Every finding on record at Wecare at South Hills Rehabilitation and NRSG CTR

Based on facility review of policy, manufacturer's instructions, clinical records, and resident and staff interviews, the facility failed to notify physicians of elevated or decreased Capillary Blood Glucose (CBG) levels, failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood sugar), and failed to ensure the provision of insulin (injectable medication to treat high blood sugar) according to physicians' orders and manufacturing instructions which resulted in immediate jeopardy for eight of fourteen residents (R4, R6, R11, R19, R25, R32, R47, and R56).Review of the United States Food and Drug Administration prescribing information dated 03/2013, indicated that Humalog (insulin lispro) is a rapid acting insulin and directed to Administer within 15 minutes before a meal or immediately after a meal. Review of the United States Food and Drug Administration prescribing information dated 02/2015, indicated that Novolog (insulin aspart) and Should be generally given immediately (within 5-10 minutes) prior to the start of a meal. Findings include: Review of the facility provided document, Diabetes Management: Glucose Monitoring, Notification, and Documentation (undated) indicated: Timely Physician Notification ProceduresNotify the provider immediately for:Hypoglycemia (BG [blood glucose] < 70 with symptoms)Severe hyperglycemia (BG > provider-specific upper limit)Changes in mental status, level of consciousness, or refusal to eat. Documentation ExpectationsDocument the BG levels in designated flow sheets and EMR (electronic medical record).Record:Time and value of BG checkActions taken (e.g. insulin administered, glucose tabs given)Notification details: who was notified, time, and responseResident's response to interventionAny deviation from normal protocol and the reason Diabetes ProtocolsFollow facility-specific protocols for:Hypoglycemia: Give juice/glucose tabs, recheck in 15 minutes, documentHyperglycemia: Monitor for ketones, increase hydration, notify providerKeep protocols accessible on the unitEnsure timely re-assessments and follow-up documentation Review of the clinical record indicated that Resident R4 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs dated 5/14/26, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time)and hemiplegia (paralysis on one side of the body). Review of Resident R4's current plan of care for diabetes initiated 5/20/24, indicated Accuchecks as ordered, call MD per order/facility protocol. Review of a physician order dated 4/2/26, through 5/27/26, indicated that Resident R4 received Humalog insulin on a sliding scale. If 0 - 70 < 71, Notify MD; 401+ = 12 units > 400, Notify MD. Review of a physician's order dated 5/27/26, indicated, Check Blood Glucose before meals. Call Provider if greater than 300 or less than 70. Review of Resident R4's blood sugar record for May 2026, revealed the following blood sugar value failed to have documentation of notification or follow-up:5/06/26, 12:12 p.m. 56.0 mg/dL No notification. Orange juice given. No recheck.5/22/26, 12:01 p.m. 58.0 mg/dL No notification. Orange juice, glucose gel given. No recheck.5/24/26, 11:39 a.m. 64.0 mg/dL No notification. Orange juice given. No recheck.5/27/26, 12:23 p.m. 56.0 mg/dL No notification. No recheck. No documentation of protocol initiated.5/28/26, 11:39 a.m. 60.0 mg/dL No notification. No documentation of protocol initiated.5/30/26, 8:21 a.m. 320.0 mg/dL No recheck. No notification. Review of the clinical record indicated that Resident R11 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and asthma (condition where the airways narrow and swell). Review of Resident R11's current plan of care for diabetes initiated 3/19/26, indicated Diabetes medication as ordered by doctor. Review of the plan of care dated 4/2/24, through 3/19/26, risk for hyperglycemia, indicated, Accu checks/BGMs/labs as ordered. Report to MD as ordered/per protocol. Medications as ordered. Review of a physician order dated 3/2/26, through 3/24/26, indicated that Resident R11 received 18 units of Humalog with meals, hold if less than 130 (mg/dl). Review of a physician order dated 3/24/26, through 4/1/26, indicated that Resident R11 received 16 units of Humalog with meals, hold if less than 130 (mg/dl). Review of a physician's order dated 4/2/26, through 4/3/26, indicated that Resident R11 received Humalog insulin on a sliding scale coverage with meals. Review of a physician's order dated 4/4/26, indicated that Resident R11 received Humalog insulin on a sliding scale coverage with meals (change in scale from previous order). Resident R11 had duplicated blood sugar levels from early morning insulin checks (between about 5:30 a.m. through 6:30 a.m.) documented at insulin provision times at breakfast (between about 8:00 a.m. through 8:30 a.m.). Documentation did not indicate a recheck was completed to ensure accuracy of the amount of insulin being given at breakfast. March: 3,4.5,6,7,9,10,11,12,13, 16,17,18,19,20,24,25,26,30,31April: 1,2,3,4,6,7,8,9,10,13,14,15,16,17,18,20,21,22,23,24,25,28,29,30May: 1,2,3,4,5,6,7,8,9,11,12,13,14,15,16,17,18,19,20,21,22,23,25,26,27,30,31 Review of Resident R11's Medication Administration Record indicated that the dosage of insulin was based upon the early morning blood glucose level. Further review of the MAR failed to reveal documentation of blood sugar level checks completed at breakfast time on 3/15/26, and 3/29/26. Review of the clinical record indicated that Resident R19 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and a seizure disorder. Review of Resident R19's current plan of care for diabetes initiated 8/22/24, indicated Accuchecks (blood glucose checks) / labs as ordered. Report to MD per order/facility protocol. Review of a physician order dated 2/18/26, through 3/26/26, indicated that Resident R19 received 30 units of insulin aspart before meals. Notify MD if blood sugar is less than 70 greater than 450. This order was increased to 35 units on 3/26/26, to 40 units on 4/9/26, to 45 units on 4/20/26, to 50 units on 4/29/26, and to 55 units on 5/20/26. Review of a physician order dated 3/29/26, through 4/8/26, indicated that Resident R19 received Novolog on sliding scale coverage. <70, Notify MD >400 Notify MD. Review of a physician order dated 4/8/26, through 4/19/26, indicated that Resident R19 received insulin aspart on sliding scale coverage. Call MD if blood glucose less than 70 blood glucose greater than 400 call MD. Review of a physician order dated 4/20/26, through 4/26/26, indicated that Resident R19 received insulin aspart on sliding scale coverage. Call MD if blood glucose less than 70 blood glucose greater than 400 call MD. Review of a physician order dated 5/20/26, indicated that Resident R19 received insulin lispro on sliding scale coverage. Call PCP (primary care physician) if bg<70 call PCP if bg>401. Review of Resident R19's blood sugar record for March 2026, through May 2026, revealed the following blood sugar values failed to have documentation of notification or follow-up: 3/07/26 8:30 p.m. 463.0 mg/dL No recheck, no notification.3/21/26 5:32 p.m. 432.0 mg/dL No recheck, no notification.3/30/26 5:17 p.m. 425.0 mg/dL No recheck, no notification.4/09/26 4:32 p.m. 431.0 mg/dL No recheck, no notification.4/23/26 5:22 p.m. 429.0 mg/dL No recheck, no notification.4/25/26 9:06 a.m. 440.0 mg/dL No recheck, no notification.5/01/26 5:46 a.m. 414.0 mg/dL No recheck, no notification.5/01/26 8:42 a.m. 414.0 mg/dL No recheck, no notification.5/12/26 5:59 p.m. 424.0 mg/dL No recheck, no notification.5/19/26 6:25 a.m. 423.0 mg/dL No recheck, no notification.5/19/26 8:40 a.m. 423.0 mg/dL No recheck, no notification.5/21/26 6:45 a.m. 518.0 mg/dL Recheck done, no notification Resident R19 had duplicated blood sugar levels from early morning insulin checks (between about 5:30 a.m. through 6:30 a.m.) documented at insulin provision times at breakfast (between about 8:00 a.m. through 8:30 a.m.). Documentation did not indicate a recheck was completed to ensure accuracy of the amount of insulin being given at breakfast. March: 3,4.5,7,9,10,12,13,15,16,17,18,19,29,21,23,24,26,29,30,31April: 1,2,3,4,7,8,9,10,13,14,15,16,17,18,19,21,22,23,24,27,28,29,30May: 1,2,4,5,6,7,8,9,11,12,13,14,15,16,17,18,18,20,22,25,26,27,30,31 Review of Resident R19's Medication Administration Record indicated that the dosage of insulin was based upon the early morning blood glucose level. Further review of the MAR failed to reveal documentation of blood sugar level checks completed at breakfast time on 3/6/26, 3/27/26, 4/6/26, or 4/20/26. Review of the clinical record indicated that Resident R25 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of Resident R25's current plan of care for diabetes initiated 5/1823, indicated Administer med as ordered. Review of a physician order dated 3/26/26, indicated Inject 20 units subcutaneously one time a day for dm2 (diabetes mellites type two). Hold if blood glucose less than 150. Review of Resident R25's blood sugar record and insulin administration revealed the following: 3/28/26 141 mg/dL Insulin documented as given at 12:57 p.m. 4/04/26 149 mg/dL Insulin documented as given at 1:16 p.m.4/10/26 146 mg/dL Insulin documented as given at 12:09 p.m. 4/13/26 134 mg/dL Insulin documented as given at 11:44 a.m.5/05/26 127 mg/dL Ordered at 11:45 a.m., documented as given at 6:32 p.m.5/27/26 135 mg/dL Insulin documented as given at 12:27 p.m. Review of the clinical record indicated that Resident R32 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and COPD. Review of Resident R32's current plan of care for diabetes initiated 8/23/26, indicated Administer med as ordered. Review of a physician order dated 2/19/26, through 3/26/26, indicated that Resident R32 received seven units of Humalog before meals. Hold if not eating or under 130. Review of a physician order dated 3/26/26, through 4/17/26, indicated that Resident R32 received ten units of Humalog before meals. Hold if not eating or under 130. Review of a physician order dated 4/17/26, indicated that Resident R32 received ten units of Humalog before meals. Hold if not eating or under 130. Review of Resident R32's blood sugar record and insulin administration revealed the following: 3/04/26 118 mg/dL Insulin documented as given at 5:42 a.m. 3/11/26 128 mg/dL Insulin documented as given at 5:35 a.m.3/16/26 128 mg/dL Insulin documented as given at 4:46 p.m.3/19/26 115 mg/dL Insulin documented as given at 5:15 p.m.4/06/26 128 mg/dL Insulin documented as given at 11:32 a.m.4/08/26 108 mg/dL Insulin documented as given at 5:34 a.m.4/13/26 113 mg/dL Insulin documented as given at 5:38 a.m.4/15/26 128 mg/dL Insulin documented as given at 5:30 a.m.4/18/26 123 mg/dL Insulin documented as given at 5:31 a.m.4/22/26 113 mg/dL Insulin documented as given at 5:30 a.m.4/23/26 118 mg/dL Insulin documented as given at 4:38 p.m.4/25/26 123 mg/dL Insulin documented as given at 5:43 a.m.4/28/26 108 mg/dL Insulin documented as given at 5:48 p.m.5/22/26 122 mg/dL Insulin documented as given at 6:23 a.m.6/01/26 128 mg/dL Insulin documented as given at 6:25 a.m. Review of the clinical record indicated that Resident R47 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and heart failure. Review of Resident R19's current plan of care for diabetes initiated 2/3/26, indicated Diabetes medication as ordered by doctor. Review of a physician order dated 3/2/26, through 6/2/26, indicated that Resident R47 received Humalog on a sliding scale before meals and at bedtime. Timing for this order was 6:30 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. Review of Resident R47's insulin administration record indicated that the order for sliding scale coverage was provided usually between 5:30 a.m. and 6:30 a.m., approximately one to two hours before receiving breakfast. Review of the clinical record indicated that Resident R56 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Review of Resident R56's current plan of care for diabetes initiated 3/5/26, indicated Fasting Serum Blood Sugar/BGM/labs as ordered by doctor. Review of a physician order dated 2/18/26, through 4/16/26, indicated that Resident R56 received Novolog insulin on a sliding scale. 401+ = 10 Call MD. Review of Resident R56's blood sugar record for March 2026, through May 2026, revealed the following blood sugar value failed to have documentation of notification or follow-up:3/30/26 5:48 a.m. 415.0 mg/dL No recheck, no notification.4/10/26 5:51 a.m. 470.0 mg/dL No recheck, no notification. During an interview on 6/1/26, at approximately 12:05 p.m. Resident R47 confirmed with the surveyor that the staff check the blood sugars daily between 5:30 a.m. and 6:00 a.m. and then the next shift nurse gives the insulin based on the prior shift blood sugar reading. Resident stated can't recall how often her blood sugar is rechecked in the morning before her insulin is given. During an interview on 6/1/26, at approximately 12:15 p.m. Resident R11 confirmed with the surveyor that the staff check the blood sugars daily between 5:30 a.m. and 6:00 a.m. and then the next shift nurse gives the insulin based on the prior shift blood sugar reading. Resident stated on occasion the nurse on the morning shift will recheck the blood sugar in the morning prior to giving the insulin. During an interview on 6/1/26, at approximately 12:30 p.m. Resident R19 confirmed with the surveyor that the staff check the blood sugars daily between 5:30 a.m. and 6:00 a.m. and then the next shift nurse gives the insulin based on the prior shift blood sugar reading. Resident stated that his blood sugar is rarely rechecked before his morning insulin is given. Staff Interviews completed on 6/1/26, between 12:00 p.m. through 1:00 p.m. revealed: Registered Nurse (RN) Employee E2 stated, The previous shift checks the blood sugars. I sometimes recheck the blood sugars. When asked if she did a recheck on Resident R19 this morning, RN Employee E2 stated, No used the blood sugar from the previous shift. Licensed Practical Nurse (LPN) Employee E3 stated, The previous shift is supposed to check blood sugars at 6:00 a.m. I often recheck and get my own blood sugars because they get them so early and I have a couple brittle diabetics. During observations completed on 6/2/26, the following meal tray delivery times were noted:E Hall (100s) passed trays at 7:33 a.m.B Hall (300s) passed trays at 7:40 a.m.A Hall (200s) passed trays at 7:46 a.m.C Hall (400s) passed trays at 7:58 a.m. Review of resident insulin administration times revealed:Resident R32 received 10 units rapid acting insulin at 5:54 a.m., 106 minutes prior to earliest possible tray receipt.Resident R6 received 8 units of rapid acting insulin at 5:54 a.m., 106 minutes prior to earliest possible tray receipt.Resident R25 received 16 units rapid acting insulin at 5:55 a.m., 123 minutes prior to earliest possible tray receipt.Resident R47 received 16 units rapid acting insulin at 5:55 a.m., 123 minutes prior to earliest possible tray receipt.Resident R56 received 8 units rapid acting insulin at 5:24 a.m., 142 minutes prior to earliest possible tray receipt. The Nursing Home Administrator (NHA) and the Director of Nursing (DON) were made aware that an Immediate Jeopardy situation existed for residents on 6/2/26, at 10:26 a.m. and a corrective action plan was requested. The Immediate Jeopardy template was provided to the facility administration at this time. The Immediate Jeopardy began March 3, 2026. On 6/2/26, at 4:00 p.m. an acceptable Corrective Action Plan was received which included the following interventions: The facility failed to ensure appropriate amounts of insulin to residents based on timely blood glucose checks. The facility failed to provide rapid-acting insulin (with a 15-30 time of onset) prior to meals. The facility failed to appropriately respond to resident blood sugar levels out of range, per the physician orders. This failure placed the residents at risk for complications related to hypoglycemia and/or hyperglycemia. Affected Residents / Immediate Actions:R19 was assessed by RN and evaluated for signs and symptoms of hypoglycemia/hyperglycemia glycemia and that RN assessed- notify dr of out of parameters; cp update as needed; provide meals at appropriate time. RN clarified blood sugar check order to ensure accuracy. R25 was assessed by RN and evaluated for signs and symptoms of hypoglycemia/hyperglycemia glycemia and that RN assessed- notify dr of out of parameters; cp update as needed; provide meals at appropriate time. RN clarified blood sugar check order to ensure accuracy. R56 was assessed by RN and evaluated for signs and symptoms of hypoglycemia/hyperglycemia glycemia and that RN assessed- notify dr of out of parameters; cp update as needed; provide meals at appropriate time. RN clarified blood sugar check order to ensure accuracy. R32 was assessed by RN and evaluated for signs and symptoms of hypoglycemia/hyperglycemia glycemia and that RN assessed- notify dr of out of parameters; cp update as needed; provide meals at appropriate time. RN clarified blood sugar check order to ensure accuracy. R4 was assessed by RN and evaluated for signs and symptoms of hypoglycemia/hyperglycemia glycemia and that RN assessed- notify dr of out of parameters; cp update as needed; provide meals at appropriate time. RN clarified blood sugar check order to ensure accuracy. R11 was assessed by RN and evaluated for signs and symptoms of hypoglycemia/hyperglycemia glycemia and that RN assessed- notify dr of out of parameters; cp update as needed; provide meals at appropriate time. RN clarified blood sugar check order to ensure accuracy. Like Residents:The following items will be completed on 6/3/26 by 9:00 a.m.: DON/Designee will conduct house audit on all residents with orders to check blood glucose to ensure appropriate measures are taken and physician orders are followed, and order is appropriate. DON/Designee will conduct house audit on all residents with orders for insulin to ensure that physician orders are followed, meals are provided timely, and appropriate documentation occurs. Facility NHA and DON will review current nursing practice for blood glucose check during AM shift and will adjust time to ensure insulin and glucose checks are provided close to meal provisions. DON/Designee will conduct audit all current diabetic residents for potential change in condition, contact MD, update orders and care plan as needed. The DON/Designee will audit diabetic residents to ensure rapid-acting insulin is provided close to meal provision; and that blood glucose checks at the time of insulin provision. Correction of System: DON/Designee will educate licensed staff by 6/3/26 by 9:00 a.m. on Diabetic Protocol, the Hypoglycemia policy, and the Resident Change in Condition policy to include hyperglycemia is a change in condition and notification of the physician of blood sugars out of range. RNs and LPNs including upcoming agency that are not on duty received education via phone and will receive in person education on their next scheduled shift Monitoring: To monitor and maintain compliance, the Director of Nursing/ designee will review residents' blood sugars daily x seven days x four weeks, weekly x four weeks, monthly x two to ensure if any blood sugars were out of range and notifications made. If notification not documented, the physician will be contacted at the time of discovery and notified and new orders implemented as needed. To monitor and maintain compliance, new admissions/readmissions with diabetes will be reviewed by the DON/designee to ensure a care plan is implemented for diabetes including approaches for diabetic emergency management five times per week for two weeks. DON/Designee will conduct random meal delivery and insulin administration coordination audits during breakfast for two weeks to ensure safety of resident. Results of the audits will be forwarded to the center QAPI (Quality Assurance and Performance Improvement) committee for review and recommendations. On 6/3/26, the whole house audit of residents with diabetes was reviewed by surveyors, revealing its completion and accuracy. During interviews beginning at approximately 6:00 a.m. on 5/6/26, seven licensed nurses on overnight and morning shift were interviewed, and education was confirmed completed. Nursing staff were able to effectively describe appropriate actions to take when blood sugar levels are out of the accepted range for the residents, the need for documentation, the onset time of rapid-acting insulin, and the need to provide insulin based on a timely blood sugar measurement and with meals. On 6/3/26, licensed nursing reeducation was reviewed, revealing its completion. Review of the QAPI meeting document confirmed its completion on 6/2/26. The Immediate Jeopardy was removed on 6/3/26, at 11:15 a.m. when the action plan implementation was verified. During an interview on 6/4/26, at approximately 3:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to notify physicians of elevated or decreased Capillary Blood Glucose (CBG) levels, failed to assess residents for hyperglycemia and hypoglycemia, and failed to ensure the provision of insulin according to physicians' orders and manufacturing instructions which resulted in immediate jeopardy for eight of fourteen residents. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of job descriptions, clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to provide care for residents with diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) consistent with standard nursing practices. This failure resulted in facility failures to notify physicians of elevated or decreased Capillary Blood Glucose (CBG) levels, failures to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood sugar), and failures to ensure the provision of insulin (injectable medication to treat high blood sugar) according to physicians' orders and manufacturing instructions which resulted in immediate jeopardy for eight of fourteen residents (R4, R5, R11, R19, R25, R32, R47, and R56).Findings include: Review of the facility-provided Nursing Home Administrator (NHA) job description indicated, Leads, guides and directs the operations of the healthcare facility in accordance with local, state and federal regulations, standards and established facility policies and procedures to provide appropriate care. Review of the facility-provided Director of Nursing (DON) job description indicated, Planning, organizing, developing and directing the overall operations of the Nursing Service Deportment in accordance with local, state and federal standards and regulations, established facility policies and procedures and as may be directed by the Administrator and the Medical Director, to provide appropriate care and services to the residents. Based on findings identified in this report, the facility failed to prevent the failed protect residents from exiting the facility unsupervised. The NHA and the previously employed DON failed to fulfill their essential job duties to ensure the federal and state guidelines and regulations were followed. During an interview on 6/4/26, at approximately 3:00 p.m. the NHA and current DON confirmed that facility administration failed to effectively manage the facility to provide care for residents with diabetes consistent with standard nursing practices. This failure resulted in facility failures to notify physicians of elevated or decreased CBG levels, failures to assess residents for hyperglycemia and hypoglycemia, and failures to ensure the provision of insulin according to physicians' orders and manufacturing instructions which resulted in immediate jeopardy for eight of fourteen residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on a review of facility policy, federal regulation, and a staff interview, it was determined that the facility failed to provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division for four of six months (December 2025 through March 2026).Findings include: Review of the facility policy Transfer or Discharge and Discharging the Resident dated 5/5/26 with a prior review date of 8/27/25, did not reveal evidence that the facility will provide notice to the Ombudsman and maintain documentation of the notice. Review of Title 42 Code of Federal Regulations S483.15(c)(3) Notice Before Transfer: indicates, before a facility transfers or discharges a resident, the facility must (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. Federal Regulations further define emergency transfers as, When a resident is temporarily transferred on an emergency basis to an acute care facility, this type of transfer is considered to be a facility-initiated transfer. A request to review facility documents on 6/1/26, of the facility's compliance in notifying the State Ombudsman Office, revealed the facility failed to provide documented evidence of notifying the State Ombudsman Office of resident transfers and discharges for the time frame of 12/2025 through 4/2026. During an interview on 6/4/26, at 9:30 a.m., the Nursing Home Administrator confirmed the facility failed to provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division for four of six months. 28 Pa. Code 201.18(b)(2) Management.

