off a toilet or commode). On January 26, 2025, at approximately 8:30 PM, Employee 1 (an agency Nurse Aide) and Employee 2 (another agency Nurse Aide) were providing evening care to Resident 5. A witness statement from Employee 2 indicated that while performing PM care, the resident began complaining of pain in her right arm. As Employee 2 removed the resident's shirt and bra, Resident 5 began yelling in pain. Concerned, Employee 2 alerted Employee 1 and the nurse supervisor. A review of witness statements from agency Nurse Aides (NAs) Employee 1 and Employee 2, both dated January 26, 2025, at 8:30 PM, did not indicate any acknowledgment of a fall or improper transfer at that time. Employee 1 documented that the incident was unwitnessed but noted that before the incident, Resident 5 was in her chair, crying, and had been uncomfortable throughout the day. Employee 2 reported that during PM care, Resident 5 complained of pain in her right arm, which intensified when her shirt and bra were removed. Employee 2 also documented that she called Employee 1 into the room to assess the situation and indicated both employees ultimately transferred the resident using the Hoyer lift at that time. A review of Resident 5's clinical record revealed that a Change in Condition Evaluation form was completed by Employee 3, a Registered Nurse (RN) Supervisor, on January 26, 2025, at 9:00 PM, it noted that Resident 5 exhibited pain with movement, vocalized distress (moaning, crying out, grimacing), and had localized swelling and bruising over her right shoulder and elbow. Removing her shirt and putting on night shirt caused discomfort, but she was able to perform full range of motion (ROM - the extent or limit to which a part of the body can be moved around a joint or a fixed point; the totality of movement a joint can do). Despite these symptoms, staff failed to immediately identify the cause of a potential serious injury. The nurse noted no history of a recent fall, but musculoskeletal pain was documented. A review of a witness statement for an injury of unknown origin completed by the DON on behalf of Resident 5 (hand contractures limited the resident's ability to write her own statement) on January 27, 2025, at approximately 8:00 AM, related to sustaining an injury to RUE. When asked if an incident happened while staff were transferring her from the wheelchair to bed on Sunday evening January 26, 2025, Resident 5 shook her head up and down and stated yes. When asked if staff used the Hoyer lift to transfer her from the wheelchair to bed, Resident shook her head from side to side and stated no. When asked if her RUE hurt earlier in the day on Sunday January 26, 2025, Resident 5 shook her head side to side, indicating no. A nurse's progress note dated January 27, 2025, at 8:09 AM, indicated that Resident 5's Responsible Party (RP) was notified of her increased pain and swelling. A physician's order for an x-ray was obtained at 10:21 AM. The mobile x-ray results, received at 2:09 PM, confirmed a mildly impacted fracture of the right humeral neck (the upper part of the right arm bone has broken near the shoulder and the broken pieces have been pushed into each other). Further review of the hospital ED (emergency department) visit summary dated January 27, 2025, at 8:39 PM, indicated a fracture of humerus and aftercare instruction included to wear a sling for support, comfort, and protection, Acetaminophen (Tylenol Extra Strength - pain reliving medication) 650 - 1000 milligrams (mg) every six hours for pain, and follow up with orthopedics. The facility's internal investigation, completed by the Director of Nursing (DON) on January 27, 2025, at 8:10 AM revealed that during the evening shift on January 26, 2025, staff failed to use the Hoyer lift as required to transfer Resident 5 from her wheelchair to her bed. Witness statements obtained from Resident 5 (BIMS of 12, indicating moderate cognitive impairment) and her roommate, Resident 81 (BIMS of 15, indicating cognitive intactness), stated the mechanical lift was not used during the evening transfer. Resident 81 reported hearing Resident 5 let out a blood-curdling scream and noted she did not see the Hoyer lift present in the room at the time of transfer. Additionally, Resident 5 confirmed that staff did not use the Hoyer lift when transferring her that evening. A review of facility provided documents entitled Agency Staff Training Sign-Off revealed A review of facility-provided documents titled Agency Staff Training Sign-Off revealed that Employee 1 completed training and signed the document on October 13, 2024, and Employee 2 signed on September 17, 2024. By signing these documents, both employees acknowledged that they had reviewed and received a copy of the facility's handbook, which included the facility's abuse and neglect policy. The signatures further confirmed that they understood and agreed to adhere to all facility policies, procedures, and guidelines. Additionally, both employees acknowledged they had completed training and were deemed proficient to perform all assigned tasks, including proper transfer techniques. A review of Employee 1 and Employee 2's agency onboarding and orientation documents further indicated that upon hire, both employees were trained and oriented to the proper use of Hoyer lifts for resident transfers. Employee 1 completed this training on August 29, 2023, at 8:45 PM, and Employee 2 completed training on October 19, 2023, at 10:38 AM Despite this documented training and acknowledgment of competency, the facility's internal investigation confirmed that Employee 1 and Employee 2 failed to adhere to established protocols by not using the required Hoyer lift to transfer Resident 5 on January 26, 2025. This failure directly violated the resident's care plan and placed the resident at significant risk, resulting in an impacted fracture of the right humerus. During the on-site survey conducted on February 13, 2025, the facility attempted to contact Employee 1 and Employee 2 via phone to gather additional details regarding the incident. However, neither Employee 1 nor Employee 2 returned the calls, and no further clarification