Every finding on record at Wecare at Rolling Meadows Rehab and Nursing Ce

Based on review of facility policy, facility documents, clinical record review, and a staff interview, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care in accordance with professional standards of practice for two of ten residents (Resident R18 and R98). Resulting in harm of change in condition without timely intervention (Resident R18) and harm of hospitalization (Resident R98) requiring a blood transfusion. Findings include:Review of facility policy Assisting the Nurse in Examining and Assessing the Resident reviewed 1/20/26, revealed the primary purpose of assessing the resident is to gather detailed information that will help to develop a plan of care that is appropriate for the resident. The assessment process is continuous. Accurately documenting and reporting your observations provides the interdisciplinary team with information that helps tailor the care plan to the specific needs of the resident. Review of the facility policy Change in Resident's Condition or Status reviewed 1/20/26, indicated the facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing. payments, resident rights, etc.). The nurse will notify the resident's Attending Physician or physician on call when there has been a specific instruction to notify the physician of changes in the resident's condition. A significant change of condition is a major decline or improvement in the resident's status that: Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting).Impacts more than one area of the resident's health status.Requires interdisciplinary review and/or revision to the care plan.Ultimately is based on the judgement of the clinical staff and guidelines outlined in the Resident Assessment Instrument. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR (Situation, Background, Assessment, and Recommendation) Communication form (Nursing tool used to provide detailed report to provider). The nurse will record in the resident's record information relative to changes in the resident's medical/mental condition or status. Review of facility policy Charting and Documentation reviewed 1/20/26, indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The following information is to be documented in the resident medical record:-Objective observations;-Medications administered;-Treatments or services preformed;-Changes in the resident's condition;-Events, incidents or accidents involving the resident; and-Progress toward or changes in the care plan goals and objectives. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions:13 - 15: cognitively intact8 - 12: moderately impaired0 - 7: severe impairment Review of the clinical record indicated Resident R18 was admitted to the facility on [DATE]. Review of Resident R18's Minimum Data Set (MDS-a periodic assessment of care needs) indicated diagnoses of hypertension (high blood pressure), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and polyarthritis (pain and stiffness in five or more joints, swelling, warmth and redness around the joints, decreased range of motion or trouble moving the joints). A review of the MDS Section C: Cognitive Patterns-Brief Interview for Mental Status: Section C0500: BIMS Summary Score-Resident score was 5-severe impairment. Review of the clinical record revealed:-7/4/26 06:34 Nursing SBAR: Resident stated she didn't know when it started that she just realized it this morning. Resident eye blood shot. No other complaints r/t her eye. RN assessed. Plan of care continued.-7/5/26 23:41 Nursing Note: Nurse notified RN that resident has been complaining of Left sided vision loss. Upon assessment RN noted Left pupil is reactive, sclera is red, loss of vision. On Right side, pupil not reactive, pinpoint and vision is normal. Resident is neuro assessed and is at baseline, with the exception of vision loss. Physician notified and RN will add resident to the list to be seen on 7/6/26.-7/7/26 16:10 Physician Note: Left vision loss, differential includes dry eyes, acute glaucoma, conjunctivitis. Needs seen by Ophthalmology, does not seem to be an ophthalmologic emergency such as a screen coming down on the eye. Urgent ophthalmology referral; that she says this comes and goes is also reassuring; more likely dry eye or a reversible process.-7/7/26 18:33 Physician Note: Provider into see resident today. Resident continues with complaints of not being able to see out of left eye well. Left eye appears to be red and resident states she is having some discomfort in it. New orders received for Bleph 10, 2 drops QID (Four times a day) x 10 days, resident aware. Message left for Resident Representative-7/17/26 09:02 Nursing Note: Late Entry (for 7/16/26 at 12:00)-Resident having increased clear drainage to left eye. Sclera remains pink in color. No itching or pain noted. C/O having visual disturbances in that eye.-7/21/26 09:26 Nursing Note: Residents sclera in left eye increasingly red/irritated. Scant amount of clear drainage noted. Resident c/o visual disturbances in that eye. RN aware/resident on physician list today.-7/22/26 10:50 Nursing Note: Late Entry (for 7/21/26 at 12:00)- Primary Care Physician (PCP) in to see residents today. Order received for Ophthalmology consult for L eye discomfort and redness. Call made to brother and sister-in-law with update. Detailed message left at this time.Review of the clinical record on 8/25/26, revealed no progress notes after 7/21/26 to indicate the Ophthalmology appointment was ordered or scheduled until 8/13/26. Review of the order from 8/13/26 at 20:02 reveals: Schedule Consult: Eye Appointment Name of Provider/Service: Eye Doctor Date/Time: 09/10/2026 at 0825. PICK-UP. During interview with resident on 8/25/26, revealed that left eye was still bothering her, appeared red and she still could not see. During an interview on 8/26/26, at 2:10 p.m. the Director of Nursing confirmed that the facility failed to assess resident and notify the physician that change of condition was still present and unchanged. Review of the clinical record indicated Resident R98 was admitted to the facility on [DATE]. Review of Resident R98's Minimum Data Set (MDS-a periodic assessment of care needs) dated 8/3/26, indicated diagnoses of transient ischemic attack (TIA temporary blockage of blood to the brain often called a mini stroke), liver transplant (removal and replacement of a diseased liver for a healthy liver), and renal insufficiency (poor kidney function impacting waste removal, fluid balance, and blood chemistry regulation). Section C0100 Cognitive Patterns: screening score indicated the resident was cognitively intact. Review of the physicians' order dated 8/6/26, indicated to administer Eliquis (blood thinner) 2.5 MG oral tablet every 12 hours for atrial fibrillation (AFib irregular heart rhythm). Additional physicians' order dated 8/7/26, included to monitor for unusual bleeding or bruising every shift. Document number of occurrences seen and notify physician. Review of the Medication and Treatment Record from every shift on 8/7/26, through 8/26/26, this activity had been marked as completed on all days and shifts except for day shift 8/20/26. No evidence of bleeding, interventions, or physician notification appears in the clinical record prior to the surveyor discussing the status with the Director of Nursing. Review of the anticoagulant therapy pathway initiated on 8/6/26, included risk for bleeding: Resident will show no signs/symptoms of bleeding Evaluate skin for evidence of impaired coagulation (bruising, petechia, bleeding from orifice) Evaluate for hematemesis (vomiting blood) Review of the care plan dated 8/5/26, indicated the resident is at risk for complications/rejection due to her liver transplant status. The goal is to be free from signs/symptoms of liver complication including abnormal or unexplained bleeding. Monitor/document/report to physician signs/symptoms of complications including gastrointestinal bleeding (any part of the digestive tract mouth, stomach, colon, and rectum) blood in stool, nosebleeds and bleeding gums. Review of the care plan dated 8/12/26, indicated anticoagulant therapy, the resident is at risk for side effects of medication. Monitor each shift blood tinged or red blood in urine or stools. Monitor skin with each encounter. During an interview and observation of Resident R98 on 8/24/26, at 10:30 a.m., revealed the resident lying in bed with what appeared to be blood on the resident's lips and chin, a small bruise was observed on her face, near the right temple area. The resident stated that this bleeding has been going on for a couple of days. The resident stated she has some pain with her lips though can eat. When asked if the nurses were aware of the bleeding the resident stated yes, they told me to keep my mouth wet, I have water, lifesavers candy, lip balm, and my moistened towel to wipe my face. These items were observed in use by the resident during the interview. During a subsequent interview and observation of Resident R98 on 8/25/26, at 8:15 a.m., revealed the resident lying in bed with gauze protruding from her mouth. When asked if it was still bleeding the resident nodded yes. A subsequent observation this same date at 11:50 a.m. revealed the resident eating lunch in bed with her spouse at her bedside. Resident confirmed the bleeding continues. During an interview on 8/25/26, at approximately 1:30 p.m., with the Director of Nursing (DON), the resident's condition was discussed along with the absence of documentation related to the observed bleeding and interventions the resident reported she was doing. The DON provided an update at approximately 2:30 p.m., this 8/25/26. A call was placed to the physician this afternoon and an order was placed for Aquaphor ointment, apply to the upper and lower lips topically every shift for wound healing. The DON did not have details as to why there was no documentation related to the bleeding or interventions, prior to the surveyor discussing the concern. Review of the clinical record entry on 8/26/26, at approximately 9:41 a.m., the DON spoke with the resident regarding the resuscitation status of the resident and hospice care. Resident current status is for a full code (all possible life saving measures) as per her choice and physician order. The resident chose to remain a full code status. The resident's family was updated as per the resident request. At approximately 11:30 a.m., on 8/26/26, the nurse practitioner was notified by the nurse, that the resident continues with red drainage from the lower lip. Orders were received for labs, the resident, is alert and oriented to person, place and time, family notified. At approximately 2:19 p.m., on 8/26/26the nurse noted labs returned with critical results, all labs were called to the physician and orders received to transfer the resident to the emergency department. The resident is awake and alert, is aware of the critical labs and wishes to remain a full code with full treatment. The resident's family was updated. Resident transferred to the emergency department via ambulance. Labs results revealed: Complete Blood Count (CBC): [NAME] Blood Count (WBC)-2.1 (Within Normal Limits (WNL) 4.0-10.7), Red Blood Count (RBC)-1.97 (WNL 3.7-5.2), Hemoglobin (Hgb)-5.6 (WNL 11.9-15.8), Hematocrit (Hct)- 17.4 (WNL 35.9-46.9), Platelets (Plt)- 46 (140-380). Prothrombin Time Test (PT/INR)- PT-17.0 (WNL 9.5-12.5), INR-1.7 (0.8-1.2). Review of the clinical record dated 8/27/26, at approximately 9:37 a.m., reveals that the resident had been admitted to the hospital for abnormal labs and had received two units of packed red blood cells (PRBC used when there is significant blood loss) and continues to have mouth bleeding. During an interview on 8/26/26, at 2:00 p.m., the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to assess Resident R98 and notify the physician with a change of condition. During exit interview on 8/27/26, at 1:30 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to ensure that residents were provided appropriate treatment and care in accordance with professional standards of practice for two of ten residents (Resident R18 and R98), resulting in harm of change in condition without timely intervention (Resident R18) and harm of hospitalization (Resident R98) requiring a blood transfusion. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 211.10 (b) (c )(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing Services.

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to properly verify sanitation levels for three-compartment sink in the Main Kitchen which created the potential for foodborne illness. Findings include: Review of the facility policy, Manual Dishwashing dated 1/20/26, indicated, All eating and drinking utensils, as well as food contact surfaces of equipment will be thoroughly washed, rinsed, and sanitized as indicated. Sanitizer test strips will be used to validate the appropriate concentration of sanitizer, 200 ppm (parts per million) for quaternary ammonia. During an observation of the three-compartment dishwashing sink in the Main Kitchen on 8/24/26, at 12:39 p.m. the Pot Sink Sanitation Record for August 2026, indicated that 100 ppm was documented for breakfast and lunch warewashing on:8/01/26: 7:40 a.m., 11:50 a.m.8/02/26: 8:20 a.m., 10:46 a.m.8/03/26: 7:50 a.m., 10:21 a.m.8/04/26: 8:15 a.m., 11:45 a.m.8/07/26: 7:40 a.m., 11:16 a.m.8/08/26: 8:30 a.m., 10:49 a.m.8/09/26: 7:45 a.m., 10:12 a.m.8/10/26: 8:26 a.m., 11:45 a.m.8/11/26: 7:40 a.m., 10:39 a.m.8/13/26: 7:40 a.m., 10:39 a.m8/14/26: 6:48 a.m., 11:06 a.m8/15/26: 7:21 a.m., 11:09 a.m No documentation for parts per million was present for:8/05/26: 12:30 p.m.8/06/26: 12:40 p.m8/16/26: No times or measurements 8/17/26: 12:00 p.m8/22/26: 12:30 p.m8/23/26: 12:50 p.m Review of all dates for the dinner-hour warewashing from 8/1/26, through 8/23/26, indicated the letters DW in place of the PPM amount. During an interview and observation on 8/27/26, at approximately 10:00 a.m. Regional Dietary Manager Employee E7 confirmed the facility uses quaternary ammonia, and that 200 PPM is the required sanitation level. During an interview on 8/27/26, at approximately 11:30 a.m. the Director of Nursing confirmed the facility failed to properly verify sanitation levels for three-compartment sink in the Main Kitchen which created the potential for foodborne illness. 28 Pa. Code: 211.6(f) Dietary Services.

