Every finding on record at Wecare at Murrysville Rehab and Nursing Center

Based on review of facility policy, clinical records, and staff interview, it was determined the facility failed to make certain a resident had an updated, person-centered care plan individualized to each specific resident's needs for one of two residents (Resident R1).Findings include: Review of the facility policy Care Plans. Comprehensive Person-Centered, dated 1/8/26, indicated that the comprehensive, person-centered care plan is developed within seven days of the completion of the required MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) i.e. Admission, Annual, or Significant Change, and no more than 21 days after admission. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Review of Resident R1's admission record indicated he was originally admitted on [DATE]. Review of Resident R1's MDS assessment dated [DATE], indicated diagnoses of high blood pressure, muscle weakness, and diabetes (a group of diseases that affect how the body uses blood sugar. Section M0100 indicated that resident has a pressure injury, a scar over bony prominence, or a non-removable dressing/device. Review of Resident R1's care plan dated 5/18/26, failed to include any revision that resident had developed a pressure injury. During an interview on 6/3/26, at 3:05 p.m. the Director of Nursing confirmed that the care plan was not updated to include Resident R1's pressure injury, and confirmed that the facility failed to make certain a resident had an updated, person-centered care plan individualized to each specific resident's needs for one of two residents (Resident R1). 28 Pa. Code 201.24(e)(1)(5) Admissions Policy28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to conduct care plan conferences and failed to ensure a resident or resident representative was notified in advance of care conference meetings for one of two residents (Resident R1).Findings include: The facility Resident participation-Assessments/Care plans policy dated 1/8/26, indicated that the resident and his or her representative are encouraged to participate in the resident's assessment and in the development of the resident's care plan. A seven day advance notice of the care plan conference is provided to the resident and his or her representative. The Social Services director is responsible for notifying the resident or representative and for maintaining records of such notices. Review of the facility policy Care Plans. Comprehensive Person-Centered, dated 1/8/26, indicated that the comprehensive, person-centered care plan is developed within seven days of the completion of the required MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) i.e. Admission, Annual, or Significant Change, and no more than 21 days after admission. Review of Resident R1's admission record indicated he was originally admitted on [DATE]. Review of Resident R1's MDS assessment dated [DATE], indicated diagnoses of high blood pressure, muscle weakness, and diabetes (a group of diseases that affect how the body uses blood sugar. Review of Resident R1's written concern dated 5/26/26, stated the following: I do not feel included in my plan of care, and I do not feel that I am being kept informed in a way that helps me understand or participate in my own care decisions. Resident R1's clinical record revealed the following MDS assessments with the following Assessment Reference Date (ARD- a look back period of time for the MDS assessment): MDS with ARD of 2/12/26, Significant change MDS with ARD of 4/1/26, and MDS with ARD of 5/8/26. Resident R1's clinical record revealed that a care plan meeting was held with the resident on 2/18/26, which was in correlation with the MDS with ARD of 2/12/26. Further review of Resident R1's clinical record lacked any evidence that the resident and/or resident representative was invited to or attended a care plan meeting in conjunction with the MDS for 4/1/26, or 5/8/26 ARD. During an interview on 6/3/25, at 2:30 p.m. Social Worker Employee E1 confirmed that the facility failed to conduct care plan conferences and failed to ensure a resident or resident representative was notified in advance of care conference meetings for Resident R1 for MDS ARD of 4/1/26, and 5/8/26. 28 Pa. Code 201.29 (a) Resident rights.

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to develop care plans that included instructions to provide person centered care for three of eight residents (Resident R4, R29, and R33).Findings include: Review of the facility policy Care Plans, Comprehensive Person-Centered dated 6/11/25, indicated the facility must develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs that is developed and implemented for each resident. Review of the admission record indicated Resident R4 admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/5/26, indicated the diagnoses of Parkinson's Disease (disorder of the nervous system that results in tremors), depression, and seizure disorder (a person experiences abnormal behaviors, symptoms and sensations, sometimes including loss of consciousness). Review of Resident R4's current Medical Diagnoses list included evidence of a vagal nerve stimulator (involves using electrical pulses to stimulate the vagus nerve). Review of Resident R4's current physician orders and care plan, failed to include instructions for care and management of the vagal nerve stimulator. Review of the admission record indicated Resident R29 admitted to the facility on [DATE]. Review of Resident R29's MDS dated [DATE], indicated the diagnoses of heart failure (heart doesn't pump blood as well as it should), high blood pressure, and weakness. Review of Resident R29's physician order dated 1/21/26, indicated trazodone (antidepressant with off label for sleeplessness) every night at bed. Review of Resident R29's Medication Administration Record (MAR) dated March 2026, indicated resident received the trazodone each night of the month as ordered. Review of Resident R29's current care plan failed to include instructions for care and management of trazodone and insomnia (sleeplessness). Review of the admission record indicated Resident R33 admitted to the facility 8/28/25. Review of Resident R33's MDS dated [DATE], indicated diagnoses diabetes mellitus (chronic condition that occurs when the body cannot properly use blood sugar (glucose) leading to high blood sugar levels), dementia (syndrome characterized by the decline in cognitive function), and heart failure. Review of Resident R33's physician order dated 8/28/25, indicated Venlafaxine HCl (antidepressant medication) ER oral capsule Extended Release 24-hour 150 mg (milligrams), give 1 capsule by mouth one time a day for depression. Review of Resident R33's physician order dated 8/28/25, indicated Apixaban (anticoagulant medication) Oral tablet 5 mg (milligrams) give 1 tablet by mouth two times a day for Factor 5 Leiden mutation. Review of Resident R33's physician order dated 11/25/25, indicated Furosemide (diuretic medication) Oral tablet 20 mg, give 20 mg by mouth one time a day for leg swelling. Review of Resident R33's physician order dated 2/18/26, indicated Insulin Degludec Subcutaneous Solution 100 unit/ml (milliliter), inject 16 units subcutaneously at bedtime for DM2 (Diabetes mellitus type 2). Review of Resident R33's physician order dated 2/18/26, indicated Novolog Solution 100 unit/ml (Insulin Aspart) inject 10 unit subcutaneously in the morning for DM2 before breakfast. Review of Resident R33's physician order dated 2/18/26, indicated Novolog Solution 100 unit/ml (Insulin Aspart) inject 8 unit subcutaneously one time a day for DM2 before lunch. Review of Resident R33's physician order dated 2/18/26, indicated Novolog Solution 100 unit/ml (Insulin Aspart) inject 10 unit subcutaneously one time a day for diabetes before dinner. Review of Resident R33's MAR dated February 2026, and March 2026, indicated that above medications were given each day as ordered. Review of Resident R33's current care plan failed to include instructions for care and management of antidepressant, anticoagulant, diuretic, and insulin medication usage. Interview on 3/20/26, at 9:12 a.m., Registered Nurse Assessment Coordinator (RNAC) Employee E13 confirmed Resident R4's vagal nerve stimulator and Resident R29's trazodone for sleeplessness were not included in the comprehensive care plan as required; confirmed that Resident R33's antidepressant, anticoagulant, diuretic, and insulin medications were not included in the comprehensive care plan as required, and that the facility failed to develop care plans that included instructions to provide person centered care for three of eight residents (Resident R4, R29, and R33). 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment by not maintaining a clean environment for three of three resident rooms (Residents R22, R50, and R65), and one of three resident wheelchairs (Resident R61).Findings Include: Review of the facility policy Homelike Environment dated 6/11/25, indicates the facility will provide an environment that is safe, clean, comfortable, and homelike. Review of the admission record indicated Resident R22 admitted to the facility on [DATE]. Observation on 3/16/26, at 9:19 a.m. Resident R22 was lying in bed. The resident's floor was sticky, stained with darkened areas, and covered in grime. Interview on 3/16/26, at 9:20 a.m. Licensed Practical Nurse (LPN) Employee E11 confirmed Resident R22's floor was sticky, stained with darkened areas, and covered in grime. Review of the admission record indicated Resident R50 admitted to the facility on [DATE]. Observation on 3/16/26, at 10:14 a.m. Resident R50 was sitting on the side of the bed. The resident's floor was sticky, stained with darkened areas, and covered in grime. The fall mat was sticky, had spots of dried liquids, and covered in grime. Interview on 3/16/26, at 10:15 a.m. LPN Employee E12 confirmed Resident R50's floor was sticky, stained with darkened areas, and covered in grime and the fall mat was sticky, had spots of dried liquids, and covered in grime. Review of the admission record indicated Resident R61 admitted to the facility on [DATE]. Observation on 3/18/26, at 10:26 a.m. Resident R61 was observed in the hallway in front of the television, sitting in a wheelchair. The wheelchair's seat and arm on the right side were completely covered in dried foods, crumbs, black grime, and were sticky. Interview on 3/18/26, at 10:27 a.m. Nurse Aide (NA) Employee E1 confirmed Resident R61's wheelchair seat and arm on the right side were completely covered in dried foods, crumbs, black grime, and were sticky. Review of the admission record indicated Resident R65 admitted to facility on 7/2/22. Observation on 3/17/26, at 11:15 a.m., Resident R65 was not in her room, however he resident's floor was sticky, stained with darkened areas, and covered in grime. The fall mat was sticky, had spots of dried liquids, and covered in grime. Interview on 3/17/26, at 11:19 a.m., LPN Employee E17 confirmed Resident R65's floor was sticky, stained with darkened areas, and covered in grime and the fall mat was sticky, had spots of dried liquids, and covered in grime. Interview on 3/18/26, at 10:30 a.m. the Nursing Home Administrator confirmed the facility failed to provide a clean, safe, comfortable, and homelike environment by not maintaining a clean environment for three of three resident rooms (Residents R22, R50, and R65), and one of three resident wheelchairs (Resident R61). 28 Pa. code: 201.14 (b) Responsibility of licensee. 28 Pa Code: 201.18 (e)(1)(2) Management. 28 Pa Code: 201.29 (a)(c) Resident Rights.