was obtained from them regarding the improper transfer. This confirms that Employee 1 and Employee 2 were aware of proper procedures but neglected to follow them, directly leading to serious harm to Resident 5. During an interview conducted on February 13, 2025, at 10:37 AM, the DON confirmed that based on interviews with Resident 5 and Resident 81, staff failed to use the required Hoyer lift during the January 26, 2025, evening transfer. This improper transfer resulted in a serious injury, a displaced, impacted fracture of the right humerus. The facility failed to assure that all NAs consistently utilized the required transfer device, a Hoyer lift, to safely transfer Resident 5 that resulted in a serious injury to her right upper arm, a fracture. An interview with the DON on February 13, 2025, at 10:37 AM, revealed that based on interviews with Resident 5 and Resident 81, the DON concluded that staff did not utilize the required Hoyer lift to transfer Resident 5 from her wheelchair to bed. Additionally, the DON confirmed that Employee 1 and Employee 2 neglected to fulfill duties required to safely render care to Resident 5 that resulted in a serious injury, an impacted fracture of the right humerus, and increased discomfort and pain. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a) Resident Rights 28 Pa. Code 211.12 (d)(5) Nursing Services

Based on a review of facility policy, the minutes from facility Resident Council meetings, and grievances lodged with the facility, and resident and staff interviews, it was determined the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints and grievances expressed during Resident Council meetings and verbal grievances, including those voiced by six of six residents attending a resident group meeting (Residents 27, 69, 63, 2, 15, and 18) and failed to keep the residents apprised of the status of the facility's decisions and efforts toward grievance resolution. Findings include: A review of the facility's Grievance Policy last revised on August 2021 indicated the residents', families, and their representatives have the right to voice grievances concerning care and treatment, behavior of staff or other residents or any concerns regarding their stay. A review of the Minutes from Resident Council meetings dated November 2024, December 2024, and January 2025 revealed repeated concerns from residents that fresh water was not consistently being provided daily. Despite these ongoing concerns, there was no documented evidence of corrective actions taken to address these issues between November 2024 and January 2025. A group meeting conducted on February 12, 2025, at 10:30 a.m. with six residents (Residents 27, 69, 63, 2, 15, and 18) revealed unanimous reports the facility failed to address their complaints regarding the inconsistent delivery of fresh water. The facility was unable to provide documented evidence that efforts had been made to resolve resident complaints concerning fresh water delivery as of the survey ending February 14, 2025, that had been repeatedly brought up during resident council meeting. During an interview on February 14, 2025, at 9:10 a.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed the absence of documented actions addressing grievances raised during Resident Council meetings or verbal complaints. 28 Pa. Code 201.18 (e)(1)(4) Management 28 Pa. Code 201.29(a) Resident Rights

Based on a review of the facility's abuse prohibition policy, employee personnel files and staff interviews, it was determined the facility failed to fully develop and implement its established abuse prohibition procedures by not adequately screening five of five employees for employment (Employee 5, 6, 7, 8 and 10). Findings include: According to regulatory requirements under SS483.12(a)(3) and 483.12(b)(1)] the facility must have written procedures for screening for prospective employees, to include reviewing: the employment history (e.g., dates of employment position or title), particularly where there is a pattern of inconsistency; information from former employers, whether favorable or unfavorable; and/or documentation of status and any disciplinary actions from licensing or registration boards and other registries. A review of the facility's Resident Abuse policy last reviewed by the facility December 2023, revealed the requirement for screening potential employees that including obtaining references from current or previous employers. Review of employee personnel files revealed the following: Employee 5 (Licensed Practical Nurse - LPN): Hired on January 13, 2025. The application listed previous employers, but there was no documentation showing the facility had contacted any former employers. Employee 6 (Nurse Aide): Hired on December 13, 2024. The application listed prior employers, yet no evidence was found to verify that the facility obtained references or employment information from previous employers. Employee 7 (Dietary Aide): Hired on November 18, 2024. The employee had indicated previous employment, but no verification of past employment was documented. Employee 8 (Licensed Practical Nurse - LPN): Hired on October 26, 2024. The application reflected prior employment, but there was no indication of efforts made to verify previous employment. Employee 10 (Director of Nursing - DON): Hired on September 26, 2024. Although the application listed previous employers, the facility did not document any contact with those employers for employment verification. Interview with the Administrator on February 13, at 12:15 p.m. the NHA verified that there was no evidence that previous employers were contacted for information regarding the employees past work history. The facility failed to follow its own abuse prohibition policy and by not verifying previous employment for five out of five new hires. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a)(c)Resident Rights 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.19 (1) Personnel records

