Every finding on record at Wesley Enhanced Living at Stapeley

Based on record review, facility policies, facility documents, observations, and staff interviews, it was determined that the facility failed to ensure the safety and adequate supervision and ensure that safety devices were in place for five of six residents reviewed for risk of wandering and elopement. (Residents 122, R21, and R39).Findings include: Review of facility policy titled Elopement of a Resident, last revised 12/17/2025, outlines procedures to ensure resident safety and prevent elopement, particularly for residents with dementia or cognitive impairment. The policy requires elopement risk assessments upon admission, family interviews, resident photographs in the medical record, Wander Guards for at-risk residents, and individualized care plans to address wandering behaviors. The policy also establishes procedures for responding to a missing resident, including staff search assignments, use of resident photographs, notification of leadership, police, SEPTA (public bus transportation system), and family members, and completion of required documentation and state reporting. The revised policy further identifies assigning staff-specific responsibilities during an elopement event, such as contacting hospitals and coordinating search efforts. Record review for Resident R122 revealed the resident was admitted on [DATE] with diagnoses including dementia, (a progressive decline in memory and cognitive functioning; probable Alzheimer's disease, a neurodegenerative brain disorder affecting memory, thinking, and behavior) Nursing documentation dated 07/02/2025 identified Resident R122 as having a history of elopement while at home. Additional nursing documentation dated 07/03/2025 indicated the resident required frequent redirection and was being monitored by nursing staff due to elopement risk. Documentation dated 07/04/2025 noted a Wander Guard was applied to the resident's ankle for safety monitoring. Review of the resident's Minimum Data Set (MDS- assessment of resident's care needs) dated July 2, 2026, revealed the resident was admitted to the facility on [DATE], and discharged to the hospital on July 7, 2026. The resident was assessed with a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment and significant loss of cognition. Diagnoses included anxiety disorder. Further review of the resident's clinical record revealed additional diagnoses including suicidal ideation (thoughts of self-harm or suicide); and unsteadiness on feet, (impaired balance or gait instability increasing risk for falls). Review of July 2025 physician's order revealed an order dated July 4, 2026, for the use of a Wander Guard (device placed on a person's wrist or ankle which activates the door locking mechanism to the outside) to resident's right ankle for safety monitoring. Review of the investigation revealed that on July 7,2025 at approximately 6:30 p.m. staff became aware that the resident was missing from the unit after last being observed at approximately 6:20 p.m. sitting in the second-floor lounge. The receptionist reviewed security cameras and observed the resident walking toward a trail located near the parking lot. At approximately 7:30 p.m., the resident was found by nursing staff sitting in bushes along the trail and was escorted safely back to the facility. No injuries were noted and vital signs were stable. Staff interviews indicated that once the resident was discovered missing, an alert was initiated and staff began searching the facility and surrounding grounds. The receptionist identified the resident on camera and reported seeing the resident walking toward the trail. A nurse located the resident sitting on the ground between trees, where the resident stated she shouldn't have done this and asked for help. Review of investigation statement of nurse aid Employee E18, stated the resident had been walking freely on the unit prior to the incident and that no alarms sounded despite the resident reportedly having a wander guard sensor device. Documentation reviewed indicated the resident was placed on one-to-one monitoring following the incident. Review of door and stairwell alarm checklists indicated alarms were documented as on and functioning at the time of review. The investigation did not identify how the resident exited the facility. Top of Form Bottom of FormReview of the Resident R21's quarterly MDS dated [DATE], revealed the resident was admitted to the facility on [DATE]. The resident was assessed with a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment and significant loss of cognition. The resident utilized both a wheelchair and walker for mobility and had diagnoses including Dementia, and depression (a mood disorder characterized by persistent sadness, loss of interest, and decreased functioning). The assessment further indicated the resident had a Wander Guard elopement alarm in place for resident safety. Review of Resident 39's quarterly MDS dated [DATE], revealed the resident was admitted to the facility on [DATE]. The resident was assessed with a Brief Interview for Mental Status (BIMS) score of 6 indicating indicates severe cognitive impairment. The resident utilized a walker for ambulation and had diagnoses including Alzheimer's disease dementia, a progressive neurodegenerative disorder causing worsening memory loss, cognitive decline, and impaired daily functioning, and psychotic disorder (a mental health condition characterized by a loss of contact with reality, which may include hallucinations, delusions, or disorganized thinking). The assessment further indicated the resident had a Wander Guard in place for resident safety. Observations conducted on May 5, 2026, at 2:00 p.m. in the second-floor resident lounge during an activity revealed Resident R21 and Resident R39 were observed without a Wander Guard device in place. This finding was confirmed by Nurse aides, Employees E15 and E16 who stated they were unable to locate the Wander Guards. Observation on May 5, 2026, at 02:45 p.m. identified multiple unsecured exit points within the facility. In the first-floor lounge, a glass sliding door was observed unsecured and without a lock or alarm system. This observation was confirmed by the Nursing Home Administrator (NHA) at the time of the observation. The NHA acknowledged that anyone could enter or exit through the door without restriction, he stated he was unaware the door opened. The stairwells accessible from the resident floors, including areas housing residents with dementia, were also observed to be unsecured. These stairwells provided direct access to the first-floor lobby area, where supervision consisted of a receptionist present only until 9:00 p.m. Further observation on May 6, 2025 at 10:00 am on the first-floor nursing unit there was a wheelchair observed with a Wander guard but Resident R22 was not seen. Identified a resident's walker with a Wander Guard attached; however, the resident was not within sight at the time. Staff confirmed the residents were independently ambulatory. Interview with The Director of Nursing (DON), Employee E2 on May 7, 2026, at 10:25 a.m. revealed that Resident R 22 stated the Wander Guard attached to the walker was not intended for elopement tracking purposes, but rather served only as a reminder device for the resident. 28 Pa. Code 211.10 (c)Care Plan Policies 28 PA Code 211.12(d)(1)(5) Nursing services

Based on policy review and record review, the facility failed to implement an effective and comprehensive water management program necessary to identify, monitor, control, and reduce hazardous conditions supporting the growth and spread of Legionella within the facility water system and failed to ensure proper infection control practices during the administration of eye drops for one of one resident observed. (Resident R101)Findings inlcude: Review of the CDC (Center for Disease Control and Prevention- a major public health agency in the United States that works to: Monitor and track diseases (like flu, COVID-19, etc.) ,Prevent outbreaks and health threats ,Provide health guidelines and research ,and Respond to emergencies (pandemics, natural disasters, bioterrorism) recommends that healthcare facilities implement a water management program to reduce the risk of Legionella growth and prevent Legionnaires' disease. The program should include a multidisciplinary team, identification of all water systems, and assessment of conditions that may promote bacterial growth such as stagnant water, improper temperatures, and low disinfectant levels. Facilities must establish control measures, monitor water systems regularly, and document temperatures, disinfectant levels, flushing, and maintenance activities. When issues are identified, corrective actions such as flushing, disinfection, or system adjustments should be taken promptly. The program should also include routine verification and review to ensure effectiveness, staff education, and updates following system changes or outbreaks, with special attention to high-risk populations such as elderly or medically vulnerable residents. Review of the facility's revised January 2024 Water Management Program policy showed the program was intended to reduce the risk of Legionella and other waterborne pathogens. The policy identified a water management team, recognized the facility's high-risk resident population, and listed potential sources and conditions that could promote Legionella growth. However, the facility failed to implement a comprehensive operational program. The policy did not establish measurable control limits for temperature, disinfectant levels, pH, or other monitoring parameters, and it lacked defined corrective actions for abnormal findings or positive Legionella results. The facility also failed to provide evidence of routine monitoring, maintenance records, water quality testing, flushing schedules, or completed logs. In addition, there was no evidence of program validation or verification activities such as audits, environmental testing, trend analysis, or annual evaluations. The facility also failed to demonstrate staff training, assigned responsibilities, or competency related to water management procedures. Lastly, the program lacked a detailed hazard analysis and building-specific risk assessment identifying high-risk areas and control points within the water system. Interview with the Maintenance Director and Regional Director on May 7, 2026, confirmed that the current program did not meet required standards. Both individuals acknowledged understanding of the requirements moving forward but were unable to describe the building's water system, identify potential high-risk hot spots, or explain what testing and preventive measures are in place to monitor and control Legionella risk. Observation on Resident R101 conducted on March 4, 2026, at 10:23 AM during medication administration revealed Licensed Nurse, Employee E4 administered the eye medication Muro 128 Ophthalmic Solution 2% (Sodium Chloride Hypertonic), 1 drop into the resident's left eye while wearing gloves. Further observation revealed Licensed Nurse, Employee E4 did not remove gloves or perform hand hygiene prior to obtaining the resident's blood pressure, touching the blood pressure machine with the same gloves. No hand hygiene was performed between administering the eye drops and use of the blood pressure equipment. Licensed Nurse E4, placed Resident R101 eyeglasses back on the resident's face wearing the same gloves. Further observation revealed Licensed Nurse, Employee E4 continued medication administration, including oral medications, while wearing the same gloves used for eye drop administration and blood pressure measurement. Interview with Licensed Nurse E4 confirmed she/he did not change gloves during the medication administration process. 28 Pa. Code 204.19 Plumbing, heating, Ventilation, air condition and electrical 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18 (b)(1)(3) Management 28 Pa. Code 211.12 (d)(1) Nursing services