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to discard expired medical supplies and ensure all drugs and biologicals were stored under proper temperature controls for one of three of three medication carts (115 Hall Medication Cart, 136 Hall Medication Cart, and East Zone Two Medication Cart), and one of two Medication Rooms (West Side Medication Room). Findings include: Review of the facility policy Storage of Medications dated [DATE], indicated that discontinued, outdated, or deteriorated drugs are returned to the dispensing pharmacy or destroyed. During an observation on [DATE], at 9:19 a.m. the [NAME] Side Medication Room contained the following expired supplies:-Two tuberculin vials (detects tuberculosis) opened and not labeled with a date as required.-Multiple bags of urine culture tubes (30 tubes or greater) with expiration dates of [DATE]. During an interview on [DATE], at 9:20 a.m. Licensed Practical Nurse (LPN) Employee E11 confirmed that the two tuberculin vials were not dated and the above supplies were expired. During an observation on [DATE], at 9:25 a.m. of the 136 Hall Medication Cart contained the following expired supplies:-One package of Ipratropium bromide (an aerosolized medication to open airways) opened and not labeled with a date as required.-Two separate packages of Budesonide (an aerosolized medication to decrease inflammation) opened and not labeled with a date as required. During an interview on [DATE], at 9:40 a.m. LPN Employee E11 confirmed that the stated medications were opened and not labeled with a date as required. During an observation on [DATE], at 9:50 a.m. of the East Zone Two Medication Cart contained the following expired supplies:-One package of Ipratropium bromide (an aerosolized medication to open airways) opened and not labeled with a date as required.-Humalog vial of insulin (rapid acting insulin) opened and not labeled with a date as required.-Lispro Quick Pen (rapid acting insulin) opened and not labeled with a date as required.-Albuterol inhalation solution (opens airways) opened and not labeled with a date as required.-Fluticasone nasal spray (treats allergy like symptoms) opened and not labeled with a date as required. During an interview on [DATE], at 9:51 a.m. LPN E12 confirmed that the stated medications were opened and not labeled with a date as required. During an observation on [DATE], at 10:35 a.m. of the 115 Hall Medication Cart contained the following expired supplies:-Three separate Albuterol inhalation solutions (opens airways) opened and not labeled with a date as required.-Trelegy inhaler (reduces inflammation in airways) opened and not labeled with a date as required.-Timolol Eye Drops (reduces pressure in the eyes) opened and not labeled with a date as required. During an interview on [DATE], at 10:36 a.m. LPN Employee E18 confirmed that the stated medications were opened and not labeled with a date as required. Interview on [DATE], at 3:00 p.m. the Director of Nursing confirmed that the facility failed to discard expired medical supplies and ensure all drugs and biologicals were stored under proper temperature controls for one of three of three medication carts (115 Hall Medication Cart, 136 Hall Medication Cart, and East Zone Two Medication Cart), and one of two Medication Rooms (West Side Medication Room). 28 Pa. Code: 211.10(c) Resident care policies.28 Pa. Code: 211.12(d)(2)(3) Nursing services.

Based on review of personnel files and staff interview it was determined that the facility failed to complete annual nurse aid employee evaluations for four of five sampled records (Nurse aide (NA) Employees E1, E2, E3 and E4).Findings include: Review of employee personnel files on 3/18/26, at 9:00 a.m. indicated the following: Review of NA Employee E1's personnel record indicated a date of hire as 1/5/23. The last performance review completed annually was 2/23/25. Review of NA Employee E2's personnel record indicated a date of hire as 9/5/22. The last performance review completed annually was 2/23/25. Review of NA Employee E3's personnel record indicated a date of hire as 12/16/06. The last performance review completed annually was 1/6/25. Review of NA Employee E4s personnel record indicated a date of hire as 1/8/18. The last performance review completed annually was 1/3/25. Interview on 3/18/26, at 9:30 a.m. Assistant Director of Nursing Employee E16 confirmed the facility failed to complete annual nurse aid employee evaluations as required. 28 Pa. Code: 201.18(b)(1) Management.