Based on a policy review, clinical record review, select document and investigation review, and resident and staff interviews, it was determined that the facility failed to protect residents from sexual abuse, resulting in psychosocial harm for one of four residents reviewed (Resident 1). Findings included: Review of current facility policy, titled Abuse, neglect, mistreatment, misappropriation of resident property and exploitation prevention, revised March 26, 2024, revealed that it is the policy that abuse, neglect, misappropriation of resident property, and exploitation of residents will not be tolerated in any manner. All staff will be provided education related to abuse and components to prevent potential abuse. A review of Resident 1's clinical record revealed an admitted [DATE], with diagnoses that included atherosclerotic heart disease (condition where a sticky substance made of cholesterol, fat, calcium, and other materials builds up inside the walls of the arteries) and diabetes (condition that affects blood sugar levels). A quarterly Minimum Data Set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated May 23, 2024, indicated that the Resident was moderately cognitively impaired, with a BIMS (Brief Interview for Mental Status - a tool to assess cognitive status) score of 7. Review of a facility investigation report dated August 2, 2024, at 7:15 AM, revealed that on that date and time Resident 1 was about to receive morning care when she disclosed to Employee 1 (Nurse Aide [NA]) that during the night (the prior 11 PM to 7 AM shift) a man came into her room, pinned her down and fucked her, and that she was sore down there. Per Employee 1, the Resident was in bed, her brief was in place, and her pajama bottoms at her knees. Employee 1 reported this to Employee 2 (Licensed Practical Nurse [LPN]), and both then reported it to the Director of Nursing (DON). The DON attempted to do a physical assessment; however, when staff attempted, the Resident refused to have her bra removed. When staff attempted to help the Resident undress her lower body, she became guarded and started crying, stating I cannot do this. It hurts and I am frightened. The examination immediately ceased. The Resident's brief had been changed related to being soaked with urine. In an attempt to maintain evidence, the Resident's brief was kept in the bathroom, the sheets were left untouched, and her clothing was kept on Resident 1. The State Police, Physician, responsible party, and Department of Aging were notified. Resident 1 was taken to the hospital for evaluation. Review of Resident 1's facility transfer to the hospital form dated August 2, 2024, at 7:48 AM, revealed she had pain in her groin and she alleged she was raped overnight; her upper body was assessed and no new skin issues were noted; when attempted to help the Resident undress her lower body, she became emotional and frightened and it was deemed okay to stop examination as the Resident would be sent to hospital for SAR (sexual assault response) kit; all clothing remained the same as overnight; and her bedding was preserved. Review of nursing documentation dated August 2, 2024, at 9:50 AM, revealed Resident 1 was sent to the hospital per order via stretcher in an ambulance. Review of hospital documentation dated August 2, 2024, at 10:55 AM, revealed that Resident 1 presented to the emergency room for a possible rape. The Resident was accompanied by her caregiver (Facility NA), who stated she went into the patient's room as usual to get her ready for the day. The patient was not acting herself, complaining of pain. Resident 1 stated, Someone came into my room during the night and 'fucked' me. (profanity is out of character for this patient). When caretaker lowered the resident's blankets, her pants were at her knees. This is also out of character for this patient. Upon questioning, the resident stated that she had vaginal bleeding since the time of the assault. The resident and her sister agreed to have a SANE examination (Sexual Assault Nurse Examiner) completed. Review of the SANE examination revealed: -abrasions noted to the labia (folds of protective skin located on each side of the vaginal opening) -lacerations to the mons pubis (rounded, fleshy area on the front of the pelvic bone) -bruising of the cervix (lower part of the uterus that separates the lower uterus and the vagina.) The county Area on Aging and protective services were at the Resident's bedside. The state police were contacted and arrived at the hospital on August 2, 2024, at 4:10 PM, to pick up the chain of custody evidence kit. Discharge instructions included sexual assault instructions. Nursing documentation dated August 2, 2024, at 8:40 PM, revealed Resident 1 returned to the facility from the hospital. Facility staff preformed a physical exam. Resident 1 had generalized discomfort to shoulder and pubic region. LPN provided Tylenol for pain management. Review of a facility deployment sheet (the daily nursing staff assigned by shift and by hallway) indicated that there was one LPN (Employee 5) and one NA (Employee 3 [Agency NA]) assigned to the hallway Resident 1 resided on the overnight shift on August 1 into 2, 2024. Review of Employee 2's witness statement dated August 2, 2024, at 7 AM, revealed It was brought to my attention during A.M. care that Resident 1 was touched by a male person, and she was in a lot of pain. I immediately went to inform the DON. There was no witness statement available at the time of the survey from Employee 1, the Employee who first saw the Resident 1 after the incident noted above. Employee 3's witness statement dated August 2, 2024 (no time indicated), stated, On first rounds, Resident 1 was taken to the bathroom. I stepped out (of the bathroom) because she wanted privacy. I helped her in and out of the wheelchair. Later, Resident 1 rang her call bell for tylenol and cough medicine. On Last rounds, I changed her in her bed. Employee 4 (Agency NA) asked if I needed help. Employee 4 changed Resident 1's roommate (nonverbal with significant cognitive impairment). When I was done with Resident 1, I went over to help Employee 4 and then we left the room. There was no witness statement available at the time of the survey from Employee 4. Employee 5's witness statement dated August 2, 2024 (no time indicated), Throughout the 11 P.M. to 7 