Based on resident and staff interviews, and facility documents reviewed, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for twenty-one of thirty-two residents (Residents R6, R7, R9, R90, R500, R501, R502, R503, R504, R505, R506, R507, R508, R509, R510, R511, R512, R513, R514, R515, and R516).Findings include: Review of the facility policy Answering the Call Light last reviewed on 1/20/26, indicated that this procedure is to ensure timely responses to the resident's requests and needs. Answer the resident call system immediately. If the resident needs assistance. Indicate the approximate time it will take for you to respond. If the resident request is something you can fulfill, complete the task within five minutes if possible. During a group interview, on 8/24/26 at approximately 1:30 p.m., when asked if they felt the facility maintained enough staff to care for resident needs and answer call lights, consensus from the group was no. Residents verbalized frustration with the lack of nurse aides in the building. Residents stated the weekends are the worst times of all; often we wait thirty or forty minutes and can be longer when you use your call light to get help, they will pull staff from one hall to another because they are short staffed, sometimes the staff come in turn the light off and say they will be back and it may be hours or they just don't return. The resident expressed being anxious when having to wait for assistance to get to the bathroom as you don't know how long it will take or when you want to get ready for some type of activity. Residents stated the staff is respectful and do the best they can though it's tough when you are dependent on when they can get to you. Review of Resident Council Minutes revealed concerns related to facility staffing, At the 4/15/26 meeting minutes included resident's concerns with staff and the weekend call off plan for the facility had been reviewed. On 4/21/26 staff education was completed that included residents are to be showered on scheduled shower days. Make sure call lights are being answered during shift changes, Afternoon shift eating at the nurse's station while call lights are going off. There should be no food at the nurse's stations at any time. During an interview on 8/24/26 at approximately 11:00 a.m., Resident R7, when asked if he felt the facility maintained sufficient staff to care for resident needs, stated no. The staff work hard he has no issues with the staff; he has issues with administration and staffing. Staff are pulled from the unit and assigned elsewhere, the staff are always busy and sometimes it can take a while to get help, it's always on days that this unit is short of staff. The staff answer call lights right away, when they don't, you know the unit is short-staffed and you will have to wait, maybe thirty minutes or longer, that is all there is to it. This happens to my roommate too. During an interview on 8/24/26 at approximately 11:15 a.m., Resident R90, when asked if she felt the facility maintained sufficient staff to care for resident needs, stated no. It takes a while to get help when you use your call light. The staff will even come in and turn off the light and say they will come back later, sometimes they do and sometimes they don't. You must plan for what you need when calling for help as it can take a half-hour or longer for someone to come and help you. During an interview on 8/24/26 at approximately 11:30 a.m., Resident R9, when asked if she felt the facility maintained sufficient staff to care for resident needs, stated no. Getting someone to answer your call light takes a while. They take a long time to answer the call lights here, it's common to wait for thirty or forty minutes. Sometimes they come in and turn the light off and say they will be back this can take an hour or longer. During an interview on 8/25/26 at approximately 12:30 p.m., Resident R6, when asked if he felt the facility maintained sufficient staff to care for resident needs, stated no. He has to wait a long time for his call light to be answered. He doesn't know if it's because he is at the end of the hall or why. They just keep you waiting and then you get mad waiting for so long. During a confidential staff interview, when asked if the staff member felt there was sufficient staff to care for resident needs, stated not all the time. The staff member stated that the facility is often short staffed and it does cause delays with resident care. The care gets done but the residents may have an extended wait time on these days and shifts. During a confidential staff interview, when asked if the staff member felt there was sufficient staff to care for resident needs, stated some of the time. The staff member stated that sometimes with the staffing pattern being short or staff being pulled to cover other units there is a delay in our care, getting people in and out of bed, showers, answering call lights, etc . We get to everyone, but the residents will tell you there are times when they wait. During a confidential staff interview, when asked if the staff member felt there was sufficient staff to care for resident needs, stated no we are short staffed on some days. The staff member stated there can be wait times of thirty minutes or more, though it depends on the facility staffing, but we do take care of everybody. During a confidential staff interview, when asked if the staff member felt there was sufficient staff to care for resident needs, stated not really to be honest. The staff member stated when we are short staff or have staff pulled to another unit, unfortunately we don't get to everyone quickly you just can't, yes, they have to wait and it can be thirty minutes sometimes maybe more depending on what is going on in the unit. We will get there and take care of what they need though. During an interview on 8/26/26, at 10:00 a.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for residents. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(e)(6) Management.28 Pa. Code: 201.20(a) Staff development.28 Pa. Code: 211.12(a)(c)(d)(1)(2)(3)(4) Nursing services.

Based on review of facility documents, observations, and staff interview, it was determined that the facility failed to provide residents with dementia (a group of symptoms that affects memory, thinking, and interferes with daily life) meaningful activities that address the resident's customary routines, interests, preferences, and choices to enhance the residents well-being on one of eight nursing units (Homestead Nursing Unit).Findings include: Review of the Facility Assessment last reviewed 6/16/26, indicated that the facility provided care for residents with dementia and Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking, and behavior). Additionally, the assessment stated that it will, provide opportunities for social activities / life enrichment (individual, small group, community). Review of the facility policy Dementia Education dated 1/20/26, indicated, Activities should be available around the clock. There are meaningful activities that can be done if the resident cannot sleep, that would not disturb other residents. Group activities should not have more than 10-15 in a group. Mentally stimulating activities should occur early in the day when cognitive function is at its highest. Review of the facility policy Activities - Cognitive Impaired dated 1/20/26, indicated, The facility will offer meaningful programs for the residents with cognitive impairments that use reality and sensory awareness techniques. Review of the Homestead Nursing Unit (memory-impaired unit) Activities Calendar for August 2026, revealed the following:All weekend activities are resident led.8/03/26: one activity, Sorting at 3:00 p.m.8/10/26: one activity, Matching at 3:00 p.m.8/11/26: one activity, 1:1 visits at 11:00 a.m.8/14/26: one activity, Creamsicles and Classics at 3:00 p.m.8/17/26: one activity, Sorting at 3:00 p.m.8/21/26: one activity, Ice-cream Social (off-unit) at 3:00 p.m.8/24/26: one activity, Matching at 3:00 p.m.8/25/26: one activity, 1:1 visits at 11:00 a.m.8/26/26: one activity, Sing-along at 3:00 p.m.8/27/26: one activity, Folding and sorting (resident-led) at 2:00 p.m.8/28/26: one activity, Water painting at 10:00 a.m.8/31/26: one activity, Sorting at 3:00 p.m. During an observation on 8/25/26, between 11:00 a.m. and 11:30 a.m., no activity staff were present on the unit for the scheduled 1:1 visits. Throughout this observation, most residents were in the lounge. The television was on, showing a game show, but no residents appeared to be watching it. Nurse aide staff interacted with residents in relation to their care, but no staff interacted with residents for recreational purposes. One resident was observed coloring, as her family member was present and interacting with her. Review of the facility provided list of activities attendance for the Homestead unit for 8/24/26, through 8/26/26, included two structured activities:8/24/26: Eight residents attended Matching.8/26/26: Residents attended Reminisce. Additionally, 8/25/26, and 8/26/26, some residents went outside to the enclosed courtyard. No additional activity documented as being done while outside, other than being outside. During an interview on 8/27/26, at approximately 9:15 a.m. Activities Director Employee E8 confirmed that residents who reside on the Homestead memory-impaired unit are not appropriate to have resident-led activities. Activities Director Employee E8 stated that the department does not have enough staff to provide a complete activities schedule, and further stated that Activities Department staff are pulled on Mondays, Wednesdays, and Fridays to meet with approximately 46 residents for dietary preferences. Review of the August 2026, Activities Department staff schedule indicated:Only one staff member is present to provide activities on Saturdays and Sundays to the whole facility.On Mondays, only one staff member is present, other than the Activities Director, to provide activities to the whole facility. During an interview on 8/27/26, at approximately 11:00 a.m. the Nursing Home Administrator confirmed the facility failed to provide residents with dementia meaningful activities that address the resident's customary routines, interests, preferences, and choices to enhance the residents well-being on one of eight nursing units. 28 Pa. Code: 201.18 (b)(1) Management. 28 Pa. Code: 211.10 (c) Resident Care Policies. 28 Pa. Code: 201.18 (d)(3)(5) Nursing Services.

Based on a review of facility documents, observations, and resident and staff interviews it was determined that the facility failed to serve food that was palatable for nineteen of thirty-two residents (Residents R9, R90, R500, R501, R502, R503, R504, R505, R506, R507, R508, R509, R510, R511, R512, R513, R514, R515, and R516).Findings include: Review of the facility policy Meal Service Line last reviewed on 1/20/26, indicated food will be prepared by methods that conserve nutritive value. Flavor and appearance. And will be placed on tray in an attractive manner as near to the time of actual tray service as possible. This is done to ensure acceptable temperatures of food when the tray is served to the resident. Review of a resident grievance filed on 5/27/26 revealed concerns related to food palatability. The resident noted the food is repulsive! I've had six or more hot dogs this week more water than oatmeal, blackened pizza, and hard grilled cheese. I've asked at food meetings for some changes that don't happen! Today we had chicken and noodles. Mine had zero chicken. Come on, the kitchen would not eat what they serve! Its's all disgusting. During an interview on 8/24/26 at approximately 11:15 a.m., Resident R90 laughed when I asked her how the meals tasted like the facility provided. The resident stated I have photos that I send to my friends so they can see what the meals look like. She stated her friends didn't believe her until they had seen the photos. The food is terrible, just terrible, thankfully I am going home. Sometimes it is not always hot when you get it, sometimes it's overcooked, sometimes it is not even what you ordered. Sometimes it's mashed up just like her roommate's mechanical soft diet like everyone gets the same thing on those days. During an interview on 8/24/26 at approximately 11:30 a.m., Resident R9 stated she has been asking to speak with someone about the food and stated I have nothing good to say about it at all. I have not been here very long, and I don't think I'll be able to tolerate the food here too much longer. During a group interview, on 8/24/26 at approximately 1:30 p.m., the residents shared their dissatisfaction with the palatability of the food served at the facility. Residents statements included it's not good, every morning your toast gets steamed sitting under the dome with your food, it's always soggy, often the cheeseburgers don't have cheese, the pepperoni pizza doesn't always have pepperoni, the pizza is often over cooked and you can only eat the center of the slice as the edges are too hard, you are to get two pieces of toast and you only get one. The residents state they bring up concerns at food committee however nothing changes, it's like our food concerns go in one ear and out the other. At times, we go to bed hungry because the food is not good. It's like whoever is making and plating the food has never done this before, often it's hard like its overcooked. On occasion it is not hot when you get it. You don't get condiments all the time. Thank God most of us have family who bring in food for us. Review of six months of facility provided Resident Dining Committee Notes indicated:Most of the minutes were dedicated to attendees' individual food preferences. None of the minutes were signed by the staff. -3/18/26: Concerns the ham is too hard and individual preferences discussed.-4/15/26: Concerns individual preferences only,-5/20/26: Concerns sometimes breakfast is cold and individual preferences discussed.-6/17/26: Concerns were not visible on the document as another document had been copied over this section and individual preferences discussed.-7/15/26: Concerns related Food is under or over cooked, eggs and burned cheese. Soggy fries and individual preferences discussed.-8/19/26: Concerns related to condiments are missing, and not receiving the slices of bread as ordered. Food temperatures are not appropriate and individual preferences discussed. During an interview on 8/27/26, at 10:00 a.m. the Nursing Home Administrator confirmed that the facility failed to serve food that was palatable. 28 Pa Code: 211.6(b)(c) Dietary services.