Based on review of facility documentation, clinical records and staff interviews, it was determined that the facility failed to ensure an appropriate, safe, and properly documented discharge process for 1 of 2 residents reviewed for discharge practices (Resident R 118). Findings include:Review of facility policy titled Transfer or Discharge Documentation dated December 2016, stated residents have the right to remain in the facility unless discharge is necessary because the facility cannot meet the resident's needs, the resident's condition has improved sufficiently, the resident poses a danger to the safety or health of others, nonpayment occurs, or the facility ceases operation. The policy further requires documentation supporting the reason for discharge, physician documentation related to safety concerns or unmet needs, documentation of attempts to meet resident needs, and communication of all necessary information to ensure a safe and effective transition of care. Review of the Resident R 118's Minimum Data Set (MDS- assessment of resident's needs) dated March 28, 2026, revealed the resident was admitted to the facility on [DATE], following hospitalization for acute on chronic congestive heart failure (condition in which the heart does not pump blood effectively causing fluid buildup and fatigue). Continued review of the MDS revealed that the resident was diagnosed was Alzheimer's disease, (a progressive brain disorder affecting memory, thinking, and daily functioning); congestive heart failure; atrial fibrillation, (an irregular and often rapid heart rhythm that increases the risk of stroke); hypertension, (high blood pressure); hyperlipidemia (elevated cholesterol or fat levels in the blood); obstructive sleep apnea, (a sleep disorder causing repeated interruptions in breathing during sleep); ventricular tachycardia (potentially serious rapid heart rhythm originating in the lower chambers of the heart); and prostate cancer. The resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment and required partial assistance with transfers, mobility, toileting, dressing, bathing, and bed mobility. The resident was receiving physical and occupational therapy services. The MDS documented physical behavioral symptoms directed toward others occurring 1-3 days during the assessment period. Review of the social service note dated March 27, 2026, revealed plans for discharge home on March 28, 2026 with home care services and family transportation. Review of the discharge plan dated March 27, 2026 revealed referral information for community services and visiting nurse services; however, the form was not signed by the resident or responsible party. Review of the physician discharge summary revealed the resident was discharged on March 28, 2026 after a four-day stay with diagnoses including acute on chronic systolic congestive heart failure, hypertension, Alzheimer's disease, atrial fibrillation, and prostate cancer. The discharge summary stated the resident completed his stay and would return home; however, there was no documentation explaining why the resident's skilled rehabilitation stay ended after four days, no evidence the resident met therapy goals, and no physician documentation indicating the resident posed a danger to others or required involuntary discharge. Review of nursing documentation dated 3/28/26 revealed the resident was discharged home with family transportation and medication reconciliation completed. Review of the clinical record failed to identify documentation that the resident or representative requested discharge, failed to identify documentation that the resident was informed of appeal rights, and failed to identify evidence supporting that discharge criteria outlined in facility policy were met. During staff interview, Social Services employee E 11 stated the resident was discharged due to behavior. However, the facility failed to document that the behaviors endangered the health or safety of others, failed to demonstrate attempts to manage the behaviors within the facility, and failed to provide physician documentation supporting discharge related to behavioral concerns. The facility's documentation describing the resident as cooperative, stable, and adjusting well conflicted with interview statements indicating the resident was discharged due to behaviors. Interview with the Nursing Home Administrator Employee E1 on May 7, 2026, at 12:20 p.m. revealed that the resident was discharged due to aggressive behaviors; however, the administrator confirmed there was no documentation in the clinical record to support this stated reason for discharge. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18 (1)(e) Management

Based on clinical record review, interviews with residents and staff, reviews of policies and procedures, nursing staffing assignments, pertinent human resource documents and the report form for investigation of alleged abuse, neglect, misappropriation of property (PB-22), it was determined that the facility failed to ensure that each resident was free from physical and mental abuse. (Resident R1)Findings include:A review of the facility policy titled abuse prevention program revealed that each resident at the facility had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The policy indicated that each resident had the right to be free from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse and physical or chemical restraint not required to treat the resident's symptoms. The policy indicated that the administrator was responsible for developing and implementing policies and procedures to prevent abuse, neglect or mistreatment of residents. The administrator was responsible for ensuring that staff were properly trained in abuse prevention, identification and reporting abuse and handling verbally or physically aggressive resident behavior. The administrator was also responsible for identifying and assessing all possible incidents of abuse. The administrator was also responsible for investigating and reporting any alleged allegations of abuse within required federal timeframes. A review of the policy titled procedure to conduct and report abuse revealed that all employees were mandated reporters and were required to report alleged abuse immediately to the supervisor on duty and a member of administration. The investigation was completed to determine the who, what, when, where, why and how the alleged abuse occurred. This abuse investigation was to be concluded within required timeframes. A documented summary of the finished investigation into the alleged abuse was filed at the facility and with the appropriate agencies according to protective services regulations. Clinical record review for Resident R1 revealed a comprehensive quarterly assessment (MDS-an assessment of care needs) dated September 28, 2025, that indicated this resident was understood (able to express ideas and wants) and had clear comprehension of others. The assessment indicated that Resident R1 had no functional limitations to upper and lower extremities. Resident R1 was using a manual wheelchair for mobility. The assessment indicated that Resident R1 was dependent on staff assistance to come to a standing position from sitting in a chair. The assessment also indicated that Resident R1 had diagnoses of cerebral vascular accident (stroke) and parkinsonism (a condition of symptoms of slowed movement, rigidity, tremor and balance issues). Clinical record review for Resident R1 revealed a physical therapy assessment dated [DATE], that indicated Resident R1 was not able to propel the wheelchair 150 feet. Interview with the physical therapist, Employee E3, at 10:00 a.m., on January 8, 2026, confirmed that due to the resident's decreased cognitive skills, Resident R1 was not capable of operating the wheelchair with full purpose. Clinical record review for Resident R1 indicated a care plan for the use of leg rests as needed for safe transportation with staff, while Resident R1 was seated in the wheelchair.Observations of resident R1 at 11:00 a.m., on January 8, 2026, revealed that this resident could propel herself in the wheelchair a short distance very slowly. A review of the Pennsylvania Department of Health report form for investigation of alleged abuse, neglect, misappropriation of property dated December 4, 2025, for the alleged abuse incident resulting in serious physical injury for Resident R1 revealed that this report contained a witness statement by a nursing assistant, Employee E5, that indicated Resident R1 was observed being pushed down the hallway on the back wheels of the manual wheelchair on December 2, 2025. The reportable event said that Resident R1 was removed from the common area/lounge during an activity for making disruptive foul statements during the planned activity. Interview with Employee E5, nursing assistant, at 10:30 a.m., on January 8, 2026, confirmed that Resident R1 was purposely angled backward in her wheelchair so that her feet were dangling and not able to touch the floor. The nursing assistant, Employee E6 had elevated the front two wheels of the chair in the air and reclined the wheelchair. Nursing assistant, Employee E6; restrained Resident R1 from normal use of the wheelchair with the hands and/or feet. Nursing assistant Employee E5 witnessed Resident R1 being wheeled down the hallway from the activities room at approximately 2:30 p.m., on December 2, 2024. Further interview with Employee E5 at 10:30 a.m., on January 8, 2026, revealed that Resident R1 was heard saying, while being pushed down the hallway by Employee E6 from the lounge/ activity area on December 2, 2025, that she did not want to go to her bedroom. Interview with Employee E5, nursing assistant, at 10:45 a.m., on January 8, 2026, revealed that after Resident R1 was placed in her room on December 2, 2025, by Employee E6. Nursing assistant, Employee E5 said that Resident R1 was found crying in her room at approximately 3:00 p.m., on December 2, 2025. The nursing assistant, Employee E5, also reported that Resident R1 told reported, at this time that that someone had bent her hand. Nursing assistant, Employee E5 also said that Resident R1 reported that if Employee E6, nursing assistant, comes back to take care of her, she was going to kill her with her gun. Interview with Employee E5 at 10:50 a.m., on January 8, 2026, confirmed that the event of alleged abuse of Resident R1 by Employee E6 on December 2, 2025, was not reported to the licensed or registered nurse on the 7 to 3 tours of duty or the 3 to 11 tours of duty as required by the facility's abuse prevention and investigation protocols. Clinical record review revealed that the registered nurse was called to assess Resident R1 with a painful and swollen left hand at 8:30 p.m., on December 2, 2025. The physician was notified and ordered an x-ray of the left hand and pain medication was administered at 8:30 p.m., on December 2, 2025. A review of the nursing schedules for December 3, 2025, revealed that Employee E6, was scheduled for work on the 7-to-3-day shift nursing assignment for the first-floor nursing unit. Resident R1 along with many other residents were living on the first-floor nursing unit. Clinical record review revealed that x-ray results were taken of Resident R1's left hand at 12:30 p.m. on December 3, 2025, and reported to the facility at 4:00 p.m., on December 3, 2025. Clinical record review revealed that on December 3, 2025, Resident R1 was sent to the hospital for further evaluation. The physician indicated being unaware that Resident R1 had fallen or sustained trauma. Observations and interview with Resident R1 at 11:30 a.m., on January 8, 2026, revealed that this resident was very upset and crying about her finger fracture. She said it was not painful right now, but it was painful. The resident reported that a staff member bent her hand backward causing the fracture. Resident R1 was not able to elaborate on the cause of the fracture in more detail. The registered nurse, Employee E11, told the resident that the person who was taking care of her when her finger was injured, no longer works at the facility. A review of the employee corrective action form for the nursing assistant Employee E6, revealed that the employee was discharged due to the severity of the infraction during resident care on December 4, 2025. Interview with the administrator and director of nursing at 2:00 p.m., on January 8, 2026, revealed that the nursing assistant, Employee E6 was seen on camera footage on December 2, 2025, pushing Resident R1 from the lounge area at about 2:30 p.m., by improper use of the wheelchair without leg rests attached. The administrator and director of nursing reported that the camera footage showed Resident R1 trying to grab an object in the hallway to prevent herself from being wheeled into her room against her will.There was no documentation to indicate if Resident R1 was successful at grasping an object while being pushed unwillingly in the manual wheelchair down the hallway to her room. There was no documentation to indicate the probable cause of the serious injury (fractured left 4th proximal phalanx) of unknown origin that was sustained by Resident R1 under the care of the facility staff. 28 PA. Code 211.10 (a)(b)(c)(d) Resident care policies28 PA. Code 211.12(d)(1)(3)(5) Nursing services28 PA. Code 201.14(a) Responsibility of licensee 28 PA. Code 201.18(b)(1)(3)(d)(e)(1) Management