Based on review of the RAI (Resident Assessment Instrument), clinical records, and staff interviews it was determined that the facility failed to make certain that resident assessments were accurate for five of eight residents (Residents R4, R11, R33, R80, and R85).Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (periodic assessments of resident care needs), dated September 2025, indicated the following:-Section N0415 - High-Risk Drug Classes: Use and Indication - Check if the resident is taking any medications by pharmacological classification.-Section M0100. Determination of Pressure Ulcer/Injury Risk - Check all that apply Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. Review of the admission record indicated Resident R4 admitted to the facility on [DATE]. Review of Resident R4's MDS dated [DATE], indicated the diagnoses of Parkinson's Disease (disorder of the nervous system that results in tremors), depression, and seizure disorder (a person experiences abnormal behaviors, symptoms and sensations, sometimes including loss of consciousness). - Section N0415 K- failed to include anticonvulsant. Review of Resident R4's physician orders indicated Depakote Sprinkles (anticonvulsant medication) 125 mg (milligrams) give 375 mg by mouth two times a day. Review of Resident R4's Medication Administration Record (MAR) dated January 2026, indicated resident received Depakote sprinkles every day. Review of the admission record indicated Resident R11 admitted to the facility on [DATE]. Review of Resident R11's MDS dated [DATE], indicated the diagnoses of atrial fibrillation (irregular heart rhythm), heart failure (heart doesn't pump blood as well as it should), and high blood pressure. Section M0100 - Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device, was not marked. M0210 - Does this resident have one or more unhealed pressure ulcers/injuries - was marked no. Section M0300 - C. Stage Three: Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling was not marked as being present. Review of facility provided wound list on 3/16/26, indicated Resident R11 had developed a sacral wound on 8/15/25, and was classified as a Stage Three ulcer. Review of Resident R11's physician order dated 3/11/26, indicated to cleanse sacrum with saline, pat dry, apply Dakins (antiseptic solution) packed gauze, cover with 4 x 4 border every day and as needed. Review of Resident R11's Treatment Administration Record (TAR) dated January 2026, indicated resident received treatment daily to the sacral wound. Interview on 3/17/26, at 11:30 a.m. Licensed Practical Nurse (LPN) Employee E11 indicated Resident R11's wound developed last fall and LPN treats resident daily with wound care to the sacrum. Interview on 3/20/26, at 9:12 a.m. Registered Nurse Assessment Coordinator (RNAC) Employee E13 confirmed Resident R4's MDS was incorrect and the anticonvulsant was not marked as required and that Resident R11's MDS was incorrect and the Stage Three ulcer was not captured as required to reflect each residents' current needs. Review of the admission record indicated Resident R33 admitted to the facility 8/28/25. Review of Resident R33's MDS dated [DATE], indicated diagnoses diabetes mellitus (chronic condition that occurs when the body cannot properly use blood sugar (glucose) leading to high blood sugar levels) , dementia (syndrome characterized by the decline in cognitive function), and heart failure. Section N0415C failed to indicate an antidepressant was taken in the past seven days or since admission. Review of Resident R33's physician order dated 8/28/25, indicated Venlafaxine HCl (antidepressant medication) ER oral capsule Extended Release 24 hour 150 mg, give 1 capsule by mouth one time a day for depression. Review of Resident R33's MAR dated August 2025, and September 2025, indicated resident received Venlafaxine every day since 8/29/25. Review of the admission record indicated Resident R80 admitted to the facility 10/13/25. Review of Resident R80's MDS dated [DATE], indicated diagnoses Alzheimer's disease, failure to thrive, and heart failure. Section O0110K1 failed to indicate that hospice care had been provided while a resident. Review of Resident R80's physician order dated 10/13/25, indicated Heartland Hospice, Dx (diagnosis) End stage late onset Alzheimer's dementia. Effective date 7/11/25. Review of current plan of care initiated 10/13/25, updated 1/21/26, indicated that Resident R80 is receiving hospice services. Review of Resident R80's MDS's dated 10/16/25, and 3/2/26, Section O0110K1 indicated hospice care was provided while a resident. Review of the admission record indicated Resident R85 admitted to the facility 7/3/24. Review of Resident R85's MDS dated [DATE], indicated diagnoses diabetes mellitus, heart disease, and high blood pressure. Section N0350 Insulin failed to indicate the number of days that insulin injections were received during the last seven days. Review of Resident R85's physician order dated 11/5/25, indicated Humalog Kwikpen Subcutaneous Solution Pen-injector 100unit/ml (milliliter) (Insulin Lispro) inject 6 units subcutaneously before meals for DM2 (diabetes mellitus type 2). Review of Resident R85's physician order dated 7/10/24, indicated Lantus Solostar Subcutaneous Solution Pen-injector 100 units/ml, Inject 28 units subcutaneously at bedtime. Review of Resident R85's MAR dated March 2026, indicated resident received Insulin injections every day. Interview on 3/19/26, at 9:10 a.m., RNAC Employee E13 confirmed that Resident R80's MDS was incorrect and hospice was not captured as required and Resident R85's MDS was incorrect and insulin was not marked as required to reflect each residents' current needs. Interview on 3/20/26, at 9:19 a.m., RNAC Employee E13 confirmed Resident R33's MDS was incorrect and the antidepressant medication was not marked as required to reflect each residents' current needs. Interview on 3/20/26, at 10:00 a.m. the Director of Nursing (DON) confirmed that the facility failed to make certain that resident assessments were accurate for five of eight residents (Residents R4, R11, R33, R80, and R85). 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing Services.

Based on facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to provide a Skilled Nursing Advanced Beneficiary Notice of Non-coverage (SNF-ABN) with the estimated amount of nursing services that will be charged for two of three residents (Residents R8, and R31). Findings include: Review of the facility policy Advanced Beneficiary Notices dated 6/11/25, indicated Medicare requires SNFs to issue the SNF-ABN to original Medicare beneficiaries prior to providing care that Medicare usually covers, but may not pay for. The SNF-ABN provides information to the beneficiary so that they can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. Review of the admission record indicated Resident R8 was admitted on [DATE]. Review of Resident R8's Minimum Data Set (MDS -a periodic assessment of care needs) dated 1/5/26, indicated the diagnoses of chronic obstructive pulmonary disease (COPD- a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), aphasia (difficulty swallowing), and hyperlipidemia (elevated fat levels within the blood). Review of Resident R8's SNF-ABN form dated 10/23/25, indicated beginning on 10/25/25, resident may have to pay out of pocket for this care if resident does not have insurance that may cover these costs. The facility estimates that these services will cost the resident $ Current PL per day/item or service. Review of the admission record indicated Resident R31 was admitted on [DATE]. Review of Resident R31's MDS dated [DATE], indicated the diagnoses COPD, high blood pressure, and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident R31's SNF-ABN form dated 11/26/25, indicated beginning on 11/29/25, resident may have to pay out of pocket for this care if resident does not have insurance that may cover these costs. The facility estimates that these services will cost the resident $ At current rate per day/item or service. Interview on 3/17/26, at 12:51 p.m. the Business Office Manager Employee E10 confirmed the facility failed to provide a Skilled Nursing Advanced Beneficiary Notice of Non-coverage (SNF-ABN) with the estimated amount of nursing services that will be charged for two of three residents (Residents R8, and R31). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(2)(3) Management