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to document delay in treatment as recommended by consult for skin infection for one of eight residents (Resident R83) failed to document skin assessments after diagnosis of fungal infection for one of eight residents (Resident R93) and failed to document assessments while administering an opioid (Resident 112) for pain/air hunger for one of eight residents.Findings include:Review of facility policy, Charting and Documentation dated 1/20/26, indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record may be electronic, manual or a combination. The following information is to be documented in the resident's medical record: objective observations, medications administered, treatments or services performed, changes in resident's condition, events, incidents or accidents involving the resident, and progress toward or changes in the car plan goal or objectives. Review of facility policy Administering Medications dated 1/20/26, indicated medications are administered in a safe and timely manner, and as prescribed. The director of nursing services supervises and directs all personnel who are administering medications and/or have related services. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. Review of facility policy Administering Pain Medication reviewed 1/20/26, indicated to administer pain medications as ordered. If there are signs of serious adverse consequences related to narcotic (opioid) analgesics (including somnolence [state of strong or persistent drowsiness or a heavy desire to sleep during normal waking hours], delirium [change in brain function that causes severe confusion, trouble focusing, and rapid shifts in awareness], respiratory depression [breathing becomes too slow or too shallow to keep proper oxygen and carbon dioxide levels in the body], notify the practitioner prior to administering. Report other information in accordance with facility policy and professional standards of practice. The Kaiser Permanente 0-to-10 pain scale uses numbers from 0 (zero) to 10 (ten) to help measure and share your level of discomfort with your care team. 0 (zero): no pain1 (one) to 3 (three) = mild: annoying or noticeable pain that does not stop you from doing normal daily tasks.4 (four) to 6 (six) = moderate: distracting pain that begins to get in the way of your activities and makes it hard to concentrate.7 (seven) to 10 (ten) = severe: strong to worst possible pain that keeps you from doing normal activities, talking, or functioning. Review of the clinical record indicated Resident R83 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS-a periodic assessment of resident care needs) dated 7/2/26, included diagnoses of hypertension (high blood pressure), anxiety (natural response to stress or a perceived which can become excessive and impaired daily living), adult failure to thrive (multi-factor syndrome of physical, mental, and functional decline most common in older adults). Review of Resident R83's care plan initiated on 4/8/25, revised on 5/19/26 and 6/9/26, for skin integrity indicated to remain free from skin breakdown daily through next review. Resident R83 will have weekly skin assessment to be performed during regularly scheduled bath/shower per facility policy. Administer treatments as ordered and monitor effectiveness. Assess/record/monitor wound healing per facility policy. Inform resident of any new skin breakdown. Revision from 6/9/26, indicated Resident R83 will have no complications from rash through the review date. Resident R83 will avoid scratching and keep hands and body parts from excessive moisture, increase out of bed activity as tolerated, and monitor skin rashes for increased spread or signs of infection. Review of Resident R83's clinical record revealed a consult with a dermatologist on 8/12/26, resident returned with recommendations for Clindamycin 1% Ointment to be applied to the back once a day after bathing. In review of orders the order was not placed until 8/20/26, no documentation noted to state that consult paperwork was reviewed and recommendation was related to facility physician. Review of the clinical record indicated Resident R93 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of hypertension, muscle weakness, diabetes (a metabolic disorder ub which the body has high sugar levels for prolonged periods of time), end-stage renal disease (final permanent stage of chronic kidney disease requiring either dialysis or kidney transplant). Review of Resident R93's care plan initiated on 4/20/25, revised on 2/12/26, for skin integrity indicated Resident R93 will remain free from skin breakdown daily through next review date. Resident R93 will have house barrier cream to buttocks, moisturizing lotions with AM and PM care, encourage/remind/assist to turn/reposition as needed or required, support surface to bed: pressure reducing mattress, support surface to chair, pressure reducing cushion for wheelchair. On 6/4/26, care plan initiated for actual impairment to skin integrity of the axilla r/t fungal rash with potential for complications. Resident R93 will have treatment applied per order, avoid scratching and keep hands and body parts from excessive moisture, and encourage good nutrition and hydration in order to promote healthier skin. On 6/7/26, care plan initiated for Resident R93 has a fungal rash under bilateral breasts with an antifungal cream. Goal is to have rash healed by review date. Resident R93 will avoid scratching and keep hands and body parts from excessive moisture, monitor skin rashes for increased spread or signs of infection, seek medical attention if skin becomes bloody or infected. Review of the clinical record revealed resident seen on 5/23/26 for Right axilla with red fungal rash. [Medical] on-call notified and new order received. Resident made aware of new orders. Further review of the clinical record-order summary revealed no new orders for this date range, care plan not updated for thirteen days regarding new issue, no further documentation regarding skin assessments after initial date of diagnosis. Review of the clinical record indicated Resident R112 was admitted to the facility on [DATE], with diagnoses that included urinary tract infection (UTI), anxiety, and difficulty in walking. Review of physician orders revealed the following:-On 7/5/26, Lorazepam (Ativan - prescription benzodiazepine used to treat anxiety disorders) one mg (milligram), give one (1) tablet by mouth one time only for agitation.-On 7/5/26, Morphine Sulfate (strong opioid pain medication) oral solution 20mg/ml (milliliter), give 0.5 ml by mouth every one (1) hour as needed for moderate to severe pain/air hunger. Review of the vital signs, and Medication Administration Record (MAR) for July 2026, revealed Resident R112 received the following:-On 7/5/26, at 2:04 a.m. Vital signs (VS): Blood pressure (BP) was 128/98; Pulse (P) 73; Oxygen (O2) level 98%; Respirations (R)18; Pain level 4/10.-On 7/5/26, at 11:18 a.m. Pain level 4/10.-On 7/5/26, at 2:03 p.m. VS: BP 118/87; P 72; O2 98%; R 18; Pain level 6/10.-On 7/5/26, at 4:50 p.m. Pain level 5/10.-On 7/5/26, at 5:25 p.m. Morphine Sulfate 20 mg/ml, 0.5 ml.-On 7/5/26, at 6:35 p.m. Morphine Sulfate 20 mg/ml, 0.5ml.-On 7/5/26, at 7:35 p.m. Morphine Sulfate 20 mg/ml, 0.5 ml.-On 7/5/26, at 8:35 p.m. Morphine Sulfate 20 mg/ml, 0.5 ml.-On 7/5/26, at 9:21 p.m. Lorazepam one mg tablet, one tablet was given.-On 7/5/26, at 9:35 p.m. Morphine Sulfate 20 mg/ml, 0.5 ml.-On 7/5/26, at 10:09 p.m. VS: BP 105/66; O2 96%; R 16; pain level 5/10.-On 7/5/26, at 11:37 p.m. Morphine Sulfate 20 mg/ml, 0.5 ml. BP 102/68: P 64; R 20; O2 94%; Pain level 3/10.-On 7/6/26, at 1:51 a.m. Morphine Sulfate 20 mg/ml, 0.5 ml.-On 7/6/26, at 6:17 a.m. Morphine Sulfate 20 mg/ml, 0.5 ml.-On 7/6/26, at 6:50 a.m. VS: BP 84/68; P 112; R 14; O2 88%.-On 7/6/26, at 9:55 a.m. VS: BP 85/58; P 58; R 24; O2 91%; pain level 0/10.-On 7/6/26, at 10:55 a.m. pain level 0/10.-On 7/6/26, at 5:21 p.m. Morphine Sulfate 20 mg/ml, 0.5 ml.-On 7/6/26, at 5:39 p.m. pain level 0/10.-On 7/6/26, at 8:21 p.m. Morphine Sulfate 20 mg/ml, 0.5 ml. Review of the progress notes failed to reveal an assessment of Resident R112's condition, side effects of medications administered, and/or behaviors observed (agitation, respiratory distress, air hunger) relating to Resident R112 receiving pain medication and lorazepam. Further review of a progress note dated 7/7/26, at 1:45 a.m. indicated Resident R112 ceased to breathe at 12:22 a.m. During an interview on 8/26/26, at approximately 9:45 a.m. the Director of Nursing confirmed that the clinical record failed to reveal further skin assessments, follow-up care, review of orders, and review of consultation documentation for Resident R83 and R93. During an interview on 8/27/26, at 11:15 a.m. the Director of Nursing confirmed the medical record failed to include documentation and assessments for Resident R112 receiving morphine sulfate and lorazepam. 28 Pa. Code 201.18 (b)(1) Management28 Pa. Code 211.10 (c)(d) Resident care policies28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained for two of three residents reviewed. (Resident R5 and R93).Findings include:Review of the facility policy Dialysis Management (Hemodialysis) dated 1/20/26. The policy indicates that the facility will develop a binder/folder to send to dialysis with the resident. A communication form is placed in the binder after completion of the pre-dialysis assessment. The facility is to complete the pre-dialysis information on the communication form and send with resident on treatment days, to ensure communication of resident information and coordinate care between dialysis center and facility. Dialysis center personnel to complete dialysis communication form and return to facility. The dialysis center may provide their EHR documentation versus manual documentation of treatment on communication form. Upon return from dialysis center, review information provided on dialysis communication form/EHR. Communicate and address as appropriate. Facility to complete post-dialysis information/data and place in resident's medical record and assess and manage post-dialysis complications. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS-a periodic assessment of care needs) dated 6/13/26, indicated diagnoses of hypertension (high blood pressure), diabetes (body does not use insulin effectively), and end-stage renal disease (kidneys fail to filter waste and balance fluids). Review of Resident R5's physician order dated 6/12/26, indicated dialysis: Monday-Wednesday-Friday at [dialysis center]. Transport time scheduled for 10:45 a.m. for a chair time of 11:00 a.m. Review of Resident R5's current care plan indicated dialysis three times a week, treatments as scheduled: Monday, Wednesday, and Friday at [dialysis center]. Review of Resident R5's dialysis communication forms from 7/3/26 through 8/24/26 revealed incomplete communication on the following dates: -Pre-dialysis information incomplete: Weight, Blood Sugar, Assessment (Medication changes, Appetite Problems, Adherence to fluid restrictions, newly developed physical symptoms, food accompanied resident) on 7/3/26, 7/6/26,7/10/26, 7/20/26, 7/22/26, 7/24/26, 7/29/26, 7/31/26, 8/3/26, 8/7/26, 8/24/26. -Post-dialysis information incomplete: Post-dialysis weight, vitals, dialysis staff signature noted on 7/6/26, 7/10/26, 7/20/26, 7/24/26, 7/29/26, 7/31/26, 8/5/26, 8/12/26, 8/17/26. Review of the dialysis sheets for Resident R5 does not show an area where the facility does an assessment upon arrival back to the facility. Review of the clinical record indicated Resident R93 was admitted to the facility on [DATE]. Review of Resident R93's MDS dated [DATE], indicated diagnoses of hypertension, muscle weakness, diabetes, and end-stage renal disease. Review of Resident R93's physician order dated 10/28/25, indicated dialysis: Tuesday-Thursday-Saturday at [dialysis center]. Transport time scheduled for 6:00 a.m. for a chair time of 7:00 a.m. Review of dialysis communication forms from 7/3/26, through 8/24/26 revealed incomplete communication on the following dates: -Pre-dialysis information incomplete: Weight, Blood Sugar, Assessment (Medication changes, Appetite Problems, Adherence to fluid restrictions, newly developed physical symptoms, food accompanied resident) on 7/8/26, 7/13/26, 7/15/26, 7/22/26, 8/7/26, 8/14/26, 8/24/26. -Post-dialysis information incomplete: Post-dialysis weight, vitals, dialysis staff signature noted on 7/17/26. During an interview on 8/26/26, at 9:39 a.m. the Director of Nursing confirmed the facility failed to make certain consistent dialysis communication was maintained in two of three residents. 28 Pa. Code 211.15(f) Clinical Records28 Pa. Code 211.12(d)(2)(3) Nursing Services.