Based on a review of select facility policy and resident and staff interviews, it was determined the facility failed to ensure that fresh drinking water was consistently readily accessible to residents to promote adequate hydration, meet resident preferences, and maintain their comfort for four of 20 residents reviewed (Residents 11, 19, 49, and 56).Findings include: Review of the facility policy Water Pitcher Pass/Cleaning dated 5/5/26 with a prior review date of 8/27/25, indicated the Nursing staff will fill water pitchers/Styrofoam cups with ice and fresh water placing them at bedside. Water will be provided/passed every shift unless contraindicated by their diagnosis or physician order. 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 2023, 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 R49 was admitted to the facility on [DATE].Review of Resident R49's Minimum Data Set (MDS-a periodic assessment of care needs) dated 3/17/26, indicated diagnoses of coronary artery disease (CAD arteries become narrowed or blocked by buildup of plaque reducing blood flow to the heart), diabetes (body does not use insulin effectively), and depression (a serious, common mood disorder causing persistent sadness, low energy, and loss of interest in life for at least two weeks). Resident BIMS is 15. During an interview on 6/1/26, at approximately 1:30 p.m. with Resident R49 stated she has to ask during the day for water to drink. They always bring water to your room during the night shift you wake up and it's there, it's not often that they bring you water during the morning or afternoon shift. Review of the clinical record indicated Resident R19 was admitted to the facility on [DATE].Review of Resident R19's Minimum Data Set (MDS-a periodic assessment of care needs) dated 5/9/26, indicated diagnoses of seizure disorder (sudden disruptions of the brain's normal electrical activity), diabetes (body does not use insulin effectively), and hypertension (high blood pressure). Resident BIMS is 15. During an interview on 6/2/26, at approximately 10:30 a.m. with Resident R19 stated you have to ask at least fifty percent of the time, during the day for water to drink. They always bring water to your room during the night shift. Resident stated he keeps a lot of bottled water in his room that he has purchased, so he always has water available. Review of the clinical record indicated Resident R56 was admitted to the facility on [DATE].Review of Resident R56's Minimum Data Set (MDS-a periodic assessment of care needs) dated 3/17/26, indicated diagnoses of coronary artery disease (CAD arteries become narrowed or blocked by buildup of plaque reducing blood flow to the heart), diabetes (body does not use insulin effectively), and hypertension (high blood pressure). Resident BIMS is 15. During an interview on 6/2/26, at approximately 9:30 a.m. with Resident R56 stated occasionally during the day they give you water to drink. They bring water to your room during the night shift every night, you need to ask for it during the day on the days they don't bring you any and they will get it. Review of the clinical record indicated Resident R11 was admitted to the facility on [DATE].Review of Resident R11's Minimum Data Set (MDS-a periodic assessment of care needs) dated 3/17/26, indicated diagnoses of bilateral below the knee amputation (both legs amputated below the knee), diabetes (body does not use insulin effectively), and depression (a serious, common mood disorder causing persistent sadness, low energy, and loss of interest in life for at least two weeks). Resident BIMS is 15. During an interview on 6/3/26, at approximately 10:30 a.m. with Resident R11 stated during the day they bring you water to drink but not consistently. They bring water to your room during the night shift every night. During an interview with the Nursing Home Administrator (NHA) on 6/3/26, at 11:00 AM, confirmed the facility failed to ensure that fresh drinking water was consistently readily accessible to residents to promote adequate hydration, meet resident preferences, and maintain their comfort. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.28 Pa. Code 211.10(a)(c)(d) Resident care policies.

Based on review of facility policy, observations, and staff interview, it was determined that the facility to make certain that medical supplies were properly stored and/or disposed of in one of two medication rooms (B/C Medication Room).Findings include: Review of the United States Food and Drug Administration prescribing information dated November 2013, indicated, Vials in use for more than 30 days should be discarded. Review of the facility policy Storage of Medications dated 5/5/26, indicated medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. During an observation of the B/C Medication Room on 6/1/26, at 2:25 p.m. the following was observed: (2) open, partially used containers of protein powder with an expiration date of 3/18/26.(2) 1500 mL bottles of tube feeding formula with a use by date of 5/1/26.(1) Set of glucometer testing solution with an expiration date of 4/9/26.(1) Uncapped vial of Procrit injection solution.(1) Bottle of eye lubricating drops with a written expiration date of 5/30/26.(1) Opened, undated vial of tuberculin solution. During an interview on 6/1/26, at approximately 2:35 p.m. Licensed Practical Nurse Employee E4 confirmed the above observations. During an interview on 6/4/26, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain that medical supplies were properly stored and/or disposed of in one of two medication rooms. 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1)(e)(1) Management.28 Pa. Code: 211.9 (a)(1) Pharmacy services.28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services.

Based on a review of facility policy, observations and staff interview it was determined that the facility failed to properly store food products at safe temperatures in the Main Kitchen, which created the potential for foodborne illness in one of one deep freezer. Findings Include: Review of the facility policy Food Storage dated 8/27/2025, indicated that the facility will maintain proper temperatures in all storage areas. The proper temperature ranges for freezer units are 0 degrees Fahrenheit or below. During an observation of the main kitchen on 3/24/26, at 1:00 p.m., it was revealed the freezer door was ajar and the external temperature gauge read 8 degrees Fahrenheit. The freezer door was closed and at 1:25 p.m. the temperature reading was noted to be 20 degrees Fahrenheit. At 1:40 p.m. the temperature of the freezer was noted to be 20 degrees Fahrenheit. It was noted at that time that the internal thermostat was set to come on at 15 degrees Fahrenheit and turn off at 10 degrees Fahrenheit. At 2:00 p.m. it was noted that the freezer temperature was at 0 degrees Fahrenheit, indicating that the freezer was out of proper range for one hour. During an interview on 3/24/26 at 2:00 p.m., The Director of Maintenance Employee E1 confirmed the above findings and that the freezer was not maintaining temperature at proper ranges which created the potential for food borne illness. During an interview on 3/24/26, at 2:30 p.m., the Nursing Home Administrator confirmed that the facility failed to properly store food products in the Main Kitchen, which created the potential for foodborne illness. Pa. 28 Code: 211.6(c)(d)(f) Dietary services.

Based on review of facility policy, resident observations, and resident and staff interviews, 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 of 10 of 15 residents (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10) and for four of five staff members (Employee E1, E2, E3, and E4).Findings Include: Review of the facility policy, Answering the Call Light dated 8/27/25, indicated, The purpose of this procedure is to ensure timely responses to the resident's requests and needs. Review of the facility policy, Activities of Daily Living, (ADL), Supporting dated 6/1/25, indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. During an observation on 2/17/26, at approximately 10:56 a.m. Resident R1 was noted to have a large amount of brown substance underneath his very long, curled over fingernails. Review of Resident R1's point of care documentation from 1/18/26, through 2/17/26, revealed Resident R1's scheduled shower days were Wednesdays and Saturdays, on evening shift. 1/21/26: Documented as Shower1/24/26: Documented as Not Applicable1/28/26: Documented as Not Applicable1/31/26: Documented as Not Applicable2/04/26: Documented as Not Applicable2/07/26: Documented as Not Applicable2/11/26: Documented as Refused2/14/26: Documented as Bed bath Review of facility census information confirmed Resident R1 was not out of the facility on any dates from 1/18/26, through 2/17/26. During an observation on 2/17/26, at approximately 10:57 a.m. Resident R2 was noted to have a large amount of dandruff and dry skin crusted on his hair. Review of Resident R2's point of care documentation from 1/18/26, through 2/17/26, revealed Resident R2 did not have documented scheduled shower days. 1/20/26: Documented as Bed/Towel Bath2/07/26: Documented as Bed/Towel Bath2/10/26: Documented as Not Applicable2/11/26: Documented as Not Applicable2/14/26: Documented as Bed/Towel Bath Review of facility census information confirmed Resident R2 was not out of the facility on any dates from 1/18/26, through 2/17/26. During an interview on 2/17/26, at approximately 11:00 a.m. Resident R3 stated that call light response times can be excessive, and it depends on what staff is working. During an interview on 2/17/26, at approximately 11:00 a.m. Resident R4 stated that they are so short-staffed. During an interview on 2/17/26, at approximately 11:10 a.m. Resident R5 stated that they are very understaffed. It stresses the aides out and it's not food for the patients. During an interview and observation on 2/17/26, at approximately 11:15 a.m. Resident R6 stated that call light response times can be excessive. Resident R6 was noted to have a large amount of brown substance underneath his fingernails. During an interview on 2/17/26, at approximately 11:18 a.m. Resident R7 stated that could always use more help. During an interview on 2/17/26, at approximately 11:18 a.m. Resident R7 stated that could always use more help. During an interview on 2/17/26, at approximately 12:41 p.m. Resident R8, when asked if the facility maintained enough staff to care for residents, stated Sometimes. When asked about call light response times, Resident R8 stated Depends. During an interview on 2/17/26, at approximately 12:45 p.m. Resident R9, when asked if the facility maintained enough staff to care for residents, stated No and further stated that there is a delay in getting people dressed and out of bed in the morning. When asked about call light response times, Resident R8 stated Call lights are long, because there isn't enough staff. During an observation on 2/17/26, at approximately 12:50 p.m. Resident R10 was noted to have a large amount of brown substance underneath his fingernails. When asked if he wanted his facial hair shaved, Resident R10 nodded his head affirmatively. Review of Resident R10's point of care documentation from 1/18/26, through 2/17/26, revealed Resident R10's scheduled shower days were Wednesdays and Saturdays, on evening shift. 1/21/26: Documented as Not Applicable1/24/26: Documented as Bed/Towel Bath1/28/26: Documented as Not Available (resident was hospitalized [DATE]: Documented as Not Available (resident was hospitalized [DATE]: Documented as Not Applicable2/07/26: No documentation2/11/26: Documented as Bed/Towel Bath2/14/26: No documentation Review of facility census information confirmed Resident R10 was in the facility from 1/18/26, through 1/27/26, and from 2/3/26, through 2/17/26. During staff interviews completed during the survey, the following was stated in response to questions about facility staffing: Employee E1, Do you want me to tell the truth, do you want me to lose my job? They are killing us. They are killing us. Employee E2, Crappy. Changes day-to-day. You never know what's going to go on. Employee E3, It's horrible. Employee E4, They just had a call off. We work short on daylight and then have to pick up on evenings and our days off. During an electronic interview on 2/17/26, at approximately 1:30 p.m. the Nursing Home Administrator and the 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 ten of fifteen 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 a review of facility policy, observations and staff interview it was determined that the facility failed to properly store food products in the Main Kitchen, which created the potential for foodborne illness.Findings include:Review of the facility policy Food Storage, dated 8/27/25, indicated that food shall be stored to facilitate thorough cleaning, and areas will be maintained in a clean, safe sanitary manner. A thermometer is available in a storeroom, freezer and refrigerator units. During an observation on 1/20/26, from 8:50 a.m., through 9:15 a.m., the following was observed:The drink/food line cooler did not have an internal thermometer. The refrigerator and deep freezer had food stored approximately 3 inches from the ceilings During an interview on 1/20/26, at 9:15 a.m., the Dietary Supervisor Employee E8 confirmed that the facility failed to properly store food products in the Main Kitchen, which created the potential for foodborne illness. Pa. 28 Code: 211.6(c)(d)(f) Dietary services.

Based on review of facility policy, resident council group interview, observations and staff interviews it was determined that the failed to provide a clean, safe, comfortable, and homelike environment for clean public shower areas and equipment for two of two resident shower rooms (B/C and A/E shower rooms), failed to provide a clean, safe, comfortable, and homelike environment for two of four resident hallways (B/C Hallways), and two of two resident lounges B/C and A/E resident lounges).Findings include:Review of the facility policy Homelike environment dated 8/27/25, indicated to provide a safe, clean and comfortable environment. Provide a clean, sanitary, and orderly environment and provide comfortable and safe temperatures between 71 and 81.During a tour on 1/21/26, at 2:20 p.m. with the Nursing Home Administrator the following observations were noted:-B/C shower room had a dark brown/black substance in the grout of the shower's floor, cracked tiles at base of the shower and the wall. Thes shower chairs were soiled with brown residue.-A/E shower room had a metal pin sticking out of stall one's rear wall, had discolored shower grout, the third stall's shower head handle with brown substance. Shower chair with brown residue and rust apparent on all four wheels.During an interview on 1/21/26, at 2:21 p.m. the Nursing Home Administrator confirmed the observations of the B/C and A/E shower rooms and equipment.During a Resident council group interview on 1/21/26, at 1:00 p.m. five out of five residents indicated the resident lounges on each side (B/C and A/E) are too cold in the winter months.During an interview and tour on 1/21/26, at 2:50 p.m. with the Nursing Home Administrator and Maintenance Director Employee the following areas indicated inadequate temperatures:-B/C lounge noted to be blowing cold air. Temperature 58.1 F (Fahrenheit).-room [ROOM NUMBER], the temperature was 68 F.-room [ROOM NUMBER], the temperature was 68.9 F.-room [ROOM NUMBER], the temperature was 65.6 F.-room [ROOM NUMBER], the temperature was 64.7 F.-room [ROOM NUMBER], the temperature was 68.3 F.During an interview on 1/21/26, at 4:00 p.m. the Nursing Home Administrator confirmed the facility failed to provide a clean, safe, comfortable, and homelike environment for two of four resident hallways (B/C Hallways), and two of two resident lounges B/C and A/E resident lounges), and failed to provide clean public shower areas and equipment for two of two resident shower rooms (B/C and A/E shower rooms).28 Pa. code: 201.14 (b) Responsibility of licensee.28 Pa Code: 201.18 (e)(1)(2) Management. 28 Pa Code: 201.29 (a)(c) Resident Rights.

