Every finding on record at Wecare at Sycamore Rehabilitation and Nursing Cent

Based on a review of select facility policies and procedures, facility documentation, and staff interview, it was determined that the facility failed to implement measures to protect residents from abuse for one of one employee reviewed (Employee 1, Resident 1).Findings include: Upon the surveyor asking the Nursing Home Administrator for the abuse reporting and investigating policy and procedure, the facility provided a blank facility document titled, Investigation Completion Checklist. The document noted that the checklist must be completed before an investigation can be closed. A section titled, Corrective Actions, included the following: employee disciplinary action taken (if applicable); resident care plan updated (if applicable); staff education completed (if applicable); and system / process improvements identified. Clinical record review for Resident 1 revealed a diagnosis list that included dementia (a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons); and bipolar disorder (characterized by significant mood swings, including manic or hypomanic episodes and depressive episodes). A quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated June 5, 2026, revealed that facility staff assessed Resident 1 as having a BIMS (Brief Interview for Mental Status) of rarely/never understood. The current care plan for Resident 1 included the following: impaired cognitive process for daily decision making and at risk for further decline in cognitive status; potential to be physically aggressive related to dementia; limited physical mobility related to limited mobility; and activities of daily living (ADL) self-care performance deficit related to confusion. Clinical documentation for Resident 1 dated August 11, 2026, at 11:32 PM, noted that at 9:35 PM the licensed practical nurse (LPN) reported that Employee 1, nurse aide, was witnessed grabbing a resident's back and throwing the resident onto the bed and the resident yelled out. Employee 1 left the facility after handing over a written statement. Staff assessed the resident with no new skin issues observed. A PB-22 (Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property) related to the event that was submitted to The Department on August 13, 2026, noted in the Conclusions section of the report form that Employee 1 will receive education on proper transfers and require acknowledgement of education prior to returning to work. A review of the facility documentation titled, Facility Investigation Summary, submitted with the PB22 also noted a section titled, Planned Education and Further Evaluation for Resident, noted that all nurse aides will be educated on person-centered ADL care for residents with dementia, including calm communication, reassurance, recognizing resistance or distress, allowing additional time, and stopping or modifying nonurgent care when necessary. This section also noted that both nurse aides involved will complete documented transfer competency validation, including two-person assistance, stand and pivot technique, safe positioning, communication between staff, and following the care plan and Kardex (documentation by nursing to note important information and care planning and facilitate resident care). A review of Employee 1's timecard provided by the facility revealed that Employee 1 returned to work on August 23, 2026 (evening shift) and worked August 25, 2026 (evening shift), and August 26, 2026 (evening shift). A request for any documentation that education was completed, including education completed prior to Employee 1 returning to work as indicated in the PB22, was made by the surveyor to the facility on August 31, 2026, at 1:28 PM. An interview with the Nursing Home Administrator on August 31, 2026, at 2:14 PM revealed that there was no formal education completed with Employee 1 prior to the employee returning to work and there was no documentation provided to the surveyor to indicate that the education was completed for staff. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on August 31, 2026, at 4:15 PM. A phone interview with the Director of Nursing on September 1, 2026, at 1:38 PM confirmed the facility could provide no further documentation that any staff were educated in the areas noted in the documentation submitted in the PB-22 Report Form. 483.12 (b) Development and Implementation of Abuse PolicyPreviously cited deficiency 3/13/26 28 Pa. Code 201.20(d) Staff Development 28 Pa. Code 211.12(d)(1)(2)(3) Nursing services

Based on closed clinical record review, clinical record review and staff interview it was determined that the facility failed to provide written notice to a resident or resident's responsible party before the resident's room change for three of five residents reviewed (Residents CR1, 3, 4).Findings include: Closed clinical record review for Resident CR1 revealed that the resident was admitted on [DATE]. A family member was listed as the resident's responsible party. Further review revealed the resident's room was changed on March 18, 2026, to a different unit of the facility. Record review revealed a progress note dated March 17, 2026, at 1:23 PM that noted Resident CR1's agreement to move to the new unit the following day. There was no evidence to indicate Resident CR1 or CR1's responsible party was provided written notification including the reason for the room change prior to the change occurring. Clinical record review for Resident 3 revealed the resident was admitted on [DATE], and the resident was her own responsible party. Further review revealed the resident's room was changed on June 29, 2026, and again on July 13, 2026. There was no evidence Resident 3 was provided with written notification including the reason for the room change prior to the change occurring. Clinical record review for Resident 4 revealed the resident had resided in the facility since November 13, 2025, and was her own responsible party. Further review revealed Resident 4's room had been changed on June 30, 2026. There was no evidence Resident 4 was provided with written notification including the reason for the room change prior to the change occurring. Interview with Employee 1 (social services) and Employee 2, (social services) on July 22, 2026, at 11:28 AM confirmed that the facility had no evidence that written notice was provided to the residents/room changes noted above. The surveyor reviewed the above findings during an interview with the Nursing Home Administrator and the Director of Nursing on July 22, 2026, at 2:45PM. 28 PA Code 201.14(a) Responsibility of licensee 29 Pa Code 201.29(a) Resident rights 28 Code 211.12(d)(3) Nursing Services

Based on clinical record review and staff interview, it was determined that the facility failed to implement interventions to maintain nutritional status for one of three residents reviewed for nutritional concerns (Resident 3).Findings include: Clinical record review for Resident 3 revealed the following weight assessments: December 16, 2026, 162.2 poundsJanuary 3, 2026, 161 poundsFebruary 3, 153.4 pounds (7.6-pound, 4.7 percent weight loss)February 8, 2026, 153 poundsMarch 5, 2026, 159 poundsApril 7, 2026, 158 poundsMay 29, 2026, 145.8 pounds (12.2 pounds, 7.7 percent and severe weight loss from previous month) Further clinical record review for Resident 3 revealed no evidence of nutrition notes or assessments between February 2026 (after the resident's 4.7 percent weight loss), until a quarterly nutritional assessment completed on May 29, 2026, by a registered dietitian. Resident 3's May 29, 2026, nutrition assessment indicated the weights noted above, although there was no evidence the resident's severe weight loss from April to May 2026, was acknowledged or addressed as a severe weight loss. Review of Resident 3's care plan revised on May 29, 2026, indicated that the resident had a potential for nutritional risk and a history of weight changes. One of the goals established for the resident was to maintain weight within five percent, although, no new interventions were added. There was no evidence that facility staff implemented any interventions to either monitor or treat the severe weight loss. As of June 26, 2026, there was no evidence resident 3 had been weighed again since May 29, 2026. Resident 3 was weighed upon request by the surveyor on June 26, 2026, at a weight of 147 pounds consistent with the resident's May 2026, weight, and loss from April 2026. The above information was reviewed with the Nursing Home Administrator and Employee 1, Regional Clinical Operator, on June 26, 2026, at 2:30 PM 483.25(g)(1) Maintains acceptable parameters of nutritional statusPreviously cited 3/13/26 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations and staff interview, it was determined that the facility failed to provide a clean, comfortable, homelike environment on two of six nursing units (Sycamore Boulevard and Maple Lane; Resident 2), and provide a safe and clean environment in the common intersection between Maple Lane, [NAME] Lane, and Little League Boulevard.Findings include: Observation on Sycamore Boulevard on June 6, 2026, at 9:00 AM revealed a pest control light secured on the wall, below the ceiling. There were a large number of dead insects noted inside the light, stuck to an adhesive. Directly below the pest control light was a drink tray which included two carafes and a mug filled with a brown powder. Concurrent interview with Employee 2, licensed practical nurse, revealed that the drink tray is where staff mix and serve hot drinks for the residents. Employee 2 confirmed that the brown powder in the mug was hot chocolate mix. Observation on June 26, 2026, at 11:35 AM of Resident 2's room revealed that dark brown dried drops were splashed/scattered on the wall to the right of the resident's bed that spanned an area of 3 feet. Resident 2's family indicated that those marks had been there since she moved into the room (clinical record review indicated the resident moved to this room on April 27, 2026). Continued observation of Resident 2's bathroom revealed that the floor had dried brown stains in front of the covered tub. The water line, which connected from a metal box to under the sink was noted to have rust-colored stains, and the metal box was also noted to have rust-colored stains. Observation of the intersection between Maple Lane, [NAME] Lane, and Little League Boulevard, on June 26, 2026, at 12:30 PM revealed that multiple flooring tiles were beginning to lift and buckle. Three separate tiles were noted to have the corner of the tile broken off, leaving a small hole in the flooring that appeared to be filled with black debris/dirt. The above findings were reviewed with the Nursing Home Administrator and Employee 1, Regional Clinical Operator on June 26, 2026, at 2:30 PM. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan regarding denture care for one of two residents reviewed (Resident 2). Findings Include: During an interview with Resident 2 on June 26, 2026, at 11:35 AM, they indicated that they had dentures. The resident showed their mouth and revealed they had a full set of upper dentures and a lower partial in place. Clinical record review for Resident 2 revealed they had been admitted on [DATE]. Further review revealed that the resident had no care plan (an outline of an individual's health needs, specific care requirements, and the actions necessary to achieve desired health outcomes) implemented since admission relating to denture care. The above information was reviewed with the Nursing Home Administrator and Employee 1, Regional Clinical Operations, on June 26, 2026, at 2:30 PM 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, review of facility documents, and resident and staff interview, it was determined that the facility failed to provide menu items as indicated for three of three residents reviewed (Residents 2, 3 and 4).Findings include: Observation on June 26, 2026, at 8:54 AM revealed Resident 3 had completed about half of her breakfast meal. Resident 3's meal ticket indicated they should receive six fluid ounces of hot chocolate. There was no evidence hot chocolate had been served on the resident's tray. Concurrent interview with Employee 3, nurse aide, revealed that dietary had not sent any hot chocolate packets to the unit this morning, so they were not able to make hot chocolate for Resident 3. Observation of Resident 4 eating lunch on June 26, 2026, at 12:56 PM, revealed the resident's meal tray ticket indicated the resident was to receive eight fluid ounces of Lactaid (a lactose-free milk substitute). There was no Lactaid served on the resident's tray. Clinical record review for Resident 2 revealed a physician's order dated February 23, 2026, indicating the resident was to receive a Magic Cup two times a day for variable meal intake and weight loss one carton at lunch and dinner. Observation of Resident 2 eating lunch on June 26, 2026, at 1:05 PM, revealed Resident 2's lunch meal ticket indicated the resident was to receive a Magic Cup (a dietary supplement to provided additional calories/protein). There was no Magic Cup on the resident's lunch tray. A concurrent interview with a family member of Resident 2 confirmed the Magic Cup had not been provided, but a cup a fortified (added nutrients) pudding was provided, although, the resident did not like it and would not eat it. The above information was reviewed with the Nursing Home Administrator and Employee 1, Regional Clinical Operator, on June 26, 2026, at 2:30 PM 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

Based on review of select facility policies and procedures, observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide a dependent resident with activities of daily living assistance for one of one resident reviewed (Resident 4).Findings include: Review of the facility's current policy entitled Answering the Call Light last revised September 2022, revealed that it is the facility's purpose to ensure timely responses to the resident's requests and needs. Clinical record review revealed the facility admitted Resident 4 on January 28, 2026. A review of Resident 4's most recent MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated May 19, 2026, indicated nursing staff assessed Resident 4 as substantial to maximum assistance in toileting, showering, toilet transfers, upper and lower body extremity dressing, personal hygiene, siting to lying and lying to siting, chair/bed-to-chair transfers, and rolling left to right. Clinical record review of Resident 4's task documentation (ADL, activities of daily living charting) for June 2026, revealed the resident is a two person assist with chair/bed-to-chair transfer, and sit to stand. Interview and observation of Resident 4 on June 26, 2026, at 9:10 AM revealed the resident in bed, in her night clothes. Resident 4 indicated she likes to be dressed and out of bed by 9:30 AM, and that she requires two staff to assist. Observation of Resident 4 on June 26, 2026, at 9:33 AM, revealed the resident remained in her bed, in her night clothes, crying, with her call light activated. Concurrently, an unknown staff member was observed entering the room, speaking to the resident, turning the call light off, and exiting the resident's room, Resident 4 remained in bed with her night clothes on. Further observations of Resident 4 revealed the following: 9:35 AM call light was activated and an unidentified staff member responded, spoke to the resident, turned the call light off and exited the room. 9:38 AM call light was activated and an unidentified staff member responded, spoke to the resident, turned the call light off and exited the room. 9:42 AM call light was activated and an unidentified staff member responded, spoke to the resident, turned the call light off and exited the room. 9:47 AM call light was activated and an unidentified staff member responded, spoke to the resident, turned the call light off and exited the room. 9:58 AM call light was activated and Employee 6 (activity director) responded to the call light, spoke to the resident, turned the call light off and exited the room. Concurrent interview with Employee 6 indicated she was going to tell Employee 7 (nurse aide) Resident 4 was ready to get dressed and out of bed. Resident 4's call light was observed as activated again at 10:01 AM. Resident 4 was still in bed, in her night clothes. Employee 5 (nurse aide) entered the room and told Resident 4 that Employee 7 was aware she wanted to get out of bed. Employee 5 turned off the call light and exited the room. Resident 4's call light was again observed activated at 10:06 AM, Employee 7 was then observed entering the room and proceeded to begin providing care for the resident. Resident 4 required staff assistance for hygiene, dressing, and getting out of bed and was not assisted per her preference prior to 9:30 AM. Resident 4 was then not assisted after alerting staff at 9:33 AM until greater than a half hour later at 10:06 AM when assistance began. The above