Based on a review of facility admission documents and staff interviews, it was determined that the facility failed to ensure resident rights to make informed decisions and choices in the residents' welfare by making certain residents understand the conditions of a binding arbitration agreement and failed to ensure the agreement is explained to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands for eight of fifteen residents (Resident R9, R17, R88, R114, R115, R117, R121, and R122).Findings include: Review of the facility policy Arbitration Agreements reviewed on 1/20/26, indicated the arbitration agreement is a legally binding contract in which a resident or their representative agrees to resolve disputes through arbitration (settling a dispute outside a court of law with a third party) rather than litigation (settling a dispute in a court of law). The facility shall provide a clear and understandable explanation of the arbitration agreement to the residents and/or their representative in a language they understand; signing is not a condition of admission. Facility administration shall monitor compliance with the Center for Medicare and Medicaid Services (CMS) rules and Pennsylvania regulations. Any violations of this policy shall result in corrective action. Review of the facility's admission packet that contained the document VOLUNTARY AGREEMENT FOR ARBITRATION, indicated (in bold print) By signing below the Resident and/or the Resident's Legal Representative acknowledge as follows: They have read and understood the Agreement. That the Agreement has been provided in a form and manner that the resident and/or their legal representative could understand. The Agreement can be rescinded within 30 days after signing it. The resident and/or their legal representative are not required to sign the agreement as a condition of admission or a requirement to continue receiving care in the facility. During an interview on 8/25/26 at 3:15 p.m. with the Nursing Home Administrator (NHA) Employee E5 Business Office representative and Employee E6 Social Worker confirmed, the arbitration documents are to indicate if arbitration is accepted or declined by the resident and/or their legal representative. The arbitration documents are processed with the resident or their legal representative electronically. Review of the arbitration documents revealed the following: Electronic signature of the resident or legal representative followed by an (X) next to the words Accept or Decline depending on what was chosen appears on the document. Electronic signature of the resident or legal representative without an indication of Accepted or Declined as this selection did not appear on the document.No signature of the resident or legal representative or indication of Accepted or Declined as this selection did not appear on the document. Review of Resident R9's admission record indicated the resident was admitted to the facility on 87/26. Arbitration document signed 8/10/26 by the resident. No indication on the document whether it was accepted or declined. Review of Resident R17's admission record indicated the resident was admitted to the facility on [DATE]. Arbitration document signed 8/7/26 by the resident's legal representative. No indication on the document whether it was accepted or declined. Review of Resident R88's admission record indicated the resident was admitted to the facility on [DATE]. Arbitration document signed 8/10/26 by the resident's legal representative. No indication on the document whether it was accepted or declined. Review of Resident R115's admission record indicated the resident was admitted to the facility on [DATE]. Arbitration document signed 8/14/26 by the resident's legal representative. No indication on the document whether it was accepted or declined. Review of Resident R117's admission record indicated the resident was admitted to the facility on [DATE]. Arbitration document signed 8/14/26 by the resident's legal representative. No indication on the document whether it was accepted or declined. Review of Resident R122's admission record indicated the resident was admitted to the facility on [DATE]. Arbitration document signed 8/13/26 by the resident. No indication on the document whether it was accepted or declined. Review of Resident R121's admission record indicated the resident was admitted to the facility on [DATE]. Arbitration document was not signed by the resident or legal representative. No indication on the document whether it was accepted or declined. Review of Resident R114's admission record indicated the resident was admitted to the facility on [DATE]. Arbitration document was not signed by the resident or legal representative. No indication on the document whether it was accepted or declined. During an interview on 8/26/36, at approximately 9:30 a.m. the NHA stated there is an issue in the software used by the facility with the arbitration agreement. The NHA confirmed the facility failed to ensure resident rights to make informed decisions and choices in the residents' welfare by making certain residents understand the conditions of a binding arbitration agreement and failed to ensure the agreement is explained to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands. 28 Pa. Code 201.24 (b) admission Policy28 Pa. Code 201.14(a) Responsibility of Licensee28 Pa. Code 201.18(b)(2) Management28 Pa. Code 201.29(a)(j) Resident Rights

Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop written policies and procedures that include training new and existing nursing home staff on abuse, neglect, misappropriation of resident property, and exploitation. This failure resulted in the actual harm of staff members being unaware that unauthorized physical restraints can be a form of physical abuse and restraining a resident to a bed with a bed sheet which caused abdominal bruising for one of eight residents (Resident R1).Findings include: Review of the United Stated Code of Federal Regulations S483.95 indicated that the facility must have written policies and procedures that include training new and existing nursing home staff in the following topics which include: Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation.Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property.Recognizing signs of abuse, neglect, exploitation and misappropriation of resident property, such as physical or psychosocial indicators.Reporting abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources, and to whom and when staff and others must report their knowledge related to any alleged violation without fear of reprisal; andUnderstanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond. Review of facility policy Identifying Involuntary Seclusion and Unauthorized Restraint dated 1/20/26, previously reviewed 1/21/25, defined a physical restraint as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: Is attached or adjacent to the resident's body;Cannot be removed easily by the resident (in the same manner it was applied by staff); andRestricts the resident's freedom of movement or normal access to his/her body. The policy further indicated that Sometimes the use of restraints in not intentional, but this does not absolve the staff of the responsibility to recognize and report the unauthorized use of restraints. Examples of physical restraints (intentional or unintentional) include: (Provided in the list of examples was) tucking in a sheet tightly so that the resident cannot get out of bed or fastening fabric or clothing so that a resident's freedom of movement is restricted. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - federally mandated assessment of a resident's abilities and care needs) dated 1/16/26, included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), anxiety, depression, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R1's score to be 9. Review of Resident R1's plan of care for risk of falls related to gait/balance problems initiated 10/13/25, indicated staff should follow the facility fall protocol. Review of Resident R1's clinical record dated 1/8/26, at 10:26 a.m. stated Head to toe assessment completed on resident. Noted scattered fading discolorations to bilateral upper extremities and scabbed areas, 0.5x 4cm left lower abdomen/pelvis linear purple discoloration. Scattered bruising to bilateral lower extremities with scabbed areas. Review of documentation submitted by the facility on 1/8/26, revealed It was reported to this DON (Director of Nursing) that resident [Resident R1] was found to be in bed with a sheet over her tied to the bed to hold her down at the beginning of 6a-2pm shift. Staff interviews being completed at this time. Alleged perpetrators noted as Nurse Aide (NA) Employee E1, NA Employee E2, and NA Employee E3, who all three worked the 10p-6a shift. No other residents were affected. Review of an employee statement written by NA Employee E1 dated 1/8/26, indicated, I was caring for the resident whenever I noticed the sheet was tied to the bed frame e on the right and left side, at two points. As I was trying to look for the RN Supervisor and the LPN (licensed practical nurse) on shift, I was answering call lights. I noticed they were not around, and the LPN was in another resident's room providing care. I finished the last round and was charting whenever dayshift CNA (nurse aide) came in. As I was giving report, I got to the resident's name, and I pulled the dayshift CNA to look at the resident. I showed her the way it was tied and asked if she wanted to help me undo it. She told me to leave it. Apparently while I was off the floor, the other CNAs were making sure she didn't fall out of the bed. I did not witness anyone tie the sheet, and I did not tie the sheet in any way to the bed frame and/or the resident. Review of a second employee statement written by NA Employee E1 dated 1/8/26, indicated, When I saw NA Employee E3, the CNA, she told me NA Employee E2 came and got her to help while I was off the floor. NA Employee E3 told me they tied the sheet to the frame to make sure the resident didn't fall out of the bed. Review of an employee statement written by NA Employee E2 dated 1/8/26, indicated, I was working 10p-6a. Resident R1 had fell out of bed twice onto her fall mat around 10:20 p.m. The RN Supervisor did not want to do a incident report and we were afraid Resident R1 would get hurt. Myself and NA Employee E3 put a bed sheet across her hips and just lightly looped it through the bed so she couldn't fall. There was no intent to hurt this resident we just didn't want her to fall, get hurt and it not get reported. We didn't know what else to do to keep her safe. We then told NA Employee E1 it was there and if she wanted to remove it she could. I did not know that the bed sheet could be considered a restraint. Review of an employee statement written by NA Employee E3 dated 1/9/26, indicated, NA Employee E2 came back to (nursing unit) because she needed help getting Resident R1 up off the floor. When I got in the room Resident R1 was laying on the fall mat. We got her back in bed. NA Employee E2 handed me a sheet and we looped it around the bed to try to keep Resident R1 safe. I didn't realize this is a restraint. Review of a facility submitted Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property dated 1/12/26, indicated, Staff did not think that placing a sheet over her was a restraint. They felt they were doing it to keep resident safe due to falls. On 2/18/26, the facility was asked to provide what literature was used to educate staff on abuse and neglect prevention, and evidence that NAs Employee E1, E2, and E3 received that education. On 2/18/26, the facility provided sign-in sheets that indicated that NA Employee E1 received education on abuse and neglect prevention on 10/29/25, and NA Employees E2 and E3 received education on abuse and neglect prevention on 10/28/25. Review of the facility provided literature used during the above education, the facility provided a copy of the facility policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program. Review of the policy stated the facility will Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. During an interview on 2/18/26, at approximately 2:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the policy utilized for abuse and neglect prevention education stated the topics that staff will have training on, but the policy did not in itself include that information, and education on those topics was not provided. During an interview on 2/18/26, at approximately 2:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to develop written policies and procedures that include training new and existing nursing home staff on abuse, neglect, misappropriation of resident property, and exploitation. This failure resulted in the actual harm of staff members being unaware that unauthorized physical restraints can be a form of physical abuse and restraining a resident to a bed with a bed sheet which caused abdominal bruising for one of eight residents. 28 Pa. Code 201.14(a): Responsibility of licensee.28 Pa. Code 201.18(b)(1)(e)(1): Management.28 Pa Code: 201.20 (b): Staff development.