Based on observations, interviews with staff, and review of facility policy, it was determined that the facility failed to ensure safe and sanitary storage and handling of personal food products brought in from outside sources for three of 21 residents. (R80, R15). Findings Include: Review of Facility Policy: Foods Brought by Family/Visitors undated, states Food brought to the community by visitors and family is permitted. Community staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. Safe food handling practices will be explained to family/visitors in a language and format they understand. Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Contains will be labeled with the resident's name, the items and the use by date. On May 20, 2025, at 11:36 a.m., an observation conducted with the unit manager, Employee E5, revealed that Resident R15 had a personal refrigerator containing Chinese takeout food in Styrofoam container, red paper, and a peach. There was no temperature log to monitor the safe temperatures. It was further confirmed that the facility had not given her any guidance on how to maintain food in accordance with health and safety standards. On May 20, 2025, at 11:58 a.m., an observation conducted with the unit manager, Employee E5, revealed that Resident R80 had a personal refrigerator containing three food containers. The containers were not labeled with dates, and the refrigerator did not have a temperature log. Resident R80 stated that her family had provided the refrigerator, and that the facility had not given her any guidance on how to maintain food in accordance with health and safety standards. On May 21, 2025, at approximately 11:20 a.m., an interview was conducted with the Administrator, Employee E1, who confirmed that the facility allowed several residents to have personal refrigerators without providing guidance on how to maintain food in accordance with health and safety standards. On May 21, 2025, at 2:00 p.m., a follow-up interview was conducted with Resident R15, who expressed frustration that her Chinese food in a Styrofoam container, a peach, and a red paper item were frozen due to the refrigerator being at a freezing temperature. 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policies, observation, interviews with residents and staff, it was determined the facility failed to promote care for residents that maintains or enhances dignity and respect related to privacy during treatment administration and ensuring residents' care and comfort is maintained by providing necessary necessities of bedding for two of eight residents reviewed. (Resident 4 and Resident 370) Findings include: Review of facility policy titled Abuse and Neglect dated March 2018, clinical protocol defines neglect as the failure of the facility, its employees or service providers, to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish or emotional distress. Review of facility policy titled Activities of Daily Living (ADL) dated March 2018 revealed residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Review of Resident R4's quarterly Minimum Data Set (MDS - federal mandated assessment tool for all residents) dated May 6, 2025, revealed that this resident was admitted into the facility on July 18, 2024 and required partial of moderate assistance with ADL's ( activities of daily living). The resident was assessed with a BIMS (Brief Interview of Mental Status) score of 12 indicating that this resident had moderate cognitive impairment. Review of Resident R4's clinical record revealed a physician order dated July 18, 2024, for the medication Lidocaine patch 5% to be administered daily to both shoulders topically one time a day for pain. Observation of medication administration on May 22, 2025, at 8:35 a.m. with Licensed nurse, Employee E13 revealed that Employee E13 prepared medications and administered the medication while the hallway to Resident R4. Licensed nurse, Employee E13, applied the Lidocaine patches to both of Resident R4's shoulders under the resident shirt, providing no privacy to the resident while in the hall, next to the activity room where six residents were observed watching television and other resident walking by toward the dining room for breakfast. Review of Resident R370's admission MDS dated [DATE], revealed that the resident entered the facility on May 14, 2025 with diagnosis' including, orthopedic condition (a condition that effects the bones, joints and or muscles), and arthritis. The resident was assessed as dependent for ADLs (activity of daily living), the resident used a wheelchair. Continued review of the MDS revealed that the resident had a BIMS (brief interview of mental status) score of 14, which indicated that Resident 370 had intact cognitive functions. Observation of Resident R370 in his room on May 21, 2025, at 9:50 a.m. who resided on the 2nd Floor nursing unit revealed the resident lying on his plastic bed mattress with no sheets, no blanket, and no pillowcase. Interview with resident at time of the above observation revealed that the resident received care earlier that morning (estimate over an hour prior) and the employee left after stripping the bed, she has not yet returned. Interview with Nurse aide, Employee E15 on May 21, 2025, at 10:15 confirmed she was assigned to Resident R370 and provided care and stripped his bed earlier. This employee stated that she was unable to complete making the bed due to lack of supplies, Employee E15 stated that there were no linens available on the unit. Interview with Nurse aide, Employee E18 on May 21, 2025, at 10:35 a.m. confirmed this employee was also assigned to the 2nd floor nursing unit and had all available linens to make all the beds assigned to her. Interview with Nurse aide, Employee E20 May 21, 2025, at 10:55 a.m. confirmed he provided care on the 2nd floor for residents also and had no shortage of linens. Employee E20 described the process of collecting supplies for each resident. Observed was a linen closet with sheets and blankets folded. There are two linen cabinets on the floor and if they run low on supplies, the laundry room is located on the second floor, and supplies can be obtained there. Tour of the laundry room revealed on May 21,2025 at 11:00 a.m. revealed lines clean, folded, stored and available , this observation confirmed by laundry Employee E16 and Unit Manager E17 . 28 Pa.Code 201.29(j) Resident Rights 28 Pa Code 211.12(d)(1)(5) Nursing Services

Based on review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers to the hospital for one of two hospitalizations reviewed (Resident R117). Findings Include: Review of Resident R117's clinical record revealed a nursing progress note dated March 18, 2025, that indicated the resident was transferred to the local hospital for evaluation. Review of documentation provided by the Nursing Home Administrator on May 23, 2025, at 10:35 a.m. revealed the Office of the State Long Term Care Ombudsman was not made aware of Resident R117's facility-initiated emergency transfers to the hospital as required until May 21, 2025. Interview on May 23, 2025, at 10:54 a.m. with the Nursing Home Administrator, Employee E1, confirmed the ombudsman was not made aware of Resident R117's hospital transfer on March 18, 2025. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(2) Management

Based on review of facility policy and review of clinical records, it was determined that the facility failed to develop and implement a baseline care plan for one of two new admissions reviewed (Resident R319). Findings Include: Review of facility policy, Care Plan-Baseline dated 2001 revealed, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admissions. Review of Resident 319's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of dementia (progressive degenerative disease of the brain). A comprehensive care plan which was initiated on May 12, 2025 did not indicate a baseline care plan for dementia. On May 21, 2025, at 1:48 p.m. an interview with the Director of Nursing, Employee E2 confirmed that Resident R319 did not have a baseline care plan. 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(5) Nursing services