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased capillary blood glucose (CBG) levels for two of five residents (Resident R11 and R52).Findings: Review of the facility policy, Nursing Care of the Older Adult with Diabetes Mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) dated 8/27/25, indicated, The provider will order the frequency of glucose monitoring and establish appropriate glycemic targets for individual residents. The policy indicated for the facility to establish provider notification guidelines, and provided examples of possible guidelines. Further review failed to reveal a specific facility protocol. Review of the clinical record indicated Resident R11 admitted to the facility on [DATE]. Review of Resident R11's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 11/9/25, included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and diabetes. Review of Resident R11's care plan revised on 9/26/24, for Potential for hypo/hyperglycemia (low blood sugar/high blood sugar levels in the blood) failed to include interventions related to physician notification for elevated blood sugar levels. Review of a physician order dated 12/30/25, indicated to inject Basaglar insulin (an injectable medication to treat diabetes) 20 units one time daily. Further review of Resident R11's physician orders failed to reveal an order for blood sugar checks or specific parameters for physician notification. Review of Resident R11's blood sugar record revealed the following elevated blood sugar levels without documentation that the provider was notified:12/31/25, at 7:08 p.m. - 524.0 mg/dL (milligrams per deciliter)01/01/26, at 2:49 a.m. - 499.0 mg/dL01/03/26, at 7:10 p.m. - 434.0 mg/dL01/04/26, at 7:01 p.m. - 402.0 mg/dL01/07/26, at 7:36 p.m. - 498.0 mg/dL01/08/26, at 7:23 p.m. - 430.0 mg/dL01/14/26, at 7:05 p.m. - 453.0 mg/dL01/18/26, at 7:07 p.m. - 486.0 mg/dL01/19/26, at 7:04 p.m. - 463.0 mg/dL01/20/26, at 7:20 p.m. - 482.0 mg/dL01/22/26, at 9:43 p.m. - 494.0 mg/dL Review of the clinical record indicated Resident R52 originally admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident R52's MDS dated [DATE], included diagnoses of epilepsy (disorder of the brain characterized by repeated seizures) and diabetes. Review of Resident R52's care plan initiated 10/19/23, for Potential for hypo/hyperglycemia (low blood sugar / high blood sugar levels in the blood) indicated Accuchecks (blood sugar checks) as ordered, call MD (doctor of medicine) per order/facility protocol. Review of a physician order dated 12/30/25, indicated to inject Lantus insulin (an injectable medication to treat diabetes) 20 units at bedtime. Further review of Resident R52's physician orders failed to reveal an order for blood sugar checks or specific parameters for physician notification. Review of Resident R52's blood sugar record revealed the following elevated blood sugar levels without documentation that the provider was notified:11/15/25, at 9:07 p.m. - 419.0 mg/dL (milligrams per deciliter)12/23/25, at 9:48 p.m. - 404.0 mg/dL01/04/26, at 9:43 p.m. - 482.0 mg/dL During an interview on 1/23/26, at approximately 1:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to notify physicians of increased and decreased capillary blood glucose levels for two of five residents. 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 update a care plan for two of six residents (Residents R50 and R58) to accurately reflect the current status of the resident. Findings include: Review of the facility policy Care Plans, Comprehensive Person-Centered dated 8/27/25, indicated the person-centered care plan describes services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being including services for each element of care. Review of the clinical record indicated Resident R50 was admitted to the facility on [DATE]. Review of Resident R50's Minimum Data Set (MDS- a periodic assessment of care needs) dated 12/9/25, indicated diagnoses of diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), obstructive sleep apnea (a chronic condition in which the throat muscles relax during sleep and the airway may become partially or fully blocked), and renal insufficiency (a condition in which the kidneys lose the ability to remove waste and balance fluids). Section O0110 G3 CPAP (non-invasive treatment for sleep apnea that uses a machine to deliver pressurized air through a mask, keeping the airway open during sleep to prevent breathing pauses) was not indicated as in use. Review of Resident R50's current physician orders included the following medications:-Glargine insulin 28 units subcutaneously (fatty tissue layer between the skin and muscle) for diabetes.-Jardiance 12.5 mg (milligrams) for diabetes.-Eliquis 5mg for anticoagulant (blood thinner).-Bumex 2mg for fluid management.-Flomax 0.4 mg for Benign prostatic hyperplasia (BPH - a common enlargement of the prostate gland in aging men that squeezes the urethra).-Finasteride 5mg for BPH.-Lyrica 50mg for neuropathy (nerve damage causing pain and numbness).-Oxycodone 5-325 mg for pain.-Metoprolol 100mg for high blood pressure. Review of Resident R50's current care plan failed to include goals and interventions for management and monitoring of diabetes, anticoagulants, fluid management, BPH, neuropathy, pain, high blood pressure, and potential for constipation related to oxycodone use. Interview on 1/23/26, at 11:55 a.m. the Director of Nursing confirmed Resident R50's care plan was lacking identified medications and disease processes as required. Review of the clinical record indicated Resident R58 was admitted to the facility on [DATE]. Review of Resident R58's MDS dated [DATE], indicated diagnoses of traumatic brain dysfunction (a disruption in the normal function of the brain), anxiety, depression, and post-traumatic stress disorder (PTSD, mental health condition triggered by experiencing or witnessing a terrifying event). Review of Resident R58's facility diagnosis listing included PTSD, dated 4/28/25. Review of a psychiatry note dated 3/6/25, indicated, [Resident R58] detailed a past event that lead to her TBI (traumatic brain injury) and long hospital stay. She reported severe trauma from the experience, and said she had been diagnosed with PTSD after the event. Often experiences mood swings and depression, as well as hypervigilance and increased anxiety and I feel nervous around other people.Review of further psychiatry notes refer to Resident R58's PTSD diagnosis on 7/14/25, 8/26/25 Review of Resident R58's current care plan failed to include goals and interventions accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident. Interview on 1/23/26, at 12:00 p.m. the Director of Nursing confirmed the facility failed to update a care plan for two of six residents (Residents R50 and R58) to accurately reflect the current status of the resident. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on facility policies, clinical record reviews, and staff interview, it was determined the facility failed to ensure each resident receives proper treatment and services to maintain hearing abilities for five of eight residents reviewed for hearing (Residents R3, R26, R36, R48 and R23). Findings include:Review of the facility policy Consults Policy and Procedures, dated 8/27/25, indicated to ensure all in-facility consults are timely, clinically indicated and in compliance, the facility nursing staff shall notify the attending provider of the consulting provider's recommendations, review the attending physician's acceptance of the recommendation and monitor the compliance with the recommended treatment.Review of the clinical record indicated Resident R3 had been admitted to the facility on [DATE], with diagnoses which included traumatic brain injury, obesity, stroke and heart fibrillation. An MDS (Minimum Data Set- a periodic review of resident needs) dated 11/4/25, indicated the diagnoses remained current.Review of Resident R3's physician orders dated 4/1/15, through current identified an order dated 12/20/16, indicating that Resident R3 may receive audiology services.Review of Resident R3's clinical record did not include an audiologist assessment being completed in the duration of Resident R3's admission from 4/1/15, through current.Review of the clinical record indicated Resident R26 had been admitted to the facility on [DATE], with diagnoses which included autism, intellectual disabilities, obesity and visual disabilities. An MDS dated [DATE] indicated the diagnoses remained current.Review of Resident R26's physician orders dated 3/20/24, through current identified an order for Resident R26 to receive audiology services.Review of Resident R26's clinical record did not include an audiologist assessment being completed in the duration of Resident R26's admission from 3/20/24, through current.Review of the clinical record indicated that Resident R36 was admitted to the facility on [DATE], with diagnoses which included quadriplegia, seizures, dementia, glaucoma and kidney disease. An MDS dated [DATE], indicated the diagnoses remained current.Review of Resident R36's physician orders dated 5/24/22 through current identified an order dated 5/24/22, indicating that Resident R36 may receive audiology services.Review of Resident R36's clinical record identified audiologist assessment on 9/17/25, identifying impacted cerumen of his left ear and Debrox ear drops to be instilled into left ear to remove cerumen.Review of Resident R36's Medication Administration Record (MAR) dated September 2025, did not include an order for Debrox ear drops as per recommendation.Review of Resident R36's clinical record identified an audiologist assessment again on 10/22/25, which again identified impacted cerumen of his left ear and Debrox drops again for left ear.Review of Resident R36's MAR dated October 2025, did not include an order for Debrox ear drops had been obtained as per recommendation.Review of the clinical record indicated Resident R48 was admitted to the facility on [DATE], with diagnoses which included anoxic brain damage and dementia. An MDS dated [DATE], indicated the diagnoses remained current.Review of Resident R48's physician orders dated 7/21/25, through current identified an order for Resident R48 to receive audiology services.Review of Resident R48's clinical record identified an audiologist assessment on 1/5/26, which identified impacted cerumen of left ear and recommendation of Debrox drops.Review of Resident R48'd MAR dated January 2026, did not include and order for Debrox drops to left ear being obtained as per recommendation. Review of the clinical record indicated Resident R23 had been admitted to the facility on [DATE], with diagnoses which included stage IV kidney disease, schizophrenia and unspecified psychosis. An MDS dated [DATE] indicated the diagnoses remained current.Review of Resident R23's physician orders dated 5/10/24, through current identified an order for Resident R23 to receive audiology services.Review of Resident R23's clinical record identified an audiologist assessment on 9/17/25, which identified impacted cerumen of both ears and recommendation of Debrox drops.Review of Resident R23's MAR dated September 2025, did not include an order for Debrox drops as per recommendation.Review of Resident R23's clinical record identified and audiologist assessment on 10/22/25, which identified impacted cerumen of both ears and recommendation of Debrox drops.Review of Resident R23's MAR dated October 2025, did not include and order for Debrox drops as per recommendation.During an interview on 1/22/26, at 10:04 a.m., the Director of Nursing on 1/22/26, at 10:04 a.m., confirmed that facility failed to ensure each resident receives proper treatment and services to maintain hearing abilities for five of eight residents reviewed for hearing (Residents R3, R26, R36, R48 and R23). 28 Pa. Code 211.12 (d) (5) Nursing services

Based on observation, review of clinical record, review of facility policy, interview with staff and residents, it was determined the facility failed to provide tracheostomy care consistent with professional standards of practice for one resident with a tracheostomy (Resident R25), and failed to provide appropriate respiratory care and maintain respiratory equipment for five of five residents (Resident R25, R41, R50, R65, and R74). Findings include: Review of the facility policy Tracheostomy Care dated 8/27/25, indicated a replacement tracheostomy tube (a hollow tube inserted into a surgical opening in the neck (stoma) directly into the windpipe to provide long-term ventilation) must be available at the bedside at all times. A suction machine must be available at the bedside at all times. Review of the facility policy Departmental (Respiratory Therapy) - Prevention of Infection last reviewed on 8/27/25, indicated that considerations related to oxygen administration include change the oxygen cannula and tubing every seven days or as needed. Keep the oxygen and tubing used as needed in a plastic bag when not in use. Considerations related to medication nebulizers/continuous aerosol include store the circuit in a plastic bag, marked with date and resident's name, between uses. Discard the administration set up every seven days. Review of the facility policy CPAP/BiPap Support dated 8/27/25, indicated Continuous Positive Airway Pressure (CPAP-keeps airways open when you sleep) or Bilevel Positive Airway Pressure (BIPAP-normalizes breathing by delivering pressurized air)are to be labeled with room number/bed and to be stored in a plastic bag when not in use. Review of the admission record indicated R25 was admitted to the facility on [DATE]. Review of Resident R25's Minimum Data Set (MDS- a periodic assessment of care needs) dated 12/28/25, indicated the diagnoses of chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe), anxiety, and hip fracture. Section O - E1 indicated that resident received tracheostomy care. Review of Resident R25's current physician orders failed to include the type and size of tracheostomy tube. Review of Resident R25's care plan dated 11/21/25, indicated resident will be free from infection related to tracheostomy and failed to include the type and size of tracheostomy tube. Observation on 1/20/26, at 9:30 a.m. Resident R25 was resting in bed with a tracheostomy tube visible and connected to oxygen. A suction cannister was at the bedside with a date that read 12/10/25. The cannister was half full of white/light yellow substance. Observation and interview on 1/20/26, at 9:35 a.m. Registered Nurse (RN) Employee E2 confirmed there was not an order or care plan for the type and size of tracheostomy tube and that the suction cannister had not been changed since 10/10/25. Review of the admission record indicated R41 was admitted to the facility on [DATE]. Review of Resident R41's MDS dated [DATE], indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), high blood pressure, and depression. Review of Resident R41's physician orders dated 11/9/25, indicated to change oxygen tubing weekly and label with date. Also apply water bottle and change it weekly to humidify oxygen. Write date on bottle. Review of Resident R41's current care plan indicated to change respiratory equipment as ordered. Observation on 1/20/26, at 9:20 a.m. Resident R41 was observed with eyes closed sleeping in bed. The oxygen bottle or tubing was dated as required. Interview on 1/20/26, at 9:25 a.m. RN Employee E2 verified the oxygen bottle and tubing were not dated as required. Review of the clinical record indicated Resident R50 was admitted to the facility on [DATE]. Review of Resident R50's MDS dated [DATE], indicated diagnoses of diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and obstructive sleep apnea (a chronic condition in which the throat muscles relax during sleep and the airway may become partially or fully blocked), and renal insufficiency (a condition in which the kidneys lose the ability to remove waste and balance fluids). Section O0110 G3 CPAP (non-invasive treatment for sleep apnea that uses a machine to deliver pressurized air through a mask, keeping the airway open during sleep to prevent breathing pauses) was not indicated as in use. Review of Resident R50's physician order dated 12/26/25, indicated CPAP with oxygen four liter bleed every evening and night for obstructive sleep apnea. Review of Resident R50's current care plan indicated oxygen at four liters/minute to the CPAP device. Observation on 1/20/26, at 9:30 a.m. Resident R50's CPAP mask was hanging off the bedside stand not contained in a bag as required. Interview on 1/20/26, at 9:30 a.m. RN Employee E2 verified the CPAP mask was not stored in a bag as required when not in use. Review of the clinical record indicated Resident R74 was admitted to the facility on [DATE], with the diagnoses of atrial fibrillation (irregular heart rhythm), heart failure (heart doesn't pump blood as well as it should), and high blood pressure. Review Resident R74's physician order dated 1/16/26, indicated CPAP unit with 2-liter bleed in of oxygen at night every evening shift. Review of Resident R74's current care plan indicated resident will be compliant with use of CPAP. Observation on 1/20/26, at 9:35 a.m. Resident R74 was out of bed. On the bedside stand was the CPAP mask, not stored in a bag as required. Interview on 1/20/26, at 9:35 a.m. RN Employee E2 verified the CPAP mask was not stored in a bag as required when not in use.Review of the clinical record indicated Resident R65 was admitted to the facility on [DATE].Review of Resident R65's MDS dated [DATE], indicated diagnoses of diabetes, obstructive sleep apnea, and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Section O0110 G1, Use of a non-invasive mechanical ventilator was documented as not indicated as in use.Review of Resident R65's physician order dated 3/27/25, indicated BiPAP use at bedtime for obstructive sleep apnea.Review of Resident R65's current care plan indicated BiPAP sat 91%, exp (expiration)-6, insp (inspiration) - 12 O2 2L bleed, assist with BiPAP as ordered.Review of Resident R65's treatment administration record dated January 2025, indicated a BiPAP was administered from 12/5/25, through 12/25/25.During an interview on 1/21/26, at approximately 11:30 a.m. Resident R65's BiPAP mask was on the floor next to her bed. When asked, Resident R65 stated she tries to use her BiPAP but is unable to put the mask on herself, and the nursing staff, doesn't get in here much to assist in applying the mask.Further discussion revealed that the current mask used is uncomfortable for Resident R65. Resident R65 stated that she has not been provided with options for other types of masks to increase comfort and compliance. Interview on 1/20/26, at 3:00 p.m. the Director of Nursing confirmed the facility failed to provide tracheostomy care consistent with professional standards of practice for one resident with a tracheostomy (Resident R25) and failed to provide appropriate respiratory care and maintain respiratory equipment for five of five residents (Resident R25, R41, R50, R65, and R74). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on staff interview it was determined that the facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department for 12 out of 12 months (February 2025 through January 2026).Findings include:During an interview on 1/20/26, at approximately 9:00 a.m., the Dietary Supervisor Employee E8 stated she was not certified and that the Dietician only works two days a week in the facility and another two days in another facility.During an interview on 1/20/26, at 11:20 a.m., the Nursing Home Administrator stated that the Registered Dietitian (RD) was not employed full time she comes two times a week.During an interview on 1/20/26, 11:20 a.m., the Nursing Home Administrator (NHA) confirmed that the facility failed to provide documented evidence that Dietary Supervisor Employee E8 met the qualifications for the position of Food Service Director. Pa Code: 201.18(e)(6) Management.