findings for Resident 4 were reviewed with the Nursing Home Administrator and Employee 1, the Regional Clinical Operations, on June 26, 2026, at 2:30 PM. S483.24(a)(2) ADLsPreviously cited 3/13/26 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on review of select facility policies, clinical record review, and staff interview, it was determined that the facility failed to ensure medication availability for two of six residents reviewed (Residents 2 and 3).Findings include: The facility policy entitled, Electronic Emergency Kit, reviewed February 10, 2026, revealed that the purpose of the policy is to provide access to medications that are needed before the next pharmacy delivery through an electronic Emergency Medication Kit (EKIT), to meet the immediate needs of a resident. The provider pharmacy will provide medications for use in STAT/emergency situations at the facility. The contents of the EKIT will be determined/approved by the pharmacy/facility and in accordance with state regulations governing EKIT, emergency, and stock medications. Each EKIT unit will be filled and maintained with controlled medications, non-controlled medications, and other supplies in accordance with state laws and statutes. The nurse/authorized personnel will document the medication administration, and any other applicable information, in the eMAR/MAR and resident's medical record per facility policy and procedure. Clinical record review for Resident 3 revealed a physician's order active March 9, 2026, to April 7, 2026, for staff to administer the anticoagulant (medication used to delay blood clotting), Eliquis, 2.5 milligrams (mg) two times a day. Review of Resident 3's MAR (Medication Administration Record, electronic documentation completed by licensed staff to attest to the administration of medications) dated April 2026 revealed that staff documented a code, 17 (Held per MD order), on April 7, 2026, for the 8:00 AM dose of the medication. Nursing documentation dated April 7, 2026, at 9:54 AM noted that Resident 3's Eliquis medication was, on order (from pharmacy). Interview with the Nursing Home Administrator and the Director of Nursing on April 16, 2026, at 12:13 PM confirmed that there was no evidence Resident 3 received her Eliquis medication as ordered as nursing staff determined there was no supply of the medication for administration. Clinical record review for Resident 2 revealed a physician order active October 4, 2025, to April 11, 2026, for staff to administer Clonazepam (Klonopin, an antianxiety medication) 0.5 mg in the morning (8:00 AM) for anxiety. A physician order active October 3, 2025, to April 11, 2026, instructed staff to administer Clonazepam 1 mg daily at 4:00 PM. Review of Resident 2's MAR dated April 2026 revealed that staff failed to administer the medication on April 2, 9, and 10, 2026, at 8:00 AM, and April 8 and 9, 2026, at 4:00 PM. Staff coded, 17, as the reason for not administering the Clonazepam medication on the following dates and times:April 8, 2026, at 4:00 PMApril 9, 2026, at 8:00 AM and 4:00 PMApril 10, 2026, at 8:00 AM Nursing documentation dated April 8, 2026, at 7:57 PM noted that the licensed practical nurse notified the supervisor that Resident 2's Clonazepam was out of stock. Nursing documentation dated April 8, 2026, at 9:42 PM noted that the pharmacy rejected an attempt to pull the Clonazepam from the, omnicell (EKIT). Nursing documentation dated April 9, 2026, at 10:09 AM noted that the Clonazepam was not administered because, awaiting (pharmacy supply). Nursing documentation dated April 9, 2026, at 7:31 PM noted that the Clonazepam was not administered because, Medication not available. Nursing documentation dated April 10, 2026, at 1:16 PM noted that the Clonazepam was not administered because, medication not on hand, RN (registered nurse) supervisor made aware. Interview with the Nursing Home Administrator and the Director of Nursing on April 16, 2026, at 12:13 PM confirmed that staff did not administer Resident 2's Clonazepam medication on the above dates and times due to an interruption in the medication availability to nursing staff. 28 Pa. Code 211.9(a)(1)(4)(k)(l)(1)(2) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, and family and staff interview, it was determined that the facility failed to ensure that a resident was free from physical restraint for one of six residents reviewed (Resident 4).Findings include: The facility policy entitled, Identifying Involuntary Seclusion and Unauthorized Restraint, last reviewed February 10, 2026, revealed that as part of the abuse prevention strategy, volunteers, employees, and contractors, hired by the facility, are expected to be able to identify involuntary seclusion and/or unauthorized restraint of residents. Residents are free from the use of any physical restraints not required to treat their medical condition. Physical restraint is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: is attached or adjacent to a resident's body; cannot be removed easily by the resident; and restricts the resident's freedom of movement or normal access to his/her body. Inappropriate or unauthorized use of restraint occurs when it is used for discipline or convenience; unnecessarily inhibits a resident's freedom of movement or activity; is not the least restrictive option or used for the least amount of time needed; and/or is not accompanied by ongoing re-evaluation of the need for the restraint. Examples of physical restraints include tucking in a sheet tightly so that the resident cannot get out of bed, or fastening fabric or clothing so that a resident's freedom of movement is restricted. Risk of falling is not considered a medical symptom or self-injurious behavior that warrants the use of restraints. Restraints that are used as a last resort to protect the safety of the resident and others must be accompanied by an order from the practitioner and documentation reflecting the circumstances that led to the decision to restrain him or her. Interview with Resident 4's daughter on April 16, 2026, at 1:56 PM indicated that the facility notified her that staff observed her mother in her wheelchair with her yellow shawl that she normally wears around her shoulders tied in a knot in the back of her chair. Resident 4's daughter understood that staff allegedly restrained her mother to her wheelchair with the explanation that they worried that she might lean too far forward and fall out of the chair. Clinical record review for Resident 4 revealed an active physician's order dated October 2, 2024, that she is not capable of understanding her rights and responsibilities. Nursing documentation dated March 25, 2026, at 9:40 PM revealed that the registered nurse supervisor entered the nursing unit and nurse aide staff reported that she found Resident 4 sitting in her wheelchair at the nurses' station with her shawl wrapped around her wheelchair and tied in a knot. Resident 4 was unable to verbalize what had happened. Resident 4's clinical record did not provide evidence of a physician's order for the use of a restraint. There was no evidence of an assessment to warrant the use of a restraint to treat a medical symptom. Interview with the Nursing Home Administrator and the Director of Nursing on April 16, 2026, at 12:13 PM confirmed that the facility investigated the incident of March 25, 2026, for Resident 4 and determined that she was inappropriately restrained in her wheelchair. 28 Pa. Code 211.8(c.1)(2)(d)(e) Use of restraints 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner and maintain equipment in a sanitary condition, in the main kitchen of the facility, main dining room, and on one of six nursing units (Little League Nursing Unit). Findings include: Initial tour of the facility's main kitchen with Employee 17, Dietary Manager, on March 10, 2026, at 8:25 AM revealed the following: A wall mounted heating / cooling unit near the dishwasher room entrance had a black-colored build-up on the vents and cobwebs on the exterior. There were dried food stains on the ceiling. There were dried food stains on a wall and the disposable gloves being stored over a stainless-steel prep area. There was a significant accumulation of dust on top of a commercial coffee machine. The covering on top of the coffee machine was peeling off. There was a broken overhead light cover in the dishwasher area. There was a significant accumulation of dust and debris on the top of the dishwasher that also included a discarded plastic bottle cap and a hair and beard retainer. There was an extensive build-up of dried stains on the wall and floor under the sink adjacent to the dishwasher. A black-colored plastic receptacle held used kitchen rags to be taken to the laundry per Employee 17. There was no liner or bag in the container. The kitchen dry storage area located in the basement of the facility had two large packages of raisins that expired in August 2025. The kitchen dry storage area had a smaller room attached to it that used to be an old bathroom per Employee 17. This room was being used for storage of items such as muffin mix and snacks. There was a pipe observed in the floor that had what appeared to be cloth rags in the pipe. A concurrent interview with Employee 17 revealed the pipe was not capped. There was a sewage-like smell coming from the pipe noted when near it. There was a built-in storage area above the pipe. There was a box of crackers on the floor next to the pipe. There were two empty snack-sized bags of chips and an empty snack-sized bag of cheese crackers discarded on top of items on the shelving. A second plastic pipe was observed behind storage shelving in this room. The pipe was not capped, and it was unclear what the pipe was for or where it originated. The walk-in cooler for the kitchen located in the basement had two single-serve butter condiment packs on the floor under the shelving. The attached walk-in freezer had ice accumulating on a box of pasta under the compressor area. Part of the freezer ceiling that was previously caulked was detached and separating at the seam. The following was observed in the main dining room: A prep area with drawers and cupboards had a drawer that was missing. The complete edge of the countertop was worn away and exposed the particle board underneath it. There was a drawer that contained salt and pepper shaker lids that had an extensive accumulation of debris in the bottom of it. A cupboard that held various items such as coffee pots, kitchen rags, and plastic lids had loose plastic lids scattered on top of the items. Another cupboard had two packages of hand sanitizer that expired in November 2025. A subsequent observation in the dining room on March 12, 2026, at 11:30 AM revealed that six of the seven observed overhead chandelier lights had cobwebs on them. Observation of the Country Kitchen Pantry Area on the Little League Nursing Unit on March 12, 2026, at 12:10 PM revealed two glass storage containers that were not labeled or dated, and one held a coffee like substance and the other held a sugar like substance. The refrigerator in the pantry area had black colored stains on the handle at the top of the door. There was cheese and meat which appeared dried out being stored in the refrigerator in an unlabeled plastic container with a set of tongs. There were dried food stains on the door shelving and stains with a pooling liquid on the bottom of the interior refrigerator in front of the storage drawers. There was an unlabeled white-powdery substance being stored in a plastic cup near the sink. The above information for the kitchen, dining room, and pantry area was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on March 12, 2026, at 2:05 PM. A review of the tray-line food temperatures for December 2025, February 2026, and January 2026, revealed the following missing temperatures: December 1-14, 2025: all temperatures (breakfast, lunch, and dinner).December 15, 2025: missing breakfast and lunch temperatures.December 16, 2025: missing dinner temperatures.December 17, 2025: missing dinner temperatures.December 18, 2025: missing breakfast, lunch, and dinner temperatures.December 19, 2025: missing breakfast, lunch, and dinner temperatures.December 20, 2025: missing breakfast, lunch, and dinner temperatures.December 21, 2025: missing breakfast, lunch, and dinner temperatures.December 24, 2025: missing dinner temperatures.December 29, 2025: missing breakfast, lunch, and dinner temperatures. February 11, 2026: missing breakfast, lunch, and dinner temperatures.February 23, 2026: missing breakfast and lunch temperatures. An interview with Employee 17 on March 13, 2026, at 9:43 AM revealed that the missing tray-line food temperatures are unaccounted for. The Nursing Home Administrator was informed of the above missing temperatures on March 13, 2026, at 11:00 AM. 483.60(i)(1)-(2) Food safety requirementsPreviously cited deficiency 2/21/25 28 Pa. Code 201.14(a) Responsibility of licensee

Based on clinical record review and staff interview, it was determined that the facility failed to monitor the use of psychotropic medications for three of five residents reviewed for potentially unnecessary medications (Residents 4, 14, and 15). Findings include: Clinical record review for Resident 4 revealed active physician orders for staff to administer the following psychotropic medications: Brexpiprazole (an atypical antipsychotic used along with antidepressant medicines to treat major depressive disorder (MDD) in adults) 0.5 milligrams (mg) in the morning for depression.Lorazepam 0.5 mg (an anti-anxiety medication) every 4 hours as needed (PRN) for anxiety for 14 DaysMirtazapine (an antidepressant) 15 mg in the morning for depressionFluoxetine (an antidepressant) 40 mg in the morning for depression A physician order instructed staff to monitor Resident 4's symptomatic target behaviors (delusions or hallucinations, unstable mood, signs and symptoms of changes, tearfulness, adjustment difficulty, and withdrawal) and non-medicinal interventions attempted (activity, backrub, position changes, fluids/food, redirection, change environment, and toileting) with Resident 4's response to those interventions until the order was discontinued on February 9, 2026. Resident 4's clinical record failed to provide evidence that the facility was monitoring for potential side effects from Resident 4's use of psychotropic medications. The surveyor confirmed during an interview with the Director of Nursing on March 13, 2026, at 8:35 AM that the facility failed to continue monitoring for potential side effects and distressing target behaviors for Resident 4's antipsychotic, antidepressant, and PRN antianxiety medication use after February 9, 2026. The interview also confirmed that Resident 4's plan of care did not instruct staff to monitor for potential side effects from Resident 4's antipsychotic medication use (only antidepressant medication use); and the facility did not develop a plan of care that included Resident 4's potential use of an antianxiety medication on an as-needed basis (PRN). Clinical record review for Resident 14 revealed active physician orders to administer the following psychotropic medications: Lexapro (an antidepressant) 5 mg daily for depressionRisperdal (an antipsychotic) 0.5 mg one time a day for schizophrenia (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking)Risperdal 0.25 mg one time a day for schizophrenia Resident 14's clinical record did not contain evidence that staff monitored for potential side effects of the antipsychotic medication use. Interview with the Director of Nursing on March 13, 2026, at 8:35 AM confirmed the above findings for Resident 14. Clinical record review for Resident 15 revealed active physician orders to administer the following psychotropic medications: Seroquel (antipsychotic medication) 25 mg two times a day for agitation Resident 15's clinical record did not contain evidence that staff monitored for potential side effects of the antipsychotic medication use. Interview with the Director of Nursing on March 12, 2026, at 9:54 AM confirmed the above findings for Resident 15. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of select facility policies and procedures, clinical record review, review of employee personnel records, and staff interview, it was determined that the facility failed to develop written procedures for screening potential employees that included all necessary components, maintain documentation of potential employee employment history screening for three of five newly hired employees (Employees 5, 6, and 7), and failed to thoroughly investigate an injury of unknown origin for one of 24 residents reviewed (Resident 15). Findings include: Interview with the Nursing Home Administrator on March 13, 2026, at 11:14 AM confirmed that the facility's human resources and abuse prohibition program and policies do not include actions taken to screen prospective employees that include obtaining information from previous and/or current employers (e.g., dates of employment position or title, disciplinary actions, etc.), whether favorable or unfavorable. Review of Employee 5's (licensed practical nurse) personnel record revealed that the facility hired her on November 4, 2025. Review of the document entitled, Professional References, contained in Employee 5's personnel record revealed no documentation that the human resources director confirmed the dates of employment alleged by Employee 5; or that references provided favorable comments, unfavorable comments, or refused to participate in a screening review.Review of Employee 6's (activity aide) personnel record revealed that the facility hired her on November 18, 2025. There was no document entitled, Professional References, contained in Employee 6's personnel record. A dated initial (no full name or title provided) on Employee 6's application page related to previous employment noted, All verified. There was no documentation that any reference verified provided favorable comments, unfavorable comments, or refused to participate in a screening review. Review of Employee 7's (registered nurse) personnel record revealed that the facility hired her on February 3, 2026. The personnel record provided by the facility for Employee 7 did not include a history of previous employment that included the employer, employer's contact information, or dates of employment. A, Professional Reference Sheet, contained in Employee 7's personnel record listed three health care providers; however, did not include documentation of an individual contacted, dates of employment verified, or if a contacted person provided favorable comments, unfavorable comments, or refused to participate in a screening review. Interview with the Nursing Home Administrator on March 13, 2026, at 11:13 AM confirmed the above findings for Employees 5, 6, and 7. The facility policy entitled Protocol for Investigation of Injury of Unknown Origin, last reviewed without changes February 1, 2026, revealed the facility shall maintain and implement a clear investigative protocol for any injury of unknown origin to ensure the safety, dignity, and protection of all residents. Injuries of unknown origin may indicate underlying risks including unrecognized falls, environmental hazards, inadequate supervision, or potential abuse or neglect. A timely and thorough investigation allows the facility to determine the cause of the injury, implement appropriate interventions, and protect the residents from further harm. When any injury of unknown origin is identified, the staff member identifying the injury shall immediately report the findings to the supervisor. The registered nurse shall immediately assess the resident to determine the resident's current condition, ensure necessary treatment is rendered, and determine whether the resident requires additional medical evaluation. The attending physician and the resident's representative shall be notified as appropriate. The charge nurse should notify the Director of Nursing, and the facility will initiate the investigative process immediately upon identification of the injury. The facility shall take immediate steps to ensure the resident is protected from potential further harm while the investigation is conducted. The investigation shall seek to determine the cause, circumstances, and individual involved, if any. The investigation shall include interviews with the residents, when possible, staff members on duty during the suspected timeframe, and any potential witnesses. The facility shall evaluate whether the injury is consistent with abuse or neglect, if there is any reasonable suspicion of abuse or neglect, the facility shall report the allegation in accordance with federal and state reporting requirements. Clinical record review revealed the facility admitted Resident 15 on April 1, 2025. Nursing documentation dated November 4, 2025, at 3:23 PM revealed observation of Resident 15's hand, noting his left knuckle was swollen and blue/purple in color Nursing documentation dated November 4, 2025, at 3:30 PM the registered nurse assessment noted Resident 15's hand was swollen at the first base knuckle, and tender upon palpitation. Resident 15 was noted to be guarding her hand. Resident 15's physician was updated and ordered a stat X-ray of Resident 15's left hand. Nursing documentation dated November 4, 2025, at 10:31 PM revealed the results of the X-rays to Resident 15's left hand revealed no acute fracture or dislocation, but an irregular alignment of the ulna (long bone in the forearm) that could represent dislocation. Resident 15's physician recommended to send Resident 15 to the emergency department for further testing and treatment of her left hand. Nursing documentation dated November 5, 2025, at 1:45 AM revealed Resident 15 returned from the emergency department. Resident 15 X-rays of her left hand showed a contusion. Nursing documentation dated November 5, 2025, at 1:22 PM revealed the facility received a call from the emergency department stating that Resident 15's X-rays showed an anomaly (abnormality) that was not seen by the emergency department provider and the radiologist recommended Resident 15 return to the emergency department immediately for re-evaluation and ortho/trauma consult. Review of emergency department notes dated November 5, 2025, at 4:31 PM revealed Resident 15 was sent back to the emergency department after a radiology discrepancy showing a questionable dorsal (back) dislocation of the ulnar head without fracture. X-ray imaging was reviewed by the orthopedic trauma team, and they recommended Resident 15 wear a Velcro splint and follow up with outpatient. Review of the facility's investigation into Resident 15's swelling and bruising to her left hand revealed that they did not obtain any witness statements from staff relating to how the injury may have occurred. Interview with the Director of Nursing on March 13, 2026, at 12:53 PM, confirmed that the facility did not complete a thorough investigation into Resident 15's swollen and bruised left hand to rule out the potential for abuse and/or neglect. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1)(3)(e)(1) Management 28 Pa Code 201.19(1)(10) Personnel policies and procedures 28 Pa. Code 201.29(a)(c) Resident rights 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, review of facility documentation, and staff and resident interview, it was determined that the facility failed to provide the highest practical care regarding physician ordered medications and/or devices for four of 24 residents reviewed (Residents 4, 11, and 12); and implement resident-directed care and treatment consistent with the resident's care plan for one of 24 residents reviewed (Resident 101). Findings include: A review of the current physician orders for Resident 11 revealed an order dated December 7, 2025, at 8:00 AM for Vitamin Deficiency System - B12 injection Kit; inject 1000 micrograms (mcg) intramuscularly one time a day every 30 days. A review of the Medication Administration Record (MAR) for Resident 11 for December 2025 to March 2026 revealed that the vitamin injection was not administered per the physician order for the following dates: February 5, 2026: no documentation on the MAR; blank.January 6, 2026: no documentation on the MAR; blank. There was no documentation for Resident 11 to indicate a rationale for why the medication was not documented as administered on the above dates per the physician orders. The above information for Resident 11 was reviewed in a meeting with the Nursing Home Administrator on March 12, 2026, at 2:05 PM. Clinical record review for Resident 12 revealed a diagnosis list that included essential hypertension (high blood pressure). A review of the current physician orders for Resident 12 revealed an order dated September 12, 2025, for Lisinopril (a medication used to treat high blood pressure and heart failure) oral tablet give one tablet by mouth in the morning. Hold for systolic blood pressure (SBP, the top number of a blood pressure reading where the heart contracts) less than 120. A review of the Medication Administration Record (MAR) for Resident 12 for September 2025 to March 2026 revealed that the Lisinopril was marked as administered outside of the physician specified parameters for the following dates: September 23, 2025; the blood pressure was documented as 118/58.November 21, 2025; the blood pressure was documented as 116/62.November 26, 2025; the blood pressure was documented as 118/62.February 3, 2026; the blood pressure was documented as 119/66.February 9, 2026, the blood pressure was documented as 117/74. There was no documentation for Resident 12 to indicate a rationale for why the medication was administered outside of the specific stated parameters. The above information for Resident 12 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on March 11, 2026, at 2:01 PM. Clinical record review for Resident 4 revealed pre-admission hospital documentation dated January 6, 2026, that identified that he required an amiodarone (heart rhythm medication used to treat and prevent a number of cardiac dysrhythmias) drip (intravenous administration) for an irregular heart rhythm (questioned to be atrial fibrillation (chaotic rhythm of the upper chamber of the heart) with rapid ventricular (fast rhythm of the lower chamber of the heart) response versus ventricular tachycardia (irregular heartbeat that starts in the lower chambers of the heart that can be life-threatening)). The document also noted Resident 4's history included ventricular tachycardia with a surgically inserted cardiac pacemaker (medical device that helps regulate the heart's rhythm by impulses to the heart muscle, ensuring it beats at a normal rate). The document indicated that Resident 4 had an ablation due to his atrial fibrillation (medical procedure that creates a scar in the heart muscle to stop abnormal electrical impulses in the heart). Other cardiac diagnoses for Resident 4 included left bundle branch block (BBB, electrical impulses to the heart are delayed or blocked) and bradycardia (slow heart rate). Facility physician progress note documentation dated January 22, 2026, at 12:42 PM noted that an AV node ablation with pacemaker insertion (permanent medical procedure that destroys the atrioventricular node/heart's natural electrical pathway to control heart rhythms that requires a lifelong pacemaker and requires long-term management of pacemaker monitoring) in 1999. The documentation indicated that Resident 4 reported, heart racing at night of unclear etiology. Interview with Resident 4 on March 11, 2026, at 11:22 AM confirmed that he has had an internal cardiac pacemaker for about 20 years and has a pacemaker machine (medical device that enables ongoing remote monitoring of a pacemaker that allows healthcare providers to receive transmitted data from implanted pacemakers to track heart health and device performance efficiently) at home; however, he did not have the cardiac pacemaker machine while at the facility. Resident 4 stated, Thanks for bringing it up. Review of plans of care developed by the facility to address Resident 4's care needs revealed no plan of care focused on Resident 4's implanted cardiac pacemaker (type, intended heartrate, frequency and method of monitoring, etc.). The surveyor reviewed the above concerns regarding Resident 4's pacemaker monitoring during an interview with the Nursing Home Administrator and the Director of Nursing on March 11, 2026, at 2:30 PM. Nursing documentation dated March 11, 2026, at 4:58 PM (following the surveyor's questioning) revealed that facility staff attempted to contact Resident 4's representative to speak to him regarding Resident 4's pacemaker transmitter device. Clinical record review revealed the facility admitted Resident 101 on November 26, 2025, with diagnosis including metabolic encephalopathy. A care plan-initiated November 26, 2025, revealed Resident 101 has a communication problem related to expressive aphasia. An intervention the facility implemented on January 21, 2026, was Resident 101 is to utilize a communication device to communicate her wants and needs. Interview with the Director of Nursing on March 12, 2026, at 2:05 PM confirmed Resident 101 is nonverbal, and utilizes an iPad to communicate. Review of Resident 101's most recent quarterly MDS (Minimum Data Set, an assessment completed at specific intervals to determine resident care needs) dated February 27, 2026, revealed Resident 101 uses a wheelchair for mobility, and is a substantial to maximum assist of one staff member for transfers. Staff also assessed Resident 101 as having a BIMS of 7 (Brief Interview for Mental Status, score 7 indicates serious cognitive impairment, suggesting significant difficulties with memory, orientation, and daily functioning). Nursing documentation dated January 16, 2026, at 3:41 PM revealed that the facility staff spoke with a nurse at the neuroscience office regarding Resident 101's recent appointment. Review of a Record of Visit to Consulting Physician with no date, revealed Resident 101 had a follow up appointment with neuroscience, but was unable to be completed due to Resident 101 being nonverbal. Review of the facility investigation into why Resident 101 was not seen at her neuroscience appointment on January 16, 2026, revealed the following. On January 16, 2026, Resident 101 was sent out to a neurology appointment at 2:00 PM. Resident 101 was dropped off by the transportation personnel. The investigation revealed the transportation driver asked the registered nurse supervisor if it is okay to send Resident 101 to an appointment without assistance and the registered nurse supervisor said yes. Resident 101 was sent back to the facility without being assessed due to Resident 101 being nonverbal and having no means of communication. The registered nurse supervisor told the staff from the neuroscience office that the facility does not have enough staff to send to resident appointments. The facility failed to provide Resident 101 with the highest practical care and implement care and treatment consistent with Resident 101's care plan. Interview with the Director of Nursing on March 12, 2026, at 8:37 AM, confirmed the above findings for Resident 101. 483.25 Quality of CarePreviously cited deficiency on 2/21/25, 5/13/25, and 10/31/25 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate and implement interventions to prevent falls for three of eight residents reviewed for fall concerns (Residents 14, 39, and 101). Findings include: The facility policy entitled, Falls - Clinical Protocol, reviewed without changes on February 10, 2026, revealed that the facility identified that many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause. The staff and practitioner will review each resident's risk factors for falling and document in the medical record the examples of risk factors. Staff will document where and when they happen and any observations of the events. The staff and practitioner will begin to try to identify possible causes within 24 hours. Based on the assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to, those that have already been identified) and reconsider the current interventions. Clinical record review for Resident 14 revealed nursing documentation dated December 6, 2026, at 8:00 AM that Resident 14 had an unwitnessed fall. He was on the ground in the hallway outside his room door. Resident 14 stated that he fell out of bed. Review of the facility's incident/accident investigation dated December 6, 2025, at 7:50 AM revealed the facility identified no predisposing physiological factors (e.g., impaired memory, non-compliance with safety interventions, etc. Although Resident 14 reported that he rolled out of bed, the facility noted that situation factors were that Resident 14 ambulated without assistance and was non-compliant with safety instructions. There was no indication on the document that the facility implemented any new interventions to deter future falls for Resident 14. Review of Resident 14's plan of care revealed that on November 3, 2021, the facility developed a plan of care to address Resident 14's impaired cognition and that he was at risk for further decline in cognitive status. A plan of care also initiated November 3, 2021, identified Resident 14's risk for falls due to confusion, altered mobility, poor vision, deconditioning, and bilateral foot drop (foot muscle abnormality that makes it difficult to lift the front part of the foot and the front of the foot might drag on the ground when walking). On August 14, 2023, the facility developed a plan of care to address Resident 14's noncompliance with using an assistive device or requesting assistance with transfers. There were no new interventions/tasks implemented on the plans of care following Resident 14's fall that indicated an investigation or alteration of Resident 14's bed despite his report that his fall occurred because he fell out of bed. Nursing documentation dated December 30, 2025, at 6:45 PM indicated that staff found Resident 14 on the floor in his room and that he, landed