Based on a review of clinical records, and interviews with residents, family members, and staff, it was determined that the facility failed to provide the necessary assistance with activities of daily living (ADLs) to maintain proper grooming for 3 of the six residents reviewed (Residents R319, R62 and R45). Findings: Review of Resident 319's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of dementia, muscle weakness, difficulty in walking, and osteoarthritis ( join disease that results in breakdown of join cartilage and underlying bone). A review of Resident R319's admission Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 7, reflecting severe cognitive impairment. A comprehensive care plan initiated on May 12, 2025, indicated: I have an ADL deficit due to cognitive deficits, impaired balance, and spinal fracture. Assistance of one person is required for transfers, bed mobility, toileting, bathing/washing, dressing/grooming, and self-care. Provide setup assistance with needed or desired items. Allow ample time for the resident to complete tasks. On May 20, 2025, at 12: 14 p.m. an interview was held with Resident 319 who was observed to have long nails. Resident R319 wanted her/his nails to be cut. On May 20, 2025, at 12:46 an confirmation of Resident R319 having long nails was confirmed by unit manager, Employee E5. On May 20, 2025, at 12:58 p.m., a family interview was held for nonverbal Resident R45, who was on receiving hospice services. The family member revealed that the resident needed a haircut, which had been brought to the facility's attention a few weeks prior, but the haircut had not yet been provided. It was further stated that his nails become long before someone cuts them and that it takes some time to get them cut. Review of Resident 45's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of dementia. A review of Resident R45's quarterly Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 99, meaning resident unable to participate in the cognitive interview due to severity of their severity of their impairment. On May 20, 2025, at 1:12 p.m. unit manager, Employee E5 confirmed the observations of resident having long nails and long hair. A comprehensive care plan dated May 4, 2025, was reviewed and revealed Resident R45 is a two person always assist with care. Dependent on staff for bathing washing, dressing/growing and self-care. On May 4, 2025, a facility developed a care plan for the resident to allow his/her nail to be filed down. A review of Resident R62's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses including parkinsonism (a condition with movement-related symptoms like Parkinson's disease), difficulty walking, right hip pain, unsteadiness on feet, and orthostatic hypotension (a sudden drop in blood pressure when standing up from a sitting or lying position). A review of Resident R62's admission Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 3, reflecting severe cognitive impairment. The functional abilities section of the MDS indicated that Resident R62 requires maximum assistance with hygiene tasks. On May 20, 2025, at 11:23 a.m., Resident R62 was interviewed and observed to have facial hair and expressed a desire to be shaved. At 12:46 p.m. the same day, the unit manager, Employee E5, confirmed that the resident was in need of a shave. 28 Pa code 211.12.(d)(1)(5) Nursing services

Based on review of facility policies, clinical record reviews and interviews with staff, it was determined the facility failed to ensure that medically related social services were provided as required for four of eight residents reviewed related to routine care plan meetings. (Residents R60, R61, R68, R97) Finds include: Review of facility policy titled Care Plans - Baseline dated March 2022 revealed the baseline plan includes instructions needed to provide effective person-centered care of the resident that meet professional standards of quality of care and must include minimum healthcare information necessary to properly care for the resident including but not limited to initial goals, physician orders, dietary orders, therapy services, social services, PASARR recommendations. The baseline care plan Is used until a staff can conduct the comprehensive assessment and develop interdisciplinary person standard comprehensive care plan the baseline care plan is updated as needed to meet the residents needs until the comprehensive care plan is developed. Review of Resident 60's clinical progress notes revealed this resident's last care plan meeting was held November 5, 2024. Participating in the care conference were representatives from Nursing, Dining Services, Recreation, and Social Services. Also participating in the Care Conference was Resident R'60's daughter. Further review of Resident R60's clinical record notes revealed that resident prior care conference meetings were dated August 9, 2024, June 25, 2024, and March 5, 2024. Review of Resident R61 clinical record revealed that this resident's last care conference was dated November 26, 2024. Participants in the care conference were nurse, dining, recreation, social services and resident's daughter. Review of Resident R68's clinical record revealed that this resident last care conference was held on November 5, 2024. Participating in the conference were representatives from nursing, dining services, recreation, and social services, also in attendance was Resident R68 POA (power of attorney). Medications and care plan were reviewed. Review of Resident R97's social service note revealed that this resident's last care conference was held on December 5, 2024, via conference call with resident's family and interdisciplinary team. Medication and care plan were reviewed. Interview with Resident R60's family member on May 20, 2025, at 12:43 p.m. revealed that she is dissatisfied with the social service communication. Resident R60 has not had a care plan meeting in over six months and there is not currently one planned. Interview with Social Service Director, Employee 24 on May 22, 2025, at 1:20 p.m. revealed that care conference should be held every quarter (every 3 months). Employee E confirmed that the care conferences have delayed due to shortness of staff in the department. 28 Pa. Code 201.14 Responsibility of Licensee 28 Pa. Code 211.16(a) Social services

Based on review of clinical records, staff interview, and pharmacy review recommendations, it was determined that the facility failed to act on the pharmacy recommendations in a timely manner for one of three residents reviewed (Resident R78). Findings include: Clinical record review revealed Resident R78 was admitted to the facility on [DATE], with a diagnosis that included but not limited to personal history of transient ischemic attach (TIA) (refers to it as a mini- stroke temporary blockage of blood flow to the brain), cerebral infarction, dementia, difficulty in walking, muscle weakness, unsteadiness on feet. Further review of Resident R78's clinical record revealed the physician ordered Diclofenac sodium external gel 1% apply to left hip and lower back topically four times a day for arthritis pain, apply 4 grams to left hip and lower back on January 14, 2025. During a drug regimen review on January 14, 2025, the pharmacist recommended that Voltaren Gel (Diclofenac Gel) should be administered as follow: lower extremities- apply 4 gram to affected area and upper extremities-apply 2 gram to affected area . Please add the gram strength to the directions for Voltaren Gel. During an interview on May 23, 2025, at 10:34 a.m., Director of Nursing E2 confirmed that the facility failed to implement the pharmacy recommendations for Resident R78, and recommendation had not been implement at all. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observations, review of facility policies and interview with staff, it was determined that the facility failed to ensure that medications carts were kept locked and refrigerated medications kept dry and at proper temperatures on one of two nursing floors. (2nd Floor) Findings include: Review facility policy titled Medication Labeling and Storage revealed the facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light and only authorized personnel have access to keys. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanctuary manner. Compartments but not limited to drawers, cabinets, rooms, refrigerators, carts and boxes containing medication biologicals are locked and such items or left are not left unattended if open or otherwise potentially available to others. Review of facility policy titled Administrating Medications revised 2012 revealed that during administration of medications, the medication cart will be kept closed and locked when out of sight of medication nurse or aide. It must be kept on the door away of the resident's room, with open drawers facing inward and all other sites closed. No medications or kept on top of the cart. The cart must be clearly visible to the personnel administrating medications, and all outward sides must be inaccessible to residents or others passing by. Observation on May 20, 2025 at 11:50 a.m. on the 2nd Floor revealed the cart assigned to Licensed nurse, Employee E22 was left unlocked. Employee E22 was observed coming out of a resident room at the end of the hallway. Interview with Licensed nurse, Employee E22 confirmed the cart was left unlocked. Observation on May 22, 2025 on the second floor nursing unit revealed that the low Cart assigned to Licensed nurse, Employee E23 was left unlocked. Interview with Nursing Supervisor, Employee E6 at time of above observation confirmed that cart was left unlocked. Interview with Licensed nurse, Employee E23 on May 22, 2025 at 9:12 a.m. revealed she was unaware the cart was unlocked. Observation of medication cart identified as middle cart on May 22, 2025 at 9:25 a. m. reveled Licensed nurse, Employee E13 leaving the cart unlocked while going to the kitchen on the nursing floor for supplies. Observation of the above confirmed by Nursing Supervisor, Employee E6 at time of the above observation. Observation of Second floor medication room on May 22, 2025 at 8:38 a.m. with Nursing Supervisor, Employee E6, revealed the medication refrigerator tempeture reading at 50 degrees and the top of the refrigerator frozen and dripping water onto the medications. All contents of the refrigerator were found to be wet. The observation above was confirmed by Nursing Supervisor, Employee E6 at time of the above observation 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) nursing services

Based on environmental observations of the food and nutrition services department, reviews of the consulting pest control operator's reports and interviews with staff, it was determined that the facility failed to maintain an effective pest control program for the building. Findings include: Observations of the main kitchen, where foods and fluids are prepared, stored and assembled for delivery to the nursing units revealed that the flooring was in need of repair. The grouting was missing and worn away by water damage in the three compartment sink area. The flooring contained pooling of water and food debris from leaking and inoperatable equipment (sink, garbage disposal and grease trap). The water and food debris were nutrients for pests and rodents. Observations of the metal doors leading directly outdoors from the hallway near the main kitchen revealed that the doors were not sealing properly upon closing. There were noted gaps (one inch) located at the threshold of the doors. These doors opened to a driveway where the dumpster unit for trash and garbage was held for pick-up and disposal by an outside contractor. A review of the pest control operators reports for the months of February, 2025 through May, 2025 indicated that the facility, together with the main kitchen was treated for common household pests and rodents (mice, roaches and ants). Interview with the director of maintenance and housekeeping, Employee E7, at 11:30 a.m., on May 20, 2025 confirmed the repairs and cleaning that were necessary to ensure that the inside of the building was pest and rodent free. 28 PA. Code 201.14(a) Responsibility of licensee 28 PA. Code 201.18(b)(1)(3)(e)(1)(2.1) Management