Based on a review of facility admission documents and staff interview, 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 two of five residents (Resident R27 and R48).Findings include: 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 facility's admission packet contained the document Alternative Dispute Resolution Agreement Between Resident and Facility, indicated With the exception of payment disputes, all other disputes are governed by this agreement, and each of the parties is giving up his/her/its right to resort to the courts and further indicated Binding arbitration means that the parties are waiving their right to a trial, including their right to a jury trial, their right to trial by judge and their right to appeal the decision of the arbitrator(s) except as provided for under applicable state and/or federal laws governing arbitration. Review of Resident R27's admission record indicated the resident was admitted to the facility on [DATE]. Review of Resident R27's admission assessment dated [DATE], indicated that Resident R27 was alert and oriented to person only. Review of Resident R27's baseline care plan dated 1/2/26, indicated that Resident R27 cannot communicate easily with staff and has cognitive needs. Review of a BIMS assessment completed on 1/2/26, revealed Resident R27's score to be 3. Review of Resident R27's admission paperwork indicated all sections, including the Alternative Dispute Resolution Agreement Between Resident and Facility, were signed by Resident R27. Review of Resident R48's admission record indicated the resident was admitted to the facility on [DATE]. Review of Resident R48's admission assessment dated [DATE], indicated that Resident R48 was alert and oriented to person only. Review of Resident R48's baseline care plan dated 7/21/25, indicated that Resident R48 was, very confused, agitated and yelling out. Review of a BIMS assessment completed on 7/22/25, revealed Resident R48's score to be 2. Review of Resident R48's admission paperwork indicated all sections, including the Alternative Dispute Resolution Agreement Between Resident and Facility, were signed by Resident R48. During an interview on 1/23/36, at approximately 1:30 p.m. the Nursing Home Administrator and the Director of Nursing 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 for two of five residents. 28 Pa. Code 201.24 (b) admission Policy 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.29(a)(j) Resident Rights

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain infection control practices to prevent the potential for cross contamination while during wound care for one of six residents (Resident R8), failed to maintain two ice machines in a sanitary manner ( A/E wing and B/C wing ice machines), failed to properly monitor residents in room personal refrigerator temperatures for two of two residents (Residents R33 and R64) which created the potential for food borne illness and failed to follow Enhanced Barrier Precautions (EBP) for one of eight residents (Resident R6).Findings include: Review of the facility policy, Dressings, Dry/Clean dated 8/27/25, indicated in the Steps in the Procedure to cleanse hands between glove changes. Review of facility policy Enhanced Barrier Precautions dated 8/27/25, indicated the facility will implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDRO). Examples of high-contact resident care activities requiring the use of gown and gloves for EBP's include wound care (any surgical wound requiring a dressing, any pressure injury that is a Stage 2, 3, 4, unstageable or deep tissue injury requiring a dressing, and lacerations that require a dressing). Review of the clinical record revealed Resident R8 was readmitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 10/24/25, included diagnoses of peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Section M: Skin Conditions indicated Resident R8 a stage four pressure ulcer (injury to the skin and underlying tissue, primarily caused by prolonged pressure on the skin, with full-thickness skin and tissue loss). Review of the plan of care for stage four pressure ulcer dated 10/23/25, indicated for staff to administer treatments as ordered and monitor for effectiveness. Review of the plan of care for enhanced barrier precautions dated 12/11/24, indicated gloves and gowns are worn for high contact care activity. Included in the list of high contact care was wound care. Review of a physician's order dated 7/6/25, indicated Resident R8 was ordered Enhanced Barrier Precautions related to the presence of a wound and a catheter. During an observation of a wound dressing change on 1/22/26, at approximately 11:00 a.m. the following was observed: -Licensed Practical Nurses (LPN) Employees E3 and E4 provided wound care without wearing gowns. -Resident R8 was noted to have a cloth underpad on his bed that was soiled with wound drainage. Per resident request, the ABD Pad (highly absorbent dressing that provides padding and protection for large wounds) covering the wound is left without a covering dressing. When the dressing change was completed, Resident R8 was rolled onto his back, onto the soiled underpad. -LPN Employee E4 did not clean her hands after removing the soiled gloves and putting on clean gloves. During an interview on 1/23/26, at approximately 1:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the failed to maintain infection control practices to prevent the potential for cross contamination while during wound care for one of six residents. Review of the facility policy Ice Machines and Ice Chests Maintenance dated 8/27/25, indicated that ice machines and ice storage/distribution containers will be used and maintained to assure a safe sanitary supply of ice. During an observation on 1/20/26, at 10:00 a.m., of the A/E and B/C pantries, each ice machine drainpipe was coiled into the drain with no space for an air gap, allowing for the potential for contamination of the ice in the ice machine. Used small heaters, paper towels gloves and wash basins were underneath the ice machines and debris such as gloves paper towels and dust were within and around the drain and ice machine drainpipe. During an interview on 1/20/26, at 10:15 a.m., Maintenance Director Employee E1 confirmed that the facility failed to maintain two of two ice machines in a sanitary manner. Review of the admission record indicated Resident R33 admitted to the facility on [DATE]. Review of Resident R33's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/14/26, indicated the diagnoses of heart failure (heart doesn't pump blood as well as it should), anxiety, and depression. Observation on 1/21/26, at 2:00 p.m. Resident R33 had a personal refrigerator in the room. The temperature log was dated October 2025. Review of the admission record indicated Resident R64 admitted to the facility on [DATE]. Review of Resident R64's MDS dated [DATE] indicated the diagnoses of atrial fibrillation (irregular heart rhythm), heart failure (heart doesn't pump blood as well as it should), and high blood pressure. Observation on 1/21/26, at 2:05 p.m. Resident R65 had a personal refrigerator in the room. The temperature log was dated October 2025. Interview on 1/21/26, at 2:10 p.m. the Nursing Home Administrator confirmed the facility failed to properly monitor residents in room personal refrigerator temperatures for two of two residents (Residents R33 and R64) which created the potential for food borne illness. Review of the facility policy Enhanced Barrier Precautions dated 8/27/25, indicated EBP employ targeted gown and glove use during high contact resident care activities. EBP are initiated for residents with wounds and MDRO (multiple drug-resistant organism). Review of the admission record indicated Resident R6 admitted to the facility on [DATE]. Review of Resident R6's MDS dated [DATE] indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), heart failure (heart doesn't pump blood as well as it should), and high blood pressure. Review of Resident R6's physician order dated 12/7/25, indicated Enhanced Barrier Precautions related to history of MDRO/wound every shift. Observation on 1/21/26, at 10:00 a.m. Nurse Aide (NA) Employee E10 was providing morning care (personal hygiene, brief change, and dressing) to Resident R6. NA Employee E10 failed to have a gown during high contact resident care activities. Interview on 1/21/26, at 10:01 a.m. NA Employee E10 indicated the sign for EBP has been on Resident R6's door forever and staff did not have to wear a gown for resident's care. Interview on 1/21/26, at 1:00 p.m. the Infection Preventionist (IP) Employee E11 indicated Resident R6 was in EBP currently and did require a gown during high contact resident care activities. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 201.20(c) Staff development. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on a review of facility policy, observations, and staff interviews, it was determined the facility failed to maintain a fully functioning resident call bell system that allows residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area in two of five rooms (Resident R10 and R46).Findings include: To ensure accessibility, the ADA (Americans with Disabilities Act) Standards for Accessible Design dated 9/15/10, indicated that emergency call system pull cords must be accessible to individuals with disabilities, ensuring they can reach the activation point from a seated or fallen position. While specific string length is not explicitly defined in inches by the ADA, the cord must be reachable, the operating mechanism must be within the ADA reach range of 15 to 48 inches from the floor Review of the facility policy Call System, Residents dated 8/27/25, indicated, Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. During an observation on 1/20/26, at 10:32 a.m. the call light in Resident R10's restroom was noted to be approximately three inches long, only the short portion of the chain extending from the wall, without a string or call pendant at the end of the string. During an observation on 1/20/26, at 10:35 a.m. the call light in Resident R46's restroom was noted to be approximately three inches long, only the short portion of the chain extending from the wall, without a string or call pendant at the end of the string. During an interview on 1/23/26, at 1:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to maintain a fully functioning resident call bell system that allows residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area in two of five rooms. 28 Pa Code 207.2(a) Administrators responsibility 28 Pa Code 205.28 (c)(1)(4) Nurses station

Based on review of facility policy, facility documentation and staff interview, it was determined that the facility failed to protect a resident from neglect for one of three residents resulting in pain and the need for Xray's to rule out possible injuries/ fractures for one of three residents (Resident R11).Findings include:Review of the facility policy Abuse and Neglect dated 8/27/25, indicated that neglect is the failure of the facility to provide services to a resident that are necessary to avoid physical harm, pain or mental anguish. Review of the clinical record indicated that Resident R11 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's dementia, obstructive uropathy, glaucoma, obesity, lack of coordination, and history of right open repair internal fixation of right hip (ORIF). An MDS (Minimum Data Set- a periodic review of a resident care needs) dated 10/24/25, indicated the diagnoses remained current. An MDS dated [DATE], Section G0110 (bed mobility) indicated bed mobility as total assistance of two staff. Section GG0170 (amount of assistance required to perform task) indicated substantial/maximum assistance for turning left and right in bed. During an interview on 1/21/26, at 10:00 a.m., Nurse Aide (NA) Employee E6 stated that substantial maximum assistance indicated the use of two staff to perform task. During an Interview on 1/21/26, at 10:03 a.m., NA Employee E7 and Licensed Practical Nurse (LPN) Employee E3 stated that substantial maximum assistance indicated the use of two staff to perform task.During an interview on 1/21/26, at 10:10 LPN Employee E5 stated that substantial maximum assistance indicated the use of two staff to perform task.Review of Resident R11's orders identified an order dated 1/16/19, which indicated the use of bilateral enabler bars for positioning for Resident R11.During a clinical record review, a progress note dated 8/22/25, at 8:19 a.m., indicated the nurse had been called into Resident R11's room at 5:10 a.m., to find the resident on the floor on her left side. Review of the facility provided document indicated that Nurse Aide Employee E9 had gone into Resident R11's room to provide incontinence care by herself, turned Resident R11 onto her side. The NA then identified that Resident R11 had had a bowel movement. NA Employee E9 then left Resident R11 on her side to go into the bathroom to wet a towel and Resident R11 rolled out of bed.Review of the facility provided documentation did not include documentation of making certain Resident R11 was protected from neglect as the facility called the physician who ordered Xray's be completed to rule out possible injury/ fracture when Resident R11 complained of pain. The documentation did not include whether or not the enabler bars were being utilized.During an interview of 1/20/26, at 1:58 p.m., the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to protect a resident from neglect for one of three residents resulting in pain and the need for Xray's to rule out possible injuries including fractures for one of three residents (Resident R11).28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(e)(1) Management.28 Pa. Code 201.29(a) Resident rights.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on a review of facility policy, information provided by the facility, clinical records and staff interview, it was determined the facility failed to promptly conduct a thorough investigation to rule out neglect and implement corrective action and submit the results of the completed investigation to the State Survey Agency within five working days of the incident as evidenced by one of three residents reviewed (Resident R11).Findings include:Review of the facility policy Abuse and Neglect dated 8/27/25, indicated that neglect is the failure of the facility to provide services to a resident that are necessary to avoid physical harm, pain or mental anguish. Staff and management will help to identify situations that might constitute neglect. The facility will investigate alleged abuse and neglect to clarify what happened and identify possible causes. Review of the facility policy Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating dated 8/27/25, indicated that all reports of resident abuse including injuries of unknown origin, neglect, etc., are reported to local, state and federal agencies as required and thoroughly investigated by the facility. Findings of the investigation are documented and reported. Review of the clinical record indicated that Resident R11 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's dementia, obstructive uropathy, glaucoma, obesity, lack of coordination, and history of right open repair internal fixation of right hip (ORIF). A Minimum Data Set (MDS- a periodic review of a resident care needs) dated 07/30/25, indicated the diagnoses remained current. Section G0110 (bed mobility) indicated bed mobility as total assistance of two staff. Section GG0170 (indicating the assistance required to perform task) indicated substantial/maximum assistance for turning left and right in bed. During an interview on 1/21/26, at 10:00 a.m., Nurse Aide (NA) Employee E6 stated that substantial maximum assistance indicated the use of two staff to perform task. During an Interview on 1/21/26, at 10:03 a.m., NA Employee E7and Licensed Practical Nurse (LPN) Employee E3 stated that substantial maximum assistance indicated the use of two staff to perform task.During an interview on 1/21/26, at 10:10 LPN Employee E5 stated that substantial maximum assistance indicated the use of two staff to perform task.Review of Resident R11's orders identified an order dated 1/16/19, which indicated the use of bilateral enabler bars for positioning for Resident R11.During a clinical record review, a progress note dated 8/22/25, at 8:19 a.m., indicated the nurse had been called into Resident R11's room at 5:10 a.m., to find the resident on the floor on her left side. Review of the facility provided document indicated that Nurse Aide Employee E9 had gone into Resident R11's room to provide incontinence care by herself, turned Resident R11 onto her side. The NA then identified that Resident R11 had had a bowel movement. NA Employee E9 then left Resident R11 on her side to go into the bathroom to wet a towel and Resident R11 rolled out of bed. The documentation did not include whether or not the enabler bar was in use.Review of the facility provided documentation did not include documentation of making certain Resident R11 was protected from neglect as the facility called the physician who ordered Xray's be completed to rule out possible injury/ fracture when Resident R11 complained of pain.During an interview of 1/20/26, at 1:58 p.m., the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to to promptly conduct a thorough investigation to rule out neglect and implement corrective action and submit the results of the completed investigation to the State Survey Agency within five working days of the incident as evidenced by one of three residents reviewed (Resident R11). 28 Pa. Code 201.14 (c) Responsibility of licensee.28 Pa. Code 201.18 (b)(1) Management.28 Pa. Code 201.29 (a) Resident rights.28 Pa. Code 211.10(d) Resident care policies.

Based on review of clinical records, facility provided documentation and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and assistance to prevent accidents for one of three residents (Resident R11).Findings include:Review of the clinical record indicated that Resident R11 was admitted to the facility on [DATE]m with diagnoses which included Alzheimer's dementia, obstructive uropathy, glaucoma, obesity, lack of coordination, and history of right open repair internal fixation of right hip (ORIF). An MDS (Minimum Data Set- a periodic review of a resident care needs) dated 10/24/25, indicated the diagnoses remained current. An MDS dated [DATE], Section G0110 (bed mobility) indicated bed mobility as total assistance of two staff. Section GG0170 How much assistance required to perform task) indicated substantial/maximum assistance for turning left and right in bed. During an interview on 1/21/26, at 10:00 a.m., Nurse Aide (NA) Employee E6 stated that substantial maximum assistance indicated the use of two staff to perform task. During an Interview on 1/21/26, at 10:03 a.m., NA Employee E and Licensed Practical Nurse (LPN) Employee E3 stated that substantial maximum assistance indicated the use of two staff to perform task. During an interview on 1/21/26, at 10:10 LPN Employee E5 stated that substantial maximum assistance indicated the use of two staff to perform task. Review of Resident R11's orders identified an order dated 1/16/19, which indicated the use of bilateral enabler bars for positioning for Resident R11. During a clinical record review, a progress note dated 8/22/25, at 8:19 a.m., indicated the nurse had been called into Resident R11's room at 5:10 a.m., to find the resident on the floor on her left side. Review of the facility provided document indicated that Nurse Aide Employee E9 had gone into Resident R11's room to provide incontinence care by herself, turned Resident R11 onto her side. The NA then identified that Resident R11 had had a bowel movement. NA Employee E9 then left Resident R11 on her side to go into the bathroom to wet a towel and Resident R11 rolled out of bed. The documentation did not include whether or not the enabler bar was in use. Review of the facility provided documentation did not include an investigation to identify why NA Employee E9 attempted to provide care alone when Resident R11 was identified to require assistance of two staff. During an interview of 1/20/26, at 1:58 p.m., the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to make certain Resident R11 received proper assistance and supervision to prevent an accident which resulted in pain and the need for Xray's to rule out injury /fractures for Resident R11. 28 Pa. Code 211.10(c)(d) Resident Care Policies28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services28 Pa. Code: 201.18(b)(1) Management.