A.M. shift, Employee 3 was mostly in the hallway. He was in patient's room once when she put on her light requesting Tylenol and cough medicine. After administering the medicine, the patient went back to sleep and remained asleep. I was on and off the hallway throughout the shift. Review of Employee 6's (LPN) witness statement dated August 2, 2024, (no time indicated) revealed, I did not see Resident 1 throughout the night. The Peach hall nurse aide [Employee 4] was at the nurse's station most of the shift and up and down the hall (not identified) many times. Aide on the floor [Employee 3] was observed several times from 3 AM to 7 AM at the other end of the hall with the other aide enter room during rounds and exit room together. Unsure of length of time in room but was not a long time. The statement further revealed that Employee 6 observed Employees 3 and 4 enter the Resident's room but not exiting the room, so Employee 6 was unsure of the length of time. Review of a Employee 7's witness statement (Registered Nurse Supervisor) date August 2, 2024 (no time indicated), revealed, Employee 3 was busy for most of the night doing his assigned tasks. Every time I saw him, he was in or around a different room. Review of Resident 1's witness statement dated, August 2, 2024 (no time indicated), revealed A man came into my room, pulled my pants down, pinned my arms, had sex with me. During an interview with Resident 1 on August 5, 2024, at approximately 10:30 AM, conducted in the presence of the facility social services director, a State police officer, and the surveyor, the Resident confirmed that on August 2, 2024, during the night shift, she was in bed and a male entered her room, pulled back the bed covers, got in her bed, pinned her arms down, covered her mouth with his hand, and put his [NAME] inside her. She stated that It really hurt me down there. I was really scared, I'm still scared. She stated that she still had pain in her groin area and the I don't want any men to take care of me. During the interview, the Resident was asked several times to describe the man. She stated that she couldn't remember and that it was dark in the room with no lights on at the time of the incident. Review of documentation revealed Employee 3 was the only male on duty the shift the incident occurred. He was an agency employee that had worked regularly at the facility since November 2023. The facility failed to ensure that Resident 1 was free from sexual abuse and psychosocial harm. An interview with the DON on August 5, 2024, at approximately 12:00 PM, confirmed the sexual assault and psychosocial harm occurred for Resident 1 as noted above. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing Services 28 Pa. Code 201.18(1) Management

Based on a review of clinical records and select investigative reports and staff interviews it was determined that the facility failed to ensure that planned safety and fall prevention measures were consistently implemented and functional to prevent a fall with serious injury, a fractured hip, for one resident out of 21 sampled residents (Resident 19). Findings include: A review of the clinical record revealed that Resident 19 was admitted to the facility on [DATE], for post surgery therapy after a fall at home and a fractured hip. The resident's diagnoses included chronic kidney disease and difficulty walking. An admission MDS Assessment January 2, 2023, (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) revealed that the resident was moderately cognitively impaired and required maximum assistance of staff with activities of daily living, including transfers and toileting. The resident's baseline care plan dated January 2, 2023, identified that the resident was at risk for falls due to a history of falls with injury. Planned interventions were to apply a bed alarm, sensor alarm pad to the wheelchair, rear antiptippers and anti roll back brakes on the wheelchair, and a lower bathroom door alarm (level with the door handle). A review of a fall investigation report dated January 16, 2023, at 10:07 PM revealed that at 3:15 PM staff found Resident 19 lying on floor of the resident's room, on her left side, between her recliner chair and bed. The resident's alarm was sounding to alert staff to the resident's fall. Staff entered into the room and heard resident yelling out for help. The RN supervisor assessed the resident and found no injury. The resident was assisted to a sitting position and then onto her feet and slippers applied. An aide transferred the resident to a wheelchair. No additional or revised safety interventions were implemented after this fall. A review of a fall investigation report dated February 18, 2023, at 3 PM revealed that Resident 19 had an unwitnessed fall in the bathroom of her room. Staff found the resident lying on her back with her feet facing the bathroom doorway, her head and torso were under the sink, and her wheelchair was next to her facing the toilet. The wheelchair alarm was not sounding at the time nor was the bathroom door alarm. Staff tested the wheelchair alarm and found that it was functioning properly but had not been turned on. The door alarm was functioning, but did not activate due to its placement on the door. The RN assessed the resident and the resident had complaints of pain with range of movement to left hip upon straightening. The resident had been incontinent of urine at the time of the fall. The report noted that staff had last toileted the resident at 1:30 PM. According to the report, the resident's family had been visiting with her prior to the fall, and left the facility around 2:40 PM. Her call bell was in her reach, but not activated at the time of the fall. After this fall the facility changed the position of the bathroom door alarm from a lower alarm, level with the door knob, to an alarm placed higher on the door. An employee witness statement from Employee 3, a nurse aide, dated February 18, 2023, indicated that the employee noted that the resident was last toileted at 1:30 PM. According to Employee 3's statement, the resident was seated in the wheelchair and alarm in working order after toileting at 1:30 PM. The