Based on a review of facility provided policies and documentation, clinical records, and staff interviews, it was determined that the facility failed to ensure residents were free from physical restraints. This failure resulted in the actual harm of staff members restraining a resident to a bed with a bed sheet which caused abdominal bruising for one of eight residents (Resident R1). This was identified as past noncompliance. Findings include: Review of facility policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 1/20/26, previously reviewed 1/21/25, indicated that each resident has the right to be free from abuse, neglect, and misappropriation of resident property and exploitation. Thisincludes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Review of facility policy Identifying Involuntary Seclusion and Unauthorized Restraint dated 1/20/26, previously reviewed 1/21/25, defined a physical restraint as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria:Is attached or adjacent to the resident's body;Cannot be removed easily by the resident (in the same manner it was applied by staff); andRestricts the resident's freedom of movement or normal access to his/her body. The policy further indicated that Sometimes the use of restraints is not intentional, but this does not absolve the staff of the responsibility to recognize and report the unauthorized use of restraints. Examples of physical restraints (intentional or unintentional) include: (Provided in the list of examples was) tucking in a sheet tightly so that the resident cannot get out of bed, or fastening fabric or clothing so that a resident's freedom of movement is restricted. Review of the facility Nurse Aid Job Description indicated, To provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan and as may be directed by your supervisor in accordance with the requirements of the policies and procedures of this facility in accordance with current federal, state, and local standards governing the facility. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2025, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - federally mandated assessment of a resident's abilities and care needs) dated 1/16/26, included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), anxiety, depression, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R1's score to be 9. Review of Resident R1's plan of care for risk of falls related to gait/balance problems initiated 10/13/25, indicated staff should follow the facility fall protocol. Review of Resident R1's clinical record progress noted dated 1/8/26, at 10:26 a.m. stated Head to toe assessment completed on resident. Noted scattered fading discolorations to bilateral upper extremities and scabbed areas, 0.5x 4cm left lower abdomen/pelvis linear purple discoloration. Scattered bruising to bilateral lower extremities with scabbed areas. Review of a Shower/Skin Weekly Evaluation completed on 1/2/26 (prior to incident), failed to reveal any new skin issues. Review of nurse aide skin observations, scheduled to be completed each shift from 1/1/26, through 1/8/26, revealed each documentation as Not applicable or None of the above observed (scratched, red area, discoloration, skin tear, or open area). Review of documentation submitted by the facility on 1/8/26, revealed It was reported to this DON (Director of Nursing) that resident [Resident R1] was found to be in bed with a sheet over her tied to the bed to hold her down at the beginning of 6a-2pm shift. Staff interviews being completed at this time. Alleged perpetrators noted as Nurse Aide (NA) Employee E1, NA Employee E2, and NA Employee E3, who all three worked the 10p-6a shift. No other residents were affected. Review of an employee statement written by NA Employee E4 dated 1/8/26, indicated, After NA Employee E5 got report from NA Employee E1, NA Employee E5 told me that NA Employee E1 had tied [Resident R1] into the bed. Me and NA Employee E6 went int the room and saw that the sheet was tied from left to right to the bed frame, across her abdomen. I reported it to the RN (registered nurse) supervisor. Me and NA Employee E6 untied her. Review of an employee statement written by NA Employee E5 dated 1/8/26, indicated, During report NA Employee E1 took me back to Resident R1's room and showed me the sheet across Resident R1's abdomen, tied to the bedframe. I told NA Employee E4 and NA Employee E6 about the sheet. They went in and untied the sheet while I was with another resident. NA said Resident R1 fell on first round on night shift. Review of an employee statement written by NA Employee E6 dated 1/8/26, indicated, NA Employee E5 told NA Employee E4 that in report NA Employee E1 said Resident R1 was tied down to the bed. I told NA Employee E1 lets go untie her. When we went in she had a sheet rolled up tight going across her with the hands underneath to where she couldn't move them. The sheet was tied from one side to another. When we went to go untie it we had a hard time getting the knot out. After we asked if she was okay. We didn't get a response. We reported to RN. Review of an employee statement written by RN Employee E7 dated 1/8/26, indicated, It has been brought to my attention by my DON about abuse allegations on a resident (Resident R1). I did not witness nor am I aware of this. I checked on this resident at 1915 (7:15) p.m. and again at 6:30 a.m. She was covered both times. Review of a second employee statement written by RN Employee E7 dated 1/8/26, indicated, It has been reported to me by my DON that a fall happened at 2230 (10:30) p.m. I was not to my knowing of this incident. It was not reported to me that any residents fell on my shift, 7p-7a 1/7/26. Review of an employee statement written by RN Employee E8 dated 1/8/26, indicated, I worked overnight Jan. 7th with my shift beginning at 11 p.m. Approximately 20 minutes into my shift, I obtained vital signs on Resident R1. At that time, I did straighten out Resident R1's upper body because she was leaning to the left. I did not notice anything abnormal at that time, and I did not re-enter Resident R1's room again during my shift. Review of an employee statement written by LPN Employee E9 dated 1/8/26, indicated, Checked resident multiple times my shift. Resident noted to have legs out of bed multiple times during my shift. Resident was repositioned many times. Resident was not noted to be on the floor during my shift that I was aware of. Review of an employee statement written by NA Employee E1 dated 1/8/26, indicated, I was caring for the resident whenever I noticed the sheet was tied to the bed frame on the right and left side, at two points. As I was trying to look for the RN Supervisor and the LPN (licensed practical nurse) on shift, I was answering call lights. I noticed they were not around, and the LPN was in another resident's room providing care. I finished the last round and was charting whenever dayshift CNA (nurse aide) came in. As I was giving report, I got to the resident's name, and I pulled the dayshift CNA to look at the resident. I showed her the way it was tied and asked if she wanted to help me undo it. She told me to leave it. Apparently while I was off the floor, the other CNAs were making sure she didn't fall out of the bed. I did not witness anyone tie the sheet, and I did not tie the sheet in any way to the bed frame and/or the resident. Review of a second employee statement written by NA Employee E1 dated 1/8/26, indicated, When I saw NA Employee E3, the CNA, she told me NA Employee E2 came and got her to help while I was off the floor. NA Employee E3 told me they tied the sheet to the frame to make sure the resident didn't fall out of the bed. Review of an employee statement written by NA Employee E2 dated 1/8/26, indicated, I was working 10p-6a. Resident R1 had fell out of bed twice onto her fall mat around 10:20 p.m. The RN Supervisor did not want to do a incident report and we were afraid Resident R1 would get hurt. Myself and NA Employee E3 put a bed sheet across her hips and just lightly looped it through the bed so she couldn't fall. There was no intent to hurt this resident we just didn't want her to fall, get hurt and it not get reported. We didn't know what else to do to keep her safe. We then told NA Employee E1 it was there and if she wanted to remove it she could. I did not know that the bed sheet could be considered a restraint. Review of an employee statement written by NA Employee E3 dated 1/9/26, indicated, NA Employee E2 came back to (nursing unit) because she needed help getting Resident R1 up off the floor. When I got in the room Resident R1 was laying on the fall mat. We got her back in bed. NA Employee E2 handed me a sheet and we looped it around the bed to try to keep Resident R1 safe. I didn't realize this is a restraint. Review of a facility submitted Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property dated 1/12/26, indicated, Staff were called to facility and interviewed completed. statements reviewed. Resident has had multiple falls. Staff did not think that placing a sheet over her was a restraint. They felt they were doing it to keep resident safe due to falls. RN supervisor was in room during shift and did not note sheet over resident's abdomen but did state that resident was moving around in bed and that he had to straight her top half up because she was leaning after getting her VS (vital signs). Resident was able to move freely within the bed with the sheet over her abdomen. CNA's claim that the sheet was looped on side of the bed and over resident's abdomen and looped on the other side of the bed through the bedframe. CNA's have been with the facility long term and have no attendance issues or any other disciplines on file. Review of the facility's plan of correction initiated 1/8/26, included:Interview with all alert and oriented residents about possible resident concerns of abuse, neglect, and restraint of movement. Skin observations on all residents not able to be interviewed for possible skin integrity concerns. In depth reeducation for NA Employees E1, E2, and E3.Education to all staff on resident rights, abuse and neglect prevention, and involuntary seclusion and restraints.Audits of resident and staff care.Review of this incident and similar during QAPI (quality assurance and performance improvement) meetings. The facility was back in compliance on 1/28/26. During an interview on 2/18/26, at approximately 2:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to ensure residents were free from physical restraints. This failure resulted in a staff member restraining a resident to a bed with a bed sheet and caused abdominal bruising for one of eight residents (Resident R1). This was identified as past noncompliance. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 201.18 (b) (1) (e) (1) Management.28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.

Based on a review of select facility policy and staff interview, it was determined the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections. Findings include:During an interview on 9/9/25, at 9:08 a.m., the Director of Nursing (DON) stated that the facility just hired the Infection Control Nurse and that she is not trained and that the DON is acting as the Infection Control Nurse at this time, as she has the training. The DON confirmed that the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(1) Management.28 Pa. Code: 201.19(3) Personnel records.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to properly store food products in two of three storage areas in the main kitchen (dry storage and cooler) and failed to ensure the high temperature dishwasher log was completed consistently for one of three months (September) in the main kitchen.Findings include: A review of facility policy Dry Food Policy dated 1/21/25, indicated food storage areas shall be maintained in a clean, safe, and sanitary manner. All food or food items not requiring refrigeration shall be stored at least six inches above the floor. During an observation in the Main Kitchen on 9/9/25, at 9:40 a.m. there were multiple boxes of dry storage supplies stacked on the floor in the hall outside of the dietary office. These items included cases of the following: Thick & Easy nectar thick drink, mandarin oranges, pears, applesauce, mashed potatoes, eight-ounce cans of cola, [NAME] pasta, Toasty-O's cereal, Frito Lay chips, Crispy [NAME] cereal, [NAME] cookies, Dole diced peaches, peanut butter cracker sandwiches, and two cases of breakfast syrup. During observation of the cooler, a broken egg was noted on the second shelf with egg white dripping onto the top of a box of liquid eggs.During an interview on 9/9/25, at 940 a.m. [NAME] Employee E16 stated they received the facility food order on 9/8/25. She confirmed there were not enough staff to put all the supplies away. She confirmed the broken egg should not be left in the cooler and disposed of properly.During an observation on 9/9/25, at 10:00 a.m. September's dishwasher temperature log was not completed for two of nine days during breakfast dishes, eight of nine days for lunch dishes, and nine of nine days for dinner dishes.During an interview on 9/9/25, at 10:50 a.m. the Nursing Home Administrator (NHA) confirmed the facility was experiencing issues with staff retention in the Dietary Services Department.During an observation on 9/10/25, at 9:00 a.m. the dry storage supplies were still located on the floor outside of the dietary office. During an interview on 9/10/25, at 12:15 p.m. the NHA confirmed that the facility failed to properly store supplies in the dry storage, broken eggs should be disposed of properly and timely, and the dishwasher temperature log was not completed completely for September 2025.28 Pa. Code: 211.6(c) Dietary Services.