on his fall mat. Review of the facility's incident/accident investigation dated December 30, 2025, at 6:30 PM revealed the facility identified predisposing physiological factors included: confusion, gait imbalance, impaired memory, non-compliance with safety interventions, and weakness. Predisposing situation factors included: self-removal of safety devices, non-compliance with care plan, and non-compliance with safety instructions. Statements obtained from staff indicated that staff last observed Resident 14 in his bed with his dinner tray table over him. The investigation did not indicate that the facility investigated or altered Resident 14's bed despite the staff report that his fall occurred after he was last noted in his bed. The investigation did not include a statement from Resident 14 as to how the fall occurred. Review of Resident 14's physician orders and plans of care indicated no intervention that indicated the facility utilized a fall mat for Resident 14 although staff statements indicated there was one in place. Nursing documentation dated January 14, 2026, at 6:11 PM revealed that staff observed Resident 14 on the floor when they were delivering his dinner tray and the licensed practical nurse was going to give medications to him. He had slid out of his chair. The facility implemented dycem (fabric that increases resistance between surfaces to reduce sliding/slipping) under his wheelchair cushion. Nursing documentation by the licensed practical nurse dated February 20, 2026, at 1:24 PM for Resident 14 noted only, as per staff fell in his room supervisor to room and assessed. Nursing documentation by the registered nurse dated February 20, 2026, at 2:24 PM indicated that staff called Resident 14's responsible party and left a voicemail to notify the person of a fall. The documentation included no additional details regarding the fall or assessment for potential injuries. Review of the facility's incident/accident investigation dated February 20, 2026, at 12:28 PM revealed that the nurse aide called the registered nurse to Resident 14's room as he was found on the floor alongside of his bed. Resident 14 did not give any response or reason as to why he was on the floor but stated that he hit his head. The document indicated that this was an isolated event, even though Resident 14 had repeated falls in two months. The document again noted that, Resident has a fall mat on the floor beside the bed on the opposite side of the bed that he fell out of, although, no physician order or care plan intervention indicate the use of a fall mat. Interview with the Director of Nursing on March 12, 2026, at 11:36 AM indicated that the facility had no further evidence of thorough investigations following Resident 14's falls or the implementation of new interventions following the falls to reduce the likelihood of repeated falls for Resident 14. Interview with Employee 20 (physical therapist assistant/director of rehabilitation) on March 13, 2026, at 10:50 AM confirmed that the facility could not provide evidence of new interventions implemented after Resident 14's repeated falls on December 6 and 20, 2025, and February 20, 2026. The interview also confirmed that a fall mat mentioned in December 30, 2025, and February 20, 2026, investigation details had no corresponding physician order or care plan intervention for Resident 14. Clinical record review revealed the facility admitted Resident 101 on September 16, 2025. Review of Resident 101's care plan-initiated November 26, 2025, revealed Resident 101 is a high risk for falls related to her gait/balance issues. Review of nursing documentation dated January 3, 2026, at 9:14 PM revealed Resident 101 was found on the floor, lying next to her bed. Review of the facility investigation into Resident 101's January 3, 2026, fall revealed that the intervention the facility implemented to prevent further falls was a referral to physical therapy. Further review of Resident 101's clinical record revealed no documentation that Resident 101 was screened following her January 3, 2026, fall. Interview with the Director of Nursing on March 13, 2026, at 11:15 AM confirmed there was no evidence of physical therapy screening Resident 101 at the time of the fall. Nursing documentation dated January 12, 2026, at 7:02 PM revealed Resident 101 was observed on the floor in front of her wheelchair. Resident 101 scooched herself up and was leaning out of the wheelchair and fell to the floor with her cushion. Review of the facility investigation into Resident 101's January 12, 2026, fall revealed that the intervention the facility implemented to prevent further falls was to place dycem under her wheelchair cushion. Further review of Resident 101's clinical record revealed no evidence that the facility implemented the dycem to Resident 101's wheelchair until March 9, 2026, and was also not added to Resident 101's plan of care until March 11, 2026, after the surveyor's questioning. Interview with the Director of Nursing on March 13, 2026, at 10:56 AM confirmed these findings. Clinical record review revealed nursing documentation dated March 8, 2026, at 5:50 PM, noting Resident 101 fell out of her wheelchair in the hallway. The staff brought Resident 101 to the nurse's station for closer monitoring. Review of the facility investigation into Resident 101's March 8, 2026, fall revealed is she is currently on therapy caseload. Interview with the Director of Nursing on March 13, 2026, at 10:56 AM, revealed that the facility did not implement the dycem recommended after the January 12, 2026, fall, until after the March 8, 2026, fall. The facility failed to implement interventions to prevent falls for Resident 101. Clinical record review for Resident 39 revealed a nursing progress note date December 25, 2025, at 7:37 AM that indicated Resident 39 was found on the floor in his bathroom. The note stated that Resident 39 said he was trying to go to the bathroom. He did not ring his call bell. No injuries were noted. Review of the facility's investigation into Resident 39's fall on December 25, 2025, at 7:15 AM revealed that the staff assisted him off the floor and onto the toilet and obtained vital signs and neuro checks. The fall investigation form had non-compliant handwritten on the bottom right corner. The investigation did not implement a new intervention to potentially prevent the fall from happening again. Clinical record review for Resident 39 revealed a nursing progress noted dated December 30, 2025, at 12:15 AM that indicated Resident 39 was found on the floor of his bathroom. He stated that he did not hit his head and there were no injuries noted. The note indicated that Resident 39 did not ring his bell even though the call bell was in reach, and he self-transferred to go to the restroom. A nursing progress note dated December 31, 2026, at 11:27 AM indicated that resident continues to self-transfer and has been reminded multiple times to ring the call bell. Review of the facility's investigation into Resident 39's fall on December 30, 2025, at 12:15 AM revealed that Resident 39 indicated that he tripped on his oxygen cord and fell. There was no evidence that facility implemented a new intervention to prevent further falls. Clinical record review for Resident 39 revealed a nursing progress note dated December 30, 2025, at 6:30 PM that indicated resident was observed by staff on the floor. He was assessed and noted to have no injuries. The note indicated he was non-compliant with his call bell. Review of the facility's investigation into Resident 39's fall on December 30, 2025, at 6:00 PM revealed that he stated he got up to get his remote for the television. The immediate action was to educate him that his slippers are not safe, and he needed to wear non-skid socks. There is no evidence that the non-skid socks were provided or put on resident after the fall, or that the slippers were removed or replaced. There was no evidence the facility implemented new interventions to potentially prevent further falls for the resident. Clinical record review for Resident 39 revealed a nursing progress note dated December 31, 2025, at 4:15 PM revealed that Resident 39 was again observed on the floor in his room. The note indicated that he had non-skid socks on and everything was in reach. The note also indicated that he had been re-educated many times about ringing his call bell and not getting up by himself. Review of the facility's investigation into Resident 39's fall on December 31, 2025, at 4:15 PM revealed a new intervention was then noted to keep the resident in an area that he can be monitored closely. There was no evidence new fall interventions were implemented for Resident 39 after his falls on December 25 or 30, 2025, only after his fall on December 31, 2025, when he fell at 4:15 PM. Interview with the Director of Nursing on March 13, 2026, at 1:15 PM confirmed the above noted information related to Resident 39's falls. The facility failed to thoroughly investigate and implement interventions to prevent falls for Residents 14, 39, and 101. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of select facility policies and procedures, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to assess all potential risks for entrapment for four of 13 residents reviewed for accident hazards (Residents 5, 8, 9, and 16) and failed to conduct ongoing assessments to assure appropriate maintenance with bedrail usage for two of 13 residents reviewed (Residents 8 and 16). Findings include: The facility policy titled, Enabler Bar Utilization for Bed Mobility, last reviewed on February 10, 2026, revealed (in part) that a nursing designee shall refer to maintenance for installation. Maintenance designee shall perform a complete bed system audit at time of installation/removal. Facility to ensure that no mattress, bolster/wedge, or enabler bar has gaps that are larger than recommended. All maintenance staff will be trained on how to properly measure the open spaces between the bed system components and assess the seven potential zones for entrapment as detailed by the Food and Drug Administration (FDA). Further review of the policy revealed a section titled, Reassessment and Ongoing Monitoring, that noted a Bed Enabler Assessment Form shall be completed quarterly at minimum and as needed for significant changes. Nursing and therapy shall monitor residents for continued appropriate use of enabler bars. Clinical record review for Resident 16 revealed an annual Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated January 30, 2026, that noted facility staff assessed the resident as having a BIMS (Brief Interview for Mental Status) of 4, which indicated cognitive impairment. Observation of Resident 16 on March 10, 2026, at 2:00 PM revealed the resident had a right sided enabler bar attached to the resident's right side of the bed. The bed had both a headboard and foot board. Review of the current physician orders for Resident 16 revealed an order dated December 4, 2025, for a right sided enabler bar to assist with bed mobility. Review of facility documentation dated February 22, 2024, revealed a document titled, Enabler Bar Bed configuration / Bed Rail / Enabler Bar, that noted Resident 16's name. The room written on the sheet was a previous room. The type of rail requested/evaluating was written in as halo's. Entrapment zones evaluated were checked as Zones 1, 2, 3, 4, and 7. Zone 6 was not checked as evaluated for entrapment risks per the documentation. The form was signed by maintenance staff. Requests for Resident 16's most recent enabler bar assessments were made during the meeting with the Nursing Home Administrator and Director of Nursing on March 11, 2026, at 2:01 PM and the facility reported the documents are in the resident's electronic health record (EHR). There was no additional documentation for Resident 16 to indicate Zone 6 was assessed or the facility conducted ongoing assessments to assure an ongoing evaluation of risks associated with bedrail usage or regularly check to ensure the bedrails remain installed properly. Clinical documentation dated December 2, 2025, at 9:34 AM and January 21, 2025, at 1:49 PM revealed therapy notes that indicated the resident benefits from use of right-side bed enabler for increased bed mobility and independence. An interview with Employee 20, Director of Rehab, on March 13, 2026, at 10:46 AM revealed that therapy staff do not assess the enabler bars for entrapment zone risks. Therapy only assesses the resident for bed mobility. An interview with the Nursing Home Administrator on March 13, 2026, at 12:22 PM revealed there was no further documentation regarding Resident 16's enabler bars. Observation of Resident 8 on March 10, 2026, at 2:51 PM revealed her in her bed that was equipped with bilateral assist bars at the head of her bed, a footboard, and a headboard. Clinical record review for Resident 8 revealed a Bed System Measurement Device Test Results Worksheet provided by facility March 12, 2026, that indicated facility staff completed the assessment on April 3, 2025 (almost one year ago) that assessed only one potential zone for entrapment, zone one. There was no evidence that the facility completed a thorough assessment of all potential zones for entrapment (e.g., zones one, two, three, four, and six) with Resident 8's assistance device use. There was no evidence that the facility regularly checked Resident 8's mattress and bed rails for potential gap areas created by movement or compression of the mattress that may have been caused by changes in Resident 8's weight, movement abilities, bed position tendencies, or device shifting or loosening over the year. Interview with the Nursing Home Administrator and the Director of Nursing on March 12, 2026, at 2:00 PM confirmed that the facility did not assess all potential zones that could potentially present an entrapment risk for Resident 8. Observation of Resident 5 on March 11, 2026, at 9:26 AM revealed him in his bed that was equipped with a circular assist device bilaterally at the head of his bed, a headboard, and a footboard. A physician order dated December 11, 2025, directed the use of an enabler bar to Resident 5's bed bilaterally to assist with bed mobility. Review of a Bed System Measurement Device Test Results Worksheet dated December 11, 2025, indicated that the facility assessed only zones one through four. The assessment did not include a review of zone six which would include the space between the device and the edge of Resident 5's headboard bilaterally. Interview with the Nursing Home Administrator and the Director of Nursing on March 12, 2026, at 2:00 PM reviewed the above siderail concerns for Resident 5. Clinical record review for Resident 9 revealed a physician's order dated January 15, 2026, for the use of an enabler bar bilaterally to assist her with bed mobility. Observation of Resident 9 on March 10, 2026, at 12:52 PM revealed her in her bed with a circular assistance device mounted to the head of her bed on each side. Review of a Bed System Measurement Device Test Results Worksheet dated January 16, 2026, revealed an assessment of zones one through four. The assessment did not include a review of zone six which would include the space between the device and the edge of Resident 9's headboard bilaterally. The surveyor reviewed the above concerns regarding bed assistive device use for Residents 5 and 9 during an interview with the Director of Nursing on March 12, 2026, at 11:36 AM. 483.25(n)(1)-(4) Bed RailsPreviously cited deficiency 2/21/25 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility documentation and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of residents with enteral tube feeding, who utilize a lift, catheter care, medication administration, donning and doffing PPE (personal protective equipment), and dressing changes for four of four employees reviewed for competencies (Employees 13,14, 10, and 16).Findings include: A review of the facility documentation revealed that the facility had a total of 119 residents receiving medications, 28 residents that utilize lifts, nine residents with indwelling urinary catheters (insertion of a tube into the bladder to remove urine), 17 residents with dressing changes, two residents with enteral tube feedings (device that allows liquid food to enter your stomach or intestine through a tube), and eight residents on transmission based precautions. A request for nursing staff competencies for enteral tube feeding, lifts, catheter care, medication administration, donning and doffing PPE, and dressing changes revealed the facility was unable to provide any competencies for Employee 13 (licensed practical nurse) and Employee 10 (registered nurse). The only competency the facility completed for Employees 14 (licensed practical nurse) and Employee 16 (registered nurse) was wound care. The findings were reviewed with the Nursing Home Administrator and Director of Nursing on March 12, 2026, at 2:30 PM They confirmed the facility could provide no documentation that ensured Employees 13, 14, 10, and 16 had specific competencies and skill sets to care for the residents' needs listed above. 483.35(a)(3) Nursing ServicesPreviously cited 2/21/25 28 Pa. Code 201.20 (a) Staff Development