resident's family was present. At 3 PM the resident was found on the bathroom floor, and no alarm was sounding. An employee witness statement dated February 18, 2023, from Employee 4, LPN, indicated that Employee 4 stated that last time I saw {Resident 19} was at 2:30 PM when I went into the room to administer her roommate's medication. {Resident 19} was sitting near her bed in the wheelchair and her family had just left the room and were headed down the hallway. Employee 5's, a nurse aide, witness statement dated February 18, 2023, noted that I heard loud yelling from {Resident 19's} room. I entered the resident's bathroom and found her lying on her back, holding onto the sink drain under the sink. Her head was up near the corner of the wall. Both legs were bent in a seated position while lying on the floor. No alarms were sounding upon entering the room. Nursing documentation dated February 18, 2023 at 5 PM revealed that Resident 19 fell and sustained a skin tear to left lower extremity. The physician was aware and ordered an x-ray and a mobile x-ray was completed in the facility at 8:30 PM Nursing noted on February 18, 2023 at 9:26 P.M that after the x-rays were completed the x-ray tech saw some irregularities on films. Resident 19 continued to complain of pain and the physician was notified. The physician directed that the resident be transferred to the hospital at the facility's request. Nursing documentation dated February 19, 2023 at 5:45 AM revealed that nursing called the hospital for update on Resident 19 and the hospital informed them that Resident 19 had been admitted to the hospital with a left hip fracture. A review of hospital documentation, a history and physical exam dated February 19, 2023, at 5:03 AM, revealed that the resident had an impacted (impacted fracture fracture in which one fragment is firmly driven into the other) left femoral neck fracture (top of the thigh bone). Orthopedic surgery was consulted and this resident had surgical repair of her left hip that day. The facility failed to ensure that the resident's wheelchair alarm was turned on and bathroom door alarm was appropriately positioned to alert staff to the resident's unsafe acts of attempting to self-transfer and toilet herself to prevent this fall with serious injury. During an interview on May 19, 2023, at approximately 11 AM, the Director of Nursing confirmed that the planned intervention, a wheelchair alarm, was not turned on at the time of the resident's fall and did not sound to alert staff to the resident's unsafe self-transfer and toileting. Additionally, the bathroom door alarm also did not sound as the facility determined that it was positioned to low to detect the resident's activity. As a result of the ineffective fall prevention measures, this resident, who was identified at risk for falls, with a history of falls and fractured hip prior to admission, sustained a fall with an impacted hip fracture during this self-toileting attempt. 28 Pa Code 211.12 (a)(d)(5) Nursing Services. 28 Pa Code 211.11 (d) Resident care plan

Based on a review of clinical records, select resident incident/accident reports, test tray results and the American Burn Society Scald (very hot, burning) Injury Prevention Guide, observations and staff and family interviews, it was determined that the facility failed to maintain the residents' environment free of accident hazards created by increased temperatures of hot liquids served to the residents including two of 18 residents reviewed, who sustained burns from spilled hot liquids (Resident 18 and Resident CR4). This failure placed the residents in immediate jeopardy of sustaining injury as the result of scalding burns. The facility further failed to timely implement sufficient safety measures to prevent a fall with serious injuries (head injury and multiple fractures) for one of 18 residents reviewed (Resident 46). Findings included: Review of the American Burn Association Scald Injury Prevention Educator's Guide (undated) revealed that older adults have thinner skin so hot liquids cause deeper burns with even brief exposure. The severity of a scald injury depends on the temperature to which the skin is exposed and how long it is exposed. When the temperature of a hot liquid is increased to 140 degrees Fahrenheit, it takes only five seconds or less for a serious burn to occur. A temperature of 148 degrees Fahrenheit takes 2 seconds for severe burns and at 155 degrees Fahrenheit takes 1 second for a severe burn to occur. The coffee, tea, and other hot beverages are usually served at 160 degrees to 180 degrees Fahrenheit resulting in almost instantaneous burns. During an observation of the lunch meal service to resident rooms on the Peach Unit on April 13, 2017, at approximately 11:30 AM a large heavy-duty plastic coffee dispenser, with a lever to dispense the coffee, was observed on top of a utility cart. Observation at that time also revealed that this coffee dispenser remained in the hallway as staff distributed meal trays to the residents. The staff would pour coffee directly from this coffee dispenser as needed for service to the residents with their meals. This coffee dispenser was observed to be intermittently unattended by the staff as they distributed the residents' meal trays during the lunch meal service. The temperature of the coffee from this plastic dispenser was obtained at approximately 12:15 PM by the facility's Dietary Manager using the facility's thermometer and in the presence of the surveyor, which revealed that the coffee temperature was 157.1 degrees Fahrenheit. A review of the clinical record of Resident 18 revealed that the resident had [DIAGNOSES REDACTED]. A review of the resident's Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 15, 2016, revealed that the resident was severely cognitively impaired, with a BIMS (Brief Interview for Mental Status - a tool to assess cognitive function), score of 6 (a score of 0-7 indicates severe cognitive impairment). This MDS assessment also noted that the resident was independent with eating after set up by staff. Nursing documentation on December 3, 2016, at 1:18 PM indicated that the resident