Based on observations of the physical environment of the food and nutrition services department and interviews with staff, it was determined that essential equipment used to operate the main kitchen where foods and beverages were prepared for the residents was not in safe functional condition. Findings include: The dish machine was not functioning to provide water hot enough for cleaning and sanitizing dishware's, utensils, pots, pans, cups, bowls, plates and mugs. The required final rinse temperature to clean and sanitize the dishware was 180 degrees Fahrenheit. Observations at 9:40 a.m., on May 20, 2025 of the final rinse temperature of the dish machine revealed the gauge and digital readings were was below the required temperature specified by the equipment manufacturer at 150 degrees Fahrenheit. Interview with the director of dietary services, Employee E9 at 9:45 a.m., on May 20, 2025 confirmed that the booster heater for the dish machine was not functioning. The director of dietary also confirmed that the water softener was not functioning for months either. Observations of the three compartment sinks revealed that the wells were in need of repair. The one well was not holding water. The sink stopper, piping and working mechanism underneath the sinks were leaking water all over this area. Observations of the food garbage disposal located adjacent to the three compartment sink revealed that this piece of equipment was not functioning according to manufacturers' specifications. The garbage disposal was spewing water onto the ceramic tiled flooring. The flooring contained deep groves with the missing grouting secondary to the water damaged tiles. The grouting on the tiled flooring in this area below the three compartment sink had been worn away from constant water leakage. The flooring contained deep groves secondary to the water damaged tiles. Observations of the grease trap that was located in the three compartment sink area revealed that it was out of commission and covered with a piece of soggy plywood. The continuous water leaking from the broken well of the three compartment sink and the constant spewing of the water from the broken garbage disposal unit saturated the plywood cover that had been placed over the broken grease trap that was installed in the floor of this area. Observations of the metal doors that open directly outdoors from the hallway located along side of the main kitchen were not sealing properly upon closing. There were noted gaps to the outside located at the threshold of the doors. Interview with the administrator, Employee E1 and the director of dietary services, Employee E9 at 10:00 a.m., on May 20, 2025 confirmed that essential equipment (dish washer, booster heater, water softener, garbage disposal, three compartment sink, grease trap and metal doors (adjacent to the main kitchen) leading directly outside the building) for the food and nutrition department was not maintained in safe mechanical and operational condition. 28 PA. Code 201.14(a) Responsibility of licensee 28 PA. Code 201.18(b)(1)(3)(d)(e)(1)(2.1) Management

Based on review of facility policy, facility documentation, and staff interviews, it was determined the facility failed to implement appropriate tracking and surveillance of infection for two of 3 months reviewed April 2025 and May 2025. (Resident R97) Findings include: Review of facility policy titled Infection Prevention and Controlled Manual dated February 2020, revealed the primary objective of the infection prevention control program is to provide an effective facility wide program that ensures that the facility develops implements and maintains an infection prevention and control program in order to prevent recognize, and control, to the extent possible, the onset and spread of the infection within the facility. The infection prevention and control program will perform surveillance, prevent and control outbreaks, use records of infection reports to improve its infection control process and outcomes by taking corrective actions as indicated, implement hand hygiene, and properly store handle process and transport linens. Review of National Health Care Safety Network NHSN tool for tracking healthcare associated infections titled Long Term Care Facility Component Manual dated January 2023 revealed surveillance is defined as an ongoing systematic collection comment analysts, interpretation, and this emanation of data. A facility infection prevention and control program should use surveillance to identify infections and monitor performance of practices to reduce infection risks among residents' staff and visitors' information collected during surveillance activities can be used to develop and track prevention priorities for the facility. Review of Resident R97's nursing notes dated April 11, 2025, revealed that eye drainage was noticed by the nurse's aide, the eye was cleaned several times on this shift, but drainage continues. Spoke with medical doctor regarding right eye drainage. Medical doctor ordered polytime eye drops one drop in eye four times a day for one week. Review of resident physician orders revealed an order dated April 11, 2024, for the antibiotic Polytrim ophthalmic solution, with instructions to instill one drop in right eye four time a day for drainage from right eye. Further review of Resident R97's nurses notes dated April 18, 2025 revealed the resident has completed antibiotic poyltrim to right eye, no redness or drainage noted. Further review of Resident R97's nurses note dated May 7, 2025, revealed Resident R97 was seen by on site ophthalmologist. New orders as follows Ofloxacin (antibiotic eye drops) instill one drop every day in both eyes for seven days related to bacterial conjunctivitis. Continued review of resident clinical record physicians' orders revealed and an ordered dated May 8, 2025, for the antibiotic Ofloxacin with instruction to instill one drop in both eyes one time a day for bacterial conjunctivitis (pink eye, very contagious bacteria infection of the eye) for seven days Interview with Infection Preventionist, Employee E21 on May 22, 2025, at 1:02 p.m. confirmed the documentation that Resident R97 was diagnosed and treated for bacterial conjunctivitis and the infection tracking for the months of April 2025 and May 2025 did not reflect this resident's infection. Resident 97 was not listed for having a bacterial infection. Employee E 21 stated she is uncertain of how that was missed in the months of April 2025 and May 2025 in infection tracking. 28 Pa. code 211.10(d) Resident Care policies 28 Pa. code 211.12(d)(1)(5) Nursing services

Based on observations of the operations of the food and nutrition services department, reviews of policies and procedures and interviews with residents and staff, it was determined that the facility failed to ensure each resident received and the facility provided foods and drinks that were palatable, attractive and at a safe and appetizing temperature. Residents (R14,R3, R86, R115, R55, R85, R94, R94, R79). Findings include: A review of the undated facility policy titled test tray evaluation revealed that the acceptable temperature for the hot food entree, starch and vegetables were 135 degrees Fahrenheit at point of service for the residents and the acceptable temperature for soup was 165 degrees Fahrenheit at point of service for the residents. The policy also indicated that the dietary department was responsible to ensure that accepatable temperatures were provided at point of service for the residents, to maximize food quality, palatability and safety the foods and beverages. Observations during the noon meal service of the foods and beverages on May 20, 2025, for the residents that were eating in the dining rooms or having tray delivery service to their rooms revealed that the main hot entree was listed as country fried steak and cream gravy. The residents did not receive the cream gravy as planned. The country fried steak was over-cooked or held hot for extended time. The residents and staff had difficulty cutting and chewing the country fried steak. Residents were heard asking for a substitute food item for their main entree that day; because the food was not palatable, attrative and appetizing. A review of the menus planned by the dietitian and prepared by the food and nutrition department staff, on May 20, 2025 revealed that all diets Regular, Mechanical, Pureed, Carbohydrate Controlled, Renal were preplanned to receive cream gravy with their meals. On May 22, 2025, at 10:30 a.m., a resident group meeting was held with nine alert and oriented residents (R14, R3, R86, R115, R55, R85, R94, R94, and R79). The residents reported that food is being served cold during all three meals-breakfast, lunch, and dinner. They stated that the food is difficult to chew, lacks flavor, and is not seasoned. Some residents also reported that they often request items from the alternative menu, which typically consists of sandwiches. A test tray evaluation was completed on May 22, 2025 and supported the residents concerns that the foods and fluids were not regularly being received and provided that were palatable, attractive and at safe and appetizing temperatures for resident satisfactiony. Observations of the meal tray pass for the residents eating in their rooms on the second floor nursing unit revealed a delay in passing food trays, the nursing staff. The corned beef and cabbage was tested at point of service to the residents and was 116 degrees Fahrenheit. Mashed potatoes were tested at point of service to the residents and were 100 degrees Fahrenheit. The director of dietary services, Employee E9, was present during the test tray evaluation on the second floor nursing unit and confirmed the delays, in meal tray pass. The low or tepid temperatures of the hot foods (below the established standard of 135 degrees Fahrenheit at point of service) was also confirmed with the food service director on May 22, 2025. A review of the pre-planned menu devised by the dietitian for May 22, 2025 revealed that lentil soup was planned; however chicken noodle soup was prepared and served. Roasted carrots, potatoes and onions were planned; however mashed potatoes were served instead. Mixed fruit dump cake was planned; however corn bread was prepared and served for the residents. A dinner roll was planned with margarine; however it was not offered/served to the residents on this day. Interview with the director of dietary service, Employee E9, at 1:30 p.m., on May 22, 2025 confirmed that the recipe for country fried steak was not followed on May 20, 2025. The director of dietary services, Employee E9 also confirmed that the menu was not followed as planned on May 22, 2025. 28 PA. Code 211.12(a)(b)(c)(d) Resident care policies 28 PA. Code 211.12(c)(d)(3)(5) Nursing services

Based on review of facility policies, clinical records, and interviews with staff, it was determined that the facility failed to ensure that grievance regarding abuse/neglect was filed, tracked and promptly resolved for one of six residents reviewed. (Resident R1). Findings Include: Review of facility policy titled, Grievances/Complaints, Filing dated April 2017 states, 8. Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint. 9. The grievance officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse, and/or misappropriation of property will be report and investigated under guidelines for reporting abuse, neglect and misappropriation of property, as per state law.10. The administrator will review the findings with grievance officer to determine what corrective actions, if any, need to be taken Review of the facility grievance log provided for the months on March, April and May 2025 revealed there was no grievance listed for the month of April 2025 for Resident R1. Interview conducted with Social Worker, Employee E7 on May 8, 2025 at 12:02 p.m. revealed that the Grievance Form was filled out because it was a reportable incident but it was not added to the Grievance Log. Employee E7 revealed she has been working at the facility for around two years. When asked about a facility Grievance Policy Employee E7 stated that she had no knowledge of a Grievance Policy since being employed at the facility. Facility Social Worker Employee E7 stated that she has the residents on the first floor but was currently filling in for the Social Worker who has the residents on the second floor. Employee E7 stated that Employee E9 has been out of Family Medical Leave since February 2025. When asked who was in charge of the Grievance Log Employee E7 stated herself and Employee E9. On May 8, 2025 at at 12:01 p.m. the Nursing Home Administrator Employee E1 was asked to provide a Grievance Policy. A Grievance Procedure was provided as a part of the facility admissions packet. The Nursing Home Administrator Employee E1 stated that he had no knowledge of one. Social Worker, Employee E7 stated that she first became aware of the situation that occurred with Resident R1 on in the morning of Monday April 21, 2024 during clinical meeting. Employee E7 stated that she met and interviewed Resident R1. Employee E7 stated that assignments sheets are gathered and she partners with unit manager to gather interviews and then sends this to the administrator. When asked if Employee E7 interviewed any other residents on the alleged perpetrator, nurse aide Employee E6 Employee E7 stated that all the other residents were deemed non-interviewable. 28 Pa. Code 201.18 (b)(1)(3)(2.1)(4) Management 28 Pa. Code 201.29 (a) Resident Rights

Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility did not ensure that all allegations of abuse and neglect were reported immediately to the Pennsylvania Department of Health for one of six residents reviewed. (Resident R1) Findings Include: Review of facility policy titled, Abuse Prevention Program revised December 2016 states, Policy Statement-Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Review of facility records revealed Resident R1 was admitted to the facility on [DATE]. The resident had the following diagnoses: Hemiplegia (paralysis to one side of the body), Morbid Obesity, and Atherosclerosis of Native Arteries of Extremities with Rest Pain (Right Leg). Review of facility grievance form titled, Resident/Family Concerns dated April 21, 2025 states, Concern-Nursing Concern states, Resident reported that she fell on 4/19/25 when [nurse aide Employee E6] attempted to hoyer her out of bed. She reported that she fell to the ground. Investigation section states, Date Initiated: 4/21/25 Date Competed was left blank next Section stated, Assignment sheet obtained, Employee E6 was the assigned nurse aide. This staff member resigned as of statements obtained from all other staff members. Review of facility investigation statements revealed an undated resident statement, Resident was interviewed regarding a report of fall from Hoyer. Resident reported early Saturday morning [Employee E6] was attempting to transfer her from bed to wheelchair using a Hoyer lift. As she was suspended in the air, she reported that she was suddenly on the floor. She reported falling on the right side of the bed next to the bathroom. Resident R1 reported that [Employee E6] called nurse aide [Employee E4] to assist her with getting her from the floor back into bed. When asked why she had not reported the fall sooner, she reported that when she fell, [Employee E6] said, Shhh I'll get fired, I have 8 kids. She stated that she reported the incident because her leg was hurting, and she found out [Employee E6] had resigned. Review of nurse aide, Employee E11 statement dated April 22, 2025 states When I came to work on 4-21-25 I had [Resident R1]. As I was doing AM care she told me that she fell. I asked how could you fall. She said they pick her up and put her in the bed. She told me what they looked like. I told the nurse. Interview with the Nursing Home Administrator held on May 8, 2025 at 1:34 p.m. revealed the Director of Nursing Employee E2 was on off Monday April 20, 2025 on the day Resident R1 reported the alleged abuse/neglect. The Nursing Home Administrator, Employee E1 stated he was working on April 21, 2025 and stated that the Social Worker Employee E7 was to enter the Incident into the Pennsylvania Electronic Event Report System as the social workers usually do. Employee E1 stated, I didn't follow up and that was my fault I should have but it was missed. The facility failed to enter the report of alleged abuse/neglect into the Pennsylvania Electronic Event Reporting System immediately of receiving the allegation from Resident R1. 28 Pa. Code: 201.14(a)(c) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management.

Based on review of facility policy, review of clinical records, and interviews with staff, it was determined that the facility failed to provide evidence that an allegation of abuse/neglect was thoroughly investigated for one of six residents reviewed. (Resident R1). Findings Include: Review of facility policy titled, Abuse Prevention Program revised December 2016 states, Policy Statement-Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Review of facility grievance form titled, Resident/Family Concerns dated April 21, 2025 states, Concern-Nursing Received complaint by section is not checked off. Lists Writing, Verbal, During Resident Council, and Other all blank. Concern states, Resident reported that she fell on 4/19/25 when nurse aide Employee E6 attempted to hoyer her out of bed. She reported that she fell to the ground. Investigation section states, Date Initiated: 4/21/25 Date Competed is left blank Section states, Assignment sheet obtained, Employee E6 was the assigned nurse aide. This staff member resigned as of statements obtained from all other staff members. Review of facility records revealed Resident R1 was admitted to the facility on [DATE]. The resident had the following diagnoses: Hemiplegia (paralysis to one side of the body), Morbid Obesity, and Atherosclerosis of Native Arteries of Extremities with Rest Pain (Right Leg). Review of facility grievance form titled, Resident/Family Concerns dated April 21, 2025 states, Concern-Nursing Concern states, Resident reported that she fell on 4/19/25 when [nurse aide Employee E6] attempted to hoyer her out of bed. She reported that she fell to the ground. Investigation section states, Date Initiated: 4/21/25 Date Competed was left blank next Section stated, Assignment sheet obtained, Employee E6 was the assigned nurse aide. This staff member resigned as of statements obtained from all other staff members. Review of facility investigation statements revealed an undated resident statement, Resident was interviewed regarding a report of fall from Hoyer. Resident reported early Saturday morning [Employee E6] was attempting to transfer her from bed to wheelchair using a Hoyer lift. As she was suspended in the air, she reported that she was suddenly on the floor. She reported falling on the right side of the bed next to the bathroom. Resident R1 reported that [Employee E6] called nurse aide [Employee E4] to assist her with getting her from the floor back into bed. When asked why she had not reported the fall sooner, she reported that when she fell, [Employee E6] said, Shhh I'll get fired, I have 8 kids. She stated that she reported the incident because her leg was hurting, and she found out [Employee E6] had resigned. Review of statement dated April 22, 2025 states When I came to work on 4-21-25 I had Resident R1. As I was doing AM care she told me that she fell. I asked how could you fall. She said they pick her up and put her in the bed. She told me what they looked like. I told the nurse. Review of statement undated by Nurse aide Employee E4 states, When I worked with [Employee E6] I was asked to help with [Resident R2] who I changed and helped show an easier way to change. Then I needed help with a change so I went in [room XXX] and [Employee E6] was pulling the covers over when I asked for her assistance. Review of an undated written statement from Licensed nurse Employee E5 stated, Resident AAO (alert and oriented) x 3 (person, place and time) reported to a care nurse that she fell Saturday when the girl who had that assignment attempted to transfer her from the bed to wheelchair, the girl did not have anyone with her in the room, while she lifted her up with the Hoyer, she slid, the next thing she noticed that she was on the floor. Resident states that the girl attempted to get her off the floor, she had difficulty because she was screaming her legs hurt, then the care nurse called another care nurse to help her out. Nurse supervisors was notified, she went into the room assessed the resident. Resident back of left leg with mild swollen and painful. She is able to move all extremities. Pain medication 650 mg (milligrams) given for pain. Doctor was made aware. New order for stat x-ray left leg. Continue review of the facility's investigation revealed no evidence that the facility attempted to call and interview the alleged perpetrator Nurse aide, Employee E6. No evidence the facility attempted to interview any other licensed nurses or nurse's aids across shifts for April 18, April 19, 2025, April 20, 2025 or April 21, 2025. No evidence the facility attempted to interview any other residents on Nurse, aide,Employee E6's assignment or on the unit. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.12(c) Nursing services