Based on a review of facility policy, clinical records, observations, and resident and staff interview, it was determined that the facility failed to provide necessary supervision of a resident with known sexually inappropriate behaviors. This failure resulted in an immediate jeopardy situation for five of 67 residents (Resident R2, R3, R4, R5, R6, ).Findings include:Review of the facility, Resident Supervision Policy & Procedures effective 2/1/25, indicated, It is the policy of this facility to ensure that all residents receive appropriate levels of supervision based on their individual needs, as identified through comprehensive and ongoing assessment. The goal of this policy is to promote resident safety, maintain dignity, and prevent accidents, neglect, or adverse events. Review of the facility, Behavior Management Policy revised 2/2/25, indicated, Patients exhibiting behavioral symptoms will be individually evaluated. The interdisciplinary team will identify underlying medical, physical, functional, psychosocial, emotional, psychiatric, or environmental causes that contribute to the resident's behavior(s). Review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2024, 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 impairmentReview of the clinical record indicated Resident R1 was initially admitted to the facility on [DATE], and readmitted on [DATE].Review of Minimum Data Set (MDS, periodic review of resident needs) dated 2/12/23, included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), history of a stroke, and a seizure disorder. Question C0500 BIMS Summary Score revealed Resident R1's score to be 1 severe impairment.Review of Resident R1's plan of care initiated on 7/10/24, indicated Resident R1 was a registered sexual offender. The goal of the care plan was Will not exhibit inappropriate sexual behaviors towards others. Interventions listed included: Counseling as indicated. Life review with resident to identify triggers and coping. No documentation Monitor resident ' s whereabouts, resident does have female friend, make sure residents are in common area. Observe for wandering into other residents ' rooms. Offer snacks to minimize wandering in search of food. Provide consistent message from all IDT. Psychology consult. Report with Megan's Law (laws that mandate the creation of public registries of convicted sex offenders) as required. Report inappropriate behavior towards others immediately to administration. Review of Resident R1's plan of care for Potential to be sexually inappropriate revealed it was not initiated until 7/30/25. The goal of the care plan was Resident will not harm self or others through the review date. Interventions listed were: Administer medications as ordered. Monitor/document for side effects and effectiveness. (Medications administered, no documentation of effectiveness). Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. No documentation that this was completed. Monitor/document/report as needed any signs/symptoms of resident posing danger to self and others. Minimal documentation completed. Psychiatric/psychogeriatric consult as indicated. When resident becomes sexually inappropriate: Intervene before behavior escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive/inappropriate, staff to ensure safety and walk calmly away, and approach later. Review of Resident R1's physician's orders dated 4/1/25, included behavior monitoring related to psychotropic medication use. Review of Resident R1's Treatment Administration Record (TAR) for April 2025, through August 2025, failed to include the option for monitoring for sexually inappropriate behavior. Listed behaviors to monitor for included unstable mood, signs and symptoms of changes, tearfulness, adjustment difficulty, withdrawal. Review of as needed nurse aide behavior monitoring revealed that the options for types of behavior that occurred were: Frequent Crying, Repeats Movement, Yelling/Screaming, Kicking/Hitting, Pushing, Grabbing, Pinching/Scratching/Spitting, Biting, Wandering, Abusive Language, Threatening Behavior, Sexually Inappropriate, Rejection of Care, None of the above observed. Review of the behavior monitoring documentation completed from 3/1/25, through 8/22/25, revealed the following: 3/22/25: Repeated movements, wandering.6/15/25: None of the above observed.8/19/25: None of the above observed.Review of Resident R1's psychiatry evaluation completed on 3/8/25, indicated, Requested by DON (Director of Nursing) to assess the patient's level of awareness, as he has been inappropriate with female peer in the facility and has a h/o (history of) these behaviors.Review of Resident R1's psychiatry evaluation completed on 8/12/25, indicated, Per the Director of Nursing, the patient has displayed sexually disinhibited behavior, specifically attempting to kiss staff. On interview, he endorsed depressed mood.Review of Resident R1's psychiatry evaluation completed on 8/22/25, indicated, He is consulted due to an incident on 8/21/25, where he was observed in an unoccupied room with a female resident where he was allegedly reported to be rubbing her leg. [Resident R1] does not recall the incident when asked. He does not want to hurt anybody when asked. He states he likes women, not men. When asked if he was touching another resident, he did state, I don't touch anyone. [Resident R1] per staff reports has a history of sexual misconduct. Within the report, collaboration with the DON was documented, Director of Nursing 8/22/25, reports [Resident R1] remains 1:1 (one-on-one monitoring by staff), he has a history of sexual misconduct, he has a history as a sex offender. Poor impulse control with incidents. No specific triggers when incidents occur. Seems to gravitate towards females. Review of facility submitted information dated 3/4/25, indicated, Housekeeper observed residents, [Resident R7] and [Resident R1], kiss in the hallway. Residents were separated. Neither of them can recall.Review of a physician order dated 3/26/25, through 8/18/15, indicated for Resident R1 to received fluoxetine (Prozac, a medication to treat depression) 10 mg daily, for depression. Review of a progress note dated 8/4/25, at 2:11 p.m. indicated, This writer spoke with [Resident R7 ' s] son, and son made me aware that his mom is dating [Resident R1] and that he does not have a problem with them holding hands and kissing. Everyone needs some affection and at this point in her life it doesn't bother me at all, and it doesn't bother her either. This writer informed son that we had to ensure that he was made aware. Son thanked writer for call.Review of a physician order dated 8/18/25, indicated for Resident R1 to receive fluoxetine 20 mg daily, for depression/sexually disinhibited behavior. During an observation on 8/21/25, at 10:40 a.m. Resident R1 was seen intently staring while grinning at Resident R2. The surveyor observed Resident R2 roll her wheelchair backwards away from Resident R1. Resident R1 followed Resident R2 in his wheelchair. Activities Director Employee E1 separated Resident R1 and Resident R2, placing Resident R2 on the opposite side of the activity.During an interview on 8/21/25, at 11:12 a.m. Activities Director Employee E2 stated she has not seen R1 sexually inappropriate, stated he does not understand personal space. Confirmed that she has heard from other staff that being sexually inappropriate can be an issue for him.During an interview on 8/21/25, at 2:08 p.m. certified registered nurse practitioner (CRNP) (8/18/25 note) stated she has not witnessed him being sexually inappropriate, but two staff members approached her on 8/18/25, and verbalized to her he has been touching residents inappropriately. One resident with permission from family, but he was touching more per staff.During an observation on 8/21/25, at 2:15 p.m. three police cars were observed arriving at the facility. Review of a progress note dated 8/21/25, at 2:00 p.m. indicated, Reported to this writer that resident was observed in an unoccupied room rubbing the leg of another resident. Resident was immediately removed and placed on 1:1.Review of a progress note written by the Nursing Home Administrator dated 8/21/25, at 3:37 p.m. indicated, This writer and Director of Nursing placed call to [Resident R1's] contact. Updated [contact] on allegation of Resident R1 inappropriately touching a female resident and actions taken, including police notification and potential to have to refer Resident R1 to an alternate facility. Stated we would keep her updated, she expressed understanding. Review of information submitted by the facility on 8/22/25, dated 8/21/25, indicated Resident R2, severe cognitive impairment, BIMS of 3, with a history of wandering, was found in an unoccupied room, with her pants down around her ankles, no brief, exposed from the hips down to her ankles where she had socks and shoes on preventing her shorts from coming off of her legs. Resident R2 was observed laying in the fetal position on her left side facing the wall. Resident R1 was observed at the bedside of where Resident R2 was laying, fully clothed. An adjacent resident was yelling up the hallway as staff were coming down the hallway to intervene. When staff entered the room, they noted that Resident R1 was close enough to reach out and touch resident, but verbal interviews and statements and indicate there was no witnessed touching. Resident that was adjacent to the room was also interviewed and indicated he saw Resident R1 smacking Resident R2 on the bare buttocks. Timeline suggests they were in the room alone for 45 seconds to one minute per ongoing investigation. Staff intervened and removed Resident R1 from the room. Director of Nursing attempted to interview Resident R2, but due to cognitive status she is not interviewable. Nursing Home Administrator called 911 and [Police Department] presented to the facility. [Police Department] notified their detective department and had them also present to the facility. Recommendation made to send Resident R2 to the emergency room for a sexual assault consultation/rape kit. Resident ' s husband was informed and presented to the facility. Resident was sent to [Hospital] and remains out of the facility at time of this report. All alert and oriented female residents will be interviewed, non-alert/oriented female residents will have a full body audit completed. Resident R1 placed on 1:1 with a staff member to ensure safety of all residents. All staff are education on abuse upon hire, annually, and as needed.During an interview on 8/21/25, at 3:25 p.m. with Resident R2 ' s husband revealed that he was not aware of what had occurred until he arrived at the facility. He stated, She is so scared of everything, doesn't like loud noises and things like that, she becomes afraid if someone pops the top on a can of soda. Is she going to be okay? He was observed consoling her and stroking her hand as she was on the stretcher.During an interview on 8/22/25, at 9:48 a.m. with Resident R8, he stated that he observed Resident R2 in a room with her pants down and no brief on with Resident R1 standing next to Resident R2 who was in bed. He yelled for assistance and was on his way to get his phone to call the police, he told someone to call them and is unsure of who made the call. He stated, This is disgusting that it has been going on, just bullshit, if that was my mother or grandmother, not sure what I would have done. During a follow-up interview on 8/29/25, at 2:35 p.m. Resident R8 confirmed he saw the incident. When asked what part of the body he observed Resident R1 touching, he stated, I saw ass. Resident R8 stated that he observed Resident R2 flailing her hand toward Resident R1, stated, She definitely didn't want it. Resident R8 stated, He's been doing it a long time. Resident R8 stated he was out smoking and a peer resident stated, Where's [Resident R1]? and the response from another resident was, He's in someone's room molesting them. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE].Review of the MDS dated [DATE], included diagnoses of heart failure (progressive heart disease that affects pumping action of the heart muscles) and physical debility. Question C0500 BIMS Summary Score revealed Resident R3's score to be 15. Review of an electronic communication dated 8/12/25, at 6:18 p.m. provided to both the facility administration and the state survey agency indicated, It has come to our family's attention in the last 2 weeks that my grandmother has been harassed (and touched at least twice) by a male resident at your facility for months. During an interview on 8/21/25, Resident R3's granddaughter provided the name of the male resident spoken of in the electronic communication, Resident R1. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), depression, and quadriplegia (paralysis of all four limbs). Question C0500 BIMS Summary Score revealed Resident R4's score to be 10. During a family interview on 8/21/25, at 7:56 p.m. Resident R4's son confirmed that she has complained to family that a male resident wheels into her room while she is sleeping and touches her. My mom, she cannot defend herself. It's not okay, but I understand he has issues. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE].Review of the MDS dated [DATE], included diagnoses of dementia, anxiety, and depression. Question C0500 BIMS Summary Score revealed Resident R5's score to be 00, which indicated that Resident R5 is so severely cognitively impaired to not be able to complete the interview. During an interview on 8/21/25, at 3:25 p.m. Resident R8 stated that Resident R1 has been observed by himself and other residents touching Resident R5 in the hallway. Resident R8 stated that Resident R1 has stuck his fingers in her mouth and then touched her groin; he has also been observed grabbing her breasts. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of Huntington's Disease (a condition that leads to progressive degeneration of nerve cells in the brain) and peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Question C0500 BIMS Summary Score revealed Resident R5 s score to be 10. During an interview on 8/21/25, at approximately 2:20 p.m. Nurse Aide Employee E2 stated that she had to keep redirecting Resident R1, that he had been trying to get to Resident R5 and R6. Review of confidential staff interviews completed during the survey revealed the following: Confidential Employee E3: Never personally witnessed, has heard from other staff that he (Resident R1) is sexually inappropriate. Has observed Resident R1 touching others, more it a patting sense. Confidential Employee E4: Stated they have seen Resident R1 sexually inappropriate. Kissing, touching. Tried to separate them and bring him back to his unit. Has seen it recently with Resident R7 and here more recently with Resident R2. I've told 'em. Everybody knows it. It's everyday like, Oh I have had to get Resident R1 away from Resident R2. Oh, I just had to get Resident R1 away from whoever. Confirmed he wanders into other rooms, Oh yeah, he's everywhere. Real bad. Confidential Employee E5: I heard that he went into R2's room. Confidential Employee E6: Confirmed they have seen Resident R1 be inappropriate with residents. A lot in the dining room. When we separate them, he follows us, and gets very combative. Resident R5 was asleep in the dining room and Resident R1 put his fingers in her mouth. We were told it's not inappropriate behavior. It really upset me. I was very uncomfortable. We were told, Do you kiss in your own home? but yes, with consent. Confidential Employee E7: He was kissing Resident R7. I told them but they say it's ok. Confidential Employee E8: He always tries to get with women Confidential Employee E9: One of our residents was her boyfriend, that was her boyfriend. Confirmed that they had heard that Resident R1 was sexually inappropriate, but not witnessed, I heard he was a pedophile. Confidential Employee E10: Touches other residents on the face. I take him away. Confidential Employee E11: I have seen him sitting close to other residents. I've never had to separate them. Other staff have spoken about his being sexually inappropriate. Confidential Employee E12: I've heard of him touching other residents, I ' ve never seen it. Confirmed they had heard from both residents and staff that Resident R1 is sexually inappropriate. I feel like if this had been handled when this started, today (referencing incident with Resident R2) would never have happened. When asked about reporting, The entire building knew. There was a lady who cannot communicate who he was touching inappropriately, [Resident R6] was her name. Confidential Employee E13: Confirmed they had seen Resident R1 be sexually inappropriate with both staff and residents. I fought with him, he literally tried to molest me. It took over an hour to get him out of the bathroom. When asked what residents, stated, Resident R7 mostly. He will go after more, any woman actually. Confirmed Resident R1 wanders into other's rooms, walks around unclothed. He's a very sexual man. Confidential Employee E14: Mostly with Resident R7. He wanders a lot. I redirect him. Employee confirmed that other residents have complained about Resident R7's behavior. Confidential Employee E18: I have not personally witnessed any behavior but have heard that it has been reported to management. Confidential Employee E20: Resident R1's behavior has been going on over a month, he goes around touching women, putting his hand up their pants, putting his fingers in their mouth, grabbing breasts. I have reported these incidents verbally but never filled out paperwork, did not know I was allowed. When I did report, I was told by the DON, They are older people and are allowed to touch. Confidential Employee E26: I have only overheard the other staff talk about Resident R1 but have never physically seen him do anything. As far as I know these incidents have been reported. Confidential Employee E32: I have brought the incidents with Resident R1 to the attention of the DON that his behaviors were getting worse, targets ladies that can't defend themselves, other residents try stopping it. The DON stated, Some of these ladies enjoy it, should we be stopping their pleasure. Told my other colleagues to keep an eye on him. The DON has stopped me from working there. Confidential Employee E33: Resident R1 is very touchy, feely, at times can be redirected but seems more aggressive acts like a baby, throwing a temper tantrum because you took away what he wants. I know an aide filed a report but the DON told her it was wrong and got rid of it. The situation is just very discouraging, was never told to file a report. I know management has known about it since February 4, 2025. Confidential Employee E34: There was a recent issue where his aide had to leave while he is being a 1:1, he was free to go into the Dining Room where he sat next to a lady (not Resident R7) and was holding her hand, we didn't want anything to escalate and tried to redirect but he became aggressive and held onto her chair. I know his issues have been reported to the current DON and the previous DON.During an interview on 8/29/25, at approximately 10:50 a.m. the Nursing Home Administrator and the Director of Nursing confirmed that the following care plan interventions had not been completed by the facility in any meaningful way: Life review with resident to identify triggers and coping. No documentation of completion. Observe for wandering into other residents' rooms. Offer snacks to minimize wandering in search of food. No documentation of wandering in behavior charting, which contrasted with multiple staff and resident interviews that described wandering behavior. Provide consistent message from all IDT. Facility administration unable to describe what the intervention would consist of. Report inappropriate behavior towards others immediately to administration. All staff interviewed stated they did not report it as everyone knows. Monitor resident's whereabouts, resident does have female friend. Make sure residents are in common areas. Multiple documented and verbal reports of resident being inappropriate with peers indicated a lack of monitoring of resident's whereabouts. Administer medications as ordered. Monitor/document for side effects and effectiveness. Initial order 3/8/25, with no lack of effectiveness documented to inform provider of the possible need of a medication adjustment. Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. No documentation that this was completed. Monitor/document/report as needed any signs/symptoms of resident posing danger to self and others. Minimal documentation completed. On 8/29/25, at 11:40 a.m. the Nursing Home Administrator and the Director of Nursing were made aware that an Immediate Jeopardy situation existed for five of 67 residents, and the Immediate Jeopardy template was provided to facility administration. This Immediate Jepordy situation existed beginning 2/4/25.On 8/29/25, at 2:00 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Immediate action(s) taken for the resident(s) found to have been affected include: Resident R1 was placed on 1:1 supervision on 8/21/2025 and continues to remain 1:1 supervision at this time. Resident R1 care plan will be updated on 08/29/2025 to individualized interventions regarding supervision based on his sex offender status. Resident R1 behavior is being monitored by the 1:1 supervisor.Facility will identify and address any allegations of inappropriate touching/behaviors via facility policy and investigative process. Follow-up and follow-through of interventions will be monitored by the Director of Nursing and Nursing Home Administrator.Any affected residents identified, reporting will be completed, notifications will be made, and support will be offered to residents and family.Staff and or consultants' failure to report any allegations timely will be addressed through the disciplinary process up to and including termination of employment or contracted services. Identification of other residents having the potential to be affected was accomplished by: An audit on all female residents from March 2025 to current will be completed by the Director of Nursing, or designee, to identify any documented inappropriate touching or sexually inappropriate behaviors. If any are found, we will follow facility policy and protocol of investigation, notification, and reporting.Current female residents who were cognitively intact are being interviewed five days per week, initiated on 08/21/2025. Current female residents who were cognitively impaired are having a complete skin assessment five days per week, initiated on 08/21/2025.No issues identified from interviews or skin assessments as of this date 08/29/2025.With resident remaining on 1:1 supervision, female residents are being kept safe from Resident R1 inappropriate touching/sexual behaviors.Actions taken/systems put into place to reduce the risk of future occurrence include: Education was completed with all staff on Abuse/Neglect, Reporting of Incident and Accidents by, and providing direct supervision with Resident R1 by the Director of Nursing on 08/21/2025.Education of all new hires will include supervision of handling residents with history of sexual aggression and behaviors. This will be updated into the new hire packet on 08/29/2025.Mandatory education will be sent to all staff on 08/29/2025 to inform staff of updates to Resident R1 care plan interventions to successfully redirect sexual aggression and behaviors. How the corrective action(s) will be monitored to ensure the practice will not recur: Resident R1 will remain on 1:1. Resident R1 is being followed by facility contracted psychiatric provider in conjunction with the facility medical director.Referrals are being made to alternate care facilities that can better meet Resident R1's needs.While Resident R1 remains in the facility audits will be completed on female residents who are cognitively intact daily x 5 days a week for two weeks, weekly for two weeks and then monthly for two months to ensure residents safety.While Resident R1 remains in the facility audits will be completed on female residents who are cognitively impaired daily x 5 days a week for two weeks, weekly for two weeks and then monthly for two months to ensure residents safety.An Ad Hoc Quality Assurance and Process Improvement Meeting was held by the Administrator or designee on 8/29/25 to address supervision of handling residents with sexual aggression and behaviors, including adding of this education to new hire orientation. This plan of correction will be monitored through facility Quality Assurance and Process Improvement meeting until such time consistent substantial compliance has been met. During staff interviews conducted on 8/29/25, between 2:00 p.m. and 3:30 p.m. ten staff members confirmed they received education on supervision of residents with known sexual behaviors and responding to residents' sexually inappropriate behavior. Review of clinical records completed on 8/29/25, confirmed care plan updates in place. Review of facility documentation completed on 8/29/25, confirmed either interviews or audits were completed on all female residents.The Immediate Jeopardy was lifted on 8/29/25, at 3:50 p.m., when the action plan implementation was verified. During an interview on 8/29/25, at approximately 4:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide necessary supervision of a resident with known sexually inappropriate behaviors. This failure resulted in an immediate jeopardy situation for five of 67 residents. 28 Pa. Code 201.18(b)(1)(3) Management28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of state laws, facility policy and documents, clinical records, and staff interview, it was determined that the facility failed to implement policies and procedures to report allegations of abuse for four of 67 residents (Resident R2, R3, R5, and R6). This failure resulted in a resident with a known history of sexually inappropriate behavior touching non-consenting residents, which created an Immediate Jeopardy situation. Findings include:Review of the Older Adult Protective Services Act of 11/6/87, amended by Act 1997-13, Chapter 7, Section 701, requires any employee or administrator of a facility who suspects abuse is mandated to report the abuse. All reports of abuse should be reported to the local area agency on aging and licensing agencies. If the suspected abuse is sexual abuse, serious bodily injury, or suspicious death, the law requires additional reporting to the Department of Aging and local law enforcement.Review of facility policy Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating dated 1/27/25, indicated The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:The state licensing/certification agency responsible for surveying/licensing the facility. The local/state ombudsman. The resident's representative.Adult protective services (where state law provides jurisdiction in long-term care).Law enforcement officials. The residents attending physician. The facility medical director.Immediately is defined as:Within two hours of an allegation involving abuse or result in serious bodily injury; or Within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE].Review of Resident R3's Minimum Data Set (MDS - periodic review of resident needs) dated 6/3/25, included diagnoses of dementia (a group of symptoms that affect memory, thinking, and interferes with daily life), history of a stroke, and a seizure disorder. Question C0500 BIMS Summary Score revealed Resident R3's score to be 1. Review of an electronic communication dated 8/12/25, at 6:18 p.m. provided to both the facility administration and the state survey agency indicated, It has come to our family's attention in the last 2 weeks that my grandmother has been harassed (and touched at least twice) by a male resident at your facility for months. During an interview on 8/21/25, at 8:45 p.m. Resident R3's granddaughter confirmed that the electronic communication provided to the facility was the same electronic communication provided to the state survey agency and provided the name of the male resident spoken of in the electronic communication as Resident R1.Review of documentation submitted by the facility to the State Survey Agency failed to include a report of possible abuse to Resident R3.During an interview on 8/21/25, at approximately 3:40 p.m. the Director of Nursing confirmed that a report was not made to the State Survey Agency related to the allegation of possible abuse reported by Resident R3's family member on 8/12/25.Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE].Review of Resident R2's MDS dated [DATE], included diagnoses of Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), anxiety, and depression. Question C0500 BIMS Summary Score revealed Resident R2 ' s score to be 3.During an interview completed during the survey, Employee E4 stated they have seen Resident R1 being sexually inappropriate. Kissing, touching. Tried to separate them and bring him back to his unit. Has seen Resident R1 recently with Resident R7 and here more recently with Resident R2. I've told 'em. Everybody knows it. It's everyday like, Oh I have had to get Resident R1 away from Resident R2. Oh, I just had to get Resident R1 away from whoever. Confirmed he wanders into other rooms, Oh yeah, he's everywhere. Real bad.Review of documentation submitted by the facility to the State Survey Agency failed to include a report of possible abuse to Resident R2.Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE].Review of the MDS dated [DATE], included diagnoses of dementia, anxiety, and depression. Question C0500 BIMS Summary Score revealed Resident R5 ' s score to be 00, which indicated that Resident R5 is so severely cognitively impaired to not be able to complete the interview.During an interview completed during the survey, Employee E6 stated they have seen Resident R1 be inappropriate with residents. A lot in the dining room. When we separate them, he follows us and gets very combative. [Resident R5] was asleep in the dining room and [Resident R1] put his fingers in her mouth. We were told it's not inappropriate behavior. It really upset me. I was very uncomfortable. We were told, 'Do you kiss in your own home?' but yes, with consent.Review of documentation submitted by the facility to the State Survey Agency failed to include a report of possible abuse to Resident R5.Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE].Review of the MDS dated [DATE], included diagnoses of Huntington's Disease (a condition that leads to progressive degeneration of nerve cells in the brain) and peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Question C0500 BIMS Summary Score revealed Resident R6 ' s score to be 10.During an interview completed during the survey, Employee E12 stated, I've heard of him touching other residents, I've never seen it. Employee E12 confirmed they had heard from both residents and staff that Resident R1 is sexually inappropriate. I feel like if this had been handled when this started, today (referring to incident with Resident R2) would never have happened. When asked about reporting, Employee E12 stated, The entire building knew. There was a lady who cannot communicate who he was touching inappropriately, [Resident R6] was her name.Review of documentation submitted by the facility to the State Survey Agency failed to include a report of possible abuse to Resident R6.During an interview completed during the survey, Employee E20 stated that Resident R1's behaviors have been going on for over a month, that he goes around touching women, up their pants, fingers in their mouth, and grabbing their breasts. Employee E20 stated that the incidents were reported verbally. Through other staff members, was told that, They are older people and allowed to touch. During an interview completed during the survey, Employee E32 stated they told the Director of Nursing that Resident R1's behaviors were increasing, that he seems to target women that cannot defend themselves, and that other residents are attempting to stop Resident R1's behaviors. Employee E32 stated the Director of Nursing said, Some of these ladies enjoy it, should we be stopping their pleasure? Employee E32 stated, I was so angry, was told we should not be taking his past and applying it to now. I redirected him and the ladies thanked me. Told my colleagues to keep an eye on him. During an interview completed during the survey, Employee E33 stated, Yeah, touchy-feely. Employee E33 stated Resident R1's behaviors have not been addressed. Employee E33 stated NA Employee E17 had reported Resident R1's behaviors to administration, with the response that the Director of Nursing told her it was wrong and get rid of it. Employee E33 stated that facility management has been aware of Resident R1's behaviors since February (2025).During an interview completed on 9/9/25, Employee E34 stated, Yesterday (9/8/25) he was holding a resident's hand and they (staff) felt it could lead to other things, tried to move him and he grabbed the chair and then became aggressive. Employee E34 stated that Resident R1's behavior has been reported to both the current Director of Nursing and the previous Director of Nursing. During an interview Employee E38: Stated, I saw him in the Dining Room with a resident being inappropriate. I reported it to nursing staff and the DON.During an interview Employee E40: Stated that she observed Resident R1 fondle a female resident's breast, she was in a wheelchair, unable to defend herself. Confirmed that the female resident was not Resident R7, with whom Resident R1 has a relationship granted by family. Employee E40 stated she reported the incident to the Director of Nursing, and was told not to worry about it. I don't want to get anyone in trouble, but it (referring to the incident involving Resident R2 on 8/22/25) never should have happened. I still picture her. It's awful.On 8/22/25, at 11:56 a.m. the Nursing Home Administrator was made aware that an Immediate Jeopardy situation existed for four of 67 residents, and the Immediate Jeopardy template was provided to facility administration.This Immediate Jeopardy situation began 2/4/25.On 8/22/25, at 2:38 p.m. an acceptable Corrective Action Plan was received which included the following interventions:Immediate action(s) taken for the resident(s) found to have been affected include: Resident R1 was placed on 1:1 8/22/25 and will remain on 1:1. Facility will ensure 1:1 is in place at all times by scheduling specific staff to perform this 1:1 duty each day on all three shifts.Residents R3, R5, and R6 will remain safe from resident initiated sexual abuse through the facility providing 1:1 to Resident R1. Resident R1 and R2 were immediately separated on 8/21/25.Resident R2 was assessed for injuries and no injuries noted on 8/21/25. Resident R2 was sent to the hospital for further evaluation on 8/21/25 and remains at hospital.Identification of other residents having the potential to be affected was accomplished by:Current female residents who were cognitively intact were interviewed on 8/21/25. Current female residents who were cognitively impaired had a skin assessment completed on 8/21/25.No issues identified from interviews or skin assessments.Actions taken/systems put into place to reduce the risk of future occurrence include:Education will be completed by all staff on Abuse/Neglect and Reporting of Incident and Accidents by the Director of Nursing or designee by 8/22/25.How the corrective action(s) will be monitored to ensure the practice will not recur: Resident R1 will remain on 1:1. Resident R1 will be evaluated by psychiatry services on 8/22/25 in conjunction with the facility medical director.While Resident R1 remains in the facility audits will be completed on female residents who are cognitively intact daily x 5 days a week for two weeks, weekly for two weeks and then monthly for two months to ensure residents safety. These audits will be completed by Social Services or designee. While Resident R1 remains in the facility adults will be completed on female residents who are cognitively impaired daily x 5 days a week for two weeks, weekly for two weeks and then monthly for two months to ensure residents safety.An Ad Hoc Quality Assurance and Process Improvement Meeting was held by the Administrator on 8/21/25.Affected residents will be seen by facility contracted psychiatry/psychology provided if they request to do so to address their emotional trauma.This plan of correction will be monitored at the Quality Assurance and Process Improvement meeting until such time consistent substantial compliance has been met. During staff interviews conducted on 8/22/25, between 12:00 p.m. and 3:30 p.m. 12 staff members confirmed they received education on abuse prevention.The Immediate Jeopardy was lifted on 8/22/25, at 3:52 p.m., when the action plan implementation was verified.During an interview on 8/22/25, at approximately 4:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to implement policies and procedures to report allegations of abuse. 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 facility provided policies and documentation, clinical records, and resident, family, and staff interviews, it was determined that the facility failed to protect residents from resident-to-resident sexual abuse. This failure resulted in a resident with a known history of sexually inappropriate behavior touching non-consenting residents, which created an Immediate Jeopardy situation for five of 67 residents (Resident R2, R3, R4, R5, R6). Findings include:Review of facility Abuse and Neglect Policy reviewed 1/27/25, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Neglect as defined as, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Sexual Abuse is defined as a non-consensual sexual contact of any type with a resident. Willful, as defined as, and as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2024, 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 impairmentReview of the clinical record indicated Resident R1 was initially admitted to the facility on [DATE], and readmitted on [DATE].Review of Minimum Data Set (MDS - periodic review of resident needs) dated 6/3/25, included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), history of a stroke, and a seizure disorder. Question C0500 BIMS Summary Score revealed Resident R1's score to be 1.Review of Resident R1's plan of care initiated on 7/10/24, indicated that Resident R1 was a registered sexual offender. The goal of this care plan was Will not exhibit inappropriate sexual behaviors towards others. Interventions listed were:-Counseling as indicated.-Life review with resident to identify triggers and coping. -Monitor resident's whereabouts, resident does have female friend, make sure residents are in common area.-Observe for wandering into other residents' rooms. Offer snacks to minimize wandering in search of food.-Provide consistent message from all IDT.-Psychology consult.-Report with Megan's Law (laws that mandate the creation of public registries of convicted sex offenders) as required.-Report inappropriate behavior towards others immediately to administration.Review of Resident R1's plan of care for Potential to be sexually inappropriate revealed it was not initiated until 7/30/25. The goal of this care plan was Resident will not harm self or others through the review date. Interventions listed were:-Administer medications as ordered. Monitor/document for side effects and effectiveness. -Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. No documentation that this was completed.-Monitor/document/report as needed any signs/symptoms of resident posing danger to self and others. -Psychiatric/psychogeriatric consult as indicated.-When resident becomes sexually inappropriate: Intervene before behavior escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive/ inappropriate, staff to ensure safety and walk calmly away, and approach later.Review of a physician order dated 8/18/25, indicated for Resident R1 to receive Fluoxetine (Prozac, an anti-depressant medication) 20 milligrams (mg) daily, for depression/sexually disinhibited behavior.During an interview on 8/29/25, at approximately 11:00 a.m. the Director of Nursing confirmed the medication adjustment was based on notification to the provider of increased sexual behaviors.Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE].Review of the MDS dated [DATE], included diagnoses of Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), anxiety, and depression. Question C0500 BIMS Summary Score revealed Resident R2's score to be 3.Review of Resident R2's plan of care initiated 5/20/25, indicated Resident R2 was at risk of mood instability related to anxiety and bipolar disorder (mood disorder characterized by extreme shifts in mood, energy, and activity levels).During an observation on 8/21/25, at 10:40 a.m. Resident R1 was seen staring fixated at Resident R2. The surveyor observed Resident R2 roll her wheelchair backwards away from Resident R1. Resident R1 followed Resident R2 in his wheelchair. Activities Director Employee E1 separated Resident R1 and Resident R2, placing Resident R2 on the opposite side of the activity.During an interview on 8/21/25, at 11:12 a.m. Activities Director Employee E2 stated she had not seen Resident R1 be sexually inappropriate, stated he does not understand personal space. Confirmed that she has heard from other staff that being sexually inappropriate can be an issue for him.During an interview on 8/21/25, at 2:08 p.m. Certified Registered Nurse Practitioner (CRNP) (8/18/25 note) stated she has not witnessed him being sexually inappropriate, but two staff members approached her on 8/18/25, and verbalized to her he has been touching residents inappropriately. One resident with permission from family, but he was touching more per staff. During an observation on 8/21/25, at 2:15 p.m. three police cars were observed arriving at the facility.Review of a progress note written by the Director of Nursing dated 8/21/25, at 2:00 p.m. indicated, reported to this writer that resident was observed in an unoccupied room rubbing the leg of another resident (Resident R2). Resident R1 was immediately removed and placed on 1:1. Review of a progress note written by the Nursing Home Administrator dated 8/21/25, at 3:37 p.m. indicated, This writer and Director of Nursing placed call to [Resident R1's] contact. Updated [contact] on allegation of Resident R1 inappropriately touching a female resident and actions taken, including police notification and potential to have to refer [Resident R1] to an alternate facility. Stated we would keep her updated, she expressed understanding.Review of facility submitted information dated 8/21/25, indicated Resident R2, severe cognitive impairment, BIMS of 3, with a history of wandering, was found in an unoccupied room, with her pants down around her ankles, no brief, exposed from the hips down to her ankles where she had socks and shoes on preventing her shorts from coming off of her legs. Resident R2 was observed laying in the fetal position on her left side facing the wall. Resident R1 was observed at the bedside of where Resident R2 was laying, fully clothed (investigations revealed Resident R2 was not fully clothed). An adjacent resident was yelling up the hallway as staff were coming down the hallway to intervene. When staff entered the room, they noted that Resident R1 was close enough to reach out and touch resident, but verbal interviews and statements indicate there was no witnessed touching. Resident that was adjacent to the room was also interviewed and indicated he saw Resident R1 smacking Resident R2 on the bare buttocks. Timeline suggests they were in the room alone for 45 seconds to one minute per ongoing investigation. Staff intervened and removed Resident R1 from the room. Director of Nursing attempted to interview Resident R2, but due to cognitive status she is not interviewable. Nursing Home Administrator called 911 and [Police Department] presented to the facility. [Police Department] notified their detective department and had them also present to the facility. Recommendation made to send Resident R2 to the emergency room for a sexual assault consultation/rape kit. Residents husband was informed and presented to the facility. Resident was sent to [Hospital] and remains out of the facility at time of this report. All alert and oriented female residents will be interviewed, non-alert/oriented female residents will have a full body audit completed. Resident R1 placed on 1:1 with a staff member to ensure safety of all residents. All staff are educated on abuse upon hire, annually, and as needed.During an interview on 8/21/25, at 3:25 p.m. with Resident R2's husband revealed that he was not aware of what had occurred until he arrived at the facility. He stated, She is so scared of everything, doesn't like loud noises and things like that, she becomes afraid if someone pops the top on a can of soda. Is she going to be okay? He was observed consoling her and stroking her hand as she was on the stretcher.Review of the clinical record indicated that Resident R8 was admitted to the facility on [DATE].Review of the MDS dated [DATE], included diagnoses of polyneuropathy (condition were multiple nerves are damaged, causing pain, decreased sensation, and weakness) and high blood pressure. Question C0500 BIMS Summary Score revealed Resident R8's score to be 15.During an interview on 8/22/25, at 9:48 a.m. with Resident R8, he stated that he observed Resident R2 in a room with her pants down and no brief on with Resident R1 standing next to Resident R2 who was in bed. He yelled for assistance and was on his way to get his phone to call the police, he told someone to call them and is unsure of who made the call. He stated, This is disgusting that it has been going on, just bullshit, if that was my mother or grandmother, not sure what I would have done.During a follow-up interview on 8/29/25, at 2:35 p.m., Resident R8 confirmed he saw the incident. When asked what part of the body he observed Resident R1 touching, he stated, I saw ass. Resident R8 stated that he observed Resident R2 flailing her hand toward Resident R1, She definitely didn' t want it. Resident R8 stated, He's been doing it a long time. Resident R8 stated (as an example) he was out smoking and a peer resident stated, Where's [Resident R1]? and the response from another resident was, He's in someone's room molesting them.Review of hospital paperwork dated 8/22/25, indicated that Resident R2 was seen on 8/21/25, in the emergency room for sexual assault.Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE].Review of the MDS dated [DATE], included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles) and physical debility. Question C0500 BIMS Summary Score revealed Resident R3's score to be 15.Review of an electronic communication dated 8/12/25, at 6:18 p.m., provided to both the facility administration and the state survey agency indicated, It has come to our family's attention in the last 2 weeks that my grandmother has been harassed (and touched at least twice) by a male resident at your facility for months.During an interview on 8/21/25, Resident R3's granddaughter provided the name of the male resident spoken of in the electronic communication as Resident R1. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE].Review of the MDS dated [DATE], included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), depression, and quadriplegia (paralysis of all four limbs). Question C0500 BIMS Summary Score revealed Resident R4's score to be 10.During a family interview on 8/21/25, at 7:56 p.m. Resident R4's son confirmed that she has complained to family that a male resident wheels into her room while she is sleeping and touches her. My mom, she cannot defend herself. It's not okay, but I understand he has issues.Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE].Review of the MDS dated [DATE], included diagnoses of dementia, anxiety, and depression. Question C0500 BIMS Summary Score revealed Resident R5's score to be 00, which indicated that Resident R5 is so severely cognitively impaired to not be able to complete the interview.During an interview on 8/21/25, at 3:25 p.m. Resident R8 stated that Resident R1 has been observed by himself and by other residents touching Resident R5 in the hallway. Resident R8 stated that Resident R1 has stuck his fingers in her mouth and then touched her groin; he has also been observed grabbing her breasts.Review of Resident R5's clinical record failed to reveal documentation that this concern (also stated by Employee E6) was reviewed by clinicians or any actions taken related to the above observation. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE].Review of the MDS dated [DATE], included diagnoses of Huntington's Disease (a condition that leads to progressive degeneration of nerve cells in the brain) and peripheral vascular disease (PVD - circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Question C0500 BIMS Summary Score revealed Resident R6's score to be 10.During an interview on 8/21/25, at approximately 2:20 p.m. Nurse Aide Employee E2 stated that she had to keep redirecting Resident R1, that he had been trying to get to Resident R5 and R6.Review of confidential staff interviews completed on 8/21/25, and 9/9/25, revealed the following: Confidential Employee E3: Never personally witnessed, has heard from other staff that he (Resident R1) is sexually inappropriate. Has observed Resident R1 touching others, more of a patting sense. Confidential Employee E4: Stated they have seen Resident R1 sexually inappropriate. Kissing, touching. Tried to separate them and bring him back to his unit. Has seen it recently with Resident R7 and here more recently with Resident R2. I've told em. Everybody knows it. Its everyday like, Oh I have had to get Resident R1 away from Resident R2. Oh, I just had to get Resident R1 away from whoever. Confirmed he wanders into other rooms, Oh yeah, he's everywhere. Real bad. Confidential Employee E5: I heard that he went into R2's room. Confidential Employee E6: Confirmed they have seen Resident R1 be inappropriate with residents. A lot in the dining room. When we separate them, he follows us, and gets very combative. Resident R5 was asleep in the dining room and Resident R1 put his fingers in her mouth. We were told its not inappropriate behavior. It really upset me. I was very uncomfortable. We were told, Do you kiss in your own home? but yes, with consent. Confidential Employee E7: He was kissing Resident R7. I told them but they say its ok. Confidential Employee E8: He always tries to get with women. Confidential Employee E9: One of our residents was her boyfriend, that was her boyfriend. Confirmed that they had heard that Resident R1 was sexually inappropriate, but not witnessed, I heard he was a pedophile. Confidential Employee E10: Touches other residents on the face. I take him away. Confirmed that she has never seen any sexual behavior, only seen him touch someone (arm) but have heard from other staff about Resident R1's behavior. Confidential Employee E11: I have seen him sitting close to other residents. I've never had to take separate them. Other staff have spoken about his being sexually inappropriate. Confidential Employee E12: I've heard of him touching other residents, I've never seen it. Confirmed they had heard from both residents and staff that Resident R1 is sexually inappropriate. I feel like if this had been handled when this started, today (referring to incident with Resident R2) would never have happened. When asked about reporting, The entire building knew. There was a lady who cannot communicate who he was touching inappropriately, [Resident R6] was her name. Confidential Employee E13: Confirmed they had seen Resident R1 be sexually inappropriate with both staff and residents. I fought with him, he literally tried to molest me. It took over an hour to get him out of the bathroom. When asked what residents, stated, Resident R7 mostly. He will go after more, any woman actually. Confirmed Resident R1 wanders into others rooms, walks around unclothed. He's a very sexual man. Confidential Employee E14: Mostly with Resident R7. He wanders a lot. I redirect him. Employee confirmed that other residents have complained about Resident R7's behavior, she allows him to put his hands on her leg and to rub her arms.- Confidential Employee E18: I've heard that he is inappropriate with residents but have never seen it myself. Confirmed that they heard it from staff and residents that it was Resident R1 that is sexually inappropriate.- Confidential Employee E20: Confirmed that they have seen Resident R1 be sexually inappropriate with other residents, stated This has been going on over a month, goes around touching women, putting his hand up their pants, sticking his fingers in their mouth, grabbing breasts, just continues to get worse. I also heard he tried to grab one of the Activity Aides between her legs. When I reported his increased behavior to the DON, she stated that they are older people and are allowed to touch.- Confidential Employee E21: I have heard that he has displayed inappropriate behavior but I have not experienced any situations to report about. - Confidential Employee E26: I have only overheard the other staff talking about it but have never physically seen it. Staff complain that he has been doing this for a while. The only thing I know is there is no consent for him to do or not to do these actions with other residents.- Confidential Employee E27: I know this has been going on for longer than 6 months and now Resident R1 has to be a 1:1 which is creating other issues. I do know there were no orders after the incident and then a couple days later orders appeared but they were placed by a corporate person. - Confidential Employee E32: I would say that it occurs Resident R1's behaviors occur frequently and he is not easily redirected. I brought it to the attention of the DON that his behaviors were getting worse and her reply was Some of these ladies enjoy it, should we be stopping their pleasure, I was so angry, and then she told me We should not be bringing his past and applying it now. I always redirect him and am thanked by the ladies that he is bothering. I visited Resident R2 at her new facility and the staff there thought she was bothersome because she is always yelling You will not sex me.- Confidential Employee E33: Confirmed that Resident R1 has been sexually inappropriate, states he is very-touchy, feely, at times can be redirected but others he becomes aggressive -and starts swearing and swinging out at staff. I would say his behavior is like a baby throwing a temper-tantrum because you took his toy away from him. I know a lot of issues occur in the Dining Room where he was free to move around. Management has been aware since February 2025.- Confidential Employee E34: Confirmed that Resident R1 has been sexually inappropriate. Incident occurred the other day when his aide had to leave, he was supposed to be watched by the DON until the next aide came in but was left alone, he sat next to a female resident and started to hold her hand (not Resident R7) and we felt things might escalate so we went to redirect and move him and he grabbed her chair and wouldn't let go becoming more aggressive. Resident R1's behaviors have been reported to the current DON and the one before this, we keep getting told we are investigating but nothing is done.- Confidential Employee E35: I really don't deal with Resident R1 that much. I know he is touchy with one resident but they are allowed (Resident R7). I also know that he is a 1:1.- Confidential Employee E36: I have personally never had to redirect Resident R1. We recently had to complete Abuse training because of the incident.- Confidential Employee E37: Confirmed that she has had to redirect Resident R1 a couple times and it is not easy, just don't understand why we are keeping him.- Confidential Employee E38: Stated, I saw him in the Dining Room with a resident being inappropriate. I reported it to nursing staff and the DON.- Confidential Employee E39: Confirmed that she has only seen Resident R1 display sexual behavior once and staff corrected his behavior, the behavior was brought to their attention by other residents.- Confidential Employee E40: Stated that she observed Resident R1 fondle a female resident's breast, she was in a wheelchair, unable to defend herself. Confirmed that the female resident was not Resident R7. Employee E40 stated she reported the incident to the Director of Nursing, and was told not to worry about it. I don't want to get anyone in trouble, but it (referring to the incident involving Resident R2 on 8/22/25) never should have happened. I still picture her. It's awful.On 8/22/25, at 11:56 a.m. the Nursing Home Administrator was made aware that an Immediate Jeopardy situation existed for five of 67 residents, and the Immediate Jeopardy template was provided to facility administration.This Immediate Jeopardy existed beginning 2/4/2025.On 8/22/25, at 2:38 p.m. an acceptable Corrective Action Plan was received which included the following interventions:Immediate action(s) taken for the resident(s) found to have been affected include: Resident R1 was placed on 1:1 8/22/25 and will remain on 1:1. Facility will ensure 1:1 is in place at all times by scheduling specific staff to perform this 1:1 duty each day on all three shifts.Residents R3, R4, R5, and R6 will remain safe from resident initiated sexual abuse through the facility providing 1:1 to Resident R1.Resident R1 and R2 were immediately separated on 8/21/25.Resident R2 was assessed for injuries and no injuries noted on 8/21/25. Resident R2 was sent to the hospital for further evaluation on 8/21/25 and remains at hospital.Identification of other residents having the potential to be affected was accomplished by:Current female residents who were cognitively intact were interviewed on 8/21/25. Current female residents who were cognitively impaired had a skin assessment completed on 8/21/25.No issues identified from interviews or skin assessments.Actions taken/systems put into place to reduce the risk of future occurrence include:Education will be completed by all staff on Abuse/Neglect and Reporting of Incident and Accidents by the Director of Nursing or designee by 8/22/25.How the corrective action(s) will be monitored to ensure the practice will not recur: Resident R1 will remain on 1:1. Resident R1 will be evaluated by psychiatry services on 8/22/25 in conjunction with the facility medical director.While Resident R1 remains in the facility audits will be completed on female residents who are cognitively intact daily x 5 days a week for two weeks, weekly for two weeks and then monthly for two months to ensure residents safety. These audits will be completed by Social Services or designee. While Resident R1 remains in the facility audits will be completed on female residents who are cognitively impaired daily x 5 days a week for two weeks, weekly for two weeks and then monthly for two months to ensure residents safety.An Ad Hoc Quality Assurance and Process Improvement Meeting was held by the Administrator on 8/21/25.Affected residents will be seen by facility contracted psychiatry/psychology provided if they request to do so to address their emotional trauma.This plan of correction will be monitored at the Quality Assurance and Process Improvement meeting until such time consistent substantial compliance has been met. During staff interviews conducted on 8/22/25, between 12:00 p.m. and 3:30 p.m. 12 staff members confirmed they received education on abuse prevention.The Immediate Jeopardy was lifted on 8/22/25, at 3:52 p.m., when the action plan implementation was verified.During an interview on 8/22/25, at approximately 4:00 p.m. the Nursing Home Administrator confirmed that the facility failed, to protect residents from resident-to-resident sexual abuse for five of 67 residents. This failure resulted in a resident with a known history of sexually inappropriate behavior touching a non-consenting resident, which created an Immediate Jeopardy situation for five of 67 residents. 28 Pa. Code 201.18(e)(1) Management28 Pa. Code 201.20(a)(b) Staff development28 Pa. Code 201.29(a)(c)(d) Resident rights