sustained [REDACTED]. Review of a corresponding incident/accident investigation report indicated that on December 3, 2016, at 11:45 AM the resident yelled out. Staff responded to the resident's room and found that hot coffee had accidently spilled on the resident's right forearm. The area was reddened (size not delineated) without blistering. The facility's planned intervention, to prevent a reoccurrence of a similar nature, was to have the nurse aides place the resident's overbed table with the resident's meal tray in front of the resident before leaving the room when serving all meals to the resident's. A written statement regarding this incident provided by Employee 3, a Nurse Aide, dated December 3, 2016, revealed that the resident was independent with eating. Employee 3 brought Resident 18's lunch into the resident's room, set the tray up and informed the resident that her lunch was ready and left the room. A written statement provided by Employee 2, a Nurse Aide, included with the facility's investigation into this incident, dated December 3, 2016, indicated that when she was delivering a lunch tray to another resident, she heard Resident 18 scream and rushed over to Resident 18. Employee 2 noticed that the resident had spilled coffee down her arm. Employee 2 summoned help and ice was applied to the resident's right arm. A form completed by Employee 4, a Registered Nurse entitled TYPE OF OCCURRENCE dated December 3, 2016, was attached to this incident report and indicated that the resident had sustained a burn. The form indicated that the resident pulled the overbed table toward her and the coffee spilled on her. The staff were not present, the resident's call bell was not in reach and the resident did not activate the call bell according to this form. The immediate intervention post (after) incident was that the nurse aides were to put the overbed table with the (meal) tray in place for the resident before leaving the room when serving all meals. Review of a Test Tray form (a facility form noting the temperatures of the food and beverages on the residents' meal trays, used to monitor service temperatures for food safety and palatability) revealed that after the resident had sustained a burn as the result of a hot coffee spill, a Test Tray form was not completed until two days later on December 5, 2016, at the dinner meal. No hot beverage was tested during that test tray. An interview conducted on April 14, 2017, at approximately 11:30 AM with the facility's Dietary Manager, revealed that the Dietary Department was not made aware of the above incident and Resident 18's burn related to coffee spillage. During an interview with the resident's responsible party on April 14, 2017, at approximately 11:15 AM she confirmed that Resident 18 had incurred a reddened area on her right forearm and that ice had to be applied. Review of the facility Test Tray forms completed between September 5, 2016 through April 10, 2017, revealed the following food/beverage temperatures upon service to the residents: 9/5/16 - (Lunch)- hot coffee-172 degrees Fahrenheit 9/16/16 - (Supper) hot tea- 176 degrees Fahrenheit 10/10/16 -(Breakfast) -hot cocoa-178 degrees Fahrenheit, hot cream of wheat cereal -174 degrees Fahrenheit 10/27/16 -(Lunch) -coffee-178 degrees Fahrenheit 11/8/16 -(Breakfast) -hot tea-182 degrees Fahrenheit, oatmeal-168 degrees Fahrenheit 12/5/16- (Dinner) - Italian wedding soup-181 degrees Fahrenheit 1/4/17- (Breakfast) - coffee-174 degrees Fahrenheit, oatmeal -178 degrees Fahrenheit 1/27/17- (Lunch) - hot chocolate-164 degrees Fahrenheit 2/24/17 - (Supper) - soup-174 degrees Fahrenheit coffee -170 degrees Fahrenheit 4/10/16 - (Lunch) - hot tea -176 degrees Fahrenheit A test tray of the food temperatures was conducted by the Dietary Manager with the facility's thermometer on April 14, 2017, at approximately 12:00 PM, on the Mauve Unit when Resident 18 began to eat her lunch tray. The test tray revealed that the coffee was 167.4 degrees Fahrenheit and the soup was 164 .1 degrees Fahrenheit. During observation of the facility's main dining room on April 14, 2017, at approximately 12:05 PM a soup kettle was observed on the countertop in the main dining room. The temperature of the soup from this soup kettle at the time of the observation was 192.7 degrees Fahrenheit. A review of the clinical record of Resident CR4 revealed that the resident had [DIAGNOSES REDACTED]. Review of the resident's MDS assessment dated [DATE], revealed that she was cognitively intact with a BIMS score of 15 (a score of 13-15 indicates that the resident is cognitively intact). The resident required limited assistance of one person with eating. According to a facility post occurrence form (a form completed following an incident/accident) dated September 26, 2016, at 6:25 PM the resident sustained [REDACTED]. Review of the corresponding incident report indicated that on September 26, 2016, at 6:00 PM Resident CR4 was eating dinner in the main dining room and the staff heard the resident yell out. The resident stated she dropped her soup. Resident CR4 was noted to have spilled soup on her right leg. A weekly wound assessment record dated September 26, 2016, indicated that Resident CR4 had an area 2 centimeters (cm) x 13 cm on her right posterior thigh described as red and raised. A second area was located on the right anterior thigh and measured 11 cm x 4.4 cm and was described as red with a fluid filled blister. The physician was notified on September 26, 2016, and a treatment to the area was ordered. The facility's incident investigation report noted that immediate interventions to prevent recurrence included for the staff to assist the resident with the remainder of that particular meal and that her soup was to be served in a handled mug. There was no documented evidence that the facility had tested the soup temperatures after this incident to ensure safe serving temperatures. There were no test tray temperature results available during the survey ending April 18, 2017, which the facility had obtained during the time period of this incident (on or around September 26, 2016) to determine the temperature of the soup served to the residents. Observations conducted on April 14, 2017, at 11:45 AM revealed that the Dietary Manager was reheating refrigerated oatmeal in the microwave on the nursing unit for service to a resident at the lunch meal. The temperature of the reheated oatmeal, that the Dietary Manager intended to serve to the resident, at 12:00 PM on April 14, 2017, was 194.6 Fahrenheit. As the result of the facility's failure to identify and consistently monitor the temperatures of hot liquids served to the residents and the risk of scalding to the residents as the result of the elevated temperatures found during the survey Immediate Jeopardy to the health and safety of the residents was identified to the Nursing Home Administrator on April 14, 2017, at 12:30 PM. The facility's corrective action plan included: 1. Food will be served at temperatures between 135-140 Fahrenheit. 