Based on observations, and staff interviews, it was determined that the facility failed to provide sufficient dietary staff to perform essential kitchen duties.Based on observation and staff interviews, it was determined that the facility failed to have sufficient dietary staff to perform essential kitchen duties.Findings include:Review of facility dietary department policy Master Staffing Plan reviewed 1/20/25, indicated the dietary department is adequately staffed to provide safe, high quality food service to residents. Staffing levels will be developed by the administrator and the department management team.During an interview on 9/9/25, at 9:40 a.m. [NAME] Employee E16 stated sometimes the facility only has two or three staff members in the kitchen to serve 110 residents (census on 9/9/25). They stated sometimes someone from housekeeping comes and helps them in the kitchen. They stated lunch tray line was supposed to start at 11:15 a.m.During an observation on 9/9/25, at 9:42 a.m. three employees were noted to be working the day shift on 9/9/25. [NAME] Employee E16, Dietary Aid Employee E18, and Dietary Aid Employee E19.Review of the posted tray delivery times indicated that the main dining room is to be served first at 11:30 a.m., for lunch meal.During an observation on 9/11/25, at 11:15 a.m. lunch tray line was delayed due to a breakfast cart that was not cleaned out of soiled resident breakfast trays that morning. Dietary Aid Employee E18 was in the process of emptying the soiled breakfast cart. Tray line began at 11:52 a.m. The trays for the residents in the dining room left the kitchen at 12:08 p.m. During an observation on 9/11/25, from 11:30 a.m., through 12:17 p.m., of the main dining room identified 12 residents sitting waiting for their lunch meals.During an interview on 9/11/25, at 11:40 a.m., Licensed Practical Nurse (LPN) Employee E3 and Nurse Aide (NA) Employee E4 stated that the food carts are often late, and residents do not get everything they are supposed to on their trays.During an observation on 9/11/25, at 11:45 a.m., LPN Employee E3 went to get cookies for five of the 12 residents as they had been given insulin and the dietary department staff indicated that the trays would be delivered late. During an interview on 9/11/25, at 11:47 a.m., LPN Employee E3 stated that if the dietary department is serving late, they should let staff know to be able to hold insulin for residents going to the dining room so there is not a problem. LPN Employee E3 stated often there is only a spoon for residents to eat their breakfast in the morning as there is not enough silverware.During an observation on 9/11/25, at 12:17 p.m., the dining room cart was delivered, 45 minutes late. The staff delivering the cart was identified as Environmental Services Employee E8, who stated the kitchen does not have enough staff so I came to help.During an interview on 9/11/25, at 11:50 a.m., the Nursing Home Administrator confirmed that the meals are late due to low staffing in the kitchen.28 Pa. Code 201.18(e)(6) Management.28 Pa. Code 201.20(b) Staff Development.

Based on review of job descriptions, and staff interviews, it was determined that the facility failed to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian. Findings include:Review of the job description for Registered Dietician (RD) indicated the primary purpose in this position is to plan, organize, coordinate, and evaluate the nutritional components of dietary services for the facility. The essential job function includes the following: -Counsels residents, their responsible parties and facility staff on sound nutritional practices to promote food health. -Oversees the duties and functions of the Dietary Manager and other staff as instructed by the facility.Review of the job description for Food Service Director indicated the primary purpose in this position is to plan, organize, develop, and direct the overall operation of the Food Services department.During an interview on 9/9/25, at 9:40 a.m. [NAME] Employee E16 confirmed there was not a Dietary Manager at the facility. A new dietary manager was hired and starting orientation on 9/9/25. They stated there has not been a dietary manager in the kitchen for two weeks.During an interview on 9/9/25, at 9:49 the new Dietary Manager Employee E17 stated she started the Dietary Manager position on 9/9/25. She stated that she currently did not have her CDM (Certified Dietary Manager) and was not currently enrolled in the program. She had her ServSafe certification.During an interview on 9/9/25, at 10:50 a.m. the Nursing Home Administrator confirmed there was not a full-time dietitian employed at the facility and that the facility did not employ a qualified dietary manager in the absence of a full-time dietitian.

Based on a review of facility policy, resident interviews, resident council meeting, resident choice menu selections, and meal observations, it was determined that the facility failed to provide resident selected menu items for 12 of 12 residents (Resident R6, R8, R24, R43, R57, R101, R2, R500, R501, R502, R503 and R504).Findings include: Review of the facility policy Resident Food Preferences, dated 1/21/25, indicated that individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent.During an interview on 9/9/25, at 10:08 a.m., with Residents R6, R24 and R101, indicated that the dietary department does not serve all items on ticket and cannot get an alternate if requested.During an interview on 9/9/25, at 10:15 a.m., Resident R57 stated the facility serves a lot of rice and eggs. Cannot get alternate if requested.During the resident council meeting on 9/10/25, at 11:15 a.m., the consensus of the group indicated that last night French fries were to be served, and some received mashed potatoes instead. If you're supposed to have 12 items on your tray, you may get six. For breakfast you may get a hard piece of unbuttered toast and a hardboiled egg.During an interview on 9/11/25, at 11:40 a.m., Licensed Practical Nurse (LPN) Employee E3 and Nurse Aide (NA) Employee E4 stated that the food carts are often late, and residents do not get everything they are supposed to on their trays.During an observation on 9/11/25, at 12:17 p.m., Resident R43 was to receive a carton of 2% milk and a can of diet cola, these items were not on her tray. Resident R43 stated this always happens. During an observation on 9/11/25, at 12:21 p.m., Resident R8 was to receive a packet of Ms. Dash and a diet ginger ale, these items were not on her tray. I am always missing things on my tray. During an interview on 9/11/25, at 2:26 p.m., the Nursing Home Administrator confirmed that the facility failed to provide resident selected menu items for 12 of 12 residents (Resident R6, R8, R24, R43, R57, R101, R2, R500, R501, R502, R503 and R504). 28 Pa. Code 201.18(e)(6) Management.28 Pa Code: 211.6(a) Dietary service.

Based on review of personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for five of five nurse aides (NA Employee E11, E12, E13, E14 and E15).Findings include:Review of personnel files revealed that Nurse Aide Employee E11 hire date was 8/27/24, there was no performance evaluation was completed.Review of personnel files revealed that Nurse Aide Employee E12 hire date was 8/27/24, there was no performance evaluation was completed.Review of personnel files revealed that Nurse Aide Employee E13 hire date was 7/18/23, there was no performance evaluations completed in file.Review of personnel files revealed that Nurse Aide Employee E14 hire date was 4/19/23, there was no performance evaluations completed in file.Review of personnel files revealed that Nurse Aide Employee E15 hire date was 4/5/23, there was no performance evaluations completed in file.During an interview on 9/12/25, at 8:37 a.m., the Director of Nursing confirmed that the facility does not have up to date performance appraisals completed on NA Employee E11, E12, E13, E14 and E15 as required. 28 Pa Code: 201.20 (a)(b)(c)(d) Staff development.28 Pa Code: 201.14 (a) Responsibility of licensee.

Based on observations, review of facility policy, resident, and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment on two of two nursing units (A and B nursing units). Based on observations, review of facility policy, resident, and staff interview, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment on two of two nursing units (A and B Nursing Units). Findings include: Review of the facility policy Homelike Environment dated 1/21/25, indicated in part the facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean bed and bath linens that are in good condition. During an interview on 9/11/25, from 11:29 a.m., through 12:25 p.m., Licensed Practical Nurse Employee E3 and Nurse Aide Employee E4 stated that they had wipes before and now the facility took them away, washcloths are to be used but staff will not reuse a washcloth on a person's face after the day before it was used to wash another resident's private areas. Staff often throw away washcloths after used on a resident's private parts when they are bathed. During an observation on 9/11/25, at 1:00 p.m., the A and B nursing unit linen carts were observed to have three to five wash cloths available for use. During an interview on 9/11/25, at 1:42 p.m., Laundry staff employees E5 and E6 stated that the facility has provided additional washcloths for staff to use however, the staff are throwing them away and it's difficult to maintain a certain number on linen carts for resident use. During an interview on 9/12/25 at 12:20 p.m., the Nursing Home Administrator stated that he is aware staff throwing away washcloths and has attempted to keep stocked. The facility failed to provide a safe, comfortable and homelike environment for the residents of the first and second floor nursing units. During an interview on 9/12/25, at 12:20 p.m., the Corporate Regional Clinical Director Employee E7 stated I told them about the need for wipes. During observations of the A wing nursing units on 9/9/25 from 9:30 a.m., through 11:10 a.m., the following was observed: Residents R11 and R35's room had the bathroom floor trim lifting and under heater soiled. Residents R58 and R60 room had bathroom floor trim lifted and clothes cabinet by bathroom edges broken and sharp. Resident R14 room had broken area at bottom of clothes cabinet and the wall near the heater was scratched. Residents R31 and R10 room had lifted floorboards, and the toilet lid was lifted. Residents R54 and R42 room had floor trim lifted in room and in bathroom and the bathroom heater was dented leaving sharp edges. Residents R67 and R89 room had lifted floor trim and bathroom and a ceiling tile above sink missing. Residents R77 and R78 room had bathroom wall trim lifted. The sink area in the kitchenette had cabinet damage and a brown substance covering the edges. The septic drain in the hall was uneven leaving a potential tripping hazard. Residents R22 and R48 room had the covering of the wall lifting. Residents R39 and R76 room had area by bathroom wall damage. Residents R20 and R57 room had the bathroom flooring completely lifting and water damaged, leaving tripping hazards and a moldy odor, Resident R57 stated that it's been like that, and the odor gets worse with the door closed. The wall trim in the room needing repaired. Residents R72 and R2 room had scraped wall by heater and cabinet and the bathroom door needing repaired. During an interview on 9/9/25, at 11:10 a.m., Maintenance Director Employee E1 confirmed that the facility failed to provide a safe, clean, comfortable, and homelike environment on two of two nursing units (A and B Nursing Units). During a tour of the B side Unit 9/9/25, between 9:30 a.m. and 10:00 a.m. the following were observed: - Resident R59's wall had gouges in it.- Resident R82's bathroom flooring with cracks approximately 1/4 inch wide in multiple areas.- Resident R83's wall with gouges in it behind the bed.- Resident R104's wall with a big white plastered spot unpainted by the door. During an interview and tour on 9/9/25, at 11:13 a.m. Maintenance Director Employee E1 confirmed the above findings. During an interview on 9/12/25/25, at 11:00 a.m. the Nursing Home Administrator confirmed that the facility failed to maintain a homelike environment on 28 Pa. Code: 201.18(b)(3) Management 28 Pa. Code: 207.2(a) Administrator's responsibility. 28 Pa. Code: 201.29(k) Resident rights.