Based on review of facility policy, clinical records, observations, and resident and staff interviews, it was determined the facility failed to ensure that one of 26 residents was free from sexual abuse that resulted in the actual harm of a newly diagnosed sexually transmitted infection for one of 26 residents (Resident R29). Findings include: A review of the facility policy titled Abuse and Neglect-Clinical Protocol, last reviewed 10/23/24, indicated that residents have the right to be free from abuse, as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, or causes physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Sexual Abuse is defined as non-consensual sexual contact of any type with a resident. The term Willful is used in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Additionally, the facility policy indicated that abuse prevention included assessing, care planning, cause identification, treatment/management and monitoring residents with needs and behaviors that may lead to conflict or neglect. Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues. The facility will strive to maintain adequate staffing on all shifts to ensure the needs of each resident are met. Review of Resident R29's clinical record revealed admission to the facility on [DATE], with diagnoses that included encephalopathy (disturbance of brain function that causes confusion, memory loss, and coma in severe cases), alcoholic cirrhosis (chronic liver disease caused by long-term, excessive alcohol consumption), depression, muscle weakness. Review of Resident R29's Minimum Data Set (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) assessment dated [DATE], section C Cognitive Patterns revealed severe cognitive impairment. Review of the resident profile revealed Resident R29 has a court appointed guardian. In court appointed guardianship paperwork dated 12/21/21, it states that due to her diagnosis, Resident R29 suffers from permanent damage to her brain and recovery is not possible. Resident R29 is unable to receive or evaluate information or to communicate decisions to such an extent that she is unable to meet her essential requirement for her personal and financial needs. Resident R29 is in need of guardianship services and is totally incapacitated. There is no less restrictive alternative to the appointment of a Plenary Guardian and of the estate of Resident R29. Review of Resident R29's comprehensive person-centered care, plan of care that was initiated on 10/21/24, and revised on 1/22/25, does not mention the resident as having behaviors related to inappropriate sexual behaviors (making sexually inappropriate statements to caregivers, engaging in relationships with other residents,or desire to be sexually active or show sexual expression). No planned interventions are noted to manage sexual behaviors, monitor and document episodes of inappropriate behaviors and/or to notify physician/nurse-practitioner/physician assistant when behaviors persist. During an interview on 2/6/25 at 3:18 p.m. Resident R29 revealed that she was in a relationship with Resident R67. She states they are engaged and plan to move in together when they both get out of the facility. When asked if they are sexually active she denied that they were. Review of Resident R67's clinical record revealed admission to the facility on [DATE], with diagnoses that included schizoaffective disorder (combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder. Symptoms may occur at the same time or at different times), Alcohol use, muscle weakness, and depression. Review of Resident R67's MDS assessment dated [DATE], section C Cognitive Patterns revealed Resident R67 had a BIMS score of 15, which indicated the resident is cognitively intact. Review of clinical progress notes on 11/26/24, indicated Resident R67 was unhappy with increased sexual dysfunction secondary to his medication and asked his psychiatrist to change his medications to alleviate the sexual dysfunction. Review of Resident R67's clinical record on 11/29/24, states the resident bought beer for a female resident because she had a migraine and she needed it. Resident R67 was given the explanation that he was not to buy alcohol for another resident and that if that resident needed alcohol it had to go through the physician. During an interview on 2/5/25, at approximately 2:40 p.m. with the DON she stated that Resident R67 did buy the alcohol for Resident R29. During an interview with Resident R67 on 2/6/25, at 2:44 p.m. he confirmed that he is in a relationship with Resident R29 and that they are engaged and his plan is to come back and visit her until she is able to be discharged and move in with him. Review of the clinical record reveals no documentation that Resident R67 is in a relationship with Resident R29. Review of Resident R29's clinical record revealed the resident was diagnosed with Trichomoniasis(sexually transmitted infection causing a foul-smelling vaginal discharge, genital itching and painful urination in women, men typically have no symptoms). Resident R29 saw a gynecologist on 1/21/25, and office reported to facility on 1/31/ 25, that results from [NAME] test (Pap test-a cervical cancer screening procedure that involves taking a cell sample from the cervix, cells are examined then under a microscope) back positive for this infection and resident would need to start antibiotics to treat the infection. During an interview with the gynecologist's office on 2/6/25, at approximately 10:30 a.m., revealed that Resident R29 stated she has been recently engaged in consensual intercourse. Resident also stated during this visit that she was engaged to a fell ow resident, Resident R67, and they plan to move in together. Resident R29's clinical record failed to reveal documented evidence that social services, medical services or managerial staff followed up with the resident post-gynecological exam finding to determine the extent of relationship with Resident R67, and failed to reveal that her person-centered plan of care was reviewed and revised with new goals and approaches to manage her sexual behavior and resident-resident relationship. Review of RN Employee E1 statement on 2/4/25 at 11:30 a.m. reported that she was notified on 1/31/25 that Resident R29 had Trichomoniasis but the facility felt that she came that way (transferred from hospital on 10/17/24), was aware that she was in a relationship with Resident R67, and there was concern that she might be pregnant due to abdomen being distended (no pregnancy test done at facility but at gynecological appointment on 1/21/25, the test was negative). During an interview on 2/6/25 at 11:00 a.m. Resident R29's guardian stated she was aware that Resident R29 was in a relationship with another resident at the facility but she was not made aware of the new diagnosis of a sexually transmitted infection. Guardian stated she feels that Resident R29 does not have the capacity to differentiate what sexual intercourse entails, meaning is it kissing, oral sex, masturbation or intercourse or what the repercussions could be such as pregnancy (Resident R29 is still in child-bearing age with monthly menstruation) or a sexually transmitted infection. During an interview on 2/6/25, at approximately 11:45 a.m. the Director of Nursing discussed Resident R29's behaviors as was noted from a previous facility, she was noted to be hypersexual in that she enjoyed flirting with the male residents and aides, talking in a sexual manner and she enjoyed sitting on men's laps, she had to be redirected of her behaviors at that facility and currently she is focused on her relationship with Resident R67. Resident R29 has never been care planned for these known hypersexual behaviors at her current facility. During multiple interviews with multiple staff members (NA Employee's E5, E8, and E9) on 2/6/25, it was noted that Resident R29 and Resident R67 are together all the time, she sometimes goes into his room, they cuddle and watch movies together on his computer, they talk about moving in together, hug in the hallway, have been seen kissing. Staff stated that they had made management aware of the seriousness of the relationship. During an interview with the Social Worker Employee E10 on 2/6/25, at 11:30 a.m, revealed that she was aware that Resident R29 and Resident R67 were friends but stated they feel Resident R29 is unable to make a decision to be in a committed relationship, Resident R67 can make that decision, they are engaged (did not mention he bought her an engagement ring), and spent time together in various areas of the facility but are never alone, also stated Resident R67 is due to be discharged soon and plans on returning to visit Resident R29. Further review with DON and NHA confirmed the facility failed to ensure proper staff supervision of Resident R29 and Resident R67 and to develop and implement necessary interventions for a resident with a severe cognitive impairment from entering a relationship with a resident with cognitive impairment. The facility failed to develop and implement interventions after suspected sexual abuse occurred and to prevent further incidents of sexual abuse from occurring. This incident was identified as a harm for one of twenty-six residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(a)(c) Resident rights. 28 Pa. Code 211.12(c)(d)(5) Nursing services.