2. Temperatures will be taken on all microwaved food when heated and logged at each microwave station in the kitchen and throughout the building. 3. Temperatures will be taken of the dining room soup pot prior to the soup being served. 4. Signage will be posted at the public microwaves to explain appropriate temperatures. a.) signage will include temperatures can be not greater than 140 degrees. 5. Temperature logs and thermometers will be placed at each microwave stations throughout the building, alcohol wipes will be placed near the stations to allow for cleaning the thermometers in between use. Following verification of the implementation of the corrective action plan and review of the temperature assessment of the hot liquids and the liquid-like foods (i.e. oatmeal, soup) served to the residents during the evening meal on April 14, 2017 and the meals on the 7 AM to 3 PM shift on April 15, 2017, the Immediate Jeopardy was lifted at 11:50 AM on April 15, 2017. Resident 46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's quarterly MDS assessment dated [DATE], indicated that the resident had a BIMS score of 11, indicating that the resident was moderately cognitively impaired (score of 8-12 indicates moderate cognitive impairment). The resident required limited assistance of one person for transferring, walking in his room, locomotion on unit, between locations in his room and an adjacent corridor on same floor and toileting. The resident's care plan initially dated April 1, 2016, indicated that he was to ambulate in his room with his rollator walker (a walker with wheels, handlebars and a built-in seat, which allows the user to stop and rest when needed) with the limited assistance of one person. An interview with Employee 1, the Director of Therapy, on April 16, 2017, at 11:30 AM confirmed that the resident required the assistance of one person when ambulating with his walker in his room. The resident was identified at moderate risk for falls according to a fall assessment completed by the facility, dated June 12, 2016. A review of an incident report revealed that the resident fell on [DATE], when he stood up quickly, without assistance, and lost his balance and fell to the floor. The resident did not sustain an injury as the result of this fall. The facility's plan to prevent future falls indicated that the staff were to assure that the resident was transferred by nursing or therapy staff. A review of an incident report indicated that the resident incurred a second fall on May 28, 2016, during which the resident explained that he was walking out of the bathroom and got light headed and fell to the floor. The resident did not sustain injury as the result of this fall. The facility's plan to prevent future falls was to remind the resident to ring his call bell. Additionally, the facility monitored the resident's blood pressure for 7 days and it remained within normal limits. A review of an incident report revealed that the resident had a third fall on July 4, 2016, and was found on the floor in a sitting position with his back against the bed; the resident's call bell was on the recliner where he had been sitting prior to the fall. The resident did not sustain injuries as a result of this fall. The resident stated that he was trying to get his personal items prior to attending hemodialysis. The resident transferred himself without assistance and fell . The facility's plan to prevent future falls was to keep the resident's walker close to him at all times. The facility planned to closely monitor the resident every 30 minutes for three days to ensure his safety and also planned to keep his walker and belongings close to him. A review of an incident report dated July 27, 2016, at 5:10 PM indicated that the resident was found on the floor of his room, lying face down with his arms behind him. The palms of his hands were facing upward and his walker was underneath him. The resident appeared to be coming out of the bathroom in his room according to the report. The resident had just returned from his hemodialysis appointment at approximately 4:50 PM according to documentation on the incident report. The staff last observed the resident at 5:05 PM as per documentation on the incident report. A review of the resident's clinical record revealed that as the result of this fall the resident sustained [REDACTED].{the bones at the top of the spine} usually caused by severe trauma, of the C2 vertebrae (the second-uppermost of the vertebrae (bone) making up the backbone)). The resident also sustained a mildly displaced impacted fracture (an impacted fracture is a bone fracture in which the parts of the broken bone are driven toward or into each other by force) of the anterior (nearer to the front) wall of the left maxillary sinus (upper jaw area) in the region of the infraorbital foramen (an opening of the jaw bone). His left cheek had a contusion (bruise) and hematoma (a solid swelling of clotted blood under the skin) and a small scalp hematoma. Further review of the resident's clinical record revealed that the resident was required to wear a cervical collar at all times to limit movement of his neck due to the above injuries. The collar was discontinued on October 10, 2016. In response to this fall with serious injuries the facility