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure a medication error rate of less than five percent (Resident 51).Findings include: The facility's medication error rate was 9.68 percent based on 31 medication opportunities with three medication errors. Before commencing with the medication administration pass, Employee 10 (registered nurse) confirmed on March 11, 2026, at 8:32 AM knowledge of the instructions to alert the surveyor of any medications scheduled but not administered for this medication administration pass to avoid an error of omission. During the observation of a medication administration pass for Resident 51, Employee 10 reported that she would not administer Resident 51's scheduled Vitamin D (vitamin supplement) or Refresh tears (artificial lubrication drops for eyes) on March 11, 2026, at 8:32 AM due to their unavailability in the medication cart. Employee 10 prepared a dose of Clear Lax (polyethylene glycol, Miralax, stool softener) 17 grams (gm) for Resident 51. The labeling on the medication bottle instructed that the bottle top is a measuring cap marked to contain 17 grams of powder when filled to the indicated line (fill to the top of the white section in the cap). Employee 10 filled the bottle cap approximately three-quarters full; she did not fill the cap to the top of the white section inside the cap as required. Before Employee 10 mixed the measured powder into water, the surveyor requested clarification of the amount of powder prepared. Employee 10 confirmed that she utilized the groove of the cap lining (that permits the cap to screw onto the bottle) rather than the top of the section utilized for measurement. Employee 10 confirmed that the depth of the groove inside the cap changed as the cap was turned; therefore, would result in a different dose depending on the angle viewed of the cap. Employee 10 confirmed that if administered as prepared, Resident 51 would receive less than 17 grams of the medication. Employee 10 prepared the following additional medications for Resident 51:Iron, ferrous sulfate (dietary supplement) 65 mg (milligrams), one tabletSenna-plus (combination of two laxatives to treat constipation) 8.6 mg-50 mg, two tabletsVitamin B12 (dietary supplement) 500 mcg (micrograms), one tabletClaritin (Loratadine, antihistamine that treats allergy symptoms) 10 mg, one tabletDuloxetine (antidepressant) 60 mg, two tabletsMetoprolol tartrate (medication used to lower blood pressure) 50 mg, one tabletPotassium Chloride (dietary supplement) 20 mEq (milliequivalents), one tabletRopinirole (prescription dopamine used for restless legs) 1 mg, one tabletTorsemide (diuretic used to reduce fluid retention) 100 mg, one tabletSpironolactone (diuretic) 25 mg, two tabletsDiltiazem (medication used to lower blood pressure) 240 mg, one tabletZyprexa (antipsychotic medication) 5 mg, one tabletDiclofenac sodium topical gel (Voltaren, non-steroidal anti-inflammatory topical gel used to relieve pain and inflammation) for application to Resident 51's knees Before leaving the medication cart to enter Resident 51's room on March 11, 2026, at 8:52 AM Employee 10 confirmed that she had 15 tablets in the medicine cup in addition to the Miralax and Voltaren gel medications for administration to Resident 51. Resident 51 took all medication tablets provided with her yogurt on March 11, 2026, at 9:00 AM.Clinical record review for Resident 51 revealed active physician orders for staff to administer the above medications at 9:00 AM. The active physician orders instructed staff to administer the following medications that were omitted by Employee 10: Baclofen (muscle relaxant) 10 mg oral tablet, two tablets by mouth three times a dayMometasone Furoate (steroidal nasal spray) 50 mcg/activation nasal spray, two sprays in both nostrils one time a day Interview with Employee 10 on March 11, 2026, at 12:03 PM indicated that she did not see the additional two medications during the medication administration pass with the surveyor and confirmed that she did not attempt to report the omissions to the surveyor until questioned. The surveyor reviewed the three medication errors above (one incorrect dose and two omissions) with the Director of Nursing on March 12, 2026, at 11:36 AM. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of select facility policies and procedures, observation, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection on three of five nursing units (Maple Court, Sycamore, and Little League; Residents 4, 11, 15, 37, 51).Findings include: Review of the facility policy entitled, Coronavirus Disease (COVID-19)- Testing Residents, last reviewed without changes on February 10, 2026, revealed that residents are to be tested for the SARS-CoV-2 virus (Severe Acute Respiratory Syndrome Coronavirus 2) to detect the presence of current infections and to help prevent the transmission of COVID-19 in the facility. Asymptomatic residents who have had close contact with someone that has the SARS-CoV-2 infection, will have a series of three viral tests for SARS-CoV-2 infection. Testing is conducted immediately (but not earlier than 24 hours after exposure) and, if negative, again 48 hours after the first negative test, and if negative again, 48 hours after the second negative test. An outbreak investigation is initiated when a single new case of COVID-19 occurs among residents or staff to determine if others have been exposed. Viral testing of all residents (regardless of vaccination status) is conducted if there is an outbreak in the facility. Testing approaches may consist of contact tracing (focused testing) or broad-based (facility-wide or group-level) testing. If the outbreak investigation is broadened to either a facility-wide or unit-based broad-based testing is conducted. Residents who have had close contact are tested immediately. Review of the facility line listing for their current COVID-19 outbreak revealed that the outbreak started on February 2, 2026. The line listing also indicated that from March 2-5, 2026, the facility had 5 new cases of COVID-19 on the Maple Court unit. Interview with the Director of Nursing, who was responsible for infection control at the time of the survey, revealed that the residents on the Maple court unit (also known as their dementia unit) will not stay in their room and will not wear masks. She also indicated that the facility continues to have dining room and activities on that unit. Further interview of the Director of Nursing revealed that they did not test other residents on that unit since the initial outbreak on February 2, 2026, even though Resident 15, who tested positive on March 5, 2026, will not wear a mask or stay in her room and has been present in common areas with groups of other residents. The facility failed to test residents that had been exposed to the SARS-CoV-2 virus to ensure an environment free from the potential spread of infection on the Maple Court Unit. Clinical record review revealed Resident 15 tested positive for COVID-19 on March 5, 2026. A physician order dated March 5, 2026, noted staff should place Resident 15 on airborne precautions (specialized infection control measures used to prevent the spread of infections transmitted through tiny aerosolized particles that can remain suspended in the air and travel long distances) until March 15, 2026, with strict isolation and all services provided in Resident 15's room. Further review of Resident 15's clinical record revealed there was no plan of care in place addressing Resident 15's positive COVID-19 diagnosis, until after the surveyor's questioning on March 11, 2026. The plan of care implemented at this time revealed Resident 15 should be on airborne precautions until March 15, 2026, placing a face mask over Resident 15's mouth and nose if she leaves her room. Observation of Resident 15's room on March 10, 2026, at 9:30 AM, and March 11, 2026, at 8:27AM revealed there was no sign alerting staff, or visitors that Resident 15 was on airborne precautions. Observation of the Maple Court nursing unit on March 10, 2026, from 9:31 AM to 12:44 PM, revealed Resident 15 was observed walking throughout the unit, talking to other residents, and entering other resident rooms. Resident 15 did not have a mask on. There were no attempts by staff to keep Resident 15 in her room or place a mask on her mouth and nose. At 11:32 AM Resident 15 was observed seated at a table in the dining room eating lunch. There were four other residents seated at the table with Resident 15. Interview with Employee 15 (nurse aide) at this time revealed if a resident is on isolation precautions and they will not remain in their room staff are to place them at a table by themselves. Employee 15 confirmed Resident 15 should have been placed at a table by herself. Observation of the Maple Court nursing unit on March 11, 2026, from 8:37 to 11:57 AM, revealed Resident 15 was seated in a chair across from the nurses' station by the television. There were 7 residents seated in a circle, including Resident 15. During this time there were no attempts by staff to keep Resident 15 distanced from other residents or place a mask on her mouth and nose. At 10:12 AM Employee 24 (occupational therapist) arrived on Maple Court without a mask. Employee 24 was within a few feet of Resident 15, working on another resident's wheelchair positioning. Interview with the Director of Nursing on March 12, 2026, at 2:20 PM confirmed that the facility does not require, but encourages staff to wear masks. The Director of Nursing confirmed that Employee 24 works with residents on all nursing units. The above findings for Resident 15 were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on March 12, 2026, at 2:15 PM. Observation of Resident 4's room (on Sycamore nursing unit) on March 10, 2026, at 12:44 PM revealed a sign on his door instructing those who enter to implement contact precautions (infection control measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment). Interview with Resident 4 on March 10, 2026, at 3:23 PM revealed that he needed staff assistance to reposition in his bed. Observation made on the date and time of the interview revealed Employee 1 (licensed practical nurse) and Employee 2 (nurse aide) donned gloves and entered the room. Employees 1 and 2 repositioned Resident 4 (pulled him up higher in his bed) as he requested. Employees 1 and 2 did not don a gown before entering Resident 4's room or providing his direct contact care. Interview with Employee 1 on March 10, 2026, at 3:25 PM indicated that Resident 4 was, CRO positive in his stool, it is extremely rare. Employee 1 indicated that she and Employee 2 forgot to don a gown but that per Resident 4's condition and the signage on the door, they should have. Interview with Employee 2 on the date and time of the observation concurred that she should have donned a gown before coming in close contact with Resident 4 and his environment. Review of current CDC guidance, infection with a carbapenem-resistant organism (CRO, bacteria that have developed resistance to carbapenem antibiotics, making infections caused by these organisms difficult to treat) requires the implementation of targeted infection control measures that include isolation and enhanced barrier or contact precautions in nursing homes (depending on the situation), and to enforce policies for core infection control practices like hand hygiene, personal protective equipment and environmental cleaning. Remind healthcare personnel on the importance of adhering to these policies when caring for a patient with CRO. A physician's order dated January 8, 2026, instructed staff to implement contact precautions for CRO (no site or body system indicated). Clinical record review for Resident 4 revealed nursing documentation dated February 8, 2026, at 10:47 AM that indicated the facility admitted Resident 4 with a urinary tract infection and pneumonia (no infections related to his stool). Physician progress note documentation dated March 6, 2026, at 12:00 PM indicated that Resident 4 was hospitalized until February 11, 2026, for problems that included sepsis (bacteremia, blood infection) and a urinary tract infection. Review of plans of care developed by the facility to address Resident 4's needs indicated that the facility did not develop a plan of care to address his CRO infection or need for contact precautions. The surveyor reviewed the above infection control concerns for Resident 4 during an interview with the Director of Nursing and the Nursing Home Administrator on March 11, 2026, at 2:45 PM. Observation of a medication administration pass on March 11, 2026, at 8:53 AM revealed Employee 10 (registered nurse) gowned and gloved to enter Resident 51's room (on the Little League nursing unit). Employee 10 obtained a blood pressure assessment for Resident 51 and came in contact with Resident 51 and her environment when applying medicated gel to Resident 51's knees. Employee 10 left Resident 51's room on March 11, 2026, at 9:02 AM to seek clarification from the registered nurse supervisor. Employee 10 did not remove her PPE before entering the hallway. Employee 10 discarded her PPE (gown and gloves) in the trash receptacle secured to the medication cart. The receptacle did not have a lid. There were no bins visible inside Resident 51's room, by her door, to discard PPE before leaving her room. Employee 10 returned to Resident 51's room on March 11, 2026, at 9:07 AM to complete Resident 51's medications and treatments. Employee 10 exited Resident 51's room on March 11, 2026, at 9:11 AM. Employee 10 did not remove her PPE before entering the hallway. Employee 10 discarded her PPE in the trash receptacle secured to the medication cart. Interview with Employee 10 on the date and time of the observation confirmed that she believed that there are supposed to be bins available for staff to discard PPE before exiting Resident 51's room. Clinical record review for Resident 51 revealed an active physician's order dated August 18, 2025, for staff to implement contact precautions for an ESBL infection (Extended-Spectrum Beta-Lactamase infection occurs when bacteria produce enzymes called ESBLs that break down and inactivate many commonly used antibiotics, including penicillins and cephalosporins, that make infections difficult to treat). Clinical record review for Resident 11 revealed an order dated August 18, 2025, for contact precautions for ESBL in the urine. Review of the care plan for Resident 11 revealed that the resident has a urinary tract infection related to decreased mobility and poor hygiene. An intervention dated August 18, 2025, included contact precautions for ESBL in the urine. Resident 11's Kardex (documentation by nursing to note important information and care planning and facilitate resident care) noted a section titled, Resident Care that indicated contact precautions for ESBL in urine. A review of the Medication Administration Record (MAR) / Treatment Administration Record (TAR) for March 2026 for Resident 11 revealed that staff were documenting contact precautions were in use as indicated with a checkmark. Clinical record review for Resident 37 (Resident 11's roommate) revealed an order dated September 4, 2025, for contact precautions related to ESBL. Review of the care plan for Resident 37 revealed that the resident has a urinary tract infection related to ESBL. An intervention dated September 5, 2025, included contact precautions for ESBL. Resident 37's Kardex noted a section titled, Resident Care that indicated contact precautions for ESBL. Observation of the room of Residents 11 and 37 on March 11, 2026 at 9:08 AM revealed a sign on the wall next to the door frame that indicated Enhanced Barrier Precautions (EBP, refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). There was also a tote on the door to the room that held various personal protective equipment (PPE) that included gloves and gowns. Continued observation of the room revealed Employee 22, therapy staff, was assisting Resident 11 from her wheelchair and into the bathroom and then back to the resident's bed. Employee 22 was observed to have only donned gloves and no gown. Upon Employee 22 leaving the room and when questioned about the signage, Employee 22 reported she believed the EBP signs were for Resident 11's roommate. An interview with Employee 10, registered nurse, on March 11, 2026, at 9:33 AM revealed that both Residents 11 and 37 were on contact precautions but stated she would have to check further when questioned about the EBP sign. The above discrepancy between the clinical record and EBP sign on the doorway was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on March 11, 2026, at 3:05 PM. 483.80(a)(1)(2)(4)(e)(f) Infection Prevention & ControlPreviously cited deficiency 2/21/2025 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services .