Based on review of clinical record, review of facility documentation and interview with staff, it was determined that the facility failed to ensure that one of six residents reviewed receive the required assistance via mechanical lift during a bed to chair transfer. This failure resulted in actual harm to Resident R1 whose left leg got twisted during transfer and sustained a fracture of the left femur (thigh bone). (Resident R1) Findings include: Review of facility policy 'Using a Mechanical Lifting Machine,' revised July 2017, states the following: 4. Prepare the environment: a. clear an unobstructed path for the lift machine; b. ensure there is enough room to pivot; c. position the lift near the receiving surface; and d. place lift at correct height. Further review of policy instructs staff to 13. Lift the resident 2 inches from the surface to check the stability of the attachments, the fit of the sling and the weight distribution. 14. Check the resident's comfort level by asking or observing for signs of pinching or pulling of the skin. Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE] with the diagnosis of legal blindness, muscle weakness, dementia (progressive degenerative disease of the brain), Poly osteoarthritis, age-related osteoporosis without current pathological fracture. Review of Resident R1's quarterly Minimum Data Set (MDS- assessment of resident's care needs) dated August 17, 2024, revealed that the resident was visually impaired. The resident was assessed with cognitive impairment and required substantial to maximum assistance with transfer from bed to chair. Review of Resident R1's care plan revised September 12, 2024, revealed that up until the date of incident the resident was care planned for exhibiting factors related to falls such as impaired cognition and visual deficit. Interventions included for the resident to be transferred via mechanical (hoyer) lift with the assistance of 2 persons. The resident was also care planned for impaired vision as evidence of blindness. Review of Resident R1's nursing notes dated October 13, 2024, at 12:23 p.m., revealed that primary nurse reported incident occurrence during patient transfer from bed to chair. Complained of pain to left lower extremity noted, PRN (as needed) Tylenol given, skin intact, with no redness observed. on call provider notified, 2 views stat (immediate) ordered. Continued review of nursing notes revealed that on October 13, 2024 at 2:42 p.m. care nurse reported that [Resident R1] complaining of leg pain. PRN (as needed) Tylenol administered for pain. left hip down to femur tender to touch. no swelling no redness observed. on call provider notified. 2 views stat (immediate) ordered. Nursing note date October 14, 2024, revealed x-ray of the left tibia-fibula demonstrate no acute fracture. Continued review of nursing notes revealed that on October 14, 2024 at 3:01 p.m. resident is monitored for left leg pain. On left knee is swollen and resident is complaining when the leg is moved. I called [physician] and she ordered an x-ray of left hip, left femur and left knee. Further review of nursing note dated October 14, 2024, at 8:33 p.m. revealed Technician during x-ray stated resident has Fracture and displacement of L (left) femur in multiple areas and requested to not transfer resident from bed to chair, should ensure she stays in bed when turning to be very careful. Continued review of nursing notes dated October 15, 2024 at 7:33 a.m. stated that the resident was admitted to the hospital with the diagnosis of left femur fracture. Review of physician notes from Resident R1's outpatient office visits on October 24, 2024, revealed that upon physical examination Resident R1 was noted to have an abrasion over the anterior aspect of her left knee she also has an abrasion over her left lateral ankle. Review of facility investigation revealed a written statement from Nurse aide, Employee E2 [Nurse aide Employee E3] gave care to [Resident R1] while I gave care to . When the time came to get [Resident R1] up into her chair we lifted her, and put her into her chair. It wasn't until [Resident R1] said It hurts! that we noticed her leg bent. [Employee E3] made sure Resident R1 was safe and secured in her chair. Review of Nurse aide, Employee E3's written statement revealed while transferring [Resident R1] with another CNA [nurse aide, Employee E2] to her chair her left leg bent to her side. Interview with Nurse aide, Employee E2, on November 4, 2024, at 1:12 p.m., revealed that at the time of incident, Employee E2 was on orientation and unfamiliar with Resident R1's care related to transfers. Per Employee E2's report - she helped another nurse aide with transfer of Resident R1 from bed to geriatric chair during which time there were no incident, however Resident R1 started to complain of pain on left lower extremity immediately after transfer. Interview with Nurse aide, Employee E3, on November 4, 2024, at 1:20 p.m., revealed that Employee E3 was not familiar with Resident R1's care related to transfers since she is not her regular nurse aide; per Employee E3's report Resident R1's left leg twisted inward during transfer from bed to chair. The facility failed to ensure that Resident R1 with a diagnosis of Osteoporosis was transferred in accordance with the resident's care plan via mechanical lift from bed to chair. This failure resulted in actual harm to Resident R1's whose left leg got bent and twisted and sustained a fracture of the left femur. 28 Pa. Code 201.18(b)(1 Management 28 Pa. Code 211.10(d)Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of clinical records, review of hospital documentation and staff interviews, it was determined that the facility failed to ensure adequate supervision during a transfer for one of two residents reviewed for falls (Resident R80). This failure resulted in actual harm to Resident R80 who did not receive the appropriate level of assistance during a transfer from bed to wheelchair and sustained displaced spiral fractures of the right distal tibial and fibular shafts. Findings include: Review of Resident R80's clinical record revealed a quarterly MDS (Minimum Data Set - resident assessment and care screening) dated May 2, 2022, which indicated that Resident R80 was admitted to the facility on [DATE], and had diagnoses of adult failure to thrive, depression (loss of interest in pleasurable activities), hypertension (high blood pressure), and heart failure. Review of the functional status section of the MDS revealed Resident R80 required extensive, two-person assistance with transfers (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position). Resident R80 was assessed as not steady for surface-to-surface transfer and was only able to stabilize with staff assistance. Review of Resident R80's care plan kardex (a document that provides direction of the care to be provided to a resident by nursing assistant) revealed that the resident transfer status was for one- person physical assist and not two person physical assist as indicated in the resident MDS assessment. Review of Resident R80's fall risk assessment dated [DATE], revealed the resident was assessed as a high fall risk. Further review of Resident R80's clinical record revealed a physical therapy evaluation and plan of treatment dated July 13, 2022. Reason for referral for physical therapy services revealed Resident R80 exhibited a new onset of decrease in strength, decrease in functional mobility, decrease in transfers, reduced ability to safely ambulate, reduced balance, reduced functional activity tolerance, reduced static and dynamic balance, and increased need for assistance from others and reduced activities of daily living participation. Review of Resident R80's clinical record revealed a nursing note dated July 16, 2022, that Resident R80's care nurse reported to the charge nurse that while Resident R80 was being assisted from the bed to the wheelchair, Resident R80's leg got caught under the wheel. Resident R80 began screaming about the leg. When the charge nurse went into the room, Resident R80 was observed lying on the bed and had difficulty moving the right leg. Resident R80 was assessed with a swollen knee area which was painful to touch. Resident R80 was ultimately transferred to the hospital for further evaluation. Review of Resident R80 's hospital records dated July 16, 2022, revealed the resident was diagnosed with osteoporosis and pathological fracture. The resident was assessed to have sustained low impact trauma, found to have displaced spiral fractures of the right distal tibial and fibular shafts . Orthopedic surgery recommended surgical management. Review of a written statement by Resident R80's nursing assistant, Employee E12, dated July 16, 2022, revealed that when transferring Resident R80 from the bed to the wheelchair, Resident R80's leg got caught under the wheel and she began screaming about her leg. Review of wrtitten statement dated July 16, 2022, by nursing assistant, Employee E14, revealed this aide was assisting another resident with care when they heard Employee E12 calling out for help. Upon entry into Resident R80's room it appeared that Employee E12 was attempting to transfer Resident R80 from the bed to the wheelchair. Resident R80 was observed sliding and yelling. The nursing assistants decided to put the resident in bed. At that point, Resident R80 verbalized pain and the charge nurse was made aware. Interview on November 15, 2022, at 11:05 a.m. with nursing assistant Employee E12, confirmed that Resident R80 was assisted with one-person physical assist during transfer and subsequent injury on July 16, 2022. The facility failed to ensure that Resident R80 was provided with a two person physical assist during a transfer which resulted in actual harm to Resident R80, who sustained a spiral fractures of the right distal tibial and fibular shafts during a transfer from bed to wheelchair. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on review of clinical records, review of facility documentation, review of facility policies and interviews with staff, it was determined that the facility failed failed to ensure that the proper assistance was provided for a resident requiring two person assistance with bed mobility which resulted in actual harm to Resident R70 sustaining a fall requiring transfer to the hospital and laceration for one of 31 residents reviewed. The facility failed to to conduct an smoking assessment to ensure the safety of a resident who smokes for one of 31 residents reviewed. (Resident R75 and Resident R70) Findings include: Review of the clinical record for Resident R70 revealed that resident was admitted to the facility on (MONTH) 10, (YEAR) with [DIAGNOSES REDACTED]. Review of Minimum Data set Assessment (MDS-periodic assessment of resident's care needs), dated (MONTH) 6, 2019 indicated resident had a BIMS (Brief Interview for Mental Status-a screening assessment to aid in in determining cognitive impairment) score of 99 that indicated that that resident's cognitive skills for daily decision making was severely impaired or the resident was unable to participate in the assessment. The MDS also revealed that Resident R70 was identified with inattention (difficulty focusing, and easily distracted ) Further review of MDS revealed that the resident required two persons assist for bed mobility. Review of care plan initiated (MONTH) 11, (YEAR) revealed that the goal was for Resident R70 to be free of injury with an intervention for two persons assist with all transfers. Review of facility document Post fall investigation dated (MONTH) 19, 2019 revealed that the nursing assistant, Employee E9, attempted to transfer Resident R70 using a sit to stand lift and placed Resident R70 on the edge of the bed. Further review of the investigation revealed that the nursing attempted to lay resident's back onto the bed during the transfer and the resident grabbed the nursing assistant's abdomen for support, where the nursing assistant had an incision from the surgery, which resulted in nursing assistant moving back and removed her hands off the resident, subsequently, resident fell forward to the floor. Review of statement by nursing assistant, Employee E9, dated (MONTH) 19, 2019 revealed that the nursing assistant attempted to lay Resident R70's upper body onto the bed and the resident grabbed her stomach for support where the nursing assistant had an incision from surgery which resulted in nursing assistant moving back and the resident fell forward to the floor. Interview with nursing assistant, Employee E9, on (MONTH) 29, 2019 at approximately 2:50 p.m. stated she was by herself while transferring Resident R70 on (MONTH) 19, 2019. Employee E9 confirmed that the resident was placed at the edge of the bed but was not in a safe position. Employee E11 stated she attempted to lay resident's upper body back in the bed and the resident grabbed her stomach for support, where the nursing assistant had an incision from the surgery, she moved back and took her hands off the resident and the resident fell forward to the floor. Review of facility document Post fall investigation dated (MONTH) 19, 2019 contained no evidence that the staff provided two persons assist during bed mobility on (MONTH) 19, 2019 for Resident R70. Interview with Director of Nursing, Employee E2, on (MONTH) 29, 2019 at approximately 1:30 p.m. confirmed that there was only one nursing assistant with Resident R70 on (MONTH) 19, 2019. Review of nursing note dated (MONTH) 19, 2019 revealed that resident sustained [REDACTED]. Moderate amount of bleeding was also noted from the area. Physician was notified and resident was transferred to the hospital per the physician's orders [REDACTED].>Review of hospital record for Resident R70 dated (MONTH) 20, 2019 revealed resident was treated for [REDACTED]. The facility failed to ensure that Resident R70 was assist into bed by two staff members on (MONTH) 19, 2019 which resulted in actual harm to Resident R70 falling from the edge of the bed, sustaining a laceration to the forehead and requiring transfer to the hospital. Review of facility policy titled Smoking Policy-Residents dated, (MONTH) (YEAR) revealed The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include: current level of tobacco consumption, method of tobacco consumption, desire to quit smoking, if a current smoker and ability to smoke safely with or without supervision (per a completed staff smoking evaluation). Observation of Resident R75 on (MONTH) 28, 2019 at approximately 8:45 a.m. and on (MONTH) 30, 2019 at approximately 9:00 a.m. revealed that Resident R75 was smoking in front of the facility without staff supervision. Interview with Resident R75 on (MONTH) 25, 2019 at approximately 11:13 a.m., stated he was an active smoker and he was smoking three times a day without staff supervision. Review of clinical records for Resident R75 did not reveal any evidence that facility conducted an evaluation to determine the ability of the resident to smoke safely with or without supervision. Interview with director of nursing on (MONTH) 30, 2019 at approximately 1:38 p.m. confirmed that Resident R75 clinical record contained no evidence that the facility conducted a smoking evaluation for Resident R75. The facility failed to conduct an assessment of a resident who smokes without staff supervision. 28 Pa Code 201.14(a) responsibility of licensee Previously cited 9/12/19, 11/27/18 28 Pa Code 201.18(b)(1) Management Previously cited 9/12/19, 11/27/18 28 Pa Code 211.10(c) Resident care policies Previously cited 9/12/19, 11/27/18 28 Pa Code 211.12(d)(1) Nursing services Previously cited 9/12/19, 11/27/18 28 Pa Code 211.12(d)(5) Nursing services Previously cited 9/12/19, 11/27/18