placed a pressure pad alarm on the resident's bed and on his chair (a pressure pad makes a loud sound when the resident releases pressure such as getting up from the chair or bed, the sound is designed to alert the staff when the resident rises without assistance). At the time of the survey ending April 18, 2017, the resident had no additional falls. The facility failed to provide evidence that this resident, identified at risk for falls and with a history of falls in the facility due to unassisted transfers and ambulation, which was known to the facility, was timely provided with adequate staff supervision and/or effective safety interventions to prevent this fall with serious injuries. During an interview with the Director of Nursing and Employee 1, Director of Therapy, on April 14, 2017, at approximately 9:30 AM these staff members were unable to explain the lack of timely evaluation of the resident's need for the degree of staff supervision necessary to provide timely assistance and/or alternate safety measures to monitor and address the resident's unsafe behaviors (unassisted transfers and ambulation) prior to the fall with serious injuries on July 26, 2016. Refer to F490, F520 28 Pa Code 211.6(d) Dietary services Previously cited 5/19/16 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services Previously cited 5/19/16, 4/9/15

Based on review of clinical records and select facility policy and staff interview, it was determined that the facility failed to timely identify the development of a pressure area and failed to consistently implement measures designed to prevent the development of a pressure area for one of 14 residents sampled (Resident 6). Findings include: The review of the facility policy entitled " Pressure Sore Risk Assessment - Skin Integrity" dated September 2011, revealed that residents with a score of 11 or above from the "Pressure Area Risk Assessment" form, indicates that the resident is at risk for skin breakdown. To assure timely detection of any change in skin condition, the resident will have a total body check done by the nurse on scheduled shower days bi-weekly and document in the Treatment Administration Record (TAR). A review of the clinical record revealed that Resident 6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The review of a quarterly Minimum Data Set (MDS) assessment (an assessment completed at specific intervals to identify care needs) dated August 11, 2011, revealed that the resident was cognitively impaired, was at risk for developing a pressure ulcer and required extensive assistance of staff for activities of daily living including transfers and turning and repositioning. A review of the resident's initial plan of care revised by the facility on August 4, 2011, revealed that Resident 6 had the potential for alteration in skin integrity related to obesity (over-weight) and non-ambulatory status. Interventions at the time included, but not limited to, a Roho cushion (pressure-reducing seating device) to her wheelchair, a heel-bows (a pressure-reliving boot) while in bed and repositioning every two hours while in bed and every one hour while in her wheelchair. A review of a "Pressure Area Risk Assessment" dated May 9, 2011, revealed that the resident scored as a moderate risk (17) due to her fair medical condition, mild confusion, loss of range of motion, total incontinence (no control of bowel/bladder) and non-ambulatory status. Review of a "Weekly Wound Assessment" dated October 16, 2011, revealed that an in-house acquired Stage IV pressure ulcer was identified (a full thickness tissue loss with the presence of eschar (dry scab/dead tissue appearing tan, brown, black) in the wound bed area) to the left heel measuring 8 centimeters (cm) x 5 cm. as reddened with eschar in the middle measuring 1.5 cm. The assessment also indicated that the tissue appearance was necrotic (dead tissue). At the time, October 16, 2011, the physician was notified and new interventions were implemented to include skin prep (skin protectant) to the area every shift and place a pillow under the left calf as noted by the registered nurse who tracks wounds (Employee 1). A review of the October 2011 Treatment Administration Record (TAR) revealed that staff completed a skin check when Resident 6 was showered on October 14, 2011, during the 3:00 p.m. to 11:00 p.m. shift, with no findings of skin impairment noted. Review of the October 2011 "Positioning Schedule with Heel Elevation" form revealed that the resident was out of bed in her geri-chair for several hours a day (a type of reclining chair) on the following dates: October 7, 2011, from 10:00 a.m., to 1:00 p.m., October 8th from 8:00 a.m. to 1:00 p.m., October 9th from 8:00 a.m. to 12:00 p.m., October 10th from 1:00 p.m. to 4:00 p.m., October 11th from 11:00 a.m. to 4:00 p.m., October 12th from 10:00 a.m. to 5:00 p.m., October 13th from 10:00 to 1:00 p.m., October 14th from 10:00 a.m. to 10:00 p.m., and on October 15th from 8:00 a.m. to 1:00 p.m. Review of a nurse's note dated October 17, 2011, at 6:00 p.m., revealed that a new physician order was received related to the change in skin integrity that included the a multi-vitamin and Vitamin C every day for wound healing. Further review of the clinical record revealed no documented evidence that when the resident was out of bed and placed in the geri-chair that the resident's heel bows were applied as the physician's order instructed staff to apply the heel bows only when in bed. Interviews with the director of nursing and Employee 1, RN on October 25, 2011, at 9:55 a.m. and 1:05 p.m., respectively, failed to provide documented evidence that the resident's pressure sore was timely identified and that preventative measures were implemented when the resident was out of bed in the chair to demonstrate prompt identification of decline in skin integrity and effective measures to prevent the development of the pressure ulcer. 28 Pa. Code 211.10 (a)(c)(d) Resident are policies. Previously cited 28 Pa. Code 211.11 (c)(e) Resident care plan. Previously cited 8/18/11 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services. Previously cited 8/18/11, 4/1/11