Based on staff interview it was determined that the facility failed to maintain documentation of staff COVID-19 vaccination status, and provide evidence that staff were offered the COVID-19 vaccine or information on obtaining the COVID-19 vaccine for three of three staff reviewed. (Employees 11, 18, and 19) Findings include: Interview with the Director of Nursing on March 13, 2026, at 2:53 PM revealed that she is unable to provide evidence that the facility maintained staff documentation of screening, education, offering of COVID-19 vaccinations, and their current COVID-19 vaccination status. She indicated that she had a call out to the previous infection preventionist to see where the documentation may be but has not received a response. There was no evidence of the above for information for Employee 11 (housekeeper), Employee 18 (licensed practical nurse), or Employee 19 (nurse aide). The facility failed to offer staff the COVID-19 vaccine or provide them with information on where to obtain the vaccine, and failed to maintain staff documentation of screening, education, offering of COVID-19 vaccinations, and their current COVID-19 vaccination status. The surveyor reviewed the above noted findings with the Director of Nursing on March 13, 2026, at 3:00 PM. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 211.12(d)(1) Nursing services

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure that residents could make choices regarding aspects of their lives that were significant to them, such as smoking, for three of three residents reviewed for concerns related to resident choices (Residents 28, 39, and 101). Findings include: Interview with the Nursing Home Administrator and Director of Nursing during the entrance conference meeting on March 10, 2026, at 8:30 AM revealed that smoking is prohibited for the residents. They confirmed that staff are allowed to smoke on the facility property. Interview with Resident 28 on March 11, 2026, at 10:35 AM revealed that he would like to smoke. Resident 28 stated that three times a week he sees people smoking before entering the dialysis (medical procedure to filter waste and excess fluid out of the blood when the kidneys cannot perform that function adequately) provider's office; and he wishes that he could join them. Resident 28 stated that he sees staff at the facility smoking in the outside parking area to the left of the front entrance when he goes to dialysis treatments three times a week and wants to tell them that he would have one with them. Resident 28 stated that he was told that the facility was a smoke-free facility and that smoking was not permitted for him. Interview with Resident 28 on March 13, 2026, at 1:23 PM confirmed that he wanted to continue to smoke after his admission to the facility but was told he could not smoke on facility premises. He confirmed that since his admission he has seen staff smoking near the building on several occasions. Clinical record review for Resident 28 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated February 2, 2026, that assessed him as: Having no range of motion impairmentsRequiring no mobility devices (e.g., cane, wheelchair, or walker)Independent of staff for dressing, showering, personal hygiene, bed mobility, transfers, and ambulationHaving no cognitive impairments (Brief Interview for Mental Status, BIMS, score of 13) Nursing documentation dated December 4, 2025, at 1:35 PM indicated that staff, Spoke with resident that this is a non-smoking facility and that he is prohibited from smoking on the facility property. Nursing documentation dated December 17, 2025, at 7:03 PM indicated that staff educated Resident 28 that he needed to leave the facility to smoke off of the property and that, he got angry about it and walked away. Nursing documentation dated December 17, 2025, at 7:28 PM revealed that staff determined that Resident 28 was smoking on the facility premises. The documentation indicated that he had been educated multiple times about the facility policy and that Resident 28 consented to staff looking for cigarettes and lighters, that he, handed over what he had willingly. Resident 28's physician provided a verbal order for Resident 28 to utilize a nicotine patch (21 milligrams) once a day. Social services documentation dated January 2, 2026, at 11:01 AM revealed that Resident 28's advocate and pastor reported that Resident 28 wanted him to get him cigarettes. Interview with the Nursing Home Administrator and the Director of Nursing on March 12, 2026, at 2:00 PM confirmed that smoking is prohibited for residents; however, it is known that staff smoke near the building. Clinical record review revealed the facility admitted Resident 101 on November 25, 2025. Review of Resident 101's plan of care-initiated November 26, 2025, revealed that Resident 101 is a smoker. The intervention the facility implemented was to administer a smoking cessation patch per provider order if applicable. Resident 101 was unable to be interviewed due to expressive aphasia. Interview with the Nursing Home Administrator and Director of Nursing on March 13, 2026, at 1:49 PM, confirmed that Resident 101 has not been permitted to smoke since admission to the facility. Clinical record review for Resident 39 revealed that the facility admitted him on October 26, 2025. Review of Resident 39's admission agreement that he signed on October 27, 2026, revealed that the facility cares about the health of residents, staff, and others and are a non-smoking facility. A nursing progress note dated December 18, 2025, at 6:27 PM indicated that Resident 39's sister was in visiting and found a cigarette in his room and gave it to the nurse. The note indicated that Resident 39 was educated that the facility is a non-smoking facility. Interview with Resident 39 on March 11, 2026, at 1:52 PM revealed that he desires to smoke and that he does not think it is fair that staff are allowed to smoke but he is no allowed to. He indicated that he often sees 10 staff out smoking and it is unfair that he cannot have one (a cigarette). An interview with the Nursing Home Administrator and Director of Nursing on March 11, 2026, at 3:15 PM confirmed the above noted findings related to Resident 39, that he is not allowed to smoke on the facility property, but facility staff are allowed to. The facility failed to ensure that Residents 28, 39, and 101 could make choices regarding aspects of their lives that were significant to them, such as smoking. 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 209.3(a) Smoking 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to implement interventions to ensure an environment free from accident hazards to prevent falls and/or injuries that caused harm for one of six residents reviewed for fall concerns (Resident 2) and implement interventions for one of six residents for fall concerns (Resident 3). Findings include: The facility policy entitled Falls and Fall Risk, Managing, last reviewed January 20, 2022, revealed that in conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling. Clinical record review for Resident 2 revealed nursing documentation dated November 8, 2021, at 2:22 PM that indicated the physical therapist identified a bruise to Resident 2's right flank measuring 19 by 14 centimeters (cm) and right shoulder measuring 4 by 2.5 cm. Review of the facility investigation revealed a temporary nurse aide reported she witnessed Resident 2 ambulating without her walker on November 7, 2021. Resident 2 stumbled and fell hitting her right side on the footboard of the bed. The temporary nurse aide (TNA) did not report this fall until the physical therapist identified the above injuries of unknown origin. Review of the temporary nurse aide statement revealed that she was in the room with Resident 2 when she was getting ready for bed, and she did not know that Resident 2 required supervision. The temporary nurse aide stated she was in Resident 2's bathroom when she witnessed Resident 2 leave her walker by the bed and walk to close to blind and when walking back to her walker Resident 2 stumbled and fell hard on her mattress hitting her right side on the foot of the bed. The TNA indicated that Resident 2 did not complain of pain and continued what she was doing before getting into bed. Review of Resident 2's MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated November 3, 2021, revealed nursing staff assessed Resident 2 as requiring supervision of one staff member for transferring and walking. Review of Resident 2's plan of care for her potential risk for falls revealed the facility implemented a chair alarm on June 28, 2021. Review of Resident 2's physician orders revealed the facility ordered a pressure alarm while Resident 2 was in bed on November 17, 2021, and then discontinued this alarm on December 7, 2021. Nursing documentation dated December 8, 2021, at 8:01 PM revealed Resident 2 was found sitting on the floor leaning up against her dresser and her right leg was externally rotated. The assessment revealed Resident 2 had a small laceration on the right side of her head, and a laceration to her right forearm. Documentation dated December 9, 2021, at 7:14 AM revealed that Resident 2 was transferred to the emergency room and diagnosed with a fracture of her right femur. Resident 2 remained in the hospital until December 15, 2021. Review of the facility's investigation into Resident 2's December 8, 2021, fall revealed three witness statements relating staff concerns with Resident 2's bed alarm being discontinued on December 7, 2021, due to Resident 2's continued independent ambulation without requesting help. The facility's investigation into Resident 2's fall was not thoroughly completed (predisposing environmental factors, predisposing physiological factors, and predisposing situation factors). The investigation did reveal that room was clear, resident had shoes on. Interview with the Director of Nursing on April 27, 2022, at 1:48 PM confirmed the facility did not determine where Resident 2 was prior to her fall with fracture and confirmed the investigation did not address Resident 2's physician ordered chair alarm. Interview with the Director of Nursing on April 27, 2022, at 12:50 PM stated that Resident 2's bed alarm was discontinued because Resident 2 was turning off her bed alarm; however, she was unable to provide any documentation from staff that indicated Resident 2 refused or turned off her bed alarm. Review of Resident 2's physician orders revealed the facility re-ordered her pressure alarm while she was in bed on December 16, 2021. Review of Resident 2's physician orders dated January 4, 2022, revealed she ordered Resident 2 to be non-weight bearing to her lower extremity at all times until February 1, 2022. Nursing documentation dated March 10, 2022, at 1:51 PM revealed the interdisciplinary team reviewed Resident 2's falls and alarms. Documentation revealed the interdisciplinary team reviewed with nursing staff on the unit their recommendation to continue with Resident 2's bed and chair alarms. Review of Resident 2's MDS dated [DATE], revealed that nursing staff assessed Resident 2 as requiring an extensive assistance of two staff for transfers. Review of Resident 2's follow up with the orthopedic surgeon on March 15, 2022, revealed that Resident 2 was to continue non weight bearing for eight weeks for continued healing. Nursing documentation dated April 10, 2022, at 4:15 PM indicated Resident 2 fell out of her chair. Resident 2 was noted to be bleeding from her right frontal scalp area. The registered nurse indicated the area was bleeding heavily, 911 was called, and Resident 2 was transferred to the emergency room . Nursing documentation dated April 10, 2022, at 4:50 PM revealed that an intervention to prevent future falls when Resident 2 returned from the hospital indicated a bed and chair alarm will be added. Documentation dated April 11, 2022, revealed Resident 2 received a stitch to her frontal lobe laceration, and she was noted to have a goose egg below the laceration. Review of the facility's investigation into Resident 2's April 10, 2022, fall did not document Resident 2's physician ordered alarms were in place. The investigation did not mention Resident 2's ordered alarms. Interview with the Director of Nursing on April 27, 2022, at 1:30 PM confirmed Resident 2's chair alarm was not in place at the time of Resident 2's fall resulting in a scalp laceration on April 10, 2022. The Director of Nursing stated upon interviewing staff after surveyor's questioning, staff confirmed the chair alarm was not in place. She stated that the staff thought the alarms were discontinued. The facility failed to implement an intervention, consistent with Resident 2's needs and plan of care to prevent a fall that caused harm. Clinical record review for Resident 3 revealed a quarterly MDS dated [DATE], which revealed the resident had a BIMS of 3. During the look-back period of seven days, Resident 3 required extensive assistance of two staff for transfers and did not walk during the look-back period. He required extensive assistance of one staff for dressing. Record review for Resident 3 revealed a care plan dated February 23, 2022, identifying the resident to be at risk for falls related to impaired mobility, confusion with decreased safety awareness, pain, and glaucoma (eye disease causing slow vision loss). An intervention initiated on February 23, 2022, was to ensure the resident was wearing non-skid socks (socks with grippers or shoes) while out of bed. Clinical record review for Resident 3 revealed a RN progress note dated April 9, 2022, at 11:51 PM indicating that the resident was heard yelling and was found sitting on the floor with his back against the bed, facing the window. He was assessed as having no injuries. He was incontinent at the time and was not wearing non-skid socks. Review of facility documentation dated April 9, 2022, revealed that the predisposing environment factor into the fall was that the non-skid socks were not in place. Review of an in-service training record that was initiated April 11, 2022, revealed that education was provided to ensure that Resident 3 wears non-skid socks when in bed. Resident 3 was incapable of applying non-skid socks independently. The facility failed to implement an intervention, consistent with Resident 3's needs and plan of care to prevent a fall. During an interview with the Director of Nursing on April 27, 2022, at 2:00 PM findings for Resident 3 were reviewed. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to assess and implement interventions, and provide physician ordered supplements to ensure acceptable parameters of nutrition placing one of 10 residents sampled at nutritional risk of severe weight loss resulting in harm (Resident 4). Findings include: The, Weight Policy, last reviewed without changes in November 2020, revealed the facility will attain/maintain a resident's weight within the recommended range as appropriate in relation to their medical and physical status. Weights will be obtained in a timely manner, documented, and responded to appropriately. The dietitian will be notified of significant changes in weights, insidious weight loss, and other concerns. Acute or chronic weight changes will be documented, and recommendations will be provided by the dietitian as appropriate. The dietitian will track weights and will review the ongoing monthly weights to determine if there has been a significant weight loss, over 5 percent within one month, 7.5 percent over three months, and/or 10 percent over six months. The dietitian will work with the facility staff during the routine weight meeting to review resident weight trends and determine any additional interventions for the resident's weight change. The physician and responsible party will be made aware of significant changes in weight. The dietitian or physician may order specific nutritional interventions, supplements, or other interventions if indicated. Clinical record review for Resident 4 revealed weight documentation in Matrix Care (electronic medical record) indicating Resident 4 weighed 137.8 pounds on January 6, 2021. Documentation dated February 1, 2021, revealed Resident 4 weighed 122.6 pounds, a 15.2-pound, 11.03 percent severe weight loss in a month. There was no documentation of any re-weights. Review of Resident 4's laboratory results from January 14, 2021, revealed a low [MEDICATION(S)] (indicator of possible malnutrition, normal range 3.4-5) of 2.1 g/dL (grams per deciliter). There were no nutrition or nursing notes/assessments addressing Resident 4's severe weight loss until February 22, 2021, (21 days after the identified severe weight loss) and no new interventions were implemented. Documentation revealed Resident 4's body mass index (BMI, value derived from a person's weight and height) was below normal at 17.8 kg/m2 (kilogram/meters; weight divided by height). Review of this weight change note indicated Resident 4 was on Prosource (supplement) every day to aid in wound healing (Resident 4 was noted with an unstageable pressure ulcer on her coccyx). Review of Resident 4's clinical record revealed no documentation of staff administration of Resident 4's Prosource. Interview with Employee 7 (Registered Dietitian) on April 9, 2021 at 2:55 PM confirmed there was no documentation that Resident 4 ever received the Prosource ordered on January 6, 2021. Employee 7 stated that the Prosource was entered in the electronic record incorrectly and was not carried over to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident 4's clinical record revealed weight documentation dated March 1, 2021, indicated Resident 4 weighed 116.6 pounds another 6-pound, 4.89 percent weight loss in a month (totaling 21.2 pounds, 15.3 percent severe weight loss in 2 months). There were no nutrition or nursing notes/assessments addressing Resident 4's continued weight loss until March 25, 2021. Review of the Medical Nutrition Therapy Progress/Quarterly note dated March 25, 2021, revealed Resident 4 continued with a Stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) on her coccyx. The note indicated that the Registered Dietitian would continue Prosource for wound support and will add Med Pass 2.0 (nutritional supplement) at 120 ml (milliliters) twice a day, and weekly weights to prevent further weight loss. Further review of Resident 4's clinical record and MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Employee 7 on April 9, 2021, at 2:55 PM revealed he recommended weekly weights and Med Pass 2.0 on March 25, 2021, and they were not ordered by the physician until April 7, 2021, when the surveyor questioned the facility regarding Resident 4's severe weight loss. Employee 7 confirmed the weekly weights were never completed and the Prosource and Med Pass 2.0 was never given to Resident 4. The facility failed to assess and implement timely interventions to address Resident 4's severe weight loss. 483.25(g)(1)-(3) Nutrition/hydration status maintenance Previously cited 10/12/18 28 Pa. Code 211.6 (d) Dietary services 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services Previously cited 10/12/18, 9/13/19, 12/24/20