Based on review of facility policy, clinical records and staff interview it was determined that the facility failed to make certain resident medication regimes were free from potentially unnecessary psychotropic medications for one of three residents (Resident R1 ).Findings include: Resident R1 was admitted on [DATE], and re-admitted to the facility on [DATE]. Review of Resident R1 MDS (minimum data set - a periodic assessment of resident needs) dated 1/8/26, indicated diagnosis of atrial fibrillation (irregular and often very rapid heart rhythm), and major depressive disorder recurrent (mood disorder that causes persistent feeling of sadness and loss of interest), and anxiety disorders (group of mental health conditions that cause fear , dread and other symptoms that are out of proportion to the situation) included on Resident R1 admit sheet. Review of Resident R1 clinical record MAR (medication administration record) for February 2026 indicated: Hydroxyzine Pamoate Capsule 50 MGGive 50 mg by mouth every 8 hours asneeded for Anxiety for 14 Days-Start Date-02/11/2026 2230-D/C Date-02/19/2026 1408 Lorazepam Oral Tablet 1 MG(Lorazepam)Give 1 mg by mouth every 8 hours asneeded for anxiety for 14 Days-Start Date-02/19/2026 1515-D/C Date-03/03/2026 1000 Review of the February MAR indicated: Hydroxyzine pamoate capsule 50 mg was given PRN (as needed) in February on the following days: 12, 13,14,15,16,17,18,and 19. Review of the February MAR indicated: Lorazepam oral table 1 mg was given PRN (as needed) in February on the following days: 20,21, and 28. Review of Resident R1 clinical records MAR for March 2026 indicated:Lorazepam OralTablet 1 MG(Lorazepam)Give 1 mg by mouthevery 8 hours asneeded for anxietyfor 14 Days-Start Date-02/19/2026 1515-D/C Date-03/03/2026 1000 Lorazepam OralTablet 1 MG(Lorazepam)Give 1 mg by mouthevery 8 hours asneeded for anxietyuntil 04/02/2026 23:59-Start Date-03/03/2026 1000 Review of the March MAR indicated Lorazepam oral tablet 1 mg was given PRN in March on the following days: 1, 2n,3,4,5,6,9,11,13,14,15,16,17, and 18. Review of the MAR failed to include what behaviors Resident R1 was experiencing and other attempts to relive potential behaviors prior to Resident R1 being given the psychotropic medication. Review of Resident R1 progress notes for February and March 2026 failed to include a description of behaviors, or non-pharmacological interventions that were given to Resident R1 prior to the psychotropic medications. During an interview on 3/20/26, at 9:15 a.m. Director of Nursing confirmed that the facilityfailed to provide non-pharmacological interventions prior to giving anti-anxiety medications to Resident R1. 28 Pa Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on a review of the facility policy, clinical record review and staff interview, it was determined that the facility failed to accurately assess the nutritional status, and failed to update an individualized care plan to address the resident's specific nutritional concerns for two of five residents (Resident R4 and R49) records reviewed.Findings include: Review of facility's policy Nutritional Assessment, dated 6/11/25, indicated as part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. The dietitian, in conjunction with the nursing staff and healthcare practioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a a change in condition that places the resident at risk for impaired nutrition. Once current conditions and risk factors for impaired nutritional are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the resident's risk for nutritional complications. Such interventions will be developed within the context of the resident's prognosis and personal preferences. Individualized care plans shall address, to the extent possible:the identified causes of impaired nutrition;the resident's personal preferences;goals and benchmarks for improvement;time frames and parameters for monitoring and reassessment. Review of facility's policy Care Plans, Comprehensive Person-Centered, dated 6/11/25, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implement on each resident. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. The interdisciplinary team reviews and updates the care plan:when there has been as significant change in the resident's condition;when the desired outcome is not met;when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly MDS assessment. Review of facility's policy Resident Food Preferences dated 6/11/25, indicated individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. When possible, staff will interview the resident directly to determine current food preferences based on the history and life patterns related to food and mealtimes. Nursing staff will document the resident's food and eating preferences in the care plan. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/5/26, indicated diagnoses of Parkinson's disease (a progressive neurological disorder characterized by the degeneration of nerve cells in the brain primarily affecting movement), dementia (syndrome characterized by the decline in cognitive function) and schizoaffective disorder (mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as mania and depression). Section K0300 was coded a 2, which indicated that Resident R4 had a weight loss of 5% or more in the last month or weight loss of 10% or greater in the last six months. Section K0520C indicated that a mechanically altered diet was used within the last seven days, and Section K0520D indicated that a therapeutic diet was used in the last seven days. Review of Resident R4's current physician order dated 9/25/24, indicated a No Added Salt diet, with mechanical soft textures. Review of Resident R4's physician orders dated 2/21/25, indicated Dietary Health Shake one time a day for weight loss, lunch tray; Frozen supplement one time a day for weight loss, dinner tray; both were discontinued 2/6/26. Review of Resident R4's physician order dated 8/18/25, indicated MedPass (oral nutritional supplement) 2.0 three times a day for weight loss 60cc's (cubic centimeters); discontinued 2/6/26. Review of Resident R4's current plan of care, initiated 12/29/22, updated 1/16/26, revealed interventions to provide and serve supplements as ordered: Dietary Health Shake, Frozen dessert supplement and MedPass 2.0. Further review of care plan failed to establish nutritional focus and goals related to mechanically altered and therapeutic diet use as identified on 1/5/26 MDS assessment. Review of Resident R4's nutritional progress notes failed to reveal clinical documentation by the Registered Dietitian and/or physician as to why Resident R4's nutritional supplements were discontinued on 2/6/26, due to a history of significant weight loss as identified on 1/5/26 MDS assessment. During an interview on 3/20/26, at 9:36 a.m., Registered Dietitian (RD) Employee E14 confirmed that Resident R4's care plan was not updated to remove discontinued oral nutritional supplements, and clinical nutrition notes failed to document reason for discontinuing Resident R4's oral nutritional supplement 2/6/26, with a history of significant weight loss. Review of the clinical record indicated Resident R49 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/16/26, indicated diagnoses cerebral infarction with aphasia (stroke with language disorder that affects communication ability), high blood pressure, and schizoaffective disorder (mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as mania and depression).Section K0520C indicated that a mechanically altered diet was used within the last seven days. Review of Resident R49's physician order dated 9/25/24, indicated a regular diet, mechanical soft textures, large portions with dinner. Review of Resident R49's physician order dated 7/3/23, indicated 2 cal (calorie) supplement 60cc with meals; discontinued 2/6/26. During an observation on 3/17/26, at 12:00 p.m., Resident R49's lunch tray failed to contain all food items indicated to provide on Resident R4's lunch tray ticket (document that identifies resident's wants and needs based on diet order and individual preferences for each meal). Resident R4's lunch tray failed to contain 2 cookies, and 2 servings of entree/meat as indicated on tray ticket:MECH SOFT 2 each Assorted cookieMECH SOFT 2 x 3 oz (ounce) Sweet & Sour Chicken During an interview on 3/17/26, at 12:02 p.m., Corporate Dietary Consultant Employee E15 confirmed that Resident R49's lunch tray as observed failed to contain MECH SOFT 2 x Assorted cookies, and MECH SOFT 2 x 3oz Sweet & Sour Chicken as indicated on lunch tray ticket. Review of Resident R49's current plan of care initiated 11/12/25, updated 2/4/26, revealed interventions to provide and serve supplements as ordered: 2CAL MedPass BID. Further review of care plan failed to establish nutritional focus and goals related to mechanically altered diet use as identified on 2/16/26 MDS assessment. Care plan also failed to contain diet order/preference for large portions at dinner. Review of facility provide meal tray tickets, dated 3/17/26, revealed that Resident R49's preferences on meal tickets indicated double portion (2x) entrees at all 3 meals. Review of Resident R49's Nutrition assessment dated [DATE], failed to identify use and reason for large portions at dinner per diet order, as either part of therapeutic nutrition program or resident personal reference. During an interview on 3/18/26, at 12:47 p.m., RD Employee E14 revealed that Resident R49's meal tray tickets were inaccurate to reflect diet order instructions for large portions at dinner, confirmed that Resident R49's care plan was inaccurate for oral nutritional supplement which were discontinued, and failed to accurately assess Resident R49's nutritional status on 2/16/26, by failing to identify rationale for use of large portions at dinner. During an interview on 3/20/26, at 1:30 p.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON)confirmed that the facility failed to accurately assess the nutritional status and failed to update an individualized care plan to address the resident's specific nutritional concerns for two of five residents (Resident R4 and R49) records reviewed. 28 Pa. Code: 201.18(b)(1)(e)(1) Management.28 Pa. Code: 211.12(d)(5) Nursing services.