Based on review of facility documents, resident clinical records and staff interviews it was determined that the facility failed to ensure residents had the capacity to understand the terms of a binding arbitration agreement (A binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not.) for one of five residents (Resident R6). Findings include: A review of the admission record indicated Resident R6 was admitted to the facility on [DATE]. A review of Resident R6's Binding Arbitration Agreement indicated that the resident signed the document on 4/28/25. A review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/13/25, indicated the diagnoses of high blood pressure, hip fracture, and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Section C0500 BIMS (Brief Interview for Mental Status - a screening test that aids in detecting cognitive impairment) indicated a score of six (score 0-7: severe impairment).During an interview on 9/11/25, at 1:54 p.m. the Nursing Home Administrator confirmed Resident R6's BIMS was a six and that the facility failed to ensure a resident had the capacity to understand the terms of a binding arbitration agreement for one of five residents (Resident R6). 28 Pa. Code: 201.18(e)(1) Management

Based on review of facility policy, clinical record review, and staff interview it was determined that the facility failed to provide adequate supervision to prevent elopement for one of three residents (Resident R120).Findings include:Review of the facility policy Accidents and Incidents dated 1/21/25, indicated that all accidents involving residents shall be investigated. Review of the facility policy Wandering and Elopements, dated 1/21/25, indicated that the facility will identify resident who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The resident's care plan will include strategies and interventions to maintain resident safety. Resident R120 was admitted to the facility on [DATE] with diagnoses which included dementia with behavioral disturbances, impulsive disorder, opioid abuse with opioid abuse disorder, aphasia, stroke and lung disease. Resident R120 was placed on the secured dementia unit upon admission as he had been identified to be an elopement risk.During an interview on 9/9/25, at 2:30 p.m., the Director of Nursing stated that Resident R120 had eloped from the facility at approximately 1:47 p.m. through a window which he had removed. Staff had stated that Resident R120 was in the solarium of the locked memory care unit and staff were passing trays to residents in their rooms and one staff member sat in the solarium assisting residents. The Nurse Aide in the solarium stated she saw the resident standing in the hallway with a brown paper bag. Nurse Aide came into the hall and noticed the window removed from the frame in room [ROOM NUMBER] adjacent to the solarium area and saw Resident R120 climbing out of the window. The staff stated they let him continue as Resident R120 can become agitated, and they were afraid he would hurt himself or them if they stopped him at that point. Resident R120 proceeded to walk to the walkway outside the window and staff watched him. Resident R120 walked to the edge of the walkway to the picnic table placed at the edge of the driveway and a staff member met him there. By this time the police had been called and an ambulance and the staff sat with him while his need to go to hospital was discussed and the police made certain he went with the ambulance attendees. Resident R120 will not be returning to the facility. The facility submitted and event report as required.During an observation of resident room [ROOM NUMBER], the window had been replaced and secured. The windows of the memory care unit all have security locks attached however, they are not alarmed. The window was difficult to keep open as it is heavy. Resident R120 had a history of being a carpenter, so the facility identified that he may have been aware of how to remove the window.Review of Resident R120's hospital record previous to his admission identified that Resident R120 had eloped from a previous facility and was found in the street jumping in front of cars. The hospital documentation indicated that he had become aggressive with staff when they tried to get him to return attempting to hit them with a stick. The hospital had adjusted his medications and indicated he had become less aggressive and seemed to have been calmer prior to his discharge to the facility. During an interview on 9/9/25, at 2:37 p.m., the DON was informed that the facility failed to provide adequate supervision to prevent elopement for one of three residents (Resident R120). 28 Pa. Code 201.14 (a) Responsibility of licensee28 Pa. Code 201.18 (b)(1) Management28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on clinical record review, resident interview and staff interview it was determined that the facility failed to inform residents of their right to choose their attending physician and discuss the options of physician participation with the resident and honor the residents' preferences for six of 11 residents (Residents R40, R94, and Residents R200, R201, R202 and R203).Findings include:Review of the admission record indicated Resident R40 was admitted to the facility on [DATE], with the diagnoses of osteoarthritis (flexible tissue at the ends of bone wears down), abnormal posture, and depression. Review of the Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/21/25, indicated the diagnoses remain current. Section C0500 indicated the Brief Interview for Mental Status (BIMS - is a screening test that aids in detecting cognitive impairment) score was 15 - cognitively intact.During an interview on 9/9/25, at 2:10 p.m. Resident R40 indicated not being satisfied with the attending physician who was the Medical Director. Indicated that resident had a tooth ache and the Medical Director refused to order Orajel (a local anesthetic that blocks the pathway of pain signals along the nerves and relieves pain by numbing the area) and told the resident to take Tylenol. When asked why they would not request a new physician if they were unsatisfied, the resident indicated being unaware of the right to choose their own attending physician and was under the assumption the Medical Director was the only physician at the facility.A review of the admission record indicated Resident R94 was admitted to the facility on [DATE], with the diagnoses of chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) and heart failure (heart doesn't pump blood as well as it should). Review of the MDS dated [DATE], indicated the diagnoses remain current. Section C0500 indicated a BIMS score of 15 - cognitively intact.During an interview on 9/11/25, at 11:20 a.m. Resident R94 indicated not being satisfied with the attending physician who was the Medical Director. Indicated the Medical Director does not listen to the residents' concerns and doesn't believe in giving pain pills, only Tylenol. When asked why they would not request a new physician if they were unsatisfied, the resident indicated being unaware of the right to choose their own attending physician and was under the assumption the Medical Director was the only physician at the facility.During a group interview with four residents (Residents R200, R201, R202, R203) on 9/10/25, at 11:00 a.m. the group's consensus was that the Medical Director was not preferred by most residents due to poor bedside manners and the group referred to the physician as Dr. Tylenol, who does not listen to the residents' concerns. The group agreed, being unaware there were other physicians to choose from for their attending physician.Interview on 9/11/25, at 11:45 a.m. the Director of Nursing confirmed the facility failed to inform residents of their right to choose their attending physician and discuss the options of physician participation with the resident and honor the residents' preferences for six of 11 residents (Resident R40, R94, and Residents R200, R201, R202, R203).28 Pa. Code: 211.2(d)(6) Medical Director28 Pa. Code: 211.2(d)(8) Medical Director