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to provide the appropriate supervision and staff assistance to prevent resident accidents with injury for three of 24 residents reviewed (Residents 2, 15, and 119), and failed to ensure an environment free from potential accident hazards on two of five nursing units observed (the Maple Lane and Little League Nursing Units). Findings include: The facility policy entitled, Falls Risk Assessment and Management, last reviewed without changes on July 8, 2016, revealed that staff develops an individualized care plan for each resident at risk for falls in an attempt to reduce the risk of falls or injury. The purpose of the policy is to ensure appropriate medical and multi-disciplinary assessment of falls and fall risk factors, to coordinate management of acute and recurrent falls, and to provide measures to help prevent falls. The charge nurse is to update the resident's plan of care and update the resident's profile in CareTracker (a system to record required resident information) or nurse aide Kardex (resident information stored in one location). In the event of a fall, the nurse shall ask the resident what happened, identify any issues or subtle changes observed by the front line staff, and write a factual nurse's note including all available information about circumstances surrounding the fall. The facility policy entitled, Falls - Clinical Protocol, last reviewed without changes on July 8, 2016, revealed that the staff would evaluate and document falls that occur while the individual is in the facility. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. Causes refer to factors that are associated with or that directly result in a fall. The current CMS (Centers for Medicare and Medicaid Services) State Operations Manual, Appendix PP-Guidance to Surveyors for Long Term Care Facilities, 483.25 (h) Free of Accident Hazards/supervision/devices, defines an elopement as when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. The facility policy entitled, Elopement, last reviewed without changes on July 8, 2016, revealed that when a resident is located, staff conducts a thorough investigation including reasons staff were not aware of the resident's location and mechanisms to prevent other residents from eloping due to the same failure. Clinical record review for Resident 2 revealed that the facility admitted him with [DIAGNOSES REDACTED]. An annual MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment dated [DATE], a quarterly MDS assessment dated [DATE], and a significant change MDS assessment dated [DATE], assessed him as requiring extensive physical assistance of two plus persons to move between surfaces (e.g. to or from bed, chair, wheelchair, standing). Resident 2's Profile History Report, ADLs (chronological information contained in the electronic medical record, CareTracker, that communicates to the nurse aide staff a resident's required level of assistance for various activities of daily living) from May 3 through 26, 2016, noted that Resident 2 transferred with a sliding board and the assistance of two staff. Lift/Mobility Evaluations (assessments completed by nursing staff that determine number of staff needed to safely transfer a resident) dated April 2, 2016, and May 25, 2016, noted that Resident 2 required two staff for movement with a mechanical lift or movement in bed. A Nursing Referral to Therapy request (referrals made to therapy to request an evaluation of changes noted in resident abilities) dated April 18, 2016, noted that Resident 2 required more assistance with transfers with the transfer board. Therapy's response dated April 20, 2016, noted, No changes noted in transfer status since discontinuation from treatment. Another Nursing Referral to Therapy request dated April 30, 2016, noted that Resident 2 could not use his legs to slide to transfer on the transfer board, his muscles were not strong enough to help, and that he could not slide from the bed to the chair on the sliding board. Therapy noted no response to this referral. Interview with Employee 8, the Assistant Director of Rehabilitation, on August 5, 2016, at 2:00 PM revealed that the April 30, 2016, Nursing Referral to Therapy, did not get, pushed through, therefore, there was no response from a therapy evaluation for that referral. Nursing documentation dated May 16, 2016, at 9:38 AM revealed that the licensed staff was called to Resident 2's room for report of a fall. Resident 2 slid off the sliding board and was lowered to the floor by the nurse aide during transfer. Nursing documentation dated May 16, 2016, at 5:09 PM noted that Resident 2 complained of pain in his right foot and leg and his wife requested an X-ray due to the fall. Nursing documentation dated May 18, 2016, at 1:13 PM noted that Resident 2 had been in bed all day. Nursing documentation dated May 19, 2016, at 12:56 PM noted that staff administered Tylenol for complaints of hip pain. Nursing documentation dated May 20, 2016, at 2:53 PM noted that staff obtained new physician orders [REDACTED]. Nursing documentation dated May 20, 2016, at 6:37 PM noted that the X-ray results for Resident 2 were positive for a distal femoral fracture (area of the bone closer to the knees). Nursing documentation dated May 21, 2016, at 10:31 AM noted that Resident 2 was taken to the operating room for repair of his right femur fracture. Review of the facility's investigation of Resident 2's May 16, 2016, incident revealed interviews with two nurse aides that substantiated that only one nurse aide attempted to transfer Resident 2 from the bed to the wheelchair. Per the licensed staff completing the report, the second nurse aide stated, I was not in the room at the time of the fall. (Resident 2) is a two assist for transfers. I was not aware he was being transferred. The facility failed to provide signed witness statements from the two nurse aides, the resident, or anyone who had direct knowledge of the details of Resident 2's fall on May 16, 2016. The Director of Nursing documentation dated May 16, 2016, at 10:38 AM noted that staff was re-educated on the number of staff needed to transfer Resident 2. Interview with the Director of Nursing, Employee 9 (the Assistant Director of Nursing), and Employee 10 (the Corporate Clinical Care Coordinator) on August 4, 2016, at 2:00 PM confirmed the above findings for Resident 2. The facility failed to provide the required level of assistance to Resident 2 on May 16, 2016, resulting in his fall with a fracture. Nursing documentation dated February 20, 2016, at 4:54 PM noted that, (Resident 2) drove himself in his wheelchair to the facility parking lot .was made aware that he cannot leave the facility without his responsible party or staff. An interview with the Director of Nursing, Employee 9, and Employee 10 on May 4, 2016, at 2:00 PM revealed that the facility did not complete an incident report regarding Resident 2's leaving the facility without required supervision, however, provided witness statements from staff pertaining to the event. A nurse aide statement dated February 20, 2016, attested to seeing Resident 2 outside at 3:30 PM without staff supervision. The nurse aide went to Resident 2's nursing unit and determined from the staff that he was not allowed to be outside alone. A statement obtained from the receptionist dated February 20, 2016, attested to seeing Resident 2 at 4:00 PM. The receptionist watched out the window to be sure that Resident 2 did not go off the sidewalk, however, there was no indication that the receptionist contacted the nursing unit to obtain necessary supervision of Resident 2 while outside. An interview with the Director of Nursing, Employee 9, and Employee 10 on May 4, 2016, at 2:00 PM, confirmed that the receptionist could not have provided 1:1 (one on one) continuous supervision of Resident 2 while outside as her duties would still include interaction with visitors and answering the phone at that time. The receptionist would also not be able to intervene immediately should Resident 2's motorized wheelchair begin propelling towards the curb of the sidewalk. The facility confirmed that they could provide no evidence that the receptionist received education regarding contacting the nursing unit when she noted Resident 2 outside without supervision. Nursing documentation dated April 19, 2016, at 1:50 PM revealed that Resident 2 sustained pink areas to the tops of his bilateral knees due to sitting outside that morning. The documentation noted that Resident 2 did not tell staff that he would be going outside and that he was reeducated about signing out. Review of a facility's investigation regarding Resident 2's, burn, did not include details regarding how Resident 2 exited the building without staff knowledge (e.g. the front entrance), where staff found Resident 2 (e.g. the sidewalk at the front of the building), which staff member found Resident 2, or how long he remained outside without staff knowledge. Clinical record review for Resident 15 revealed nursing documentation dated January 20, 2016, at 2:00 PM indicating that staff assessed Resident 15 who was found on the floor next to her bed. The documentation indicated that Resident 15's chair alarm was in place but not sounding at the time of the incident. Review of the facility's investigation of Resident 15's fall on January 20, 2016, revealed that Resident 15 had a small skin tear to her left knee from the fall. The investigation reiterated that Resident 15's alarm did not sound/function, however, failed to address any potential reasons for the failure (e.g. staff neglect or device malfunction). An annual MDS assessment for Resident 119 dated January 4, 2016, and a quarterly MDS assessment dated [DATE], revealed that she required extensive physical assistance of two plus persons to move between surfaces (e.g. to or from bed, chair, wheelchair, standing). The assessments also indicated that Resident 119's cognitive status and decision making skills are impaired. A fall risk evaluation completed March 25, 2016, at 12:36 AM indicated that Resident 119 was a moderate risk for falls. Nursing documentation dated June 14, 2016, at 12:33 AM revealed that Resident 119 fell while ambulating back from the bathroom. She was wearing her gripper socks. She did not ring for assistance. Resident 119 revealed that she hit her head. She also complained of back pain when staff were attempting to sit her up. The facility transferred Resident 119 to the emergency room for further evaluation. Nursing documentation dated June 14, 2016, at 8:34 AM revealed that Resident 119 returned from the emergency room . The X-ray confirmed a [DIAGNOSES REDACTED]. Review of the facility's investigation of Resident 119's June 14, 2016, fall determined that no abuse or neglect occurred, however, interview with a nurse aide substantiated that she escorted Resident 119 to the bathroom, placed her onto the commode, and left her to assist another resident into a bathroom across the hall. Resident 119 began to walk alone and this caused her to fall. Resident 119's care plan entitled, At risk for fall, initiated October 9, 2015, revealed an intervention for Resident 119 to have an alarm on her wheelchair. Interview with the Director of Nursing, Employee 9 and Employee 10 on August 4, 2016, at 2:00 PM revealed that if a resident is required to have an alarm on a wheelchair, staff should not leave them alone in the bathroom. The facility failed to provide signed witness statements from the nurse aide, the resident, or anyone who had direct knowledge of the details of Resident 119's fall on June 14, 2016. The facility failed to provide the required level of assistance to Resident 119 by leaving her alone unsupervised in the bathroom, on June 14, 2016, resulting in her fall with a fracture. The initial tour of the Maple LaneNursing Unit with Employee 1 (a Registered Nurse Unit Manager) on August 2, 2016, at 10:48 AM revealed partially removed flooring in the room containing residents' personal laundry facilities. The curled edges of the flooring that remained in front of the washer and dryer created a potential tripping hazard for any resident utilizing the facilities. The initial tour of the Little League Nursing Unit with Employee 1 on August 2, 2016, at 11:30 AM revealed an unlocked and unattended soiled utility room that contained a spray bottle of Spit Fire RTU Power Cleaner, an aerosol can of Lysol Foam Cleaner, and a spray bottle of Glance HC glass and multi-surface cleaner. Review of the Material Safety Data Sheet (MSDS) for the Spitfire RTU Power Cleaner noted, May be mildly irritating to eyes. May be mildly irritating to skin. Review of the MSDS for the Lysol Foam Cleaner noted, Hazardous to humans and domestic animals. Causes moderate eye irritation. Keep out of reach of children. Avoid skin contact. Symptoms may include redness, edema, drying, defatting and cracking of the skin. Symptoms of overexposure may be headache, dizziness, tiredness, nausea, and vomiting. Review of the MSDS for the Glance cleaner noted, May be mildly irritating to eyes. May be mildly irritating to skin. The facility failed to ensure the security of potentially hazardous materials on the Little League nursing unit. 483.25(h) Free of Accident Hazards/supervision/devices Previously cited deficiency 9/2/15 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 10/27/15, 10/14/15, 9/2/15 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 10/14/15, 9/2/15

Based on observation, clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to complete skin assessments to promote healing of a pressure ulcer for one of five sampled residents (Resident 20). Findings include: Review of the Pressure Ulcer Prevention and Management Program, last reviewed without changes on August 17, 2015, revealed that the facility is committed to providing a comprehensive pressure ulcer prevention and management program to ensure that resident's admitted to the facility without pressure ulcers do not develop them unless the individual's clinical condition demonstrates they are unavoidable. Any resident with a pressure ulcer will receive treatment and services consistent with the resident's goals of treatment. All nursing staff is involved in prevention measures and, in accordance with their level of education and competency, is involved in treatment measures. Daily resident skin inspections are performed during personal care by nursing staff. Weekly full body resident skin inspections are performed during the shower/bath by nursing staff. Individualized skin care services for each resident are provided in accordance with the resident's total plan of care. Pressure ulcers are assessed weekly (or more frequently, if necessary) by a licensed nurse, in conjunction with the facility's wound team. The facility utilizes wound care treatment protocols that are consistent with clinical practice guidelines and current standards of care. Licensed nurses, dieticians, physicians, and other staff utilizing facility specified forms and progress notes document risk and other assessments, treatment administration, and wound measurements. Documentation is maintained in the resident's medical record. The attending physician is notified of the presence of any Stage 2 or greater pressure ulcer within 24 hours of identification. The wound team and dietician are notified at the time of identification of the presence of any Stage 2 or greater pressure ulcer and/or deterioration in wound status. A resident's care plan addresses risk factors and interventions. Clinical record review for Resident 20 revealed current [DIAGNOSES REDACTED]. from loss of tissue), and Hydro[DIAGNOSES REDACTED] (where the kidney becomes swollen due to the failure of normal drainage of urine from the kidney to the bladder). She also receives artificial nutrition via a Peg (Percutaneous Endoscopic Gastrostomy) tube inserted into her stomach. Resident 20's physician order [REDACTED]. Review of the September and October 2015 TAR (treatment administration record, a form to document treatment administration) revealed that staff was completing this body audit weekly. There was no documentation available indicating any skin concerns from these weekly body audits. Review of Resident 20's bath/shower weekly body audits from August 3, 2015, to September 24, 2015, revealed that staff documented that her skin was within normal limits (meaning no bruises, discolorations, lacerations, pressure areas, and other questionable markings). Resident 20's care plan initiated on February 14, 2015, indicated that she was at risk for potential skin alterations related to contractures, impaired mobility, and chronic progressive disease(s). On July 13, 2015, staff implemented a left heel protector without the strap. On September 28, 2015, staff implemented moon boots (padded, oversized, pillow-type boot that wraps the resident's foot and provides padding between the foot and the surface) on both of Resident 20's heels. Interview with the Director of Nursing on October 29, 