Based on review of facility policy, clinical records, and staff and resident interview, it was determined that the facility failed to ensure Total Parenteral Nutrition (TPN) was administered consistent with professional standards of practice and in accordance with physician orders for one of three residents (R96). Findings include: Review of the facility policy Parenteral Nutrition dated 6/11/25, indicated the purpose of PN is to provide guidelines for the safe and aseptic administration of partial nutrition to residents who have a need for supplemental nutrition. (PN or TPN is a sterile pharmacy-prepared form of nutrition that is delivered through an intravenous route.) A physician's order is necessary for this treatment. The PN order should include the formula, total volume and rate of administration. Review of the admission record indicated Resident R96 admitted to the facility on [DATE], with the diagnoses of persistent small bowel obstructions (SBOs), small bowel mesenteric desmoid tumor (an abnormal mass of tissue. It forms when cells grow and divide more than they should or do not die when they are supposed to), and heart failure (heart doesn't pump blood as well as it should). Review of Resident R96's physician order dated 1/8/26, indicated administer 2500 milliliters (ml) over 18hours. Infuse continuous over 18hours once daily at 74 ml/hr (ml/hour) for the first hour, 147 ml/hr for 16 hours, and then 74 ml/hr for the last hour via infusion pump intravenously (IV), Review of Resident R96's progress note dated 1/9/26, at 11:50 a.m. indicated Resident R96 on TPN for SBO. Registered Nurse was alerted that the IV pump was beeping and complete. TPN initiated on at 8:00 p.m. on 1/8/26. Resident received correct medication and concentration with a rate discrepancy. Provider notified. Review of facility provided Medication Incident form dated 1/9/26, indicated the TPN rate ordered at 147ml/hr for 16 hours was set at the rate of 174 ml/hr in error. Interview on 3/17/26, at 1:00 p.m. the Director of Nursing confirmed that the facility failed to ensure TPN was administered consistent with professional standards of practice and in accordance with physician orders for one of three residents (R96). 28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing Services.

Based on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to use proper hand washing to prevent cross contamination during a dressing change for one of three residents (Resident R11). Findings include: Review of the facility policy Handwashing/Hand Hygiene dated 6/11/25, indicated use alcohol-based hand rub containing at least 62% alcohol and/or soap and water before handling clean or soiled dressings, gauze pads, etc.; After handling used dressings, contaminated equipment, etc.; The use of gloves does not replace hand washing/hand hygiene. Review of the facility policy Wound Care dated 6/11/25, indicated wash and dry hands thoroughly. Put on clean gloves, loosen tape and remove dressing. Pull glove over dressing and discard into appropriate receptacle. Wash and dry hands thoroughly. Review of the admission record indicated Resident R11 admitted to the facility on [DATE]. Review of Resident R11's MDS dated [DATE], indicated the diagnoses of atrial fibrillation (irregular heart rhythm), heart failure (heart doesn't pump blood as well as it should), and high blood pressure. Review of Resident R11's physician order dated 3/11/26, indicated to cleanse sacrum with saline. Pat dry, apply Dakins (antiseptic solution) packed gauze, cover with 4 x 4 border every day and as needed. During a dressing change observation on 3/17/26, at 11:30 a.m. Licensed Practical Nurse (LPN) Employee E11 washed their hands, applied new gloves and removed the old, soiled dressing. Nurse then removed the gloves, did not wash hands, and applied new gloves. Cleansed the wounds with saline and removed the gloves, did not wash hands, and applied new gloves to complete the dressing change. Interview on 3/17/26, at 11:35 a.m. LPN Employee E11 indicated washing the hands after each glove change would be a big waste of products. Interview on 3/17/26, at 11:40 a.m. the Director of Nursing confirmed the facility failed to use proper hand washing to prevent cross contamination during a dressing change for one of three residents (Resident R11). 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.28 (b)(1)(e )(1) Management.28 Pa Code: 211.10 (d ) Resident care policies.

Based on observations and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for one of three shower chairs (Resident R82).Findings include: Review of the facility policy Assistive Devices and Equipment dated 6/11/25, indicated device condition and equipment are maintained on schedule and according to manufacturer's instructions. Defective or worn devices are discarded or repaired. Review of the admission record indicated Resident R82 admitted to the facility on [DATE]. Review of Resident R82's Minimum Data Set (MDS- a periodic assessment of care needs dated 12/29/25, indicated the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), Parkinson's Disease (disorder of the nervous system that results in tremors), and Bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Observation on 3/16/26, at 10:35 a.m. Nurse Aide (NA) Employee E1 was pulling Resident R82 backwards down the hall. Interview on 3/16/26, at 10:36 a.m. NA Employee E1 indicated being aware of not pulling resident backward; however, the wheels of the shower chair are all messed up and if staff push forward as required the chair drives out of control so it's easier to pull the chair backwards. Interview on 3/16/26, at 3:00 p.m. the Director of Nursing confirmed the facility failed to make certain that equipment was in safe operating condition for one of three shower chairs (Resident R82). 28 Pa Code: 201.14(a) Responsibility of licensee.

Based on review of facility policy and documentation, resident and staff interview it was determined that the facility failed to address residents' council ongoing concerns for three of three months (March, February and January of 2026).Findings include: Review of facility policy Skilled Nursing Care Facility Policy Grievances Policy dated 6/11/25, indicated: Residents and their representatives must be assured that; They can submit grievances orally or in writing/. Their concerns will be investigated and responded to promptly. Review of facility documentation Resident Council Minutes indicated: Meeting Date 3/5/.26: Call bells were an issue and continued to be an issues since last meeting - call bells not being answered on time - wait time: (2 - 2 1/2 hours)(7 of 17 residents).Employees on phones while working (6 of 17 residents), and snacks not being offered or passed to residents (7 out of 17 residents). Meeting Date 2/5/26: call bells not being answered on time wait time (30 minutes - 2 1/2 hours - 5 out of 13 residents), Employees on phones while working (6 out of 13 residents), and snacks not being offered or passed to residents (8 out of 13 residents). Meeting Date 1/8/26: call bells not being answered, 9 of 18 residents, Employees on phones while working, (11 of 18 residents). During a resident group interview on 3/18/26, at 1:30 p.m. Residents indicated the above concerns of call bells not being answered timely, snacks not being passed or offered and employees on their phones are on-going, that residents continue to express the same concern as each meeting without resolution. During an interview on 3/20/26, at 9:05 a.m. Nursing Home Administrator confirmed that the residents' concerns during on resident council have been on going and that the facility failed to address resident council concerns for three of three months (January, February and March 2026). 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code:201.18(b)(1) Management.

Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to provide trauma survivors with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents (Resident R9).Findings include: Review of facility policy Trauma Informed Care and Culturally Competent Care dated 6/11/25, indicated: purpose: To address the needs of trauma survivors and/or re-traumatization. Trauma informed care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. Trigger is a psychological stimulus that prompts recall of a previous traumatic event , even if the stimulus itself is not traumatic or frightening. Review of the clinical record indicated Resident R9 was admitted to the facility on [DATE]. Review of Resident R9 MDS (minimum data set - a periodic assessment of care needs), dated 1/14/26, indicated diagnosis of PTSD (a mental health condition that caused by an extremely stressful or terrifying event) and TBI (happens when a sudden, external, physical assault damages the brain). Review of Resident R9 care plan for PTSD identified that a traumatic event occurred, but failed to identify triggers for Resident R9's as related to PTSD. During an interview on 3/20/26, at 9:28 a.m. Director of Nursing confirmed that the facility failed to provide trauma survivors with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for Resident R9. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1) Management.

Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to conduct a thorough investigation of an allegation of abuse for one of two residents (Resident R1).Findings include: Review of facility Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy dated 5/30/25, indicated all reports of resident abuse, neglect, exploitation or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/8/25, indicated diagnoses of depression, chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Resident R1's MDS assessment section C0200 Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment. Resident R1's BIMS score was 14 indicating Resident R1 was cognitively intact. Review of facility documentation submitted to the state survey office dated 12/3/25, at 9:00 a.m. indicated that Resident R1 alleged Nurse Aide (NA) Employee E1 grabbed her arm to force her to go to the dining room for lunch. Review of Resident R1's progress note dated 12/3/25, by Registered Nurse Employee E2 indicated Resident R1's family member called the facility claiming Resident R1 was mishandled by a nurse aide. Resident on her part reported her right arm was sore because NA Employee E1 grabbed her arm forcefully during lunch time. On assessment of the right arm, nothing was seen that was unusual, skin was dry and intact. An X-ray was ordered for the right arm. Review of Resident R1's statement obtained on 12/4/25, by Licensed Practical Nurse (LPN) Employee E3 stated the following, They attempted to take me to therapy, but there was a long line, and I wanted to return to my room. I began to take myself back to my room from therapy and NA Employee E1 attempted to take me elsewhere (dining room), so I held onto the hand railing. He then grabbed my right arm, and it hurt. He should not be putting his hands on me no matter what. Two nurses then approached me, assisted me back to my room, and helped me into bed. During a review of witness statements, including NA Employee E1's, provided by the facility on 12/17/25, at 10:00 a.m. indicated that witness statements were completed and focused on care and treatment that was provided to Resident R1 while in her room. The witness' statements failed to include any information about an incident involving Resident R1's allegation of forcefully moving her hand off the handrail in the hallway. During an interview on 12/17/25, at 11:22 a.m. with NA Employee E1 indicated that nursing supervisor asked him to write a statement concerning providing care to Resident R1 on 12/3/25. She told me that I was being investigated and to write a statement about the care I provided. I wrote about helping resident out of bed with others in the room. Nobody asked me about the resident grabbing the handrail. We took her to the dining room, where trays were ready to be passed to all the residents. Resident R1 was going back to her room, and I asked that she not transfer back to bed without assistance because she may fall. Resident R1 stated she didn't care and that she was getting back into bed. She started to self-propel towards her room. I approached her and turned her wheelchair back towards the dining room so she wouldn't self-transfer and fall. She grabbed the handrail. I lifted her arm that she had a hold of the railing with so I could take her back to the dining room. I lifted her arm easily. Resident R1 never complained about me or the incident the rest of the day. During an interview on 12/17/25, at 1:13 p.m. Director of Nursing stated that the facility failed to fully investigate Resident R1's allegation of abuse and that five out of six witness statements failed to reveal information about the actual allegation of NA Employee E1 forcefully grabbing Resident R1's arm which was reported by resident and reported to the state survey office. During an interview on 12/17/25, at 2:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to conduct a thorough investigation of an allegation of abuse for one of two residents (Resident R1). 28 Pa Code: 201.18 (e)(1)(2) Management.28 Pa Code: 201.29 (a)(c) Resident Rights.28 Pa Code: 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on review of facility policy, observations and staff interview it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for eight of 15 resident rooms (Rooms 114, 116, 119, 122, 139, 140, 143, and 144). Findings include: Review of facility Homelike Environment policy dated 5/30/25, indicated residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. During a tour of the facility on 11/4/25, from 11:30 a.m. to 12:00 p.m. with the Nursing Home Administrator (NHA), Director of Nursing, Assistant Director of Nursing, and the Regional Maintenance Director Employee E1 the following were observed: Resident room [ROOM NUMBER]'s bathroom had stained, grime tiles around the toilet and the plaster behind the toilet was chipped and stained dark brown. Resident room [ROOM NUMBER]'s bathroom had stained, grime tiles around the toilet and the plaster behind the toilet was chipped and stained dark brown. Resident room [ROOM NUMBER]'s bathroom had brown, grime tiles throughout the bathroom and a missing vent cover on the ceiling. Resident room [ROOM NUMBER]'s bathroom had brown, grime tiles throughout the bathroom. Resident room [ROOM NUMBER]'s bathroom had brown, grime tiles around the toilet and throughout the bathroom. Resident room [ROOM NUMBER]'s bathroom had incomplete patchwork below the sink. Resident room [ROOM NUMBER]'s bathroom had no toilet. Resident room [ROOM NUMBER]'s bathroom had brown, grime tiles around the toilet and throughout the bathroom. During an interview on 11/4/25, at 12:01 p.m. the NHA and the Regional Maintenance Director Employee E1 confirmed the above findings and that the facility failed to provide a clean, safe, comfortable, and homelike environment for eight of 15 resident rooms (Rooms 114, 116, 119, 122, 139, 140, 143, and 144). 28 Pa. code: 201.14 (b) Responsibility of licensee. 28 Pa Code: 201.18 (e)(1)(2) Management. 28 Pa Code: 201.29 (a)(c) Resident Rights.

Based on clinical record review and staff interview, it was determined that the facility failed to complete a significant change Minimum Data Set (MDS- assessments completed indicating a change in condition of a resident requiring change in care) assessment for one of two residents (Residents R1). Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual (reference used to complete an MDS) effective October 2024, indicated that the facility must conduct a comprehensive assessment of a resident within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's quarterly MDS dated [DATE], indicated diagnoses of high blood pressure, difficulty swallowing, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of physician order dated 8/1/25, indicated Resident R3 was admitted under hospice services. Review of Resident R3's MDS assessments revealed a MDS significant change was not completed to include hospice services. During an interview on 9/19/25, at 2:54 a.m. Registered Nurse Assessment Coordinator Employee E1 confirmed that the facility failed to complete a significant change MDS for Resident R1. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 211.12(d)(2) Nursing services

Based on a review of resident clinical records, and staff interview, it was determined the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for one of two residents (Resident R1).Findings include: Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's quarterly MDS dated [DATE], indicated diagnoses of high blood pressure, difficulty swallowing, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of physician order dated 8/1/25, indicated Resident R3 was admitted under hospice services. Review of Resident R1's current comprehensive care plan failed to indicate a plan of care by the facility that displayed the coordination of hospice services by failing to include contact information for the hospice agency and how to access the hospice's 24 hour on-call system. During an interview on 9/9/25, at 2:55 p.m. the Director of Nursing confirmed that the facility failed to include contact information for the hospice agency and how to access the hospice's 24 hour on-call system and that the facility failed to ensure the coordination of hospice services with facility services to meet the needs of Residents R1. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.12(d)(3) Nursing services.