Based on review of facility policy, clinical records and incident reports and staff interviews, it was determined that the facility failed to ensure that food was served in a form to meet the individual needs of one of three residents sampled (Resident R72), which resulted in actual harm of aspiration into the airway and acute [CONDITION(S)] requiring transfer to the hospital for admission and treatment. This was identified as harm for past non-compliance for one resident (Resident R72). Findings include: A review of the facility's policy, Serving of Food, dated 12/21/21, indicated that food shall be prepared and served in a manner that meets the individual needs of each resident. A pureed diet is a texture modification of a regular diet designed for persons with poor oral abilities to protect the airway. It should be pudding like. A review of the clinical record revealed that Resident R72 was admitted to the facility on [DATE], with diagnoses that included dementia and TIA ([CONDITION(S)] - a brief stroke like attack). A review of the Minimum Data Set (resident assessment) dated 11/16/21, indicated that Resident R72 limited assistance of one person for eating. A review of a Speech Therapy Progress report and Updated Therapy Plan dated 9/29/21, indicated to continue with a pureed diet. A review of a physician order dated 10/5/21, indicated regular diet with pureed texture. A review of the care plan dated 11/11/10/21, indicated diet per physician orders. A review of a Nutrition assessment dated [DATE], indicated Resident R72 receives a pureed diet. A review of a nurse progress note dated 12/29/21, indicated resident was eating dinner and began to choke, and lips turned blue. Resident was suctioned and [MEDICATION(S)] maneuver performed times two. Resident given oxygen and 911 called. The resident was sent to the hospital for evaluation. A review of an incident report dated 12/29/21, indicated Resident R72 was eating dinner in the hallway when they began to choke, and rapid response was called. A review of facility witness statements dated 12/30/21, indicated the following: Nursing Assistant (NA) Employee E13 indicated when they were trying to get the food out of the resident's mouth, they noticed it was the wrong tray. Licensed Practical Nurse (LPN) Employee E14 indicated this nurse informed the NA that the slip she had belonged to another resident, and the resident was given the wrong tray, and would be why they were choking. LPN Employee E15 indicated this nurse witnessed Resident R72 sitting in her chair eating a sandwich. The NA took the sandwich, split it into two pieces and handed it back to the resident. The resident was suctioned and removed pieces of a peanut butter sandwich. Attempts made to remove the lodged food, until EMS (emergency medical services) took over. NA Employee E16 indicated the resident had the wrong tray. Registered Nurse (RN) Employee E17 indicated the resident was choking on some food they had been eating. It was a peanut butter sandwich. The [MEDICATION(S)] maneuver was performed twice and able to dislodge part of the sandwich. 911 was called. A review of a hospital Transfer Report dated 1/3/22, indicated diagnoses of aspiration into the airway and acute [CONDITION(S)]. During an interview on 2/3/22, at 3:00 p.m. the Director of Nursing (DON) confirmed Resident 72 received food (peanut butter sandwich) that was not in a form to meet the resident's needs for safe swallowing to prevent the resident from choking. On 12/30/21, the facility initiated education for all nursing staff including Registered Nurse's (RN's), Licensed Practical Nurses (LPN's), and Nurse Aides (NA's) to ensure that physician's orders regarding diets, meal service, and meal types are followed as ordered. This plan included the following: Immediate education included direct care competencies on the meal service process of all direct care staff employed at the time. The facility provided documentation of the in-service training that was provided to the nursing staff, including Registered Nurses, Licensed Practical Nurses and Nurse Aides, at the facility on 12/30/21, which addressed following the physician orders regarding diets, meal service, and meal types. The facility reviewed like residents for non-compliance with diet orders and meal service on 12/31/21, and audited all in house residents' meals (breakfast, lunch, and dinner) for accuracy 12/31/21 through 1/3/22. It was determined that this was an isolated incident. The facility has demonstrated compliance with the regulation since 12/30/21. During an interview on 2/4/22, at 12:00 p.m. with the DON and NHA and review of the facility's immediate actions, education, and review of the QAPI monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction and achieved compliance ensuring that food shall be prepared and served in a manner that meets the individual needs of each resident. 483.60 (d)(3) Food in form individual needs 28 Pa. Code 211.6 (c) Dietary Services. 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services