2015, at 10:40 AM, revealed that there was no documentation available indicating that staff applied a left heel protector to Resident 20's heel or acknowledged that they were not to utilize the strap when applying the protector. She also confirmed that there was no documentation available that staff applied moon boots to Resident 20's heels. On September 23, 2015, the facility completed a Braden scale (a skin assessment that determines a person's risk of developing a pressure ulcer). Resident 20's Braden score was 13, indicating that she was at moderate risk of developing a pressure ulcer. Staff indicated that she was slightly limited in her ability to respond meaningfully to pressure related discomfort, her skin was usually dry and rarely moist, is bedfast, completely immobile, and requires moderate to maximum assistance with moving. She does have adequate food intakes, as she receives tube feedings (liquid nutrition via a surgically created opening into the stomach). Nursing documentation dated September 26, 2015, at 8:46 PM revealed that Resident 20 was bedridden and wears blue boots to protect her feet. During care this shift, a 5 centimeter (cm) unstageable area was noted on her left heel. Staff cleaned the area, applied skin prep (a skin protectant) and derma foam (a treatment for [REDACTED]. On September 26, 2015, staff completed a pressure ulcer evaluation (a form used to document pressure ulcers) for Resident 20's left heel, indicating that the area was first observed on September 26, 2015, and measured 5 cm long by 5 cm wide by 0 cm deep and was unstageable (when the area is completely covered by slough and/or eschar). There was black eschar firmly adhered in the wound bed, with calloused and rolled wound edges. On September 28, 2015, facility staff completed a bath/shower weekly body audit for Resident 20, indicating that her skin was within normal limits, but also noted a black eschar (thick dead tissue) area that was not new. Staff indicated that the wound nurse was aware. On September 28, 2015, at 10:27 AM Employee 3, registered nurse, wound nurse, documented that she was asked to look at Resident 20's black area on her left heel. The area measured 5 cm by 5 cm by an unknown depth and was malodorous (foul smelling). It had a moveable black center with slough (dead skin) surrounding it. On September 28, 2015, at 11:54 AM Employee 1, licensed practical nurse, documented that she completed treatment to Resident 20's left heel/ankle area. She found that the skin was reddened and around the eschar area, the skin was sloughing. Employee 1 did not feel that she should apply skin prep to the area as it would burn and requested that Employee 3 look at it. On September 30, 2015, Resident 20's physician visited and observed her left heel. He noted that facility staff was not aware of the wound until two days ago (September 28, 2015). The physician documented that Resident 20 has an area on her left heel measuring 5 cm in diameter at the heel, which is almost black in color. The edges are somewhat boggy, there was no discharge or drainage, and the skin was intact at the time. He also noted that we have only been made aware of this a few days ago, this obviously has been present for quite some time, this is concerning. Review of a written statement by Employee 4, licensed practical nurse, dated September 27, 2015, revealed that Employees 5 and 6, nurse aides, saw the heel on (Resident 20) last week (the week of September 20, 2015, to September 26, 2015). Employee 5 thought that since it was so bad, everyone knew about it. Employee 6 indicated that she forgot to tell Employee 4 about it. Employee 4 stated that (Resident 20's) heel was also seen during her shower and never reported. Employee 4 indicated that all the pressure was placed on Resident 20's left foot and that she only put skin prep on (Resident 20's) ankles. Review of a written statement by Employee 7, nurse aide, dated September 28, 2015, revealed that she showered Resident 20 on September 24, 2015. At that time, Employee 7 noted that Resident 20 did not have an open wound on her left heel. Employee 7 revealed that Resident 20 had a black round mark on her (left) heel that has been there for quite some time. She noted, I would have reported it on September 24, 2015, but (the left heel) was not open, and was not new. Referencing the above noted bath/shower weekly body audit dated September 24, 2015, Employee 7 documented that Resident 20's skin (was) within normal limits. There was no documentation available indicating that Resident 20 had a black round mark on her left heel, as indicated in Employee 7's written statement. Review of a written statement by Employee 1, dated September 28, 2015, revealed that Resident 20 had a black intact area to her left heel, which was not new in nature. The skin was intact around the heel/black eschar area and there was no odor noted. Review of a written statement by Employee 8, registered nurse, assistant director of nursing, dated October 27, 2015, revealed that she spoke to Employee 5 via the telephone. Employee 5 confirmed that she saw Resident 20's left heel and did not report it as new because Employee 5 thought that the nurses knew about the area. Employee 5 thought that licensed staff was aware because Resident 20 had a special mattress and boots (padded, oversized, pillow-type boot that wraps the resident's foot and provides padding between the foot and the surface). Review of a written statement by Employee 8, registered nurse, assistant director of nursing, dated October 27, 2015, revealed that she spoke to Employee 6 via the telephone regarding Resident 20's left heel area noted on September 28, 2015. Employee 6 revealed that she forgot to tell the licensed practical nurse, but thought the nurses knew about Resident 20's left heel. She indicated that Resident 20's left heel was black but was not open. There was no documentation available indicating when the black eschar area on Resident 20's left heel began. There was also no documentation available between September 20 to 25, 2015, indicating that licensed facility staff was aware of any concerns with Resident 20's left heel. Interview with the Director of Nursing (DON) on October 27, 2015, at 2:00 PM, and 3:50 PM, and on October 28, 2015, at 11:35 AM, confirmed the above findings. Review of Resident 20's nursing documentation dated October 25, 2015, at 1:24 PM, revealed that staff completed her left heel dressing, and identified a new area on the top of her foot where her leg meets her foot. Staff received a new physician's orders [REDACTED]. Review of Resident 20's non-pressure ulcer skin conditions form (a form used to document skin concerns) dated October 25, 2015, revealed that the anterior (top) of the foot at the base of the lower extremity was reddened with a skin tear appearance in the middle of the red area, appearing to be like an abrasion. The area measures 1.6 cm long by 0.4 cm wide by 0 cm deep. Resident 20's October 2015 TAR revealed that on October 26, 2015, staff did not document completion of the dressing to the top of her left foot. Observation on October 27, 2015, at 10:15 AM, of Resident 20's left foot and heel dressing revealed that Resident 20 was positioned on her right side in bed between two bed bolsters (large pads used to help with positioning). Both of her legs are severely contracted, similar to the fetal position (the limbs are bent and drawn up close to the torso), with her heels touching her buttocks. Resident 20 had bilateral moon boots on at the time of the observation and prior to the dressing change. Employees 1 and 2, licensed practical nurses, wiped the skin around the top of her foot where the above noted abrasion was located with skin prep (which was not part of the physician's orders [REDACTED]. Interview with Employees 1 and 2 on October 27, 2015, at 12:57 PM, revealed that both staff members reviewed the physician's orders [REDACTED]. Both confirmed that the dressing was not completed per her physician's orders [REDACTED].>Review of Resident 20's October 2015 TAR revealed that Employee 2 documented that she completed Resident 20's left anterior foot abrasion dressing per the physician's orders [REDACTED]. Observation of Resident 20 on October 27, 2015, at 11:20 AM revealed that she had a gown on and was covered with a blanket. She was sitting in an oversized lounge chair in one of the facility's shower rooms. Facility staff and registered nursing students and their instructor were preparing to transfer her via lift onto a shower bed and shower her. Concurrent observation of Resident 20's right ear revealed an open, abraded area with the skin peeling away. The area was approximately 0.25 inches long by 0.125 inches wide and located on the back, outer aspect of the ear cartilage. This surveyor had to roll the ear cartilage toward Resident 20's ear canal to visualize the open area. The skin around the open area was reddened with a deeper red color where the skin was open, peeling, and abraded. After this observation, facility staff and the nursing students completed Resident 20's shower. Review of Resident 20's last bath/shower weekly body audit dated October 21, 2015, revealed that staff did not identify any concerns with Resident 20's right ear. Review of Resident 20's bath/shower weekly body audit dated October 27, 2015, revealed that neither the nursing students, nor their instructor, identified any concerns with Resident 20's right ear. Observation of Resident 20's right ear and concurrent interview with the DON on October 27, 2015, at 2:10 PM and 2:20 PM, confirmed the above findings and indicated that the facility was unaware of the open area. 483.25(c) Treatment/svcs To Prevent/heal Pressure Sores Previously cited 9/2/15 28 Pa. Code 201.18(b)(1) Management. Previously cited 9/2/15 and 10/14/15 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 211.10(a)(d) Resident care policies. Previously cited 9/2/15 28 Pa. Code 211.12 (d)(1)(5) Nursing services. Previously cited 9/2/15 and 10/14/15 28 Pa. Code 211.12 (d)(2) Nursing services.

Based on clinical record review, staff interview, and review of select facility policies, it was determined that the facility failed to provide the highest practicable care regarding diabetes management for one of six sampled residents (Resident 8). Findings include: The policy entitled, "Medication Orders," last reviewed without changes on December 15, 2014, indicated that nursing staff administer medications only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. Clinical record review for Resident 8 revealed that the facility admitted her on January 16, 2001, with diabetes mellitus (metabolic disease in which there are high blood sugar levels over a prolonged period). physician's orders [REDACTED]. This is a diabetes medication considered to be long acting, intended to help control blood sugars over a long period. Staff are to also administer eight units of Humalog (diabetes medication considered to be short acting, intended to help blood sugars over a short period of time) SQ at 8:00 AM, 12 units at 12:00 PM and four units at 4:00 PM. On November 20, 2014, the physician signed an order to decrease the [MEDICATION NAME] to 16 units at HS. Physician orders [REDACTED]. Staff is to administer this for five days and refer to the physician for further orders. Clinical record review for Resident 8 revealed that on November 27, 2014, nursing staff faxed Resident 8's physician notification indicating that the [MEDICATION NAME] order had changed from November 22 through 27, 2014, and had ended as of November 27, 2014 at 9:00 PM. Nursing staff listed the current orders for Resident 8's Humalog and listed [MEDICATION NAME] as 11 units at HS. On November 28, 2014, nursing staff alerted the covering physician that Resident 8's blood sugars were 588 mg/dL (milligrams per deciliter) that morning. The physician ordered staff to give a total of 14 units of Humalog and "continue previous orders." The previous order that was faxed to the physician the day before was [MEDICATION NAME] 11 units at HS. Nursing staff did not continue this previous order or call the physician to seek clarification regarding his intention for the long acting insulin coverage ([MEDICATION NAME]). Review of Resident 8's MAR (Medication Administration Record, [REDACTED]. Nursing documentation dated December 1, 2014, at 6:50 AM revealed that staff tested Resident 8's blood sugar and it was greater than 600 mg/dL. Nursing staff called the physician to inform him that staff did not administer [MEDICATION NAME] since November 26, 2014. The physician ordered staff to administer Humalog 6 Units now, a snack, and to monitor blood sugars. Nursing staff did not seek clarification regarding the physician's intention for the long acting insulin coverage ([MEDICATION NAME]). Nursing notes dated December 1, 2014, at 7:37 AM revealed that staff again obtained Resident 8's blood sugar and it was still greater than 600 mg/dL. The physician ordered staff to administer an additional 14 Units of Humalog. Nursing staff did not seek clarification regarding the physician's intention for the long acting insulin coverage ([MEDICATION NAME]). Nursing documentation indicated that on December 1, 2014, at 12:00 PM staff transferred Resident 8 to the emergency room due to her uncontrolled high blood sugars. Review of the history and physical dated December 1, 2014, from the local emergency room , revealed that the emergency room physician diagnosed Resident 8 with diabetic ketoacidosis, elevated troponin levels (indicated heart problems), acute kidney injury, and a urinary tract infection. WebMD (www.webmd.com) describes diabetic ketoacidosis as a life threatening condition that develops when cells in the body are unable to get the sugar they need for energy because there is not enough insulin. When the sugar cannot get into the cells, it stays in the blood. The kidneys filter some of the sugar from the blood and remove it from the body through urine. Fatty acids then enter the blood stream causing a chemical imbalance. emergency room staff administered intravenous insulin and monitored her potassium levels. The emergency room physician stated that the cause of this (ketoacidosis) "is from lack of her long-acting insulin." Interview on January 8, 2015, at 12:30 PM with the Administrator and the Director of Nursing confirmed that the facility could not provide evidence that indicated that staff acquired a [MEDICATION NAME] order or clarified orders from the physician to administer Resident 8's long-standing routine diabetes medication regimen to aid in controlling her blood sugars on November 27, 28, 29, and 30, 2014. 483.25 Quality of Care Previously cited August 8, 2014 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services. Previously cited 8/8/14

Based on family and staff interview, and clinical record review, it was determined that the facility failed to implement planned safety measures to prevent an accident with injury for one of seven sampled residents (Resident 15). Findings include: Clinical record review for Resident 15 revealed that the facility admitted her on December 3, 2009, with [DIAGNOSES REDACTED]. Review of Resident 15's plan of care regarding her risk for falls included assistive devices and prosthetics within reach, and prosthesis to bilateral lower extremities when out of bed. The plan of care to address Resident 15's total assistance with activities of daily living related to her impaired mobility, secondary to bilateral prosthesis to lower extremities, and comorbid diagnoses, as of February 24, 2011, included total assistance with donning of prosthetics, and prosthetics off while in bed. Nursing documentation dated March 7, 2011, at 5:24 PM, revealed that because Resident 15 was yelling out at the beginning of the shift, nursing staff transferred her out of bed to a wheelchair. Review of nursing documentation dated March 7, 2011, at 8:50 PM, noted that at 6:10 PM, staff heard a thud noise, looked over, and noted Resident 15 on the floor, in front of her wheelchair. Resident 15 was face down with the wheelchair still standing. The licensed practical nurse documented that upon further assessment, Resident 15 sustained a lip laceration three centimeters (cm) wide by 0.4 cm long, an abrasion to the side of her nose 3 cm by 3 cm, and an abrasion to her chin 1 cm by 1 cm. The registered nurse documentation dated March 7, 2011, at 10:23 PM, confirmed that she was called to the nursing unit by staff, and noted that Resident 15 was on the floor, on her stomach, in front of her wheelchair. The documentation noted that staff observed bleeding from her nose and upper lip. The staff surmised that Resident 15's upper dentures lacerated her upper lip during the fall. The nurse notified Resident 15's physician, and obtained an order to transfer her to the emergency room . The documentation noted that when Resident 15 returned from the emergency room , her upper lip was, "stitched with dissolving stitches" (sutured to bring the edges of the wound together). Review of the facility's investigation of the incident dated March 8, 2011, revealed that the facility determined the root cause of the fall was the lack of Resident 15's prosthetics while she was in her wheelchair. Interview with Resident 15's daughter on March 8, 2011, at 3:05 PM, revealed that her mother wore her prosthetic legs daily from morning until evening with the exception of times while in bed during the day. Interview with the Director of Nursing on March 8, 2011, at 4:00 PM, revealed that the facility staff donned Resident 15's bilateral leg prosthetics for her when she became too debilitated to do this for herself. Her previous history was to wear them from morning to evening as she was out of her bed for most of the day. The facility could not provide evidence of any condition that prevented staff from applying Resident 15's prosthetics when they transferred her out of bed before her fall. 28 Pa. Code 201.18 (e)(1) Management. Previously cited 8/20/10. 28 Pa. Code 211.12 (d)(1)(5) Nursing services. Previously cited 8/20/10 and 2/15/11.