Based on review of facility policies, clinical records, incident reports, resident and staff interviews, it was determined that the facility failed to provide adequate supervision and implement effective transfer interventions as per physician order to promote resident safety, resulting in a preventable accident and actual harm (13 centimeter laceration) for one out of six residents (Resident R1). Findings include: The facility Safe resident handling and movement policy, last reviewed on 7/16/21, indicated that residents are evaluated upon admission and periodically in order to determine the amount of assistance required for mobility, ambulation, repositioning, and transfer. The team will use the facility lift evaluation form when determining and identifying the means for providing transfer and mobility assistance for residents. Manual lifting of residents who are unable to bear weight or ambulate without total assistance will be avoided or minimized to the extent possible. Review of Resident R1's admission record indicated resident was recently admitted on [DATE], with diagnoses that included hypertension, fall history, depressive disorder, fracture to left hip joint, [CONDITION(S)] (a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), and anxiety disorder. Review of Resident R1's admission MDS assessment (MDS-Minimum Data Set Assessment: periodic assessment of resident care needs) dated 6/25/21, indicated that the diagnoses remain current. Review of Resident R1's lift/transfer evaluation form dated 6/18/21, indicated resident was an assist of two persons and non-weight bearing on her lower left extremity. Review of Resident R1's physician orders dated 6/28/21, indicated resident was ordered a transfer assist of two persons, with wheeled walker, and non-weight bearing on lower left leg extremity. Review of Resident R1's Kardex (document nurse aides use to quickly obtain care needs and concerns) dated 7/29/21, indicated that Resident R1's was a transfer assist of two persons with wheeled walker, and was non-weight bearing on left lower extremity. Review of Resident R1's nurse progress note dated 7/29/21, indicated LPN (Licensed Practical Nurse) stated resident received a laceration during transfer. Assessed resident and observed a 13 cm x 6 cm laceration posterior LLE (left lower extremity). Area cleansed pressure applied, bleeding ceased. Notified physician and order received to transfer to hospital; also notified daughter. Talked with staff and was informed by Agency Nurse Aide (NA) Employee E1 that he transferred resident from wheelchair to bed and leg got caught on area of chair where the wheelchair legs attach. Resident is transfer with assist of two and is non-weight bearing (NWB) on LLE. Review of Resident R1's skin alteration/incident report dated 7/29/21, indicated that Resident R1's was observed with left leg bleeding. Area was open with adipose tissue (fatty tissue under the skin) visible. Leg assessed and observed with 13 cm x 6 cm laceration, pressure applied. Physician notified and received order to transport her to the hospital. Agency NA Employee E1 was documented as a witness. Review of Staff witness statement dated 7/29/21, indicated Agency NA Employee E1 was transferring Resident R1's into bed when her leg got caught onto the wheelchair causing a cut. Agency NA Employee E1 stated that he did not look in the careplan to check residents actual transfer status. Review of Licensed Practical Nurse (LPN) Employee E2 Staff witness statements dated 7/29/21, indicated that NA Employee E1 contacted her for help because Resident R1's leg was bleeding. Review of Resident R1's physician order dated 7/29/21, indicated to transfer Resident R1's to the hospital for evaluation to left lower leg laceration. Review of Resident R1's nurse progress note dated 7/29/21, at 5:00 p.m. indicated that Therapy notified to assess wheelchair post incident for any sharp edges. Upper wheelchair arms and areas padded earlier in day for arm protection by therapy. Therapy did not see any sharp areas to lower parts of the wheelchair, area to back of leg may be consistent with area where leg rests attach, per therapy. Leg rests attachment are not sharp, and edges are smooth. Review of Resident R1's hospital discharge record dated 7/29/21, indicated resident was admitted to the hospital emergency department on 7/29/21, at 4:28 p.m. due to left lower leg laceration that occurred while at a nursing home. Hospital record indicated that Resident R1's laceration was eight centimeters in length and she received 14 sutures. Review of Resident R1's nurse progress note dated 7/29/21, at 8:44 p.m. indicated that Resident R1's returned from hospital via stretcher, Left lower posterior leg with 14 sutures intact, suture line well approximated, no drainage, dressing dry and intact, denies any pain to site. Review of Agency NA employee E1 personnel record indicated he was hired by his agency on 12/22/2020. His record included a professional service agreement, which was first signed on 6/1/21, between himself and the facility indicating his start date. Review of Agency NA Employee E1 personnel record indicated training on resident safety titled National patient safety goals with a completion date of 12/24/2020. This training included fall prevention and identifying safety risks. Review of Agency NA Employee E1 personnel file indicated he received in-service training on resident rights, abuse and neglect on 12/24/20, 12/25/20, 12/30/20, and 1/5/21. During observations on 8/11/21, at 9:58 a.m. Resident R1's was observed with left leg wrapped from ankle to mid-calf, no odors, no discoloration, resident appears well groomed, wearing shorts, sitting in her wheelchair with foam on the wheelchair arms. During an interview on 8/11/21, at 10:00 a.m. Resident R1 stated that leg was wrapped up because one of the aides ran a wheelchair into my leg. She got 11 stitches and the wheelchair was not locked. Resident stated the aide involved with the incident was still working at the facility. Resident stated currently felt safe but was in mild pain, four out of ten. During an interview on 8/11/21, at 10:17 a.m. LPN Employee E2 stated that Agency NA Employee E1 came out of Resident R1's room and said Resident R1's had a skin tear. RN Supervisor Employee E4 and LPN Employee E2 entered the room and assessed leg, they obtained saline and gauze and applied pressure. She paged RN Supervisor Employee E3 to come over. Agency LPN Employee E6 was also present. LPN Employee E2 stated the laceration looked about 10cm long at first, blood was dripping from Resident R1's left leg. During an interview on 8/11/21, at 10:34 a.m. Registered Nurse (RN) Supervisor Employee E3 stated that the other RN supervisor Employee E3 was contacted by RN Supervisor Employee E4. RN Supervisor E3 went into the room and looked at the left leg. RN supervisor E3 spoke to Agency NA Employee E1 and he stated that he transferred the resident by himself. The leg got caught on the wheelchair where he had taken the leg rest off. RN Supervisor Employee E3 saw Resident R1's sitting on the bed, denied any major pain. RN Supervisor Employee E3 stated that Resident R1's leg looked like there was some yellow adiposity tissue, minimal bleeding at the time. Resident's skin is thin. RN Supervisor Employee E4 had already done some first aide. Laceration length was maybe about seven centimeters long. RN Supervisor Employee E3 stated that Resident R1's was a transfer assist of two persons. She stated the Director of Nursing was alerted immediately about the incident. Resident R1's was given fist aide, wound was cleansed, called physician, and was transferred out for sutures. RN Supervisor Employee E3 requested the therapy department assess Resident R1's wheelchair that evening. The next morning, therapy padded the wheelchair on round nodules and pegs as a prevention. During an interview on 8/11/21, at 12:12 p.m. Agency Nurse NA Employee E1 stated that he took care of Resident R1 the date the incident happened. Agency NA Employee E1 was notified resident was an assist of one, and he did not check the Kardex. Agency NA Employee E1 was assisting resident on 7/29/21. The little hooks located on the chair rest is what caught resident's leg. He took the feet rest off to transfer. When he transferred Resident R1's, left leg caught onto the hook. Agency NA Employee E1 stated Resident R1's pain level was a 10 out of 10 during the incident. He stated resident was not a hoyer lift, but an assist of two persons for transfers. He stated that staff review the Kardex to know transfer status. Agency NA Employee E1 recalled getting assistance from LPN Employee E2 and RN Supervisor Employee E4. He stated he received training on abuse prevention and transfers prior to working with Resident R1's. During an interview on 8/11/21, at 12:47 p.m. RN Supervisor Employee E4 stated that Resident R1's suffered a laceration to the left lower leg. She saw Resident R1's laying in bed, she contacted the physician about the laceration, and Resident R1 was sent out to the hospital. She recalled seeing fatty tissue in the laceration. The laceration length was eight or ten centimeters, not a lot of blood. We cleansed wound and then sent resident to hospital. Used saline and wrapping. She stated that the cause of the laceration was the left leg got caught on pin where wheelchair leg fits. Resident R1's has thin skin. Resident R1's was very frail. During an interview on 8/11/21, at 1:17 p.m. Physical therapy assistant Employee E5 stated that Resident R1's ability to transfer is an assist of two persons due to her inability to bear weight on her legs. She stated the weight bearing status was two person assist prior to 7/29/21 incident, and that has not changed. Resident R1 should still be assistance of two to transfer. During an interview on 8/11/21, at 2:01 pm. Agency LPN Employee E6 stated that she remembers someone coming out and saying the Resident R1's leg was bleeding. She placed dressing on it wound to slow the bleeding. She stated Resident R1's laceration was rather deep. The laceration did not bleed a lot and Resident R1's was in moderate pain. During an interview on 8/12/21, at 12:31 p.m. Occupational Therapy assistant Employee E7 stated that she provided a yellow foam cover for the arms of Resident R1's wheelchair. Nursing department requested the wheelchair be looked at and she padded the wheelchair as a prevention measure. During an interview on 8/16/21, at 3:54 p.m. the Director of Nursing (DON) and Nursing Home Administrator (NHA) both confirmed that the faiclity failed to provide adequate supervision and implement effective transfer interventions as per physician order to promote resident safety resulting in a preventable accident and actual harm to Resident R1. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 7/16/21. 28 Pa. Code 211.10(d) Resident care policies 28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policies, clinical records, incident reports, personnel records, resident and staff interviews, it was determined that the facility failed to ensure that a resident was free from neglect by providing the necessary services, which resulted in actual physical harm (13 centimeter laceration) for one out of six residents (Resident R1). Findings include: The facility Abuse policy, last reviewed on 7/16/21, indicated that the facility prohibits the mistreatment, neglect, and abuse of residents and misappropriation of resident property by anyone. The facility has designed and implemented processes, which strive to ensure the prevention of alleged resident abuse, neglect, and mistreatment. Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of Resident R1's admission record indicated she was recently admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's admission MDS assessment (MDS-Minimum Data Set Assessment: periodic assessment of resident care needs) dated 6/25/21, indicated that the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident R1's lift/transfer evaluation form dated 6/18/21, indicated she was an assist of two persons and non-weight bearing on her lower left extremity. Review of Resident R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's Kardex (document nurse aides use to quickly obtain care needs and concerns) dated 7/29/21, indicated that Resident R1's was a transfer assist of two persons with wheeled walker, and she was non-weight bearing on her left lower extremity. Review of Resident R1's nurse progress note dated 7/29/21, indicated LPN (Licensed Practical Nurse) stated resident received a laceration during transfer. Assessed resident and observed a 13 x 6 cm laceration posterior left lower extremity (LLE). Area cleansed pressure applied, bleeding ceased. The physician was notified and an order received to transfer to hospital; also notified daughter. Talked with staff and was informed by Agency Nurse Aide (NA) Employee E1 that he transferred resident from wheelchair to bed and her leg caught on an area of the chair where wheelchair legs attach. Resident R1 is transfer with assist of two and is non-weight bearing (NWB) on LLE. Review of Resident R1's skin alteration/incident report dated 7/29/21, indicated that Resident R1's was observed with left leg bleeding. Area was open with adipose tissue (fatty tissue under the skin) visible. Leg assessed and observed with 13cm x 6cm laceration, pressure applied. physician was notified and received order to transport resident to the hospital. Agency NA Employee E1 was documented as a witness. Review of staff witness statement dated 7/29/21, indicated Agency NA Employee E1 was transferring Resident R1 into bed when resident's leg got caught onto the wheelchair causing a cut. He stated that he did not look in the careplan to check her actual transfer status. Review of Licensed Practical Nurse (LPN) Employee E2 Staff witness statements dated 7/29/21, indicated that Nurse aide Employee E1 contacted her for help because Resident R1's leg was bleeding. Review of Resident R1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's nurse progress note dated 7/29/21, at 5:00 p.m. indicated that Therapy Department was contacted to assess Resident R1's wheelchair post incident for any sharp edges. The upper wheelchair arms and areas padded earlier in day for arm protection by therapy. Therapy did not see any sharp areas to lower wheelchair, area to the back of leg may be consistent with area where leg rests attach, per therapy. Leg rests attachment are not sharp, edges smooth. Review of Resident R1's hospital discharge record dated 7/29/21, indicated that resident was admitted to the hospital emergency department on 7/29/21, at 4:28 p.m. due to left lower leg laceration that occurred while at a nursing home. Hospital record indicated that Resident R1's laceration was eight centimeters in length and received 14 sutures. Review of Resident R1's nurse progress note dated 7/29/21, at 8:44 p.m. indicated that resident returned from hospital via stretcher, Left lower posterior leg with 14 sutures intact, suture line well approximated, no drainage, dressing dry and intact, denies any pain to site. Review of Agency NA employee E1 personnel record indicated he was hired by his agency on 12/22/20. His personnel record included a professional service agreement, which was first signed on 6/1/21, between himself and the facility indicating his start date. Review of Agency NA Employee E1 personnel record indicated a training on resident safety titled National patient safety goals with a completion date of 12/24/20. This training included fall prevention and identifying safety risks. Review of Agency NA Employee E1 personnel record indicated that he received in-service training on resident rights, abuse and neglect on 12/24/20, 12/25/20, 12/30/20, and 1/5/21. During observations on 8/11/21, at 9:58 a.m. Resident R1's was observed with her left leg wrapped from ankle to mid-calf, no odors, no discoloration, resident appears well groomed, wearing shorts, sitting in her wheelchair with foam on the wheelchair arms. During an interview on 8/11/21, at 10:00 a.m. Resident R1 stated that her leg was wrapped up because one of the aides ran a wheelchair into my leg. Resident wheelchair was not locked. Resident R1 stated the aide involved in the incident was still working at the facility. Resident stated currently felt safe but was in mild pain, 4 out of 10. During an interview on 8/11/21, at 10:17 a.m. LPN Employee E2 stated that Agency NA Employee E1 came out of Resident R1's room and said Resident R1 had a skin tear. Registared Nurse (RN) Supervisor Employee E4 and LPN Employee E2 entered the room and assessed her leg, they obtained saline and gauze and applied pressure. Paged RN Supervisor Employee E3 to come over. Agency LPN Employee E6 was also present. LPN Employee E2 stated the laceration looked about 10cm long at first, blood was dripping from Resident R1's left leg. During an interview on 8/11/21, at 10:34 a.m. RN Supervisor Employee E3 stated that the other RN supervisor Employee E3 was contacted by RN Supervisor Employee E4. RN Supervisor E3 went into the room and looked at the left leg. RN supervisor E3 spoke to Agency NA Employee E1 and he stated that he transferred the resident by himself. The leg got caught on the wheelchair where he had taken the leg rest off. RN Supervisor Employee E3 saw Resident R1's sitting on the bed, resident denied any major pain. RN Supervisor Employee E3 stated that Resident R1's leg looked like there was some yellow adiposity tissue, minimal bleeding at the time. Resident R1's skin is thin. RN Supervisor Employee E4 had already done some first aide on it. Laceration length was approximatley seven centimeters long. RN Supervisor Employee E3 stated that Resident R1 was a transfer assist of two persons. She stated the Director of Nursing was alerted immediately about the incident. Resident R1's was given fist aide, Resident's wound was cleansed, called physician, and was transferred out for sutures. RN Supervisor Employee E3 requested the therapy department assess Resident R1's wheelchair that evening. The next morning, therapy padded the wheelchair on round nodules and pegs as a prevention. During an interview on 8/11/21, at 12:12 p.m. Agency NA Employee E1 stated that he took care of Resident R1 the date the incident happened. He stated he was notified she was an assist of one, and he did not check the Kardex. Agency NA Employee E1 was assisting resident on 7/29/21 and the little hooks located on the chair rest is what caught residents leg. He took her feet rest off to transfer her. When he transferred Resident R1's, left leg caught onto the hook. Agency NA Employee E1 stated Resident R1's pain level was a 10 out of 10 during the incident. He stated Resident R1 was not a hoyer lift, but an assist of two persons for transfers. He stated that staff review the Kardex to know transfer status. Agency NA Employee E1 recalled getting assistance from LPN Employee E2 and RN Supervisor Employee E4. He stated he received training on abuse prevention and transfers prior to working with Resident R1. During an interview on 8/11/21, at 12:47 p.m. RN Supervisor Employee E4 stated that Resident R1's suffered a laceration to the left lower leg. She saw Resident R1's laying in her bed, she contacted the physician about the laceration, and Resident R1 was sent out to the hospital. She recalled seeing fatty tissue in the laceration. The laceration length was eight or ten centimeters, not a lot of blood. Staff cleansed her wound and then sent her out. Used saline and wrapping. She stated that the cause of the laceration was the left leg got caught on pin where wheelchair leg fits. Resident R1 has thin skin and was very frail. During an interview on 8/11/21, at 1:17 p.m. Physical therapy assistant Employee E5 stated that Resident R1's ability to transfer is an assist of two persons due to inability to bear weight on legs. She stated the weight bearing status was two person assist prior to 7/29/21, incident, and that has not changed. Resident R1 should still be assistance of two to transfer. During an interview on 8/11/21, at 2:01 pm. Agency LPN Employee E6 stated that she remembers someone coming out and saying the Resident R1's leg was bleeding. She applied a dressing (4x4 gauze), to slow the bleeding. She stated Resident R1's laceration was rather deep. The laceration did not bleed a lot and Resident R1's was in moderate pain. During an interview on 8/12/21, at 12:31 p.m. Occupational Therapy assistant Employee E7 stated that she provide a yellow foam cover for the arms of Resident R1's wheelchair. Nursing department requested the wheelchair be looked at and she padded the wheelchair as a prevention measure. During an interview on 8/16/21, at 3:54 p.m. the Director of Nursing (DON) and Nursing Home Administrator (NHA) both confirmed that the facility failed to ensure that Resident R1 was free from neglect by providing the necessary services, which resulted in her suffering a laceration and actual physical harm. 28 Pa Code 201.14(a) Responsibility of licensee. 28 Pa Code 201.18(b)(1)(e)(1) Management. 28 Pa Code 201.29(a)(j) Resident rights. 28 Pa Code 211.12(d)(1)(5) Nursing services. 28 Pa Code 211.12(d)(3) Nursing services.