Based on review of facility policies, clinical record review, facility reports, job descriptions and staff interviews, it was determined that the facility failed to provide the necessary assistance for a safe transfer that resulted in harm for one of 14 residents reviewed (Resident R1). Findings include: The facility's, Reporting and Investigation of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source, and Misappropriation of Resident's Property policy dated 1/5/15, indicated that steps were taken by the facility to prevent the occurrence of neglect by training their employees. The training included the importance of following the plan of care for the resident. The facility's, Care Plan policy dated 1/5/15, indicated that all disciplines involved in providing care to the residents, had access to the care plan and that the care plan included information about equipment ordered by the physician. The facility's, Transfer Activities policy dated 1/5/15, instructed staff to obtain ordered equipment and the assistance of another person, if necessary, for a safe transfer. The job description for the, Care Specialist CNA (certified nurse aide) dated 5/15/15, included duties to comply with all company policies related to safety, including the proper use of mechanical lifts (device used to move those who are unable to stand on their own or whose weight makes it unsafe to move or lift them manually) and the assistance of two staff persons when using lifts. The Admission Record indicated that Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set assessment (MDS-a periodic assessment of resident care needs) dated 8/15/15, included the same [DIAGNOSES REDACTED]. The September 2015, recapitulation orders (a summary of the physician's orders [REDACTED]. The care plan last revised by the facility on 9/4/15, identified Resident R1 as a fall risk and high risk for injuries due to the MS and [MEDICAL CONDITION] and instructed staff to use the Marisa lift for transfers and have the resident wear the left shoe with the metal uprights (shoe with metal bars extending from the shoe up the sides of the leg to the knee area to support the leg) when out of bed. A nurses' note dated 9/30/15, indicated that Resident R1's legs buckled while being transferred into bed with the sit to stand lift (lift used for transfers when a person has some capacity to support themselves), the resident complained of left leg pain, the physician was notified, and an order was received for an X-ray of the left knee and left hip. The results of the left knee and left hip X-ray dated 9/30/15, showed that Resident R1 had an, acute midshaft femur fracture (long, straight part of the thigh bone). The physician order [REDACTED]. A nurses' note dated 10/1/15 at 10:32 a.m., indicated that Resident R1 had bruising of the right knee region and complained of pain in the right leg. The physician was notified and an X-ray of the right knee was ordered. The results of the right knee X-ray showed that Resident R1 had, acute (newly acquired) minimally displaced fractures of the proximal (upper) shafts (long,straight parts) of the tibia and fibula (lower leg bones). The physician was notified of the results on 10/1/15 and the resident was transferred to the hospital. The hospital records dated 10/2/15, indicated that Resident R1 had multiple fractures that included fractures of the shaft and supracondylar (above the knee) sections of the femur in the left leg and fractures of the bicondylar plateau (shin bone), shaft, tubercle (front part) sections of the tibial bone (largest lower leg bone) and proximal fibula (lower calf bone) in the right leg. On 10/2/15, Resident R1 required surgery for [REDACTED]. The facility investigation dated 9/30/15, indicated that Nurse Aide (NA), Employee E1, used the incorrect lift to transfer Resident R1 and on 10/1/15, concluded that, on investigation, after speaking with various staff members about different lifts, many staff members thought that the sit to stand lift was called the Marisa lift. During an interview on 10/14/15 at 12:15 p.m., the Director of Nursing (DON) and the Staff Development Director, Employee E2, confirmed that Resident R1 was ordered the full body lift for transfers and that two staff persons were required to use this lift. During a phone interview on 10/14/15 at 2:20 p.m., Employee E1, reported that, I thought that (the sit to stand lift) was the one to use and confirmed not checking Resident R1's care plan prior to providing care and using the sit to stand lift because, I have seen other persons use that lift so I didn't know any difference. During interviews on 10/14/15 at 2:50 p.m., and at 3:15 p.m., the DON and the Nursing Home Administrator confirmed that Resident R1, because of the progression of the MS, did not have the strength required to use the sit to stand lift and that the facility failed to provide the necessary assistance for safe transfer that resulted in actual harm to the resident. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 08/31/15. 28 Pa. Code 201.18(b)(1) Management. Previously cited 08/31/15, 1/16/15. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 201.29(a)(c)(d) Resident rights. 28 Pa. Code 211.12(c) Nursing services. 28 Pa. Code 211.12(d)(1)(3) Nursing services. Previously cited 01/16/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 08/31/15, 01/16/15.

Based on review of facility policies, review of clinical records and staff interviews, it was determined that the facility failed to follow the care plan for the required transfer needs of the resident resulting in harm to one of 14 residents reviewed (Resident R1). Findings include: The facility's, Care Plan policy dated 1/5/15, indicated that all disciplines involved in providing care to the residents, had access to the care plan and that the care plan included information about equipment ordered by the physician. The facility's, Transfer Activities policy dated 1/5/15, instructed staff to obtain ordered equipment and the assistance of another person, if necessary, for a safe transfer. The Admission Record indicated that Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set assessment (MDS-a periodic assessment of resident care needs) dated 8/15/15, included the same [DIAGNOSES REDACTED]. The September 2015, recapitulation orders (a summary of the physician's orders [REDACTED]. The care plan last revised by the facility on 9/4/15, identified Resident R1 as a fall risk and high risk for injuries due to the MS and [MEDICAL CONDITION] and instructed staff to use the Marisa lift for transfers and have the resident wear the left shoe with the metal uprights (shoe with metal bars extending from the shoe up the sides of the leg to the knee area to support the leg) when out of bed. A nurses' note dated 9/30/15, indicated that Resident R1's legs buckled while being transferred into bed with the sit to stand lift (lift used for transfers when a person has some capacity to support themselves), the resident complained of left leg pain, the physician was notified and an order was received for an X-ray of the left knee and left hip. The results of the left knee and left hip X-ray dated 9/30/15, showed that Resident R1 had an, acute midshaft femur fracture (long, straight part of the thigh bone). The physician order [REDACTED]. A nurses' note dated 10/1/15 at 10:32 a.m., indicated that Resident R1 had bruising of the right knee region and complained of pain in the right leg. The physician was notified and an X-ray of the right knee was ordered. The results of the right knee X-ray showed that Resident R1 had, acute (newly acquired) minimally displaced fractures of the proximal (upper) shafts (long,straight parts) of the tibia and fibula (lower leg bones). The physician was notified of the results on 10/1/15 and the resident was transferred to the hospital. The hospital records dated 10/2/15, indicated that Resident R1 had multiple fractures that included fractures of the shaft and supracondylar (above the knee) sections of the femur in the left leg and fractures of the bicondylar plateau (shin bone), shaft, tubercle (front part) sections of the tibial bone (largest lower leg bone) and proximal fibula (lower calf bone) in the right leg. On 10/2/15, Resident R1 required surgery for [REDACTED]. The facility investigation dated 9/30/15, indicated that Nurse Aide (NA), Employee E1, used the incorrect lift to transfer Resident R1. During an interview on 10/14/15 at 12:15 p.m., the Director of Nursing (DON) and the Staff Development Director, Employee E2, confirmed that Resident R1 was ordered and care planned for use of the full body lift for transfers and that two staff persons were required to use this lift. During a phone interview on 10/14/15 at 2:20 p.m., NA, Employee E1, reported that, I thought that (the sit to stand lift) was the one to use and confirmed not checking Resident R1's care plan prior to providing care to the resident. During interviews on 10/14/15 at 2:50 p.m. and at 3:15 p.m., the DON and the Nursing Home Administrator confirmed that the facility failed to follow the care plan for the required safe transfer needs of Resident R1 resulting in harm. 42 CFR 483.20(k)(1) Develop Comprehensive Care Plans. Previously cited 01/16/15 28 Pa. Code 211.11(a) Resident care plan. Previously cited 01/16/15. 28 Pa. Code 211.11(b)(d) Resident care plan. 28 Pa. Code 211.12(d)(2)(3) Nursing services. Previously cited 01/16/15.

Based on review of facility policies, review of the clinical record, facility reports, job descriptions and staff interviews, it was determined that the facility failed to utilize the proper lift for transfers resulting in harm for one of 14 residents reviewed (Resident R1). Findings include: The facility's, Reporting and Investigation of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source, and Misappropriation of Resident's Property policy dated 1/5/15, indicated that steps were taken by the facility to prevent the occurrence of neglect by training their employees. The training included the importance of following the plan of care for the resident. The facility's, Care Plan policy dated 1/5/15, indicated that all disciplines involved in providing care to the residents had access to the care plan and that the care plan included information about equipment ordered by the physician. The facility's, Transfer Activities policy dated 1/5/15, instructed staff to obtain ordered equipment and the assistance of another person, if necessary, for a safe transfer. The job description for the, Care Specialist CNA (certified nurse aide) dated 5/15/15, included duties to comply with all company policies related to safety, including the proper use of mechanical lifts (device used to move those who are unable to stand on their own or whose weight makes it unsafe to move or lift them manually) and the assistance of two staff persons when using lifts. The Admission Record indicated that Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set assessment (MDS-a periodic assessment of resident care needs) dated 8/15/15, included the same [DIAGNOSES REDACTED]. The September 2015, recapitulation orders (a summary of the physician's orders [REDACTED]. The care plan last revised by the facility on 9/4/15, identified Resident R1 as a fall risk and high risk for injuries due to the MS and osteoporosis and instructed staff to use the Marisa lift for transfers and have the resident wear the left shoe with the metal uprights (shoe with metal bars extending from the shoe up the sides of the leg to the knee area to support the leg) when out of bed. A nurses' note dated 9/30/15, indicated that Resident R1's legs buckled while being transferred into bed with the sit to stand lift (lift used for transfers when a person has some capacity to support themselves), the resident complained of left leg pain, the physician was notified and an order was received for an X-ray of the left knee and left hip. The results of the left knee and left hip X-ray dated 9/30/15, showed that Resident R1 had an, acute midshaft femur fracture (long, straight part of the thigh bone). The physician order [REDACTED]. A nurses' note dated 10/1/15 at 10:32 a.m., indicated that Resident R1 had bruising of the right knee region and complained of pain in the right leg. The physician was notified and an X-ray of the right knee was ordered. The results of the right knee X-ray showed that Resident R1 had, acute (newly acquired) minimally displaced fractures of the proximal (upper) shafts (long,straight parts) of the tibia and fibula (lower leg bones). The physician was notified of the results on 10/1/15 and the resident was transferred to the hospital. The hospital records dated 10/2/15, indicated that Resident R1 had multiple fractures that included fractures of the shaft and supracondylar (above the knee) sections of the femur in the left leg and fractures of the bicondylar plateau (shin bone), shaft, tubercle (front part) sections of the tibial bone (largest lower leg bone) and proximal fibula (lower calf bone) in the right leg. On 10/2/15, Resident R1 required surgery for [REDACTED]. The facility investigation dated 9/30/15, indicated that Nurse Aide (NA), Employee E1, used the incorrect lift to transfer Resident R1 and on 10/1/15, concluded that, on investigation, after speaking with various staff members about different lifts, many staff members thought that the sit to stand lift was called the Marisa lift. During an interview on 10/14/15 at 12:15 p.m., the Director of Nursing (DON) and the Staff Development Director, Employee E2, confirmed that Resident R1 was ordered the full body lift for transfers and that two staff persons were required to use this lift. During a phone interview on 10/14/15 at 2:20 p.m., Employee E1 reported that, I thought that (the sit to stand lift) was the one to use and confirmed not checking Resident R1's care plan prior to providing care and using the sit to stand lift because, I have seen other persons use that lift so I didn't know any difference. During interviews on 10/14/15 at 2:50 p.m., and at 3:15 p.m., the DON and the Nursing Home Administrator confirmed that the facility staff failed to use the proper lift and the assistance of two staff persons when transferring Resident R1 and this resulted in actual harm to the resident. 42 CFR 483.25(h) Free of Accident Hazards/supervision/devices. Previously cited 08/31/15 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 08/31/15. 28 Pa. Code 201.18(b)(1) Management. Previously cited 08/31/15, 1/16/15. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code: 201.29(a)(c)(d) Resident rights. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 08/31/15, 1/16/15. 28 Pa. Code 211.12(c) Nursing services. 28 Pa. Code 211.12(d)(1)(3) Nursing services. Previously cited 01/16/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 08/31/15, 01/16/15.