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for one of six residents (Resident R1) reviewed, relating to wandering/elopement.Findings include: Review of facility policy Care Plans, Comprehensive Person-Centered dated 5/30/35, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implement for each resident. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents conditions change. Review of facility policy Wandering and Elopement dated 5/30/25, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Elopement risk screenings with be completed on residents upon admission, re-admission, quarterly, significant change in status, and as needed. When a resident is identified to be at risk for elopement, this will be care planned along with interventions identified to reduce the resident's risk for elopement. Wander guard tag/bracelet shall be placed on resident. Review of the clinical record indicated Resident R1 was admitted to facility 8/7/25. Review of Resident 1's Minimum Data Set (MDS, periodic assessment of resident care needs) dated 8/10/25, included diagnoses of unspecified intercranial injury with loss of consciousness, hepatitis C (viral infection that causes liver swelling (inflammation), potentially leading to serious liver damage) , and liver cirrhosis (chronic condition characterized by replacement of healthy liver tissue with scar tissue, leading to impaired liver function and potentially life-threatening complications). Review of Section E: Behavior indicated Resident R1 had failed to display wandering behaviors. Review of clinical record form WEC: Admission/Re-Admit Eval, Section N Elopement Risk Evaluation dated 8/7/25, indicated Resident R1 as No, not at risk for elopement. Review of Resident R1's physician order dated 8/8/25, indicated Wander guard (wander management system designed to ensure safety of individuals): Check placement of Wander guard every shift. Monitor skin integrity every shift. RLE (right lower extremity) every shift for history of Wandering. Review of Resident R1's physician order dated 8/8/25, indicated to verify Wander Guard functionality every HS (hour of sleep) every night shift for Wander Guard verify functionality. Review of Resident R1's clinical record failed to indicate any documentation or assessment of wandering or elopement behaviors resulting in the use of a Wander Guard. Review of Resident R1's clinical progress note on 8/12/25, at 6:55p.m, identified as a late entry, revealed that Registered Nurse (RN) Employee E1 received notification from a staff member who was outside the facility that this resident (R1) was in the front of the building. Nurse Aide stated that she was with the resident in the front of the building. Resident R1 was immediately brought back into the facility. Resident R1 was taken to his room for a complete head to toe assessment with no injuries noted. Review of Resident R1 current care plan on 8/27/25, initiated 8/8/25, failed to indicate that a plan of care was developed from 8/8/25, through 8/12/25, for interventions related to use of a Wander Guard, as well as failing to establish problem area and their causes, and measurable objectives for use of the Wander Guard. During an interview on 8/27/25, at 3:30 p.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs for one of six residents (Resident R1) reviewed, relating to wandering/elopement. 28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12 (d)(5) Nursing Services.

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and assistance for bed mobility to prevent accidents which resulted in actual harm of a head injury for one of four residents (Resident CR1). Findings include: Review of the facility policy Accidents and Incidents-Investigating and Recording, dated 7/24/23, indicated all accidents occurring on our premises must be investigated and reported to the administrator. Review of facility policy Flow of Care dated 7/24/23, indicated care will be provided to residents, as needed 24-hours a day to attain and maintain the highest level of functioning. Review of Libre Texts Medicine procedure 12.8.5: Procedure- Turning and Positioning the Patient in Bed, indicated to position yourself on the side of the bed that the patient will be turned to. Review of admission record indicated Resident CR1 was admitted to the facility 7/27/23. Review of Resident CR1's Minimum Data Set (MDS - a periodic assessment of resident care needs) dated 11/2/23, indicated diagnoses of high blood pressure, blood clots, and prostate disease. Bed mobility was a moderate assist of one person. Review of CR1's Kardex dated 1/20/24, indicated two people in the room at all times for care. Review of Resident CR1's care plan dated 11/7/23, indicated the resident required assistance with bed mobility and two people in room at all times for care. Resident CR1 had left side weakness due to previous stroke. Review of Resident CR1's progress note dated, on 1/5/24, at 3:34 p.m. indicated called to resident's room by nurse aide. Resident CR1 lying face down between both beds. Top of head touching wall. Blood noted under resident's face. Nurse Aide (NA) Employee E3 stated she was cleaning resident after being returned from an appointment. NA went to place a brief under resident and resident fell . Resident rolled over too far and out of the bed. Resident sustained a two and a half inch laceration (a deep cut) to center of the forehead. Review of NA Employee E3's Statement Form for Investigative Purpose Falls dated 1/5/24, indicated During a change after ambulance returned resident, I washed and completely cleaned resident. I was finishing closing up the brief and turned him away from me to apply cream to buttocks. Instead of staying still as instructed he continued to go over and the only thing I could grab was his arm before lowering him to the floor to immediately get nurse. Head was gashed from falling on bed controller while going to the floor. Review of Registered Nurse (RN) Employee E4's Witness Statement dated 1/5/24, indicated Called to resident room by NA. Resident CR1 on floor in middle of room lying face down on door side of bed. Moderate amount of bleeding noted from mid forehead. Resident alert and oriented stating he fell out of bed during care. Resident left with emergency medical team to the emergency room . Review of facility submitted investigation dated 1/13/24, at 10:30 a.m. indicated Conclusions NA Employee E3 rolled Resident CR1 away from her. Resident CR1 received five sutures at the hospital. NA Employee E3 was reported to the vendor and removed from all future shifts and will not return to facility. Interview on 1/22/24, at 1:20 p.m. NA Employee E5 indicated always towards you when asked how to roll a resident in bed by yourself. Interview on 1/22/24, at 1:22 p.m. NA Employee E6 indicated I always roll the resident towards me when asked how to roll a resident in bed by yourself. Interview on 1/22/24, at 1:24 p.m. NA Employee E7 indicated towards you when asked how to roll a resident in bed by yourself. Interview on 1/22/24, at 1:26 p.m. NA Employee E8 indicated roll them towards you when asked how to roll a resident in bed by yourself. Interview on 1/22/24, at 1:27 p.m. NA Employee E9 indicated I'd roll them towards me when asked how to roll a resident in bed by yourself. Any attempts to reach NA Employee E3 were unsuccessful. Interview on 1/22/24, at 2:00 p.m. the Director of Nursing confirmed NA Employee E3 was removed from the schedule for not rolling resident towards her as is the standard of practice. Interview on 1/22/24, at 3:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed that NA Employee E3 did not have two people in the room for care and rolled the resident improperly and that the facility failed to make certain each resident received adequate supervision and assistance to prevent accidents which resulted in actual harm of a head injury for one of four residents (Resident CR1). 28 Pa. Code 201.14(a)(c)(d)(e) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.29(a) Resident Rights. 28 Pa. Code 207.2(a) Administrator's responsibility. 28 Pa. Code 211.10(a)(d) Resident care policies. 28. Pa. Code. 211.12(d)(1)(2)(5) Nursing Services.