Based on review of clinical records and facility policies and procedures, and interviews with staff, it was determined that the facility did not accurately monitor and assess the nutritional and hydration status of one resident identified as severely malnourished, resulting in actual harm to that resident (Resident R1). Findings include: Review of the clinical record revealed that Resident R1, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of an initial Minimum Data Set (MDS-assessment tool) dated April 8, 2014, revealed that the resident had severe cognitive impairments, required extensive assistance from two or more staff persons for dressing, eating, and personal hygiene. The MDS further indicated that the resident had identified care needs in the areas of cognitive loss and nutritional status. A comprehensive nutrition assessment completed on May 6, 2014, revealed that, upon admission, the resident was five feet nine inches tall and weighed 116 pounds and was severely underweight. Further review of the nutritional assessment indicated that the resident was to receive supplemental snacks twice daily to aid in weight gain. Additionally, the resident was enrolled in the hydration program to encourage increased fluid intake. The nutritional summary further indicated that the registered dietitian would continue to monitor the resident's weight and food and fluid intake. Review of the weight history log for Resident R1 dated April 24, 2014, through February 1, 2015, revealed an alternating pattern of weight gain and weight loss. Further review of the resident's weight record indicated that on December 3, 2014, the resident weighed 126.6 pounds, on January 1, 2015, the resident weighed 129.3 pounds. On January 6, 2015, the resident weighed 113.0 pounds. This change in weight represented a 16.3 pound weight loss in five days. The resident was subsequently reweighed on January 7, 2015, and was noted to weigh 113.8 pounds, which represented a 15.5 pound weight loss over five days. A review of facility policy, "weight measurement", dated June 15, 2006, revealed "When a +/- five pound weight change is identified for a resident greater than 100 pounds... nursing is to notify the Dietitian of recognized weight change..." and "nursing is to notify the resident's physician of the significant weight change... and "Nursing is too notify the responsible party of the significant weight change...". Review of the clinical record for Resident R1 revealed no documentation that the dietitian or the attending physician were notified of the resident's weight loss until January 12, 2015, five days after the weight loss was confirmed. In addition, the clinical record revealed no documentation that the resident's responsible party had been notified of the resident's weight loss. An interview with Employee E2, registered dietitian, on February 4, 2015, at 10:50 a.m., confirmed that the dietitian had not been notified of the weight loss until January 12, 2015, five days after the weight loss had occurred. Further interview with Employee E2, revealed that the dietitian was unable to track the total amount of fluid or snacks that Resident R1 consumed on a daily basis. Employee E2 was unable to determine what individual food items the resident received as a snack and/or how many calories were provided in the snacks. Additionally, the interview revealed that the dietitian could not access that information through the facility's electronic medical record system and that the employee was "very dependant upon nursing staff to track and report any resident with decreased oral intake". An interview with Employee E3, unit manager, on February 4, 2015, at 12;30 p.m., revealed that the nursing assistants are responsible for providing supplemental snacks and hydration to the residents. Further interview with the unit manager confirmed that staff do not track and/or document the type or amount of the snacks or drinks that the residents consume. The unit manager was unable to determine if Resident R1 had consumed any of the supplemental snacks or drinks staff had provided. Review of a quarterly Nutritional assessment dated [DATE], revealed that Resident R1's estimated daily fluid needs were 1300-1560 ml (milliliter) per day. A review of the fluid intake report dated January 2015, revealed the following documented fluid intakes for Resident R1: January 15, 2015, total fluid intake 720 ml, January 16, 2015, total fluid intake 600 ml, January 17, 2015, total fluid intake 960 ml, January 18, 2015, total fluid intake 620 ml, January 19, 2015, total fluid intake 960 ml, January 20, 2015, total fluid intake 360 ml, January 21, 2015, total fluid intake 960 ml, January 22, 2015, total fluid intake 900 ml, January 23, 2015, total fluid intake 480 ml, January 24, 2015, total fluid intake 508 ml and January 25, total fluid intake 50 ml. Interview with Employee E3, unit manager, on February 4, 2015, at 12:30 p.m., confirmed that facility staff had not documented any additional fluid intake for Resident R1, and that the unit manager was unaware of the actual quantity of fluid the resident had received on a daily basis. Interview with Employee E2, dietitian, on February 4, 2015, at 10:50 a.m., confirmed that the dietitian was unable to access Resident R1's daily fluid intake and/or determine the amount of fluids the resident had received through the hydration program. Further interview with Employee E2 revealed the dietitian was unable to determine if Resident R1's oral intake had met the established minimum recommendations. Further clinical record review revealed that on January 25, 2015, the resident developed "uncontrollable twitching noted" and was transferred to the emergency room for further evaluation. A review of the hospital record dated January 25, 2015, at 3:15 p.m., indicated that the resident was admitted to the hospital with [REDACTED]. Further review of the hospital record revealed laboratory results on January 25, 2015, were as follows: blood urea nitrogen (BUN- a test to determine kidney function) 41 milligrams (mgs) per deciliter (dl), normal BUN is considered 7-20 mg/dl, Creatinine (a test to determine kidney function), 1.92 mg/dl, normal value for Creatinine is 0.6-1.2 mg/dl and Sodium 171 milliequivalents per liter (mEq/L) normal value for Sodium is considered 136 to to 145 mEq/L. Additional documentation in the hospital record indicated that Resident R1's Creatinine level was "high", BUN level was "high" and Sodium level was "critical", at the time of the resident's admission. Upon admission to the facility Resident R1 was identified as severely malnourished and at increased risk for weight loss. The facility did develop interventions to reduce the risk of nutritional decline to the resident, however; the facility did not establish a standardized process to accurately monitor the effectiveness of the interventions they had developed. The resident subsequently sustained [REDACTED]. Facility staff did not follow their established protocol for significant weight loss. The facility failed to notify the dietitian or the attending physician in a timely manner, as required, so that new interventions could be developed for the resident. In addition, facility staff were unable to accurately assess and monitor this resident's fluid intake. Clinical documentation for fluid intake dated January 2015 indicted that Resident R1 did not receive the daily recommended amount of fluids. The resident was subsequently transferred to the hospital on January 25, 2015, with [DIAGNOSES REDACTED]. The resident remain hospitalized until February 1, 2015, a period of seven days. The facility failed to ensure that Resident R1 received the appropriate care and services necessary to maintain the resident's highest practicable physical, mental and psychosocial well-being. This failure caused actual harm to the resident. 42 CFR 483.25 Quality of Care. 28 Pa. Code: 201.18(b)(1) Management. Previously cited 11/21/14. 28 Pa. Code: 211.10 (c) Resident Care Policies. 28 Pa. Code: 211.5(f) Clinical Records. 28 Pa. Code: 211.12(d)(1) Nursing Services. Previously cited 11/21/14.