Based on observations, review of facility policies and documentation and staff interviews, it was determined that the facility failed to ensure water temperatures for two out of two nursing units (East wing and West wing) in resident bathroom hands sinks, and resident shower rooms and shower hand sinks were maintained at safe temperatures. This failure placed residents at each Nursing Units at risk for serious injury from a burn and resulted in an Immediate Jeopardy situation for 37 out of 78 residents (Residents R32, R83, R34, R76, R40, R52, R17, R35, R51, R14 , R8, R45, R14, R60, R85, R82, R28, R46, R36, R10, R26, R79, R2, R22, R75, R3, R18, R101, R6, R64, R21, R37, R31, R39, R57, R1, and Resident R87). Findings include: Review of facility policy Shower Temps last updated 3/7/22, instructs staff if water temperature if above 110 degrees, do not shower resident and contact maintenance. Review of facility policy Shower Checking Water Temperatures developed by facility on 5/3/22, during the survey, instructs staff monitor water temperatures prior to showering resident to ensure water temperatures are at a safe range and prior to showering any resident, a water temperature must be obtained to ensure it is a safe range at 110 degrees or below. Review of the, American Burn Association Scald Injury Prevention Educator's Guide dated April of 2017, indicated Older adults, have thinner skin so hot liquids cause deeper [CONDITION(S)] with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor micro-circulation, heat is removed from burned tissue rather slowly compared to younger adults. The American Burn Association Guide also provided this table: Time and Temperature Relationship to Serious [CONDITION(S)] Water Temperature and Time Required for a 3rd Degree Burn to Occur 155°F - 1 sec 148°F - 2 sec 140°F - 5 sec 133°F - 15 sec 127°F - 1 min 124°F - 3 min 120°F - 5 min 100°F - Safe Temperatures for Bathing Review of Water temperature logs for the facility from January, February, March, and April 2022 identified water temperatures above 110 degrees in the following locations: West Shower room, East Shower room, and ACU shower room. During observations on 5/2/22, at 10:36 a.m. Room 133 water was tempted with Maintenance Supervisor Employee E8 and was found to be at 127 degrees. During an interview on 5/2/22, at 10:36 a.m. Maintenance Supervisor Employee E8 confirmed that the water temperature was above 110 degrees and posed a risk to residents. During water temperature observations, which started on 5/2/22, at 10:39 a.m. the surveying team and the Director of Maintenance, Housekeeping Director and the Regional Clinical Director identified the following: East Shower Room Sink 127F First shower stall 73F Second shower stall 109F Third shower 116 F Fourth shower 112 F West Shower Room Sink 129 F First shower stall 104F Second shower stall 104F Third shower stall 102F ACU Shower Room (West wing back) Sink 115 F Shower stall 87.3F East Wing 101 121F 102 120F 103 118F 104 122F 105 120F 106 122F 107 120F 108 122F 109 122F 110 123F 111 123F 112 124F 113 121F 114 126F 115 89 F 116 123F 117 117F 118 115F 119 122F 120 123F 121 124F 122 125F 123 124F 124 118F West Wing 125 124F 126 123F 127 117F 128 89 F 129 119F 130 119F 131 125f 132 125F 133 127F 134 113F 136 124F 137 126F 138 127F 139 126F 140 126F 141 126F 142 127F 143 124F 144 126F 145 129F 146 128F 147 128F 148 no hot water 149 109.8 F 150 116F 151 116F 152 116F 153 116F 154 109F 155 116F 156 115F 157 118F 158 117F 68 water outlets 11 safe temps 19 111-119 Fahrenheit 38 120-129 Fahrenheit During a meeting on 5/2/22, at 3:26 p.m. the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were made aware that Immediate Jeopardy existed, an immediate Jeopardy template was provided, and a corrective action plan was requested. During a meeting on 5/2/22, at 6:21 p.m. the Nursing Home Administrator (NHA) and the Director of Nursing (DON) submitted an Immediate Jeopardy corrective action plan was provided and accepted. The Immediate Jeopardy corrective action plan consisted of the following: 1) Facility maintenance immediately lowered the mixing valve and hot water tanks that supply hot water to the mixing valve. 2) Maintenance department staff flushed additional water through the piping system to bring water to safe temperature ranges. 3) Whole house audit of water temperatures in all resident rooms and showers to validate water temperatures are at safe ranges and were below 110 degrees. 4) Immediate education started with all staff to ensure water temperatures do not exceed 110 degrees at any location within the facility. If temperatures exceeded 110 degrees, staff educated to notify the NHA, DON and Maintenance staff immediately. 5) The facility will continue to monitor water temperatures at every area throughout the facility and both shower rooms every hour for 24 hours, and then every 4 hours for 24 hours, and then every 8 hours for 48 hours to ensure water temperatures are at safe ranges. 6) The facility developed a policy on obtaining water temperatures prior to showering residents, documenting the temperature and use a thermometer and a clipboard available in the shower rooms, if water temperature exceeds 110 degrees, policy included not to shower the residents when temperature exceeds 110 degrees, and notifying appropriate personnel. 7) Root cause of water temperature concern was minor seasonal adjustment that was not performed due to extreme changes in outside weather and no mechanical concern was identified. 8) An Ad Hoc Quality Assurance and Performance Improvement Committee will be added within 24 hours to review audits for recommendations and the audits will be forwarded to the monthly quality assurance and performance improvement committee for review and recommendations. Review of water temperature audits on 5/3/22, at 9:10 a.m. identified the following: On 5/2/22, the 1:45 a.m. , 2:45 a.m., 3:45 a.m. and 4:45 a.m. water temperatures audits identified no temperature for room 148. Review of water temperature audits on 5/3/22, at 11:21 a.m. identified no concerns. During Staff interviews on 5/3/22, from 11:25 a.m. to 12:00 p.m. Corrective action plan interviews about water temp education with Temporary Nurse aide (TNA) Employee E3, Certified Nurse aide (CNA) Employee E4, Certified Occupational Therapy Assistant (COTA) Employee E6, Registered Nurse Assessment Coordinator (RNAC) Employee E10, Registered Nurse (RN) Supervisor Employee E11, Certified Nurse aide Employee E27, Licensed Practical Nurse (LPN) Employee E28, , Licensed Practical Nurse (LPN) Employee E29, Registered Nurse (RN) Employee E30, Registered Nurse (RN) Employee E31, Certified Occupational Therapy Assistant (COTA) Employee E32, Physical therapist (PT) Employee E33, and Physical Therapy Assistant (PTA) Employee E34 identified no concerns. During a meeting on 5/3/22 at 3:45 p.m. with the Nursing Home Administrator (NHA) and the Director of Nursing (DON), the facility was found to be in substantial completion of their corrective action plan and the Immediate Jeopardy was lifted. During an interview on 5/9/22, at 12:55 p.m. Interim Nursing Home Administrator (NHA) confirmed that the facility failed to ensure water temperatures for two out of two nursing units (East wing and West wing) in resident bathroom hands sinks, and resident shower rooms and shower hand sinks were maintained at safe temperatures. This failure placed residents at each Nursing Units at risk for serious injury from a burn and resulted in an Immediate Jeopardy situation for Residents R32, R83, R34, R76, R40, R52, R17, R35, R51, R14 , R8, R45, R14, R60, R85, R82, R28, R46, R36, R10, R26, R79, R2, R22, R75, R3, R18, R101, R6, R64, R21, R37, R31, R39, R57, R1, and Resident R87. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.18(e)(1)Management. 28 Pa. Code 201.29(a) Resident Rights. 28 Pa. Code 205.37(e) Equipment for bathrooms. 28 Pa. Code 205.63(c) Plumbing and piping systems required for existing and new construction. 28 Pa. Code 207.2(a) Administrator's responsibility. 28 Pa. Code 211.10(d) Resident care policies. 28. Pa. Code. 211.12(d)(1)(5) Nursing Services.